Dietary Intake, Behaviors and Psychosocial Factors Among Women from Food-Secure and Food-Insecure Households in the United States.

OBJECTIVE: Determine whether macro- and micro-nutrient intake, energy intake, diet quality, adherence to recommended dietary intake, and psychosocial and behavioral factors are associated with household food security. DESIGN: Baseline data from in-person interviews and telephone-based, 24-hour dietary recall from women recruited to a diet and physical activity controlled trial. SETTING: Neighborhoods encompassing 18 urban census tracts in South Carolina. PARTICIPANTS: Participants (n=202) were predominantly African American (87%), overweight or obese women aged 25 to 51 years with mean body mass index of 40.6±8.7. MAIN OUTCOME MEASURES: Macro- and micro-nutrient intake, energy intake, diet quality, adherence to recommended dietary intake (via multi-pass, 24-h recall); diet-related self-efficacy and social support, healthy/lowfat and emotional eating behaviors, and depressive symptoms. RESULTS: Women in food-secure (FS) and food insecure (FI) households were not different on health and sociodemographic characteristics. Women in FI households had lower self-efficacy and healthy/low-fat eating behaviors, and higher emotional eating and depressive symptoms compared with women in FS households. The groups did not differ on social support. Significant dietary differences were few (FS>FI on protein and lean meat; FS

Process Evaluation of the Project SHINE Intervention for African American Families: An Integrated Positive Parenting and Peer Monitoring Approach to Health Promotion.

This study describes the process evaluation of Project SHINE, a randomized family-based health promotion intervention that integrated parenting and peer monitoring for improving sedentary behavior, physical activity, and diet in African American families. Adolescent-parent dyads (n = 89) were randomized to a 6-week behavioral, positive parenting, and peer monitoring skills intervention or a general health education comparison condition. Process evaluation included observational ratings of fidelity, attendance records, psychosocial measures, and qualitative interviews. Results indicated that the intervention was delivered with high fidelity based on facilitator adherence (>98% of content delivered) and competent use of theoretically based behavior change and positive parenting skills (100% of ratings >3 on a 1-4 scale). Although only 43% of peers attended the "bring a friend" session, overall attendance was high (4.39 ± 1.51 sessions) as was the retention rate (88%). Parents in the intervention condition reported significant improvements in communication related to adolescents' engagement in health behaviors both on their own and with peers. These findings were supported by qualitative themes related to improvements in family communication and connectedness. This study provides an innovative example of how future family-based health promotion trials can expand their process evaluation approaches by assessing theoretically relevant positive parenting variables as part of ongoing monitoring.

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).

Identifying emergent social networks at a federally qualified health center-based farmers' market.

Identifying potential mechanisms connecting farmers' market interventions with health, economic, and community outcomes could inform strategies for addressing health disparities. The present study used social network theory to guide the in-depth examination of naturally occurring social interactions at a farmers' market located at a federally qualified health center located in a rural, low-income community. Trained observers recorded 61 observation logs at the market over 18 weeks. Thematic analysis revealed a range of actors and nonhuman facilitators instrumental to the farmers' market context. These actors connected with one another for communication and relationship development, economic and financial exchange, education, resource sharing, community ownership of the farmers' market, and conflict resolution. These interactions provided opportunities for social networks to develop among attendees, which may have facilitated the acquisition of social supports related to improved health, economic and community outcomes. Results provide insight into the role social networks may play in mediating the relationship between a farmers' market intervention and individual benefits. Findings also contribute to defining the typology of social networks, which may further disentangle the complex relationships between social networks and health outcomes. Future research should identify strategies for purposefully targeting social networks as a way to reduce diet-related health disparities.

Project SHINE: effects of parent-adolescent communication on sedentary behavior in African American adolescents.

OBJECTIVE: This study examined parenting variables (communication, monitoring) as moderators of a family-based intervention for reducing sedentary behavior (SB) in African American adolescents. As a secondary aim, a similar model was tested using adolescent weight status as the outcome. METHODS: African American adolescents (n = 73; 12.45 ± 1.45 years; 60% girls; 63% overweight/obese) and caregivers were randomized to a 6-week interactive, parent-based intervention or general health condition. Parent-adolescent communication and monitoring of health behaviors were self-reported by parents. Adolescent SB was self-reported by youth. RESULTS: There was a significant intervention by communication interaction, such that intervention families with more positive communication showed lower adolescent SB than those with less positive communication or those in the comparison condition. No effects were found for monitoring on SB or for the model with weight status as the outcome. CONCLUSIONS: Parent-adolescent communication may be an effective component to integrate into health promotion programs for African American adolescents.

