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1.  Talking Health, A pragmatic randomized-controlled health literacy trial targeting sugar-sweetened beverage consumption among adults: Rationale, design & methods 
Contemporary clinical trials  2013;37(1):43-57.
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 ounces 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.
doi:10.1016/j.cct.2013.11.003
PMCID: PMC3939427  PMID: 24246819
beverages; health literacy; research design; behavioral research; randomized controlled trial; rural population
2.  Disparities in obesity among rural and urban residents in a health disparate region 
BMC Public Health  2014;14(1):1051.
Background
The burden of obesity and obesity-related conditions is not borne equally and disparities in prevalence are well documented for low-income, minority and rural adults in the United States. The current literature on rural versus urban disparities is largely derived from national surveillance data which may not reflect regional nuances. There is little practical research that supports the reality of local service providers such as county health departments that may serve both urban and rural residents in a given area. Conducted through a community-academic partnership, the primary aim of this study is to quantify the current levels of obesity (BMI), fruit and vegetable (FV) intake and physical activity (PA) in a predominately rural health disparate region. Secondary aims are to determine if a gradient exists within the region in which rural residents have poorer outcomes on these indicators compared to urban residents.
Methods
Conducted as part of a larger ongoing community-based participatory research (CBPR) initiative, data were gathered through a random digit dial telephone survey using previously validated measures (n = 784). Linear, logistic and quantile regression models are used to determine if residency (i.e. rural, urban) predicts outcomes of FV intake, PA and BMI.
Results
The majority (72%) of respondents were overweight (BMI = 29 ± 6 kg/m2), with 29% being obese. Only 9% of residents met recommendations for FV intake and 38% met recommendations for PA. Statistically significant gradients between urban and rural and race exist at the upper end of the BMI distribution. In other words, the severity of obesity is worse among black compared to white and for urban residents compared to rural residents.
Conclusions
These results will be used by the community-academic partnership to guide the development of culturally relevant and sustainable interventions to increase PA, increase FV intake and reduce obesity within this health disparate region. In particular, local stakeholders may wish to address disparities in BMI by allocating resources to the vulnerable groups identified.
doi:10.1186/1471-2458-14-1051
PMCID: PMC4198673  PMID: 25297840
Community-based participatory research; Physical activity; Fruit and vegetable intake; Health disparities
3.  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.
doi:10.5888/pcd11.130269
PMCID: PMC3976232  PMID: 24698531
4.  Qualitative Application of the Theory of Planned Behavior to Understand Beverage Behaviors among Adults 
Despite strong scientific data indicating associations among sugar-sweetened beverages (SSB) and numerous adverse health outcomes, little is known about culturally specific beliefs and potential individual-level behavioral strategies to reduce SSB intake. The primary objective of this formative study targeting adults residing in rural southwest Virginia was to apply the Theory of Planned Behavior (TPB) to investigate culturally specific attitudes, subjective norms and perceived behavioral control constructs related to the consumption of SSB, water, and artificially sweetened beverages. Using a homogenous sampling strategy, eight focus groups were conducted with 54 adult participants who exceeded recommendations of <1 cup of SSB/day. An experienced moderator and co-moderator utilized a semi-structured script, grounded in the TPB, to execute the focus group. All focus groups were audio taped and transcribed verbatim. Three researchers independently coded meaning units (MU) to the major themes and subsequently met to gain consensus in coding. Important beverage specific themes emerged for attitudes, subjective norms, perceived behavioral control, and intentions. Across all beverages, the most notable themes included taste (n= 161 MU), availability/convenience (n= 95 MU), habit/addiction (n=57 MU), and cost (n= 28 MU). Health consequences associated with beverages and water quality issues also surfaced, as well as normative beliefs including the influence of doctors and peers. The identified themes and sub-themes provides critical insight into understanding culturally-relevant context and beliefs associated with beverage behaviors and helps inform the development and evaluation of future intervention efforts targeting SSB consumption in the health disparate region of southwest Virginia.
doi:10.1016/j.jand.2012.06.368
PMCID: PMC3500704  PMID: 23102176
qualitative research; health behavior; beverages; dietary habits; health status disparities
5.  The Comparative Validity of Interactive Multimedia Questionnaires to Paper-Administered Questionnaires for Beverage Intake and Physical Activity: Pilot Study 
JMIR Research Protocols  2013;2(2):e40.
