Qualitative study of perceptions of factors contributing to success or failure among participants in a US weight loss trial of financial incentives and environmental change strategies.

BACKGROUND: The use of financial incentives and environmental change strategies to encourage health behaviour change is increasingly prevalent. However, the experiences of participants in incentive interventions are not well characterised. Examination of participant perceptions of financial incentives and environmental strategies can offer insights about how these interventions are facilitating or failing to encourage behaviour change. OBJECTIVE: This study aimed to learn how participants in a randomised trial that tested financial incentives and environmental interventions to support weight loss perceived factors contributing to their success or failure in the trial. DESIGN: Qualitative study with one-time interviews of trial participants with high and low success in losing weight, supplemented by study records of incentive payments and weight loss. PARTICIPANTS: 24 trial participants (12 with substantial weight loss and 12 with no weight loss) stratified equally across the 4 trial arms (incentives, environmental strategies, combined and usual care) were interviewed. ANALYTICAL APPROACH: Transcribed interviews were coded and interpreted using an iterative process. Explanation development was completed using an abductive approach. RESULTS: Responses of trial participants who were very successful in losing weight differed in several ways from those who were not. Successful participants described more robust prior attempts at dietary and exercise modification, more active engagement with self-limitations, more substantial social support and a greater ability to routinise dietary and exercise changes than did participants who did not lose weight. Successful participants often stated that weight loss was its own reward, even without receiving incentives. Neither group could articulate the details of the incentive intervention or consistently differentiate incentives from study payments. CONCLUSIONS: A number of factors distinguished successful from unsuccessful participants in this intervention. Participants who were successful tended to attribute their success to intrinsic motivation and prior experience. Making incentives more salient may make them more effective for participants with greater extrinsic motivation. TRIAL REGISTRATION NUMBER: NCT02878343.

Association of the social disorganization index with time to first septic shock event in children with acute myeloid leukemia.

BACKGROUND: Pediatric acute myeloid leukemia (AML) chemotherapy increases the risk of life-threatening complications, including septic shock (SS). An area-based measure of social determinants of health, the social disorganization index (SDI), was hypothesized to be associated with SS and SS-associated death (SS-death). METHODS: Children treated for de novo AML on two Children's Oncology Group trials at institutions contributing to the Pediatric Health Information System (PHIS) database were included. The SDI was calculated via residential zip code data from the US Census Bureau. SS was identified via PHIS resource utilization codes. SS-death was defined as death within 2 weeks of an antecedent SS event. Patients were followed from 7 days after the start of chemotherapy until the first of end of front-line therapy, death, relapse, or removal from study. Multivariable-adjusted Cox regressions estimated hazard ratios (HRs) comparing time to first SS by SDI group. RESULTS: The assembled cohort included 700 patients, with 207 (29.6%) sustaining at least one SS event. There were 233 (33%) in the SDI-5 group (highest disorganization). Adjusted time to incident SS did not statistically significantly differ by SDI (reference, SDI-1; SDI-2: HR, 0.84 [95% confidence interval (CI), 0.51-1.41]; SDI-3: HR, 0.70 [95% CI, 0.42-1.16]; SDI-4: HR, 0.97 [95% CI, 0.61-1.53]; SDI-5: HR, 0.72 [95% CI, 0.45-1.14]). Nine patients (4.4%) with SS experienced SS-death; seven of these patients (78%) were in SDI-4 or SDI-5. CONCLUSIONS: In a large, nationally representative cohort of trial-enrolled pediatric patients with AML, there was no significant association between the SDI and time to SS.

Food Insecurity, Neighborhood Food Environment, and Health Disparities: State of the Science, Research Gaps and Opportunities.

