Examining Patient- and Community-Level Factors Associated with Pediatric Mental Healthcare Access Within a Patient Navigation Program.

In 2021, national leaders in the United States declared a "national youth mental health crisis." Still, only 1-in-4 children receive adequate mental healthcare access. Patient Navigator Programs (PNPs) can improve children's referral-to-connection to mental health services. We examined patient- and community-level factors associated with pediatric mental healthcare access. Pediatric Support Services (PSS) is a PNP that triages mental and behavioral health referrals within a large health system in a southeastern state. This study analyzes PSS data from September 2017-March 2023 and Child Opportunity Index 2.0 state-normed zip-code level data to assess social drivers of health estimates. Structural equation modeling was conducted between patient- and community-level factors and connection to mental health services. Overall, 62.7% of children connected to mental health services since PSS' inception. Regardless of SDOH, as children get older, they are more likely to connect with mental health services (ß = .053, SE = .010, p < .001). Children with greater number of referral needs are more likely to connect with mental health services (ß = .034, SE = .011, p = .002). Further, children who live in communities with higher opportunity levels are more likely to connect with mental health services (ß = .016, SE = .008, p = .040), suggesting that children who live in low-income communities experience more barriers to mental healthcare. Social drivers may inform referral practices and tiered navigation support for optimal mental healthcare access among children. Further research should demonstrate the effectiveness of PNPs integrated within healthcare and community-based settings.

Systematic examination of methodological inconsistency in operationalizing cognitive reserve and its impact on identifying predictors of late-life cognition.

BACKGROUND: Cognitive reserve (CR) is the ability to maintain cognitive performance despite brain pathology. CR is built through lifecourse experiences (e.g., education) and is a key construct in promoting healthy aging. However, the operationalization of CR and its estimated association with late-life cognition varies. The purpose of this study was to systematically examine the operationalization of CR and the relationship between its operationalization and late-life cognition. METHODS: We performed a comprehensive review of experiences (proxies) used to operationalize CR. The review informed quantitative analyses using data from 1366 participants of the Memory and Aging Project to examine 1) relationships between proxies and 2) the relationship between operationalization and late-life cognition. We also conducted a factor analysis with all identified CR experiences to create a composite lifecourse CR score. Generalized linear mixed models examined the relationship between operationalizations and global cognition, with secondary outcomes of five domains of cognition to examine consistency. RESULTS: Based on a review of 753 articles, we found the majority (92.3%) of the 28 commonly used proxies have weak to no correlation between one another. There was substantial variability in the association between operationalizations and late-life global cognition (median effect size: 0.99, IQR: 0.34 to 1.39). There was not strong consistency in the association between CR operationalizations and the five cognitive domains (mean consistency: 56.1%). The average estimate for the 28 operationalizations was 0.91 (SE = 0.48), compared to 2.48 (SE = 0.40) for the lifecourse score and it was associated with all five domains of cognition. CONCLUSIONS: Inconsistent methodology is theorized as a major limitation of CR research and barrier to identification of impactful experiences for healthy cognitive aging. Based on the weak associations, it is not surprising that the relationship between CR and late-life cognition is dependent on the experience used to operationalize CR. Scores using multiple experiences across the lifecourse may help overcome such limitations. Adherence to a lifecourse approach and collaborative movement towards a consensus operationalization of CR are imperative shifts in the study of CR that can better inform research on risk factors related to cognitive decline and ultimately aid in the promotion of healthy aging.

Identifying Risk Factors Associated with Repeated Referrals Within a Pediatric Navigation Program.

