Barriers and facilitators to resilience for rural cancer survivors during COVID-19

The purpose of this study was to identify the barriers and facilitators of resilience for rural cancer survivors during COVID-19. A descriptive qualitative study design was used to achieve the study objected. We recruited six posttreatment cancer survivors, four caregivers of cancer survivors, and one survivor who also identified as a caregiver, all from rural Southwest Virginia. Participants completed 60-90 minute virtual interviews that were recorded, transcribed, and verified in Dedoose qualitative software. Data was analyzed using an inductive and deductive coding strategies, and thematic analysis was used to develop key themes. Four key themes emerged from the data: 1) Religious faith is a primary source of resilience, 2) Spiritual cancer care strengthens resilience, 3) Virtual platforms provide critical connections to faith communities, and 4) Fearful and fatalistic cancer beliefs reduce resilience. The findings provide critical descriptive evidence that faith facilitates resilience for rural cancer survivors, while rural cultural norms of fearful and fatalistic cancer beliefs reduce resilience. In the context of COVID-19, rural survivors prioritize utilizing virtual support groups to strengthen their resilience. Nurses should incorporate a spiritual assessment into survivorship care, and guide survivors to existing virtual support groups.

Knowing Is Not Doing: A Qualitative Study of Parental Views on Family Beverage Choice

OBJECTIVE

Sugary drink consumption is associated with adverse health outcomes in children, highlighting the need for scalable family interventions that address barriers to water consumption. To inform development of a scalable, health-care-system-based intervention targeting family beverage choice, a formative qualitative study was conducted using semi-structured interviews with parents whose children were identified as over-consuming sugar-sweetened beverages (SSB) and/or fruit juice (FJ). The first goal of these interviews was to understand, in a diverse real-world patient population, what parents viewed as the primary drivers of their family's beverage choices, and explore how these drivers might need to be addressed in order to make changes to beverage consumption. A second goal was to explore parental preferences for planned intervention components. An exploratory goal of the interviews was to examine whether knowledge, attitudes, and beliefs around family beverage choice differed across racial and ethnic groups in this sample.

DESIGN

Semi-structured phone interviews were conducted and interviews audio-recorded and transcribed.

PARTICIPANTS

39 parents/caregivers of children ages 1-8 who over-consumed sugary drinks as determined by screenings at pediatric visits.

PHENOMENON OF INTEREST

Parents were interviewed about family beverage choices and preferences to inform development of a multi-component intervention.

ANALYSIS

Thematic analysis was performed, including comparison of themes across racial/ethnic groups.

RESULTS

Parents expressed that sugary drinks were unhealthy and water was a better alternative. Most were familiar with the health consequences of excess sugar consumption. They identified many reasons why sugary drinks are chosen over water despite this knowledge. One common reason was concern about tap water safety. Few differences were noted across racial and ethnic groups in our sample. Parents were enthusiastic about a technology-based intervention to be delivered through their child's doctor's office.

CONCLUSIONS AND IMPLICATIONS

Knowledge is not enough to change behavior. Beverage interventions need to be easy to access, make water more appealing, and elevate beverage choice above the "white noise" of everyday life. Delivering an intervention in a clinical setting could provide an extra level of care, while technology would reduce the amount of live contact and decrease the burden for clinicians and parents.

Potential role of fructose on human colon DNA methylation in racial disparities observed for colorectal cancer risk

Background and aims

An increasing body of observational studies has linked fructose intake to colorectal cancer (CRC). African Americans (AAs) are significantly more likely than European Americans to consume greater quantities of fructose and to develop right-side colon cancer. Yet, a mechanistic link between these two associations remains poorly defined. We aimed to identify differentially methylated regions (DMRs) associated with dietary fructose consumption measures obtained from food frequency questionnaires in a cohort of normal colon biopsies derived from AA men and women (n=79).

Methods

DNA methylation data from this study was obtained using the Illumina Infinium MethylationEPIC kit and is housed under accession GSE151732. DMR analysis was carried out using DMRcate in right and matched left colon, separately. Secondary analysis of CRC tumors was carried out using data derived from TCGA-COAD, GSE101764 and GSE193535. Differential expression analysis was carried out on CRC tumors from TCGA-COAD using DESeq2 .

Results

We identified 4,263 right-side fructose-DMRs. In contrast, only 24 DMRs survived multiple testing corrections (FDR<0.05) in matched, left colon. To identify targets by which dietary fructose drives CRC risk, we overlaid these findings with data from three CRC tumor datasets. Remarkably, almost 50% of right-side fructose-DMRs overlapped regions associated with CRC in at least one of three datasets. TNXB and CDX2 ranked among the most significant fructose risk DMRs in right and left colon respectively that also displayed altered gene expression in CRC tumors.

Conclusions

Our mechanistic data support the notion that fructose has a greater CRC-related effect in right than left AA colon, alluding to a potential role for fructose in contributing to racial disparities in CRC.

Preschool- and childcare center-based interventions to increase fruit and vegetable intake in preschool children in the United States: a systematic review of effectiveness and behavior change techniques

BACKGROUND

Fruit and vegetable (FV) consumption in children in the United States (US) is very low. Adequate FV consumption is required for proper development during childhood, and dietary habits are established during preschool-age and tend to persist into adulthood. As most U.S. preschool-aged children attend childcare or preschool, this may be an opportune time and setting to conduct interventions to improve FV intake. These interventions should be based in theory and use behavior change techniques (BCTs) to explain mechanisms for expected change. To date, no published reviews have examined the effectiveness of childcare- or preschool-based FV interventions in preschoolers and their use of theoretical frameworks and BCTs.

METHODS

This systematic review was completed adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria were randomized controlled trials (RCTs) published between 2012 and 2022 of interventions to improve diet or FV intake in preschoolers (aged 2-5 years) in childcare or preschool-settings. A search of four databases was conducted between in September 2022 using search terms pertaining to the study's primary aim (FV consumption), age group (preschool-aged), settings (US childcare or preschool settings), and study design (RCT). Additional criteria were objective measures of FV consumption or skin carotenoids, as a proxy for FV intake. Included studies were narratively synthesized based on intervention type, measured effect, and use of theory and BCTs.

RESULTS

The search resulted in six studies that reported on nine interventions. Overall, six interventions increased FV intake, of which five used nutrition education and one manipulated the feeding environment. Among the three interventions with no measured effect, two manipulated the feeding environment and one used peer modeling. Effective studies used at least three BCTs, though no pattern was observed between use of theory or BCTs and intervention effect.

CONCLUSIONS

While several studies have shown promising results, the limited number of studies identified in this review highlights key gaps in this field: there is a need for studies to test FV interventions in US childcare settings that use objective measures of FV intake, directly compare intervention components and BCTs, are theory-based, and assess long-term behavior change.

A Technology-Driven, Healthcare-Based Intervention to Improve Family Beverage Choices: Results from a Pilot Randomized Trial in the United States

Background: Healthcare-based interventions to address sugary beverage intake could achieve broad reach, but intensive in-person interventions are unsustainable in clinical settings. Technology-based interventions may provide an alternative, scalable approach. Methods: Within an academic health system in the United States that already performs electronic health record-based sugary drink screening, we conducted a pilot randomized trial of a technology-driven family beverage choice intervention. The goal of the intervention was to reduce sugar-sweetened beverage (SSB) and fruit juice (FJ) consumption in 60 parent-child dyads, in which children were 1-8 years old. The pediatrician-initiated intervention consisted of a water promotion toolkit, a video, a mobile phone application, and 14 interactive voice-response phone calls to parents over 6 months. The study was conducted between June 2021 and May 2022. The aim of the pilot study was to assess the potential feasibility and efficacy of the newly developed intervention. Results: Intervention fidelity was excellent, and acceptability was high for all intervention components. Children in both the intervention and the control groups substantially decreased their consumption of SSB and FJ over follow-up (mean combined baseline 2.5 servings/day vs. 1.4/day at 6 months) and increased water consumption, but constrained linear mixed-effects models showed no differences between groups on these measures. Compared to parents in the control group, intervention parents had larger decreases in SSB intake at 3 months (-0.80 (95% CI: -1.54, -0.06, p = 0.03) servings daily), but these differences were not sustained at 6 months. Conclusion: These findings suggest that, though practical to implement in a clinical care setting and acceptable to a diverse participant group, our multicomponent intervention may not be universally necessary to achieve meaningful behavior changes around family beverage choice. A lower-intensity intervention, such as EHR-based clinical screening alone, might be a less resource-intense way for health systems to achieve similar behavioral outcomes. Future studies might therefore explore whether, instead of applying a full intervention to all families whose children overconsume SSB or FJ, a stepped approach, starting with clinical screening and brief counseling, could be a better use of health system resources.

