A guide for developing intervention tools addressing environmental factors to improve diet and physical activity

Using Neighborhood-Level Census Data to Predict Diabetes Progression in Patients with Laboratory-Defined Prediabetes

CONTEXT

Research on predictors of clinical outcomes usually focuses on the impact of individual patient factors, despite known relationships between neighborhood environment and health.

OBJECTIVE

To determine whether US census information on where a patient resides is associated with diabetes development among patients with prediabetes.

DESIGN

Retrospective cohort study of all 157,752 patients aged 18 years or older from Kaiser Permanente Northern California with laboratory-defined prediabetes (fasting plasma glucose, 100 mg/dL-125 mg/dL, and/or glycated hemoglobin, 5.7%-6.4%). We assessed whether census data on education, income, and percentage of households receiving benefits through the US Department of Agriculture's Supplemental Nutrition Assistance Program (SNAP) was associated with diabetes development using logistic regression controlling for age, sex, race/ethnicity, blood glucose levels, and body mass index.

MAIN OUTCOME MEASURE

Progression to diabetes within 36 months.

RESULTS

Patients were more likely to progress to diabetes if they lived in an area where less than 16% of adults had obtained a bachelor's degree or higher (odds ratio [OR] =1.22, 95% confidence interval [CI] = 1.09-1.36), where median annual income was below $79,999 (OR = 1.16 95% CI = 1.03-1.31), or where SNAP benefits were received by 10% or more of households (OR = 1.24, 95% CI = 1.1-1.4).

CONCLUSION

Area-level socioeconomic and food assistance data predict the development of diabetes, even after adjusting for traditional individual demographic and clinical factors. Clinical interventions should take these factors into account, and health care systems should consider addressing social needs and community resources as a path to improving health outcomes.

Examining Key Stakeholder and Community Residents' Understanding of Environmental Influences to Inform Place-Based Interventions to Reduce Obesity in Rural Communities, Kentucky 2015

PURPOSE

Rural residents report high rates of obesity, physical inactivity, and poor eating habits. The objectives of this study were to (1) use the collective impact model to guide efforts to elicit community members' perceptions of county-specific factors influencing high obesity rates; (2) determine the association between utilization of food retail venues and concern about obesity and healthy eating; and (3) determine community members' utilization of physical activity infrastructure and concern about physical inactivity.

METHODS

The study was conducted in 6 rural counties in Kentucky with adult obesity prevalence rates >40%. Community stakeholders met to assess counties' needs and assets in implementing interventions to reduce obesity in their communities. A random-digit dial survey (n = 756) also was conducted to examine awareness and availability of community resources for healthy eating and physical activity.

FINDINGS

Stakeholders identified lack of access to fruits and vegetables and poor physical activity infrastructure as contributors to obesity. Reporting moderate and serious concern about obesity and healthy eating was associated with higher odds of shopping at a supercenter compared with those expressing little concern. Reported access to information about physical activity opportunities was associated with higher odds of reporting the availability of safe places for physical activity, sidewalks, and trails compared with those who reported that information was difficult to obtain.

CONCLUSIONS

This study elicits community-identified barriers to healthy behaviors and provides foundational data to inform future place-based obesity reduction interventions.

Evaluation of the Arthritis Foundation's Camine Con Gusto Program for Hispanic Adults With Arthritis

INTRODUCTION

Camine Con Gusto (CCG) is the Hispanic version of an evidence-based walking program for people with arthritis. This study examined CCG outcomes, feasibility, tolerability, safety, and acceptability and potential tailoring.

METHOD

A pre and post 6-week evaluation was conducted in Hispanic people with arthritis. Outcomes included pain, stiffness, fatigue, functional capacity, helplessness, and self-efficacy. A formative evaluation with program participants and key stakeholders explored program tailoring.

