A site-specific literature review of policy and environmental interventions that promote physical activity and nutrition for cardiovascular health: what works?

The Big Picture of Individual Differences in Physical Activity Behavior Change: A Transdisciplinary Approach

The goal of this research is to utilize a transdisciplinary framework to guide the selection of putative moderators of the effectiveness of an intervention to promote physical activity behavior adoption and maintenance in the context of a randomized controlled intervention trial. Effective interventions to increase physical activity are sorely needed, and one barrier to the identification and development of such interventions is the lack of research targeted at understanding both the mechanisms of intervention efficacy and for whom particular interventions are effective. The purpose of this paper is to outline our transdisciplinary approach to understanding individual differences in the effectiveness of a previously successful exercise promotion intervention. We explain the rationale for and operationalization of our framework, characteristics of the study to which we apply the framework, and planned analyses. By embracing a transdisciplinary orientation for individual differences important in the prediction of physical activity (spanning molecular approaches, animal models, human laboratory models, and social psychological models), we hope to have a better understanding of characteristics of individuals that are important in the adoption and maintenance of physical activity.

Psychometric Characteristics of the Physical Education Activities Scale

Measuring adolescent perceptions of physical education (PE) activities is necessary in understanding determinants of school PE activity participation. The purpose of this study was to test initial estimates of reliability and validity of a new scale assessing high school adolescent perceptions of school PE activity with the Physical Education Activities Scale (PEAS). The 41-item visual analog scale consisted of 6 subscales: Self-Efficacy, PE Enjoyment, Personal Factors Influencing PE Participation, Behavioral Control, Barriers, and Subjective Norms that were tested on a sample (N = 90) interurban high school adolescents Grades 9–12. Cronbach’s alpha coefficient of the total PEAS was α = .89, and for the subscales α ranged from .57–.81. Using known-groups analysis with male vs. female data, initial estimates of construct validity were supported with t tests for the total scale showing boys scoring significantly higher than girls for the total scale (t = −3.26, df = 88, p = .002) and for 5 of the 6 subscales: Self-Efficacy (t = −2.65, df = 88, p = .01); PE Enjoyment (t = −3.05, df = 88, p = .003); Personal Factors Influencing PE Participation (t = −2.66, df = 88, p = .009); Behavioral Control (t = −2.20, df = 88, p = .03), and Barriers (t = −3.41, df = 88, p = .001). There was not a gender difference for the subjective norms subscale. Evidence indicated that the PEAS was sensitive enough to distinguish between female and male perceptions in the expected direction on factors that influence PE activity participation. The PEAS demonstrated acceptable reliability and validity evidence in measuring adolescents’ perception of school PE activities.

The physical activity climate in Minnesota middle and high schools

BACKGROUND

This article describes policies, practices, and facilities that form the physical activity climate in Minneapolis/St. Paul, Minnesota metro area middle and high schools and examines how the physical activity climate varies by school characteristics, including public/private, school location and grade level.

METHODS

Surveys examining school physical activity practices, policies and environment were administered to principals and physical education department heads from 115 middle and high schools participating in the Transdisciplinary Research on Energetics and Cancer-Identifying Determinants of Eating and Activity (TREC-IDEA) study.

RESULTS

While some supportive practices were highly prevalent in the schools studied (such as prohibiting substitution of other classes for physical education); other practices were less common (such as providing opportunity for intramural (noncompetitive) sports). Public schools vs. private schools and schools with a larger school enrollment were more likely to have a school climate supportive of physical activity.

CONCLUSIONS

Although schools reported elements of positive physical activity climates, discrepancies exist by school characteristics. Of note, public schools were more than twice as likely as private schools to have supportive physical activity environments. Establishing more consistent physical activity expectations and funding at the state and national level is necessary to increase regular school physical activity.

Use of mass media campaigns to change health behaviour

Mass media campaigns are widely used to expose high proportions of large populations to messages through routine uses of existing media, such as television, radio, and newspapers. Exposure to such messages is, therefore, generally passive. Such campaigns are frequently competing with factors, such as pervasive product marketing, powerful social norms, and behaviours driven by addiction or habit. In this Review we discuss the outcomes of mass media campaigns in the context of various health-risk behaviours (eg, use of tobacco, alcohol, and other drugs, heart disease risk factors, sex-related behaviours, road safety, cancer screening and prevention, child survival, and organ or blood donation). We conclude that mass media campaigns can produce positive changes or prevent negative changes in health-related behaviours across large populations. We assess what contributes to these outcomes, such as concurrent availability of required services and products, availability of community-based programmes, and policies that support behaviour change. Finally, we propose areas for improvement, such as investment in longer better-funded campaigns to achieve adequate population exposure to media messages.

Pepsi and Coca Cola in Delhi, India: availability, price and sales

OBJECTIVE

India is experiencing increased consumption of sugar-sweetened carbonated drinks, consumption that may be associated with increased risk of type 2 diabetes and obesity. The aim of the study was to determine the availability, price and quantity sold of 'Pepsi' and 'Coca Cola' in their 'regular' and 'diet' forms in Delhi and London.

DESIGN

A questionnaire about the availability, price and quantity sold per day of both regular and diet Pepsi and Coca Cola was devised and piloted. Using this, a survey of food and drink outlets within a 100 m radius of randomly selected Metro stations was conducted in both cities.

SUBJECTS

Store vendors, owners and staff of food and drink outlets.

SETTING

Delhi, India; London, United Kingdom.

RESULTS

In Delhi, of the outlets stocking regular Pepsi and Coca Cola, only 34% sold diet versions and these were more readily available in the most affluent areas than in the poorest areas (34% v. 6%, Z=3.67, P<0.001). This social patterning was not observed in London. Little price differential between regular and diet versions of Pepsi and Coca Cola was observed in Delhi; however, profit margins were better for regular, relative to diet, Coca Cola. Sales of regular products were significantly greater than those of diet products (P<0.002).

