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1.  Menu-Labeling Usage and Its Association with Diet and Exercise: 2011 BRFSS Sugar Sweetened Beverage and Menu Labeling Module 
Introduction
The primary objective of our study was to investigate the association between menu-labeling usage and healthy behaviors pertaining to diet (consumption of fruits, vegetables, sodas, and sugar-sweetened beverages) and exercise.
Methods
Data from the 2011 Behavioral Risk Factor Surveillance System, Sugar Sweetened Beverage and Menu-Labeling module, were used. Logistic regression was used to determine the association between menu-labeling usage and explanatory variables that included fruit, vegetable, soda, and sugar-sweetened beverage consumption as well as exercise.
Results
Nearly half (52%) of the sample indicated that they used menu labeling. People who used menu labeling were more likely to be female (odds ratio [OR], 2.29; 95% confidence interval [CI], 2.04–2.58), overweight (OR, 1.13; 95% CI, 1.00–1.29) or obese (OR, 1.29; 95% CI, 1.12–1.50), obtain adequate weekly aerobic exercise (OR, 1.18; 95% CI, 1.06–1.32), eat fruits (OR, 1.20; 95% CI, 1.12–1.29) and vegetables (OR, 1.12; 95% CI, 1.05–1.20), and drink less soda (OR, 0.76; 95% CI, 0.69–0.83).
Conclusion
Although obese and overweight people were more likely to use menu labeling, they were also adequately exercising, eating more fruits and vegetables, and drinking less soda. Menu labeling is intended to combat the obesity epidemic; however the results indicate an association between menu-labeling usage and certain healthy behaviors. Thus, efforts may be necessary to increase menu-labeling usage among people who are not partaking in such behaviors.
doi:10.5888/pcd11.130231
PMCID: PMC3879000  PMID: 24384303
2.  The Tennessee Department of Health WORKshops on Use of Secondary Data for Community Health Assessment, 2012 
Community health assessment is a core function of public health departments, a standard for accreditation of public health departments, and a core competency for public health professionals. The Tennessee Department of Health developed a statewide initiative to improve the processes for engaging county health departments in assessing their community’s health status through the collection and analysis of secondary data. One aim of the Tennessee Department of Health was to position county public health departments as trusted leaders in providing population data and engaging community stakeholders in assessments. The Tennessee Department of Health’s Division of Policy, Planning, and Assessment conducted regional 2-day training workshops to explain and guide completion of computer spreadsheets on 12 health topics. Participants from 93 counties extracted data from multiple and diverse sources to quantify county demographics, health status, and resources and wrote problem statements based on the data examined. The workshops included additional staff development through integration of short lessons on data analysis, epidemiology, and social-behavior theory. Participants reported in post-workshop surveys higher degrees of comfort in interpreting data and writing about their findings on county health issues, and they shared their findings with health, hospital, school, and government leaders (including county health council members) in their counties. Completion of the assessments enabled counties and the Tennessee Department of Health to address performance-improvement goals and assist counties in preparing to meet public health accreditation prerequisites. The methods developed for using secondary data for community health assessment are Tennessee’s first-phase response to counties’ request for a statewide structure for conducting such assessments.
doi:10.5888/pcd11.130206
PMCID: PMC3879001  PMID: 24384302
3.  Physical Activity Surveillance in Parks Using Direct Observation 
Introduction
Primary features of observational public health surveillance instruments are that they are valid, can reliably estimate physical activity behaviors, and are useful across diverse geographic settings and seasons by different users. Previous studies have reported the validity and reliability of Systematic Observation of Play and Recreation in Communities (SOPARC) to estimate park and user characteristics. The purpose of this investigation was to establish the use of SOPARC as a surveillance instrument and to situate the findings from the study in the context of the previous literature.
Methods
We collected data by using SOPARC for more than 3 years in 4 locations: Philadelphia, Pennsylvania; Columbus, Ohio; Chapel Hill/Durham, North Carolina; and Albuquerque, New Mexico during spring, summer, and autumn.
Results
We observed a total of 35,990 park users with an overall observer reliability of 94% (range, 85%–99%) conducted on 15% of the observations. We monitored the proportion of park users engaging in moderate-to-vigorous physical activity (MVPA) and found marginal differences in MVPA by both city and season. Park users visited parks significantly more on weekend days than weekdays and visitation rates tended to be lower during summer than spring.
