Process evaluation of the Yéego! Program to increase healthy eating and gardening among American Indian elementary school children.

BACKGROUND: American Indian children are at increased risk for obesity and diabetes. School-based health promotion interventions are one approach to promoting healthy behaviors to reduce this risk, yet few studies have described their implementation and fidelity. We conducted a qualitative process evaluation of the Yéego! Healthy Eating and Gardening Program, a school-based intervention to promote healthy eating among Navajo elementary school children. The intervention included a yearlong integrated curriculum, as well as the construction and maintenance of a school-based garden. METHODS: Our process evaluation included fidelity checklists completed by program staff and qualitative interviews with program staff and classroom teachers after the intervention was implemented. We used content analysis to identify themes. RESULTS: We identified several themes related to evidence of delivery adherence, program satisfaction, and lessons learned about delivery. Intervention staff followed similar procedures to prepare for and deliver lessons, but timing, teaching styles, and school-level factors also impacted overall implementation fidelity. Teachers and students had positive perceptions of the program, especially lessons that were highly visual, experiential, and connected to Navajo culture and the surrounding community. Teachers and program staff identified ways to enhance the usability of the curriculum by narrowing the scope, relating content to student experiences, and aligning content with school curriculum standards. CONCLUSIONS: The program was implemented with moderately high fidelity across contexts. We identified areas where modifications could improve engagement, acceptability, efficacy, and sustainability of the program. Our results have implications for the evaluation and dissemination of school-based health interventions to promote healthy eating among children, especially in American Indian communities.

Development of an Assessment Tool to Measure Healthy Eating in Navajo Children and Their Families.

Background: To estimate the efficacy of interventions to improve healthy eating, valid measures are essential. Although simple dietary intake tools have been developed with other populations, few have been culturally tailored and assessed for validity and reliability among Navajo. Objectives: This study aimed to develop a simple dietary intake tool tailored to Navajo culture, derive healthy eating indices, and assess their validity and reliability in Navajo children and adults and to describe the process used to develop this tool. Methods: A picture-sort tool using typically consumed foods was developed. Elementary school children and family members provided qualitative feedback in focus groups, used to refine the tool. Next, school-aged children and adults completed assessments at baseline and follow-up. Baseline behavior measures including child self-efficacy for fruits and vegetables (F&V) were examined for internal consistency. Healthy eating indices were derived from intake frequencies from picture sorting. The convergent validity of the indices and behavior measures for children and adults were examined. The reliability of the indices at the 2 time points was derived using Bland-Altman plots. Results: The picture-sort was refined from feedback provided by the focus groups. Baseline measures from 25 children and 18 adults were obtained. In children, a modified Alternative Healthy Eating Index (AHEI) and 2 other indices from the picture-sort were correlated with self-efficacy for eating F&V and had good reliability. In adults, the modified AHEI and 3 other indices from the picture-sort had significant correlations with adult abbreviated food frequency of F&V or obesogenic dietary index and had good reliability. Conclusions: The Navajo foods picture-sort tool developed for Navajo children and adults is proven to be acceptable and feasible to implement. Indices derived from the tool has good convergent validity and repeatability, supporting use in evaluating dietary change interventions in Navajo, with the potential for broader use of the approach in other underserved populations.

Adapting a cooking, food budgeting and nutrition intervention for a rural community of American Indians with type 2 diabetes in the North-Central United States.

American Indian (AI) communities experience persistent diabetes-related disparities, yet few nutrition interventions are designed for AI with type 2 diabetes or address socio-contextual barriers to healthy eating. We describe our process of adapting the evidence-based Cooking Matters® program for use by AI adults with type 2 diabetes in a rural and resource-limited setting in the North-Central United States. We conducted three focus groups with AI adults with diabetes to (i) identify Cooking Matters® adaptations and (ii) gather feedback on appropriateness of the adapted intervention using Barrera and Castro's cultural adaptation framework. Transcripts were coded using an inductive, constant comparison approach. Queries of codes were reviewed to identify themes. Contextual considerations included limited access to grocery stores and transportation barriers, reliance on government food assistance and the intergenerational burden of diabetes. Adaptations to content and delivery included incorporating traditional and locally available foods; appealing to children or others in multigenerational households and prioritizing visual over written content. Our use of Barrera and Castro's framework adds rigor and structure to the cultural adaptation process and increases the likelihood of future intervention success. Other researchers may benefit from using this framework to guide the adaptation of evidence-based interventions in AI communities.

