Cigarette smoking prevalence among gay men is twice that of population levels. A pilot community-level intervention was developed and evaluated aiming to meet UK Government cessation and cancer prevention targets.Four 7-week withdrawal-oriented treatment groups combined nicotine replacement therapy with peer support. Self-report and carbon monoxide register data were collected at baseline and 7 weeks. N = 98 gay men were recruited through community newspapers and organisations in London UK.At 7 weeks, n = 44 (76%) were confirmed as quit using standard UK Government National Health Service monitoring forms. In multivariate analysis the single significant baseline variable associated with cessation was previous number of attempts at quitting .This tailored community-level intervention successfully recruited a high-prevalence group, and the outcome data compares very favourably to national monitoring data (which reports an average of 53% success). Implications for national targeted services are considered. Analysis of tobacco marketing has demonstrated lesbian and gay youth as an emerging target community , therebyGay men have been disproportionately affected by HIV/AIDS disease in developed countries. HIV risk-taking behaviour is associated with cigarette smoking among HIV-negative gay men , and amoThe National Health Service (NHS) Cancer Plan, a UK Government health strategy, recommends that Primary Care Trusts (PCTs) take a commissioning lead in forming local alliances involving community groups, harnessing community efforts, and dissemination of effective interventions. . In ordeThis innovative pilot study aimed to design, recruit to, and deliver a series of pilot smoking cessation group interventions and to evaluate outcomes using standard UK Government assessment criteria.Setting up and running specialist Smoking Cessation Clinics", part of the Smoking Cessation Training and Research Programme (SCTRP) at St Bartholomew's and Royal London School of Medicine and St George's Hospital Medical School. The programme of withdrawal-oriented treatment combines groupwork, nicotine replacement therapy  and ongoing peer support throughout. An initial information session is followed by 6 closed group sessions, setting a quit data for week 3. This pilot consisted of 4 delivered groups, and each group consisted of 7 closed weekly meetings each of 2 hours.The intervention was developed and delivered by a community-based volunteer-led charity in London UK, with a remit to promote the health of gay men. Potential acceptability and effectiveness were maximised by providing an NHS-approved programme adapted for an appropriate service wholly facilitated and attended by gay men. Seven volunteers experienced in delivering group interventions within the organisation were trained in the 3 day course "The service principle was for a non-judgemental environment where gay men could address socialising and gay social spaces, recreational drug use, sexuality and HIV and the impact of these on their motivations, and ability, to quit smoking. Several specific modifications were made to the taught model. Our intervention modified the SCTRP program's use of "Quit buddies" which promoted partnered support, instead creating "Quit cells" of 3 or 4 participants. This design modification was made in the light of other group interventions delivered by this community organisation in which reliance of a participant on more than one person for support has found to be more reliable. The information on Zyban was expanded to address contraindications with HIV antiretroviral combination therapies. Exercises from assertiveness training courses were imported to assist participants in clearly communicating the intention to remain a non-smoker. In general, group discussion and processes were focussed on culturally-specific contexts to gay men. A detailed intervention programme was written in order to promote consistency across the cycles of intervention delivery.Week 1: information on the course content as well as expectations of quit date are given along with information regarding potential side effects and how to deal with them. Week 2: what to expect when you quit and how to deal with reactions, information on the effects of carbon monoxide, preparation for quit date, personal action plan and the how to use a smoking diary. Week 3: information on how to use nicotine replacements, role play of assertive refusal of cigarettes, selection and formation of quit support cells, and personal statements of cessation. Week 4: group review of challenges of the first week of not smoking with reference to smoking diary and personal action plan, exploration of potential "alternative" support such as meditation and exercise, discussion of the challenges of drug use with respect to smoking cessation. Week 5: group review of previous week's experience, information on health benefits achieved to date and weight gain issues. Week 6: review of previous week's experience, identification of future sources of support. Week 7: review of previous week's experience, information of health benefits to date, elaboration on support sources, small celebration of the group's achievement.Twenty-four recruitment advertisements were placed in free London-wide and national gay press, and accompanying editorial and articles were secured to support the recruitment process.Prior to the initial session, participants were sent the required UK Department of Health self-completion Smoking Cessation Service NHS Client Assessment Form. Carbon monoxide readings were taken at each session from week 2, using the "Smokealyser" calibrated carbon monoxide register, and readings were used in addition to self-report data to confirm smoking cessation at week 7. All intervention attendees were asked to give written permission for data collection purposes and were given guarantees of confidentiality.All data were entered into SPSS for windows V11. In line with NHS monitoring data requirements, the percentage of successful quitters was calculated as those who gave carbon monoxide readings and confirmed they had quit at week 7 as a percentage of those who set a quit date for week 3. Variables were entered individually into univariate binary logistic regressions, with cessation outcome as the dependent variable and participant baseline characteristics, attitudes and behaviour, and nicotine replacement methods as independent variables. Variables with p values below 0.25 were then entered stepwise into a multivariate logistic regression, with 95% confidence intervals (95% CI) reported.Ninety-eight men registered to attend the intervention, and of these 76 attended at least the first session. Sixty-nine of men returned the assessment sheet, and the outcome analysis is of those 69 men.The mean age of participants was 37.1 years , and n = 63 (90%) reported their ethnicity as White. Forty-four men (64%) had been educated to degree level or higher, and n = 52 (75%) were in full time employment with a further 9 (13%) men medically retired, n = 5 (7%) unemployed, n = 2 (3%) in full time education and n = 1 (1%) retired. Seventeen men (25%) were entitled to free prescriptions (i.e. the welfare state pays for their prescribed medications). Sixty-five men (94%) reported that they drink alcohol, consuming a mean of 22.8 units per week .The daily number of cigarettes smoked was as follows: 1–5 ; 5–10 ; 11–20 ; 21–30 ; 31–40 ; 41+ . The first cigarette after waking was smoked during the following number of minutes after waking: 5 minutes ; 6–30 minutes ; 31–60 minutes ; 61+ minutes . Smoking motivations are summarised in Table Participants reported a mean 2.6 of consultations with their primary care General Practitioner (GP) in the previous year . Secondary/hospital consultations in the previous year were reported by n = 35 (52%) men, with a mean of 2.26 consultations for these men . Thirty-four men (51%) had been recommended by their GP to give up cigarette smoking, and n = 26 (38%) men were currently on prescribed medication. Fourteen men (20%) were diagnosed HIV-positive, n = 25 (51%) HIV-negative, n = 16 (23%) untested and n = 4 (6%) refused to answer. The participants rated their health as follows: excellent n = 10 (14.5%); good n = 36 (52%); moderate n = 20 (29%); poor n = 2 (3%); very poor n = 1 (1%).Sixty-one men (90%) had made a previous attempt to quit, and of those who had made an attempt the mean was 2.85 attempts . Previously employed nicotine replacement methods were gum n = 30 (49%), patches n = 30 (49%), nasal spray n = 3 (5%), inhalor n = 12 (20%), microtabs n = 3 (5%), nicotine lozenges n = 4 (7%), and Bupropion (Zyban) n = 12 (20%).Participants described the importance of this current attempt to quit as extremely important ; very important ; quite important ; not at all important (n = 0). Participants rated their chances of quitting for good on this attempt as extremely high ; very high ; quite high ; not very high ; very low .Attendance at sessions was consistently high, of 532 person-sessions 13 sessions were missed. Non-attendance did not apparently cluster around a particular session.At week 3, of the 69 men who gave data, n = 58 men (84%) set a quit date. At week 7 (4 weeks after the quit date) n = 44 men (64%) were confirmed as having quit using the CO monitor, representing 58% of those who attended the first session, 76% of those who set a quit date and 64% of those who gave data at baseline and week 7.A further 3 men reported by telephone that they had quit smoking but did not attend the final session to give clinical data to verify. Nine men (13%) reported not having stopped smoking, n = 6 men (9%) set a quit date at week 3 and did not return to group, n = 7 men (10%) attended the first session only. For the purposes of this analysis, these 25 men were coded as not having quit in the following modelling.This analysis considers those 44 men confirmed as having ceased compared to those 25 categorised as not having quit. Following univariate analysis (see Table This pilot intervention has targeted a hitherto overlooked high smoking prevalence group, and has adapted a Government-approved intervention to meet the specific needs of gay men in an appropriate and acceptable setting. The success rate of 76% of men who had set a quit date being confirmed as having quit at week 7 compares extremely favourably to national monitoring data, which reports a success rate nationally 2001–2002 for smoking cessation services as 53% .Public health targets must consider the needs of high prevalence communities, and this may be achieved through innovative development of existing effective services. However, this study has highlighted the lack of targeted interventions for gay men, and the evidence demonstrates further elevated health needs compared to the general population in the fields of alcohol and drug use  mental hFurther research may identify the factors which contributed to the effectiveness of this pilot complex participative intervention, including offering recruitment and delivery outside of community settings, measuring success rates for gay men in non-gay specific or tailored groups, and the usefulness of "quit cells". Longer-term follow-up data and increasing dosage to include a follow-up session would also provide further useful data. In order to refine the intervention for trial testing, qualitative data regarding the utility, acceptability and preferences for the content of specific sessions would be illuminating. Further, the non-randomised design without comparison group limits presents a limitation to the generalisability of findings, yet still offers cessation outcomes much better than standard national cessation data quoted above which were collected without quasi-experimental design using the same follow-up period. Data were not available on the 29 men who registered for the course but did not attend or complete baseline data, and so it is not possible to compare their demographics or smoking behaviours to those who took up the intervention. Certainly, replication of this first pilot would be necessary in other settings, e.g. non-metropolitan communities, where issues of feasibility and uptake should be addressed. Commissioners may consider the purchase of existing facilitators from cities to deliver in non-metropolitan areas where demand is likely to be lower, as smoking cessation service recommendations state that group leaders need to keep up to date with their skills and to use them