Integrating individual and public health perspectives for treatment of tobacco dependence under managed health care: A combined stepped-care and matching model

Does sleep relate to next-day cannabis use during treatment? Findings from an adolescent and young adult motivational enhancement and cognitive behavioral therapy plus topiramate intervention

BACKGROUND

Interventions for youth cannabis use have limited efficacy. Sleep is likely to affect treatment response, as sleep difficulties are cross-sectionally associated with use and common during treatment. This analysis examined how sleep duration and subjective trouble sleeping related to next-day cannabis use among youth during cannabis treatment.

METHOD

Participants (N=64) received a psychosocial intervention plus topiramate versus placebo while completing a 6-week ecological momentary assessment study. Time-varying effect modeling (TVEM) examined within- and between-person associations between sleep and cannabis use and how the strength of within-person associations varied over the course of treatment.

RESULTS

TVEM resvealed that, between-participants, youth with longer average sleep duration used cannabis less often controlling for baseline cannabis use, topiramate, and weekend status. Daily within-person fluctuations in sleep duration and trouble were not associated with use.

CONCLUSIONS

Findings suggest regularly shorter sleep may impede treatment outcomes. Adolescents who regularly have insufficient sleep durations likely need additional intervention to improve sleep difficulties in tandem with cannabis use reduction.

Operational demonstration and process evaluation of non-pneumatic anti-shock garment (NASG) introduction to the public health system of Northern Province, Zambia

BACKGROUND

A disproportionate burden of maternal deaths occurs in low- and middle-income countries (LMICs), and obstetric hemorrhage (OH) is a leading cause of excess mortality. In Zambia, most of maternal deaths are directly caused by OH. The Non-Pneumatic Anti-Shock Garment (NASG) is a first aid tool that uses compression to the abdomen and lower body to stop and reverse hypovolemic shock secondary to OH. We describe the process and experiences introducing the NASG into the Zambia public health system to encourage the development of national policies, clinical guidelines, and implementation plans that feature the NASG.

METHODS

We conducted an observational study of NASG introduction to 143 public health facilities in Northern Province, Zambia, organizing observations into the five dimensions of the RE-AIM evaluation framework: reach, effectiveness, adoption, implementation, and maintenance. The NASG was introduced in August 2019, and the introduction was evaluated for 18 months. Data on healthcare worker training and mentorship, cases where NASG was used, and NASG availability and use during the study period were collected and analyzed.

RESULTS

The NASG was successfully introduced and integrated into the Zambia public health system, and appropriately used by healthcare workers when responding to cases of OH. Sixteen months after NASG introduction, NASGs were available and functional at 99% of study sites and 88% reported ever using a NASG. Of the 68 cases of recorded OH where a NASG was applied, 66 were confirmed as clinically appropriate, and among cases where shock index (SI) could be calculated, 59% had SI ≥ 0.9. Feedback from healthcare providers revealed that 97% thought introducing the NASG was a good decision, and 92% felt confident in their ability to apply the NASG after initial training. The RE-AIM average for this study was 0.65, suggesting a public health impact that is not equivocal, and that NASG introduction had a positive population-based effect.

CONCLUSIONS

A successful NASG demonstration took place over the course of 18 months in the existing health system of Northern Province, Zambia, suggesting that incorporation of NASG into the standard of care for obstetric emergency in the Zambia public sector is feasible and can be maintained without external support.

The implementation of ask-advise-connect in a federally qualified health center: a mixed methods evaluation using the re-aim framework

Ask-Advise-Connect (AAC) efficiently links smokers in healthcare settings with evidence-based Quitline-delivered tobacco treatment through training clinic staff to systematically ask patients about smoking status, advise smokers to quit, and connect patients with state Quitlines using the electronic health record. This study utilized a mixed-methods approach, guided by the RE-AIM framework, to evaluate the implementation of AAC in a Federally Qualified Health Center (FQHC). AAC was implemented for 18 months at a FQHC serving primarily low-socioeconomic status (SES) Latinos and Latinas. Results are presented within the RE-AIM conceptual framework which includes dimensions of reach, effectiveness, adoption, implementation, and maintenance. Quantitative patient-level outcomes of reach, effectiveness, and Impact were calculated. Post-implementation, in-depth interviews were conducted with clinic leadership and staff (N = 9) to gather perceptions and inform future implementation efforts. During the implementation period, 12.0% of GNHC patients who reported current smoking both agreed to have their information sent to the Quitline and were successfully contacted by the Quitline (Reach), 94.8% of patients who spoke with the Quitline enrolled in treatment (Effectiveness), and 11.4% of all identified smokers enrolled in Quitline treatment (Impact). In post-implementation interviews assessing RE-AIM dimensions, clinic staff and leadership identified facilitators and advantages of AAC and reported that AAC was easy to learn and implement, streamlined existing procedures, and had a positive impact on patients. Staff and leadership reported enthusiasm about AAC implementation and believed AAC fit well in the clinic. Staff were interested in AAC becoming the standard of care and made suggestions for future implementation. Clinic staff at a FQHC serving primarily low-SES Latinos and Latinas viewed the ACC implementation process positively. Findings have implications for streamlining clinical smoking cessation procedures and the potential to reduce tobacco-related disparities.

Keep It Up! 3.0: Study protocol for a type III hybrid implementation-effectiveness cluster-randomized trial

BACKGROUND

Despite evidence that eHealth approaches can be effective in reducing HIV risk, their implementation requirements for public health scale up are not well established, and effective strategies to bring these programs into practice are still unknown. Keep It Up! (KIU!) is an online program proven to reduce HIV risk among young men who have sex with men (YMSM) and ideal candidate to develop and evaluate novel strategies for implementing eHealth HIV prevention programs. KIU! 3.0 is a Type III Hybrid Effectiveness-Implementation cluster randomized trial designed to 1) compare two strategies for implementing KIU!: community-based organizations (CBO) versus centralized direct-to-consumer (DTC) recruitment; 2) examine the effect of strategies and determinants on variability in implementation success; and 3) develop materials for sustainment of KIU! after the trial concludes. In this article, we describe the approaches used to achieve these aims.

METHODS

Using county-level population estimates of YMSM, 66 counties were selected and randomized 2:1 to the CBO and DTC approaches. The RE-AIM model was used to drive outcome measurements, which were collected from CBO staff, YMSM, and technology providers. Mixed-methods research mapped onto the domains of the Consolidated Framework for Implementation Research will examine determinants and their relationship with implementation outcomes.

DISCUSSION

In comparing our implementation recruitment models, we are examining two strategies which have shown effectiveness in delivering health technology interventions in the past, yet little is known about their comparative advantages and disadvantages in implementation. The results of the trial will further the understanding of eHealth prevention intervention implementation.

Stepped care for suicide prevention in teens and young adults: Design and methods of a randomized controlled trial

BACKGROUND

Suicide is the second‑leading cause of death among adolescents and young adults in the United States, with rates rising over much of the last decade. The design, testing, and implementation of interventions to prevent suicide in this population is a public health priority. This manuscript outlines the design and methods for a research study that compares two interventions aimed at reducing suicide and suicide attempts in youth.

METHODS

We will enroll 300 youth aged 12-24 at high risk for suicide in this randomized controlled parallel group superiority trial. Participants will be randomly assigned to one of two study arms: (1) Zero Suicide Quality Improvement (ZSQI) implemented within the Kaiser Permanente Northwest (KPNW) health system, or (2) ZSQI plus a stepped care intervention for suicide prevention (SC-SP), where the services offered (including care management and dialectical behavior therapy [DBT]) increase based on risk level. Outcomes will be assessed at baseline, as well as 3-, 6-, and 12-months post randomization. The study was conceptualized and designed collaboratively by investigators at UCLA and KPNW.

RESULTS

To be reported in future manuscripts.

CONCLUSION

The main objective of the study is to determine whether the SC-SP intervention is superior to ZSQI with regard to lowering rates of fatal and nonfatal suicide attempts. Interventions that incorporate the latest research need to be designed and tested under controlled conditions to make progress toward the goal of achieving zero suicide. The results from this trial will directly inform those efforts.

TRIAL REGISTRATION

CLINICALTRIALS

gov, NCT03092271, https://clinicaltrials.gov/ct2/show/NCT03092271https://clinicaltrials.gov/ct2/show/NCT01379027.

