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1.  Children's Objective Physical Activity by Location: Why the Neighborhood Matters 
Pediatric exercise science  2013;25(3):468-486.
Knowledge of where children are active may lead to more informed policies about how and where to intervene and improve physical activity. This study examined where children aged 6–11 were physically active using time-stamped accelerometer data and parent-reported place logs and assessed the association of physical-activity location variation with demographic factors. Children spent most time and did most physical activity at home and school. Although neighborhood time was limited, this time was more proportionally active than time in other locations (e.g., active 42.1% of time in neighborhood vs. 18.1% of time at home). Children with any neighborhood-based physical activity had higher average total physical activity. Policies and environments that encourage children to spend time outdoors in their neighborhoods could result in higher overall physical activity.
PMCID: PMC4074079  PMID: 23877357
Cancer causes & control : CCC  2013;24(4):695-704.
Recognition of the complex, multidimensional relationship between excess adiposity and cancer control outcomes has motivated the scientific community to seek new research models and paradigms.
The National Cancer Institute developed an innovative concept to establish a centers grant mechanism in nutrition, energetics, and physical activity; referred to as the Transdisciplinary Research on Energetics and Cancer (TREC) Initiative. This paper gives an overview of the 2011-2016 TREC Collaborative Network and the 15 research projects being conducted at the Centers.
Four academic institutions were awarded TREC center grants in 2011: Harvard University, University of California San Diego, University of Pennsylvania, and Washington University in St. Louis. The Fred Hutchinson Cancer Research Center is the Coordination Center. The TREC research portfolio includes 3 animal studies, 3 cohort studies, 4 randomized clinical trials, 1 cross-sectional study, and 2 modeling studies. Disciplines represented by TREC investigators include basic science, endocrinology, epidemiology, biostatistics, behavior, medicine, nutrition, physical activity, genetics, engineering, health economics, and computer science. Approximately 41,000 participants will be involved in these studies, including children, healthy adults, and breast and prostate cancer survivors. Outcomes include biomarkers of cancer risk, changes in weight and physical activity, persistent adverse treatment effects (e.g., lymphedema, urinary and sexual function), and breast and prostate cancer mortality.
The NIH Science of Team Science group will evaluate the value-added by this collaborative science. However, the most important outcome will be whether this transdisciplinary initiative improves the health of Americans at risk for cancer as well as cancer survivors.
PMCID: PMC3602225  PMID: 23378138
energetics; obesity; diet; physical activity; cancer; transdisciplinary
3.  Melanoma Genetic Testing, Counseling, and Adherence to Skin Cancer Prevention and Detection Behaviors 
Little is known about the impact of knowledge of CDKN2A and MC1R genotype on melanoma prevention behaviors like sun avoidance and skin examination in the context of familial melanoma.
73 adults with a family history of melanoma were randomly assigned to be offered individualized CDKN2A and MC1R genotyping results in the context of a genetic counseling session, or the standard practice of not being offered counseling or disclosure of genotyping results. Mixed effects or longitudinal logistic models were used to determine whether the intervention affected change in sun protection habits, skin examinations and perception and beliefs related to melanoma risk, prevention, and genetic counseling.
All participants in the intervention group who attended genetic counseling sessions chose to receive their test results. From baseline to follow-up, participants in the intervention group reported an increase in the frequency of skin self-examinations compared to a slight decrease in the control group (p=0.002). Participants in the intervention group reported a smaller decrease in frequency of wearing a shirt with long sleeves than did participants in the control group (p =0.047). No effect of the intervention was noted for other outcomes.
Feedback of CDKN2A and MC1R genotype among families without known pathogenic CDKN2A mutations does not appear to decrease sun protection behaviors.
While disclosure of CDKN2A and MC1R genotype did not have negative effects on prevention, the benefits of communicating this information remain unclear. The small number of families who tested positive for CDKN2A mutations in this study is a limitation.
PMCID: PMC3617083  PMID: 23392000
skin cancer; genetic testing; sun exposure; sun protection; surveys
4.  Attitudes and barriers towards participation in an acupuncture trial among breast cancer patients: a survey study 
As breast cancer patients increasingly use complementary and alternative medicine (CAM), clinical trials are needed to guide appropriate clinical use. We sought to identify socio-demographic, clinical and psychological factors related to willingness to participate (WTP) and to determine barriers to participation in an acupuncture clinical trial among breast cancer patients.
We conducted a cross-sectional survey study among post-menopausal women with stage I-III breast cancer on aromatase inhibitors at an urban academic cancer center.
