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Wong BKC, Veldhuizen S, Minian N, Zawertailo L, Selby P. The effects of alcohol use on smoking cessation treatment with nicotine replacement therapy: An observational study. Addict Behav 2024; 155:108045. [PMID: 38692071 DOI: 10.1016/j.addbeh.2024.108045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 04/10/2024] [Accepted: 04/26/2024] [Indexed: 05/03/2024]
Abstract
INTRODUCTION Concurrent users of tobacco and alcohol are at greater risk of harm than use of either substance alone. It remains unclear how concurrent tobacco and alcohol use affects smoking cessation across levels of alcohol use and related problems. This study assessed the relationship between smoking cessation and levels of alcohol use problems. METHODS 59,018 participants received nicotine replacement therapy through a smoking cessation program. Alcohol use and related symptoms were assessed using the Alcohol Use Disorders Identification Test (AUDIT-10) and the AUDIT-Concise (AUDIT-C). The primary outcome was 7-day point prevalence cigarette abstinence (PPA) at 6-month follow-up. We evaluated the association between alcohol use (and related problems) and smoking cessation using descriptive methods and mixed-effects logistic regression. RESULTS 7-day PPA at 6-months was lower in groups meeting hazardous alcohol consumption criteria, with the lowest probability of smoking abstinence observed in the highest risk group. The probability of successful tobacco cessation fell with increasing levels of alcohol use and related problems. Adjusted predicted probabilities were 30.3 (95 % CI = 29.4, 31.1) for non-users, 30.2 (95 % CI = 29.4, 31.0) for low-risk users, 29.0 (95 % CI = 28.1, 29.9) for those scoring below 8 on the AUDIT-10, 27.3 (95 % CI = 26.0, 28.6) for those scoring 8-14, and 24.4 (95 % CI = 22.3, 26.5) for those scoring 15 or higher. CONCLUSION Heavy, hazardous alcohol use is associated with lower odds of successfully quitting smoking compared to low or non-use of alcohol. Targeting alcohol treatment to this group may improve tobacco cessation outcomes.
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Affiliation(s)
- Benjamin K C Wong
- INTREPID Lab, Centre for Addiction and Mental Health, Toronto, ON, Canada; Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Scott Veldhuizen
- INTREPID Lab, Centre for Addiction and Mental Health, Toronto, ON, Canada; Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Nadia Minian
- INTREPID Lab, Centre for Addiction and Mental Health, Toronto, ON, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada; Campbell Family Mental Health Research Institute, IMHPR, Centre for Addiction and Mental Health, Toronto, ON, Canada; Institute of Medical Sciences, University of Toronto, Toronto, Canada
| | - Laurie Zawertailo
- INTREPID Lab, Centre for Addiction and Mental Health, Toronto, ON, Canada; Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada; Campbell Family Mental Health Research Institute, IMHPR, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Peter Selby
- INTREPID Lab, Centre for Addiction and Mental Health, Toronto, ON, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada; Campbell Family Mental Health Research Institute, IMHPR, Centre for Addiction and Mental Health, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
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Pengpid S, Peltzer K. Tobacco use and heavy episodic drinking among persons aged 18-69 years in Bolivia in 2019. Public Health 2024; 233:8-14. [PMID: 38810508 DOI: 10.1016/j.puhe.2024.04.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 04/01/2024] [Accepted: 04/29/2024] [Indexed: 05/31/2024]
Abstract
OBJECTIVES The aim of this study was to estimate the prevalence and sociodemographic factors associated with tobacco use and heavy episodic drinking (TUHED), current tobacco use only (TU), and current heavy episodic drinking only (HED) among people 18-69 years in Bolivia in 2019. STUDY DESIGN Cross-sectional study. METHODS The analysis used cross-sectional data from Bolivia's STEPS 2019 survey; 4472 individuals answered questions about substance use and socio-demographic information. RESULTS The sample included 50.2% women and 49.8% men, 52.1% had secondary or higher education, 48.6% were Mestizo and 28.0% Quechua. The prevalence of TUHD was 6.0% (10.5% for men, 1.6% for women), TU 12.2% (20.0% for men, 4.4% for women), and HED 11.2% (13.4% for men and 9.1% for women). Male sex increased the risk of TU, HED and TUHED and belonging to the Amara ethnic group decreased the risk of TU and TUHED. Higher education was increased the odds of HED and among women of TUHED. Urban residence increased the risk of TUHED and among women of HED. For women, unemployment was associated with TU and marriage or cohabitation was inversely associated with TU, and for men, belonging to another ethnic group (such as Castellano or Tacana) increased the risk of TU and TUHED. CONCLUSION More than 10% of the general adult population in Bolivia participated in TU and HED, and among men in TUHED. Various factors associated with the different categories of substance use were identified.
