A three-year multifaceted intervention to prevent obesity in children of Mexican-heritage.

BACKGROUND: Obesity and overweight have increased dramatically in the United States over the last decades. The complexity of interrelated causal factors that result in obesity needs to be addressed within the cultural dynamic of sub-populations. In this study, we sought to estimate the effects of a multifaceted, community-based intervention on body mass index (BMI) among Mexican-heritage children. METHODS: Niños Sanos, Familia Sana (Healthy Children, Healthy Family) was a quasi-experimental intervention study designed to reduce the rate of BMI growth among Mexican-heritage children in California's Central Valley. Two rural communities were matched based on demographic and environmental characteristics and were assigned as the intervention or comparison community. The three-year intervention included parent workshops on nutrition and physical activity; school-based nutrition lessons and enhanced physical education program for children; and a monthly voucher for fruits and vegetables. Eligible children were between 3 and 8 years old at baseline. Intent-to-treat analyses were estimated using linear mixed-effect models with random intercepts. We ran a series of models for each gender where predictors were fixed except interactions between age groups and obesity status at baseline with intervention to determine the magnitude of impact on BMI. RESULTS: At baseline, mean (SD) BMI z-score (zBMI) was 0.97 (0.98) in the intervention group (n = 387) and 0.98 (1.02) in the comparison group (n = 313) (NS). The intervention was significantly associated with log-transformed BMI (ß = 0.04 (0.02), P = 0.03) and zBMI (ß = 0.25 (0.12), P = 0.04) among boys and log-transformed BMI among obese girls (ß = - 0.04 (0.02), P = 0.04). The intervention was significantly and inversely associated with BMI in obese boys and girls across all age groups and normal weight boys in the oldest group (over 6 years) relative to their counterparts in the comparison community. CONCLUSIONS: A community-based, multifaceted intervention was effective at slowing the rate of BMI growth among Mexican-heritage children. Our findings suggest that practitioners should consider strategies that address gender disparities and work with a variety of stakeholders to target childhood obesity. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01900613 . Registered 16th July 2013.

A Web-Based Application to Improve Data Collection in an Interventional Study Targeting Childhood Obesity: Pre-Post Analysis.

BACKGROUND: Although participatory action research (PAR) studies have proliferated in recent years, the development of technological resources to manage these types of projects has not kept pace. Few studies show how Web-based applications can be used to efficiently manage the data collection process. OBJECTIVE: This study described the development, use, and impact of a Web-based application to facilitate data management in Niños Sanos, Familia Sana (Healthy Children, Healthy Family), an interventional multifaceted PAR field study. METHODS: We described the transformation of the data management process and evaluated the impact of the application in terms of time efficiency of data collection and engagement of community-based data collectors. We defined time efficiency as the total number of days it took to collect 3 main surveys, per year of data collection. The engagement of data collectors was assessed based on qualitative reports. RESULTS: The amount of time it took to perform a round of data collection was reduced after implementation of the field team application (between 382 and 383 days and 198 and 233 days). Secondary data were also collected in a tighter time frame around collection of the primary outcome, and communication among data collectors, the field staff, and the research team was streamlined. In focus groups, community-based data collectors reported feeling more empowered and engaged in the data collection process after implementation of the application. CONCLUSIONS: A Web-based management application was successful in improving data collection time efficiency and engagement among data collectors.

A Community Cultural Wealth Model to Train Promotoras as Data Collectors.

The literature has documented the use of community health workers as an effective strategy to work with underserved communities. However, there is scant research on the strategies community health workers use when working in research studies. This qualitative study examines how promotoras (community health workers) implement their community cultural wealth to participate as data collectors in the control site of the Niños Sanos, Familia Sana (Healthy Children, Healthy Family) study. Our findings indicate that promotoras implement their cultural values, knowledge, and practices to recruit study participants and facilitate the data collection process. This study has implications for the recruitment and development of culturally and relevant linguistic training targeting promotoras in Mexican-origin communities.

Purchases Made with a Fruit and Vegetable Voucher in a Rural Mexican-Heritage Community.