RESULTS

Participants' mean age was 46.9 years, 44.4% had a high school degree or less, 2.5% were born in United States, 60.1% spoke only Spanish, and 74.7% were female. Moderate effect sizes were found: 0.50 for pain, 0.75 for fatigue, 0.49 for stiffness, 0.33 for function, 0.26 for helplessness, and 0.24 for self-efficacy. There were 285 participants recruited with an 82% 6-week retention (feasibility), no adverse events were reported (safety), and 98% reported program satisfaction (acceptability). Recommended adaptations included simpler language, more pictures and content addressing nutrition and chronic conditions, shortened materials, and inclusion of motivational strategies.

CONCLUSION

CCG showed improvement in outcomes in Hispanic individuals comparable to those noted in non-Hispanic White and Black individuals with arthritis.

Promotoras Can Facilitate Use of Recreational Community Resources: The Mi Corazón Mi Comunidad Cohort Study

INTRODUCTION

Limited research has documented interventions aimed at promoting use of existing recreational community resources among underserved populations. This study (HEART [Health Education Awareness Research Team] Phase 2) reports findings of an intervention (Mi Corazón Mi Comunidad) where community health workers facilitated use of diet and exercise programming at local recreational facilities among Mexican American border residents. The aim was to evaluate overall attendance rates and to assess which factors predicted higher attendance.

METHOD

The design was a cohort study. From 2009 to 2013, a total of 753 participants were recruited across 5 consecutive cohorts. The intervention consisted of organized physical activity and nutrition programming at parks and recreational facilities and a free YWCA membership. Attendance at all activities was objectively recorded. Regression analyses were used to evaluate whether demographic factors, health status, and health beliefs were associated with attendance. Results Participants included mostly females at high risk for cardiovascular disease (72.4% were overweight/obese and 64% were [pre-]hypertensive). A total of 83.6% of participants attended at least one session. On average, total attendance was 21.6 sessions (range: 19.1-25.2 sessions between the different cohorts), including 16.4 physical activity and 5.2 nutrition sessions. Females (p = .003) and older participants (p < .001) attended more sessions. Participants low in acculturation (vs. high) attended on average seven more sessions (p = .003). Greater self-efficacy (p < .001), perceived benefits (p = .038), and healthy intentions (p = .024) were associated with higher attendance. Conclusions The intervention was successful in promoting use of recreational facilities among border residents at high risk for cardiovascular disease. Findings were similar across five different cohorts.

A Water and Education Provision Intervention Modifies the Diet in Overweight Mexican Women in a Randomized Controlled Trial

BACKGROUND

There is minimal information on the impact of replacing sugar-sweetened beverage (SSB) consumption with water on diet quality from randomized controlled trials.

OBJECTIVE

We evaluated the effect of a water intake intervention on diet quality in overweight Mexican women.

METHODS

Women with a body mass index ≥25 and <39, 18-45 y old, and a self-reported high intake of SSBs (≥250 kcal/d) were randomly allocated to either the water and education provision (WEP) group (n = 120) or the education provision (EP) only group (n = 120). Each group received monthly nutrition counseling, and the WEP group received biweekly water deliveries for 9 mo. Three 24-h recalls, anthropometry, and demographic information were collected at baseline, and 3, 6, and 9 mo. Energy, macronutrient, sugar, SSB, fruit and vegetable, salty snack, cake and cookie, and fast food intakes were assessed in study completers (n = 189) classified by intervention assignment and by actual water intake at every time point (low <1200 vs. high ≥1200 mL/d).

RESULTS

The WEP group reported greater decreases in SSB intake than the EP group (from 20.9% to 10.3% of energy/d vs. from 20.1% to 17.8%). Thirty-eight percent of the EP group and 84.3% of the WEP group reported attaining a water intake ≥1200 mL/d. Reductions in energy intake and food groups were similar across intervention groups. However, the high actual water intake group reported greater increases vs. the lower intake group in intake of fruits and vegetables (117 vs. 47 g/d), as well as larger reductions in salty snacks (4.6 vs. 0.7 g/d) and cakes and cookies (31.7 vs. 14.7 g/d).