Conclusion
SOPARC is a highly reliable observation instrument that can be used to collect data across diverse geographic settings and seasons by different users and has potential as a surveillance system.
doi:10.5888/pcd11.130147
PMCID: PMC3879002  PMID: 24384304
4.  Online Grocery Store Coupons and Unhealthy Foods, United States 
doi:10.5888/pcd11.130211
PMCID: PMC3887050  PMID: 24406094
5.  The Mobilizing Action Toward Community Health Partnership Study: Multisector Partnerships in US Counties with Improving Health Metrics 
Introduction
Multisector partnerships are promoted as a mechanism to improve population health. This study explored the types and salient features of multisector partnerships in US counties with improving population health metrics.
Methods
We used the “Framework for Understanding Cross-Sector Collaborations” proposed by Bryson, Crosby, and Stone to guide data collection and interpretation. Comparative case studies were conducted in 4 counties selected on the basis of population, geographic region, an age-adjusted mortality decline better than the US average, and stable per capita income. Data were collected through website and report reviews and through in-depth interviews with key informants (N = 59) representing multiple sectors. County reports were developed and cross-case themes related to partnership types and salient features were derived.
Results
Multisector collaboration was common in all 4 counties despite substantial variations in population, geographic size, demographic diversity, and other characteristics. Most partnerships were formed by professionals and organizations to improve delivery of health and social services to vulnerable populations or to generate policy, system, and environment changes. Multisector collaboration was valued in all cases. Outcomes attributed to partnerships included short- and long-term effects that contributed to improved population health.
Conclusion
The Bryson, Crosby, and Stone model is a useful framework for conducting case study research on multisector partnerships. Outcomes attributed to the multisector partnerships have the potential to contribute to improvement in population health. Further study is needed to confirm whether multisector partnerships are necessary for improving population health within counties and to understand which partnership characteristics are critical for success.
doi:10.5888/pcd11.130103
PMCID: PMC3887051  PMID: 24406092
6.  Obesity Prevalence by Occupation in Washington State, Behavioral Risk Factor Surveillance System 
Introduction
Data that estimate the prevalence of and risk factors for worker obesity by occupation are generally unavailable and could inform the prioritization of workplace wellness programs. The aims of this study were to estimate the prevalence of obesity by occupation, examine the association of occupational physical activity and a range of health behaviors with obesity, and identify occupations in which workers are at high risk of obesity in Washington State.
Methods
We conducted descriptive and multivariable analyses among 37,626 employed Washington State respondents using the Behavioral Risk Factor Surveillance System in odd numbered years, from 2003 through 2009. We estimated prevalence and prevalence ratios (PRs) by occupational groups adjusting for demographics, occupational physical activity level, smoking, fruit and vegetable consumption, and leisure-time physical activity (LPTA).
Results
Overall obesity prevalence was 24.6% (95% confidence interval [CI], 24.0–25.1). Workers in protective services were 2.46 (95% CI, 1.72–3.50) times as likely to be obese as workers in health diagnosing occupations. Compared with their counterparts, workers who consumed adequate amounts of fruits and vegetables and had adequate LTPA were significantly less likely to be obese (PR = 0.91; 95% CI, 0.86–0.97 and PR = 0.63; 95% CI, 0.60–0.67, respectively). Workers with physically demanding occupational physical activity had a lower PR of obesity (PR = 0.83; 95% CI, 0.78–0.88) than those with nonphysically demanding occupational physical activity.
Conclusion
Obesity prevalence and health risk behaviors vary substantially by occupation. Employers, policy makers, and health promotion practitioners can use our results to target and prioritize workplace obesity prevention and health behavior promotion programs.
doi:10.5888/pcd11.130219
PMCID: PMC3887052  PMID: 24406093
7.  Policy Changes to Implement Intramural Sports in North Carolina Middle Schools: Simulated Effects on Sports Participation Rates and Physical Activity Intensity, 2008–2009 
Introduction
Extracurricular school sports programs can provide adolescents, including those who are economically disadvantaged, with opportunities to engage in physical activity. Although current models favor more exclusionary interscholastic sports, a better understanding is needed of the potential effects of providing alternative school sports options, such as more inclusive intramural sports. The purpose of this study was to simulate the potential effect of implementing intramural sports programs in North Carolina middle schools on both the rates of sports participation and on energy expenditure related to physical activity levels.
