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Background To determine associations between household motor vehicle ownership and obesity among Indian adults. Methods Bivariate and multivariable analyses were conducted using the 2005–2006 and 2015–2016 Indian Demographic and Health surveys, with over 800 000 respondents. Results Obesity prevalence (body mass index ≥25 kg/m2) rose in females (16.87% to 20.35%) and in males (12.55% to 18.74%). In 2005, having both types of vehicles (motorcycle/motor scooter and car) significantly increased the odds of obesity in females (OR, 1.63; 95% CI 1.50 to 1.76) and males (OR, 2.49; 95% CI 2.24 to 2.77) as well as in 2015 (OR, 1.10; 95% CI 1.07 to 1.13 and OR, 1.56; 95% CI 1.45 to 1.68, respectively). The wealthiest were more likely to be obese in 2005 (OR, 14.95; 95% CI 16.06 to 17.12 for females; OR, 12.69; 95% CI 10.17 to 15.70 for males) and in 2015 (OR, 7.69; 95% CI 7.43 to 7.95 for females and OR, 6.40; 95% CI 5.40 to 7.01 for males). Higher education levels, being younger and rural residence were significant protective factors in 2005 and 2015. Conclusions After adjusting for confounders, motor vehicle ownership was significantly associated with obesity at both time points, but the effect of vehicle ownership presents differently by gender. With obesity prevalence increasing in India, policies promoting active vs motorized transport could attenuate this problem.

Background Workplace violence against healthcare workers is a global issue that is on the rise, with Chinese healthcare workers facing growing challenges with hospital violence. Attacks on medical staff have increased in recent years with no clear resolution. Prior research focused on policies to improve the doctor-patient relationship and better protect clinicians, but few studies addressed the patient perspective. This paper examines patients’ choices when facing a medical dispute and identifies groups who are more likely to respond to conflict with violence or other serious actions. Methods Patient survey responses were collected in 12 leading public hospitals in five Chinese provinces with 5556 participants. The survey asked sociodemographic information, patients’ attitudes (e.g., general optimism, trust in their physicians, perceived healthcare quality), and their primary response to a medical dispute. From least to most severe, the options range from “complaining within the family” to “violence.” We used t-tests and Chi-square tests to explore the relationships between reactions and patient characteristics. We also performed multivariable logistic regressions to determine the impact of sociodemographics and provider trust on the seriousness of responses. Results The primary response of a third of respondents was complaining to hospital or health department officials (32.5%). Seeking legal help (26.3%) and direct negotiation with doctors (19.6%) were other frequent responses. More serious responses included 83 stating violence (1.5%), 9.7% expressing a desire to expose the issue to the news media, and 7.4% resorting to seeking third-party assistance. Patients who were more likely to report “violence” were male (OR = 1.81, p p p p Conclusion Most respondents reported mild reactions when facing a medical dispute. Among those who reported the intent of serious reactions, some sociodemographic characteristics and the trust of physicians could be predictive. To prevent future hospital violence, this work helps identify the characteristics of patients who are more likely to seek severe approaches to medical dispute resolution, including resorting to violence. From these results, hospitals will be better able to target specific groups for interventions that build patient-provider trust and improve general patient satisfaction.

Background The Healthy Hawai‘i Initiative was created in 2000 with tobacco settlement funds as a theory-based statewide effort to promote health-supporting environments through systems and policy change. Still active today, it is imbedded explicitly in a multi-sectoral, social ecological approach, effectively striving to build a culture of health before this was the name for such an ambitious effort. Methods From interviews with key informants, we analyze two decades of the Healthy Hawai‘i Initiative (HHI) in the context of the Robert Wood Johnson Foundation (RWJF) Culture of Health Action Framework (CHAF). We list HHI accomplishments and examine how the Initiative achieved notable policy and environmental changes supportive of population health. Results The Healthy Hawai‘i Initiative started with an elaborate concept-mapping process that resulted in a common vision about making “the healthy choice the easiest choice.” Early on, the Initiative recognized that making health a shared value beyond the initial stakeholders required coalition and capacity building across a broad range of governmental and nonprofit actors. HHI coalitions were designed to promote grassroots mobilization and to link community leaders across sectors, and at their height, included over 500 members across all main islands of the state. Coalitions were particularly important for mobilizing rural communities. Additionally, the Initiative emphasized accessibility to public health data, published research, and evaluation reports, which strengthened the engagement to meet the shared vision and goals between diverse sector partners and HHI. Over the past two decades, HHI has capitalized on relationship building, data sharing, and storytelling to encourage a shared value of health among lawmakers, efforts which are believed to have led to the development of health policy champions. All of these factors combined, which centered on developing health as a shared value, have been fundamental to the success of the other three action areas of the CHAF over time. Conclusions This evidence can provide critical insights for other communities at earlier stages of implementing broad, diverse, multifaceted system change and fills a key evidence gap around building a culture of health from a mature program in a notably multicultural state.

