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The COVID-19 pandemic has highlighted existing crises and introduced new stressors for various populations. We suggest that a multilevel ecological perspective, one that researchers and practitioners have used to address some of public health's most intransigent challenges, will be necessary to address emotional distress and mental health problems resulting from the COVID-19 pandemic. Multiple levels of influence (individual, interpersonal, organizational, community, and policy) each contribute (individually and in combination) to population health and individual well-being. We use the convergence strategy to illustrate how multilevel communication strategies designed to raise awareness, educate, or motivate informed decision-making or behavior change can address various sources of information surrounding a person to synergistically affect mental health outcomes. Looking ahead, dissemination and implementation researchers and practitioners will likely need to coordinate organizations and networks to speak in complementary and resonant ways to enhance understanding of complex information related to the pandemic, mitigate unnecessary anxiety, and motivate healthy behavior to support population mental health. Plain language abstract: The current COVID-19 pandemic has threatened the mental health and well-being of various populations. The pandemic also has compounded health disparities experienced by communities of color and magnified the vast treatment gaps they experience related to behavioral health and substance use treatment access. A multilevel approach to future communication interventions focused on mental health likely will be useful, as we need to know about and address interactions with health care professionals, mass media information sources, social networks, and community influences rather than solely trying to reach people with carefully crafted videos or advertisements. Implementation researchers and practitioners likely will need to coordinate organizations and networks to speak in complementary and resonant ways to support population mental health.

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OBJECTIVE: Over half of pregnant women in India are affected by anaemia, which can lead to premature birth, low birth weight and maternal and child mortality. Using formative research, we aimed to understand social and cultural factors around iron and folic acid (IFA) supplement provision and adherence to identify potential strategies for improving adherence and behaviours to prevent and treat anaemia among pregnant and lactating Indian women. DESIGN: In-depth interviews and focus group discussions with women and key informant interviews with health officials and workers. SETTING: Four districts in two Indian states: Allahabad and Bara Banki districts in Uttar Pradesh and Chikkballapura and Mandya districts in Karnataka. PARTICIPANTS: Pregnant and lactating women (n 65) and district officials and community health workers (n 14). RESULTS: Most women were aware of anaemia but did not understand its seriousness and consequences. All women received IFA supplements (predominantly for free), but many were not adherent because of side effects; lack of information from healthcare providers on the causes of anaemia, its seriousness and solutions and low social support. To address anaemia, women were most confident in their ability to prepare and eat healthier foods but lacked control over resources such as appropriate food availability. CONCLUSIONS: Based on the findings, we recommend multicomponent interventions to train healthcare providers, address systemic barriers and involve family members to support IFA supplement adherence and dietary changes. Future research will determine which strategies are most effective to reduce the burden of anaemia in India among pregnant and lactating women.

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Responding to an emerging health threat often requires rapid deployment of behavior change communication. Health communication best practices include developing and testing draft messages and materials to ensure that they resonate with and inspire priority groups to act. However, when faced with an emergency health threat, the timeline for these activities can be compressed from months to weeks. This article discusses the rapid development and implementation of a Zika virus prevention campaign for pregnant women in Puerto Rico. The goal of the campaign was to increase knowledge among and motivate pregnant women, their partners and family members, and the community to follow Zika virus prevention recommendations. The steps in campaign development include environmental scanning, concept development and testing, and message testing to ensure development of campaign materials that resonated with and were well-received by key audience groups. The materials adhere to principles of behavior change communication, and offer our insights for development of future campaigns when under time constraints.

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Direct-to-consumer (DTC) television ads for prescription drugs are required to disclose the product's major risks in the audio or audio and visual parts of the presentation (sometimes referred to as the "major statement"). The objective of this content analysis was to determine how the major statement of risks is presented in DTC television ads, including what risk information is presented, how easy or difficult it is to understand the risk information, and the audio and visual characteristics of the major statement. We identified 68 DTC television ads for branded prescription drugs, which included a unique major statement and that aired between July 2012 and August 2014. We used subjective and objective measures to code 50 ads randomly selected from the main sample. Major statements often presented numerous risks, usually in order of severity, with no quantitative information about the risks' severity or prevalence. The major statements required a high school reading level, and many included long and complex sentences. The major statements were often accompanied by competing non-risk information in the visual images, presented with moderately fast-paced music, and read at a faster pace than benefit information. Overall, we discovered several ways in which the communication of risk information could be improved.

