The psychometric testing of the functional, communicative, and critical health literacy tool.

OBJECTIVE: The purpose of this study is to assess the validity and reliability of the English version of the FCCHL tool in urban and rural, socioeconomically vulnerable or unstable, chronic comorbid adults in the United States. METHODS: A cross-sectional study measuring both validity and reliability. RESULTS: A total of 276 participants were recruited. Internal consistency was measured using Cronbach's alpha of α = 0.87. External reliability was measured by test-retest methodology. Construct validity was measured using Confirmatory Factor Analysis that showed good fit. Criterion validity was measured by comparing the mean scores of the FCCHL tool sub-scales. Concurrent validity was measured by comparison of means of the FCCHL tool and education level compared to the NVS and s-TOFHLA. CONCLUSION: The results demonstrated that the FCCHL tools is measuring three different concepts. Overall, the FCCHL tool was seen to have good validity and reliability in the identified population. PRACTICE IMPLICATIONS: The FCCHL tool is a 14-item, self-report health literacy tool measuring more than functional health literacy. The tool can be used in practice to improve not only functional health literacy, but also communicative and critical which is highly applicable.

Mobile technology intervention for weight loss in rural men: protocol for a pilot pragmatic randomised controlled trial.

INTRODUCTION: Men who are overweight or obese in the rural Midwestern USA are an unrepresented, at-risk group exhibiting rising rates of cardiovascular disease, poor access to preventive care and poor lifestyle behaviours that contribute to sedentary lifestyle and unhealthy diet. Self-monitoring of eating and activity has demonstrated efficacy for weight loss. Use of mobile technologies for self-monitoring eating and activity may address rural men's access disparities to preventive health resources and support weight loss. Our pilot trial will assess the feasibility and acceptability of two mobile applications for weight loss in rural men to inform a future, full-scale trial. METHODS AND ANALYSIS: A 6-month randomised controlled trial with contextual evaluation will randomise 80 men using a 1:1 ratio to either a Mobile Technology Plus (MT+) intervention or a basic Mobile Technology (MT) intervention in rural, midlife men (aged 40-69 years). The MT+ intervention consists of a smartphone self-monitoring application enhanced with discussion group (Lose-It premium), short message service text-based support and Wi-Fi scale. The MT group will receive only a self-monitoring application (Lose-It basic). Feasibility and acceptability will be evaluated using number of men recruited and retained, and evaluative focus group feedback. We seek to determine point estimates and variability of outcome measures of weight loss (kg and % body weight) and improved dietary and physical activity behaviours (Behavioral Risk Factor Surveillance System (BRFSS) physical activity and fruit and vegetable consumption surveys, data from Lose-It! application (kcal/day, steps/day)). Community capacity will be assessed using standard best practice methods. Descriptive content analysis will evaluate intervention acceptability and contextual sensitivity. ETHICS AND DISSEMINATION: This protocol was approved by the University of Nebraska Medical Center Institutional Review Board (IRB# 594-17-EP). Dissemination of findings will occur through ClinicalTrials.gov and publish pilot data to inform the design of a larger clinical trial. TRIAL REGISTRATION NUMBER: NCT03329079; preresults. Protocol V.10, study completion date 31 August 2020. Roles and responsibilities funder: NIH/NINR Health Disparities Section 1R15NR017522-01.

Behavior-Specific Cognitions Moderate Rural Women's Responsiveness to Web-Based Interventions for Weight Loss.

OBJECTIVE: To examine whether baseline behavior-specific cognitions moderated the effects of 2 Web-based interventions with enhanced features on weight loss success in rural women. DESIGN: Secondary analysis of behavior-specific cognition data from a community-based, randomized controlled trial, as potential moderators of weight loss over 30 months. PARTICIPANTS: Women, overweight or obese, from rural communities, aged 40-69 years (n = 200). INTERVENTIONS: Theory-based Web interventions, with enhanced features of either peer-led Web discussion or professional e-mail counseling. MAIN OUTCOME MEASURES: Benefits and barriers to healthy eating and activity; self-efficacy and interpersonal support for healthy eating and activity using validated surveys; and weight. ANALYSIS: Longitudinal multilevel models. RESULTS: Women in the professional e-mail counseling group were more likely to lose weight if they perceived fewer barriers to and higher self-efficacy for healthy eating and activity. Greater weight loss in the peer-led discussion group was observed for women with lower self-efficacy and higher perceptions of barriers. Interpersonal support did not moderate the effects of the interventions. CONCLUSIONS AND IMPLICATIONS: Although women in 2 different Web-enhanced interventions achieved similar weight loss, their baseline perceptions of behavior-specific cognitions moderated their relationship with the type of intervention and weight loss success. These findings, although exploratory, may assist in matching women to Web interventions that would best maximize weight loss success. Further research is needed.