Objective: To develop a core set of capabilities and tasks for local health departments (LHDs) to engage in land use and transportation policy processes that promote active transportation. Design: We conducted a 3-phase modified Delphi study from 2015 to 2017. Setting: We recruited a multidisciplinary national expert panel for key informant interviews by telephone and completion of a 2-step online validation process. Participants: The panel consisted of 58 individuals with expertise in local transportation and policy processes, as well as experience in cross-sector collaboration with public health. Participants represented the disciplines of land use planning, transportation/public works, public health, municipal administration, and active transportation advocacy at the state and local levels. Main Outcome Measures: Key informant interviews elicited initial capabilities and tasks. An online survey solicited rankings of impact and feasibility for capabilities and ratings of importance for associated tasks. Feasibility rankings were used to categorize capabilities according to required resources. Results were presented via second online survey for final input. Results: Ten capabilities were categorized according to required resources. Fewest resources were as follows: (1) collaborate with public officials; (2) serve on land use or transportation board; and (3) review plans, policies, and projects. Moderate resources were as follows: (4) outreach to the community; (5) educate policy makers; (6) participate in plan and policy development; and (7) participate in project development and design review. Most resources were as follows: (8) participate in data and assessment activities; (9) fund dedicated staffing; and (10) provide funding support. Conclusions: These actionable capabilities can guide planning efforts for LHDs of all resource levels., Centers for Disease Control and Prevention (U.S.) (Agreement U48DP005031)

Objectives: The purpose of this study was to test a small-scale intervention and its ability to decrease total sugar intake and number of calories offered at youth sports games. Methods: This study was a pre/post-test quasi-experimental design. A flier was developed and distributed to parents. The flier aimed to decrease the sugar-sweetened beverages and increase the nutritional quality of food brought to games. Baseline data were collected in 2018 (n = 61). The flier was distributed prior to the start of the league, once during the league, and posted online in 2019. Postintervention data were collected in the intervention group (n = 122) and a comparison group (n = 74). Nutritional information was collected through direct observation. Results: The average amount of total sugar provided per game per child was 25.5 g at baseline when snacks/beverages were provided at games. After the intervention, the average amount of total sugar provided significantly decreased (16.7 g/game/child, p &lt, 0.001). Conclusions: The intervention reduced total sugar offered and the number of sugar-sweetened beverages brought to games. It was low-cost and could be easily implemented by public health practitioners and/or parks and recreation administrators. Further, considerations could be made to implement policies relative to snacks and beverages at youth sports games.

Background: Worldwide, tobacco use has caused over 100 million deaths in the twentieth century and is projected to cause death in up to one billion people in the twenty-first century. It is a leading cause of early death and disability in over 100 countries and accounts for over 11% of global deaths, disproportionately affecting low- and middle-income countries. The purpose of the study was to examine a variety of social determinants of tobacco use in the Democratic Republic of the Congo, including region, sex, ethnicity, education, literacy, wealth index and place of residence, to gain insights with regard to tobacco use among sub-national groups. Methods: This project was a secondary data analysis of the 2013-2014 Demographics and Health Survey (DHS) for the Democratic Republic of the Congo. Logistic regressions predicting smoking, use of snuff and smoking cigars or natural tobacco as dichotomous variables were conducted. Independent variables included age, educational level, religion, rurality, literacy, wealth index, occupation and ethnicity. Results: Tobacco use is highest among those with less education and low literacy. It was also highest among the working poor. Older age and living in larger cities were predictive of smoking, although the relationship between age and smoking was not linear. There was a strong linear effect for wealth. Being in a professional, technical or managerial position was highly protective against smoking while being engaged in services, skilled and unskilled manual labor, and the army had significantly greater odds of smoking. Conclusions: Data indicate that tobacco use in the DRC, as is common in the developing world, is heavily concentrated in the working poor with lower educational status. Higher educational status is consistently predictive of avoiding tobacco use. Additionally, examining only national-level data to ascertain tobacco use levels and patterns may lead to mistaken conclusions that can lead to inefficient and ineffective allocation of resources aimed at controlling tobacco use.

Sharing of physical activity spaces is supported by the American Heart Association and other leading public health authorities as one strategy to increase access to physical activity. The purpose of this study was to identify facilities within Pasadena, TX, that currently provide opportunities for active recreation, sport, and other forms of physical activity and analyze community access to these spaces from a geospatial perspective. Geospatial analysis was used to identify physical activity spaces and issues relevant to access. Using a community-based approach, the research team worked with partners to create a list of individuals responsible for each of the physical activity spaces. These “facility administrators” were contacted by email and then phone for a total of four attempts. Respondents were asked to complete an online shared use survey. An asset map was created from both local geospatial data (Pasadena, TX) and data from a facility access and shared use survey. Of the 39 facility administrators, 23 responded to the survey and consisted of the park director, school principals, lead pastors and clergy, and business owners. A total of 53 facilities were identified within the priority zip codes, including 30 parks, 25 schools, 9 faith-based organizations, and 4 others (a business, a nonprofit health care center, and two community-based organizations). Overall, there were 131 total amenities, and playgrounds, outdoor basketball courts, and ball fields were the most common types. Some facilities had multiple amenities at their location, including many of the parks and schools. Additionally, respondents noted other types of amenities where activity took place such as parking lots, grassy areas, classrooms, and other indoor areas. Many of the amenities, 102, were open to the general public and 28 were found to be in good condition. Findings suggest that there is inadequate access to physical activity spaces in this underserved community. There is a need for additional play spaces in Northern Pasadena and for future research bridging community health and geospatial mapping.