on a regular basis .In order to meet the smoking cessation needs of this hitherto overlooked population, and to meet public health policy targets, a rigorous research agenda must be established. While the use of required standard outcome monitoring must be continued, rigorous experimental trials using longer term follow up and commonly reported measures are required. Complex participative interventions must be developed, as in this pilot, from evidence-based interventions with full programme description to ensure replication. The development of appropriate interventions must first pilot services to ensure that they are appropriately adapted to maximise acceptability and uptake among target communities.Lastly, provision of the service by skilled volunteer facilitators has ensured an acceptable, low-cost intervention with a rate of effectiveness in these four pilot groups that compares favourably to national non-targeted interventions outcomes calculated using standard assessment formula. Acceptability of the model appears high with respect to the low number of missed sessions. Voluntary sector provision and delivery should be considered as a low-cost and highly acceptable point of delivery for effective community-level smoking cessation interventions.The authors declare that they have no competing interests.JB and NH managed the pilot study. RH was responsible for data management and analysis and drafted the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Prospective users of preventive therapies often must evaluate complex information about therapeutic risks and benefits. The purpose of this study was to evaluate the effect of relative and absolute risk information on patient decision-making in scenarios typical of health information for patients.Factorial experiments within a telephone survey of the Michigan adult, non-institutionalized, English-speaking population. Average interview lasted 23 minutes. Subjects and sample design: 952 randomly selected adults within a random-digit dial sample of Michigan households. Completion rate was 54.3%.When presented hypothetical information regarding additional risks of breast cancer from a medication to prevent a bone disease, respondents reduced their willingness to recommend a female friend take the medication compared to the baseline rate (66.8% = yes). The decrease was significantly greater with relative risk information. Additional benefit information regarding preventing heart disease from the medication increased willingness to recommend the medication to a female friend relative to the baseline scenario, but did not differ between absolute and relative risk formats. When information about both increased risk of breast cancer and reduced risk of heart disease were provided, typical respondents appeared to make rational decisions consistent with Expected Utility Theory, but the information presentation format affected choices. Those 11% – 33% making decisions contrary to the medical indications were more likely to be Hispanic, older, more educated, smokers, and to have children in the home.In scenarios typical of health risk information, relative risk information led respondents to make non-normative decisions that were "corrected" when the frame used absolute risk information. This population sample made generally rational decisions when presented with absolute risk information, even in the context of a telephone interview requiring remembering rates given. The lack of effect of gender and race suggests that a standard strategy of presenting absolute risk information may improve patient decision-making. In contemporary U.S. society, prospective users of preventive therapies often must evaluate complex information about therapeutic risks and benefits. While health information is increasingly available, it is frequently incomplete and sometimes inaccurate ,2. For pPrior research on presentation formats that are most effective, comprehensible, and likely to lead to effective decision-making suggests that a critical element is the format of risk information . Mazur  suggestsA key format difference is absolute versus relative gain or loss ,10. AbsoPrior clinical studies have found that presenting information in absolute versus relative risk formats can affect the interpretation of information about medications and personal risks of developing diseases. For example, in a sample of family practice patients, Hux and Naylor  found thData were collected as a part of a cross-sectional telephone survey of the adult, non-institutionalized resident population of Michigan. The telephone survey was part of a continuing series of quarterly surveys in Michigan known as the State of the State Survey (SOSS) conducted by Michigan State University's Institute for Public Policy and Social Research (IPPSR). 952 interviews were completed within the designated interviewing period. The margin of sampling error for the sample as a whole is ± 3.2%. The average interview lasted approximately 22.8 minutes . A more detailed description of the SOSS methodology, sample design, procedures, and content, is provided in Hembroff and Silver .The sampling design for the State of the State Surveys is a disproportionate stratified random sample of phone numbers across the state's regions, over-sampling the less populated regions, and the city of Detroit. Trained interviewers called the random-digit dial (RDD) sample of telephone numbers to identify those that were actually working household phone numbers. Within identified households, interviewers interviewed a single adult selected using the "next birthday" technique  in whichThe data being reported have been weighted to adjust appropriately for the unequal probabilities of respondent selection based on the number of phone lines to the household and the number of adults within the household. Cases were also weighted to adjust for differential response rates among categories of race, gender, age and to adjust for regional disproportionate sampling. The final weighted data file very closely matches the demographic profile of Michigan's adult population.Interviews were conducted using the computer assisted telephone interviewing facility (CATI) of IPPSR's Office for Survey Research (OSR). Interviewing took place over a six week time period during June and July of 1997. The overall completion rate among eligible households was 54.3%. The calculated response rate is based on assigning final outcome dispositions codes according to Standard Definitions, the American Association of Public Opinion Research  guidelinThe interview contained a split-ballot experiment to examine the effects of alternative ways of communicating risks. All respondents were presented with a baseline scenario. In this case, we asked respondents to ..."Suppose you had a friend who was told that she was very likely to get a bone disease that would gradually make her crippled. Suppose the doctor said that there was a medication she could take on a daily basis that would greatly reduce her chances of getting the bone disease."Respondents were asked if they would recommend that their friend take or not take the medication. Respondents were then randomly assigned to be presented one of four follow-up questions. Each follow-up question provided additional information about the hypothetical medication in terms of its benefits or risks. Half of the respondents were told that the medication would increase the patient's risk of breast cancer while the other half were told that the medication would decrease the patient's risk of heart disease. For each half, however, the information was presented in one of two randomly assigned alternative formats. Regarding a decreased risk of heart disease, respondents were told either that:"by taking the medication she would also reduce her risk of heart disease by more than half," or that"by taking the medicine she would also reduce her risk of heart disease from 1 in 200 to 1 in 500."Regarding the increased risk of breast cancer, respondents were told either that"by taking the medication she would also double her risk of breast cancer," or that"by taking the medication she would also increase her risk of breast cancer from 1 in 10,000 to 2 in 10,000."Based on the additional information received, respondents were asked what they would recommend that their friend do. Subsequently, each of these four groups was randomly divided again and given the additional information about increased risk of breast cancer or decreased risk of heart disease that they had not yet received. Then they were asked one more time to indicate what they would recommend to the friend about taking the medication. Thus, respondents were asked to indicate their treatment recommendations three separate times, under three of nine sets of conditions represented by the table below.An initial treatment recommendation was made based on the information given in condition 1, and then again based on the combinations of information represented by conditions 2, 3, 4, or 7. A third and final recommendation was made based on the combination of information represented in conditions 5, 6, 8, or 9. Comparing the results for conditions 2 through 9 to the results from the baseline in condition 1 allows an assessment of the incremental effect of each additional piece of information on the treatment recommendation.The dependent variable is the decision to recommend the medication or not. We hypothesized responses to vary by risk format and number of competing risks. For example, the number of "don't know" responses would be greater in conditions where complete information about competing risks was given. The benefits-only format would produce a majority of positive recommendations. However, we could not predict how large those proportions might be. Direction of change was expected to be positive for added benefit information, negative for more risk information, and reflecting trade-offs when risks and benefits were present. That is, we expected respondents to make a "rational" choice based on the perceived greatest expected utility.To assess whether additional risk information about breast cancer or heart disease affected decisions in conditions 2 through 9, we compared the distributions of change responses for each condition. A "non-change response" occurs when the respondent gives the same answer to the follow-up question as to the baseline question. All other patterns of answers, such as a "don't know" or a "don't take the medication response to the follow-up after giving a "take the medication" response to the baseline, or vice versa, constitute change responses. Although some error variance would be expected, analyzing the distributions of change responses across baseline decisions for the individual treatment conditions determines whether or not the experimental manipulations had any systematic effect.If the added information supports rational decision-making, the percentage of "don't knows" and recommendations against taking the medication would go down if the net effect of the additional information is further risk reduction. Conversely, if the net effect of the additional information is to increase the risk of health problems, the percentage of change responses would be greater among those who initially said "don't know" or to take the medication. The greater the magnitude in the new absolute risk, the greater should be the percentage of respondents who should change their decisions. To test for the effect of risk information format, we aggregated the respondents' decisions. We dummy-coded whether the risk information had been presented in absolute risk terms or not. We also dummy-coded whether the information was given for breast cancer (= 1) or heart disease (= 0). To test the effect of format using logistic regression, we also aggregated recommendations. A dummy variable was created to indicate whether or not the risk information for breast cancer was presented in absolute risk terms (= 1), and similarly for heart disease risk.To develop a profile of those who could not make a recommendation, we dummy-coded recommendations to the baseline scenario into those recommending either to take or to not take the medication (DONTKNOW = 0) and those who said they did not know what to recommend (= 1). To develop a profile of those who made seemingly non-rational recommendations, we dummy-coded recommendations to the baseline scenario into those recommending to take the medication (WRONG = 0) and