Food insecurity and the lack of access to affordable, nutritious food are associated with poor dietary quality and an increased risk of diet-related diseases, including cardiovascular disease, diabetes, and certain types of cancer. Those of lower socioeconomic status and racial and ethnic minority groups experience higher rates of food insecurity, are more likely to live in under-resourced food environments, and continue to bear the greatest burden of diet-related chronic diseases in the United States. Despite the growing body of literature in this area, there are still significant gaps in our understanding of the various pathways that link food insecurity and neighborhood food environments to racial/ethnic and socioeconomic disparities in health and the most effective intervention strategies to address these disparities. To better understand the science in this area, the National Institutes of Health, in collaboration with the Centers for Disease Control (CDC) and Prevention and the United States Department of Agriculture (USDA), convened a virtual 3-d workshop 21-23 September 2021: Food Insecurity, Neighborhood Food Environment, and Nutrition Health Disparities: State of the Science. The workshop brought together a diverse group of researchers, practitioners, policymakers, and federal partners with expertise in nutrition, the food environment, health and social policy, and behavioral and social sciences. The workshop had the following 3 research objectives: 1) summarize the state of the science and knowledge gaps related to food insecurity, neighborhood food environments, and nutrition health disparities, 2) identify research opportunities and strategies to address research gaps, and 3) examine evidence-based interventions and implementation approaches to address food insecurity and neighborhood food environments to promote health equity. This article summarizes workshop proceedings and describes research gaps and future opportunities that emerged from discussions.

Associations Between Food Insecurity and Neighborhood Safety, Social Cohesion, Social Control, and Crime Among Mothers of Preschool-Aged Children.

Food insecurity has myriad associations with poor health, and low-income communities have higher than average prevalence of food insecurity. Living in a supportive neighborhood social environment may protect against food insecurity, while adverse neighborhood social conditions, such as crime, may increase the likelihood of food insecurity. To examine associations between food insecurity and neighborhood social factors among families with young children, we administered a cross-sectional survey to 300 mothers and female caregivers of Medicaid-enrolled two- to four-year-old children in Philadelphia. We used multivariable regression to examine associations between food insecurity and perceived neighborhood safety, social cohesion, informal social control, and crime, adjusted for demographics, socioeconomic status, and neighborhood characteristics. Lower food insecurity prevalence was associated with higher perceived neighborhood safety and social cohesion, and lower police-recorded violent crime rates. Future work to increase food security among low-income households may benefit from targeting the neighborhood social environment.

Association of Neighborhood Social Context and Perceived Stress Among Mothers of Young Children.

BACKGROUND: Chronic parental stress may negatively impact health among both parents and children. Adverse neighborhood social conditions like crime may increase stress while a supportive neighborhood may buffer stress and promote well-being. Our objective was to examine associations between neighborhood social factors and stress among mothers of young children. METHODS: We surveyed 300 mothers/female caregivers of Medicaid-enrolled 2 to 4-year-old children in Philadelphia. Maternal stress was measured via the 10-item Perceived Stress Scale (range 0-40). Mothers' perceived neighborhood safety and collective efficacy were assessed using validated scales. Addresses were geocoded to link census tract-level violent crime rates. We used multivariable linear regression to examine associations of neighborhood safety, collective efficacy, and crime with maternal stress, adjusted for demographics, household socioeconomic status, and neighborhood poverty. RESULTS: Among mothers (mean age 31, 60% Black/African American), higher perceived neighborhood safety and collective efficacy were associated with lower stress scores after adjustment for covariates. Each 1-point increase (on a 5-point scale) in perceived neighborhood safety was associated with a 2.30-point decrease in maternal stress (95% CI: -3.07, -1.53). Similarly, each 1-point increase in perceived collective efficacy was associated with a 3.08-point decrease in maternal stress (95% CI: -4.13, -2.02). Police-recorded violent crime rates were not associated with maternal stress. CONCLUSION: Mothers of young children who perceive their neighborhood social environment more favorably report less stress compared to those who feel their neighborhood environment is less safe and cohesive. Future work is warranted to investigate whether interventions that increase perceived neighborhood safety and collective efficacy reduce stress.

Design of a randomized controlled trial of digital health and community health worker support for diabetes management among low-income patients.

BACKGROUND: Insulin-dependent diabetes is a challenging disease to manage and involves complex behaviors, such as self-monitoring of blood glucose. This can be especially challenging in the face of socioeconomic barriers and in the wake of the COVID-19 pandemic. Digital health self-monitoring interventions and community health worker support are promising and complementary best practices for improving diabetes-related health behaviors and outcomes. Yet, these strategies have not been tested in combination. This protocol paper describes the rationale and design of a trial that measures the combined effect of digital health and community health worker support on glucose self-monitoring and glycosylated hemoglobin. METHODS: The study population was uninsured or publicly insured; lived in high-poverty, urban neighborhoods; and had poorly controlled diabetes mellitus with insulin dependence. The study consisted of three arms: usual diabetes care; digital health self-monitoring; or combined digital health and community health worker support. The primary outcome was adherence to blood glucose self-monitoring. The exploratory outcome was change in glycosylated hemoglobin. CONCLUSION: The design of this trial was grounded in social justice and community engagement. The study protocols were designed in collaboration with frontline community health workers, the study aim was explicit about furthering knowledge useful for advancing health equity, and the population was focused on low-income people. This trial will advance knowledge of whether combining digital health and community health worker interventions can improve glucose self-monitoring and diabetes-related outcomes in a high-risk population.