Methods
Simulations were conducted by using a school-level data set developed by integrating data from multiple sources. Baseline rates of sports participation were extrapolated from individual-level data that were based on school-level characteristics. A regression model was estimated by using the simulated baseline school-level sample. Participation rates and related energy expenditure for schools were calculated on the basis of 2 policy change scenarios.
Results
Currently, 37.2% of school sports participants are economically disadvantaged. Simulations suggested that policy changes to implement intramural sports along with interscholastic sports could result in more than 43,000 new sports participants statewide, of which 64.5% would be economically disadvantaged students. This estimate represents a 36.75% increase in economically disadvantaged participants. Adding intramural sports to existing interscholastic sports programs at all middle schools in North Carolina could have an annual effect of an additional 819,892.65 kilogram calories expended statewide.
Conclusion
Implementing intramural sports may provide economically disadvantaged students more access to sports, thus reducing disparities in access to school sports while increasing overall physical activity levels among all children.
doi:10.5888/pcd11.130195
PMCID: PMC3894929  PMID: 24433623
8.  Recommendations for a Culturally Relevant Internet-Based Tool to Promote Physical Activity Among Overweight Young African American Women, Alabama, 2010–2011 
Introduction
Innovative approaches are needed to promote physical activity among young adult overweight and obese African American women. We sought to describe key elements that African American women desire in a culturally relevant Internet-based tool to promote physical activity among overweight and obese young adult African American women.
Methods
A mixed-method approach combining nominal group technique and traditional focus groups was used to elicit recommendations for the development of an Internet-based physical activity promotion tool. Participants, ages 19 to 30 years, were enrolled in a major university. Nominal group technique sessions were conducted to identify themes viewed as key features for inclusion in a culturally relevant Internet-based tool. Confirmatory focus groups were conducted to verify and elicit more in-depth information on the themes.
Results
Twenty-nine women participated in nominal group (n = 13) and traditional focus group sessions (n = 16). Features that emerged to be included in a culturally relevant Internet-based physical activity promotion tool were personalized website pages, diverse body images on websites and in videos, motivational stories about physical activity and women similar to themselves in size and body shape, tips on hair care maintenance during physical activity, and online social support through social media (eg, Facebook, Twitter).
Conclusion
Incorporating existing social media tools and motivational stories from young adult African American women in Internet-based tools may increase the feasibility, acceptability, and success of Internet-based physical activity programs in this high-risk, understudied population.
doi:10.5888/pcd11.130169
PMCID: PMC3899848  PMID: 24433625
9.  Prevalence of Chronic Conditions Among Medicare Part A Beneficiaries in 2008 and 2010: Are Medicare Beneficiaries Getting Sicker? 
Introduction
Medicare beneficiaries who have chronic conditions are responsible for a disproportionate share of Medicare fee-for-service expenditures. The objective of this study was to analyze the change in the health of Medicare beneficiaries enrolled in Part A (hospital insurance) between 2008 and 2010 by comparing the prevalence of 11 chronic conditions.
Methods
We conducted descriptive analyses using the 2008 and 2010 Chronic Conditions Public Use Files, which are newly available from the Centers for Medicare and Medicaid Services and have administrative (claims) data on 100% of the Medicare fee-for-service population. We examined the data by age, sex, and dual eligibility (eligibility for both Medicare and Medicaid).
Results
Medicare Part A beneficiaries had more chronic conditions on average in 2010 than in 2008. The percentage increase in the average number of chronic conditions was larger for dual-eligible beneficiaries (2.8%) than for nondual-eligible beneficiaries (1.2%). The prevalence of some chronic conditions, such as congestive heart failure, ischemic heart disease, and stroke/transient ischemic attack, decreased. The deterioration of average health was due to other chronic conditions: chronic kidney disease, depression, diabetes, osteoporosis, rheumatoid arthritis/osteoarthritis. Trends in Alzheimer’s disease, cancer, and chronic obstructive pulmonary disease showed differences by sex or dual eligibility or both.
