Evaluating the public health impact of health promotion interventions: the RE-AIM framework

The Victorian Active Script Programme: promising signs for general practitioners, population health, and the promotion of physical activity

BACKGROUND

The Active Script Programme (ASP) aimed to increase the number of general practitioners (GPs) in Victoria, Australia who deliver appropriate, consistent, and effective advice on physical activity to patients. To maximise GP participation, a capacity building strategy within Divisions of General Practice (DGPs) was used. The objectives of the programme were to (a) train and support GPs in advising sedentary patients, and (b) develop tools and resources to assist GPs.

OBJECTIVE

To evaluate the effectiveness of the ASP.

METHODS

A systems approach was used to promote capacity in Victorian general practice. Economic analyses were incorporated into the programme's evaluation. Participants were selected DGPs and their GP members. The programme worked with DGPs to train GPs and provide relevant resources. The main outcome measures were (a) changes in GP knowledge and behaviour and (b) cost effectiveness, based on modelled estimates of numbers of patients advised and adopting physical activity and gaining the associated health benefits.

RESULTS

GP awareness and provision of physical activity advice increased. Although the programme's reach was modest, based on actual GP involvement, the cost effectiveness figures (138 Australian dollars per patient to become sufficiently active to gain health benefits, and 3647 Australian dollars per disability adjusted life year saved) are persuasive.

CONCLUSIONS

The ASP increased DGPs' capacity to support GPs to promote physical activity. There is a strong economic argument for governments to invest in such programmes. However, caution is warranted about the maintenance of patients' activity levels. Programme refinement to encourage GPs to use community supports more effectively will guide future development. Further research on long term patient adherence through a multisectorial approach is warranted.

The feasibility and effectiveness of an expressive writing intervention for rheumatoid arthritis via home-based videotaped instructions

BACKGROUND

Expressive emotional writing has demonstrated efficacy for improving health status in a wide variety of healthy persons and recently in patients with chronic disease.

PURPOSE

This study was a randomized, controlled effectiveness trial with 4 arms: 2 active treatment writing groups, 1 inactive writing group, and 1 attention control group. It represents the first attempt to translate the expressive writing intervention into a low-cost, community-based intervention in the form of a videotaped program.

METHODS

Feasibility of the approach and patient adherence were examined in a community rheumatology practice with rheumatoid arthritis patients (N = 373).

RESULTS

The videotape format was able to convey the intervention instructions accurately and produced the expected and differential ratings of stressfulness and emotional provocation across the 3 writing programs. Seventy-nine percent of eligible patients agreed to take the program home; 49% of these patients reported that they followed the protocol. Physician Disease Activity Rating and the Physical Component Summary of the SF36v2 Health Survey were assessed pre and post program.

CONCLUSIONS

Intent-to-treat analyses found no effect of the treatment. Pretreatment differences among the protocol-adherent patients complicated treatment outcome interpretation. The standard writing instructions did not yield an effect; a modified set of instructions to extract meaning from the traumatic event yielded equivocal results. Contrasts between efficacy and effectiveness trials and the challenge of achieving significant outcomes in effectiveness trials are discussed.

Effects of the Quebec Heart Health Demonstration Project on adult dietary behaviours

BACKGROUND

There are few studies which have evaluated the dietary impact of multiple community-based cardiovascular disease prevention programs.

METHODS

A 5-year, multifactorial community-based heart disease prevention program was conducted by regional public health departments in three sites: urban, suburban and rural. The experimental and control communities were composed of independent samples of 4,863 adults in 1993 and 5,260 in 1997. The impact of the program on diet was assessed by a validated, self-administered food frequency questionnaire which yielded a Global Dietary Index (GDI).

RESULTS

The urban and suburban sites showed improvements in mean GDI in both exposed and non-exposed groups while the rural site mean GDI showed deterioration in both groups (n.s.). The analysis of variance showed that the group x year interaction terms were not significant for each site and sex, indicating that the intervention did not have measurable effects on dietary behaviours. Inclusion of confounding variables did not alter those findings. Analyses of specific food group indices gave similar results.

CONCLUSIONS

Future intervention programs could benefit from considering physical and social environments as well as public policy changes to improve efficacy.

Introduction to the Special Section on the Future of Health Psychology

Following 25 years of landmark progress, health psychology faces even greater change in the foreseeable future. Evolving patterns of health and illness and developments in medicine and related fields will shape the future of health psychology. The articles in this special section discuss these future issues in several areas: the biopsychosocial model, changes in demographics, prevention, clinical health psychology interventions, health care financing, and new technologies. In every case, the future holds a variety of important challenges and opportunities in research, practice, training, and policy.

It ain't over till it's over: the case for offering relapse-prevention interventions to former smokers

Most people who attempt to quit tobacco smoking eventually relapse. Although treatment strategies have been developed to prevent smoking relapse, they tend to be available only to the small proportion of smokers who enroll in intensive smoking cessation treatments. It is argued that freestanding relapse-prevention interventions could be offered to persons who recently ceased smoking, whether they used a formal treatment program or quit on their own. A line of research is described demonstrating that a series of relapse-prevention booklets mailed to recent quitters significantly reduces smoking relapse. Moreover, the intervention seems to be highly cost-effective. If disseminated widely, such an approach has the potential to make a significant public health impact.

What have we learned from 20 years of research on smokeless tobacco cessation?