Vicarious Experience to Affect Physical Activity in Women: A Randomized Control Trial.

People compare themselves to others for self-evaluation, practical information, and motivation for healthy behaviors. The effect of active peer models on comparative thinking is unknown. The purpose of this 12-week, randomized, two-group pilot study was to evaluate the effect of a workplace peer modeling intervention on self-efficacy, motivation, and comparative thinking. The attention control group (ACG; n = 24) received general health information. The intervention group (n = 26) met with active peer models, received an exercise prescription and information. No significant group by time interaction effects were found. Comparisons on ability (how well am I doing), opinions (what should I think or believe), future self (think about my future), and modeling (be like someone else) all increased in the intervention group (n = 21) but decreased in the ACG (n = 22). Active peer models may support physical activity behavior change through specific lines of comparative thinking.

Early life adversity and depressive symptoms predict cortisol in pregnancy.

Evidence suggests that exposure to early life adversity (ELA) programs the hypothalamic-pituitary-adrenal (HPA) axis to influence responses to later adversity and predisposes women to depression. However, few studies have examined whether ELA moderates the HPA cortisol response to adulthood adversity and depressive symptoms in pregnant women. The aims of this study were to determine (a) whether ELA, adulthood adversity, and depressive symptoms differentially predict patterns of cortisol and (b) whether ELA moderates the relationship of adulthood adversity or depressive symptoms to cortisol. This was a descriptive, cross-sectional study of pregnant women (N = 58, mean = 26.5 weeks gestation). Participants completed the Stress and Adversity Inventory and Edinburgh Depression Scale and collected salivary cortisol five times per day for 3 days to assess cortisol awakening response (CAR), diurnal cortisol slope, and cortisol area under the curve (AUC). ELA predicted a larger CAR, while depressive symptoms predicted a blunted CAR and higher cortisol AUC. Adulthood adversity predicted a blunted CAR and steeper diurnal slope, but only in women with high ELA. ELA also moderated the effect of depressive symptoms on diurnal slope. Early adversity and depressive symptoms appear to have significant effects on the HPA axis during pregnancy, with early adversity also moderating effects of depressive symptoms and adulthood adversity on cortisol regulation. Early adversity may be an important factor in identifying unique HPA phenotypes and risk for HPA axis dysregulation in pregnancy.

Weight loss is associated with improved quality of life among rural women completers of a web-based lifestyle intervention.

INTRODUCTION: The evidence for whether weight loss following longer-term lifestyle interventions results in improved health-related quality of life (HRQoL) is inconclusive. This study examines whether women who lose weight after completing an 18-month web-based lifestyle modification intervention would report a corresponding improvement in HRQoL as measured using the Patient-Reported Outcomes Measurement Information System 29-item profile (PROMIS-29 v1.0). METHODS: Data from 216 rural women, ages 40 to 69, with baseline and 18-month PROMIS-29 data were analyzed in this secondary analysis of the Women Weigh-in for Wellness clinical trial. This trial promoted lifestyle modification for initial weight loss (baseline to 6 months) and guided weight loss (6 months to 18 months) using a web-delivery format. RESULTS: After adjusting for age, number of comorbidities, change in physical activity from baseline, intervention group, and baseline PROMIS-29 scores, change in weight was associated with improved health-related quality of life (HRQoL) in the domains of depression, physical function, pain interference, fatigue, and satisfaction with social role. Logistic regressions, adjusting for the same factors, indicated women with ≥ 10% weight loss were more likely to report lower depression, higher physical function and less pain interference, compared to women who gained weight or lost < 5%. CONCLUSIONS: Among our rural women, a loss in weight from baseline appeared to be associated with overall improvement in multiple PROMIS-29 v 1.0 domains, noting the likelihood of achieving improvement was significantly higher among women who attained ≥ 10% weight loss. These findings may positively influence a woman's adherence to lifestyle modification weight loss and weight maintenance program. TRIAL REGISTRATION: ClinicalTrials.gov NCT01307644.

