Shawn M. Boles

Evaluating the public health impact of health promotion interventions: the RE-AIM framework.

Progress in public health and community-based interventions has been hampered by the lack of a comprehensive evaluation framework appropriate to such programs. Multilevel interventions that incorporate policy, environmental, and individual components should be evaluated with measurements suited to their settings, goals, and purpose. In this commentary, the authors propose a model (termed the RE-AIM model) for evaluating public health interventions that assesses 5 dimensions: reach, efficacy, adoption, implementation, and maintenance. These dimensions occur at multiple levels (e.g., individual, clinic or organization, community) and interact to determine the public health or population-based impact of a program or policy. The authors discuss issues in evaluating each of these dimensions and combining them to determine overall public health impact. Failure to adequately evaluate programs on all 5 dimensions can lead to a waste of resources, discontinuities between stages of research, and failure to improve public health to the limits of our capacity. The authors summarize strengths and limitations of the RE-AIM model and recommend areas for future research and application.

A Sketch of the Implicit Relational Assessment Procedure (IRAP) and the Relational Elaboration and Coherence (REC) Model

The current article outlines a behavior-analytic approach to the study of so-called implicit attitudes and cognition. The Implicit Relational Assessment Procedure (IRAP), the conceptual basis of which was derived from relational frame theory, is offered as a methodology that may be used in the experimental analysis of implicit attitudes and beliefs. The relational elaboration and coherence (REC) model provides a possible relational-frame account of the findings that have emerged from the IRAP. The article first outlines the research history that led to the development of the IRAP, followed by a description of the method. The REC model and how it explains a range of IRAP data are then considered. The article also outlines how both the IRAP and the REC model overlap with, and differ from, similar research found in the non-behavior-analytic literature.

Take heart: results from the initial phase of a work-site wellness program.

OBJECTIVES The purpose of this study was to evaluate the short-term effects of a low-intensity work-site heart disease risk reduction program using a matched pair design with work site as the unit of analysis. METHODS Twenty-six heterogeneous work sites with between 125 and 750 employees were matched on key organization characteristics and then randomly assigned to early or delayed intervention conditions. Early intervention consisted of an 18-month multifaceted program that featured an employee steering committee and a menu approach to conducting key intervention activities tailored to each site. RESULTS Cross-sectional and cohort analyses produced consistent results. At the conclusion of the intervention, early and delayed intervention conditions did not differ on changes in smoking rates, dietary intake, or cholesterol levels. There was considerable variability in outcomes among work sites within each condition. CONCLUSIONS Despite documented implementation of key intervention activities and organization-level changes in terms of perceived support for health promotion, this intervention did not produce short-term improvements beyond secular trends observed in control work sites. Research is needed to understand determinants of variability between work sites.

Evaluation of an Internet-based smoking cessation program: Lessons learned from a pilot study

The potential contribution of the Internet to smoking cessation seems huge, given that a majority of Americans now have both computers and telephones. Despite the proliferation of Web sites offering smoking cessation support, there is little empirical evidence regarding the efficacy of Internet-delivered cessation programs. We developed a cessation Web site and conducted a short-term evaluation of it, examining recruitment approaches, Web site use patterns, alternative retention incentives and re-contact modes, satisfaction, and cessation rate. The intervention included modules on social support and cognitive-behavioral coping skills configured to take advantage of the interactive and multimedia capabilities of the Internet. Cessation and satisfaction data were obtained from a subsample of 370 subjects followed for 3 months. The program was rated as easy to use, and the social support group component was used most frequently. The cessation rate (abstinence for the previous 7 days) at 3 months was 18%, with nonrespondents (n~161) considered smokers. Among a variety of traditional and Internet-based recruitment strategies, the most successful made use of Internet user groups and search engines. Methodological and procedural issues posed in conducting research on the Internet are discussed.

Who Participates in Internet-Based Self-Management Programs? A Study Among Novice Computer Users in a Primary Care Setting:

PURPOSE the purpose of this study was to evaluate the participation rates and factors associated with nonparticipation among primary care patients who were invited to join an Internet-based self-management research program. METHODS Primary care providers invited their patients with type 2 diabetes to participate in an Internet-based diabetes self-management support program. Research staff contacted these patients by phone to assess their eligibility and interest in participating. Reasons for declining were assessed and demographic/medical status information was collected. RESULTS Of the eligible patients, 60% participated in the program. No significant differences were found between participants and decliners in gender, insulin use, computer familiarity, or computer ownership. There were significant differences in age and years since diagnosis. Participants were slightly younger and had diabetes for a fewer number of years than nonparticipants. Nonparticipation was not related to computer or Internet issues. CONCLUSIONS Most older diabetes patients without previous Internet experience will-takepart in Internet-based self-managment support programs if barriers to participation are addressed.