Although smoking cessation continues to get most of the attention from both researchers and practitioners, treatment for smokeless tobacco (SLT) dependence gets little consideration. The reasons are varied, but essentially smoking is more prevalent, has greater public health implications, and has been the subject of clean air laws and environmental issues that have focused the attention on a burned tobacco, thereby leaving SLT with scant public health attention. This is unfortunate, because the sales of SLT products, especially moist snuff, have increased consistently over the past decade; regular use of these products can result in oral cancer, other negative effects on oral health, and nicotine dependence or addiction. This article will review some unique issues of SLT use that affect cessation and the empirical research on interventions.

Why don't we see more translation of health promotion research to practice? Rethinking the efficacy-to-effectiveness transition

The gap between research and practice is well documented. We address one of the underlying reasons for this gap: the assumption that effectiveness research naturally and logically follows from successful efficacy research. These 2 research traditions have evolved different methods and values; consequently, there are inherent differences between the characteristics of a successful efficacy intervention versus those of an effectiveness one. Moderating factors that limit robustness across settings, populations, and intervention staff need to be addressed in efficacy studies, as well as in effectiveness trials. Greater attention needs to be paid to documenting intervention reach, adoption, implementation, and maintenance. Recommendations are offered to help close the gap between efficacy and effectiveness research and to guide evaluation and possible adoption of new programs.

Designing effective HIV/AIDS social and behavioral interventions for the population of those age 50 and older

Social and behavioral HIV/AIDS prevention interventions designed to test their effects on older cohorts are sorely lacking in the scientific literature even though middle-aged and older people represent a significant minority of both existing and new AIDS cases. This article raises key issues relevant in developing and evaluating HIV/AIDS social and behavioral interventions for older cohorts. These interventions must build on our current understanding of behavior change and HIV prevention successes with younger populations while considering important intervention principles gathered from work with older populations in other health arenas. In addition, the authors expand on recent national panels and published reviews relevant to the topic and provide a set of intervention recommendations for use in tandem with these intervention principles. The article also calls for additional research into the sociocultural contexts that influence risk-taking among older cohorts and for the development of interventions at multiple levels. Pragmatic considerations such as identifying and dismantling ageism in interventions, delineating intervention outcomes, and planning for intervention transferability, dissemination, and sustainability also are raised.

The D-Net diabetes self-management program: long-term implementation, outcomes, and generalization results

BACKGROUND

A prerequisite to translating research findings into practice is information on consistency of implementation, maintenance of results, and generalization of effects. This follow-up report is one of the few experimental studies to provide such information on Internet-based health education.

METHODS

We present follow-up data 10 months following randomization on the "Diabetes Network (D-Net)" Internet-based self-management project, a randomized trial evaluating the incremental effects of adding (1) tailored self-management training or (2) peer support components to a basic Internet-based, information-focused comparison intervention. Participants were 320 adult type 2 diabetes patients from participating primary care offices, mean age 59 (SD = 9.2), who were relatively novice Internet users.

RESULTS

All intervention components were consistently implemented by staff, but participant website usage decreased over time. All conditions were significantly improved from baseline on behavioral, psychosocial, and some biological outcomes; and there were few differences between conditions. Results were robust across on-line coaches, patient characteristics, and participating clinics.

CONCLUSIONS

The basic D-Net intervention was implemented well and improvements were observed across a variety of patients, interventionists, and clinics. There were, however, difficulties in maintaining usage over time and additions of tailored self-management and peer support components generally did not significantly improve results.

Tobacco use patterns and attitudes among teens being seen for routine primary care

PURPOSE

To describe the tobacco-related attitudes, behaviors, and needs of smoking and nonsmoking teens being seen for routine pediatric care and to identify predictors of tobacco use.

DESIGN

Cross-sectional survey of adolescent primary care patients who completed self-administered questionnaires in medical office waiting rooms while waiting for routine care visits.

SETTING

A group-practice HMO in the Pacific Northwest.

SUBJECTS

A sample of 2526 teenagers, ages 14 to 17, who consented to receive health promotion interventions as a part of a randomized trial in seven pediatric and family practice offices.

MEASURES

A 38-item questionnaire assessed tobacco use history, attitudes, quit attempts, and stage of acquisition or cessation along with gender, age, race/ethnicity, body mass index, educational plans, frequency of exercise, attempts to lose weight, and depressed mood.

RESULTS

Sixty-seven percent of teens approached (2526 of 3747) consented to complete a questionnaire and receive tobacco- or diet-related interventions as a part of their medical visit. About 23% of teen patients reported smoking at least one cigarette in the last month, although only 14% described themselves as current "smokers." Most current smokers (84%) smoked at least 20 days in the last month. Logistic regression predictors of smoking included older age, Native American ethnicity, lower educational aspirations, lower body mass index, smoking among half or more friends, smokers at home, and a positive depression screen. Among ever-regular smokers, most were in the action (28%), preparation (21%), or contemplation (22%) readiness to quit smoking stages, and 77% of current smokers had made one or more serious quit attempts in the last year.

CONCLUSIONS

Most teens in these medical facilities consented to receive tobacco and diet interventions, and most self-described current smokers were contemplating or preparing to quit. Medical visits provide attractive opportunities for tobacco intervention, but messages should be tailored based on the patient's tobacco status and stage of acquisition or cessation.