Recent recommendations for US food assistance programs are intended to ensure foods provided through these programs help households consume a varied, healthful diet. From a policy viewpoint, it is important to examine the impact of economic incentives to purchase healthy foods across subpopulations, particularly low-income Latinos, who comprise 40% of the WIC program nationwide. Our aim was to determine how rural, Mexican-heritage households (N = 227) residing in California's Central Valley distributed fruit and vegetable (F/V) voucher spending among F/V subgroups and specific items over a 1-year period. Households contained at least one child who was between 3 and 8 years old at baseline and had a parent of Mexican-heritage. F/V voucher purchase data were collected via grocery store scanners. Expenditure and frequency shares of subgroups and individual items were analyzed to determine purchasing habits. Fruits were the most commonly purchased subgroup, representing 55% of spending and 45% of frequency. Households allocated low percentages of their voucher to dark green and red/orange vegetables-7 and 9% respectively. Approximately 20% of purchases were good potassium sources and 30% of purchases were good fiber sources. Many of the most frequently purchased items were of cultural significance (tomatillo, chayote, chili/jalapeño pepper, and Mexican squash). This study suggests that economic incentives can contribute important nutrients to participants' diets and targeted vouchers provided by food assistance programs should continue to include culturally important foods and be aware of the cultural values of their participants.

Prevalence and Perception of Childhood Obesity in California's Farmworker Communities.

In California's central valley, childhood obesity rates are above the national average. The majority of families living in the rural, agricultural communities of this region are immigrant of Mexican heritage, and face numerous social and environmental challenges. Demographic and anthropometric data were collected from a population of Mexican-heritage children 3-8 years (N = 609) and families (N = 466) living in two central valley communities. Overall, 45 % of children and 82 % of mothers were classified as overweight or obese. Multivariable analyses indicated that mother's BMI and acculturation level were positively associated with child BMI z-score. Most children classified as overweight or obese (92 % and 53 %, respectively) were perceived as having 'normal' weight by their mothers. Childhood obesity remains a major public health issue in Mexican-heritage, central valley communities. Our model indicates that mother's BMI is predictor of child obesity, and parents tend to underestimate their child's weight status. These findings highlight a need for family-targeted and culturally-tailored approaches to address relevant perceptions of obesity and risk factors in these communities.

Social and Environmental Determinants of Child Physical Activity in a Rural Mexican-Origin Community.

California's rural agricultural communities face an increased burden of obesity and metabolic disease. The present objective is to define the social and environmental influences to child obesity and physical activity within Mexican-origin communities in California's Central Valley. A range of data (anthropometric, socioeconomic, demographic, cultural and environmental) were collected on more than 650 children enrolled in Niños Sanos, Familia Sana. Physical activity data were gathered from a subsample of children 4-7 years of age (n = 148) via accelerometer. Cross sectional analyses explored the relationship between BMI and physical activity and the influence of numerous social and environmental variables. In this sample 45 % of children were determined to be overweight or obese. Boys had a higher daily average moderate-to-vigorous physical activity than girls (p = 0.008). Chi square analyses showed weight status was associated with activity level in girls (p = 0.03) but not boys. Multivariate regression revealed several social and environmental indicators influenced BMI and physical activity (p = 0.004). In this population of school-age children of Mexican-origin, girls may benefit more from targeted efforts to increase MVPA. Family and community support systems may also boost child participation in physical activities.

Correlates of food patterns in young Latino children at high risk of obesity.

OBJECTIVE: The present paper examines the influence of age and gender on food patterns of Latino children. DESIGN: Data are from baseline of a 5-year, quasi-experimental obesity prevention study: Niños Sanos, Familia Sana (NSFS; Healthy Children, Healthy Families). In 2012, the researchers interviewed Latino parents, using a thirty-item questionnaire to ask about their children's food consumption and feeding practices. Statistical tests included t tests and ANCOVA. SETTING: Rural communities in California's Central Valley, USA. SUBJECTS: Two hundred and seventeen parents (87-89% born in Mexico) and their children (aged 2-8 years). RESULTS: Fifty-one per cent of the children were overweight or obese (≥85th percentile of BMI for age and gender). Mean BMI Z-scores were not significantly different in boys (1·10 (SD 1·07)) and girls (0·92 (SD 1·04); P=0·12). In bivariate analysis, children aged 2-4 years consumed fast and convenience foods less often (P=0·04) and WIC (Supplemental Nutrition Program for Women, Infants, and Children)-allowable foods more often than children aged 5-8 years (P=0·01). In ANCOVA, neither age nor gender was significantly related to food patterns. Mother's acculturation level was positively related to children's consumption of fast and convenience foods (P=0·0002) and negatively related to consumption of WIC foods (P=0·01). Providing role modelling and structure in scheduling meals and snacks had a positive effect on the vegetable pattern (P=0·0007), whereas meal skipping was associated with more frequent fast and convenience food consumption (P=0·04). CONCLUSIONS: Acculturation and child feeding practices jointly influence food patterns in Latino immigrant children and indicate a need for interventions that maintain diet quality as children transition to school.