Approximately 1-in-5 children have a diagnosed mental, behavioral, and/or developmental disorder or delay by age 8 in the United States. Children with such conditions often require complex, complicated diagnostic and specialty care, making them susceptible to repeated referrals and ongoing unmet healthcare needs. Patient navigation programs (PNPs) are designed to integrate care from primary care providers to community-based services, using trained navigators to help patients and their families manage referrals and connect with referred services. This study examines factors associated with repeated referrals to an active PNP to inform ongoing referral patterns and adaptations to standard navigation support within a large healthcare system in South Carolina (SC). Data is sourced from the inception of the PNP in 2017 through 2022, including 15,702 referrals. Overall, 71.07% had no repeated referrals. Children who are older, diagnosed with attention deficit disorder(s), behavioral concerns, depression, multiple referral needs, and insured by Medicaid were found to be most susceptible to repeated referrals. Conversely, children who are non-Hispanic Black, were referred at a well-child visit, and are primarily insured by private insurance or Tricare were least likely to have repeated referrals. Children who are insured by Medicaid are more likely to be younger, identify as non-Hispanic Black, Hispanic, or another race/ethnicity, and have multiple needs at time of initial referral, identifying a potentially compounded risk for those who hold multiple risk factors to experiencing repeated referrals. Findings may inform adaptations to this PNP model to adjust navigator protocol for at-risk populations and equitably optimize referral-to-service connection.

Food Insecurity, the Food Environment, and COVID-19 in Rural South Carolina.

In this study, we explored the relationship between the food environment and food security among rural adults during the COVID-19 pandemic. Researchers, with assistance from community partners, conducted a cross-sectional survey assessing the impact of COVID-19 on food access, food security, and physical activity in 9 rural South Carolina (SC) counties. This survey was administered to a purposive sample (N = 587) from August 2020 to March 2021. The dependent variable was a binary indicator of food insecurity (past 3 months), in accordance with the USDA Household Food Security Survey Module. Independent variables were sociodemographic characteristics, food environment factors (eg, shopping at grocery stores, partial markets, and farmers' markets), and shopping behaviors during the pandemic. Overall, 31% of respondents were food insecure. Food security status differed by income and household composition. Results indicate that the odds of food insecurity were higher for respondents who shopped frequently at partial markets (adjusted odds ratio [AOR] = 1.61, 95% confidence interval [CI]: 1.01-2.56) and shopped more for food before the pandemic than during the pandemic (AOR = 1.68, 95% CI: 1.07-2.64). Findings underscore the importance of examining the relationship between the food environment and food insecurity during COVID-19 in rural settings.

Differences in Rural Built Environment Perceptions Across Demographic and Social Environment Characteristics.

The benefits of physical activity to health and obesity prevention are well established. However, attributes of the built environment influence participation in physical activity. The purpose of this study is to assess differences in perceptions of neighborhood walkability across demographic characteristics and social environment factors among rural residents. In a telephone survey, adult respondents (N = 448) across nine rural counties in a southeastern state answered questions about perceived neighborhood walkability, demographic characteristics, and their neighborhood social environment. Study recruitment for a convenience sample occurred through collaborations with local community organizations. Prevalence of destinations and barriers were estimated according to demographic and neighborhood social environment characteristics. Multiple logistic regression models assessed the association of demographic and neighborhood social environment characteristics with neighborhood walkability and calculated adjusted prevalence. Relaxing places to walk were the most often reported destinations (62.0%), followed by retail destinations (45.7%), and communal destinations (42.6%). Traffic was the most reported barrier to safe walking (40.4%), followed by animals (37.5%), and crime (30.5%). Perceptions of retail and communal destinations varied by age and race. Perceptions of traffic and crime as barriers varied by race, weight status, and income. Community belonging and social cohesion were associated with lower perceptions of barriers. Study findings present demographic characteristics and social environment attributes as key factors that shape perceived neighborhood walkability. Findings can help inform programmatic efforts and environmental change strategies to improve walking in rural areas.

Enhancing Patient Activation and Self-Management Activities in Patients With Type 2 Diabetes Using the US Department of Defense Mobile Health Care Environment: Feasibility Study.