PTSD Coach Version 3.1: A Closer Look at the Reach, Use, and Potential Impact of This Updated Mobile Health App in the General Public

BACKGROUND

With widespread smartphone ownership, mobile health apps (mHealth) can expand access to evidence-based interventions for mental health conditions, including posttraumatic stress disorder (PTSD). Research to evaluate new features and capabilities in these apps is critical but lags behind app development. The initial release of PTSD Coach, a free self-management app developed by the US Departments of Veterans Affairs and Defense, was found to have a positive public health impact. However, major stakeholder-driven updates to the app have yet to be evaluated.

OBJECTIVE

We aimed to characterize the reach, use, and potential impact of PTSD Coach Version 3.1 in the general public. As part of characterizing use, we investigated the use of specific app features, which extended previous work on PTSD Coach.

METHODS

We examined the naturalistic use of PTSD Coach during a 1-year observation period between April 20, 2020, and April 19, 2021, using anonymous in-app event data to generate summary metrics for users.

RESULTS

During the observation period, PTSD Coach was broadly disseminated to the public, reaching approximately 150,000 total users and 20,000 users per month. On average, users used the app 3 times across 3 separate days for 18 minutes in total, with steep drop-offs in use over time; a subset of users, however, demonstrated high or sustained engagement. More than half of users (79,099/128,691, 61.46%) accessed one or more main content areas of the app (ie, Manage Symptoms, Track Progress, Learn, or Get Support). Among content areas, features under Manage Symptoms (including coping tools) were accessed most frequently, by over 40% of users (53,314/128,691, 41.43% to 56,971/128,691, 44.27%, depending on the feature). Users who provided initial distress ratings (56,971/128,691, 44.27%) reported relatively high momentary distress (mean 6.03, SD 2.52, on a scale of 0-10), and the use of a coping tool modestly improved momentary distress (mean -1.38, SD 1.70). Among users who completed at least one PTSD Checklist for DSM-5 (PCL-5) assessment (17,589/128,691, 13.67%), PTSD symptoms were largely above the clinical threshold (mean 49.80, SD 16.36). Among users who completed at least two PCL-5 assessments (4989/128,691, 3.88%), PTSD symptoms decreased from the first to last assessment (mean -4.35, SD 15.29), with approximately one-third (1585/4989, 31.77%) of these users experiencing clinically significant improvements.

CONCLUSIONS

PTSD Coach continues to fulfill its mission as a public health resource. Version 3.1 compares favorably with version 1 on most metrics related to reach, use, and potential impact. Although benefits appear modest on an individual basis, the app provides these benefits to a large population. For mHealth apps to reach their full potential in supporting trauma recovery, future research should aim to understand the utility of individual app features and identify strategies to maximize overall effectiveness and engagement.

Engaging Patients in Smoking Cessation Treatment within the Lung Cancer Screening Setting: Lessons Learned from an NCI SCALE Trial

Offering smoking cessation treatment at lung cancer screening (LCS) will maximize mortality reduction associated with screening, but predictors of treatment engagement are not well understood. We examined participant characteristics of engagement in an NCI SCALE cessation trial. Eligible LCS patients (N = 818) were randomized to the Intensive arm (8 phone counseling sessions +8 weeks of nicotine replacement therapy (NRT)) vs. Minimal arm (3 sessions + 2 weeks of NRT). Engagement was measured by number of sessions completed (none, some, or all) and NRT mailed (none vs. any) in each arm. In the Intensive arm, those with ≥some college (OR = 2.1, 95% CI = 1.1, 4.0) and undergoing an annual scan (OR = 2.1, 95% CI = 1.1, 4.2) engaged in some counseling vs. none. Individuals with higher nicotine dependence were more likely (OR = 2.8, 95% CI = 1.3, 6.2) to request NRT. In the Minimal arm, those with higher education (OR = 2.1, 95% CI = 1.1, 3.9) and undergoing an annual scan (OR = 2.0, 95% CI = 1.04, 3.8) completed some sessions vs. none. Requesting NRT was associated with more pack-years (OR = 1.9, 95% CI = 1.1, 3.5). Regardless of treatment intensity, additional strategies are needed to engage those with lower education, less intensive smoking histories, and undergoing a first scan. These efforts will be important given the broader 2021 LCS guidelines.

Does environmental message framing impact proportional reach and sample representativeness related to motivational characteristics?

Physical activity (PA) promotion messages are commonly used to engage target populations in PA programs. However, little is known about how recruitment messages impact program reach. Evidence suggests that framing messages to be congruent with individuals' motivational orientation can maximize effectiveness. This congruency effect has not been tested in the context of brief PA promotion messages used in a recruitment environment. It is plausible that framed messages attract certain individuals, while deterring others. The purpose of this study was to determine whether message framing influences representativeness of a sample recruited for a PA program with regards to motivational factors. Three messaging conditions (gain-framed, neutral, loss-framed) were counterbalanced across days of data collection in a primary care waiting room. Patients were asked to complete a questionnaire including surveys on personality and PA, and basic demographic questions. Respondents were offered the chance to participate in a low-burden PA program. Interested respondents were instructed to provide contact information. The proportion and representativeness, with respect to motivational orientation, of individuals volunteering for program participation was assessed using chi-squared tests, and two-way (condition × group) ANOVAs, respectively. After controlling for demographic and behavioral covariates, there was no effect of message framing on the motivational orientation of the resultant samples. Results did not support a congruency effect of a covert message-framing manipulation. More work should aim to understand how recruitment materials and strategies influence motivational characteristics of the resulting sample to maximize intervention outcomes, and target individuals who are more likely to engage in risky health behaviors.

An Evaluation Service for Digital Public Health Interventions: User-Centered Design Approach

Background

Digital health interventions (DHIs) have the potential to improve public health by combining effective interventions and population reach. However, what biomedical researchers and digital developers consider an effective intervention differs, thereby creating an ongoing challenge to integrating their respective approaches when evaluating DHIs.

Objective

This study aims to report on the Public Health England (PHE) initiative set out to operationalize an evaluation framework that combines biomedical and digital approaches and demonstrates the impact, cost-effectiveness, and benefit of DHIs on public health.

Methods

We comprised a multidisciplinary project team including service designers, academics, and public health professionals and used user-centered design methods, such as qualitative research, engagement with end users and stakeholders, and iterative learning. The iterative approach enabled the team to sequentially define the problem, understand user needs, identify opportunity areas, develop concepts, test prototypes, and plan service implementation. Stakeholders, senior leaders from PHE, and a working group critiqued the outputs.

Results

We identified 26 themes and 82 user needs from semistructured interviews (N=15), expressed as 46 Jobs To Be Done, which were then validated across the journey of evaluation design for a DHI. We identified seven essential concepts for evaluating DHIs: evaluation thinking, evaluation canvas, contract assistant, testing toolkit, development history, data hub, and publish health outcomes. Of these, three concepts were prioritized for further testing and development, and subsequently refined into the proposed PHE Evaluation Service for public health DHIs. Testing with PHE’s Couch-to-5K app digital team confirmed the viability, desirability, and feasibility of both the evaluation approach and the Evaluation Service.

Conclusions

An iterative, user-centered design approach enabled PHE to combine the strengths of academic and biomedical disciplines with the expertise of nonacademic and digital developers for evaluating DHIs. Design-led methodologies can add value to public health settings. The subsequent service, now known as Evaluating Digital Health Products, is currently in use by health bodies in the United Kingdom and is available to others for tackling the problem of evaluating DHIs pragmatically and responsively.