Engaging School and Family in Navajo Gardening for Health: Development of the Yéego Intervention to Promote Healthy Eating among Navajo Children.

OBJECTIVE: Navajo children are at increased risk for obesity, in part due to limited access to healthy foods. School garden interventions have been shown to increase access to fresh fruit and vegetables and consumption of healthy foods. Our study describes the development and pilot testing of a school garden intervention for Navajo elementary school children. METHODS: We reviewed existing school garden interventions and conducted formative research with students, caregivers, and school staff to inform the intervention. The intervention consisted of a garden built at the school and a yearlong curriculum on gardening and healthy eating. We pilot tested the intervention in an elementary school on the Navajo Nation. RESULTS: Formative research revealed the importance of incorporating Diné culture, including traditional growing practices and the preparation of traditional foods into the curriculum. School staff also stressed the value of tying the curriculum to state and Diné educational standards. Students enjoyed opportunities for hands-on activities and snack preparation. CONCLUSIONS: Schools have a meaningful role to play in addressing childhood obesity disparities among Navajo children. School-based interventions that draw on cultural strengths and include healthy traditional practices can be a promising strategy for increasing fruit and vegetable consumption.

Cooking for Health: a healthy food budgeting, purchasing, and cooking skills randomized controlled trial to improve diet among American Indians with type 2 diabetes.

BACKGROUND: The prevalence of poor diet quality and type 2 diabetes are exceedingly high in many rural American Indian (AI) communities. Because of limited resources and infrastructure in some communities, implementation of interventions to promote a healthy diet is challenging-which may exacerbate health disparities by region (urban/rural) and ethnicity (AIs/other populations). It is critical to adapt existing evidence-based healthy food budgeting, purchasing, and cooking programs to be relevant to underserved populations with a high burden of diabetes and related complications. The Cooking for Health Study will work in partnership with an AI community in South Dakota to develop a culturally-adapted 12-month distance-learning-based healthy food budgeting, purchasing, and cooking intervention to improve diet among AI adults with type 2 diabetes. METHODS: The study will enroll 165 AIs with physician-diagnosed type 2 diabetes who reside on the reservation. Participants will be randomized to an intervention or control arm. The intervention arm will receive a 12-month distance-learning curriculum adapted from Cooking Matters® that focuses on healthy food budgeting, purchasing, and cooking skills. In-person assessments at baseline, month 6 and month 12 will include completion of the Nutrition Assessment Shared Resources Food Frequency Questionnaire and a survey to assess frequency of healthy and unhealthy food purchases. Primary outcomes of interest are: (1) change in self-reported intake of sugar-sweetened beverages (SSBs); and (2) change in the frequency of healthy and unhealthy food purchases. Secondary outcomes include: (1) change in self-reported food budgeting skills; (2) change in self-reported cooking skills; and (3) a mixed-methods process evaluation to assess intervention reach, fidelity, satisfaction, and dose delivered/received. DISCUSSION: Targeted and sustainable interventions are needed to promote optimal health in rural AI communities. If effective, this intervention will reduce intake of SSBs and the purchase of unhealthy foods; increase the purchase of healthy foods; and improve healthy food budgeting and cooking skills among AIs with type 2 diabetes - a population at high risk of poor health outcomes. This work will help inform future health promotion efforts in resource-limited settings. TRIAL REGISTRATION: This study was registered on ClinicalTrials.gov on October 9, 2018 with Identifier NCT03699709 .

Can Community Gardens with Workshops Increase Gardening Behavior? A Navajo Wellness Collaboration.

