Abstract
Introduction
Tobacco use is the leading cause of preventable death and disease and contributes significantly to socioeconomic health disparities. The prevalence of smoking among individuals of lower socioeconomic status (SES) in the US, many of whom are African American (AA), is three to four times greater than the prevalence of smoking among individuals of higher SES. The disparity in tobacco dependence treatment outcomes between lower and higher SES smokers contributes to tobacco-related health disparities and calls for adapting evidence-based treatment to more fully meet the needs of lower SES smokers.
Aims
We sought to adapt the evidence-based treatment for tobacco dependence using recommended frameworks for adapting evidence-based treatments.
Methods
We systematically applied the recommended steps for adapting evidence-based treatments described by Barrera and Castro and Lau. The steps included information gathering, preliminary adaptation design, preliminary adaptation tests, and adaptation refinement. We also applied the PEN-3 Model for incorporating AA values and experiences into treatment approaches and a community-engaged approach.
Results/Findings
Findings from each step in the process contributed to the results. The final results were incorporated into a revised treatment called the RITCh Study Tobacco Dependence Treatment Manual and Toolkit.
Conclusions
To our knowledge, this is the first adaptation of evidence-based treatment for tobacco dependence that has systematically applied these recommended frameworks. The efficacy of the treatment to reduce treatment outcome disparities is now being examined in a randomized controlled trial in which the revised treatment is being compared with a standard, individualized cognitive-behavioral approach.
Keywords: Cultural adaptation, Evidence-based treatments, Tobacco dependence, Smoking cessation
Introduction
Tobacco dependence is the greatest cause of preventable death and disease in the United States [1,2] and a significant constributor to socioeconomic health disparities [1,3-6]. While motivation and attempts to quit smoking show few socioeconomic differences, smokers of lower socioeconomic status (SES) are less likely to achieve long term abstinence once they begin smoking [7-15]. Standard evidence-based treatments for tobacco dependence attract lower SES smokers [16-20]; however, there are significant socioeconomic disparities in treatment retention and long-term treatment outcomes even when treatment adherence, clinical, environmental, and demographic factors are accounted for [17-24]. Estimates indicate that the highest SES smokers are at least twice as likely to achieve long-term abstinence as the lowest SES smokers after treatment regardless of treatment modality [18,20].
In health research, SES is a broad construct describing relative access to basic resources required to achieve and/or maintain good health [25,26]. Conceptual models propose that health disparities emerge because of higher levels of stress, less access to physical and environmental resources, greater environmental constraints, fewer affective and cognitive resources, and poorer health behaviors [25,27-29]. Consistent with these models, SES is empirically related to achieving abstinence from smoking through complex reciprocal relations among numerous clinical and environmental factors including stress, coping resources, psychological factors, exposure to other smokers, and use of treatment resources [30-35]. In the US, ethnic minority status affects access to the basic resources to achieve and maintain good health, but the magnitude of socioeconomic disparities within ethnic minority groups is greater than between groups; thus, the effects of ethnic minority status on health are often reduced or eliminated after statistically adjusting for socioeconomic factors [36-38]. Nonetheless, in the US and elsewhere, ethnic minority groups tend to live in different social and physical environments and ethnic minority status includes a constellation of stressors separate from and additive to SES [36]. Moreover, ethnic minority status affects SES, but SES does not affect ethnic minority status, and thus, statistically adjusting for SES has the effect of over-controlling for the causal effects of ethnic minority status on health [26,36,39]. African Americans are the largest ethnic minority group in the US, have some of the highest poverty and smoking prevalence rates, and are among those smokers who respond less robustly to evidence-based tobacco dependence treatment [40,41]. These relations indicate the need to address tobacco-related health disparities within the context of both socioeconomic and ethnic minority disparities [36].
Adaptations to evidence-based treatments are indicated when groups show differences in engagement and/or treatment outcomes [42,43]. Adaptation of the standard evidence-based treatment for tobacco dependence is indicated because it is less effective at retaining lower SES smokers in treatment and demonstrates significant socioeconomic disparities in abstinence outcomes. Adapting interventions for particular groups has been shown to increase treatment engagement and the salience of treatment strategies for participants [44,45], but existing attempts to adapt tobacco dependence treatment for African Americans are limited because they utilized only print materials [46-48],or were not evaluated with controlled and/or comparable methods [49,50]. Additionally, although many treatment providers offer specialized protocols for “ethnic populations”[51], there is considerable confusion about when to implement protocols for African American smokers relative to individuals’ racial identities, acculturation status, and experience, and there is no evidence that these protocols reduce treatment outcome disparities [22,52]. Furthermore, given the associations among SES, African American ethnic minority status, and tobacco use, adaptations aimed solely at addressing relevant ethnic minority cultural issues are unlikely to address the significant socioeconomic factors associated with disparities experienced by many African Americans (i.e., socioeconomic stress, access to resources, environmental constraints, affective and cognitive resources). This evidence supports the need to adapt the standard evidence-based treatment for tobacco dependence to more fully meet the needs of lower SES groups and incorporate the needs of African American groups as well.
The specific aim of this study was to adapt a well-established, evidence-based treatment for tobacco dependence to more fully meet the needs of smokers of lower SES, many of whom are African American, with the overall goal of preparing a revised treatment to be compared with the standard treatment in a randomized trial. Two relevant and prominent frameworks for adapting interventions were applied to the development of the revised treatment: The framework developed by Barrera and Castro and Lau [42,43], and the PEN-3 Model [53,54]. The Barrera and Castro framework is specifically designed to adapt evidence-based treatments for disparate groups. The logical framework of adaptation includes a systematic step-by-step process. The first phase is information gathering; the second, preliminary adaptation; the third, preliminary adaptation tests; and finally adaptation refinement [42,43]. The PEN-3 Model is specifically designed to incorporate African American values and experiences into treatment approaches [53,54]. The PEN-3 Model includes three dimensions a) understanding the role of the individual within the family, extended family, neighborhood, and community; b) recognizing perceptions, enablers, and nurturers; and c) evaluating the cultural appropriateness of the intervention. Perceptions are knowledge, attitudes, values, and beliefs that facilitate or hinder personal motivation to engage in an intervention. Enablers are societal, systematic, or structural influences that enhance or create barriers to engaging in an intervention. Nurturers are reinforcing factors provided by others (e.g., interventionists, peers, family, employers, religious leaders, etc.). Perceptions, enablers, and nurturers that lead to improved health status are positive; that are inconsistent with the mainstream, but have no harmful health consequences are exotic; and that lead to harmful health consequences are negative. These frameworks provided the structure and rationale for the methods and procedures described in this study.