Of the 300 participants (92% response rate), 148 (49.8%) reported WTP in an acupuncture clinical trial. Higher education (p = 0.001), increased acupuncture expectancy (p < 0.001), and previous radiation therapy (p = 0.004) were significantly associated with WTP. Travel difficulty (p = 0.002), concern with experimentation (p = 0.013), and lack of interest in acupuncture (p < 0.001) were significant barriers to WTP. Barriers differed significantly by socio-demographic factors with white people more likely to endorse travel difficulty (p = 0.018) and non-white people more likely to report concern with experimentation (p = 0.024). Older patients and those with lower education were more likely to report concern with experimentation and lack of interest in acupuncture (p < 0.05).
Although nearly half of the respondents reported WTP, significant barriers to participation exist and differ among subgroups. Research addressing these barriers is needed to ensure effective accrual and improve the representation of individuals from diverse backgrounds.
PMCID: PMC3893614  PMID: 24400734
Acupuncture; Breast neoplasm; Clinical trial; Aromatase inhibitors/*adverse effects; Musculoskeletal; Joint pain; Attitudes; Barriers
5.  Objective and Self-Reported Factors Associated With Food-Environment Perceptions and Fruit-And-Vegetable Consumption: A Multilevel Analysis 
Few studies have assessed how people’s perceptions of their neighborhood environment compare with objective measures or how self-reported and objective neighborhood measures relate to consumption of fruits and vegetables.
A telephone survey of 4,399 residents of Philadelphia, Pennsylvania, provided data on individuals, their households, their neighborhoods (self-defined), their food-environment perceptions, and their fruit-and-vegetable consumption. Other data on neighborhoods (census tracts) or “extended neighborhoods” (census tracts plus 1-quarter–mile buffers) came from the US Census Bureau, the Philadelphia Police Department, the Southeastern Pennsylvania Transportation Authority, and the federal Supplemental Nutrition Assistance Program. Mixed-effects multilevel logistic regression models examined associations between food-environment perceptions, fruit-and-vegetable consumption, and individual, household, and neighborhood characteristics.
Perceptions of neighborhood food environments (supermarket accessibility, produce availability, and grocery quality) were strongly associated with each other but not consistently or significantly associated with objective neighborhood measures or self-reported fruit-and-vegetable consumption. We found racial and educational disparities in fruit-and-vegetable consumption, even after adjusting for food-environment perceptions and individual, household, and neighborhood characteristics. Having a supermarket in the extended neighborhood was associated with better perceived supermarket access (adjusted odds ratio for having a conventional supermarket, 2.04 [95% CI, 1.68–2.46]; adjusted odds ratio for having a limited-assortment supermarket, 1.28 [95% CI, 1.02–1.59]) but not increased fruit-and-vegetable consumption. Models showed some counterintuitive associations with neighborhood crime and public transportation.
We found limited association between objective and self-reported neighborhood measures. Sociodemographic differences in individual fruit-and-vegetable consumption were evident regardless of neighborhood environment. Adding supermarkets to urban neighborhoods might improve residents’ perceptions of supermarket accessibility but might not increase their fruit-and-vegetable consumption.
PMCID: PMC3970773  PMID: 24674635
6.  Nutrition-Labeling Regulation Impacts on Restaurant Environments 
Recent attempts to improve the healthfulness of away-from-home eating include regulations requiring restaurants to post nutrition information. The impact of such regulations on restaurant environments is unknown.
To examine changes in restaurant environments from before to after nutrition-labeling regulation in a newly regulated county versus a nonregulated county.
Using the Nutrition Environment Measures Surveys–Restaurant version audit, environments within the same quick-service chain restaurants were evaluated in King County (regulated) before and 6 and 18 months after regulation enforcement and in Multnomah County (nonregulated) restaurants over a 6-month period. Data were collected in 2008–2010 and analyses conducted in 2011.
Overall availability of healthy options and facilitation of healthy eating did not differentially increase in King County versus Multnomah County restaurants aside from the substantial increase in onsite nutrition information posting in King County restaurants required by the new regulation. Barriers to healthful eating decreased in King County relative to Multnomah County restaurants, particularly in food-oriented establishments. King County restaurants demonstrated modest increases in signage that promotes healthy eating, although the frequency of such promotion remained low, and the availability of reduced portions decreased in these restaurants. The healthfulness of children’s menus improved modestly over time, but not differentially by county.
A restaurant nutrition-labeling regulation was accompanied by some, but not uniform, improvements in other aspects of restaurant environments in the regulated compared to the nonregulated county. Additional opportunities exist for improving the healthfulness of awayfrom- home eating beyond menu labeling.
PMCID: PMC3479434  PMID: 23079173
7.  Impact of a Health Communication Intervention to Improve Glaucoma Treatment Adherence: Results of the I-SIGHT Trial 
Archives of ophthalmology  2012;130(10):1252-1258.