BACKGROUND: Past mobile health (mHealth) efforts to empower type 2 diabetes (T2D) self-management include portals, text messaging, collection of biometric data, electronic coaching, email, and collection of lifestyle information. OBJECTIVE: The primary objective was to enhance patient activation and self-management of T2D using the US Department of Defense's Mobile Health Care Environment (MHCE) in a patient-centered medical home setting. METHODS: A multisite study, including a user-centered design and a controlled trial, was conducted within the US Military Health System. Phase I assessed preferences regarding the enhancement of the enabling technology. Phase II was a single-blinded 12-month feasibility study that randomly assigned 240 patients to either the intervention (n=123, received mHealth technology and behavioral messages tailored to Patient Activation Measure [PAM] level at baseline) or the control group (n=117, received equipment but not messaging. The primary outcome measure was PAM scores. Secondary outcome measures included Summary of Diabetes Self-Care Activities (SDSCA) scores and cardiometabolic outcomes. We used generalized estimating equations to estimate changes in outcomes. RESULTS: The final sample consisted of 229 patients. Participants were 61.6% (141/229) male, had a mean age of 62.9 years, mean glycated hemoglobin (HbA1c) of 7.5%, mean BMI of 32.7, and a mean duration of T2D diagnosis of 9.8 years. At month 12, the control group showed significantly greater improvements compared with the intervention group in PAM scores (control mean 7.49, intervention mean 1.77; P=.007), HbA1c (control mean -0.53, intervention mean -0.11; P=.006), and low-density lipoprotein cholesterol (control mean -7.14, intervention mean 4.38; P=.01). Both groups showed significant improvement in SDSCA, BMI, waist size, and diastolic blood pressure; between-group differences were not statistically significant. Except for patients with the highest level of activation (PAM level 4), intervention group patients exhibited significant improvements in PAM scores. For patients with the lowest level of activation (PAM level 1), the intervention group showed significantly greater improvement compared with the control group in HbA1c (control mean -0.09, intervention mean -0.52; P=.04), BMI (control mean 0.58, intervention mean -1.22; P=.01), and high-density lipoprotein cholesterol levels (control mean -4.86, intervention mean 3.56; P<.001). Significant improvements were seen in AM scores, SDSCA, and waist size for both groups and in diastolic and systolic blood pressure for the control group; the between-group differences were not statistically significant. The percentage of participants who were engaged with MHCE for ≥50% of days period was 60.7% (68/112; months 0-3), 57.4% (62/108; months 3-6), 49.5% (51/103; months 6-9), and 43% (42/98; months 9-12). CONCLUSIONS: Our study produced mixed results with improvement in PAM scores and outcomes in both the intervention and control groups. Structural design issues may have hampered the influence of tailored behavioral messaging within the intervention group. TRIAL REGISTRATION: ClinicalTrials.gov NCT02949037; https://clinicaltrials.gov/ct2/show/NCT02949037. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/resprot.6993.

Family and Friend Influences on Fruit and Vegetable Intake in Elementary Aged Children.

The purpose of this study was to investigate the eating behaviors and social cognitive factors that affect fruit and vegetable consumption. Strategies to change, pros & cons, enjoyment, family support, and peer influence were measured in children ages 8-10 years both pre- and post- Zest Quest® program (pre: n = 82; post: n = 80). Children for a comparison group were selected from comparable elementary schools and pre- and post- measures were evaluated (pre: n = 92; post: n = 87). Chi-squared analyses were conducted on individual measures and Spearman correlations & linear regression were used for composite variables with fruit and vegetable consumption as the dependent variable. Results from the study demonstrated significant moderate correlations for fruit change strategies pre- (rs = 0.39) and post-intervention (rs = 0.33) and vegetable change strategies pre-intervention (rs = 0.42) in the Zest Quest® group. Peer influence (rs = 0.33) and enjoyment (rs = 0.38) showed significant moderate correlations with fruit intake in the comparison group. The regression analysis showed pros (ß = 0.24, p value 0.05) and cons (ß = 0.14, p value 0.05) to be significant predictors for fruit intake post-intervention in the Zest Quest® group. Prior to the intervention, strategies to change (ß = 0.10, p value 0.02) was a significant predictor for fruit intake and cons (ß = 0.15, p value = 0.03) for vegetable intake in this group. Family support and peer influence were not significant in the regression models, but demonstrated significance in the crude model. Eating behaviors and social cognitive factors may have an effect on fruit and vegetable consumption, but these measures are difficult to capture. Future research should continue exploring the impact of family support and peer influence on fruit and vegetable intake.

