Adoption, Sustainability, and Dissemination of Chronic Disease Prevention Policies in Community-Based Organizations.

Introduction. Despite increasing interest in structural (policy, systems, and environmental) changes to improve health, little attention has focused on the adoption, implementation, sustainability, and potential for dissemination of these changes among local community-based organizations. Method. A mixed methods approach was used for this process evaluation. Representatives of nine community-based organizations were surveyed using closed-ended questions and in-depth qualitative interviews to describe 32 policy changes. Diffusion of Innovation theory was used to inform the development of survey questions and the interview guide. Results. Policies adopted by local community-based organizations concerned types of food/beverages provided to staff/clients, methods to encourage physical activity, breastfeeding support, and tobacco control. The majority of the policies were either fully (66%) or partially (31%) implemented 1 year after their initial adoption. In general, participants somewhat/strongly agreed that policies had characteristics that predict sustainability/diffusion (relative advantage, compatibility, complexity, trialability, observability). In-depth interview responses described a generally smooth process for policy adoption and high levels of optimism for continued sustainability but revealed few efforts to disseminate the policies beyond the original organization. Conclusions. Structural changes in community-based organizations are a valuable tool for encouraging healthy changes in communities and have great potential to be adopted, sustained, and diffused.

The Perceived Role of Direct Support Professionals in the Health Promotion Efforts of Adults With Developmental Disabilities Receiving Support Services.

Direct support professionals (DSPs) play a large social role in the lives of people with developmental disabilities (DD) and have the potential to influence their health behaviors. Six qualitative focus groups ( n = 48) were conducted with DD community agency administrators, DSPs, family members and adults with DD to better understand the perceived role of DSPs in the health promotion efforts of those with DD. Findings from this study suggest that DSPs experience several barriers when trying to promote the health of those with DD, one of which is fear of violating the rights of people with DD. Future work should identify ways to overcome the barriers experienced by DSPs, so that they can better assist people with DD with health promotion efforts.

Smoking behaviors of adults with developmental disabilities and their direct support professional providers.

BACKGROUND: People with developmental disabilities are not immune from the addictive effects and poor health outcomes associated with cigarette use. Direct support professionals often play a large role in the social environments of people with developmental disabilities and the literature suggests that one's environment can influence behavior. OBJECTIVES: To examine the relationship between the smoking behaviors of people with developmental disabilities and their direct support professional providers. Two exploratory aims of the study were to assess how direct support professionals facilitate smoking behaviors and to describe the use of home smoking policies. METHODS: The Ohio Department of Disabilities' online provider search database was used to randomly select participants. A total of 398 direct support professionals completed an online survey about smoking. Direct support professionals served as proxy reporters for the smoking behaviors of those with developmental disabilities. Descriptive statistics were calculated and Chi-Square tests were used. RESULTS: Findings suggest that there was no significant relationship (χ12 = 0.300, p = 0.584) between the current smoking behaviors of people with developmental disabilities and their direct support providers. Direct support professionals were most likely to facilitate smoking behaviors by allowing people with developmental disabilities to smoke in front of them and waiting for them to finish smoking before moving on to a new activity. Approximately 46% of people with developmental disabilities were reported to have some type of home smoking policy. CONCLUSIONS: Future research is needed to better understand the reasons why people with developmental disabilities initially start smoking and continue to smoke.

Dietary and physical activity behaviors of adults with developmental disabilities and their direct support professional providers.