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Affiliation(s)
- Supa Pengpid
- Department of Health Education and Behavioral Sciences, Faculty of Public Health, Mahidol University, Bangkok, Thailand; Department of Public Health, Sefako Makgatho Health Sciences University, Pretoria, South Africa; Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan
| | - Karl Peltzer
- Department of Health Education and Behavioral Sciences, Faculty of Public Health, Mahidol University, Bangkok, Thailand; Department of Psychology, University of the Free State, Bloemfontein, South Africa; Department of Psychology, College of Medical and Health Science, Asia University, Taichung, Taiwan.
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Krolo-Wicovsky F, Baumann S, Tiede A, Bischof G, John U, Gaertner B, Freyer-Adam J. Do in-person and computer-based brief alcohol interventions reduce tobacco smoking among general hospital patients? Secondary outcomes from a randomized controlled trial. Addict Sci Clin Pract 2023; 18:68. [PMID: 37957757 PMCID: PMC10644412 DOI: 10.1186/s13722-023-00425-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 11/06/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND At-risk alcohol use and tobacco smoking often co-occur. We investigated whether brief alcohol interventions (BAIs) among general hospital patients with at-risk alcohol use may also reduce tobacco smoking over 2 years. We also investigated whether such effects vary by delivery mode; i.e. in-person versus computer-based BAI. METHODS A proactively recruited sample of 961 general hospital patients with at-risk alcohol use aged 18 to 64 years was allocated to three BAI study groups: in-person BAI, computer-based BAI, and assessment only. In-person- and computer-based BAI included motivation-enhancing intervention contacts to reduce alcohol use at baseline and 1 and 3 months later. Follow-ups were conducted after 6, 12, 18 and 24 months. A two-part latent growth model, with self-reported smoking status (current smoking: yes/no) and number of cigarettes in smoking participants as outcomes, was estimated. RESULTS Smoking participants in computer-based BAI smoked fewer cigarettes per day than those assigned to assessment only at month 6 (meannet change = - 0.02; 95% confidence interval = - 0.08-0.00). After 2 years, neither in-person- nor computer-based BAI significantly changed smoking status or number of cigarettes per day in comparison to assessment only or to each other (ps ≥ 0.23). CONCLUSIONS While computer-based BAI also resulted in short-term reductions of number of cigarettes in smoking participants, none of the two BAIs were sufficient to evoke spill-over effects on tobacco smoking over 2 years. For long-term smoking cessation effects, multibehavioural interventions simultaneously targeting tobacco smoking along with at-risk alcohol use may be more effective. TRIAL REGISTRATION NUMBER NCT01291693.
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Affiliation(s)
- Filipa Krolo-Wicovsky
- Institute for Medical Psychology, University Medicine Greifswald, Walther-Rathenau-Str. 48, 17475, Greifswald, Germany.
- German Centre for Cardiovascular Research, Partner site Greifswald, Fleischmannstr. 42-44, 17475, Greifswald, Germany.