Group Prenatal Care Attendance and Women's Characteristics Associated with Low Attendance: Results from Centering and Racial Disparities (CRADLE Study).

OBJECTIVES: Group prenatal care (GPC), an alternative to individual prenatal care (IPC), is becoming more prevalent. This study aimed to describe the attendance and reasons of low attendance among pregnant women who were randomly assigned to receive GPC or IPC and explore the maternal characteristics associated with low-attendance. METHODS: This study was a descriptive study among Medically low risk pregnant women (N = 992) who were enrolled in an ongoing prospective study. Women were randomly assigned to receive CenteringPregnany GPC (N = 498) or IPC (N = 994) in a single clinical site The attendance frequency and reason for low-attendance (i.e. ≤ 5/10 sessions in GPC or ≤ 5 visits in IPC) were described separately in GPC and IPC. Multivariable logistic regressions were performed to explore the associations between maternal characteristics and low-attendance. RESULTS: On average, women in GPC attended 5.32 (3.50) sessions, with only 6.67% attending all 10 sessions. Low-attendance rate was 34.25% in GPC and 10.09% in IPC. The primary reasons for low-attendance were scheduling barriers (23.19%) and not liking GPC (16.43%) in GPC but leaving the practice (34.04%) in IPC. In multivariable analysis, lower perceived family support (P = 0.01) was positively associated with low-attendance in GPC, while smoking in early pregnancy was negatively associated low-attendance (P = 0.02) in IPC. CONCLUSIONS FOR PRACTICE: Scheduling challenges and preference for non-group settings were the top reasons for low-attendance in GPC. Changes may need to be made to the current GPC model in order to add flexibility to accommodate women's schedules and ensure adequate participation. TRIAL REGISTRATION: NCT02640638 Date Registered: 12/20/2015.

Associations Between Parental BMI and the Family Nutrition and Physical Activity Environment in a Community Sample.

The purpose of this study was to examine the relationship between parental BMI and the family environment and determine if differences exist in child diet and physical activity related parenting behaviors by parental BMI in a community sample of families recruited through elementary schools in a local school district. We found an association between parental BMI category and family nutrition and physical activity (FNPA) score. Families with an underweight or normal weight parent had a larger proportion (64.3%) of high (indicating a healthier family environment) FNPA scores and families with an overweight or obese parent had a smaller proportion (45.2%) of high FNPA scores (χ 2 = 5.247, P = 0.022). Families with a parent who was overweight or obese had 2.18 times the odds (95% CI 1.11-4.27) of being in the low FNPA ("less healthy" environment) group. Further, underweight/normal weight parents reported higher levels of monitoring of child diet (Z = -3.652, P < 0.0001), higher levels of parental monitoring of child physical activity (Z = -3.471, p < 0.001), and higher levels of parental limit setting related to child sedentary activities compared to overweight/obese parents (Z = -2.443, P = 0.01). Parent BMI and parenting behaviors are known to have a major impact on childhood obesity. In this study, lower parent BMI and authoritative parenting behaviors were associated with a less obesogenic home environment and a positive parenting style related to child eating and physical activity behaviors.

The Results of the "Positive Action for Today's Health" (PATH) Trial for Increasing Walking and Physical Activity in Underserved African-American Communities.

BACKGROUND: The "Positive Action for Today's Health" (PATH) trial tested an environmental intervention to increase walking in underserved communities. METHODS: Three matched communities were randomized to a police-patrolled walking plus social marketing, a police-patrolled walking-only, or a no-walking intervention. The 24-month intervention addressed safety and access for physical activity (PA) and utilized social marketing to enhance environmental supports for PA. African-Americans (N=434; 62% females; aged 51±16 years) provided accelerometry and psychosocial measures at baseline and 12, 18, and 24 months. Walking attendance and trail use were obtained over 24 months. RESULTS: There were no significant differences across communities over 24 months for moderate-to-vigorous PA. Walking attendance in the social marketing community showed an increase from 40 to 400 walkers per month at 9 months and sustained ~200 walkers per month through 24 months. No change in attendance was observed in the walking-only community. CONCLUSIONS: Findings support integrating social marketing strategies to increase walking in underserved African-Americans (ClinicalTrials.gov #NCT01025726).

