Healthy Choices Catch On: Data-informed Evolution of a Social Marketing Campaign.

OBJECTIVE: Describe how a multiyear, mixed-methods evaluation informed the evolution of a healthy eating and physical activity social marketing campaign. DESIGN: Focus groups, A/B survey to test messages and images, telephone interviews (2019) with local programmers, and an annual outcome survey. SETTING: Statewide through multiple channels: billboards, transit signs, social media, website, and program resources like banners and posters. PARTICIPANTS: Supplemental Nutrition Assistance Program-Education eligible adults, focusing on mothers and caregivers. INTERVENTION(S): Healthy Choices Catch On originally launched in 2006 and has since evolved. MAIN OUTCOME MEASURE(S): Fruit and vegetable consumption, physical activity, and campaign recall. ANALYSIS: Univariate descriptive statistics and multivariate, weighted linear regression modeling. Interview transcriptions were analyzed for common themes. RESULTS: The multiyear evaluation demonstrated a steady increase in campaign exposure from 2013 to 2017, followed by a decline when new messages and images were introduced in 2018 and 2020. People with greater exposure to messages were more likely to eat more fruits and vegetables and be physically active. CONCLUSIONS AND IMPLICATIONS: Using a combination of evaluation methods can help inform campaign design and evolution while also demonstrating reach and impact.

Policy, Systems, and Environmental Change Strategies in the Supplemental Nutrition Assistance Program-Education (SNAP-Ed).

OBJECTIVE: To categorize and quantify how states planned to use policy, systems, and environmental (PSE) change strategies in the Supplemental Nutrition Assistance Program-Education (SNAP-Ed). METHODS: Qualitative content analysis of SNAP-Ed annual plans from all 50 states, District of Columbia, Guam, and the US Virgin Islands between fiscal years 2014 and 2016. RESULTS: Between 2014 and 2016, the percentage of states that included PSEs as a statewide goal increased from 25% to 47%, and the percentage that planned to implement at least 1 PSE increased from 56% to 98%. Among states that planned to implement PSEs in 2016, the 3 most common settings were places in which people learn (92%), live (90%), and work (83%). CONCLUSIONS AND IMPLICATIONS: The increased planned use of PSEs in SNAP-Ed was considerable and encouraging as PSEs are important to use in conjunction with direct education and social marketing to improve nutrition and prevent obesity.

Breastfeeding Duration Is Associated With WIC Site-Level Breastfeeding Support Practices.

OBJECTIVE: To describe Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) site-level breastfeeding support practices and associations with breastfeeding outcomes. DESIGN: Secondary analysis of WIC Infant and Toddler Feeding Practices Study-2, including data from interviews with caregivers of infants and interviews and surveys with staff from 27 WIC state agencies and 80 study sites. PARTICIPANTS: A total of 1,235 mothers of breastfed infants participating in the WIC Infant and Toddler Feeding Practices Study-2. MAIN OUTCOME MEASURE: Any and fully breastfeeding 2, 6, and 12 months postpartum. ANALYSIS: Descriptive statistics described WIC site-level breastfeeding supports. Multilevel mixed modeling of breastfeeding at 2, 6, and 12 months, controlling for site- and participant-level characteristics. RESULTS: Five WIC site-level supports were significantly and independently associated with any and fully breastfeeding: access to breastfeeding peer counselors, access to International Board Certified Lactation Consultants, postnatal home visits, allowing any WIC staff member to provide breast pump education, and having a policy not to provide formula during the first 30 days postpartum. Likelihood of any and fully breastfeeding increased with each additional site-level support present (odds ratio = 1.09, 95% confidence interval, 1.06-1.12; and odds ratio = 1.26, 95% confidence interval, 1.21-1.31, respectively). CONCLUSIONS AND IMPLICATIONS: Positive associations between site-level supports and breastfeeding at 2, 6, and 12 months were observed. Additional research is needed to understand how site-level supports interrelate and whether specific combinations are more effective, and to identify variations in implementation of breastfeeding supports.

Community-Based Efforts to Prevent and Manage Diabetes in Women Living in Vulnerable Communities.