Objective: The purpose of this review is to uncover some best practices for increasing access to physical activity opportunities by examining efforts used within low income and diverse communities. The theoretical lens used is from the Active Living by Design (ALbD) Community Action Model, with a focus on the 6 essential practices (health equity focus, community engagement, facilitative leadership, sustainable thinking, culture of learning, and strategic communication) describing how partnerships can guide and sustain meaningful change in a community. Methods: A 2-step process guided the literature search. In step 1, 4 databases (PubMed, Psych INFO, Social Science Citation Index, and Cochrane Library) were searched using Boolean connections and variations in the key terms. Step 2 assessed articles by title, abstract, and full text to determine whether the studies met the inclusion and exclusion criteria guided by Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Additionally, included articles were compared against the 6 essential practices outlined by the ecological framework, ALbD. Results: Of 1775 total articles, 14 studies met inclusion criteria. Most of the studies were case studies located in the United States using several different approaches including, changes in the built environment, implementation of a community-based physical activity program, creating partnerships to leverage resources, and policy change. This review compared the 14 studies against the 6 essential practices of the ALbD model and found 2 studies that met all 6 criteria, and only a few studies meeting more than 2 criteria. Conclusions: Overall, the conclusions are 2-fold, (1) only 14 cases demonstrate success in increasing access to physical activity opportunities, suggesting that more can be done to address inequalities. (2) Of the existing efforts, few utilize crucial components to create a sustainable change in the community. Future research should take into consideration the ALbD ecological framework, the best existing theory for this type of work, to guide the creation and implementation of a sustainable community access effort.

Background:Obesity and lack of physical activity are major public health problems in the United States. Well-designed, active living communities (ALCs) can help support physically active lifestyles. This study assessed attitudes of Hawaii decision makers in 2007 and 2013 to determine if priorities toward ALCs changed. Methods:Elected and appointed state and county officials were mailed surveys both years. Respondents rated the importance of 23 specified problems, which included 1 obesity variable and 5 ALC variables.Results:The survey was completed by 126 (70.4%) respondents in 2007 and 117 (60.9%) in 2013. Among the specific problems, only obesity increased in rank from 14th to ninth place. Three variables fell more than 2 places: increasing traffic (fifth to seventh place), poorly planned development and sprawl (seventh to 11th place) and pedestrian safety (12th to 17th place). The other 2 stayed relatively the same: lack of pedestrian walkways, sidewalks, and crosswalks (16th to 15th place) and lack of recreational activities (22nd to 23rd place).Conclusions:Across years, obesity concerns have increased but do not appear to be tied to increases in concern for ALC variables. More education for policymakers on the link between obesity, physical activity, and the built environment is necessary.

Objective The purpose of this study was to examine primary cesarean delivery rates among women with low risk pregnancies in urban and rural hospitals in Hawaii. Methods This is a retrospective study of all low-risk women (term, vertex, singleton) who had a primary cesarean delivery in any Hawaii hospital from 2010 to 2011 using a statewide health information database. Hospitals were divided into two categories: rural and urban. Results Of the 27,096 women who met criteria for this study, 7105 (26.2 %) delivered in a rural hospital. Low-risk women who delivered in a rural hospital had a primary cesarean delivery rate of 18.5 % compared to 11.8 % in the urban hospitals, p

Introduction Transportation and land-use policies can affect the physical activity of populations. Local health departments (LHDs) are encouraged to participate in built-environment policy processes, which are outside their traditional expertise. Cross-sector collaborations are needed, yet stakeholders’ perceptions of LHD involvement are not well understood. The objective of this study was to describe the perceived value of LHD participation in transportation and land-use decision making and potential contributions to these processes among stakeholders. Methods We analyzed qualitative data from 49 semistructured interviews in 2015. Participants were professionals in 13 US states and 4 disciplines: land-use planning (n = 13), transportation/public works (n = 11), public health (n = 19), and other (municipal administration and bike and pedestrian advocacy [n = 6]). Two analysts conducted directed content analysis. Results All respondents reported that LHDs offer valuable contributions to transportation and land-use policy processes. They identified 7 contributions (interrater agreement 91%): 1) physical activity and health perspective (n = 44), 2) data analysis and assessment (n = 41), 3) partnerships in the community and across sectors (n = 35), 4) public education (n = 27), 5) knowledge of the public health evidence base and best practices (n = 23), 6) resource support (eg, grant writing, technical assistance) (n = 20), and 7) health equity (n = 8). Conclusion LHDs can leverage their strengths to foster cross-sector collaborations that promote physical activity opportunities in communities. Our results will inform development of sustainable capacity-building models for LHD involvement in built-environment decision making.