CONCLUSIONS

Low availability of diet versions of Pepsi and Coca Cola in less affluent areas of Delhi is likely to exacerbate the obesity and diabetes trends. Price differentials to promote diet versions and other healthier or traditional low-energy drinks may be beneficial.

Capability and clinical success

Better outcomes for chronic diseases remain elusive because success depends on events outside the control of the health care system: patients' ability to mange their health behaviors and chronic diseases. Among the most powerful influences on self-management are the social and environmental constraints on healthy living, yet the clinical response to these environmental determinants is poorly developed. A potential approach for addressing social determinants in practice, as well as planning and evaluating community responses, is the capability framework. Defined as the real opportunity to achieve a desired lifestyle, capability focuses attention on the material conditions that constrain real opportunity and how opportunity emerges from the interaction between personal resources and the social environment. Using examples relevant to chronic disease and behavior change, we discuss the clinical application of the capability framework.

A graphical, computer-based decision-support tool to help decision makers evaluate policy options relating to physical activity

This pilot study builds on efforts to develop evaluation methods to compare and contrast potential strategies designed to increase population physical activity generally, and to reduce disparities in activity levels more specifically. The study presents a user-friendly, semi-quantitative decision-support tool of intermediate complexity that may better enable quick, flexible first-pass "ballpark" decision making by state and local health agencies instead of traditional evidence-based scientific reviews. The tool produces a summary score from ratings on 18 criteria, adjusted by fixed or variable weights to incorporate salient community contextual factors. Stair use, workplace activity breaks, and school construction siting are presented as samples. This first iteration of the decision-support tool is intended to be refined empirically by the experiences and policy outcomes of agencies adopting the innovation. This decision-support tool may expand the capacity of public health practitioners to conduct first-pass assessments of policy options for physical activity promotion in underserved communities.

Healthy Eating Strategies in the Workplace

PURPOSE

There is a clear link between dietary behavior and a range of chronic diseases, and overweight and obesity constitute an indirect risk in relation to these diseases. The worksite is a central venue for influencing dietary behavior. The purpose of this paper is to provide an overview of workplace influences on worker dietary patterns.

DESIGN/METHODOLOGY/APPROACH

The paper reviews the evidence of the effectiveness of dietary health promotion, and provides a brief overview of appropriate theoretical frameworks to guide intervention design and evaluation. The findings are illustrated through research examples.

FINDINGS

Through case studies and published research, it is found that workplace dietary interventions are generally effective, especially fruit and vegetable interventions. There is less consistent evidence on the long term effectiveness of workplace weight management interventions, underscoring the need for further research in this area. This paper also reports evidence that changes in the work environment, including through health and safety programs, may contribute to enhancing the effectiveness of workplace health promotion, including dietary interventions. Organizational factors such as work schedule may also influence dietary patterns. The social ecological model, the social contextual model and political process approach are presented as exemplar conceptual models that may be useful when designing or assessing the effects of workplace health promotion.

ORIGINALITY/VALUE

Using the worksite as setting for influencing health by influencing dietary patterns holds considerable promise and may be instrumental in reducing workers' risk of chronic diseases.

The Worksite Supportive Environments for Active Living Survey: Development and Psychometric Properties

Purpose.

The purpose of this study was to develop a self-report instrument to measure perceived physical and social environmental factors in the worksite setting that are shown to influence physical activity.

Design.

Initial items were generated from a review of the literature and were sent out for peer and expert panel review. A revised questionnaire was sent to 1250 participants to determine and test the emerging factor structure.

Setting.

The instrument was tested at two worksites in the mid-South.

Participants.

Participants consisted of a random sample of regular full-time employees at the two worksites.

Measures.

Principal axis factoring with a varimax rotation was used to explore the data in the first group of participants. Confirmatory factor analysis was used to test the fit of the final model in the second group of participants. Measures used included the comparative fit index, parsimony goodness of fit index, root mean square error of approximation, and the root mean square residual.

Results.

The final analysis showed an adequate fit of the data to the hypothesized factor structure (n = 683). The instrument showed good internal consistency, temporal stability, construct reliability, and discriminant validity.

Conclusion.

The Worksite Supportive Environments for Active Living Survey is a reliable and valid tool for investigating perception of the worksite environment related to physical activity.

Second-year results of an obesity prevention program at the Dow Chemical Company

OBJECTIVE

Evaluate innovative, evidence-based approaches to organizational/supportive environmental interventions aimed at reducing the prevalence of obesity among Dow employees after 2 years of implementation.

METHODS

A quasi-experimental study design compared outcomes for two levels of intervention intensity with a control group. Propensity scores were used to weight baseline differences between intervention and control subjects. Difference-in-differences methods and multilevel modeling were used to control for individual and site-level confounders.

RESULTS

Intervention participants maintained their weight and body mass index, whereas control participants gained 1.3 pounds and increased their body mass index values by 0.2 over 2 years. Significant differences in blood pressure and cholesterol values were observed when comparing intervention employees with controls. At higher intensity sites, improvements were more pronounced.

CONCLUSIONS

Environmental interventions at the workplace can support weight management and risk reduction after 2 years.

Systematic prevention of overweight and obesity in adults: a qualitative and quantitative literature analysis

To date, most interventions aimed at preventing obesity have underemphasized the application of systematic intervention development, implementation and evaluation. The present review provides a thorough insight in factors promoting implementation and/or effectiveness in interventions aimed at preventing overweight/obesity among adults. A total of 46 studies evaluating interventions aimed at preventing obesity were reviewed, followed by both qualitative and quantitative analyses. The Intervention Mapping protocol and the Environmental Research framework for weight Gain prevention (EnRG) were applied to analyse and classify the included studies. The interventions were categorized by setting (workplace, community, health care) and target group (ethnic minorities, pregnant women, [pre]menopausal women, smokers, people with intellectual disabilities). Generally, interventions were found to have potential in changing energy balance-related behaviours and anthropometric outcomes. Effect sizes for changes in body mass index ranged between -0.09 and 0.45. When the programme goal specifically aimed at weight management, the intervention was found to be more successful than interventions with programme goals that were aimed at preventing cardiovascular disease or improving general health status. Although a considerable part of studies included motivational interventions, only some actually assessed the effects on potential cognitive mediators. A general lack of reporting underlying theoretical models for behaviour change was observed as well as the inclusion of linkage groups and strategies to promote empowerment.