Feasibility of an Adapted Community-Based Lifestyle Intervention to Prevent Cancer in the Rural South: Healthy Living Partnerships to Prevent Cancer (HELP PC)

Obesity increases risk of cancer onset and promulgates cancer mortality. Healthy Living Partnerships to Prevent Cancer (HELP PC) is an adapted intensive lifestyle intervention that is facilitated by community health workers (CHWs). The primary objective of this one-arm pilot study was to test the feasibility of evaluating HELP PC in a rural community by assessing participant recruitment, retention, and adherence to the intervention. The secondary objectives of this study were to evaluate the feasibility of collecting study measures and analyze intervention effects to inform future studies. Adults of all races and a BMI ≥ 25 kg/m2 who resided in the Dan River Region of Southern Virginia were recruited. Participants received 24 weekly (hour-long) group sessions led by a CHW and two consultations with a registered dietitian (RDN). Seventy-five percent (21/28) of eligible subjects were enrolled (n = 21; mean age = 46 years; 67% African American; 90% female; median BMI = 36.1), and recruitment was completed in 2 weeks. Fifty-two percent (11/21) of participants attended >70% of group sessions (adherence) and 98% of RDN consultations were attended. Eighty-six percent (n=18) of participants completed the 6-month follow-up visit (retention), and showed improvements in moderate physical activity, health literacy, general health, energy, and emotional well-being. Feasibility of HELP PC was established through efficient participant recruitment, modest attendance, high retention, and execution of data collection procedures. Importantly, findings can be applied to advance cancer prevention lifestyle interventions in rural communities.

Development of a Digital Behavioral Intervention to Reduce the Consumption of Sugar-Sweetened Beverages Among Rural Appalachian Adults: Multiphased, Human-Centered Design Approach

BACKGROUND

To avoid the low engagement and limited efficacy of digital behavioral health interventions, robust human-centered design (HCD) processes are needed.

OBJECTIVE

The primary objective of this study was to describe a flexible, step-by-step HCD process to develop digital behavioral health interventions by illustrating iSIPsmarter as an example. iSIPsmarter is a digital intervention for reducing the consumption of sugar-sweetened beverages (SSBs) that comprises 6 internet-based cores metered out over time to deliver the program content, an integrated SMS text message strategy to engage users in reporting SSB behaviors, and an electronic cellular-enabled scale for in-home weighing. The secondary objective is to illustrate the key components and characteristics of iSIPsmarter that resulted from the HCD process.

METHODS

The methods were guided by the Model for Internet Interventions and by best practices in HCD and instructional design processes (eg, rapid prototype development and think-aloud protocol). The 3-phased (ie, contextual, prototype testing, end user testing phases) process followed in this study included a series of 13 semistructured one-on-one interviews with 7 advisory team participants from the targeted Appalachian user group. The interviews were content coded by 2 researchers and then deductively coded to the suggested areas of digital behavioral health interventions.

RESULTS

The participants provided rich perspectives pertaining to iSIPsmarter's appearance, behavioral prescriptions, burdens, content, delivery, message, participation, and assessment. These inputs included requests for built-in flexibility to account for varying internet and SMS text message accessibility among users; ideas to resolve the issues and problems encountered when using the prototypes, including those related to navigation and comprehension of content; ideas to enhance personalized feedback to support motivation and goal setting for SSB consumption and weight; and feedback to refine the development of realistic and relatable vignettes. The participants were able to interact with multiple prototype drafts, allowing researchers to capture and incorporate feedback related to the iSIPsmarter dashboard, daily SSB and weight diaries, action planning, core content, interactions, and vignettes.

CONCLUSIONS

Using scientific models and established processes is critical for building robust and efficacious interventions. By applying an existing model and HCD and instructional design processes, we were able to identify assumptions and address the key areas of the iSIPsmarter intervention that were hypothesized to support users' engagement and promote behavior change. As evidenced by the rich feedback received from the advisory team members and the resulting iSIPsmarter product, the HCD methodology was instrumental in the development process. Although the final iSIPsmarter content is specific to improving SSB consumption behaviors among adults in rural areas, the intent is that this HCD process will have wide applications in the development of digital behavioral health interventions across multiple geographic and behavioral contexts.

Contributing Factors of Sugar-Sweetened Beverage Intake in the Latinx Population: A Narrative Review Using the Social-Ecological Model

Sugar-sweetened beverage (SSB) consumption in the Latinx population has been a topic of increasing interest due to higher rates of consumption in this population, as well as higher prevalence of chronic health conditions, such as diabetes and obesity. SSB behaviors are influenced by multiple factors across the socio-ecological model. Understanding these factors can inform future intervention development and improve SSB consumption and overall health. Therefore, this narrative review identifies factors contributing to SSB consumption, as well as interventions conducted to address SSB consumption in the Latinx population residing in the United States. Contributing factors that are not currently addressed in published interventions are highlighted with the intent to inform the development of future comprehensive interventions.

Diet Quality and Dietary Inflammatory Index Score among Women's Cancer Survivors

The purpose of this study was to investigate Healthy Eating Index 2015 (HEI-2015) and Energy-Adjusted Dietary Inflammatory Index (E-DII^TM) scores in women's cancer survivors and to examine socio-economic (SES) characteristics associated with these two diet indices. In this cross-sectional study, survivors of women's cancers completed a demographic questionnaire and up to three 24-h dietary recalls. HEI-2015 and E-DII scores were calculated from average intakes. One-way ANOVA was used to examine the association of various demographic factors on HEI-2015 and E-DII scores. Pearson Correlation was used to calculate the correlation between the two scores. The average HEI-2015 score was 55.0 ± 13.5, lower than the national average, and average E-DII was -1.14 ± 2.24, with 29% of women having a more pro-inflammatory and 71% a more anti-inflammatory diet. Diets with higher HEI-2015 scores were associated with more anti-inflammatory diets (r = -0.67, p < 0.001). Those having a graduate degree (F(2,49) = 3.6, p = 0.03) and completing cancer treatment > 4 years ago (F(2,49) = 4.8, p = 0.01) had higher HEI-2015 scores. There were no associations between SES and E-DII scores. The diet quality of women's cancer survivors is comparatively low, but many achieved an anti-inflammatory diet; a promising avenue for preventing recurrence. There is an urgent need to involve health care professionals in the guidance of women's cancer survivors to improve diet quality and prevent cancer recurrence.

Pointers and Pitfalls in Interpreting Nutrition and Dietetics Research: The Importance of Statistical and Clinical Significance

This monograph focuses on understanding statistical and clinical significance and is one of a research and statistics series published by the statistical team of the Journal of the Academy of Nutrition and Dietetics. The content covers the research questions, the definition of clinical significance, hypothesis testing, p-values, effect sizes, sample sizes, confidence intervals, power analyses, minimal clinically important differences, and validity. This monograph concludes with a summary of the importance of clinical and statistical results, for nutrition professionals to consider when assessing statistical and clinical significance. The assessment will help readers make subjective clinical judgements in the application of research findings based on their experience.

Cruciferous Vegetable Intervention to Prevent Cancer Recurrence in Non-Muscle Invasive Bladder Cancer Survivors: Development using a Systematic Process (Preprint)

Background

Bladder cancer is one of the top 10 most common cancers in the United States. Most bladder cancers (70%-80%) are diagnosed at early stages as non–muscle-invasive bladder cancer (NMIBC), which can be removed surgically. However, 50% to 80% of NMIBC cases recur within 5 years, and 15% to 30% progress with poor survival. Current treatments are limited and expensive. A wealth of preclinical and epidemiological evidence suggests that dietary isothiocyanates in cruciferous vegetables (Cruciferae) could be a novel, noninvasive, and cost-effective strategy to control NMIBC recurrence and progression.

