Pragmatic Adaptations to Kids SIPsmartER's Implementation Protocol Supported Its Delivery During the COVID-19 Pandemic.

OBJECTIVE: Describe the adaptation, implementation, and perceptions of Kids SIPsmartER's classroom component during the coronavirus disease-impacted 2020-2021 school year. DESIGN: Mixed methods process evaluation. SETTING: Seven rural Appalachian middle schools (US). PARTICIPANTS: Middle-school teachers (n = 14) and principals (n = 6). INTERVENTION: Kids SIPsmartER was a multilevel, school-based intervention designed to decrease sugar-sweetened beverage intake. The 12-lesson classroom component was supported by an implementation protocol. MEASURES: Implementation protocol adaptations, program perceptions, and the school context were assessed using teacher and principal interviews, teacher-completed fidelity checklists, and researcher-maintained field notes. Adaptations were mapped to the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME). ANALYSIS: Qualitative data were content coded. Quantitative data were summarized using descriptive statistics. RESULTS: All schools maintained Kids SIPsmartER and delivered 100% of lessons. Ten adaptations were made to the implementation protocol. Schools used adapted delivery approaches to meet individual needs. Teachers and principals identified more benefits than barriers to implementing the program. CONCLUSIONS AND IMPLICATIONS: Using a strategically adapted implementation protocol that was flexible to schools' individual needs allowed all middle schools to deliver Kids SIPsmartER during the 2020-2021 school year. Findings identify adaptation considerations that other school-based evidence-based interventions could incorporate to facilitate delivery during high-stress times.

Student and caregiver acceptability of a school-based intervention to improve sugar-sweetened beverage behaviors: a mixed methods study.

Kids SIPsmartER is a 6-month behavioral and health literacy intervention effective at reducing sugar-sweetened beverage (SSB) intake among middle school students and their caregivers in the rural Appalachian region. This exploratory mixed methods study utilized a convergent parallel design to assess participant acceptability of a school-based curriculum for students and a text messaging program for caregivers. Acceptability was assessed using surveys (873 students and 453 caregivers), five focus groups (34 students) and telephone interviews (22 caregivers). Quantitative data were analyzed descriptively, and qualitative data were content coded. On a 5-point scale, average quantitative survey acceptability ratings ranged from 2.7 to 3.3 among three student-rated questions and 4.1 to 4.2 among four caregiver-rated questions. Qualitative focus group findings suggested that students preferred curricular activities that were hands-on and involved social interaction, while caregiver interview results showed high acceptability of the text messaging program's design, including usability, content messages and personalization. Students and caregivers reported similar program benefits: increased knowledge of SSBs and health risks, increased awareness of SSB behaviors and support to make beverage behavior changes. Results from this study can be used to understand Kids SIPsmartER's effectiveness data, communicate the intervention's acceptability with stakeholders and plan for future implementation studies.

Associations of Body Mass Index with Self-Rated Health and Weight Perceptions Among Rural Appalachian Adolescent Students.

BACKGROUND: Adolescents with overweight or obesity are at greater risk of having physical and psychosocial consequences. With increased disparities and inadequate literature on prevalence of adolescent weight status in rural Appalachia, there is potential for further complications. Unfortunately, adolescent obesity treatment options are often limited, especially in medically underserved regions. METHODS: This cross-sectional study of adolescents at eight rural Appalachian schools examined weight status among and associations between body mass index percentile (BMIp) categories and health-related perceptions and weight-control intentions. Previously validated instruments were utilized. Analyses included independent samples t-tests, ANOVA tests, and chi-squared tests. RESULTS: Of 814 adolescents (ages 11-13; 55.0% girls), BMIp revealed 20.8% overweight, 22.7% obese, and 10.6% severely obese. Adolescents with higher BMIp categories reported poorer self-rated health, inaccurate weight perceptions, and greater weight loss intentions (all p < .05). CONCLUSIONS: Findings, including high prevalence of adolescents with overweight and obesity, emphasize the need for more obesity prevention and treatment options. Schools may be an ideal setting to reach at-risk adolescents and provide obesity prevention and treatment options, especially in medically underserved regions such as rural Appalachia. Opportunities and challenges to apply findings, including school-based obesity programs, are discussed.

Factors Influencing the Sugar-Sweetened Beverage Intake of Caregivers of Adolescents in Appalachia.

OBJECTIVE: To identify factors that influence the sugar-sweetened beverage (SSB) intake of caregivers of middle school-aged adolescents. DESIGN: Cross-sectional. SETTING: Southwestern Virginia, US, part of Central Appalachia. PARTICIPANTS: Caregivers (n = 362) of adolescents enrolled in the Kids SIPsmartER trial. Participants were mostly female (91%) and non-Hispanic White (96%), and 21% received Supplemental Nutrition Assistance Program (SNAP) benefits. MAIN OUTCOME MEASURES: Caregiver daily SSB intake and demographics, personal-level, interpersonal-level, and environmental-level determinants. ANALYSIS: Descriptive statistics, 1-way ANOVA, and stepwise regression. RESULTS: On average, caregivers consumed 25.7 (SD, 33.2) fluid ounces of SSB per day. In the final model, which included all variables, age (ß = -0.41; P < 0.05), receiving SNAP benefits (ß = 14.19; P ≤ 0.01), behavioral intentions (ß = -5.48; P ≤ 0.001), affective attitudes (ß = -2.15, P < 0.05), perceptions of whether their adolescent frequently consumes high amounts of SSB (ß = 1.92; P ≤ 0.001), and home availability (ß = 7.43; P ≤ 0.01) were significantly associated with SSB intake. CONCLUSIONS AND IMPLICATIONS: Caregivers of Appalachian middle school students are high SSB consumers. Findings highlight the importance of implementing behavioral interventions for caregivers of adolescents that target multiple levels of influence, including demographic, personal-level, interpersonal-level, and environmental-level factors. Interventions may be particularly important for communities and groups with higher SSB intakes, such as those in Appalachia and who receive SNAP benefits.

