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1.  Sex Differences in Barriers to Antihypertensive Medication Adherence: Findings From the Cohort Study of Medication Adherence Among Older Adults (CoSMO) 
Objectives
We assessed whether socio-demographic, clinical, health care system, psychosocial, and behavioral factors are differentially associated with low antihypertensive medication adherence scores among older men and women.
Design / Setting
A cross-sectional analysis using baseline data from the Cohort Study of Medication Adherence in Older Adults (CoSMO, n=2,194).
Measurements
Low antihypertensive medication adherence was defined as a score <6 on the 8-item Morisky Medication Adherence Scale. Risk factors for low adherence were collected using telephone surveys and administrative databases.
Results
The prevalence of low medication adherence scores did not differ according to sex (15.0% in women and 13.1% in men p=0.208). In sex-specific multivariable models, having issues with medication cost and practicing fewer lifestyle modifications for blood pressure control were associated with low adherence scores among both men and women. Factors associated with low adherence scores in men but not women included reduced sexual functioning (OR = 2.03; 95% CI: 1.31, 3.16 for men and OR = 1.28; 95% CI: 0.90, 1.82 for women), and BMI ≥25 (OR = 3.23; 95% CI: 1.59, 6.59 for men and 1.23; 95% CI: 0.82, 1.85 for women). Factors associated with low adherence scores in women but not men included dissatisfaction with communication with their healthcare provider (OR = 1.75; 95% CI: 1.16, 2.65 for women and OR =1.16 95% CI: 0.57, 2.34 for men) and depressive symptoms (OR = 2.29; 95% CI: 1.55, 3.38 for women and OR = 0.93; 95% CI: 0.48, 1.80 for men).
Conclusion
Factors associated with low antihypertensive medication adherence scores differed according to sex. Interventions designed to improve adherence in older adults should be tailored to account for the sex of the target population.
doi:10.1111/jgs.12171
PMCID: PMC3628283  PMID: 23528003
medication adherence; hypertension; older adults; gender differences
2.  Adiposity and Physical Activity Are Not Related to Academic Achievement in School-Aged Children 
Objective
To investigate the hypotheses that in elementary school students: 1) adiposity and academic achievement are negatively correlated and 2) physical activity and academic achievement are positively correlated.
Method
Participants were 1963 children in fourth through sixth grades. Adiposity was assessed by calculating body mass index (BMI) percentile and percent body fat and academic achievement with statewide standardized tests in four content areas. Socioeconomic status and age were control variables. A subset of participants (n = 261) wore an accelerometer for three days to provide objective measurement of physical activity. Additionally, the association between weight status and academic achievement was examined by comparing children who could be classified as “extremely obese” and the rest of the sample, as well as comparing children who could be classified as normal weight, overweight, or obese. Extreme obesity was defined as >= 1.2 times the 95th percentile.
Results
Results indicated that there were no significant associations between adiposity or physical activity and achievement in students. No academic achievement differences were found between children with BMI percentiles within the extreme obesity range and those who did not fall within the extreme obesity classification. Additionally, no academic achievement differences were found for children with BMI percentiles within the normal weight, overweight, or obese ranges.
Conclusion
These results do not support the hypotheses that increased adiposity is associated with decreased academic achievement or that greater physical activity is related to improved achievement. However, these results are limited by methodological weaknesses, especially the use of cross-sectional data.
doi:10.1097/DBP.0b013e31825b849e
PMCID: PMC3897206  PMID: 22617499
childhood; academic achievement; adiposity; physical activity
3.  A Cross-sectional and Longitudinal Study of Travel by Walking Before and After School among Eighth Grade Girls 
Purpose
To examine “travel by walking” (TBW) before and after school among eighth grade girls.
Methods
Participants attended 36 middle schools from Arizona, Maryland, Minnesota, New Orleans, California and South Carolina participating in the Trial of Activity for Adolescent Girls (TAAG). The cross-sectional sample consisted of 3,076 eighth grade girls, and the longitudinal sample included 1,017 girls who participated in both 6th and 8th grades. Travel by walking before or after school status was determined from the 3-Day Physical Activity Recall (3DPAR). The main outcomes were body mass index (BMI) and physical activity, which was measured by accelerometry, estimated for total physical activity (light, moderate, vigorous) and moderate to vigorous physical activity (MVPA).
Results
Eighth grade girls who reported TBW had 4 more minutes (95% confidence interval ([CI], 2.1–6.1.) of MVPA before and after school than non-walkers, and 2 more minutes of MVPA (95% CI, 1.1–3.1) on an average weekday. In the longitudinal sample, girls who reported TBW before and after school in both 6th and 8th grades (consistent walkers) accumulated more minutes of MVPA for an average weekday than inconsistent walkers in both sixth (27 min.±2.2 vs. 25 min.±1.9; p=.03) and eighth grades (28 min.±2.6 vs. 25 min.±2.3; p=.003). There were no differences in BMI by walking status.