Effect of Financial Incentives and Environmental Strategies on Weight Loss in the Healthy Weigh Study: A Randomized Clinical Trial.

Importance: Modest weight loss can lead to meaningful risk reduction in adults with obesity. Although both behavioral economic incentives and environmental change strategies have shown promise for initial weight loss, to date they have not been combined, or compared, in a randomized clinical trial. Objective: To test the relative effectiveness of financial incentives and environmental strategies, alone and in combination, on initial weight loss and maintenance of weight loss in adults with obesity. Design, Setting, and Participants: This randomized clinical trial was conducted from 2015 to 2019 at 3 large employers in Philadelphia, Pennsylvania. A 2-by-2 factorial design was used to compare the effects of lottery-based financial incentives, environmental strategies, and their combination vs usual care on weight loss and maintenance. Interventions were delivered via website, text messages, and social media. Participants included adult employees with a body mass index (BMI; weight in kilograms divided by height in meters squared) of 30 to 55 and at least 1 other cardiovascular risk factor. Data analysis was performed from June to July 2021. Interventions: Interventions included lottery-based financial incentives based on meeting weight loss goals, environmental change strategies tailored for individuals and delivered by text messages and social media, and combined incentives and environmental strategies. Main Outcome and Measures: The primary outcome was weight change from baseline to 18 months, measured in person. Results: A total of 344 participants were enrolled, with 86 participants each randomized to the financial incentives group, environmental strategies group, combined financial incentives and environmental strategies group, and usual care (control) group. Participants had a mean (SD) age of 45.6 (10.5) years and a mean (SD) BMI of 36.5 (7.1); 247 participants (71.8%) were women, 172 (50.0%) were Black, and 138 (40.1%) were White. At the primary end point of 18 months, participants in the incentives group lost a mean of 5.4 lb (95% CI, -11.3 to 0.5 lb [mean, 2.45 kg; 95% CI, -5.09 to 0.23 kg]), those in the environmental strategies group lost a mean of a 2.2 lb (95% CI, -7.7 to 3.3 lb [mean, 1.00 kg; 95% CI, -3.47 to 1.49 kg]), and the combination group lost a mean of 2.4 lb (95% CI, -8.2 to 3.3 lb [mean, 1.09 kg; 95% CI, -3.69 to 1.49 kg]) more than participants in the usual care group. Financial incentives, environmental change strategies, and their combination were not significantly more effective than usual care. At 24 months, after 6 months without an intervention, the difference in the change from baseline was similar to the 18-month results, with no significant differences among groups. Conclusions and Relevance: In this randomized clinical trial, across all study groups, participants lost a modest amount of weight but those who received financial incentives, environmental change, or the combined intervention did not lose significantly more weight than those in the usual care group. Employees with obesity may benefit from more intensive individualized weight loss strategies. Trial Registration: ClinicalTrials.gov Identifier: NCT02878343.

Cost, reach, and representativeness of recruitment efforts for an online skin cancer risk reduction intervention trial for young adults.

Despite its increasing use, few studies have reported on demographic representativeness and costs of research recruitment via social media. It was hypothesized that cost, reach, enrollment, and demographic representativeness would differ by social media recruitment approach. Participants were 18-25 year-olds at moderate to high risk of skin cancer based on phenotypic and behavioral characteristics. Paid Instagram, Facebook, and Twitter ads, unpaid social media posts by study staff, and unpaid referrals were used to recruit participants. Demographic and other characteristics of the sample were compared with the 2015 National Health Interview Survey (NHIS) sample. Analyses demonstrated significant differences among recruitment approaches regarding cost efficiency, study participation, and representativeness. Costs were compared across 4,274 individuals who completed eligibility screeners over a 7-month period from: Instagram, 44.6% (of the sample) = 1,907, $9 (per individual screened); Facebook, 31.5% = 1,345, $8; Twitter, 1% = 42, $178; unpaid posts by study staff, 10.6% and referred, 6.5%, $1. The lowest rates of study enrollment among individuals screened was for Twitter. Most demographic and skin cancer risk factors of study participants differed from those of the 2015 NHIS sample and across social media recruitment approaches. Considering recruitment costs and number of participants enrolled, Facebook and Instagram appeared to be the most useful approaches for recruiting 18-25 year-olds. Findings suggest that project budget, target population and representativeness, and participation goals should inform selection and/or combination of existing and emerging online recruitment approaches.