Consumer-oriented evaluation of health education services

The objective of this study was to evaluate the effect of the presence of formal health education units in health plans on the health education reported by the consumer. The research consisted of interviews with health educators in the Israeli health plans and a random sample of telephone interviews with 793 Israeli residents between the ages of 45 and 75. The interviews with consumers included measures of counseling on smoking, physical activity, weight reduction, hypertension and diabetes. Two of the four Israeli health plans have formal health education units. After adjustment for other variables, however, the quality and quantity of counseling reported by the consumers does not differ, in most subjects, between health plans with or without health education units. The presence of a health education unit within a health plan had little effect on the counseling reported by the consumer. The reasons for and implications of the results are discussed.

Reporting of validity from school health promotion studies published in 12 leading journals, 1996-2000

A targeted review was conducted of school-based, controlled intervention studies that promoted good nutrition, physical activity, or smoking cessation/prevention, and were published in one of 12 leading health behavior journals between 1996 and 2000. The RE-AIM framework was used to evaluate the extent to which each paper reported on elements of reach, efficacy, adoption, implementation, and maintenance. Thirty-two publications were reviewed. Reporting rates across the RE-AIM dimensions varied substantially: Reach = 59.3%; Efficacy = 100%; Adoption = 14.8%; Implementation = 37%; Maintenance = 25.9% for individuals, 0% for schools. Few studies reported if characteristics of the study sample were representative of those found in the broader population of students or schools. Among studies reporting on the RE-AIM dimensions, participation rates generally were high (median 82%), adoption rates were moderate (median 72.5%), and reports of implementation were high (87%). To increase the potential to translate controlled research to "real-world" practice conditions, a stronger emphasis should be placed on reporting the representativeness of the sample of students and schools.

Challenges to improving the impact of worksite cancer prevention programs: comparing reach, enrollment, and attrition using active versus passive recruitment strategies

OBJECTIVE

The impact of worksite intervention studies is maximized when reach and enrollment are high and attrition is low. Differences in reach, enrollment, and retention were investigated by comparing 2 different employee recruitment methods for a home-based cancer-prevention intervention study.

METHODS

Twenty-two worksites (N = 10,014 employees) chose either active or passive methods to recruit employees into a home-based intervention study. Reach (e.g., number of employees who gave permission to be called at home), Enrollment (e.g., number of employees who joined the home intervention study), and Attrition (e.g., number who did not complete the 12- and 24-month follow-ups) were determined. Analysis at the cluster level assessed differences between worksites that selected active (n = 12) versus passive (n = 10) recruitment methods on key outcomes of interest. Employees recruited by passive methods had significantly higher reach (74.5% vs. 24.4% for active) but significantly lower enrollment (41% vs. 78%) and retention (54% vs. 70%) rates (all ps < .0001). Passive methods also successfully enrolled a more diverse, high-risk employee sample. Passive (vs. active) recruitment methods hold advantages for increased reach and the ability to retain a more representative employee sample. Implications of these results for the design of future worksite studies that involve multilevel recruitment methods are discussed.

If you build it, will they come? Reach and Adoption associated with a comprehensive lifestyle management program for women with type 2 diabetes

This paper describes recruitment and participation of physicians and patients in a randomized study to evaluate the effects of a moderately intensive (2-year) lifestyle management intervention for post-menopausal women with type 2 diabetes at risk for coronary heart disease (CHD). The purpose of this report is to answer two practical public health questions: (1) "Will physicians refer their patients with type 2 diabetes to such an intensive lifestyle change program?" and, if so, (2) "Will these patients participate?" Results showed high (70%) acceptance among physicians. About 51% of eligible patients agreed to participate, which was encouraging given the substantial time commitment involved. Main reasons for refusal were lack of eligible patients (among physicians) and lack of time (among patients). Patient participants and non-participants did not differ significantly on age, body mass, and other demographic and medical variables. Based on these results, it appears that appropriate recruitment procedures will yield a representative sample of women willing to participate in intensive lifestyle management programs.

Implementation, generalization and long-term results of the "choosing well" diabetes self-management intervention

Prerequisites for translating intervention research findings into practice are maintenance of results, generalization of effects and consistency of implementation. This report presents 12 months follow-up information on a randomized 2x2 factorial trial evaluating the incremental effects of adding (1) telephone follow-up or (2) a community resources utilization component to a basic touchscreen computer-assisted dietary goal-setting intervention for 320 type 2 diabetes patients. All conditions evidenced significant improvement from baseline to the 12 months follow-up across behavioral, biological and psychosocial measures. There were few consistent differences between conditions, but results were robust across interventionists and clinics. The telephone follow-up component appeared to enhance long-term results on some measures. When considered along with earlier results from a randomized trial that included a control condition without goal setting, it is concluded that this basic goal-setting intervention can be consistently implemented by a variety of interventionists and produce lasting improvements.

Do Internet-based support interventions change perceptions of social support?: An experimental trial of approaches for supporting diabetes self-management

Internet-based support groups are a rapidly growing segment of mutual aid programs for individuals with chronic illnesses and other challenges. Previous studies have informed us about the content of online exchanges between support group members, but we know little about the ability of these interventions to change participants' perceptions of support. A randomized trial of 160 adult Type 2 diabetes patients provided novice Internet users with computers and Internet access to 1 of 4 conditions: (a) diabetes information only, (b) a personal self-management coach, (c) a social support intervention, or (d) a personal self-management coach and the support intervention. After 3 months, individuals in the 2 support conditions reported significant increases in support on a diabetes-specific support measure and a general support scale. Participants' age was significantly related to change in social support, but intervention effects were still significant after accounting for this relationship. This report is a critical first step in evaluating the long-term effects of Internet-based support for diabetes self-management. The discussion identifies directions for future research.

