Victor J. Strecher - US grants

Antismoking efforts by physicians appear to have great potential in getting patients to quit or reduce their smoking. However, despite the fact that most physicians believe it is their responsibility to encourage their patients who smoke to stop, most do not feel well prepared to counsel patients about the quitting process. We propose to extend an ongoing randomized controlled trial of two interventions to increase and improve smoking cessation counseling by physicians by adding an evaluation of the effect of counseling on patient behavior. The two interventions are: (1) a physician tutorial; and (2) an intake/prompting system. Specifically, we are requesting funding for the biochemical verification of patients who report having quit smoking at 12 months following the interventions and for assistance in collecting and analyzing data collected from this 12-month follow-up. We have developed this study in conjunction with the nine Fellows of the University of North Carolina Faculty Development Program who are conducting the ongoing randomized trial. The trial will involve nine sites across North Carolina with 250 resident physicians and approximately 2,000 patients. Currently, the primary outcome of the trial is change in physician counseling behavior. We propose to evaluate more important (but more expensive-to-collect) one-year changes in patient smoking behavior. The importance of reducing cancer morbidity and mortality and its association with smoking cessation, as well as the size and scope of the study, make this a significant research opportunity.

lifestyle; health behavior; cancer risk; cancer prevention; disease /disorder proneness /risk; cardiovascular disorder; behavioral medicine; cardiovascular disorder prevention; tobacco abuse prevention; cervix neoplasms; breast neoplasms; neoplasm /cancer diagnosis; human middle age (35-64); young adult human (21-34); cardiovascular disorder diagnosis; cholesterol; mass screening; tobacco abuse; data collection methodology /evaluation; questionnaires; interview; health education; physicians; patient care management;

We propose a three part study to: 1) develop two nutrition intervention modules for southern patients with low literacy skills that are designed to reduce the risk of cardiovascular disease, 2) test the efficacy of these modules against standard care in a randomized, controlled, clinical trial, and 3) determine the feasibility of disseminating these interventions to worksites, churches, and county health departments through the state health department system. The study is divided into three phases which address each of these aims. The goal of Phase I is to develop two innovative care modules that use demographic, psycho-social, nutritional, and behavioral information to individually tailor nutrition treatment programs for southern patients with less than ninth grade reading skills. Counselor Directed innovative care consists of a structured assessment and intervention package of simply written, graphically-oriented printed materials to guide the patient and health counselor (nutritionist, health educator, nurse, or physician). Computer Assisted innovative care makes use of a user-friendly, interactive, computer assisted program permitting more sophisticated tailoring to individual needs, conveying nutrition information in a vivid, understandable format, and extending the services of the health counselor. We will use focus groups of patients with low literacy skills to aid in concept development and refinement of intervention delivery strategies. Reliable and valid assessments of readability and comprehension will help us further refine the materials. In Phase II, we will conduct a randomized trial to determine if our innovative modules produce a meaningful reduction in cholesterol and overall cardiovascular risk compared to standard care. We will identify 400 patients with high cholesterol and low literacy skills served by four community health centers and will randomly assign them to one of four groups: Innovative Care-Counselor Directed, Innovative Care-Computer Assisted, Standard Care, and Usual Care for dietary treatment of cholesterol, obesity, and hypertension. Standard Care will involve the same amount of time and health counselor exposure as Innovative Care, but will use currently available materials. Usual Care patients will be referred to their usual provider for treatment. After four months and again at one year, we will assess changes in lipids, blood pressure, and weight. Phase Ill will consist of a feasibility study to test the ability of both innovative care modules to reach low literacy adults through county health departments, worksites, and churches. Results of the feasibility assessment will help us refine a dissemination strategy using the state health department as a centralized coordinating agency, and county health departments to implement the interventions at the community level.

