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Objective: Examine factors impacting U.S. parents' intention to vaccinate their children against COVID-19., Methods: Data were collected February-May 2021 from parents living in six geographically diverse locations. The COVID-19 Exposure and Family Impact Survey assessed perceived susceptibility and severity to adverse outcomes from the pandemic. Semi-structured interviews assessed perceptions about benefits and risks of vaccinating children., Results: Fifty parents of 106 children (newborn-17 years) were included; half were Spanish-speaking and half English-speaking. 62% were hesitant about vaccinating their children against COVID-19. Efficacy and safety were the main themes that emerged: some parents perceived them as benefits while others perceived them as risks to vaccination. Parent hesitancy often relied on social media, and was influenced by narrative accounts of vaccination experiences. Many cited the lower risk of negative outcomes from COVID-19 among children, when compared with adults. Some also cited inaccurate and constantly changing information about COVID-19 vaccines., Conclusion: Main drivers of parent hesitancy regarding child COVID-19 vaccination include perceived safety and efficacy of the vaccines and lower severity of illness in children., Practice Implications: Many vaccine-hesitant parents may be open to vaccination in the future and welcome additional discussion and data., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Objective: We examined users' preferences for and engagement with text messages delivered as part of an emergency department (ED)-based intervention to improve antihypertensive medication adherence., Methods: We recruited ED patients with elevated blood pressure for a pilot randomized trial evaluating a medication adherence intervention with text messages. Intervention participants chose text content and frequency, received texts for 45 days, and completed a feedback survey. We defined engagement via responses to texts. We examined participant characteristics associated with text preferences, engagement, and feedback., Results: Participants (N = 101) were 57% female and 46% non-White. Most participants (71%) chose to receive both reminder and informational texts; 94% chose reminder texts once per day and 97% chose informational texts three times per week. Median text message response rate was 56% (IQR 26-80%). Participants who were Black (p < 0.01), had lower income (p = 0.03), or had lower medication adherence (p < 0.01) rated the program as more helpful and wanted additional functionalities for adherence support., Conclusions and Practice Implications: While overall engagement was modest, participants at risk of worse health outcomes expressed more value and interest in the program. Findings inform the design of text messaging interventions for antihypertensive medication adherence and support targeting vulnerable patients to reduce health disparities., Clinical Trials Registration: NCT02672787., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objective: This study describes the development of the Health Coaching Index (HCI), an observational tool for assessing fidelity to implementing health coaching practical skills., Methods: Initial HCI items were developed, adapted following cognitive interviews, and refined during coding training. Participants (n = 42) were trainees who completed a National Board for Health and Wellness Coaching (NBHWC)-approved training program and coached a standardized patient. Interrater reliability for the HCI was determined by calculating interclass correlations from ten videos coded by three raters. Construct validity was evaluated from 42 recordings using Spearman's Rho between HCI and Roter Interaction Analysis System (RIAS) codes., Results: The interclass correlation (ICC) for HCI total score was 0.81, considered an excellent level of inter-rater agreement. Some significant correlations between HCI and RIAS codes supported construct validity (e.g., patient activation: Rho = 0.32; empathy: Rho = 0.36)., Conclusion: The HCI total score can reliably be used to assess fidelity to health coaching skills, and the HCI has construct validity similar to the RIAS as a measure of patient activation., Practice Implications: Adoption and further study of the HCI tool will allow for a more consistent implementation of health coaching skills, and may facilitate more robust training of health coaches for clinical practice and research., Competing Interests: Declaration of Competing Interest RQW serves as the Chief Science Officer for eMindful Inc., is on the Board of Directors for the National Board for Health and Wellness Coaching, and has grant funding from the National Institutes of Health, Abbie Vie and Meharry Medical College. RLR has previously been (not currently) a paid consultant for Abbott and edLogics and has grant funding from the National Institutes of Health, Patient-Centered Outcomes Research Institute, Food and Drug Administration/Nest Coordinating Center, Centers for Medicare and Medicaid Services, and Agency for Healthcare Research and Quality, not specifically related to this research. SJS and EHI have other grant funding from the National Institutes of Health, not specifically related to this research., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: To compare the effectiveness of different approaches to nutrition education in diabetes self-management education and support (DSME/S)., Methods: We randomized 150 adults with type 2 diabetes to either certified diabetes educator (CDE)-delivered DSME/S with carbohydrate gram counting or the modified plate method versus general health education. The primary outcome was change in HbA1C over 6 months., Results: At 6 months, HbA1C improved within the plate method [-0.83% (-1.29, -0.33), P<0.001] and carbohydrate counting [-0.63% (-1.03, -0.18), P=0.04] groups but not the control group [P=0.34]. Change in HbA1C from baseline between the control and intervention groups was not significant at 6 months (carbohydrate counting, P=0.36; modified plate method, P=0.08). In a pre-specified subgroup analysis of patients with a baseline HbA1C 7-10%, change in HbA1C from baseline improved in