Methods
We began with a well-established, manual-driven, multicomponent cognitive-behavioral treatment for tobacco dependence with which we had considerable experience and expertise. We sought to maintain the same amount of treatment contact in the revised treatment as the standard treatment to maintain comparability for a planned randomized controlled trial. The adaptation procedures were conducted in four Phases: 1) information gathering, 2) preliminary adaptation design, 3) preliminary adaptation tests, and 4) adaptation refinement. The PEN-3 Model was used in Phase 2 to ensure that the interventions were adapted with systematic consideration of relevant values and experiences. Phases 2-4 were guided by community-based participatory research principles, as described by Israel [55]. This study was approved by the Institutional Review Board at the City College of New York.
The standard evidence-based treatment
The standard treatment was developed and refined over the course of 30 years at the University of Mississippi Medical Center/ GV (Sonny) Montgomery VA Medical Center. This manual-driven, multicomponent cognitive behavioral treatment for tobacco dependence has been delivered in multiple modalities (i.e., group, individual, and telephone), used in numerous studies [17-20,56-59], and is considered comprehensive, well-established, and consistent with the Public Health Service Clinical Practice Guideline [22]. When delivered in the group treatment modality, the treatment consists of 6 weekly closed-group 60-minute sessions with 5-10 participants. The treatment includes an overview of the biopsychosocial underpinnings of tobacco dependence and the trigger-urge-response cycle, scheduled gradual rate reduction, self-monitoring, stimulus control, problem-solving, conflict management, cigarette refusal training, enhancing social support, goal setting, relapse prevention, and stress management.
Phase 1: Information gathering
The objective of this phase was to identify factors that, if addressed, have theoretical and/or empirical support for reducing the disparity in treatment outcomes [42,43]. The research team reviewed conceptual models of socioeconomic and tobacco use disparities [12,25,28,30-35,60] and the findings associated with disparities in tobacco dependence treatment outcomes [17,18,20,58,61,62]. We identified eight modifiable factors associated with socioeconomic disparities that were prominent in both theoretical frameworks and treatment outcome studies: stress and stress management, negative affect regulation, smoking in response to negative affect, delay discounting, locus of control, impulsiveness, smoking policies in the home, and treatment utilization (e.g., medication and session attendance).
Phase 2: Preliminary adaptation design
The objective of this phase was to incorporate the factors identified in the first phase into a draft of the revised treatment manual [42,43]. Barrera and Castro (2006) indicate that this phase provides a good opportunity to incorporate qualitative research from community experts and potential participants [42]. Preliminary procedures for adaptation took place in two steps: 1) clinical adaptations addressing the eight modifiable factors selected in Phase 1, and 2) cultural adaptations addressing relevant perceptions, enablers, and nurturers using the PEN-3 Model.
Phase 2: Step 1: Clinical adaptations
We systematically adapted the standard treatment manual to incorporate interventions addressing the eight factors identified in Phase 1. Table 1 provides a detailed description of the revisions incorporated to address each of the eight factors. In addition, a specific technique, behavioral rehearsal, is explicitly introduced as an important strategy in the first session and more frequently utilized throughout treatment as the emphasis is placed on generating, rehearsing, and evaluating specific strategies as well as encouraging engagement. New laboratory research was applied in the development of an episodic future thinking goal setting exercise used to reduce delay discounting [63]. The health education component in first session and two traditional relapse prevention exercises focused on the Abstinence Violation Effect [64] were deleted.
Table 1.
Clinical and environmental factors associated with disparities in tobacco dependence treatment outcomes and addressed in the revised treatment.
Clinical or Environmental Factor | Revisions to specific intervention components |
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Stress: Increased emphasis is placed on stress management. Stress management is introduced earlier in treatment, and discussed during every treatment session. The management of particular stressors associated with restriction of resources and /or of being of minority status are explicitly explored. |
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Negative affect: Proactive emphasis on recognizing and managing negative affect. |
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Smoking in response to negative affect: Proactive, explicit emphasis on recognizing and managing negative affect as a cue to smoke and a risk for relapse. |
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Discounting the value of delayed rewards: New explicit emphasis placed on recognizing and choosing long-term versus immediate rewards. |
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Locus of control: New proactive emphasis placed on supporting perceived personal control. |
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Impulsiveness: New explicit emphasis placed on identifying and addressing impulsive decision-making. |
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Smoking policies in the home: New explicit emphasis placed on developing smoking policies in the home. |
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Treatment utilization: New emphasis placed on increasing the positive valance of treatment. |
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Phase 2: Step 2, Cultural adaptations
Community consultants led the research team in procedures for adapting the treatment manual from Phase 2, step 1 using the PEN-3 Model. The community consultants included an unemployed African American woman, living in the New York City metropolitan area who was in recovery from cancer and who had been experiencing significant financial hardship for an extended period of time. Her perspective was informed by having been treated with the standard treatment. She had successfully maintained abstinence from smoking after treatment with the standard tobacco dependence treatment for three years. The second and third community consultants were two veteran community health advocates and experts in understanding lower income and African American community perspectives. These experts were from the Arkansas Mississippi Delta and are co-investigators on this study and included an African American woman (NC) who was the director Walnut Street Works, Inc., a non-profit community health organization and a white woman (MO) who is a community health advocate with Walnut Street Work, Inc. and a pastor. To facilitate the systematic application of the PEN-3 model, the research team developed worksheets that cross-listed components of the PEN-3 Model with each intervention component through-out the revised manual. While acknowledging the role of the individual, the extended family, the neighborhood, and the community, the research team completed the worksheets commenting on perceptions, enablers, and nurturers and then determining whether the perceptions, enablers, and nurturers were positive, exotic, or negative. After reviewing all the intervention components in each of the six treatment sessions, the community consultants were asked: How can we incorporate themes relevant to people of limited means? How can we incorporate themes relevant to African Americans? Is there enough detail (i.e., choices for tailoring) in terms of socio-culturally specific triggers, smoking contexts, barriers to cessation?