Dissemination of cancer early detection and prevention activities in a community involves the education of both providers and lay persons. A significant bottleneck found in community settings is the practice pattern of the primary care physician. Cancer early detection and prevention is often removed from the routine delivery of medical care in a community-based office practice, often occurring in an idiosyncratic, as requested, manner. Our ability to affect physician practice patterns, and particularly to increase the frequency and quality of early detection and prevention regimens within primary care practices must be based on our ability to convey state-of-science information and resources to the total office practice. Thus, we are proposing the development, implementation, and dissemination of an interactive computer program, entitled CAN-Interact that will allow physicians and their staff to: (a) access and manipulate a cancer early detection and prevention information/ database, (b) enhance their knowledge of cancer prevention and screening techniques, (c) generate preventive care models for individual patients, (d) create a patient database, and (e) provide cancer prevention newsletters that are specifically tailored for each patient. The CAN-Interact software will be integrated into a medical office -system intervention currently being developed through another NCI-funded research project -- North Carolina Prescribe For Health. Through the North Carolina Prescribe For Health study, we will deliver the CAN-Interact program to 34 community-based medical practices with membership in the Old North State Medical Society (the North Carolina affiliate of the National Medical Association, and nation's largest organization of African-American physicians), the North Carolina chapter of the American Academy of Family Physicians, and the North Carolina chapter of the American College of Physicians. The three professional associations provide a unique opportunity to assess and intervene in primary care practices in predominantly rural areas serving minority populations. We anticipate that the national professional associations, the American College of Physicians, the American Academy of Family Physicians, and the National Medical Association, will also help sponsor the CAN-Interact program, and will work to diffuse the program beyond the study period and assist in the dissemination of study results.

The University of Michigan's Health Media Research Laboratory (HMRL), in collaboration with the Henry Ford Health System (HFHS), will develop and test a computer-based, longitudinally- tailored, print material intervention and a complementary computer-based, longitudinally-tailored, telecounseling intervention among a generalizable group of individuals served by the Henry Ford Health System. Through a randomized, 2x2 factorial trial, we intend to determine effectiveness of the two generalizable interventions, both individually and in combination, in achieving behavior change of four targeted health risk behaviors. The health risk behaviors include cigarette smoking, diet, sedentary behavior and alcohol problems. The trial involves an estimated 3,100 individuals, who, after initial data collection and random assignment to experimental group, will receive treatments at four periods of time over the first 18 weeks of their intervention period. Three data collection follow-up periods, at 3, 12 and 18 months, will allow us to assess both short- and long- term behavioral effects of the individual and combined treatments. Through this research, we also intend to develop a better understanding of how the presence of multiple risk behaviors affects the probability of changing all or any of them; and to evaluate the joint action of these behaviors with demographic characteristics, stage of change, social support, health beliefs and health services utilization.

DESCRIPTION (provided by applicant): The purpose of the University of Michigan Center for Health Communications Research (UMCHCR) is to develop an efficient, theory-driven model for generating tailored health behavior interventions that is generalizable across health behaviors and sociodemographic populations. The research conducted by the Center will advance the evidence base, methodologies, technologies, and conceptual frameworks relevant to developing and implementing tailored web- and print-based cancer prevention and control materials. The proposed UMCHCR will support three Research Projects: Project 1 will aim to facilitate smoking cessation; Project 2 will focus on promoting fruit and vegetable intake among African American adults; and Project 3 will develop a decision aid to help women decide whether to undergo tamoxifen prophylaxis for breast cancer prevention. All Projects will employ a resolution IV fractional factorial design to determine the potential active ingredients of tailoring, including, but not limited to, communication factors such as message content, message framing, message source, and graphical presentation; individual factors such as culture and socio-demographics; and psychometric factors such as motivation and self-efficacy. The UMCHCR will collaborate with the Cancer Research Network and three of its members: Group Health Cooperative of Seattle, Henry Ford Health System of Detroit, and Kaiser Permanente of Atlanta to recruit and enroll research subjects. The Center will also employ many internationally recognized consultants to serve as committee staff, advisory board members, and co-investigators. Further, the Center will support a number of Developmental Projects that will contribute to the methodological knowledge relevant to enhancing intervention delivery and data collection in the UMCHCR's Projects. All UMCHCR research will be supported by a set of Core Resources including and Administration Core, a Biostatistics Core, a Theory and Measurement Core, a Tailoring Technology Core, and a Recruitment and Data Collection Core. Each Core will interact with the Projects and other Cores, creating both a significant economy of scale and a conceptual and technological synergy unavailable through the sum of individual projects. The Center will also place great emphasis on Career Development opportunities by hosting pre-and post-doctoral fellowship, cancer communication seminars, and a two-week tailoring training institute.

