Interpersonal and Print Nutrition Communication for a Spanish-Dominant Latino Population: Secretos de la Buena Vida

Effectiveness of different methods for delivering tailored nutrition education to low income, ethnically diverse adults

BACKGROUND

Computer-tailored written nutrition interventions have been shown to be more effective than non-tailored materials in changing diet, but continued research is needed. Your Healthy Life/Su Vida Saludable (YHL-SVS) was an intervention study with low income, ethnically diverse, English and Spanish-speaking participants to determine which methods of delivering tailored written nutrition materials were most effective in lowering fat and increasing fruit and vegetable (F&V) intake.

METHODS

YHL-SVS was a randomized controlled trial with four experimental conditions: 1) Nontailored (NT) comparison group; 2) Single Tailored (ST) packet; 3) Multiple Tailored (MT) packet mailed in four installments; 4) Multiple Re-Tailored (MRT) MT packets re-tailored between mailings via brief phone surveys. A baseline telephone survey collected information for tailoring as well as evaluation. Follow-up evaluation surveys were collected 4- and 7-months later. Primary outcomes included F&V intake and fat related behaviors. Descriptive statistics, paired t-test and ANOVA were used to examine the effectiveness of different methods of delivering tailored nutrition information.

RESULTS

Both the ST and MT groups reported significantly higher F&V intake at 4-months than the NT and MRT groups. At 7 months, only the MT group still had significantly higher F&V intake compared to the NT group. For changes in fat-related behaviors, both the MT and MRT groups showed more change than NT at 4 months, but at 7 months, while these differences persisted, they were no longer statistically significant. There was a significant interaction of experimental group by education for change in F&V intake (P = .0085) with the lowest educational group demonstrating the most change.

CONCLUSION

In this study, tailored interventions were more effective than non-tailored interventions in improving the short-term dietary behaviors of low income, ethnically diverse participants. Delivery of information in multiple smaller doses over time appeared to improve effectiveness. Future studies should determine which variables are mediators of dietary change and whether these differ by participant demographics. Moreover, future research should differentiate the effects of tailoring vs. cultural adaptation in ethnically diverse populations and study the dissemination of tailored interventions into community-based settings.

TRIAL REGISTRATION

Current Controlled Trials # NCT00301691.

Underreporting of food intake among Mexican/Mexican-American Women: rates and correlates

BACKGROUND

Under-reporters are those individuals who report a dietary intake level that is not biologically plausible given their physiological status and physical activity level. Underreporting of food intake threatens the validity of dietary assessment; yet, little is known about the prevalence or correlates of underreporting in the Mexican/Mexican-American community.

OBJECTIVE

To examine underreporting rates and correlates among Mexican/Mexican-American women using dietary data based on repeated 24-hour recalls and the Goldberg equation.

DESIGN

Cross-sectional study of baseline data collected as part of a larger randomized controlled trial through structured interviews and anthropometric measurements.

SUBJECTS/SETTING

A random sample of 357 Mexican/Mexican-American women, ranging in age from 21 to 67 years, living in south San Diego near the United States/Mexico border.

STATISTICAL ANALYSES PERFORMED

Age, income level, education level, and weight status, all correlates of underreporting in samples of non-Hispanic white participants, were examined as potential correlates of underreporting among Mexican/Mexican-American women using binary logistic regression. Acculturation was examined to determine if it accounted for additional variance in underreporting. Finally, multivariate analyses using backward stepwise regression were conducted to determine which correlates remained significant in the final model.

RESULTS

Rates of underreporting varied across the five detection methods employed, from 11.9% (n=42) to 81.3% (n=286). Obese weight status was the only significant correlate across all five underreporting detection methods and remained significant in the final model. Using backward stepwise regression, the final model showed weight status to be a significant correlate of underreporting both at the overweight (P<0.05) and obese levels (P<0.01). In addition, Anglo orientation score (P<0.05) remained significant in the final model, as well as the age group of 51 years or older (P<0.05).

CONCLUSIONS

Consistent with previous studies, under-reporters in this Mexican/Mexican-American sample were more likely to be overweight or obese, and were older. They also were more likely to identify with the dominant Anglo culture. Additional studies are needed to further examine underreporting error in dietary assessment among Latinos, and to determine whether the effects of acculturation on underreporting are found in other Latino subgroups.