Conclusion
Analyzing the prevalence of 11 chronic conditions by using Medicare claims data provides a monitoring tool that can guide health care providers and policy makers in devising strategies to address chronic conditions and rising health care costs.
doi:10.5888/pcd11.130118
PMCID: PMC3899849  PMID: 24433626
10.  Prevalence of Smoke-Free Car and Home Rules in Maine Before and After Passage of a Smoke-Free Vehicle Law, 2007–2010 
Introduction
This is the first study to examine the prevalence of self-reported smoke-free rules for private cars and homes before and after the passage of a smoke-free vehicle law.
Methods
Data were examined for 13,461 Maine adults aged 18 or older who participated in the Behavioral Risk Factor Surveillance System, a state-based telephone survey covering health topics. Self-reported smoke-free car and home rules, smoking behavior, and demographic variables of age, sex, education, income, and children in household were analyzed for prevalence before and after the state’s smoke-free vehicle law was passed.
Results
Prevalence of smoke-free car and home rules was significantly higher after Maine’s smoke-free vehicle law was passed in the state (P = .004 for car rules and P = .009 for home rules). Variations in smoking rules differed by smoking and demographic variables. People with household incomes of less than $20,000 saw an increase of 14.3% in smoke-free car rules; overall, those with annual incomes of less than $20,000 and those with less than a high school education reported a lower prevalence of smoke-free car rules both before and after the law was passed than did people with higher incomes and higher education levels. The prevalence of smoke-free home rules after the law was implemented was higher among those with 4 or more years of college education than among those with lower levels of education (P = .02).
Conclusion
The prevalence of smoke-free car and home rules among Maine adults was significantly higher after the passage of a statewide smoke-free vehicle law. This apparent change in smoke-free rule prevalence may be indicative of changing social norms related to the unacceptability of secondhand smoke exposure.
doi:10.5888/pcd11.130132
PMCID: PMC3899850  PMID: 24433624
11.  The Program Sustainability Assessment Tool: A New Instrument for Public Health Programs 
Introduction
Public health programs can deliver benefits only if they are able to sustain programs, policies, and activities over time. Although numerous sustainability frameworks and models have been developed, there are almost no assessment tools that have demonstrated reliability or validity or have been widely disseminated. We present the Program Sustainability Assessment Tool (PSAT), a new and reliable instrument for assessing the capacity for program sustainability of various public health and other programs.
Methods
A measurement development study was conducted to assess the reliability of the PSAT. Program managers and staff (n = 592) representing 252 public health programs used the PSAT to rate the sustainability of their program. State and community-level programs participated, representing 4 types of chronic disease programs: tobacco control, diabetes, obesity prevention, and oral health.
Results
The final version of the PSAT contains 40 items, spread across 8 sustainability domains, with 5 items per domain. Confirmatory factor analysis shows good fit of the data with the 8 sustainability domains. The subscales have excellent internal consistency; the average Cronbach’s α is 0.88, ranging from 0.79 to 0.92. Preliminary validation analyses suggest that PSAT scores are related to important program and organizational characteristics.
Conclusion
The PSAT is a new and reliable assessment instrument that can be used to measure a public health program’s capacity for sustainability. The tool is designed to be used by researchers, evaluators, program managers, and staff for large and small public health programs.
doi:10.5888/pcd11.130184
PMCID: PMC3900326  PMID: 24456645
12.  Using the Program Sustainability Assessment Tool to Assess and Plan for Sustainability 
Implementing and growing a public health program that benefits society takes considerable time and effort. To ensure that positive outcomes are maintained over time, program managers and stakeholders should plan and implement activities to build sustainability capacity within their programs. We describe a 3-part sustainability planning process that programs can follow to build their sustainability capacity. First, program staff and stakeholders take the Program Sustainability Assessment Tool to measure their program’s sustainability across 8 domains. Next, managers and stakeholders use results from the assessment to inform and prioritize sustainability action planning. Lastly, staff members implement the plan and keep track of progress toward their sustainability goals. Through this process, staff can more holistically address the internal and external challenges and pressures associated with sustaining a program. We include a case example of a chronic disease program that completed the Program Sustainability Assessment Tool and engaged in program sustainability planning.