Environmental exposomics and lung cancer risk assessment in the Philadelphia metropolitan area using ZIP code-level hazard indices.

To illustrate methods for assessing environmental exposures associated with lung cancer risk, we investigated anthropogenic based air pollutant data in a major metropolitan area using United States-Environmental Protection Agency (US-EPA) Toxic Release Inventory (TRI) (1987-2017), and PM2.5 (1998-2016) and NO2 (1996-2012) concentrations from NASA satellite data. We studied chemicals reported according to the following five exposome features: (1) International Agency for Research on Cancer (IARC) cancer grouping; (2) priority EPA polycyclic aromatic hydrocarbons (PAHs); (3) component of diesel exhaust; (4) status as a volatile organic compound (VOC); and (5) evidence of lung carcinogenesis. Published articles from PubChem were tallied for occurrences of 10 key characteristics of cancer-causing agents on those chemicals. Zone Improvement Plan (ZIP) codes with higher exposures were identified in two ways: (1) combined mean exposure from all features, and (2) hazard index derived through a multi-step multi-criteria decision analysis (MMCDA) process. VOCs, IARC Group 1 carcinogens consisted 82.3% and 11.5% of the reported TRI emissions, respectively. ZIP codes along major highways tended to have greater exposure. The MMCDA approach yielded hazard indices based on imputed toxicity, occurrence, and persistence for risk assessment. Despite many studies describing environmental exposures and lung cancer risk, this study develops a method to integrate these exposures into population-based exposure estimates that could be incorporated into future lung cancer screening trials and benefit public health surveillance of lung cancer incidence. Our methodology may be applied to probe other hazardous exposures for other cancers.

The Cancer Prevention and Control Research Network: Accelerating the implementation of evidence-based cancer prevention and control interventions.

This editorial provides a high level overview of the articles included in this supplement.

The Healthy Weigh study of lottery-based incentives and environmental strategies for weight loss: Design and baseline characteristics.

Identifying effective strategies for treating obesity is a clinical challenge and a public health priority. The present study is an innovative test of the relative effectiveness of lottery-based financial incentives and environmental strategies on weight loss and maintenance. The Healthy Weigh study is evaluating the comparative effectiveness of behavioral economic financial incentives and environmental strategies, separately and together, in achieving initial weight loss and maintenance of weight loss, in obese urban employee populations. Healthy Weigh is a multi-site, 4-arm randomized controlled trial (RCT) in which 344 employed participants were randomized to one of four arms. The study arms are: 1) standard employee wellness benefits and weigh-ins every 6 months (control arm/usual care); and the control/usual care plus either: 2) daily lottery incentives tied to achievement of weight loss goals (incentive arm); 3) individually tailored environmental strategies around food intake and physical activity (environmental arm); or 4) a combination of incentives and environmental strategies (combined arm). This trial used a web-based platform to enroll, communicate with, and track participant weight change. Wireless scales were used by participants in the three treatment group arms to digitally transmit daily/weekly weights. For females, the baseline median (interquartile range, IQR) for BMI and weight were 37.0 (33.5, 40.6) and 219.9 (198.1, 248.6), respectively; and for males, they were 36.0 (32.8, 39.8) and 247.9 (228.1, 279.5), respectively. The population was generally well-educated. This study demonstrated that multi-site employee-based recruitment for a weight-control intervention study is feasible but may need additional time for coordination between diverse environments.

Use of Evidence-Based Interventions and Implementation Strategies to Increase Colorectal Cancer Screening in Federally Qualified Health Centers.

