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Abstract Background Strong Hearts, Healthy Communities 2.0 (SHHC-2.0) was a 24-week cardiovascular disease prevention program that was effective in improving physical activity and nutrition behaviors and clinical outcomes among women in 11 rural New York, USA towns. This study evaluated the delivery of SHHC-2.0 to prepare the intervention for further dissemination. Methods This process evaluation was guided by the Medical Research Council recommendations and engaged program leaders and participants (i.e., women over age 40) using quantitative and qualitative methods. The quantitative evaluation included examination of enrollment and retention data, a participant survey, and a fidelity checklist completed after classes. Descriptive and comparative statistics were used to assess implementation measures: program reach, participant attendance, dose delivered, program length, perceived effectiveness, fidelity, and participant satisfaction. The qualitative evaluation included focus groups (n = 13) and interviews (n = 4) using semi-structured guides; audio was recorded and transcripts were deductively coded and analyzed using directed content analysis and iterative categorization approaches. Comparisons across towns and between intervention and waitlist control groups were explored. Results Average reach within towns was 7.5% of the eligible population (range 0.7-15.7%). Average attendance was 59.8% of sessions (range 42.0-77.4%). Average dose delivered by leaders was 86.4% of curriculum components (range 73.5-95.2%). Average session length was 51.8 ± 4.8 min across 48 sessions. Leaders’ perceived effectiveness rating averaged 4.1 ± 0.3 out of 5. Fidelity to curricular components was 81.8% (range 67.4-93.2%). Participants reported being “more than satisfied” with the overall program (88.8%) and the health benefits they obtained (72.9%). Qualitative analysis revealed that participants: (1) gained new knowledge and enjoyable experiences; (2) perceived improvements in their physical activity, nutrition, and/or health; (3) continued to face some barriers to physical activity and healthy eating, with those relating to social support being reduced; and (4) rated leaders and the group structure highly, with mixed opinions on the research elements. Conclusions SHHC-2.0 had broad reach, was largely delivered as intended, and participants expressed high levels of satisfaction with the program and its health benefits. Our findings expand on best practices for implementing cardiovascular disease prevention programs in rural communities. Clinical trials Registration www.clinicaltrials.gov #NCT03059472.

Abstract This study aims to explore the perspectives of community leaders (CL) on trusted sources of health information, examine their roles, challenges, and needs in disseminating COVID-19 health information, and identify opportunities to improve public health reach and access for underserved communities. This qualitative study included seven focus groups conducted via online video conferencing from April-June 2021. The participants (n = 9) were CL recruited from the Texas Community Engagement Alliance (CEAL) for their experience working with underserved communities in Dallas, Texas. Data were coded deductively and analyzed thematically. The analysis resulted in three themes: (1) Information fatigue, mistrust, and desensitization were experienced by community members and leaders; (2) CL were expected to process, verify, and share accurate and timely COVID-19 health information; (3) CL identified potential strategies to improve COVID-19 health info access and reach. CLs were critical in addressing mis/disinformation and fostering trust in public health communication, particularly in underserved communities. They acted as vital intermediaries for health information, striving to debunk mis/disinformation and disseminate accurate health information. Public health strategies could benefit from prioritizing the integration of CL in communicating health information during crises and rebuilding trust within historically and racially marginalized and underserved communities. Supporting CLs, for example, through resources and training programs to counter misinformation and provide access to culturally and linguistically tailored health resources, may significantly enhance the access and reach of evidence-based health communication during health crises.

Abstract Introduction Healthy School Recognized Campus (HSRC) is a Texas A&M AgriLife Extension initiative that promotes the delivery of multiple evidence-based physical activity and nutrition programs in schools. Simultaneous delivery of programs as part of HSRC can result in critical implementation challenges. The study examines how the inner setting constructs from the Consolidated Framework for Implementation Research (CFIR) impact HSRC program delivery. Methods We surveyed (n = 26) and interviewed (n = 20) HSRC implementers (n = 28) to identify CFIR inner setting constructs related to program acceptability, appropriateness, and feasibility. Using a concurrent mixed-methods design, we coded interviews using the CFIR codebook, administered an inner setting survey, tested for relationships between constructs and implementation outcomes via chi-square tests, and compared quantitative and qualitative results. Results Stakeholders at schools that implemented one program vs. more than one program reported no differences in acceptability, appropriateness, or feasibility outcomes (p > .05); however, there was a substantial difference in reported program minutes (1118.4 ± 951.5 vs. 2674.5 ± 1940.8; p = .036). Available resources and leadership engagement were related to HSRC acceptability (r = .41; p = .038 and r = .48; p = .012, respectively) and appropriateness (r = .39; p = .046 and r = 0.63; p = .001, respectively). Qualitative analyses revealed that tangible resources (e.g., curriculum, a garden) enabled implementation, whereas intangible resources (e.g., lack of time) hindered implementation. Participants also stressed the value of buy-in from many different stakeholders. Quantitative results revealed that implementation climate was related to HSRC acceptability (r = .46; p = .018), appropriateness (r = .50; p = .009), and feasibility (r = .55; p = .004). Learning climate was related to HSRC appropriateness (r = .50; p = .009). However, qualitative assessment of implementation climate subconstructs showed mixed perspectives about their relationship with implementation, possibly due to differences in the compatibility/priority of different programs following COVID-19. Networks/communication analysis showed that schools have inner and outer circles of communication that can either benefit or hinder implementation. Conclusion Few differences were found by the number of programs delivered. Implementation climate (i.e., compatibility, priority) and readiness for implementation (i.e., resources and leadership engagement) were important to HSRC implementation. Strategies that focus on reducing time-related burdens and engaging stakeholders may support HSRC’s delivery. Other constructs (e.g., communication, access to knowledge) may be important to the implementation of HSRC but need further exploration.