User Engagement Associated with Web-Intervention Features to Attain Clinically Meaningful Weight Loss and Weight Maintenance in Rural Women.

Objective: Purely web-based weight loss and weight-loss maintenance interventions show promise to influence behavior change. Yet, little is known about user engagement with features of web-based interventions that predict clinically meaningful weight loss (≥5% bodyweight loss). This study examines level of website feature engagement with the likelihood of attaining ≥5% bodyweight loss after 6 and 18 months participation in a web-based intervention, among rural women at high risk of obesity-related diseases and disability. Methods: In this secondary analysis of clinical trial data of 201 rural women, we examined weight change and user engagement, measured as clicks on specific web-based intervention features (messaging and self-tracking), as associated with clinically meaningful weight loss (baseline to 6 months) and weight-loss maintenance (6 to 18 months). Results: Generalized estimating equations, adjusted for age, intervention group, and intervention phase, revealed high engagement with messaging predicted whether women achieved ≥5% weight loss at 6 months and at 18 months. There was no effect of self-tracking. Conclusions: Being engaged with messages was associated with attaining clinically meaningful short-term and longer-term weight loss. This trial is registered with NCT01307644.

Health and appearance reasons for weight loss as predictors of long-term weight change.

This study investigated whether women's initial reasons (health, appearance to others, or appearance to self) for wanting to lose weight influenced their weight change over a 30-month web-based intervention. Multilevel modeling with 1416 observations revealed that only appearance in relation to one's self was a significant (negative) predictor. Women highly motivated to lose weight to improve their appearance in relation to themselves gained weight at 30 months, whereas those not motivated for this reason achieved clinically significant weight loss. Results suggest examining participants' initial reasons for weight loss as an important component of intervention failure or success.

Perceptions of a Peer Modeling Workplace Physical Activity Intervention for Women.

A workplace physical activity (PA) study tested a novel use of peers to deliver the intervention. Peer models provided vicarious experience for living physically active lifestyles to a group of inactive women. The purpose of this study was to describe participants' perceptions of the peer modeling intervention. Nine women from the intervention group ( n = 26) participated in a 90-minute focus group. Qualitative description using thematic analysis was used to identify themes from the focus group transcript. Two themes about the intervention were "I am left wanting more" and "focus on food." Two themes about the peer models were "real people" and "it is doable." Focus group participants perceived the peer modeling PA intervention favorably; however, they desired more attention to healthy eating and more time with peer models. Replication of the study accounting for themes identified by focus group participants is needed to strengthen the peer modeling intervention.

Feasibility and Effect of a Peer Modeling Workplace Physical Activity Intervention for Women.

Most working women do not meet current guidelines for physical activity (PA). A 12-week pilot study tested a workplace, peer modeling PA intervention. Inactive female employees from a health system were randomized to an attention control group (ACG; n = 26) or an intervention group (IG; n = 26). The ACG received health information. The IG participated in six group sessions with an active peer model and received an exercise prescription and PA information. Pre and post measures were PA (ActiGraph), Estimated VO2max (cycle ergometer), resting heart rate (HR), glucose and lipids, and cardiovascular risk. Using hierarchical linear modeling, no significant group by time effects were found. Although PA increased in both groups, F( df = 1) = 11.4, p = .002, the IG had greater improvements in fitness (VO2max, HR) and cardiovascular risk (total cholesterol, triglyceride, low density lipoprotein [LDL], calculated risk score) compared with ACG. Results support repeating this intervention in a fully powered study.

Physical Function and Health-Related Quality of Life in Overweight and Obese Rural Women Who Meet Physical Activity Recommendations.