DESCRIPTION (provided by applicant): While the theoretical basis and effectiveness of print-based, tailored smoking cessation interventions have been examined in numerous studies, very little research has been conducted on the effectiveness of computer-tailored smoking cessation interventions delivered via the World Wide Web. Further, researchers in public health communications have little knowledge about the active ingredients of tailoring, the components that contribute to its effectiveness. This project proposes to examine the significance of a potential active ingredient: depth of tailoring. Depth of tailoring refers to the level of detail of tailoring and the interactions among theory-based tailoring constructs. A low-depth intervention may generate thousands of message combinations, while a high-depth program may generate billions of variations. High-depth interventions can create extensively tailored cessation messages, but do they result in better outcomes? Is it worth the time and energy to develop such comprehensive interventions? In a randomized 1x3 factorial design among 3,000 smokers, the study will compare the effectiveness of low versus medium-versus high-depth of tailoring in achieving 12-month smoking cessation rates. The study will also examine the impact of tailoring depth on smoking reduction, stage of change, and baseline characteristics such as gender, income, and education. The study will collaborate with Henry Ford Health System of Detroit to recruit participants and to implement the web-based interventions. As the number of web-based cessation programs increases and more people turn to the World Wide Web for health information, a highly interactive medium which is capable of reaching large numbers of smokers at any time and at little cost, we believe the field is posed to examine specific aspects of tailoring that influence its effectiveness in web-based smoking cessation interventions. Such research may provide understanding of why some tailored interventions positively influence cessation and insight into how to create other highly effective tailored interventions.

HEALTH COMMUNICATIONS The Health Communications Core (HCC) of the University of Michigan Comprehensive Cancer Center (UMCCC) is a new service that will provide the communications and communications technology support and capacity to UMCCC investigators. The interactions between the HCC and investigators are intended to maximize the internal validity and scientific integrity to the communications components of interventions, clinical trial recruitment of underserved populations, and adherence to therapeutic and non-therapeutic protocols. Domains of HCC support will focus on cancer prevention, cancer control, and clinical research endeavors. The HCC will be housed in the University of Michigan Center for Health Communications Research, an organization with a history of providing a coordination of resources, economy of scale, and product sophistication that would not be feasible through more independent outside vendor models. The HCC will work with UMCCC investigators to: 1) Assist with communications and technological analysis of their intervention, recruitment, and/or retention needs; 2) Design, develop, deploy, and maintain high-quality print-, hand-held device, web-based, or other relevant communications channels and strategies; 3) Disseminate knowledge of advanced health communication interventions to researchers, practitioners, other NCI Centers, and other parties interested in advanced cancer communications. The HCC will rely on a successful production and quality assurance model used in advanced health communications since 1997 at the University of Michigan. This new core strengthens and institutionalizes a long-standing commitment by the Center for Health Communications Research to provide a robust resource for Cancer Center investigators committed to providing the highest quality, innovative, health communications tailored to the needs of individuals and special populations.

[unreadable] DESCRIPTION (provided by applicant): While tailored smoking cessation interventions have generally demonstrated positive outcomes, the mechanisms by which people respond to these interventions are less well understood. We are proposing a series of studies that examines the neural substrates associated with smoking cessation messages individually tailored to smokers' needs and interests. The proposed project uniquely combines cognitive neuroscience and public health communications methods to investigate how smokers respond to tailored smoking cessation messages. We have demonstrated in a preliminary functional magnetic resonance imaging (fMRI) study that smokers receiving high-tailored smoking cessation messages (compared to low-tailored cessation messages) showed greater medial prefrontal cortex (MPFC) activation, consistent with the role of MPFC in processing self-relevant material. To further investigate the neural substrates that respond to specific tailored smoking cessation messages and importantly the relationship of these findings to subsequent actual smoking cessation, we propose two studies, each with two phases. Study 1a (Phase I) investigates the role of self-relevance in targeted messaging for smoking cessation. We will examine the relative activation of the MPFC in each subject during exposure to highly self-relevant, high-tailored smoking cessation messages in contrast to low-tailored self-relevant messages and a control self-relevance task. 88 cigarette smokers will receive high-tailored and low-tailored self-relevant smoking cessation messages during fMRI, and will also complete a control task testing self-relevance (Phan et al., 2004). The findings will inform whether greater MPFC activation to high- tailored self-relevant smoking cessation messages is associated with greater self-referential processing. In Study 1b (Phase 2), we will administer to each Study 1a participant a previously tested web-based tailored smoking cessation program immediately following the fMRI scanning (Study 1a) session. Subjects will be followed up in four months and assessed on actual smoking abstinence. Study 1b will explore associations between specific brain region activations from self-relevant smoking messages and subsequent cessation. Study 2 investigates the role of two different types of smoking cessation messages: motivational messages (why to quit) and instructional messages (how to quit) in targeted messaging for smoking cessation. In Study 2a (Phase1), another 88 cigarette smokers will receive high-tailored motivational messages, high-tailored instructional messages, and neutral messages during fMRI. In Study 2b (Phase 2), Study 2a participants will receive the web-based tailored smoking cessation program immediately after the fMRI scanning session and then be followed up in four months to determine actual smoking abstinence. Study 2b will explore the relationship between specific brain region activations in response to tailored motivational and instructional cessation messages and subsequent cessation. The results of these studies will begin to identify specific pathways for optimal message tailoring to make the largest impact on smoking cessation. Nicotine addiction is an important public health concern. The project combines public health, psychology, and neuroscience research methods to understand how smokers respond to individualized smoking cessation messages in an effort to improve smoking cessation programs. [unreadable] [unreadable] [unreadable]