BACKGROUND: People with developmental disabilities lead more sedentary lifestyles, consume poorer diets, as well as have higher rates of chronic conditions such as diabetes and heart disease when compared to members of the general population. Direct support professionals play a large social role in the lives of their clients with developmental disabilities, and thus have the ability to influence the health behaviors of their clients. OBJECTIVES: The overall purpose of this study was to examine the relationship between the dietary and physical activity behaviors of direct support professionals and their clients with developmental disabilities, as well as to assess how direct support professionals facilitate the health behaviors of their clients. METHODS: A statewide random sample of direct support professionals (n = 398) completed an online survey about their own dietary/physical activity behaviors and these same health behaviors of their adult clients with developmental disabilities. Pearson/Spearman correlations were used to examine the relationship between the health behaviors of direct support professionals and their clients with developmental disabilities. RESULTS: Small-to-moderate correlations (ρ or r = 0.127-0.333) between direct support professionals' and clients' behaviors existed for all dietary and physical activity health behaviors except for participation in some sort of moderate-to-vigorous physical activity each week (ρ = 0.098, p = 0.06). CONCLUSIONS: Direct support professionals appear to play a role in the dietary/physical activity behaviors of their clients; however, future research on this topic should also include other key members of the social networks of adults with developmental disabilities such as family members, roommates, and day-habilitation providers.

Obesity Prevention Practices and Policies in Child Care Settings Enrolled and Not Enrolled in the Child and Adult Care Food Program.

Objectives The United States Department of Agriculture's Child and Adult Care Food Program (CACFP) provides meals and snacks to low-income children in child care. This study compared nutrition and physical activity practices and policies as well as the overall nutrition and physical activity environments in a sample of CACFP and non-CACFP child care settings. Methods A random stratified sample of 350 child care settings in a large Midwestern city and its suburbs, was mailed a survey on obesity prevention practices and policies concerning menu offerings, feeding practices, nutrition and physical activity education, activity levels, training, and screen time. Completed surveys were obtained from 229 of 309 eligible child care settings (74.1 % response rate). Chi square tests were used to compare practices and policies in CACFP and non-CACFP sites. Poisson and negative binomial regression were used to examine associations between CACFP and total number of practices and policies. Results Sixty-nine percent of child care settings reported CACFP participation. A significantly higher proportion of CACFP sites reported offering whole grain foods daily and that providers always eat the same foods that are offered to the children. CACFP sites had 1.1 times as many supportive nutrition practices as non-CACFP sites. CACFP participation was not associated with written policies or physical activity practices. Conclusions for Practice There is room for improvement across nutrition and physical activity practices and policies. In addition to food reimbursement, CACFP participation may help promote child care environments that support healthy nutrition; however, additional training and education outreach activities may be needed.

Mass media for smoking cessation in adolescents.

Theory-driven, mass media interventions prevent smoking among youth. This study examined effects of a media campaign on adolescent smoking cessation. Four matched pairs of media markets in four states were randomized to receive or not receive a 3-year television/radio campaign aimed at adolescent smoking cessation based on social cognitive theory. The authors enrolled 2,030 adolescent smokers into the cohort (n = 987 experimental; n = 1,043 comparison) and assessed them via annual telephone surveys for 3 years. Although the condition by time interaction was not significant, the proportion of adolescents smoking in the past month was significantly lower in the experimental than comparison condition at 3-year follow-up when adjusted for baseline smoking status. The media campaign did not impact targeted mediating variables. A media campaign based on social cognitive constructs produced a modest overall effect on smoking prevalence among adolescents, but the role of theory-based constructs is unclear.

American Indian breastfeeding attitudes and practices in Minnesota.

OBJECTIVES: We examined the breastfeeding attitudes and practices in an American Indian population in Minnesota. METHODS: We interviewed women prenatally (n = 380), at 2-weeks (n = 342) and at 6-months postpartum (n = 256). We conducted multivariable analyses to examine the demographic, behavioral, and attitudinal correlates of breastfeeding initiation and duration. RESULTS: Factors positively associated with breastfeeding initiation included positive breastfeeding attitudes and social support for breastfeeding from the woman's husband/boyfriend and her mother. Factors positively associated with breastfeeding at 2-weeks postpartum were support from the woman's mother and positive attitudes about breastfeeding. The prenatal use of traditional American Indian medicines and cigarette smoking were both significantly associated with breastfeeding at 6-months postpartum. CONCLUSIONS: Programs to encourage breastfeeding in American Indian communities may be strengthened with protocols to encourage social support, recognition of the perceived health, developmental, and practical benefits of breastfeeding, and a focus on traditional American Indian health practices.