Self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycemic control

OBJECTIVE

To evaluate the efficacy of self-management education on GHb in adults with type 2 diabetes.

RESEARCH DESIGN AND METHODS

We searched for English language trials in Medline (1980-1999), Cinahl (1982-1999), and the Educational Resources Information Center database (ERIC) (1980-1999), and we manually searched review articles, journals with highest topic relevance, and reference lists of included articles. Studies were included if they were randomized controlled trials that were published in the English language, tested the effect of self-management education on adults with type 2 diabetes, and reported extractable data on the effect of treatment on GHb. A total of 31 studies of 463 initially identified articles met selection criteria. We computed net change in GHb, stratified by follow-up interval, tested for trial heterogeneity, and calculated pooled effects sizes using random effects models. We examined the effect of baseline GHb, follow-up interval, and intervention characteristics on GHb.

RESULTS

On average, the intervention decreased GHb by 0.76% (95% CI 0.34-1.18) more than the control group at immediate follow-up; by 0.26% (0.21% increase - 0.73% decrease) at 1-3 months of follow-up; and by 0.26% (0.05-0.48) at > or = 4 months of follow-up. GHb decreased more with additional contact time between participant and educator; a decrease of 1% was noted for every additional 23.6 h (13.3-105.4) of contact.

CONCLUSIONS

Self-management education improves GHb levels at immediate follow-up, and increased contact time increases the effect. The benefit declines 1-3 months after the intervention ceases, however, suggesting that learned behaviors change over time. Further research is needed to develop interventions effective in maintaining long-term glycemic control.

Behavior change intervention research in healthcare settings: a review of recent reports with emphasis on external validity

BACKGROUND

Information to judge both the internal and external validity of health behavior research conducted in healthcare settings is vital to translate research findings to practice. This paper reviews the extent to which this research has reported on elements of internal and external validity, with emphasis on the extent to which research has been conducted in representative settings with representative populations.

METHODS

A comprehensive review was conducted of controlled interventions for dietary change, physical activity, or smoking cessation conducted in healthcare settings and published in 12 leading health behavior journals between 1996 and 2000. Using the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework, the characteristics and results of these studies were summarized to document the extent to which intervention reach, adoption, implementation, and maintenance were reported and what has been learned about each of these dimensions.

RESULTS

A total of 36 studies qualified for review. Participation rates among eligible patients were reported in 69% of studies and were generally quite high; in contrast, only 30% of studies reported on participation rates among either healthcare settings or providers. Implementation data were reported in 77% of the studies and these rates were generally high, with the caveat that intervention was often delivered by paid research staff. Long-term maintenance results were reported very consistently at the individual level, but program continuation was almost never reported at the setting level.

CONCLUSIONS

We conclude that a much stronger emphasis needs to be placed on the representativeness of providers and settings that are studied. Examples of how this can be done and recommendations for future research are provided.

Increasing use of mammography among older, rural African American women: results from a community trial

OBJECTIVES

A community trial was undertaken to evaluate the effectiveness of the North Carolina Breast Cancer Screening Program, a lay health advisor network intervention intended to increase screening among rural African American women 50 years and older.

METHODS

A stratified random sample of 801 African American women completed baseline (1993-1994) and follow-up (1996-1997) surveys. The primary outcome was self-reported mammography use in the previous 2 years.

RESULTS

The intervention was associated with an overall 6 percentage point increase (95% confidence interval [CI] = -1, 14) in community-wide mammography use. Low-income women in intervention counties showed an 11 percentage point increase (95% CI = 2, 21) in use above that exhibited by low-income women in comparison counties. Adjustment for potentially confounding characteristics did not change the results.

CONCLUSIONS

A lay health advisor intervention appears to be an effective public health approach to increasing use of screening mammography among low-income, rural populations.

Recruitment of older participants in frailty/injury prevention studies

Despite the lifelong health benefits of physical activity, frailer older adults have typically been excluded from studies promoting more active lifestyles. This study documents the recruitment process and costs from a multisite study to identify effective strategies for recruiting older adults in frailty/injury prevention research. Randomized controlled clinical trials were conducted at 7 sites; an 8th site was a compliance study. Interventions reflected center- and home-based health promotion programs. Site objectives, eligibility criteria, and contact and screening methods were obtained from manuals of operation. Recruitment results (number screened, eligibility rates, randomized to screened ratios) were ascertained from recruitment data. Sites furnished estimated recruitment costs (nonlabor expenses, investigator and staff time, fringe benefits) up to signing the consent form. The sites targeted diverse populations and sample sizes. The majority revised recruitment methods to meet their recruitment goals. Most sites estimated costs of recruitment at over $300 per participant randomized. Recruitment costs were affected by staff time spent alleviating concerns about participants' health, essential interactions with family members, and arranging for transportation. Neither frailty nor intervention intensity was found to be a major predictor of recruitment outcomes. Recruitment expense was associated with selection criteria and frailty status of the target population. Older people can be successfully recruited into beneficial health promotion programs, but it is often challenging. In planning health promotion studies, investigators need to be aware of the numbers of older people they may need to screen and different strategies for increasing recruitment success.