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BACKGROUND: Virtual focus groups-such as online chat and video groups-are increasingly promoted as qualitative research tools. Theoretically, virtual groups offer several advantages, including lower cost, faster recruitment, greater geographic diversity, enrollment of hard-to-reach populations, and reduced participant burden. However, no study has compared virtual and in-person focus groups on these metrics. OBJECTIVE: To rigorously compare virtual and in-person focus groups on cost, recruitment, and participant logistics. We examined 3 focus group modes and instituted experimental controls to ensure a fair comparison. METHODS: We conducted 6 1-hour focus groups in August 2014 using in-person (n=2), live chat (n=2), and video (n=2) modes with individuals who had type 2 diabetes (n=48 enrolled, n=39 completed). In planning groups, we solicited bids from 6 virtual platform vendors and 4 recruitment firms. We then selected 1 platform or facility per mode and a single recruitment firm across all modes. To minimize bias, the recruitment firm employed different recruiters by mode who were blinded to recruitment efforts for other modes. We tracked enrollment during a 2-week period. A single moderator conducted all groups using the same guide, which addressed the use of technology to communicate with health care providers. We conducted the groups at the same times of day on Monday to Wednesday during a single week. At the end of each group, participants completed a short survey. RESULTS: Virtual focus groups offered minimal cost savings compared with in-person groups (US $2000 per chat group vs US $2576 per in-person group vs US $2,750 per video group). Although virtual groups did not incur travel costs, they often had higher management fees and miscellaneous expenses (eg, participant webcams). Recruitment timing did not differ by mode, but show rates were higher for in-person groups (94% [15/16] in-person vs 81% [13/16] video vs 69% [11/16] chat). Virtual group participants were more geographically diverse (but with significant clustering around major metropolitan areas) and more likely to be non-white, less educated, and less healthy. Internet usage was higher among virtual group participants, yet virtual groups still reached light Internet users. In terms of burden, chat groups were easiest to join and required the least preparation (chat = 13 minutes, video = 40 minutes, in-person = 78 minutes). Virtual group participants joined using laptop or desktop computers, and most virtual participants (82% [9/11] chat vs 62% [8/13] video) reported having no other people in their immediate vicinity. CONCLUSIONS: Virtual focus groups offer potential advantages for participant diversity and reaching less healthy populations. However, virtual groups do not appear to cost less or recruit participants faster than in-person groups. Further research on virtual group data quality and group dynamics is needed to fully understand their advantages and limitations.

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Although lung cancer is the deadliest type of cancer, survival rates are improving. To address the dearth of literature about the concerns of lung cancer survivors, the authors conducted 21 in-depth interviews with lung cancer survivors that focused on experiences during diagnosis, treatment, and long-term survivorship. Emergent themes included feeling blamed for having caused their cancer, being stigmatized as throwaways, and long-term survivors' experiencing surprise that they are still alive, given poor overall survival rates. Survivors also desired increased public support. It is imperative for healthcare and public health professionals to learn more about needs of this population.

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In situ simulations allow healthcare teams to practice teamwork and communication as well as clinical management skills in a team's usual work setting with typically available resources and equipment. The purpose of this video is to demonstrate how to plan and conduct in situ simulation training sessions, with particular emphasis on how such training can be used to improve communication and teamwork. The video features an in situ simulation conducted at a labour and delivery unit in response to postpartum hemorrhage.

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PURPOSE ­: This study aims to explore peoples cognitive perceptions of HIV and other sexually transmitted diseases (STDs) to inform decisions on message development with regard to message bundling, with limited research on the concept of bundling-related prevention messages and no studies that consider the bundling of HIV and other STD prevention messages. DESIGN/METHODOLOGY/APPROACH ­: Individual and small-group interviews were conducted with 158 African American men and women to explore perceptions of STDs and communication preferences. Open-ended questions and a pile-sort exercise were used to elicit individuals' judgments on similarities of 12 STDs, including HIV. Interview data were coded and analyzed for themes and patterns; pile sort data were analyzed using multidimensional scaling (MDS) and cluster analysis to visualize the set of relations identified from the piles. FINDINGS ­: STDs and HIV are associated with stigma, risk behaviors and personal responsibility. The card sorting activity revealed two primary dimensions by which people organized STDs: seriousness and curability. Potential clusters of STDs that correspond to participants described sorting strategies were identified and they may have implications for message bundling. Disaggregation of the data by sex and age revealed slight variations in the relationships of HIV and human papillomavirus (HPV) to other STDs. ORIGINALITY/VALUE ­: By identifying a set of cognitive attributes people use in organizing the overall semantic domain of STDs, ideas can be generated for how best to combine STD and HIV messages to meet public health communication goals.

