Online Behavioral Screener with Tailored Obesity Prevention Messages: Application to a Pediatric Clinical Setting

Obesity prevention involves promoting healthy eating and physical activity across all children. Can we leverage technology to feasibly survey children’s health behaviors and deliver theory-based and user-tailored messages for brief clinical encounters? We assessed the acceptability and utility of an online pediatric-adapted liking survey (PALS) and tailored messages among children receiving non-urgent care in a pediatric emergency department (PED). Two hundred and forty-five children (average age = 10 years, racially/ethnically diverse, 34% overweight/obese from measured indices, 25% of families reporting food insecurity) and their parents/caregivers participated. Each reported the child’s activity and behaviors using the online PALS and received two to three messages tailored to the responses (aligned with elaboration likelihood and transtheoretical models) to motivate behavioral improvements or reinforce healthy behaviors. Most children and parents (>90%) agreed the PALS was easy to complete, encouraging thought about their own/child’s behaviors. The child’s PALS responses appeared reasonable (fair-to-good child–parent intraclass correlations). Most children and parents (≥75%) reported the tailored messages to be helpful and favorable for improving or maintaining the targeted behavior. Neither message type (motivating/reinforcing) nor favorability responses varied significantly by the child’s weight or family’s food security status. In summary, children and parents found the PALS with tailored messages acceptable and useful. The message types and responses could help focus brief clinical encounters.     

Suicide Prevention Media Campaigns: A Systematic Literature Review

Suicide prevention media campaigns are gaining traction as a means of combatting suicide. The current review set out to synthesize information about the effectiveness of these campaigns. We searched four electronic databases for studies that provided evidence on the effectiveness of media campaigns. We focused on studies that described an evaluation of the effectiveness of an entire campaign or a public service announcement explicitly aimed at suicide prevention. We identified 20 studies of varying quality. Studies that looked at whether campaign exposure leads to improved knowledge and awareness of suicide found support for this. Most studies that considered whether campaign materials can achieve improvements in attitudes toward suicide also found this to be the case, although there were some exceptions. Some studies found that media campaigns could boost help-seeking, whereas others suggested that they made no difference or only had an impact when particular sources of help or particular types of help-seeking were considered. Relatively few studies had sufficient statistical power to examine whether media campaigns had an impact on the ultimate behavioral outcome of suicides, but those that did demonstrated significant reductions. Our review indicates that media campaigns should be considered in the suite of interventions that might be used to prevent suicide. Evidence for their effectiveness is still amassing, but there are strong suggestions that they can achieve positive results in terms of certain suicide-related outcomes. Care should be taken to ensure that campaign developers get the messaging of campaigns right, and further work is needed to determine which messages work and which ones do not, and how effective messages should be disseminated. There is an onus on those developing and delivering campaigns to evaluate them carefully and to share the findings with others. There is a need for evaluations that employ rigorous designs assessing the most pertinent outcomes. These evaluations should explore the nature of given campaigns in detail – in particular the messaging contained within them – in order to tease out which messages work well and which do not. They should also take into account the reach of the campaign, in order to determine whether it would be reasonable to expect that they might have their desired effect.     

Evaluation of a Social Norms Approach to a Suicide Prevention Campaign

Suicide is a leading cause of death for college-aged youth, and university counseling centers (UCC) strive to educate students about mental health issues and available campus services. The current research evaluates a college campus social norms campaign that used both peer and celebrity sources to promote help seeking among college students as a suicide prevention strategy. Postcampaign surveys of this quasi-experiment (n = 391) revealed that compared to students in the control neighborhood condition, students exposed to the campaign messages in the experimental neighborhood conditions were more likely to perceive students would refer a friend to the UCC and more likely to visit the UCC for a mental health concern. Students living in the intervention neighborhood with a peer message source reported a greater willingness to refer friends to the UCC compared to those who lived in the celebrity and control neighborhoods. Regardless of condition, students who reported seeing UCC messages reported greater effects than those who reported not viewing the messages (e.g., greater intentions to seek help and to talk to others about the UCC). Results of this study are discussed within a social norms framework and support the need for continued exposure to campaign messages to impact health outcomes.     

Suicide Prevention: The Hospital's Role

The acute suicidal state is short, and all but a few persons who succeed in killing themselves actually have a passionate desire to go on living. These facts set the stage for a prophylactic approach to the problem, says Dr. Shneidman. Alertness by physicians and other hospital personnel to premonitory signs in the suicidal individual, followed by prompt mobilization of personal and community resources, can result in the prevention of many suicides.     