This project evaluated the potential efficacy of a community gardening intervention on the Navajo Nation to increase gardening and healthy eating behaviors, which are potentially important in preventing obesity and related health conditions. Rates of obesity are high among American Indians, including those living on Navajo Nation land. Eating fresh fruits and vegetables is part of healthy eating. However, availability and access to fresh fruits and vegetables are severely limited due to distance and cost. One way to increase both availability and consumption of fresh fruits and vegetables is through community gardening, yet many on the Navajo Nation have limited knowledge and capacity to garden. METHODS: We used a quasi-experimental pre-post study design to estimate the effect of a community gardening intervention. Primary outcomes of interest were gardening frequency and fruit and vegetable consumption. Community gardens were constructed and planted in two communities on the Navajo Nation. In addition, a series of gardening workshops were held in each community. Community members were recruited to complete surveys at time points before and after the workshops. The time between baseline and follow-up was approximately one year. RESULTS: We surveyed 169 participants at one time point at least, across both communities, and 25 of these participated in the gardening workshops. Within the 169, there was a cohort of 32 participants completing both baseline and follow-up surveys. For this cohort, interest in gardening increased from 78% to 97% (p=0.014), but none of the changes in gardening self-efficacy, knowledge or gardening frequency reached statistical significance. There were no measurable changes in reported fruit and vegetable consumption, self-efficacy or knowledge. Overall, the reported financial barriers to gardening increased from baseline to follow-up from 4.6 to 5.5 (p=0.035). Among those who completed follow-up, those who attended at least one workshop gardened more frequently than those who did not attend any workshops (21 times per month compared to 10 times per month (p=0.065). CONCLUSION: Despite enthusiasm for the community garden in both the communities studied and the increased interest in gardening, workshop attendance and participant retention in the study were low. These factors limited our ability to evaluate the potential efficacy of the intervention on gardening and healthy eating behaviors. Nonetheless, we found some evidence that participating in gardening workshops may lead to increased gardening frequency. Future studies should augment the intervention to include explicit efforts to reduce barriers to long term engagement and extend intervention reach.

Associations of social, physical, and financial factors with diet quality among older, community-dwelling women.

OBJECTIVE: This analysis examined whether specific social, physical, and financial factors were associated with diet quality among older, community-dwelling women. METHODS: This cross-sectional analysis was conducted in a subset of 6,094 community-dwelling Women's Health Initiative participants who completed a food frequency questionnaire, administered from 2012 to 2013, and a self-administered supplemental questionnaire, administered approximately 1 year later. The supplemental questionnaire included five questions assessing social, physical, and financial factors related to eating. Diet quality was assessed with the Healthy Eating Index-2010 (HEI-2010; range of 0-100; higher score indicates a higher quality diet). The total HEI-2010 score was calculated by summing individual scores representing the intake of nine adequacy components (beneficial food groups) and three moderation components (food groups to limit). Associations of responses to the five questions on the supplemental questionnaire with HEI-2010 scores were examined with multiple linear regression, adjusting for relevant covariates. RESULTS: Mean ±â€Šstandard deviation age of participants was 78.8 ±â€Š6.7 years. Reporting eating fewer than two meals per day, having dental or other mouth problems causing problems with eating, and not always being able to shop, cook, or feed oneself were associated with statistically significantly lower HEI-2010 scores, compared with those not reporting these issues, after multivariable adjustment: 5.37, 2.98, and 2.39 lower scores, respectively (all P values <0.0001). Reporting eating alone most of the time and not always having enough money to buy food were not associated with HEI-2010 scores. CONCLUSIONS: Among older, community-dwelling women, eating fewer than two meals per day, dental and other mouth problems, and diminished ability to shop for food, prepare meals, and feed oneself were associated with lower diet quality. These are potential targets for interventions to improve diet quality in older women. : Video Summary:http://links.lww.com/MENO/A561.

Video Summary:http://links.lww.com/MENO/A561.

Environmental and Individual Predictors of Healthy Dietary Behaviors in a Sample of Middle Aged Hispanic and Caucasian Women.