Context Built environment-focused interventions and policies are recommended as sustainable approaches for promoting physical activity. Physical activity has not traditionally been considered in land use and transportation decision making. Effective collaboration with non-public health partners requires knowledge of their perceived barriers to such consideration. Objective This analysis sought to (a) establish prevalence estimates of selected barriers to the consideration of physical activity in community design and layout decisions and (b) describe how barrier reporting by public health officials differs from other municipal officials among a wide range of job functions and departments in a geographically diverse sample. Design A Web-based survey was conducted among municipal officials in 94 cities and towns with populations of at least 50 000 residents in 8 states. Participants A total of 453 municipal officials from public health, planning, transportation/public works, community and economic development, parks and recreation, city management, and municipal legislatures in 83 cities and towns responded to the survey. Main outcome measures Five barriers to consideration of physical activity in community design and layout were assessed. Results The most common barriers included lack of political will (23.5%), limited staff (20.4%), and lack of collaboration across municipal departments (16.2%). Fewer participants reported opposition from the business community or residents as barriers. Public health department personnel were more likely to report the barriers of limited staff and lack of collaboration across municipal departments than other professionals. They were also more likely to report lack of political will than city managers or mayors and municipal legislators. Conclusions Barriers to increasing consideration of physical activity in decision making about community design and layout are encouragingly low. Implications for public health practice include the need to strategically increase political will despite public health staffing constraints and perceived lack of collaboration with relevant departments such as planning and public works/transportation.

Context Physical activity coalitions are increasingly forming to meet the demands associated with policy, systems, and environmental change necessary to realize increases in population levels of physical activity. Little is known about what makes physical activity coalitions successful; however, evidence from community-based coalitions in other public health domains suggests that factors related to each organization that joins a coalition may explain coalition success or failure. Objective The objective of this study was to employ qualitative methods to understand the factors related to organizations' decisions to join and remain committed to the coalition that developed and launched the US National Physical Activity Plan (NPAP). Design/setting Qualitative semistructured phone interviews were conducted with key informants from the NPAP coalition's partner organizations. Interviews were transcribed verbatim and coded separately by members of the research team. Participants Fourteen individuals representing 13 NPAP partner organizations participated in the study. Main outcome measures Analysis focused on key factors explaining why and how partner organizations decided to join and remain committed to the NPAP coalition. Results Five primary factors emerged: (1) strategic alignment, (2) organizational alignment, (3) provide input, (4) seminal event, and (5) cost/benefit ratio. Conclusions Building and maintaining a physical activity coalition with highly committed partners may hinge upon the ability to fully understand how each current or prospective partner perceives it could benefit from strategic alignment with the coalition, aligning with other organizations involved with the coalition, having input with the coalition's activities, participating in important events and products of the coalition, and realizing more overall advantages than disadvantages for participating in the coalition.

Background With rapid economic development in China, traditional patterns of health behaviors are changing, concurrent with a rise in childhood obesity. While the home environment and parenting behaviors are modifiable factors that could be targeted for intervention, little is known about their relationship with children’s health behaviors. Therefore, the purpose of this study was to investigate the relationship between obesity and home and parenting factors in Chinese children. Methods A cross-sectional survey was conducted in Nanchang, China in 2013 with caregivers (N = 470) of a child between the ages of 2 and 10 years. Regression analyses were conducted to determine risk factors for childhood obesity. Results Obesity prevalence (21.7%) did not differ by demographic variables. Eight physical activity, nutrition, and sedentary variables had significant relationships to obesity status. Logistic regression analysis revealed three significant predictors of obesity: the number of days the family eats meals together (odds ratio = 0.84, 95% CI 0.73–0.96) and parental home computer use time (odds ratio = 0.83, 95% CI 0.72–0.96) were related to lower levels of obesity, while parental television time (odds ratio = 1.25 95% CI 1.07–1.47) was related to higher levels of obesity. Conclusion The prevalence of obesity among children is high in Nanchang. Family and environmental risk factors are significantly related to obesity.