doi:10.5888/pcd11.130185
PMCID: PMC3900327  PMID: 24456644
13.  From Menu to Mouth: Opportunities for Sodium Reduction in Restaurants 
Restaurant foods can be a substantial source of sodium in the American diet. According to the Institute of Medicine, the significant contribution made by restaurants and food service menu items to Americans’ sodium intake warrants targeted attention. Public health practitioners are uniquely poised to support sodium-reduction efforts in restaurants and help drive demand for lower-sodium products through communication and collaboration with restaurant and food service professionals and through incentives for restaurants. This article discusses the role of the public health practitioner in restaurant sodium reduction and highlights select strategies that have been taken by state and local jurisdictions to support this effort.
doi:10.5888/pcd11.130237
PMCID: PMC3900328  PMID: 24456646
14.  Factors Associated With the Adoption of a Patient Education Intervention Among First Responders, King County, Washington, 2010–2011 
Introduction
This study investigated facilitators and barriers to adoption of an at-scene patient education program by firefighter emergency medical technicians (EMTs) in King County, Washington.
Methods
We consulted providers of emergency medical services (EMS) to develop a patient education pamphlet in the form of a tear-off sheet that could be attached to the EMT medical incident report. The pamphlet included resources for at-scene patient education on high blood pressure, blood glucose, falls, and social services. The program was launched in 29 fire departments in King County, Washington, on January 1, 2010, and a formal evaluation was conducted in late 2011. We developed a survey based on diffusion theory to assess 1) awareness of the pamphlet, 2) evaluation of the pamphlet attributes, 3) encouragement by peers and superiors for handing out the pamphlet, 4) perceived behavioral norms, and 5) demographic variables associated with self-reported adoption of the at-scene patient education program. The survey was completed by 822 (40.1%) of 2,047 firefighter emergency medical technicians. We conducted bivariate and multivariable analyses to assess associations between independent variables and self-reported adoption of the program.
Results
Adoption of the at-scene patient education intervention was significantly associated with positive evaluation of the pamphlet, encouragement from peers and superiors, and perceived behavioral norms. EMS providers reported they were most likely to hand out the pamphlet to patients in private residences who were treated and left at the scene.
Conclusion
Attributes of chronic disease prevention programs and encouragement from peers and supervisors are necessary in diffusion of patient education interventions in the prehospital care setting.
doi:10.5888/pcd11.130221
PMCID: PMC3917608  PMID: 24480631
15.  Diabetes Interactive Atlas 
The Diabetes Interactive Atlas is a recently released Web-based collection of maps that allows users to view geographic patterns and examine trends in diabetes and its risk factors over time across the United States and within states. The atlas provides maps, tables, graphs, and motion charts that depict national, state, and county data. Large amounts of data can be viewed in various ways simultaneously. In this article, we describe the design and technical issues for developing the atlas and provide an overview of the atlas’ maps and graphs. The Diabetes Interactive Atlas improves visualization of geographic patterns, highlights observation of trends, and demonstrates the concomitant geographic and temporal growth of diabetes and obesity.
doi:10.5888/pcd11.130300
PMCID: PMC3917609  PMID: 24503340
16.  Public Support for Smoke-Free Air Strategies Among Smokers and Nonsmokers, New York City, 2010–2012 
Introduction
From 2010 through 2012, the New York City Department of Health and Mental Hygiene engaged in multiple smoke-free-air activities in collaboration with community, institution, and government partners. These included implementing a law prohibiting smoking in all parks and beaches as well as working to increase compliance with existing Smoke-free Air Act provisions.
Methods
We investigated trends in awareness of existing smoke-free rules publicized with new signage and public support for new smoke-free air strategies by using 3 waves of survey data from population-based samples of smoking and nonsmoking adults in New York City (2010–2012). Analyses adjusted for the influence of sociodemographic characteristics.
Results
Among both smokers and nonsmokers, we observed increased awareness of smoke-free regulations in outdoor areas around hospital entrances and grounds and in lines in outdoor waiting areas for buses and taxis. Regardless of smoking status, women, racial/ethnic minorities, and adults aged 25 to 44 years were more likely than men, non-Hispanic whites, and adults aged 65 years or older to support smoke-free air strategies.
Conclusion
New signage was successful in increasing population-wide awareness of rules. Our analysis of the association between demographic characteristics and support for tobacco control over time provide important contextual information for community education efforts on secondhand smoke and smoke-free air strategies.
doi:10.5888/pcd11.130263
PMCID: PMC3917610  PMID: 24480633
17.  Disability Status as an Antecedent to Chronic Conditions: National Health Interview Survey, 2006–2012 
Introduction
A strong relationship exists between disability and poor health. This relationship could exist as a result of disabilities emerging from chronic conditions; conversely, people with disabilities may be at increased risk of developing chronic conditions. Studying health in relation to age of disability onset can illuminate the extent to which disability may be a risk factor for future poor health.
