Health Education Research - current issue

Balancing rigor against the inherent limitations of investigating hard-to-reach populations

Crosby, R. A., Salazar, L. F., DiClemente, R. J., Lang, D. L. — Tue, 12 Jan 2010 07:26:40 PST

Maintaining rigor in research is critical; however, this need must be balanced by the necessity of conducting studies in populations where inherent barriers exist relative to key issues such as recruitment, attrition, sampling, sample size, assessment techniques, psychometric rigor, the identification of mediators and moderators and the practical relevance of the research question itself. Ultimately, the value of a study in health promotion should be judged on the practicality of the research question within the context of the target population. Striking the perfect balance between rigor and practicality to the field is a question that health promotion researchers and professionals need to determine through ongoing dialogue and debate.

Participation rates and representativeness of African Americans recruited to a health promotion program

Tue, 12 Jan 2010 07:26:40 PST

When using community-based participatory methods to develop health promotion programs for specific communities, it is important to determine if participation differs based on sociodemographics and the extent to which program participants are demographically representative of the target community, especially when non-random recruitment methods are used. We evaluated rates of participating in a health promotion program among African American residents in an urban community and determined if program participants were representative of community residents in terms of sociodemographic factors. While participation in the program was modest, participation did not differ based on psychological factors or body mass index. However, individuals who were unemployed were significantly more likely to participate in the program compared with those who were employed. Our sample included a greater proportion of individuals who only had a high school education compared with community residents but was similar to community residents in terms of gender, marital status and employment.

Interviewer effects in public health surveys

Davis, R. E., Couper, M. P., Janz, N. K., Caldwell, C. H., Resnicow, K. — Tue, 12 Jan 2010 07:26:40 PST

Interviewer effects can have a substantial impact on survey data and may be particularly operant in public health surveys, where respondents are likely to be queried about racial attitudes, sensitive behaviors and other topics prone to socially desirable responding. This paper defines interviewer effects, argues for the importance of measuring and controlling for interviewer effects in health surveys, provides advice about how to interpret research on interviewer effects and summarizes research to date on race, ethnicity and gender effects. Interviewer effects appear to be most likely to occur when survey items query attitudes about sociodemographic characteristics or respondents’ engagement in sensitive behaviors such as substance use. However, there is surprisingly little evidence to indicate whether sociodemographic interviewer–respondent matching improves survey response rates or data validity, and the use of a matched design introduces possible measurement bias across studies. Additional research is needed to elucidate many issues, including the influence of interviewers’ sociodemographic characteristics on health-related topics, the role of within-group interviewer variability on survey data and the simultaneous impact of multiple interviewer characteristics. The findings of such research would provide much-needed guidance to public health professionals on whether or not to match interviewers and respondents on key sociodemographic characteristics.

Process evaluation of the Intervention with Microfinance for AIDS and Gender Equity (IMAGE) in rural South Africa

Tue, 12 Jan 2010 07:26:40 PST

The Intervention with Microfinance for AIDS and Gender Equity (IMAGE) combines microfinance, gender/HIV training and community mobilization (CM) in South Africa. A trial found reduced intimate partner violence among clients but less evidence for impact on sexual behaviour among clients’ households or communities. This process evaluation examined how feasible IMAGE was to deliver and how accessible and acceptable it was to intended beneficiaries during a trial and subsequent scale-up. Data came from attendance registers, financial records, observations, structured questionnaires (378) and focus group discussions and interviews (128) with clients and staff. Gender/HIV training and CM were managed initially by an academic unit (‘linked’ model) and later by the microfinance institution (MFI) (‘parallel’ model). Microfinance and gender/HIV training were feasible to deliver and accessible and acceptable to most clients. Though participation in CM was high for some clients, others experienced barriers to collective action, a finding which may help explain lack of intervention effects among household/community members. Delivery was feasible in the short term but both models were considered unsustainable in the longer term. A linked model involving a MFI and a non-academic partner agency may be more sustainable and is being tried. Feasible models for delivering microfinance and health promotion require further investigation.