Assessing Child Obesity and Physical Activity in a Hard-to-Reach Population in California's Central Valley, 2012-2013.

INTRODUCTION: In California's agricultural Central Valley, the rate of childhood obesity is higher than the national average. Adequate physical activity contributes to obesity prevention and its assessment is useful to evaluate the impact of interventions. METHODS: Niños Sanos, Familia Sana (Healthy Children, Healthy Family [NSFS]) uses community-based participatory research to implement an intervention program to reduce childhood obesity among people of Mexican origin in the Central Valley. Anthropometric measurements were conducted on more than 650 children enrolled in NSFS. Physical activity data from a subgroup of children aged 4 to 7 years (n = 134) were collected via a wearable accelerometer. RESULTS: Children were classified on the basis of age and sex-adjusted body mass index as healthy weight (57.7%); overweight (19.3%), or obese (23%). Logistic regression showed that moderate to vigorous physical activity (MVPA) was associated with a child's likelihood of having a healthy BMI (odds ratio: 1.03; 95% CI, 1.01-1.05; P = .017). CONCLUSION: NSFS's community-based participatory approach resulted in successful use of a commercial electronic device to measure physical activity quantity and quality in this hard-to-reach population. Promotion of adequate daily MVPA is an appropriate and necessary component of NSFS's childhood obesity prevention strategy.

Adaptation of a culturally relevant nutrition and physical activity program for low-income, Mexican-origin parents with young children.

Latino children experience higher rates of obesity than do non-Latino white children. Family-centered nutrition interventions can slow the rate of weight gain in this population. Niños Sanos, Familia Sana (Healthy Children, Healthy Family) is a 5-year, community-based, participatory research study that targets rural Mexican-origin farmworker families with children aged 2 to 8 years in California's Central Valley. Adaptation of a culturally relevant obesity prevention program involved qualitative research to tailor key obesity prevention messages, pilot testing and implementation of key messages and activities at family nights, and continual modification to incorporate culturally innovative elements. Of the 238 families enrolled, 53% (125) attended the recommended minimum of 5 (of 10 possible) classes during the first year. A university and community partnership can guide development of a culturally tailored obesity prevention program that is suitable for reaching a high-risk Mexican-origin audience through cooperative extension and other public health programs.

Niños Sanos, Familia Sana: Mexican immigrant study protocol for a multifaceted CBPR intervention to combat childhood obesity in two rural California towns.

BACKGROUND: Overweight and obese children are likely to develop serious health problems. Among children in the U.S., Latino children are affected disproportionally by the obesity epidemic. Niños Sanos, Familia Sana (Healthy Children, Healthy Family) is a five-year, multi-faceted intervention study to decrease the rate of BMI growth in Mexican origin children in California's Central Valley. This paper describes the methodology applied to develop and launch the study. METHODS/DESIGN: Investigators use a community-based participatory research approach to develop a quasi-experimental intervention consisting of four main components including nutrition, physical activity, economic and art-community engagement. Each component's definition, method of delivery, data collection and evaluation are described. Strategies to maintain engagement of the comparison community are reported as well. DISCUSSION: We present a study methodology for an obesity prevention intervention in communities with unique environmental conditions due to rural and isolated location, limited infrastructure capacity and limited resources. This combined with numerous cultural considerations and an unstable population with limited exposure to researcher expectations necessitates reassessment and adaptation of recruitment strategies, intervention delivery and data collection methods. Trial registration # NCT01900613. TRIAL REGISTRATION: NCT01900613.

Injection drug use as a mediator between client-perpetrated abuse and HIV status among female sex workers in two Mexico-US border cities.

We examined relationships between client-perpetrated emotional, physical, and sexual abuse, injection drug use, and HIV-serostatus among 924 female sex workers (FSWs) in Tijuana and Ciudad Juarez, two large Mexico-US border cities. We hypothesized that FSWs' injection drug use would mediate the relationship between client-perpetrated abuse and HIV-seropositivity. The prevalence of client-perpetrated emotional, physical, and sexual abuse in the past 6 months was 26, 18, and 10% respectively; prevalence of current injection drug use and HIV was 12 and 6%, respectively. Logistic regression analyses revealed that client-perpetrated sexual abuse was significantly associated with HIV-seropositivity and injection drug use, and that injection drug use was positively associated with HIV-seropositivity. Injection drug use partially mediated the relationship between client-perpetrated sexual abuse and HIV-seropositivity. Results suggest the need to address client-perpetrated violence and injection drug use when assessing HIV risk among FSWs.