Qualitative developmental research among low income African American adults to inform a social marketing campaign for walking.

BACKGROUND: This study describes the development of a social marketing campaign for increasing walking in a low income, high crime community as part of the Positive Action for Today's Health (PATH) trial. METHODS: Focus groups were conducted with 52 African American adults (ages 18 to 65 yrs), from two underserved communities to develop themes for a social marketing campaign to promote walking. Participants responded to questions concerning social marketing principles related to product, price, place, promotion, and positioning for increasing neighbourhood walking. RESULTS: Focus group data informed the development of the campaign objectives that were derived from the "5 Ps" to promote physical and mental health, social connectedness, safety, and confidence in walking regularly. Focus group themes indicated that physical and mental health benefits of walking were important motivators. Walking for social reasons was also important for overcoming barriers to walking. Police support from trusted officers while walking was also essential to promoting safety for walking. Print materials were developed by the steering committee, with a 12-month calendar and door hangers delivered to residents' homes to invite them to walk. Pride Stride walks empowered community walkers to serve as peer leaders for special walking events to engage new walkers. CONCLUSIONS: Essential elements for developing culturally tailored social marketing interventions for promoting walking in underserved communities are outlined for future researchers.

Contextualizing physical activity in rural adults: Do relationships between income inequality, neighborhood environments, and physical activity exist?

OBJECTIVE: To examine if income inequality, social cohesion, and neighborhood walkability are associated with physical activity among rural adults. DATA SOURCE: Cross-sectional data came from a telephone survey (August 2020-March 2021) that examined food access, physical activity, and neighborhood environments across rural counties in a southeastern state. STUDY DESIGN: Multinomial logistic regression models assessed the likelihood of being active versus inactive and insufficiently active versus inactive in this rural population. Coefficients are presented as relative risk ratios (RRRs). Statistical significance was determined using 95% confidence intervals (CIs). All analyses were performed in STATA 16.1. DATA COLLECTION/EXTRACTION METHODS: Trained university students administered the survey. Students verbally obtained consent, read survey items, and recorded responses into Qualtrics software. Upon survey completion, respondents were mailed a $10 incentive card and printed informed consent form. Eligible participants were ≥18 years old and current residents of included counties. PRINCIPAL FINDINGS: Respondents in neighborhoods with relatively high social cohesion versus low social cohesion were more likely to be active than inactive (RRR = 2.50, 95% CI: 1.27-4.90, p < 0.01), after accounting for all other variables in the model. Income inequality and neighborhood walkability were not associated with different levels of physical activity in the rural sample. CONCLUSIONS: Study findings contribute to limited knowledge on the relationship between neighborhood environmental contexts and physical activity among rural populations. The health effects of neighborhood social cohesion warrant more attention in health equity research and consideration when developing multilevel interventions to improve the health of rural populations.

School-Based Mental Health Service Utilization Through the COVID-19 Pandemic and Beyond.

BACKGROUND: We examined trends in mental health service utilization before, during, and in the immediate return to in-person learning throughout the COVID-19 pandemic. METHODS: Retrospective chart review was assessed for changes in odds of any visit being a mental health encounter from five school-based health centers from the 2018-2019 to the 2021-2022 school years. Data are limited to the in-person school year from mid-August to early June. RESULTS: Data were assessed from 1239 students seen through 2256 visits over the 4 school years (Mage = 12.93). The odds of any visit being related to a mental health encounter increased each school year, with the 2020 to 2021 and 2021 to 2022 school years having significant increases in odds (both compared to the first and to the antecedent school year). In addition, during the 2019 to 2020 and 2020 to 2021 school years, the odds of a repeated mental health encounter significantly increased from year to year. CONCLUSIONS: Findings indicate a steadily increasing number of mental health service utilization needs among adolescent students that was significantly exponentiated throughout the COVID-19 pandemic.