Conclusions
Adolescent girls who reported TBW before and after school accumulated more minutes of MVPA than non-walkers. Efforts to prevent the decline in walking to school in middle school girls could contribute to their overall physical activity.
doi:10.1016/j.jadohealth.2012.03.003
PMCID: PMC3505283  PMID: 23174472
Active travel; Adolescents; Girls; Physical activity; School; Travel by walking; Transportation
4.  Life Events, Coping, and Antihypertensive Medication Adherence Among Older Adults 
American Journal of Epidemiology  2012;176(Suppl 7):S64-S71.
The authors examined the association between life events and antihypertensive medication adherence in older adults and the moderating role of coping. A cross-sectional analysis was conducted by using data (n = 1,817) from the Cohort Study of Medication Adherence among Older Adults (recruitment conducted from August 2006 through September 2007). Life events occurring in the 12 months preceding the study interview were assessed via the Holmes Rahe Social Readjustment Rating Scale (SRRS), and coping levels were assessed via an adapted version of the John Henry Active Coping Scale. Low adherence to antihypertensive medication was defined as scores less than 6 on the 8-item Morisky Medication Adherence Scale (known as “MMAS-8”). Of study participants, 13.2% had low adherence, and 27.2% and 5.0% had medium (150–299) and high (≥300) SRRS scores, respectively. After multivariable adjustment, the odds ratios for low adherence associated with medium and high, versus low, SRRS were 1.50 (95% confidence interval: 1.11, 2.02) and 2.11 (95% confidence interval: 1.24, 3.58), respectively. When multivariable models were stratified by coping level, the association between life events and adherence was evident only among participants with low coping levels.
doi:10.1093/aje/kws233
PMCID: PMC3530357  PMID: 23035146
coping; hypertension; medication adherence; older adults; stress
5.  A longitudinal study of sedentary behavior and overweight in adolescent girls 
Obesity (Silver Spring, Md.)  2009;17(5):1003-1008.
Objective
To examine sedentary and light activity in relation to overweight in adolescent girls.
Methods and Procedures
Adolescent girls were randomly recruited from thirty-six schools participating in the Trial of Activity for Adolescent Girls (TAAG). Assessments included age, ethnicity, socioeconomic status, and body composition estimated from weight, height, and triceps skinfold. Sedentary and light activity was measured for six days using accelerometry in 6th and in 8th grade among two randomly sampled cross sections of girls.
Results
Sedentary activity increased from the 6th to 8th grade by 51.5 minutes/day. In the 8th grade, a significantly higher number of hours in sedentary activity for each of the 6-days of measurement were evident with higher tertiles of percent body fat (30-35%, >35% fat) (P<0.05), but not across all increasing tertiles of BMI (5th-85th, 85-95th, and >95th percentiles). The increase in sedentary activity was observed on weekdays, but not on weekends for percent body fat tertiles. In the cohort of girls measured in both 6th and 8th grades, the mean cross-sectional coefficient estimates were significant for percent body fat, but not BMI for sedentary and light activities.
Discussion
Adolescent girls from the 6th to 8th grade are shifting their time from light to more sedentary activity as measured by accelerometers. In addition, the increase in sedentary activity is not associated with an adverse effect on BMI or percent body fat. The eventual impact of this shift to a more sedentary lifestyle on body composition and other outcomes needs to be evaluated further.
doi:10.1038/oby.2008.598
PMCID: PMC3739452  PMID: 19165170
Activity monitors; physical activity; overweight
6.  Predictors of decline in medication adherence: Results from CoSMO 
Hypertension  2011;58(5):804-810.
Few data are available on the predictors of decline in antihypertensive medication adherence and the association of decline in adherence with subsequent blood pressure (BP) control. The current analysis included 1,965 adults from the Cohort Study of Medication Adherence among Older Adults (CoSMO) recruited between August 2006 and September 2007. Decline in antihypertensive medication adherence was defined as a ≥ 2 point decrease on the 8-item Morisky Medication Adherence Scale assessed during telephone surveys 1 and 2 years following baseline. Risk factors for decline in adherence were collected using telephone surveys and administrative databases. BP was abstracted from outpatient records. The annual rate for a decline in adherence was 4.3% (159 participants experienced a decline). After multivariable adjustment, a decline in adherence was associated with an odds ratio (OR) for uncontrolled BP (≥140/90 mm Hg) at follow up of 1.68 (95% CI: 1.01, 2.80). Depressive symptoms (OR 1.84, 95%CI 1.20, 2.82) and a high stressful life events score (OR 1.68, 95% CI 1.19, 2.38) were associated with higher ORs for a decline in adherence. Female gender (OR 0.61, 95% CI 0.42, 0.88); being married (OR 0.68, 95% CI 0.47, 0.98); and calcium channel blocker use (OR 0.68, 95% CI 0.48, 0.97) were associated with lower ORs for decline. In summary, a decline in antihypertensive medication adherence was associated with uncontrolled BP. Modifiable factors associated with decline were identified. Further research is warranted to determine if interventions can prevent the decline in antihypertensive medication adherence and improve BP control.