The objective of this effort is to gather data to tailor interventions appropriately. Greater understanding of the correlates of socioeconomic status and obesogenic dietary behaviors was the focus of this manuscript. Using multistage sampling, women with varied education levels completed a baseline assessment in a longitudinal study of women aged 30 to 50 years. This study was conducted in low-SES areas of South King County, Washington State. This study included 530 Caucasian and 510 Hispanic women. Fruit and vegetable consumption was positively associated and soft drink consumption inversely associated with the level of education in Caucasian women. In contrast, percentage calories from fat was positively associated with the level of education in Hispanic women. In Hispanic women, level of education interacted significantly with food security in relation to percentage calories from fat, and with eating norms in relation to soft drink consumption. Neighborhood presence of ethnic food stores was associated with outcomes for Hispanic women, but for Caucasians, presence of fast food restaurants was important. Education was consistently associated with two of the three obesogenic dietary behaviors studied among Caucasian women. Education played a moderating role in the associations of food security and eating norms, independent of area level food availability, in two of three obesogenic dietary behaviors studied. However, these patterns differed for Hispanic women, indicating the need for more research into important variables to support change in Hispanic women. Women of differing ethnic groups did not respond similarly to environmental conditions and policy-relevant surroundings. These data have meaning for considering urban policy that impacts obesity levels in the population.

Gardening for Health: Patterns of Gardening and Fruit and Vegetable Consumption Among the Navajo.

American Indians, including Navajo, are disproportionately affected by obesity and diabetes, in part due to diet-related health behaviors. The purpose of this study was to assess the patterns of gardening and fruit and vegetable (FV) consumption among residents in two communities on the Navajo Nation in order to inform a community gardening intervention. We analyzed survey data collected from participants in the Yéego Gardening study conducted in two communities in the Navajo Nation (N = 169). We found that 51% of the sample gardened, and on average participants gardened 8.9 times per month. Lack of time (53%) and financial barriers, such as gas for transportation or irrigation (51 and 49%, respectively), were reported as barriers to gardening. Most participants reported low levels of self-efficacy (80%) and behavioral capability (82%) related to gardening. Those with higher levels of gardening self-efficacy and behavioral capability reported more frequent gardening. Average daily FV consumption was 2.5 servings. Most participants reported high levels of self-efficacy to eat FV daily (64%) and high behavioral capability to prepare FV (66%). There was a positive association between FV consumption and gardening, with those gardening more than 4 times per month eating about 1 more serving of FV per day than those gardening 4 or fewer times per month. Further research is needed to better understand how gardening can increase fruit and vegetable availability and consumption among residents of the Navajo Nation.

Availability and Cost of Healthy Foods in a Large American Indian Community in the North-Central United States.

To understand the local food environment in a rural American Indian community, we assessed the availability and price of healthy foods offered at all stores (n = 27) within a 90-mile radius of the town center of a large American Indian reservation. Stores were classified by type, and availability and cost of foods were measured using the Nutrition Environment Measures Survey in Stores (January-February 2016). Healthy foods were available at most grocery stores (>97%), although the price of foods varied considerably among stores. Having quantified the availability and cost of food, efforts must focus on understanding other structural and contextual factors that influence diet in this community.

Estimating the costs and cost-effectiveness of promoting mammography screening among US-based Latinas.

PURPOSE: We characterize the costs and cost-effectiveness of a community health worker (CHW)-based intervention to promote screening mammography among US-based non-adherent Latinas. METHODS: The parent study was a randomized controlled trial for 536 Latinas aged 42-74 years old who had sought care within a safety net health center in Western Washington. Participants were block-randomized within clinic to the control arm (usual care) or intervention arm (CHW-led motivational interviewing intervention). We used the perspective of the organization implementing promotional activities to characterize costs and cost-effectiveness. Cost data were categorized as program set-up and maintenance (initial training, booster/annual training) program implementation (administrative activities, intervention delivery); and, overhead/miscellaneous expenses. Cost-effectiveness was calculated as the incremental cost of screening for each additional woman screened between the intervention and control arms. RESULTS: The respective costs per participant for standard care and the intervention arm were $69.96 and $300.99. There were no study arm differences in 1-year QALYs were small among women who completed a 12-month follow-up survey (intervention= 0.8827, standard care = 0.8841). Most costs pertained to program implementation and administrative activities specifically. The incremental cost per additional woman screened was $2,595.32. CONCLUSIONS: Our findings are within the ranges of costs and cost-effectiveness for other CHW programs to promote screening mammography among underserved populations. Our strong study design and focus on non-adherent women provides important strengths to this body of work, especially give implementation and dissemination science efforts regarding CHW-based health promotion for health disparity populations.

