The Social Construction of Aging Among a Clinic-Based Population and Their Healthcare Workers in Zambia.

Objectives: We sought to understand the social construction of aging in a clinic-based population, with and without HIV, to address gaps in care for older individuals living with HIV in Zambia. Methods: Our exploratory qualitative study included 36 in-depth interviews with clinic clients and four focus group discussions with 36 professional and lay healthcare workers providing services to the clients. We identified themes based on social construction theory. Results: At the individual level, aging was multidimensional, perceived both as an achievement in the HIV era and as a period of cognitive, physical, and economic decline. In social interactions, older individuals were often stereotyped and treated as helpless, poor, and "witches." Those living with HIV faced the additional stigma of being labeled as promiscuous. Some of the participants living without HIV refused to take daily medication for non-communicable diseases to avoid being mistaken for taking antiretroviral therapy for HIV. Older individuals wanted quality healthcare and family support to address the intersectional stigma of aging, poverty, and chronic illness. Conclusion: Multifaceted interventions are required to combat age-related prejudice, intersectional stigma, and discriminatory practices, particularly for people living with HIV.

Federal Food Assistance Accessibility and Acceptability Among Indigenous Peoples in the United States: A Scoping Review.

The purpose of this scoping review was to determine the extent to which accessibility and acceptability of federal food assistance programs in the United States have been evaluated among indigenous peoples and to summarize what is currently known. Twelve publications were found that examine aspects of accessibility or acceptability by indigenous peoples of 1 or more federal food assistance programs, including the supplemental nutrition assistance program (SNAP) and/or the Food Distribution Program on Indian Reservations (n = 8), the Special Supplemental Nutrition Program for Women, infants, and children (WIC) (n = 3), and the national school lunch program (n = 1). No publications were found to include the commodity supplemental food program or the child and adult care food program. Publications ranged in time from 1990-2023, and all reported on findings from rural populations, whereas 3 also included urban settings. Program accessibility varied by program type and geographic location. Road conditions, transportation access, telephone and internet connectivity, and an overall number of food stores were identified as key access barriers to SNAP and WIC benefit redemption in rural areas. Program acceptability was attributed to factors such as being tribally administered, providing culturally sensitive services, and offering foods of cultural significance. For these reasons, Food Distribution Program on Indian Reservations and WIC were more frequently described as acceptable compared to SNAP and national school lunch programs. However, SNAP was occasionally described as more acceptable than other assistance programs because it allows participants autonomy to decide which foods to purchase and when. Overall, little attention has been paid to the accessibility and acceptability of federal food assistance programs among indigenous peoples in the United States. More research is needed to understand and improve the participation experiences and health trajectories of these priority populations.

Effect of an Arsenic Mitigation Program on Arsenic Exposure in American Indian Communities: A Cluster Randomized Controlled Trial of the Community-Led Strong Heart Water Study Program.