Background
Brief, valid, and reliable dietary and physical activity assessment tools are needed, and interactive computerized assessments (ie, those with visual cues, pictures, sounds, and voiceovers) can reduce administration and scoring burdens commonly encountered with paper-based assessments.
Objective
The purpose of this pilot investigation was to evaluate the comparative validity and reliability of interactive multimedia (IMM) versions (ie, IMM-1 and IMM-2) compared to validated paper-administered (PP) versions of the beverage intake questionnaire (BEVQ-15) and Stanford Leisure-Time Activity Categorical Item (L-Cat); a secondary purpose was to evaluate results across two education attainment levels.
Methods
Adults 21 years or older (n=60) were recruited to complete three laboratory sessions, separated by three to seven days in a randomly assigned sequence, with the following assessments–demographic information, two IMM and one paper-based (PP) version of the BEVQ-15 and L-Cat, health literacy, and an IMM usability survey.
Results
Responses across beverage categories from the IMM-1 and PP versions (validity; r=.34-.98) and the IMM-1 and IMM-2 administrations (reliability; r=.61-.94) (all P<.001) were significantly correlated. Paired t tests revealed significant differences in sugar-sweetened beverage (SSB) grams and kcal (P=.02 and P=.01, respectively) and total beverage kcal (P=.03), on IMM-1 and IMM-2; however, comparative validity was demonstrated between IMM-2 and the PP version suggesting familiarization with the IMM tool may influence participant responses (mean differences: SSB 63 grams, SEM 87; P=.52; SSB 21 kcal, SEM 33; P=.48; total beverage 65 kcal, SEM 49; P=.19). Overall mean scores between the PP and both IMM versions of the L-Cat were different (both P<.001); however, responses on all versions were correlated (P<.001). Differences between education categories were noted at each L-Cat administration (IMM-1: P=.008; IMM-2: P=.001; PP: P=.002). Major and minor themes from user feedback suggest that the IMM questionnaires were easy to complete, and relevant to participants' typical beverage choices and physical activity habits.
Conclusions
In general, less educated participants consumed more total beverage and SSB energy, and reported less engagement in physical activity. The IMM BEVQ-15 appears to be a valid and reliable measure to assess habitual beverage intake, although software familiarization may increase response accuracy. The IMM-L-Cat can be considered reliable and may have permitted respondents to more freely disclose actual physical activity levels versus the paper-administered tool. Future larger-scale investigations are warranted to confirm these possibilities.
doi:10.2196/resprot.2830
PMCID: PMC3806551  PMID: 24148226
validity and reliability; multimedia; dietary assessment; beverages; physical activity
6.  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.
doi:10.2196/jmir.2745
PMCID: PMC3806547  PMID: 24095951
physical activity; mobile technology; review; generalizability
7.  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.
doi:10.4236/ojpm.2013.31007
PMCID: PMC3755775  PMID: 23997992
beverages; health literacy; health education; public health; health behavior; pilot projects
8.  Exploring the Theory of Planned Behavior to Explain Sugar-Sweetened Beverage Consumption 
Objective
To describe sugar-sweetened beverage (SSB) consumption, establish psychometric properties and utility of a Theory of Planned Behavior (TPB) instrument for SSB consumption.
Methods
This cross-sectional survey included 119 southwest Virginia participants. Respondents were majority female (66%), white (89%), ≤ high school education (79%), and averaged 41.4 (±13.5) years. A validated beverage questionnaire was used to measure SSB. Eleven TPB constructs were assessed with a 56-item instrument. Analyses included descriptive statistics, one-way ANOVAs, Cronbach alphas, and multiple regressions.