To determine the efficacy of an automated, interactive, telephone-based health communication intervention for improving glaucoma treatment adherence among patients in two hospital-based eye clinics.
Randomized controlled trial.
Two eye clinics located in hospitals in the Southeastern United States.
312 glaucoma patients aged 18 to 80 years, non-adherent with medication taking, medication refills, and/or appointment keeping
The treatment group received an automated, interactive, tailored telephone intervention and tailored printed materials. The control group received usual care.
Main Outcome Measures
Adherence with medication taking, prescription refills, and appointment keeping measured by interviews, medical charts, appointment records, and pharmacy data.
A statistically significant increase was found for all adherence measures in both the intervention and control groups. Interactive phone calls and tailored print materials did not significantly improve adherence measures compared to controls.
During the study period, patient adherence to glaucoma treatment and appointment keeping improved in both study arms. Participation in the study and interviews may have contributed. Strategies that address individuals’ barriers and facilitators may increase the impact of telephone calls, especially for appointment keeping and prescription refills.
PMCID: PMC3593648  PMID: 22688429
8.  Association Between Longer Therapy With Thiazolidinediones and Risk of Bladder Cancer: A Cohort Study 
The use of pioglitazone, a thiazolidinedione (TZD), may increase the risk of bladder cancer in patients with type 2 diabetes. In this study, we assessed the risk of bladder cancer associated with the use of TZDs and between pioglitazone and rosiglitazone, an alternative TZD.
We conducted a retrospective cohort study of patients with type 2 diabetes mellitus who initiated treatment with a TZD (n = 18 459 patients) or a sulfonylurea (SU) (n = 41 396 patients) between July 1, 2000, and August 31, 2010, using The Health Improvement Network database in the United Kingdom. Incident cancers were identified for 196 708 person-years of follow-up. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for risk of bladder cancer in the TZD cohort compared with the SU cohort (referent), adjusted for potential confounders. Risk associated with increasing duration of drug exposure was also examined. All statistical tests were two-sided.
We identified 60 incident bladder cancers in the TZD cohort and 137 cancers in the SU cohort. No difference in bladder cancer risk was found between the two cohorts (TZD vs SU, HR = 0.93, 95% CI = 0.68 to 1.29) in analyses that did not account for duration of exposure. However, the risk of bladder cancer was increased among patients with the longest duration of TZD vs SU therapy (≥5 years of use, HR = 3.25, 95% CI = 1.08 to 9.71) and among those with the longest time since initiation of therapy (≥5 years since first use, HR = 2.53, 95% CI = 1.12 to 5.77). Risk of bladder cancer also increased with increasing time since initiation of pioglitazone (P trend < .001) and rosiglitazone (P trend = .006). Comparison of pioglitazone to rosiglitazone use did not demonstrate difference in cancer risk (P = .49).
Long-term TZD therapy (≥5 years) in patients with type 2 diabetes may be associated with an increased risk of bladder cancer, which may be common to all TZDs.
PMCID: PMC3529598  PMID: 22878886
9.  Changes in sunburn and tanning attitudes among lifeguards over a summer season 
Skin cancer is one of the most common cancers in the United States. Lifeguards are at increased risk of excessive sun exposure and sunburn.
We sought to examine changes in: (1) sunburn frequency over a summer while controlling for sun exposure, sun protection habits, and participation in a skin cancer prevention program; and (2) tanning attitudes while controlling for participation in the program.
Participants in this study were lifeguards (n = 3014) at swimming pools participating in the Pool Cool program in 2005. Lifeguards completed surveys at the beginning and end of the summer. Sequential regression analyses were used to assess changes in sunburn frequency and tanning attitudes.
Sunburn frequency decreased between baseline and follow-up. Having a sunburn over the summer was significantly predicted by baseline sunburn history, ethnicity, skin cancer risk, and sun exposure. The tanning attitude, “People are more attractive if they have a tan,” was significantly predicted from baseline tanning attitude and ethnicity. The second tanning attitude, “It helps to have a good base suntan,” was significantly predicted by baseline tanning attitude, ethnicity, basic/enhanced group, and moderate skin cancer risk.
Self-reported data and limited generalizability to lifeguards at other outdoor pools are limitations.
The findings showed that previous sunburn history is an important predictor of sunburn prospectively. In addition, a more risky tanning attitude is an important predictor of future attitudes toward tanning. Active involvement in targeted prevention programs may help to increase preventive behavior and health risk reduction.
PMCID: PMC3728666  PMID: 21745696
prevention; skin cancer; sun exposure; sun protection habits; sunburn; tanning attitudes
10.  Measured Occupational Solar UVR Exposures of Lifeguards in Pool Settings 
The aim of this study was to measure ultraviolet radiation (UVR) exposures of lifeguards in pool settings and evaluate their personal UVR protective practices.
