Challenges and future directions for tailored communication research

The functions of adequate communication in the neonatal care unit: A systematic review and meta-synthesis of qualitative research

OBJECTIVE

To assess the main functions of parent-provider communication in the neonatal (intensive) care unit (NICU) and determine what adequate communication entails according to both parents and health professionals.

METHODS

A systematic review and meta-synthesis of qualitative research. PubMed, Ebsco/PsycINFO, Wiley/Cochrane Library, Ebsco/CINAHL, Clarivate Analytics/Web of Science Core Collection, and Elsevier/Scopus were searched in October-November 2019 for records on interpersonal communication between parents and providers in neonatal care. Title/abstract screening and full-text analysis were conducted by multiple, independent coders. Data from included articles were analyzed using deductive and inductive thematic analysis.

RESULTS

43 records were included. Thematic analysis of data resulted in the development of the NICU Communication Framework, including four functions of communication (1. building/maintaining relationships, 2. exchanging information, 3. (sharing) decision-making, 4. enabling parent self-management) and five factors that contribute to adequate communication across these functions (topic, aims, location, route, design) and, thereby, to tailored parent-provider communication.

CONCLUSION

The NICU Communication Framework fits with the goals of Family Integrated Care to encourage parent participation in infants' care. This framework forms a first step towards the conceptualization of (adequate) communication in NICU settings.

PRACTICE IMPLICATIONS

Findings can be used to improve NICU communication in practice, in particular through the mnemonic TAILORED.

Presenting patients with information on their oral health risk: the PREFER three-arm RCT and ethnography

Background

A new NHS dental practice contract is being tested using a traffic light (TL) system that categorises patients as being at red (high), amber (medium) or green (low) risk of poor oral health. This is intended to increase the emphasis on preventative dentistry, including giving advice on ways patients can improve their oral health. Quantitative Light-Induced Fluorescence (QLF™) cameras (Inspektor Research Systems BV, Amsterdam, the Netherlands) also potentially offer a vivid portrayal of information on patients’ oral health.

Methods

Systematic review – objective: to investigate how patients value and respond to different forms of information on health risks. Methods: electronic searches of nine databases, hand-searching of eight specialist journals and backwards and forwards citation-chasing followed by duplicate title, abstract- and paper-screening and data-extraction. Inclusion criteria limited studies to personalised information on risk given to patients as part of their health care. Randomised controlled trial (RCT) – setting: NHS dental practice. Objective: to investigate patients’ preferences for and response to different forms of information about risk given at check-ups. Design: a pragmatic, multicentred, three-arm, parallel-group, patient RCT. Participants: adults with a high/medium risk of poor oral health attending NHS dental practices. Interventions: (1) information given verbally supported by a card showing the patient’s TL risk category; (2) information given verbally supported by a QLF photograph of the patient’s mouth. The control was verbal information only (usual care). Main outcome measures: primary outcome – median valuation for the three forms of information measured by willingness to pay (WTP). Secondary outcomes included toothbrushing frequency and duration, dietary sugar intake, smoking status, self-rated oral health, a basic periodontal examination, Plaque Percentage Index and the number of tooth surfaces affected by caries (as measured by QLF). Qualitative study – an ethnography involving observations of 368 dental appointments and interviews with patients and dental teams.

Results

Systematic review – the review identified 12 papers (nine of which were RCTs). Eight studies involved the use of computerised risk assessments in primary care. Intervention effects were generally modest, even with respect to modifying risk perceptions rather than altering behaviour or clinical outcomes. RCT – the trial found that 51% of patients identified verbal information as their most preferred form, 35% identified QLF as most preferred and 14% identified TL information as most preferred. The median WTP for TL was about half that for verbal information alone. Although at 6 and 12 months patients reported taking less sugar in drinks, and at 12 months patients reported longer toothbrushing, there was no difference by information group. Qualitative study – there was very little explicit risk talk. Lifestyle discussions were often cursory to avoid causing shame or embarrassment to patients.

Limitations

Only 45% of patients were retained in the trial at 6 months and 31% were retained at 12 months. The trial was conducted in four dental practices, and five dental practices were involved in the qualitative work.

Conclusions

Patients prefer personal, detailed verbal advice on oral health at their check-up. A new NHS dental practice contract using TL categorisation might make this less likely.

Future work

Research on how to deliver, within time constraints, effective advice to patients on preventing poor oral health. More research on ‘risk work’ in wider clinical settings is also needed.

Trial registration

Current Controlled Trials ISRCTN71242343.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 3. See the NIHR Journals Library website for further project information.

Community pharmacists' attitudes towards patient leaflets: Exploring perceptions underlying an electronic local production of tailored written information

Introduction

Low health literacy in Portugal, revealed by limited patients' knowledge of their medication, may be improved by written information that is individually tailored for each patient. Tailored content can be produced through computer software and delivered by community pharmacies to patients.

Objective

To assess community pharmacists' real-life management, usage and perceived utility of software developed to produce individually tailored patient leaflets at community pharmacies.

Methods

The software contained five different pharmacist-selected clinical information fields which allows for the adjustment of information to each patient's information needs. Using an exploratory study design, community pharmacists' perceptions were purposively selected and qualitatively assessed. Interviews were recorded, transcribed verbatim and iteratively coded using a thematic approach outlined by attitudinal theory.

Results

Eight participants took part in the study. Emerging codes led to the construction of two main themes: Current PLs usage in Portuguese community pharmacy; and Tailored PLs usage in Portuguese community pharmacy. Pharmacists exhibited a generally positive attitude concerning the relevance and use of patient leaflets to address individual patient's information needs, including an improvement in health literacy. The model was considered effective, functional, satisfying and user-friendly.

Conclusion

Although additional studies are needed, the introduction of a leaflet-tailoring software in Portuguese community pharmacies seems to be feasible as an additional resource to improve the quality of patient information and counselling. The next research steps should address the impact on patients' medicines-related information, including the level to which patients are able to correctly interpret the information and to adjust accordingly their health behaviours.

Practice implications

The software fits present community pharmacy practice and routines, bringing advantages to pharmacists' willingness to deliver meaningful written information to patients, thus contributing to improved patient health literacy.