CONCLUSIONS

Other than SSBs, improvements in food group intake did not differ by intervention group in overweight Mexican women. However, post hoc analyses suggested that achieving a high actual water intake was associated with additional beneficial changes in food group intake. This trial was registered at clinicaltrials.gov as NCT01245010.

Promoting Policy, Systems, and Environment Change to Prevent Chronic Disease: Lessons Learned From the King County Communities Putting Prevention to Work Initiative

CONTEXT

Initiatives that convene community stakeholders to implement policy, systems, environment, and infrastructure (PSEI) change have become a standard approach for promoting community health.

OBJECTIVE

To assess the PSEI changes brought about by the King County, Washington, Communities Putting Prevention to Work initiative and describe how initiative structures and processes contributed to making changes.

DESIGN

The impact evaluation used a logic model design, linking PSEI changes to longer-term behavioral impacts in healthy eating active living and tobacco use and exposure. Qualitative methods, including stakeholder interviews and surveys, were used to identify initiative success factors.

SETTING

Communities Putting Prevention to Work activities occurred throughout King County, with a focus on 7 low-income communities in South Seattle/King County.

PARTICIPANTS

The focus communities had a combined population of 652 000, or 35% of the county total, with lower incomes and higher rates of physical inactivity, tobacco use, poor diet, and chronic disease.

INTERVENTION

Twenty-four PSEI strategies were pursued by organizations in sectors including schools, local governments, and community organizations, supported by the public health department. There were 17 healthy eating active living strategies (eg, enhancements to school menus, city planning policies) and 7 tobacco strategies (eg, smoke-free policies in schools, housing, and hospitals).

MAIN OUTCOME MEASURE

PSEI changes made and numbers of residents reached.

RESULTS

Twenty-two of the 24 strategies achieved significant progress toward implementing PSEI changes. The most common success factor was a "dyad" consisting of a dedicated technical assistance provider-either an outside consultant or public health department staff-working closely with a champion from the participating organizations to bring about PSEI changes.

CONCLUSIONS

An initiative structure that creates and supports external consultant/internal organizational champion dyads in key community sectors offers a promising approach that may be adopted by similar community health efforts in the future.

Kaiser Permanente's Community Health Initiative in Northern California: evaluation findings and lessons learned

PURPOSE

To describe the evaluation findings and lessons learned from the Kaiser Permanente Healthy Eating Active Living-Community Health Initiative.

DESIGN

Mixed methods design: qualitative case studies combined with pre/post population-level food and physical activity measures, using matched comparison schools for youth surveys.

SETTING

Three low-income communities in Northern California (combined population 129,260).

SUBJECTS

All residents of the three communities.

INTERVENTION

Five-year grants of $1.5 million awarded to each community to support the implementation of community- and organizational-level policy and environmental changes. Sectors targeted included schools, health care settings, worksites, and neighborhoods.

MEASURES

Reach (percentage exposed) and strength (effect size) of the interventions combined with population-level measures of physical activity (e.g., minutes of physical activity) and nutrition (e.g., fruit and vegetable servings).

ANALYSIS

Pre/post analysis of population level measures, comparing changes in intervention to comparison for youth survey measures.

RESULTS

The population-level results were inconclusive overall, but showed positive and significant findings for four out of nine comparisons where "high-dose" (i.e., greater than 20% of the population reached and high strength) strategies were implemented, primarily physical activity interventions targeting school-age youth.

CONCLUSION

The positive and significant changes for the high-dose strategies suggest that if environmental interventions are of sufficient reach and strength they may be able to favorably impact obesity-related behaviors.

A community assessment to inform a multilevel intervention to reduce cardiovascular disease risk and risk disparities in a rural community

To complete a formative evaluation to identify community-level assets and barriers to healthy lifestyle choices, we conducted qualitative interviews, community audits, and secondary data analyses. We solicited local leaders' perspectives regarding winnability of obesity prevention policy options. Participants noted that many resources were available, yet a barrier was high cost. There were more parks per capita in low-income areas, but they were of lower quality. The most winnable obesity prevention policy was incentives for use of food from local farms. Results are being used to inform an intervention to reduce cardiovascular disease risk in rural eastern North Carolina.

