A Salient Belief Elicitation Examining Adolescents' Meditation Beliefs Using the Reasoned Action Approach.

The purpose of this study was to identify adolescents' consequence, referent, and circumstance beliefs about trying to meditate at least twice in the next week in order to inform subsequent meditation intervention design. A survey based on reasoned action approach (RAA) constructs was developed and pilot-tested. Thereafter, adolescents (N = 129), recruited from a northeastern U.S. high school, responded to open-ended survey questions eliciting beliefs underlying intention to try meditating. Thematic analysis was executed to examine beliefs and frequencies of beliefs. Five types of salient meditation beliefs were identified: advantages (e.g., reduces stress, increases relaxation, improves focus), disadvantages (e.g., slows everything down), supporters and disapprovers (e.g., family and friends), and facilitating circumstances (e.g., more time, fewer distractions). Adolescents recognize meditation as having health benefits but as also taking time. They further viewed meditation as socially acceptable but need sufficient time and a conducive environment to try it. To be effective, interventions designed to promote adolescents' self-regulation through meditation should address identified salient beliefs.

Identifying Factors Underlying the Decision for Sickle Cell Carrier Screening Among African Americans Within Middle Reproductive Age.

Guidelines recommend that African Americans know their sickle cell trait status to inform reproductive health decisions. Few studies have applied a behavioral theory to identify factors associated with sickle cell trait screening to inform intervention targets to increase this behavior. We applied a Sickle Cell Trait Screening Framework to identify factors associated with African Americans' intention to ask for sickle cell trait screening. Participants (N = 300), ages 18 to 35, completed a cross-sectional survey. A three-step sequential ordinary least squares regression analysis identified factors influencing intention. Results indicated socio-demographic factors (age, education), knowledge and fear beliefs (screening knowledge, perceived threat), and reasoned action approach (RAA) constructs were associated with intention. RAA constructs influenced intention over knowledge and fear beliefs with an increase in R2 of .468. Perceived behavioral control was more predictive of intention (ß = .576, p < .001). Attitude and perceived norm also had significant weights (ß = .325 and ß = .192, both p < .001, respectively). Findings from this study can inform strategies (e.g., eliminating costs associated with screening, reducing fear of painful tests) to increase sickle cell trait screening among African Americans. Ultimately, more sickle cell carriers will become aware of their trait status and be able to make informed reproductive health decisions.

'It means everyone should know their status': exploring lay conceptions of sickle cell trait and sickle cell trait screening among African Americans within middle reproductive age.

OBJECTIVE: This study examined the meaning of sickle cell trait and sickle cell trait screening from the lay perspective of African Americans. DESIGN AND METHODS: African Americans (N = 300), ages 18-35 and unaware of their sickle cell trait status, completed two open-ended questions from a larger survey. One question asked for their understanding of sickle cell trait; the other asked for their understanding of sickle cell trait screening. Content analysis occurred in two phases: (1) In vivo and holistic coding; and (2) focused coding. RESULTS: Four categories emerged illustrating lay conceptions of sickle cell trait; (1) Perceived as an illness; (2) Perceived recognition of the inheritance pattern of sickle cell trait; (3) Perceived lack of knowledge of sickle cell trait; and (4) Perceived importance of sickle cell trait. Five categories emerged illustrating lay conceptions for sickle cell trait screening: (1) Perceived recognition that screening means getting tested for sickle cell trait; (2) Perceived lack of knowledge of sickle cell trait screening; (3) Perceived health benefit of sickle cell trait screening; (4) Perceived importance of sickle cell trait screening; and (5) Perceived barriers to sickle cell trait screening. CONCLUSIONS: Sickle cell trait and sickle cell trait screening are concepts that are both regarded as important among this high-risk population. However, there is still misunderstanding concerning the hereditary nature and reproductive implications of sickle cell trait. Interventions seeking to improve communication on the need for sickle cell trait screening should begin by identifying what the population at large understands, knows and/or believes to improve their ability to make informed health decisions.

Does the Relationship Between Cigarette Smoking and Other Key Health Behaviors Vary by Geographic Area Among US Young Adults? A Multilevel Analysis.