Toward the Tailoring of Sexual Health Education Messages for Young Women: A Focus on Tourist Experiences

Perceived anonymity and decreased influence of sexual double standards in tourism provide female travelers with opportunities for sexual experimentation and risk taking. The purpose of this study was (a) to identify the clusters of risk takers among young women based on their perceptions of and motivations for sexual risk taking in tourism and (b) to profile the clusters with respect to the psychological, sexual, demographic, and tourist characteristics. The data were collected through an online survey of 853 women (age in years: M = 23.5, SD = 6.67). Five clusters of sexual risk takers emerged based on their factor-analyzed risk perceptions and motivations. These clusters were interpreted as (a) diversely motivated broad risk perceivers; (b) fun-seeking broad risk perceivers; (c) diversely motivated physical risk perceivers; (d) anonymity- and empowerment-seeking risk disregarders; and (e) unmotivated broad risk perceivers. Women in these clusters differed in their intentions to engage in sexual risk taking in tourism, sensation-seeking propensities, perceptions of tourist characteristics, levels of sexual experience, and demographic backgrounds. Results suggest tailoring sexual health promotion messages based on cluster affiliation, leveraging cluster-specific risk perceptions, motivations, and personal characteristics. This study provides recommendations for individually tailored, context-specific, age-appropriate, and gender-sensitive sexual health education programs.

Does information form matter when giving tailored risk information to patients in clinical settings? A review of patients' preferences and responses

Neoliberal emphasis on "responsibility" has colonized many aspects of public life, including how health care is provided. Clinical risk assessment of patients based on a range of data concerned with lifestyle, behavior, and health status has assumed a growing importance in many health systems. It is a mechanism whereby responsibility for self (preventive) care can be shifted to patients, provided that risk assessment data is communicated to patients in a way which is engaging and motivates change. This study aimed to look at whether the form in which tailored risk information was presented in a clinical setting (for example, using photographs, online data, diagrams etc.), was associated with differences in patients' responses and preferences to the material presented. We undertook a systematic review using electronic searching of nine databases, along with handsearching specialist journals and backward and forward citation searching. We identified eleven studies (eight with a randomized controlled trial design). Seven studies involved the use of computerized health risk assessments in primary care. Beneficial effects were relatively modest, even in studies merely aiming to enhance patient-clinician communication or to modify patients' risk perceptions. In our paper, we discuss the apparent importance of the accompanying discourse between patient and clinician, which appears to be necessary in order to impart meaning to information on "risk," irrespective of whether the material is personalized, or even presented in a vivid way. Thus, while expanding computer technologies might be able to generate a highly personalized account of patients' risk in a time efficient way, the need for face-to-face interactions to impart meaning to the data means that these new technologies cannot fully address the resource issues attendant with this type of approach.

Effects of a Fingerprint Reader on Survey Responses of Primary Care Patients

Given the potential of patients using computer programs in health care settings, we studied the effect of a fingerprint reader on responses to a computerized health screener. We randomized 76 primary care patients into two conditions: (1) fingerprint reader prior to screener; and (2) control condition. Overall, the reader was well accepted and those who used it had more positive attitudes toward using it than those who did not. The fingerprint reader had a positive effect on reporting low fruit and vegetable intake and poorer health status, but no effect on reporting physical inactivity, smoking, excessive alcohol intake or being overweight.

Assessment and Enhancement of Social and Community Resources Utilization for Disease Self-Management

This article describes an integrated intervention to encourage the use of community resources for dietary behavior change in older adults. Conducted as part of a randomized trial of Type 2 diabetes patients, the intervention components were designed to be broadly useful across chronic diseases and settings. A community resources guidebook, a survey and feedback procedure to assess and suggest resources for supporting chronic disease management at multiple levels (e.g., family, work, community), a newsletter, and postcards to document resource use were evaluated. All components were developed from a conceptual model of a pyramid of social and environmental support influences based on social-ecological theory. For each intervention component, the authors describe the rationale for development; present process and utilization, reach, and satisfaction data (when available); and discuss lessons learned. The authors conclude that such an intervention is promising, but the specific menu of intervention activities should be tailored to the participant, community, and resources available.

Online social networks and smoking cessation: a scientific research agenda

BACKGROUND

Smoking remains one of the most pressing public health problems in the United States and internationally. The concurrent evolution of the Internet, social network science, and online communities offers a potential target for high-yield interventions capable of shifting population-level smoking rates and substantially improving public health.

OBJECTIVE

Our objective was to convene leading practitioners in relevant disciplines to develop the core of a strategic research agenda on online social networks and their use for smoking cessation, with implications for other health behaviors.

METHODS

We conducted a 100-person, 2-day, multidisciplinary workshop in Washington, DC, USA. Participants worked in small groups to formulate research questions that could move the field forward. Discussions and resulting questions were synthesized by the workshop planning committee.

RESULTS

We considered 34 questions in four categories (advancing theory, understanding fundamental mechanisms, intervention approaches, and evaluation) to be the most pressing.

CONCLUSIONS

Online social networks might facilitate smoking cessation in several ways. Identifying new theories, translating these into functional interventions, and evaluating the results will require a concerted transdisciplinary effort. This report presents a series of research questions to assist researchers, developers, and funders in the process of efficiently moving this field forward.

Efficacy of tailored-print interventions to promote physical activity: a systematic review of randomised trials

OBJECTIVE

Computer-tailored physical activity interventions are becoming increasingly popular. Recent reviews have comprehensively synthesised published research on computer-tailored interventions delivered via interactive technology (e.g. web-based programs) but there is a paucity of synthesis for interventions delivered via traditional print-based media in the physical activity domain (i.e. tailored-print interventions). The current study provides a systematic review of the tailored-print literature, to identify key factors relating to efficacy in tailored-print physical activity interventions.

METHOD

Computer-tailored print intervention studies published up until May 2010 were identified through a search of three databases: Medline, CINAHL, and Psycinfo; and by searching reference lists of relevant publications, hand searching journals and by reviewing publications lists of 11 key authors who have published in this field.