La Clínica del Pueblo: a model of collaboration between a private media broadcasting corporation and an academic medical center for health education for North Carolina Latinos

La Clínica del Pueblo, a health education collaboration between the Maya Angelou Center for Health Equity at Wake Forest University School of Medicine and Qué Pasa Media, Inc., disseminates culturally appropriate health information to the North Carolina (NC) Latino community. The program includes a weekly radio show and corresponding newspaper column addressing four areas: childhood health, adult health, safety, and utilization. The radio show format includes a didactic presentation followed by a call-in question and answer period. Over 200 consecutive weeks of programming have been completed, averaging 11 calls per show. A Latino healthcare resource guide and hotline also provide resource information. Participant demographic information indicates that 50% of the target population comes from Mexico, 60% are women, and 70% of the community is younger than 38 years. There was an increase in the use of the media as a source of health information over the course of the project, from an initial 33% of respondents to 58% in the last survey. Listenership to La Clínica del Pueblo displayed a pronounced increase (18% initial survey to 55% in last survey, P < 0.05). We also observed a statistically significant increase in medical knowledge from initial survey to the last survey (P < 0.001). By multiple regression analysis, we identified 4 predictors of medical knowledge: order of surveys (1 < 3, P < 0.001), education level (P < 0.0001), female gender (P < 0.01) and radio listenership (P < 0.05). The first three variables predicted higher scores; however, radio listening recognition of our radio program was more common among individuals who had lower scores. In conclusion, La Clínica del Pueblo is a model for a novel approach that can reach the Latino community to improve medical knowledge and possibly affect health behaviors in a positive manner.

Predictors of trying to lose weight among overweight and obese Mexican-Americans: a signal detection analysis

OBJECTIVE

Signal detection analysis, a form of recursive partitioning, was used to identify combinations of sociodemographic and acculturation factors that predict trying to lose weight in a community-based sample of 957 overweight and obese Mexican-American adults (ages 18-69 years).

DESIGN

Data were pooled from the 2004 and 2006 Behavioral Risk Factor Surveillance System conducted in a low-income, semi-rural community in California.

RESULTS

Overall, 59 % of the population reported trying to lose weight. The proportion of adults who were trying to lose weight was highly variable across the seven mutually exclusive groups identified by signal detection (range 30-79 %). Significant predictors of trying to lose weight included BMI, gender, age and income. Women who were very overweight (BMI > 28.5 kg/m2) were most likely to be trying to lose weight (79 %), followed by very overweight higher-income men and moderately overweight (BMI = 25.0-28.5 kg/m2) higher-income women (72 % and 70 %, respectively). Moderately overweight men, aged 28-69 years, were the least likely to be trying to lose weight (30 %), followed by moderately overweight lower-income women (47 %) and very overweight lower-income men (49 %). The latter group is of particular concern since they have characteristics associated with medical complications of obesity (low education and poor access to medical care).

CONCLUSIONS

Our findings highlight opportunities and challenges for public health professionals working with overweight Mexican-American adults - particularly lower-income adults who were born in Mexico - who are not trying to lose weight and are therefore at high risk for obesity-related co-morbidities.

Adaptation of a lay health advisor model as a recruitment and retention strategy in a clinical trial of college student smokers

This study describes and provides results from a process evaluation of a lay health advisor (LHA) model to enhance participation in a clinical trial of the effectiveness of motivational interviewing on smoking cessation in college fraternity and sorority members. The implementation of the model had two phases: (a) the selection and training of LHAs as liaisons between research staff and participants and (b) LHAs' roles in recruitment and retention. Perceptions of the LHA model were explored using survey questionnaires. Trial participants (N = 118) and LHAs (N = 8) were generally satisfied with the model and identified LHAs as helpful to participation. Seventy-four percent of chapter members were screened and 73% of participants received three of the four motivational interviewing sessions. These results indicate the LHA model was well received and met the needs of the research project.