Associations between neighbourhood characteristics and depression: a twin study.

BACKGROUND: Depression is an important contributor to the global burden of disease. Besides several known individual-level factors that contribute to depression, there is a growing recognition that neighbourhood environment can also profoundly affect mental health. This study assessed associations between three neighbourhood constructs-socioeconomic deprivation, residential instability and income inequality-and depression among adult twin pairs. The twin design is used to examine the association between neighbourhood constructs and depression, controlling for selection factors (ie, genetic and shared environmental factors) that have confounded purported associations. METHODS: We used multilevel random-intercept Poisson regression among 3738 same-sex twin pairs from a community-based twin registry to examine the association between neighbourhood constructs and depression. The within-pair association controls for confounding by genetic and environmental factors shared between twins within a pair, and is the main parameter of interest. Models were adjusted for individual-level income, education and marital status, and further by neighbourhood-level population density. RESULTS: When twins were analysed as individuals (phenotypic model), all neighbourhood constructs were significantly associated with depression. However, only neighbourhood socioeconomic deprivation showed a significant within-pair association with depression. A 10-unit within-pair difference in neighbourhood socioeconomic deprivation was associated with 6% greater depressive symptoms (1.06, 95% CI 1.01 to 1.11); the association did not substantially change in adjusted models. CONCLUSION: This study provides new evidence linking neighbourhood socioeconomic deprivation with greater depression. Future studies should employ longitudinal designs to better test social causation versus social selection.

The Interaction between Dietary Fiber and Fat and Risk of Colorectal Cancer in the Women's Health Initiative.

Combined intakes of specific dietary fiber and fat subtypes protect against colon cancer in animal models. We evaluated associations between self-reported individual and combinations of fiber (insoluble, soluble, and pectins, specifically) and fat (omega-6, omega-3, and docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), specifically) and colorectal cancer (CRC) risk in the Women's Health Initiative prospective cohort (n = 134,017). During a mean 11.7 years (1993-2010), 1952 incident CRC cases were identified. Cox regression models computed multivariate adjusted hazard ratios to estimate the association between dietary factors and CRC risk. Assessing fiber and fat individually, there was a modest trend for lower CRC risk with increasing intakes of total and insoluble fiber (p-trend 0.09 and 0.08). An interaction (p = 0.01) was observed between soluble fiber and DHA + EPA, with protective effects of DHA + EPA with lower intakes of soluble fiber and an attenuation at higher intakes, however this association was no longer significant after correction for multiple testing. These results suggest a modest protective effect of higher fiber intake on CRC risk, but not in combination with dietary fat subtypes. Given the robust results in preclinical models and mixed results in observational studies, controlled dietary interventions with standardized intakes are needed to better understand the interaction of specific fat and fiber subtypes on colon biology and ultimately CRC susceptibility in humans.

Contribution of health behaviors to the association between area-level socioeconomic status and cancer mortality.

Cancer mortality is higher among residents of low-socioeconomic status (SES) areas than those of high-SES areas; however, the contribution of modifiable risk factors to this disparity is not known. We used data from 54,737 participants in the VITamins And Lifestyle (VITAL) Study, aged 50-76 with no history of cancer at baseline (2000-2002). Of these, 1488 died of cancer over an average of 7.7 years of follow-up. Data on modifiable risk factors including body mass index (BMI), physical activity, diet, alcohol, smoking and screening were taken from baseline questionnaires. We constructed a block group-level SES index using data from the 2000 United States Census and fit Cox proportional hazards models estimating the association between area-level SES and total cancer mortality with and without control for modifiable risk factors. All statistical tests are 2-sided. Cancer mortality was 77% (95% CI: 50%, 111%) higher in the lowest-SES areas compared with the highest. Modifiable risk factors accounted for 45% (95% CI: 34%, 62%) of this association. Smoking explained the greatest proportion (29%; 95% CI: 22%, 40%) of the observed association, followed by diet (11%; 95% CI: 7%, 17%), physical activity (10%; 95% CI: 7%, 16%), screening (9%; 6%, 13%), and BMI (5%; 95% CI: 1%, 10%). Results were similar in models controlling for individual education and income. The association between area-level SES and cancer mortality is partially explained by modifiable risk factors, which could suggest the appropriate targets to reduce socioeconomic disparities.