BACKGROUND: Chronic arsenic exposure has been associated with an increased risk of cardiovascular disease; diabetes; cancers of the lung, pancreas and prostate; and all-cause mortality in American Indian communities in the Strong Heart Study. OBJECTIVE: The Strong Heart Water Study (SHWS) designed and evaluated a multilevel, community-led arsenic mitigation program to reduce arsenic exposure among private well users in partnership with Northern Great Plains American Indian Nations. METHODS: A cluster randomized controlled trial (cRCT) was conducted to evaluate the effectiveness of the SHWS arsenic mitigation program over a 2-y period on a) urinary arsenic, and b) reported use of arsenic-safe water for drinking and cooking. The cRCT compared the installation of a point-of-use arsenic filter and a mobile Health (mHealth) program (3 phone calls; SHWS mHealth and Filter arm) to a more intensive program, which included this same program plus three home visits (3 phone calls and 3 home visits; SHWS Intensive arm). RESULTS: A 47% reduction in urinary arsenic [geometric mean (GM)=13.2 to 7.0µg/g creatinine] was observed from baseline to the final follow-up when both study arms were combined. By treatment arm, the reduction in urinary arsenic from baseline to the final follow-up visit was 55% in the mHealth and Filter arm (GM=14.6 to 6.55µg/g creatinine) and 30% in the Intensive arm (GM=11.2 to 7.82µg/g creatinine). There was no significant difference in urinary arsenic levels by treatment arm at the final follow-up visit comparing the Intensive vs. mHealth and Filter arms: GM ratio of 1.21 (95% confidence interval: 0.77, 1.90). In both arms combined, exclusive use of arsenic-safe water from baseline to the final follow-up visit significantly increased for water used for cooking (17% to 53%) and drinking (12% to 46%). DISCUSSION: Delivery of the interventions for the community-led SHWS arsenic mitigation program, including the installation of a point-of-use arsenic filter and a mHealth program on the use of arsenic-safe water (calls only, no home visits), resulted in a significant reduction in urinary arsenic and increases in reported use of arsenic-safe water for drinking and cooking during the 2-y study period. These results demonstrate that the installation of an arsenic filter and phone calls from a mHealth program presents a promising approach to reduce water arsenic exposure among private well users. https://doi.org/10.1289/EHP12548.

Obesity contagion among classmates: Children's relation with each other regarding weight status, physical activity, and dietary intake.

A series of influential articles suggests that obesity may spread between couples, siblings, and close friends via an obesity contagion phenomenon. Classmates, as important structural equivalents in one's social network, may experience obesity contagion. However, this has rarely been examined. Anthropometric measurements, questionnaire surveys, and geographic information were collected from 3670 children from 26 schools in Northeast China. We found that classmates were positively related in terms of body mass index (BMI), body fat, physical activity, and intake of vegetables, fruits, fast food, snacks, and sugar-sweetened beverages. One standard deviation (SD) increase in classmates' mean BMI and percentage body fat was associated with 0.19 SD higher individual BMI (95% confidence interval [CI]: 0.00, 0.39) and 0.31 SD higher percentage body fat (95% CI: 0.13, 0.48). Coefficients ranged from 0.48 to 0.76 in models for physical activity, and the dietary intake of vegetables, fruit, fast food, snacks, and sugar-sweetened beverages. Children's BMI and body fat were more strongly associated with the maximum and minimum body fat levels of their same-sex classmates than with those of their general classmates. Their dietary intake and physical activity were more strongly associated with the mean/median levels of their general classmates than with those of their same-sex classmates. This study suggests that children's BMI, body fat, physical activity, and dietary intake may be related to those of their classmates. Modeling healthy behaviors in the classroom may help children develop habits that support achieving and maintaining a healthy weight. Future interventions should consider the inclusion of classmates as a social network strategy for obesity prevention.

Lifestyle Medicine Implementation in 8 Health Systems: Protocol for a Multiple Case Study Investigation.