Associations of physical function and health-related quality of life in 297 rural women, ages 40-69 years (body mass index of 28-45 kg/m2) who met activity criterion were examined using cross-sectional baseline data from the Women Weigh-in for Wellness trial (ClinicalTrials.gov NCT01307644). Assessments included demographics, 400-m walk, timed chair stands, and health-related quality of life using the Patient-Reported Outcomes Measurement Information System (PROMIS-29). Women were classified as active if they had ≥500 metabolic equivalent·min/week by the Behavioral Risk Factor Surveillance System survey (n = 103, 34.7%), or ≥150 weekly minutes of greater than or equal to moderate intensity activity by accelerometry (n = 222, 74.8%). Ordinal logistic regression models adjusted for age, comorbidities, and body mass index were calculated. Meeting activity guidelines per self-report was associated with perceptions of less fatigue and greater satisfaction with social roles, whereas meeting guidelines as measured by accelerometry was associated with faster gait speed.

Web-Based Interventions Alone or Supplemented with Peer-Led Support or Professional Email Counseling for Weight Loss and Weight Maintenance in Women from Rural Communities: Results of a Clinical Trial.

Objective. This trial compared the effectiveness of a web-based only (WO) intervention with web-based supplemented by peer-led discussion (WD) or professional email counseling (WE) across 3 phases to achieve weight loss and weight maintenance in women from underserved rural communities. Methods. 301 women (BMI of 28-45 kg/m2) randomly assigned to groups participated in guided weight loss (baseline to 6 months), guided weight loss and maintenance (6 to 18 months), and self-managed weight maintenance (18 to 30 months). Results. Retention was 88.7%, 76.5%, and 71.8% at 6, 18, and 30 months, respectively. Intent-to-treat analyses demonstrated no group differences in change in weight within any phases. At 6 months, observed mean (SD) weight loss was 5.1 (6.0) kg in WO, 4.1 (5.6) kg in WD, and 6.0 (6.3) kg in WE, with 42%, 38%, and 51%, respectively, meeting ≥ 5% weight loss. These proportions dropped by a third after phase 2 with no further change during phase 3. Conclusion. Web-based interventions assisted women from rural communities in achieving 6-month weight loss, with weight regain by half at 30 months. No group differences were potentially due to the robust nature of the web-based intervention. Trial Registration. This trial is registered with ClinicalTrials.gov NCT01307644.

Cardiovascular risk factors among college students: Knowledge, perception, and risk assessment.

OBJECTIVE: To assess college students' knowledge and perception of cardiovascular risk factors and to screen for their cardiovascular risks. PARTICIPANTS: The final sample that responded to recruitment consisted of 158 college students from a midwestern university. METHODS: A cross-sectional, descriptive study was performed using convenience sampling. RESULTS: College students were knowledgeable about cardiovascular risk factors but did not perceive themselves at risk for cardiovascular disease (CVD). Knowledge of cardiovascular risk factors was correlated with the lifetime risk estimates (ρ = .17, p = .048), and perception of cardiovascular risk was positively associated with 30-year CVD risk estimates (ρ = .16, p = .048). More than 50% of the participants had 1 or more cardiovascular risk factors. CONCLUSIONS: High knowledge level of cardiovascular risk factors was not sufficient to lower cardiovascular risks within this study population, but changing perception of cardiovascular risk factors may play a bigger role in reducing long-term cardiovascular risks.

Acceptability of mHealth Technology for Self-Monitoring Eating and Activity among Rural Men.

OBJECTIVE: To examine rural men's use and perceptions of mobile and wireless devices to self-monitor eating and physical activity (mHealth). DESIGN AND SAMPLE: Men in this 3-week pilot study used FitBit One® to log daily food intake and monitor activity. A companion application (app) allowed activity monitoring of fellow participants. Health-related text messages were received 1-3 times daily. A purposive sample of 12 rural men (ages 40-67) was recruited by community leaders. MEASURES: (1) baseline heart rate, blood pressure, and BMI, (2) FitBit One® usage, (3) investigator-generated surveys on acceptability of mHealth, and (4) focus group on experience with mHealth. RESULTS: Men were overweight (n = 3) or obese (n = 9) and 9 of 12 were hypertensive. Nine of twelve wore FitBit One® all 21 days. Eleven of 12 men logged food, with 9 of 12 doing this at least 15 of 21 days. Self-monitoring and daily text messaging increased awareness of energy intake and output. Companion app's food log needed targeting for rural foods. Rotating seasons (occupational, religious, recreational) and weak cellular signals created contextual barriers to self-monitoring eating and activity. CONCLUSIONS: FitBit One® and text messaging were perceived as useful among the rural men, while the companion apps require adaptation to reflect dietary norms.