Messages from moms: barriers to and facilitators of behavior change in a lead poisoning preventive education project.

Qualitative focus group data from participants of an intensive, culture-specific, lead poisoning preventive education research project were analyzed to assess success of communication strategies, and, specifically, to identify barriers to and facilitators of adopting behavior changes encouraged in the project. Effectiveness of education in preventing lead poisoning is addressed elsewhere. Education focused on housecleaning, hygiene, water, and nutrition. Ninety-five participants (89% of 107 eligible) of six ethnicities agreed to participate in focus groups. Seventy-eight (82%) actually attended. Barriers to behavior change included the effort required or unpleasantness of a prevention strategy, presentation of familiar information, denial of the problem, busyness, perceived lack of control, lack of social support, cultural traditions, and misunderstandings. Requiring one-time behavior changes; teaching simple, easy strategies; making less appealing tasks fun; demonstrating concepts; and presenting novel material that piques interest were features of the education that facilitated behavior change. Factors internal to the participant, such as love of the child or cultural practices, also served to motivate the participant to change behavior or to facilitate adoption of a prevention strategy. We offer recommendations to assist others in designing effective health education and risk communication prevention or intervention programs.

Early otitis media among Minnesota American Indians: the Little Ears Study.

OBJECTIVES: We examined relationships between otitis media risk factors, sociodemographic characteristics, and maternal knowledge and attitudes and early onset of otitis media. METHODS: Pregnant women from Minnesota American Indian reservations and an urban clinic were enrolled in our study between 1998 and 2001. Follow-up was performed on enrollees' infants until the children were 2 years old. Research nurses collected data by ear examination, from interviews and questionnaires given to enrolled mothers, and otitis media episodes that were abstracted from medical records. RESULTS: Sixty-three percent of infants had experienced an otitis media episode by 6 months of age. Logistic regression analyses showed that maternal otitis media history, infant history of upper respiratory infection, and compliance with study visits were significantly related to early otitis media onset. Although high percentages of infants were exposed to cigarette smoke and other children and were formula fed, these factors were not related to otitis media. Mothers' prenatal awareness of otitis media risks associated with environmental tobacco smoke exposure and formula feeding did not predict their postpartum behaviors. CONCLUSIONS: We found that infant history of upper respiratory infection and maternal otitis media history are risk factors for early otitis media in American Indian infants. Mothers' prepartum knowledge and attitudes regarding otitis media did not predict their postpartum avoidance of risk behaviors.

Self-efficacy and outcome expectations for quitting among adolescent smokers.

Relatively little is known about smoking cessation self-efficacy and outcome expectations for quitting smoking in adolescent smokers. In this study, we created measures of these two constructs and conducted factor analyses with data from a diverse sample of 1126 adolescent smokers. Results yielded a two-factor solution for the self-efficacy measure, and a four-factor solution for the outcome expectations scale. In a subset of the original sample (n=515), we re-administered the measures one year later and also examined the longitudinal associations between the baseline sub-scale scores and cigarettes smoked per week at follow-up. Results revealed significant relationships between the negative affect sub-scales of the self-efficacy and outcome expectations measures and weekly smoking level. These associations remained when adjusting for baseline smoking level and other sub-scales. The findings lend support for the possible role of affect regulation in smoking reduction in adolescents.

Empowering youth for tobacco control.