| | - Sophie Baumann
- Department of Methods in Community Medicine, Institute of Community Medicine, University Medicine Greifswald, Walther-Rathenau-Str. 48, 17475, Greifswald, Germany
| | - Anika Tiede
- Institute for Medical Psychology, University Medicine Greifswald, Walther-Rathenau-Str. 48, 17475, Greifswald, Germany
- German Centre for Cardiovascular Research, Partner site Greifswald, Fleischmannstr. 42-44, 17475, Greifswald, Germany
| | - Gallus Bischof
- Department of Psychiatry and Psychotherapy, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Ulrich John
- German Centre for Cardiovascular Research, Partner site Greifswald, Fleischmannstr. 42-44, 17475, Greifswald, Germany
- Department of Prevention Research and Social Medicine, Institute of Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Beate Gaertner
- Department of Epidemiology and Health Monitoring, Robert Koch Institute Berlin, Berlin, General-Pape-Str. 62-66, 12101, Berlin, Germany
| | - Jennis Freyer-Adam
- Institute for Medical Psychology, University Medicine Greifswald, Walther-Rathenau-Str. 48, 17475, Greifswald, Germany
- German Centre for Cardiovascular Research, Partner site Greifswald, Fleischmannstr. 42-44, 17475, Greifswald, Germany
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Gravely S, Driezen P, McClure EA, Smith DM, Fong GT. Prevalence of depressive symptoms and cannabis use among adult cigarette smokers in Canada: cross-sectional findings from the 2020 International Tobacco Control Policy Evaluation Project Canada Smoking and Vaping Survey. CMAJ Open 2023; 11:E516-E526. [PMID: 37311596 DOI: 10.9778/cmajo.20220081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Tobacco smoking and cannabis use are independently associated with depression, and evidence suggests that people who use both tobacco and cannabis (co-consumers) are more likely to report mental health problems, greater nicotine dependence and alcohol misuse than those who use either product exclusively. We examined prevalence of cannabis use and depressive symptoms among Canadian adults who smoke cigarettes and tested whether co-consumers of cannabis and tobacco were more likely to report depressive symptoms than cigarette-only smokers; we also tested whether cigarette-only smokers and co-consumers differed on cigarette dependence measures, motivation to quit smoking and risky alcohol use by the presence or absence of depressive symptoms. METHODS We analyzed cross-sectional data from adult (age ≥ 18 yr) current (≥ monthly) cigarette smokers from the Canadian arm of the 2020 International Tobacco Control Policy Evaluation Project Four Country Smoking and Vaping Survey. Canadian respondents were recruited from Leger's online probability panel across all 10 provinces. We estimated weighted percentages for depressive symptoms and cannabis use among all respondents and tested whether co-consumers (≥ monthly use of cannabis and cigarettes) were more likely to report depressive symptoms than cigarette-only smokers. Weighted multivariable regression models were used to identify differences between co-consumers and cigarette-only smokers with and without depressive symptoms. RESULTS A total of 2843 current smokers were included in the study. The prevalence of past-year, past-30-day and daily cannabis use was 44.0%, 33.2% and 16.1%, respectively (30.4% reported using cannabis at least monthly). Among all respondents, 30.0% screened positive for depressive symptoms, with co-consumers being more likely to report depressive symptoms (36.5%) than those who did not report current cannabis use (27.4%, p < 0.001). Depressive symptoms were associated with planning to quit smoking (p = 0.01), having made multiple attempts to quit smoking (p < 0.001), the perception of being very addicted to cigarettes (p < 0.001) and strong urges to smoke (p = 0.001), whereas cannabis use was not (all p ≥ 0.05). Cannabis use was associated with high-risk alcohol consumption (p < 0.001), whereas depressive symptoms were not (p = 0.1). INTERPRETATION Co-consumers were more likely to report depressive symptoms and high-risk alcohol consumption; however, only depression, and not cannabis use, was associated with greater motivation to quit smoking and greater perceived dependence on cigarettes. A deeper understanding of how cannabis, alcohol use and depression interact among people who smoke cigarettes is needed, as well as how these factors affect cessation activity over time.
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Affiliation(s)
- Shannon Gravely
- Department of Psychology (Gravely, Driezen, Fong), University of Waterloo, Waterloo, Ont.; Hollings Cancer Center (McClure), Medical University of South Carolina, Charleston, SC; Roswell Park Comprehensive Cancer Center (Smith), Buffalo, NY; Ontario Institute for Cancer Research (Fong), Toronto, Ont.