doi:10.1161/HYPERTENSIONAHA.111.176859
PMCID: PMC3220657  PMID: 21968751
hypertension; medication adherence; blood pressure control; older women and men; cohort; risk factors
7.  Health-related quality of life and antihypertensive medication adherence among older adults 
Age and Ageing  2010;39(4):481-487.
Purpose: health-related quality of life (HRQOL) is an important psycho-social characteristic which may impact an individual’s ability to manage their chronic disease. We examined the association between HRQOL and antihypertensive medication adherence in older adults.
Methods: participants were part of a cohort study of older adults enrolled in a managed care organisation and treated for hypertension (n = 2,180). Physical and Mental Component Summary Scores (PCS and MCS) of HRQOL were assessed using the RAND Medical Outcomes Study 36-item tool. Adherence to antihypertensive medication was assessed with the eight-item Morisky Medication Adherence Scale.
Results: the mean age of participants was 75.0 ± 5.6 years, 69.3% were white, 58.5% were women and 14.1% had low antihypertensive medication adherence. Low HRQOL scores were associated with lower levels of antihypertensive medication adherence in older adults. After adjustment for covariates, those with low PCS and MCS scores were 1.33 (95% CI 1.01, 1.74) and 2.26 (95% CI 1.74, 2.97) times more likely, respectively, to have low antihypertensive medication adherence than those with PCS and MCS scores in the top 2 tertiles.
Conclusions: low HRQOL may be an important barrier to achieving high medication adherence.
doi:10.1093/ageing/afq040
PMCID: PMC2886202  PMID: 20513770
HRQOL; medication adherence; hypertension; older adults; elderly
8.  Association of Depression with Antihypertensive Medication Adherence in Older Adults: Cross-Sectional and Longitudinal Findings from CoSMO 
Background
Little is known about the associations between depressive symptoms, social support and antihypertensive medication adherence in older adults.
Purpose
We evaluated the cross-sectional and longitudinal associations between depressive symptoms, social support and antihypertensive medication adherence in a large cohort of older adults.
Methods
A cohort of 2,180 older adults with hypertension was administered questionnaires, which included the Center for Epidemiologic Studies-Depression Scale, the Medical Outcomes Study Social Support Index, and the hypertension-specific Morisky Medication Adherence Scale at baseline and 1 year later.
Results
Overall, 14.1% of participants had low medication adherence, 13.0% had depressive symptoms, and 33.9% had low social support. After multivariable adjustment, the odds ratios that participants with depressive symptoms and low social support would have low medication adherence were 1.96 (95% confidence interval (CI) 1.43, 2.70) and 1.27 (95% CI 0.98, 1.65), respectively, at baseline and 1.87 (95% CI 1.32, 2.66) and 1.30 (95% CI 0.98, 1.72), respectively, at 1 year follow-up.
Conclusion
Depressive symptoms may be an important modifiable barrier to antihypertensive medication adherence in older adults
doi:10.1007/s12160-010-9217-1
PMCID: PMC3109732  PMID: 20703839
Hypertension; Medication adherence; Depressive symptoms; Social support; Medication possession ratio; Older adults
9.  Correlates of Physical Activity in Black, Hispanic and White Middle School Girls 
Background
A need exists to better understand multilevel influences on physical activity among diverse samples of girls. This study examined correlates of moderate-to-vigorous physical activity (MVPA) among adolescent girls from different racial/ethnic backgrounds.
Methods
1,180 6th grade girls (24.5% black, 15.7% Hispanic and 59.8% white) completed a supervised self-administered questionnaire that measured hypothesized correlates of PA. MVPA data were collected for six days using the ActiGraph accelerometer. Hierarchical regression analysis was used to examine correlates of PA in each racial/ethnic group.
Results
Hispanic girls (n=185) engaged in 21.7 minutes of MVPA per day, black girls (n=289), 19.5 minutes and white girls (n=706), 22.8 minutes. Perceived transportation barriers (+; p=0.010) were significantly and positively related to MVPA for Hispanic girls. For black girls, Body Mass Index (BMI) (−; p=0.005) and social support from friends (+; p=0.006) were significant correlates of MVPA. For white girls, BMI (−; p <0.001), barriers (−; p=0.012), social support from friends (+; p=0.010), participation in school sports (+; p=0.009), and community sports (+; p=0.025) were significant correlates of MVPA. Explained variance ranged from 30 to 35%.