While colorectal cancer (CRC) screening rates have been increasing in the general population, rates are considerably lower in Federally Qualified Health Centers (FQHCs), which serve a large proportion of uninsured and medically vulnerable patients. Efforts to screen eligible patients must be accelerated if we are to reach the national screening goal of 80% by 2018 and beyond. To inform this work, we conducted a survey of key informants at FQHCs in eight states to determine which evidence-based interventions (EBIs) to promote CRC screening are currently being used, and which implementation strategies are being employed to ensure that the interventions are executed as intended. One hundred and forty-eight FQHCs were invited to participate in the study, and 56 completed surveys were received for a response rate of 38%. Results demonstrated that provider reminder and recall systems were the most commonly used EBIs (44.6%) while the most commonly used implementation strategy was the identification of barriers (84.0%). The mean number of EBIs that were fully implemented at the centers was 2.4 (range 0-7) out of seven. Almost one-quarter of respondents indicated that their FQHCs were not using any EBIs to increase CRC screening. Full implementation of EBIs was correlated with higher CRC screening rates. These findings identify gaps as well as the preferences and needs of FQHCs in selecting and implementing EBIs for CRC screening.

Neighborhood built environment and socioeconomic status in relation to physical activity, sedentary behavior, and weight status of adolescents.

INTRODUCTION: The study examined the association of neighborhood walkability to multiple activity-related outcomes and BMI among adolescents and evaluated socioeconomic status as an effect modifier. METHOD: Cross-sectional study, with adolescents recruited from neighborhoods that met criteria for a 2 × 2 matrix defined by high/low GIS-defined walkability and high/low median income. Adolescents aged 12-16 years (n = 928) were recruited from selected neighborhoods in Maryland and King County, Washington regions in 2009-2011. There were 50.4% girls, and 66.3% were non-Hispanic white, with no medical restrictions on physical activity (PA) or diets. Total PA and sedentary time was assessed by 7 days of accelerometer monitoring. Adolescents self-reported active transport, time spent on 6 sedentary behaviors, and height and weight, used to compute BMI percentiles. Mixed model linear and logistic regressions examined outcomes for association with walkability and income, adjusting for demographic covariates and clustering within block groups. RESULTS: Walkability was positively and significantly related to objectively-measured PA (p < .001) and more frequent walking for transportation (p < .001). Total self-reported sedentary time (p = .048) and TV time (p < .007) were negatively related to walkability. Time in vehicles was negatively related to walkability only among higher-income adolescents. CONCLUSIONS: Neighborhood walkability was strongly and consistently associated with adolescents' objectively-assessed total physical activity and reported active transportation. A novel finding was that adolescents living in walkable neighborhoods reported less television time and less time in vehicles. Most results were similar across income categories. Results strengthen the rationale for recommendations to improve walkability.

Perceived and Observed Food Environments, Eating Behaviors, and BMI.

INTRODUCTION: This study examines relationships between perceived and observed nutrition environments, diet, and BMI, in order to examine the criterion validity of the Nutrition Environment Measures Survey-Perceived (NEMS-P). METHODS: In a cross-sectional study, perceived nutrition environments were assessed (NEMS-P) among 221 adults from four neighborhoods in the Philadelphia area in 2010 and 2011. A total of 158 food store environments were observed using the NEMS-Stores. Data analyses were conducted in 2016. Bivariate Spearman rank correlations were used to examine relationships between perceived and observed availability, quality, and price of fruits and vegetables in respondents' neighborhoods. Linear regression models were used to examine relationships between perceived neighborhood and home food environments and daily fruit and vegetable consumption and BMI. RESULTS: A significant, positive relationship was found between perceived and observed availability of fruits and vegetables in the neighborhood (r = 0.36, p<0.001). A similar relationship was seen between perceived and observed quality of fruits and vegetables (r = 0.34, p<0.001). Perceived availability and quality of fruits and vegetables in the neighborhood, and availability and accessibility of fruits and vegetables in the home, were significantly related to daily fruit and vegetable consumption. Perceived price of food in the neighborhood was significantly associated with BMI. CONCLUSIONS: Responses to a self-reported survey to assess perceived food environments related to fruits and vegetables were significantly associated with observed nutrition environments, fruit and vegetable consumption, and BMI. The perceived prices of fruits and vegetables were modestly associated with BMI and warrant further testing in prospective studies. When observations of food environments are not feasible, residents' survey responses are an acceptable indicator, with reasonable criterion validity.

Does the Screening Status of Message Characters Affect Message Effects?