Beyond "Safe and Effective": The urgent need for high-impact smoking cessation medications

Smoking cessation medications (SCMs) are an evidence-based cornerstone of comprehensive tobacco control programs globally. However, the impact of SCMs on population smoking prevalence is controversial, with inconsistencies between randomized controlled trials (RCTs) and population-based observational studies. We estimated SCM impact on permanent cessation and population smoking prevalence by extrapolating efficacy estimates from meta-analyses of RCTs, using the standard population impact formula: efficacy*reach. We calculated the potential SCM impact under a range of assumptions for permanent cessation (20%,14%), behavioral support (yes/no), reach (40%-2%), and underlying smoking prevalence. Assuming behavioral support for all, depending on reach, 8%-0.3% of smokers are expected to quit permanently. Without behavioral support, permanent cessation is estimated to be 6.4%-0.2%. Assuming an underlying population smoking prevalence of 14%, (current U.S. prevalence), the maximum impact on population smoking prevalence is 1.12%. Impact on prevalence increases with increasing underlying country-specific levels of prevalence. With current U.S. levels of reach, behavioral support and smoking prevalence, we estimate that, based on a single course of treatment, 2.3% of smokers would quit permanently, contributing to a 0.3% decrease in population level smoking prevalence. Even under ideal conditions, the potential of current first-line SCMs to increase cessation in a substantial proportion of smokers, and reduce population smoking prevalence, is limited. In order to avert the predicted billion tobacco-caused deaths in this century, "safe and effective" medications are not sufficient: SCMs with high population impact are urgently needed. Policies to ensure the availability and accessibility of highly efficacious SCMs, with behavioral support, are crucial.

Tailored Web-Based Smoking Interventions and Reduced Attrition: Systematic Review and Meta-Analysis

Background

The increasing number of internet users presents an opportunity to deliver health interventions to large populations. Despite their potential, many web-based interventions, including those for smoking cessation, face high rates of attrition. Further consideration of how intervention features impact attrition is needed.

Objective

The aim of this systematic review is to investigate whether tailored web-based smoking cessation interventions for smokers are associated with reduced rates of attrition compared with active or passive untailored web-based interventions. The outcomes of interest were dropout attrition at 1-, 3-, 6-, and 12-month follow-ups.

Methods

Literature searches were conducted in May 2018 and updated in May 2020 on MEDLINE (Medical Literature Analysis and Retrieval System Online), PsycINFO (Psychological Information), EMBASE (Excerpta Medica dataBASE), CINAHL (Cumulated Index to Nursing and Allied Health Literature), Scopus, and the Cochrane Tobacco Addiction Group Specialized Register with the following search terms: smoking cessation, tailored, or web- or internet-based. Included studies were published in English before or in May 2020 using a randomized controlled trial design. Studies were restricted to those with web-based delivery, a tailored intervention group, an untailored control group, and a reported outcome of smoking cessation. Studies were assessed for methodological quality using the Cochrane Risk of Bias tool. Two reviewers independently extracted the study characteristics and the number of participants lost to follow-up for each treatment group.

Results

A total of 13 studies were included in the systematic review, of which 11 (85%) were included in the meta-analysis. Tailoring had no statistically significant effect on dropout attrition at 1-month (risk ratio [RR]=1.02, 95% CI 0.95-1.09; P=.58; I²=78%), 3-month (RR=0.99, 95% CI 0.95-1.04; P=.80; I²=73%), 6-month (RR=1.00, 95% CI 0.95-1.05; P=.90; I²=43%), or 12-month (RR=0.97, 95% CI 0.92-1.02; P=.26; I²=28%) follow-ups. Subgroup analyses suggested that there was a statistically significant effect of tailoring between the active and passive subgroups at 1-month (P=.03), 3-month (P<.001), and 6-month (P=.02) follow-ups but not at 12-month follow-up (P=.25).

Conclusions

The results suggest that tailoring of web-based smoking cessation interventions may not be associated with reduced rates of dropout attrition at 1-, 3-, 6-, or 12-month follow-ups. Significant differences between studies that include untailored active and passive control groups suggest that the role of tailoring may be more prominent when studies include a passive control group. These findings may be because of variability in the presence of additional features, the definition of smokers used, and the duration of smoking abstinence measured. Future studies should incorporate active web-based controls, compare the impact of different tailoring strategies, and include populations outside of the Western countries.

Evaluating the Efficacy of a Mobile App (Drinks:Ration) and Personalized Text and Push Messaging to Reduce Alcohol Consumption in a Veteran Population: Protocol for a Randomized Controlled Trial

Background

Alcohol misuse is higher in the UK Armed Forces than in the general population. Previous research has shown that interventions delivered via smartphones are efficacious in promoting self-monitoring of alcohol use, have utility in reducing alcohol consumption, and have a broad reach.

Objective

This single-blinded randomized controlled trial (RCT) aims to assess the efficacy of a 28-day brief alcohol intervention delivered via a smartphone app (Drinks:Ration) in reducing weekly self-reported alcohol consumption between baseline and 3-month follow-up among veterans who drink at a hazardous or harmful level and receive or have received support for mental health symptoms in a clinical setting.

Methods

In this two-arm, single-blinded RCT, a smartphone app that includes interactive features designed to enhance participants’ motivation and personalized messaging is compared with a smartphone app that provides only government guidance on alcohol consumption. The trial will be conducted in a veteran population that has sought help through Combat Stress, a UK veteran’s mental health charity. Recruitment, consent, and data collection will be carried out automatically through the Drinks:Ration platform. The primary outcome is the change in self-reported weekly alcohol consumption between baseline (day 0) and 3-month follow-up (day 84) as measured using the Time-Line Follow back for Alcohol Consumption. Secondary outcome measures include (1) change in the baseline to 3-month follow-up (day 84) Alcohol Use Disorder Identification Test score and (2) change in the baseline to 3-month follow-up (day 84) World Health Organization Quality of Life-BREF score to assess the quality of adjusted life years. Process evaluation measures include (1) app use and (2) usability ratings as measured by the mHealth App Usability Questionnaire. The primary and secondary outcomes will also be reassessed at the 6-month follow-up (day 168) to assess the longer-term benefits of the intervention, which will be reported as a secondary outcome.

Results

The study will begin recruitment in October 2020 and is expected to require 12 months to complete. The study results will be published in 2022.

Conclusions

This study assesses whether a smartphone app is efficacious in reducing self-reported alcohol consumption in a veteran population that has sought help through Combat Stress using personalized messaging and interactive features. This innovative approach, if successful, may provide a means to deliver a low-cost health promotion program that has the potential to reach large groups, in particular those who are geographically dispersed, such as military personnel.

Trial Registration

ClinicalTrials.gov NCT04494594; https://clinicaltrials.gov/ct2/show/NCT04494594

International Registered Report Identifier (IRRID)

PRR1-10.2196/19720

Gambling Industry Employees' Experiences with an Onsite Responsible Gambling Program

We examined gambling venue employees' experiences with GameSense, an onsite responsible gambling information center designed to be a resource for casino employees as well as patrons. Participants included 492 employees who reported on their engagement with, and opinions and knowledge of, the GameSense information center and its staff (i.e., GameSense Advisors), as well as their own employment department and gambling involvement. A minority of participants (33.5%) reported having spoken with a GameSense Advisor about responsible gambling or problem gambling; the remaining 66.5% either did not ever speak to a GameSense Advisor or only had a casual conversation with one. Most participants (88.9%) indicated that casino patrons could use the GameSense program, but less than half (37.9%) believed that casino staff/employees could do the same. Participants generally had positive opinions about the program, endorsing positive potential impacts (e.g., "It helps people avoid gambling beyond their limits") more often than negative potential impacts (e.g., "It encourages people to gamble beyond their limits"). However, gambling venue employees with more extensive gambling histories were less likely to endorse positive potential impacts. Participants' department also was associated with GameSense experiences: those in security/surveillance were the most likely to report having interacted with GameSense Advisors (83.3%) and those in food/beverage/retail were least likely to have done so (28.6%). Some of these findings have implications for improving casino employees' experiences with the GameSense program.

A Machine-Learning Approach to Predicting Smoking Cessation Treatment Outcomes

AIMS

Most cigarette smokers want to quit smoking and more than half make an attempt every year, but less than 10% remain abstinent for at least 6 months. Evidence-based tobacco use treatment improves the likelihood of quitting, but more than two-thirds of individuals relapse when provided even the most robust treatments. Identifying for whom treatment is effective will improve the success of our treatments and perhaps identify strategies for improving current approaches.

METHODS

Two cohorts (training: N = 90, validation: N = 71) of cigarette smokers enrolled in group cognitive-behavioral therapy (CBT). Generalized estimating equations were used to identify baseline predictors of outcome, as defined by breath carbon monoxide and urine cotinine. Significant measures were entered as candidate variables to predict quit status. The resulting decision trees were used to predict cessation outcomes in a validation cohort.