Methods
We used data from the 2006–2012 National Health Interview Survey and conducted weighted logistic regression analyses to compare chronic conditions in adults with lifelong disabilities (n = 2,619) and adults with no limitations (n = 122,395).
Results
After adjusting for sociodemographic differences, adults with lifelong disabilities had increased odds of having the following chronic conditions compared with adults with no limitations: coronary heart disease (adjusted odds ratio [AOR] = 2.92; 95% confidence interval [CI], 2.33–3.66) cancer (AOR = 1.61; 95% CI, 1.34–1.94), diabetes (AOR = 2.57; 95% CI, 2.10–3.15), obesity (AOR = 1.81; 95% CI, 1.63–2.01), and hypertension (AOR = 2.18; 95% CI, 1.94–2.45). Subpopulations of people with lifelong disabilities (ie, physical, mental, intellectual/developmental, and sensory) experienced similar increased odds for chronic conditions compared with people with no limitations.
Conclusion
Adults with lifelong disabilities were more likely to have chronic conditions than adults with no limitations, indicating that disability likely increases risk of developing poor health. This distinction is critical in understanding how to prevent health risks for people with disabilities. Health promotion efforts that target people living with a disability are needed.
doi:10.5888/pcd11.130251
PMCID: PMC3917726  PMID: 24480632
18.  Effect of a Liver Cancer Education Program on Hepatitis B Screening Among Asian Americans in the Baltimore–Washington Metropolitan Area, 2009–2010 
Introduction
Asian Americans have the highest incidence of hepatocellular carcinoma (HCC), the major form of primary liver cancer, of all ethnic groups in the United States. Chronic hepatitis B virus (HBV) infection is the most common cause of HCC, and as many as 1 in 10 foreign-born Asian Americans are chronically infected with HBV. We tested the effectiveness of a culturally tailored liver cancer education program for increasing screening for HBV among Chinese, Korean, and Vietnamese Americans residing in the Baltimore–Washington metropolitan area, from November 2009 through June 2010.
Methods
We used a cluster randomized controlled trial to recruit volunteer participants from community-based organizations (CBOs) in the Baltimore–Washington metropolitan area. We selected 877 participants by using a pretest survey. People were eligible to participate if they had not attended a hepatitis B–related education program in the past 5 years. The intervention group (n = 441) received a 30-minute educational program, and the control group (n = 436) received an educational brochure. After attending the educational program, the intervention group completed a post-education survey. Six months later, participants in both groups were followed up by telephone. Receipt of HBV screening was the outcome measure.
Results
Approximately 79% (n = 688) of participants completed the 6-month follow-up telephone survey. Among those who had not had HBV screening at baseline (n = 446), the adjusted odds of self-reported receipt of HBV screening at the 6-month follow-up to the educational program were significantly higher for the intervention group than for the control group (odds ratio = 5.13; 95% confidence interval, 3.14–8.39; P < .001). Chinese Americans and Vietnamese Americans had significantly higher odds of having HBV screening in the 6-month period than Korean Americans.
Conclusion
Culturally tailored education programs that increase liver cancer awareness can be effective in increasing HBV screening among underserved Asian American populations.
doi:10.5888/pcd11.130258
PMCID: PMC3921910  PMID: 24503341
19.  Community-Led Cancer Action Councils in Queens, New York: Process Evaluation of an Innovative Partnership With the Queens Library System 
Introduction
Community-based participatory research (CBPR) has great potential to address cancer disparities, particularly in racially and ethnically diverse and underserved neighborhoods. The objective of this study was to conduct a process evaluation of an innovative academic–community partnership, Queens Library HealthLink, which aimed to reduce cancer disparities through neighborhood groups (Cancer Action Councils) that convened in public libraries in Queens, New York.
Methods
We used a mixed-methods approach to conduct 69 telephone survey interviews and 4 focus groups (15 participants) with Cancer Action Council members. We used 4 performance criteria to inform data collection: action or attention to sustainability, library support for the council, social cohesion and group leadership, and activity level. Focus group transcripts were independently coded and cross-checked for consensus until saturation was achieved.