| | - Pete Driezen
- Department of Psychology (Gravely, Driezen, Fong), University of Waterloo, Waterloo, Ont.; Hollings Cancer Center (McClure), Medical University of South Carolina, Charleston, SC; Roswell Park Comprehensive Cancer Center (Smith), Buffalo, NY; Ontario Institute for Cancer Research (Fong), Toronto, Ont
| | - Erin A McClure
- Department of Psychology (Gravely, Driezen, Fong), University of Waterloo, Waterloo, Ont.; Hollings Cancer Center (McClure), Medical University of South Carolina, Charleston, SC; Roswell Park Comprehensive Cancer Center (Smith), Buffalo, NY; Ontario Institute for Cancer Research (Fong), Toronto, Ont
| | - Danielle M Smith
- Department of Psychology (Gravely, Driezen, Fong), University of Waterloo, Waterloo, Ont.; Hollings Cancer Center (McClure), Medical University of South Carolina, Charleston, SC; Roswell Park Comprehensive Cancer Center (Smith), Buffalo, NY; Ontario Institute for Cancer Research (Fong), Toronto, Ont
| | - Geoffrey T Fong
- Department of Psychology (Gravely, Driezen, Fong), University of Waterloo, Waterloo, Ont.; Hollings Cancer Center (McClure), Medical University of South Carolina, Charleston, SC; Roswell Park Comprehensive Cancer Center (Smith), Buffalo, NY; Ontario Institute for Cancer Research (Fong), Toronto, Ont
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Minian N, Baliunas D, Noormohamed A, Zawertailo L, Giesbrecht N, Hendershot CS, Le Foll B, Rehm J, Samokhvalov AV, Selby PL. The effect of a clinical decision support system on prompting an intervention for risky alcohol use in a primary care smoking cessation program: a cluster randomized trial. Implement Sci 2019; 14:85. [PMID: 31443663 PMCID: PMC6708174 DOI: 10.1186/s13012-019-0935-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 08/15/2019] [Indexed: 01/31/2023] Open
Abstract
Background Clinical decision support systems (CDSSs) may promote practitioner adherence to evidence-based guidelines. This study examined if the addition of a CDSS influenced practitioner delivery of a brief intervention with treatment-seeking smokers who were drinking above recommended alcohol consumption guidelines, compared with practitioners who do not receive a CDSS prompt. Methods This was a cluster randomized controlled trial conducted in primary health care clinics across Ontario, Canada, implementing the Smoking Treatment for Ontario Patients (STOP) smoking cessation program. Clinics randomized to the intervention group received a prompt when a patient reported consuming alcohol above the Canadian Cancer Society (CCS) guidelines; the control group did not receive computer alerts. The primary outcome was an offer of an appropriate educational alcohol resource, an alcohol reduction workbook for patients drinking above the CCS guidelines, and an abstinence workbook to patients scoring above 20 points in the AUDIT screening tool; the secondary outcome was patient acceptance of the resource. The tertiary outcome was patient abstinence from smoking, and alcohol consumption within CCS guidelines, at 6-month follow-up. Results were analyzed using a generalized estimation approach for fitting logistic regression using a population-averaged method. Results Two hundred and twenty-one clinics across Ontario were randomized for this study; 110 to the intervention arm and 111 to the control arm. From the 15,222 patients that enrolled in the smoking cessation program, 15,150 (99.6% of patients) were screened for alcohol use and 5715 patients were identified as drinking above the CCS guidelines. No statistically significant difference between groups was seen in practitioner offer of an educational alcohol resource to appropriate patients (OR = 1.19, 95% CI 0.88–1.64, p = 0.261) or in patient abstinence from smoking and drinking within the CCS guidelines at 6-month follow-up (OR = 0.93, 95% CI 0.71–1.22, p = 0.594). However, a significantly greater proportion of patients in the intervention group accepted the alcohol resource offered to them by their practitioner (OR = 1.48, 95% CI 1.01–2.16, p = 0.045). Conclusion A CDSS may not increase the likelihood of practitioners offering an educational alcohol resource, though it may have influenced patients’ acceptance of the resource. Trial registration This trial is registered with ClinicalTrials.gov, number NCT03108144, registered on April 11, 2017, “retrospectively registered”. Electronic supplementary material The online version of this article (10.1186/s13012-019-0935-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nadia Minian
- Nicotine Dependence Services, Centre for Addiction and Mental Health, 175 College St, Toronto, ON, M5T1P7, Canada.,Department of Family and Community Medicine, University of Toronto, 500 University Ave, Toronto, ON, M5G 1V7, Canada
| | - Dolly Baliunas
- Nicotine Dependence Services, Centre for Addiction and Mental Health, 175 College St, Toronto, ON, M5T1P7, Canada.,Dalla Lana School of Public Health, University of Toronto, 155 College, Toronto, ON, M5T 3M7, Canada
| | - Aliya Noormohamed
- Nicotine Dependence Services, Centre for Addiction and Mental Health, 175 College St, Toronto, ON, M5T1P7, Canada
| | - Laurie Zawertailo