Effects of parenting style and parent-related weight and diet on adolescent weight status.

OBJECTIVE: This study examined the interaction between parental limit setting of sedentary behaviors and health factors (weight status, physical activity [PA], fruit and vegetable [FV] intake) on standardized body mass index (zBMI) in African American adolescents. METHODS: Data were from 67 parent-adolescent dyads. Parental limit setting, PA and FV intake were assessed via self-report, and objective height and weight measurements were collected. RESULTS: Regressions examined the interaction between parental limit setting and BMI, PA, FV intake on adolescent zBMI. The model for parent BMI and FV intake accounted for 31% of the variance in adolescent zBMI. A significant interaction for parent BMI by limit setting showed that as parental BMI increased, higher (vs. lower) limit setting was associated with lower adolescent zBMI. Higher parent FV consumption was associated with lower adolescent zBMI. CONCLUSION: Future interventions should integrate parent limit setting and target parent fruit and vegetable intake for obesity prevention in underserved adolescents.

Formative process evaluation for implementing a social marketing intervention to increase walking among African Americans in the Positive Action for Today's Health trial.

OBJECTIVES: Evaluating programs targeting physical activity may help to reduce disparate rates of obesity among African Americans. We report formative process evaluation methods and implementation dose, fidelity, and reach in the Positive Action for Today's Health trial. METHODS: We applied evaluation methods based on an ecological framework in 2 community-based police-patrolled walking programs targeting access and safety in underserved African American communities. One program also targeted social connectedness and motivation to walk using a social marketing approach. Process data were systematically collected from baseline to 12 months. RESULTS: Adequate implementation dose was achieved, with fidelity achieved but less stable in both programs. Monthly walkers increased to 424 in the walking-plus-social marketing program, indicating expanding program reach, in contrast to no increase in the walking-only program. Increased reach was correlated with peer-led Pride Strides (r = .92; P < .001), a key social marketing component, and program social interaction was the primary reason for which walkers reported participating. CONCLUSIONS: Formative process evaluation demonstrated that the walking programs were effectively implemented and that social marketing increased walking and perceived social connectedness in African American communities.

Multilevel Associations of Neighborhood Poverty, Crime, and Satisfaction With Blood Pressure in African-American Adults.

BACKGROUND: African-American adults experience the highest rates of elevated blood pressure (BP), and this disparity may be linked to socioeconomic and neighborhood-related disadvantage. Based on a bioecological stress-buffering framework, relations of poverty and neighborhood environmental perceptions with BP were assessed using multilevel regression in at-risk African-American adults. METHODS: This cross-sectional study used baseline data that were collected in 2008 as part of the Positive Action for Today's Health (PATH) trial (N = 409), a community-based intervention to increase walking in low-income, high-crime neighborhoods. BP and perceived neighborhood crime and satisfaction were investigated as individual-level indicators of health and neighborhood environment. Census block groups (N = 22) served as geographic proxies for neighborhoods, and poverty was obtained using 2010 U.S. Census data, to characterize the neighborhood-level socioeconomic environment. RESULTS: There were no individual-level direct associations. Significant cross-product interactions demonstrated that with higher perceived crime, high satisfaction was associated with lower systolic (γ = 3.34) and diastolic (γ = -1.37) BP, but low satisfaction was associated with higher systolic (γ = 15.12) and diastolic (γ = 7.57) BP. Neighborhood-level poverty was associated with diastolic (γ = 11.48, SE = 4.08, P = 0.008) and systolic BP (γ = 12.79, SE = 6.33, P = 0.052). Variance in BP across block groups was low (intraclass correlation coefficients = 0.002-0.014) and there were no significant random effects. CONCLUSIONS: Results supported hypotheses, with greater neighborhood satisfaction linked to lower systolic and diastolic BP when perceived crime was high. Neighborhood poverty was also linked to higher systolic and diastolic BP. Prevention efforts should further investigate whether attending to issues of poverty and related neighborhood perceptions reduces high BP in at-risk African-American communities.