RESULTS

The search identified 12 interventions with evaluations reported in 26 publications. Seven out of the 12 identified studies reported positive intervention effects on physical activity behaviour, ranging from one month to 24 months post-baseline and 3 months to 18 months post-intervention. The majority of studies reporting positive intervention effects were theory-based interventions with multiple intervention contacts.

CONCLUSION

There is preliminary evidence that tailored-print interventions are a promising approach to promoting physical activity in adult populations. Future research is needed to further identify key factors relating to efficacy and to determine if this approach is cost-effective and sustainable in the long-term.

The effects of informational interventions on household water management, hygiene behaviors, stored drinking water quality, and hand contamination in peri-urban Tanzania

Safe water storage and hand hygiene have been shown to reduce fecal contamination and improve health in experimental settings; however, triggering and sustaining such behaviors is challenging. This study investigates the extent to which personalized information about Escherichia coli contamination of stored water and hands influenced knowledge, reported behaviors, and subsequent contamination levels among 334 households with less than 5-year-old children in peri-urban Dar es Salaam, Tanzania. One-quarter of the study participants received information about strategies to reduce risk of water- and sanitation-related illness. Respondents in another three study cohorts received this same information, along with their household's water and/or hand-rinse test results. Findings from this study suggest that additional work is needed to elucidate the conditions under which such testing represents a cost-effective strategy to motivate improved household water management and hand hygiene.

Tailored Health Communication to Change Lifestyle Behaviors

Tailored health communication research represents a very promising line of inquiry that has the potential to produce major impacts on lifestyle behaviors. This study defines tailoring and discusses how tailored interventions operate, including comparing/ contrasting different tailoring channels. Next, the authors review the literature on tailored interventions to change lifestyle behaviors, with a focus on smoking cessation, dietary change, and physical activity, as well as interventions that address multiple lifestyle behaviors. Finally, future directions for tailoring research are discussed. To date, a large literature has amassed showing the promise of tailored programs delivered via print, Internet, local computer/kiosk, telephone, and interpersonal channels. Numerous studies demonstrate that these programs are capable of significant impacts on smoking cessation, dietary change, physical activity, and multiple behavior change. It is concluded that the potential of tailoring will be more fully realized as (a) the field builds a more cumulative science of tailoring and (b) greater dissemination of efficacious tailored programs takes place.

Preventing the obesity epidemic by second generation tailored health communication: an interdisciplinary review

BACKGROUND

The prevention of obesity and health concerns related to obesity are major challenges worldwide. The use of eHealth communication and the tailoring of information delivered via the Internet at the individual level may increase the effectiveness of interventions. Mastering behaviors related to nutrition, physical activity, and weight management are the main issues in preventing obesity, and the need for interdisciplinary knowledge within this area is obvious.

OBJECTIVE

The objectives were to review the literature on tailored health communication and to present an interdisciplinary analysis of studies on "second" generation tailored interventions aimed at behavior change in nutrition, physical activity, or weight management.

METHODS

A literature search was conducted of the main electronic information sources on health communication. Selection criteria were defined, and 23 intervention studies were selected. The content analysis focused on the following: study designs, objectives of behavior change, target groups, sample sizes, study lengths, attrition rates, theories applied, intervention designs, computer-based channels used, statistically significant outcomes from the perspective of tailoring, and possible biases of the studies. However, this was not a structured meta-analysis and cannot be replicated as such.

RESULTS

Of the 23 studies, 21 were randomized controlled trials, and all focused on behavior change: 10 studies focused on behavior change in nutrition, 7 on physical activity, 2 on nutrition and physical activity, and 4 on weight management. The target groups and the number of participants varied: 8 studies included more than 500 participants, and 6 studies included less than 100. Most studies were short; the duration of 20 studies was 6 months or less. The Transtheoretical Model was applied in 14 of the 23 studies, and feedback as a tailoring mechanism was used in addition to an Internet site (or program) in 15 studies and in addition to email in 11 studies. Self-reporting was used in 15 studies, and 14 studies did not have a no-information control group. Tailoring was more effective in nutrition interventions than in physical activity and weight management interventions. The outcomes were mixed or negative in 4 studies of physical activity interventions and in 3 studies of weight management. The use of a no-information control group seemed to have been linked to statistically significant between-group effects in measuring physical activity. This bias effect related to intervention design may explain the differences in the outcomes of the physical activity studies.

CONCLUSIONS

Tailoring was shown to have been an effective method in nutrition interventions, but the results for physical activity were mixed, which is in line with previous studies. Nevertheless, the effect of possible biases, such as relying solely on self-reports and on intervention design without a no-information control group, should not be underestimated. Thus, the issue of bias merits more attention in planning interventions and in future meta-analyses.

Asthma management simulation for children: translating theory, methods, and strategies to effect behavior change

Translating behavioral theories, models, and strategies to guide the development and structure of computer-based health applications is well recognized, although a continued challenge for program developers. A stepped approach to translate behavioral theory in the design of simulations to teach chronic disease management to children is described. This includes the translation steps to: 1) define target behaviors and their determinants, 2) identify theoretical methods to optimize behavioral change, and 3) choose educational strategies to effectively apply these methods and combine these into a cohesive computer-based simulation for health education. Asthma is used to exemplify a chronic health management problem and a computer-based asthma management simulation (Watch, Discover, Think and Act) that has been evaluated and shown to effect asthma self-management in children is used to exemplify the application of theory to practice. Impact and outcome evaluation studies have indicated the effectiveness of these steps in providing increased rigor and accountability, suggesting their utility for educators and developers seeking to apply simulations to enhance self-management behaviors in patients.

The systematic development of a tailored e-mail intervention for health behavior change toward increasing intentional physical activity

Although the benefits of physical activity are well known, most adults in the United States are relatively sedentary, with about 60% of adults not regularly physically active and 25% of those not active at all. This inactivity places the population at risk for many chronic diseases. Understanding optimal ways of both communicating with and educating employees regarding intention to reduce risk of ill health and enhance well-being through physical activity was the fundamental aim of this health communication research study. The authors designed a series of theory-based, tailored e-mail messages, which were evaluated for content validity by health care experts and focus groups. Focus groups were held according to the stage-of-change level of the participants, and two clear domains emerged: persuasion and decision domains. Improving societal well-being in a cost-effective manner using e-mail remains to be seen; however, creating interventions to engineer sufficient impact on health behavior decision making is an investment worth exploring.