those who recommended not to take the medication or said they did not know what to recommend (WRONG = 1).All analyses were performed using SPSS for Windows 7.5.A total of 952 individuals were interviewed. In the weighted datafile, 54% were female; 12% were African Americans and 3% were Other non-whites; 26% were under age 30, 40% were 30–49, 18% were 50–64, and 16% were 65 or older; and 43% had a high school education or less, 31% had some college, and 26% had a college degree or more education. The reported median household income was between $40,000 and $50,000. In terms of health indicators, 15% rated their health as only "fair" or "poor;" 14% reported engaging in no leisure time exercise; 25% were current smokers; 38% were overweight or obese; and 1% were heavy drinkers. This profile shows that the sample obtained was representative of the general population of Michigan. All demographic and clinical characteristics were within the survey's margin of sampling error for the prevalence rates for these reported by the Centers for Disease Control and Prevention (CDCP) for Michigan in 1997 except for leisure time exercise.not take the medication.In the baseline condition, two-thirds of the respondents (66.8%) said they would recommend their friend take the medication, one in nine (11.2%) said they did not know what to recommend, and 22.0% recommended that their friend Table As shown in Table Similarly, in conditions 5, 6, 8, and 9, the percentage of respondents who changed their recommendation from baseline differed. That is, the information in conditions 5, 6, 8 and 9 were similarly effective at creating systematic changes in respondents' recommendations. Furthermore, those who changed a response from "don't know" at baseline, made changes consistent with the health outcome logically effected. This was true across all eight non-baseline conditions.Table Table Table Where the increased absolute risk of breast cancer due to the medication was given along with information about the decreased relative risk of heart disease, decisions to recommend the medication were nearly as great as in the baseline condition. However, the evidence clearly suggests respondents paid attention to both additional pieces of information. Where the very low absolute risk of breast cancer was presented, the increased risk appeared to be more acceptable in the face of the benefit in reducing the risk of heart disease. Where respondents were given information in absolute risk terms for both breast cancer and heart disease, twice as many chose to recommend the medication as did where both risks were given only in relative terms. This was only two-thirds as many as did so in the baseline condition. Compared to the baseline condition, respondents seemed to use both additional pieces of information. This is consistent with Expected Utility theory predictions, but was clearest under absolute risk conditions.Table Table The table (again) shows that the interaction term is significant, indicating that the effect of the risk information format for each disease differs depending on what is known about the other disease. In this case, the table indicates that communicating risk information about both heart disease and breast cancer in absolute risk terms significantly changes positive recommendations compared to scenarios in which respondents received risk information in other combinations of formats.A third of the cross-sectional sample chose something other than to recommend taking the medication in the baseline condition. While the primary purpose of this experiment was to explore the effect of information format on treatment decisions, additional analyses were performed to better understand individuals who seem to make decisions contrary to the evidence given, or who indicated an inability/unwillingess to make a decision. The two dummy variables constructed for this purpose, DONTKNOW and WRONG were analyzed against a broad set of demographic and clinical variables, including gender, race, ethnicity, living as a couple or not, age (in categories), rural/urban dwelling, education (in 4 categories), current smoker, current heavy drinker, perceived health as only fair or poor, physical activity, overweight, employed, and avoids medical care or uses alternative sources of care. (Heavy drinker and overweight definitions were taken from the Centers for Disease Control and Prevention (CDCP) Behavioral Risk Factor Surveillance System.Table Table In general, the risk presentation format appeared to influence the resulting decisions. Without knowing the absolute risks, respondents appeared to assume the risk of breast cancer was much greater than the risk of heart disease, or that the perceived likely consequences of breast cancer were significantly less acceptable than those of heart disease. The pattern of recommendations was made to avoid the greater perceived risk. When the competing risks were stated in absolute risk terms, respondents changed their recommendations appreciably. The results of the experiment strongly suggest that people's prospective preventive treatment decisions can be greatly affected by the manner in which potential risks and benefits are communicated to them. When given information regarding the absolute risks associated with a proposed treatment, individuals make remarkably "rational" decisions, clearly indicating the weighing of risks and benefits.It appears that presenting risks in absolute rather than relative risk formats may be more effective in helping respondents make decisions that are consistent with maximization of expected utility. It appears, in the scenarios devised here, this may be due to the previously documented finding that people exaggerate the risk of cancer -17. TheyOur findings seem to indicate that, in the absence of explicit information regarding the absolute risks of particular outcomes, patients interpret information about relative benefits or risks based on whatever preconceptions they may have about their chances of getting the disease in question. That is, they make reasonable use of the relative risk information if they do not know the base risk rates. However, to the extent that these preconceptions may be quite inaccurate, relative risk information may lead them to make decisions that seem irrational and inconsistent with their actual preference. Without information about the absolute risks, health information may become misleading and individuals may reach conclusions that go quite counter to what they actually think about the appropriate balance of benefits and risks of treatments.Framing the scenarios as recommendations to a friend made the decision-making relevant to both males and females. The logistic regression analyses found no significant differences in decisions based on race, gender, or other demographic characteristics in this relatively large and representative sample. This suggests that these results may represent a general population response pattern. It is clear from the results that members of the public will generally use explicit absolute risk information in quite rational ways when it is available. Consequently, providers of health information, both public and clinical, would be well-advised wherever possible to provide patients with the necessary risk/benefit information in terms of the absolute risks associated with treatment options. Making the best information readily available and comprehensible may reduce reliance on errant preconceptions and opinions. This research suggests that having absolute risk information routinely available to patients and physicians for use in making clinical decisions may be an important part of improving health care decisions.This study is unique in surveying the general public rather than clinical populations on the effects of risk formats on decision-making. However, it was limited to presenting risks only in terms of the chances of an outcome occurring. It did not address the magnitude of the outcome's impact on the individual's life or the acceptability to the individual of the relevant alternatives. Future research should address these aspects of risk as well as explicitly investigating assumptions about risks of specific diseases. Research that explicitly assesses general public risk perceptions may be valuable in determining the need for absolute risk information in specific disease contexts. Providing baseline absolute risk information in certain disease contexts may lead to improved patient treatment decision-making.The author(s) declare that they have no competing interests.LAH conceived and carried out the survey. MHR and CEW provided medical decision making context for interpretation and discussion. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Healthy Communities pilot projects were developed to test approaches and recommendations of the Washington State Nutrition and Physical Activity Plan and to provide a statewide model for implementation. The Healthy Communities program included plans for ongoing process evaluation to ensure implementation. Two years into the first project, however, the evaluation team recognized that data for evaluation were inadequate to explain the experiences of the pilot community partnership. The team sought a framework through which to better understand how the community partnership functioned, including what worked well and how guidance and technical assistance could best be provided. The evaluation team identified the community health governance model of Lasker and Weiss through a literature search and applied this model to existing Healthy Communities project evaluation data. The team also designed a new survey tool based on the model and used it in the second pilot community. The new tool provides feedback to community partners to help guide project implementation and tests the applicability of a theoretical model to public health practice.Washington State's  Preventing Childhood Obesity , DOH recruited the city of Moses Lake in 2002 as the first pilot community to test implementation of the Washington State Nutrition and Physical Activity Plan  has lead efforts to prevent obesity and overweight on both the state and community policy levels. Community efforts have been organized as ity Plan . Table 1Initial planning for the Moses Lake pilot project was conducted by an advisory committee composed of leaders and representatives of civic organizations, city and county agencies, businesses, and interest groups as well as community residents. Members of the advisory committee identified three initial strategies from the state plan and created and formalized an action plan for their implementation. In the next phase, activity shifted from the advisory committee to the three project teams: 1) trails and paths, 2) breastfeeding, and 3) community garden. Many members of the advisory committee served on a project team and recruited new members. During this phase, the advisory committee as a whole met less frequently. The leadership group (planning team), including the project coordinator, advisory committee, three team leaders, and DOH staff, continued to meet to coordinate the subprojects and monitor overall progress.Healthy Communities included staff from the University of Washington (UW) and DOH. Because our initial tools did not adequately explain the Moses Lake pilot project experiences, we searched for a theoretical framework that would include constructs that describe factors we identified as barriers to or enhancers of the success of Healthy Communities Moses Lake. We conducted a literature review of available frameworks and identified the community health governance (CHG) model developed by Lasker and Weiss  provide feedback to the project leadership team so that the community development process could be improved and 2) gather ongoing needs assessment data from new stakeholders in Moses Lake. The survey consisted of 14 scaled questions that asked members of the advisory committee to evaluate the committee structure and function, leadership facilitation, technical assistance that was provided, their commitment and personal values, and their understanding of the project's purpose and goals. Open-ended questions asked about partnership values as well as barriers to and motivators for participation; these questions also provided an opportunity to identify other people who might want to be involved in the project.Healthy Communities work across agencies and programs.A survey of Moses Lake