Lifeguards (n = 168) wore UVR sensitive polysulfone (PS) film badges in wrist bracelets on 2 days and completed a survey and diary covering sun protection use. Analyses were used to describe sun exposure and sun protection practices, to compare UVR exposure across locations, and to compare findings with recommended threshold limits for occupational exposure.
The measured UVR exposures varied with location, ranging from high median UVR exposures of 6.2 standard erythemal doses (SEDs) to the lowest median of 1.7 SEDs. More than 74% of the lifeguards’ PS badges showed UVR above recommended threshold limits for occupational exposure. Thirty-nine percent received more than four times the limit and 65% of cases were sufficient to induce sunburn. The most common protective behaviors were wearing sunglasses and using sunscreen, but sun protection was often inadequate.
At-risk individuals were exposed to high levels of UVR in excess of occupational limits and though appropriate types of sun protection were used, it was not used consistently and more than 50% of lifeguards reported being sunburnt at least twice during the previous year.
PMCID: PMC3728671  PMID: 19572325
lifeguards; occupational UVR exposure; sun protection behaviors
11.  A Controlled Trial of Objective Measures of Sunscreen and Moisturizing Lotion 
Taking an alcohol swab of a person’s forearm and analyzing it using a spectrophotometer has been shown to be a reliable method for detecting the presence of sunscreen. The aims of this study were to determine if moisturizing lotions or other non-sun-screen products influence the absorbance readings from skin swabs in a controlled setting, and to establish the cutoff point in determining the presence or absence of sunscreen using a crystal cuvette instead of a plastic one. In a controlled trial of 30 volunteer office workers, absorbance readings from two popular brands of sunscreen with sun-protection factors (SPF) of 30 and 45 were compared with absorbance readings from two different moisturizing lotions, one with an SPF of 15 and another with no stated SPF. Moisturizers with SPF 15 tested positive for sunscreen, with absorbance readings (mean, 3.77; min, 3.30) comparable to sunblock with SPF 30 or 45 (mean, 3.51; min, 2.02). Moisturizers with no stated SPF factor tested negative for the presence of sunscreen, with extremely low absorbance readings (mean, 0.06; max, 0.19) similar to control readings. The skin swabbing technique remains a valid and useful method for detecting the presence of sunscreen and does not result in false positives when moisturizers with no stated SPF are present. Using a conservative cutoff point of 0.30 with a crystal cuvette reduces any chance of false-positive readings and remains robust when sunscreen of SPF 15 or higher is present.
PMCID: PMC3725572  PMID: 19423519
12.  Linking Agents’ Activities and Communication Patterns in a Study of the Dissemination of an Effective Skin Cancer Prevention Program 
Linking agents connect program developers with end users, enhancing implementation and sustainability of health promotion programs. However, little is known about how linkage systems work in practice and research settings.
This article describes the activities and communication patterns of field coordinators in a 4-year, national study of the dissemination of an effective skin cancer prevention program.
Descriptive and content analyses were completed for all e-mails between field coordinators and program staff and for field coordinator activity logs.
A total of 5 215 e-mails were sent to or from 62 field coordinators from 2003 to 2006. E-mails most often concerned program administration, data collection, and management of program materials. The most common activities recorded in activity logs were communication with program staff and study sites, management of surveys, and delivery and management of program materials.
Field coordinators carried out activities related to program administration and data collection across a large number of study sites. The high volume of e-mails and their emphasis on program administration issues demonstrate the importance of communication between program staff and field coordinators. It is recommended that public health researchers and practitioners implement similar linkage systems when taking effective programs to scale.
PMCID: PMC3725579  PMID: 19704309
diffusion of innovation; public health; qualitative research
13.  A Pilot Study of the Validity of Self-reported Ultraviolet Radiation Exposure and Sun Protection Practices Among Lifeguards, Parents and Children 
Photochemistry and photobiology  2008;84(3):774-778.
Outdoor recreation settings, such as swimming pools, provide a promising venue to assess UVR exposure and sun protection practices among individuals who are minimally clothed and exposed to potentially high levels of UVR. Most studies assessing sun exposure/protection practices rely on self-reported data, which are subject to bias. The aim of this study was to establish the feasibility of conducting a multimethod study to examine the validity of self-reported measures within a swimming pool setting. Data were collected from 27 lifeguards, children and parents in Hawaii. Each participant filled out a survey and a 4 day sun habits diary. On two occasions, researchers assessed observable sun protection behaviors (wearing hats, shirts, sunglasses), swabbed the skin to detect the presence of sunscreen, and subjects wore polysulphone dosimeters to measure UVR exposure. Overall, observed sun protection behaviors were more highly correlated with diary reports than with survey reports. While lifeguards and children reported spending comparable amounts of time in the sun, dosimeter measures showed that lifeguards received twice as much UVR exposure. This study demonstrated the feasibility of implementing a multimethod validity study within a broader population of swimming pools.