Barriers to participation in a worksite wellness program

The purpose of this research was to determine barriers that prevent participation in an employee wellness program, Wellness Wednesdays: "Eat & Meet" About Healthy Living, conducted at East Carolina University (ECU) in Greenville, North Carolina. All ECU ARAMARK employees (n = 481) over the age of 18 were eligible to participate in the wellness program. Weekly 30 minute classes, taught by a Registered Dietitian, on various nutrition- and health-related topics were conducted for 10-weeks. Five question knowledge quizzes were administered to participants at the end of each class to determine the comprehension of material presented. Qualitative interviews (n = 19) were conducted with employees (participants and non-participants) and the program organizer after the completion of the 10-week program to identify barriers to program participation. A total of 50 (10.4% of the total number of potential participants) ECU ARAMARK employees, managers, and leadership team directors attended Wellness Wednesdays at least once during the 10-week program. Employees, on average, scored 71-100% on the weekly knowledge quizzes administered at the end of each class. The most common barriers to participation reported included (most often to least often reported): insufficient incentives, inconvenient locations, time limitations, not interested in topics presented, undefined reasons, schedule, marketing, health beliefs, and not interested in the program. Results showed that employee wellness programs can be effective in increasing knowledge of employees on nutrition- and health-related topics. However, program planning that addresses identified barriers including insufficient incentives, inconvenient locations, and time limitations may facilitate higher participation in future worksite wellness opportunities.

Enhancing community capacity to support physical activity: the development of a community-based indoor-outdoor walking program

The University at Albany Prevention Research Center, guided by a needs assessment in two underserved communities (one urban, one rural), initiated a pilot project that opened a public school for community walking in a rural setting. This study examined a 9-week program for potential barriers, benefits, influential factors, and the physical activity levels of program participants. Evaluation was based on daily logs, pedometer diaries, participant surveys, and focus groups. Results indicated that rural schools provide a useful resource for residents and increase participants' physical activity levels. A more comprehensive rural community walking program has been implemented as a result of these findings.

Are perceptions about worksite neighborhoods and policies associated with walking?

PURPOSE

To examine associations of the built environment surrounding worksites and of work policies with walking behaviors.

DESIGN

Cross-sectional convenience sample survey.

SETTING

Workplace.

SUBJECTS

Employed adults residing in Montgomery County, Maryland.

MEASURES

Four different step measures taken at or near work as recorded using an accelerometer and a fifth measure indicated self-reported walking from work. Participants reported on eight built environment characteristics surrounding the worksite (e.g., the presence of sidewalks, crosswalks, and pedestrian signals) and on four worksite policies (e.g, the presence of exercise facilities and exercise programs).

ANALYSIS

Cross-sectional associations of self-reported built environment characteristics surrounding worksites and worksite policies with walking behavior were examined.

RESULTS

Although participants reported worksites exhibiting built environment characteristics that were supportive of walking (seven of eight characteristics were reported by >50% of participants), no built environment characteristic was associated with walking more than the median number of average weekday steps (p > or = .05). All four worksite policies were associated with walking more than the median number of average weekday steps (p < .05). In addition, a perception of few cul-de-sacs and of the presence of litter, sidewalks, crosswalks, and pedestrian signals surrounding the worksites was associated with a higher proportion of participants taking at least one walking trip from work in the past month (p < .05).

CONCLUSIONS

Locating worksites in walkable environments and implementing worksite policies may favorably influence employee walking. Future studies should consider a prospective design and examine a larger, more diverse employee population and worksite environment to examine these associations.

A social ecological conceptual framework for understanding adolescent health literacy in the health education classroom

With the rising concern over chronic health conditions and their prevention and management, health literacy is emerging as an important public health issue. As with the development of other forms of literacy, the ability for students to be able to access, understand, evaluate and communicate health information is a skill best developed during their years of public schooling. Health education curricula offer one approach to develop health literacy, yet little is known about its influence on neither students nor their experiences within an educational context. In this article, we describe our experience applying a social ecological model to investigating the implementation of a health education curriculum in four high schools in British Columbia, Canada. We used the model to guide a conceptual understanding of health literacy, develop research questions, select data collection strategies, and interpret the findings. Reflections and recommendations for using the model are offered.

Short-term results of a community-based program on promoting healthy lifestyle for prevention and control of chronic diseases in a developing country setting: Isfahan Healthy Heart Program

The objective of the study is to investigate the effect of a comprehensive community trial on behavioral modification after 2 years of intervention. The interventions of this 6-year, comprehensive community-based study target the whole population, of nearly 2 180 000, living in 2 cities in Iran and are compared with another Iranian city considered as reference. Educational, environmental, and legislative interventions are being conducted at the population level. From the baseline to the second year of evaluation of this study, the consumption of hydrogenated fat decreased significantly in the intervention community, but it remained nearly constant in the reference area. Meanwhile, the consumption of liquid oil increased in the intervention community, whereas it decreased in the reference area. The prevalence of current smoking and attempt to smoke decreased, respectively, in men and youths living in the intervention area but increased or remained constant in the reference area; however, no favorable change was seen for smoking among women. Leisure time physical activity increased in women and declined in men of both communities; the slopes of these changes were greater in the intervention area. Although the consumption of salty/fat snacks slightly decreased in the school students of the intervention area, it had a sharp increase in the reference area. This program succeeded in improving some aspects of lifestyle in its different target groups. The authors suggest that the synergy of activities intensified the dose of interventions and led to this improvement.

Meta-analysis of workplace physical activity interventions

CONTEXT

Most adults do not achieve adequate physical activity levels. Despite the potential benefits of worksite health promotion, no previous comprehensive meta-analysis has summarized health and physical activity behavior outcomes from such programs. This comprehensive meta-analysis integrated the extant wide range of worksite physical activity intervention research.