Child outdoor physical activity is reduced by prevalence of the Asian tiger mosquito, Aedes albopictus

We tested the hypothesis that day-biting mosquitoes contribute to child obesity by reducing opportunities for summer outdoor play. The influence of Asian tiger mosquito (Aedes albopictus) prevalence on child outdoor physical activity was compared in 2 matched urban communities, one treated for mosquito abatement and one untreated. More time was spent outdoors by children where abatement took place.

Managing metabolic syndrome in women

Cardiovascular disease (CVD) death rates in women in the United States are rising. This is attributed to the obesity epidemic and its contribution to cardiometabolic risk. Various gender-related factors and strategies must be considered to effectively manage metabolic syndrome in women and improve outcomes.

Faith communities and their assets for health promotion: the views from health professionals and faith leaders in Dundee, in Scotland

Within the European Union, as well as in Canada and the United States (US), health promoters employ a number of strategies to encourage community-based health improvements. This involves the creation of innovative health promotion partnerships to support and enable people to choose and engage in healthy living practices. Compared to the US, in other Western countries, such as the United Kingdom, faith communities have largely been ignored in health promotion partnerships. This study established existing evidence about health promotion in faith communities in Scotland by examining the perceptions and attitudes concerning health promotion among faith leaders and health promotion professionals. We conducted 33 semi-structured interviews with health promotion professionals (n = 9) and representatives of Christian and non-Christian faith communities (n = 24). The majority of participants expressed an interest in the concept of health promotion in a faith community and could readily envision its application in their area of work. Both groups identified multiple physical assets, as well as social supports within faith communities that could be directed towards healthy living activities. Faith groups and church organisations may constitute potential partners and new settings to increase community capacity for health promotion. Further research and funding for demonstration projects may be particularly helpful to provide evidence of the strengths and limitations of faith-based health promotion in Scotland, which in turn could inform health promotion practice and policy.

Promoting use of nutrition and physical activity community resources among women in a family planning clinic setting

Research increasingly supports promotion of nutrition and physical activity community resources to support individual-level health promotion interventions. However, even when such resources exist, they are often not well used. In this article, the authors describe the results of formative research regarding patient and health promotion professionals' perspectives on methods to encourage use of community resources among patients accessing family planning services at a local health department in eastern North Carolina. In March through May of 2010, the authors conducted qualitative in-depth interviews with 30 female patients, aged 18-44 years, and five local key informants. Interviews were transcribed verbatim, imported into Atlas Ti for data management, and independently double-coded. Free, easily accessible, and family-friendly resources were most appealing to participants. Key informants offered creative ideas for promoting the use of resources, such as parks and farmers' markets, and included integration of such resources into health care provider prescriptions and taking group trips to resources. Results of this study can guide similar programs attempting to promote the use of resources among hard-to-reach groups.

Exploring the feasibility of a physical activity intervention for midlife African American men

BACKGROUND

This study tested the initial efficacy of implementing a physical activity (PA) behavior change intervention for midlife African American (AA) men.

METHODS

Intervention components were based on information gathered during formative research preceding the intervention. Eligible participants were underactive AA men ages 45-66 years. In a quasi-experimental pre-post design, participants attended 90-min program sessions twice weekly for 8 weeks. Session topics specific to PA included overcoming barriers, gaining social support, setting goals, tracking progress and integrating into one's lifestyle. Participants were assigned to teams to facilitate group discussion, problem solving, accountability and camaraderie.