- Nicotine Dependence Services, Centre for Addiction and Mental Health, 175 College St, Toronto, ON, M5T1P7, Canada.,Department of Pharmacology and Toxicology, University of Toronto, 1 King's College Cir, Toronto, ON, M5S 1A8, Canada
| | - Norman Giesbrecht
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, 33 Russell St, Toronto, ON, M5S 2S1, Canada
| | - Christian S Hendershot
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 60 White Squirrel Way, Toronto, ON, M6J 1H4, Canada.,Department of Psychiatry, University of Toronto, 250 College Street, Toronto, ON, M5T 1R8, Canada
| | - Bernard Le Foll
- Department of Family and Community Medicine, University of Toronto, 500 University Ave, Toronto, ON, M5G 1V7, Canada.,Department of Pharmacology and Toxicology, University of Toronto, 1 King's College Cir, Toronto, ON, M5S 1A8, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 60 White Squirrel Way, Toronto, ON, M6J 1H4, Canada.,Department of Psychiatry, University of Toronto, 250 College Street, Toronto, ON, M5T 1R8, Canada
| | - Jürgen Rehm
- Dalla Lana School of Public Health, University of Toronto, 155 College, Toronto, ON, M5T 3M7, Canada.,Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, 33 Russell St, Toronto, ON, M5S 2S1, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 60 White Squirrel Way, Toronto, ON, M6J 1H4, Canada.,Department of Psychiatry, University of Toronto, 250 College Street, Toronto, ON, M5T 1R8, Canada.,Institute of Medical Science, University of Toronto, 1 King's College Cir, Toronto, ON, M5S 3K1, Canada.,Institute for Clinical Psychology and Psychotherapy, TU Dresden, Chemnitzer Str. 46, 01187, Dresden, Germany
| | - Andriy V Samokhvalov
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, 33 Russell St, Toronto, ON, M5S 2S1, Canada.,Department of Psychiatry, University of Toronto, 250 College Street, Toronto, ON, M5T 1R8, Canada.,Institute of Medical Science, University of Toronto, 1 King's College Cir, Toronto, ON, M5S 3K1, Canada
| | - Peter L Selby
- Nicotine Dependence Services, Centre for Addiction and Mental Health, 175 College St, Toronto, ON, M5T1P7, Canada. .,Department of Family and Community Medicine, University of Toronto, 500 University Ave, Toronto, ON, M5G 1V7, Canada. .,Dalla Lana School of Public Health, University of Toronto, 155 College, Toronto, ON, M5T 3M7, Canada. .,Department of Psychiatry, University of Toronto, 250 College Street, Toronto, ON, M5T 1R8, Canada.
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Constant HMRM, Moret-Tatay C, Benchaya MC, Oliveira MDS, Barros HMT, Ferigolo M. CBI-20: Psychometric Properties for the Coping Behaviors Inventory for Alcohol Abuse in Brazil. Front Psychiatry 2018; 9:585. [PMID: 30483165 PMCID: PMC6243092 DOI: 10.3389/fpsyt.2018.00585] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 10/25/2018] [Indexed: 12/21/2022] Open
Abstract
For any professional, it is of crucial importance to know not only how coping styles and strategies are present in an individual, but to know about its role to the treatment of alcohol abuse. Moreover, new approaches have emerged in this area in terms of relapse prevention and the counseling by phone can be an alternative. The aim of this study is to examine the factor structure of the Coping Behaviors Inventory (CBI) and to test its invariance across groups face-to-face and phone counseling in Brazil. For this purpose, two studies were carried out: study I, the factor structure was revisited in terms of exploratory factor analysis. Study II, face-to-face and phone counseling were examined through confirmatory factor analysis and multigroup analysis. The results confirmed the 4-factor solution with a revised model for the removal of 16 items. Thus presented, a reduced version with better indexes than the previous versions developed over the last 30 years that was ones reformulated from 60 items. The Internal consistency for study I presented α = 0.90 and homogeneity was between 0.17 and 0.5). In addition the KMO = 0.9 = 0.932, X ( df = 630 ) 2 = 6091.94, p < 0.0 < 0.001. In study II, cronbach's alpha = 0.91 and homogeneity 0.23-0.61 (telemedicine treatment) and α = 0.90 0.17 to 0.63 (face-to-face treatment). In the CFA, the examination of the current version has better fit than the that the traditional model. Moreover, the new version showed convergent validity with the IDHEA questionnaire. In the multigroup analysis no significant changes between groups to a metric level. Finally, the Brazilian version of inventory showed no differences between the phone counseling and face-to-face participants in a metric level after a multigroup analysis.
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Affiliation(s)
- Hilda M R M Constant
- Federal University of Health Sciences of Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | | | | | - Margareth da S Oliveira
- Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Helena M T Barros
- Federal University of Health Sciences of Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Maristela Ferigolo
- Federal University of Health Sciences of Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
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