Results
Sugar-sweetened beverage intake averaged 457 (±430) kilocalories/day. The TPB model provided a moderate explanation of SSB intake (R2=0.38; F=13.10, P<0.01). Behavioral intentions had the strongest relationships with SSB consumption, followed by attitudes, perceived behavioral control, and subjective norms. The six belief constructs did not predict significant variance in the models.
Conclusions and Implications
Future efforts to comprehensively develop and implement interventions guided by the TPB hold promise for reducing SSB intake.
doi:10.1016/j.jneb.2011.06.010
PMCID: PMC3290682  PMID: 22154130
beverages; health behavior; psychometrics
9.  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.
doi:10.5888/pcd10.120296
PMCID: PMC3684353  PMID: 23764345
10.  Several steps/day indicators predict changes in anthropometric outcomes: HUB City Steps 
BMC Public Health  2012;12:983.
Background
Walking for exercise remains the most frequently reported leisure-time activity, likely because it is simple, inexpensive, and easily incorporated into most people’s lifestyle. Pedometers are simple, convenient, and economical tools that can be used to quantify step-determined physical activity. Few studies have attempted to define the direct relationship between dynamic changes in pedometer-determined steps/day and changes in anthropometric and clinical outcomes. Hence, the objective of this secondary analysis was to evaluate the utility of several descriptive indicators of pedometer-determined steps/day for predicting changes in anthropometric and clinical outcomes using data from a community-based walking intervention, HUB City Steps, conducted in a southern, African American population. A secondary aim was to evaluate whether treating steps/day data for implausible values affected the ability of these data to predict intervention-induced changes in clinical and anthropometric outcomes.
Methods
The data used in this secondary analysis were collected in 2010 from 269 participants in a six-month walking intervention targeting a reduction in blood pressure. Throughout the intervention, participants submitted weekly steps/day diaries based on pedometer self-monitoring. Changes (six-month minus baseline) in anthropometric (body mass index, waist circumference, percent body fat [%BF], fat mass) and clinical (blood pressure, lipids, glucose) outcomes were evaluated. Associations between steps/day indicators and changes in anthropometric and clinical outcomes were assessed using bivariate tests and multivariable linear regression analysis which controlled for demographic and baseline covariates.
Results
Significant negative bivariate associations were observed between steps/day indicators and the majority of anthropometric and clinical outcome changes (r = -0.3 to -0.2: P < 0.05). After controlling for covariates in the regression analysis, only the relationships between steps/day indicators and changes in anthropometric (not clinical) outcomes remained significant. For example, a 1,000 steps/day increase in intervention mean steps/day resulted in a 0.1% decrease in %BF. Results for the three pedometer datasets (full, truncated, and excluded) were similar and yielded few meaningful differences in interpretation of the findings.
Conclusions
Several descriptive indicators of steps/day may be useful for predicting anthropometric outcome changes. Further, manipulating steps/day data to address implausible values has little overall effect on the ability to predict these anthropometric changes.
doi:10.1186/1471-2458-12-983
PMCID: PMC3551779  PMID: 23153060
Pedometer; Steps/day; Anthropometric measures; African American
11.  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.
doi:10.1186/1479-5868-9-105
PMCID: PMC3490978  PMID: 22954386
Built environment; Health disparities; Community-based participatory research; Spatial autocorrelation
12.  Health Literacy is associated with Healthy Eating Index Scores and Sugar-Sweetened Beverage Intake: Findings from the Rural Lower Mississippi Delta 
Background
Although health literacy has been a public health priority area for over a decade, the relationship between health literacy and dietary quality has not been thoroughly explored.
Objective
To evaluate health literacy skills in relation to Healthy Eating Index scores (HEI) and Sugar-Sweetened Beverage (SSB) consumption, while accounting for demographic variables.
Design
Cross-sectional survey.