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In an effort to inform communication efforts to promote sexual health equity in the United States, the Centers for Disease Control and Prevention sought to explore African-Americans' perceptions of the sexually transmitted disease (STD) problem in their communities, reactions to racially comparative STD data and opinions about dissemination of such information. Semi-structured triads and individual interviews were conducted with African-American adults (N = 158) in the Southeastern and Midwestern United States. Most participants believed that STDs are a problem in their communities but were unaware of the extent to which STDs disproportionately affect African Americans. Once informed about racial differences in STD rates, participants commonly reacted with shock, fear and despair; a minority raised questions about the information's source and credibility. Most felt it was critical to get the information out to African-American communities as a 'wake-up call' to motivate change, though some raised concerns about its dissemination. Findings suggest that information about racial differences in STD rates must be strategically crafted and delivered through targeted channels to be acceptable to African Americans. So as not to further harm communities burdened by other social/health inequities, alternative (strength-based) approaches should be considered for motivating positive change.

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BACKGROUND: Unintentional, non-fire-related carbon monoxide (CO) poisoning is a leading cause of poisoning death and injury in the USA. Residential poisonings caused by faulty furnaces are the most common type of CO exposure. However, these poisonings are largely preventable with annual furnace inspections and CO alarm installation. OBJECTIVE: This study aimed to identify the knowledge, attitudes and beliefs that might lead consumers to adopt these protective behaviours. METHODS: In August 2009, four focus groups (n=29) were conducted with homeowners in Chicago, Illinois, USA, to identify the knowledge, attitudes and beliefs that lead consumers to adopt risk and protective behaviours. Discussions were transcribed and the findings were analysed using an ordered meta-matrix. RESULTS: Focus group participants were aware of CO poisoning and supported the idea of regular furnace inspections. However, few participants consistently scheduled professional inspections for fear of costly repairs and unscrupulous contractors. Participants often owned CO alarms, but many did not locate them properly, nor maintain them. Some participants confused CO and natural gas and were unsure how to react if a CO alarm sounds. Participants stated that incentives, such as discounts and inspector selection tips, would make them more likely to schedule furnace inspections. Participants also identified trustworthy sources for CO education, including realtors, fire departments, home insurance agents and local media outlets. CONCLUSIONS: Participants' residential CO risk behaviours are not random but driven by underlying knowledge, attitudes and beliefs. Correcting misperceptions, providing incentives and partnering with trustworthy sources might encourage greater consumer adoption of protective behaviours.

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Carbon monoxide (CO) poisonings in the United States consistently occur when residents improperly use portable gasoline-powered generators and other tools following severe storms and power outages. However, protective behaviors-such as installing CO alarms and placing generators more than 20 feet away from indoor structures-can prevent these poisonings. This study identified knowledge, attitudes, and beliefs that lead consumers to adopt risk and protective behaviors for storm-related CO poisoning and post-storm generator use. Four focus groups (32 participants in total) were conducted with generator owners in winter and summer storm-prone areas to explore home safety, portable generator use, CO poisoning knowledge, and generator safety messages. Discussions were transcribed, and findings analyzed using an ordered meta-matrix approach. Although most generator owners were aware of CO poisoning, many were unsure what constitutes a safe location for generator operation and incorrectly stated that enclosed areas outside the home-such as attached garages, sheds, and covered porches-were safe. Convenience and access to appliances often dictated generator placement. Participants were receptive to installing CO alarms in their homes but were unsure where to place them. These findings suggest a deficit in understanding how to operate portable generators safely and a need to correct misconceptions around safe placement. In terms of behavioral price, the simple installation and maintenance of inexpensive CO alarms may be the most important strategy for ultimately protecting homes from both storm-related and other CO exposures.

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Rates of heavy drinking are consistently higher among U.S. military personnel than among civilians, particularly among young male personnel. In addressing drinking in the military, more information is needed on contextual factors influencing drinking to better understand the conditions that lead to or facilitate drinking. Results from 15 focus groups conducted with enlisted personnel at 2 Navy and 2 Marine Corps installations as part of formative research for an alcohol abuse prevention trial are reported in this article. The study explored the "drinking climate" of each installation in terms of shared attitudes and recognized norms regarding alcohol use and installation personnel's general understanding of policies concerning alcohol consumption. Analysis revealed several contextual factors that add to our understanding of drinking behaviors.