Examining the minimal required elements of a computer-tailored intervention aimed at dietary fat reduction: results of a randomized controlled dismantling study

This study investigated the minimally required feedback elements of a computer-tailored dietary fat reduction intervention to be effective in improving fat intake. In all 588 Healthy Dutch adults were randomly allocated to one of four conditions in an randomized controlled trial: (i) feedback on dietary fat intake [personal feedback (P feedback)], (ii) P feedback and feedback on one's own behavior relative to that of peers [personal-normative feedback (PN feedback)], (iii) PN feedback and practical suggestions on how to change fat intake [personal-normative-action feedback (PNA feedback)] and (iv) generic information. Data on fat intake, awareness of one's own fat intake and intention to change were collected 1 and 6 months post-intervention. Between-group differences were tested with analysis of variance. Among respondents with high fat intakes at baseline (risk consumers) and those who underestimated their fat intake at baseline (underestimators), differences in awareness and (saturated) fat intake were found between the generic and PNA feedback conditions. Compared with generic information P feedback was more effective in changing awareness and intention among the underestimators, and PN feedback was more effective in changing intention among both risk consumers and underestimators. In conclusion, the combination of personal, normative and action feedback is required for inducing change in fat intake and improving awareness of fat intake.

Lessons learned from developing a tailored print intervention: a guide for practitioners and researchers new to tailoring

Although some "how-to" guides have been written on tailored messaging, we found no reports on lessons learned from the process of developing a tailored intervention. Such lessons may be useful for practitioners and researchers who are new to tailored intervention development. The authors describe lessons gleaned from the process of developing a repeat mammography tailored print intervention. Lessons learned include the following: Selection of determinants appropriate for tailoring should be based on a theoretic framework and refined through assessment of the target population; researchers should anticipate threats to fidelity of intervention delivery because of incomplete or illogical survey data; fingerprinting enables assessment of intervention dose and how it relates to effectiveness of the tailored intervention; and a systematic process for conducting a systems test is needed to check for inconsistencies and errors before final tailored letter production. These lessons are discussed in the context of challenges and possible solutions for tailored health communication.

Web-based smoking-cessation programs: results of a randomized trial

BACKGROUND

Initial trials of web-based smoking-cessation programs have generally been promising. The active components of these programs, however, are not well understood. This study aimed to (1) identify active psychosocial and communication components of a web-based smoking-cessation intervention and (2) examine the impact of increasing the tailoring depth on smoking cessation.

DESIGN

Randomized fractional factorial design.

SETTING

Two HMOs: Group Health in Washington State and Henry Ford Health System in Michigan.

PARTICIPANTS

1866 smokers.

INTERVENTION

A web-based smoking-cessation program plus nicotine patch. Five components of the intervention were randomized using a fractional factorial design: high- versus low-depth tailored success story, outcome expectation, and efficacy expectation messages; high- versus low-personalized source; and multiple versus single exposure to the intervention components.

MEASUREMENTS

Primary outcome was 7 day point-prevalence abstinence at the 6-month follow-up.

FINDINGS

Abstinence was most influenced by high-depth tailored success stories and a high-personalized message source. The cumulative assignment of the three tailoring depth factors also resulted in increasing the rates of 6-month cessation, demonstrating an effect of tailoring depth.

CONCLUSIONS

The study identified relevant components of smoking-cessation interventions that should be generalizable to other cessation interventions. The study also demonstrated the importance of higher-depth tailoring in smoking-cessation programs. Finally, the use of a novel fractional factorial design allowed efficient examination of the study aims. The rapidly changing interfaces, software, and capabilities of eHealth are likely to require such dynamic experimental approaches to intervention discovery.

Feasibility of combining e-health for patients with e-learning for students using synchronous technologies

AIM

This paper is a report of a project to introduce and evaluate methods for using information and communication technologies to involve academic staff, students, and patients in a common synchronous e-learning environment.

BACKGROUND

Although there is no strong evidence for this, there may be benefits in 'efficiency' and for patients and students from shared e-learning. Asynchronous e-learning methods in nursing education are well-established, but synchronous methods have received less attention. However, if feasible, because they are more akin to face-to-face contact, they may be more suitable for patients and may provide a quicker development path for e-learning.

METHOD

We evaluated three synchronous technologies: (1) non-commercial satellite interactive television (TV); (2) Internet videoconferencing; and (3) webcasting, through feasibility studies of 'TV-style' panel discussions on health topics and seminars with interaction with viewers by e-mail, inter-site research meetings with face-to-face interaction, user surveys and literature reviews.

RESULTS

Interactive satellite TV required the booking of rooms with specialized receiving equipment. This limited accessibility contributed to the high cost per participant. Videoconferencing proved acceptable for cross-site research meetings and is proposed for joint meetings for doctoral students with overseas centres but has the same access issues as interactive satellite TV. Webcasting is accessible to most users with Internet access and provides a feasible means of delivery of synchronous interactive material. Reported live webcasts have had audiences of thousands. Presentation formats: panel discussions with mixed patient-professional membership and mixed patient-professional audiences were acceptable to participants but engaging academic staff and students was problematic. This may be overcome with webcasting but there may still be barriers such as timetabling and students' concerns about learning in the same 'live' environment as patients.

CONCLUSIONS

Limitations in accessibility have been demonstrated for both satellite broadcasts and videoconferencing. Webcasting proved the most acceptable way of supporting a common synchronous environment. Having identified a feasible synchronous method we can now investigate hypothesized benefits for staff, students, and patients of combined e-health e-learning.