PURPOSE: To investigate common youth group activities and how they relate to young people's attitudes of empowerment around tobacco control. DESIGN: A mailed survey was administered to 940 Minnesota youth involved in locally organized tobacco prevention groups. By multivariate linear regression, participation in eight tobacco-related activities and selected personal characteristics were examined in relation to youths'perceived influence on youth smoking. RESULTS: Two activities--developing materials with antismoking messages and taking action to change school smoking policies--were associated with significantly higher perceived influence scores for the youth involved (p < .05). Youth in groups who had worked to raise awareness of how the tobacco industry targets teens also had significantly higher influence scores (p < .001). Associated personal factors included high involvement in extracurricular activities (p < .001), having never experimented with smoking (p < .01), leadership experience (p < .001), and being white (p < .01). DISCUSSION: Some youth group activities and strategies may be particularly effective at instilling attitudes of empowerment for tobacco control among youth.

Outcomes of a statewide anti-tobacco industry youth organizing movement.

PURPOSE: To outline the design and present select findings from an evaluation of a statewide anti-tobacco industry youth organizing movement. DESIGN: A telephone survey was administered to teenagers to assess associations between exposure to anti-industry youth organizing activities and tobacco-related attitudes and behaviors. A group-level comparison between areas high and low in youth organizing activities was planned. Methodological obstacles necessitated a subject-level analytic approach, with comparisons being made between youth at higher and lower levels of exposure. SETTING: Six rural areas (comprising 13 counties) and two urban regions of Minnesota were selected for survey. SUBJECTS: The study comprised 852 youth, aged 15 to 17 years old, randomly selected from county-specific sampling frames constructed from a marketing research database. MEASURES: Exposure index scores were developed for two types of activities designed to involve youth in the anti-industry program: branding (creating awareness of the movement in general) and messaging (informing about the movement's main messages). Attitudinal outcomes measured attitudes about the tobacco industry and the effectiveness of youth action. Behavioral outcomes included taking action to get involved in the organization, spreading an anti-industry message, and smoking susceptibility. RESULTS: Branding index scores were significantly correlated with taking action to get involved (p < or = .001) and spreading an anti-industry message (p < or = .001). Messaging index scores were significantly correlated with all five attitudinal constructs (all associations, p < or = .001), taking action to get involved (p < or = .001), and spreading an anti-industry message (p < or = . 01). The hypothesized association between messaging scores and susceptibility was not significant. CONCLUSION: A youth organizing effort, in combination with an intensive countermarketing media campaign, can be an effective strategy for involving youth in tobacco prevention and generating negative attitudes about the industry.

Recommendations from lead poisoning prevention program participants: best practices.

We present a program evaluation of the Phillips Lead Project, a 5-year study of the effectiveness of culture-specific, peer education in maintaining low blood lead levels of children in an inner-city neighborhood. We conducted focus groups to understand how project participants felt about the various strategies employed by the Lead Project. The purpose of this article is to describe their reactions to the project and make recommendations concerning appropriate educational strategies for lead poisoning prevention projects being undertaken in similar communities. Although this project was a research study, many of its methods, and participants' reactions to those methods, are relevant to non-research prevention programs and may be generalizable to other health issues besides lead poisoning.

Self exposure to secondhand smoke among prenatal smokers, abstainers, and nonsmokers.

PURPOSE: Prenatal smoking cessation will not eliminate health risks if women continue to be exposed to passive smoking. This study compared the risks of secondhand smoke (SHS) exposure for low-income prenatal nonsmokers, abstainers, and smokers. METHODS: A questionnaire was administered to 225 pregnant women. Exposure to six sources of SHS was compared across smoking groups using chi-square and multivariate logistic regression. RESULTS: In adjusted analyses, patterns of SHS exposure were consistent. Abstainers were at lower risk of exposure than smokers for all sources except for having a partner who smoked. Abstainers were at higher risk of exposure than nonsmokers for most sources. For example, 11.7% of nonsmokers were exposed to < 4 hours of SHS daily compared with 33.3% of abstainers (adjusted odds ratio = .32, 95% confidence interval = .12-.88). Mean number of exposures for nonsmokers, abstainers, and smokers were 1.4, 2.7, and 4.2, respectively (p < .001). DISCUSSION: Interventions need to address the full range of health risks posed by cigarette smoke exposure during pregnancy.

