Persistence and transience of food insecurity and predictors among residents of two disadvantaged communities in South Carolina.

BACKGROUND: Little is known about patterns of household food insecurity (HFI) across more than two time points in adults in the United States, the frequency predictors of different trajectories. The distinctions between persistent and transient food insecurity trajectories may be crucial to developing effective interventions. OBJECTIVE: To characterize dominant trajectories of food security status over three time points between 2013 and 2016 and identify demographic, socioeconomic and health-related predictors of persistent and transient HFI. DESIGN: Cohort study in disadvantaged communities in South Carolina. SETTING: and subjects: 397 middle-aged participants, predominantly female, African American, living in USDA-designated food deserts. MAIN OUTCOME MEASURE: Household food insecurity over time using the 18-item USDA's Household Food Security Survey Module. STATISTICAL ANALYSES PERFORMED: Descriptive analyses of food security trajectories and multinomial regression analyses. RESULTS: At baseline (2013-2014), 61% of households reported HFI during the previous 12 months, which decreased to 54% in 2015 and to 51% in 2016. Only 27% of households were persistently food secure, 36% experienced transient and 37% persistent food insecurity. Female sex (OR 2.7, 95%CI 1.2-5.9), being married or living with a partner (OR 2.4, 95CI% 1.1-5.3) and fair health status (OR 4.4, 95%CI 2.2-8.8) were associated with increased odds of persistent food insecurity. Fair health was also a significant predictor of transient food insecurity. CONCLUSIONS: These findings suggest that future research should focus on persistent versus transient trajectories separately and that tailored interventions may be needed to make progress on alleviating food insecurity among disadvantaged communities.

Recruitment and Retention for the Evaluation of a Healthy Food Initiative in Economically Disadvantaged, Majority African American Communities.

Effective recruitment and retention supports equitable participation in research. The aim of this article is to describe recruitment and retention methods among residents of highly disadvantaged, predominantly African American communities in the southeastern United States during the evaluation of a healthy food access initiative. We proposed that active and passive recruitment methods, intensive retention strategies, community outreach and involvement, over-enrollment to anticipate attrition, and applied principles of community participation would achieve the study's recruitment and retention goals. The enrollment goal of 560 was met at 94% (n = 527), and the retention goal of 400 was achieved (n = 408).

Effects of a food hub initiative in a disadvantaged community: A quasi-experimental evaluation.

A quasi-experiment evaluated a food hub's (FH) impact in a low-income/low-access (food desert) setting on fruit and vegetable (F&V) intake, diet quality, kilocalories, perceived food environment, BMI, and farmers' market shopping versus a matched community (n = 265 FH, n = 262 Comparison). Comparison shoppers had better baseline perceptions of their food environment, but FH shoppers improved significantly more than Comparison shoppers. Comparison shoppers significantly increased F&V intake versus FH shoppers. Effects were not significant for other diet outcomes, BMI, or farmers' market shopping. Factors besides spacial access to healthy food need consideration to address dietary intake and obesity in disadvantaged communities.

Community Health Advisors' Characteristics and Behaviors, Role Performance, and Volunteer Satisfaction in a Church-Based Healthy Eating and Physical Activity Intervention.

Community Health Advisors (CHAs) contribute to health promotion program effectiveness, but their role in faith-based programs is understudied, and little is known about their role performance or satisfaction. In a dissemination and implementation study, 19 CHAs were trained to provide healthy eating (HE) and physical activity (PA) program training to church committees. Of these, 17 CHAs trained 347 attendees from 115 churches. Thirteen CHAs remained for the 12-month period and provided telephone-based technical assistance (TA) to churches. To evaluate their experiences and satisfaction, CHAs completed questionnaires at baseline and 12 months. Staff observers and church committee members evaluated CHAs' effectiveness as trainers. There were no significant changes in the CHAs' own body mass index, PA, fruit and vegetable intake, or self-rated health but significant increases in their perceived knowledge of PA (p = 0.01) and HE (p = 0.02). CHAs reported high agreement regarding the quality of their training for the role and moderate volunteer satisfaction on average but thought that the time required of them was somewhat more than expected, though they were interested in volunteering for a future, similar role. Church committee members agreed with CHAs' effectiveness as trainers and the helpfulness of the TA calls. Staff observers rated CHAs' as having covered 87.8% of church training content and agreed that, on average, the CHAs were effective trainers. Assessing CHAs' availability, clear communication about the time requirements, and over-recruitment to offset attrition and decrease the workload may be needed to improve retention and support satisfaction.