RESULTS

In the training cohort, the decision trees significantly improved on chance classification of smoking status following treatment and at 6-month follow-up. The first split of all decision trees, which was delay discounting, significantly improved on chance classification rates in both the training and validation cohort. Delay discounting emerged as the single best predictor of group CBT treatment response with an average baseline discount rate of ln(k) = -7.1, correctly predicting smoking status of 80% of participants at posttreatment and 81% of participants at follow-up.

CONCLUSIONS

This study provides a first step toward personalized care for smoking cessation though future work is needed to identify individuals that are likely to be successful in treatments beyond group CBT.

IMPLICATIONS

This study provides a first step toward personalized care for smoking cessation. Using a novel machine-learning approach, baseline measures of clinical and executive functioning are used to predict smoking cessation outcomes following group CBT. A decision point is recommended for the single best predictor of treatment outcomes, delay discounting, to inform future research or clinical practice in an effort to better allocate patients to treatments that are likely to work.

Cost-effectiveness of population-level proactive tobacco cessation outreach among socio-economically disadvantaged smokers: evaluation of a randomized control trial

AIMS

To estimate the cost-effectiveness at population-level of the OPT-IN proactive tobacco cessation outreach program for adult smokers enrolled in publicly funded health insurance plans for low-income persons (e.g. Medicaid).

DESIGN

Cost-effectiveness analysis using a state transition model based on data from the Offering Proactive Treatment Intervention (OPT-IN) randomized control trial.

SETTING

The trial was conducted in Minnesota, USA, and the economic analysis was conducted from the Medicaid program perspective.

PARTICIPANTS

Data were used from 2406 smokers who were randomized into the intervention or comparator groups.

INTERVENTION AND COMPARATOR

The intervention was comprised of proactive outreach (mailed invitation and telephone calls) and free cessation treatment (nicotine replacement therapy and intensive telephone counseling). The comparator was usual care, which comprised access to a primary care physician, insurance coverage of Food and Drug Administration (FDA)-approved smoking cessation medications and the state's telephone quitline.

MEASUREMENTS

Smoking status, quality of life and health-care use at varying times, including at baseline and 1 year.

FINDINGS

The OPT-IN program cost an average of $84 per participant greater than the comparator. One year after randomization, the population-level, 6-month prolonged smoking abstinence rate was 16.5% in the proactive outreach intervention group and 12.1% in the usual care group (P < 0.05). The model projected that the proactive outreach intervention added $78 in life-time cost and generated 0.005 additional quality-adjusted life-years (QALYs), with an expected incremental cost-effectiveness ratio of $4231 per QALY. Probabilistic sensitivity analysis found that the proactive outreach intervention would be cost-effective against a willingness-to-pay threshold of $50 000/QALY approximately 68% of the time.

CONCLUSIONS

Population-level proactive tobacco treatment with personal telephone outreach was effective in achieving higher population-level quit rates and was cost-effective at various willingness-to-pay thresholds, compared with usual care (i.e. reactive treatment). Taken together with prior research, population-level proactive tobacco cessation outreach programs are judged to be highly cost-effective over the long term.

Physical Activity Promotion: Highlights from the 2018 Physical Activity Guidelines Advisory Committee Systematic Review

PURPOSE

This article describes effective interventions to promote regular physical activity and reduce sedentary behavior that were identified as part of the 2018 Physical Activity Guidelines Advisory Committee Scientific Report.

METHODS

A comprehensive literature search was conducted of eligible systematic reviews, meta-analyses, and relevant governmental reports published between 2011 and 2016. For the physical activity promotion question, articles were first sorted by four social ecological levels of impact (i.e., individual, community, communication environment, and physical environment and policy levels) and then further sorted into more specific categories that emerged during the review process. For the sedentary behavior reduction question, the literature was sorted directly into emergent categories (i.e., youth, adult, and worksite interventions).

RESULTS

Effective physical activity promotion strategies were identified at each level of impact, including those based on behavior change theories and those occurring at different settings throughout the community. Effective interventions also included those delivered in person by trained staff or peer volunteers and through different information and communication technologies, such as by phone, Web or Internet, and computer-tailored print. A range of built environment features were associated with more transit-based and recreational physical activity in children and adults. Effective sedentary reduction interventions were found for youth and in the workplace.

CONCLUSIONS

A promising number of interventions with demonstrated effectiveness were identified. Future recommendations for research include investigating the most useful methods for disseminating them to real-world settings; incorporating more diverse population subgroups, including vulnerable and underrepresented subgroups; collecting cost data to inform cost-effectiveness comparisons; and testing strategies across different levels of impact to determine which combinations achieve the greatest effects on different modes of physical activity across the week.

Improving quit rates of web-delivered interventions for smoking cessation: full-scale randomized trial of WebQuit.org versus Smokefree.gov

BACKGROUND AND AIMS

Millions of people world-wide use websites to help them quit smoking, but effectiveness trials have an average 34% follow-up data retention rate and an average 9% quit rate. We compared the quit rates of a website using a new behavioral approach called Acceptance and Commitment Therapy (ACT; WebQuit.org) with the current standard of the National Cancer Institute's (NCI) Smokefree.gov website.

DESIGN

A two-arm stratified double-blind individually randomized trial (n = 1319 for WebQuit; n = 1318 for Smokefree.gov) with 12-month follow-up.

SETTING

United States.

PARTICIPANTS

Adults (n = 2637) who currently smoked at least five cigarettes per day were recruited from March 2014 to August 2015. At baseline, participants were mean [standard deviation (SD)] age 46.2 years (13.4), 79% women and 73% white.

INTERVENTIONS

WebQuit.org website (experimental) provided ACT for smoking cessation; Smokefree.gov website (comparison) followed US Clinical Practice Guidelines for smoking cessation.

MEASUREMENTS

The primary outcome was self-reported 30-day point prevalence abstinence at 12 months.

FINDINGS

The 12-month follow-up data retention rate was 88% (2309 of 2637). The 30-day point prevalence abstinence rates at the 12-month follow-up were 24% (278 of 1141) for WebQuit.org and 26% (305 of 1168) for Smokefree.gov [odds ratio (OR) = 0.91; 95% confidence interval (CI) = 0.76, 1.10; P = 0.334] in the a priori complete case analysis. Abstinence rates were 21% (278 of 1319) for WebQuit.org and 23% (305 of 1318) for Smokefree.gov (OR = 0.89 (0.74, 1.07; P = 0.200) when missing cases were imputed as smokers. The Bayes factor comparing the primary abstinence outcome was 0.17, indicating 'substantial' evidence of no difference between groups.

CONCLUSIONS

WebQuit.org and Smokefree.gov had similar 30-day point prevalence abstinence rates at 12 months that were descriptively higher than those of prior published website-delivered interventions and telephone counselor-delivered interventions.

Smoking cessation: Exploration of perceived technology-related information value

This study describes a unique approach to information transfer affecting the perceived value of this information and related impact on smoker behavior. Data were collected via survey, sampling approximately 120 participants. An online survey tool was used for the survey creation, data collection and monitoring. Another online tool was used by participants to create short animation videos as a means of increasing their engagement with information in an experiential fashion. Study findings included that the process experienced by the test group was influential and facilitated participants' change of mind regarding enrollment in a smoking cessation workshop. This was partly attributable to the IKEA effect. The study provides evidence that a change in habits crucial to improve health and enhance positive lifestyle choices can be stimulated through active engagement with artifact creation in a technology-mediated environment.

Treatment non-response: Associations with smoking expectancies among treatment-seeking smokers

Despite the high rate of smoking cessation treatment non-response, relatively little empirical work has examined predictors of treatment non-response. The present study sought to explore the effect of smoking outcome expectancies on treatment response in a sample of treatment-seeking adult daily smokers (N=182; 53.3% female; M_age=40.67; SD=13.63). Results indicated that expectancies for smoking to reduce negative affect were related to an increased likelihood of treatment non-response (OR=0.73, CI: 0.54, 0.98). These findings remained significant after controlling for sex, presence of Axis I disorder, tobacco-related health problems, tobacco dependence, anxiety sensitivity, and condition assignment as well as other smoking expectancy dimensions. Post hoc analyses revealed that this relation was stronger for smokers in the integrated care condition vs. the standard care condition (Interaction: OR=1.69, CI: 1.05, 2.73). Additionally, expectancies for smoking to enhance positive affect and provide sensory satisfaction were associated with an increased likelihood of treatment response in the standard care condition. The current findings suggest expectancies that smoking will alleviate negative affect may be a risk factor of smoking cessation treatment non-response. Additionally, findings provide evidence that the relation between smoking expectancies and treatment non-response may differ by smoking cessation treatment.

