Effectiveness of implementing evidence-based approaches to promote physical activity in a Midwestern micropolitan area using a quasi-experimental hybrid type I study design.

BACKGROUND: Much evidence-based physical activity (PA) interventions have been tested and implemented in urban contexts. However, studies that adapt, implement, and evaluate the effectiveness of these interventions in micropolitan rural contexts are needed. The study aimed to evaluate the effectiveness of the Active Ottumwa intervention to promote PA in a micropolitan community. METHODS: Between 2013 - 2019, we implemented Active Ottumwa in a micropolitan setting, and subsequently implemented and evaluated its effectiveness using a Hybrid Type I design. In this paper, we describe the intervention's effectiveness in promoting PA. We collected PA data over 24 months from a cohort of community residents using accelerometers and PA data from two cross-sectional community surveys administered in 2013 and 2018, using the Global Physical Activity Questionnaire. RESULTS: From the cohort, we found significant change in PA over 24 months (P = 0.03) corresponding to a 45-min daily decrease in sedentary activity, a daily increase of 35-min in light PA and 9 min in moderate-to-vigorous PA. There was a statistically significant (P = 0.01) increasing trend at the population-level in the moderate-to-vigorous composition of 7 min between the two cross-sectional assessments (95% CI: 0.1%-1.34%). CONCLUSIONS: The study demonstrates that the adapted evidence-based PA interventions in a micropolitan context is effective.

Critical Elements of Community Engagement to Address Disparities and Related Social Determinants of Health: The Centers of Disease Control and Prevention Community Approaches to Reducing Sexually Transmitted Disease Initiative.

BACKGROUND: Community Approaches to Reducing Sexually Transmitted Disease (CARS), a unique initiative of the US Centers for Disease Control and Prevention, promotes the use of community engagement to increase sexually transmitted disease (STD) prevention, screening, and treatment and to address locally prioritized STD-related social determinants of health within communities experiencing STD disparities, including youth, persons of color, and sexual and gender minorities. We sought to identify elements of community engagement as applied within CARS. METHODS AND MATERIALS: Between 2011 and 2018, we collected and analyzed archival and in-depth interview data to identify and explore community engagement across 8 CARS sites. Five to 13 interview participants (mean, 7) at each site were interviewed annually. Participants included project staff and leadership, community members, and representatives from local community organizations (e.g., health departments; lesbian, gay, bisexual, transgender, and queer-serving organizations; faith organizations; businesses; and HIV-service organizations) and universities. Data were analyzed using constant comparison, an approach to grounded theory development. RESULTS: Twelve critical elements of community engagement emerged, including commitment to engagement, partner flexibility, talented and trusted leadership, participation of diverse sectors, establishment of vision and mission, open communication, reducing power differentials, working through conflict, identifying and leveraging resources, and building a shared history. CONCLUSIONS: This study expands the community engagement literature within STD prevention, screening, and treatment by elucidating some of the critical elements of the approach and provides guidance for practitioners, researchers, and their partners as they develop, implement, and evaluate strategies to reduce STD disparities.

Building Leadership, Capacity, and Power to Advance Health Equity and Justice through Community-Engaged Research in the Midwest.

The Health Equity Advancement Lab (HEAL) at the University of Iowa College of Public Health began in 2012 to support students, researchers, and community members interested in tackling persistent health inequities through a community-based participatory research (CBPR) approach. Using concepts from critical consciousness theory, we developed an approach to building students', faculty members', and community partners' capacity to engage in CBPR to promote health equity that involved immersion in developing CBPR projects. Our paper describes the evolution of HEAL as a facilitating structure that provides a support network and engages diverse stakeholders in critical reflection as they participate in research to advance health equity, and resulting political efficacy and social action. We describe one HEAL-affiliated research project that employs a CBPR approach and has a strong focus on providing transformative learning experiences for students, faculty, and community members. We highlight challenges, successes, and lessons learned in the application of critical consciousness as a framework that engages diverse academic and community partners seeking to promote health equity. We argue that critical consciousness is a relevant theoretical framework to promote transformative learning among students, faculty, and community partners to promote health equity research in diverse communities.

Human Papillomavirus Vaccination in the United States: Uneven Uptake by Gender, Race/Ethnicity, and Sexual Orientation.