Socioeconomic factors associated with diet quality and meeting dietary guidelines in disadvantaged neighborhoods in the Southeast United States.

Objective: To examine diet quality and dietary intake among residents of disadvantaged neighborhoods in the Southeast United States (U.S.) and to examine associations between dietary and socioeconomic factors. Design: We examined baseline data from an evaluation study of a healthy food access initiative. Participants were recruited from two urban settings comprising seven neighborhoods of high household poverty (17% to 62%). Participants completed in-person interviews with measures of education, household income, and food security and one unannounced 24-hour dietary recall by telephone with trained registered dietitians. Food desert residence was coded based on U.S. Census data. Proportions meeting 2010 Dietary Guidelines for Americans and Healthy Eating Index 2010 (HEI-2010) scores were computed. Associations between dietary variables and participant's education, household income, food security, and food desert residence were tested. Results: Participants (n = 465) were predominantly African American (92%), women (80%), and overweight or obese (79%), and 52 ± 14 years of age. Sixty-three percent had low or very low food security, and 82% lived in census tracts of low income and low access to supermarkets (urban food desert). HEI-2010 scores averaged 48.8 ± 13.1. A minority of participants met dietary guidelines. Diet quality was lower among participants with lower education and among those from food insecure households (p < .05). Household income and food security were positively associated with meeting several dietary guidelines (p < .05). Food desert residence was unrelated to diet variables. Conclusions: In this disadvantaged population, significant nutritional concerns were observed, and socioeconomic factors were associated with diet quality and meeting dietary guidelines. Interventions must address broader economic, social, and policy issues such as access to affordable healthy foods.

Socioecological Path Analytic Model of Diet Quality among Residents in Two Urban Food Deserts.

BACKGROUND: Diet is critical to chronic disease prevention, yet there are persistent disparities in diet quality among Americans. The socioecological model suggests multiple factors, operating at multiple levels, influence diet quality. OBJECTIVE: The goal was to model direct and indirect relationships among healthy eating identity, perceived control of healthy eating, social support for healthy eating, food retail choice block scores, perceptions of healthy food availability, and food shopping behaviors and diet quality measured using Healthy Eating Index-2010 scores (HEI-2010) for residents living in two urban communities defined as food deserts. DESIGN: A cross-sectional design was used including data collected via self-reported surveys, 24-dietary recalls, and through objective observations of food retail environments. PARTICIPANTS/SETTING: Data collection occurred in 2015-2016 in two low-income communities in Cleveland (n=243) and Columbus (n=244), OH. MAIN OUTCOME MEASURE: HEI-2010 scores were calculated based on the average of three 24-hour dietary recalls using the Nutrition Data System for Research. ANALYSIS: Separate path models, controlled for income, were run for each community. Analysis was guided by a conceptual model with 15 hypothesized direct and indirect effects on HEI-2010 scores. Associations were considered statistically significant at P<0.05 and P<0.10 because of modest sample sizes in each community. RESULTS: Across both models, significant direct effects on HEI-2010 scores included healthy eating identity (ß=.295, Cleveland; ß=.297, Columbus, P<0.05) and distance traveled to primary food store (ß=.111, Cleveland, P<0.10; ß=.175, Columbus, P<0.05). Perceptions of healthy food availability had a significant, inverse effect in the Columbus model (ß=-.125, P<0.05). The models explained greater variance in HEI-2010 scores for the Columbus community compared with Cleveland (R2=.282 and R2=.152, respectively). CONCLUSIONS: Findings highlight the need for tailored dietary intervention approaches even within demographically comparable communities. Interventions aimed at improving diet quality among residents living in food deserts may need to focus on enhancing healthy eating identity using culturally relevant approaches while at the same time addressing the need for transportation supports to access healthy food retailers located farther away.

A food hub to address healthy food access gaps: Residents' preferences.

Interventions aimed at improving access to healthy food in low-income communities should consider the preferences of residents. Household food shoppers in two urban, low-income communities were asked about their preferences for vendors at, and qualities of, a potential nearby food hub. Universally, participants preferred availability of whole foods, primarily fruits and vegetables. They also favored cleanliness, quality, and affordability. The demographics and preferences of potential customers raise central issues that would need to be integrated into the development of a food hub, namely affordability (likely through subsidization), attention to accommodation and cultural accessibility, and programming that builds community.