Take Heart II: Replication of a Worksite Health Promotion Trial

The purpose of this study was to evaluate the effects of a revised worksite health promotion program that featured an employee steering committee/menu approach to intervention. The “Take Heart II” program was evaluated using a quasi-experimental matched-pair design with worksite as the unit of analysis. Experimental and control worksites did not differ on baseline organizational or employee demographic variables or on baseline levels of dependent variables. Outcome and process results revealed consistent, but modest effects favoring intervention worksites on most measures. Cross-sectional analyses generally failed to produce statistically significant intervention effects, but cohort analyses revealed significant beneficial effects of the Take Heart II intervention on eating patterns, behavior change attempts, and perceived social support. Neither analysis detected a beneficial effect of intervention on cholesterol levels.

Concern about weight gain associated with quitting smoking: Prevalence and association with outcome in a sample of young female smokers.

This study investigated the relationship between weight gain concern and outcomes of a large-scale smoking cessation study among 506 young female smokers attending Planned Parenthood clinics. Results of this prospective study did not support the clinical importance of weight gain concerns. Using an index of weight concern that was predictive in previous research, baseline weight concern was unrelated to smoking cessation efforts, whether participants made a quit attempt, reduced the number of cigarettes they smoked, or reported a change in self-efficacy for stopping smoking. Both the overall level of concern expressed in this sample of predominantly White young women and the lack of relationship between weight gain concern and smoking cessation outcomes suggest that weight gain concern may not be a critical factor for cessation programs targeting similar female smokers.

Prevalence and Prediction of Overweight and Obesity among Elementary School Students.

BACKGROUND The high rates of childhood overweight and obesity in the United States have generated interest in schools as sites for monitoring body mass index (BMI) information. This study established baseline values for a 5-year longitudinal assessment of BMI of elementary school children and examined variation across the schools, because little is known about factors that affect the distribution of overweight and obesity within school districts. METHODS Height and weight measurements were collected on 2317 elementary school children in 1 school district. BMI was calculated using the Centers for Disease Control and Preventions NutStat program. Child characteristics included gender, age, eligibility for free and reduced lunch (proxy for socioeconomic status [SES]), school, grade, and ethnicity/race. Children were grouped into 2 BMI categories, <85th percentile or ≥85th percentile (overweight/obesity). Logistic regression was used to examine potential predictors of overweight/obesity. RESULTS Prevalence of ≥85th percentile was 30.9%, 34.4%, 35.3%, 36.4%, 37.1%, and 44.5% for K-5, respectively. Prevalence of ≥85th percentile was highest among Hispanic children. Ethnicity was the strongest predictor of inclusion in the ≥85th percentile category followed by grade and free and reduced lunch eligibility. CONCLUSION The data are consistent with the prevalence of overweight/obesity among American children and Hispanic children in particular. District prevalence of overweight/obesity is higher than available state statistics. Most of the BMI variation is accounted for by ethnicity, SES, and grade. The grade effect and high prevalence of overweight/obesity provide a rationale for BMI screening retention at the schools.

Diabetes Care Practices in Primary Care: Results from Two Samples and Three Measurement Sets

PURPOSE here has been substantial recent interest in diabetes disease management interventions, guidelines, and care practices. As the vast majority of diabetes care occurs in primary care settings, it makes sense to evaluate current levels of recommended practices in different primary care settings. METHODS We report on two separate studies that included a combined total of 389 patients seen by over 30 different providers. Three different sets of recommended practices were assessed: (1) the ADA provider recognition measures, (2) the proposed Diabetes Quality Improvement Project measures, and (3) the state of Oregon Population-Based Guidelines for Diabetes. RESULTS In general, there was only a moderate level of adherence to recommended practices, and adherence was much lower for behavioral or patient-focused practices as contrasted with laboratory tests. There was considerable variability across providers and across different guidelines activities. CONCLUSIONS Policy and quality improvement implications and future research issues are discussed, including the need for studying different measurement approaches for evaluating guidelines adherence.

Behavioral and social correlates of methamphetamine use in a population-based sample of early and later adolescents

This paper reports relationships between methamphetamine use and behaviors and social influences using data from a population-based survey of 8th- and 11th-grade students in Oregon for the 2001-2003 school years. We analyze methamphetamine use within a general problem behavior framework to identify malleable correlates of behavior for future prevention interventions. We specifically test two models of methamphetamine use employing logistic regression analysis: one comprised of behaviors and traits of the individual students and another focusing on peer and parental influences. This study finds adolescent methamphetamine use related to several problem behaviors. However, the specific problems vary by grade and are moderated by gender. Findings indicate the need for tailored interventions targeting gender/grade-specific behaviors or problems such as antisocial activities, risky sex, and depression, as well as social influences such as peers engaging in antisocial behaviors or using drugs and parents favoring drug use or poorly monitoring or setting limits for their children.