Social determinants of health likely play a significant role in the development of type 2 diabetes for women in vulnerable communities. Adult African American women diagnosed with or at-risk for diabetes in Inkster, Michigan (n = 113) and a group of demographically similar women in Flint, Michigan (n = 48) participated in programs aimed at increasing diabetes-related self-management behaviors through peer coaching, health literacy training, and social support. Participants completed surveys to measure changes in health, health behaviors, health literacy, and social support. We found that these diabetes programs with a focus on increasing women's capacity to practice health management behaviors, navigate the health care system, and connect with social support, led to an increase in healthy behaviors and a reported increase in both overall and diabetes-specific health over an 18 month period. Overall health, general diet and specific diet improved significantly (p < 0.05) from baseline to follow-up, when controlled for age, diabetes status and site. Exercise also improved, but the change was not statistically significant. Women who participated in the intervention changed health behaviors, and increased their sense of health literacy and social support. Improvement in women's access to and use of community preventive services, and the provision of outreach support using community health workers (CHWs) and peer mentorship was an integral part of creating these changes. Although this study found that a variety of diabetes prevention and management programs provided opportunities for positive health changes, findings also suggest that it is critical to address the burdens women from vulnerable communities face in order to participate in these programs.

Cooking Matters for Adults Improves Food Resource Management Skills and Self-confidence Among Low-Income Participants.

OBJECTIVE: Determine the impact of Cooking Matters for Adults (CM) on food resource management (FRM) skills and self-confidence 6 months after course completion. DESIGN: Quasi-experimental design with nonequivalent comparison group and 6-month follow-up. SETTING: Cooking Matters for Adults programs in CA, CO, ME, MA, MI, and OR. PARTICIPANTS: Participants in CM attending classes in April to July, 2016 (n = 332); comparison group (n = 336). INTERVENTION: Cooking Matters for Adults educated low-income adults to shop for and prepare healthy meals economically using hands-on meal preparation, facilitated discussion, and an interactive grocery store tour. Classes met for 2 hours, once a week for 6 weeks. MAIN OUTCOME MEASURE(S): Food resource management practices; FRM self-confidence (ie, in shopping for and preparing healthy foods on a budget); worrying that food might run out. ANALYSIS: Pearson's chi-square test and t tests identified measures associated with outcomes of interest and between-group differences. Repeated-measures linear mixed models with fixed and random effects were used to examine differences in outcomes between participants in CM and nonequivalent comparison group and to estimate the treatment effect of the program at 3 and 6 months after course completion. RESULTS: Six months after course completion, CM participants demonstrated improvements in all outcome measures of interest: Use of FRM practices improved (P = .002) as did FRM confidence (P < .001). Participants also worried less that food would run out before they had money to buy more (P = .03). CONCLUSIONS AND IMPLICATIONS: This study demonstrated a positive impact of including FRM skills and confidence building in a nutrition education program, the effects of which could be seen for 6 months after participation in the program. Equipping low-income families with FRM skills allowed them to access healthier foods even during times of hardship.

A randomized clinical trial of a culturally responsive intervention for African American women with asthma.

BACKGROUND: Few interventions have focused on the difficulties that African American women face when managing asthma. OBJECTIVE: To evaluate a telephone-based self-regulation intervention that emphasized African American women's management of asthma in a series of 6 sessions. METHODS: A total of 422 African American women with persistent asthma were randomly assigned to either an intervention or control group receiving usual care. Behavioral factors, symptoms and asthma control, asthma-related quality of life, and health care use at baseline and 2 years after baseline were assessed. Generalized estimating equations were used to assess the long-term effect of the intervention on outcomes. RESULTS: Compared with the control group, those who completed the full intervention (6 sessions) had significant gains in self-regulation of their asthma (B estimate, 0.73; 95% CI, 0.17-1.30; P < .01), noticing changes to their asthma during their menstrual cycle (B estimate, 1.42; 95% CI, 0.69-2.15; P < .001), and when having premenstrual syndrome (B estimate, 1.70; 95% CI, 0.67-2.72; P < .001). They also had significant reductions in daytime symptoms (B estimate, -0.15; 95% CI, -0.27 to -0.03; P < .01), asthma-related hospitalization (B estimate, 0.51; 95% CI, 0.00-1.02; P < .05), and improved asthma control (B estimate, 1.34; 95% CI, 0.57-2.12; P < .001). However, neither grouped changed over time in outcomes. CONCLUSION: Despite high comorbidity, African American women who completed a culturally responsive self-management program had improvements in asthma outcomes compared with the control group. Future work should address significant comorbidities and psychosocial issues alongside asthma management to improve asthma outcomes in the long term. TRIAL REGISTRATION: clinicaltrials.gov Identifier NCT01117805.