Sumter County on the Move! Evaluation of a Walking Group Intervention to Promote Physical Activity Within Existing Social Networks.

BACKGROUND: Social network-driven approaches have promise for promoting physical activity in community settings. Yet, there have been few direct investigations of such interventions. This study tested the effectiveness of a social network-driven, group-based walking intervention in a medically underserved community. METHODS: This study used a quasi-experimental pretest-posttest design with 3 measurement time points to examine the effectiveness of Sumter County on the Move! in communities in Sumter County, SC. A total of 293 individuals participated in 59 walking groups formed from existing social networks. Participants were 86% females, 67% black, and 31% white, with a mean age of 49.5 years. Measures included perceptions of the walking groups; psychosocial factors such as self-regulation, self-efficacy, and social support; and both self-reported and objectively measured physical activity. RESULTS: The intervention produced significant increases in goal setting and social support for physical activity from multiple sources, and these intervention effects were sustained through the final measurement point 6 months after completion of the intervention. Nonetheless, few of the desired changes in physical activity were observed. CONCLUSION: Our mixed results underscore the importance of future research to better understand the dose and duration of intervention implementation required to effect and sustain behavior change.

Food Acquisition and Shopping Patterns among Residents of Low-Income and Low-Access Communities in South Carolina.

BACKGROUND: Little is known about the food acquisition and shopping habits of residents living in food deserts. OBJECTIVE: To identify distinct food acquisition and shopping patterns among residents, most of whom (81%) live in food desert (low income and low access) census tracts, and characterize these patterns with respect to the residents' socioeconomic status, nutrition knowledge, and perceptions of their food environment. DESIGN: This is a cross-sectional study. PARTICIPANTS/SETTING: Four hundred sixty-six primary food shoppers were included from two counties in South Carolina during 2013-2014. MAIN OUTCOME MEASURES: Participants' self-reported food acquisition and shopping habits, including shopping distance; frequency; store type; transportation mode; use of farmers' markets, food banks/pantries, and church/social service organizations, were used to develop shopping patterns and group residents. Supplemental Nutrition Assistance Program participation, food security, income, and education, nutrition knowledge, and perceptions of the food environment were used to characterize these groups. STATISTICAL ANALYSES PERFORMED: Latent class analysis and multinomial logistic regression were used to identify and characterize patterns, respectively. RESULTS: Three patterns were identified, including those who use community food resources, are infrequent grocery shoppers, and use someone else's car or public transportation when shopping (Class 1) (35%), those who use community food resources and are more frequent and proximal shoppers (Class 2) (41%), and those who do not use community food resources and are distal shoppers (Class 3) (24%). Compared with Class 3, Class 1 had comparatively lower socioeconomic status. Class 2 also had comparatively lower socioeconomic attributes except for income. Class 2 was not significantly different from Class 1 except that a higher proportion in Class 1 saw food access as a problem. No significant differences across classes were found regarding fruit and vegetable recommendation knowledge. CONCLUSIONS: Shopping frequency, use of community food resources, transportation methods, and shopping distance were the key factors that defined distinct patterns among residents living in low-income areas. Future interventions to increase healthy food access in underserved areas should not only consider accessibility but also community food resource use.

Impact on Dietary Choices After Discount Supermarket Opens in Low-Income Community.

OBJECTIVE: To examine (1) the association of a new supermarket opening with dietary intake and perceptions of healthy food availability, and (2) associations of distance to the primary food store and mean prices of fruits, vegetables, and sugary beverages with levels of consumption of these foods and body mass index in a low-income, southeastern community. METHODS: The researchers used cross-sectional, self-administered questionnaire data and supermarket audit data collected in the supermarket community and comparison community before (2015) and after (2016) the supermarket opening. A difference-in-difference analysis employed propensity scores to compare pretest and posttest differences between communities. RESULTS: There were no significant differences between communities on dietary behaviors. There was a significant cross-sectional, inverse association between distance to the primary food store and fruit and vegetable consumption among all respondents in 2016. CONCLUSIONS AND IMPLICATIONS: The results suggest that adding a new discount supermarket is not necessarily associated with improvements in residents' fruit, vegetable, or sugary beverage consumption, or in their perceptions of the availability of healthy food in the neighborhood. However, distance to the store may be important.

Faith, Activity, and Nutrition Randomized Dissemination and Implementation Study: Countywide Adoption, Reach, and Effectiveness.