Pilot study of a cognitive intervention program for persons with multiple sclerosis

Shevil, E., Finlayson, M. — Tue, 12 Jan 2010 07:26:40 PST

Cognitive impairments are prevalent in multiple sclerosis (MS) and can significantly limit participation in daily activities. Although the clinical depiction of cognitive impairments in MS has been well investigated, strategies to manage cognitive difficulties are less well studied. This pilot study tested a 5-week, group-based community program addressing strategies to self-manage MS cognitive changes. The goals of the program were to increase participants’ knowledge of cognitive impairments, increase levels of self-efficacy to manage cognitive difficulties and increase use of management strategies. Participants were taught various cognitive compensatory strategies and practiced their implementation between sessions. Thirty-five individuals with MS with mild-to-moderate cognitive impairments participated in the program. All participants exhibited increased knowledge of cognitive impairments and their daily impact. Participants significantly increased levels of self-efficacy in their ability to manage cognitive difficulties (₂²=37.15, P ≤ 0.0001). Self-efficacy scores were maintained at follow-up (₁²=1.48, P = 0.2230). Although the number of strategies participants used did not change significantly (₂²=2.82, P = 0.2446), they reported increased effectiveness of strategies and being able to generalize strategies to other activities. Study results point to the potential benefits of self-management programs to address cognitive symptoms in MS. Study limitations include no control group and use of non-standardized outcome measures.

The identification of framed messages in the New York State Smokers' Quitline materials

Tue, 12 Jan 2010 07:26:40 PST

Research suggests that smoking cessation messages are most persuasive when framed in terms of the benefits achieved from quitting (i.e. gain-framed) than when framed in terms of the costs of not quitting (i.e. loss-framed). It is unknown, however, if these findings about optimal message frames have been translated into public health practice. The current study examined message framing in telephone counseling sessions with smokers calling the New York State Smokers’ Quitline (NYSSQ). We conducted a content analysis of all NYSSQ print material and 12 Quitline service calls. Two independent raters coded each message within these documents as being gain-framed, loss-framed or non-framed. Messages from the service calls also were coded for their function (e.g. information provision, information gathering). Interrater reliability was acceptable (kappa > 0.80). Of the 997 print messages evaluated, 21.6% were gain-framed, 13.8% were loss-framed and 64.6% were non-framed. For the service calls, only the messages with an information provision function included framed content. Of the 420 information provision messages, 10.2% were gain-framed, 1.7% were loss-framed and 88.1% were non-framed. The loss-framed and non-framed messages indicate missed opportunities for providing gain-framed messages within the Quitline services, thus emphasizing a possible gap between research and practice.

Does a typical contemplator exist? Three clusters of smokers in contemplation

Smit, E. S., Hoving, C., de Vries, H. — Tue, 12 Jan 2010 07:26:40 PST

The aim of this study is to test whether subtypes exist among smokers in contemplation. Data from 194 adult smokers that participated in a randomized controlled trial testing the effectiveness of a computer-tailored smoking cessation program in Dutch general practices were used for secondary analysis. Cluster analysis was conducted based on baseline scores on pros and cons of quitting and self-efficacy to quit. Clusters were cross-sectionally compared for demographic variables and smoking characteristics with analyses of variance (ANOVA) and Chi-square tests. Logistic and multinomial regression analyses were used for longitudinal comparison for smoking behavior and stage of change at 6 months follow-up. Three clusters were identified: Early, Progressing and Disengaged Contemplators. Clusters differed significantly on all clustering variables (P < 0.001). Disengaged smokers were significantly less addicted than Early Contemplators. Cluster membership was not predictive of outcome measures. No subtype was identified representing the Classic Contemplator, scoring high on both pros and cons of quitting and low on self-efficacy, as found in previous studies among US samples. The predictive validity of the clusters found was limited.

Cannabis and tobacco use: where are the boundaries? A qualitative study on cannabis consumption modes among adolescents

Akre, C., Michaud, P.-A., Berchtold, A., Suris, J.-C. — Tue, 12 Jan 2010 07:26:40 PST

The purpose of this article is to identify tobacco and cannabis co-consumptions and consumers’ perceptions of each substance. A qualitative research including 22 youths (14 males) aged 15–21 years in seven individual interviews and five focus groups. Discussions were recorded, transcribed verbatim and transferred to Atlas.ti software for narrative analysis. The main consumption mode is cannabis cigarettes which always mix cannabis and tobacco. Participants perceive cannabis much more positively than tobacco, which is considered unnatural, harmful and addictive. Future consumption forecasts thus more often exclude tobacco smoking than cannabis consumption. A substitution phenomenon often takes place between both substances. Given the co-consumption of tobacco and cannabis, in helping youths quit or decrease their consumptions, both substances should be taken into account in a global approach. Cannabis consumers should be made aware of their tobacco use while consuming cannabis and the risk of inducing nicotine addiction through cannabis use, despite the perceived disconnect between the two substances. Prevention programs should correct made-up ideas about cannabis consumption and convey a clear message about its harmful consequences. Our findings support the growing evidence which suggests that nicotine dependence and cigarette smoking may be induced by cannabis consumption.