Objective

The aim of this study is to develop a scalable dietary intervention that increases isothiocyanate exposure through Cruciferae intake in NMIBC survivors.

Methods

We worked with a community advisory board (N=8) to identify relevant factors, evidence-based behavior change techniques, and behavioral theory constructs used to increase Cruciferae intake in NMIBC survivors; use the PEN-3 Model focused on incorporating cultural factors salient to the group’s shared experiences to review the intervention components (eg, the saliency of behavioral messages); administer the revised intervention to community partners for their feedback; and refine the intervention.

Results

We developed a multicomponent intervention for NMIBC survivors consisting of a magazine, tracking book, live telephone call script, and interactive voice messages. Entitled POW-R Health: Power to Redefine Your Health, the intervention incorporated findings from our adaptation process to ensure saliency to NMIBC survivors.

Conclusions

This is the first evidence-based, theoretically grounded dietary intervention developed to reduce bladder cancer recurrence in NMIBC survivors using a systematic process for community adaptation. This study provides a model for others who aim to develop behavioral, community-relevant interventions for cancer prevention and control with the overall goal of wide-scale implementation and dissemination.

Understanding Teach-Back and Teach-To-Goal Strategies Embedded in Support Calls for a Health Literacy-Sensitive Childhood Obesity Treatment Trial

BACKGROUND

Low caregiver health literacy (HL) is related to increased obesity risk for their children. Teach-Back and Teach-to-Goal (TB/TTG) are strategies that may improve comprehension of key concepts for people who have low HL but have yet to be examined in the context of childhood obesity treatment.

OBJECTIVE

This study evaluated TB/TTG strategies integrated within support calls delivered to caregivers as part of a 3-month childhood obesity intervention.

METHODS

Ninety-four caregivers (60% Black, 42% high school education or less, 53% with income ≤$29,999, and 34% low HL) with overweight/obese children age 8 to 12 years enrolled in a childhood obesity intervention. Caregiver HL was assessed at baseline using the Newest Vital Sign and caregivers were dichotomized to low and adequate HL groups for analyses. Caregivers received 6 bi-weekly support calls that alternated with in-person, family sessions. Call completion rates, comprehension of key content (correct responses on TB/TTG questions), and satisfaction with support calls were evaluated. Qualitative information on call satisfaction was gathered at the 3-month time point.

KEY RESULTS

Average completion rate across all calls was 62% with a mean call time of 26 minutes (no significant difference between HL groups). Caregivers had an average score of 0.90 out of 1 when evaluating overall call comprehension by scoring TB/TTG performance. Content comprehension in calls 1, 3, and 4 was significantly higher among caregivers with adequate HL relative to low HL (p < .1). Caregivers from both HL groups felt satisfied with calls [9.1 (2.0)/10-point scale] and agreed that calls helped them learn class material better [8.1 (2.7)]. Qualitatively, caregivers provided 81 (75%) positive responses (e.g., good content) and 27 (25%) negative responses (e.g., too lengthy) regarding the support calls.

CONCLUSIONS

Support calls using TB/TTG strategies were feasible, well received, and should be considered for incorporation into childhood obesity interventions. [HLRP: Health Literacy Research and Practice. 2021;5(3):e208-e217.] Plain Language Summary: This study evaluated support calls that used Teach-Back and Teach-to-Goal health literacy strategies as part of a childhood obesity treatment trial. Support calls were well accepted and facilitated comprehension of the key learning objectives in caregivers, regardless of health literacy level. These strategies should be considered for incorporation into childhood obesity treatment interventions to increase uptake of main concepts.

Diet Quality and Inflammatory Index Score Among Women's Cancer Survivors

Objectives

In 2018, women's cancers accounted for 38.6% of new cases and 26.9% of cancer deaths in females worldwide. The risk of recurrence is partially attributed to lifestyle factors linked to inflammation, including diet quality. Adherence to U.S Department of Agriculture Dietary Guidelines, measured with the Healthy Eating Index (HEI-2015), and consuming an anti-inflammatory diet, measured with the Energy-adjusted Dietary Inflammatory Index (E-DII), are found to improve quality of life and reduce recurrence risk. The purpose of this study was to investigate HEI-2015 and E-DII scores in women's cancer survivors.

Methods

Survivors of women's cancers (N = 52, 65 ± 12 yrs) were recruited to complete a demographic questionnaire and three 24-hour dietary recalls using the Nutrient Data System for Research (NDSR). HEI-2015 and E-DII scores were calculated from average intakes. Linear regression analysis was used to examine the association between demographic factors (age, BMI, education, rurality, income, financial security, years since active treatment, and weight goals) and HEI-2015 and E-DII scores. Pearson Correlation was used to examine correlation between the two.

Results

On average, HEI-2015 score was 55 ± 13.5 (29.7–84.6), lower than the national average, and E-DII score was -1.14 ± 2.24 (−5.66–3.22). 54% of women had anti- inflammatory (&lt;−1), 17% had pro-inflammatory (&gt;1), and 29% women had relatively neutral (−1 to 1) diets. Women with a graduate degree (P = 0.03) and who completed treatment more than 4 years prior (P = 0.01) had higher HEI-2015 scores. There were no associations between SES and E-DII scores. Most notably, higher diet quality was associated with more anti-inflammatory diets (r = −0.67, P &lt; 0.001).

Conclusions

While diet quality of women cancer survivors is comparatively low, the association with its inflammatory potential is a promising avenue for preventing recurrence. Higher E-DII scores are correlated with increased inflammatory markers, cardiovascular disease and metabolic syndrome risk, greater risk ratio and 75% increased mortality for several cancers. Guidelines for reducing inflammation will allow Registered Dietitians to provide specific, evidence-based oncology nutrition services, such as education, counseling, and medical nutrition therapy (MNT).

Funding Sources

This was funded by the University of Virginia Cancer Center.

Understanding and Advancing Organizational Health Literacy Within a Public Health Setting

Background:

Organizational health literacy (OHL) within the public health setting is lacking.

Objective:

The aim of this study was to form a health literacy (HL) improvement team consisting of university researchers and Virginia Department of Health (VDH) district directors and staff to assess and improve OHL practices of VDH staff in four medically underserved health districts in southwest Virginia.

Methods:

The Agency for Healthcare Research and Quality Health Literacy Universal Precautions Toolkit guided this mixed-methods needs assessment and improvement plan. VDH staff completed a 44-item survey adapted from this Toolkit and a roundtable discussion to indicate their perceptions of current OHL practices. VDH clients completed a survey including seven items measuring perceptions of staff OHL practices and three items measuring subjective HL.

Key Results:

About one-half of VDH staff (n = 252, 88% female, average age 49 ± 12 years, 23% ≤ high school education [HS]) reported “doing well” across all OHL domains. Staff survey and roundtable discussion revealed the need to strengthen the written communication domain. Among 185 VDH clients (82% female, average age 33 ± 14 years, 40% ≤ HS), perceptions of staff OHL practices were high, ranging from 3.07 to 3.64 (scale of 1–4). Client HL status was significantly positively correlated (p < .01–.05) with 5 of 7 OHL practices. Findings aided development and initial implementation of an OHL improvement plan, including e-newsletters and in-person workshops. On average, 60% of staff opened quarterly e-newsletters. Staff ratings of the Clear Communication Index workshop were high in terms of utility and applicability of content.

Conclusions:

Results reflected notable strengths and weaknesses in current OHL practices from staff and client perspectives, with the greatest need identified in written communication. E-newsletter series and in-person workshops on the Clear Communication Index helped lay groundwork for additional HL improvement activities for VDH staff. Limitations and future recommendations for public health settings are discussed. [HLRP: Health Literacy Research and Practice. 2021;5(1):e35–e48.]