The feedback from the community consultants was extensive. The consultants provided numerous comments and recommendations that sometimes involved completely re-structuring the manner in which intervention components were delivered in order to improve the acceptability, suitability, and/or tolerability of the interventions. Table 2 gives a description of the perceptions, enablers, and nurturers for each intervention strategy and revisions suggested by the community consultants. Overall, the consultants endorsed the use of an overall theme of viewing helpful ideas, interventions, and strategies as “tools,” and overtly highlighted opportunities to enhance a sense of personal control. They recommended that we develop a culturally congruent participant workbook and call it a “Toolkit” to be provided in a binder with pockets to help participants organize and preserve information about the process of quitting for reference at a later date. Suggestions for the Toolkit included a review of material presented in the treatment sessions, tracking sheets, and information about health risks of smoking and benefits of quitting, obtaining support from others, stress management ideas, and myths about using nicotine replacement, etc. They suggested that the Toolkit include positive messages and images relatable to lower SES and African American communities. This feedback was incorporated into the revised treatment manual.
Table 2.
Summary of community consultants' review of intervention strategies in terms of the PEN-3 Model.
Intervention Strategy | Perceptions, Enablers, Nurturers | Suggested Revision |
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Description of intervention components throughout the treatment. |
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Pre-session assessment of motivation, self-efficacy, cigarettes per day, carbon monoxide levels, and progress toward goals. |
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Preparing for abstinence after the group; countering beliefs that group is like a class; encouraging conceptualization of treatment as changing thoughts, behaviors, and feelings. |
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Quit date set for session 3 |
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Multiple interventions to increase internal locus of control |
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Increase positive valence of treatment, reinforce attendance, and reinforce contributions to the group. |
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Diaphragmatic breathing to manage stress and negative affect |
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Nicotine replacement |
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Review and inform participants about limits of confidentiality. |
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Triggers include negative affect and significant stressors related to having limited resources and suffering from discrimination. |
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Managing smoking in the home, social situations, and reinforcing rights as a nonsmoker |
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Using religion and/or spirituality to support quitting |
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Phase 3: Preliminary adaptation tests
The objectives of this phase were to determine if the revised treatment could be delivered in six one-hour closed-group treatment sessions to ensure comparability with the standard treatment in the clinical trial; to ensure that the revised treatment was acceptable and understandable to participants; and to identify and discuss difficulties with implementation, program content, and/or activities [42]. Pilot studies with small groups followed by a qualitative inquiry are often used to assess program elements from participants’ perspectives as well as gather suggestions for improvement [42]. Qualitative information was also gathered from the treatment provider and the focus group facilitators. Thus, we administered the revised treatment to two pilot study groups and then invited the group participants to participate in a focus group to obtain feedback. Throughout the process, we sought to reduce demand characteristics by minimizing the amount of personal data collected from participants, using community members to facilitate the focus groups, and ensuring no university presence during the focus groups.
Participants
Pilot study participants were recruited into one of two pilot study groups by flyers placed in the West Harlem community and word of mouth. Inclusion criteria included: a) smoking cigarettes daily, b) expressing a desire to quit smoking in the next 30 days, c) no regular use of other tobacco products, d) age 18 years or older, e) willing to comply with study commitments, and f) able to engage in treatment. The exclusion criteria included: a) any contra-indication for use of the nicotine patch (i.e., uncontrolled high blood pressure, allergic reaction to patch adhesive, pregnancy, etc.), b) current use of mediations for smoking cessation (bupropion, varenicline, or any form of nicotine replacement), c) consumption of more than 20 alcoholic drinks per week, and d) current symptoms that would prohibit engagement in treatment (active psychotic disorder, acute major depressive episode, significantly cognitively impaired). Participants (n=25) were 100% African American and 48% male with a mean age of 44 years (SD 12.4). One participant also identified as Hispanic. Group one (n=13) was 38% male with a mean age of 51 years. Group two (n=12) was 58% male with a mean age of 55 years.
Procedure
Participants were screened for inclusion/exclusion criteria over the telephone and if eligible, scheduled for a pilot study group and consented immediately prior to the first treatment session. Treatment sessions were delivered to the pilot groups by an experienced tobacco dependence treatment provider (CS). Pilot sessions were timed. One week after completing the treatment sessions, participants were invited to discuss their experience of the treatment with their respective groups in one of two focus groups. Participants were compensated $30 for each visit. Community-based participatory research principles and a democratic deliberative approach were used to pilot test the revised treatment. The democratic deliberative approach is widely used to understand a number of sensitive social questions [65,66]. The approach assumes that those most affected by use or nonuse of a program can most accurately answer questions pertaining to that program and acknowledges the importance of context in interpretation. Discussion must take place in a setting in which anonymity is supported and values are not judged. Two community consultants (NC and MO) with expertise in both community-based research and democratic deliberative methods facilitated the focus group discussions. This approach was chosen because it supports the study objectives and was the method of choice for the community partners. To reduce demand characteristics, university staff and team members were not present during the focus group discussions.