Internet methods for delivering behavioral and health-related interventions (eHealth)

Emerging communications technologies allow us to potentially reach more individuals with effective health-related advice and information at a very low cost. As we begin a new era of "personalized medicine," advances in consumer health informatics will parallel and eventually merge with those being made in bioinformatics (e.g., genomic information), medical informatics (e.g., electronic medical records), and public health informatics (e.g., disease surveillance). This article discusses access, use, quality, and types of eHealth programming with a focus on the Internet as the initial instantiation of this programming. Also discussed are criteria relevant to the dissemination of eHealth programming in real-world settings. Finally, possible directions for future eHealth research are presented.

Evaluation of an interactive computer-tailored nutrition intervention in a real-life setting

BACKGROUND

Studies testing Web-based computer-tailored education in real-life settings are now needed.

PURPOSE

The aim of this study is to examine the effectiveness and applicability of an interactive computer-tailored fat reduction intervention, which was previously tested as efficacious in a controlled setting, delivered to a broader population by local health promotion services. The impact of the computer-tailored intervention is compared with a generic intervention and with a no-intervention control group.

METHODS

A quasi-experimental design was used assigning 6 companies randomly to (a) the computer-tailored intervention condition, (b) the generic intervention condition, and (c) the no-intervention control condition. Participants (N = 337) completed validated baseline and posttest questionnaires and received the personal feedback immediately through the company's intranet. A structured interview with the project coordinators assessed the process that the companies had passed through to disseminate the fat intake intervention.

RESULTS

Six months postbaseline, the results showed that the computer-tailored intervention to reduce fat intake implemented through worksites was more effective in decreasing employees' fat intake compared with a generic intervention, F = 23.5, p < .001, or no intervention, F = 28.1, p < .001. Moreover, the dissemination strategy used is feasible for local health promotion services.

CONCLUSIONS

This study can be regarded as an effective "real-life" trial with an implementation strategy that can be used for large scale dissemination.

Tools for health: the efficacy of a tailored intervention targeted for construction laborers

OBJECTIVES

Novel approaches to worksite health promotion are needed for high-risk workers who change job sites frequently, and thus may have limited access to worksite health promotion efforts. The objective of this study was to test a behavioral intervention among construction laborers.

METHODS

Using a randomized-controlled design, we tested the efficacy of a tailored telephone-delivered and mailed intervention to promote smoking cessation and increased fruit and vegetable consumption (n = 582).

RESULTS

At baseline, 40% of control group participants and 45% of intervention group participants reported using any tobacco in the last seven days. At final, 8% of baseline cigarette smokers in the control group had quit, compared to 19% in the intervention group (p = 0.03). In both groups, the mean consumption of fruits and vegetables at baseline was over five servings per day. At final, the intervention group had increased consumption by approximately one and one-half servings, compared to a slight decrease in consumption in the control group (p < 0.001).

CONCLUSIONS

A tailored intervention can be efficacious in promoting tobacco use cessation and increased fruit and vegetable consumption among construction laborers, a high-risk, mobile workforce.

Tailored program evaluation: Past, present, future

This paper discusses measurement issues related to the evaluation of computer-tailored health behavior change programs. As the first generation of commercially available tailored products is utilized in health promotion programming, programmers and researchers are becoming aware of the unique challenges that the evaluation of these programs presents. A project is presented that used an online tailored health behavior assessment (HBA) in a worksite setting. Process and outcome evaluation methods are described and include the challenges faced, and strategies proposed and implemented, for meeting them. Implications for future research in tailored program development, implementation, and evaluation are also discussed.

Applying Transdisciplinary Research Strategies to Understanding and Eliminating Health Disparities

This overview for the special issue of Health Education & Behavior on “Health Disparities and Social Inequities” briefly outlines the transdisciplinary (TD) approach to research and examines the scope of TD science. The need to embrace basic science as well as several domains of applied research is discussed along the TD “pipeline” from discovery to development to delivery to policy. The overview concludes with selected examples of the emerging TD science of disparities. One central challenge for a TD approach is the need to strengthen what is being called “the science of dissemination” along with improving the “dissemination of evidence-based science.”

Promoting physical activity in independent living communities

PURPOSE

Recent studies evaluating physical activity programming in independent living facilities reveal that oftentimes programs have poor attendance rates, with difficulty in motivating older residents identified as a primary barrier. To better understand how to promote physical activity in the independent living setting, a brief cognitive-behavioral feedback intervention was evaluated as a means to mobilize older adults to attend introductory activity programs.

METHODS

Residents in three independent living communities (N = 79; mean age = 81.6 (SD = 6.1) yr) were randomly assigned to either a brief tailored feedback session, based on social cognitive theory and recent research on risk perception, or to a standard information-only condition. All participants were provided information advertising an introductory physical activity session.

RESULTS

Of the 38 participants randomized to the cognitive-behavioral intervention, 20 attended the physical activity session, as compared to five of the 41 participants in the information-only condition. The difference between groups for attendance at the session was significant (chi2 (1, N = 79) = 24.31, P < 0.001).

CONCLUSION

The findings support the efficacy of a brief intervention to generate interest in physical activity. Effective and feasible interventions intended to make environments more engaging are warranted and should include individualized feedback that emphasizes the role played by physical activity in independent living.

The health information national trends survey: research from the baseline

The decades surrounding the turn of the millennium will be remembered as a time of extraordinary opportunity in cancer communication. In 1990, the number of age-adjusted deaths due to cancer in the U.S. population began a slow steady decline after a century of disparaging increase. Reasons for this decline have been attributed to long-awaited successes in primary prevention, especially related to tobacco, and early detection for cervical, breast, prostate, and colorectal cancers, as well as advances in treatment. This was also a time of unparalleled change in the cancer communication environment. Scientific health discoveries escalated with the completion of the Human Genome project in 2003, and penetration of the Internet made health information available directly to consumers. To seize the opportunity afforded by these changes, the National Cancer Institute (NCI) launched the Health Information National Trends Survey (HINTS). Fielded for the first time in 2003, the HINTS is a nationally representative, general population survey of noninstitutionalized adults in the United States 18 years and older. This supplement contains a compilation of original research conducted using the data generated by the first administration of the HINTS telephone interviews. Covering topics in cancer knowledge, cancer cognition, risk perception, and information seeking, the articles represent an interdisciplinary view of cancer communication at the turn of the millennium and offer insight into the road ahead.