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OBJECTIVE: To examine the effects of a community-based intervention on decisions about prostate-specific antigen (PSA) screening using multiple measures of informed decision making (IDM). DATA SOURCES/STUDY SETTING: Nonequivalent control group time series design collecting primary data in late 2004 and 2005. STUDY DESIGN: We developed a multimodal intervention designed to convey the medical uncertainty about the benefits of PSA screening and early treatment and the limited predictive ability of both the PSA test and pathological specimens collected from prostate biopsy. We examined (1) patients' recognition that there is a decision to be made about PSA screening, (2) prostate cancer knowledge levels, (3) their preferred and actual levels of participation in decision making about screening at three points in time, and (4) screening decision. DATA COLLECTION: Baseline data collection occurred in community-based organizations. These organizations served as recruiting sources and as sites for the intervention. We collected follow-up data by mail with telephone reminders. PRINCIPAL FINDINGS: Our intervention was associated with greater recognition of the PSA test as a decision to be made, levels of knowledge, both preferred and actual levels of involvement in decision making, but did not have an impact on the screening decision. CONCLUSIONS: Community-based interventions can influence key measures of IDM about PSA screening.

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BACKGROUND: This community-based intervention study examined the effects of 2 different message strategies for presenting information about the prostate specific antigen (PSA) test. METHODS: A quasi-experimental longitudinal design with 2 intervention and 1 control group. RESULTS: Knowledge increased significantly among participants who received either version of the intervention message and remained elevated at 12 months. Presenting information in the context of other men's health issues was associated with greater increases in knowledge relative to PSA only. CONCLUSIONS: Community-based interventions can increase knowledge about prostate cancer screening. Clinicians need to take careful account of what their patients understand and correct misperceptions.

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BACKGROUND: Most medical associations recommend that patients make informed decisions about whether to be screened for prostate cancer with the prostate-specific antigen (PSA) test. Studies assessing how to promote PSA informed decision-making (IDM) have been conducted almost exclusively in healthcare settings; there is a need for similar research in community settings. METHODS: This paper describes the results of a 5-year study (2002--2007) in which two community-level interventions were developed, implemented, and evaluated in matched upper- and lower-SES comparison communities in Greensboro and Wilmington, North Carolina. Both interventions promoted PSA informed decision-making. One intervention (PSA-Only) consisted of educational information about prostate cancer and the PSA test, and the other (Men's Health) included additional information about recognizing and preventing heart attack, stroke, and colon cancer. Structured survey, semistructured interview, and structured observational data were combined to compare participating community residents' pre/post changes in knowledge, intentions, and behaviors related to PSA IDM. RESULTS: The community-level interventions successfully engaged community participants in discussions, educated individuals, encouraged deliberation of information, and facilitated PSA test discussions with physicians. Men who participated in the PSA-Only educational sessions were more likely than those who attended the Men's Health educational sessions to discuss the PSA test with their physician (p=0.037). CONCLUSIONS: When prospective SES-related confounding factors are matched across comparison communities, PSA IDM interventions can be shown to promote IDM. Framing the PSA test decision relative to less-ambiguous screening decisions does not appear to increase the likelihood of PSA IDM.

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CONTEXT: While literature exists on sexual risks for HIV among rural populations, the specific role of stimulants in increasing these risks has primarily been studied in the context of a single drug and/or racial group. PURPOSE: This study explores the use of multiple stimulants and sexual risk behaviors among individuals of different races and sexual identities in rural North Carolina. METHODS: In-depth interviews were conducted with 41 individuals in 3 rural North Carolina counties between June 2004 and December 2005. Interviews were audiotaped, transcribed and reviewed for accuracy. Edited interviews were imported into Atlas.ti and askSam for analysis. FINDINGS: Along with marijuana, stimulants-including powder cocaine, crack, and methamphetamine-were the most frequently used illicit drugs in these counties. Powder cocaine use was more closely associated with white participants, crack with African Americans, and both were more commonly used by female participants. Participants reported 3 overlapping behaviors involving stimulant use that may be associated with increased risk of HIV infection: engaging in sex while using drugs, sex trading and group sex. Nearly half of participants reported engaging in group sex activity. CONCLUSIONS: HIV risk through injection appears to be low in these rural counties. However, nearly all study participants reported some form of sexual risk behavior that may increase transmission of HIV and other sexually transmitted infections. Further research is warranted focusing on the nexus between substance abuse and risky sexual behaviors.

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