Research on tailoring for health-related behaviors and decision-making has increased dramatically since the early 1990's. Results from numerous randomized trials suggest that tailored communications for cancer prevention and control have a greater influence on behavioral and decision making outcomes than one-size-fits-all approaches. Until recently, however, we had little understanding of why tailored communications influenced behavior, or which components of these communications were effective. CECCR1 funding helped us to organize a concerted interdisciplinary effort to open the black box of health communications interventions, which led to identifying a broad array of psychosocial and communications components relevant to health behavior change and decision making. We also identified important individual characteristics that moderate the impact of health communications messages. Results from several of these studies have already been published, and are leading to significant new research funding and a new generation of health communications investigators. Moreover, CECCR1 results are also being adopted i health care, employer, pharmaceutical, and government settings of the U.S. and other parts of the world The overarching aims of CECCR2 are to: (1) Extend our tailoring research beyond the prevention area to the broader cancer care continuum, including early detection, treatment, and long-term survival; (2) Extend our tailoring research to new clinical and post-treatment settings; (3) Deepen our understanding of the key psychosocial and communications components identified in CECCR1, including motivation, ethnic identity, risk perception, and cognitive processing; (4) Explore methods of tailoring to patient preferences for shared decision making; (5) Develop new social and cognitive neuroscience strategies for identifying immediat impact and mechanisms of health communications messages; (6) Develop new interdisciplinary collaborations with scientists and research institutions; (7) Train a new generation of health communications scientists and practitioners; and (8) Disseminate both the scientific and practical results of our research efforts. Woven through CECCR2 research are crosscutting interests related to: tailoring and relevant communications channels; reaching underserved populations through more relevant and easier-to-proces content; physiological mechanisms of communication effect; and methodological issues of design, data collection, and measurement CECCR2 involves four primary research sites and networks, and collaborations with 34 research investigators from 13 institutions. Because of the ambitious scope of our proposed studies, we have obtained over $10 million in matched funding from other sources to help us carry out the proposed research.

Research on tailoring for health-related behaviors and decision-making has increased dramatically since the early 1990's. Results from numerous randomized trials suggest that tailored communications for cancer prevention and control have a greater influence on behavioral and decision making outcomes than one-size-fits-all approaches. Until recently, however, we had little understanding of why tailored communications influenced behavior, or which components of these communications were effective. CECCR1 funding helped us to organize a concerted interdisciplinary effort to open the black box of health communications interventions, which led to identifying a broad array of psychosocial and communications components relevant to health behavior change and decision making. We also identified important individual characteristics that moderate the impact of health communications messages. Results from several of these studies have already been published, and are leading to significant new research funding and a new generation of health communications investigators. Moreover, CECCR1 results are also being adopted i health care, employer, pharmaceutical, and government settings of the U.S. and other parts of the world The overarching aims of CECCR2 are to: (1) Extend our tailoring research beyond the prevention area to the broader cancer care continuum, including early detection, treatment, and long-term survival; (2) Extend our tailoring research to new clinical and post-treatment settings; (3) Deepen our understanding of the key psychosocial and communications components identified in CECCR1, including motivation, ethnic identity, risk perception, and cognitive processing; (4) Explore methods of tailoring to patient preferences for shared decision making; (5) Develop new social and cognitive neuroscience strategies for identifying immediat impact and mechanisms of health communications messages; (6) Develop new interdisciplinary collaborations with scientists and research institutions; (7) Train a new generation of health communications scientists and practitioners; and (8) Disseminate both the scientific and practical results of our research efforts. Woven through CECCR2 research are crosscutting interests related to: tailoring and relevant communications channels; reaching underserved populations through more relevant and easier-to-proces content; physiological mechanisms of communication effect; and methodological issues of design, data collection, and measurement CECCR2 involves four primary research sites and networks, and collaborations with 34 research investigators from 13 institutions. Because of the ambitious scope of our proposed studies, we have obtained over $10 million in matched funding from other sources to help us carry out the proposed research.