advisory committee members was conducted again in January 2004. This survey was similar to the December 2002 survey except that it included new questions to identify partnerships that had been formed among committee members and new questions to measure the degree of integration of Healthy Communities Moses Lake shifted from the advisory committee to the three project teams. During this time, the membership fluctuated, and the project evaluation team asked additional questions to better understand the reasons for the fluctuation. In June 2004, a new telephone survey was conducted that included most of the questions from the December 2002 survey as well as additional open-ended questions that asked about members' motivation, perceived support, priorities, barriers, project impact, costs and benefits, and understanding of project purpose. The full survey was given to members of the three project teams. In addition, three advisory committee members who had responded to the survey in January 2004 were selected to answer only the new set of open-ended questions.In the second year, the focus of The survey results provided feedback about how the project was progressing and how the partnership was functioning, and the new set of open-ended questions added qualitative information about members' experiences. However, the data did not systematically integrate the reported experiences with other reports  of how tHealthy Communities project. In the CHG model, critical characteristics take into account who participates in a project and how they participate in the collaborative process. The proximal outcomes of the partnership process are the empowerment of individuals and groups to come together in partnership, create and enhance social ties, and work to resolve community health problems. The roles of leadership and management are crucial to ensuring that the critical characteristics of the collaborative partnership process can occur. Leadership and management roles include promoting active participation that is broad and representative of the community, facilitating the group processes, promoting incremental growth and development of the partnership, and providing training and technical assistance as needed. The CHG model elaborates on examples of these elements of the collaborative partnership process.At this time, the evaluation team began to use the CHG model  as a wayEleven of the scaled questions in the two Moses Lake surveys touched on components of the CHG model, including individual empowerment, bridging social ties, synergy, critical characteristics of who was involved and how they were involved, the scope of the process, and leadership and management parameters, including promoting participation and facilitation. However, the survey questions did not provide adequate data to apply an integrated overview of the CHG model, and the survey was substantially revised to include additional CHG constructs .Healthy Communities project began in Mount Vernon in January 2004, and the revised survey tool was administered to members of the Mount Vernon advisory committee in September. The survey was administered at the end of the committee's planning phase before it launched its three projects. The purpose of the new survey was to be able to understand how leadership, management, and process and community dynamics contributed to the long-term success or failure of initiatives to improve community health. In the revised survey, the focus shifted from individuals' experiences and perceptions to their views of the partnership itself and how the partnership functioned.The second The evaluation team used published studies of community partnership functioning and related survey tools to create the new survey . The revThe survey was easy to administer and score, and conducting the survey by telephone permitted evaluation staff to clarify questions and take notes of comments and feedback. Most of the UW staff who administered the survey reported that the questions seemed to be readily understood. The survey took 20 to 25 minutes to complete.For all of the surveys, triangulation was an integral part of data analysis. Results of the surveys were compared with objective observations of the project, including community involvement, attendance and participation at meetings, and progress toward project objectives and goals . Overallleadership and management forbroad and active participation indicated that Hispanic residents were not adequately represented on the advisory committee. The advisory committee had recognized from the outset the need to include diverse groups in the community and had made efforts to do so, but findings from the survey emphasized a need for change and resulted in additional outreach efforts to include the local Hispanic population in Healthy Communities Mount Vernon. Results were used for further planning. For instance, responses to questions about integrationand scope of the project indicated that respondents were confused about their role in sustaining Healthy Communities initiatives. Many of the members believed that their commitment to the project was over at the end of the initial planning phase. In fact, as documented by meeting minutes and memos, that was how the initiative was presented when community involvement in the advisory committee was initially solicited. When the transition from planning to implementation took place, many members left the project, so new members had to be recruited to replace them. In Moses Lake, there was 50% turnover. Community leaders and DOH staff concluded that this two-part recruitment may be a necessary component of this type of intervention. If the initial recruitment had suggested that volunteers were signing up for a 5- to 7-year project, there may have been far less community involvement. In addition, the planning and implementation phases may attract people with different interests and skills, so membership turnover should be expected during the transition from planning to implementation.Other survey results also affected future plans. Responses to questions about Healthy Communities project outlined in the Washington State Nutrition and Physical Activity Plan was based on the social–ecological model (The al model , and deval model  and valual model -24. We fal model  includesIntegral to the CHG model is the assumption that processes of community participation are crucial to effective solutions for community health problems . The modSimilarly, the CHG model affects program evaluation. Rather than focusing only on behavior change and long-term health outcomes as measures of health promotion interventions, the CHG model provides a framework for examining the intermediate processes of the partnership as proximal outcomes. Use of the CHG model to organize information can aid in assessing processes in which individuals and organizations work together to identify and address health problems at the community level. The model can also help to guide public health workers in project management. A well-designed process evaluation guides the use of limited staff time and project funding and thus can improve efficiency and effectiveness.The CHG model shows how the dynamic and complex interactions of community partners using community resources can lead to improved community health. The model identifies markers that can reinforce partnership activities. The markers, such as representation of community diversity and mechanisms for accountability within a collaborative process, are not ends in themselves, but the presence and strength of these markers become guides for public health practitioners in promoting community-based interventions.Healthy Communities pilot projects in Washington. The model was used to develop a telephone survey tool to assess community partners' perceptions of a Healthy Communities project. Results from the survey provided feedback for DOH staff, university partners, and community leaders. In addition to scaled questions that addressed elements of the CHG model, several open-ended questions were important for identifying issues raised by the scaled questions. These open-ended questions provided the opportunity for respondents to voice their opinions and provided essential information for translating survey findings into meaningful directions for actions.The CHG model served as a guide for evaluating the


Members of the Deaf community face communication barriers to accessing health information. To resolve these inequalities, educational programs must be designed in the appropriate format and language to meet their needs.Deaf men (102) were surveyed before, immediately following, and two months after viewing a 52-minute prostate and testicular cancer video in American Sign Language (ASL) with open text captioning and voice overlay. To provide the Deaf community with information equivalent to that available to the hearing community, the video addressed two cancer topics in depth. While the inclusion of two cancer topics lengthened the video, it was anticipated to reduce redundancy and encourage men of diverse ages to learn in a supportive, culturally aligned environment while also covering more topics within the partnership's limited budget. Survey data were analyzed to evaluate the video's impact on viewers' pre- and post-intervention understanding of prostate and testicular cancers, as well as respondents' satisfaction with the video, exposure to and use of early detection services, and sources of cancer information.From baseline to immediately post-intervention, participants' overall knowledge increased significantly, and this gain was maintained at the two-month follow-up. Men of diverse ages were successfully recruited, and this worked effectively as a support group. However, combining two complex cancer topics, in depth, in one video appeared to make it more difficult for participants to retain as many relevant details specific to each cancer. Participants related that there was so much information that they would need to watch the video more than once to understand each topic fully. When surveyed about their best sources of health information, participants ranked doctors first and showed a preference for active rather than passive methods of learning.After viewing this ASL video, participants showed significant increases in cancer understanding, and the effects remained significant at the two-month follow-up. However, to achieve maximum learning in a single training session, only one topic should be covered in future educational videos. Interpersonal communication problems are present throughout the health care system. These problems take on greater significance when compounded by language and cultural barriers. The Deaf community, whose predominant language is American Sign Language (ASL), faces the same barriers to accessing health information and services as other communities whose members use English as a second language -22. In aThis paper reports on the evaluation of a prostate and testicular cancer education video, filmed in ASL, to increase Deaf men's access to health information. Prostate cancer is the most common, life-threatening cancer in older American men (age 50 and older), and testicular cancer is a potentially curable disease that affects younger men (ages 15–40) . Deaf meProstate and Testicular Cancer: Know your Options, was produced in 2002 through a partnership composed of Deaf Community Services of San Diego, Inc. (DCS), the Rebecca and John Moores UCSD Cancer Center, Bovee Productions, and Gallaudet University. The film was a New York Festivals Certificate of Distinction Finalist Winner in 2004. The educational video, filmed in ASL, shows two trainers providing answers to their audience's questions. Although the focus of this study was on the Deaf community, the addition of open text captioning and voice overlay without ambient music enabled the video to be accessed by both deaf and hard-of-hearing individuals, as well as their hearing loved ones. The video can be viewed at .The 52-minute video used for this study, entitled Participants in the authors' prior studies had recommended that the ASL videos should include the same amount and complexity of information as that which would be available to the hearing community. Further, they recommended that men, like women, needed access to quality information about their gender specific cancers. In the light of the demonstrated need for increased access to health information, the