BACKGROUND: Although researchers and practitioners have long been aware of interdependence among health behaviors, they tend to compartmentalize health behaviors in research and practice. This kind of approach often fails to acknowledge the syndemic nature of health behaviors. PURPOSE: This study investigated differences in the relationship between cigarette smoking and other key health behaviors, such as vigorous physical activity, fruit and vegetable consumption, and binge drinking among young adults (ages 18 to 30 years) across 180 metropolitan and micropolitan statistical areas (MMSAs) in the USA. METHOD: A total of 19,027 young adults in the 2009 Behavioral Risk Factor Surveillance System (BRFSS) data were analyzed using multilevel logistic regression models. RESULTS: Both vigorous physical activity and fruit and vegetable consumption were negatively associated with cigarette smoking, whereas binge drinking was positively associated with smoking. There were significant differences in the relation of smoking with vigorous physical activity, fruit and vegetable consumption, and binge drinking across the 180 MMSAs. These differences were associated with the prevalence of cigarette smoking and binge drinking for each MMSA. CONCLUSION: As indicated by the social learning theory, geographic area-specific prevalence of health behaviors appears to reflect group norms regarding those behaviors which, in turn, affect the clustering of health behaviors in the respective area.

An evidence review of gender-integrated interventions in reproductive and maternal-child health.

Evidence-based behavior change interventions addressing gender dynamics must be identified and disseminated to improve child health outcomes. Interventions were identified from systematic searches of the published literature and a web-based search (Google and implementer's websites). Studies were eligible if an intervention addressed gender dynamics (i.e., norms, unequal access to resources), measured relevant behavioral outcomes (e.g., family planning, antenatal care, nutrition), used at least a moderate evaluation design, and were implemented in low- or middle-income countries. Of the 23 interventions identified, 22 addressed reproductive and maternal-child health behaviors (e.g., birth spacing, antenatal care, breastfeeding) that improve child health. Eight interventions were accommodating (i.e., acknowledged, but did not seek to change gender dynamics), and 15 were transformative (i.e., sought to change gender dynamics). The majority of evaluations (n = 12), including interventions that engaged men and women to modify gender norms, had mixed effects. Evidence was most compelling for empowerment approaches (i.e., participatory action for maternal-child health; increase educational and economic resources, and modify norms to reduce child marriage). Two empowerment approaches had sufficient evidence to warrant scaling-up. Research is needed to assess promising approaches, particularly those that engage men and women to modify gender norms around communication and decision making between spouses.

Determinants of middle-school students asking parents for fruits and vegetables: a theory-based salient belief elicitation.

OBJECTIVE: Despite the benefits of fruit and vegetable intake, many young Americans do not consume them at adequate levels. The present study sought to determine the beliefs that children have about asking their parents to have fruits and vegetables available at home in order to better understand the role children may play in influencing their own fruit and vegetable consumption. DESIGN: An instrument utilizing the Reasoned Action Approach, with closed-ended questions on demographic and behavioural variables and open-ended questions eliciting the belief structure underlying asking parents to make fruits and vegetables available, was distributed. Thematic and frequency analyses were performed for open-ended questions. Statistical analyses were conducted to assess differences between children who had v. had not asked for fruits and vegetables. SETTING: Three middle schools in rural Indiana, U.S.A. SUBJECTS: A sub-sample of sixty students aged 12­15 years from a larger study of 344 students. RESULTS: Qualitative analysis identified benefits (i.e., make me healthier; make parents happy), disadvantages (i.e., will upset my parents) and strategies (i.e., asking when you are at the store) that could be used to improve fruit and vegetable intake. Findings also revealed that students who asked their parents for fruits and vegetables were significantly more likely to perform several healthy eating and physical activity behaviours. CONCLUSIONS: Data suggest that young people's view of parental reactions is critical. While additional research is necessary, the findings support a role for children in shaping their own environment and suggest multilevel interventions that simultaneously address parents and children.

Salient beliefs about eating and buying dark green vegetables as told by Mid-western African-American women.

Vegetables in the dark green group are the most nutritious, yet intake is low. Studies suggest that an increase in fruit and vegetables may improve diet-related health outcomes of African Americans. The aim of this exploratory study was to use the Reasoned Action Approach (RAA) to qualitatively assess salient, top-of-the-mind, beliefs (consequences, circumstances and referents) about eating and buying more dark green leafy vegetables each week over the next 3months. Adult (n=30), Midwestern African-American women, who buy and prepare food for their household participated in a face-to-face salient belief elicitation. A content analysis of verbatim text and a descriptive analysis were conducted. Findings suggest that the RAA can be used to identify salient consequences, circumstances and referents about eating and buying more dark green leafy vegetables. The use of the RAA allowed for the extraction of specific beliefs that may aid in the development of nutrition education programs that consider the varying priorities, motivators and barriers that subgroups within the population have in regard to buying and consuming dark green leafy vegetables.