PMCID: PMC3725580  PMID: 18179624
14.  Tobacco Use among Native Hawaiian Middle School Students: Its Prevalence, Correlates and Implications 
Ethnicity & health  2007;12(3):227-244.
This study sought to explore whether Native Hawaiian primary ethnic identity is associated with cigarette use among Native Hawaiian middle school students. This study also explored whether social influence, psychosocial and cultural factors are associated with cigarette use in this sample.
The data are from a cross-sectional survey of 1,695 Native Hawaiian middle school students at 22 public and private schools on five islands in Hawaii. A subset of these students from Native Hawaiian serving schools (N = 136) completed additional measures of Hawaiian cultural variables.
Based on univariate analyses, students whose primary ethnic identification was Hawaiian were more likely to have tried smoking (p<0.001) and to be current smokers (p<0.05) as compared to those classified as part Hawaiian. However, these findings were no longer significant in multivariate analyses. Social influence variables (i.e. peer and parental smoking) were most influential in explaining both prior and current smoking. Attendance at public school was also an important factor in explaining previous (OR = 2.43; 95% CI = 1.74, 3.38) and current (OR = 7.20; 95% CI = 4.58, 11.32) smoking behavior. Finally, cultural variables such as valuing Hawaiian folklore, customs, activities and lifestyle were largely unassociated with smoking behavior among Native Hawaiian middle school youth.
Additional research is needed to understand what aspects of ethnic identity are associated with smoking behavior among Native Hawaiian youth. The strong influence of peer and parental smoking suggests the need for interventions that support the creation of social environments that discourage tobacco use.
PMCID: PMC3724355  PMID: 17454098
Tobacco; Adolescents; Native Hawaiian; Smoking
15.  Characteristics of swimming pools with high rates of objectively measured sunscreen use 
A combination of verbal reports, observations, and physical assessments can improve understanding of prevention programs.
Skin swabbing techniques were used to detect the presence of sunscreen as part of a sun protection measurement study at 16 swimming pools. Three pools demonstrated much higher sunscreen use (>95%) than the others (47.1%). This paper compares these three pools to the other 13 to examine whether they have common features and if different sources of data can help interpret the findings.
Data were collected from skin swabs detecting the presence of sunscreen; observations of participants; observations of pool environments; and surveys.
Pool observations showed a higher use of shade structures, sun safety signs, and other supporting items at the three high–sunscreen use pools. These three pools had significantly more year-round and long-term employees than did the other 13 pools.
Sunscreen characteristics could not be determined using the swabbing technique. Publicity about the study, or the weather, may have influenced behaviors at the pools.
Supportive environments were associated with consistent high levels of sunscreen use. This study also confirms the importance of using multiple data sources to interpret findings.
PMCID: PMC3724408  PMID: 19293015
16.  Developer and Realtor Perspectives on Factors That Influence Development, Sale, and Perceived Demand for Activity-Friendly Communities 
Although public support for physical activity-friendly Traditional Neighborhood Developments (TNDs) appears to be growing, information is lacking on private sector perspectives and how economic factors (eg, fuel prices) might influence the development and sale of TNDs.
A sample of realtors from the National Association of Realtors (n = 4950) and developers from the National Association of Home Builders (n = 162) were surveyed in early 2009 to assess factors influencing homebuyers’ decisions; incentives and barriers to developing TNDs; effects of depressed housing market conditions and financing on sales; trends in buying; and energy considerations (eg, green building).
Realtors believed that homebuyers continue to rank affordability, safety and school quality higher than TND amenities. Developers reported numerous barriers to TNDs, including the inability to overcome governmental/political hurdles, lack of cooperation between government agencies, and lack of market demand. Yet, realtors believed clients are increasingly influenced by gas and oil prices, and developers reported that clients are looking for energy efficient homes, reduced commute time, and walkable neighborhoods. Respondents reported consumers are more interested in living in a TND than 5 years ago.
Activity-friendly TNDs appear to be increasing in demand, but developers and realtors reported significant barriers to creating these communities.
PMCID: PMC3718394  PMID: 20440012
physical activity; built environment; survey research; health; motivation; public health
17.  Factors Influencing Teachers’ Implementation of an Innovative Tobacco Prevention Curriculum for Multiethnic Youth: Project SPLASH 
The Journal of school health  2008;78(5):264-273.
The effectiveness of school-based tobacco use prevention programs depends on proper implementation. This study examined factors associated with teachers’ implementation of a smoking prevention curriculum in a cluster randomized trial called Project SPLASH (Smoking Prevention Launch Among Students in Hawaii).