'Smoking': use of cigarettes, cigars and blunts among Southeast Asian American youth and young adults

Lee, J. P., Battle, R. S., Lipton, R., Soller, B. — Tue, 12 Jan 2010 07:26:40 PST

Increased use of cigars has been noted among youth, as well as use of blunts (hollowed-out cigars filled with marijuana). Three types of relationships have been previously hypothesized between use of tobacco and marijuana in substance use progression. We aimed to assess these relationships for Southeast Asian American youth and adults in an urban population. We conducted in-person interviews with 164 Southeast Asians, smokers and non-smokers, in two low-income urban communities in Northern California, collecting both quantitative and qualitative data. Analysis of the quantitative data indicated distinct use patterns for blunts, cigars and other forms of marijuana in terms of associations with generation in the United States. The use of these items was also found to be related: ever having smoked cigarettes or blunts increased the risk of ever having smoked the other three items. Qualitative data found indications of all three hypothesized relationships between tobacco and marijuana for youths but not for older adults. For youths in the study, ‘smoking’ was found to constitute a social construct within which use of cigarettes, cigars and blunts were somewhat interchangeable. Youths in similar settings may initiate into and progress through smoking as an activity domain rather than any one of these items.

Correlates of availability and accessibility of fruits and vegetables in homes of low-income Hispanic families

Dave, J. M., Evans, A. E., Pfeiffer, K. A., Watkins, K. W., Saunders, R. P. — Tue, 12 Jan 2010 07:26:40 PST

Availability and accessibility (AA) has been consistently shown across studies as the most important correlate of fruits and vegetables (FV) intake. However, there is little data on factors that influence AA of FV, especially in Hispanic families. The objective of this cross-sectional study was to examine the association between parental factors, child's preferences for FV and AA of FV in homes of low-income Hispanic families with children 5–12 years old. A convenience sample of 184 parents of low socioeconomic status recruited through public elementary schools completed a self-administered questionnaire about demographics, language spoken at home and food insecurity (FI). Parental factors and child's preferences were measured using a 16-item questionnaire, which was developed specifically for the study. AA of FV was measured using a validated nine-item index. Hierarchical multiple regression analysis indicated that language spoken at home, parental practices that promote consumption of FV, parental role modeling and perceived benefits of fast food had significant and independent associations with AA of FV at home. Intervention programs should take into consideration the language spoken at home and target at improving parental factors in order to improve AA of FV.

Portion size: a qualitative study of consumers' attitudes toward point-of-purchase interventions aimed at portion size

Vermeer, W. M., Steenhuis, I. H. M., Seidell, J. C. — Tue, 12 Jan 2010 07:26:40 PST

This qualitative study assessed consumers’ opinions of food portion sizes and their attitudes toward portion-size interventions located in various point-of-purchase settings targeting overweight and obese people. Eight semi-structured focus group discussions were conducted with 49 participants. Constructs from the diffusion of innovations theory were included in the interview guide. Each focus group was recorded and transcribed verbatim. Data were coded and analyzed with Atlas.ti 5.2 using the framework approach. Results showed that many participants thought that portion sizes of various products have increased during the past decades and are larger than acceptable. The majority also indicated that value for money is important when purchasing and that large portion sizes offer more value for money than small portion sizes. Furthermore, many experienced difficulties with self-regulating the consumption of large portion sizes. Among the portion-size interventions that were discussed, participants had most positive attitudes toward a larger availability of portion sizes and pricing strategies, followed by serving-size labeling. In general, reducing package serving sizes as an intervention strategy to control food intake met resistance. The study concludes that consumers consider interventions consisting of a larger variety of available portion sizes, pricing strategies and serving-size labeling as most acceptable to implement.

Does socio-economic status moderate the associations between psychosocial predictors and fruit intake in schoolchildren? The Pro Children study

Sandvik, C., Gjestad, R., Samdal, O., Brug, J., Klepp, K.-I. — Tue, 12 Jan 2010 07:26:40 PST

This study tested whether socio-economic status (SES) moderated the association between the psychosocial constructs included in the attitude–social influence–self-efficacy (ASE) model and fruit intake in Norwegian schoolchildren. The sample consisted of 962 Norwegian sixth graders, mean age 11.3 years. They were split into three SES groups, and multi-group structural equation modeling (MSEM) was used. Children in the highest SES group reported eating fruit more frequently and reported more positive ASE variables than children in the lower SES groups. This was particularly true for social environmental factors, home availability of fruit and intention to eat fruit. MSEM showed that the relationships specified in the adapted ASE model were moderated by SES, as we did not find support for equal model structure across the three samples. Model modification for each SES group separately showed that the relation between home availability and fruit intake was not significant for the medium and low SES groups, and the relation between self-efficacy and intention to eat fruit was not significant for the medium SES group. Future interventions aiming at increasing fruit intake in children need to be sensitive to such SES-related differences and should in particular affect factors that may impede fruit intake in the lower SES groups.