INTRODUCTION: Faith-based organizations can contribute to improving population health, but few dissemination and implementation studies exist. This paper reports countywide adoption, reach, and effectiveness from the Faith, Activity, and Nutrition dissemination and implementation study. DESIGN: This was a group-randomized trial. Data were collected in 2016. Statistical analyses were conducted in 2017. SETTING/PARTICIPANTS: Churches in a rural, medically underserved county in South Carolina were invited to enroll, and attendees of enrolled churches were invited to complete questionnaires (n=1,308 participated). INTERVENTION: Churches (n=59) were randomized to an intervention or control (delayed intervention) condition. Church committees attended training focused on creating opportunities, setting guidelines/policies, sharing messages, and engaging pastors for physical activity (PA) and healthy eating (HE). Churches also received 12 months of telephone-based technical assistance. Community health advisors provided the training and technical assistance. MAIN OUTCOMES MEASURES: The Reach, Efficacy/Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework guided measurement of adoption and reach. To assess effectiveness, church attendees completed post-test only questionnaires of perceptions of church environment, PA and fruit and vegetable (FV) self-efficacy, FV intake, and PA. Regression models controlled for church clustering and predominant race of congregation, as well as member age, gender, education, and self-reported cancer diagnosis. RESULTS: Church adoption was 42% (55/132). Estimated reach was 3,527, representing 42% of regular church attendees and 15% of county residents. Intervention church attendees reported greater church-level PA opportunities, PA and HE messages, and PA and HE pastor support (p<0.0001), but not FV opportunities (p=0.07). PA self-efficacy (p=0.07) and FV self-efficacy (p=0.21) were not significantly higher in attendees of intervention versus control churches. The proportion of inactive attendees was lower in intervention versus control churches (p=0.02). The proportion meeting FV (p=0.27) and PA guidelines (p=0.32) did not differ by group. CONCLUSIONS: This innovative dissemination and implementation study had high adoption and reach with favorable environmental impacts, positioning it for broader dissemination. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT02868866.

Community Health Advisors' Participation in a Dissemination and Implementation Study of an Evidence-Based Physical Activity and Healthy Eating Program in a Faith-Based Setting.

Community health advisors (CHAs) have been widely involved in health promotion, but few details on role expectations, retention, and evaluation have been reported. In a dissemination and implementation (D&I) study of an evidence-based healthy eating and physical activity program, 59 churches were randomized to an intervention (n = 39) or control (delayed intervention) (n = 20) condition. In a novel approach, CHAs worked with church committees rather than congregants by providing training (n = 59) and technical assistance (n = 54) to the committees to implement a program focused on structural and policy-level changes to support congregants' behavioral changes. CHA training comprised self-study via electronic training modules, in-person training, and telephone-based training. Evaluation methods were pilot test participants' and CHAs' ratings of their training; observers' ratings of CHAs' church training delivery; church committee members' ratings of the training experience, including CHAs' performance; and data from the TA database to assess CHAs' adherence to the protocol. The main challenge was the early dropout of one CHA and the reduced role of another. CHAs trained 142 intervention and 60 control church committee members in nine sessions; they covered 99% (intervention) and 90% (control) of training content, indicating high fidelity. Observers' scored CHAs' teaching and facilitation skills at 96.7% (intervention) and 80% (control) of the possible score. CHAs completed 92% of intervention and 93% of control TA calls. The great majority of church participants' comments regarding CHAs were positive. This study demonstrates that with training and support, CHAs demonstrate high levels of intervention fidelity, confidence, and competence.

Household food security and use of community food sources and food assistance programs among food shoppers in neighborhoods of low income and low food access.

Food insecurity exceeds the 14% national level in severely disadvantaged households, and food shoppers seek food sources and assistance. In 513 predominantly African American households in South Carolina, USA, food security was a significant predictor of sources used, adjusted for socio-demographic characteristics (least-squares means = high food security, 2.10; marginal, 2.96; low, 2.91; very low, 3.40). The top sources were churches/social services, food bank/pantry, farmers' market, family/friend/neighbor, soup kitchen/shelter, and hunting/fishing/trapping. Adjusted odds were significantly greater among households of lower food security levels compared to high food security for food from church/social services, food bank/pantry, family/friend/neighbors, soup kitchen/shelter, and community/school/church garden.

Food Shopping and Acquisition Behaviors in Relation to BMI among Residents of Low-Income Communities in South Carolina.