Applying the RE-AIM conceptual framework for the promotion of physical activity in low- and middle-income countries

ABSTRACT Objective: the RE-AIM framework has been widely used to evaluate internal and external validity of interventions aimed to promote physical activity, helping to provide comprehensive evaluation of the reach, efficacy, adoption, implementation and maintenance of research and programming. Despite this progress, the RE-AIM framework has not been used widely in Latin America. The purpose of this manuscript is to describe the RE-AIM framework, the process and materials developed for a one-day workshop in Guadalajara, and the acceptability and satisfaction of participants that attended the workshop. Methods: lecture, interactive examples and an agenda were developed for a one-day RE-AIM workshop over a three month period. Results: thirty two health care practitioners (M age = 30.6, SD=9.9 years) attended the workshop. Most (100%) rated the workshop as credible, useful (100%) and intended to apply it in current or future research (95%). Conclusion: results suggest intuitive appeal of the RE-AIM framework, and provide a strategy for introducing the utility and practical application of the framework in practice settings in Mexico and Latin America.

Effects of a web-based intervention on women's breast health behaviors

Helping women make choices to reduce cancer risk and to improve breast health behaviors is important, but the best ways to reach more people with intervention assistance is not known. To test the efficacy of a web-based intervention designed to help women make better breast health choices, we adapted our previously tested, successful breast health intervention package to be delivered on the Internet, and then we tested it in a randomized trial. We recruited women from the general public to be randomized to either an active intervention group or a delayed intervention control group. The intervention consisted of a specialized website providing tailored and personalized risk information to all participants, followed by offers of additional support if needed. Follow-up at one-year post randomization revealed significant improvements in mammography screening in intervention women compared with control women (improvement of 13 percentage points). The intervention effects were more powerful in women who increased breast health knowledge and decreased cancer worry during intervention. These data indicate that increases in mammography can be accomplished in population-based mostly insured samples by implementing this simple, low resource intensive intervention.

Oral health 4 life: Design and methods of a semi-pragmatic randomized trial to promote oral health care and smoking abstinence among tobacco quitline callers

Smokers are at high risk for oral disease. As a result, they represent an important target group for population-level, public oral health promotion efforts. While dental health professionals often address smoking with their patients, no systematic efforts have been made to offer smokers an intervention to improve their use of oral health care. This paper details the rationale, design, and methods of a large, semi-pragmatic, randomized clinical trial designed to address this gap. Participants are recruited via the Oregon, Nebraska and Louisiana state-sponsored tobacco quitlines and randomized to receive standard quitline care versus standard care plus a multi-modal oral health promotion program (Oral Health 4 Life) integrated within the quitline services. All participants are followed for 6months to assess the impact of the intervention on smoking abstinence and utilization of professional dental care. In addition, the study will assess the cost of the intervention and provide practical guidance to states on whether the intervention is financially feasible to implement, should the intervention be effective. This study protocol may be useful to others interested in promoting oral health among smokers, those interested in partnering with tobacco quitlines to extend standard services to address other high risk health behaviors among smokers, or those interested in semi-pragmatic trial design.

Step Care treatment for smoking cessation

We compared the effectiveness of a ‘stepped care’ approach with increasing treatment intensity (‘Step Care’) to one with repeated treatments (‘Recycle’) among cigarette smokers interested in quitting smoking. Step 1 of the Step Care intervention consisted of a single counseling session, nicotine patch for six weeks and telephonic contact. For smokers not achieving tobacco abstinence 6 months after randomization with Step 1, the intensity of the intervention increased to four counseling sessions, bupropion sustained-release, nine telephone calls and three mailings (Step 2). For those not achieving tobacco abstinence 12 months after randomization, smokers received six behavioral counseling sessions, nicotine patch and nicotine gum, nine telephone calls and three mailings (Step 3). The Recycle participants received one session of health behavior counseling, six weeks of the nicotine patch and a telephone call at each step. 270 cigarette smokers were randomized. At 24 months after randomization using an intention to treat analysis, no statistically significant difference was observed in prolonged smoking abstinence between the Step Care and Recycle condition (16.9% versus 9.4%; adjusted OR = 1.88; 95% CI 0.88–4.01; P =0.10). Additional research is needed to explore whether a stepped care intervention increases long-term smoking abstinence rates compared with repeating the same intervention.

A pragmatic examination of active and passive recruitment methods to improve the reach of community lifestyle programs: The Talking Health Trial

Background

A primary challenge for behavior change strategies is ensuring that interventions can be effective while also attracting a broad and representative sample of the target population. The purpose of this case-study was to report on (1) the reach of a randomized controlled trial targeting reduced sugary beverages, (2) potential participant characteristic differences based on active versus passive recruitment strategies, and (3) recruitment strategy cost.

Methods

Demographic and recruitment information was obtained for 8 counties and for individuals screened for participation. Personnel activities and time were tracked. Costs were calculated and compared by active versus passive recruitment.

Results

Six-hundred and twenty, of 1,056 screened, individuals were eligible and 301enrolled (77% women; 90% white; mean income $21,981 ± 16,443). Eighty-two and 44% of those responding to passive and active methods, respectively, enrolled in the trial. However, active recruitment strategies yielded considerably more enrolled (active = 199; passive = 102) individuals. Passive recruitment strategies yielded a less representative sample in terms of gender (more women), education (higher), and income (higher; p’s <0.05). The average cost of an actively recruited and enrolled participant was $278 compared to $117 for a passively recruited and enrolled participant.

Conclusions

Though passive recruitment is more cost efficient it may reduce the reach of sugary drink reduction strategies in lower educated and economic residents in rural communities.

Trial registration

Clinicaltrials.gov; ID: NCT02193009, July 2014, retrospectively registered.

RE-AIM Analysis of a School-Based Nutrition Education Intervention in Kindergarteners

BACKGROUND

Few nutrition interventions in kindergarten classes have been evaluated, and none has been tested for program effectiveness, implementation, and dissemination. Building a Healthy Me (BHM) is a nutrition intervention for kindergarteners that is classroom-based and includes a family component. This study evaluated the public health impact of BHM in California kindergarten classrooms using the RE-AIM (reach, efficacy, adoption, implementation, and maintenance) framework.

METHODS

A quasi-experimental design assessed pre-to-post changes in nutrition knowledge, dietary consumption, and parent behaviors of 25 intervention classrooms (414 students, 264 parents); and postintervention differences in nutrition knowledge between the intervention classrooms and 4 control classrooms measured at postintervention only (103 students).

RESULTS

Intervention students improved in knowledge of food groups and healthy breakfast/snack options, and scored higher than control students in food group knowledge at postintervention (ps < .05). Parents of intervention group children increased their use of food labels, and intervention group children increased intake of several healthy foods and decreased intake of candy and fried potatoes (ps < .05). The BHM program reached 41% of kindergarteners attending public schools in California, and teachers implemented most lesson material.

CONCLUSIONS

The BHM program was effective, implemented with fidelity, and broadly disseminated, highlighting its potential public health impact for kindergarteners.

Internet-Based Delivery of Evidence-Based Health Promotion Programs Among American Indian and Alaska Native Youth: A Case Study

Background

American Indian and Alaska Native (AI/AN) youth face multiple health challenges compared to other racial/ethnic groups, which could potentially be ameliorated by the dissemination of evidence-based adolescent health promotion programs. Previous studies have indicated that limited trained personnel, cultural barriers, and geographic isolation may hinder the reach and implementation of evidence-based health promotion programs among AI/AN youth. Although Internet access is variable in AI/AN communities across the United States, it is swiftly and steadily improving, and it may provide a viable strategy to disseminate evidence-based health promotion programs to this underserved population.

Objective

We explored the potential of using the Internet to disseminate evidence-based health promotion programs on multiple health topics to AI/AN youth living in diverse communities across 3 geographically dispersed regions of the United States. Specifically, we assessed the Internet’s potential to increase the reach and implementation of evidence-based health promotion programs for AI/AN youth, and to engage AI/AN youth.