Project 1 aims to improve two fundamental aspects of population-based smoking cessation programming: reach through a media campaign encouraging use of a web-based cessation intervention and efficacy of the web-based smoking cessation intervention. Working with the New York State Tobacco Control Program and targeting adult smokers throughout the state (excluding the New York City area), Project 1 consists of two linked randomized trials, conducted in collaboration with the Roswell Park Cancer Center Institute's Transdisciplinary Tobacco Use and Treatment Research Center (TTURC) and the New York State Department of Health. In the Media Component, two media message factors will be developed and tested using a 2X2 factorial design: positive versus negative affect messages, and narrative versus rhetorical formats. In the Cessation Component, enhancements relevant to a web-based smoking cessation intervention will be tested, including: (1) an Interactive Voice Response (IVR) system to encourage continued engagement with the webbased cessation intervention;(2) narrative success stories linked to the narrative ads of the Media Component; (3) prompting to use a Quitline counselor;(4) a daily online chat room facilitated by a Quitline counselor;(5) 4 weeks of nicotine replacement therapy (NRT) added to an initial 2-week course of NRT;and (6) a relapse prevention and recycling module. The State of New York's Department of Health is devoting $4 million of their media campaign funding to Project 1 for media ad development and another $5 million for placement of television, radio, and newspaper advertisements covering four large media market regions over a two-year period. The study therefore effectively leverages interactions and resources of an opinion-leading tobacco control program to evaluate integrated media and web-based smoking cessation intervention components that could be distributed at minimal cost to other states and countries.

Area; Behavioral; Cancer, Oncology; Cancers; Classification; Clinical; Communication; Communication Research; Decision Making; Development; Development Plans; Development and Research; Discipline; EXTMR; Environmental Health; Environmental Health Science; Epidemiology; Extramural; Extramural Activities; Face; Faculty; Fellowship; Funding; Generations; Grant; Grips; Health; Health Communication; Health Services; Health behavior; Information Technology; Institutes; Intervention; Intervention Strategies; Investigators; Investments; Knowledge; Malignant Neoplasms; Malignant Tumor; Mentorship; Plans, Development; Policies; Position; Positioning Attribute; Postdoc; Postdoctoral Fellow; Process; Public Health; Purpose; R &D; R&D; Research; Research Associate; Research Personnel; Research Training; Researchers; Role; Schools, Medical; Science; Series; Solutions; Specialist; Standards; Standards of Weights and Measures; Students; Survey Instrument; Surveys; Systematics; Training; Universities; Week; Work; base; career; college; experience; facial; grasp; health administration; health care service; interest; interventional strategy; malignancy; medical schools; neoplasm/cancer; oncology; post-doc; post-doctoral; pre-doc; pre-doctoral; predoc; predoctoral; public health medicine (field); research and development; social; social role; tool

Research on tailoring for health-related behaviors and decision-making has increased dramatically since the early 1990's. Results from numerous randomized trials suggest that tailored communications for cancer prevention and control have a greater influence on behavioral and decision making outcomes than one-size-fits-all approaches. Until recently, however, we had little understanding of why tailored communications influenced behavior, or which components of these communications were effective. CECCR1 funding helped us to organize a concerted interdisciplinary effort to open the "black box" of health communications interventions, which led to identifying a broad array of psychosocial and communications components relevant to health behavior change and decision making. We also identified important individual characteristics that moderate the impact of health communications messages. Results from several of these studies have already been published, and are leading to significant new research funding and a new generation of health communications investigators. Moreover, CECCR1 results are also being adopted in health care, employer, pharmaceutical, and government settings of the U.S. and other parts of the world. The overarching aims of CECCR2 are to: (1) Extend our tailoring research beyond the prevention area to the broader cancer care continuum, including early detection, treatment, and long-term survival;(2) Extend our tailoring research to new clinical and post-treatment settings;(3) Deepen our understanding of the key psychosocial and communications components identified in CECCR1, including motivation, ethnic identity, risk perception, and cognitive processing;(4) Explore methods of tailoring to patient preferences for shared decision making;(5) Develop new social and cognitive neuroscience strategies for identifying immediate impact and mechanisms of health communications messages;(6) Develop new interdisciplinary collaborations with scientists and research institutions;(7) Train a new generation of health communications scientists and practitioners;and (8) Disseminate both the scientific and practical results of our research efforts. Woven through CECCR2 research are crosscutting interests related to: tailoring and relevant communications channels;reaching underserved populations through more relevant and easier-to-process content;physiological mechanisms of communication effect;and methodological issues of design, data collection, and measurement. CECCR2 involves four primary research sites and networks, and collaborations with 34 research investigators from 13 institutions. Because of the ambitious scope of our proposed studies, we have obtained over $10 million in matched funding from other sources to help us carry out the proposed research.