Public health messages can be used to increase awareness about colorectal cancer screenings. Free or inexpensive images for creating health messages are readily available, yet little is known about how a pictured individual's engagement in the behavior of interest affects message outcomes. Participants ( N = 360), aged 50 to 75 years, completed an online survey in which they viewed a colorectal cancer screening message and were then randomly assigned to view one of four different messages about the pictured individual's screening status. Analyses revealed no significant differences in message credibility, message effectiveness, or screening intention among the four conditions. The pictured individual's level of knowledge was rated significantly lower among those participants who were told the screening status of the pictured individual was unknown, compared with those who received no screening status information, U = 3574.50, p = .005. Future studies could build on the design of this study to examine the effects of using free or purchased images on intent to screen and other message outcomes over time.

A Trial of Financial and Social Incentives to Increase Older Adults' Walking.

INTRODUCTION: Despite evidence that regular physical activity confers health benefits, physical activity rates among older adults remain low. Both personal and social goals may enhance older adults' motivation to become active. This study tested the effects of financial incentives, donations to charity, and the combined effects of both interventions on older adults' uptake and retention of increased levels of walking. STUDY DESIGN: RCT comparing three interventions to control. Data collection occurred from 2012 to 2013. Analyses were conducted in 2013-2016. PARTICIPANTS: Ninety-four adults aged ≥65 years from Philadelphia-area retirement communities. INTERVENTION: All participants received digital pedometers, walking goals of a 50% increase in daily steps, and weekly feedback on goal attainment. Participants were randomized to one of four groups: (1) Control: received weekly feedback only; (2) Financial Incentives: received payment of $20 each week walking goals were met; (3) Social Goals: received donation of $20 to a charity of choice each week walking goals were met; and (4) Combined: received $20 each week walking goals were met that could be received by participant, donated to a charity of choice, or divided between the participant and charity. MAIN OUTCOME MEASURES: Mean proportion of days walking goals were met during the 16-week intervention and 4-week follow-up period. RESULTS: After adjusting for baseline walking, the proportion of days step goals were met during the 16-week intervention period was higher in all intervention groups versus controls (relative risk, 3.71; 95% CI=1.37, 10.01). During the 4-week follow up period, the proportion of days step goals were met did not differ in intervention groups compared to control (relative risk, 2.91; 95% CI=0.62, 13.64). CONCLUSIONS: Incentive schemes that use donations to a charity of choice, personal financial incentives, or a combination of the two can each increase older adults' initial uptake of increased levels of walking. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT01643538.

Disparities in Pedestrian Streetscape Environments by Income and Race/Ethnicity.

Growing evidence suggests that microscale pedestrian environment features, such as sidewalk quality, crosswalks, and neighborhood aesthetics, may affect residents' physical activity. This study examined whether disparities in microscale pedestrian features existed between neighborhoods of differing socioeconomic and racial/ethnic composition. Using the validated Microscale Audit of Pedestrian Streetscapes (MAPS), pedestrian environment features were assessed by trained observers along »-mile routes (N = 2117) in neighborhoods in three US metropolitan regions (San Diego, Seattle, and Baltimore) during 2009 to 2010. Neighborhoods, defined as Census block groups, were selected to maximize variability in median income and macroscale walkability factors (e.g., density). Mixed-model linear regression analyses explored main and interaction effects of income and race/ethnicity separately by region. Across all three regions, low-income neighborhoods and neighborhoods with a high proportion of racial/ethnic minorities had poorer aesthetics and social elements (e.g., graffiti, broken windows, litter) than neighborhoods with higher median income or fewer racial/ethnic minorities (p<.05). However, there were also instances where neighborhoods with higher incomes and fewer racial/ethnic minorities had worse or absent pedestrian amenities such as sidewalks, crosswalks, and intersections (p<.05). Overall, disparities in microscale pedestrian features occurred more frequently in residential as compared to mixed-use routes with one or more commercial destination. However, considerable variation existed between regions as to which microscale pedestrian features were unfavorable and whether the unfavorable features were associated with neighborhood income or racial/ethnic composition. The variation in pedestrian streetscapes across cities suggests that findings from single-city studies are not generalizable. Local streetscape audits are recommended to identify disparities and efficiently allocate pedestrian infrastructure resources to ensure access and physical activity opportunities for all residents, regardless of race, ethnicity, or income level.

Socioeconomic and race/ethnic disparities in observed park quality.