Plain Language Summary:

This study describes use of the Agency for Healthcare Research and Quality Health Literacy Universal Precautions Toolkit to conduct an organizational health literacy needs assessment and improvement plan in a public health setting, the Virginia Department of Health. Assessment of staff and clients revealed strengths and weaknesses in organizational health literacy practices. Feedback guided efforts to improve organizational health literacy capacity.

A Multilevel Approach to Understand the Context and Potential Solutions for Low Colorectal Cancer (CRC) Screening Rates in Rural Appalachia Clinics

PURPOSE

To explore system/staff- and patient-level opportunities to improve colorectal cancer (CRC) screening within an 11-clinic Federally Qualified Health Center (FQHC) in rural Appalachia with CRC screening rates around 22%-30%.

METHODS

Using a convergent parallel mixed-methods design, staff (n = 26) and patients (n = 60, age 50-75, 67% female, 83% <college, 47% Medicare, 23% Medicaid) were interviewed about CRC-related screening practices. Staff and patient interviews were guided by the Consolidated Framework for Implementation Research and Health Belief Model, respectively, and analyzed using a hybrid inductive-deductive approach.

RESULTS

Among staff, inner setting factors that could promote CRC screening included high workplace satisfaction, experiences tracking other cancer screenings, and a highly active Performance Improvement Committee. Inner setting hindering factors included electronic medical record inefficiencies and requiring patients to physically return fecal tests to the clinic. Outer setting CRC screening promoting factors included increased Medicaid access, support from outside organizations, and reporting requirements to external regulators, while hindering factors included poor social determinants of health, inadequate colonoscopy access, and lack of patient compliance. Among patients, perceived screening benefits were rated relatively higher than barriers. Top barriers included cost, no symptoms, fear, and transportation. Patients reported high likelihood of getting a stool-based test and colonoscopy if recommended, yet self-efficacy to prevent CRC was considerably lower.

CONCLUSIONS

Contextualized perceptions of barriers and practical opportunities to improve CRC screening rates were identified among staff and patients. To optimize multilevel CRC screening interventions in rural Appalachia clinics, future quality improvement, research, and policy efforts are needed to address identified challenges.

Consumption of Added Sugars by Rural Residents of Southwest Virginia

Introduction

Nationally, rural residents have high consumption of added sugars, yet the top sources have not been explored. Characterizing added-sugar intake in high sugar-sweetened beverage (SSB) consumers in rural areas is an important step to help inform interventions and policies.

Purpose

The objective of this study was to explore the top food and beverage sources of added sugar and to examine variations by sociodemographic characteristics.

Methods

This cross-sectional study analyzed data from a randomized-controlled trial to reduce SSB in eight rural Appalachian counties. Data were obtained from baseline demographic surveys and three 24-hour dietary recalls. Dietary analyses included deriving AS grams and percentage of total energy intake from added sugar from individual food categories.

Results

This study had 301 participants, of which 93% were White (non-Hispanic), 81% were female, 49% were aged 35 to 54 years, 43% had an income of ≤$14,000, 33% had low health literacy, and 32% had < college education. Males and those with an income of ≤$14,000 had significantly higher consumption of added sugar. Added sugar contributed to 21% of total energy intake. The top source of added sugar was soda. SSB contributed to 66% of added sugar and 14% of total energy intake. Within SSB, soda contributed to 40% of added sugar, and 8% of total energy intake. Cola and citrus flavored drinks were the main varieties consumed.

Implications

Study findings can be used to adapt evidence-based interventions to reflect commonly consumed food and beverages and help inform food- and beverage-based dietary guidelines and policies specific to rural populations.

Feasibility of Delivering a Mobile Nutrition Literacy Intervention via Pediatric Primary Care

Objectives

The objective of this pilot study was to test the feasibility of implementing a mobile health intervention, “Nutricity,” within pediatric well-care and explore outcomes on child diet quality, child BMI and parental nutrition literacy.

Methods

Participants in this single-arm intervention pilot study were 18 parent-child dyads recruited from pediatric primary care before a scheduled well-care visit. Parents were English-speaking, identified as primary food decision-maker, had internet access at home, and owned a web-enabled device; children were 1–5 years old with unrestricted diets. Dyads were given three months’ access to Nutricity mobile tools during the child's well-care visit and were guided on use. Nutricity tools included a mobile formatted website to access instructional videos, games for kids, and quizzes for parents, and weekly text messages for nutrition goal setting. Content was focused on applying nutrition information at supermarkets, home, and restaurants. Feasibility was evaluated by % completion, parent likability survey, website usage, and % text responses logged. At baseline and three months, parent nutrition literacy (Nutrition Literacy Assessment Instrument, NLit); diet quality (2,24-hour diet recalls used to calculate a Healthy Eating Index, HEI – 2015 score), and BMI were collected with differences analyzed by paired t-tests.

Results

Of 18 dyads enrolled, 17 (94%) completed the study. Parents rated likability of the website and text messages as ‘good-excellent,’ reporting they applied ‘half-most’ of goals set through text-messaging. A common emergent theme was need for more individualized text messages. Mean response rate to text messages was 62%, and dyads logged an average of 43.7 minutes and 5.2 sessions on the website. Non-significant improvements were seen in parent NLit and overall child HEI scores, and no difference was seen in child BMI. However, HEI component scores improved for dairy by 1.2 points (P = .055) and seafood/plant proteins by 1.3 points (P = 0.046).

Conclusions

Delivering Nutricity via a pediatric well-care visit is feasible and demonstrated potential for improving child diet quality. A larger, adequately powered study is warranted.

Funding Sources

This work was funded by a CTSA grant from NCATS and the School of Health Professions.

The Adoption of the Healthy Eating Standards in Local Afterschool Programs Does Not Improve Quality of Snacks

OBJECTIVES

In 2011, the National Afterschool Association adopted the Healthy Eating and Physical Activity (HEPA) standards to address snack quality and physical activity in afterschool programs. Although research has indicated promise in the adoption of these policies by national organizations, less is known about local adoption, implementation, and effectiveness. In this study, we aimed to compare the quality of snacks served at program sites pre- and post-adoption and to determine the quality of non-program snacks compared to program snacks.

METHODS

An interrupted time series design was used to measure snack quality and consumption at 3 policy adopting sites and 2 non-policy adopting sites that served as a comparison control. Trained research staff collected snack type, brand, and amount consumed using a modified quarter-waste method. Analysis on nutrient content of snacks was completed using Nutrition Data System for Research software.

RESULTS

Adoption of the HEPA standards among policy adopting sites did not result in significantly better snack quality. Across all sites, program snacks were healthier than non-program snacks.

CONCLUSION

Pursuing additional components of the HEPA standards related to implementation may be necessary to significantly improve snack quality. Environmental supports such as limiting the amount of non-program snacks available onsite may improve snack quality.

Capacity Development and Evaluation of a Parent Advisory Team Engaged in Childhood Obesity Research

Guided by community-based participatory research principles, this mixed-methods process evaluation explored the experience and capacity of a newly formed Parental Advisory Team (PAT) engaged in childhood obesity research in a medically underserved region. Following the successful completion of a 3-month evidence-based childhood obesity treatment program (iChoose), 13 parents/caregivers who completed iChoose consented to participate in the PAT. Between June 2015 and March 2016, the PAT had nine monthly meetings and completed mixed-methods capacity assessments. They engaged in activities related to understanding iChoose outcomes, defining their role and purpose as a partnership, initiating content development, and pilot testing maintenance intervention components for future iChoose efforts. Assessments included a quantitative survey administered at baseline and 9 months, and a qualitative interview completed at 9 months. Results indicated that PAT members' perceptions of the identified capacity dimensions were positive at baseline (3.8-4.3 on a 5-point scale) and remained positive at follow-up (3.9-4.4 on a 5-point scale); changes were not statistically significant. Qualitative data revealed that PAT members were satisfied with group participation and desired to enhance their role in subsequent iChoose research. Understanding and promoting parental engagement in the research process fills an important gap in childhood obesity literature.