A process evaluation was conducted and a cross-condition comparison used to examine whether teacher characteristics, teacher training, external facilitators and barriers, teacher attitudes, and curriculum attributes were associated with the dose of teacher implementation in the intervention and control arms of the study. Data were collected from a total of 62 middle school teachers in 20 public schools in Hawaii, during the 2000-2001 and 2001-2002 school years. Sources included teacher questionnaires and interviews. Chi-square test and t test revealed that implementation dose was related to teachers’ disciplinary backgrounds and skills and student enjoyment of the curriculum.
Content analysis, within case, and cross-case analyses of qualitative data revealed that implementing the curriculum in a yearlong class schedule and high teacher self-efficacy supported implementation, while high perceived curriculum complexity was associated with less complete implementation.
The results have implications for research, school health promotion practice, and the implementation of evidence-based youth tobacco use prevention curricula.
PMCID: PMC3715092  PMID: 18387026
smoking and tobacco; school health instruction; teaching techniques
18.  Validity of covering-up sun-protection habits: Association of observations and self-report 
Few studies have reported the accuracy of measures used to assess sun-protection practices. Valid measures are critical to the internal validity and use of skin cancer control research.
We sought to validate self-reported covering-up practices of pool-goers.
A total of 162 lifeguards and 201 parent/child pairs from 16 pools in 4 metropolitan regions in the United States completed a survey and a 4-day sun-habits diary. Observations of sun-protective behaviors were conducted on two occasions.
Agreement between observations and diaries ranged from slight to substantial, with most values in the fair to moderate range. Highest agreement was observed for parent hat use (κ = 0.58–0.70). There was no systematic pattern of over- or under-reporting among the 3 study groups.
Potential reactivity and a relatively affluent sample are limitations.
There was little over-reporting and no systematic bias, which increases confidence in reliance on verbal reports of these behaviors in surveys and intervention research.
PMCID: PMC3715114  PMID: 19278750
concurrent validity; measurement; observation; self-report assessment; sun protection
19.  Using mHealth Technology to Enhance Self-Monitoring for Weight Loss A Randomized Trial 
Self-monitoring for weight loss has traditionally been performed with paper diaries. Technologic advances could reduce the burden of self-monitoring and provide feedback to enhance adherence.
To determine if self-monitoring diet using a PDA only or the PDA with daily tailored feedback (PDA+FB), was superior to using a paper diary on weight loss and maintenance.
The Self-Monitoring and Recording Using Technology (SMART) Trial was a 24-month RCCT; participants were randomly assigned to one of three self-monitoring groups.
From 2006 to 2008, 210 overweight/obese adults (84.8% female, 78.1% white) were recruited from the community. Data were analyzed in 2011.
Participants received standard behavioral treatment for weight loss which included dietary and physical activity goals, encouraged the use of self-monitoring, and was delivered in group sessions.
Main outcome measures
Percentage weight change at 24 months, adherence to self-monitoring over time.
Study retention was 85.6%. The mean percentage weight loss at 24 months was not different among groups (paper diary: −1.94% [95% CI= −3.88, 0.01], PDA: −1.38% [95% CI= – 3.38, 0.62], PDA+FB: –2.32% [95% CI= –4.29, −0.35]); only the PDA+FB group (p=0.02) demonstrated a significant loss. For adherence to self-monitoring, there was a time-by-treatment group interaction between the combined PDA groups and the paper diary group (p=0.03) but no difference between PDA and PDA+FB groups (p=0.49). Across all groups, weight loss was greater for those who were adherent ≥60% versus <30% of the time, p<0.001.
PDA+FB use resulted in a small weight loss at 24 months; PDA use resulted in greater adherence to dietary self-monitoring over time. However, for sustained weight loss, adherence to self-monitoring is more important than the method used to self-monitor. A daily feedback message delivered remotely enhanced adherence and improved weight loss, which suggests that technology can play a role in improving weight loss.
PMCID: PMC3563396  PMID: 22704741
20.  Cancer Outcomes Research in a Rural Area: A Multi-Institution Partnership Model 
Journal of community health  2009;34(1):23-32.