Impact of a campaign on the public's attitudes towards depression

Dietrich, S., Mergl, R., Freudenberg, P., Althaus, D., Hegerl, U. — Tue, 12 Jan 2010 07:26:40 PST

A public campaign was launched in 2000 as part of the four-level community-based intervention ‘Nuremberg Alliance Against Depression’ (NAD) in Nuremberg, Germany. Evaluation results will be presented. A baseline survey was done before the campaign in Nuremberg and Wuerzburg (control region), two surveys followed 10 and 22 months after the implementation. Multiple regression analyses were performed, with time, place and the interaction of time and location as independent and the corresponding items as dependent variables. For the general population, the campaign was successful in creating awareness for the NAD. For persons who reported experience with depression and persons aware of the NAD, analyses showed positive desirable effects: more awareness of depression and the NAD. In addition, among those aware, more positive attitudes towards medication treatment and antidepressants developed and also ‘lack of self-discipline’ declined as causal explanation as did the notion ‘pull yourself together’ as treatment option. The campaign induced relevant changes mainly in persons aware of the NAD and persons who reported to have had experience with depression. The fact that many of the changes in the general population declined in the second year of the campaign, when activities were done with lower intensity, illustrates the need for permanent depression awareness action.

Longitudinal analysis of domain-level breast cancer literacy among African-American women

Mabiso, A., Williams, K. P., Todem, D., Templin, T. N. — Tue, 12 Jan 2010 07:26:40 PST

Functional breast cancer literacy was assessed among African-American women and measured at the domain level over time. We used the Kin Keeper^SM Cancer Prevention Intervention to educate 161 African-American women on three domains of breast cancer literacy: (i) cancer awareness, (ii) knowledge of breast cancer screening modalities and (iii) cancer prevention and control. A breast cancer literacy assessment was administered pre- and post-educational intervention at two time points followed by another assessment 12 months after the second intervention. Generalized estimating equations were specified to predict the probability of correctly answering questions in each domain over time. Domain-level literacy differentials exist; at baseline, women had higher test scores in the breast cancer prevention and control domain than the cancer awareness domain (odds ratio = 1.67, 95% confidence interval 1.19–2.34). After Kin Keeper^SM Cancer Prevention Intervention, African-American women consistently improved their breast cancer literacy in all domains over the five time stages (P < 0.001) though at different rates for each domain. Differences in domain-level breast cancer literacy highlight the importance of assessing literacy at the domain level. Interventions to improve African-American women's breast cancer literacy should focus on knowledge of breast cancer screening modalities and cancer awareness domains.

What influences the uptake of information to prevent skin cancer? A systematic review and synthesis of qualitative research

Garside, R., Pearson, M., Moxham, T. — Tue, 12 Jan 2010 07:26:40 PST

Skin cancer is an increasing problem in Europe, America and Australasia, although largely preventable by avoiding excessive ultraviolet (UV) exposure. This paper presents the findings of a systematic review of qualitative research about the prevention of skin cancer attributable to UV exposure. The aim is to understand elements that may contribute to the successful or unsuccessful conveyance of skin cancer prevention messages and their uptake by the public. A systematic review was undertaken using evidence identified through searching electronic bibliographic databases and Web sites and reference list checks. Predefined inclusion and exclusion criteria were used. Sixteen study reports (relating to 15 separate studies) were included from the United Kingdom, United States, Australia, Canada and New Zealand. Each included study was quality appraised, and the findings were extracted into an evidence table. A coding scheme, framed by the Health Belief Model, was developed by the reviewers and informed analysis and synthesis. This showed that most people perceived their susceptibility to skin cancer, and its severity, as low. While benefits of adopting changed behaviour were acknowledged, there were substantial barriers to this, including positive perceptions of a tan as healthy and attractive and the hassle of covering up or using sunscreen. Peers, parents and media may offer ‘cues to action’ that encourage adoption of preventative behaviour and finally self-efficacy or the perceived ability to make such changes. Effective health education messages will need to address the barriers to adopting protective behaviours identified through this review.