Results
Members reported benefits and barriers to participation. Thirty-three original focus group transcript codes were organized into 8 main themes related to member experiences: 1) library as a needed resource, 2) library as a reputable and nondenominational institution, 3) value of library staff, 4) need for a HealthLink specialist, 5) generation of ideas and coordination of tasks, 6) participation challenges, 7) use of community connections, and 8) collaboration for sustainability.
Conclusion
In response to the process evaluation, Cancer Action Council members and HealthLink staff incorporated member suggestions to improve council sustainability. The councils merged to increase intercouncil collaboration, and institutional changes were made in funding to sustain a HealthLink specialist beyond the grant period.
doi:10.5888/pcd11.130176
PMCID: PMC3921904  PMID: 24503342
20.  Tailoring Community-Based Wellness Initiatives With Latent Class Analysis — Massachusetts Community Transformation Grant Projects 
Introduction
Community-based approaches to preventing chronic diseases are attractive because of their broad reach and low costs, and as such, are integral components of health care reform efforts. Implementing community-based initiatives across Massachusetts’ municipalities presents both programmatic and evaluation challenges. For effective delivery and evaluation of the interventions, establishing a community typology that groups similar municipalities provides a balanced and cost-effective approach.
Methods
Through a series of key informant interviews and exploratory data analysis, we identified 55 municipal-level indicators of 6 domains for the typology analysis. The domains were health behaviors and health outcomes, housing and land use, transportation, retail environment, socioeconomics, and demographic composition. A latent class analysis was used to identify 10 groups of municipalities based on similar patterns of municipal-level indicators across the domains.
Results
Our model with 10 latent classes yielded excellent classification certainty (relative entropy = .995, minimum class probability for any class = .871), and differentiated distinct groups of municipalities based on health-relevant needs and resources. The classes differentiated healthy and racially and ethnically diverse urban areas from cities with similar population densities and diversity but worse health outcomes, affluent communities from lower-income rural communities, and mature suburban areas from rapidly suburbanizing communities with different healthy-living challenges.
Conclusion
Latent class analysis is a tool that may aid in the planning, communication, and evaluation of community-based wellness initiatives such as Community Transformation Grants projects administrated by the Centers for Disease Control and Prevention.
doi:10.5888/pcd11.130215
PMCID: PMC3929338  PMID: 24524425
21.  Knowledge and Behavioral Effects in Cardiovascular Health: Community Health Worker Health Disparities Initiative, 2007–2010 
Introduction
Cardiovascular disease is the leading cause of death in the United States, and disparities in cardiovascular health exist among African Americans, American Indians, Hispanics, and Filipinos. The Community Health Worker Health Disparities Initiative of the National Heart, Lung, and Blood Institute (NHLBI) includes culturally tailored curricula taught by community health workers (CHWs) to improve knowledge and heart-healthy behaviors in these racial/ethnic groups.
Methods
We used data from 1,004 community participants in a 10-session curriculum taught by CHWs at 15 sites to evaluate the NHLBI’s health disparities initiative by using a 1-group pretest–posttest design. The curriculum addressed identification and management of cardiovascular disease risk factors. We used linear mixed effects and generalized linear mixed effects models to examine results.
Results
Average participant age was 48; 75% were female, 50% were Hispanic, 35% were African American, 8% were Filipino, and 7% were American Indian. Twenty-three percent reported a history of diabetes, and 37% reported a family history of heart disease. Correct pretest to posttest knowledge scores increased from 48% to 74% for heart healthy knowledge. The percentage of participants at the action or maintenance stage of behavior change increased from 41% to 85%.
Conclusion
Using the CHW model to implement community education with culturally tailored curricula may improve heart health knowledge and behaviors among minorities. Further studies should examine the influence of such programs on clinical risk factors for cardiovascular disease.
doi:10.5888/pcd11.130250
PMCID: PMC3929339  PMID: 24524426
22.  Implementing a Client Reminder Intervention for Colorectal Cancer Screening at a Health Insurance Worksite 
Background
Among cancers that affect both men and women, colorectal cancer is one of the leading causes of cancer-related death in Michigan. The American Cancer Society estimates 4,730 new cases and 1,700 deaths due to colorectal cancer in Michigan for 2013. Screening can detect colorectal cancer earlier, when treatment is more successful.