Nationwide Newspaper Coverage of Physician-Assisted Suicide: A Community Structure Approach

Using a community structure approach linking city characteristics and variations in media coverage, the authors examined newspaper coverage of physician-assisted suicide. A nationwide sample of 15 city newspapers yielded 288 articles in a four year period. Content analysis of article “prominence” (placement, headline size, story length, presence of photos) and overall article direction (favorable, unfavorable, or balanced/neutral) yielded a combined and widely varied single score “Media Vector” or measure of issue “projection” for each newspaper. Correlation and factor analysis yielded two significant city characteristic factors: a “stakeholder” factor, age (percent over 75) associated with unfavorable coverage of physician-assisted suicide (r = ? .491; p = 000); and an “access” factor—combining media access (newspaper circulation, cable stations, FM or AM stations) and health care access (health care facilities, physicians)—linked to favorable coverage (r = .472; p = .000), combining to account for 46.3 percent of the variance. Western US newspapers and public opinion are most favorable to physician-assisted suicide.     

Suicide Stigma in Online Social Interactions: Impacts of Social Capital and Suicide Literacy

ABSTRACT

This study examined whether and when people are more likely to conform to stigmatizing views on suicide in online social interactions. Two key factors in the study included characteristics of individuals’ social capital and suicide literacy. Study 1 analyzed national survey data to explore the relationships, and Study 2 involved a vignette to gauge the extent to which people conform to stigmatizing attitudes toward suicidal people under group pressure. Results showed that those emphasizing social networks demonstrated higher levels of suicide stigma, while those with more interpersonal trust showed lower levels of stigma. However, in relation to interpersonal trust, suicide literacy played a moderating role in that those with lower levels of interpersonal trust showed significantly less conformity when they had high suicide literacy.     

A Randomized Trial of Tailored Skin Cancer Prevention Messages for Adults: Project SCAPE

Objectives. We evaluated the impact of a mailed, tailored intervention on skin cancer prevention and skin self-examination behaviors of adults at moderate and high risk for skin cancer.Methods. Adults at moderate and high risk for skin cancer were recruited in primary health care settings in Honolulu, HI, and Long Island, NY. After completing a baseline survey, participants were randomized to 2 groups. The treatment group received tailored materials, including personalized risk feedback, and the control group received general educational materials. Multivariate analyses compared sun protection and skin self-examination between groups, controlling for location, risk level, gender, and age.Results. A total of 596 adults completed the trial. The tailored materials had a significant effect on overall sun-protection habits, the use of hats, the use of sunglasses, and the recency of skin self-examination. Some effects were moderated by location and risk level.Conclusions. Tailored communications including personalized risk feedback can improve sun-protection behaviors and skin self-examination among adults at increased risk for skin cancer. These convenient, low-cost interventions can be implemented in a variety of settings and should be tested further to assess their long-term effectiveness.Skin cancer is the most commonly diagnosed cancer in the United States,¹ with more than 1 million Americans diagnosed with skin cancer each year.² The incidence of skin cancer has increased dramatically worldwide in the last decade.³ Both main types of skin cancer—malignant melanoma and nonmelanoma skin cancer—are now significant and costly public health concerns.^2,4 Although skin cancer rates are increasing, it is considered one of the most preventable types of cancer. Prevention guidelines include reducing exposure to ultraviolet radiation (UVR); adopting sun-protection habits including the use of sunscreen, hats, shirts, and sunglasses^5,6; performing regular skin self-examination; and seeking professional evaluation of suspicious skin changes. Nevertheless, levels of knowledge, concern, and the practice of prevention and early detection remain relatively low.^7,8Risk factors for skin cancer include age, sun-sensitive phenotypes, excess sun exposure, family history, personal history of skin cancer or precancerous lesions, and other medical conditions.⁹ Most skin cancer prevention interventions reported to date are directed at the general population through school-based curricula and media campaigns,¹⁰ and some recent trials have targeted people who experience high sun exposure at work or during outdoor recreation.^11–15 Only 2 reported studies have targeted groups at high risk: patients who have been treated for nonmelanoma skin cancer,¹⁶ and siblings of melanoma patients.¹⁷ There is a need for low-cost, effective interventions to improve skin cancer prevention and early detection behaviors among a broader population of persons at moderate and high risk.Tailored, mailed communications hold great promise for skin cancer prevention and detection among individuals at increased risk, but these interventions have not been widely tested. Interventions that are tailored to individuals'' characteristics, behaviors, needs, and beliefs are more likely to be seen as personally relevant and thus may be more motivating.¹⁸ Tailored interventions have been shown to be effective in the past for other health behaviors, particularly for prevention and screening behaviors.¹⁹ The aim of Project SCAPE (Skin Cancer Awareness, Prevention and Education) was to evaluate the impact of tailored interventions on skin cancer prevention and skin self-examination among adults at high and moderate risk for skin cancer in a randomized trial.     