Development and validation of a scale to measure Latino parenting strategies related to children's obesigenic behaviors. The parenting strategies for eating and activity scale (PEAS)

Research has shown that children's dietary and activity-related behaviors are shaped by the family environment and parenting behaviors. The present study describes the development and validation of a bilingual (Spanish and English) scale assessing parenting strategies associated with children's dietary and activity-related behaviors in the home. Items were generated from focus groups with Latina mothers and a review of the literature, and two different samples were used to assess the scale's psychometric properties, including an examination of predictive validity using measured child body mass index. Factor analysis of the first sample (N=91) yielded a 5-factor solution (limit setting, monitoring, discipline, control and concern) and accounted for 65% of the variance. Confirmatory factor analyses on a second sample of Latina mothers recruited into a childhood obesity prevention study (N=714) showed that a 26-item 5-factor solution (limit setting, monitoring, discipline, control and reinforcement) provided the best fit for the data. Parenting strategies characterized as controlling were associated with a lower BMI among children. After using multiple samples and establishing its validity, the parenting strategies for eating and activity scale (PEAS) was found to be valid and reliable in measuring Latino parenting strategies related to children's dietary and activity-related behaviors.

Away-from-home food intake and risk for obesity: examining the influence of context

OBJECTIVE

This study examined sociodemographic and cultural determinants of away-from-home food consumption in two contexts and the influence of frequency of away-from-home food consumption on children's dietary intake and parent and child weight status.

METHODS AND PROCEDURES

Parents of children (N=708) in grades K-2 were recruited from 13 elementary schools in Southern California. Parents were asked through a questionnaire the frequency with which they eat meals away from home and the restaurant they frequented most often. The height and weight of the parents and their children were measured to calculate BMI.

RESULTS

Consuming foods at least once a week from relatives/neighbors/friends (RNF) homes was associated with children's dietary intake and children's risk for obesity. For example, children of parents with weekly or greater RNF food consumption drank more sugar-sweetened beverages. Parents of families who ate at restaurants at least weekly reported that their children consumed more sugar-sweetened beverages, more sweet/savory snacks, and less water compared with families who did not frequent restaurants this often. The type of restaurant visited did not affect diet intake or obesity. More acculturated families exhibited less healthy dietary behaviors than less acculturated families.

DISCUSSION

Restaurants remain an important setting for preventing child and adult obesity, but other settings outside the home need to be considered in future intervention research. This may especially involve eating in the homes of RNF.

Implementation, outcomes, and lessons learned from a collaborative primary health care program to improve diabetes care among urban Latino populations

A collaborative primary health care service demonstration program was conducted to improve diabetes care among limited English-proficient (LEP) Latino patients. The intervention provided a multilevel approach aimed at patients and health care providers: Community health workers (CHWs) were mobilized to offer diabetes education in Spanish to LEP Latino diabetes patients, and health professions students and providers were offered intensive Spanish language training and cultural competency workshops. Positive outcomes for patients included a significant decrease in HbA1c. Health care providers reported improved patient communication and greater appreciation for cultural influences on health. Collaborating institutions realized ongoing benefits from expansion of CHWs' role and incorporation of cultural and language classes into health professions students' and house officers' training programs. Lessons learned included the importance of working together at every stage to identify and provide for the CHWs' training and support needs and to link the program's intervention with evaluation of multilevel outcomes.

Acceptance of a nutrition curriculum for HIV-positive Latinos Living on the U.S.-Mexico border

Patient-centered nutrition education and counseling can improve the health of HIV-positive persons. This article describes the development and implementation of a Spanish-language, community clinic-based, individually tailored, and culturally specific nutrition curriculum for HIV-positive Latinos living on the U.S.-Mexico border. Important considerations made in serving this population include low acculturation to U.S. culture, monolingual Spanish speaking, cross-border mobility, and dietary behaviors influenced by access to culturally preferred regional foods, some of which may not be nutritionally optimal. Challenges to curriculum implementation and lessons learned for replication of the curriculum in other clinical settings are discussed.

Evaluating psychosocial and behavioral mechanisms of change in a tailored communication intervention

This study examined the impact of a tailored nutrition intervention at 3 and 6 months postintervention. In all, 357 Latinas were randomly assigned to one of three conditions: (1) a control condition comprised of previously developed Spanish language targeted materials, (2) tailored print materials, or (3) tailored print materials accompanied by personalized dietary counseling via lay heath advisors (promotoras). At 6 months postintervention, significant group by time interactions were observed on the dietary behavioral strategies scales. The promotora condition resulted in significant behavior change initially; however, receipt of tailored and control materials was instrumental in continued behavior change after intervention activities had ceased. Group main effects suggested that the promotora condition was superior at reducing barriers and improving family interactions supporting healthy behaviors. The promotora model is an effective method for changing important dietary behaviors and psychosocial determinants, but longer term behavior change is achievable with less expensive intervention methods.