EVIDENCE ACQUISITION

Extensive searching located published and unpublished intervention studies reported from 1969 through 2007. Results were coded from primary studies. Random-effects meta-analytic procedures, including moderator analyses, were completed in 2008.

EVIDENCE SYNTHESIS

Effects on most variables were substantially heterogeneous because diverse studies were included. Standardized mean difference (d) effect sizes were synthesized across approximately 38,231 subjects. Significantly positive effects were observed for physical activity behavior (0.21); fitness (0.57); lipids (0.13); anthropometric measures (0.08); work attendance (0.19); and job stress (0.33). The significant effect size for diabetes risk (0.98) is less robust given small sample sizes. The mean effect size for fitness corresponds to a difference between treatment minus control subjects' means on VO2max of 3.5 mL/kg/min; for lipids, -0.2 on the ratio of total cholesterol to high-density lipoprotein; and for diabetes risk, -12.6 mg/dL on fasting glucose.

CONCLUSIONS

These findings document that some workplace physical activity interventions can improve both health and important worksite outcomes. Effects were variable for most outcomes, reflecting the diversity of primary studies. Future primary research should compare interventions to confirm causal relationships and further explore heterogeneity.

A Case Study in Teaching Tobacco Policy Advocacy at a Historically Black University

Policy advocacy is increasingly recognized as a crucial component of the training provided to health educators but relatively few universities offer advocacy training as part of their professional preparation programs for health educators. Historically Black colleges and universities (HBCUs) represent a natural setting for creating strong Black leaders in tobacco policy advocacy. This case study focuses on experiential education at an HBCU to develop advocacy skills around tobacco issues among Black college students. The authors describe the structure and content of two tobacco policy courses, their efforts to evaluate these courses, and the lessons they learned planning and conducting them. They believe their experience can prove useful to others developing curricula for teaching policy advocacy skills to health education students.

Embodied work: insider perspectives on the work of HIV/AIDS peer counselors

Our aim in this study was to explore HIV/AIDS peer counseling from the perspective of women actively engaged in this work within the context of a community-based program in rural areas of the southeastern United States. Based on this research we suggest that the embodied work of HIV/AIDS peer counselors is constructed around their personal identities and experiences. This work involves gaining entry to other HIV-positive women's lives, building relationships, drawing on personal experiences, facing issues of fear and stigma, tailoring peer counseling for diversity, balancing risks and benefits, and terminating relationships. Peer counselors recognize the personal and collective value of their work, which, like much of women's work within the context of family and community, lacks public visibility and acknowledgment. We discuss implications for the training and support of peer-based interventions for HIV and other women's health issues across diverse contexts and settings.

Predictors of inactive lifestyle among adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study

BACKGROUND

: Participation in physical activity is important for childhood cancer survivors, because inactivity may compound cancer/treatment-related late effects. However, some survivors may have difficulty participating in physical activity, and these individuals need to be identified so that risk-based guidelines for physical activity, tailored to specific needs, can be developed and implemented. The objectives of the current study were to document physical activity patterns in the Childhood Cancer Survivor Study (CCSS) cohort, to compare the physical activity patterns with siblings in the CCSS and with a population-based sample from the Behavioral Risk Factor Surveillance System, and to evaluate associations between diagnosis, treatment, and personal factors in terms of the risk for an inactive lifestyle.

METHODS

: Percentages of participation in recommended physical activity were compared among survivors, siblings, and population norms. Generalized linear models were used to evaluate the associations between cancer diagnosis and therapy, sociodemographics, and the risk for an inactive lifestyle.

RESULTS

: Participants included 9301 adult survivors of childhood cancer and 2886 siblings. Survivors were less likely than siblings (46% vs 52%) to meet physical activity guidelines and were more likely than siblings to report an inactive lifestyle (23% vs 14%). Medulloblastoma (35%) and osteosarcoma (27%) survivors reported the highest levels of inactive lifestyle. Treatments with cranial radiation or amputation were associated with an inactive lifestyle as were being a woman, black race, older age, lower educational attainment, underweight or obese status, smoking, and depression.

CONCLUSIONS

: Childhood cancer survivors were less active than a sibling comparison group or an age- and sex-matched population sample. Survivors who are at risk for an inactive lifestyle should be considered high priority for developing and testing of intervention approaches. Cancer 2009. (c) 2009 American Cancer Society.

Enhanced life functioning: Initial efficacy of a theoretical approach to integrate multiple health behavior interventions in young adults

OBJECTIVES

We propose a new theoretical model that integrates health interventions targeting multiple health behaviors around a common framework of enhancing life functioning. We then test an enhanced life functioning message against an enhanced physical health message in increasing participants' perceived importance of engaging in multiple health behaviors.

METHODS

94 undergraduate participants were exposed to either an enhanced life functioning message or an enhanced physical health message and then completed measures of health behavior importance and benefits associated with enhanced life functioning importance in the spring of 2008 at Rutgers University.

RESULTS

Results indicate the efficacy of an enhanced life functioning message in increasing participants' perceived importance of engaging in multiple health behaviors. Moreover, the effect of an enhanced life functioning message on perceived health behavior importance is mediated by perceived importance of the benefits associated with enhanced life functioning.

CONCLUSIONS

Emphasizing enhanced life functioning as an outcome of engaging in multiple health behaviors increases the perceived importance of performing multiple health behaviors, which may influence the performance of multiple health behaviors.

Determinants of participation in worksite health promotion programmes: a systematic review

Background

The workplace has been identified as a promising setting for health promotion, and many worksite health promotion programmes have been implemented in the past years. Research has mainly focused on the effectiveness of these interventions. For implementation of interventions at a large scale however, information about (determinants of) participation in these programmes is essential. This systematic review investigates initial participation in worksite health promotion programmes, the underlying determinants of participation, and programme characteristics influencing participation levels.

Methods

Studies on characteristics of participants and non-participants in worksite health promotion programmes aimed at physical activity and/or nutrition published from 1988 to 2007 were identified through a structured search in PubMed and Web of Science. Studies were included if a primary preventive worksite health promotion programme on PA and/or nutrition was described, and if quantitative information was present on determinants of participation.