Participants/setting
A community-based proportional sample of adults residing in the rural Lower Mississippi Delta.
Methods
Instruments included a validated 158-item regional food frequency questionnaire and the Newest Vital Sign (scores range 0–6) to assess health literacy.
Statistical analyses performed
Descriptive statistics, ANOVA, and multivariate linear regression.
Results
Of 376 participants, the majority were African American (67.6%), without a college degree (71.5%), and household income level <$20,000/year (55.0%). Most participants (73.9%) scored in the two lowest health literacy categories. The multivariate linear regression model to predict total HEI scores was significant (R2=0.24; F=18.8; p<0.01), such that every 1 point increase in health literacy was associated with a 1.21 point increase in healthy eating index scores, while controlling for all other variables. Other significant predictors of HEI scores included age, gender, and SNAP participation. Health literacy also significantly predicted sugar-sweetened beverages consumption (R2=0.15; F=6.3; p<0.01), while accounting for demographic variables. Every 1 point in health literacy scores was associated with 34 fewer SSB kilocalories/day. Age was the only significant covariate in the SSB model.
Conclusion
While health literacy has been linked to numerous poor health outcomes, to our knowledge this is the first investigation to establish a relationship between health literacy and HEI scores and SSB consumption. Our study suggests that understanding the causes and consequences of limited health literacy is an important factor in promoting compliance to the Dietary Guidelines for Americans.
doi:10.1016/j.jada.2011.04.010
PMCID: PMC3160591  PMID: 21703379
Health literacy; diet quality; beverages; health disparities
13.  Overweight in Childhood 
Background
Some low-income minority children in the U.S. remain at normal weight throughout their childhood despite high risk of obesity.
Purpose
This study examined whether resilient caregiving accounted for children’s healthy weight maintenance and dietary compliance over a 4-year period among poverty-stricken African-American families.
Methods
A representative sample of 317 African-American caregiver–children (aged 3–5 years) pairs from low-income areas of Detroit, Michigan was examined in 2002–2003 with a follow-up assessment in 2007. Capacity for resilience among caregivers was defined using 5 individual and environmental protective factors. A BMI score for the children was computed from recorded height and weight, and converted into one of three categories (normal weight, overweight, obese) using age- and gender-specific national references. Dietary information was collected using the Block Food Frequency Questionnaire (FFQ) and Block Kids FFQ. Data were analyzed in 2010 to test whether children’s weight transition and dietary compliance varied according to their caregivers’ capacity for resilience.
Results
In all, 95 caregivers (29%) were identified as having capacity for resilience. They were younger, had higher levels of educational attainment, and had lower levels of daily soda consumption. The children of these caregivers had a lower likelihood of remaining overweight or obese than being of normal weight (Relative Risk Ratio = 0.5, 95% CI = 0.2, 0.9), and had persistently lower soda consumption over 4 years compared with other children.
Conclusions
This finding demonstrates that some caregivers positively influence children’s health weight management and dietary compliance despite material deprivation. Interventions to initiate and promote resilient caregiving could benefit the health and health-related behaviors of low-income African-American children.
doi:10.1016/j.amepre.2010.11.006
PMCID: PMC3056409  PMID: 21335265
14.  Environmental perceptions and objective walking trail audits inform a community-based participatory research walking intervention 
Background
Given the documented physical activity disparities that exist among low-income minority communities and the increased focused on socio-ecological approaches to address physical inactivity, efforts aimed at understanding the built environment to support physical activity are needed. This community-based participatory research (CBPR) project investigates walking trails perceptions in a high minority southern community and objectively examines walking trails. The primary aim is to explore if perceived and objective audit variables predict meeting recommendations for walking and physical activity, MET/minutes/week of physical activity, and frequency of trail use.