Community Context
The Michigan Department of Community Health represents 1 of 25 states and 4 tribes to receive a multiyear grant from the Centers for Disease Control and Prevention (CDC) to increase colorectal cancer screening rates through population health interventions and clinical services for the underserved. Michigan’s Colorectal Cancer Control Program is implemented in partnership with its Comprehensive Cancer Control Program, which supports the Michigan’s cancer control coalition composed of 114 partner organizations.
Methods
This project had 2 primary objectives: 1) develop a collaborative partnership with 1 Michigan Cancer Consortium organization in which to pilot the intervention and 2) increase colorectal cancer screening rates by implementing a client reminder intervention and measuring the increase in screening rates.
Outcomes
A partnership was established with HealthPlus of Michigan. Of the 95 HealthPlus employees and spouses who received the intervention, 15 completed screening, accounting for a 16% increase in the screening rate. The project was considered successful because both of its objectives were achieved.
Interpretation
Translating evidence-based interventions into practice requires building a relationship with a partner organization, incorporating flexibility, and establishing a realistic timeline.
doi:10.5888/pcd11.130276
PMCID: PMC3929340  PMID: 24524424
24.  “Everyone Should Be Able to Choose How They Get Around”: How Topeka, Kansas, Passed a Complete Streets Resolution 
Background
Regular physical activity can help prevent chronic diseases, yet only half of US adults meet national physical activity guidelines. One barrier to physical activity is a lack of safe places to be active, such as bike paths and sidewalks. Complete Streets, streets designed to enable safe access for all users, can help provide safe places for activity.
Community Context
This community case study presents results from interviews with residents and policymakers of Topeka, Kansas, who played an integral role in the passage of a Complete Streets resolution in 2009. It describes community engagement processes used to include stakeholders, assess existing roads and sidewalks, and communicate with the public and decision-makers.
Methods
Key informant interviews were conducted with city council members and members of Heartland Healthy Neighborhoods in Topeka to learn how they introduced a Complete Streets resolution and the steps they took to ensure its successful passage in the City Council. Interviews were recorded, transcribed, and analyzed by using focused-coding qualitative analysis.
Outcome
Results included lessons learned from the process of passing the Complete Streets resolution and advice from participants for other communities interested in creating Complete Streets in their communities.
Interpretation
Lessons learned can apply to other communities pursuing Complete Streets. Examples include clearly defining Complete Streets; educating the public, advocates, and decision-makers about Complete Streets and how this program enhances a community; building a strong and diverse network of supporters; and using stories and examples from other communities with Complete Streets to build a convincing case.
doi:10.5888/pcd11.130292
PMCID: PMC3938956  PMID: 24556251
25.  Understanding and Use of Nicotine Replacement Therapy and Nonpharmacologic Smoking Cessation Strategies Among Chinese and Vietnamese Smokers and Their Families 
Introduction
Population-based studies have reported high rates of smoking prevalence among Chinese and Vietnamese American men. Although nicotine replacement therapy (NRT) is effective, recommended, and accessible without prescription, these populations underuse NRT for smoking cessation. The aim of this study was to assess understanding and use of NRT and nonpharmacologic treatments among Chinese and Vietnamese American male smokers and their families.
Methods
In-depth qualitative interviews were conducted with 13 smoker–family pairs, followed by individual interviews with each participant. A total of 39 interviews were conducted in Vietnamese or Chinese, recorded, translated, and transcribed into English for analysis.
Results
Four themes were identified: use and understanding of NRT, nonpharmacologic strategies, familial and religious approaches, and willpower. Both smokers and their family members believed strongly in willpower and a sense of personal responsibility as the primary drivers for stopping smoking. Lack of these 2 qualities keeps many Chinese and Vietnamese men from using NRT to quit smoking. Those who do use NRT often use it incorrectly, following their own preferences rather than product instructions.
Conclusion
Our findings indicate the importance of culturally appropriate patient education about NRT. It may be necessary to teach smokers and their families at an individual level about NRT as a complementary approach that can strengthen their resolve to quit smoking. At a community level, public health education on the indication and appropriate use of evidence-based smoking cessation resources, such as NRT, would be an important component of effective tobacco control.
doi:10.5888/pcd11.130299
PMCID: PMC3938957  PMID: 24556252

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