Community interventions for reducing smoking among adults

BACKGROUND

Since smoking behaviour is determined by social context, the best way to reduce the prevalence of smoking may be to use community-wide programmes which use multiple channels to provide reinforcement, support and norms for not smoking.

OBJECTIVES

To assess the effectiveness of community interventions for reducing the prevalence of smoking.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group specialised register, MEDLINE (1966-August 2001) and EMBASE (1980-August 2001) and reference lists of articles.

SELECTION CRITERIA

Controlled trials of community interventions for reducing smoking prevalence in adult smokers. The primary outcome was smoking behaviour.

DATA COLLECTION AND ANALYSIS

Data were extracted by one person and checked by a second.

MAIN RESULTS

Thirty two studies were included, of which seventeen included only one intervention and one comparison community. Only four studies used random assignment of communities to either the intervention or comparison group. The population size of the communities ranged from a few thousand to over 100,000 people. Change in smoking prevalence was measured using cross-sectional follow-up data in 27 studies. The estimated net decline ranged from -1.0% to 3.0% for men and women combined (10 studies). For women, the decline ranged from -0.2% to + 3.5% per year (n=11), and for men the decline ranged from -0.4% to +1.6% per year (n=12). Cigarette consumption and quit rates were only reported in a small number of studies. The two most rigorous studies showed limited evidence of an effect on prevalence. In the US COMMIT study there was no differential decline in prevalence between intervention and control communities, and there was no significant difference in the quit rates of heavier smokers who were the target intervention group. In the Australian CART study there was a significantly greater quit rate for men but not women.

REVIEWER'S CONCLUSIONS

The failure of the largest and best conducted studies to detect an effect on prevalence of smoking is disappointing. A community approach will remain an important part of health promotion activities, but designers of future programmes will need to take account of this limited effect in determining the scale of projects and the resources devoted to them.

Reaching those most in need: a review of diabetes self-management interventions in disadvantaged populations

There has been increased recognition of the importance of developing diabetes self-management education (DSME) interventions that are effective with under-served and minority populations. Despite several recent studies in this area, there is to our knowledge no systematic review or synthesis of what has been learned from this research. An electronic literature search identified five formative evaluations and ten controlled DSME intervention trials focused on under-served (low-income, minority or aged) populations. The RE-AIM (Reach, Efficacy, Adoption, Implementation, Maintenance) evaluation framework was used to evaluate the controlled studies on the dimensions of reach, efficacy, adoption, implementation, and maintenance. Fifty percent of the studies identified reported on the percentage of patients who participated, and the percentages were highly variable. The methodological quality of the articles was generally good and the short-term results were encouraging, especially on behavioral outcomes. Data on adoption (representativeness of settings and clinicians who participate) and implementation were almost never reported. Studies of modalities in addition to group meetings are needed to increase the reach of DSME with under-served populations. The promising formative evaluation work that has been conducted needs to be extended for more systematic study of the process of intervention implementation and adaptation with special populations. Studies that explicitly address the community context and that address multiple issues related to public health impact of DSME interventions are recommended to enhance long-term results.

Using theory to understand the multiple determinants of low participation in worksite health promotion programs

Low participation at the employee or worksite level limits the potential public health impact of worksite-based interventions. Ecological models suggest that multiple levels of influence operate to determine participation patterns in worksite health promotion programs. Most investigations into the determinants of low participation study the intrapersonal, interpersonal, and institutional influences on employee participation. Community- and policy-level influences have not received attention, nor has consideration been given to worksite-level participation issues. The purpose of this article is to discuss one macrosocial theoretical perspective--political economy of health--that may guide practitioners and researchers interested in addressing the community- and policy-level determinants of participation in worksite health promotion programs. The authors argue that using theory to investigate the full spectrum of determinants offers a more complete range of intervention and research options for maximizing employee and worksite levels of participation.

Worksite tobacco control programs: the role of occupational health

Worksite tobacco control initiatives face a crucial challenge: the growing occupational disparity in smoking prevalence. Blue-collar workers are more likely to be smokers than workers are in white-collar jobs. Blue-collar workers also experience a high prevalence of hazardous exposures on the job. Given these multiple risks, it is imperative that successful comprehensive programs be developed to promote and protect the health of blue-collar workers. Although evidence is still accruing about the efficacy of workplace interventions integrating tobacco control and occupational health, it is possible to identify promising intervention strategies by drawing on the preliminary evidence on effective worksite interventions. The effectiveness of worksite tobacco control interventions will be enhanced when coordinated interventions aim to promote cessation among individual smokers, build social support for quitting and social norms that support non-smoking, engage management in assuring a healthy work environment, involve workers' families in non-smoking initiatives, and provide links to community and public policy initiatives that support tobacco control as well as a broader effort promoting worker health.

Who enrolls in a self-help cessation program for smokeless tobacco?