Community features' varying insight into emergency department use for different childhood injuries.

BACKGROUND: Community-level factors, including poverty level, minority population, and rurality are predictive of child injury rates. Community-based interventions targeting high-risk communities have been suggested for prevention and are reliant on understanding details of the community and prevalent types of injuries. The present study assessed injury rates based on characteristics of the community and for different types of injuries. METHOD: A retrospective review of emergency department visits identified zip-code and injury type data for children 0-19. Injuries related to bicycles, falls, motor-vehicle traffic (MTV), and violence were examined. Poverty level, minority population, rural classification, and insured population were obtained at the zip-code level. Regression models examined the association between community features and injury rates for the four categories of injuries. RESULTS: The results showed that the relationship between community features and injury rates was dependent on injury type. Rurality was associated with a lower rate for bicycle and falls, but a higher rate of MVT; higher insured population was associated with higher MVT and violence rates; higher minority population was associated with lower rates for falls and MTV; and higher population in poverty was associated with lower rate for MTV. CONCLUSIONS: The findings indicate that injury rates not only cluster among community-level characteristics, but also the type of injury. Variation in community features and injury types offer insight into a holistic approach to child health. PRACTICAL APPLICATIONS: In addition to other factors related to risk for injuries, health providers' knowledge of features of the local community and prevalent injuries in the environment may be helpful additions to programming geared toward lessening the burden of injuries on children and healthcare systems.

The Association between Food Security Status and the Home Food Environment among a Sample of Rural South Carolina Residents.

Prior research suggests that food security status may have an effect on the home food environment. Further, the literature suggests that food access factors may function to influence said relationship. The purpose of this research is to fill a gap in the literature on this relationship, as well as to identify potential food access effect modifiers. This research employs linear mixed effects modeling with a random intercept variable (zip codes). Eleven food access variables are included in regression analyses and are tested as potential effect modifiers in the association between food security status and the home food environment. Food security status is significantly associated with the home food environment (95% CI = 0.1-1.38) in the unadjusted model. In the adjusted model, food pantry usage is found to be a significant effect modifier on the association between food security status and the home food environment. This research concludes that food security status has a significant but disparate effect on the home food environment depending on participant food pantry usage. Practical implications from this research would be for relevant stakeholders to potentially improve rural food pantry access in order to increase the home food environment among rural and food insecure populations.

Content, placement, and acquisition of cancer education for Latino patient care: a qualitative study of medical and nursing students.

A focus group study was conducted with five medical and nursing education programs in Southeastern USA. Twenty-five third and fourth year students were queried about their experiences, beliefs, and attitudes regarding Latino patients and cancer care. A general inductive process using open coding and content comparison to identify emerging themes was used to analyze the qualitative data. Investigators used a process of constant comparison to identify emerging themes. Themes included: (1) importance of cultural specificity and relevance in cancer training, (2) timing and placement of cancer education in the curriculum, including classes and/or clinical rotations, (3) anatomical system specificity of cancer training-studying cancer in the context of a specific body system, and (4) the prevention-focused nature of cancer training. Results of the focus groups have been used to inform a web-based survey of medical and nursing students to identify gaps in cancer education specific to Latino populations.

Parent/Guardian Experiences With the Healthcare System and Community Supports for Pediatric Asthma Management.

Determinants of pediatric asthma management include child, family, healthcare, and community factors. The purpose of this study is to investigate how parents/guardians are impacted by and act on these factors to aid in their child's asthma self-management. Interviews were conducted in Fall 2020 with 12 female parents/guardians of Black/African American children who participated in a community paramedic pilot study with their child in South Carolina. Children in the initial study had an asthma diagnosis of moderate persistent asthma, had Medicaid insurance, and were determined high-risk for emergency room presentation. Inductive and deductive qualitative analysis identified that child management self-efficacy and independence, parent/guardian health literacy, parent and child negative experiences related to asthma diagnosis and management, asthma management tools, and social support from multiple sources impact child self-management. Findings from this study highlight the importance of clear asthma education and management tool recommendations from healthcare and community providers, particularly for parents/guardians with low health literacy. Health literacy impacted parental responses and likely how families comprehend Medicaid and clinical asthma guidance.