OBJECTIVES: To assess national differences in human papillomavirus (HPV) vaccine uptake among young adults in the United States by gender, race/ethnicity, and sexual orientation. METHODS: We tested group differences in initiation and completion of the HPV vaccine series (i.e., 3 doses) by Rao-Scott χ(2) test among 6444 respondents aged 18 to 30 years from the 2013 National Health Interview Survey. RESULTS: Among men, 5% reported receiving the HPV vaccine, with no differences in uptake by race/ethnicity or sexual orientation. By contrast, 30% of the women reported receiving the HPV vaccine, with women of color having lower odds of initiating and completing the vaccine series compared with White women. CONCLUSIONS: In the United States, HPV vaccine rates are lagging in men and show disparities among women. Increasing HPV vaccine uptake and series completion among women of color and all men may provide considerable long-term public health benefits.

Establishing a Community-Based Participatory Research Partnership in a Rural Community in the Midwest.

BACKGROUND: Rural health disparities are well-documented. "New destination" communities in predominantly rural states have emerged in recent years, with immigrants moving into these communities for better opportunities. Few reports of community-based participatory partnerships with these communities have been previously described in the literature. OBJECTIVES: We report on the formation and implementation of a community-academic partnership to reduce health disparities in a rural Midwestern community. METHODS: We describe the creation of a partnership between the University of Iowa (UI) Prevention Research Center (PRC) and the Ottumwa, Iowa community. RESULTS: We describe the partnership formation, activities, and results of the implementation of the partnership, and challenges encountered, including balancing attention to different health disparities populations and ensuring mechanisms for hearing from the different voices in the community. CONCLUSIONS: Our experience suggests the importance and challenge of considering the multiple dimensions of health disparities in rural new destination Midwestern communities.

A multi-site case study of community-clinical linkages for promoting HPV vaccination.

Human papillomavirus (HPV) vaccination rates in the U.S. are suboptimal, requiring innovative partnerships between community and clinical entities to remedy this issue. A rigorous evaluation of HPV-related community-clinical linkages (CCLs) was conducted to understand their components, processes, and outcomes to increase HPV vaccination. Cancer Prevention and Control Research Network (CPCRN) investigators explored CCLs in their communities employing an iterative, case study approach. Information describing nine CCLs on HPV vaccination was collected from representatives from the community organization and clinical setting. Thematic content analysis was used to analyze and interpret data. Five CCLs included a federally qualified health center as the clinical partner, and five included a non-profit organization as the community partner. Five reflected clinically focused integration wherein engagement occurs in the community but vaccine delivery and follow-up occur in the clinical setting. The main impetus was the need to improve HPV vaccination and a community's strong interest in preventing cancer. Noted critical components were a designated person to support the CCL and funding. Results will guide HPV vaccination promotion, education, and intervention efforts. CCLs provide an opportunity to study the adaption, integration, and enhancement of evidence-based approaches to increase HPV vaccination.

Active Ottumwa: Adapting Evidence-Based Recommendations to Promote Physical Activity in a Micropolitan New Destination Community.

Background: Evidence-based interventions have been developed and tested to promote physical activity, but fewer studies have focused on identifying effective intervention strategies for mid-size rural communities, especially new immigrant destinations. We report here on the design and implementation of Active Ottumwa, a community-wide intervention using a lay health advisor approach to increase physical activity in a micropolitan new destination community in the rural state of Iowa. Methods: The Active Ottumwa study is part of a community-academic partnership in Ottumwa, IA. Evidence-based strategies recommended by the Community Guide for Preventive Services guided study implementation and included behavioral and social, campaign and informational, and environmental and policy approaches. Evaluation methods for this study are multi-faceted and include a cross-sectional community survey, longitudinal cohort assessment, observational data, key informant interviews, and project records. Results: We are currently in our second year of intervention implementation, with 45 lay health advisors (termed physical activity leaders here) trained to carry out behavioral and social intervention approaches, including walking groups, tai chi, and yoga. We have completed a communication and informational campaign utilizing five channels. Our longitudinal cohort has been recruited, with baseline and 12-month data collection completed. Conclusions: This study will assess the effectiveness and impact of a community-wide intervention to support physical activity.

The intersection between masculinity and health among rural immigrant Latino men.