Abstract Background In the United States, cardiovascular diseases (CVD) are the leading cause of death and disability in women. CVD-modifiable risk factors, including poor diet quality and inadequate physical activity, can be addressed through evidence-based interventions (EBIs). Strong Hearts Healthy Communities (SHHC) is an EBI that has demonstrated effectiveness in reducing CVD risk and improving health outcomes among rural white women. The aims of this study were to understand the general health, diet, and physical activity-related needs and goals of women living in an urban community, to inform the tailoring and adaptation of the SHHC EBI to an urban setting and more diverse population. Methods Focus groups (FGs) were conducted with African American/Black and Hispanic/Latinx women in the Dallas metropolitan area who had a BMI ≥ 25 kg/m2 and engaged in ≤ 150 min per week of moderate physical activity. The data were coded using a team-based, deductive, and thematic analysis approach, that included multiple coders and in-depth discussions. Results Four FGs with a total of 18 participants (79% Black and 21% Latinx) were conducted, and three themes were developed: (1) participants had adequate knowledge and positive attitudes towards healthy living but faced many barriers to practicing healthy behaviors; (2) culturally-based beliefs and community practices exerted a strong influence on behaviors related to food and stress, revealing barriers to healthy eating and generational differences in stress and stress management; (3) participants desired a more individualized approach to nutrition and physical activity interventions that included familiar and enjoyable activities and social support centered around shared health goals. Conclusions The SHHC intervention and similar health programs for Black/African American and Hispanic/Latinx women in urban settings should emphasize individualized nutrition and practical skills for healthy eating with accessible, familiar, and enjoyable exercises. Additionally, stress management strategies should be culturally and generationally sensitive and social support, whether through family, friends, or other program participants, should be based on shared health goals.

Abstract Background The food system has a dynamic influence on disparities in food security and diet-related chronic disease. Community supported agriculture (CSA) programs, in which households receive weekly shares of produce from a local farmer during the growing season, have been examined as a possible food systems-based approach for improving diet and health outcomes. The purpose of this study was to estimate the cost of implementing and participating in a multi-component subsidized community supported agriculture intervention and calculate cost-effectiveness based on diet and food security impacts. Methods Using data from the Farm Fresh Foods for Healthy Kids (F3HK) randomized controlled trial in New York, North Carolina, Vermont, and Washington (n = 305; 2016–2018), we estimated programmatic and participant costs and calculated incremental cost-effectiveness ratios (ICERs) for caregivers’ daily fruit and vegetable (FV) intake, skin carotenoids, and household food security from program and societal perspectives. Results F3HK cost $2,439 per household annually ($1,884 in implementation-related expenses and $555 in participant-incurred costs). ICERs ranged from $1,507 to $2,439 per cup increase in caregiver’s FV intake (depending on perspective, setting, and inclusion of juice); from $502 to $739 per one thousand unit increase in skin carotenoid score; and from $2,271 to $3,137 per household shifted out of food insecurity. Conclusions Given the known public health, healthcare, and economic consequences of insufficient FV intake and living in a food insecure household, the costs incurred to support these positive shifts in individual- and household-level outcomes via a F3HK-like intervention may be deemed by stakeholders as a reasonable investment. This work helps to advance a critical body of literature on the cost-effectiveness of subsidized CSAs and other economic and food system interventions for the sake of evidence-based allocation of public health resources. Trial registration : ClinicalTrials.gov. NCT02770196. Registered 5 April 2016. Retrospectively registered. https://www.clinicaltrials.gov/ct2/show/NCT02770196 .