Correspondence avoid surgery in rapidly progressive or chemo-insensitive disease. 4 Genotyping of pancreatic tumours via fine needle aspiration could influence the clinical management of pancreatic cancer. Fine-needle aspiration sequencing was used to identify subgroups of patients with specific actionable mutations related to resectable or locally advanced tumours. 5 In patients with radiologically resectable or borderline resectable tumours, preoperative fine-needle aspiration sequencing could distinguish between patients with a genetic pattern associated with micrometastatic tumours, who should undergo neoadjuvant therapy, and those with a truly localised disease that would be amenable to a surgery-first strategy. Michele Reni has served as a consultant for or on the advisory boards of Celgene, Boehringer-Ingelheim, Lilly, Genentech, Baxalta, Novocure, Astra-Zeneca, Pfizer, and Merck-Serono, and has received honoraria from Celgene. Massimo Falconi has received honoraria from Celgene, Ipsen and Novartis. The other authors declare no competing interests. *Stefano Crippa, Michele Reni, Gianpaolo Balzano, Claudio Doglioni, Massimo Falconi crippa1.stefano@hsr.it Division of Pancreatic Surgery, IRCCS San Raffaele Hospital, Milan, Italy (SC, GB, MF); Medical Oncology Department, IRCCS San Raffaele Hospital , Milan, Italy (MR); Department of Pathology, IRCCS San Raffaele Hospital , Milan, Italy (CD); Clinical and Translational Research Program on Pancreatic Cancer, IRCCS San Raffaele Hospital, Milan, Italy (SC, MR, GB, CD, MF) e178 Barreto SG, Windsor JA. Justifying vein resection with pancreatoduodenectomy. Lancet Oncol 2016; 17: e118–24 Giovinazzo F, Turri G, Katz MH, Heaton N, Ahmed I. Meta-analysis of benefit of portal-superior mesenteric vein resection in pancreatic resection for ductal adenocarcinoma. Br J Surg 2016; 103: 179–91. Bapat AA, Hostetter G, Von Hoff DD, Han H. Perineural invasion and associated pain in pancreatic cancer. Nat Rev Cancer 2011; Sohal DP, Walsh RM, Ramanathan RK, Khorana AA. Pancreatic adenocarcinoma: treating a systemic disease with systemic therapy. J Natl Cancer Inst 2014; 106: dju011 Valero V, Saunders TJ, He J, et al. Reliable detection of somatic mutations in fine needle aspirates of pancreatic cancer with next-generation sequencing: implications for surgical management. Ann Surg 2016; Author’s reply Stefano Crippa and colleagues, in responding to our manuscript, 1 agree that increasing the radicality of surgery for pancreatic ductal adenocarcinoma, including synchronous vein resection, is suspect. Indeed, a recent meta-analysis 2 indicates that synchronous vein resection, as reported, increases mortality and decreases survival. Crippa and colleagues put forward two interesting ideas that warrant further discussion. The first is that the surgery-first approach for pancreatic ductal adenocarcinoma might ultimately be retired, given that pancreatic ductal adenocarcinoma is usually systemic at presentation, local treatments have little effect, and neoadjuvant therapy has possible benefits. For now, the absence of high-level evidence for neoadjuvant therapy leaves largely theoretical benefits; namely that neoadjuvant therapy will reveal the biology (ie, those patients that can progress on neoadjuvant therapy will avoid futile surgery), or alter the biology (ie, those patients that are downstaged will become resectable). The preliminary results of the ALLIANCE trial 3 damages the lustre of these purported benefits with no improvement in the number of resections (10 [50%] of 20 patients who completed all preoperative therapy), and no rescue of aggressive tumour biology. This leads to the second idea, in which Crippa and colleagues suggest a biological (rather than radiological) basis for selecting patients for neoadjuvant therapy with a view to reduce the number of synchronous vein resections. Endoscopic ultrasonography- guided genotyping is a possible way to select subgroups of patients with heterogenous pancreatic ductal adenocarcinoma 4 who will benefit from neoadjuvant therapy. In support of this method, Hruban and colleagues 5 suggested that an intact SMAD4/DPC4 gene might be used to select surgery because there is lesser risk of distant metastases for this genotype. 6 In the future, we hope to more accurately select a subgroup of patients in whom a surgery-first approach, and even synchronous vein resection, is justified, but it is much more likely that precision neoadjuvant therapy will ultimately result in less radical surgery and the introduction of non-surgical techniques to support the response to neoadjuvant therapy. We declare no competing interests. Savio G Barreto, *John A Windsor j.windsor@auckland.ac.nz Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India (SGB); Hepatobiliary Pancreatic and Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand (JAW) Barreto S, Windsor J. Justifying vein resection with pancreatoduodenectomy. Lancet Oncol 2016; 17: e118–24. Giovinazzo F, Turri G, Katz MH, Heaton N, Ahmed I. Meta-analysis of benefits of portal-superior mesenteric vein resection in pancreatic resection for ductal adenocarcinoma. Br J Surg 2016; Varadhachary G, Fleming J, Crane C, et al. Phase II study of preoperation mFOLFIRINOX and chemoradiation for high-risk resectable and borderline resectable pancreatic adenocarcinoma. Proc Am Soc Clin Oncol 2015; 33 (suppl 3): abstr 362. Killock D. Pancreatic cancer: a problem quartered—new subtypes, new solutions? Nat Rev Clin Oncol 2016; 13: 201. Hruban RH, Adsay NV. Molecular classification of neoplasms of the pancreas. Hum Pathol Iacobuzio-Donahue CA, Fu B, Yachida S, et al. DPC4 gene status of the primary carcinoma correlates with patterns of failure in patients with pancreatic cancer. J Clin Oncol 2009; The US Cancer Moonshot initiative We recently sent the following letter to Vice President of the USA, Joe Biden, to state that we, as Deans and Directors of Public Health schools and programmes around the USA, strongly support the goals of the Cancer Moonshot initiative to www.thelancet.com/oncology Vol 17 May 2016

In 2007, the State of Hawaii, Healthy Hawaii Initiative conducted a statewide social-marketing campaign promoting increased physical activity and nutrition. The campaign included substantial formative research to develop messages tailored for Hawaii's multiethnic Asian and Pacific Islander populations. The authors conducted a statewide random digital dialing telephone survey to assess the campaign's comparative reach among individuals with different ethnicities and different levels of education and income. This analysis suggests that the intervention was successful in reaching its target ethnic audiences. However, a knowledge gap related to the campaign appeared among individuals with incomes less than 130% of the poverty level and those with less than a high school education. These results varied significantly by message and the communication channel used. Recall of supermarket-based messages was significantly higher among individuals below 130% of the poverty level and those between 18 and 35 years of age, 2 groups that showed consistently lower recall of messages in other channels. Results suggest that cultural tailoring for ethnic audiences, although important, is insufficient for reaching low-income populations, and that broad-based social marketing campaigns should consider addressing socioeconomic status-related channel preferences in formative research and campaign design.