BACKGROUND: Though park presence and access disparities are well studied for their associations with physical activity (PA), disparities in the availability and quality of amenities and facilities within parks have been infrequently examined. METHODS: Five hundred forty-three parks from 472 block groups in the Seattle, WA and Baltimore, MD regions were audited using the Environmental Assessment of Public Recreation Spaces (EAPRS) to assess presence and quality (e.g., condition, cleanliness) of amenities (e.g., restrooms, seating) and facilities (e.g., fields, courts). General linear model regressions investigated Census 2000-derived neighborhood race/ethnicity and income main effect and interactive relationships with 7 park quality summary scores: 1) trails, 2) open space, 3) sports facilities, 4) PA facilities count, 5) PA facilities quality, 6) aesthetics, and 7) overall amenities, controlling for park size. The regions were analyzed separately due to differing race/ethnicity distributions. RESULTS: In the Seattle region, neighborhood income was significantly negatively associated with sports quality score (p < .043), PA facilities total count (p < .015) and the overall amenities quality score (p < .004) (unexpected direction). In the Baltimore region, neighborhood race/ethnicity (percent White/non-Hispanic) was significantly positively related to the open spaces quality score (p < .011) (expected direction). A significant income-by-race/ethnicity interaction was found for PA facilities quality (p = .014), with high-percent minority neighborhoods having higher quality parks in high- vs. low-income neighborhoods, yet was opposite in mostly White/non-Hispanic neighborhoods. The other income-by-race/ethnicity interaction was for overall amenities quality score (p = .043), where scores in high-percent minority neighborhoods were best in high- vs. low-income neighborhoods. There was little difference in scores within mostly White or mixed neighborhoods by income. CONCLUSIONS: Patterns of association of neighborhood race/ethnicity and income with park qualities differed between regions. In the Seattle region, "equitable differences" were found, where lower income neighborhoods had better park quality on average. In the Baltimore region, park quality was more consistently negatively associated with income and race/ethnic diversity, and complex interactions of race/ethnicity by income were detected. These findings emphasize the need to explore other factors that may explain variations in park quality, like local policy, citizen involvement in park decision-making, park funding and allocation, sources of funding and park priorities.

Measures of Retail Food Store Environments and Sales: Review and Implications for Healthy Eating Initiatives.

OBJECTIVE: This review describes available measures of retail food store environments, including data collection methods, characteristics of measures, the dimensions most commonly captured across methods, and their strengths and limitations. METHODS: Articles were included if they were published between 1990 and 2015 in an English-language peer-reviewed journal and presented original research findings on the development and/or use of a measure or method to assess retail food store environments. Four sources were used, including literature databases, backward searching of identified articles, published reviews, and measurement registries. RESULTS: From 3,013 citations identified, 125 observational studies and 5 studies that used sales records were reviewed in-depth. Most studies were cross-sectional and based in the US. The most common tools used were the US Department of Agriculture's Thrifty Food Plan and the Nutrition Environment Measures Survey for Stores. The most common attribute captured was availability of healthful options, followed by price. Measurement quality indicators were minimal and focused mainly on assessments of reliability. IMPLICATIONS FOR RESEARCH AND PRACTICE: Two widely used tools to measure retail food store environments are available and can be refined and adapted. Standardization of measurement across studies and reports of measurement quality (eg, reliability, validity) may better inform practice and policy changes.

The impact of home, work, and church environments on fat intake over time among rural residents: a longitudinal observational study.

BACKGROUND: Dietary behaviors are influenced by many individual and environmental factors. This study explores how dietary fat intake in high-risk midlife adults living in the rural south is influenced by three behavior settings, i.e. in the home, at work, and at church. METHODS: Self-report data were collected from rural African American or Caucasian adults age 40-70 at three time points at baseline, 6, and 12 months post baseline. Multilevel analyses investigated the impact of determinants of fat intake over time. RESULTS: Home and work environments varied significantly over time in regard to healthy eating while church environments remained stable. Age, gender, and self-efficacy for healthy eating were individual factors associated with fat intake. In the home, presence of more high fat items, a time-varying variable, was significant. In the work environment, having access to healthy foods as well as healthy eating programs has positive impact as did hearing healthy eating messages and availability of healthy foods at church. CONCLUSIONS: Understanding stability and variability of dietary fat intake from a social ecologic perspective will aid in identifying targets of change for intervention. Understanding which components of key behavior settings are dynamic and which are relatively stable will help to disentangle the complexity of multi-level determinants of dietary behavior.