Methods
A proportional sampling plan was used to survey community residents in this cross-sectional study. Previously validated instruments were pilot tested and appropriately adapted and included the short version of the validated International Physical Activity Questionnaire, trail use, and perceptions of walking trails. Walking trails were assessed using the valid and reliable Path Environmental Audit Tool which assesses four content areas including: design features, amenities, maintenance, and pedestrian safety from traffic. Analyses included Chi-square, one-way ANOVA's, multiple linear regression, and multiple logistic models.
Results
Numerous (n = 21) high quality walking trails were available. Across trails, there were very few indicators of incivilities and safety features rated relatively high. Among the 372 respondents, trail use significantly predicted meeting recommendations for walking and physical activity, and MET/minutes/week. While controlling for other variables, significant predictors of trail use included proximity to trails, as well as perceptions of walking trail safety, trail amenities, and neighborhood pedestrian safety. Furthermore, while controlling for education, gender, and income; for every one time per week increase in using walking trails, the odds for meeting walking recommendations increased 1.27 times, and the odds for meeting PA recommendation increased 3.54 times. Perceived and objective audit variables did not predict meeting physical activity recommendations.
Conclusions
To improve physical activity levels, intervention efforts are needed to maximize the use of existing trails, as well as improve residents' perceptions related to incivilities, safety, conditions of trail, and amenities of the walking trails. This study provides important insights for informing development of the CBPR walking intervention and informing local recreational and environmental policies in this southern community.
doi:10.1186/1479-5868-9-6
PMCID: PMC3283478  PMID: 22289653
15.  Simulated reductions in consumption of sugar-sweetened beverages improves diet quality in Lower Mississippi Delta adults 
Food & Nutrition Research  2011;55:10.3402/fnr.v55i0.7304.
Background
Although the effects of replacing sugar-sweetened beverages (SSBs) with water on energy intake and body weight have been reported, little is known about how these replacements affect diet quality.
Objective
To simulate the effects of replacing SSBs with tap water on diet quality and total energy intake of Lower Mississippi Delta (LMD) adults.
Design
Retrospective analysis of cross-sectional dietary intake data using a representative sample of LMD adults (n=1,689). Diet quality was measured using the Healthy Eating Index-2005 (HEI-2005) scores that were computed using the population ratio method. The effects of substituting SSBs with water on diet quality were simulated by replacing the targeted items’ nutrient profile with tap water's profile.
Results
Simulating the replacement of SSBs with tap water at 25, 50, and 100% levels resulted in 1-, 2.3-, and 3.8-point increases, respectively, in the HEI-2005 total score. Based on a mean daily intake of 2,011 kcal, 100% substitution of SSBs with tap water would result in 11% reduction in energy intake.
Conclusions
Replacing SSBs with water could substantially improve the diet quality of the LMD adult population and potentially lead to significant weight loss overtime. Prioritizing intervention efforts to focus on the replacement of SSBs with energy-free drinks may be the most efficacious approach for conveying potentially substantial health benefits in this and similar disadvantaged populations.
doi:10.3402/fnr.v55i0.7304
PMCID: PMC3198507  PMID: 22022303
added sugars; water; total energy intake; Southeastern United States
16.  Who participates in internet-based worksite weight loss programs? 
BMC Public Health  2011;11:709.
Background
The reach and representativeness are seldom examined in worksite weight loss studies. This paper describes and illustrates a method for directly assessing the reach and representativeness of a internet-based worksite weight loss program.
Methods
A brief health survey (BHS) was administered, between January 2008 and November 2009, to employees at 19 worksites in Southwest Virginia. The BHS included demographic, behavioral, and health questions. All employees were blinded to the existence of a future weight loss program until the completion of the BHS.
Results
The BHS has a participation rate of 66 percent and the subsequent weight loss program has a participation rate of 30 percent. Employees from higher income households, with higher education levels and health literacy proficiency were significantly more likely to participate in the program (p's < .01).