Study protocol for iSIPsmarter: A randomized-controlled trial to evaluate the efficacy, reach, and engagement of a technology-based behavioral intervention to reduce sugary beverages among rural Appalachian adults.

Sugar-sweetened beverage (SSB) consumption is disproportionately high among rural Appalachian adults, with intakes double the national average and nearly four times the recommended amount. This trial targets this major dietary risk factor and addresses notable gaps in the rural digital health intervention literature. iSIPsmarter is a technology-based behavior and health literacy intervention aimed at improving SSB behaviors. It is comprised of six Internet-delivered, interactive Cores delivered weekly, an integrated short message service (SMS) strategy to engage users in tracking and reporting SSB behaviors, and a cellular-enabled scale for in-home weighing. iSIPsmarter is adapted from an evidence-based intervention and is grounded by the Theory of Planned Behavior and health literacy, numeracy, and media literacy concepts. The RCT is guided by the RE-AIM framework and targets 244 rural Appalachian adults. The goal is to examine the efficacy of iSIPsmarter to reduce SSB in a two-group design [iSIPsmarter vs. static Participant Education website] with four assessment points. Changes in secondary outcomes (e.g., diet quality, weight, quality of life) and maintenance of outcomes will also be evaluated. Additional secondary aims are to examine reach and representativeness, patterns of user engagement, and cost. Two tertiary aims are exploratory mediation analyses and a systems-level, participatory evaluation to understand context for future organizational-level adoption of iSIPsmarter. The long-term goal is to sustain an effective, scalable, and high reach behavioral intervention to reduce SSB-related health inequities and related chronic conditions (i.e., obesity, diabetes, some obesity-related cancers, heart disease, hypertension, dental decay) in rural Appalachia and beyond. ClinicalTrial registry: NCT05030753.

Low Health Literacy Is Associated With Energy-Balance-Related Behaviors, Quality of Life, and BMI Among Rural Appalachian Middle School Students: A Cross-Sectional Study.

BACKGROUND: Many studies document associations between low health literacy (HL) and poor health behaviors and outcomes. Yet, HL is understudied among adolescents, particularly from underserved, rural communities. We targeted rural adolescents in this cross-sectional study and explored relationships between HL and (1) energy-balance-related health behaviors and (2) body mass index (BMI) and quality of life (QOL). METHODS: Surveys were administered to 7th graders across 8 middle schools in rural Appalachia. HL was assessed using the Newest Vital Sign. Energy-balance-related behaviors and QOL were assessed using validated instruments. Height and weight were objectively measured. Analyses were conducted using the Hodges-Lehmann nonparametric median difference test. RESULTS: Of the 854 adolescent students (mean age = 12; 55% female), 47% had limited HL. Relative to students with higher HL, students with lower HL reported significantly lower frequency of health-promoting behaviors (water, fruit and vegetable intake, physical activity, sleep), higher frequency of risky health behaviors (sugar-sweetened beverages, junk food, screen time), and had higher BMI percentiles and lower QOL (all p < .05). CONCLUSIONS: Low HL is associated with energy-balance-related behaviors, BMI, and QOL among rural, Appalachian adolescents. Findings underscore the relevance of HL among rural middle school students and highlight implications for school health.

Applying the socio-ecological model to understand factors associated with sugar-sweetened beverage behaviours among rural Appalachian adolescents.

OBJECTIVE: The objective of the current study was to identify factors across the socio-ecological model (SEM) associated with adolescents' sugar-sweetened beverage (SSB) intake. DESIGN: This cross-sectional study surveyed adolescents using previously validated instruments. Analyses included descriptive statistics, ANOVA tests and stepwise nonlinear regression models (i.e., two-part models) adjusted to be cluster robust. Guided by SEM, a four-step model was used to identify factors associated with adolescent SSB intake - step 1: demographics (i.e., age, gender), step 2: intrapersonal (i.e., theory of planned behaviour (attitudes, subjective norms, perceived behavioural control, behavioural intentions), health literacy, media literacy, public health literacy), step 3: interpersonal (i.e., caregiver's SSB behaviours, caregiver's SSB rules) and step 4: environmental (i.e., home SSB availability) level variables. SETTING: Eight middle schools across four rural southwest Virginia counties in Appalachia. PARTICIPANTS: Seven hundred ninety seventh grade students (55·4 % female, 44·6 % males, mean age 12 (sd 0·5) years). RESULTS: Mean SSB intake was 36·3 (sd 42·5) fluid ounces or 433·4 (sd 493·6) calories per day. In the final step of the regression model, seven variables significantly explained adolescent's SSB consumption: behavioural intention (P < 0·05), affective attitude (P < 0·05), perceived behavioural control (P < 0·05), health literacy (P < 0·001), caregiver behaviours (P < 0·05), caregiver rules (P < 0·05) and home availability (P < 0·001). CONCLUSIONS: SSB intake among adolescents in rural Appalachia was nearly three times above national mean. Home environment was the strongest predictor of adolescent SSB intake, followed by caregiver rules, caregiver behaviours and health literacy. Future interventions targeting these factors may provide the greatest opportunity to improve adolescent SSB intake.