Conclusions
Correlates of MVPA varied by racial/ethnic groups. Effective interventions in ethnically diverse populations may require culturally tailored strategies.
PMCID: PMC2937261  PMID: 20484757
Black; Hispanic; white; race/ethnicity analysis; accelerometry
10.  ACTION Live: Using Process Evaluation to Describe Implementation of a Worksite Wellness Program 
Objective
Process evaluation is a necessary component of randomized controlled field trials. This is a descriptive paper that reviews process evaluation for the ACTION Wellness Program for Elementary School Personnel.
Methods
Methods included self-report by participants, documentation by program staff, and school administrator report. Variables evaluated were program dose, fidelity and reach, exposure to materials and activities, and school factors that could influence program implementation and/or outcomes.
Results
Dose and exposure were high across intervention schools and intervention years. Reach was variable across schools and activities. Schools on the East Bank of the Mississippi River generally had slightly better reach than schools on the West Bank. Some nutrition activities had higher levels of participation than physical activities.
Conclusions
High program dose reflected good effort and cooperation by program staff and schools. A disconnect between exposure and reach showed that high exposure did not always translate to high participation.
doi:10.1097/JOM.0b013e3181c81ade
PMCID: PMC2897048  PMID: 20061882
11.  Adverse effects of Complementary and Alternative Medicine Use on Antihypertensive Medication Adherence: Findings from CoSMO 
Objectives
To determine the association between complementary and alternative medicine (CAM) use and antihypertensive medication adherence in older black and white adults.
Design
Cross-sectional
Setting
Patients enrolled in a managed care organization
Participants
2180 black and white adults, 65 years of age and older and prescribed antihypertensive medication.
Measurements
CAM use (i.e., health food and herbal supplements, relaxation techniques) for blood pressure control as well as antihypertensive medication adherence were collected via telephone survey between August 2006 and September 2007. Low medication adherence was defined as scores < 6 using the 8-item Morisky Medication Adherence Scale.
Results
The mean age of participants was 75.0 + 5.6 years, 30.7% were black, 26.5% used CAM, and 14.1% had low antihypertensive medication adherence. In managing blood pressure, 30.5% of black and 24.7% of white participants used CAM in the last year and 18.4% of black and 12.3% of white participants reported low adherence to antihypertensive medication (P=0.005 and <0.001, respectively). After multivariable adjustment for socio-demographics, depressive symptoms and reduction in antihypertensive medications due to cost, the prevalence ratios of low antihypertensive medication adherence associated with CAM use were 1.56 (95% CI: 1.14–2.15; P=0.006) and 0.95 (95% CI 0.70, 1.29; P=0.728) among blacks and whites, respectively (P value for interaction=0.069).
Conclusion
In this cohort of older managed care patients, CAM use was associated with low adherence to antihypertensive medication among blacks but not whites.
doi:10.1111/j.1532-5415.2009.02639.x
PMCID: PMC2920063  PMID: 20122040
complementary and alternative medicine; hypertension; medication adherence; older adults
12.  Are school employees healthy role models? Dietary intake results from the ACTION worksite wellness trial 
Background
Little is known about the dietary intake of school employees, a key target group for improving school nutrition.
Objective
To investigate selected dietary variables and weight status among elementary school personnel.
Design
Cross-sectional, descriptive study.
Subjects/setting
Elementary school employees (n=373) from 22 schools in a suburban parish (county) of southeastern Louisiana were randomly selected for evaluation at baseline of ACTION, a school-based worksite wellness trial.
Methods
Two 24-hour dietary recalls were administered on non-consecutive days by registered dietitians using the Nutrition Data System for Research. Height and weight were measured by trained examiners and body mass index calculated as weight (kilograms)/height (meters squared).
Statistical analyses performed
Descriptive analyses characterized energy, macronutrient, fiber, and MyPyramid food group consumption. Inferential statistics (t-tests, analysis of variance, chi-square) were used to examine differences in intake and compliance with recommendations by demographic and weight status categories.
Results
Approximately 31% and 40% of the sample were overweight and obese, respectively, with higher obesity rates than state and national estimates. Mean daily energy intake among women was 1862 kilocalories (kcal) (±492) and among men was 2668 kcal (±796). Obese employees consumed more calories (+288 kcal, p<0.001) and more calories from fat (p<0.001) than those who were normal weight. Approximately 45% of the sample exceeded dietary fat recommendations. On average, only 9% had fiber intakes at or above their Adequate Intake, which is consistent with the finding that over 25% of employees did not eat fruit, 58% did not eat dark green vegetables, and 45% did not eat whole grains on the recalled days. Only 7% of employees met the MyPyramid recommendations for fruits or vegetables, and 14% of the sample met those for milk and dairy foods.