To further our understanding of the representativeness of the smokeless tobacco (SLT) user recruited to various treatment settings, and to suggest gaps in services available to SLT users, we first compared participants who enrolled in a self-help cessation program with two samples of nontreatment-seeking SLT users: SLT users identified through a random digit dialing (RDD) survey, and SLT users who came to 1 of 75 dental practices for a routine cleaning visit. We found that those in the self-help SLT cessation program were older, more educated, more likely to have made a serious quit attempt, and used more SLT weekly than those who did not seek treatment. Secondly, we compared SLT users seeking treatment in three different treatment settings varying in accessibility and intensity: self-help study participants, SLT users enrolled in a clinic-based study, and callers to the California Help Line for SLT cessation. Participants differed across the three studies on demographics, some measures of dependence, and history of SLT use.

The RE-AIM framework for evaluating interventions: what can it tell us about approaches to chronic illness management?

BACKGROUND

The RE-AIM framework is used as a method of systematically considering the strengths and weaknesses of chronic illness management interventions in order to guide program planning.

METHOD

The RE-AIM dimensions of Reach, Efficacy, Adoption, Implementation, and Maintenance are used to rate one-on-one counseling interventions, group sessions, interactive computer-mediated interventions, telephone calls, mail interventions, and health system policies.

RESULTS

The RE-AIM ratings suggest that, although often efficacious for those participating, traditional face-to-face intervention modalities will have limited impact if they cannot be delivered consistently to large segments of the target population. Interventions using new information technologies may have greater reach, adoption, implementation, and maintenance, and thereby greater public health impact. Policy changes received high ratings across a variety of RE-AIM dimensions.

CONCLUSIONS

Program planners should make decisions regarding implementing and funding health services based on multiple dimensions, rather than only considering efficacy in randomized clinical trials. Doing so may improve the resulting public health impact. Directions for future chronic illness management research related to RE-AIM, and implications for decision making, are described.

Psychiatric outpatients report their experiences as participants in a randomized clinical trial

We conducted exit interviews with 45 outpatients with severe and persistent mental illness (SPMI) who had participated in a randomized clinical trial. The interviews followed a semistructured format and were audiotaped for later transcription and rating by two independent raters. Content analyses of the interviews revealed that most participants evaluated their experiences quite favorably. For example, most noted that the assessment process was thought-provoking and motivational and that the intervention groups led to increased self-confidence and new friendships. Although a few participants noted that the assessment contained sensitive material, all appreciated the frequent reminders that information disclosed was strictly confidential. These results indicate that persons living with a SPMI often enjoy participating in behavioral research, which can yield immediate benefits to patient-participants. Exit interview research such as this can help investigators to understand reasons for consent and participation, to identify needs for protocol modifications, and to facilitate the integration of evidence-based interventions into the mental health care systems.

Maintaining prevention in practice: survival of PPIP in primary care settings. Put Prevention Into Practice

INTRODUCTION

Put Prevention Into Practice (PPIP) consists of a kit of office-based tools intended to support the provision of preventive services by primary care providers. The purpose of this study was to examine the institutionalization of PPIP within five primary care clinics funded by the Texas Department of Health to implement PPIP, and to examine the organizational determinants of program institutionalization.

METHODS

We utilized an adaptation of the Level of Institutionalizaton (LoIn) scales for qualitative data collection and for development of an institutionalization score for each site. The determinants of institutionalization were derived from the organizational behavior and health promotion literatures and used as categories for analysis. In addition, for purposes of triangulation, chart audit data for three documentation behaviors were also collected.

RESULTS

PPIP has been maintained--at varying degrees of integration--in four of the five sites studied, for 6 years after adoption. Organizational factors that facilitated the institutionalization process were the site's institutional strength, the integration of PIPP within extant programs and services, visibility of the program within and outside the site, planning for the termination of grant funding, and presence of a program champion with mid- to upper-level managerial authority. Successful initiation of the program was not a predictor of institutionalization outcomes.

CONCLUSIONS

We have highlighted the need to consider organizational determinants of institutionalization in relation to their specific sociopolitical contexts, and in relation to each other, not in isolation.

Searching for evidence about health education and health behavior interventions

Evidence is fundamental to science, but finding the right evidence in health education and health behavior (HEHB) is often a challenge. The authors discuss some of the controversies about the types of evidence that should be considered acceptable in HEHB, the tension between the use of qualitative versus quantitative data, the need for measures of important but neglected constructs, and interpretation of data from experimental and nonexperimental research. This article discusses some of the challenges to the use of evidence and describes a number of strategies and some forces encouraging the use of evidence-based interventions. Finally, the authors suggest ways to improve the practice and dissemination of evidence-based HEHB. Ultimately, if evidence-based interventions are not disseminated, the interventions will not achieve their potential. The goal should be to develop more effective interventions and disseminate them to improve the public's health.

Smoking cessation interventions among hospitalized patients: what have we learned?

BACKGROUND

We conducted a structured review of controlled studies on inpatient hospital-based smoking cessation interventions.

METHODS

Electronic searches were conducted with two different search engines, and reference sections of articles located were also reviewed. The RE-AIM framework was used to organize the review around the issues of reach, efficacy, adoption, implementation, and maintenance of interventions.

RESULTS

Thirty-one intervention articles were located, 20 of which included a comparison condition and were included in the review. Overall, a moderate number of studies (13/20) reported on reach, which was highly variable and limited (30-50% in most studies), while few reported on implementation (7/20). Longer term cessation results produced relative risk ratios of 0.9-2.3, with a median of 1.5. Increases in quit rates above the control condition ranged from -1 to 10% (median 4%) among general admission patients and from 7 to 36% (median 15%) among cardiac admission patients. Studies with a dedicated smoking cessation counselor and 3-5 months of relapse prevention had a significant impact on cessation rates. Study settings (adoption) were limited to university, Veterans affairs, and HMO hospitals. Maintenance at the individual level was variable and related to the presence of a relatively intensive initial intervention and a sustained relapse prevention intervention.