Promoting oral cancer examinations to medical primary care providers: a cluster randomized trial.

OBJECTIVES: To compare the percentage of patients who had an oral cancer examination (OCE) by their primary care provider (PCP) in medical clinics participating in a web-based education with poster reminder intervention to that of patients in control clinics. To also determine the effects for PCPs in medical clinics participating in the web-based education with poster reminder intervention as compared with those in control clinics regarding: a) index of knowledge of oral cancer risk factors (RiskOC) and b) index of knowledge of oral cancer diagnostic procedures (DiagOC). METHODS: Six medical clinics were recruited to participate in this study and randomly assigned to an intervention group or a control group. PCPs (physicians, physician assistants, and advanced practice registered nurses) took a pretest; 2 weeks later, they participated in the web-based educational program, including a posttest (intervention group) or took a posttest only (control group). In each clinic, 1 week following completion of the PCPs' posttests, 94 patients were recruited to complete a one-page survey. RESULTS: The intervention clinics were found to be a significant factor for the PCPs to perform patient OCEs, after controlling for significant covariates, that is, age, main reason for clinic visit, OCE for patient in the past year, clinic's mean DiagOC score, and clinic's mean RiskOC score. The intervention also resulted in the PCPs increasing their pretest to posttest RiskOC scores. CONCLUSIONS: The use of intervention has the potential to increase PCPs' short-term knowledge and to increase the frequency of PCPs' routine, nonsymptomatic opportunistic OCE on patients.

Sleep and health-related factors in overweight and obese rural women in a randomized controlled trial.

This secondary analysis describes sleep and health-related factors in healthy overweight and obese mid-life and older rural women enrolled in the" Women Weigh-In for Wellness" randomized clinical trial. The aim of the trial was to promote healthy behaviors and weight-loss. We analyzed demographic, anthropometric, and biomarker variables, self-reported measurements of sleep disturbance and pain interference, and objective 24-h sleep/wake patterns at baseline, 6 months, and the change over time. Although self-reported sleep disturbance reflected normal sleep, pain interference was slightly higher than normal. There were associations between higher self-reported sleep disturbance, pain interference and several other variables. Women who achieved 5 % or more weight loss exhibited positive associations between sleep, pain, and health-related factors. Weight loss and lower pain predicted lower self-reported sleep disturbance. Our results suggest that overweight and obese rural women who adopt healthy behaviors and achieve weight loss also may experience improved sleep and other health benefits. Clinical trial # NCT01307644.

Evaluating a Web-Based Educational Module on Oral Cancer Examination Based on a Behavioral Framework.

Patients at risk of developing oral and/or oropharyngeal cancer (OPC) are more likely to see primary care providers (PCPs) than a dentist. Many PCPs do not regularly perform oral cancer examination (OCE). The purpose of this study was to design a web-based educational program based on a behavioral framework to encourage PCPs to conduct OCE. PCPs were solicited to provide feedback on the program and to evaluate their short-term knowledge. The integrated behavioral model was used to design the program. Fifteen PCPs (five in each group: physicians, physician assistants, and nurse practitioners) reviewed the program and took a posttest: (1) index of knowledge of risk factors for oral cancer (RiskOC) and (2) index of knowledge of diagnostic procedures for oral cancer (DiagOC). Findings from the process evaluation were mainly positive, with comments on the length of the program comprising the ten negative comments. No significant difference among groups of PCPs (physicians, physician assistants, and nurse practitioners) was detected for DiagOC (p = 0.43) or RiskOC (p = 0.201). A program on OPC for PCPs should be less than 40 min. Postviewing knowledge outcomes were similar for all PCPs. The web-based program on OPC based on a behavioral framework could have similar short-term knowledge outcomes for all PCPs and may increase the number of PCPs performing OCEs.