Pediatric Asthma Care Coordination in Underserved Communities: A Quasiexperimental Study.

OBJECTIVES: To assess the effect of care coordination on asthma outcomes among children in underserved urban communities. METHODS: We enrolled children, most of whom had very poorly or not well-controlled asthma, in medical-social care coordination programs in Los Angeles, California; Chicago, Illinois; Philadelphia, Pennsylvania; and San Juan, Puerto Rico in 2011 to 2014. Participants (n = 805; mean age = 7 years) were 60% male, 50% African American, and 42% Latino. We assessed asthma symptoms and health care utilization via parent interview at baseline and 12 months. To prevent overestimation of intervention effects, we constructed a comparison group using bootstrap resampling of matched control cases from previous pediatric asthma trials. RESULTS: At follow-up, intervention participants had 2.2 fewer symptom days per month (SD = 0.3; P < .01) and 1.9 fewer symptom nights per month (SD = 0.35; P < .01) than did the comparison group. The relative risk in the past year associated with the intervention was 0.63 (95% confidence interval [CI] = 0.45, 0.89) for an emergency department visit and 0.69 (95% CI = 0.47, 1.01) for hospitalization. CONCLUSIONS: Care coordination may improve pediatric asthma symptom control and reduce emergency department visits. POLICY IMPLICATIONS: Expanding third-party reimbursement for care coordination services may help reduce pediatric asthma disparities.

The extent and patterns of multiple chronic conditions in low-income children.

BACKGROUND AND OBJECTIVES: Little is known about the magnitude of multiple chronic conditions (MCC) in children. This study describes the prevalence of and patterns of comorbidities in children receiving Medicaid assistance. METHODS: Diagnoses from 5 years of Medicaid claims data were reviewed and identified 128,044 children with chronic conditions. The relationship between comorbidities and significant urgent health care events was analyzed using logistic regression modeling. RESULTS: More than 15,000 children (12%) had claims for more than 1 condition. The most frequent combination was asthma and allergic rhinitis. Significant health care events ranged from 18% to 51% in children, and the odds of having a significant event increased with each additional condition. Those with ≥4 conditions had 4.5 times the odds of a significant event compared with those with 1 condition (P < .0001). CONCLUSION: MCC are prevalent in low-income children and are associated with greater risk for urgent health care use.

Policy and system change and community coalitions: outcomes from allies against asthma.

Objectives. We assessed policy and system changes and health outcomes produced by the Allies Against Asthma program, a 5-year collaborative effort by 7 community coalitions to address childhood asthma. We also explored associations between community engagement and outcomes. Methods. We interviewed a sample of 1,477 parents of children with asthma in coalition target areas and comparison areas at baseline and 1 year to assess quality-of-life and symptom changes. An extensive tracking and documentation procedure and a survey of 284 participating individuals and organizations were used to ascertain policy and system changes and community engagement levels. Results. A total of 89 policy and system changes were achieved, ranging from changes in interinstitutional and intrainstitutional practices to statewide legislation. Allies children experienced fewer daytime (P = .008) and nighttime (P = .004) asthma symptoms than comparison children. In addition, Allies parents felt less helpless, frightened, and angry (P = .01) about their child's asthma. Type of community engagement was associated with number of policy and system changes. Conclusions. Community coalitions can successfully achieve asthma policy and system changes and improve health outcomes. Increased core and ongoing community stakeholder participation rather than a higher overall number of participants was associated with more change.

Study protocol for improving asthma outcomes through cross-cultural communication training for physicians: a randomized trial of physician training.