Beginning with the application in mind: designing and planning health behavior change interventions to enhance dissemination

Failing to retain an adequate number of study participants in behavioral intervention trials poses a threat to interpretation of study results and its external validity. This qualitative investigation describes the retention strategies promoted by the recruitment and retention committee of the Behavior Change Consortium, a group of 15 university-based sites funded by the National Institutes of Health to implement studies targeted toward disease prevention through behavior change. During biannual meetings, focus groups were conducted with all sites to determine barriers encountered in retaining study participants and strategies employed to address these barriers. All of the retention strategies reported were combined into 8 thematic retention categories. Those categories perceived to be most effective for retaining study participants were summarized and consistencies noted among site populations across the life course (e.g., older adults, adults, children, and adolescents). Further, possible discrepancies between site populations of varying health statuses are discussed, and an ecological framework is proposed for use in future investigations on retention.

The effectiveness of a community outreach intervention to improve follow-up among underserved women at highest risk for cervical cancer

BACKGROUND

A disproportionate number of women diagnosed with cervical cancer are from low-income and/or ethnically diverse groups. This study was designed to evaluate the effectiveness of an outreach and counseling intervention at improving the rate of follow-up of abnormal Pap smears among women at Alameda County Medical Center, Oakland, CA.

METHODS

Between September 1, 1999 and August 31, 2001, 348 women with abnormal Pap test results were randomly assigned to intervention or usual care. The main outcome was rate of follow-up.

RESULTS

The intervention produced a significant increase in the rate of follow-up visits within 6 months. Women in the intervention group were much more likely to obtain timely follow-up at Highland Hospital than were those in the control group (61% vs. 32%, P = 0.001). The intervention was equally effective when delivered to women in the control group who had no follow-up by 6 months. Overall, we were able to contact 90% of women in the intervention group.

CONCLUSIONS

An outreach intervention is highly effective at increasing follow-up of abnormal Pap smears in a public hospital setting. Institutions offering cervical cancer screening to low-income, high-risk women should consider the use of outreach workers to reduce loss to follow-up.

The effect of web-based, personalized, osteoarthritis quality improvement feedback on patient satisfaction with osteoarthritis care

To address gaps in the quality of care for osteo-arthritis, the authors developed a Web-based computer program to provide patients with personalized feedback designed to improve the quality of their osteoarthritis care. The current study was designed to examine satisfaction as well as the potential effects of the feedback on patients' perceptions of their osteoarthritis care by randomizing patients to use the site before or after they answered questions about the quality of their osteoarthritis care. On average, participants received 8.7 recommendations to change their osteoarthritis care. Satisfaction with osteo-arthritis care was similar between subjects in both groups. Most subjects believed that the Web site would help them get better care from their doctor (77.7%), and most would recommend it to others (94.3%). Overall, the Web site is well accepted and has no negative effect on patients' satisfaction with their osteo-arthritis care.

Reducing the cancer burden of lifestyle factors: opportunities and challenges of the Internet

This paper focuses on the Internet as a tool for enhancing behavior and lifestyle changes to reduce the burden of cancer at a population level. The premise of this paper is that the Internet can and should be leveraged to bridge the chasm between basic science, clinical trials, and public health. Our focus is specifically on the opportunity to disseminate effective behavioral science interventions via the Internet in order to decrease the prevalence of behavioral risk factors for cancer. The examples herein are primarily drawn from tobacco use to illustrate issues that can be applied more generally to other behavioral risk factors for cancer. Four areas will be addressed: (1) the scientific basis and rationale for delivering lifestyle behavior change interventions via the Internet; (2) the need to determine the quality of Internet interventions; (3) methodological considerations in conducting evaluations of Internet interventions; and (4) recommendations for a transdisciplinary approach to Internet intervention development and evaluation.

Differences between Latino and non-Latino White smokers in cognitive and behavioral characteristics relevant to smoking cessation

Adult smokers were recruited during routine health care visits at primary care clinics located in three urban hospitals and were given a brief intervention and nicotine replacement therapy. Analyses compared bicultural (BC: n=60) or less acculturated (LA: n=138) Latinos and non-Latino White (NL: n=417) participants. Both Latino groups were significantly different from NL subjects in smoking rate and nicotine dependence. However, BC and NL subjects differed significantly from LA subjects in perceived benefits of quitting, perceived risk from smoking, and negative affect smoking. LA subjects had higher cessation rates than either BC or NL groups. Regression analyses showed that nicotine dependence and confidence in quitting predicted cessation at month 6, and acculturation appeared to moderate the relationship between smoking cessation and both confidence in quitting and nicotine dependence. These results provide support for the viability of brief interventions for smoking provided through health care delivery systems. Results also suggest that characteristics previously shown to be predictive of successful cessation in mixed or non-Latino populations may not be equally predictive of cessation across members of diverse populations.

Initial evaluation of a real-world Internet smoking cessation system

To significantly reduce smoking prevalence, treatments must balance reach, efficacy, and cost. The Internet can reach millions of smokers cost-effectively. Many cessation Web sites exist, but few have been evaluated. As a result, the potential impact of the Internet on smoking prevalence remains unknown. The present study reports the results, challenges, and limitations of a preliminary, large-scale evaluation of a broadly disseminated smoking cessation Web site used worldwide (QuitNet). Consecutive registrants (N=1,501) were surveyed 3 months after they registered on the Web site to assess 7-day point prevalence abstinence. Results must be interpreted cautiously because this is an uncontrolled study with a 25.6% response rate. Approximately 30% of those surveyed indicated they had already quit smoking at registration. Excluding these participants, an intention-to-treat analysis yielded 7% point prevalence abstinence (for the responders only, abstinence was 30%). A range of plausible cessation outcomes (9.8%-13.1%) among various subgroups is presented to illustrate the strengths and limitations of conducting Web-based evaluations, and the tensions between clinical and dissemination research methods. Process-to-outcome analyses indicated that sustained use of QuitNet, especially the use of social support, was associated with more than three times greater point prevalence abstinence and more than four times greater continuous abstinence. Despite its limitations, the present study provides useful information about the potential efficacy, challenging design and methodological issues, process-to-outcome mechanisms of action, and potential public health impact of Internet-based behavior change programs for smoking cessation.