Conclusions
These results suggest that greater attention be directed to understanding and improving the diets of school employees given their high rates of overweight and obesity, poor diets, and important role in student health.
doi:10.1016/j.jada.2009.06.366
PMCID: PMC2799115  PMID: 19699834
school employees; MyPyramid; macronutrients
13.  Energy density of foods, but not beverages, is positively associated with body mass index in adult women 
European journal of clinical nutrition  2009;63(12):1411-1418.
Background/Objectives
Energy density (kJ/g) may have a strong influence on energy balance. Although beverages are a considerable source of energy in the US diet, rarely have studies among free-living populations investigated the energy density of foods (EDF) and the energy density of beverages (EDB) simultaneously. We examined the independent simultaneous associations of EDF and EDB on energy intake and Body Mass Index (BMI) in adult women.
Subjects/Methods
This cross-sectional design focused on 348 elementary school employees randomly selected at baseline of a worksite wellness trial in southeastern Louisiana. Two 24-hour recalls were collected, and measured heights and weights were converted into BMI (kg/m2).
Results
Those in the highest EDF tertile consumed more energy and had higher BMIs than those in the lowest tertile (P<0.05). Employees in the highest EDB tertile consumed more energy than those in the lowest, yet there was no difference in BMIs between the two groups. Multivariate regression, with controls for demographic and health variables, confirmed the positive association between EDF and BMI; a 1 kJ/g increase in EDF was associated with a 0.39 kg/m2 increase in BMI (P=0.038). Models that did not control for EDB gave estimates of EDF that were 8% to 10% lower.
Conclusions
These findings suggest that EDF and EDB play important, yet distinct, roles in energy intake and BMI. Future studies should evaluate both types of energy density as independent predictors since our results suggest that EDB can confound the association of EDF with BMI.
doi:10.1038/ejcn.2009.102
PMCID: PMC2790027  PMID: 19707221
energy density; energy intake
14.  The Effect of a Physical Activity Intervention on Bias in Self-Reported Activity 
Annals of epidemiology  2009;19(5):316-322.
Purpose
A positive outcome in self-reported behavior could be detected erroneously if an intervention caused over-reporting of the targeted behavior. Data collected from a multi-site randomized trial were examined to determine if adolescent girls who received a physical activity intervention over-reported their activity more than girls who received no intervention.
Methods
Activity was measured using accelerometers and self-reports (3-Day Physical Activity Recall, 3DPAR) in cross-sectional samples pre- (6th grade, n=1464) and post-intervention (8th grade, n=3114). Log-transformed accelerometer minutes were regressed on 3DPAR blocks, treatment group, and their interaction, while adjusting for race, BMI, and timing of data collection.
Results
Pre-intervention, the association between measures did not differ between groups, but post-intervention 3DPAR blocks were associated with fewer log-accelerometer minutes of moderate-vigorous physical activity (MVPA) in intervention girls than control girls (p = 0.002). The group difference was primarily in the upper 15% of the 3DPAR distribution, where control girls had >1.7 more accelerometer minutes of MVPA than intervention girls who reported identical activity levels. Group differences in this sub-sample were 8.5–16.2% of the mean activity levels; the intervention was powered to detect a difference of 10%.
Conclusion
Self-report measures should be interpreted with caution when used to evaluate a physical activity intervention.
doi:10.1016/j.annepidem.2009.01.001
PMCID: PMC2746093  PMID: 19230711
bias (epidemiology); intervention studies; adolescent; exercise; questionnaires; social desirability
15.  Age-Related Change in Physical Activity in Adolescent Girls 
Purpose
To determine the annual rate at which physical activity changes in girls during middle school using both objective and self-report measures of physical activity.
Methods
Participants were 6th and 8th grade girls from the control schools in the Trial of Activity for Adolescent Girls (TAAG). Random cross-sectional samples initially were drawn from 6th grade girls (n=786) and two years later from 8th grade girls (n=1545). A cohort of 501 girls was in both the 6th and the 8th grade samples. The girls wore an accelerometer for six days and completed the 3-Day Physical Activity Recall (3DPAR). Data were summarized using 3.0–4.6- and 6.5-MET cutpoints for accelerometry and self-reported physical activity. Analyses were performed using repeated measures ANOVA in PROC MIXED.
Results
More than 40% of the girls were White, approximately 20% were African-American, and 20% were Hispanic. The annual percent decrease in physical activity in the cross-sectional sample was approximately 4% (−1.76 min MVPA/day), using accelerometer data. The percent decrease in physical activity based on self-report data was higher, 6–13%, depending on the physical activity variable. Declines tended to be larger in African-American girls, but the ethnic differences were not statistically significant.