Beliefs of University Employees Leaving During a Fire Alarm: A Theory-based Belief Elicitation.

Background: Despite workplaces having policies on fire evacuation, many employees still fail to evacuate when there is a fire alarm. The Reasoned Action Approach is designed to reveal the beliefs underlying people's behavioral decisions and thus suggests causal determinants to be addressed with interventions designed to facilitate behavior. This study is a uses a Reasoned Action Approach salient belief elicitation to identify university employees' perceived advantages/disadvantages, approvers/disapprovers, and facilitators/barriers toward them leaving the office building immediately the next time they hear a fire alarm at work. Methods: Employees at a large public United States Midwestern university completed an online cross-sectional survey. A descriptive analysis of the demographic and background variables was completed, and a six-step inductive content analysis of the open-ended responses was conducted to identify beliefs about leaving during a fire alarm. Results: Regarding consequence, participants perceived that immediately leaving during a fire alarm at work had more disadvantages than advantages, such as low risk perception. Regarding referents, supervisors and coworkers were significant approvers with intention to leave immediately. None of the perceived advantages were significant with intention. Participants listed access and risk perception as significant circumstances with the intention to evacuate immediately. Conclusion: Norms and risk perceptions are key determinants that may influence employees to evacuate immediately during a fire alarm at work. Normative-based and attitude-based interventions may prove effective in increasing the fire safety practices of employees.

The combined effect of behavioral intention and exposure to a smoke-free air law on taking measures to quit smoking.

Because of the large burden of disease attributable to cigarette smoking, a variety of tobacco control interventions, some focused on changing individual behavior and others focused on influencing societal norms, have been introduced. The current study tested the combined effect of behavioral intention and exposure to a comprehensive smoke-free air law as a prospective predictor of taking measures to quit smoking. Participants were 187 adults living in 7 Texas cities, 3 with a comprehensive smoke-free air law and 4 without such a law, who reported current cigarette smoking at baseline and completed a 1-month follow-up interview. Data were collected by telephone administration of a questionnaire. Results showed that, compared with smokers with low behavioral intention to take measures to quit smoking and no exposure to a comprehensive smoke-free air law, the smokers with high behavioral intention and exposure to a comprehensive law had the greatest odds of taking measures to quit smoking. This longitudinal study provides further evidence that the most successful smoking cessation campaigns will be multifaceted addressing individual factors with educational strategies designed to change beliefs and intentions and environmental factors with policy-based interventions.

Catalyzing transdisciplinary studies in public health: a college health survey and data platform.

Researchers, educators, and service providers recognize that health behaviors and conditions are interdependent, yet they are too often addressed compartmentally. This "silo" approach is unfortunate because it leads to inefficiencies and less effective approaches to prevention. This article describes a process designed to promote better understanding of the interrelatedness of health behaviors and outcomes through a multidimensional Internet-based health survey aimed at undergraduate college students. In addition, we describe a data-sharing platform whereby faculty and students from across disciplines may access the raw data for a variety of uses. An analysis is performed illustrating a syndemic between binge drinking, sexually transmitted diseases, and using alcohol or drugs prior to sexual intercourse. Potential applications of the multidomain survey are discussed, as well as lessons learned and limitations of this approach.

Belief Factors Associated With Employees' Intention to Evacuate During a Fire Alarm.

BACKGROUND: Nonresidential fires and resultant injuries and deaths have been on the rise the last decade in the United States. Although evacuation is a primary prevention method, people in the workplace still fail to evacuate when they hear a fire alarm. The current formative study applied the Reasoned Action Approach (RAA) to identify belief factors associated with university employees' intention evacuate. METHODS: Data were collected from employees at a large public university (N = 490) through an online survey. Multiple linear regression quantified the relative contribution of six RAA constructs that represent belief factors underlying employees' intention to leave the office building immediately the next time they hear a fire alarm. FINDINGS: Nearly 60% of the variation in employees' intention to leave was predicted from the belief factors, adjusted R2 = 0.598, F(17, 472) = 43.80, p < .001. Controlling for demographic characteristics, five of the six RAA global constructs showed statistically significant independent associations with intention: instrumental attitude (B = .272, SE = .026, p < .001), experiential attitude (B = -.073, SE = .026, p = .024), injunctive norm (B = .210, SE = .075, p < .001), descriptive norm (B = .347, SE = .070, p < .001), and capacity (B = .178, SE = .077, p < .001). CONCLUSIONS/APPLICATIONS TO PRACTICE: These findings show the RAA can be successfully applied to provide employees' perspective on safety decisions like evacuation. The belief factors' relative contributions can help safety professionals prioritize interventions to facilitate leaving immediately. Here the high weights for the two normative factors suggest addressing employees' descriptive beliefs that others like them leave and their injunctive beliefs that significant others, like supervisors and safety personnel, approve of their leaving.