Short-term efficacy of a web-based computer-tailored nutrition intervention: Main Effects and Mediators

BACKGROUND

This study evaluates the short-term efficacy and respondents' evaluations of a Web-based computer-tailored nutrition intervention, aiming to decrease saturated fat intake and increase fruit and vegetable intake. Perceived personal relevance, individualization, and interestingness of the information were tested as mediators of the effects of the tailored intervention.

PURPOSE

The objective was to study the short-term effects of a Web-based computer-tailored nutrition intervention.

METHODS

Respondents (N = 782) were randomly assigned to a tailored intervention group, a generic nutrition information control group, or a no-information control group. Fat, fruit, and vegetable intakes and behavioral determinants were measured at baseline and at 3 weeks postintervention. Posttest group differences were determined by multiple linear regression analyses.

RESULTS

The computer-tailored intervention produced significant effects for the determinants of fat, fruit, and vegetable intake and for vegetable and fruit intake. The tailored information was rated as more personally relevant, individualized, interesting, and new than the generic nutrition information. Perceived personal relevance, individualization, and interestingness were identified as mediators of some of the tailoring effects.

CONCLUSIONS

The findings of this study indicate that Web-based, computer-tailored nutrition information can have a short-term effect on the determinants of fat, fruit, and vegetable intake. The effect of the tailored information may be partly explained by the perceived personal relevance and individualization of the information.

Motivating cancer prevention and early detection behaviors using psychologically tailored messages

Tailoring health messages to make them salient to recipients is a strategy to motivate cancer prevention and early detection behaviors. Various tactics can be used to tailor health materials; our approach involves tailoring messages to individual differences in the psychological processes by which people understand health information. To summarize our tailoring approach, we review findings from six field experiments (four published, two pending publication) conducted in collaboration with the National Cancer Institute's (NCI's) Cancer Information Service (CIS) examining the utility of psychologically tailored messages. Messages were tailored to individual variability in the following: (a) need for cognition, (b) monitor/blunting coping style, (c) health locus of control, and (d) regulatory focus. Collectively, the findings suggest that, as hypothesized, messages congruent with the recipients' psychological style of health information processing (i.e., matched messages) are more persuasive in promoting screening mammography and fruit and vegetable consumption than mismatched messages. This line of research provides evidence for the utility of psychological tailoring as a health communication strategy and direction for developing effective health messages in a variety of settings.

Efficacy and cost-effectiveness of a minimal intervention to prevent smoking relapse: dismantling the effects of amount of content versus contact

Relapse prevention remains a major challenge to smoking cessation efforts. T. H. Brandon, B. N. Collins, L. M. Juliano, and A. B. Lazev (2000) found that a series of 8 empirically based relapse-prevention booklets mailed to ex-smokers over 1 year significantly reduced relapse. This study dismantled 2 components of that intervention: the amount of content (number of booklets) and the frequency of contact. Content and contact were crossed in a 2 X 2 factorial design. The criteria of at least 1 week of abstinence at baseline was met by 431 participants, 75%-85% of whom returned 12-, 18-, and 24-month follow-up questionnaires. Eight booklets produced consistently higher point-prevalence abstinence rates than did a single booklet, but frequency of contact did not affect outcome. Moreover, the high-content interventions were highly cost-effective.

Lessons learned from community-based cancer screening intervention research

Behaviors associated with cancer screening have been the focus of intensive research over the past 2 decades, primarily in the form of intervention trials to improve screening based in both clinical and community settings. Meta-analyses and literature reviews have synthesized and organized the resulting literature. From the accumulated work, this review distilled lessons learned from cancer screening intervention research in community settings. The authors posed the question, "What do we know about the development of effective community-based interventions (the level of good over harm achieved in real-world conditions)?" Framed around the concept of focal points (the simultaneous combination of target population, behavioral objective, and setting for an intervention), 13 lessons were derived. One lesson was cross-cutting, and the other lessons addressed the three focal-point components and the major intervention categories (access-enhancing strategies, mass media, small media, one-on-one and small-group education, and combinations of these categories). To build more systematically on existing research, recommendations are made for new directions in basic behavioral and intervention research.

A tailored minimal self-help intervention to promote condom use in young women: results from a randomized trial

OBJECTIVE

To evaluate the efficacy of a theory-based tailored minimal self-help intervention to increase condom use among young women at risk for HIV/sexually transmitted disease (STD).

DESIGN

Randomized controlled trial on an intent-to-treat basis in two managed care plans, in Washington state and North Carolina, with follow-up at 3 and 6 months.

PARTICIPANTS

A proactively recruited sample of 1210 heterosexually active, non-monogamous, non-pregnant women, aged 18-24 years recruited June 1999-April 2000; 85% completed the 6-month follow-up.

METHOD

Arm 1 received usual care. Arm 2 received a mailed computer-generated self-help magazine, individually tailored on survey items including stage of readiness to use condoms, barriers to condom use, partner type; condom samples and a condom-carrying case were included in the packet; this was followed 3 months later by a tailored 'booster' newsletter. The a priori 6-month main outcomes were percentage of women using condoms during the previous 3 months (overall and by partner type) and proportion of total episodes of intercourse during which condoms were used in the previous 3 months.

RESULTS

Relative to usual care, intervention group women reported significantly more condom use overall [adjusted odds ratio (OR), 1.86; 95% confidence interval (CI), 1.32-2.65; P = 0.0005] and with recent primary partners (OR, 1.97; 95% CI, 1.37-2.86; P = 0.0003). They also reported using condoms for a higher proportion of intercourse episodes (52.7% versus 47.9%; P = 0.05). Significantly more intervention women carried condoms, discussed condoms with partners, and had higher self-efficacy to use condoms with primary partners.

CONCLUSIONS

Tailored cognitive/behavioral minimal self-help interventions hold promise as HIV/STD prevention strategies for diverse populations of young at-risk women.