BACKGROUND: Lifestyle medicine (LM) is the use of therapeutic lifestyle changes (including a whole-food, plant-predominant eating pattern; regular physical activity; restorative sleep; stress management; avoidance of risky substances; and positive social connection) to prevent and treat chronic illness. Despite growing evidence, LM is still not widely implemented in health care settings. Potential challenges to LM implementation include lack of clinician training, staffing concerns, and misalignment of LM services with fee-for-service reimbursement, but the full range of factors facilitating or obstructing its implementation and long-term success are not yet understood. To learn important lessons for success and failure, it is crucial to understand the experiences of different LM programs. OBJECTIVE: This study aims to describe in depth the protocol used to identify barriers and facilitators impacting the implementation of LM in health systems. METHODS: The study team comprises team members at the American College of Lifestyle Medicine (ACLM), including staff and researchers with expertise in public health, LM, and qualitative research. We recruited health systems that were members of the ACLM Health Systems Council. From among 15 self-nominating health systems, we selected 7 to represent a diversity of geographic location, type, size, expertise, funding, patients, and LM services. Partway through the study, we recruited 1 additional contrasting health system to serve as a negative case. For each case, we conducted in-depth interviews, document reviews, site visits (limited due to the COVID-19 pandemic), and study team debriefs. Interviews lasted 45-90 minutes and followed a semistructured interview guide, loosely based on the Consolidated Framework for Implementation Research (CFIR) model. We are constructing detailed case narrative reports for each health system that are subsequently used in cross-case analyses to develop a contextually rich and detailed understanding of various predetermined and emergent topics. Cross-case analyses will draw on a variety of methodologies, including in-depth case familiarization, inductive or deductive coding, and thematic analysis, to identify cross-cutting themes. RESULTS: The study team has completed data collection for all 8 participating health systems, including 68 interviews and 1 site visit. We are currently drafting descriptive case narratives, which will be disseminated to participating health systems for member checking and shared broadly as applied vignettes. We are also conducting cross-case analyses to identify critical facilitators and barriers, explore clinician training strategies to facilitate LM implementation, and develop an explanatory model connecting practitioner adoption of LM and experiences of burnout. CONCLUSIONS: This protocol paper offers real-world insights into research methods and practices to identify barriers and facilitators to the implementation of LM in health systems. Findings can advise LM implementation across various health system contexts. Methodological limitations and lessons learned can guide the execution of other studies with similar methodologies. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/51562.

Design of an innovative digital application to facilitate access to healthy foods in low-income urban settings.

Background: Under-resourced urban minority communities in the United States are characterized by food environments with low access to healthy foods, high food insecurity, and high rates of diet-related chronic disease. In Baltimore, Maryland, low access to healthy food largely results from a distribution gap between small food sources (retailers) and their suppliers. Digital interventions have the potential to address this gap, while keeping costs low. Methods: In this paper, we describe the technical (I) front-end design and (II) back-end development process of the Baltimore Urban food Distribution (BUD) application (app). We identify and detail four main phases of the process: (I) information architecture; (II) low and high-fidelity wireframes; (III) prototype; and (IV) back-end components, while considering formative research and a pre-pilot test of a preliminary version of the BUD app. Results: Our lessons learned provide valuable insight into developing a stable app with a user-friendly experience and interface, and accessible cloud computing services for advanced technical features. Conclusions: Next steps will involve a pilot trial of the app in Baltimore, and eventually, other urban and rural settings nationwide. Once iterative feedback is incorporated into the app, all code will be made publicly available via an open source repository to encourage adaptation for desired communities. Trial Registration: ClinicalTrials.gov NCT05010018.

Shared Perceptions on Upstream Factors that Influence Water and Sugar-Sweetened Beverage Consumption Among Hispanic Families in the Greater Washington, DC, Metro Area: Qualitative Results From Focus Group Discussions.

BACKGROUND: Hispanics in the United States are among those with highest consumption of sugar-sweetened beverages (SSBs) and lowest consumption of water. These dietary disparities are rooted in systemic influences that must be identified and addressed. OBJECTIVE: The study aimed to describe how Hispanic parents currently living in the greater Washington, DC, metro area and born outside of the United States, perceived upstream factors that influenced their current beverage choice. DESIGN: Six qualitative focus groups were conducted in Spanish in 2021. PARTICIPANTS/SETTING: Hispanic parents (n = 31) of children enrolled in Early Head Start in the greater Washington, DC, metro area were recruited (all women, born outside the United States, and spoke Spanish as a first language). STATISTICAL ANALYSIS: Verbatim transcripts were analyzed deductively using the Community Energy Balance Framework. RESULTS: The five key findings were: Growing up (in their countries of origin in Central America and Mexico) participants were used to drinking water, often gathered it from the source, and liked its flavor. Relatives passed down their knowledge about potabilization of water, the health benefits of drinking water, and health consequences of drinking SSBs. Growing up, prepackaged SSBs were not as accessible compared with where they now live in the United States. Participants perceived that sociocultural hospitality norms dictated that guests should be served SSBs and not water. Participants noted that messages regarding juice and water across US public health programs and policies were not aligned. CONCLUSIONS: These findings suggest there are opportunities for public health messaging and procurement of safe, palatable drinking water in lieu of SSBs and juice.