Results

In total, 23 studies were included with 10 studies on educational or counselling programmes, 6 fitness centre interventions, and 7 studies examining determinants of participation in multi-component programmes. Participation levels varied from 10% to 64%, with a median of 33% (95% CI 25–42%). In general, female workers had a higher participation than men (OR = 1.67; 95% CI 1.25–2.27]), but this difference was not observed for interventions consisting of access to fitness centre programmes. For the other demographic, health- and work-related characteristics no consistent effect on participation was found. Pooling of studies showed a higher participation level when an incentive was offered, when the programme consisted of multiple components, or when the programme was aimed at multiple behaviours.

Conclusion

In this systematic review, participation levels in health promotion interventions at the workplace were typically below 50%. Few studies evaluated the influence of health, lifestyle and work-related factors on participation, which hampers the insight in the underlying determinants of initial participation in worksite health promotion. Nevertheless, the present review does provide some strategies that can be adopted in order to increase participation levels. In addition, the review highlights that further insight is essential to develop intervention programmes with the ability to reach many employees, including those who need it most and to increase the generalizability across all workers.

State legislation to improve employee wellness

OBJECTIVE

Categorize and describe the content and status of state legislation of worksite wellness.

METHODS

State worksite wellness legislation was compiled from the Centers for Disease Control's Division of Nutrition, Physical Activity and Obesity State Legislative Database (http://apps.nccd.cdc.gov/DNPALeg/index.asp) and from LexisNexis (http://www.lexisnexis. com). Key word searches were used to gather worksite wellness legislation (2001-2006), with the exception of resolutions and those bills not pertaining to general employee wellness. Legislation was individually examined, categorized, and analyzed for content and status.

RESULTS

The four categories of state legislation that appeared to be most common were tax credits (n = 34; 0 passed), wellness policies and programs (n = 21; 4 passed), alternative transportation (n = 18; 4 passed), and health insurance (n = 14; 3 passed).

CONCLUSION

During 2001 to 2006, seven of 27 states enacted worksite wellness bills. In the three categories in which bills passed (wellness policies and programs, alternative transportation, and health insurance), 19% to 22% were enacted. This proportion, similar to other health promotions bills, indicates that worksite health promotion legislation passed as favorably as other health promotion topics. Further, the language in the bills did not recommend a specific standard for employee health, such as that in the national Healthy People 2010 objectives.

Impact of targeted financial incentives on personal health behavior: a review of the literature

Over the past decade, there has been a substantial increase in the use of financial incentives by private employers and public programs to encourage healthy behaviors, wellness activities, and use of preventive services. The research evidence regarding the effectiveness of this approach is reviewed, summarizing relevant findings from literature reviews and from recent evaluations. The article concludes that financial incentives, even relatively small incentives, can influence individuals' health-related behaviors. However, the findings regarding health promotion and wellness are based primarily on analyses of a limited number of private sector initiatives, whereas the evidence regarding preventive services is based on evaluations of initiatives sponsored predominantly by public programs and directed at low-income populations. In either case, there are several important limitations in the ability of the published findings to provide clear guidance for public program administrators or private purchasers seeking to design and implement effective incentive programs.

Assessing coordination of legal-based efforts across jurisdictions and sectors for obesity prevention and control

America’s increasing obesity problem requires federal, state, and local lawyers, policymakers, and public health practitioners to consider legal strategies to encourage healthy eating and physical activity. The complexity of the legal landscape as it affects obesity requires an analysis of coordination across multiple sectors and disciplines. Government jurisdictions can be viewed “vertically,” including the local, state, tribal, and federal levels, or “horizontally” as agencies or branches of government at the same vertical level. Inspired by the successful tobacco control movement, obesity prevention advocates seek comprehensive strategies to “normalize” healthy behaviors by creating environmental and legal changes that ensure healthy choices are the default or easy choices. With many competing demands on diminishing municipal budgets, strategic coordination both vertically and horizontally is essential to foster the environmental and social changes needed to reverse the obesity epidemic.

Prevalence of metabolic syndrome and associated risk factors in Illinois

PURPOSE

To examine the prevalence of metabolic syndrome (MS) in Illinois and associated risk factors to document emerging problems as a basis for preventive and/or therapeutic interventions.

DESIGN

The 2005 Illinois Behavioral Risk Factor Surveillance System data were analyzed for prevalence rates and relative risk (RR) of risk factors for MS.

SETTING

Illinois.

SUBJECTS

Representative sample of 5077 noninstitutionalized Illinoisans aged > or = 18.

MEASURES

Presence of diabetes, hypertension, hypercholesterolemia, angina, and obesity; adequate fruit/vegetable intake; adequate daily physical activity; routine consumption of calcium-rich foods; smoking; and demographic variables.

ANALYSIS

Prevalence, chi-square, RR, and analyses of variance.

RESULTS

MS prevalence was 16.2%. The RR for MS was 8 for those having diabetes; 20 for those with hypertension; 14 for those with hypercholesterolemia; 6 for those with angina; and 7 for those with obesity. Fruit/vegetable intake did not significantly influence the RR (RR = 1.01), but RR was greater when calcium-rich foods were not routinely consumed (RR = 1.61) and with inadequate physical activity (RR = 1.85). MS prevalence was highest in those over 65 years; with incomes < $15,000; and among Blacks. Differences among those with one through five indicators of MS were not significant for fruit/vegetable intake, but were for physical activity, age group, income, and education level (p < .001).

CONCLUSION

These findings reveal that MS prevention should be emphasized for lower-income, older Blacks. Increasing physical activity and calcium-rich foods are areas for community-based education.

Ethnic minorities and weight control research priorities: where are we now and where do we need to be?