Dissemination of an Electronic Manual to Build Capacity for Implementing Farmers' Markets with Community Health Centers.

Community-university partnerships can lend themselves to the development of tools that encourage and promote future community health development. The electronic manual, "Building Farmacies," describes an approach for developing capacity and sustaining a community health center-based farmers' market that emerged through a community-university partnership. Manual development was guided by the Knowledge to Action Framework and experiences developing a multivendor, produce-only farmers' market at a community health center in rural South Carolina. The manual was created to illustrate an innovative solution for community health development. The manual was disseminated electronically through 25 listservs and interested individuals voluntarily completed a Web-based survey to access the free manual. During the 6-month dissemination period, 271 individuals downloaded the manual. Findings highlighted the value of translating community-based participatory research into user-friendly manuals to guide future intervention development and dissemination approaches, and demonstrate the need to include capacity building opportunities to support translation and adoption of interventions.

A Participatory Model for Evaluating a Multilevel Farmers' Market Intervention.

BACKGROUND: Well-designed evaluation is necessary to document the impact of farmers' markets (FMs) on health, economic, and community outcomes. However, the complex nature of FMs poses challenges for evaluation. OBJECTIVE: Our goal is to describe a participatory, multilevel framework used to evaluate a FM implemented at a federally qualified health center (FQHC) in a rural community in the Southeastern United States. METHODS: An iterative, collaborative process involving three feedback loops was used to engage community stakeholders in the development, implementation, and utilization of the multilevel evaluation plan. LESSONS LEARNED: A participatory approach helped to navigate the complexities of evaluating FMs and promoted stakeholder engagement. The evaluation became a core element of the intervention that informed continuous quality improvement (CQI). The development of strong university- community partnerships facilitated the ongoing use of results. CONCLUSIONS: The evaluation framework presented may be used to promote community engagement and rigor for evaluation of future FMs.

Development of an innovative process evaluation approach for the Families Improving Together (FIT) for weight loss trial in African American adolescents.

UNLABELLED: This study demonstrates how a multi-theoretical, multilevel process evaluation was used to assess implementation of the Families Improving Together (FIT) for weight loss intervention. FIT is a randomized controlled trial evaluating a culturally tailored, motivational plus family-based program on weight loss in African American adolescents and their parents. Social Cognitive, Self Determination, Family Systems theories and cultural tailoring principles guided the conceptualization of essential elements across individual/family, facilitator, and group levels. Data collection included an observational rating tool, attendance records, and a validated psychosocial measure. RESULTS: Attendance records (0=absent, 1=present, criteria=≥70%) indicated that 71.5% of families attended each session. The survey (1=false, 6=true, criteria=≥4.5) indicated that participants perceived a positive group climate (M=5.16, SD=0.69). A trained evaluator reported that facilitator dose delivered (0=no, 1=yes, criteria=≥75%) was high (99.6%), and fidelity (1=none to 4=all, criteria=≥3) was adequate at facilitator (M=3.63, SD=0.41) and group levels (M=3.35, SD=0.49). Five cultural topics were raised by participants related to eating (n=3) and physical activity (n=2) behaviors and were integrated as part of the final curriculum. DISCUSSION: Results identify areas for program improvement related to delivery of multi-theoretical and cultural tailoring elements. Findings may inform future strategies for implementing effective weight loss programs for ethnic minority families.

An overview of the Families Improving Together (FIT) for weight loss randomized controlled trial in African American families.