Background:The U.S. Community Guide to Preventive Services strongly recommends changes in urban design, land use and accessibility to increase physical activity. To achieve these goals, policy change is often needed. This study assessed attitudes of decision makers in Hawaii to determine if physical activity related issues are among their priorities.Methods:State and county officials (n = 179) were mailed surveys. Respondents listed the three most important problems (open-ended) in Hawaii and rated the importance of 23 specified problems, of which six directly related to physical activity.Results:The survey was completed by 126 (70.4%) respondents. The most frequently mentioned categories for the open-ended questions were affordable housing, environment/sustainability, sprawl/traffic/population growth, and healthcare. Among the closed-ended physical activity related items, increasing traffic was ranked highest (43.9%) and fourth overall. Less than 12% of decision makers rated other physical activity issues as important.Conclusions:Future work is needed to increase the visibility and importance of physical activity related issues among policymakers.

OBJECTIVE: To examine policy makers' public policy priorities related to physical activity and the built environment, identify classes of policy makers based on priorities using latent class analysis, and assess factors associated with class membership. DESIGN: Cross-sectional survey data from municipal officials in 94 cities and towns across 6 US states were analyzed. PARTICIPANTS: Participants (N = 423) were elected or appointed municipal officials spanning public health, planning, transportation/public works, community and economic development, parks and recreation, and city management. MAIN OUTCOME MEASURES: Participants rated the importance of 11 policy areas (public health, physical activity, obesity, economic development, livability, climate change, air quality, natural resource conservation, traffic congestion, traffic safety, and needs of vulnerable populations) in their daily job responsibilities. Latent class analysis was used to determine response patterns and identify distinct classes based on officials' priorities. Logistic regression models assessed participant characteristics associated with class membership. RESULTS: Four classes of officials based on policy priorities emerged: (1) economic development and livability; (2) economic development and traffic concerns; (3) public health; and (4) general (all policy areas rated as highly important). Compared with class 4, officials in classes 1 and 3 were more likely to have a graduate degree, officials in class 2 were less likely to be in a public health job/department, and officials in class 3 were more likely to be in a public health job/department. CONCLUSIONS: Findings can guide public health professionals in framing discussions with policy makers to maximize physical activity potential of public policy initiatives, particularly economic development. Language: en

Background and purpose. Stress has been recognized as a public health problem. However, little research has been done on gender differences in sources of stress and coping strategies in Hawaii. In this study, we hypothesized that: 1) women will report higher levels of stress than men; 2) women will report being stressed by family and health related stressors while men will report stress related to finances and work-related issues; 3) women will report using adaptive coping strategies more frequently while men will report using maladaptive and avoidance strategies more frequently; 4) there will be no gender differences in the readiness to use stress management strategies. Method. A statewide cross-sectional telephone-survey of 1518 participants was conducted during the spring and summer of 2006. Results. Women reported higher overall perceived stress levels, but there was no difference in the experienced social stressors and health stressors between genders. Men perceived more stress from personal factors. There were no gender differences in the perceived ability to cope with stress. However, women were more likely to use adaptive coping strategies, whereas men were more likely to use maladaptive and avoidance coping strategies. There were no significant gender differences in stages of change for stress management. Conclusion. Based on this study, interventions can be developed to help people better cope with stress. Interventions for women may focus on increasing the use of adaptive strategies such as praying and talking to friends and family, while interventions for men may introduce the use of adaptive coping strategies such as exercise and actively fighting causes of stress. This study shows that gender differences in stress levels and coping in Hawaii are similar to previous studies conducted on the mainland. More research into specific stressors and coping strategies may help tailor interventions that are more effective and comprehensive.

Introduction Legislation and regulation at the state and local level can often have a greater impact on the public’s health than individual-based approaches. Elected and appointed officials have an essential role in protecting and improving public health. Despite this important role, little systematic research has been done to assess the relative importance of public health issues compared to other policy issues in times of economic hardship. This study assessed attitudes of elected and appointed decision makers in Hawaii in 2007 and 2013 to determine if priorities differed before and after the economic recession. Methods Elected and appointed state and county officials were mailed surveys at both time points. Respondents rated the importance of 23 specified problems, of which 9 asked about specific public health issues. Results The survey was completed by 126 (70.4%) respondents in 2007 and 117 (60.9%) in 2013. Among the public health issues, five saw significant mean decreases. These variables included climate change, pedestrian safety, government response to natural disasters, access to healthcare, and pandemic influenza. Obesity was the only public health issue to increase in importance across the two time points. In terms of relative ranking across the time points, only drug abuse and obesity were among the top 10 priorities. Lack of public health training, pandemic influenza, and government response to natural disasters were among the bottom five priorities. Conclusion After the economic recession, many public health issues have a lower priority among Hawaii’s policy makers than before the downturn. Additional education and advocacy is needed to keep public health issues on the minds of decision makers during tough economic times.