Whereas, most cancer research data come from high-profile academic centers, little is known about the outcomes of cancer care in rural communities. We summarize the experience of building a multi-institution partnership to develop a cancer outcomes research infrastructure in Southwest Georgia (SWGA), a primarily rural 33-county area with over 700,000 residents. The partnership includes eight institutions: the Emory University in Atlanta, the Centers for Disease Control and Prevention (CDC), the Georgia Comprehensive Center Registry (the Registry), the Southwest Georgia Cancer Coalition (the Coalition), and the four community cancer centers located within the SWGA region. The practical application of the partnership model, its organizational structure, and lessons learned are presented using two specific examples: a study evaluating treatment decisions and quality of life among prostate cancer patients, and a study of treatment discontinuation among prostate, breast, lung, and colorectal cancer patients. Our partnership model allowed us to (1) use the Coalition as a link between Atlanta-based researchers and local community; (2) collaborate with the area cancer centers on day-to-day study activities; (3) involve the Registry personnel and resources to identify eligible cancer cases and to perform data collection; and (4) raise community awareness and sense of study ownership through media announcements organized by the Coalition. All of the above activities were performed in consultation with the funding institution (CDC) and its project directors who oversee several other studies addressing similar research questions throughout the country. Our partnership model may provide a useful framework for cancer outcomes research projects in rural communities.
PMCID: PMC3697054  PMID: 18850070
Cancer; Rural population; Outcomes research; Partnership
21.  Obesogenic Neighborhood Environments, Child and Parent Obesity 
Identifying neighborhood environment attributes related to childhood obesity can inform environmental changes for obesity prevention.
To evaluate child and parent weight status across neighborhoods in King County/Seattle and San Diego County differing in GIS-defined physical activity environment (PAE) and nutrition environment (NE) characteristics.
Neighborhoods were selected to represent high (favorable) versus low (unfavorable) on the two measures, forming four neighborhood types (low on both measures, low PAE/high NE, high PAE/low NE, and high on both measures). Weight and height of children aged 6–11 years and one parent (n=730) from selected neighborhoods were assessed in 2007–2009. Differences in child and parent overweight and obesity by neighborhood type were examined, adjusting for neighborhood-, family-, and individual-level demographics.
Children from neighborhoods high on both environment measures were less likely to be obese (7.7% vs 15.9% OR=0.44, p=0.02) and marginally less likely to be overweight (23.7% vs 31.7%; OR=0.67, p=0.08) than children from neighborhoods low on both measures. In models adjusted for parent weight status and demographic factors, neighborhood environment type remained related to child obesity (high vs low on both measures; OR=0.41, p<0.03). Parents in neighborhoods high on both measures (versus low on both) were marginally less likely to be obese (20.1% vs 27.7%; OR=0.66; p=0.08), although parent overweight did not differ on this variable. The lower odds of parent obesity in neighborhoods with environments supportive of physical activity and healthy eating remained in models adjusted for demographics (high vs low on the environment measures; OR=0.57, p=0.053).
Findings support the proposed GIS-based definitions of obesogenic neighborhoods for children and parents that consider both physical activity and nutrition environment features.
PMCID: PMC3332077  PMID: 22516504
22.  Implementation and Spread of Interventions Into the Multilevel Context of Routine Practice and Policy: Implications for the Cancer Care Continuum 
The promise of widespread implementation of efficacious interventions across the cancer continuum into routine practice and policy has yet to be realized. Multilevel influences, such as communities and families surrounding patients or health-care policies and organizations surrounding provider teams, may determine whether effective interventions are successfully implemented. Greater recognition of the importance of these influences in advancing (or hindering) the impact of single-level interventions has motivated the design and testing of multilevel interventions designed to address them. However, implementing research evidence from single- or multilevel interventions into sustainable routine practice and policy presents substantive challenges. Furthermore, relatively few multilevel interventions have been conducted along the cancer care continuum, and fewer still have been implemented, disseminated, or sustained in practice. The purpose of this chapter is, therefore, to illustrate and examine the concepts underlying the implementation and spread of multilevel interventions into routine practice and policy. We accomplish this goal by using a series of cancer and noncancer examples that have been successfully implemented and, in some cases, spread widely. Key concepts across these examples include the importance of phased implementation, recognizing the need for pilot testing, explicit engagement of key stakeholders within and between each intervention level; visible and consistent leadership and organizational support, including financial and human resources; better understanding of the policy context, fiscal climate, and incentives underlying implementation; explication of handoffs from researchers to accountable individuals within and across levels; ample integration of multilevel theories guiding implementation and evaluation; and strategies for long-term monitoring and sustainability.
PMCID: PMC3482959  PMID: 22623601
23.  Development, scoring, and reliability of the Microscale Audit of Pedestrian Streetscapes (MAPS) 
BMC Public Health  2013;13:403.
Streetscape (microscale) features of the built environment can influence people’s perceptions of their neighborhoods’ suitability for physical activity. Many microscale audit tools have been developed, but few have published systematic scoring methods. We present the development, scoring, and reliability of the Microscale Audit of Pedestrian Streetscapes (MAPS) tool and its theoretically-based subscales.