CONCLUSIONS

Efficacious inpatient smoking programs have been developed and validated. The challenge now is to translate these interventions more widely into practice, given changing hospitalization patterns.

Barriers to mammography and Pap smear screening among women who recently had neither, one or both types of screening

There is legitimate concern about whether cancer screening programs and other types of prevention and early detection programs are designed to reach those most in need of services. Previous research on barriers to screening has generally addressed screening for specific cancers. The purpose of this study was to evaluate and compare the types and strengths of barriers to both mammography and Pap smear screening experienced by three groups of women. Five hundred and twenty-two women, aged 52-69, who were members of a large health maintenance organization (HMO), completed a survey about cancer screening and associated barriers. Women with no mammogram in the preceding 2 years and with no Pap smear in 3 years were classified into a "safety net" program. We classified women as falling into both (Pap smear and mammography), one (Pap smear or mammography), or neither safety nets. Results consistently revealed that women needing both tests had more numerous and more intense barriers than other women to both types of screening. Factor analyses and descriptive analyses both showed that the types of barriers experienced were very similar for mammography and Pap smear screening. The discussion addresses intervention implications and the additional research needed on women who need both mammogram and Pap smear screening and who have much higher cancer risk than other women.

Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials

OBJECTIVE

To systematically review the effectiveness of self-management training in type 2 diabetes.

RESEARCH DESIGN AND METHODS

MEDLINE, Educational Resources Information Center (ERIC), and Nursing and Allied Health databases were searched for English-language articles published between 1980 and 1999. Studies were original articles reporting the results of randomized controlled trials of the effectiveness of self-management training in people with type 2 diabetes. Relevant data on study design, population demographics, interventions, outcomes, methodological quality, and external validity were tabulated. Interventions were categorized based on educational focus (information, lifestyle behaviors, mechanical skills, and coping skills), and outcomes were classified as knowledge, attitudes, and self-care skills; lifestyle behaviors, psychological outcomes, and quality of life; glycemic control; cardiovascular disease risk factors; and economic measures and health service utilization.

RESULTS

A total of 72 studies described in 84 articles were identified for this review. Positive effects of self-management training on knowledge, frequency and accuracy of self-monitoring of blood glucose, self-reported dietary habits, and glycemic control were demonstrated in studies with short follow-up (<6 months). Effects of interventions on lipids, physical activity, weight, and blood pressure were variable. With longer follow-up, interventions that used regular reinforcement throughout follow-up were sometimes effective in improving glycemic control. Educational interventions that involved patient collaboration may be more effective than didactic interventions in improving glycemic control, weight, and lipid profiles. No studies demonstrated the effectiveness of self-management training on cardiovascular disease-related events or mortality; no economic analyses included indirect costs; few studies examined health-care utilization. Performance, selection, attrition, and detection bias were common in studies reviewed, and external generalizability was often limited.

CONCLUSIONS

Evidence supports the effectiveness of self-management training in type 2 diabetes, particularly in the short term. Further research is needed to assess the effectiveness of self-management interventions on sustained glycemic control, cardiovascular disease risk factors, and ultimately, microvascular and cardiovascular disease and quality of life.

Report of the health care delivery work group: behavioral research related to the establishment of a chronic disease model for diabetes care

As one of four work groups for the November 1999 conference on Behavioral Science Research in Diabetes, sponsored by the National Institute on Diabetes and Digestive and Kidney Diseases, the health care delivery work group evaluated the status of research on quality of care, patient-provider interactions, and health care systems' innovations related to improved diabetes outcomes. In addition, we made recommendations for future research. In this article, which was developed and modified at the November conference by experts in health care delivery, diabetes and behavioral science, we summarize the literature on patient-provider interactions, diabetes care and self-management support among underserved and minority populations, and implementation of chronic care management systems for diabetes. We conclude that, although the quality of care provided to the vast majority of diabetic patients is problematic, this is principally not the fault of either individual patients or health care professionals. Rather, it is a systems issue emanating from the acute illness model of care, which still predominates. Examples of proactive population-based chronic care management programs incorporating behavioral principles are discussed. The article concludes by identifying barriers to the establishment of a chronic care model (e.g., lack of supportive policies, understanding of population-based management, and information systems) and priorities for future research in this area needed to overcome these barriers.

Identification and management of domestic violence: a randomized trial

BACKGROUND

Diagnosis of domestic violence (DV) in primary care is low compared to its prevalence. Care for patients is deficient. Over a 1-year period, we tested the effectiveness of an intensive intervention to improve asking about DV, case finding, and management in primary care. The intervention included skill training for providers, environmental orchestration (posters in clinical areas, DV questions on health questionnaires), and measurement and feedback.

METHODS

We conducted a group-randomized controlled trial in five primary care clinics of a large health maintenance organization (HMO). Outcomes were assessed at baseline and follow-up by survey, medical record review, and qualitative means.