Ours to eat and own: assessing the feasibility of a cooperative meal-kit service to improve food access.

OBJECTIVE: Although typically serving higher income and younger demographic groups, meal-kit subscription services have the potential to improve food availability and dietary quality in communities experiencing low food access due to systemic discrimination. This study describes the development and characteristics of a pilot community-led meal-kit service (SouthEats) and evaluates key implementation outcomes of adoption, acceptability, and feasibility among households experiencing less income. DESIGN: We utilised a mixed methods study design, including data from administrative records, customer surveys and worker interviews. Thematic qualitative analyses and descriptive quantitative analyses were conducted to illuminate the characteristics and extent the pilot meal-kit service was adopted, acceptable, and financially feasible among the target populations. SETTING: The study took place in Washington DC, USA. PARTICIPANTS: Study participants included SouthEats consumers (n 35) and workers (n 3). RESULTS: During the pilot period, sixty-seven community members signed up for the meal-kit service, with 52 % making recurring purchases. Our results suggest that the meal-kit service is acceptable among people living in low food access areas. Our feasibility analysis indicates that, although not without challenges, the SouthEats model could be financially feasible. CONCLUSION: These preliminary insights can inform the scalability and potential replication of this service and provide foundational evidence for an approach that may be used to improve food access.

Preconception Maternal Mentoring for Improved Fetal Growth among Indonesian Women: Results from a Cluster Randomized Controlled Trial.

The prevalence of stunting in young children is associated with poor growth during the prenatal and early postnatal periods. A maternal mentoring program was developed for Indonesian women to improve birth outcomes. A cluster-randomized controlled trial (CRCT) was conducted in three sub-districts of the Special Region of Yogyakarta, Indonesia. A total of 384 eligible participants were randomly allocated to either an intervention (received the maternal mentoring program and standard care; n = 189) or control (received standard care only; n = 195) group. The maternal mentoring program provided preconception health education; health monitoring; and text message reminders for preconception women. Fetal growth was measured between gestational weeks 27 and 30 using the estimated fetal weight generated from ultrasonographic measurements. Birth weight was measured within 24 h of birth. A structured questionnaire captured women's demographics, pregnancy readiness, and body mass indexes (BMIs). After adjustment, fetal weight was 14% (95% CI: 5.1-23.0) higher in the intervention group than in the control group, and the average weight-for-length Z-score at birth was 0.16 (95% CI: 0.04-0.30) higher in the intervention group than in the control group. The maternal mentoring program was associated with improved fetal growth and birth weight in this population and should be considered for scale-up to other settings, nationally and globally.

Food access narratives as told by consumers and retailers engaging in a COVID-19-stricken urban food system: A brief report.

Small food retail ("corner") stores in many underserved urban settings face challenges to stocking healthy, affordable foods. The food supply chain is considered one of the most important sectors of the economy and has suffered recent negative impacts due to the Coronavirus disease 2019 (COVID-19) pandemic, from farm to consumer. As part of the larger Baltimore Urban food Distribution (BUD) Study, we examine corner store owner and consumer perceptions of the impact of COVID-19 on navigating an urban food environment using a brief, reflective, semi-structured oral interview framed as "storytelling." Open-ended responses are documented, transcribed, and analyzed for key themes. Presently, we discuss initial key findings in hopes of helping to ensure sufficient value added for corner store owners and consumers who will interact with the BUD mobile application as part of a full-scale trial being implemented in Baltimore, Maryland.

Cardiometabolic risk among rural Native American adults in a large multilevel multicomponent intervention trial.