BACKGROUND: Massive resources are expended every year on cross-cultural communication training for physicians. Such training is a focus of continuing medical education nationwide and is part of the curriculum of virtually every medical school in America. There is a pressing need for evidence regarding the effects on patients of cross-cultural communication training for physicians. There is a need to understand the added benefit of such training compared to more general communication. We know of no rigorous study that has assessed whether cross-cultural communication training for physicians results in better health outcomes for their patients. The current study aims to answer this question by enhancing the Physician Asthma Care Education (PACE) program to cross cultural communication (PACE Plus), and comparing the effect of the enhanced program to PACE on the health outcomes of African American and Latino/Hispanic children with asthma. METHODS/DESIGN: A three-arm randomized control trial is used to compare PACE Plus, PACE, and usual care. Both PACE and PACE Plus are delivered in two, two-hour sessions over a period of two weeks to 5-10 primary care physicians who treat African American and Latino/Hispanic children with asthma. One hundred twelve physicians and 1060 of their pediatric patients were recruited who self-identify as African American or Latino/Hispanic and experience persistent asthma. Physicians were randomized into receiving either the PACE Plus or PACE intervention or into the control group. The comparative effectiveness of PACE and PACE Plus on clinician's therapeutic and communication practices with the family/patient, children's urgent care use for asthma, asthma control, and quality of life, and parent/caretaker satisfaction with physician performance will be assessed. Data are collected via telephone survey and medical record review at baseline, 9 months following the intervention, and 21 months following the intervention. DISCUSSION: This study aims to reduce disparities in asthma outcomes among African American and Latino/Hispanic children through cross-cultural communication training of their physicians and assessing the added value of this training compared to general communication. The results of this study will provide important information about the value of cross-cultural training in helping to address persistent racial disparities in outcomes. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01251523 December 1, 2010.

Asthma coalition effects on vulnerable sub groups of children: the most frequent users of health care and the youngest.

OBJECTIVE: To examine the impact of Allies Against Asthma, community-based coalitions working to improve asthma outcomes, on vulnerable children: those with the most urgent health care use and those of youngest age. METHODS: Allies zip codes were matched with comparison communities on demographic factors. Five years of Medicaid data (n = 26,836) for significant health care events: hospitalizations, ED and urgent care facility visits, were analyzed. Longitudinal analyses using generalized estimating equations and proportional hazards models compared Allies and comparison group children. RESULTS: In the two start-up years of Allies, odds of having a significant event were greater for Allies children than for comparison children (p < 0.05). During the third and fourth years when Allies activities were fully implemented, for frequent health care users at baseline, odds of an asthma event were the same for both Allies and comparison children, yet in the less frequent users, odds of an event were lower in Allies children (p < 0.0001). In the initial year of Allies efforts, among the youngest, the Allies children had greater odds than comparison children of an event (p < 0.01), but by the fourth year the Allies group had lower odds (p = 0.02) of an event. Hazard ratios over all years of the study for the youngest Allies children and most frequent baseline users of urgent care were lower than for comparison children (p = 0.01 and p = 0.0004). CONCLUSION: Mobilizing a coalition of diverse stakeholders focused on policy and system change generated community-wide reductions over the long-term in health care use for vulnerable children.

Sustaining school-based asthma interventions through policy and practice change.

BACKGROUND: Schools are an ideal setting for implementation of asthma interventions for children; however, sustaining school-based programs can be challenging. This study illustrates policy and practice changes brought about through the Childhood Asthma Linkages in Missouri (CALM) program to sustain such programs. METHODS: Researchers analyzed caregiver-reported quantitative data regarding asthma-related outcomes in preintervention and postintervention surveys and qualitative data regarding sustainability efforts in schools reported by CALM grantees. A grounded theory approach was used to identify key concepts and themes that emerged. RESULTS: In 330 children, significant improvements were seen in asthma symptoms, rescue inhaler use, health care utilization, school absenteeism, and activity limitations. Overall, 27 school-based policy and practice changes supporting program sustainability were reported, with policy changes most often concerning the assessment and/or monitoring of children with asthma in the school setting, and practice changes most often regarding institution of regular asthma education programs for students and school personnel. CONCLUSIONS: Sustaining school-based asthma programs is challenging, but can be realized through the participation of diverse partners in enacting policy and practice changes that support the institutionalization of programs into the day-to-day processes of the schools.

Improvements in health care use associated with community coalitions: long-term results of the allies against asthma initiative.

OBJECTIVES: We assessed changes in asthma-related health care use by low-income children in communities across the country where 6 Allies Against Asthma coalitions (Hampton Roads, VA; Washington, DC; Milwaukee, WI; King County/Seattle, WA; Long Beach, CA; and Philadelphia, PA) mobilized stakeholders to bring about policy changes conducive to asthma control. METHODS: Allies intervention zip codes were matched with comparison communities by median household income, asthma prevalence, total population size, and race/ethnicity. Five years of data provided by the Center for Medicare and Medicaid Services on hospitalizations, emergency department (ED) use, and physician urgent care visits for children were analyzed. Intervention and comparison sites were compared with a stratified recurrent event analysis using a Cox proportional hazard model. RESULTS: In most of the assessment years, children in Allies communities were significantly less likely (P < .04) to have an asthma-related hospitalization, ED visit, or urgent care visit than children in comparison communities. During the entire period, children in Allies communities were significantly less likely (P < .02) to have such health care use. CONCLUSIONS: Mobilizing a diverse group of stakeholders, and focusing on policy and system changes generated significant reductions in health care use for asthma in vulnerable communities.