Within the overall obesity epidemic, the burden of obesity and related health problems is particularly high among African Americans, Hispanic/Latino Americans, American Indians, and Pacific Islanders--both children and adults. The often asked question of what types of obesity interventions work in these populations reflects uncertainty about how applicable standard interventions are to diverse socio-cultural groups and socio-environmental contexts. A meta-analysis in this issue of Preventive Medicine (Seo and Sa, 2008. A meta-analysis of psycho-behavioral obesity interventions among US multiethnic and minority adults) includes selected multi-ethnic and minority-focused studies that in total had 40% minority participants. Although the authors' conclusions were congruent with current general guidance for weight loss programs, insights about how to intervene with minority populations were limited by the small amount and nature of the available evidence. Ethnic minorities in the aggregate are now a third of the U.S. population. We should be purposeful in identifying research needs and quality standards for conducting and reporting studies with these populations and in motivating related research. Improving the relevance to and quality of evidence on obesity prevention and treatment for a more diverse set of populations will also improve the weight control literature as a whole.

Physical activity and diabetes: opportunities for prevention through policy

Over the past decade, the prevalence of type 2 diabetes mellitus has reached epidemic levels in the United States and other developed countries. With a concomitant rise in obesity levels in the United States and advances in the treatment of diabetes and its complications, the prevalence of diabetes is expected to continue to rise through the year 2050. Despite strong evidence that regular physical activity can prevent or delay the onset of diabetes, too many Americans are not meeting the recommended levels of regular physical activity. Although most physical activity interventions to date have been focused on characteristics of the individual, more-recent studies have considered how changing characteristics of the social and physical environment in which people live may ultimately have a greater impact on increasing population levels of physical activity. Policy interventions are a way to make sustainable changes in the physical environment of a community and thus provide support for other intrapersonal and interpersonal behavioral change interventions. Policy changes also can affect the social norms that shape behavior. The purposes of this perspective article are: (1) to describe the rationale for population approaches to primary prevention of type 2 diabetes, (2) to discuss how policy interventions can increase physical activity levels within populations, and (3) to provide recommendations for the role of physical therapists in interventions that can increase the level of physical activity in communities. Public health approaches to curb the diabetes epidemic are urgently needed. Policy interventions to increase population levels of physical activity show promise for diabetes prevention. Physical therapists are uniquely suited to influence primary prevention efforts for diabetes.

Worksite policies and environments supporting physical activity in midwestern communities

PURPOSE

To examine the association of worksite policies and environments to physical activity.

METHODS

Between 2001 and 2003, 977 adults from Missouri, Tennessee, and Arkansas participated in two random-digit-dialed telephone surveys regarding physical activity behaviors and worksite policies supporting physical activity. Logistic regression was used to investigate relationships between meeting national physical activity recommendations and supportive policies or environmental conditions (e.g., facilities, equipment, financial rewards) at worksites.

RESULTS

Having multiple policies at worksites was associated with meeting physical activity recommendations, specifically the provision of accessible stairways and personal services (e.g., fitness testing, counseling). Meeting recommendations through walking was associated with having exercise facilities (e.g., gym, shower) and equipment (e.g., treadmill, weights).

DISCUSSION

This study highlights the importance of supplementing health promotion information in workplaces with policies and environmental interventions. Particular consideration should be given to accessible stairways for onsite exercise and provision of exercise facilities and equipment. Future interventions should combine policy change with program delivery.

Population-based prevention of obesity: the need for comprehensive promotion of healthful eating, physical activity, and energy balance: a scientific statement from American Heart Association Council on Epidemiology and Prevention, Interdisciplinary Committee for Prevention (formerly the expert panel on population and prevention science)

Obesity is a major influence on the development and course of cardiovascular diseases and affects physical and social functioning and quality of life. The importance of effective interventions to reduce obesity and related health risks has increased in recent decades because the number of adults and children who are obese has reached epidemic proportions. To prevent the development of overweight and obesity throughout the life course, population-based strategies that improve social and physical environmental contexts for healthful eating and physical activity are essential. Population-based approaches to obesity prevention are complementary to clinical preventive strategies and also to treatment programs for those who are already obese. This American Heart Association scientific statement aims: 1) to raise awareness of the importance of undertaking population-based initiatives specifically geared to the prevention of excess weight gain in adults and children; 2) to describe considerations for undertaking obesity prevention overall and in key risk subgroups; 3) to differentiate environmental and policy approaches to obesity prevention from those used in clinical prevention and obesity treatment; 4) to identify potential targets of environmental and policy change using an ecological model that includes multiple layers of influences on eating and physical activity across multiple societal sectors; and 5) to highlight the spectrum of potentially relevant interventions and the nature of evidence needed to inform population-based approaches. The evidence-based experience for population-wide approaches to obesity prevention is highlighted.

Comparing Perception-Based and Geographic Information System (GIS)-based characterizations of the local food environment

Measuring features of the local food environment has been a major challenge in studying the effect of the environment on diet. This study examined associations between alternate ways of characterizing the local food environment by comparing Geographic Information System (GIS)-derived densities of various types of stores to perception-based measures of the availability of healthy foods. Survey questions rating the availability of produce and low-fat products in neighborhoods were aggregated into a healthy food availability score for 5,774 residents of North Carolina, Maryland, and New York. Densities of supermarkets and smaller stores per square mile were computed for 1 mile around each respondent's residence using kernel estimation. The number of different store types in the area was used to measure variety in the food environment. Linear regression was used to examine associations of store densities and variety with reported availability. Respondents living in areas with lower densities of supermarkets rated the selection and availability of produce and low-fat foods 17% lower than those in areas with the highest densities of supermarkets (95% CL, -18.8, -15.1). In areas without supermarkets, low densities of smaller stores and less store variety were associated with worse perceived availability of healthy foods only in North Carolina (8.8% lower availability, 95% CL, -13.8, -3.4 for lowest vs. highest small-store density; 10.5% lower 95% CL, -16.0, -4.7 for least vs. most store variety). In contrast, higher smaller store densities and more variety were associated with worse perceived healthy food availability in Maryland. Perception- and GIS-based characterizations of the environment are associated but are not identical. Combinations of different types of measures may yield more valid measures of the environment.