the carbohydrate counting [-0.86% (-1.47, -0.26), P=0.006] and plate method groups [-0.76% (-1.33, -0.19), P=0.01] compared to controls., Conclusion: CDE-delivered DSME/S focused on carbohydrate counting or the modified plate method improved glycemic control in patients with an initial HbA1C between 7 and 10%., Practice Implications: Both carbohydrate counting and the modified plate method improve glycemic control as part of DSME/S., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Objective: Diabetes patients with limited resources often experience suboptimal care. Less is known about the role of effective health communication (HC) in caring for low income diabetes patients., Methods: Ten health department clinics in TN participated in a trial evaluating a literacy-sensitive communication intervention. We assessed the quality of baseline HC and measured associations with diabetes outcomes. Assessments included: demographics, measures of HC, health literacy, self-care behaviors, self-efficacy, medication non-adherence, treatment satisfaction, and A1C. Unadjusted and adjusted multivariable regression models were used to test associations., Results: Participants (N=411) were 49.7±9.5 years, 61% female, uninsured (96%), with A1C 9.6±2.1. In unadjusted analyses, better communication, was associated with lower medication non-adherence (OR 0.40-0.68, all p<0.05), higher treatment satisfaction (OR 1.76-1.96, all p<0.01), portion size reduction (OR 1.43, p<0.05), diabetes self-efficacy (OR 1.41, p<0.05), and lower A1C (β=-0.06, p<0.01). In adjusted analyses, communication quality remained associated with lower medication non-adherence (AOR 0.39-0.68, all p<0.05), and higher treatment satisfaction (AOR 1.90-2.21, all p<0.001)., Conclusions: Better communication between low-income patients and providers was independently associated with lower medication non-adherence and higher treatment satisfaction., Practice Implications: Communication quality may be an important modifiable approach to improving diabetes care for vulnerable populations., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objective: Problem solving is a critical diabetes self-management skill. Because of a lack of clinically feasible measures, our aim was to develop and validate a self-report self-management problem solving questionnaire for adolescents with type 1 diabetes (T1D)., Methods: A multidisciplinary team of diabetes experts generated questionnaire items that addressed diabetes self-management problem solving. Iterative feedback from parents and adolescents resulted in 27 items. Adolescents from two studies (N=156) aged 13-17 were recruited through a pediatric diabetes clinic and completed measures through an online survey. Glycemic control was measured by HbA1c recorded in the medical record., Results: Empirical elimination of items using principal components analyses resulted in a 13-item unidimensional measure, the diabetes adolescent problem solving questionnaire (DAPSQ) that explained 56% of the variance. The DAPSQ demonstrated internal consistency (Cronbach's alpha=0.92) and was correlated with diabetes self-management (r=0.53, p<.001), self-efficacy (r=0.54, p<.001), and glycemic control (r=-0.24, p<.01)., Conclusion: The DAPSQ is a brief instrument for assessment of diabetes self-management problem solving in youth with T1D and is associated with better self-management behaviors and glycemic control., Practice Implications: The DAPSQ is a clinically feasible self-report measure that can provide valuable information regarding level of self-management problem solving and guide patient education., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objective: This cross sectional study examined the relationship between parental health literacy (HL), diabetes related numeracy, and parental perceived diabetes self-efficacy on glycemic control in a sample of young children with Type 1 DM., Methods: Seventy primary caregivers of children (age 3-9 years) with Type 1 DM were recruited and surveyed at diabetes outpatient clinic visits. Patients' medical histories were obtained by medical chart review., Results: Parental diabetes related numeracy (r=-.52, p<01), but not reading skills (r=-.25, p=NS) were inversely correlated with the child's glycemic control (HbA1c). Parental perceived diabetes self-efficacy was also negatively correlated to their child's HbA1c (r=-.47, p<01). When numeracy and parental perceived diabetes self-efficacy were included as predictors of HbA1c, the model was significant (F=12.93, p<.01) with both numeracy (β=-.46, p<.01) and parental perceived diabetes self-efficacy (β=-.36, p=.01) as significant predictors of HbA1c., Conclusions: Data from this study highlight the importance of considering the role of parental numeracy, in health outcomes for children with Type 1 DM., Practice Implications: Practitioners should assess parental health literacy and consider intervention when needed., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: To describe a systematic assessment of patient educational materials for the Growing Right Onto Wellness (GROW) trial, a childhood obesity prevention study targeting a low health literate population., Methods: Process included: (1) expert review of educational content, (2) assessment of the quality of materials including use of the Suitability Assessment of Materials (SAM) tool, and (3) material review and revision with target population., Results: 12 core modules were developed and assessed in an iterative process. Average readability was at the 6th grade reading level (SMOG Index 5.63 ± 0.76, and Fry graph 6.0 ± 0.85). SAM evaluation resulted in adjustments to literacy demand, layout & typography, and learning stimulation & motivation. Cognitive interviews with target population revealed additional changes incorporated to enhance participant's perception of acceptability and feasibility for behavior change., Conclusion: The GROW modules are a collection of evidence-based materials appropriate for parents with low health literacy and their preschool aged children, that target the prevention of childhood overweight/obesity., Practice Implications: Most trials addressing the treatment or prevention of childhood obesity use written