Higher rates of obesity in rural compared to urban districts suggest environmental differences that affect student health. This study examined urban–rural differences in districts’ local wellness policies (LWPs) and LWP implementation environments. Cross-sectional data from two assessments in Texas were analyzed. In assessment one, each district’s LWP was reviewed to see if 16 goals were included. In assessment two, an audit was conducted to identify the presence of a wellness plan (a document with recommendations for implementing LWPs), triennial LWP assessment, and school health advisory councils (SHACs) on the district website. Rural districts’ LWPs had a smaller number of total goals (B = −2.281, p = 0.014), nutrition education goals (B = −0.654, p = 0.005), and other school-based activity goals (B = −0.675, p = 0.001) in their LWPs, compared to urban districts. Rural districts also had lower odds of having a wellness plan (OR = 0.520, 95% CI = 0.288–0.939), p = 0.030) and a SHAC (OR = 0.201, 95% CI = 0.113–0.357, p < 0.001) to support LWP implementation, compared to urban districts. More resources may be needed to create effective SHACs that can help develop and implement LWPs in rural areas. Important urban–rural differences exist in Texas LWPs and LWP implementation environments.

Abstract Background Physical inactivity is a risk factor for numerous adverse health conditions and outcomes, including all-cause mortality. Aging rural women are at particular risk for physical inactivity based on environmental, sociocultural, and psychosocial factors. This study reports on changes in physical activity and associated factors from a multicomponent community-engaged intervention trial. Methods Strong Hearts, Healthy Communities 2.0 (SHHC-2.0) was a 24-week cluster (community) randomized controlled trial building on the results from the previous trial of SHHC-1.0. Rural women (n = 182) aged 40 and over living in 11 rural communities in upstate New York were recruited. The intervention consisted of twice-weekly experiential classes focused on exercise, nutrition, and civic engagement. Physical activity outcomes included accelerometry and self-report as well as related psychosocial measures at midpoint (12 weeks) and post-intervention (24 weeks). Data were analyzed using multilevel linear regression models with the community as the random effect. Results Compared to participants from the control communities, participants in the intervention communities showed a significant increase in objectively measured moderate to vigorous intensity physical activity: at 12 weeks (increase of 8.1 min per day, P

Abstract Background Prior studies demonstrate associations between risk factors for obesity and related chronic diseases (e.g., cardiovascular disease) and features of the built environment. This is particularly true for rural populations, who have higher rates of obesity, cancer, and other chronic diseases than urban residents. There is also evidence linking health behaviors and outcomes to social factors such as social support, opposition, and norms. Thus, overlapping social networks that have a high degree of social capital and community cohesion, such as those found in rural communities, may be effective targets for introducing and maintaining healthy behaviors. Methods This study will evaluate the effectiveness of the Change Club (CC) intervention, a civic engagement intervention for built environment change to improve health behaviors and outcomes for residents of rural communities. The CC intervention provides small groups of community residents (approximately 10–14 people) with nutrition and physical activity lessons and stepwise built environment change planning workshops delivered by trained extension educators via in-person, virtual, or hybrid methods. We will conduct process, multilevel outcome, and cost evaluations of implementation of the CC intervention in a cluster randomized controlled trial in 10 communities across two states using a two-arm parallel design. Change in the primary outcome, American Heart Association’s Life’s Simple 7 composite cardiovascular health score, will be evaluated among CC members, their friends and family members, and other community residents and compared to comparable samples in control communities. We will also evaluate changes at the social/collective level (e.g., social cohesion, social trust) and examine costs as well as barriers and facilitators to implementation. Discussion Our central hypothesis is the CC intervention will improve health behaviors and outcomes among engaged citizens and their family and friends within 24 months. Furthermore, we hypothesize that positive changes will catalyze critical steps in the pathway to improving longer-term health among community residents through improved healthy eating and physical activity opportunities. This study also represents a unique opportunity to evaluate process and cost-related data, which will provide key insights into the viability of this approach for widespread dissemination. Trial registration ClinicalTrials.gov: NCT05002660 , Registered 12 August 2021.

The built environment can influence physical activity behavior. Walk Score is a widely used measure of the neighborhood built environment to support walking. However, studies of the association between Walk Score and accelerometer-measured physical activity are equivocal and no studies have examined this relationship among older adults. We analyzed data from a large, diverse sample of women (n = 5650) with a mean age of 79.5 (SD = 6.7) at time of accelerometry wear in the Women’s Health Initiative Objective Physical Activity Cardiovascular Health Study in the United States to examine associations between neighborhood Street Smart Walk Score (SSWS) and accelerometer-measured physical activity. Participants wore triaxial accelerometers for seven days and SSWS was determined from home addresses. 67 % of the sample lived in “car-dependent” locations (SSWS 0–49 out of 100); only 3 % lived in “walker’s paradise” locations (SSWS 90–100). The multivariable model indicated an association between SSWS and accelerometer-measured physical activity (steps/day) in the total sample. The association varied by neighborhood socioeconomic status; in high socioeconomic status neighborhoods, higher SWSS was associated with greater steps per day, while no significant association between SWSS and physical activity was observed in low socioeconomic neighborhoods. This study should catalyze furtherresearch regarding the utility of SSWS in determining neighborhood walkability for older women across different neighborhood settings and suggests other built environment factors must be considered when determining walkability. Future studies should examine what factors influence walkability and develop age-relevant methods to assess and characterize neighborhood walkability.