The advice-giving role of female friends and relatives during pregnancy.

Disparities in prenatal smoking rates indicate the need for new smoking cessation intervention strategies tailored to low-income pregnant women. Information about natural patterns of advice-giving during pregnancy would facilitate this goal. This study examines the advice-giving role of close female friends and relatives ('confidantes') during pregnancy, and assesses the utility of including them in an intervention. A questionnaire was administered verbally to 225 low-income pregnant women to assess: (1) the prevalence and characteristics of confidantes, (2) the persuasiveness of confidante advice in general and with respect to smoking, specifically, and (3) the permissiveness of confidante smoking advice. Comparisons were made with doctors and partners. Most women (91.4%) identified a confidante, the majority of whom were their own mothers. Doctors were rated most persuasive in their general prenatal advice, followed by confidantes and partners (all differences, P < 0.05). A similar pattern was observed among prenatal smokers in relation to advice given about prenatal smoking. As compared to doctors, confidante advice was significantly more permissive of smoking during pregnancy. While women value their doctors' advice during pregnancy, close female friends and relatives also have an important and unique role. Educational efforts may be effective when directed at these advice-givers.

Regulation of tattooing in Minneapolis and St. Paul, Minnesota: tattooists' attitudes and relationship between regulation and practice.

OBJECTIVE: This study investigated tattooists' attitudes regarding government regulation and the relationship between existing tattooing regulation and tattooists' knowledge and practice of infection control. METHODS: Self-reported and observational data were collected in a cross-sectional study of professional tattooists. A written survey was used to investigate knowledge and practice of infection control and attitudes toward government regulation. Infection control practice was also examined through direct observation of tattooing. Rating scales were used to compare tattoo artists subject to local tattooing ordinances with those in areas without ordinances. RESULTS: Sixty-one tattooists (45 regulated, 16 unregulated) completed surveys and 25 (17 regulated, 8 unregulated) were observed. Attitudes toward regulation were generally positive. Most participants supported health department inspections and training requirements. The presence of local tattooing ordinances was not associated with tattooists' knowledge (p=0.53), but was associated with self-reported practices (p=0.05). A more positive attitude toward regulation was associated with the use of more self-reported infection control procedures (p<0.01). CONCLUSION: Tattoo artists in areas with local tattooing ordinances may implement more bloodborne pathogen precautions than those in areas without ordinances, despite working from a similar knowledge base. Tattooists most in need of improvement may be difficult to reach due to opposition to government intrusion. Federal guidelines, clarification of OSHA rules applying to tattooists, and statewide regulation are needed. Tattooists should be involved in the development of regulations.

Abuse history and nonoptimal prenatal weight gain.

OBJECTIVE: The purpose of this study was to examine the differences between women who reported current and past physical or sexual abuse and those who did not in terms of mean total prenatal weight change, the odds for inadequate prenatal gain, and the odds for excessive prenatal gain. METHODS: This study used a matched retrospective cohort design. Data were from the charts of 578 clients of an urban prenatal care clinic. Multiple regression analyses, stratified by maternal age, were conducted to examine the association of past and current abuse with total prenatal weight change and with adequacy of prenatal weight gain for Body Mass Index category. RESULTS: For teens, abuse was not associated with prenatal weight change. For adults, mean total gains were 6.9 pounds greater for those who reported current abuse than for those who reported no abuse. Compared to women who reported no abuse, adults who reported only a history of physical abuse had 3.1 times the odds, and those who reported a history of sexual abuse (with or without physical abuse) had 3.0 times the odds for inadequate prenatal weight gains. Adults who reported a history of sexual abuse were 2.4 times as likely to have excessive prenatal weight gains as adults who reported no abuse. CONCLUSIONS: The relationship of abuse and prenatal weight gain was different in adults and teens. This study may be the first to report an association between abuse and excessive prenatal gains, suggesting that addressing the psychosocial needs of women may help optimize prenatal weight gain.