Preliminary Investigation of a Mobile Nutrition Literacy Website for Parents and Young Children

Parental nutrition literacy (PNL) correlates positively with child diet quality, but interventions for improving PNL are lacking. “Nutricity” is a novel bilingual (English/Spanish) mobile tool designed by the research team to engage parents and young children to interact with nutrition information to make nutrition decisions. The purpose of this study was to inform a future intervention through (1) assessing parental likability of Nutricity, and (2) collecting perceptions of pediatric clinic personnel on the feasibility of introducing Nutricity in pediatric clinics. PNL scores and feedback about Nutricity were collected using mixed methods from 15 English-speaking and 15 Spanish-speaking parents of 1–5 year-old children. Three parents from each language group provided additional feedback via semi-structured interviews. Interviews with 11 pediatric clinic personnel were also conducted to anticipate barriers and formulate strategies for implementing Nutricity as a clinic-based intervention. Nutricity was liked by both language groups and across all PNL levels, with a mean rating of 4.6 on a 5-point scale. Clinic personnel interviews affirmed need for and feasibility of offering Nutricity in clinics.

Kids SIP smartER: A Feasibility Study to Reduce Sugar-Sweetened Beverage Consumption Among Middle School Youth in Central Appalachia

PURPOSE

To test the feasibility of Kids SIP smartER, a school-based intervention to reduce consumption of sugar-sweetened beverages (SSBs).

DESIGN

Matched-contact randomized crossover study with mixed-methods analysis.

SETTING

One middle school in rural, Appalachian Virginia.

PARTICIPANTS

Seventy-four sixth and seventh graders (5 classrooms) received Kids SIP smartER in random order over 2 intervention periods. Feasibility outcomes were assessed among 2 teachers.

INTERVENTION

Kids SIP smartER consisted of 6 lessons grounded in the Theory of Planned Behavior, media literacy, and public health literacy and aimed to improve individual SSB behaviors and understanding of media literacy and prevalent regional disparities. The matched-contact intervention promoted physical activity.

MEASURES

Beverage Intake Questionnaire-15 (SSB consumption), validated theory questionnaires, feasibility questionnaires (student and teacher), student focus groups, teacher interviews, and process data (eg, attendance).

ANALYSIS

Repeated measures analysis of variances across 3 time points, descriptive statistics, and deductive analysis of qualitative data.

RESULTS

During the first intervention period, students receiving Kids SIP smartER (n = 43) significantly reduced SSBs by 11 ounces/day ( P = .01) and improved media ( P < .001) and public health literacy ( P < .01) understanding; however, only media literacy showed between-group differences ( P < .01). Students and teachers found Kids SIP smartER acceptable, in-demand, practical, and implementable within existing resources.

CONCLUSION

Kids SIP smartER is feasible in an underresourced, rural school setting. Results will inform further development and large-scale testing of Kids SIP smartER to reduce SSBs among rural adolescents.

The Relationship Between the Stanford Leisure-Time Activity Categorical Item and the Godin Leisure-Time Exercise Questionnaire Among Rural Intervention Participants of Varying Health Literacy Status

BACKGROUND

A pragmatic, self-reported physical activity measure is needed for individuals of varying health literacy status.

METHODS

This study is a secondary analysis of a 6-month behavioral intervention for rural Appalachian adults developed using health literacy strategies. We examined the relationship and responsiveness of the Stanford Leisure-Time Activity Categorical Item (L-Cat) and adapted Godin Leisure-Time Exercise Questionnaire (GLTEQ) and determined if baseline health literacy status moderates intervention effects.

RESULTS

Of 301 enrolled participants, 289 completed the L-Cat at baseline and 212 at 6 months. Approximately 33% were low health literate and 43% reported annual income of ≤$14,999. There was high agreement (84.1%) between the L-Cat and adapted GLTEQ for classifying individuals as meeting physical activity recommendations with little differences by health literacy level (low literacy 80.4% and high literacy 85.9%). The primary source of incongruent classification was the adapted GLTEQ classified almost 20% of individuals as meeting recommendations, whereas the L-Cat classified them as not meeting recommendations. There were differences in responsiveness between measures, but baseline health literacy status did not moderate change in any L-Cat or adapted GLTEQ measures.

CONCLUSION

Implications and recommendations for using the L-Cat 2.3 and GLTEQ among individuals of varying health literacy status are discussed.

The Influence of Health Literacy on Reach, Retention, and Success in a Worksite Weight Loss Program

PURPOSE

To examine if employee health literacy (HL) status moderated reach, retention, and weight outcomes in a worksite weight loss program.

DESIGN

The study was a two-group cluster randomized controlled weight loss trial.

SETTING

The study was conducted in 28 worksites.

SUBJECTS

Subjects comprised 1460 employees with a body mass index >25 kg/m(2).

INTERVENTIONS

Two 12-month weight loss interventions targeted diet and physical activity behaviors: incentaHEALTH (INCENT; incentivized individually targeted Internet-based intervention) and Livin' My Weigh (LMW; less-intense quarterly newsletters).

MEASURES

A validated three-item HL screening measure was self-completed at baseline. Weight was objectively assessed with the Health Spot scale at baseline and 12-month follow-up.

ANALYSIS

The impact of HL on program effectiveness was assessed through fixed-effect parametric models that controlled for individual (i.e., age, gender, race, ethnicity, income, education) and worksite random effects.

RESULTS

Enrolled employees had significantly higher HL status [13.54 (1.68)] as compared to unenrolled [13.04 (2.17)] (p < .001). This finding was consistent in both interventions. Also, HL moderated weight loss effects (beta = .66; SE = 027; p = .014) and losing >5% weight (beta = -1.53; SE = .77; p < .047). For those with lower baseline HL, the INCENT intervention produced greater weight loss outcomes compared to LMW. The HL level of employees retained was not significantly different from those lost to follow-up.

CONCLUSION

HL influences reach and moderates weight effects. These findings underscore the need to integrate recruitment strategies and further evaluate programmatic approaches that attend to the needs of low-HL audiences.

Development and Evaluation of the Sugar-Sweetened Beverages Media Literacy (SSB-ML) Scale and Its Relationship With SSB Consumption

Understanding how adults' media literacy skill sets impact their sugar-sweetened beverage (SSB) intake provides insight into designing effective interventions to enhance their critical analysis of marketing messages and thus improve their healthy beverage choices. However, a media literacy scale focusing on SSBs is lacking. This cross-sectional study uses baseline data from a large randomized controlled trial to (a) describe the psychometric properties of an SSB Media Literacy Scale (SSB-ML) scale and its subdomains, (b) examine how the scale varies across demographic variables, and (c) explain the scale's concurrent validity to predict SSB consumption. Results from 293 adults in rural southwestern Virginia (81.6% female, 94.0% White, 54.1% receiving SNAP and/or WIC benefits, average 410 SSB kcal daily) show that overall SSB-ML scale and its subdomains have strong internal consistencies (Cronbach's alphas ranging from 0.65 to 0.83). The Representation & Reality domain significantly predicted SSB kilocalories, after controlling for demographic variables. This study has implications for the assessment and inclusion of context-specific media literacy skills in behavioral interventions.

One-Year Mixed-Methods Case Study of a Community-Academic Advisory Board Addressing Childhood Obesity

OBJECTIVE

Using a community-based participatory research and systems-based approach, the purpose of this community case study is to describe the planning process and first-year experiences of community-academic advisory board (CAB) partners involved with the development of an evidence-based childhood obesity treatment program in a medically underserved region.

METHOD

Regional community partners ( n = 9; Pittsylvania/Danville Health District, Children's Healthcare Center, Danville Parks & Recreation, and Danville Boys & Girls Club) and academic partners ( n = 9) met monthly to select and adapt an evidence-based childhood obesity program, develop evaluation and recruitment protocols, and plan for program implementation. In the first 3 months, members developed a mixed-methods capacity evaluation, administered at 3 and 11 months following the first CAB meeting.

RESULTS

Most capacity dimensions were rated highly and demonstrated no significant change over time. However, perceptions of trust approached a significant increase ( p = .055), the ability to resolve conflicts significantly increased ( p = .018), and participation and influ-ence perceptions significantly decreased ( p = .001). Qualitative analysis elucidated members' experiences and key facilitator and barrier themes emerged.