A Theoretical Approach to School-based HIV Prevention

To develop effective school-based programs to prevent the spread of AIDS, programmers must apply principles related to learning and behavior change. Due to the complexity of influencing contemporary adolescent sexual behavior, a multidisciplinary approach using multiple intervention strategies is essential. Health promotion efforts should include policy mandates, direct intervention, instruction, environmental support, media, role modeling, and social support. Consistent, continuous messages through multiple channels (school, home, community, and media) and by multiple agents (parents, peers, and health and education professionals) need to be provided. Examples of appropriate intervention strategies that may be employed by the professionals working in the school and the community are provided.     

Chemotherapy-Induced Nausea and Vomiting: Optimizing Prevention and Management

Background

Nausea and vomiting are serious side effects of cancer chemotherapy that can cause significant negative impacts on patients’ quality of life and on their ability to tolerate and comply with therapy. Despite advances in the prevention and management of chemotherapy-induced nausea and vomiting (CINV), these side effects remain among the most distressing for patients.

Objective

To discuss CINV and the current pharmacologic approaches to its management.

Discussion

This article outlines the mechanism of CINV followed by a review of current approaches to pharmacologic therapy and current practice guidelines from national cancer organizations. This information will help providers and payers understand the optimal management of patients with CINV including practical considerations and value-based decision-making that considers cost issues.

Conclusion

Numerous preventive and treatment options are available to manage CINV Addressing antiemetic regimens requires ongoing patient evaluation to determine the best approach for each individual patient.Nausea and vomiting are 2 serious and related side effects of cancer chemotherapy. These adverse effects can cause significant negative impacts on patients’ quality of life and on their ability to comply with therapy. Also, nausea and vomiting can result in anorexia, decreased performance status, metabolic imbalance, wound dehiscence, esophageal tears, and nutritional deficiency.1,2 Despite advances in the prevention and management of chemotherapy-induced nausea and vomiting (CINV), these side effects remain among the most distressing for patients. The use of emerging antiemetic medications has reduced the incidence of vomiting substantially, but evaluations show that approximately 30% to 60% of patients still experience either acute or delayed nausea after chemotherapy.3 Serial evaluations throughout the 1980s and into the 2000s show that, although vomiting has fallen further down on the list of side effects that patients perceive as being their most severe, nausea remains either the first or second most severe side effect of chemotherapy.4–8Risk factors for CINV can be divided into patient-specific and treatment-specific risk factors. Female sex and history of motion or morning sickness are clear risk factors for nausea and vomiting.5,6 Younger age has also been correlated with increased risk, although this may be explained by the more aggressive chemotherapy regimens that tend to be administered to younger patients who have more aggressive diseases.5–7 Finally, alcohol intake tends to be inversely correlated with the risk of developing CINV. Many factors contribute to the treatment-specific risk, including (1) the emetogenicity of the agents being used, (2) the dose and schedule of each agent, and (3) in the case of radiation-induced or postoperative nausea, the site of radiation or surgery.“Emetogenicity” refers to an agent''s tendency to cause nausea and/or vomiting. Initially described in 1997, the emetogenicity scale, also known as the Hesketh scale, divided chemotherapy agents and doses into 5 levels, based on their likelihood to cause CINV.9 Since then, the American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN) have modified this scale to be divided into the following 4 categories10,11:

• Highly emetogenic: medications or doses that cause CINV in >90% of patients
• Moderately emetogenic: medications that induce CINV in 30% to 90% of patients
• Low emetogenic: medications that are associated with CINV rates of 10% to 30%
• Minimally emetogenic: medications that cause CINV in <10% of patients.

“CINV” is a broad term used to describe the many types of nausea and vomiting that can occur in patients with cancer. The major subtypes of nausea and vomiting associated with chemotherapy are12–16:

• Acute: onset of nausea and vomiting within minutes to hours after administration of chemotherapy and resolving within 24 hours
• Delayed: occurs 24 hours or later after administration of chemotherapy
• Anticipatory: occurs before chemotherapy administration; thought to be an indicator of previous poor control of nausea and vomiting
• Breakthrough/refractory: nausea and vomiting that occur despite appropriate prophylaxis; requires the use of rescue medications.

Because there are so many independent and variable risk factors that can influence the risk for CINV in any particular patient, it becomes paramount for providers to individualize the approach to the prevention and treatment of CINV in every patient case.     