Methods

This randomized controlled trial was conducted in 25 participating sites in Alaska, Arizona, and the Pacific Northwest. Predominantly AI/AN youth, aged 12-14 years, accessed 6 evidence-based health promotion programs delivered via the Internet, which focused on sexual health, hearing loss, alcohol use, tobacco use, drug use, and nutrition and physical activity. Adult site coordinators completed computer-based education inventory surveys, connectivity and bandwidth testing to assess parameters related to program reach (computer access, connectivity, and bandwidth), and implementation logs to assess barriers to implementation (program errors and delivery issues). We assessed youths’ perceptions of program engagement via ratings on ease of use, understandability, credibility, likeability, perceived impact, and motivational appeal, using previously established measures.

Results

Sites had sufficient computer access and Internet connectivity to implement the 6 programs with adequate fidelity; however, variable bandwidth (ranging from 0.24 to 93.5 megabits per second; mean 25.6) and technical issues led some sites to access programs via back-up modalities (eg, uploading the programs from a Universal Serial Bus drive). The number of youth providing engagement ratings varied by program (n=40-191; 48-60% female, 85-90% self-identified AI/AN). Across programs, youth rated the programs as easy to use (68-91%), trustworthy (61-89%), likeable (59-87%), and impactful (63-91%). Most youth understood the words in the programs (60-83%), although some needed hints to complete the programs (16-49%). Overall, 37-66% of the participants would recommend the programs to a classmate, and 62-87% found the programs enjoyable when compared to other school lessons.

Conclusions

Findings demonstrate the potential of the Internet to enhance the reach and implementation of evidence-based health promotion programs, and to engage AI/AN youth. Provision of back-up modalities is recommended to address possible connectivity or technical issues. The dissemination of Internet-based health promotion programs may be a promising strategy to address health disparities for this underserved population.

Trial Registration

Clinicaltrials.gov NCT01303575; https://clinicaltrials.gov/ct2/show/NCT01303575 (Archived by WebCite at http://www.webcitation.org/6m7DO4g7c)

New Strategies to Prioritize Nutrition, Physical Activity, and Obesity Interventions

Interventions for obesity have not often been based on considerations that could predict their effectiveness. However, advances in research provide several new approaches that can inform priorities for public health interventions directed at nutrition, physical activity, and obesity. These approaches include estimation of the effect size, comparison of the calorie gap with the caloric deficit induced by the intervention, population reach and impact, cost and cost effectiveness of the intervention, time required to evaluate the effect of the intervention on weight change, and feasibility of the intervention. Incorporation of these considerations by policymakers and public health practitioners will help identify those interventions most likely to achieve changes in the prevalence of obesity.

Health Communication and Social Marketing Campaigns for Sexually Transmitted Disease Prevention and Control: What Is the Evidence of their Effectiveness?

BACKGROUND

Despite the ubiquity of sex in the media, a culture of silence surrounds sexual health in the United States, serving as a barrier to sexually transmitted disease (STD) prevention, testing, and treatment. Campaigns can increase STD-related knowledge, communication, and protective behaviors. This review assesses the effectiveness of STD prevention and testing campaigns in the United States to inform the field on their use as a strategy for affecting behavior change.

METHODS

A comprehensive literature search was conducted to identify original research articles, published between 2000 and 2014, which report on US media campaigns promoting community- or population-level STD testing or prevention behaviors and are evaluated for impact on one or more behavioral outcomes. Titles and abstracts were independently reviewed by 2 researchers.

RESULTS

The review yielded 26 articles representing 16 unique STD testing and/or prevention campaigns. Most campaigns were developed using formative research and social marketing or behavioral theory. Most campaigns (68.75%) used posttest-only or pretest-posttest designs without comparison groups for evaluation; only 5 campaigns used control groups, and these proved challenging (i.e., achieving necessary exposure and avoiding contamination). Nearly all campaigns found differences between exposed and unexposed individuals on one or more key behavioral outcomes. Several campaigns found dose-response relationships. Among evaluations with uncontaminated control groups whose campaigns achieved sufficient exposure, sustained campaign effects were observed among targeted populations.

CONCLUSIONS

Current findings suggest that campaigns can impact targeted STD-related behaviors and add to the evidence that greater exposure is associated with greater behavior change.

Abstinence Reinforcement Therapy (ART) for rural veterans: Methodology for an mHealth smoking cessation intervention

INTRODUCTION

Smoking is the most preventable cause of morbidity and mortality in U.S. veterans. Rural veterans in particular have elevated risk for smoking and smoking-related illness. However, these veterans underutilize smoking cessation treatment, which suggests that interventions for rural veterans should optimize efficacy and reach.

OBJECTIVE

The primary goal of the current study is to evaluate the effectiveness of an intervention that combines evidenced based treatment for smoking cessation with smart-phone based, portable contingency management on smoking rates compared to a contact control intervention in a randomized controlled trial among rural Veteran smokers. Specifically, Veterans will be randomized to receive Abstinence Reinforcement Therapy (ART) which combines evidenced based cognitive-behavioral telephone counseling (TC), a tele-medicine clinic for access to nicotine replacement (NRT), and mobile contingency management (mCM) or a control condition (i.e., TC and NRT alone) that will provide controls for therapist, medication, time and attention effects.

METHODS

Smokers were identified using VHA electronic medical records and recruited proactively via telephone. Participants (N=310) are randomized to either ART or a best practice control consisting of telephone counseling and telemedicine. Participating patients will be surveyed at 3-months, 6-months and 12-months post-randomization. The primary outcome measure is self-reported and biochemically validated prolonged abstinence at 6-month follow-up.

DISCUSSION

This trial is designed to test the relative effectiveness of ART compared to a telehealth-only comparison group. Dissemination of this mHealth intervention for veterans in a variety of settings would be warranted if ART improves smoking outcomes for rural veterans and is cost-effective.

Transdisciplinary Work with Psychology from a Population Health Perspective: An Illustration

One of the important implications of a population health perspective in public health is an increase in the need for transdisciplinary ways of working. The Community Health Research Unit (CHRU) is presented as an example of an environment where psychology and psychologists work with other disciplines to conduct applied research in population health. Research activities were examined to identify how the disciplines collaborate and to provide evidence of successful interdisciplinary and transdisciplinary approaches which incorporate health psychology. The strengths and challenges of multi-, inter-, and transdisciplinary approaches were examined through a poll of CHRU members. Further, members' views about the contributions of psychology to their work were gathered. Issues of working with different disciplines in a transdisciplinary approach are highlighted and future directions are suggested.

Practice Notes: Strategies in Health Education

The Practice Notes section is intended to keep readers informed about health education practice around the country. It is an attempt to spread the word about exemplary strategies, initiatives, and programs and share successes in overcoming obstacles or challenges. Periodically, articles presenting perspectives on practice-related issues are also included in Practice Notes.

Integrating Prenatal-Postnatal Smoking Interventions into Usual Care in a Health Maintenance Organization

Consistent with the increasing national emphasis on providing health promotion in clinical care settings, Stop Smoking for OuR Kids (STORK), a research-derived, prenatal-postnatal smoking cessation intervention, was implemented throughout prenatal clinics, inpatient postpartum services, and pediatric clinics of Kaiser Permanente Northwest. Process data collected during the project rollout and maintenance to monitor the clinical practices of clinicians and staff members, patient responses to the intervention, and penetration of the intervention into the health maintenance organization priority population of prenatal smokers highlighted barriers to intervention delivery. These barriers fell into three categories related to the smoking intervention design, clinicians and staff members, and the organization. By monitoring the intervention implementation process, such problems were identified early. This allowed for implementing strategies to overcome many of these barriers and to assess their effectiveness. Keys to implementation success included simplifying the intervention activities, considering stakeholder needs, and providing tangible organizational resources and goals.

Work Site Health Promotion Research: To what Extent can we Generalize the Results and what is Needed to Translate Research to Practice?

Information on external validity of work site health promotion research is essential to translate research findings to practice. The authors provide a literature review of work site health behavior interventions. Using the RE-AIM framework, they summarize characteristics and results of these studies to document reporting of intervention reach, adoption, implementation, and maintenance. The authors reviewed a total of 24 publications from 11 leading health behavior journals. They found that participation rates among eligible employees were reported in 87.5% of studies; only 25% of studies reported on intervention adoption. Data on characteristics of participants versus nonparticipants were reported in fewer than 10% of studies. Implementation data were reported in 12.5% of the studies. Only 8% of studies reported any type of maintenance data. Stronger emphasis is needed on representativeness of employees, work site settings studied, and longer term results. Examples of how this can be done are provided.