This cross-sectional analysis of the baseline evaluation sample of the Obesity Prevention and Evaluation of InterVention Effectiveness in Native Americans 2 (OPREVENT2) study included 601 Native American adults ages 18-75 living in rural reservation communities in the Midwest and Southwest United States. Participants completed a self-report questionnaire for individual and family history of hypertension, heart disease, diabetes and obestiy. Body mass index (BMI), percent body fat, and blood pressure were measured by trained research staff. About 60% of respondents had a BMI >30 kg/m2. Approximately 80% had a waist-to-hip ratio and percent body fat classified as high risk, and nearly 64% had a high-risk blood pressure measurement. Although a large proportion of participants reported a family history of chronic disease and had measurements that indicated elevated risk, relatively few had a self-reported diagnosis of any chronic disease. Future studies should examine potential connections between healthcare access and discordance in self-reported versus measured disease risks and diagnoses.

Dietary Outcomes of a Multilevel, Multicomponent, Cluster Randomized Obesity Intervention in 6 Native American Communities in the Upper Midwest and Southwest United States.

Background: Impacts of colonization on dietary intake have led to high rates of obesity and noncommunicable diseases among Native American adults. Multilevel, multicomponent (MLMC) interventions may improve dietary intake. Objectives: To assess the impact of a MLMC obesity intervention, OPREVENT2 (Obesity Prevention and Evaluation of InterVention Effectiveness in NaTive North Americans 2; clinicaltrials.gov NCT02803853), on dietary intake in Native American adults in Intervention versus Comparison communities. Methods: A cluster-randomized controlled trial was performed among participants in 6 communities randomized to Intervention (n = 3 and Comparison (n = 3). Adults aged 18 to 75 were recruited from tribal communities in the Southwest and upper Midwest United States from September 2016 to May 2017 (n = 601). This analysis included participants who completed baseline and follow-up surveys (82% retention), reported dietary intake between 500 and 7000 kcal/d, and had no missing data for outcomes of interest (n = 446). The intervention was implemented from May 2017, to November 2018. OPREVENT2 integrated individual, environmental, social, and structural factors and was implemented in food stores, worksites, schools, and community media outlets in Intervention communities. Activities included taste tests, cooking demonstrations, and stocking healthier items in food stores and were reinforced by a social m)edia campaign, posters, brochures, and booklets focused on nutrition. Individual-level dietary intake among participating Native American adults was assessed via modified Block food-frequency questionnaire at preintervention and postintervention. Multilevel mixed-effects linear regression, with clustering at the community level, was performed. Results: Between-group effects were significant (P < 0.05) for intake of carbohydrates (-23 g/d), total fat (-9 g/d), saturated fats (-3 g/d), and monounsaturated fats (-4 g/d), with greater decreases in Intervention communities. Between-group effect for total sugar (-12 g/d in Intervention communities) was not statistically significant. Conclusions: This MLMC intervention was associated with significantly improved carbohydrate, total fat, and saturated fat intake among Native American adults. These changes are important for improving health within this population.

Lifestyle Medicine Practitioners Implementing a Greater Proportion of Lifestyle Medicine Experience Less Burnout.

PURPOSE: To identify reasons for burnout, characterize the effect of lifestyle medicine (LM) practice on burnout, and assess the risk of burnout in relation to the proportion of LM practice. DESIGN: Analysis of mixed methods data from a large, cross-sectional survey on LM practice. SETTING: Web-based survey platform. PARTICIPANTS: Members of an LM medical professional society at the time of survey administration. METHODS: Practitioner members of a medical professional society were recruited to a cross-sectional, online survey. Data were collected on LM practice and experiences with burnout. Free-text data were thematically grouped and counted, and the association of burnout with the proportion of lifestyle-based medical practice was analyzed using logistic regression. RESULTS: Of 482 respondents, 58% reported currently feeling burned out, 28% used to feel burned out but no longer do, and 90% reported LM had positively impacted their professional satisfaction. Among LM practitioners surveyed, practicing more LM was associated with a 43% decrease (0.569; 95% CI: 0.384, 0.845; P = 0.0051) in the odds of experiencing burnout. Top reasons for positive impact included professional satisfaction, sense of accomplishment, and meaningfulness (44%); improved patient outcomes and patient satisfaction (26%); enjoyment of teaching/coaching and engaging in relationships (22%); and helps me personally: quality of life and stress (22%). CONCLUSION: Implementing LM as a greater proportion of medical practice was associated with lower likelihood of burnout among LM practitioners. Results suggest that increased feelings of accomplishment due to improved patient outcomes and reduced depersonalization contribute to reduced burnout.