Conclusions
Based on comparisons of cross-sectional samples of 6th and 8th grade girls, objectively-measured physical activity declined at a rate of 4% per year.
doi:10.1016/j.jadohealth.2008.07.003
PMCID: PMC2702137  PMID: 19237114
physical activity; adolescents; girls; middle school; accelerometry
16.  New medication adherence scale versus pharmacy fill rates in hypertensive seniors 
Objective
The availability of self-report scales that accurately identify low adherers to antihypertensive medication in real time could improve outpatient management of this disease. We evaluated the association and concordance of the new 8-item self-report Morisky Medication Adherence Scale (MMAS) with pharmacy fill data in a sample of community dwelling seniors with hypertension.
Study Design
Cross-sectional study
Methods
Pharmacy records for antihypertensive medications were abstracted for managed care adult hypertensive patients, ≥65 years, who completed a survey that included the 8-item MMAS (n=87). Continuous single-interval medication availability (CSA), medication possession ratio (MPR), and continuous multiple-interval medication gaps (CMG) were calculated using pharmacy data. MMAS adherence was categorized as high, medium, and low (MMAS scores of 8, 6 to <8, and <6, respectively); pharmacy fill non-persistency was defined as <0.8 for CSA and MPR and >0.2 for CMG.
Results
Overall, 58%, 33%, and 9% of participants had high, medium, and low medication adherence by MMAS. After adjustment for demographics and compared to high adherers on MMAS, patients with low MMAS adherence were 6.89 (95% confidence interval (CI): 2.48 – 19.1) times more likely to have non-persistent pharmacy fill rates by CSA and 5.22 (95% CI:1.88 – 14.5) times more likely to have non-persistent pharmacy fill rates by MPR. Concordance between MMAS and CSA, MPR, and CMG was ≥75%.
Conclusions
The MMAS is significantly associated with anti-hypertensive pharmacy refill adherence. Although further validation of the MMAS is needed, it may be useful in identifying low medication adherers in clinical settings.
PMCID: PMC2728593  PMID: 19146365
medication adherence; hypertension; Morisky Medication Adherence Scale; pharmacy fill; managed care
17.  Increased Obesity in Children Living in Rural Communities of Louisiana 
Objective
Rates of obesity among children have been rising in recent years. Information on the prevalence of obesity in children living in rural communities is needed. We report the prevalence of overweight and obesity in children enrolled in grades 4 to 6 who live in rural areas of Louisiana, U.S.
Methods and Procedures
These data were collected as baseline assessment for the Louisiana (LA) Health project. Height, weight, and estimates of body fat (using body impedance analysis) were collected on 2709 children. Average age was 10.5 years and the sample composition was 57.3% girls, 61.7% African-American, 36.0% Caucasian, and 2.3% other minority. A majority of children (77%) met the criterion for poverty status.
Results
The distribution of body mass index (BMI) percentile was highly skewed toward obesity. The most frequent BMI percentile scores were 98th and 99th percentile. Using Centers for Disease Control and Prevention (CDC) norms, the overall prevalence of obesity was 27.4% and for overweight was 45.1% of which 17.7% were between the 85th and 95th percentile. The prevalence of childhood overweight and obesity were much higher than the national norm and this increased prevalence was observed in both genders and in Caucasian and African American children.
Discussion
The prevalence of childhood overweight and obesity was found to be much higher in rural and primarily poor (77%) children living in Louisiana when compared to national norms. This observation suggests that rural children from Louisiana may be experiencing an epidemic of obesity that exceeds national prevalence estimates.
doi:10.1080/17477160802596148
PMCID: PMC2725211  PMID: 19089707
childhood obesity; population studies; rural health; childhood gender differences; ethnicity
18.  Process Evaluation of an In-School Anti-Tobacco Media Campaign in Louisiana 
Public Health Reports  2008;123(6):781-789.
SYNOPSIS
Objectives.
In light of challenges imposed by the changing media landscape and decreasing classroom time available for health interventions, new approaches are needed to disseminate anti-tobacco messages to adolescents. This study reported process evaluation of an in-school three-year anti-tobacco media campaign conducted in 10 schools in Louisiana.
Methods.
Over three years, 10 schools received an in-school anti-tobacco media campaign. The media campaign was one intervention component of the Acadiana Coalition of Teens against Tobacco. Campaign measures were tracked over the campaign's three-year duration. The campaign and evaluation were designed to target the students as they progressed through high school. The number of students who completed the surveys were 1,823 in Year 1, 1,552 in Year 2, and 1,390 in Year 3. Schools eligible for participation were publicly funded schools with no magnet or special populations and within a two-hour driving distance of the New Orleans study office.
Results.
In a self-report survey (Year 1, n=1,823; Year 2, n=1,552; Year 3, n=1,390), more than 75% and 50% of students reported being exposed to posters and public service announcements, respectively. Recognition of campaign theme was more than 80%. Almost half of respondents reported that the posters were interesting, one-third reported that the posters prevented them from smoking, and 10% reported that the posters encouraged them to cease smoking. Stock media posters had a significantly higher affective reaction than the customized media posters.