BACKGROUND: The Families Improving Together (FIT) randomized controlled trial tests the efficacy of integrating cultural tailoring, positive parenting, and motivational strategies into a comprehensive curriculum for weight loss in African American adolescents. The overall goal of the FIT trial is to test the effects of an integrated intervention curriculum and the added effects of a tailored web-based intervention on reducing z-BMI in overweight African American adolescents. DESIGN AND SETTING: The FIT trial is a randomized group cohort design the will involve 520 African American families with an overweight adolescent between the ages of 11-16 years. The trial tests the efficacy of an 8-week face-to-face group randomized program comparing M + FWL (Motivational Plus Family Weight Loss) to a comprehensive health education program (CHE) and re-randomizes participants to either an 8-week on-line tailored intervention or control on-line program resulting in a 2 (M + FWL vs. CHE group) × 2 (on-line intervention vs. control on-line program) factorial design to test the effects of the intervention on reducing z-BMI at post-treatment and at 6-month follow-up. INTERVENTION: The interventions for this trial are based on a theoretical framework that is novel and integrates elements from cultural tailoring, Family Systems Theory, Self-Determination Theory and Social Cognitive Theory. The intervention targets positive parenting skills (parenting style, monitoring, communication); cultural values; teaching parents to increase youth motivation by encouraging youth to have input and choice (autonomy-support); and provides a framework for building skills and self-efficacy through developing weight loss action plans that target goal setting, monitoring, and positive feedback.

A pilot study of the effects of a tailored web-based intervention on promoting fruit and vegetable intake in African American families.

BACKGROUND: The current study examined the effects of a Web-based tailored parenting intervention on increasing fruit and vegetable intake in African American families. METHODS: Forty-seven African American parents (mean age, 41.32 ± 7.30; 93.6% female) with an adolescent (mean age, 13.32 ± 1.46; 59.6% female) participated in a Web-based autonomy-support parenting tailored intervention session to increase both parent and youth fruit and vegetable (F&V) intake. The session lasted 45-60 minutes and included three phases: a feedback phase; a Web-based information phase, and a goal-setting and action plan phase. Self-reported measures of parenting skills [based on autonomy (choice), support, and communication] and F&V intake (assessed as average daily intake) were assessed at baseline and at a 1-week follow-up session. RESULTS: There was a significant increase in parents' self-reports of daily fruit intake from pretest to the 1-week follow-up. Parent and adolescent combined F&V intake also significantly increased from pretest to 1-week follow-up. Overall, parents reported that the program was easy to navigate and that they enjoyed participating in the Web-based online program. CONCLUSIONS: Current findings provide preliminary support for an autonomy-support parent tailored Web-based program for improving dietary intake in African American families.

Imputational modeling of spatial context and social environmental predictors of walking in an underserved community: the PATH trial.

BACKGROUND: This study examined imputational modeling effects of spatial proximity and social factors of walking in African American adults. PURPOSE: Models were compared that examined relationships between household proximity to a walking trail and social factors in determining walking status. METHODS: Participants (N=133; 66% female; mean age=55 years) were recruited to a police-supported walking and social marketing intervention. Bayesian modeling was used to identify predictors of walking at 12 months. RESULTS: Sensitivity analysis using different imputation approaches, and spatial contextual effects, were compared. All the imputation methods showed social life and income were significant predictors of walking, however, the complete data approach was the best model indicating Age (1.04, 95% OR: 1.00, 1.08), Social Life (0.83, 95% OR: 0.69, 0.98) and Income <$10,000 (0.10, 95% OR: 0.01, 0.97) were all predictors of walking. CONCLUSIONS: The complete data approach was the best model of predictors of walking in African Americans.

The associations of parenting factors with adolescent body mass index in an underserved population.

BACKGROUND: The current study examined parental factors related to risk of adolescent obesity within the context of a family systems framework. METHODS: Seventy predominantly African American, low-income caregiver-adolescent dyads participated in the study. Validated measures of parental perceived child risk for development of type 2 diabetes mellitus, parental limit setting for sedentary behavior, and parental nurturance were evaluated as predictors of adolescent body mass index. RESULTS: In this cross-sectional study, multiple linear regression demonstrated that parents of adolescents with higher zBMI reported worrying more about their child's risk of developing type 2 diabetes mellitus. Parent limit setting was also a significant predictor of adolescent zBMI. Contrary to expectations, higher levels of nurturance were associated with higher adolescent zBMI. Post hoc analyses revealed a trend towards a significant interaction between nurturance and limit setting, such that high levels of both parental nurturance and limit setting were associated with lower adolescent zBMI. CONCLUSIONS: Current findings suggest the importance of authoritative parenting and monitoring of adolescent health behaviors in the treatment of obesity.