CONCLUSIONS

Similarities and differences between community and academic members' experiences allowed synthesis of best practices and lessons learned. The methodological framework and best practices can inform the capacity development for new community-academic collaborations.

A pragmatic examination of active and passive recruitment methods to improve the reach of community lifestyle programs: The Talking Health Trial

Background

A primary challenge for behavior change strategies is ensuring that interventions can be effective while also attracting a broad and representative sample of the target population. The purpose of this case-study was to report on (1) the reach of a randomized controlled trial targeting reduced sugary beverages, (2) potential participant characteristic differences based on active versus passive recruitment strategies, and (3) recruitment strategy cost.

Methods

Demographic and recruitment information was obtained for 8 counties and for individuals screened for participation. Personnel activities and time were tracked. Costs were calculated and compared by active versus passive recruitment.

Results

Six-hundred and twenty, of 1,056 screened, individuals were eligible and 301enrolled (77% women; 90% white; mean income $21,981 ± 16,443). Eighty-two and 44% of those responding to passive and active methods, respectively, enrolled in the trial. However, active recruitment strategies yielded considerably more enrolled (active = 199; passive = 102) individuals. Passive recruitment strategies yielded a less representative sample in terms of gender (more women), education (higher), and income (higher; p’s <0.05). The average cost of an actively recruited and enrolled participant was $278 compared to $117 for a passively recruited and enrolled participant.

Conclusions

Though passive recruitment is more cost efficient it may reduce the reach of sugary drink reduction strategies in lower educated and economic residents in rural communities.

Trial registration

Clinicaltrials.gov; ID: NCT02193009, July 2014, retrospectively registered.

A Systematic Review to Assess Sugar-Sweetened Beverage Interventions for Children and Adolescents across the Socioecological Model

Sugar-sweetened beverage (SSB) consumption among children and adolescents is a determinant of childhood obesity. Many programs to reduce consumption across the socioecological model report significant positive results; however, the generalizability of the results, including whether reporting differences exist among socioecological strategy levels, is unknown. This systematic review aimed to examine the extent to which studies reported internal and external validity indicators defined by the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) model and assess reporting differences by socioecological level: Intrapersonal/interpersonal (Level 1), environmental/policy (Level 2), and multilevel (Combined Level). A systematic literature review was conducted in six major databases (PubMed, Web of Science, Cinahl, CAB Abstracts, Education Research Information Center, and Arcola) to identify studies from 2004-2015 meeting inclusion criteria (children aged 3 to 12 years, adolescents aged 13 to 17 years, and young adults aged 18 years, experimental or quasiexperimental, and substantial SSB component). Interventions were categorized by socioecological level, and data were extracted using a validated RE-AIM protocol. One-way analysis of variance assessed differences between levels. There were 55 eligible studies accepted, including 21 Level 1, 18 Level 2, and 16 Combined Level studies. Thirty-six studies (65%) were conducted in the United States, 19 studies (35%) were conducted internationally, and 39 studies (71%) were implemented in schools. Across levels, reporting averages were low for all RE-AIM dimensions (reach=29%, efficacy or effectiveness=45%, adoption=26%, implementation=27%, and maintenance=14%). Level 2 studies had significantly lower reporting on reach and effectiveness (10% and 26%, respectively) compared with Level 1 (44% and 57%, respectively) or Combined Level studies (31% and 52%, respectively) (P<0.001). Adoption, implementation, and maintenance reporting did not vary among levels. Interventions to reduce SSB consumption in children and adolescents across the socioecological spectrum do not provide the necessary information for dissemination and implementation in community nutrition settings. Future interventions should address both internal and external validity to maximize population influence.

Using Teach-Back to Understand Participant Behavioral Self-Monitoring Skills Across Health Literacy Level and Behavioral Condition

OBJECTIVE

To assess differences, by health literacy status and behavioral condition, in participants' abilities to self-monitor behaviors accurately and recall key behavioral messages using data from a teach-back call.

DESIGN

Cross-sectional.

SETTING

Rural, southwestern Virginia.

PARTICIPANTS

Adults (n = 301). The majority were female (81.1%), 31.9% had a high school education or less, 66.1% earned < $25,000/y, and 32.9% were low health literate.

INTERVENTION

First class session of 2 community-based behavioral interventions: SIPsmartER (reduce sugar-sweetened beverage intake) or MoveMore (increase physical activity).

MAIN OUTCOME MEASURES

Reported accuracy of behavioral diary completion, proportion of behavioral messages recalled during the first round of teach-back, and rounds of teach-back.

ANALYSIS

Descriptive statistics and generalized linear model.

RESULTS

Low health literate participants were significantly less accurate in diary completion (P < .001), recalled fewer behavioral messages correctly (P < .001), and needed more rounds of teach-back (P < .001) than high health literate participants. Compared with SIPsmartER participants, MoveMore participants more accurately completed diaries (P = .001) but recalled a lower proportion of behavioral messages correctly (P < .001) and required more rounds of teach-back (P < .001).

CONCLUSIONS AND IMPLICATIONS

Health literacy status and behavioral target affect the ability to self-monitor and recall key concepts. Researchers should consider using teach-back early in the intervention to assess and reinforce participants' ability to self-monitor.

A randomized trial using motivational interviewing for maintenance of blood pressure improvements in a community-engaged lifestyle intervention: HUB city steps

Little is known about the effective dose of motivational interviewing for maintaining intervention-induced health outcome improvements. The purpose of this study was to compare effects of two doses of motivational interviewing for maintaining blood pressure improvements in a community-engaged lifestyle intervention conducted with African-Americans. Participants were tracked through a 12-month maintenance phase following a 6-month intervention targeting physical activity and diet. For the maintenance phase, participants were randomized to receive a low (4) or high (10) dose of motivational interviewing delivered via telephone by trained research staff. Generalized linear models were used to test for group differences in blood pressure. Blood pressure significantly increased during the maintenance phase. No differences were apparent between randomized groups. Results suggest that 10 or fewer motivational interviewing calls over a 12-month period may be insufficient to maintain post-intervention improvements in blood pressure. Further research is needed to determine optimal strategies for maintaining changes.

Examining the Feasibility of Smartphone Game Applications for Physical Activity Promotion in Middle School Students

OBJECTIVE

The objective of this study was to determine the feasibility (i.e., limited efficacy testing, practicality, and acceptability) of a 6-week smartphone game-based applications program for promoting physical activity (PA) in adolescents in an afterschool program.

MATERIALS AND METHODS

This mixed-method, quasi-experimental design study included 27 adolescents who evaluated four smartphone PA game-based applications in two Boys & Girls Clubs of America. After an initial baseline week (i.e., usual activity during their visit to the Club), adolescents played each game for 1 week. During a final week, the participants could choose to play any combination of the four games. An established conceptual framework was used to assess feasibility. Efficacy was assessed by changes in PA via wrist-worn accelerometers (model GT3x+; ActiGraph LLC, Pensacola, FL). Practicality was measured through field notes, the number of players attending each session, and the proportion of attendees who played the games. Acceptability was measured using poststudy focus groups.

RESULTS

Compared with baseline (3.22 metabolic equivalents [METs]), mean accelerometer values were significantly (P<0.05) higher during "Space Rayders" (4.33 METs) and "Color Hunt" (3.67 METs). Attendance did not differ among games, and weekly number of players averaged 12 of 27 participants. Qualitative findings indicated that participants perceived "Space Rayders" as the most acceptable game. Overall, participants found the games to be enjoyable and easy to use, although they had suggestions to improve graphics and sounds.

CONCLUSIONS

Smartphone games can be feasible for adolescents to use for PA. Lessons learned will be used to provide improvements for future game development and evaluation.

Improvements in blood pressure among undiagnosed hypertensive participants in a community-based lifestyle intervention, Mississippi, 2010

Introduction

Effective strategies are needed to reach and treat people who lack awareness of or have uncontrolled hypertension. We used data from a community-based participatory research initiative, Hub City Steps, to quantify the prevalence of undiagnosed hypertension and determine the relationship between hypertension status at baseline and postintervention improvements in blood pressure and health-related quality of life.