The questions used to initiate discussion were developed by the community consultants and included: Was the treatment and the discussion understandable? Discuss the good and the bad of it. Was the treatment something that you feel you can apply in your life in terms of helping you to stop smoking? Were there ways you could apply it other than smoking? Was the treatment acceptable? Let's discuss what was good and bad about it. What would you add to the program and why? What worked most for you? What worked least for you? Would you sign up again without the stipend? Let's discuss common ground. As the last word about the treatment, anything you would like to share? Responses were recorded in large text notes on newsprint and taped on the walls of the conference room for continuous review during the discussions. After the discussion group, the research team transcribed the notes from the newsprint and met as a team to extract relevant themes and recommend revisions.
Results
Eighteen (n=18) of the pilot group participants returned for focus groups. Focus group attendees were 56% male with a mean age of 53 (SD 13.5). Chi-square and analysis of variance indicated no significant sex and age differences among those who attended the focus groups and those who did not (sex: χ2=1.47, df=1, p=.23; age: F=.054, df=1,23, p=.82).
Was the treatment understandable and acceptable? Discuss the good and the bad of it
The participants uniformly reported that the treatment and the discussion were understandable and acceptable; that the treatment helped them to feel hopeful about quitting; and that being able to talk about quitting increased their desire to quit. Relaxation training was reported to be the most favorite and useful intervention component. Participants reported that they also liked the tips about quitting, the cinnamon toothpicks available during treatment, carbon monoxide monitoring, and the tips about managing stress. Some participants reported that they didn't realize how harmful smoking was to their health. The facilitators interpreted this to mean that even if the participants had been told about the health effects before, they felt ready to know and hear more about the health effects during treatment. Some participants reported that although they did not quit, they cut down significantly and planned to quit soon. Participants liked the idea of understanding triggers and of quitting gradually. They noted that learning about particular triggers including sex, eating, routines, alcohol, bowel movements, habits, and emotions were especially helpful. Most agreed that the discussions were good because the topics were debatable and their opinions were respected. Participants repeatedly acknowledged that each person had different story to tell and that they valued the effort made by the group leader to ensure that everyone and all efforts were viewed positively. They especially liked the acknowledgement that they weren't bad people because they smoked cigarettes or when they slipped or when they didn't meet their goals every week. They liked knowing that they were not alone in their struggle to quit. Participants reported that they liked having the participant workbook.
Participants reported that they would have liked more sessions per week and more sessions in general. They reported that they were engaged, that the hour went quickly, and that they had many more questions than could be answered during the six sessions. This appeared to be especially true of the nicotine patches. Participants reported that it “was good that patches were offered” even though they didn't think the patches “worked” or were a “good idea” and most participants didn't use them even though they agreed to use them when they enrolled. The facilitators interpreted the comments about patches to mean that participants didn't want to use patches because of previous experience, but might try patches later if they felt more comfortable. Some participants reported that they were “scared of” the patches so didn't even try them. Complaints about the patches included causing the “shakes,” making the “taste in my mouth disgusting,” or causing them to “break out.” One participant noted that, “If someone put a patch on you and you didn't know it – you wouldn't know it was there. It is a mental thing,” implying that they perceived the origin of the complaints about the patches to be psychological in nature. Nonetheless, participants agreed that there should have been more information about the patches in the treatment. They suggested that there be less time between sessions to provide support for using the patch and to talk about their concerns and what they felt. Participants reported that they would have liked to discuss “how to handle stress” more in-depth. They suggested “a whole session on a stress.” In addition, they reported that they would have liked to have used the participant workbook more during treatment and would like more written education about smoking and scientific facts about smoking. Participants agreed that the sidebar conversations and cell phone ringing and use during treatment were distracting. Some participants reported that they would have liked to have a celebration with food or snacks at some point during the treatment.
Were there ways you could apply it other than in smoking?
Participants reported that there were some things they learned that they could apply to other areas of life including the practice of stopping and “thinking before behaving,” waking up earlier and meditating, planning the day out ahead of time, eating breakfast, deep breathing, exercising, being in the company of others with the same goals, and lifestyle changes in general. They reported that achieving a goal helped them to feel like they could achieve other goals and that the process of trying to quit helped them to “find out that your real friends are – a very positive thing.”
What would you add to the program and why?
Participants reported that they would like to know more about electronic cigarettes, more sessions, more time to talk, and a list of other programs so they would get more support. One group also suggested detailed revisions to the Group Guidelines.
What worked the most and the least?
Participants listed the “breathing exercises,” the coping skills, discussions during the feedback sessions, discussions about meeting their goals, discussions about faith, the carbon monoxide monitoring, and the everyday talk about quitting and sharing their progress toward quitting as working the most for them. Some did not think that others commenting on their personal smoking was helpful and reported that sometimes talking about smoking during treatment “made them want a cigarette more.”
Would you sign up again without the stipend?
Participants uniformly reported that they would sign up again with or without the stipend, but the stipend was helpful. One participant reported that they were proud of the fact that they “didn't buy cigarettes with the stipend.” When asked why they would participate again they reported the primary reasons would be “togetherness, engagement, support, and bonding.”
Common ground and last word
Participants agreed that the common ground included “the support from each other, togetherness, engagement, support, and bonding,” and “good to hear from peers.” During last words, participants in both groups asked whether it was possible for them to attend the treatment again. Some reported that they “would not have gotten this far with quitting without the sessions,” and “Would like to see what percent of people actually quit.” One participant apologized for having a bad attitude during the sessions, but noted that the sessions tended to “bring out the best of the people.” All felt that, “This was a good use of our time,” and “Will recommend it to others.” Most indicated that they will continue to try and quit or stay quit. Most reported that they acquired “tools for life – stress management, planning, people who are committed to stopping,” and that “Tools that help you with life are the tools that lead to smoking cessation.” The final words included, “All these are life skills and life skills empower one to quit smoking.”