Suicide Prevention Among High School Students: Evaluation of a Nonrandomized Trial of a Multi-stage Suicide Screening Program

Background

Suicide is a leading cause of death among youth. Suicide screening programs aim to identify mental health issues and prevent death by suicide.

Objective

The present study evaluated outcomes of a multi-stage screening program implemented over 3 school years in a moderately-sized Midwestern high school.

Methods

One hundred ninety-three 9th-grade students were screened in the program. Students who screened positive were referred to mental health services and followed. Suicide-related thoughts and behaviors among 9th-grade students in the school with screening were compared to those of students in a similar school without screening.

Results

There was a significant increase in utilization of mental health services among students who screened positive and a decrease in rates of suicidal ideation and attempts among 9th-grade students at the school with screening.

Conclusions

This multi-stage screening program shows promise in addressing suicide-related behaviors in schools. Randomized trials are needed to confirm program efficacy.

     

How Children Search for Health Information Online: An Observational Study

ObjectiveTo evaluate whether children could find the correct answers to obesity-related health questions on the Internet and observe the search strategies children use when searching for such information.MethodsTwenty-five parent-child dyads, from a southwestern US summer day camp, participated in this cross-sectional study. Parents’ health literacy skills were evaluated. Children searched the Internet for 6 questions related to nutrition and physical activity. Search activities were recorded via Camtasia. Quantitative (ie, time spent per question) and qualitative data (ie, themes related to difficulties searching) were extracted by rewatching the recordings.ResultsAll parents had either proficient or basic levels of health literacy. The question that had the highest rating for being correctly answered pertained to physical activity recommendations, whereas none of the children were able to find recommended servings of food groups.Conclusions and ImplicationsChildren were not successful in finding correct answers to most of the questions and used ineffective search strategies. Interventions that teach children effective search strategies for health information are needed.     

The SOS Suicide Prevention Program: Further Evidence of Efficacy and Effectiveness

This study replicated and extended previous evaluations of the Signs of Suicide (SOS) prevention program in a high school population using a more rigorous pre-test post-test randomized control design than used in previous SOS evaluations in high schools (Aseltine and DeMartino 2004; Aseltine et al. 2007). SOS was presented to an ethnically diverse group of ninth grade students in technical high schools in Connecticut. After controlling for the pre-test reports of suicide behaviors, exposure to the SOS program was associated with significantly fewer self-reported suicide attempts in the 3 months following the program. Ninth grade students in the intervention group were approximately 64 % less likely to report a suicide attempt in the past 3 months compared with students in the control group. Similarly, exposure to the SOS program resulted in greater knowledge of depression and suicide and more favorable attitudes toward (1) intervening with friends who may be exhibiting signs of suicidal intent and (2) getting help for themselves if they were depressed or suicidal. In addition, high-risk SOS participants, defined as those with a lifetime history of suicide attempt, were significantly less likely to report planning a suicide in the 3 months following the program compared to lower-risk participants. Differential attrition is the most serious limitation of the study; participants in the intervention group who reported a suicide attempt in the previous 3 months at baseline were more likely to be missing at post-test than their counterparts in the control group.     

A Systematic Review of School-Based Suicide Prevention Interventions for Adolescents,and Intervention and Contextual Factors in Prevention

Prevention Science - Suicide is the fourth leading cause of death among adolescents, globally. Though post-primary, school-based suicide prevention (PSSP) has the potential to be a key strategy for...     

Nutrition in Cancer Prevention: An Integrated Approach

There is considerable evidence that the war on cancer is not being won. There is, however, strong evidence that a substantial fraction of cancer can be prevented by using existing nutritional knowledge. In this paper we discuss strategies for reducing cancer incidence by implementing this knowledge. The most obvious route for persuading large numbers to change their diets is by individual counseling in a health-care setting, public education campaigns and interventions at the worksite. However, such health promotion actions have met with only limited success. For efforts to change population diets to be successful, a vital component must include changes in government policies. Examples of the tools that need to be employed are restrictions on advertising and marketing. Effective action will likely require an economic dimension, namely the employment of taxation and subsidies, for instance, by taxing unhealthy food choices and by subsidizing fruit and vegetables.     