Methods

Hub City Steps was a 6-month preintervention–postintervention lifestyle intervention targeting hypertension risk factors. Outcome measures were collected at baseline, 3 months, and 6 months. Generalized linear mixed models were used to test for effects by time and hypertension status.

Results

Of the enrolled sample (N = 269), most were overweight or obese (91%), African American (94%), and women (85%). When considering hypertension status, 42% had self-reported diagnosis of hypertension (self-reported subgroup; 84% with antihypertensive medication use); 36% had no self-reported medical history of hypertension, but when blood pressure was measured they had a clinical diagnosis of prehypertension or hypertension (undiagnosed subgroup); and 22% had no self-reported or clinical hypertension diagnosis (no hypertension subgroup). From baseline to 6 months, systolic blood pressure significantly improved for participants with self-reported hypertension [8.2 (SD, 18.2) mm Hg] and undiagnosed hypertension [12.3 (SD, 16.3) mm Hg], with undiagnosed participants experiencing the greatest improvements (P < .001). Effects remained significant after controlling for covariates. Health-related quality of life significantly improved for all 3 hypertension subgroups, with no apparent subgroup differences.

Conclusion

This study reveals advantages of a culturally appropriate community-based participatory research initiative to reach those with undetected hypertension and effectively improve blood pressure status and health-related quality of life.

HUB city steps: a 6-month lifestyle intervention improves blood pressure among a primarily African-American community

The effectiveness of community-based participatory research (CBPR) efforts to address the disproportionate burden of hypertension among African Americans remains largely untested. The objective of this 6-month, noncontrolled, pre-/post-experimental intervention was to examine the effectiveness of a CBPR intervention in achieving improvements in blood pressure, anthropometric measures, biological measures, and diet. Conducted in 2010, this multicomponent lifestyle intervention included motivational enhancement, social support provided by peer coaches, pedometer diary self-monitoring, and monthly nutrition and physical activity education sessions. Of 269 enrolled participants, 94% were African American and 85% were female. Statistical analysis included generalized linear mixed models using maximum likelihood estimation. From baseline to 6 months, blood pressure decreased significantly: mean (± standard deviation) systolic blood pressure decreased from 126.0 ± 19.1 to 119.6 ± 15.8 mm Hg, P=0.0002; mean diastolic blood pressure decreased from 83.2 ± 12.3 to 78.6 ± 11.1 mm Hg, P<0.0001). Sugar intake also decreased significantly as compared with baseline (by approximately 3 tsp; P<0.0001). Time differences were not apparent for any other measures. Results from this study suggest that CBPR efforts are a viable and effective strategy for implementing nonpharmacologic, multicomponent, lifestyle interventions that can help address the persistent racial and ethnic disparities in hypertension treatment and control. Outcome findings help fill gaps in the literature for effectively translating lifestyle interventions to reach and engage African-American communities to reduce the burden of hypertension.

Using the RE-AIM Framework in formative evaluation and program planning for a nutrition intervention in the Lower Mississippi Delta

OBJECTIVE

Identification of prominent themes to be considered when planning a nutrition intervention using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework.

DESIGN

Qualitative formative research.

SETTING

Women's social and civic organizations in the Lower Mississippi Delta.

PARTICIPANTS

Thirty-seven (5 white and 32 black) women with a college degree or higher.

PHENOMENON OF INTEREST

Impact of dietary and contextual factors related to the Lower Mississippi Delta culture on intervention planning.

ANALYSIS

Case analysis strategy using question-by-question coding.

RESULTS

Major themes that emerged were "healthy eating focus" and "promoting a healthy lifestyle" when recruiting organizations (Reach); "positive health changes" as a result of the intervention (Effectiveness); "logistics: time commitment, location, and schedule" to initiate a program (Adoption); "expense of healthy foods" and "cooking and meal planning" as barriers to participation (Implementation); and "resources and training" and "motivation" as necessary for program continuation (Maintenance). The "health of the Delta" theme was found across all dimensions, which reflected participants' compassion for their community.

CONCLUSIONS AND IMPLICATIONS

Results were used to develop an implementation plan promoting optimal reach, effectiveness, adoption, implementation, and maintenance of a nutrition intervention. This research emphasizes the benefits of formative research using a systematic process at organizational and individual levels.

Talking health, a pragmatic randomized-controlled health literacy trial targeting sugar-sweetened beverage consumption among adults: rationale, design & methods

High consumption of sugar-sweetened beverages (SSB) contributes to a wide range of poor health outcomes. Further, few US adults drink less than the recommended ≤8 oz per day; and individuals with low socioeconomic, low health literacy status, and in rural areas are even less likely to meet recommendations. Unfortunately, few SSB behavioral interventions exist targeting adults, and none focus on low health literacy in rural areas. Talking Health, a type 1 effectiveness-implementation hybrid trial targeting adults in rural southwest Virginia, was developed using the RE-AIM planning and evaluation framework (reach, effectiveness, adoption, implementation, maintenance). The primary aim of this pragmatic randomized-controlled trial was to determine the effectiveness of a scalable 6-month intervention aimed at decreasing SSB consumption (SIPsmartER) when compared to a matched contact physical activity promotion control group (MoveMore). SIPsmartER was developed based upon the Theory of Planned Behavior and uses health literacy strategies to improve comprehension of the intervention content among participants. MoveMore is based on a research-tested intervention that was adapted to address all theory of planned behavior constructs and health literacy principles. Secondary aims include additional health outcomes (e.g., physical activity, weight) and reach, adoption, implementation, and maintenance indicators. This paper highlights the opportunities and considerations for developing health behavior trials that aim to determine intervention effectiveness, provide all study participants an opportunity to benefit from research participation, and collect key information on reach and the potential for organizational adoption, implementation, and maintenance with the longer-term goal of speeding translation into practice settings.

Assessing the internal and external validity of mobile health physical activity promotion interventions: a systematic literature review using the RE-AIM framework

Background

Mobile health (mHealth) interventions are effective in promoting physical activity (PA); however, the degree to which external validity indicators are reported is unclear.

Objective

The purpose of this systematic review was to use the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework to determine the extent to which mHealth intervention research for promoting PA reports on factors that inform generalizability across settings and populations and to provide recommendations for investigators planning to conduct this type of research.

Methods

Twenty articles reflecting 15 trials published between 2000 and 2012 were identified through a systematic review process (ie, queries of three online databases and reference lists of eligible articles) and met inclusion criteria (ie, implementation of mobile technologies, target physical activity, and provide original data). Two researchers coded each article using a validated RE-AIM data extraction tool (reach, efficacy/effectiveness, adoption, implementation, maintenance). Two members of the study team independently abstracted information from each article (inter-rater reliability >90%) and group meetings were used to gain consensus on discrepancies.

Results

The majority of studies were randomized controlled trials (n=14). The average reporting across RE-AIM indicators varied by dimension (reach=53.3%, 2.67/5; effectiveness/efficacy=60.0%, 2.4/4; adoption=11.1%, 0.7/6; implementation=24.4%, 0.7/3; maintenance=0%, 0/3). While most studies described changes in the primary outcome (effectiveness), few addressed the representativeness of participants (reach) or settings (adoption) and few reported on issues related to maintenance and degree of implementation fidelity.

Conclusions

This review suggests that more focus is needed on research designs that highlight and report on both internal and external validity indicators. Specific recommendations are provided to encourage future mHealth interventionists and investigators to report on representativeness, settings, delivery agents for planned interventions, the extent to which protocol is delivered as intended, and maintenance of effects at the individual or organizational level.

Pilot Evaluation of a Media Literacy Program for Tobacco Prevention Targeting Early Adolescents Shows Mixed Results

Purpose.

The purpose of this pilot study was to assess the impact of media literacy for tobacco prevention for youth delivered through a community site.

Design.

A randomized pretest-posttest evaluation design with matched-contact treatment and control conditions.

Setting.