Food Pantry Clients' Needs, Preferences, and Recommendations for Food Pantries: A Qualitative Study.

A qualitative formative approach was used to explore food pantry clients' needs, preferences, and recommendations regarding food received from food pantries. Fifty adult clients of six Arkansas food pantries were interviewed in English, Spanish, or Marshallese. Data analysis used the constant comparative qualitative methodology. In choice and minimal choice pantries, three themes emerged: clients need increased quantities of food, particularly more proteins and dairy; clients desire higher quality food, including healthy food and food not close to expiration; and clients desire familiar foods and food appropriate for their health needs. System level policy changes are needed to address clients' recommendations.

The associations of continuity of care with inpatient, outpatient, and total medical care costs among older adults with urinary incontinence.

INTRODUCTION: Urinary incontinence is a significant health problem with considerable social and economic consequences among older adults. The objective of this study was to investigate the financial impact of continuity of care (CoC) among older urinary incontinence patients in South Korea. METHODS: We used the NHIS-Senior cohort patient data between January 1, 2010, and December 31, 2010. Patients who were diagnosed with urinary incontinence in 2010 were included. Operational definition of CoC included referrals, number of providers, and number of visits. A generalized linear model (GLM) with γ-distributed errors and the log link function was used to examine the relationship between health cost and explanatory variables. Additionally, we conducted a two-part model analysis for inpatient cost. Marginal effect was calculated. RESULTS: Higher CoC was associated with a decrease in total medical cost (-0.63, P < .0001) and in outpatient costs (-0.28, P < .001). Higher Charlson Comorbidity Index (CCI) score was a significant predictor for increasing total medical cost (0.59, P < .0001) and outpatient cost (0.22, P < .0001). Higher CoC predict a reduced medical cost of $360.93 for inpatient cost (P = 0.044) and $23.91 for outpatient cost (P = 0.008) per patient. CONCLUSION: Higher CoC was associated with decrease in total medical costs among older UI patients. Policy initiatives to promote CoC of older UI patients in the community setting could lead to greater financial sustainability of public health insurance in South Korea.

A Systems Approach to Identify Factors Influencing Participation in Two Tribally-Administered WIC Programs.

Native American populations experience highly disproportionate rates of poor maternal-child health outcomes. The WIC program aims to safeguard health by providing greater access to nutritious foods, but for reasons not well understood, participation in many tribally-administered WIC programs has declined to a greater extent compared to the national average decline in participation over the last decade. This study aims to examine influences on WIC participation from a systems perspective in two tribally-administered WIC programs. In-depth interviews were conducted with WIC-eligible individuals, WIC staff, tribal administrators, and store owners. Interview transcripts underwent qualitative coding, followed by identifying causal relationships between codes and iterative refining of relationships using Kumu. Two community-specific causal loop diagrams (CLDs) were developed and compared. Findings from interviews in the Midwest yielded a total of 22 factors connected through 5 feedback loops, and in the Southwest a total of 26 factors connected through 7 feedback loops, resulting in three overlapping themes: Reservation and Food Store Infrastructure, WIC Staff Interactions and Integration with the Community, and State-level Administration and Bureaucracy. This study demonstrates the value of a systems approach to explore interconnected barriers and facilitators that can inform future strategies and mitigate declines in WIC participation.

Childhood obesity inequality in northeast China: joint effect of social economic status and school neighborhood environment.