authors opted to create a video that addressed prostate cancer and testicular cancer. This offered a way of reducing redundancy, encouraging men of diverse ages to interact in a supportive, culturally aligned, learning environment, and also covered more topics on the partnership's limited budget. As a result, the final video was complex, particularly in light of the community's limited prior exposure to cancer information and the many new medical terms and concepts that needed to be introduced. As such, the film was intended for multiple viewings to achieve mastery all of the information. The study looked at the impact of only a single viewing.Using a train-the-trainers model, the video was presented to small groups of Deaf men and women in community settings. Recruitment strategies were accomplished in collaboration with Deaf community service agencies throughout California: Deaf Community Services of San Diego, Inc.; Center on Deafness-Inland Empire; Deaf and Hard of Hearing Service Center, Inc.; Deaf Counseling, Advocacy and Referral Agency; NorCal Center on Deafness; Greater Los Angeles Agency on Deafness, Inc. These strategies included in-person and e-mailed word-of-mouth dissemination and IRB-approved flyers ,29. StudAfter passing a knowledge competency exam, six native signers were trained how to use the educational video. Sixteen educational sessions were held with a total of 102 men and 59 women attending. Attendance per session ranged from five to 32 persons. Only men were invited to take part in the evaluation of the video, and of those 102 men who attended the sessions, all consented to participate. All participants were offered the option of having the consent process, the consent documents, and the surveys translated into ASL, a service required to varying degrees. The consented participants completed the baseline survey before viewing the video. The video had been filmed in a question and answer format to make it easy for the trainers to stop and start the video to stimulate audience discussion and assure comprehension of content. Study participants and other attendees were to watch the video under the direction of the local grassroots trainers with the oversight of the project coordinator, both native signers. At the conclusion of the video, participants completed post-education intervention surveys. Participants and other audience members  then engaged in a focus group discussion lead by the facilitators, lasting approximately 30 minutes to 60 minutes. Two months later, follow-up meetings were set up via e-mail, TTY, or in-person for completion of the final survey, with 95 men  completing the follow-up survey.The paper and pen surveys collected socio-demographic data and used multiple-choice, true or false, and open-ended questions related to the presentation. All data collection instruments were approved by the University's Institutional Review Board (IRB).The surveys were analyzed using t-tests and McNemar chi-square tests to assess for differences between pre, post, and two-month responses. Comparisons made between the pre/post video surveys and the two-month follow-up surveys examined only the 95 men who responded at two months. Unanswered questions were omitted from the analysis.The study participants all resided in Southern California and were between 18 and 86 years of age . Participants completed an average of 13.68 (SD 3.32) years of school with a range from four years to 24 years. While 28.4% (29) of the group completed high school, 28.4% (29) completed some college, 20.6% (21) completed college, 14.7% (15) completed education beyond college, and 6.9% (7) did not answer the question. The group was composed of: 62.7% (64) Caucasians; 7.8% (8) African Americans; 5.9% (6) Asian/Pacific Islanders; 16.7% (17) Hispanics; 2.9% (3) Mixed; and 3.9% (4) Other. For health care expenses, 6.9% (7) paid for their health care out of pocket; the others had MediCal/Medicaid (27.5% (28)), Medicare (25.5% (26)), other health insurance (39.2% (40)), or other sources (1% (1)). Of the sample, 43.1% (44) reported having friends with prostate cancer, and 19.6% (20) reported having friends with testicular cancer. There were seven men (6.9%) who reported having had prostate cancer themselves, and there was one man (1%) who reported having had testicular cancer.Table When the men were asked whether they felt that there needed to be more programs on cancer and other health concerns specifically made for the Deaf community, 94.1% (96) responded affirmatively. Before and after the educational intervention, the participants were asked to rate their perception of the Deaf community's access to health information on a one to five scale with one being "very little" access and five being "a lot" of access. The results, shown in Table 1 = 15.2, post-video X2 = 18.4, t = -9.698, p < 0.05). X denotes the mean number of correct responses; all the participants' scores (number correct/25) were added, and the total was divided by the number of participants. From baseline to the two-month follow-up, participants maintained their overall statistically significant increase in knowledge . These questions are clustered by format, and the results are shown in Tables A total of 25 knowledge questions were asked on the surveys to assess whether there was any significant change in the participants' knowledge about prostate and testicular cancer from pre- to post-intervention and whether this increase was maintained at the two-month time point. From baseline to immediately post-intervention, participants' overall knowledge increased significantly  felt that the video provided useful information, but 88 (86.3%) felt that too much information was provided. Most of the men (85 (83.3%)) agreed that the video needed to be watched more than once to understand all the information, and 92 (90.2%) of the men planned on watching the video again. Seventy-six (74.5%) felt that most in the Deaf community would be interested in the video, and 95 (93.1%) were comfortable showing the video to their friends. At the two-month survey, 67 (65.7%) of the participants reported they had watched the video again, and 28 (27.5%) had already shared the video with someone else.The goals of this study were to gain knowledge of participants' baseline screening behaviors and knowledge, evaluate the effectiveness of a prostate and testicular cancer video program in increasing knowledge about these cancers in the Deaf community, and gain feedback from the participants about their experience with the program and with other cancer information sources. An additional aim was to increase the Deaf community's awareness of available health resources.This study demonstrates that the provision of culturally and linguistically aligned educational strategies can increase the community's access to health information. There was near universal agreement that the video provided useful information and that there needs to be more special health programs designed for the Deaf community. Most men viewed the video again, and many shared it with others. After viewing the video, which provided websites and TTY numbers to access additional information, and learning that the video could be accessed on the Internet, participants perceived that the Deaf community had increased access to health information. Consensus reached in the focus group discussions was that the video was a culturally aligned method of education about these two cancer topics. Thus, the participants' perception of an increase in access to information was the result of having information available in ASL and having knowledge of where to find additional resources.Participants also demonstrated a significant increase in knowledge after viewing the video just once. Overall, there was an increase in the number of correct responses after the video in sixteen of the 25 knowledge questions. While this gain was not fully maintained at two months, it still remained above baseline at a statistically significant level. Since the men all received copies of the video and were aware of the video's presence on the Internet, they also knew they could access the information again to review or to deal with a health related crisis.While including as much information in this video as possible was an admirable goal, given the dearth of information available in ASL, participants' feedback suggests that a single health topic focus would be better for future videos. Most of the participants felt that the video offered too much information to absorb in a single viewing. This is not surprising, given that the video attempted to explain highly complex scientific concepts like chemotherapy, metastasis, benign prostatic hypertrophy, and malignancy to a non-medical audience. While the video's focus on two cancers may have reduced participants' long-term retention of details, it allowed men of diverse ages to lend support and encouragement to each other during the training sessions and facilitated subject recruitment. Because the video was filmed as question and answer dyads, it is possible to view the two topics, prostate cancer and testicular cancer, separately. Another study is currently underway to explore the impact of just viewing the video dyads related to testicular cancer.This feedback highlights the need for programs that continually reinforce health concepts in the Deaf community rather than just one-time seminars. This study also reinforces the importance of long-term follow-up in the assessment of educational interventions. Studies that simply survey participants before and after the intervention fail to recognize that long-term retention of information does not always correlate with short-term learning. Moreover, this study underscores the challenge health care providers face even when trying to explain complex medical issues through a medical interpreter. Videos such as this one should help to bridge the communication gaps.While a strength of this study is its diverse sample, generalizations must still be drawn with caution since this group of men collectively had a relatively high level of education. It is unclear whether this video and educational format would be equally effective for deaf persons who have a low ASL literacy or more limited education. Additional evaluation of this educational format is therefore warranted with those audiences. Further, as with all studies, these men were self selected by their interest in learning about cancer, so their motivation to gain knowledge was probably higher than average. They may not be representative of all patients who will present for medical care.The most popular sources of information among the surveyed individuals included physicians, Internet, DCS, and health education programs. The available literature reports communication problems and mistrust between deaf and hard-of-hearing persons and their health care providers ,21,30,31 and through the National Association of the Deaf's Caption Media Resource library, health care providers can encourage their patients to view this and other videos provided in ASL or with captioning. While such educational resources will offer a valuable tool to providers and their deaf patients, the focus group discussions showed that the provision of high level certified medical interpreters would be the single most important improvement health care providers could offer to their deaf patients to reduce the difficulties they experience when seeking medical care. With the growing number of certified medical interpreters and technology advances that have made video relay services available, it should be increasingly easier for physicians and their patients to access high level interpreting services more efficiently.This educational intervention was created specifically to help health care providers meet the information needs of the Deaf community. Since the video can be viewed on the Internet at the Rebecca and John Moores UCSD Cancer Center website When the participants' responses regarding sources of cancer information were analyzed according to whether English literacy was required and according to whether the learning was based on social interaction, participants overwhelmingly preferred interactive forms of learning. This further reinforces the importance of providing information in the correct format to properly meet the needs of Deaf community. Ideally, an ASL video should be accompanied by person-to-person interaction between the viewer and another