Conclusion.
Findings suggest that in-school media programs are useful and should be considered as a viable approach to health education for adolescents.
PMCID: PMC2556723  PMID: 19711659
19.  A description of the social–ecological framework used in the trial of activity for adolescent girls (TAAG) 
Health education research  2006;22(2):155-165.
Social–ecological (SE) models are becoming more widely used in health behavior research. Applying SE models to the design of interventions is challenging because models must be tailor-made for each behavior and population, other theories need to be integrated into multilevel frameworks, and empirical research to guide model development is limited. The purpose of the present paper is to describe a SE framework that guided the intervention and measurement plans for a specific study. The trial of activity for adolescent girls (TAAG) is a multi-center study of interventions to reduce the decline of physical activity in adolescent girls. The TAAG framework incorporates operant learning theory, social cognitive theory, organizational change theory and the diffusion of innovation model in a multi-level model. The explicit and practical model developed for TAAG has already benefited the study and may have elements that can generalize to other health promotion studies.
doi:10.1093/her/cyl059
PMCID: PMC2764407  PMID: 16855014
20.  Co-use of Alcohol and Tobacco Among Ninth-Graders in Louisiana 
Preventing Chronic Disease  2009;6(3):A85.
Introduction
The co-use of alcohol and tobacco by adolescents is a public health problem that continues well into adulthood and results in negative behavioral, social, and health consequences. The purpose of this study was to examine the co-use of alcohol and tobacco among ninth-graders in south-central Louisiana.
Methods
We created a health habits survey to collect data from 4,750 ninth-grade students, mean age 15.4 years. Cross-sectional analysis used χ 2, 1-way analysis of variance, and logistic regression methods.
Results
Almost 20% of students were co-users. Students who were white, performed poorly in school, did not expect to graduate high school, and had more discretionary money to spend were more likely to be co-users. Co-users had friends who got drunk weekly and were more likely to approve of alcohol use among friends than among adults. Significant differences in attitudes toward drinking and smoking were observed between co-users and nonusers. For adolescent drinkers, including girls, hard liquor was the preferred beverage.
Conclusion
These data for high school students are applicable for prevention strategies at a critical age when harmful health behaviors can mark the start of lifelong habits. Intervention efforts will be successful only if they account for multiple levels of influence.
PMCID: PMC2722390  PMID: 19527586
21.  Sedentary Activity and Body Composition of Middle School Girls: The Trial of Activity for Adolescent Girls 
This study describes the relationships between sedentary activity and body composition in 1,458 sixth-grade girls from 36 middle schools across the United States. Multivariate associations between sedentary activity and body composition were examined with regression analyses using general linear mixed models. Mean age, body mass index, and percentage of body fat were 12.0 ± 0.51, 21.1 kg/m2 ± 4.8, 28.5 ± 8.9, respectively. Girls averaged 7.7 ± 1.2 sedentary hours per day and about 13 hr (~ 97% of the day) of both sedentary and light activities. Overweight girls were significantly more (13 min; p < .003) sedentary, especially after school (> 2 p.m.; p < .01), and less physically active (p < .0001) than normal weight girls. The study documents small but significant associations between sedentary activity and adiposity.
PMCID: PMC2701393  PMID: 19177947
accelerometry; body fat; body mass index; sedentary behavior
22.  A School-Based Environmental Intervention to Reduce Smoking among High School Students: The Acadiana Coalition of Teens against Tobacco (ACTT) 
A school-based environmental program to reduce adolescent smoking was conducted in 20 schools (10 intervention; 10 control) in south central Louisiana. The 9th grade cohort (n = 4,763; mean age = 15.4 yrs; 51% female; 61% Caucasian; 30-day smoking prevalence at baseline = 25%) was followed over four years for 30-day smoking prevalence with the school as the unit of analysis. Although prevalence decreased in intervention schools and increased in control schools in Year 2 the significant difference between the two groups at baseline was not overcome by the intervention and increases in prevalence were observed in both groups in Years 3 and 4. The higher the percentage of white students in a school the higher the prevalence rates regardless of intervention/control status. Boys’ and girls’ smoking rates were similar. These outcome data, student feedback and process evaluation provide a basis for continuing to create more innovative adolescent tobacco control programs.
doi:10.3390/ijerph6041298
PMCID: PMC2681204  PMID: 19440519
Smoking prevalence; adolescents; high school; health promotion
23.  Relationships among Fitness, Body Composition, and Physical Activity 
Purpose
This study was designed to examine the associations of physical activity and body composition with cardiorespiratory fitness in eighth grade girls.