The effect of a smoke-free campus policy on college students' smoking behaviors and attitudes.

OBJECTIVE: To evaluate the impact of a smoke-free campus policy on college students' smoking behaviors and attitudes. METHODS: The current study utilized repeated cross-sectional surveys with a nested 4-wave longitudinal cohort design. Data were collected from undergraduate students at two large matched public universities in Indiana before and after one of the campuses went smoke-free in January 2008. Baseline data were collected in fall 2007 (n=3266) and follow-up data were collected in fall 2009 (n=3207). In addition, volunteers provided longitudinal follow-up data at four different time points. RESULTS: In the cross-sectional analyses, students exposed to the smoke-free campus policy demonstrated significant favorable changes in smoking behavior (16.5% to 12.8%, p<0.001), perceptions of peer tobacco use (73.6% to 66.8%, p<0.001), and smoking norms (45.5% to 40.4%, p<0.001) compared to students on the control campus. In the longitudinal analyses, students exposed to the smoke-free campus policy demonstrated these changes plus significant favorable changes in attitudes toward regulation of tobacco (83.2% to 89.9%, p<0.01). CONCLUSIONS: The implementation of a smoke-free campus policy may be an effective intervention for reducing tobacco use among college students.

The Role of Self-Efficacy and Injunctive Norms in Helping Older Adults Decide to Stay Home During the COVID-19 Pandemic.

Purpose: Because older adults are at elevated risk of COVID-19-related adverse health outcomes, and staying at home is an effective strategy to avoid unnecessary exposures, the current formative study used the Reasoned Action Approach (RAA) to identify the beliefs underlying older adults' decision to stay home for the next month. Methods: The participants (weighted n = 206, age 65-94) for the current study were selected from a nationally representative online survey of US adults from April 10-20, 2020. We used multiple linear regression to estimate the relative contribution of the four RAA global constructs (instrumental attitude, injunctive norms, descriptive norms, and self-efficacy) in explaining intention to stay home after controlling for demographic covariates. We also conducted a content analysis to identify beliefs about advantages, disadvantages, and facilitators of staying home. Results: After controlling for demographic characteristics, injunctive norms (b = 0.208; SE = 0.059; B = 0.213, p < 0.01) and self-efficacy (b = 0.532; SE = 0.058; B = 0.537, p < 0.001) showed statistically significant independent associations with intention to stay home. The specific beliefs underlying the decision to stay home spanned across health and wellness dimensions and suggested interpersonal, mental health, and leisure/recreational facilitators. Conclusions: These findings suggest three public health intervention targets. First, self-efficacy building interventions could enhance older adults' perceptions of their ability to stay home to avoid unnecessary exposures. Second, health communication messages to address injunctive norms could emphasize that people important to older adults think they should stay home. Third, for the youngest of the older adults, health communication messages could emphasize the advantages of staying home.

Sexual behaviors, condom use, and sexual health of Americans over 50: implications for sexual health promotion for older adults.

INTRODUCTION: In the contemporary U.S., men and women are living longer and healthier lives. As such, many people spend greater portions of their lives as sexually active individuals. Yet, little is known about the myriad of ways that older adults experience their sexual lives. AIM: This study sought to assess the context and frequency of sexual behaviors, condom use, sexual pleasure, and sexual experience of men and women over age 50. METHODS: Information regarding the sexual experiences of a nationally representative sample of men and women over age 50 within the past year was examined. MAIN OUTCOME MEASURES: Sexual behavior over the past year was assessed in relation to several situational and contextual characteristics (e.g., event location, type of partner, health status, condom use). Participants were also asked about their experience (i.e., pleasure, arousal, pain, lubrication/erectile difficulties, and orgasm) during their most recent partnered sexual event. Bivariate or ordinal logistic regression models were used to investigate the relationship of age, health and partner status to sexual frequency and experience. RESULTS: Although sizable proportions (20-30%) of both men and women remained sexually active well into their 80s age was related to a lower likelihood of solo and most partnered sexual behaviors. When controlling for age, relationship status, and health remained significant predictors of select sexual behaviors. The participant's evaluation of their most recent sexual experience in terms of arousal, erectile difficulty, and orgasm all declined with age. Health status was related to men's evaluation of the experience. Relationship status was the most consistent predictor of women's evaluation of the experience. Condom use rates remained low for participants across age groups. CONCLUSION: Many older adults continue be sexually active well into advanced age (80+). Thus, providers need to be attentive to the diverse sexual health needs of older adults.