Lay health advisor interventions among Hispanics/Latinos: a qualitative systematic review

BACKGROUND

With an expanding Hispanic/Latino community in the United States, practitioners and researchers working to promote health and prevent disease have relied on lay health advisor (LHA) models to address a variety of health issues. The primary goal of this systematic review was to explore how LHA approaches have been used and evaluated within Hispanic/Latino communities in the U.S.

METHODS

Ten literature databases were searched from their inception through July 2006, using keywords associated with LHA approaches. This review consisted of human studies that included adult Hispanics or Latinos of either gender, were conducted in the U.S., were published in English-language peer-reviewed journals, and contained enough abstractable information. Data abstraction was completed independently by three data abstractors using a standardized abstraction form that collected intervention characteristics and study results.

RESULTS

A total of 172 studies were identified and 37 met the inclusion criteria. Of these, 28 included female LHAs exclusively and five included a small number of male as well as female LHAs. Training for LHAs ranged from 6 to 160 hours. Primary roles of LHAs included: supporting participant recruitment and data collection, serving as health advisors and referral sources, distributing materials, being role models, and advocating on behalf of community members. Fourteen studies found evidence of effectiveness.

CONCLUSIONS

Given the long history of using LHAs as an approach to health promotion and disease prevention and the current emphasis of LHA approaches as a potential solution to health disparities in general, and among Hispanics/Latinos in particular, few rigorous studies have been published that document the effectiveness of LHAs on a variety of public health concerns. A stronger empirical evidence base is clearly needed.

Association between family variables and Mexican American children's dietary behaviors

OBJECTIVE

To examine the association between family variables and children's diets.

DESIGN

Cross-sectional study with households sampled using random-digit dialing. Children completed a one-time, self-administered survey, and mothers participated in a face-to-face structured interview.

SETTING

Data collection occurred in southern San Diego County on the U.S.-Mexico border.

PARTICIPANTS

One hundred sixty-seven Mexican American children between 8 and 18 years of age and their mothers.

MAIN OUTCOME MEASURES

Diet: number of snacks, candies and sweets, and sodas consumed daily; dietary fat and fiber; and money spent weekly on fast food and snacks. Family variables: household size, family support for healthful eating, number of meals eaten together, availability of fast food in the home, food ads seen on television, and parent purchasing food products that children saw advertised on television.

DATA ANALYSES

Regression analyses were used to examine the independent contributions of family variables on dietary intake. Statistical significance was set at P < .05.

RESULTS

Greater family support for healthful eating was associated with fewer snacks and more fiber consumed. Children of parents who purchased food products that their children had seen advertised on television reported consuming more snacks and more fat, and they spent more money on fast food and snacks.

CONCLUSIONS AND IMPLICATIONS

Family-based interventions are needed to moderate the potential influence of television-advertised food products on children's requests for these food products.

Acculturation and body image perception among Latino youth

OBJECTIVES

Examine the prevalence and predictors of body image dissatisfaction and disordered eating among Latino youth.

DESIGN

One hundred and sixty-seven Latino youth were surveyed as part of a tailored nutrition communication intervention. The youth's mean age was 12.81 years (SD = 2.74) and 54% were female. Mean self-rated health was 2.59 (SD = 1.02; range: 1 = good to 5 = poor), despite 70% reporting a desire to be thinner. Using age and gender-specific growth charts, 16% of the youth were classified as at risk for overweight and 34% were classified as overweight.

RESULTS

Among adolescents, girls (p < or = 0.001), youth who were classified as at risk for or being overweight (p < or = 0.001), and who more strongly recognized and agreed with socially sanctioned standards of appearance as represented in the media (Standardized beta St. beta = 1.86, p < or = 0.001) were more dissatisfied with their body image (R(2) = 0.57). Among children, being at risk for or overweight (p < or = 0.001), reporting a stronger affiliation with the Mexican culture (St. beta = 0.84, p < or = 0.01) and stronger expectations that a healthy diet was associated with improved appearance (St. beta = 0.63, p < or = 0.05) predicted greater body image dissatisfaction (R(2) = 0.55).

CONCLUSION

Interventions that address sociocultural attitudes toward appearance may be effective at reducing both the prevalence of body image dissatisfaction and disordered eating.