The 1% or Less Campaign is an effective research-tested program for reducing saturated fat intake by encouraging individuals to switch to low-fat milk. All published studies have been conducted in small communities with mostly White populations. The 6-week intervention included a media campaign, public relations, and taste tests. Campaign effectiveness was measured using sales data and cross-sectional telephone surveys. Survey results showed a significant increase in low-fat milk consumption from 30.2% to 40.8% of milk drinkers ( p < .001) with a reduced yet sustained increase at 3 months. This translates to approximately 65,000 people switching to low-fat milk during the campaign with a sustained effect of approximately 32,000 people three months postcampaign. Sales data show an increase of low-fat milk sales from 32.7% to 39.9%. Results are similar to smaller community initiatives, indicating the program is effective in promoting population behavior change but may need booster sessions for sustained effects.

Background:Physical inactivity is a growing problem in the United States, one that is being addressed through the development of active living communities. However, active living promotion requires collaboration among organizations that may not have previously shared goals.Methods:A network analysis was conducted to assess Hawaii’s active living promotion network. Twenty-six organizations playing a significant role in promoting active living in Hawaii were identified and surveyed about their frequency of contact, level of collaboration, and funding flow with other agencies.Results:A communication network was identified linking all agencies. This network had many long pathways, impeding information flow. The Department of Health (DOH) and the State Nutrition and Physical Activity Coalition (NPAC) were central nodes, but DOH connected state agencies while NPAC linked county and voluntary organizations. Within the network, information sharing was common, but collaboration and formal partnership were low. Linkages between county and state agencies, between counties, and between state agencies with different core agendas were particularly low.Conclusions:Results suggest that in the early stages of development, active living networks may be divided by geography and core missions, requiring work to bridge these divides. Network mapping appears helpful in identifying areas for network development.

Obesity is rapidly becoming one of the most critical public health challenges of our time. An estimated 73 million adults and 12 million children nd youth in the U.S. are already obese. Childhood obesity is of particular concern because obese children are muchmore likely to become obese adults. The number of years carrying excess weight appears to have a cumulative effect on morbidity and mortality. A recent report by the IOM recommended five goals to accelerate the progress in obesity prevention. One of these goals is trengthening schools as the heart of health. Schools are an essential cornerstone in the prevention f childhood obesity. Children spend most of their wakng hours in school and afterschool programs. National uidelines recommend that children and adolescents get hour a day of physical activity. With many children getting to school before 8:00AM and leaving afterschool programs at 5:00PM, school time is needed to meet the physical activity requirements. However, only 46% of high school boys and 27% of high school girls met this goal on 5 or more days of the week. In the Child Nutriion andWICReauthorization Act of 2004, the U.S. Conress required that all school districts with a federally unded school meals program develop and implement ellness policies that address nutrition and physical acivity by the start of the 2006–2007 school year. The aper by Smith et al. in this issue of theAmerican Journal f Preventive Medicine examines the strength and comrehensiveness of school wellness guidelines and comares locally developed policies with those following state evel templates. The study finds that locally developed olicies are somewhat better than those following temlates, but the main finding is the overall weakness of the olicies. Their study showed that only 17.4% of schools in he sample addressed all federal guidelines, and the trength of the included policies was mediocre at best.

Translating research into practice remains a challenge for public health and active living. Several issues have been identified as barriers to effective translation, including increasing the understanding of practice-based evidence, reframing dissemination challenges, placing greater emphasis on public health workforce development, and making research more accessible to policy audiences. Despite continued calls for better collaborations between researchers and practitioners, embedded structural issues exist that decrease collaborative opportunities. These include publication bias favoring studies with high internal validity, often at the expense of external validity; funding opportunities that focus exclusively on either research or practice; training of researchers by other researchers and not by practitioners; difficulties in creating and deepening relationships required to collaborate due to differences in structures and operating principles; and a lack of formal public health training among public health practitioners. Although these issues are common among many areas of public health, the problems are exacerbated by the multidisciplinary nature of the field of active living. There is a divide not only between researchers and practitioners but also across disciplines including transportation, education, parks and recreation, urban planning, and architecture. Although these structural issues make effective practice-based research difficult, they do not make it impossible. This commentary explores the case example of the Healthy Hawaii Initiative (HHI), where overcoming these barriers has been attempted and achieved to some extent. In 1999, the Hawaii state legislature passed legislation mandating that the Department of Health (HDOH) allocate 25% of the state’s tobacco settlement money for disease prevention programs targeting physical activity and nutrition. The state used these funds to create the HHI. Since the inception of the initiative, the HDOH has realized the need to have a strong evaluation of all components of the HHI and partnered with the University of Hawaii’s Department of Public Health Sciences to create the Healthy Hawaii Initiative Evaluation Team (HHIET). The HHIET is comprised of university-based faculty, research staff, and graduate students, who make up the research and evaluation arm of the initiative. The overall goal of the HHI is to increase years of healthy life for all people of Hawaii and reduce existing health disparities among ethnic groups in Hawaii. This goal is addressed by creating sustainable changes that promote healthy lifestyles, in particular through nutrition and physical activity, and by reducing health disparities throughout the state. Interventions are targeted at the individual, social, and environmental levels and use a variety of channels including public education, education of health professionals, school-based programs, and community initiatives. I have had the good fortune of leading the HHIET since the start of the initiative in 2000. The University and HDOH teams have discovered shared goals including making Hawaii a healthier place to live, work, learn, and play. We have also learned how to work together and to acknowledge our sometimes-competing priorities to create a strong partnership. For the university, competing priorities include conducting research studies for peer-reviewed publications. For the HDOH, they often mean answering to the priorities of a variety of stakeholders including elected officials, the Director of Health, and the Centers for Disease Control and Prevention. These different perspectives have helped us to examine what practice-based research is. It needs to be highly relevant to proposed interventions, have strong external validity, and not take years to get results. These were and still are challenging issues that are not typically part of graduate school training. Next, I describe a series of practicebased research studies we have conducted and how they were vastly different from typical randomized trial biomedical research. Our first study examined changing the bell schedule of a local elementary school to offer recess before lunch for some grades. Intuitively, this makes sense. Students can run around without a stomach full of food, and lunch wait time is decreased, because the students can go to lunch when they are ready and not all at the same time. Because of the need to complete the study quickly with limited resources, we were only able to test the program in one school using a pretestposttest design. The intervention worked well in increasing access to recess equipment, decreasing plate waste, and, Jay E. Maddock, PhD, is with the Department of Public Health Sciences, University of Hawaii at Manoa, Manoa, Hawaii.