RESULTS

25 AA men (mean age = 54.7 ± 4.8 years) completed the intervention. After 8 weeks, significant (P < 0.05) positive changes were observed for moderate to vigorous-intensity PA (+7.3 hour week(-1)) and overall PA (+9.4 hour week(-1)), self-efficacy for PA (+12%), social support for PA from family (+28%) and friends (+53%), self-regulation for planning (+33%) and goal setting (+48%) and each fitness component (+9 to +144%). Based on a post-intervention satisfaction survey, participants rated the program very positively.

CONCLUSION

These positive results attest to the feasibility of successfully engaging midlife AA men in a tailored PA behavior change program.

Methodological Tips for Overcoming Formative Evaluation Challenges

Formative evaluation is an effective first step in guiding program improvement by identifying participant preferences and yielding information pertinent to making program decisions. As program evaluators working with service providers are increasingly encouraged to adopt evidence-based health promotion programs, a discrete set of real-world recommendations may help extend the use of this methodology to respond to community-specific contexts and improve health impact. This article describes the authors’ step-by-step process of conducting a formative evaluation of the Arthritis Foundation Walk With Ease (WWE) program. Data collection targets (leaders, coordinators, and participants in the original program and leaders and participants in the revised piloted program) as well as methods (written surveys, focus groups, structured telephone interviews, and expert reviews) were triangulated. The authors describe the challenges they faced and conclude with practical methodological recommendations about managing time and resources, communications with respondents, and accountability systems for organizing triangulated data.

Strategies to improve chronic disease management in seven metro Boston community health centers

BACKGROUND

The Community, Health Center, and Academic Medicine Partnership Project (CHAMPP) is a partnership between medical researchers, community health centers (CHCs), and a community advisory committee focused on reducing cardiovascular morbidity related to hypertension and diabetes for non-Hispanic Black and Hispanic populations in Boston, Massachusetts.

OBJECTIVE

We conducted site visits at seven participating CHCs, located in Boston. The visits were to solicit health center staff opinions about site-specific barriers and enabling factors for optimum preventative cardiovascular care for racial/ethnic minority patients receiving hypertension and diabetes care at their centers.

METHODS

Site visits included a tour of each health center and a series of directed interviews with center personnel. Site visit notes were reviewed to identify themes that emerged during the course of each site visit. A summary matrix was developed for each health center, which included information regarding the most salient and persistent themes of the visit.

RESULTS

Site visits uncovered several patient-, provider-, CHC-, and community-based factors that either facilitate or hinder optimal care of chronic disease patients. Commonly referenced barriers included the need for improved patient adherence to provider recommendations; insufficient time for providers to address complex health issues presented by patients and the need for a broader range of healthier food options in surrounding communities. Interactive patient groups and community health workers (CHWs) have been well received when implemented.

CONCLUSION

Recommendations included adopting case management as a part of usual care for chronic disease patients; additionally, widespread implementation of CHWs may to provide a platform for more comprehensive care for patients.

Promoting Policy and Environmental Change Using Photovoice in the Kaiser Permanente Community Health Initiative

Creative ways must be found to engage both community residents and political leaders around policy and environmental solutions to public health issues. Photovoice is a community-based, participatory approach to documentary photography that provides people with training on photography, ethics, critical discussion, and policy advocacy. Photovoice projects have been implemented across the nation as part of Kaiser Permanente’s Community Health Initiative—a community-based obesity prevention effort. This article focuses on the first Photovoice project implemented in three communities in Colorado. Photovoice themes related to healthy eating and active living include a lack of access to healthy food choices in stores and schools, unsafe street crossings and sidewalks, and the need to redevelop certain areas to encourage safe recreation. The involvement of policy leaders in the project combined with several dissemination activities has contributed to healthier food offerings in schools and neighborhoods and city planning efforts that emphasize walkability and access to healthy food, and park revitalization.

Perceptions of the community food environment and related influences on food choice among midlife women residing in rural and urban areas: a qualitative analysis

INTRODUCTION

Qualitative research on food choice has rarely focused on individuals' perceptions of the community food environment. Women remain gatekeepers of the family diet and food purchasing. Therefore we assessed midlife, Southern women's perceptions of the food environment. Related influences on food choices at work and at home were also examined.