Phase 4: Adaptation refinement
The objective of this phase was to incorporate feedback from Phase 3 and develop a treatment manual that could be compared with the standard treatment for efficacy in a randomized control trial. The final phase of the adaptation included bringing the research team together to integrate findings from the adaptation test. Several components required revision. For example, during Phase 2, Step 2, community consultants suggested that we use a rotating within-group leader to facilitate preliminary group procedures and enhance the positive valence of treatment. This procedure did not function well and was eliminated during the refinement. The image of a tree for the social network identification exercise was found to be confusing and was replaced by a network-related image with circles representing individuals. As per the focus group recommendations, the Group Guidelines were revised. Procedures were revised to include review of the Group Guidelines prior to every session. The group size was limited to six participants to enable tobacco treatment specialists to address the complexity of participants’ presentations. The research team also revised the procedure for assessing carbon monoxide levels to encourage an internal locus of control. Instead of having staff administer the CO assessment to participants before each group session, participants are taught how to use the CO monitor in the first session. Every session thereafter, CO monitors are left out for participants to asses and record CO levels on their Feedback sheets prior to group. Finally, the language in the manual was further refined to be more accessible and reference to the Toolkit and other key factors like Personal Control and Keeping the Big Picture in Mind, were increased throughout treatment.
Results and Discussion
The final treatment manual and participant handbook are called the RITCh (Reducing Disparities in Tobacco Dependence Treatment Outcomes) Tobacco Dependence Treatment Manual and Toolkit. The manual comprises six 1-hour, closed group sessions, identical in terms of overall time of exposure to the standard treatment; however, the treatment components have been revised to address factors associated with the development and maintenance of the disparities associated with the standard treatment. The treatment appears to be understandable and acceptable to lower income individuals and African American individuals. To our knowledge, this is the first adaptation of evidence-based treatment for tobacco dependence that has systematically applied the well-accepted frameworks proposed by Barrera and Castro and Airhihenbuwa and used a community based participatory approach [43,55]. The revised treatment is currently being compared with the standard treatment in a randomized controlled trial. We expect the socioeconomic disparities in treatment outcomes from the standard treatment to be greater than the treatment outcome disparities from the revised treatment.
Whether or not the revised treatment is found to be more efficacious for lower SES groups, the results from the focus groups suggest that the RITCh Tobacco Dependence Treatment Manual and Toolkit are likely to be well received among many smokers. Many of the elements were refined, adapted, and sometimes instituted by community members invested in engaging the current population of smokers and particularly African Americans and perhaps other minority communities who might identify with the experiences of African Americans. The goal of the participant workbook, the Toolkit, is to support relapse prevention by providing participants with adjunctive and supportive information as well as to serve as a tool to organize and preserve information about the process of quitting. It is designed to be provided in a 1-inch black binder with internal pockets to enable participants to save copies of their feedback sheets, goals, and other relevant information for reference at a later date. The Toolkit is organized by topic, reflects the new components in the treatment manual, and includes motivational quotes from notable African Americans, facts about African Americans and smoking, tracking charts and worksheets to be used during treatment, tips, and adjunctive information about goal setting, stress, lifestyle changes, and myths about nicotine replacement and tobacco use in general. The RITCh Treatment manual includes multiple references to the content in the Toolkit as well as how to use the Toolkit for relapse prevention. Although currently constructed to be delivered in groups, similar to the standard treatment, the revised treatment manual can be easily adapted to be delivered over the telephone or individually. Of note, there is nothing in the materials that precludes or excludes the experience of groups who are not of lower SES or African American.
We speculate that the revised treatment is likely to be acceptable, understandable, and address the needs of other groups who experience increased stress from discrimination, restricted resources, and/or struggles with negative affect as well as possess a perceived external locus and fewer positive expectations from treatment. Increased stress and restricted resources appear to cultivate an increased focus on the present that translate into increased impulsivity and delay discounting rates [67] all of which have been shown to affect cessation. These groups might include women, sexual minorities, and lower SES groups who are not of minority status.
Conclusions
Tobacco disparities are a significant contributor to socioeconomic and ethnic minority health disparities. Adaptation of the standard, intensive, evidence-based treatment for tobacco dependence is indicated because lower socioeconomic groups demonstrate significant disparities in treatment retention and outcomes. African Americans are disproportionately represented among lower socioeconomic groups and among smokers and thus adaptations must recognize and address the values, experiences, and concerns of African Americans.
The RITCh Treatment approach is important, distinctive, and relevantly addresses the current tobacco-related health disparities because it adapted an existing, well-established standard treatment to more fully address the needs of significant disparate groups in a manner consistent with the conceptual and empirical evidence as well as with significant input from community members who are likely to use the treatment and community partners who served to interpret and incorporate community values and experiences. This treatment is also distinctive and important because it is actively inclusive, does not preclude active participation among smokers from all walks of life, and is perhaps, given the current demographics of the smoking population, more relatable to more smokers than the standard treatment. For instance, the discussion about stress from everyday discrimination includes racial, socioeconomic, gender/sex, sexual minority, and other types of discrimination with the goal of helping participants become of aware of and manage this significant source of stress. Moreover, the disparate groups for which this treatment has been adapted are fast becoming highly representative of the majority of smokers. Thus, there exists a rationale for adopting the revised treatment as a new standard, eliminating the problems inherent in using special protocols for special populations. In other words, we propose that creatively addressing the conceptual and empirical underpinnings of disparities within a singular approach might be more effective at retaining and effectively treating smokers from disparate groups than offering special protocols for special groups.
The RITCh Tobacco Dependence Treatment Manual and Toolkit are currently being compared with the standard treatment and a generic participant workbook in a randomized control trial. We expect the RITCh Treatment to reduce long-term treatment outcome disparities and RITCh participants to demonstrate improvement on the eight modifiable factors associated with treatment outcome disparities (Table 1), but this is yet to be determined. If the RITCh Treatment is effective in reducing treatment outcome disparities, then perhaps the treatment can be further revised to more fully incorporate the needs of other groups including women, sexual minorities, and individuals with mental illness and substance use disorders.
Acknowledgement
This project was supported by a grant from the National Institutes of Health, National Institute on Minority Health and Health Disparities (R01 MD007054) awarded to Dr. Christine Sheffer. In addition, S.D. Evas was supported by a postdoctoral training program (T32 MH19139; Program Director: T.G.M. Sanfort, Phd).