Abstract Background Adults and children in the U.S. consume inadequate quantities of fruit and vegetables (FV), in part, due to poor access among households with lower socioeconomic status. One approach to improving access to FV is community supported agriculture (CSA) in which households purchase a ‘share’ of local farm produce throughout the growing season. This study examined the effects of cost-offset (half-price) CSA plus tailored nutrition education for low-income households with children. Methods The Farm Fresh Foods for Healthy Kids (F3HK) randomized controlled trial in New York, North Carolina, Vermont, and Washington (2016–2018) assigned caregiver-child dyads (n = 305) into cost-offset CSA plus education intervention or control (delayed intervention) groups. Following one growing season of CSA participation, changes in children’s diet quality, body mass index (BMI), and physical activity; caregivers’ nutrition knowledge, attitudes, behaviors, and diet quality; and household food access and security were examined using multiple linear or logistic regression, with adjustment for baseline value within an intent-to-treat (ITT) framework in which missing data were multiply imputed. Results No significant net effects on children’s dietary intake, BMI, or physical activity were observed. Statistically significant net improvements were observed after one growing season for caregivers’ cooking attitudes, skills, and self-efficacy; FV intake and skin carotenoid levels; and household food security. Changes in attitudes and self-efficacy remained one-year after baseline, but improvements in caregiver diet and household food security did not. The number of weeks that participants picked up a CSA share (but not number of education sessions attended) was associated with improvements in caregiver FV intake and household food security. Conclusions Cost-offset CSA plus tailored nutrition education for low-income households improved important caregiver and household outcomes within just one season of participation; most notably, both self-reported and objectively measured caregiver FV intake and household food security improved. Households that picked up more shares also reported larger improvements. However, these changes were not maintained after the CSA season ended. These results suggest that cost-offset CSA is a viable approach to improving adult, but not child, FV intake and household food security for low-income families, but the seasonality of most CSAs may limit their potential to improve year-round dietary behavior and food security. Trial registration ClinicalTrials.gov . NCT02770196 . Registered 5 April 2016. Retrospectively registered.

The coronavirus disease 2019 (COVID-19) pandemic requires urgent implementation of effective community-engaged strategies to enhance education, awareness, and inclusion of underserved communities in prevention, mitigation, and treatment efforts. The Texas Community-Engagement Alliance Consortium was established with support from the United States’ National Institutes of Health (NIH) to conduct community-engaged projects in selected geographic locations with a high proportion of medically underserved minority groups with a disproportionate burden of COVID-19 disease and hospitalizations. The purpose of this paper is to describe the development of the Consortium. The Consortium organized seven projects with focused activities to address COVID-19 clinical and vaccine trials in highly affected counties, as well as critical statewide efforts. Five Texas counties (Bexar, Dallas, Harris, Hidalgo, and Tarrant) were chosen by NIH because of high concentrations of underserved minority communities, existing community infrastructure, ongoing efforts against COVID-19, and disproportionate burden of COVID-19. Policies and practices can contribute to disparities in COVID-19 risk, morbidity, and mortality. Community engagement is an essential element for effective public health strategies in medically underserved minority areas. Working with partners, the Consortium will use community engagement strategies to address COVID-19 disparities.

Post-secondary coursework related to agriculture and the food supply has been at the core of the United States' land-grant system for more than 150 years. However, as the complexity of food systems has grown, so too have critiques that the education provided in these programs is too narrow to adequately prepare graduates to address pressing food systems issues. In response, some higher education institutions have developed degrees in food systems. To support development of this burgeoning field, we created, tested, and refined four evidence-informed, interdisciplinary, equity-oriented, open-access teaching modules. These modules are based on our experience conducting a multi-site, multi-year transdisciplinary investigation of subsidized, or “cost-offset”, community supported agriculture and a survey asking instructors at land-grant institutions (n = 66) about topic offerings and current unmet needs for instructional materials. Our collaboration illuminated the potential and challenges of food systems research; underscored the value of transdisciplinary research teams; and identified several equity-oriented topics related to the design, implementation, and evaluation of local food initiatives suitable for advancing sustainable foods systems education. Instructors reported that the most helpful teaching aids would be case studies, lesson plans with active learning components, and reference lists with relevant peer-reviewed publications. The final modules seek to shed light on the complexity of food systems projects and build knowledge, vocabularies, and skills across disciplines engaged with food systems. Per instructor-defined needs, each module features a case study, active-learning activities, and references. We anticipate that the adaptable modules will be suitable for a wide range of students and courses.