Tailored messages for breast and cervical cancer screening of low-income and minority women using medical records data

Barriers to screening and early detection often result in cancers in low-income and minority women diagnosed at stages too advanced for optimal treatment. This randomized controlled trial examined whether a personalized form (PF) letter containing generic cancer information and a personalized tailored (PT) letter containing minimally tailored individualized risk factor information based on medical records data affected breast and cervical cancer screening among 1574 urban low-income and minority women. The personalized form-letter group was significantly more likely to schedule a screening appointment and to have undergone a Pap test and mammography within 1 year after the intervention than were the tailored letter and control groups (P<0.001 for all comparisons). Personalized tailored letters that contain individualized cancer risk factor information may decrease the likelihood of receiving cancer screening among medically underserved low-income and minority women, but personalized form letters that contain generic cancer information may improve these rates in this disadvantaged population.

One-year results from a brief, computer-assisted intervention to decrease consumption of fat and increase consumption of fruits and vegetables

BACKGROUND

Current cancer prevention recommendations include reducing consumption of fat and increasing consumption of fruits and vegetables.

METHODS

Healthy women health maintenance organization members (n = 616) ages 40-70 were randomly assigned to either a nutrition intervention or a control intervention unrelated to diet. Intervention included two 45-min counseling sessions plus two brief follow-up telephone contacts. Counseling sessions included a 20-min, interactive, computer-based intervention using a touch-screen format. Intervention goals were reducing dietary fat and increasing fruit and vegetable consumption. Outcome measures included a food frequency questionnaire and the Fat and Fiber Behavior Questionnaire (FFBQ). Total serum cholesterol was also measured at baseline and 12 months.

RESULTS

Twelve-month follow-up data showed improvements on all dietary outcome variables. Compared to the control, intervention participants reported significantly less fat consumption (3.75 points less for percentage of energy from fat), significantly greater consumption of fruit and vegetables combined (0.93 more servings per day), and a significant reduction in a behavioral measure of fat consumption (0.20 point change in the FFBQ). Group differences in total serum cholesterol, while in the desired direction, were not significant.

CONCLUSIONS

In appropriate circumstances, moderate-intensity dietary interventions can show significant effects for periods of at least 1 year.

Applying Persuasion Strategies to Alter HIV-Relevant Thoughts and Behavior

Health communication strategies are at the core of both mass media campaigns and public health interventions conducted at the community level concerning the prevention of HIV/AIDS. They are often nested in complex contexts that prevent us from being able to identify the persuasive impact of a specific message. The authors attempt to account for an array of factors contributing to the persuasiveness of messages about HIV. The aim is to synthesize the psychological literature on persuasion and thus provide a conceptual framework for understanding message effects in HIV communications. This discussion concerns fear appeals, message framing, tailoring, cultural targeting, and additional factors pertaining to the message, source, and channel of the communication. Whenever possible, recommendations for further research are formulated.

Patient-centered interventions

Patient-centered care is valued in nursing. However, until recently, nurse-researchers have focused on testing the effects of standardized rather than patient-centered interventions (PCIs). The latter are those interventions that are altered to address selected patient characteristics (e.g., beliefs, habits, or goals). PCIs have been well received, and in some studies they have been associated with improved health outcomes. In this article we describe briefly the concept patient centered, summarize the development of research on PCIs, discuss kinds of PCIs, provide examples of PCIs and how they have been derived and implemented, and raise issues for theory and future research.

Smoking cessation: progress, priorities, and prospectus

The authors review developments in understanding smoking cessation interventions over the past decade. Noteworthy is the unprecedented growth of research and knowledge that has left a deeper understanding of how best to use new and existing behavioral and pharmacologic tools and strategies to help smokers quit. The status of public-health-level interventions is evaluated, questions are raised concerning their efficacy, and suggestions are offered for further refinement of these intervention strategies. Development of cessation guidelines is reviewed, and the state of knowledge concerning behavioral and pharmacologic interventions is summarized. The authors also present agendas for behavioral and pharmacologic research related to smoking cessation and discuss individual difference factors among smokers that may prove to be important in designing new and refining existing treatments.

The effects of mailed reminders and tailored messages on mammography screening

A mail campaign to promote mammography screening was tested with 3,887 Medicare recipients in North Dakota who had not had a mammogram in 2 1/2 years. Three types of mailings were compared: (1) a simple reminder message, (2) a reminder accompanied by a persuasive communication emphasizing personal risk, and (3) a reminder accompanied by a message tailored to the participants' chief barrier to having a mammogram. Overall, subsequent mammography rates for women in these conditions did not differ from the rate observed among women who did not receive any mailing. However, post-hoc analyses suggested that women who reported a barrier to having a mammogram were more likely to have a mammogram. Population-wide mail campaigns of the kinds tested here may be generally ineffective for Medicare recipients who are obtaining screenings infrequently. Tailoring messages may be one potentially effective intervention, if investigators can develop ways to increase responses to inquiries about barriers.

Computer use and physical inactivity in young adults: public health perils and potentials of new information technologies

Physical inactivity contributes to premature mortality and morbidity and increasing prevalences of overweight and obesity in industrialized countries. Computer use is an increasingly common sedentary behaviour, potentially displacing physical activity. Physical activity and computer use were examined in 697 young adults (18-30 years). Energy expenditure estimates were derived from self-reported walking, moderate, and vigorous activity; participants were classified as sedentary, low, moderate, or high in their level of activity. For multivariate analyses, two categories of physical activity were used: inactive (sedentary/low activity; < 800 kcal.week-1) or active (moderate/high activity; > or = 800 kcal.week-1). Time spent in computer-related activities was summed, and computer use tertiles calculated (< 3 hours.week-1; 3-8 hours.week-1; > 8 hours.week-1). Those in the highest tertile of computer use were most likely to be inactive (p = 0.003) and most likely to report computer use as a barrier to physical activity (p < 0.001). The majority of those in the top two tertiles of computer use, and of the inactive, preferred obtaining information from computers than from conventional print media. These findings suggest that computer use plays a significant role in the discretionary time of young adults and is negatively associated with physical activity. Computer-mediated communication has potential in disseminating interventions to increase physical activity in young adults.