The pilot study was delivered through the YMCA in a lower-income suburban and rural area of Southwest Virginia, a region long tied, both economically and culturally, to the tobacco industry.

Subjects.

Children ages 8 to 14 (76% white, 58% female) participated in the study (n = 38).

Intervention.

The intervention was an antismoking media literacy program (five 1-hour lessons) compared with a matched-contact creative writing control program.

Measures.

General media literacy, three domains of tobacco-specific media literacy (“authors and audiences,” “messages and meanings,” and “representation and reality”), tobacco attitudes, and future expectations were assessed.

Analysis.

Multiple regression modeling assessed the impact of the intervention, controlling for pretest measures, age, and sex.

Results.

General media literacy and tobacco-specific “authors and audiences” media literacy improved significantly for treatment compared with control (p < .05); results for other tobacco-specific media literacy measures and for tobacco attitudes were not significant. Future expectations of smoking increased significantly for treatment participants ages 10 and younger (p < .05).

Conclusion.

Mixed results indicated that improvements in media literacy are accompanied by an increase in future expectations to smoke for younger children.

Randomized controlled trial targeting obesity-related behaviors: Better Together Healthy Caswell County

Introduction

Collaborative and multilevel interventions to effectively address obesity-related behaviors among rural communities with health disparities can be challenging, and traditional research approaches may be unsuitable. The primary objective of our 15-week randomized controlled pilot study, which was guided by community-based participatory research (CBPR) principles, was to determine the effectiveness of providing twice-weekly access to group fitness classes, with and without weekly nutrition and physical activity education sessions, in Caswell County, North Carolina, a rural region devoid of medical and physical activity resources.

Methods

Participants were randomly divided into 2 groups: group 1 was offered fitness sessions and education in healthful eating and physical activity; group 2 was offered fitness sessions only. Outcome measures were assessed at baseline and immediately after the intervention. Standardized assessment procedures, validated measures, and tests for analysis of variance were used.

Results

Of 91 enrolled participants, most were African American (62%) or female (91%). Groups were not significantly different at baseline. Group 1 experienced significantly greater improvements in body mass index (F = 15.0, P < .001) and waist circumference (F = 7.0, P = .01), compared with group 2. Both groups significantly increased weekly minutes of moderate physical activity (F = 9.4, P < .003). Participants in group 1 also had significantly greater weight loss with higher attendance at the education (F = 14.7, P < .001) and fitness sessions (F = 18.5, P < .001).

Conclusion

This study offers effective programmatic strategies that can reduce weight and increase physical activity and demonstrates feasibility for a larger scale CBPR obesity trial targeting underserved residents affected by health disparities. This study also signifies successful collaboration among community and academic partners engaged in a CBPR coalition.

Examining the diet of post-migrant Hispanic males using the precede-proceed model: predisposing, reinforcing, and enabling dietary factors

OBJECTIVE

To examine socio-environmental, behavioral, and predisposing, reinforcing, and enabling (PRE) factors contributing to post-migration dietary behavior change among a sample of traditional Hispanic males.

DESIGN

In this descriptive study, semistructured interviews, a group interview, and photovoice, followed by group interviews, were used to examine dietary change and contributing factors. The behavioral, environmental, organizational, and educational assessment phases of the PRECEDE-PROCEED model guided the organization of dietary contributing factors for development of a nutrition intervention.

SETTING

The southern region of Mississippi.

PARTICIPANTS

Traditional Hispanic males (n = 19) were identified from 35 Hispanic males who participated in a larger study. The traditional Hispanic males were identified by the Acculturation Rating Scale for Mexican Americans-II and the Marginality Scale.

ANALYSIS

Using the Grounded Theory approach to data analysis, themes and core categories relating to dietary behavior were identified and defined during the analysis process. The constant comparison method was used to identify key themes among coders.

RESULTS

Cultural gender role and living structure, as socio-environmental factors, influenced the PRE dietary factors.

CONCLUSIONS AND IMPLICATIONS

Multiple factors influence dietary behavior in the target population. The identified socio-environmental factors underlie the PRE factors and, therefore, must first be addressed in nutrition interventions.

Evaluating community capacity to address obesity in the Dan River region: a case study

OBJECTIVE

To qualitatively evaluate community capacity among an emerging coalition initiated to address complex regional obesity problems.

METHODS

Guided by dimensions of community capacity, this case study applies semistructured qualitative interviews among 12 key stakeholders engaged in the Dan River Partnership for a Healthy Community (DRPHC).

RESULTS

In-depth qualitative data reveals important contextualized information related to community capacity dimensions such as participation, community power, resources, leadership, organizational structure, and partnership.

CONCLUSION

Findings have provided critical direction for the continued development and sustainability of DRPHC efforts. Others could apply a similar evaluation to better understand factors that promote the development and maintenance of their coalitions.

Mixed methods evaluation of a randomized control pilot trial targeting sugar-sweetened beverage behaviors

This Excessive sugar-sweetened beverage (SSB) consumption and low health literacy skills have emerged as two public health concerns in the United States (US); however, there is limited research on how to effectively address these issues among adults. As guided by health literacy concepts and the Theory of Planned Behavior (TPB), this randomized controlled pilot trial applied the RE-AIM framework and a mixed methods approach to examine a sugar-sweetened beverage (SSB) intervention (SipSmartER), as compared to a matched-contact control intervention targeting physical activity (MoveMore). Both 5-week interventions included two interactive group sessions and three support telephone calls. Executing a patient-centered developmental process, the primary aim of this paper was to evaluate patient feedback on intervention content and structure. The secondary aim was to understand the potential reach (i.e., proportion enrolled, representativeness) and effectiveness (i.e. health behaviors, theorized mediating variables, quality of life) of SipSmartER. Twenty-five participants were randomized to SipSmartER (n=14) or MoveMore (n=11). Participants' intervention feedback was positive, ranging from 4.2-5.0 on a 5-point scale. Qualitative assessments reavealed several opportunties to improve clarity of learning materials, enhance instructions and communication, and refine research protocols. Although SSB consumption decreased more among the SipSmartER participants (-256.9 ± 622.6 kcals), there were no significant group differences when compared to control participants (-199.7 ± 404.6 kcals). Across both groups, there were significant improvements for SSB attitudes, SSB behavioral intentions, and two media literacy constructs. The value of using a patient-centered approach in the developmental phases of this intervention was apparent, and pilot findings suggest decreased SSB may be achieved through targeted health literacy and TPB strategies. Future efforts are needed to examine the potential public health impact of a large-scale trial to address health literacy and reduce SSB.

Does availability of physical activity and food outlets differ by race and income? Findings from an enumeration study in a health disparate region

BACKGROUND

Low-income, ethnic/racial minorities and rural populations are at increased risk for obesity and related chronic health conditions when compared to white, urban and higher-socio-economic status (SES) peers. Recent systematic reviews highlight the influence of the built environment on obesity, yet very few of these studies consider rural areas or populations. Utilizing a CBPR process, this study advances community-driven causal models to address obesity by exploring the difference in resources for physical activity and food outlets by block group race and income in a small regional city that anchors a rural health disparate region. To guide this inquiry we hypothesized that lower income and racially diverse block groups would have fewer food outlets, including fewer grocery stores and fewer physical activity outlets. We further hypothesized that walkability, as defined by a computed walkability index, would be lower in the lower income block groups.

METHODS

Using census data and GIS, base maps of the region were created and block groups categorized by income and race. All food outlets and physical activity resources were enumerated and geocoded and a walkability index computed. Analyses included one-way MANOVA and spatial autocorrelation.

RESULTS

In total, 49 stores, 160 restaurants and 79 physical activity outlets were enumerated. There were no differences in the number of outlets by block group income or race. Further, spatial analyses suggest that the distribution of outlets is dispersed across all block groups.

CONCLUSIONS

Under the larger CPBR process, this enumeration study advances the causal models set forth by the community members to address obesity by providing an overview of the food and physical activity environment in this region. This data reflects the food and physical activity resources available to residents in the region and will aid many of the community-academic partners as they pursue intervention strategies targeting obesity.