BACKGROUND: Obesogenic environment is important in driving obesity epidemic. Children spend large amount of their time in schools. School neighborhood environment, as well as its interaction with socioeconomic status (SES) needs to be explored to provide evidence for children obesity prevention policies. METHODS: Objective anthropometric measurement, a household structured questionnaire, and school geospatial analyses were carried out on 3670 children (aged 9-12 years) of 26 schools in northeast China. Interaction between SES inter-categorical intersectionality group and school neighborhood environment was tested for the effect on children's body mass index z scores (z-BMI) and waist-hip ratio z scores (z-WHR), following formulation of SES inter-categorical intersectionality group based on household wealth, parental education, and parental occupation. RESULTS: SES groups formed by household wealth, parental education and parental occupation was associated with z-BMI and z-WHR for girls. Those from moderate wealth & self-employed (M&S) families had the highest adjusted z-BMI and z-WHR among all SES groups. School neighborhood environment factors interacted with SES groups in association with WHR for girls. Number of school neighborhood supermarkets and residential sites were negatively associated with z-WHR for girls from M&S families (ß= -0.45 (95%CI: -0.76, -0.15) for supermarkets; ß= -0.01 (95%CI: -0.03, 0.00) for residential sites). Number of school neighborhood convenience stores and public transport stops were positively associated with z-WHR for girls from M&S families (ß = 0.02 (95%CI: 0.00, 0.03) for convenience stores; ß = 0.23 (95%CI: 0.15, 0.31) for public transport stops). While non-significant association was found for number of vegetable stores. CONCLUSION: Girls from moderate wealth & self-employed families may be the group susceptible to school neighborhood environment. Local policies targeted at improving the school neighborhood environment may be one avenue for reducing socioeconomic disparities in obesity especially for girls.

Implementing a Community-Led Arsenic Mitigation Intervention for Private Well Users in American Indian Communities: A Qualitative Evaluation of the Strong Heart Water Study Program.

Arsenic is a naturally occurring toxicant in groundwater, which increases cancer and cardiovascular disease risk. American Indian populations are disproportionately exposed to arsenic in drinking water. The Strong Heart Water Study (SHWS), through a community-centered approach for intervention development and implementation, delivered an arsenic mitigation program for private well users in American Indian communities. The SHWS program comprised community-led water arsenic testing, point-of-use arsenic filter installation, and a mobile health program to promote sustained filter use and maintenance (i.e., changing the filter cartridge). Half of enrolled households received additional in-person behavior change communication and videos. Our objectives for this study were to assess successes, barriers, and facilitators in the implementation, use, and maintenance of the program among implementers and recipients. We conducted 45 semi-structured interviews with implementers and SHWS program recipients. We analyzed barriers and facilitators using the Consolidated Framework for Implementation Research and the Risks, Attitudes, Norms, Abilities, and Self-regulation model. At the implementer level, facilitators included building rapport and trust between implementers and participating households. Barriers included the remoteness of households, coordinating with community plumbers for arsenic filter installation, and difficulty securing a local supplier for replacement filter cartridges. At the recipient level, facilitators included knowledge of the arsenic health risks, perceived effectiveness of the filter, and visual cues to promote habit formation. Barriers included attitudes towards water taste and temperature and inability to procure or install replacement filter cartridges. This study offers insights into the successes and challenges of implementing an arsenic mitigation program tailored to American Indian households, which can inform future programs in partnership with these and potentially similar affected communities. Our study suggests that building credibility and trust between implementers and participants is important for the success of arsenic mitigation programs.

Barriers, facilitators, and opportunities to promote healthy weight behaviors among preschool-aged children in two rural U.S communities.