An exploration of contextual factors that influence HIV risk in female sex workers in Mexico: The Social Ecological Model applied to HIV risk behaviors.

The present study examined the applicability of the Social Ecological Model for explaining condom use in a sample of female sex workers (FSWs) (N=435) participating in a behavioral intervention to increase condom use in Tijuana, Mexico. Using a multigroup path analysis, we compared women who work in bar settings (n=233) to those who worked on the street (n=202) with regard to an individual factor (self-efficacy), an interpersonal factor (client financial incentives), and a structural factor (condom access). Competing models showed differential impacts of these factors in the two venue-based groups. Having access to condoms was associated with greater self-efficacy and less unprotected sex in women who worked in bars. Among street-based FSWs, having clients offer monetary incentives for unprotected sex was related to greater unprotected sex, while having access to condoms was not. Understanding the contextual factors associated with condom use among subgroups of FSWs has important implications for the development of HIV prevention interventions.

History of abuse and psychological distress symptoms among female sex workers in two Mexico-U.S. border cities.

This study examined histories of past emotional, physical, and sexual abuse as correlates of current psychological distress using data from 916 female sex workers (FSWs) who were enrolled in a safer-sex behavioral intervention in Tijuana and Ciudad (Cd.) Juarez, Mexico. We hypothesized that histories of abuse would be associated with higher symptom levels of depression and somatization and that social support would moderate the relationship. Nonparametric correlations and a series of hierarchical regression analyses revealed that all forms of past abuse predicted higher levels of depressive symptoms, and physical and sexual abuse were significantly associated with higher levels of somatic symptoms. Social support was also significantly associated with fewer symptoms of distress; however, it was not shown to moderate the relationship between abuse history and distress.

Efficacy of a brief behavioral intervention to promote condom use among female sex workers in Tijuana and Ciudad Juarez, Mexico.

OBJECTIVES: We examined the efficacy of a brief behavioral intervention to promote condom use among female sex workers in Tijuana and Ciudad Juarez, Mexico. METHODS: We randomized 924 female sex workers 18 years or older without known HIV infection living in Tijuana and Ciudad Juarez who had recently had unprotected sex with clients to a 30-minute behavioral intervention or a didactic control condition. At baseline and 6 months, women underwent interviews and testing for HIV, syphilis, gonorrhea, and chlamydia. RESULTS: We observed a 40% decline in cumulative sexually transmitted illness incidence (P = .049) in the intervention group. Incidence density for the intervention versus control groups was 13.8 versus 24.92 per 100 person-years for sexually transmitted illnesses combined (P = .034) and 0 versus 2.01 per 100 person-years for HIV (P < .001). There were concomitant increases in the number and percentage of protected sex acts and decreases in the number of unprotected sex acts with clients (P < .05). CONCLUSIONS: This brief behavioral intervention shows promise in reducing HIV and sexually transmitted illness risk behaviors among female sex workers and may be transferable to other resource-constrained settings.

Correlates of injection drug use among female sex workers in two Mexico-U.S. border cities.

OBJECTIVE: To characterize the overlap between injection drug use and sex work by women in Tijuana and Cd. Juarez, situated on the Mexico-U.S. border. METHODS: FSWs aged > or =18 years who were not knowingly HIV-positive and reported having unprotected sex with > or =1 client in the prior 2 months underwent interviews and testing for HIV, syphilis, gonorrhea and Chlamydia. Logistic regression identified factors associated with injecting drugs within the last month. RESULTS: Of 924 FSWs, 18.0% had ever injected drugs. Among FSW-IDUs (N=114), prevalence of HIV, syphilis titers > or =1:8, gonorrhea and Chlamydia was significantly higher at 12.3%, 22.7%, 15.2% and 21.2% compared to 4.8%, 13.1%, 5.2% and 11.9% among other FSWs (N=810). FSW-IDUs also had more clients in the past 6 months (median: 300 versus 240, p=0.02). Factors independently associated with injecting drugs in the past month included living in Tijuana, being younger, being married/common-law, longer duration in the sex trade, speaking English, earning less for sex without condoms, often using drugs before sex, and knowing other FSWs who injected drugs. CONCLUSIONS: FSW-IDUs had higher STI levels, engaged in riskier behaviors and were more vulnerable to having unsafe sex with clients compared to other FSWs, indicating that this subgroup is an important bridge population requiring focused prevention.

Attitudes and Social Norms Are Related to Attendance at Childhood Obesity Prevention Classes in a Rural Mexican-Heritage Community.