Rural communities are at higher risk for physical inactivity, poor dietary behaviors, and related chronic diseases and obesity. These disparities are largely driven by built environment, socioeconomic, and social factors. A community-based cluster randomized controlled trial of an intervention, the Change Club, aims to address some of these disparities via civic engagement for built environment change. Baseline data collection began in February 2020, only to be paused by the COVID-19 pandemic. In this context, the investigators evaluated multiple approaches for collecting data when the study resumed, focusing on Life’s Simple 7, and additional anthropometric, physiologic, and behavioral outcomes in rural and micropolitan (

Abstract Background Accurate assessment of fruit and vegetable intake (FVI) is essential for public health nutrition research and surveillance. Blood carotenoid concentrations are robust biomarkers of FVI, but collecting blood samples typically is not feasible in population-based studies. Understanding how well non-invasive measures compare to blood estimates is important for advancing surveillance and evaluation. The objective of this study was to examine the associations between serum carotenoids and four non-invasive measures of FVI in overweight and obese women. Methods This study utilized baseline data from 157 overweight or obese women (95.5% white, mean age 58.56 years ± 9.49 years) enrolled in the Strong Hearts, Healthy Communities randomized trial, including two direct measures of carotenoids and three self-reported measures of FVI. Participants completed a fasting blood draw, dermal carotenoid scans using resonance Raman spectroscopy (RRS), a two-item FVI screener modeled after the American Heart Association’s Life’s Simple 7 “My Life Check” tool (modified AHA tool), the National Cancer Institute’s All-Day Fruit and Vegetable Screener (FVS), multiple 24-h dietary recalls, physical measurements, and demographic and health behavior questions. We analyzed blood for total carotenoids and derived total FVI estimates from self-report tools. We used multivariate linear regression models to examine associations between each non-invasive tool and serum carotenoids under four scenarios analogous to different research contexts in which varying breadths of participant data are available. We also calculated adjusted Pearson’s correlations between serum carotenoids, dermal carotenoids, and the self-reported measures. Results Dermal carotenoids were strongly correlated with serum carotenoids (0.71, P

Abstract Background Women living in rural areas face unique challenges in achieving a heart-healthy lifestyle that are related to multiple levels of the social-ecological framework. The purpose of this study was to evaluate changes in diet and physical activity, which are secondary outcomes of a community-based, multilevel cardiovascular disease risk reduction intervention designed for women in rural communities. Methods Strong Hearts, Healthy Communities was a six-month, community-randomized trial conducted in 16 rural towns in Montana and New York, USA. Sedentary women aged 40 and older with overweight and obesity were recruited. Intervention participants (eight towns) attended twice weekly exercise and nutrition classes for 24 weeks (48 total). Individual-level components included aerobic exercise, progressive strength training, and healthy eating practices; a civic engagement component was designed to address social and built environment factors to support healthy lifestyles. The control group (eight towns) attended didactic healthy lifestyle classes monthly (six total). Dietary and physical activity data were collected at baseline and post-intervention. Dietary data were collected using automated self-administered 24-h dietary recalls, and physical activity data were collected by accelerometry and self-report. Data were analyzed using multilevel linear regression models with town as a random effect. Results At baseline, both groups fell short of meeting many recommendations for cardiovascular health. Compared to the control group, the intervention group realized significant improvements in intake of fruit and vegetables combined (difference: 0.6 cup equivalents per day, 95% CI 0.1 to 1.1, p = .026) and in vegetables alone (difference: 0.3 cup equivalents per day, 95% CI 0.1 to 0.6, p = .016). For physical activity, there were no statistically significant between-group differences based on accelerometry. By self-report, the intervention group experienced a greater increase in walking MET minutes per week (difference: 113.5 MET-minutes per week, 95% CI 12.8 to 214.2, p = .027). Conclusions Between-group differences in dietary and physical activity behaviors measured in this study were minimal. Future studies should consider how to bolster behavioral outcomes in rural settings and may also continue to explore the value of components designed to enact social and environmental change. Trial registration clinicaltrials.gov Identifier: NCT02499731. Registered 16 July 2015.

Abstract Background Rural women experience health disparities in terms of cardiovascular disease (CVD) risk compared to urban women. Cost-effective CVD-prevention programs are needed for this population. The objective of this study was to conduct cost analysis and cost-effectiveness analyses (CEAs) of the Strong Hearts, Healthy Communities (SHHC) program compared to a control program in terms of change in CVD risk factors, including body weight and quality-adjusted life years (QALYs). Methods Sixteen medically underserved rural towns in Montana and New York were randomly assigned to SHHC, a six-month twice-weekly experiential learning lifestyle program focused predominantly on diet and physical activity behaviors (n = 101), or a monthly healthy lifestyle education-only control program (n = 93). Females who were sedentary, overweight or obese, and aged 40 years or older were enrolled. The cost analysis calculated the total and per participant resource costs as well as participants’ costs for the SHHC and control programs. In the intermediate health outcomes CEAs, the incremental costs were compared to the incremental changes in the outcomes. The QALY CEA compares the incremental costs and effectiveness of a national SHHC intervention for a hypothetical cohort of 2.2 million women compared to the status quo alternative. Results The resource cost of SHHC was $775 per participant. The incremental cost-effectiveness ratios from the payer’s perspective was $360 per kg of weight loss. Over a 10-year time horizon, to avert per QALY lost SHHC is estimated to cost $238,271 from the societal perspective, but only $62,646 from the healthcare sector perspective. Probabilistic sensitivity analyses show considerable uncertainty in the estimated incremental cost-effectiveness ratios. Conclusions A national SHHC intervention is likely to be cost-effective at willingness-to-pay thresholds based on guidelines for federal regulatory impact analysis, but may not be at commonly used lower threshold values. However, it is possible that program costs in rural areas are higher than previously studied programs in more urban areas, due to a lack of staff and physical activity resources as well as availability for partnerships with existing organizations. Trial registration ClinicalTrials.gov identifier NCT02499731, registered on July 16, 2015.

The Farmers’ Market Nutrition Program (FMNP) in the U.S. provides coupons for the purchase of fruit and vegetables (FV) to pregnant women and children enrolled in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), and to income-eligible adults 60+ years of age. The New York State FMNP Education Event Guide was developed to support cooperative extension educators in providing information, food tastings, and cooking demonstrations at farmers’ markets (FM) to encourage consumption of FV. This paper describes implementation at seven FM in New York City, and shopping and eating behaviors in a cross-sectional survey of FM shoppers (n = 377). Three of nine lessons were implemented more than once, typically with food sampling (78.9%). FM shoppers were primarily women (81.5%), racially diverse (30.5% Black, 23.1% White), frequent shoppers (2.4 times/month), and had high FV consumption (2.24 cups fruit; 2.44 cups vegetables daily). Most FM shoppers participated in the FM education event (84%), and participants and non-participants had equivalent shopping and eating behaviors. More than 70% of FM education participants believed that the event positively impacted their knowledge, self-efficacy, and behavioral intentions. FMNP education events at FM were broadly accepted by FM shoppers of all characteristics, and may improve knowledge, self-efficacy, and behavioral intention.

Abstract Objective To describe our use of intervention mapping as a systematic method to adapt an evidence-based physical activity and nutrition program to reflect the needs of rural Latinas. Methods An intervention mapping process involving six steps guided the adaptation of an evidence based physical activity and nutrition program, using a community-based participatory research approach. We partnered with a community advisory board of rural Latinas throughout the adaptation process. Results A needs assessment and logic models were used to ascertain which program was the best fit for adaptation. Once identified, we collaborated with one of the developers of the original program (StrongWomen - Healthy Hearts) during the adaptation process. First, essential theoretical methods and program elements were identified, and additional elements were added or adapted. Next, we reviewed and made changes to reflect the community and cultural context of the practical applications, intervention strategies, program curriculum, materials, and participant information. Finally, we planned for the implementation and evaluation of the adapted program, Mujeres Fuertes y Corazones Saludables, within the context of the rural community. A pilot study will be conducted with overweight, sedentary, middle-aged, Spanish-speaking Latinas. Outcome measures will assess change in weight, physical fitness, physical activity, and nutrition behavior. Conclusions The intervention mapping process was feasible and provided a systematic approach to balance fit and fidelity in the adaptation of an evidence-based program. Collaboration with community members ensured that the components of the curriculum that were adapted were culturally appropriate and relevant within the local community context.

Rural populations face unique challenges to physical activity that are largely driven by environmental conditions. However, research on rural built environments and physical activity is limited by a paucity of rural-specific environmental assessment tools. The aim of this paper is to describe the development and testing of a rural assessment tool: Inventories for Community Health Assessment in Rural Towns (iCHART). The iCHART tool was developed in 2013 through a multistep process consisting of an extensive literature search to identify existing tools, an expert panel review, and pilot testing in five rural US communities. Tool items represent rural built environment features that influence active living and physical activity: community design, transportation infrastructure, safety, aesthetics, and recreational facilities. To assess reliability, field testing was performed in 26 rural communities across five states between July and November of 2014. Reliability between the research team and community testers was high among all testing communities (average percent agreement = 77%). Agreement was also high for intra-rater reliability (average kappa = 0.72) and inter-rater reliability (average percent agreement = 84%) among community testers. Findings suggest that the iCHART tool provides a reliable assessment of rural built environment features and can be used to inform the development of contextually-appropriate physical activity opportunities in rural communities.