BACKGROUND: Obesity levels are higher in rural versus urban children. Multi-level community-based interventions can be effective in promoting healthy child weight, but few of such interventions have focused on rural children. This formative study assessed barriers, facilitators, and opportunities to promote healthy child weight in two rural communities. METHODS: Multiple data collection methods were used concurrently in two rural communities in Indiana and North Carolina. Focus groups and interviews were conducted with participants, including parents of children aged 2-5 years (n = 41), childcare providers (n = 13), and stakeholders from 23 community organizations. Observational audits were conducted at 19 food outlets (grocery stores) and 50 publicly-accessible physical activity resources. Focus groups/interviews were analyzed thematically. Surveys were analyzed using descriptive statistics, Fisher's exact test, and t-tests. RESULTS: Family level barriers included limited financial resources and competing priorities, whereas parental role-modeling was perceived as a facilitator of healthy weight behaviors. At the organizational level, childcare providers and community stakeholders cited limited funding and poor parental engagement in health promotion programs as barriers. Childcare providers explained that they were required to comply with strict nutrition and physical activity guidelines, but expressed concerns that similar messages were not reinforced at home. Facilitators at the organizational level included healthy meals provided at no cost at childcare programs, and health promotion programs offered through community organizations. At the community level, lack of public transportation, and limited access to healthy food outlets and physical activity-promoting resources posed barriers, whereas existing physical activity resources (e.g., parks) and some ongoing investment to improve physical activity resources in the community were assets. In designing/implementing a potential child obesity prevention intervention, participants discussed the need to garner community trust, emphasize wellness instead of obesity prevention, establish community partnerships, and leverage existing community resources. CONCLUSIONS: Rural areas experience multiple challenges that make it difficult for children/families to engage in healthy weight behaviors. This study highlights several assets (existing programs/resources, expertise within communities) that can be leveraged as facilitators. Findings will guide the study team in developing a child obesity prevention intervention for the two rural communities.

Use of a Water Filter at Home Reduces Sugary Drink Consumption among Parents and Infants/Toddlers in a Predominantly Hispanic Community: Results from the Water Up!@ Home Intervention Trial.

BACKGROUND: Water is recommended as an alternative for sugar-sweetened beverages (SSBs). Low-income, minority groups in the United States continue to exhibit high SSB and low water consumption, and are more likely to exceed 100% fruit juice recommendations. OBJECTIVE: To test the effects of a home-based intervention designed to replace SSBs with tap water and reduce excess juice consumption among parents and their infants/toddlers. DESIGN: Randomized controlled trial. PARTICIPANTS: Parents (n = 92) of infants/toddlers who participated in three Early Head Start home-visiting programs that serve predominantly Hispanic, low-income communities during 2019-2021. INTERVENTION: The 12-week intervention (Water Up!@Home) simultaneously addressed physical barriers to tap water consumption (via a water filter) and sociocultural barriers to replacing SSBs and juice with water (via a curriculum). Comparison group received a water filter only. We hypothesized that the intervention would lead to a reduction of 6 fl oz/d in SSB and juice consumption. MAIN OUTCOMES: Parent-reported self and infant/toddler SSBs, water (filtered, tap, or bottled), and 100% fruit juice consumption. STATISTICAL ANALYSES: Analysis of covariance to compare changes in consumption between experimental groups was performed. We also conducted t tests to assess changes within groups. RESULTS: Participants in both groups reported significant reductions in SSBs from baseline (parents: intervention [-11.2 fl oz/d; P < 0.01]; comparison [-8.0 fl oz/d; P < 0.01]; children: intervention [-1.50 fl oz/d; P = 0.03]; comparison [-1.56 fl oz/d; P = 0.02]), increased water consumption (parents in both groups [+5.6 fl oz/d]; children: intervention [+3.61 fl oz/d; P = 0.01], comparison [+2.24 fl oz/d; P = 0.05]), mostly from filtered tap water. Differences between groups were not statistically significant. Intervention participants reported significant reductions in 100% fruit juice vs comparison (parents: -3.6 fl oz/d vs -1.0 fl oz/d; P < 0.01; children: -0.73 fl oz/d vs +0.48 fl oz/d; P = .03). CONCLUSIONS: The intervention effectively reduced 100% fruit juice consumption. Water security should be examined as a contributor to SSB consumption in this population.