individual familiar with the health topic in order to facilitate better retention and understanding of the material. Television was rarely mentioned and radio was never mentioned as a source of information; this highlights the fact that these popular sources of information for the hearing public are not adequate means to address the needs of the Deaf community.An unforeseen benefit of this program for the Deaf community was that it exposed many individuals to the process of research studies and allowed them to become familiar with the consenting process, data collection procedures, and protocol adherence. Considerable time was devoted to explaining the reasons why one does a pre- and post-survey and how the results of these surveys could be used to design even better programs for the Deaf community. Study coordinators remarked on the audience's enthusiasm about understanding how the video was made and how the research study worked. They were uniformly appreciative of the intervention and willing to share the experience with loved ones and friends outside of the sessions. In the future, this positive exposure may encourage members of the Deaf community to consider invitations to participate in clinical trials and other research studies.Prostate and Testicular Cancer: Know Your Options. At the two-month follow-up survey, this increase in knowledge was still significant, although slightly diminished. This relative lack of sustainability is due in part to the complexity of the material, but it also highlights that multiple viewings are needed to gain the full benefit of the educational intervention. The Deaf community, like other communities, will benefit from being exposed to multiple repetitions of the same message. Future videos should be focused on one cancer and shorter in duration. The men in the study confirmed the need for more health education materials aimed at the Deaf community and rated doctors as their number one source of health information. Ideally, increasing distribution of health education materials to physician's offices would facilitate better access to and trust in educational interventions.ASL videos provide an effective tool for bringing cancer information to the Deaf community. Deaf men in the study showed significant increases in their short and long-term understanding of prostate and testicular cancers after viewing the film, The author declares that he has no competing interests.AF wrote the script and designed the graphics for the video, participated in the data analysis, and drafted the manuscript. GRS conceived the study, oversaw the day-to-day operation of the project, and drafted the manuscript. CK performed the statistical analysis and assisted with review of the manuscript. PB and SM were co-leaders in the study's training sessions, conducted the informed consenting process, collected and managed the database, and assisted with the cultural interpretation of the results. MB produced the video, and assisted with review of the manuscript. All authors have read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


As the United States population ages, an unprecedented proportion of the population will be aged 70 and older. Knowledge of alcohol use and its consequences in this age group is not well known. In light of the disparate findings pointing to negative outcomes with excessive drinking yet also benefits of moderate drinking, the true risk of alcohol use in late life needs more investigation.This study examined the correlates and 2-year health outcomes related to alcohol use in 7,434 elders aged 70 years or older. Data was collected as part of the Assets and Health Dynamics of the Oldest Old (AHEAD), a nationwide health and economic study of elders. Data from Wave 1 and Wave 2 of AHEAD are presented. Frequency and quantity of drinking was assessed by self-report as was health status, lifetime alcohol or psychiatric problems, presence of chronic illness, functional impairment, and depressive symptoms. Cognitive status was assessed using a brief measure.Approximately 44% of the sample reported any alcohol use in the past three months, with the majority of drinking less than daily. Daily drinking was associated with being Caucasian, married, in relatively good health, and having good affective and cognitive status. Drinking was not associated with negative health outcomes two years later and was protective against stroke and functional impairment. Decline in drinking between Wave 1 and Wave 2 was strongly associated with poor health.This study offers no evidence of negative health outcomes for drinking moderately and confirms the U-shaped curve often found in studies of alcohol and health. Nonetheless, cessation of drinking was associated with poor health suggesting the health benefits of moderate drinking may result from selection of a healthy group of people capable of sustained moderate drinking. Public health recommendations for moderate drinking must take this phenomenon into account. The age structure of the US population is making an unprecedented shift towards growing proportions aged 65 and older. The number of Americans aged 65 and older grew from 3.1 million in 1900 to 35.3 million in 2001[The aging of the US population calls for more research on the prevalence, risk factors and consequences of alcohol use in late-life. In contrast to the vast literature on alcohol use and abuse in younger age groups, relatively little is known about drinking patterns in the elderly, particularly the oldest-old. Of the two largest community based studies of psychiatric disorders, the Epidemiologic Catchment Area Study (ECA) and the National Comorbidity Survey, only the former included people aged 65 and older. The ECA estimates alcohol abuse in this age group to range from 1.9 to 4.6% for men and from 0.1% to 0.7% for women. This stDrinking in late-life has become a more complicated issue in light of the growing literature on the health benefits of moderate drinking and the relatively lower risk for alcohol abuse. Whereas abstinence was once considered the healthiest option, more and more physicians and public health leaders are following an informal clinical policy of recommending moderate drinking, usually defined as one drink per day. Several studies in predominantly middle aged samples (mean age between 50 and 60 years) have found a benefit of moderate drinking, particularly for cardiovascular outcomes . Both meThose that propose a direct benefit of alcohol cite the effect of raising high- density lipoprotein (HDL) cholesterol levels in moderate users ,10. FurtIn support of this, the British Regional Heart Study of middle aged British men found that 70% of non-drinkers are ex-drinkers; thereby contaminating comparisons of the long-term health risks and benefits of alcohol use,16. SimiIt is unclear if these benefits of moderate drinking hold in late-life. A separate examination of elders only is needed because of the issue of competing risks, particularly in more vulnerable elderly. Taking into account competing risks means examining the full risk profile for a certain behavior rather than examining its impact on one outcome. Although cardiovascular health is enormously important in aging, the recommendation of moderate alcohol use must take into account alcohol's potential to cause other negative outcomes in late-life. The benefits of moderate drinking need to be weighed in light of the risk they pose to other key geriatric syndromes such as cognitive impairment, depression, falls, and hip fracture.The negative effects of alcohol use relate mostly to excessive drinking. Alcohol abuse can lead to pancreatitis, cirrhosis, or alcohol-related cardiomyopathy. It may This study presents data collected as part of a nationwide community-based survey of elders aged 70 and older who participated in the Assets and Health Dynamics of the Oldest Old (AHEAD). It has AHEAD is a companion study to the Health and Retirement Survey and is intended to investigate the impact of health transitions on personal financial management, service and public program utilization, and intergenerational transfer of assets,23. WaveThe sample used in this study were all who participated in the first wave of AHEAD  excluding spouses under the age of 70. Of these, 727 died between Wave1 and Wave 2. Of the living at Wave 2, 6,222 completed the second interview yielding a 93% follow-up rate. There is some variability in sample size for individual analyses due to missing data. Minor variability is due to non-response of participants and alters sample size by no more than ten observations. In addition, when proxy informants were used, the depression measure was not administered limiting the sample size to N = 6649 for analyses using this variable. Likewise, the cognitive measure was not administered when proxy interviews were done or the respondent was unable to complete the measure, limiting analyses including cognitive status to N = 6351. Demographic characteristics of the entire sample are provided in the second column of Table All health assessments were based on self report, except for cognitive status, which was based on the Telephone Interview of Cognitive Status-Revised. MortaliIn Waves I and II, all participants were asked about frequency and quantity of drinking in the three months prior to the interview. Two questions assessed quantity of drinking "Do you ever drink any alcoholic beverages such as beer, wine, or liquor?" which was followed by "In general, do you have less than one drink a day, one or two drinks a day, three or four drinks a day, or five or more drinks a day." Participants were also asked the first item from the CAGE screen foThese too, were based on self-report. Participants were asked to rate their health as excellent, very good, good, fair or poor. Participants reported whether a medical doctor had diagnosed them with cancer, heart disease, diabetes mellitus, high blood pressure, lung disease, stroke, or arthritis. They also reported whether they were current, former, or never smokers.Participants were asked "Have you fallen down in the past 12 months?" and "Have you ever fractured your hip?"Measure of participant's functioning on activities of daily living (ADL's) and instrumental activities of daily living (IADLs) were assessed. In the ADL assessment, participants reported whether they needed help walking, dressing, bathing, eating, getting into bed, and using the bathroom. These iThe AHEAD cognitive measure was adapted from the Telephone Interview for Cognitive Status, which wAll statistical analyses were conducted on SAS statistical software. Descriptive analyses were conducted using chi-square tests for categorical variables and a Wilcoxon rank-sum test or the Kruskal-Wallis Test for continuous variables. The longitudinal analysis used logistic regression for categorical variables and a general linear model for continuous variables. Two sets of longitudinal analyses were conducted which examined the impact of Wave 1 drinking on health outcomes at Wave 2 occurring two years later. The first set controlled only for the Wave 1 value for the predicted Wave 2 outcome. The second set controlled for age, sex and education and the Wave 1 value for the predicted Wave 2 outcome. Because the results were largely similar, only the latter are presented, and the former are available upon request.Similarly, generalized estimating equations were conducted on the initial bivariate analyses presented in Tables Table Table The demographic correlates of drinking are provided in Table Most of the negative health outcomes examined were higher in the non-drinkers and lower in the moderate drinkers Table . DiabeteTable 2(df = 3) = 38.5, p < 0.0001). Twelve percent of the non-drinkers died while the mortality rate for those drinking less than once a day, once to twice a day or three or more times a day were approximately the same ranging from 6.5% to 7.6%. Therefore, any health benefits presented in Table Of note, 727 participants died between Wave 1 and Wave 2. Alcohol use was strongly associated with mortality , but may not be appropriate for the general population.The author(s) declare that they have no competing interests.CT conceived of the study, participated in its design and helped to draft the manuscript.DK conceived of the study and helped to draft the manuscript.SS participated in the design of the study and helped to draft the manuscript.All authors read and approved the final manuscript.