Latino men experience health disparities in STI/HIV, diabetes, hypertension, and cancer. Gender roles likely play a role in risk behaviors and outcomes; however, there has been little focus on masculinity in Latino men. We conducted 20 semi-structured interviews with Latino men living in North Carolina. The interviews, conducted by a trained bilingual/bicultural Latino male, prompted discussion around work, family, and stress. Four themes were identified: masculine roles of being a family provider and protector, sources of stress, family responsibility and interconnectedness to health, and coping mechanism. For Latino men, masculinity may have both positive and negative influences on health. For example, the role of family provider may contribute to coping and be a stressor simultaneously. Future research should examine masculinity as a positive and a negative health influence and the additional impacts of gender roles on mens' health.

Alcohol Outcomes by Sexual Orientation and Race/Ethnicity: Few Findings of Higher Risk.

OBJECTIVE: This study sought to confirm a previously identified race by sexual orientation interaction and to clarify men's alcohol-related risk by using an expanded classification of sexual orientation. METHOD: We collapsed three waves of National Alcohol Survey data, restricting the analytic sample to White (n = 5,689), Black (n = 1,237), and Latino (n = 1,549) men with complete information on sexual orientation and alcohol use. Using self-reported sexual identity and behavior, respondents were categorized as exclusively heterosexual (referent), behaviorally discordant heterosexuals (i.e., heterosexual identity and same-sex partners), or gay/bisexually identified men. We used multivariable logistic regression to model lifetime alcohol dependence symptoms, lifetime drinking-related consequences, and past-year hazardous drinking, controlling for age, education, employment, and relationship status and accounting for the complex survey design. RESULTS: There was no difference in risk of past-year hazardous drinking and lifetime drinking-related consequences between heterosexual, behaviorally discordant heterosexual, and gay/bisexual men, independent of race/ ethnicity. Among Black men, behaviorally discordant heterosexuals had three-fold higher odds of lifetime alcohol dependence symptoms than exclusively heterosexual peers (aOR = 3.30, 95% CI [1.19, 9.18], p = .02). Gay/bisexual Latino men had marginally significantly lower odds of lifetime alcohol dependence symptoms (aOR = 0.36, 95% CI [0.12, 1.03], p = .06). CONCLUSIONS: There is little support for broad statements of greater alcohol risk among gay/bisexual men; however, for some subgroups and outcomes the direction and degree of risk depend on race/ ethnicity. Thus, this study underscores the importance of considering the potential interaction of sexual orientation and race/ethnicity, which may exacerbate or attenuate.

Prevalence of Physical Activity Policies and Environmental Strategies in Communities and Worksites: The Iowa Community Transformation Grant.

OBJECTIVE: This study describes results of community and worksite assessments of physical activity policies and environmental strategies in 26 Iowa counties. METHODS: Community coalition members completed the Community Health Assessment and Group Evaluation tool. The study explored findings using descriptive statistics and examined rural-urban differences in two of the five assessed sectors: community and worksites. RESULTS: Lower community scores (ie, needing improvement) were found for complete streets, bicycle use, and street calming. Higher scores (ie, identified strengths) were found for land use plans, maintain parks, and sidewalks Americans with Disabilities Act compliant. Worksites scored lower on promote stairwells, encourage non-motorized commuting, and implement activity breaks but higher on subsidize gym membership and provide area for physical activity. No rural-urban differences were found. CONCLUSIONS: Results identify opportunities to enhance community and worksite policies and environmental strategies to increase physical activity.

Behavioral HIV Prevention Interventions Among Latinas in the US: A Systematic Review of the Evidence.

Compared to White women, Latinas are 4 times more likely to contract HIV. In an effort to determine the overall state of the science meant to address this disparity, we reviewed the current HIV prevention intervention literature for U.S. Latinas. We searched 5 online electronic databases from their inception through July, 2014, for HIV prevention interventions including a majority sample of Latinas. Of 1041 articles identified, 20 studies met inclusion criteria. We documented study designs, participant characteristics, outcomes, theories used, and other intervention characteristics. Overall, HIV knowledge and attitudes were the predominant outcome; a small minority of studies included self-reported condom use or STD incidence. Strategies used to address cultural factors specific to Latinas and HIV included; lay health advisors, using ethnographic narratives, or using the Theory of Gender and Power, however few of the interventions adopted these strategies. This study identified several gaps in the intervention literature that need to be addressed. In addition to including more direct measures of decreased HIV risk (ex. condom use), more systematic use of strategies meant to address gender and cultural factors that may place Latinas at increased risk (e.g., gender inequity, traditional gender role norms such as machismo and marianismo, and relationship power dynamics).