Disparities in cancer incidence and mortality by area-level socioeconomic status: a multilevel analysis.

BACKGROUND: Disparities in cancer incidence and mortality have been observed by measures of area-level socioeconomic status (SES); however, the extent to which these disparities are explained by individual SES is unclear. METHODS: Participants included 60 756 men and women in the VITamins And Lifestyle (VITAL) study cohort, aged 50-76 years at baseline (2000-2002) and followed through 2010. We constructed a block group SES index using the 2000 US Census and fit Cox proportional hazards models to estimate the association between area-level SES (by quintile) and total and site-specific cancer incidence and total cancer mortality, with and without household income and individual education in the models. RESULTS: Lower area-level SES was weakly associated with higher total cancer incidence and lower prostate cancer risk, but was not associated with risk of breast cancer. Compared with the highest-SES areas, living in the lowest-SES areas was associated with higher lung (HR: 2.21, 95% CI 1.69 to 2.90) and colorectal cancer incidence (HR: 1.52, 95% CI 1.11 to 2.09) and total cancer mortality (HR: 1.68, 95% CI 1.47 to 1.93). Controlling for individual education and household income weakened the observed associations, but did not eliminate them (lung cancer HR: 1.43, 95% CI 1.07 to 1.91; colorectal cancer HR: 1.35, 95% CI 0.97 to 1.88; cancer mortality HR: 1.28, 95% CI 1.11 to 1.48). CONCLUSIONS: Area-level socioeconomic disparities exist for several cancer outcomes. These differences are not fully explained by individual SES, suggesting area-level factors may play a role.

Simultaneous association of total energy consumption and activity-related energy expenditure with risks of cardiovascular disease, cancer, and diabetes among postmenopausal women.

Total energy consumption and activity-related energy expenditure (AREE) estimates that have been calibrated using biomarkers to correct for measurement error were simultaneously associated with the risks of cardiovascular disease, cancer, and diabetes among postmenopausal women who were enrolled in the Women's Health Initiative at 40 US clinical centers and followed from 1994 to the present. Calibrated energy consumption was found to be positively related, and AREE inversely related, to the risks of various cardiovascular diseases, cancers, and diabetes. These associations were not evident in most corresponding analyses that did not correct for measurement error. However, an important analytical caveat relates to the role of body mass index (BMI) (weight (kg)/height (m)(2)). In the calibrated variable analyses, BMI was regarded, along with self-reported data, as a source of information on energy consumption and physical activity, and BMI was otherwise excluded from the disease risk models. This approach cannot be fully justified with available data, and the analyses herein imply a need for improved dietary and physical activity assessment methods and for longitudinal self-reported and biomarker data to test and relax modeling assumptions. Estimated hazard ratios for 20% increases in total energy consumption and AREE, respectively, were as follows: 1.49 (95% confidence interval: 1.18, 1.88) and 0.80 (95% confidence interval: 0.69, 0.92) for total cardiovascular disease; 1.43 (95% confidence interval: 1.17, 1.73) and 0.84 (95% confidence interval: 0.73, 0.96) for total invasive cancer; and 4.17 (95% confidence interval: 2.68, 6.49) and 0.60 (95% confidence interval: 0.44, 0.83) for diabetes.

Multi-level Intervention to increase participation in mammography screening: ¡Fortaleza Latina! study design.