Little is known regarding the cardiovascular disease risk factors among Chamorros residing in the United States.The Chamorro Directory International and the CDC's Behavioral Risk Factor Surveillance System Questionnaire (BRFSS) were used to assess the health related practices and needs of a random sample of 228 Chamorros.Inactivity, hypertension, elevated cholesterol and diabetes mellitus were more prevalent in this Chamorro sample compared to the US average. Participants who were 50-and-older or unemployed were more likely to report hypertension, diabetes and inactivity, but they were also more likely to consume more fruits and vegetables than their younger and employed counterparts. Women were more likely to report hypertension and diabetes, whereas men were more likely to have elevated BMI and to have never had their blood cholesterol checked.The study provides data that will help healthcare providers, public health workers and community leaders identify where to focus their health improvement efforts for Chamorros and create culturally competent programs to promote health in this community. Cardiovascular disease, which encompasses heart disease, stroke and hypertension, was responsible for 16.7 million deaths in 2003. This number represented one-third of total deaths worldwide [Cardiovascular disease is the leading cause of death across all ethnic groups, including Caucasians, African-Americans, Hispanics, American Indians/Alaskan Natives. Among Asian Americans and Pacific Islanders (AAPI) ,3 it is Cardiovascular disease is a major cause of morbidity and mortality within the AAPI community, accounting for over 25% of all AAPI deaths in 2001 . ComplicThus to develop a niche social marketing campaign, it is first necessary to understand the audience, the outcomes to be accomplished, and the messages to be delivered toward this end. In this study, Chamorros and cardiovascular disease were the focus of the research team. While Pacific Islanders comprise only 0.3% of the total U.S. population , they arThe Pacific Islands are divided into three large geographical regions: Micronesia, Polynesia, and Melanesia. Chamorros are indigenous people of the Mariana Islands, a sub-division of Micronesia. The vast majority of this ethnic group is found in Guam, an island of the Marianas archipelago, and the continental United States. According to the 2000 Census, of those Chamorros living in the continental United States, more than one-third resided in California, with San Diego County home to the largest Chamorro community outside of Guam ,15. ThusIn this paper, the authors report on the risk factors for cardiovascular disease that were identified in San Diego's Chamorro community. By documenting such baseline data in this rapidly growing minority group, health care providers and community leaders can identify and create culturally competent, specific interventions for Chamorros.The Center for Disease Control and Prevention's 2001 core Behavioral Risk Factor Surveillance System (BRFSS)  and fiveChamorro Directory International (a telephone directory composed exclusively of people who self-identified as members of the Chamorro community) was used to reach members of the local Chamorro community. Leaders of the Chamorro Community have maintained the Directory since 1995, updating and reprinting it every 5 years. Data is gathered by word-of-mouth requests for entry information and more recently, by Internet solicitations. As identifiable information is received, every potential entry is contacted to confirm the accuracy of the information and to secure written approval to publish the information. Using a University of California San Diego IRB-approved protocol, all 658 names in the Chamorro Directory International [The national  for the A midpoint review of the sample's socio-demographic data indicated an under-representation of men and male and female Chamorros less than 50 years of age. To address this problem, the recruitment strategy was modified such that surveyors randomly asked to speak with the oldest adult, youngest adult, or any adult male in the family throughout the remainder of the data collection process. Completed surveys were individually reviewed for specific health problems and risk factors. Based on their perceived needs, participants were mailed a packet of personalized health promotion information such as preventive care and self-help resources. At the end of the project, a second packet was mailed containing a letter describing the project's findings and information regarding the community's most pressing overall health risks and needs. All transactions were mailed first-class, so that undelivered mail could be tracked. Only one packet of the 250 mailed was returned as undeliverable. Three of the 228 participants requested that no packet be mailed. All were given this opportunity.The collected data were entered into an ACCESS 2000 database and analyzed with SPSS for Windows 10.0 . Chi-squFrequencies of the eight known risk factors for cardiovascular disease  were also contrasted with the American Heart Association data ,27.This study sample consisted of 100 male and 128 female Chamorros from San Diego County. The male participants ranged in age from 18 to 87 years. Average age for the men was 48.7 years (SD = 17.7); the median, 47.0. The female participants ranged in age from 19 to 88 years. Average age for the women was 54.7 years (SD = 15.2); the median, 57.5. The median education category for this sample group was "1 to 3 years of college," with a range from grade school to at least four years of college. More than half of the study participants withheld information regarding household income, so all results related to income should be interpreted with caution. Of the 49.6% who reported an income, the median household income was "$35,000 – $50,000." Women were much more willing than men to volunteer their income data: 63% of female versus only 33% of male participants reported their income. The vast majority (93%) of participants had healthcare coverage, while a large portion (47%) reported excellent/very good health. Most of the participants were middle-aged (47%), married (61%), and had no children living in the household (62%). Participants' sociodemographic data are presented in Table According to the National Heart, Lung and Blood Institute (NHLBI), an ideal BMI ranges from 18.5 to 24.9. Any person with a BMI of 25 to 29.9 is considered overweight, while a BMI of 30 and greater is considered obese . In thisPhysical activity was calculated as number of days/week multiplied by amount of time/day a person spent doing either moderate or strenuous physical exercise. The CDC recommends a minimum of 150 minutes of moderate exercise or 60 minutes of vigorous exercise per week  and the Daily consumption of fruits and vegetables was calculated for each participant. Total fruit included fruit and fruit juices, whereas total vegetables included green salad, non-fried potatoes, carrots, and others. The AHA's Food Pyramid recommends eating at least 3 servings of vegetable and 2 servings of fruit per day . Sixty pOf the 228 study participants, 42.5% reported they had been diagnosed with hypertension, but only 34.2% reported taking medication for their hypertension  of those who smoked had tried to quit within the last year Table . The aveThe daily consumption of alcoholic beverages was calculated for each participant as the number of days per month in which one had at least one drink, multiplied by the average number of drinks consumed on each of those days, then divided by 30 to obtain a daily average. The AHA recommends drinking should be limited to an average of one to two drinks per day for men, and one drink per day for women . Out of The mean number of cumulative cardiovascular disease risk factors (CRF) for this study population was 2.01 per person. As seen in Table Table Cardiovascular disease is the number one cause of death in the U.S., making it a major national health threat with far-reaching consequences. Since individual health behaviors are highly predictive of disease development and mortality, an effective disease prevention campaign begins with an assessment of modifiable disease behaviors. This study provides an assessment of the cardiovascular disease-related health behaviors of San Diego's Chamorro population. The data can be used by health care providers, public health advocates, and indigenous community leaders to develop cardiovascular disease prevention and intervention strategies that are culturally specific, sensitive, and appropriate to this AAPI ethnic subgroup.While the data in this study has not been age-adjusted, compared to state and national data  the ChamAs expected, the sociodemographic characteristics of age, gender, and employment status were often aligned with the behavioral risk factors. Participants who were 50 years and older and unemployed tended to report hypertension, diabetes, and low physical activity, but they also consumed more fruits and vegetables than their younger and employed counterparts. Women were more likely than men to be hypertensive and diabetic; but men were more likely than women to have an elevated BMI and to have never had their blood cholesterol checked. Men were more likely than women to have set a optimal weight goal that would result in an unhealthy BMI. These are clearly opportunities for interventions by primary care health providers, public health policy makers, the media, and community leaders. Women started smoking later than men, at an age (19.1 years ± 7.8 SD) which coincides with the beginning of gynecology care. This may indicate a role for gynecologists in the primary prevention of smoking in Chamorro women. Conversely, the fact that male participants started smoking at a much younger age (14.9 years ± 4.2 SD) indicates the need for earlier intervention in the male Chamorro population.Among the eight behavioral risk factors examined, BMI is considered to be of great importance due to its relationship to the other risk factors. There has been discussion within the scientific community as to whether the BMI used in the U.S. is applicable to other ethnic minority groups. Some research suggests that there are bone size differences among various ethnic groups that make the simple calculation using height and weight recordings less accurate than a calculation that includes bone size considerations. Further, while these studies suggest that ethnic specific cut-off points for BMI would be more appropriate, there are no widely accepted standards for Pacific Islanders. Therefore, for this community health assessment, the standard BMI cut-off point was necessarily used.Reducing BMI has also been shown to reduce one's risk of developing diabetes, hypertension, and elevated blood cholesterol. Given the immense health benefits of BMI reduction to patients, it is important to ensure patients' related health knowledge and access to supportive services. If health professionals can broach and discuss the topic in a culturally sensitive manner, patients will be more receptive to recommendations and also more likely to cooperate. When helping patients plan a weight loss program, it is important to set attainable goals. The concept of an ideal weight is inherently related to ideal body image, which in turn