Comparative Effectiveness of an Internet-Based Smoking Cessation Intervention Versus Clinic-Based Specialty Care for Veterans

INTRODUCTION

The primary objective of this project was to examine the effectiveness of an Internet-based smoking cessation intervention combined with a tele-health medication clinic for nicotine replacement therapy (NRT) compared to referral to clinic-based smoking cessation care.

METHODS

A total of 413 patients were proactively recruited from the Durham VA Medical Center and followed for 12 months. Patients were randomized to receive either a referral to VA specialty smoking cessation care (control) or to the Internet intervention and tele-health medication clinic. Primary outcomes included (1) intervention reach, (2) self-reported 7-day point prevalence abstinence rates at 3 months and 12 months, and 3) relative cost-effectiveness.

RESULTS

Reach of the Internet intervention and use of smoking cessation aids were significantly greater compared to the control. At 3 months-post randomization, however, there were no significant differences in quit rates: 17% (95% CI: 12%–23%) in the Internet-based intervention compared to 12% (95% CI: 8%–17%) in the control arm. Similarly, there were no differences in quit rates at 12 months (13% vs. 16%). While costs associated with the Internet arm were higher due to increased penetration and intensity of NRT use, there were no statistically significant differences in the relative cost effectiveness (e.g., life years gained, quality adjusted life years) between the two arms.

CONCLUSIONS

Current results suggest that using an electronic medical record to identify smokers and proactively offering smoking cessation services that are consistent with US Public Health Guidelines can significantly reduce smoking in veterans. Novel interventions that increase the reach of intensive treatment are needed to maximize quit rates in this population.

Treatment of prescription opioid disorders in Canada: looking at the 'other epidemic'?

The magnitude and consequences of prescription opioid (PO) misuse and harms (including rising demand for PO disorder treatment) in Canada have been well-documented. Despite a limited evidence-base for PO dependence treatment, opioid maintenance therapy (OMT) - mostly by means of methadone maintenance treatment (MMT) - has become the de facto first-line treatment for PO-disorders. For example in the most populous province of Ontario, some 50,000 patients - large proportions of them young adults - are enrolled in MMT, resulting in a MMT-rate that is 3-4 times higher than that of the United States. MMT in Ontario has widely proliferated towards a quasi-treatment industry within a system context of the public fee-payer offering generous incentives for community-based MMT providers. Contrary to the proliferation of MMT, there has been no commensurate increase in availability of alternative (e.g., detox, tapering, behavioral), and less intrusive and/or costly, treatments which may provide therapeutic benefits at least for sub-sets of PO-dependent patients. Given the extensive PO-dependence burden combined with its distinct socio-demographic and clinical profile (e.g., involving many young people, less intensive or risky opioid use), an evidence-based 'stepped-care' model for PO dependence treatment ought to be developed in Canada where MMT constitutes one, but likely a last resort or option, for treatment. Other, less intrusive treatment options as well as the best mix of treatment options should be systematically investigated and implemented. This case study has relevance and implications for evidence-based treatment also for the increasing number of other jurisdictions where PO misuse and disorders have been rising.

Proactive tobacco treatment offering free nicotine replacement therapy and telephone counselling for socioeconomically disadvantaged smokers: a randomised clinical trial

Background

Evidenced-based tobacco cessation treatments are underused, especially by socioeconomically disadvantaged smokers. This contributes to widening socioeconomic disparities in tobacco-related morbidity and mortality.

Methods

The Offering Proactive Treatment Intervention trial tested the effects of a proactive outreach tobacco treatment intervention on population-level smoking abstinence and tobacco treatment use among a population-based sample of socioeconomically disadvantaged smokers. Current smokers (n=2406), regardless of interest in quitting, who were enrolled in the Minnesota Health Care Programs, the state's publicly funded healthcare programmes for low-income populations, were randomly assigned to proactive outreach or usual care. The intervention comprised proactive outreach (tailored mailings and telephone calls) and free cessation treatment (nicotine replacement therapy and intensive, telephone counselling). Usual care comprised access to a primary care physician, insurance coverage of Food and Drug Administration-approved smoking cessation medications, and the state's telephone quitline. The primary outcome was self-reported 6-month prolonged smoking abstinence at 1 year and was assessed by follow-up survey.

Findings

The proactive intervention group had a higher prolonged abstinence rate at 1 year than usual care (16.5% vs 12.1%, OR 1.47, 95% CI 1.12 to 1.93). The effect of the proactive intervention on prolonged abstinence persisted in selection models accounting for non-response. In analysis of secondary outcomes, use of evidence-based tobacco cessation treatments were significantly greater among proactive outreach participants compared with usual care, particularly combination counselling and medications (17.4% vs 3.6%, OR 5.69, 95% CI 3.85 to 8.40).

Interpretation

Population-based proactive tobacco treatment increases engagement in evidence-based treatment and is effective in long-term smoking cessation among socioeconomically disadvantaged smokers. Findings suggest that dissemination of population-based proactive treatment approaches is an effective strategy to reduce the prevalence of smoking and socioeconomic disparities in tobacco use.

Trial registration number

NCT01123967.

Longitudinal Care Improves Cessation in Smokers Who Do Not Initially Respond to Treatment by Increasing Cessation Self-Efficacy, Satisfaction, and Readiness to Quit: A Mediated Moderation Analysis

BACKGROUND

The Tobacco Longitudinal Care study was a randomized controlled trial for smoking cessation. It demonstrated that longitudinal care for smoking cessation, in which telephone-based counseling and nicotine replacement therapy were offered for 12 months, was more effective than the standard 8-week treatment.

PURPOSE

This study aims to identify for whom and how longitudinal care increased the likelihood of abstinence.

METHODS

Mediated moderation analyses were utilized across three time points.

RESULTS

There was a trend towards smokers who did not respond to treatment (i.e., were still smoking) by 21 days being more likely to be abstinent at 6 months if they received longitudinal care rather than usual care. Similarly, those who did not respond to treatment by 3 months were more likely to be abstinent at 12 months if they received longitudinal care. At both time points, the likelihood of abstinence did not differ across treatment conditions among participants who responded to treatment (i.e., quit smoking). The effect on 6-month outcomes was mediated by satisfaction and readiness to quit. Cessation self-efficacy, satisfaction, and readiness to quit mediated the effect on 12-month outcomes. The effect of treatment condition on the likelihood of abstinence at 18 months was not moderated by response to treatment at 6 months.

CONCLUSIONS

Smokers who did not respond to initial treatment benefited from longitudinal care. Differential effects of treatment condition were not observed among those who responded to early treatment. Conditional assignment to longitudinal care may be useful. Determining for whom and how interventions work over time will advance theory and practice.

Framework for Selecting Best Practices in Public Health: A Systematic Literature Review

Evidence-based public health has commonly relied on findings from empirical studies, or research-based evidence. However, this paper advocates that practice-based evidence derived from programmes implemented in real-life settings is likely to be a more suitable source of evidence for inspiring and guiding public health programmes. Selection of best practices from the array of implemented programmes is one way of generating such practice-based evidence. Yet the lack of consensus on the definition and criteria for practice-based evidence and best practices has limited their application in public health so far. To address the gap in literature on practice-based evidence, this paper hence proposes measures of success for public health interventions by developing an evaluation framework for selection of best practices. The proposed framework was synthesised from a systematic literature review of peer-reviewed and grey literature on existing evaluation frameworks for public health programmes as well as processes employed by health-related organisations when selecting best practices. A best practice is firstly defined as an intervention that has shown evidence of effectiveness in a particular setting and is likely to be replicable to other situations. Regardless of the area of public health, interventions should be evaluated by their context, process and outcomes. A best practice should hence meet most, if not all, of eight identified evaluation criteria: relevance, community participation, stakeholder collaboration, ethical soundness, replicability, effectiveness, efficiency and sustainability. Ultimately, a standardised framework for selection of best practices will improve the usefulness and credibility of practice-based evidence in informing evidence-based public health interventions. Significance for public healthBest practices are a valuable source of practice-based evidence on effective public health interventions implemented in real-life settings. Yet, despite the frequent branding of interventions as best practices or good practices, there is no consensus on the definition and desirable characteristics of such best practices. Hence, this is likely to be the first systematic review on the topic of best practices in public health. Having a single widely accepted framework for selecting best practices will ensure that the selection processes by different agencies are fair and comparable, as well as enable public health workers to better appreciate and adopt best practices in different settings. Ultimately, standardisation will improve the credibility and usefulness of practice-based evidence to that of research-based evidence.