The Association between Food Insecurity and Making Hunger-Coping Trade-Offs during the COVID-19 Pandemic: The Role of Sources of Food and Easiness in Food Access.

Many individuals make financial, health and food related trade-offs to cope with the challenges of food insecurity and to meet their household needs for healthy, affordable food. A survey (n = 652) was conducted in nine rural counties in South Carolina, USA, during the COVID-19 pandemic from August 2020 to July 2021. We examine if level of food insecurity predicts hunger-coping trade-offs, and whether this relationship is moderated by easiness in food access and dependence on different food source types. Nearly one-third of the respondents experienced food insecurity. Making trade-offs between paying for food and other household expenses was common among the rural residents as on average they made nearly one type of trade-off in the past three months. The number of trade-offs was the highest among highly food insecure respondents (mean = 2.64), followed by moderately food insecure respondents (mean = 1.66); low food insecure respondents had the lowest number of trade-offs (mean = 0.39). The moderating effects of easiness in food access and dependence on food sources varied by level of food insecurity. The results show that individuals at different levels of food insecurity use different strategies to fulfill their food needs and social programs are more often utilized than personal food sources. We conclude with implications for addressing food insecurity in order to reduce the possibility of making trade-offs.

Commentary: A social-ecological perspective on obesity among Latinos.

The Southeast United States has experienced rapid growth in the Latino population - mostly Mexican immigrants - with the number of Latinos in the region nearly quadrupling over the past decade. These states, known as new settlement areas, are not as well prepared to meet the health needs of Spanish-speaking immigrants compared to traditional settlement states like Florida, Texas, and California. Unfortunately for these families, immigration to the United States is often associated with becoming obese, or having children at a higher risk for obesity. Rates of obesity have risen dramatically among all racial and ethnic groups in the past few decades, however, Latinos of all ages have the highest rates of overweight and obesity compared to other racial and ethnic groups. One explanation is that although adjustment to a new environment and culture takes considerable time, the adoption of a more sedentary lifestyle and unhealthy diet occurs more rapidly, leading to significant increases in obesity between first and subsequent generations. Families are important referents in establishing health behaviors in children, and there are broader social and physical environmental factors that have strong associations with the development of obesity as well. Moreover, immigrant families must strive to be healthy while coping with acculturative stressors. Relationships between all of these factors are typically studied in isolation. This article explores obesity among new settlement Latino families and provides an integrated conceptual model anchored in the social ecological perspective.

A university, community coalition, and town partnership to promote walking.

Less than half of all US adults report meeting physical activity recommendations of 30 minutes or more of moderate to vigorous physical activity on at least 5 days per week. Thus, community-wide ecological initiatives are needed to create environments that support incorporating physical activity into residents' daily lives. In this article we describe an ongoing collaborative service-learning partnership between Clemson University, a community coalition, and a neighboring small rural town to address local social and physical environment supports for walking. Years 1 to 3 of this collaborative initiative were evaluated using a mixed-method approach to assess physical environment changes, social environment changes, community perceptions of support for walking, community perceptions of collaborating with university students, and students' skill development. Results revealed several key environmental changes such as mapping and marking 3 walking trails in the community, development of broad marketing efforts linked to the trails that promote community health and heritage, and annual community events to promote walking and the newly developed walking trails. Interview data with community leaders identified several key themes critical to facilitating and enhancing our university and community collaboration. Lastly, students developed skills in developing partnerships, mapping, advocacy, event planning, critical reflection, and qualitative and quantitative data collection and analysis. Through this process community members and students learn evidence-based public health skills for using data and planning frameworks to guide local initiatives, engage community members in decision making, and conducting evaluations.