is determined partly by culture. It is a well-known fact that body image varies widely among cultures. Fat and obesity carry a powerful stigma in modern-day Western society, but are held in high regard among many of the Pacific Islander traditional cultures . Among HOnce a patient's weight and fitness goals have been established, the next step is to devise a weight loss and exercise program that will fit into the community's cultural structure. An earlier paper that assessed this community's risk for diabetes began to address the cultural challenges health care providers will need to be sensitive to, as they strive to help the community improve its over all health status . Diet haThe Chamorro leaders who helped to initiate this community health assessment have demonstrated their ability to undertake a campaign to improve the health of their community. Through focus groups and community town hall meetings, as well as the exchange of information with other Chamorro communities, these same leaders can next begin to evaluate the universality of these findings. Where appropriate, they can also begin to develop strategies to address identified problems or develop plans for further investigation. The interventions they develop are likely to be closely aligned with the values and social fabric of their community. To be optimally resourceful in their program development, Chamorro leaders will need to call upon available public health educators and clinicians to help them interpret the latest medical literature to assure that the health promotion goals they set are grounded on evidence-based research.This study is only the first step in the process of understanding how to optimize the health and well being of the Chamorro community. This study has definite limitations as regards the generalizability of the findings, including the potential for self-selection bias (62.8% response rate), the use of self-reported information that could not be verified in person, the small sample size, the unwillingness of those contacted to report about household income and body mass index and the narrow geographic eligibility for the sample. However, as an exploratory study, the information gathered and analyzed can lay the groundwork for the development of future studies and testable interventions to address those behaviors which increase this community's risk of cardiovascular disease.This baseline health risk assessment for the Chamorro community was initiated by the leaders of the local Chamorro community to identify and address the factors that contribute to improving and diminishing the health of their community. It is a demonstration of a community-campus partnership in action. Through this collaboration with members of the local scientific community, the Chamorro leaders now have preliminary knowledge to help their members gain more personalized insight into their cardiovascular risk status and how to improve it. In turn, the University and the Chamorro community leaders now have a solid partnership that they can use as a foundation for future mutually beneficial undertakings.Healthcare providers play a crucial role in the crusade against cardiovascular disease. Their frequent interactions with patients give them the opportunity to alter the course of this deadly illness by stressing behavioral risk reductions and other prevention strategies. Increasing awareness of the health needs of the Chamorro community and providing culturally competent intervention will enhance health providers' effectiveness as counselors with this ethnic group. Chamorro leaders have an equally important role to play in guiding their community toward the adoption of optimally healthful life styles. This paper presents baseline cardiovascular disease-related health data specific to the continental U.S. Chamorro population. It also relates various Pacific Islander cultural values and practices that may affect Chamorro patients' responsiveness to health professionals.The author(s) declare that they have no competing interests.All of the authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


We conducted an additional case-control study in order to further explore the role of non-alcoholic beverages in bladder carcinogenesis.Bladder cancer is the fourth most frequent malignancy among Uruguayan men. A previous study from Uruguay suggested a high risk of bladder cancer associated with maté, coffee, tea, and soft drinks. Statistical analysis was carried out by unconditional multiple logistic regression.In the time period 1996–2000, 255 incident cases with transitional cell carcinoma of the bladder and 501 patients treated in the same hospitals and in the same time period were frequency matched on age, sex, and residence. Both cases and controls were face-to-face interviewed on occupation, tobacco smoking, alcohol drinking and intake of Ever maté drinking was positively associated with bladder cancer  and the risk increased for increasing duration and amount of maté drinking. Both coffee and tea were strongly associated with bladder cancer risk . These results were confirmed in a separate analysis of never-smokers.maté, coffee and tea may be risk factors for bladder carcinoma in Uruguay.Our results suggest that drinking of  Bladder cancer is the fourth most frequent malignancy among Urugan men, with age-standardized incidence rate of 19.7 per 100,000 pyrene in eight commercial samples of maté leaf bought in Germany; however, the beverage resulting from infusion of the leaves contained only 0.02–0.12 micrograms/liter [maté could have carcinogenic effects due to its contents in tannins [maté leaves) has carcinogenic effects on the kidney [maté displayed mutagenic and clastogenic activities in cell cultures [maté. Recently, Fagundes and colleagues  studied the urine in maté drinkers and found evidences of high levels of PAH derived from tobacco and maté.The most important finding of our study was the significant increase in risk of bladder cancer associated with n cancer -9,13-15 ms/liter . Other c tannins ,18. Expee kidney . Experimcultures ,21. Finacultures  was ablematé could contain chemicals with carcinogenic activity, it was suggested that epidemiologic studies on maté drinking and cancer sites not related with maté temperature in humans could be a useful model to test this possibility. Up to date five such studies were conducted. Three case-control studies conducted in Uruguay [maté drinking and lung, renal cell and bladder cancers. One additional case-control from Argentina study was characterized by a strong direct association between coffee consumption and bladder cancer, but no effect of maté drinking [maté was associated with bladder cancer risk [maté on bladder cancer risk.Since there exist the possibility that  Uruguay ,23,24 didrinking . Finallycer risk . No datamaté drinking could be carcinogenic to cancer sites not related with a direct contact with the beverage. In other words, our findings of a strong direct association between maté drinking and bladder cancer risk are partially supported by previous chemical, experimental and epidemiological studies in cancer of the bladder and of other organs.Thus, it remains the strong possibility that maté drinking by tobacco smoking. In the present study, the analysis of maté drinking was adjusted for smoking status, cigarettes per day and years since quit. Moreover, since there were a sizeable number of never smokers, this allowed to estimate the effect of maté drinking among this subset. Although results among never smokers were less precise than those obtained in the whole study population, the increased risk for heavy drinking of maté obtained in this subgroup detracts from the hypothesis of confounding by tobacco smoking.Another possibility is related with residual confounding of Concerning the effect of other non-alcoholic beverages, both coffee and tea drinking were directly associated with bladder cancer risk, mainly when coffee is ingested with milk. The latter result was unexpected and can be due to chance or residual confounding. It might also indicate the presence of bladder carcinogens in black tea. Previous studies on tea intake and bladder cancer risk yielded controversial results. At least one prospective study  and two maté, coffee or tea would associated with low overall fluid intake. The lack of information on source of drinking water and potential exposure to drinking water contaminants such as chlorination by-products and nitrates is an additional limitation of our study.We did not ask about intake of water. However, this would create a bias only if drinking of water were associated with bladder cancer risk and is correlated to drinking of the beverages under study. Indeed, low overall fluid intake (represented mainly by water) has been suggested as a possible risk factor for bladder cancer , but thiThe present study, as other hospital-based case-control studies, is subjected to several limitations. Selection bias is almost impossible to rule out. We tried to minimize this bias by frequency matching controls and cases on age, sex and residence. Although matching for the latter variable was not complete, we adjusted for it in all analyses. Furthermore, we have adjusted the risk estimates for possible determinants of selection of cases and controls, such as urban/rural status and education.maté drinking has occurred in our study. Furthermore, although current intake of non-alcoholic beverages among controls might have been modified by their disease, we consider unlikely that the use of hospital controls has created a bias in the prevalence of lifetime exposure. A further limitation is the relatively small sample size of the study, which reduced the power of detecting interactions between risk factors  and differences according to subtle differences in exposure . On the other hand our study has strengths. Perhaps the more important strength is related with the high response rate in both series of patients (cases and controls). Another strength is the absence of proxy interviews. Finally, the sizeable number of never smokers, which allowed to estimate OR's of maté drinking among these subset of patients, is a strength of the study.Misclassification bias is also difficult to exclude. It is important to note that the role of nonalcoholic beverages in bladder cancer risk is unknown, both by the general population, the hospital population and the interviewers. Thus, is rather unlikely that differential or nondifferential exposure to maté in bladder carcinogenesis. Also, the effect of maté drinking among never smokers suggest that this beverage is an independent factor. Future studies should confirm or reject the hypothesis of a role of maté in bladder carcinoma. If these findings are confirmed, maté drinking is likely to contribute to the high risk of bladder cancer in Uruguay and other South American countries in which the habit is widespread.The present study replicates previous findings from Uruguay suggesting a role of The author(s) declare that they have no competing interests.EDS, PB, PC and PBr designed the study; EDS, HDP, ALR, GA and MM collected the data; EDS, PB and GF analyzed the data; EDS and PB drafted the manuscript. All authors reviewed and approved the manuscript.The pre-publication history for this paper can be accessed here: