A culturally adapted telecommunication system to improve physical activity, diet quality, and medication adherence among hypertensive African-Americans: a randomized controlled trial.

BACKGROUND: Hypertension is more prevalent and clinically severe among African-Americans than whites. Several health behaviors influence blood pressure (BP) control, but effective, accessible, culturally sensitive interventions that target multiple behaviors are lacking. PURPOSE: We evaluated a culturally adapted, automated telephone system to help hypertensive, urban African-American adults improve their adherence to their antihypertensive medication regimen and to evidence-based guidelines for dietary behavior and physical activity. METHODS: We randomized 337 hypertensive primary care patients to an 8-month automated, multi-behavior intervention or to an education-only control. Medication adherence, diet, physical activity, and BP were assessed at baseline and every 4 months for 1 year. Data were analyzed using longitudinal modeling. RESULTS: The intervention was associated with improvements in a measure of overall diet quality (+3.5 points, p < 0.03) and in energy expenditure (+80 kcal/day, p < 0.03). A decrease in systolic BP between groups was not statistically significant (-2.3 mmHg, p = 0.25). CONCLUSIONS: Given their convenience, scalability, and ability to deliver tailored messages, automated telecommunications systems can promote self-management of diet and energy balance in urban African-Americans.

A randomized trial of tailoring and motivational interviewing to promote fruit and vegetable consumption for cancer prevention and control.

BACKGROUND: Healthful dietary patterns, including eating fruits and vegetables (F&V) and avoiding obesity, may decrease the risk of cancer and other chronic diseases. In addition to promoting health for the general population, a cancer diagnosis may provide a "teachable moment," facilitating the adoption of more healthful eating habits and leading to lower risk of chronic disease and better overall health. PURPOSE: This study was designed to test the effectiveness of two health communication interventions in increasing F&V consumption and physical activity in a sample of older adults (average age of 66 years), including both colorectal cancer (CRC) survivors and noncolorectal cancer-affected (N-CRC) individuals. METHODS: CRC survivors and N-CRC individuals were recruited from a population-based case-control study and randomly assigned to four conditions using a 2 x 2 design. We tested two different methods of communicating and promoting health behavior change alone or in combination: tailored print communication (TPC) and brief telephone-based motivational interviewing (TMI). RESULTS: A significant increase in F&V consumption was found for the combined intervention group in the entire sample (p < 0.05). When stratified by cancer survivor status, the effect was concentrated in the N-CRC subset (p < 0.01) versus CRC survivors. The combined intervention was also found to be most cost-effective for the N-CRC group, with TPC more cost-effective than TMI. For physical activity, none of the interventions produced statistically significant improvements. CONCLUSIONS: This study indicates that combining tailoring and motivational interviewing may be an effective and cost-effective method for promoting dietary behavior change among older healthy adults. More research is needed to identify the optimal dose and timing for intervention strategies to promote dietary and physical activity change among both CRC survivors and the general population.

The private partners of public health: public-private alliances for public good.

OBJECTIVE: We sought to convey lessons learned by the Centers for Disease Control and Prevention's (CDC's) Prevention Research Centers (PRCs) about the value and challenges of private-sector alliances resulting in innovative health promotion strategies. Several PRCs based in a variety of workplace and community settings contributed. METHODS: We conducted interviews with principal investigators, a literature review, and a review of case studies of private-sector alliances in a microbusiness model, a macrobusiness model, and as multiparty partnerships supporting public health research, implementation, and human resource services. RESULTS: Private-sector alliances provide many advantages, particularly access to specialized skills generally beyond the expertise of public health entities. These skills include manufacturing, distribution, marketing, business planning, and development. Alliances also allow ready access to employee populations. Public health entities can offer private-sector partners funding opportunities through special grants, data gathering and analysis skills, and enhanced project credibility and trust. Challenges to successful partnerships include time and resource availability and negotiating the cultural divide between public health and the private sector. Critical to success are knowledge of organizational culture, values, mission, currency, and methods of operation; an understanding of and ability to articulate the benefits of the alliance for each partner; and the ability and time to respond to unexpected changes and opportunities. CONCLUSION: Private-public health alliances are challenging, and developing them takes time and resources, but aspects of these alliances can capitalize on partners' strengths, counteract weaknesses, and build collaborations that produce better outcomes than otherwise possible. Private partners may be necessary for program initiation or success. CDC guidelines and support materials may help nurture these alliances.

The WORD (wholeness, oneness, righteousness, deliverance): a faith-based weight-loss program utilizing a community-based participatory research approach.

Despite multidisciplinary efforts to control the nation's obesity epidemic, obesity has persisted as one of the U.S.'s top public health problems, particularly among African Americans. Innovative approaches to address obesity that are sensitive to the unique issues of African Americans are needed. Thus, a faith-based weight-loss intervention using a community-based participatory research approach was developed, implemented, and evaluated with a rural African American faith community. A two-group, quasi-experimental, delayed intervention design was used, with church as the unit of assignment (treatment n=2, control n=2) and individual as the unit of observation (treatment n=36, control n=37). Weekly small groups led by trained community members met for 8 weeks and emphasized healthy nutrition, physical activity, and faith's connection with health. The mean weight loss of the treatment group was 3.60+/-0.64 lbs. compared to the 0.59+/-0.59-lb loss of the control group.

Process evaluation of an effective church-based diet intervention: Body & Soul.

Body & Soul has demonstrated effectiveness as a dietary intervention among African American church members. The process evaluation assessed relationships between program exposure and implementation factors and study outcomes and characterized factors important for adoption, implementation, and maintenance. Data sources included participant surveys and qualitative interviews with program staff, church liaisons, and volunteer advisors who conducted motivational interviewing (MI) calls. Outcomes included changes in dietary intake and psychosocial variables. Process variables included program exposure, participation, and dose and perceptions about MI calls. Results showed that attendance at project events, receiving educational materials, and self-reported quality of the MI calls were associated with significantly (p < .05) greater fruit and vegetable intake, decreased fat consumption, and other secondary outcomes. Interviews indicated implementation and sustainability issues and needs including more training to enhance MI implementation as well as ongoing support and resources. The results have implications for future dissemination efforts of Body & Soul.

Psychosocial mediation of fruit and vegetable consumption in the body and soul effectiveness trial.

In this study the authors examined psychosocial variables as mediators for fruit and vegetable (FV) intake in a clustered, randomized effectiveness trial conducted in African American churches. The study sample included 14 churches (8 intervention and 6 control) with 470 participants from the intervention churches and 285 participants from the control churches. The outcome of FV intake and the proposed mediators were measured at baseline and at 6-month follow-up. Structural equation modeling indicated that the intervention had direct effects on social support, self-efficacy, and autonomous motivation; these variables also had direct effects on FV intake. Applying the M. E. Sobel (1982) formula to test significant mediated effects, the authors confirmed that social support and self-efficacy were significant mediators but that autonomous motivation was not. Social support and self-efficacy partially mediated 20.9% of the total effect of the intervention on changes in FV intake. The results support the use of strategies to increase social support and self-efficacy in dietary intervention programs.

Positive affect, exercise and self-reported health in blue-collar women.

OBJECTIVES: To determine if positive affect is related to the self-reported health and health behaviors of blue-collar women. METHODS: Analysis of baseline survey data of 1093 women participating in a worksite health promotion intervention at 12 workplaces in 5 rural counties. RESULTS: Positive affect was related to women's self-reported health and exercise. Also, positive coping behaviors were related to exercise. CONCLUSIONS: These findings suggest that incorporating strategies to encourage positive emotional states and positive coping into health promotion interventions might be helpful for improving women's levels of physical activity and overall reported health.

Differences in fruit and vegetable intake among categories of dietary supplement users.

BACKGROUND: People who choose to take dietary supplements are often classified as having a healthful lifestyle; however, it is probable that several health behavior patterns exist among users. OBJECTIVE: Data from the North Carolina Strategies to Improve Diet, Exercise, and Screening study (N = 727) were used to identify and describe five different categories of dietary supplement use and evaluate how these categories are associated with both quantity and quality of fruit and vegetable consumption. DESIGN: Five nonoverlapping dietary supplement use categories were created and descriptive demographic statistics were compared. Least-squares means were calculated for knowledge and fruit and vegetable quality and quantity measures. Logistic regression was performed to calculate adjusted odds ratios to examine associations among the dietary supplement use categories and the fruit and vegetable measures, using nonusers as the reference category. RESULTS: Demographic profiles and dietary intake varied among the dietary supplement categories. People reporting both a multivitamin/multimineral and a single supplement (Multi Plus category) and any nonvitamin/nonmineral products (Herbals category) were more likely to be consuming more vegetables and higher-quality fruits and vegetables than those not taking any dietary supplements (Nonusers category), whereas people taking multivitamins/multiminerals only (Multis category) had patterns that were more consistently similar to those not taking any dietary supplements (Nonusers). CONCLUSIONS: Study participants exhibited dietary supplement use patterns that were associated with differences in fruit and vegetable consumption. Simply characterizing people as users and nonusers will not capture critical demographic and dietary differences and will likely further cloud investigations of diet-disease relationships.

Qualitative comparison of dietary choices and dietary supplement use among older adults with and without a history of colorectal cancer.

OBJECTIVE: To explore colorectal cancer survivors' beliefs about diet, dietary supplements, health, and cancer in relation to beliefs of a similar group without colorectal cancer. DESIGN: In-depth, semistructured, open-ended interviews were used to examine perceptions. PARTICIPANTS: Twenty-two participants (10 colorectal cancer survivors and 12 from a comparison group) from the North Carolina Strategies for Improving Diet, Exercise, and Screening Study. ANALYSIS: Verbatim interview transcripts were coded and analyzed. Comparisons were made between colorectal cancer survivors and the comparison group. RESULTS: Three main themes emerged: the influence of significant life events on dietary change, concerns about contaminants in the food supply, and a lack of physician guidance in dietary supplement selection. CONCLUSION AND IMPLICATIONS: The experience of colorectal cancer is significant and may lead to dietary change among some survivors, but these findings do not suggest that it is necessarily more influential than other life events. Participants sought to control diet (for coping or survival) and also felt that diet cannot be controlled (due to the contamination of the food supply). Although many lacked guidance from physicians about dietary supplements, they were comfortable making their own decisions to self-treat. Enhanced understanding of the themes that guide selection of diet and dietary supplements can provide a context for dietitians in practice and researchers conducting behavioral interventions.

Recruitment of religious organisations into a community-based health promotion programme.

Programmes concerned with health promotion activities frequently rely on community organisations to deliver health behaviour change interventions. This paper presents data on the recruitment of religious organisations (ROs) into a research project focused on dietary change. The authors contacted the membership list of a local multi-denominational religious umbrella organisation by mail. The recruitment process consisted of a screening survey followed by an informational meeting with RO representatives, with additional meetings as necessary. The ROs were surveyed by telephone, and the initial and follow-up meetings were held at a location convenient to the RO representatives, often the RO's building. For this paper, the unit of analysis is the RO. The ROs approached during the recruitment process were of a variety of faiths and denominations. All were located within the metropolitan area of Seattle, WA, USA. The screening survey was used to determine RO eligibility, and collect further information on the RO and its membership. The survey included questions adapted from previous RO surveys and questions developed by the project team. The recruitment strategy yielded a 26% enrollment rate of eligible ROs. In comparison to eligible ROs, those that did not meet the eligibility criteria were less stable, smaller and had a membership that was less white, less college-educated and more working class. The size of the RO and the number of years that the religious leader had been with the RO were the strongest predictors of the RO's interest in participating in the project. These data will be helpful in recruiting community organisations into health promotion programmes.

Perceived barriers and benefits to colon cancer screening among African Americans in North Carolina: how does perception relate to screening behavior?

This study investigated perceived barriers and benefits, as conceptualized by the Health Belief Model,in relation to screening for colorectal cancer (CRC) among African-American adults participating in a church-based health promotion program. CRC is one of the most common cancers and is the second leading cause of cancer death for men and women. Screening can be effective at detecting cancer at treatable stages, but a large proportion of people at risk have not been screened or are not screened regularly, as recommended by national guidelines. In this study, logistic regression was used to assess the relation of barriers and benefits to self-reported history of fecal occult blood testing (FOBT), flexible sigmoidoscopy, and colonoscopy. Barriers were significantly negatively related to recent FOBT and recent sigmoidoscopy. Benefits were significantly related to having a recent sigmoidoscopy and a recent colonoscopy but not to recent FOBT. Results suggest that the way people perceive sigmoidoscopy and colonoscopy may differ from FOBT with respect to the relative importance of perceived benefits versus barriers. Findings are discussed within the context of these Health Belief Model constructs and implications for health promotion programming.

Body and soul. A dietary intervention conducted through African-American churches.

OBJECTIVES: Body and Soul was a collaborative effort among two research universities, a national voluntary agency (American Cancer Society), and the National Institutes of Health to disseminate and evaluate under real-world conditions the impact of previously developed dietary interventions for African Americans. METHODS: Body and Soul was constructed from two successful research-based interventions conducted in African-American churches. Components deemed essential from the prior interventions were combined, and then tested in a cluster randomized-effectiveness trial. The primary outcome was fruit and vegetable intake measured with two types of food frequency questionnaires at baseline and 6-month follow-up. RESULTS: At the 6-month follow-up, intervention participants showed significantly greater fruit and vegetable (F&V) intake relative to controls. Post-test differences were 0.7 and 1.4 servings for the 2-item and 17-item F&V frequency measures, respectively. Statistically significant positive changes in fat intake, motivation to eat F&V, social support, and efficacy to eat F&V were also observed. CONCLUSIONS: The results suggest that research-based interventions, delivered collaboratively by community volunteers and a health-related voluntary agency, can be effectively implemented under real-world conditions.

Improving multiple behaviors for colorectal cancer prevention among african american church members.

The WATCH (Wellness for African Americans Through Churches) Project was a randomized trial comparing the effectiveness of 2 strategies to promote colorectal cancer preventive behaviors among 587 African American members of 12 rural North Carolina churches. Using a 2 X 2 factorial research design, the authors compared a tailored print and video (TPV) intervention, consisting of 4 individually tailored newsletters and targeted videotapes, with a lay health advisor (LHA) intervention. Results showed that the TPV intervention significantly improved (p <.05) fruit and vegetable consumption (0.6 servings) and recreational physical activity (2.5 metabolic task equivalents per hour) and, among those 50 and older (n = 287), achieved a 15% increase in fecal occult blood testing screening (p =.08). The LHA intervention did not prove effective, possibly because of suboptimal reach and diffusion.

Behavior-specific social support for healthy behaviors among african american church members: applying optimal matching theory.

This study used data from 850 African Americans to test optimal matching theory (OMT). OMT predicts that 1) the most important dimensions of social support depend on the controllability of the behavior and 2) different network members often provide support across health behaviors. Data were gathered on social support source for physical activity, healthy diet, and colorectal cancer (CRC) screening; perceived levels of informational, instrumental, and emotional support specific to these behaviors; self-efficacy around the behaviors; and engagement in the behaviors. Within individuals, the primary support source varied considerably across the behaviors under consideration. Multivariate models regressing behaviors on dimension-specific support indicated partial support for OMT: Informational support was associated with a healthy diet and CRC screening; instrumental support was associated with a healthy diet and CRC screening; and emotional support was associated with CRC screening and, among women, physical activity. Implications of the findings are discussed in terms of developing more effective interventions.

Disaster down East: using participatory action research to explore intimate partner violence in eastern North Carolina.

In the aftermath of Hurricane Floyd in 1999, a Community Advisory Committee requested assistance from its university partners (University of North Carolina) to address stress and increased risk for intimate partner violence (IPV). Collected from 12 study work sites, baseline data indicated that IPV rates were higher among blue-collar women in eastern North Carolina than national population-based rates suggest. IPV victims reported higher levels of perceived stress, psychological distress, somatic complaints, and post-traumatic stress disorder (PTSD) symptoms than did nonvictimized coworkers. As for the relationship of the flood to IPV, no significant increase in IPV incidence occurred after the flood. Regardless of their flood experience, however, IPV victims consistently reported greater stress, PTSD symptoms, and somatic and psychological problems. Moreover, IPV victims may be at higher risk for stress-mediated chronic illnesses and for using negative coping behaviors. This study uses an established trusting relationship between researchers and community members to explore community needs and inform intervention design.

Mediation of adult fruit and vegetable consumption in the National 5 A Day for Better Health community studies.

BACKGROUND: The 5 A Day for Better Health community studies demonstrated in randomized trials the efficacy of population-based strategies to increase fruit and vegetable consumption in diverse geographic areas and settings. PURPOSE: Mediation analysis can help to elucidate the theoretical basis of changing dietary habits. This is important for informing more powerful cancer prevention and control interventions to achieve broad public health impact. METHODS: Five sites that focused on adults were included in mediation analyses to determine whether theoretically derived constructs assessed at baseline and follow-up contributed to explaining change in fruit and vegetable (F&V) consumption. These variables were knowledge, self-efficacy, and autonomy/responsibility. Stage of change also was considered as a potential moderating variable. RESULTS: Self-efficacy and knowledge of the 5 A Day recommendation increased in those who received the interventions and were positively associated with higher F&V. Mediation of intervention effect was demonstrated for these variables. Autonomy/responsibility did not meet the criteria for mediation. There was no evidence of differential effect of mediators according to baseline stage. CONCLUSIONS: The present study findings provide strong support for mediation of F&V consumption by two variables: self-efficacy and knowledge. The authors discuss the findings in relation to study limitations and future research directions.

Church-based health promotion interventions: evidence and lessons learned.

Church-based health promotion (CBHP) interventions can reach broad populations and have great potential for reducing health disparities. From a socioecological perspective, churches and other religious organizations can influence members' behaviors at multiple levels of change. Formative research is essential to determine appropriate strategies and messages for diverse groups and denominations. A collaborative partnership approach utilizing principles of community-based participatory research, and involving churches in program design and delivery, is essential for recruitment, participation, and sustainability. For African Americans, health interventions that incorporate spiritual and cultural contextualization have been effective. Evidence indicates that CBHP programs have produced significant impacts on a variety of health behaviors. Key elements of CBHP are described with illustrations from the authors' research projects.

Facilitators and barriers to adoption of evidence-based perinatal care in Latin American hospitals: a qualitative study.

Selective episiotomy and the active management of labor have been shown by numerous studies to benefit women's experience of labor as well as its outcomes. However, many Latin American public hospitals have not updated their clinical practices to reflect these findings. Limited access to new knowledge, limited time and physical resources and attitudes resistant to change are factors limiting the adoption of new practices in such hospitals. Interviews were conducted with three department heads, and focus groups were conducted with 31 physicians and midwives working in 10 public hospitals in Argentina and Uruguay. All were asked about facilitators and barriers to making changes in clinical practice. In addition, three focus groups were conducted with 16 pregnant women served by public hospitals. Responses were grouped according to stages of change in incorporating new evidence into practice. Numerous facilitators and barriers were identified by participants, as well as potential strategies for promoting change that could be incorporated into interventions. Barriers included limited access to information, negative attitudes toward changes in practice, lack of skills in performing new practices, lack of medical resources and explicit guidelines and a perceived need to practice defensive medicine. Changing long-standing clinical practice is difficult. Interventions must be adapted to translate evidence-based approaches to new cultures and contexts. Improving information access, use of role models, skill development and improved resources and support may be effective ways to overcome barriers to change in Latin American obstetric care.

The influence of health behavior clusters on dietary change.

BACKGROUND: The goal of this study was to identify cancer preventive health behavior clusters and to determine if clusters responded differently to a year-long intervention to increase fruit and vegetable consumption. METHODS: The North Carolina Strategies for Improving Diet, Exercise, and Screening (NC STRIDES) is a health communications intervention (n = 595) among colorectal cancer survivors and a comparison population. Cluster analysis was used to identify nonoverlapping groups based on fruit and vegetable intake (servings/day), physical activity (minutes/day), multivitamin use (yes/no), and body mass index (kg/m2). Logistic regression was performed to assess positive change in fruit and vegetable servings, using the healthiest cluster as the reference group. RESULTS: Five clusters were formed; they differed significantly by health behaviors and demographics. Clusters 1 and 2 (those following the "Healthy Choices" and "Eating Well" patterns) were eating more than 5 A Day before the intervention (8.6 and 6.9 servings/day), and did not show any increase. Cluster 3 ("Physically Active") reported an increase of 1.3 servings/day to reach 5.4 servings/day, and Clusters 4 and 5 ("Average Americans" and "Most Challenged") improved one serving/day for final intakes of 5.2 and 5.0 servings/day. CONCLUSIONS: These findings illustrate some differences in magnitude of response to a fruit and vegetable intervention based on health behavior profiles. Creating clusters or other categories from baseline health behaviors may help to further improve targeting and/or tailoring in health promotion interventions.

Effects of a tailored health promotion program for female blue-collar workers: health works for women.

BACKGROUND: This study assessed the effects of the Health Works for Women (HWW) intervention on improving multiple behaviors including nutrition and physical activity among rural female blue-collar employees in North Carolina. METHODS: Nine small to mid-size workplaces were randomly assigned to either intervention or delayed intervention conditions. After a baseline survey, an intervention consisting of two computer-tailored magazines and a natural helpers program was conducted over 18 months. Delayed worksites received one tailored magazine. Approximately 77 and 76% of baseline respondents completed follow-up surveys at 6 and 18 months, respectively, and 538 women (63%) completed all three surveys. RESULTS: At the 18-month follow-up, the intervention group had increased fruit and vegetable consumption by 0.7 daily servings compared to no change in the delayed group (P < 0.05). Significant differences in fat intake were observed at 6 months (P < 0.05) but not at 18 months. The intervention group also demonstrated improvements in strengthening and flexibility exercise compared to the delayed group. The rates of smoking cessation and cancer screening did not differ between study groups. CONCLUSIONS: The HWW project was a successful model for achieving certain health behavior changes among blue-collar women.