Low-income areas in which residents have poor access to healthy foods have been referred to as "food deserts." It is thought that improving food access may help curb the obesity epidemic. Little is known about where residents of food deserts shop and if shopping habits are associated with body mass index (BMI). We evaluated the association of food shopping and acquisition (e.g., obtaining food from church, food pantries, etc.) with BMI among 459 residents of low-income communities from two South Carolina counties, 81% of whom lived in United States Department of Agriculture-designated food deserts. Participants were interviewed about food shopping and acquisition and perceptions of their food environment, and weight and height were measured. Distances to food retail outlets were determined. Multivariable linear regression analysis was employed. Our study sample comprising largely African-American women had an average BMI of 32.5 kg/m². The vast majority of study participants shopped at supermarkets (61%) or supercenters/warehouse clubs (27%). Shopping at a supercenter or warehouse club as one's primary store was significantly associated with a 2.6 kg/m² higher BMI compared to shopping at a supermarket, independent of demographics, socioeconomics, physical activity, and all other food shopping/acquisition behaviors. Persons who reported shopping at a small grocery store or a convenience or dollar store as their tertiary store had a 2.6 kg/m² lower BMI. Respondents who perceived lack of access to adequate food shopping in their neighborhoods as a problem had higher BMI. Living in a food desert census tract was not significantly associated with BMI. Other shopping attributes, including distance to utilized and nearest grocery stores, were not independently associated with BMI. These findings call into question the idea that poor spatial access to grocery stores is a key underlying factor affecting the obesity epidemic. Future research should consider assessing foods purchased and dietary intake within a comprehensive study of food shopping behaviors and health outcomes among persons living in food deserts.

The Association between Food Security and Store-Specific and Overall Food Shopping Behaviors.

BACKGROUND: Food security is a severe problem in the United States. Few studies have examined its relationship with food shopping behaviors. OBJECTIVE: This study aimed to examine the association between food security and store-specific and overall food shopping among residents of low-income neighborhoods. DESIGN: We conducted a cross-sectional study. PARTICIPANTS/SETTING: Five hundred twenty-seven households were recruited from two counties in South Carolina from November 2013 to May 2014, and 474 households were included in the final analysis. MAIN OUTCOMES MEASURES: Food security was assessed using the 18-item US-Household Food Security Module questionnaire, and classified into three categories: high or marginal food security (FS), low food security (LFS), and very low food security (VLFS). Store-specific shopping behaviors including frequency, store type, and transportation were queried via in-person interview for the three most-frequented grocery stores. Distance from participants' homes to their reported stores was calculated using Geographic Information Systems. STATISTICAL ANALYSES: Multivariate linear regression for analyses of distance and frequency and multinomial/ordinary logistic regression for analyses of store type and transportation were used. RESULTS: Compared to FS participants, a significantly higher proportion of VLFS participants reported a convenience/dollar store as their most-frequented store (odds ratio [OR] 2.31, 95% CI 1.08 to 4.95) or a lack of transportation (OR 2.04, 95% CI 1.25 to 3.33). They also shopped less frequently (b=-.31, P=0.03) at their third most-frequented store and traveled fewer total miles for shopping (b=-4.71, P=0.04). In analyses considering all stores jointly, LFS participants had lower odds of shopping at both supermarkets and convenience/dollar stores (OR 0.44, 95% CI 0.21 to 0.91) compared to food-secure residents. CONCLUSIONS: The current findings suggest that households with VLFS tend to shop more frequently in stores that have less-healthful options, such as convenience/dollar stores. These findings lend support to ongoing community and policy interventions aimed at improving food access among food-insecure populations.

Living in Limbo: Latinas' Assessment of Lower Rio Grande Valley Colonias Communities.

Community asset mapping (CAM) is the collective process of identifying local assets and strategizing processes to address public health issues and concerns and improve quality of life. Prior to implementing a community-based physical activity intervention with Latinas in the Texas Lower Rio Grande Valley, promotoras [community health workers] conducted 16 interactive sessions in 8 colonias. The analysis of the transcribed CAM recordings and on-site observational data resulted in the construction of Living in Limbo as the thematic representation of these Latinas' social isolation and marginalization associated with pervasive poverty, undocumented immigration status or lack of citizenship, their fears emanating from threats to physical and emotional safety, and the barriers created by lack of availability and access to resources.

"Participation, satisfaction, perceived benefits, and maintenance of behavioral self-management strategies in a self-directed exercise program for adults with arthritis".