Fall Prevention Research and Practice: A Total Worker Safety Approach

Slips, trips, and falls (STF) represent a serious hazard to workers andoccupants in many industries, homes, and communities. Often, the cause of a STF incidentis multifactorial, encompassing human, environmental, and task risk factors. A STF-relateddisability can greatly diminish the occupational capability and quality of life ofindividuals in both the workplace and the home. Countering STF hazards and risks both onand off the job and on all aspects of control measures is a “total worker safety” matter,a challenging yet tangible undertaking. As the federal organization responsible forconducting research for the prevention of work-related injuries in the United States, theNational Institute for Occupational Safety and Health (NIOSH) has been conducting researchon STF controls for some decades. Many NIOSH research outcomes have been utilized for STFprevention in workplaces, with potential for prevention in homes as well. This papersummarizes the concept of total worker safety for STF control, NIOSH priority researchgoals, major activities, and accomplishments, and some emerging issues on STF. Thestrategic planning process for the NIOSH research goals and some identified researchfocuses are applicable to the development and implementation of global STF researchgoals.     

The US Air Force Suicide Prevention Program: Implications for Public Health Policy

Objectives. We evaluated the effectiveness of the US Air Force Suicide Prevention Program (AFSPP) in reducing suicide, and we measured the extent to which air force installations implemented the program.Methods. We determined the AFSPP''s impact on suicide rates in the air force by applying an intervention regression model to data from 1981 through 2008, providing 16 years of data before the program''s 1997 launch and 11 years of data after launch. Also, we measured implementation of program components at 2 points in time: during a 2004 increase in suicide rates, and 2 years afterward.Results. Suicide rates in the air force were significantly lower after the AFSPP was launched than before, except during 2004. We also determined that the program was being implemented less rigorously in 2004.Conclusions. The AFSPP effectively prevented suicides in the US Air Force. The long-term effectiveness of this program depends upon extensive implementation and effective monitoring of implementation. Suicides can be reduced through a multilayered, overlapping approach that encompasses key prevention domains and tracks implementation of program activities.Although much is known about risk factors for suicide, there are few examples of multifaceted, sustainable programs for reducing morbidity and mortality attributable to suicide and suicidal behaviors. The Air Force Suicide Prevention Program (AFSPP) has been found to have achieved significant relative risk reductions of rates of suicide and other violence-related outcomes, including accidental death and domestic violence.¹ The AFSPP, now in its 13th year, is an example of a sustained community-based effort that directly addresses suicide as a public health problem.The AFSPP, launched in 1996 and fully implemented by 1997,¹ emphasizes leadership involvement and a community approach to reducing deaths from suicide. The program is an integrated network of policy and education that focuses on reducing suicide through the early identification and treatment of those at risk. It uses leaders as role models and agents of change, establishes expectations for airman behavior regarding awareness of suicide risk (i.e., policymaking), develops population skills and knowledge (i.e., education and training), and investigates every suicide (i.e., outcomes measurement). The program represents the air force''s fundamental shift from viewing suicide and mental illness solely as medical problems and instead seeing them as larger service-wide community problems (Gen T. S. Moorman Jr, US Air Force, personal communication, June 2001).The program''s approach is predicated on current knowledge that individuals at risk exhibit warning signs and that intervention at an early stage lowers risk and results in improved outcomes. Thus, the program aims to reduce stigma and encourage early help-seeking behavior by changing social norms through education and policy. This is achieved at the community level by changing the community''s knowledge, values, beliefs, attitudes, and behaviors concerning distress, help-seeking, and suicide. The AFSPP affirms and encourages help-seeking behavior, normalizes the experience of distress, promotes the development of coping skills, fights the stigma associated with receiving mental health care, and educates the community about the absence of negative career consequences for seeking and receiving treatment. The program also seeks to improve outcomes in putative distal risk factors for suicide, including family violence, alcohol and substance use, diminishing work performance, and depression. The result over the years has been the creation of an atmosphere of responsibility and accountability for reducing deaths from suicide that includes new expectations for behavior at the community and individual levels.With little theoretical guidance available in 1996 to shape the program, the air force developed an overlapping programmatic design, resulting in far-reaching enhanced capacity of organizational responsiveness in critical areas at multiple levels. These overlapping components became known formally as the 11 Initiatives of the Air Force Suicide Prevention Program, which are described briefly in the box on the next page and in detail online (AFPAM 44–160; available at http://afspp.afms.mil/idc/groups/public/documents/afms/ctb_056459.pdf).We studied the effect of the AFSPP on air force suicide rates from 1997, when the program was fully implemented, through 2008. We examined rates in the context of a 27-year period, from 1981 through 2008, during which time there have been 3 military conflicts and a major downsizing of the air force during the early 1990s. This 27-year period provides an important historical perspective on suicide rates in an organization that underwent rapid, widespread change in force structure and that dealt with the onset and continuation of Operation Enduring Freedom in Afghanistan in 2001 and Operation Iraqi Freedom in 2003. We also conducted a naturalistic experiment from 2004 through 2006, when we measured the implementation of program components during and after a transient increase in suicide rates.