Eating Self-Regulation in Overweight and Obese Adults: A Concept Analysis.

BACKGROUND: Poor eating behaviors greatly influence the development of becoming overweight or obese. Learning to better self-regulate eating is one area in which individuals can positively influence their own health. PURPOSE: The purpose of this concept analysis is to provide an in-depth analysis of the concept eating self-regulation as it pertains to overweight and obese adults using Walker and Avant's method. RESULTS: The definition for eating self-regulation formulated as a result of this concept analysis and based on the critical attributes is the ability to initiate goal-related behaviors, to consistently self-monitor dietary intake, to regularly apply willpower to resist temptations, to self-evaluate where one stands in relationship to goal attainment, and finally to maintain motivation to positively change eating behaviors. Cognitive restraint, moderation, mindfulness, disinhibition, delayed gratification, emotions and moods, self-efficacy, social support, the environment, and physical activity are the antecedents that may influence eating self-regulation. CONCLUSION: Examining an individual's weight, body mass index, lipid levels, or blood pressure are some ways to determine if self-regulation of eating behavior is achieved. With a consistent definition of self-regulation and a better understanding of the critical factors that influence eating behaviors, research can better explore how to help individuals change their eating behaviors more effectively.

Motivational Factors Predict Weight Loss in Rural Adults.

OBJECTIVE: The objective was to: (a) describe the changes over time in motivational factors of weight loss and (b) to examine predictors of weight loss in rural adults enrolled in a weight loss program. DESIGN AND SAMPLE: A longitudinal study was conducted in a convenience sample of 50 adults recruited from a rural Young Men's Christian Association. MEASURES: Questionnaires were completed at baseline (preprogram), 1, 2 and 3 months (end of program). RESULTS: Mean age was 42.4 (SD ± 11.8); 84% were female and mean BMI was 32.9 (SD ± 4.3). Individuals lost an average of 12.1 pounds. Barriers to healthy eating decreased significantly over time (p < .001). Significant predictors of weight loss included gender (ß = .501, p < .001), and the amount of change between baseline and 3 months in controlled regulation (ß = .270, p < .05), barriers to healthy eating (ß = -0.225, p < .05), and physical activity (ß = .238, p < .05) explaining 45% of the variance (F[(8, 41] = 5.92, p < .001) in weight loss. CONCLUSIONS: Rural adults were more likely to lose weight if they had higher levels of controlled regulation, if barriers were reduced, and if physical activity levels increased during the 3-month weight loss program.

Do Modifiable Cardiovascular Risk Factors Differ By Rural Classification in Women Who Enroll in a Weight Loss Intervention?

PURPOSE: If clinicians and researchers are aware of specific cardiovascular risks associated with women's rural status, whether it be large or small/isolated rural areas, it may help in developing more relevant rural resources. The purpose of this study was to examine whether there were differences in modifiable cardiovascular risk factors of overweight and obese rural women living in large or small/isolated rural areas. SAMPLE: This secondary analysis examined baseline cross-sectional data from the "Web-based Weight Loss and Weight Maintenance Intervention for Older Rural Women" clinical trial. Analysis included data from 299 rural Midwestern women, ages 40-69 years with a baseline body mass index of 28-45 kg/m2, who provided rural classification data and were randomized into groups. METHODS: Demographic and biomarker baseline data were used. Chi-square and independent t-tests were used for data analyses. FINDINGS: There are no significant differences found in overweight and obese women with cardiovascular risk factors when compared to rural classification, with one exception. Total cholesterol was associated with rural classification (p=0.047), where women living in large rural areas were more likely to have elevated total cholesterol levels (≥240 mg/dL) compared to women living in small/isolated areas (18.5% vs. 10.0%, respectively). Demographic characteristics such as age and education demonstrated no significant differences by rural classification; however, the majority of women in this study were of high socioeconomic status. CONCLUSIONS: Although this secondary analysis found that rural women have similar cardiovascular risk factors and demographic characteristics, this study highlights the need for clinicians to carefully consider the rural community characteristics for primary prevention.