A process evaluation was conducted in conjunction with a controlled trial of a self-directed exercise program among people with arthritis to describe the program's reach; self-management behaviors, exposure to materials, program perceptions, satisfaction, and perceived benefits; compatibility with targeted participants' needs; and maintenance. Participants (n=197) were predominantly white, middle-aged, college-educated women. At 12 weeks, 73.2% had read ≥90% of the program materials (at nine months>70% had "occasionally" or "often" looked back over each of the five parts of the materials); 63.3% had set goals (52.5% at nine months), and 83.9% had "some" or "a lot" of success following their plan (64.2% at nine months), while 90.4% rated the program "good" or "excellent" (87.5% at nine months). At 12 weeks, the majority (89.3%) used written logs to self-monitor (mean=9.3 logs); by nine months, >70% never kept logs. Most (>80%) rated twelve of thirteen program components as helpful, and 98.6% would recommend the program. From 38% to 62.4% endorsed each of eight program benefits, with small declines of ≤9% at nine months. Qualitative response identified ways the program met and did not meet expectations. The main program compatibility issue was targeting all adults with arthritis, while featuring older adults in materials.

Preferred Healthy Food Nudges, Food Store Environments, and Customer Dietary Practices in 2 Low-Income Southern Communities.

OBJECTIVE: To examine how food store environments can promote healthful eating, including (1) preferences for a variety of behavioral economics strategies to promote healthful food purchases, and (2) the cross-sectional association between the primary food store where participants reported shopping, dietary behaviors, and body mass index. METHODS: Intercept survey participants (n = 342) from 2 midsized eastern North Carolina communities completed questionnaires regarding preferred behavioral economics strategies, the primary food store at which they shopped, and consumption of fruits, vegetables, and sugary beverages. RESULTS: Frequently selected behavioral economic strategies included: (1) a token and reward system for fruit and vegetable purchases; and (2) price discounts on healthful foods and beverages. There was a significant association between the primary food store and consumption of fruits and vegetables (P = .005) and sugary beverages (P = .02). CONCLUSIONS AND IMPLICATIONS: Future studies should examine associations between elements of the in-store food environment, purchases, and consumption.

Process for massage therapy practice and essential assessment.

BACKGROUND: Little evidence exists about processes in massage therapy practice. Investigating current frameworks is warranted. This qualitative study is a secondary data analysis using grounded theory to understand how massage therapy experts describe massage therapy practice. METHODS: 31 massage therapy experts were invited to a 2-day symposium to discuss best practices for the profession. Through qualitative analysis, memoing, and discussion, the data were summarized into themes. RESULTS: Three themes were identified around massage therapy practice: 1) client centered, 2) structure for practice, and 3) influencing factors. Each theme is clarified and expanded. DISCUSSION: Conceptual models were developed for research and clinical practice and a definition for massage therapy practice was identified. Challenges and limitations are discussed. CONCLUSION: The goal of providing these models is to give massage therapists tools to deliver the best possible care. The models need testing to see if they help advance the profession.

Clarifying Definitions for the Massage Therapy Profession: the Results of the Best Practices Symposium.

BACKGROUND: Massage therapists are at times unclear about the definition of massage therapy, which creates challenges for the profession. It is important to investigate the current definitions and to consider the field as a whole in order to move toward clarity on what constitutes the constructs within the profession. PURPOSE: To determine how a sample of experts understand and describe the field of massage therapy as a step toward clarifying definitions for massage and massage therapy, and framing the process of massage therapy practice. SETTING: A two-day symposium held in 2010 with the purpose of gathering knowledge to inform and aid in the creation of massage therapy best practice guidelines for stress and low back pain. PARTICIPANTS: Thirty-two experts in the field of massage therapy from the United States, Europe, and Canada. DESIGN: Qualitative analysis of secondary cross-sectional data using a grounded theory approach. RESULTS: Three over-arching themes were identified: 1) What is massage?; 2) The multidimensional nature of massage therapy; and 3) The influencing factors on massage therapy practice. DISCUSSION: The data offered clarifying definitions for massage and massage therapy, as well as a framework for the context for massage therapy practice. These clarifications can serve as initial steps toward the ultimate goal of creating new theory for the field of massage therapy, which can then be applied in practice, education, research, and policy. CONCLUSIONS: Foundational research into how experts in the profession understand and describe the field of massage therapy is limited. Understanding the potential differences between the terms massage and massage therapy could contribute to a transformation in the profession in the areas of education, practice, research, policy and/or regulation. Additionally, framing the context for massage therapy practice invites future discussions to further clarify practice issues.