Methods
A random sample of 1440 eighth grade girls at 36 schools participated in this cross-sectional investigation, which represented an ethnically and geographically diverse group. Cardiorespiratory fitness was assessed using a modified physical work capacity test on a cycle ergometer that predicted workload at a heart rate of 170 beats·min−1. Physical activity was assessed over 6 d in each girl using an accelerometer and body composition was estimated from body mass index and triceps skinfolds using a previously validated equation. Pearson correlations and multiple regression analyses were used to determine the relationships among fitness, physical activity, and body composition.
Results
Significant linear relationships among cardiorespiratory fitness, body composition, and physical activity were found. The combination of fat and fat-free mass along with racial group and a race by fat-free-mass interaction accounted for 18% (R2) of the variation in physical fitness. Adding moderate-to-vigorous physical activity to the regression model increased the R2 to 22%. Black girls had somewhat lower fitness levels (P < 0.05) especially at higher levels of fat and fat-free mass than other racial/ethnic groups.
Conclusions
Physical activity, fat-free mass, and the interaction between fat-free mass and racial group are significantly associated with cardiorespiratory fitness in adolescent girls.
doi:10.1249/MSS.0b013e318165c86b
PMCID: PMC2561299  PMID: 18460987
ADOLESCENT; FATNESS; ACCELEROMETRY; PHYSICAL FITNESS; RACE/ETHNICITY
24.  Objectively Measured Physical Activity in 6th Grade Girls 
Objectives
To describe the objectively-measured physical activity (PA) characteristics of a diverse sample of 6th grade girls, to examine influences on PA, and to report compliance with PA guidelines.
Design
Cross-sectional study.
Setting
Six locations across the United States.
Participants
1578 6th grade girls. Actigraph accelerometers were worn for 7 days, and data for 6 days were included in the analyses.
Main exposure
Race/ethnicity, free-or-reduced price lunch (FRPL), and geographic region
Main outcome measure
Six operational definitions of adequate activity (60 min or 30 min of daily MVPA at or above 4.6, 3.8 or 3.0 METS (metabolic equivalents)) were applied to examine whether girls met physical activity guidelines.
Results
Average time spent in sedentary, light, moderate, and vigorous activities was 460, 342, 18, and 6 min/day, respectively. White girls were more active than girls in other race/ethnic groups, and girls who did not receive FRPL were more active than girls who did. Girls in western states were most active. Percentages of girls in compliance with the 6 thresholds for adequate activity varied widely, and ranged from 0.6% to 99.8%.
Conclusions
When physical activity is measured objectively and a 4.6 MET cutpoint for MVPA is applied, most 6th grade girls fall below guidelines for adequate physical activity. One notable finding was the impact of different accelerometer scoring protocols on estimates of compliance. Conceptual and empirical work is needed to define appropriate physical activity for youth using objective physical activity measures.
doi:10.1001/archpedi.160.12.1262
PMCID: PMC2443855  PMID: 17146024
25.  Girls' Activity Levels and Lesson Contexts in Middle School PE: TAAG Baseline 
Purpose
To assess girls' physical activity (PA) in middle school physical education (PE) as it relates to field site, lesson context and location, teacher gender, and class composition.
Methods
We observed girls' PA levels, lesson contexts, and activity promotion by teachers in 431 lessons in 36 schools from six field sites participating in the Trial of Activity for Adolescent Girls. Interobserver reliabilities exceeded 90% for all three categories. Data were analyzed using mixed-model ANOVA with controls for clustering effects by field site and school.
Results
Mean lesson length was 37.3 (± 9.4) min. Time (13.9 ± 7.0 min) and proportion of lessons (37.9 ± 18.5%) spent in moderate to vigorous PA (MVPA), and time (4.8 ± 4.2 min) and proportion of lessons (13.1 ± 11.7%) in vigorous PA (VPA) differed by field site (P < 0.004). Lesson time for instructional contexts differed by field site, with overall proportions as follows: game play (27.3%), management (26.1%), fitness activities (19.7%), skill drills (12.1%), knowledge (10.6%), and free play (4.4%). Coed classes were 7.9 min longer than girls-only classes (P = 0.03). Although 27 s shorter, outdoor lessons were more intense (MVPA% = 45.7 vs 33.7% of lesson, P < 0.001) and provided 4.0 more MVPA minutes (P < 0.001). MVPA, VPA, and lesson contexts did not differ by teacher gender. There was little direct promotion of PA by teachers during lessons.
Conclusions
Substantial variation in the conduct of PE exists. Proportion of lesson time girls spent accruing MVPA (i.e., 37.9%) fell short of the Healthy People 2010 objective of 50%. Numerous possibilities exist for improving girls' PA in PE.
doi:10.1249/01.mss.0000227307.34149.f3
PMCID: PMC2431981  PMID: 16826019
CHILDREN; EXERCISE; FEMALES; INTERVENTION; PHYSICAL; SPORTS

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