Abstract Background Childhood obesity persists in the United States and is associated with serious health problems. Higher rates of obesity among children from disadvantaged households may be, in part, attributable to disparities in access to healthy foods such as fruits and vegetables. Community supported agriculture can improve access to and consumption of fresh produce, but the upfront payment structure, logistical barriers, and unfamiliarity with produce items may inhibit participation by low-income families. The aim of this project is to assess the impact of subsidized, or “cost-offset,” community supported agriculture participation coupled with tailored nutrition education for low-income families with children. Methods/design The Farm Fresh Foods for Healthy Kids community-based, randomized intervention trial will build on formative and longitudinal research to examine the impact of cost-offset community supported agriculture on diet and other health behaviors as well as the economic impacts on local economies. The intervention will involve reduced-price community supported agriculture shares which can be paid for on a weekly basis, nine skill-based and seasonally-tailored healthy eating classes, and the provision of basic kitchen tools. Low income families with at least one child aged 2–12 years will be recruited to join existing community supported agriculture programs in New York, North Carolina, Vermont, and Washington. In each program, families will be randomized 1:1 to intervention or delayed intervention groups. Data will be collected at baseline, and in the fall and spring for 3 years. The primary outcomes are children’s intake of fruits and vegetables and foods high in sugar and/or (solid) fat, as well as diet quality; secondary outcomes include physical, behavioral, psychosocial, and environmental variables. Cost-effectiveness and economic impact at the farm and community levels also will be assessed. Discussion This integrated project will provide important information and contribute to the evidence base regarding the use of local agricultural interventions to improve children’s dietary behaviors and weight maintenance. Findings also will inform the development of a toolkit for farmers and education modules related to local food system innovations for undergraduate and graduate students. Trial registration ClinicalTrials.gov NCT02770196 . Registered 5 April 2016.

Abstract Background Despite increased risk for cardiovascular disease (CVD) and related conditions, evaluations of health interventions indicate that Black/African American women are less likely to benefit than their white counterparts and are not as likely to engage in behaviors that reduce CVD risk. The purpose of this study was to test the feasibility and effectiveness of civic engagement as an intervention strategy to address heart health in Black/African American women. Methods Using a quasi-experimental pre-post study design, civic engagement was tested by convening a convenience sample of self-identified Black/African American women, ages 30–70 years, English-speaking, and BMI ≥25.0 (n = 28) into “Change Clubs” in four churches. Feasibility was examined through adherence, satisfaction, retention, and ability of Change Clubs to meet at least 50% of self-identified action steps for community change. Effectiveness data included: dietary intake, measures of physical activity, cardiorespiratory fitness, blood pressure, and anthropometrics. Psychosocial factors hypothesized to serve as the mechanisms by which civic engagement enacts behavior change were also assessed. Results At baseline, the study sample (n = 28) had a mean age of 50.5 y; 53.6% had an associate degree or higher; 60.7% had an income of $35,000 or higher; and 57.4% were employed full time. At the conclusion of the study, all participants were satisfied with the progress of their Change Club and with the overall experience and Change Clubs met their self-identified action steps for community change. The intervention had a significant effect on finish time on the cardiorespiratory fitness test (p

Accurate measurement of fruit and vegetable (FV) intake is important for nutrition surveillance and evaluation of dietary interventions. We compared two tools for reporting FV intake to objective measurement of skin carotenoids among children. FV cups/day was assessed by repeated 24 h dietary recalls (24H FV) and the National Cancer Institute’s All-Day Fruit and Vegetable Screener (NCI FV). Skin carotenoids were measured by repeated resonance Raman spectroscopy (RRS) of the palm. FV cups were regressed on RRS scores in unadjusted, field-based, and research-setting models with covariates feasible in each scenario. Data were baseline values from children aged 2–12 years in low-income households enrolled in a healthy eating randomized trial in four U.S. states (n = 177). Twenty-four-hour FV cups were associated with skin carotenoids in all models (p < 0.001) but NCI FV cups were not. Predicted RRS scores for discrete 24H FV cups provide a guide to interpretation of RRS in children (2 cups FV intake ~36,000 RRS units), with the research-setting scenario generally providing the narrowest prediction range (+/−1924). When self-reported data are required, 24 h recalls are more accurate than NCI FV screener data; and, when limited time, resources, or literacy must be considered, RRS scores can be quickly obtained and easily interpreted.