OBJECTIVE: To examine factors related to attendance of Mexican-heritage parents at community-based nutrition classes to prevent childhood obesity. METHODS: Starting in 2011, interviewers collected baseline data from Niños Sanos Familia Sana (Healthy Children, Healthy Families) participants in rural California. Educators maintained attendance logs from 2012 to 2014. Informed by the Theory of Planned Behavior, interviewers administered an exit survey in 2015 to collect data on attitudes, subjective norms, health motivations, and perceived control related to attendance. Multivariable ordinal logistic regression analysis examined the correlates of attendance (n = 194, intervention group only). RESULTS: Controlling for mother's age, marital status, acculturation, and employment, attitudes and subjective norms were significantly related to attendance (odds ratio = 1.27; 95% confidence interval [CI], 1.18-1.37; P < .001). CONCLUSIONS AND IMPLICATIONS: In these Mexican-heritage participants, attitudes and subjective norms were significant correlates of attendance. The Theory of Planned Behavior may shed light on attendance of high-risk groups but further testing of instruments is needed.

Cost analysis in telemedicine: empirical evidence from sites in Arizona.

CONTEXT: Support of telemedicine for largely rural and ethnically diverse populations is premised on expectations that it increases opportunities for appropriate and timely medical services, and that it improves cost-effective service delivery. PURPOSE: To understand the cost-effectiveness of telemedicine in 8 small and/or rural sites in Arizona. METHODS: A cost analysis framework was used to measure the efficacy of telemedicine in the selected sites from May 1, 2000, to April 30, 2001. FINDINGS: The costs for telemedicine services in half the study sites were more than the costs for conventional face-to-face diagnosis when the volume of telemedicine services used at a site was relatively low. This result persisted even when the opportunity cost for the patients in accessing more traditional types of care was included in the cost estimates. CONCLUSIONS: These preliminary findings suggest that telemedicine in some instances may not be cost-effective for providing medical specialists for underserved communities, particularly if these networks are underutilized by the patient population. Further analyses are needed to assess factors influencing utilization patterns of telemedicine services by underserved and ethnic communities before implementing these programs at clinical sites.

Comparison of sexual and drug use behaviors between female sex workers in Tijuana and Ciudad Juarez, Mexico.

Female sex workers (FSWs) have been documented to have high rates of sexually transmitted diseases and HIV in many parts of the world. However, little work has been done to characterize the prevalence of these infections along the U.S.-Mexican border, where sexual tourism and culturally sanctioned sex work among nationals is widespread. The objective of this study was to compare differences in background characteristics, HIV risk behaviors, drug use, and sexually transmitted infection/HIV prevalence between FSWs who participated in a behavioral risk intervention in two U.S.-Mexican border cities. Baseline data were collected from March 2004 through September 2005. Data from 295 FSWs were compared between Tijuana and Ciudad (Cd.) Juarez. Among 155 FSWs in Tijuana and 140 in Cd. Juarez, HIV seroprevalence was 4.8% and 4.9%, respectively. FSWs in Cd. Juarez were more likely to test positive for active syphilis (31.3%) compared with Tijuana (11.8%) but did not differ in terms of the prevalence of gonorrhea and chlamydia. FSWs in both sites reported high levels of unprotected sex and use of drugs; however, FSWs in Cd. Juarez were more likely than those in Tijuana to ever have injected drugs (75% vs. 25%, p <.001). Heroin and cocaine use and injection drug use were significantly more common in Cd. Juarez, whereas methamphetamine use was more common in Tijuana. Injection of vitamins was common in both cities. Logistic regression analyses suggested that being younger, working in Cd. Juarez, and using heroin or cocaine were independently associated with active syphilis infection. In Tijuana, methamphetamine use was strongly associated with active syphilis infection. These preliminary results suggest that risk profiles for HIV/sexually transmitted infection among FSWs in these two Mexico-U.S. border cities differ, suggesting a need to tailor interventions to the specific needs in each city.

Public health needs and scientific opportunities in research on Latinas.

Much of the research on women's health has not deepened our understanding of health issues affecting Latinas. Yet integration of research on Latinas into the women's health agenda is important for at least 2 reasons. First, critical public health issues facing Latinas must be better understood if effective interventions designed to eliminate racial and ethnic disparities in health are to be developed and implemented. Second, studies on the health of Latinas represent unique opportunities to advance scientific understandings of underlying processes relevant to the health of other populations. Such research can further our knowledge of the processes underlying cultural adaptation and negotiation of changing sex roles and how these issues affect the health of women. Critical research and empirical approaches that help us to understand how race, ethnicity, sex, and class shape the health of Latinas will inform broader public health issues.