A Randomized mHealth Trial to Promote Vegetable Intake Through Counting and Goal Setting.

OBJECTIVE: To determine if counting and goal setting can increase red/orange vegetable intake. DESIGN: Pre-posttest experimental. SETTING: Midwestern university. PARTICIPANTS: Undergraduate students (n = 165). INTERVENTION: Those in the intervention group (n = 85) were asked to count the number of times they ate red/orange vegetables and set a goal to eat 1 more time. MAIN OUTCOME MEASURE: An estimate (number of times/d) of vegetable intake based on an independent review of uploaded photographs and descriptions of meals from smartphones. ANALYSIS: Generalized estimating equations. RESULTS: For the intervention group, mean frequency intake increased from 0.9 times/d on Monday to 1.6 times/d on Tuesday and to 1.3 times/d on Wednesday, whereas mean intakes for the control group were 1.0, 0.8, and 0.8 times/d, respectively. There were significant group × time interactions for Tuesday (ß = 0.8; P < 0.001) and Wednesday (ß = 0.5; P = 0.006). CONCLUSIONS AND IMPLICATIONS: A mobile method that helped people count their daily red/orange vegetable intake and set a goal appeared to increase consumption. This finding suggests that nutrition education programs that provide people with easy ways to track specific dietary behaviors might be effective at helping them attain goals.

Is E-cigarette use a gateway to marijuana use? Longitudinal examinations of initiation, reinitiation, and persistence of e-cigarette and marijuana use.

BACKGROUND: Concerns have been raised regarding e-cigarette use as a potential stepping-stone to marijuana use. Based on Kandel's gateway hypothesis, this study investigated if e-cigarette use could lead to marijuana use by testing two hypotheses with a longitudinal national U.S. adult sample, including (1) primary hypothesis: e-cigarette use is a gateway to marijuana use; and (2) falsification hypothesis: marijuana use is not a gateway to e-cigarette use. METHODS: Adults were extracted from the Population Assessment of Tobacco and Health Study Waves 1-3 (2013-2016). For primary hypotheses, based on baseline e-cigarette use statuses, three study groups were defined, and three logistic regressions were conducted to examine associations between baseline e-cigarette use and follow-up marijuana use initiation, reinitiation, and persistence, respectively. Similarly, for falsification hypotheses, three additional study groups were defined, and three logistic regressions were conducted to examine associations between baseline marijuana use and follow-up e-cigarette use behaviors. RESULTS: Baseline e-cigarette use was associated with marijuana use initiation and reinitiation (ORs = 2.08, 1.37, respectively, both ps < .05) but not persistence at follow-up. Additionally, baseline marijuana use was associated with only e-cigarette use initiation (OR = 2.23, p < .01) but not reinitiation or persistence at follow-up. CONCLUSIONS: Findings partially support the gateway hypothesis that e-cigarette use could be a steppingstone to marijuana use reinitiation among the U.S. adults. The mechanisms and behavioral characteristics, such as etiological and psychosocial factors, that may pertain to the progression from e-cigarette use to reinitiation of other substance use should be further investigated to inform effective behavioral, educational, and policy interventions.

Predicting Voluntary Exercise Training among Korean Firefighters: Using Elicitation Study and the Theory of Planned Behavior.

Background: Firefighters are required to have high levels of aerobic and anaerobic power because they often perform physically demanding work in dangerous environments. Therefore, it is important to find out salient factors influencing voluntary exercise training among Korean firefighters based on well-validated theory. Methods: The present study conducted an elicitation study to elicit salient behavioral, normative, and control beliefs about exercise training among Korean firefighters and identified salient beliefs that have a significant indirect effect on behavior through intention using structural equation modeling. Results: Although ten modal salient beliefs obtained from our elicitation study are similar to those elicited from previous TPB belief-based research with a focus on exercise behavior, only three of these (i.e., "improves my physical ability" (coef. = 0.078, p = 0.006), "takes too much time" (coef. = 0.064, p = 0.023), and "colleagues" (coef. = 0.069, p = 0.016) indirectly influenced exercise training behavior through intention among Korean firefighters. Conclusions: Our results may contribute to the literature by providing important information suggesting that three modal salient beliefs are major cognitive determinants of exercise training behavior among Korean firefighters and they may play an essential role in developing effective programs or policies for promoting Korean firefighters' exercise training.