A quasi-experimental prospective study was conducted to assess the stage of change progression and elimination of unhealthy behaviors among active duty Army soldiers and their spouses (N = 245) before and after attending a community-based wellness program. Significant differences in stage progression between the intervention group and a comparison group was seen in the fitness (p = 0.05) and communication risk categories (p = 0.03) immediately after the intervention; significant differences in stage progression in fitness (p = 0.05) and spirituality (p = 0.005) risk categories 6 months after baseline. There was a significant increase in seat belt use (p = 0.008), a decrease in reported tobacco use (p < 0.05), and a reduction in family stress (p = 0.06) and personal stress (p < 0.02) in the intervention group. Targeting multiple behavior changes and risk reduction in a single intervention program presents several challenges. In this pilot study, there were many positive nonsignificant trends in risk reduction that might translate into significant changes with a larger sample.

Obesity rates continue to steadily rise in the United States, with nine states having more than 30% of adults reporting body mass indices in the obese range. Despite widespread attention and millions of dollars spent in researching, preventing, and treating obesity, every state experienced a significant increase between 1999 and 2009, with an overall increase of 1.1% between 2007 and 2009. Although there are numerous ideas on what might work, we do not have a single real world–tested example of a state reversing the obesity trend. Tobacco control is often held up as an example of a public health success story in changing health behaviors. A comprehensive approach with a focus on policy change helped to greatly reduce tobacco use rates in numerous states. However, the tobacco policy landscape (i.e., smoking bans, taxes, and sales to minors) is much smaller than the potential policy changes for physical activity and nutrition. As Chaufan et al. point out in their thoughtful accompanying article, there is no clear data that taxes on sugar-sweetened beverages will have an impact on obesity rates. Although this is probably true, it is unclear what polices, if any, will have an effect on obesity rates. For physical activity, more than 150 jurisdictions have passed complete street policies. These policies mandate that any new street accommodate all types of users including pedestrians, bicyclists, and mass transit. Although this is a desirable goal for numerous reasons, the effect on obesity may not be seen for some time or at all. Chaufan et al. argue that increases in taxes on sugarsweetened beverages would not greatly reduce consumption or move it to other unhealthy beverages based on price elasticity. However, as seen in tobacco and hard alcohol, children and young adults are often the most sensitive to changes in price. Because obesity often starts in childhood, prevention at this age may be influenced by reductions in sugar-sweetened beverage consumption; however, the effects on adults might be nonexistent. Given the experience with other consumable substances, this is at least a plausible model that can really only be tested once communities start adopting these taxes. Chaufan et al. finish their article by supporting the idea of taxes on sugar-sweetened beverages as a means of revenue generation for public health programs, including those dedicated to obesity and dental hygiene. Although this is a noble and rationale argument, it is not often how legislative bodies operate. Elected officials are much more likely to support these types of taxes if the funds go into the general fund to help balance the budget or pay for other needed services. Earmarking of tax funds often leads to supplanting of current general funded programs or changes to the statute when the budget gets tight. For example in fiscal year 2010, the 46 states that settled with the tobacco companies received more than $25 billion in payments but spent only 2.3% of that on tobacco prevention and control, Given this track record, it is hard to believe that any significant portion of revenues generated by taxes on sugar-sweetened beverages will be used for public health programs at least until public health advocates become more effective in protecting public health resources.

The purpose of this study was to identify unique characteristics for seeking emergency contraception (EC) among sexually active unmarried women who attended a university-based women's health clinic (WHC).Three hundred nine consecutive women who attended the women's health clinic for 3 months of the 2006 spring semester completed an anonymous self-administered questionnaire. Fisher exact and Student t tests were used to assess bivariate associations, and step-wise regression was used to determine independent associations.Women who requested EC were more likely to have previously used EC (P.001), to have had unprotected sex in the past 6 months (P.001), to have experienced an unintended pregnancy in the past year (P = .009), and to perceive the need for EC use in the next 3 months (P.001) but were less likely to use hormonal contraception or an intrauterine device (P.001).Our findings support the need for increased education that would include the use of and access to effective primary contraceptive methods in conjunction with EC awareness.