References
- 1.U.S. Department of Health and Human Services Surgeon General's report: The health Consequences of Smoking - 50 Years of Progress. 2014.
- 2.Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004;291:1238–1245. doi: 10.1001/jama.291.10.1238. [DOI] [PubMed] [Google Scholar]
- 3.ACS . A.C.S., Cancer facts and figures 2012. American Cancer Society; Atlanta, GA: 2012. [Google Scholar]
- 4.Harper S, Lynch J. Trends in socioeconomic inequalities in adult health behaviors among U.S. states, 1990-2004. Public Health Rep. 2007;122:177–189. doi: 10.1177/003335490712200207. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Kanjilal S, Gregg EW, Cheng YJ, Zhang P, Nelson DE, et al. Socioeconomic status and trends in disparities in 4 major risk factors for cardiovascular disease among US adults, 1971-2002. Arch Intern Med. 2006;166:2348–2355. doi: 10.1001/archinte.166.21.2348. [DOI] [PubMed] [Google Scholar]
- 6.Jha P, Peto R, Zatonski W, Boreham J, Jarvis MJ, et al. Social inequalities in male mortality, and in male mortality from smoking: indirect estimation from national death rates in England and Wales, Poland, and North America. Lancet. 2006;368:367–370. doi: 10.1016/S0140-6736(06)68975-7. [DOI] [PubMed] [Google Scholar]
- 7.Agrawal A, Sartor C, Pergadia ML, Huizink AC, Lynskey MT. Correlates of smoking cessation in a nationally representative sample of U.S. adults. Addict Behav. 2008;33:1223–1226. doi: 10.1016/j.addbeh.2008.04.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Barbeau EM, Krieger N, Soobader MJ. Working class matters: socioeconomic disadvantage, race/ethnicity, gender, and smoking in NHIS 2000. Am J Public Health. 2004;94:269–278. doi: 10.2105/ajph.94.2.269. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Fagan P, et al. Employment characteristics and socioeconomic factors associated with disparities in smoking abstinence and former smoking among U.S. workers. J Health Care Poor Underserved. 2007;18(4 Suppl):52–72. doi: 10.1353/hpu.2007.0119. [DOI] [PubMed] [Google Scholar]
- 10.Fagan P, Shavers V, Lawrence D, Gibson JT, Ponder P. Cigarette smoking and quitting behaviors among unemployed adults in the United States. Nicotine Tob Res. 2007;9:241–248. doi: 10.1080/14622200601080331. [DOI] [PubMed] [Google Scholar]
- 11.Fagan P, Augustson E, Backinger CL, O'Connell ME, Vollinger RE, Jr, et al. Quit attempts and intention to quit cigarette smoking among young adults in the United States. Am J Public Health. 2007;97:1412–1420. doi: 10.2105/AJPH.2006.103697. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Ferguson J, Bauld L, Chesterman J, Judge K. The English smoking treatment services: one-year outcomes. Addiction. 2005;100(Suppl 2):59–69. doi: 10.1111/j.1360-0443.2005.01028.x. [DOI] [PubMed] [Google Scholar]
- 13.Reid JL. Socioeconomic disparities in quit intentions, quit attempts, and smoking abstinence among smokers in four western countries: findings from the International Tobacco Control Four Country Survey. Nicotine Tob Res. 2010;12:S20–33. doi: 10.1093/ntr/ntq051. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Trinidad DR, Pérez-Stable EJ, White MM, Emery SL, Messer K. A nationwide analysis of US racial/ethnic disparities in smoking behaviors, smoking cessation, and cessation-related factors. Am J Public Health. 2011;101:699–706. doi: 10.2105/AJPH.2010.191668. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Wetter DW, Cofta-Gunn L, Irvin JE, Fouladi RT, Wright K, et al. What accounts for the association of education and smoking cessation? Prev Med. 2005;40:452–460. doi: 10.1016/j.ypmed.2004.07.001. [DOI] [PubMed] [Google Scholar]
- 16.Lichtenstein E, Zhu SH, Tedeschi GJ. Smoking cessation quitlines: an underrecognized intervention success story. Am Psychol. 2010;65:252–261. doi: 10.1037/a0018598. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Sheffer CE, Stitzer M, Payne TJ, Applegate BW, Bourne D, et al. Treatment for tobacco dependence for rural, lower-income smokers: outcomes, predictors, and measurement considerations. Am J Health Promot. 2009;23:328–338. doi: 10.4278/ajhp.06031933. [DOI] [PubMed] [Google Scholar]
- 18.Sheffer CE, Stitzer M, Landes R, Brackman SL, Munn T, et al. Socioeconomic disparities in community-based treatment of tobacco dependence. Am J Public Health. 2012;102:e8–16. doi: 10.2105/AJPH.2011.300519. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Sheffer C, Stitzer M, Landes R, Brackman SL, Munn T. In-person and telephone treatment of tobacco dependence: a comparison of treatment outcomes and participant characteristics. Am J Public Health. 2013;103:e74–82. doi: 10.2105/AJPH.2012.301144. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Varghese M. Socioeconomic Disparities in telephone treatment-based treatment of tobacco dependence. American Journal of Public Health. 2014:e1–e9. doi: 10.2105/AJPH.2014.301951. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Burgess DJ. Employment, gender, and smoking cessation outcomes in low-income smokers using nicotine replacement therapy. Nicotine Tob Res. 2009;11:1439–47. doi: 10.1093/ntr/ntp158. [DOI] [PubMed] [Google Scholar]
- 22.Fiore MC. Clinical practice guideline. U.S. Department of Health and Human Services. Public Health Service; Rockville, MD: 2008. Treating tobacco use and dependence: 2008 update. [Google Scholar]