MAPS was based on prior instruments and was developed to assess details of streetscapes considered relevant for physical activity. MAPS sections (route, segments, crossings, and cul-de-sacs) were scored by two independent raters for reliability analyses. There were 290 route pairs, 516 segment pairs, 319 crossing pairs, and 53 cul-de-sac pairs in the reliability sample. Individual inter-rater item reliability analyses were computed using Kappa, intra-class correlation coefficient (ICC), and percent agreement. A conceptual framework for subscale creation was developed using theory, expert consensus, and policy relevance. Items were grouped into subscales, and subscales were analyzed for inter-rater reliability at tiered levels of aggregation.
There were 160 items included in the subscales (out of 201 items total). Of those included in the subscales, 80 items (50.0%) had good/excellent reliability, 41 items (25.6%) had moderate reliability, and 18 items (11.3%) had low reliability, with limited variability in the remaining 21 items (13.1%). Seventeen of the 20 route section subscales, valence (positive/negative) scores, and overall scores (85.0%) demonstrated good/excellent reliability and 3 demonstrated moderate reliability. Of the 16 segment subscales, valence scores, and overall scores, 12 (75.0%) demonstrated good/excellent reliability, three demonstrated moderate reliability, and one demonstrated poor reliability. Of the 8 crossing subscales, valence scores, and overall scores, 6 (75.0%) demonstrated good/excellent reliability, and 2 demonstrated moderate reliability. The cul-de-sac subscale demonstrated good/excellent reliability.
MAPS items and subscales predominantly demonstrated moderate to excellent reliability. The subscales and scoring system represent a theoretically based framework for using these complex microscale data and may be applicable to other similar instruments.
PMCID: PMC3728214  PMID: 23621947
24.  Results From an Intervention to Improve Rural Home Food and Physical Activity Environments 
Ecological models of healthy eating and physical activity emphasize the influence of behavioral settings such as homes and worksites in shaping behavior. Research on home environments suggests that both social and physical aspects of the home may impact physical activity and healthy eating.
Using a community-based participatory research (CBPR) approach, the Emory Prevention Research Center (EPRC), Cancer Coalition of South Georgia, and the EPRC’s Community Advisory Board (CAB) designed and tested a coach-based intervention to make the home environment more supportive of healthy eating and physical activity for rural adults.
The 6-week intervention consisted of a tailored home environment profile, goal-setting, and behavioral contracting delivered through two home visits and two telephone calls. The study used a quasi-experimental design with data collected via telephone interviews at baseline, 2 and 4 months post-baseline. Ninety households (n = 90) completed all three telephone interviews.
Multilevel models indicated that intervention households reported significant improvements in household food inventories, purchasing of fruit and vegetables, healthier meal preparation, meals with the TV off, and family support for healthy eating, relative to comparison households. Intervention households also reported increased exercise equipment and family support for physical activity relative to comparison households. Percent of fat intake decreased significantly, but no changes were observed for fruit and vegetable intake, physical activity, or weight among intervention relative to comparison households, although trends were generally in a positive direction.
Coaching combined with a focus on the home environment may be a promising strategy for weight gain prevention in adults.
PMCID: PMC3630069  PMID: 22982840
Rural; family; obesity prevention; physical activity; nutrition; intervention
25.  Children’s physical activity and parents’ perception of the neighborhood environment: neighborhood impact on kids study 
Physical activity is important to children’s physical health and well-being. Many factors contribute to children’s physical activity, and the built environment has garnered considerable interest recently, as many young children spend much of their time in and around their immediate neighborhood. Few studies have identified correlates of children’s activity in specific locations. This study examined associations between parent report of their home neighborhood environment and children’s overall and location-specific physical activity.
Parents and children ages 6 to 11 (n=724), living in neighborhoods identified through objective built environment factors as high or low in physical activity environments, were recruited from Seattle and San Diego metropolitan areas, 2007–2009. Parents completed a survey about their child’s activity and perceptions of home neighborhood environmental attributes. Children wore an accelerometer for 7 days. Multivariate regression models explored perceived environment correlates of parent-reported child’s recreational physical activity in their neighborhood, in parks, and in general, as well as accelerometry-based moderate-to-vigorous activity (MVPA) minutes.
Parent-reported proximity to play areas correlated positively with both accelerometery MVPA and parent-reported total child physical activity. Lower street connectivity and higher neighborhood aesthetics correlated with higher reported child activity in the neighborhood, while reported safety from crime and walk and cycle facilities correlated positively with reported child activity in public recreation spaces.
Different aspects of parent’s perceptions of the neighborhood environment appear to correlate with different aspects of children’s activity. However, prioritizing closer proximity to safe play areas may best improve children’s physical activity and, in turn, reduce their risk of obesity and associated chronic diseases.
PMCID: PMC3615958  PMID: 23531282
Built environment; Perceptions; Recreation; Play

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