Abstract Background Rural men are known to have poor health behaviors, which contribute to their elevated burden of cardiometabolic disorders in the United States. Although regular physical activity, healthy eating, and avoiding tobacco can reduce cardiometabolic risk, little is known about how to engage rural men in health promotion programs. To bridge this gap in evidence, we investigate knowledge of modifiable cardiometabolic risk factors among rural men in the western United States, identify their concerns related to heart health and motivation to reduce risk, and explore individual, social, and community-level influences on heart-healthy behaviors, specifically diet, physical activity, and tobacco use. Methods We conducted seven focus groups with 54 sedentary, overweight/obese men (mean body mass index [BMI] = 31.3 ± 4.6) aged 43–88 residing in government-designated “medically underserved” rural Montana towns in September and October 2014. All sessions were audio-recorded and transcribed verbatim. Transcripts were coded and analyzed thematically using Nvivo software. Participants also completed a brief questionnaire about personal characteristics and health behaviors. These data were explored descriptively. Results Despite being classified as overweight/obese and sedentary, no participants reported to be in poor health. Many men described health relative to self-reliance and the ability to participate in outdoor recreation; concern with health appeared to be related to age. Participants were generally knowledgeable of heart-healthy behaviors, but many felt fatalistic about their own risk. Catalysts for behavior change included a serious medical event in the household and desire to reduce aging-associated functional decline. Barriers to adopting and maintaining healthy eating and physical activity habits and abstaining from tobacco included normative beliefs around masculinity and individual liberty, the limited social universe of small towns, winter weather, time constraints, and preferences for unhealthy foods. Facilitators included behavioral self-monitoring, exercising with a partner, and opportunities for preferred activities, such as hunting and team sports. Conclusions These findings provide important insight about influences on rural men’s health behaviors and provide guidance for possible intervention strategies to promote cardiometabolic health. Trial registration ClinicalTrials.gov NCT02499731 . Registered 1 July 2015.

Innovative programming is needed to improve diets among low-income individuals. Incorporating a healthy food access program within existing Extension community nutrition education programming at the local government level may be an effective approach to improve access and eating behaviors. Program development should be informed by the community nutrition program educators (herein educators) who would implement this type of program. We sought to understand educators’ perspectives as part of a formative evaluation to guide the development of a program pairing reduced price community supported agriculture (CSA) membership with tailored educational programming. Educators from four U.S. states (one southeastern, two northeastern, and one northwestern) participated in in-depth interviews and focus groups. These were audio-recorded with detailed hand-written notes, transcribed verbatim, independently double-coded using a detailed code­book, and analyzed for themes and salient quotes. Feedback was linked with the Diffusion of Innova­tions model and RE-AIM framework. Educators had mostly positive initial thoughts of the pro­posed food access program, suggesting that it would complement current education program­ming. Educators suggested making the CSA shares reasonably priced. They also suggested offering pickup and education classes at a convenient loca­tion. Educators wanted additional training and resources in order to facilitate the program, but thought the existing infrastructure and resources of Extension and local government would help in implementation and sustainability. Local govern­ment priorities should seek to meet educator interests and needs given the potential for more successful program outcomes. These findings could be used to inform the development of food access programming within community nutrition education programs.

Community-supported agriculture (CSA) participation has been associated with high fruit and vegetable (FV) consumption, which may be due to better access to FV for CSA purchasers, or to positive knowledge, attitudes, and beliefs (KAB) regarding healthy eating among CSA applicants. The objective of this study was to examine KAB and consumption, in association with application to a cost-offset CSA (CO-CSA) program, and with CO-CSA purchase among applicants. We conducted a cross-sectional survey of CO-CSA applicants and a comparison sample in August 2017. All respondents were English-reading adults with a child 2−12 years old and household income of ≤185% of the federal poverty level. Among CO-CSA applicants, some were CO-CSA purchasers (n = 46) and some were not (n = 18). An online comparison sample met equivalent eligibility criteria, but had not participated in CSA for three years (n = 105). We compared CO-CSA applicants to the comparison sample, and compared purchasers and non-purchaser sub-groups, using Mann-Whitney U tests and chi-square analysis. CO-CSA applicants reported better knowledge, self-efficacy, home habits, and diet than the comparison sample. Among applicants, CO-CSA purchasers and non-purchasers had equivalent KAB, but children in purchaser households had higher FV consumption than in non-purchaser households (4.14 vs. 1.83 cups, p = 0.001). Future research should explore associations between CO-CSA participation and diet using experimental methods.

This paper examines fruit and vegetable intake (FVI) in low-income households that participated in a cost-offset (CO), or 50% subsidized, community-supported agriculture (CSA) program. CSA customers paid farms upfront for a share of the harvest, and received produce weekly throughout the growing season. A cohort of adults and children 2–12 y in a summer CO-CSA were surveyed online twice: August 2015 (n = 41) and February 2016 (n = 23). FVI was measured by the National Cancer Institute’s (NCI) Fruit and Vegetable Screener (FVS) and an inventory of locally grown fruits and vegetables. FVI relative to United States (US) recommendations and averages, and across seasons, were tested with non-parametric tests and paired t-tests (p < 0.05). Both adults and children in the CO-CSA had higher FVI than the US averages, and more often met recommendations for vegetables. Some summer fruits and vegetables were more often eaten when locally in-season. The CO-CSA model warrants further examination as an avenue for improving vegetable consumption among adults and children in low-income households. However, causality between CO-CSA participation and FVI cannot be inferred, as CO-CSA participants may be positive deviants with respect to FVI. A multi-state randomized controlled trial is currently underway to evaluate impacts of CO-CSAs on FVI and related outcomes.