- 23.Judge K, Bauld L, Chesterman J, Ferguson J. The English smoking treatment services: short-term outcomes. Addiction. 2005;100(Suppl 2):46–58. doi: 10.1111/j.1360-0443.2005.01027.x. [DOI] [PubMed] [Google Scholar]
- 24.Foulds J, Gandhi KK, Steinberg MB, Richardson DL, Williams JM, et al. Factors associated with quitting smoking at a tobacco dependence treatment clinic. Am J Health Behav. 2006;30:400–412. doi: 10.5555/ajhb.2006.30.4.400. [DOI] [PubMed] [Google Scholar]
- 25.Adler NE, Stewart J. Health disparities across the lifespan: meaning, methods, and mechanisms. Ann N Y Acad Sci. 2010;1186:5–23. doi: 10.1111/j.1749-6632.2009.05337.x. [DOI] [PubMed] [Google Scholar]
- 26.Shavers VL. Measurement of socioeconomic status in health disparities research. J Natl Med Assoc. 2007;99:1013–1023. [PMC free article] [PubMed] [Google Scholar]
- 27.Adler NE, Newman K. Socioeconomic disparities in health: pathways and policies. Health Aff (Millwood) 2002;21:60–76. doi: 10.1377/hlthaff.21.2.60. [DOI] [PubMed] [Google Scholar]
- 28.Gallo LC, Matthews KA. Understanding the association between socioeconomic status and physical health: do negative emotions play a role? Psychol Bull. 2003;129:10–51. doi: 10.1037/0033-2909.129.1.10. [DOI] [PubMed] [Google Scholar]
- 29.Stronks K, van de Mheen H, van den Bos J, Mackenbach JP. The interrelationship between income, health and employment status. Int J Epidemiol. 1997;26:592–600. doi: 10.1093/ije/26.3.592. [DOI] [PubMed] [Google Scholar]
- 30.Fernander AF, Shavers VL, Hammons GJ. Abiopsychosocial approach to examining tobacco-related health disparities among racially classified social groups. Addiction. 2007;2:43–57. doi: 10.1111/j.1360-0443.2007.01954.x. [DOI] [PubMed] [Google Scholar]
- 31.Honjo K, Tsutsumi A, Kawachi I, Kawakami N. What accounts for the relationship between social class and smoking cessation? Results of a path analysis. SocSci Med. 2006;62:317–328. doi: 10.1016/j.socscimed.2005.06.011. [DOI] [PubMed] [Google Scholar]
- 32.Businelle MS, Kendzor DE, Reitzel LR, Costello TJ, Cofta-Woerpel L, et al. Mechanisms linking socioeconomic status to smoking cessation: a structural equation modeling approach. Health Psychol. 2010;29:262–273. doi: 10.1037/a0019285. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Stronks K, van de Mheen HD, Looman CW, Mackenbach JP. Cultural, material, and psychosocial correlates of the socioeconomic gradient in smoking behavior among adults. Prev Med. 1997;26:754–766. doi: 10.1006/pmed.1997.0174. [DOI] [PubMed] [Google Scholar]
- 34.Manfredi C, Cho YI, Crittenden KS, Dolecek TA. A path model of smoking cessation in women smokers of low socio-economic status. Health Educ Res. 2007;22:747–756. doi: 10.1093/her/cyl155. [DOI] [PubMed] [Google Scholar]
- 35.Witkiewitz K, Marlatt GA. Relapse prevention for alcohol and drug problems: that was Zen, this is Tao. Am Psychol. 2004;59:224–235. doi: 10.1037/0003-066X.59.4.224. [DOI] [PubMed] [Google Scholar]
- 36.Kawachi I, Daniels N, Robinson DE. Health disparities by race and class: why both matter. Health Aff (Millwood) 2005;24:343–352. doi: 10.1377/hlthaff.24.2.343. [DOI] [PubMed] [Google Scholar]
- 37.King AC, Cao D, Southard CC, Matthews A. Racial differences in eligibility and enrollment in a smoking cessation clinical trial. Health Psychol. 2011;30:40–48. doi: 10.1037/a0021649. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.King G, Polednak A, Bendel RB, Vilsaint MC, Nahata SB. Disparities in smoking cessation between African Americans and Whites: 1990-2000. Am J Public Health. 2004;94:1965–1971. doi: 10.2105/ajph.94.11.1965. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Cooper R. A note on the biologic concept of race and its application in epidemiologic research. Am Heart J. 1984;108:715–722. doi: 10.1016/0002-8703(84)90662-8. [DOI] [PubMed] [Google Scholar]
- 40.Centers for Disease Control and Prevention . Behavioral risk factor surveillance system survey data, US Department of Health and Human Services. Public Health Service; Rockville: 2013. [Google Scholar]; Bureau MD. In: U.C., US Census Profile of General Demographic Characteristics. Bureau UC, editor. US Census Bureau; Washington, DC: 2010. [Google Scholar]
- 41.DeNavas-Walt C, Proctor BD, Smith JC. Current Population Reports, P60-245, Income, Poverty, and Health Insurance Coverage in the United States: 2012. U.G.P. Office; Washington DC: 2013. [Google Scholar]
- 42.Barrera M, FG Castro A. heuristic framework for the cultural adaptation of interventions. Clinical Psychology-Science and Practice. 2006;13:311–316. [Google Scholar]
- 43.Lau AS. Making the case for selective and directed cultural adaptations of evidence-based treatments: Examples from parent training. Clinical Psychology-Science and Practice. 2006;13:295–310. [Google Scholar]
- 44.Kreuter MW, Lukwago SN, Bucholtz RD, Clark EM, Sanders-Thompson V. Achieving cultural appropriateness in health promotion programs: targeted and tailored approaches. Health EducBehav. 2003;30:133–146. doi: 10.1177/1090198102251021. [DOI] [PubMed] [Google Scholar]
- 45.Kreuter MW, McClure SM. The role of culture in health communication. Annu Rev Public Health. 2004;25:439–455. doi: 10.1146/annurev.publhealth.25.101802.123000. [DOI] [PubMed] [Google Scholar]