Conclusions
Worksite weight loss programs should include targeted marketing strategies to engage employees with lower income, education, and health literacy.
doi:10.1186/1471-2458-11-709
PMCID: PMC3190353  PMID: 21933429
17.  H.U.B city steps: methods and early findings from a community-based participatory research trial to reduce blood pressure among african americans 
Background
Community-based participatory research (CBPR) has been recognized as an important approach to develop and execute health interventions among marginalized populations, and a key strategy to translate research into practice to help reduce health disparities. Despite growing interest in the CBPR approach, CBPR initiatives rarely use experimental or other rigorous research designs to evaluate health outcomes. This behavioral study describes the conceptual frameworks, methods, and early findings related to the reach, adoption, implementation, and effectiveness on primary blood pressure outcomes.
Methods
The CBPR, social support, and motivational interviewing frameworks are applied to test treatment effects of a two-phased CBPR walking intervention, including a 6-month active intervention quasi experimental phase and 12-month maintenance randomized controlled trial phase to test dose effects of motivational interviewing. A community advisory board helped develop and execute the culturally-appropriate intervention components which included social support walking groups led by peer coaches, pedometer diary self-monitoring, monthly diet and physical activity education sessions, and individualized motivational interviewing sessions. Although the study is on-going, three month data is available and reported. Analyses include descriptive statistics and paired t tests.
Results
Of 269 enrolled participants, most were African American (94%) females (85%) with a mean age of 43.8 (SD = 12.1) years. Across the 3 months, 90% of all possible pedometer diaries were submitted. Attendance at the monthly education sessions was approximately 33%. At the 3-month follow-up 227 (84%) participants were retained. From baseline to 3-months, systolic BP [126.0 (SD = 19.1) to 120.3 (SD = 17.9) mmHg; p < 0.001] and diastolic BP [83. 2 (SD = 12.3) to 80.2 (SD = 11.6) mmHg; p < 0.001] were significantly reduced.
Conclusions
This CBPR study highlights implementation factors and signifies the community's active participation in the development and execution of this study. Reach and representativeness of enrolled participants are discussed. Adherence to pedometer diary self-monitoring was better than education session participation. Significant decreases in the primary blood pressure outcomes demonstrate early effectiveness. Importantly, future analyses will evaluate long-term effectiveness of this CBPR behavioral intervention on health outcomes, and help inform the translational capabilities of CBPR efforts.
doi:10.1186/1479-5868-8-59
PMCID: PMC3127969  PMID: 21663652
18.  Nutrition Literacy Status and Preferred Nutrition Communication Channels Among Adults in the Lower Mississippi Delta 
Preventing Chronic Disease  2009;6(4):A128.
Introduction
The objective of this cross-sectional study was to examine the nutrition literacy status of adults in the Lower Mississippi Delta.
Methods
Survey instruments included the Newest Vital Sign and an adapted version of the Health Information National Trends Survey. A proportional quota sampling plan was used to represent educational achievement of residents in the Delta region. Participants included 177 adults, primarily African Americans (81%). Descriptive statistics, χ2 analysis, analysis of variance, and multivariate analysis of covariance tests were used to examine survey data.
Results
Results indicated that 24% of participants had a high likelihood of limited nutrition literacy, 28% had a possibility of limited nutrition literacy, and 48% had adequate nutrition literacy. Controlling for income and education level, the multivariate analysis of covariance models revealed that nutrition literacy was significantly associated with media use for general purposes (F = 2.79, P = .005), media use for nutrition information (F = 2.30, P = .04), and level of trust from nutrition sources (F = 2.29, P = .005). Overall, the Internet was the least trusted and least used source for nutrition information. Only 12% of participants correctly identified the 2005 MyPyramid graphic, and the majority (78%) rated their dietary knowledge as poor or fair.
Conclusion
Compared with other national surveys, rates of limited health literacy among Delta adults were high. Nutrition literacy status has implications for how people seek nutrition information and how much they trust it. Understanding the causes and consequences of limited nutrition literacy may be a step toward reducing the burden of nutrition-related chronic diseases among disadvantaged rural communities.
PMCID: PMC2774642  PMID: 19755004

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