RE-AIM analysis of a randomized school-based nutrition intervention among fourth-grade classrooms in California

Childhood overweight and obesity are major health problems. School-based programs enable intervening with large groups of children, but program overall health impact is rarely completely assessed. A RE-AIM (Reach, Efficacy, Adoption, Implementation, Maintenance) analysis tested the overall public health impact of the fourth-grade "Nutrition Pathfinders" school-based nutrition-education program. A randomized controlled trial in 47 fourth-grade California classrooms (1713 students) tested program efficacy, and a secondary analysis of archival data tested program dissemination. Desired effects were seen in child nutrition knowledge, attitudes, consumption of low-nutrient high-density foods, sugar-sweetened beverages, proteins, grains, and parent willingness to serve new foods. The program was disseminated to ∼25 % of public school fourth-grade classrooms in California and cost about $1.00 per student to implement. The Nutrition Pathfinders program demonstrates potential for moderate to high public health impact due to its wide dissemination, effectiveness in altering attitudes and behaviors, and its relatively inexpensive cost of implementation.

The comparative effectiveness of individual and group brief motivational interventions for mandated college students

Individual brief motivational intervention (iBMI) is an efficacious strategy to reduce heavy drinking by students who are mandated to receive an alcohol intervention following an alcohol-related event. However, despite the strong empirical support for iBMI, it is unknown if the results from rigorously controlled research on iBMI translate to real-world settings. Furthermore, many colleges lack the resources to provide iBMI to mandated students. Therefore, group-delivered BMI (gBMI) might be a cost-effective alternative that can be delivered to a large number of individuals. The purpose of this study was to conduct a comparative effectiveness evaluation of iBMI and gBMI as delivered by staff at a university health services center. Participants (N = 278) were college students who were mandated to receive an alcohol intervention following an alcohol-related incident. Participants were randomized to receive an individual (iBMI; n = 133) or a Group BMI (gBMI; n = 145). Results indicated that both iBMI and gBMI participants reduced their peak estimated blood alcohol concentration (BAC) and the number of negative alcohol-related consequences at 1-, 3-, and 6-months postintervention. The iBMI and gBMI conditions were not significantly different at follow-up. These findings provide preliminary support for the use of iBMI and gBMIs for college students in real-world settings.

Using the RE-AIM framework to evaluate physical activity public health programs in México

Background

Physical activity (PA) public health programming has been widely used in Mexico; however, few studies have documented individual and organizational factors that might be used to evaluate their public health impact. The RE-AIM framework is an evaluation tool that examines individual and organizational factors of public health programs. The purpose of this study was to use the RE-AIM framework to determine the degree to which PA programs in Mexico reported individual and organizational factors and to investigate whether reporting differed by the program’s funding source.

Methods

Public health programs promoting PA were systematically identified during 2008–2013 and had to have an active program website. Initial searches produced 23 possible programs with 12 meeting inclusion criteria. A coding sheet was developed to capture behavioral, outcome and RE-AIM indicators from program websites.

Results

In addition to targeting PA, five (42%) programs also targeted dietary habits and the most commonly reported outcome was change in body composition (58%). Programs reported an average of 11.1 (±3.9) RE-AIM indicator items (out of 27 total). On average, 45% reported reach indicators, 34% reported efficacy/effectiveness indicators, 60% reported adoption indicators, 40% reported implementation indicators, and 35% reported maintenance indicators. The proportion of RE-AIM indicators reported did not differ significantly for programs that were government supported (M = 10, SD = 3.1) and programs that were partially or wholly privately or corporately supported (M = 12.0, SD = 4.4).

Conclusion

While reach and adoption of these programs were most commonly reported, there is a need for stronger evaluation of behavioral and health outcomes before the public health impact of these programs can be established.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1474-2) contains supplementary material, which is available to authorized users.

Clinician advice to quit smoking among seniors

OBJECTIVE

Little smoking research in the past 20years includes persons 50 and older; herein we describe patterns of clinician cessation advice to US seniors, including variation by Medicare beneficiary characteristics.

METHOD

In 2012-4, we analyzed 2010 Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data from Medicare beneficiaries over age 64 (n=346,674). We estimated smoking rates and the proportion of smokers whose clinicians encouraged cessation.

RESULTS

12% of male and 8% of female respondents aged 65 and older smoke. The rate decreases with age (14% of 65-69, 3% of 85+) and education (12-15% with no high school degree, 5-6% with BA+). Rates are highest among American Indian/Alaskan Native (16%), multiracial (14%), and African-American (13%) seniors, and in the Southeast (14%). Only 51% of smokers say they receive cessation advice "always" or "usually" at doctor visits, with advice more often given to the young, those in low-smoking regions, Asians, and women. For all results cited p<0.05.

CONCLUSIONS

Smoking cessation advice to seniors is variable. Providers may focus on groups or areas in which smoking is less common or when they are most comfortable giving advice. More consistent interventions are needed, including cessation advice from clinicians.

mHealth in the Wild: Using Novel Data to Examine the Reach, Use, and Impact of PTSD Coach

BACKGROUND

A majority of Americans (58%) now use smartphones, making it possible for mobile mental health apps to reach large numbers of those who are living with untreated, or under-treated, mental health symptoms. Although early trials suggest positive effects for mobile health (mHealth) interventions, little is known about the potential public health impact of mobile mental health apps.

OBJECTIVE

The purpose of this study was to characterize reach, use, and impact of "PTSD Coach", a free, broadly disseminated mental health app for managing posttraumatic stress disorder (PTSD) symptoms.

METHODS

Using a mixed-methods approach, aggregate mobile analytics data from 153,834 downloads of PTSD Coach were analyzed in conjunction with 156 user reviews.

RESULTS

Over 60% of users engaged with PTSD Coach on multiple occasions (mean=6.3 sessions). User reviews reflected gratitude for the availability of the app and being able to use the app specifically during moments of need. PTSD Coach users reported relatively high levels of trauma symptoms (mean PTSD Checklist Score=57.2, SD=15.7). For users who chose to use a symptom management tool, distress declined significantly for both first-time users (mean=1.6 points, SD=2.6 on the 10-point distress thermometer) and return-visit users (mean=2.0, SD=2.3). Analysis of app session data identified common points of attrition, with only 80% of first-time users reaching the app's home screen and 37% accessing one of the app's primary content areas.

CONCLUSIONS

These findings suggest that PTSD Coach has achieved substantial and sustained reach in the population, is being used as intended, and has been favorably received. PTSD Coach is a unique platform for the delivery of mobile mental health education and treatment, and continuing evaluation and improvement of the app could further strengthen its public health impact.

Feasibility, acceptability, and initial efficacy of an online sexual health promotion program for LGBT youth: the Queer Sex Ed intervention

Lesbian, gay, bisexual, and transgender (LGBT) youth experience multiple sexual health inequities driven, in part, by deficits in parental and peer support, school-based sex education programs, and community services. Research suggests that the Internet may be an important resource in the development of sexual health among LGBT youth. We examined the feasibility of recruiting youth in same-sex relationships into an online sexual health intervention, evaluated intervention acceptability, and obtained initial estimates of intervention efficacy. LGBT youth (16 to 20 years old) completed Queer Sex Ed (QSE), an online, multimedia sexual health intervention consisting of five modules. The final sample (N = 202) completed the pretest, intervention, and posttest assessments. The primary study outcomes were sexual orientation identity and self-acceptance (e.g., coming-out self-efficacy), sexual health knowledge (e.g., sexual functioning), relationship variables (e.g., communication skills), and safer sex (e.g., sexual assertiveness). Analyses indicated that 15 of the 17 outcomes were found to be significant (p < .05). Effect sizes ranged from small for sexual orientation (e.g., internalized homophobia) and relationship variables (e.g., communication skills) to moderate for safer sex (e.g., contraceptive knowledge) outcomes. This study demonstrated the feasibility, acceptability, and initial efficacy of QSE, an innovative online comprehensive sexual health program for LGBT youth.