- 46.Nollen N, Ahluwalia JS, Mayo MS, Richter K, Choi WS, et al. A randomized trial of targeted educational materials for smoking cessation in African Americans using transdermal nicotine. Health EducBehav. 2007;34:911–927. doi: 10.1177/1090198106294652. [DOI] [PubMed] [Google Scholar]
- 47.Orleans CT. A self-help intervention for African American smokers: tailoring cancer information service counseling for a special population. Prev Med. 1998;27:S61–70. doi: 10.1006/pmed.1998.0400. [DOI] [PubMed] [Google Scholar]
- 48.Webb MS. Culturally specific interventions for African American smokers: an efficacy experiment. J Natl Med Assoc. 2009;101:927–935. doi: 10.1016/s0027-9684(15)31041-5. [DOI] [PubMed] [Google Scholar]
- 49.Lawrence D, Graber JE, Mills SL, Meissner HI, Warnecke R. Smoking cessation interventions in U.S. racial/ethnic minority populations: an assessment of the literature. Prev Med. 2003;36:204–216. doi: 10.1016/s0091-7435(02)00023-3. [DOI] [PubMed] [Google Scholar]
- 50.Matthews AK, Sánchez-Johnsen L, King A. Development of a culturally targeted smoking cessation intervention for African American smokers. J Community Health. 2009;34:480–492. doi: 10.1007/s10900-009-9181-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 51.Cummins SE, Bailey L, Campbell S, Koon-Kirby C, Zhu SH. Tobacco cessation quitlines in North America: a descriptive study. Tob Control. 2007;16(Suppl 1):i9–15. doi: 10.1136/tc.2007.020370. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 52.Webb MS. Does one size fit all African American smokers? The moderating role of acculturation in culturally specific interventions. Psychol Addict Behav. 2008;22:592–596. doi: 10.1037/a0012968. [DOI] [PubMed] [Google Scholar]
- 53.Airhihenbuwa CO. A conceptual model for culturally appropriate health education programs in developing countries. Int Q Community Health Educ. 1990;11:53–62. doi: 10.2190/LPKH-PMPJ-DBW9-FP6X. [DOI] [PubMed] [Google Scholar]
- 54.Airhihenbuwa CO. Health promotion and disease prevention strategies for African Americans: A conceptual model. In: R.L.B.S.E.T., editor. Health issues in the Black community. Jossey-Bass; San Francisco: 1992. 1992. pp. 267–280. [Google Scholar]
- 55.Israel BA. Community-based participatory research: lessons learned from the Centers for Children's Environmental Health and Disease Prevention Research. Environ Health Perspect. 2005;113:1463–71. doi: 10.1289/ehp.7675. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 56.Payne TJ, Smith PO, Adams SG, Diefenbach L. Pretreatment cue reactivity predicts end-of-treatment smoking. Addict Behav. 2006;31:702–710. doi: 10.1016/j.addbeh.2005.05.053. [DOI] [PubMed] [Google Scholar]
- 57.Schmitz JM, Rosenfarb IS, Payne TJ. Cognitive and affective responses to successful coping during smoking cessation. J Subst Abuse. 1993;5:61–72. doi: 10.1016/0899-3289(93)90123-s. [DOI] [PubMed] [Google Scholar]
- 58.Sheffer C. Delay discounting, locus of control, and cognitive impulsiveness independently predict tobacco dependence treatment outcomes in a highly dependent, lower socioeconomic group of smokers. Am J Addict. 2012;21:221–32. doi: 10.1111/j.1521-0391.2012.00224.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 59.Smith PO, Sheffer CE, Payne TJ, Applegate BW, Crews KM. Smoking cessation research in primary care treatment centers: the SCRIPT-MS project. Am J Med Sci. 2003;326:238–241. doi: 10.1097/00000441-200310000-00017. [DOI] [PubMed] [Google Scholar]
- 60.Businelle MS, Kendzor DE, Reitzel LR, Vidrine JI, Castro Y, et al. Pathways linking socioeconomic status and postpartum smoking relapse. Ann Behav Med. 2013;45:180–191. doi: 10.1007/s12160-012-9434-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 61.Kaplan SA, Madden VP, Mijanovich T, Purcaro E. The perception of stress and its impact on health in poor communities. J Community Health. 2013;38:142–149. doi: 10.1007/s10900-012-9593-5. [DOI] [PubMed] [Google Scholar]
- 62.Siahpush M, Yong HH, Borland R, Reid JL, Hammond D. Smokers with financial stress are more likely to want to quit but less likely to try or succeed: findings from the International Tobacco Control (ITC) Four Country Survey. Addiction. 2009;104:1382–1390. doi: 10.1111/j.1360-0443.2009.02599.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 63.Peters J, Buchel C. Episodic future thinking reduces reward delay discounting through an enhancement of prefrontal-mediotemporal interactions. Neuron. 2010;66:138–48. doi: 10.1016/j.neuron.2010.03.026. [DOI] [PubMed] [Google Scholar]
- 64.Marlatt G, Gordon J. Situational determinants of relapse and skill-training interventions. Relapse Prevention Guilford Press; New York: 1985. [Google Scholar]
- 65.Abelson J, Forest PG, Eyles J, Smith P, Martin E, et al. Deliberations about deliberative methods: issues in the design and evaluation of public participation processes. SocSci Med. 2003;57:239–251. doi: 10.1016/s0277-9536(02)00343-x. [DOI] [PubMed] [Google Scholar]
- 66.Abelson J. Understanding the role of contextual influences on local health-care decision making: case study results from Ontario, Canada. SocSci Med. 2001;53:777–793. doi: 10.1016/s0277-9536(00)00386-5. [DOI] [PubMed] [Google Scholar]
- 67.Bickel WK, Moody L, Quinsenberry AJ, Ramey CT, Sheffer C.E. A competing neurobehavioral decision systems model of SES-related health and behavioral disparities. Preventative Medicine. 2014;68:37–43. doi: 10.1016/j.ypmed.2014.06.032. [DOI] [PMC free article] [PubMed] [Google Scholar]