Policy and system change and community coalitions: outcomes from allies against asthma.

OBJECTIVES: We assessed policy and system changes and health outcomes produced by the Allies Against Asthma program, a 5-year collaborative effort by 7 community coalitions to address childhood asthma. We also explored associations between community engagement and outcomes. METHODS: We interviewed a sample of 1477 parents of children with asthma in coalition target areas and comparison areas at baseline and 1 year to assess quality-of-life and symptom changes. An extensive tracking and documentation procedure and a survey of 284 participating individuals and organizations were used to ascertain policy and system changes and community engagement levels. RESULTS: A total of 89 policy and system changes were achieved, ranging from changes in interinstitutional and intrainstitutional practices to statewide legislation. Allies children experienced fewer daytime (P = .008) and nighttime (P = .004) asthma symptoms than comparison children. In addition, Allies parents felt less helpless, frightened, and angry (P = .01) about their child's asthma. Type of community engagement was associated with number of policy and system changes. CONCLUSIONS: Community coalitions can successfully achieve asthma policy and system changes and improve health outcomes. Increased core and ongoing community stakeholder participation rather than a higher overall number of participants was associated with more change.

Selected diet and lifestyle factors are associated with estrogen metabolites in a multiracial/ethnic population of women.

Diet and lifestyle factors, body size, and smoking behavior may influence estrogen metabolism, but the nature of these relations may vary according to race/ethnic groups. We evaluated the association of lifestyle factors with estrogen metabolites 2-hydroxyestrone (2-OHE1) and 16alpha-hydroxyestrone (16alpha-OHE1) in a racially diverse population. With a cross-sectional study design, urine samples from 1881 African-American, Caucasian, Chinese, Japanese, and Hispanic women, aged 42-52 y, from the Study of Women's Health Across the Nation (SWAN) were assayed by EIA for 2-OHE1 and 16alpha-OHE1. Dietary factors and beverages were measured using a modified Block FFQ. Dietary fiber, vegetable and fruit servings, Brassica vegetables, polyphenols, coffee, caffeine, green and black tea, and total alcohol and wine were related to metabolite values using multiple variable regression analyses. In adjusted analyses, 2-OHE1 concentrations were significantly associated with race/ethnicity, weight, smoking, and consumption of hydroxybenzoic acid, anthocyanidins, wine, and caffeine (P < 0.05). Regression models incorporating these variables explained 19-20% of the variation in 2-OHE1 concentrations. Regression models for 16alpha-OHE1, which explained 16-17% of the variability, included race/ethnicity, smoking, caffeine, total dietary fiber, and fiber from fruits and vegetables as variables. These associations may reflect why increased consumption of polyphenol-containing foods and fruit as well as decreased smoking, caffeine intake, and body size would be consistent with hypothesized benefits and risks for selected health outcomes.

Sarcopenia is related to physical functioning and leg strength in middle-aged women.

BACKGROUND: In the aging process, loss of muscle is relatively continuous, but the initiation, timing, and amount of muscle loss that relate to functional compromise are poorly described. Also poorly understood is whether strength and functioning in aging are related to the amount of lean mass and its change as well as to the amount of fat mass and its change. METHODS: The purpose of the study was to ascertain whether 3-year lean and fat mass change predicted functional status in 712 African American and Caucasian women, aged 34-58 years. Fat and lean mass were assessed with bioelectrical impedance. Lower leg strength (torque) was measured with a portable isometric chair, and two indices of physical functioning, walking velocity and double support (both feet touching the surface while walking), were measured with an instrumented gait mat. RESULTS: Almost 9% of middle-aged women had at least a 6% loss (>2.5 kg) of lean mass over the 3-year observation period. Women who lost at least 2.5 kg of lean mass had slower walking velocity and less leg strength, although women who simultaneously gained more than 2.5 kg of fat mass (at least 7.5%) did not have less leg strength. Age was significantly associated with less velocity, less leg strength, and more time in double support. CONCLUSIONS: Even in middle-aged women, there is loss of lean mass among almost 1 woman in 10, and this loss of lean mass (sarcopenia) is associated with greater compromise in physical functioning.