materials. Due to the ubiquitous prevalence of limited health literacy, our described methods may assist researchers in ensuring their content is both understood and actionable., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: Because existing numeracy measures may not optimally assess 'health numeracy', we developed and validated the General Health Numeracy Test (GHNT)., Methods: An iterative pilot testing process produced 21 GHNT items that were administered to 205 patients along with validated measures of health literacy, objective numeracy, subjective numeracy, and medication understanding and medication adherence. We assessed the GHNT's internal consistency reliability, construct validity, and explored its predictive validity., Results: On average, participants were 55.0 ± 13.8 years old, 64.9% female, 29.8% non-White, and 51.7% had incomes ≤$39K with 14.4 ± 2.9 years of education. Psychometric testing produced a 6-item version (GHNT-6). The GHNT-21 and GHNT-6 had acceptable-good internal consistency reliability (KR-20=0.87 vs. 0.77, respectively). Both versions were positively associated with income, education, health literacy, objective numeracy, and subjective numeracy (all p<.001). Furthermore, both versions were associated with participants' understanding of their medications and medication adherence in unadjusted analyses, but only the GHNT-21 was associated with medication understanding in adjusted analyses., Conclusions: The GHNT-21 and GHNT-6 are reliable and valid tools for assessing health numeracy., Practice Implications: Brief, reliable, and valid assessments of health numeracy can assess a patient's numeracy status, and may ultimately help providers and educators tailor education to patients., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: Describe intervention processes associated with an Internet self-management problem solving program for adolescents with type 1 diabetes, and relate participant characteristics to program use., Methods: Forty-one adolescents with type 1 diabetes, aged 13-17, participated in an Internet intervention., Results: Participants reported psychosocial self-management barriers related to social issues (45%), time pressures (22%), and emotions (25%). Most adolescents (76%) completed the two guided problem solving cycles, and most (97%) problems were appropriate and specific to diabetes. Of the 61 diabetes problems reported, 92% were mostly or completely solved. Baseline hemoglobin A1c, diabetes duration, and age were not related to online activities, however females posted more often to the forum (U=130.0, Z=2.13, p=.033). The majority of parents (87%) interacted with their child about the website., Conclusion: Adolescents experience psychosocial barriers to self-management that can be addressed by teaching problem solving via the Internet., Practice Implications: An Internet self-management problem solving program with minimal external support provides a viable option for diabetes clinics to improve pediatric diabetes outcomes., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Unlabelled: Development and pilot testing of a disease management program for low literacy patients with heart failure., Background: Randomized trials have shown that disease management programs can reduce hospitalizations and improve symptoms for patients with congestive heart failure. We sought to create and pilot test such a program for patients with low literacy skills., Methods: We used focus groups and individual cognitive response interviews (CRIs) to develop an educational booklet for low literacy patients with heart failure. We incorporated the booklet into a disease management intervention that also included an initial individualized 1-h educational session and scheduled supportive phone calls that were tapered over 6 weeks. We then conducted a 3-month before-after study on patients with low literacy skills (<9th grade literacy level) in a university internal medicine clinic to test the acceptability and efficacy of our program. Outcomes of interest included heart failure-related knowledge, self-care behavior and heart failure-related symptoms measured on the Minnesota Living with Heart Failure (MLwHF) scale., Results: Twenty-five patients were enrolled and 23 (92%) completed 3-month follow-up. Mean age was 60 years (range 35-74), 60% were men, 60% were African-American, and 74% had household income under $15,000 per year. The median reading level was fifth grade with 32% reading at or below the third grade level. Mean knowledge score at baseline was 67% and did not improve after the intervention. The proportion of patients reporting weighing themselves daily increased from 32% at baseline to 100% at 12 weeks. Mean improvement on the MLwHF scale was 9.9 points over the 3-month trial (95% CI: 0.5, 19.2), which corresponds to an improvement in one class on the New York Heart Association heart failure scale., Conclusion: A heart failure disease management program designed specifically for patients with low literacy skills is acceptable and is associated with improvement in self-care behavior and heart failure related symptoms.

Smoking after a cancer diagnosis shortens survival time, increases risk of recurrence and the development of another primary tumor, reduces treatment efficacy, and increases treatment complications. Nevertheless, many patients who smoked prior to their illness continue to smoke after diagnosis and treatment. The development of effective smoking cessation interventions for cancer patients has been slowed by the lack of data concerning psychological correlates of smoking in this population. This study, with 74 cancer patients, showed that smoking and lower readiness to quit was associated with: having relatives at home who smoke, a longer time between diagnosis and assessment, completion of medical treatment, greater nicotine dependence, lower self-efficacy, quitting pros, and risk perceptions, and higher quitting cons, fatalistic beliefs, and emotional distress. Thus, smoking cessation treatments for cancer patients should include pharmacotherapy, relapse prevention, and counseling designed to facilitate self-efficacy, quitting pros, and risk awareness and to reduce the quitting cons, fatalism, and distress.