Long-term effects of a communication intervention for Spanish-dominant Latinas

BACKGROUND

Few studies compare the influence of different types of dietary interventions on the dietary practices of Latinas in the short and long term. The present study examined the 1-year impact of two innovative behavior-change approaches to reduce dietary fat and increase fiber.

DESIGN

Three-group randomized controlled trial: (1) personalized dietary counseling via lay heath advisors (promotoras) plus tailored print materials delivered via the mail, (2) tailored mailed print materials only, and (3) targeted mailed "off-the-shelf" materials.

SETTING/PARTICIPANTS

A total of 357 Latinas were randomly assigned to the three aforementioned conditions.

INTERVENTION

Promotora and tailored print materials.

MAIN OUTCOME MEASURES

Fat intake (total grams of fat and percent calories from dietary fat) and number of grams of dietary fiber.

RESULTS

Earlier work reported that at immediate post-intervention the promotora group achieved significantly lower levels of total fat grams, and lower levels of energy intake, total saturated fat, total carbohydrates, glucose, and fructose than the targeted group. However, the present longitudinal analyses suggest that the effects achieved by the promotoras dissipated over the 12-month follow-up period while the effects of the tailored group concurrently improved.

CONCLUSIONS

The high interactivity (i.e., calls, visits) of the promotora condition may have been the most salient reinforcer and may have led to further tailoring, making this type of intervention more effective than the comparison groups in the short term. Further research should explore whether booster sessions involving promotoras help to maintain the impact over time.

Association of a traditional vs shared meal decision-making and preparation style with eating behavior of Hispanic women in San Diego County

OBJECTIVE

To examine the influence of meal decision-making and preparation on Hispanic women's dietary practices.

DESIGN

One-on-one structured interviews were conducted, assessing meal decision-making and preparation practices, barriers, and behavioral strategies to eating low-fat and high-fiber diets, fat and fiber intake, demographic, and other psychosocial factors.

SUBJECTS/SETTING

The study population included 357 Hispanic women living in the southern or central regions of San Diego County. Participants were recruited via random-digit dialing to a tailored nutrition communication intervention.

MAIN OUTCOME MEASURE

Household decision-making style (alone vs with family) by household activity (decides meals, prepares meals, and decides snacks).

STATISTICAL ANALYSES PERFORMED

Multiple logistic regressions were used to evaluate associations between the predictors and dependent variable. All models included adjustments for potential confounders, such as marital status, education, employment, age, and acculturation.

RESULTS

A positive statistical association between Hispanic women's acculturation level and shared decision-making style was found. Also, Hispanic women in shared decision-making households faced greater psychosocial barriers to healthful eating and reported less healthful eating compared with Hispanic women in traditional households. Women in shared decision-making households were more likely to eat at fast-food restaurants, less likely to engage in behavioral strategies promoting fiber consumption, eat more saturated fat, and encounter more barriers to reduce dietary fat as compared with Hispanic women in traditional households. Acculturation did not attenuate differences in psychosocial and dietary practices between shared decision-making and traditional households.

CONCLUSIONS

Study findings suggest intervention efforts should focus on different aspects of healthful eating among Hispanic women in shared-decision, compared with traditional, households.

A demonstration of modeling count data with an application to physical activity

Counting outcomes such as days of physical activity or servings of fruits and vegetables often have distributions that are highly skewed toward the right with a preponderance of zeros, posing analytical challenges. This paper demonstrates how such outcomes may be analyzed with several modifications to Poisson regression.

Five regression models 1) Poisson, 2) overdispersed Poisson, 3) negative binomial, 4) zero-inflated Poisson (ZIP), and 5) zero-inflated negative binomial (ZINB) are fitted to data assessing predictors of vigorous physical activity (VPA) among Latina women. The models are described, and analytical and graphical approaches are discussed to aid in model selection.

Poisson regression provided a poor fit where 82% of the subjects reported no days of VPA. The fit improved considerably with the negative binomial and ZIP models. There was little difference in fit between the ZIP and ZINB models. Overall, the ZIP model fit best. No days of VPA were associated with poorer self-reported health and less assimilation to Anglo culture, and marginally associated with increasing BMI. The intensity portion of the model suggested that increasing days of VPA were associated with more education, and marginally associated with increasing age. These underutilized models provide useful approaches for handling counting outcomes.