Meta-analysis of patient education interventions to increase physical activity among chronically ill adults

OBJECTIVE

This meta-analysis integrates primary research testing the effect of patient education to increase physical activity (PA) on behavior outcomes among adults with diverse chronic illnesses.

METHODS

Extensive literature searching strategies located published and unpublished intervention studies that measured PA behavior outcomes. Primary study results were coded. Fixed- and random-effects meta-analytic procedures included moderator analyses.

RESULTS

Data were synthesized across 22,527 subjects from 213 samples in 163 reports. The overall mean weighted effect size for two-group comparisons was 0.45 (higher mean for treatment than control). This effect size is consistent with a difference of 48 min of PA per week or 945 steps per day. Preliminary moderator analyses suggest interventions were most effective when they targeted only PA behavior, used behavioral strategies (versus cognitive strategies), and encouraged PA self-monitoring. Differences among chronic illnesses were documented. Individual strategies unrelated to PA outcomes included supervised exercise sessions, exercise prescription, fitness testing, goal setting, contracting, problem solving, barriers management, and stimulus/cues. PA outcomes were unrelated to gender, age, ethnicity, or socioeconomic distribution among samples.

CONCLUSION

These findings suggest that some patient education interventions to increase PA are effective, despite considerable heterogeneity in the magnitude of intervention effect.

PRACTICE IMPLICATIONS

Moderator analyses are preliminary and provide suggestive evidence for further testing of interventions to inform practice.

Availability of recreational resources in minority and low socioeconomic status areas

BACKGROUND

Differences in availability of recreational resources may contribute to racial and socioeconomic status (SES) disparities in physical activity. Variations in the location and density of recreational resources were examined by SES and racial composition of neighborhoods.

METHODS

Densities of resources available in recreational facilities and parks were estimated for census tracts between April 2003 and June 2004 in North Carolina, New York, and Maryland using kernel estimation. The probability of not having a facility or park was modeled by tract racial composition and SES, adjusting for population and area, using binomial regression in 2006. Mean densities of tract resources were modeled by SES and racial composition using linear regression.

RESULTS

Minority neighborhoods were significantly more likely than white neighborhoods not to have recreational facilities (relative probability [RP]=3.27 [95% CI=2.11-5.07] and 8.60 [95% CI=4.48-16.51], for black and Hispanic neighborhoods, respectively). Low-income neighborhoods were 4.5 times more likely to not have facilities than high-income areas (95% CI=2.87-7.12). Parks were more equitably distributed. Most resources located in recreational facilities required a fee and were less dense in minority and low-income areas. Those located inside parks were usually free to use, sports-related, and denser in poor and minority neighborhoods.

CONCLUSIONS

Recreational facilities and the resources they offer are not equitably distributed. The presence of parks in poor and minority areas suggest that improving the types and quality of resources in parks could be an important strategy to increase physical activity and reduce racial/ethnic and socioeconomic disparities.

Development of ACTION! Wellness Program for Elementary School Personnel

OBJECTIVE

The prevalence of overweight and obesity has increased dramatically in the adult population over the past 2 decades. Almost two-thirds of the adult population works outside the home; thus, interventions implemented at the worksite are viable for obesity reduction. Elementary schools are worksites that have a number of resources that can encourage a healthy lifestyle. The purpose of this paper is to describe the formative research activities and how these were used to design the ACTION! Wellness Program for Elementary School Personnel.

RESEARCH METHODS AND PROCEDURES

Formative data were collected using focus groups, a school survey, and an environmental audit. Focus groups were conducted in three elementary schools, whereas the school survey and environmental audit were collected in 24 elementary schools. The intervention was then tested as a pilot study in one school to determine feasibility and receptivity and refine its components.

RESULTS

Participants in the focus groups indicated that most had experience with trying to lose weight, some had positive social support, and most had little free time at school; however, most were very receptive to having a weight control intervention program at their school. Eighteen (75%) of the schools had snack vending machines on the school site, and all had cold drink machines. All 24 schools had at least one indoor site that could be used for physical activity programs. All schools were in neighborhoods conducive for walking.

DISCUSSION

ACTION! will take advantage of the school resources in implementing an environmental intervention to reduce overweight and obesity. This paper describes the progression of events that led to the final trial.

The (cost-)effectiveness of an individually tailored long-term worksite health promotion programme on physical activity and nutrition: design of a pragmatic cluster randomised controlled trial

Background

Cardiovascular disease is the leading cause of disability and mortality in most Western countries. The prevalence of several risk factors, most notably low physical activity and poor nutrition, is very high. Therefore, lifestyle behaviour changes are of great importance. The worksite offers an efficient structure to reach large groups and to make use of a natural social network. This study investigates a worksite health promotion programme with individually tailored advice in physical activity and nutrition and individual counselling to increase compliance with lifestyle recommendations and sustainability of a healthy lifestyle.

Methods/Design

The study is a pragmatic cluster randomised controlled trial with the worksite as the unit of randomisation. All workers will receive a standard worksite health promotion program. Additionally, the intervention group will receive access to an individual Health Portal consisting of four critical features: a computer-tailored advice, a monitoring function, a personal coach, and opportunities to contact professionals at request. Participants are employees working for companies in the Netherlands, being literate enough to read and understand simple Internet-based messages in the Dutch language.

A questionnaire to assess primary outcomes (compliance with national recommendations on physical activity and on fruit and vegetable intake) will take place at baseline and after 12 and 24 months. This questionnaire also assesses secondary outcomes including fat intake, self-efficacy and self-perceived barriers on physical activity and fruit and vegetable intake. Other secondary outcomes, including a cardiovascular risk profile and physical fitness, will be measured at baseline and after 24 months.

Apart from the effect evaluation, a process evaluation will be carried out to gain insight into participation and adherence to the worksite health promotion programme. A cost-effectiveness analysis and sensitivity analysis will be carried out as well.

Discussion

The unique combination of features makes the individually tailored worksite health promotion programme a promising tool for health promotion. It is hypothesized that the Health Portal's features will counteract loss to follow-up, and will increase compliance with the lifestyle recommendations and sustainability of a healthy lifestyle.