RESULTS

Improved provider self-efficacy, decreased fear of offense and safety concerns, and increased perceived asking about DV were documented at 9 months, and also at 21 months (except for perceived asking) after intervention initiation. Documented asking about DV was increased by 14.3% with a 3.9-fold relative increase at 9 months in intervention clinics compared to controls. Case finding increased 1.3-fold (95%, confidence interval 0.67-2.7).

CONCLUSIONS

The intervention improved documented asking about DV in practice up to 9 months later. This was mainly because of the routine use of health questionnaires containing DV questions at physical examination visits and the placement of DV posters in clinical areas. A small increase in case finding also resulted. System changes appear to be a cost-effective method to increase DV asking and identification.

Brief, computer-assisted diabetes dietary self-management counseling: effects on behavior, physiologic outcomes, and quality of life

OBJECTIVES

The objective of this work was to evaluate the reach, effectiveness, adoption, and implementation of a brief behavioral dietary intervention and 2 supplemental components of diabetes self-management support: telephone follow-up calls and community resources enhancement.

DESIGN AND SUBJECTS

This was a 2 x 2 randomized, controlled trial investigating the incremental effects of telephone follow-up and community resources enhancement with 320 adult type 2 diabetes outpatients. METHODS. Key outcomes included behavioral (dietary patterns, fat intake), physiologic (HbA1c, lipids), and quality-of-life/patient satisfaction measures and were collected at baseline and 3- and 6-month follow-up.

RESULTS

Despite high reach (76% patient participation), excellent adoption (all 12 primary care practices approached participated), and good implementation, there were few outcome differences among treatment conditions. There was significant improvement across conditions in most outcomes in each category at both follow-ups.

CONCLUSIONS

A brief, computer-assisted, dietary goal-setting intervention basic treatment condition was moderately successful in producing dietary improvements but less so in producing biologic or quality-of-life outcomes. Additions of follow-up phone calls or a community resources enhancement component did not produce incremental improvements over this basic intervention.

A brief smoking cessation intervention for women in low-income planned parenthood clinics

OBJECTIVES

The purpose of this study was to evaluate a brief smoking cessation intervention for women 15 to 35 years of age attending Planned Parenthood clinics.

METHODS

Female smokers (n = 1154) were randomly assigned either to advice only or to a brief intervention that involved a 9-minute video, 12 to 15 minutes of behavioral counseling, clinician advice to quit, and follow-up telephone calls.

RESULTS

Seventy-six percent of those eligible participated. Results revealed a clear, short-term intervention effect at the 6-week follow-up (7-day self-reported abstinence: 10.2% vs 6.9% for advice only, P < .05) and a more ambiguous effect at 6 months (30-day biochemically validated abstinence: 6.4% vs 3.8%, NS).

CONCLUSIONS

This brief, clinic-based intervention appears to be effective in reaching and enhancing cessation among female smokers, a traditionally underserved population.

Characteristics of the adult learner

PURPOSE

This article provides an overview of adult learner characteristics, with an emphasis on those characteristics studied in diabetes patient education research.

METHODS

A selected review of the conceptual and research literature on general adult education and adult learning was conducted, with particular attention to diabetes patient education studies.

RESULTS

Characteristics reviewed included learning styles, literacy level, age/aging, ethnicity or culture, gender, and knowledge. Studies of the learning style of group vs individual education indicated some positive benefits for group learning; questions remain about optimal size or periodicity. Studies evaluating the benefits of culturally specific interventions for diabetes management have yielded some information. Characteristics related to gender and age have been studied, but often in pilot or feasibility studies without the power to answer the study questions.

CONCLUSIONS

There continue to be many gaps in knowledge related to adult learner characteristics in diabetes education. Lessons from both general adult learning literature and patient education literature from other chronic diseases should be evaluated and incorporated. The complexities of these learner characteristics create challenges in designing studies. However, evidence to support the need for effective educational interventions is of great importance for implementing change in health care.

Interactive technology applications for behavioral counseling: issues and opportunities for health care settings

This article discusses the rationale for, and the potential benefits and limitations of, computer-based interactive health communication (IHC) programs for health behavior counseling. We describe common barriers to health behavior counseling in medical settings and show how IHCs can address these issues. Following an overview of current and likely near-future IHCs, the potential impact of IHCs on the patient-provider relationship is considered. Results from evaluations of IHCs are summarized and important and unique issues in evaluating IHCs are discussed. We conclude with recommendations for clinical applications, including recommendations for consumers considering purchase or adoption of IHCs and recommendations for future research.

Outcomes of and for diabetes education research

PURPOSE

The purpose of this paper is to review outcome measures used to evaluate diabetes self-management education and make recommendations for future research.

METHODS

Three perspectives were used: (1) the frequency with which different measures were collected prior to 1990 was compared with a sample of the 1997 to 1999 literature, (2) a multilevel pyramid model of psychosocial-environmental factors was used to evaluate the level of outcomes assessed, and (3) the RE-AIM evaluation framework was used to assess the public health impact of studies reported in the literature.

RESULTS

Knowledge and HbA1c measures are often collected to the exclusion of other, possibly more appropriate outcomes. Research has focused almost exclusively on individual or family level outcomes and paid little attention to effects at systems levels, such as neighborhoods, communities, or healthcare systems. More recent studies have been evaluating the reach of interventions, but more practice-oriented research needs to be conducted with representative patients, providers, and settings.

CONCLUSIONS

Much has been learned about the efficacy of diabetes self-management and about measurement issues. Future research should now focus on effectiveness and generalization issues.