Incorporating environmental variables as precursor background variables of the theory of planned behavior to predict quitting-related intentions: a comparative study between adult and young adult smokers.

BACKGROUND: As previous studies suggest that the theory of planned behavior (TPB) is open to the inclusion of further predictors, identifying a number of additional background variables within the context of the TPB may help improve the predictive power of the theory. The purpose of this study is to incorporate environmental variables as precursor background variables of the TPB to predict quitting-related intentions. METHODS: This study consists of two sub-studies. Sub-study 1 and 2 analyzed different data sets and were conducted using the similar methodology for the comparison. A total of 395 Texas adult smokers (sub-study 1) and 379 university student smokers (sub-study 2) were analyzed using multiple structural equation modeling. RESULTS: The extent of agreement with regulating smoking in public places had positive indirect effects on intention to quit through subjective norm among both Texas adult smokers (ß = 0.03, p < .01) and university students (ß = 0.01, p < .05), and through attitude among Texas adult smokers only (ß = 0.02, p < .01). The number of smokers among 5 closest friends had negative indirect effect on intention to take measures to quit through subjective norm among Texas adult smokers (ß = - 0.02, p < .05). CONCLUSIONS: The results of this study indicate that environmental variables need to be considered as precursor background variables of the TPB to predict quitting-related intentions.

Psychosocial factors underlying physical activity.

BACKGROUND: Given the increasing importance of obesity in China, prevention interventions encouraging physical activity by middle school students are needed. The purpose of this study is to illustrate how a rapid elicitation method can be used to identify salient consequences, referents, and circumstances about physical activity as perceived by middle school students and to provide suggestions for interventions and quantitative research. METHOD: A theory-based qualitative study using a self-completion elicitation was conducted with 155 students from two middle schools in Beijing, China. Following the Theory of Planned Behavior, six open-ended questions asked students for their perceptions about performing physical activity at least 60 minutes each day: advantages of participating in physical activity; disadvantages of doing so; people who approve of participation; people who disapprove; things that make it easy; and things that make it hard. Content analysis revealed categories of salient consequences, reference groups, and circumstances. RESULTS: While the three most frequently mentioned advantages elicited from the students were physical health consequences (e.g., will strengthen my body (58.7%)), four of the salient advantages were not (e.g., will improve my grades (12.2%)). Parents were the most frequently mentioned social referent (42.6% as approving; 27.7% as disapproving) when students were asked who might approve or disapprove of their participation. Circumstances perceived to hinder daily physical activity included having too many assignments and not having enough time. CONCLUSION: While many of the beliefs about physical activity elicited from this study were similar to those found with students from England and the US, several were unique to these students from Beijing. The results of this qualitative research suggest that interventions to encourage physical activity among middle school students should address: perceived consequences of physical activity on academic achievement and other factors beyond physical health; barriers of not having enough time and having too many assignments perceived to hinder frequent physical activity; and parental approval. More rigorous research on psychosocial determinants with close-ended items developed from these open-ended data and with larger sample sizes of students is necessary. Research with parents and school staff will be needed to understand the perceptions of these stakeholder groups key to creating the students' social environment.

A county-level cross-sectional analysis of positive deviance to assess multiple population health outcomes in Indiana.

OBJECTIVE: To test a positive deviance method to identify counties that are performing better than statistical expectations on a set of population health indicators. DESIGN: Quantitative, cross-sectional county-level secondary analysis of risk variables and outcomes in Indiana. Data are analysed using multiple linear regression to identify counties performing better or worse than expected given traditional risk indicators, with a focus on 'positive deviants' or counties performing better than expected. PARTICIPANTS: Counties in Indiana (n=92) constitute the unit of analysis. MAIN OUTCOME MEASURES: Per cent adult obesity, per cent fair/poor health, low birth weight per cent, per cent with diabetes, years of potential life lost, colorectal cancer incidence rate and circulatory disease mortality rate. RESULTS: County performance that outperforms expectations is for the most part outcome specific. But there are a few counties that performed particularly well across most measures. CONCLUSIONS: The positive deviance approach provides a means for state and local public health departments to identify places that show better health outcomes despite demographic, social, economic or behavioural disadvantage. These places may serve as case studies or models for subsequent investigations to uncover best practices in the face of adversity and generalise effective approaches to other areas.