Does comparing alcohol use along a single dimension obscure within-group differences? Investigating men's hazardous drinking by sexual orientation and race/ethnicity.

BACKGROUND: Some studies have found that gay, bisexual, and other men who have sex with men (MSM) have higher odds of alcohol abuse and dependence than heterosexual men, but others have found no differences. We investigated whether the association between sexual orientation and hazardous drinking varied by race/ethnicity. METHODS: We estimated the odds of past-year heavy daily, heavy weekly, and binge drinking by sexual orientation and race/ethnicity among non-Latino White, non-Latino Black, and Latino (any race) men (n = 9689) who reported current alcohol use in the 2004-2005 National Epidemiological Survey of Alcohol and Related Conditions (NESARC). Interaction terms were included in multivariable logistic regression models to evaluate possible effect modification. RESULTS: In most comparisons, sexual minority men reported equivalent or lower levels of hazardous drinking than heterosexual peers. There was no association between sexual orientation and heavy daily drinking. Sexual minority Black men had lower odds of heavy weekly drinking and binge drinking than both heterosexual White men and heterosexual Black men. Among Latinos, the odds of heavy weekly drinking were higher for sexual minority men than heterosexuals; there was no difference by sexual orientation for binge drinking among Latinos. CONCLUSIONS: With one exception, sexual minority men were at equivalent or lower risk of hazardous drinking than heterosexual men. The Black-White advantage observed in other alcohol studies was observed in our study and was heightened among sexual minority men, suggesting the presence of protective factors that curb hazardous drinking. Additional research is necessary to identify the mechanisms responsible for these patterns.

Latino men's qualitative perspectives on a lay health advisor intervention to promote their sexual health.

Lay health advisor (LHA) approaches are a promising strategy to reduce health disparities among communities considered 'hard to reach' by researchers and practitioners. LHAs have addressed a variety of health issues, but limited studies have included men as LHAs. The purpose of this study was to better understand the roles of male LHAs and their male-helping relationships. We used an inductive approach to explore Latino men's perspectives on serving as LHAs for other Latino men and Latino men's views on receiving sexual health information from a male LHA. We collected qualitative data in 2009 and 2010 as part of an LHA intervention designed to reduce the risk of HIV infection among immigrant Latinos through the social networks of soccer teams. We analysed and interpreted data from 30 in-depth interviews with Latino men who served as LHAs and their social networks in North Carolina, USA. Participants shared perceptions on social network importance for immigrant Latinos, facilitators and challenges of helping other men, recommendations for intervention modification and suggestions for future work involving the Latino community. Findings revealed that Latino men are receptive to fulfilling the roles of health advisors and opinion leaders, and can effectively serve as LHAs. Social network members valued the social support they received. Working through sports teams and identifying existing leaders to be LHAs may be a culturally congruent approach to meeting Latino community needs. More research is needed on the potential of male LHAs to address other health issues.

Predictors of Heavy Episodic Drinking and Weekly Drunkenness Among Immigrant Latinos in North Carolina.

Few studies have examined correlates of heavy drinking among rural immigrant Latino men. This analysis identified correlates of typical week drunkenness and past 30-day heavy episodic drinking, within a sample of immigrant Latino men in rural North Carolina (n = 258). In the bivariate analyses, Mexican birth, entering the United States as an adult, and year-round employment were associated with increased odds of typical week drunkenness, and higher acculturation and affiliation with a religion with strict prohibitions against drinking alcohol were associated with lower odds of typical week drunkenness. Being older, Mexican birth, entering the United States as an adult, and lower acculturation were associated with increased odds of heavy episodic drinking, and affiliation with a religion with strict prohibitions against drinking alcohol and completing high school were associated with decreased odds of heavy episodic drinking. In multivariable modeling, only religious affiliation was associated with typical week drunkenness. Mexican birth, entering the United States as an adult, and lower acculturation were associated with increased odds of heavy episodic drinking, and affiliation with a religion with strict prohibitions against drinking alcohol and completing high school were associated with lower odds of heavy episodic drinking. The health of minority men in the United States has been neglected, and immigrant Latino men comprise a particularly vulnerable population. This analysis provides initial data on some factors associated with heavy drinking within a population about which little is known. Future studies should examine moderating or mediating factors between age, acculturation, religiosity, and heavy drinking that might be targets for behavioral interventions.