BACKGROUND: Breast cancer is the most common cancer and the leading cause of death among Latinas in the United States. The Multi-level Intervention to Increase Participation in Mammography Screening study (¡Fortaleza Latina!) is a partnership among research institutions, a Latino-serving community-based primary care clinic organization, and a cancer treatment center. The study will assess the efficacy of a clinic- and patient-level program to increase breast cancer screening among Latinas in Western Washington. METHODS/DESIGN: The intervention is a multi-level breast cancer screening program in four participating primary care clinics. The study is a parallel randomized controlled trial of 600 Latino women aged 42-74 who are non-compliant with breast cancer screening guidelines. Participants will be randomized within clinic using block randomization to: (1) a control arm (usual care); and (2) a theory-based counseling program consisting of a 'promotora' or community health worker-led home-based intervention to encourage breast cancer screening. At the clinic-level, two clinics will offer additional mammography services provided by a mobile mammography unit operated by the Seattle Cancer Care Alliance. The primary endpoint is the rate of mammography uptake over the 1-year follow-up period. DISCUSSION: This multi-level intervention aims to raise rates of participation in breast cancer screening among Latino women. If effective, the program may improve rates of early detection of breast cancer in Latino women. Clinicaltrials.gov REGISTRATION NUMBER: NCT02010008.

Understanding the patient-provider communication needs and experiences of Latina and non-Latina White women following an abnormal mammogram.

Latinas are more likely to delay recommended follow-up care than non-Latina White (NLW) women after an abnormal mammogram result. Ethnic differences in communication needs and experiences with health-care staff and providers may contribute to these delays as well as satisfaction with care. Nonetheless, little research has explored the aspects of communication that may contribute to patient comprehension, adherence to follow-up care, and satisfaction across ethnicity. The purpose of this exploratory, qualitative study was to identify patients' communication needs and experiences with follow-up care among Latina and NLW women who received an abnormal mammogram. We conducted 41 semi-structured interviews with 19 Latina and 22 NLW women between the ages of 40 and 74 who had received an abnormal mammogram. Communication themes indicated that women's needs and experiences concerning abnormal mammograms and follow-up care varied across ethnicity. Latinas and NLW women appeared to differ in their comprehension of abnormal results and follow-up care as a result of language barriers and health literacy. Both groups of women identified clear, empathic communication as being important in patient-provider communication; however, Latinas underscored the need for warm communicative styles, and NLW women emphasized the importance of providing more information. Women with high levels of satisfaction with patient-provider interactions appeared to have positive perspectives of subsequent screening and cancer treatment. To improve patient satisfaction and adherence to follow-up care among Latinas, educational programs are necessary to counsel health-care professionals with regard to language, health literacy, and empathic communication needs in health-care service delivery.

Neighborhood socioeconomic deprivation, perceived neighborhood factors, and cortisol responses to induced stress among healthy adults.

Associations between measures of neighborhood socioeconomic deprivation and health have been identified, yet work is needed to uncover explanatory mechanisms. One hypothesized pathway is through stress, yet the few studies that have evaluated associations between characteristics of deprived neighborhoods and biomarkers of stress are mixed. This study evaluated whether objectively measured neighborhood socioeconomic deprivation and individual perceived neighborhood characteristics (i.e. social control and fear of crime) impacted cortisol responses to an induced stressor among older healthy adults. Data from Heart Scan, a sub-study of the Whitehall II cohort, were used to generate multilevel piecewise growth-curve models of cortisol trajectories after a laboratory stressor accounting for neighborhood and demographic characteristics. Neighborhood socioeconomic deprivation was significantly associated with individual perceptions of social control and fear of crime in the neighborhood while an association with blunted cortisol reactivity was only evidence among women. Social control was significantly associated with greater cortisol reactivity and mediation between neighborhood socioeconomic deprivation and cortisol reactivity was suggested among women. These findings support a gender-dependent role of neighborhood in stress process models of health.

Health promotion in smaller workplaces in the United States.

Most American workplaces are smaller, with fewer than 1,000 employees. Many of these employees are low-wage earners and at increased risk for chronic diseases. Owing to the challenges smaller workplaces face to offering health-promotion programs, their employees often lack access to health-promotion opportunities available at larger workplaces. Many smaller employers do not offer health insurance, which is currently the major funding vehicle for health-promotion services. They also have few health-promotion vendors to serve them and low internal capacity for, and commitment to, delivery of on-site programs. The programs they offer, whether aimed at health promotion alone or integrated with health protection, are rarely comprehensive and are understudied. Research priorities for health promotion in smaller workplaces include developing programs feasible for the smallest workplaces with fewer than 20 employees. Policy priorities include incentives for smaller workplaces to implement comprehensive programs and an ongoing system for monitoring and evaluation.