METHODS

We recruited 28 low- and moderate-income, midlife (37-67 years) women from rural and urban areas of southeastern North Carolina, using typical case and snowball sampling. They responded to questions about multilevel influences on food choice in semi-structured, in-depth interviews.

RESULTS

Women perceived differences between urban and rural food environments, with rural areas having fewer supermarkets and fast food restaurants compared to urban areas, which had fewer produce stands. Workplace food choices were affected by the social environment (co-workers), personal health concerns, and the surrounding food environment. Food chosen at home was primarily influenced by family members, health concerns, and convenient food sources.

DISCUSSION

While future studies should explore findings in more representative populations, potential intervention strategies can be inferred, including emphasizing healthful aspects of the food environment. Intervention and advocacy efforts are needed to improve aspects of the food environment that make healthy choices difficult.

A new tool for epidemiology: the usefulness of dynamic-agent models in understanding place effects on health

A major focus of recent work on the spatial patterning of health has been the study of how features of residential environments or neighborhoods may affect health. Place effects on health emerge from complex interdependent processes in which individuals interact with each other and their environment and in which both individuals and environments adapt and change over time. Traditional epidemiologic study designs and statistical regression approaches are unable to examine these dynamic processes. These limitations have constrained the types of questions asked, the answers received, and the hypotheses and theoretical explanations that are developed. Agent-based models and other systems-dynamics models may help to address some of these challenges. Agent-based models are computer representations of systems consisting of heterogeneous microentities that can interact and change/adapt over time in response to other agents and features of the environment. Using these models, one can observe how macroscale dynamics emerge from microscale interactions and adaptations. A number of challenges and limitations exist for agent-based modeling. Nevertheless, use of these dynamic models may complement traditional epidemiologic analyses and yield additional insights into the processes involved and the interventions that may be most useful.

Randomized trial of a clinic-based, community-supported, lifestyle intervention to improve physical activity and diet: the North Carolina enhanced WISEWOMAN project

OBJECTIVE

To determine if a clinic-based behavioral intervention program for low-income mid-life women that emphasizes use of community resources will increase moderate intensity physical activity (PA) and improve dietary intake.

METHODS

Randomized trial conducted from May 2003 to December 2004 at one community health center in Wilmington, NC. A total of 236 women, ages 40-64, were randomized to receive an Enhanced Intervention (EI) or Minimal Intervention (MI). The EI consisted of an intensive phase (6 months) including 2 individual counseling sessions, 3 group sessions, and 3 phone calls from a peer counselor followed by a maintenance phase (6 months) including 1 individual counseling session and 7 monthly peer counselor calls. Both phases included efforts to increase participants' use of community resources that promote positive lifestyle change. The MI consisted of a one-time mailing of pamphlets on diet and PA. Outcomes, measured at 6 and 12 months, included the comparison of moderate intensity PA between study groups as assessed by accelerometer (primary outcome) and questionnaire, and dietary intake assessed by questionnaire and serum carotenoids (6 months only).

RESULTS

For accelerometer outcomes, follow-up was 75% at 6 months and 73% at 12 months. Though moderate intensity PA increased in the EI and decreased in the MI, the difference between groups was not statistically significant (p=0.45; multivariate model, p=0.08); however, moderate intensity PA assessed by questionnaire (92% follow-up at 6 months and 75% at 12 months) was greater in the EI (p=0.01; multivariate model, p=0.001). For dietary outcomes, follow-up was 90% for questionnaire and 92% for serum carotenoids at 6 months and 74% for questionnaire at 12 months. Dietary intake improved more in the EI compared to the MI (questionnaire at 6 and 12 months, p<0.001; serum carotenoid index, p=0.05; multivariate model, p=0.03).

CONCLUSION

The EI did not improve objectively measured PA, but was associated with improved self-reported and objective measures of dietary intake.