Trial registration

Current Controlled Trials ISRCTN52854353.

Tobacco interventions delivered by pharmacists: a summary and systematic review

BACKGROUND

As one of the most accessible health care professionals, pharmacists are in an ideal position to provide tobacco-cessation and prevention services. Although there is growing interest in expanding the pharmacist's role in tobacco treatment, few published studies have assessed the efficacy or effectiveness of tobacco-cessation services delivered by pharmacists in the United States.

OBJECTIVE

To summarize and critique studies that examined pharmacist-delivered tobacco-cessation services.

METHODS

Articles written in English that appeared in peer-reviewed journals were identified from a systematic review of literature published from 1980-2006. Publications were selected for review if the interventions were delivered by pharmacists, if the intervention included United States Food and Drug Administration-approved drugs (if drug therapy was used), and if smoking-cessation rates could be calculated.

RESULTS

Fifteen studies met inclusion criteria. Fourteen of the studies targeted smoking, and one targeted spit (chewing) tobacco. Five studies were controlled, and 10 were uncontrolled. One of the controlled studies (chewing tobacco) and eight of the uncontrolled studies were conducted in the United States. Findings of the uncontrolled U.S. studies suggest that pharmacists can deliver smoking-cessation services. Three of the controlled studies found statistically significant differences between the pharmacist-based intervention and the control group, and the trend in the other two studies was toward the effectiveness of the pharmacist-delivered intervention. Only six of the 15 studies reviewed used biochemical measures to verify self-reported cessation.

CONCLUSION

The uncontrolled and controlled studies reviewed demonstrate that pharmacists can deliver tobacco-cessation interventions, and the evidence strongly suggests that they are effective in helping smokers to quit. Future studies conducted in the United States that are well controlled and include biochemical verification of smoking status are needed to provide definitive confirmation that pharmacist-delivered interventions are effective for smoking cessation. With the availability and expanded training of pharmacists, this is an opportune time for testing and disseminating evidence-based research evaluating the effectiveness of pharmacist-delivered tobacco-cessation services.

A Brief Review on Correlates of Physical Activity and Sedentariness in Youth

INTRODUCTION

Better understanding of the correlates of physical activity and sedentary behaviors in youth will support the development of effective interventions that promote a physically active lifestyle and prevent a sedentary lifestyle. The main goal of this systematic review is to summarize and update the existing literature on correlates of young people's physical activity, insufficient physical activity, and sedentary behavior.

METHODS

A systematic review was conducted and included studies published between January 1999 and January 2005.

RESULTS

The 60 reviewed studies showed that for children (age range 4-12), gender (male), self-efficacy, parental physical activity (for boys), and parent support were positively associated with physical activity. For adolescents (age range 13-18), positive associations with physical activity were found for gender (male), parental education, attitude, self-efficacy, goal orientation/motivation, physical education/school sports, family influences, and friend support. For adolescents, a positive association was found between gender (male) and sedentary behavior, whereas an inverse association was found between gender and insufficient physical activity. Ethnicity (Caucasian), socioeconomic status, and parent education were found to be inversely associated with adolescents' sedentary behaviors. For children, the evidence was insufficient to draw conclusions about correlates of insufficient physical activity and sedentary behavior.

CONCLUSION

To gain more insight in the correlates of change in physical activity levels, more prospective studies are needed. Moreover, further research is needed examining the correlates of insufficient physical activity and sedentary behaviors, to develop effective interventions that may help children and adolescents diminish the time they spend on inactive behaviors.

Attributes of environments supporting walking

PURPOSE

This study established a framework to audit environments supporting walking in neighborhoods.

DESIGN

Cross-sectional analysis using a telephone survey and 200 objective environmental variables. SETTING. Urbanized King County, WA. SUBJECTS. 608 randomly sampled adults. Measures. Walking measures constructed from survey questions; objective environmental measures taken from parcel-level databases in Geographic Information Systems.

ANALYSIS

Multinomial models estimated the odds of people engaging in moderate walking (<149 min/wk) and in walking sufficiently to meet recommendations for health (150+ min/ wk), relative to not walking" and in walking sufficiently, relative to walking moderately. A base model consisted of survey variables, and final models incorporated both survey and environmental variables. RESULTS. Survey variables strongly associated with walking sufficiently to enhance health included household income, not having difficulty walking, using transit, perceiving social support for walking walking outside of the neighborhood, and having a dog (p < .01). The models isolated 14 environmental variables associated with walking sufficiently (pseudo R2 up to 0. 46). Measures of distance to neighborhood destinations dominated the results: shorter distances to grocery stores/markets, restaurants, and retail stores, but longer distances to offices or mixed-use buildings (p < .01 or .05). The density of the respondent's parcel was also strongly associated with walking sufficiently (p < .01). Conclusions. The study offered valid environmental measures of neighborhood walkability.

The NHF-NRG In Balance-project: the application of Intervention Mapping in the development, implementation and evaluation of weight gain prevention at the worksite

Very few examples of theory-driven and systematically developed weight gain prevention interventions for adults have been described in the literature. The present paper systematically describes the development, implementation and evaluation framework of a weight gain prevention programme directed at young adults at the worksite, namely the NHF-NRG In Balance-project. It not only can be used as a guide to systematically develop weight gain prevention interventions, but also gives an overview of the current theoretical and empirical knowledge-base in the field of obesity prevention. The outline of the paper follows the Intervention Mapping protocol, which includes a systematic inventory of important health issues, their risk behaviours and determinants of these risk behaviours, and specification of the proximal objectives of the programme directed at both energy intake and energy expenditure. The objectives are translated into behaviour change methods and strategies, which are combined in a stepwise intervention programme, and used for a detailed evaluation plan (process and effect evaluation). The NHF-NRG In Balance-project combines mass media and individually tailored communications with worksite environmental changes to raise awareness, to motivate and to enable energy balance behaviour changes. A quasi-experimental pre-test-multiple post-test control group design was applied in 12 worksites (>500 employees).