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Determinants of pediatric asthma management include child, family, healthcare, and community factors. The purpose of this study is to investigate how parents/guardians are impacted by and act on these factors to aid in their child’s asthma self-management. Interviews were conducted in Fall 2020 with 12 female parents/guardians of Black/African American children who participated in a community paramedic pilot study with their child in South Carolina. Children in the initial study had an asthma diagnosis of moderate persistent asthma, had Medicaid insurance, and were determined high-risk for emergency room presentation. Inductive and deductive qualitative analysis identified that child management self-efficacy and independence, parent/guardian health literacy, parent and child negative experiences related to asthma diagnosis and management, asthma management tools, and social support from multiple sources impact child self-management. Findings from this study highlight the importance of clear asthma education and management tool recommendations from healthcare and community providers, particularly for parents/guardians with low health literacy. Health literacy impacted parental responses and likely how families comprehend Medicaid and clinical asthma guidance.

Osteoarthritis (OA) is one of the most common diseases that cause disability among older adults. The objective of this study was to assess the association between adherence to the Dietary Approaches to Stop Hypertension (DASH) and OA in American adults. This study included adults (≥ aged 20 years) who participated in the National Health and Examination Survey (NHANES) 2007-2016 in the United States. Adherence to the DASH score was calculated from 8 food groups. Higher scores indicate better adherence to the DASH dietary pattern. Among the 21,901 participants included in this study, 10.26% reported having OA. Results of our multivariable logistic regression indicated a statistically significant inverse association between DASH score tertiles and OA. The adjusted ORs (95% CI) were 1.00 (ref), 0.89 (0.72; 1.10), and 0.78 (0.60; 1.00) across increasing DASH score tertiles (P for trend = 0.045). In this representative sample of American adults, greater adherence to the DASH dietary pattern was associated with lower likelihood of having OA.

BackgroundThe Stopping Elderly Accidents, Deaths and Injuries (STEADI) screening algorithm aligns with current fall prevention guidelines and is easy to administer within clinical practice. However, the stratification into low, moderate and high risk categories limits the meaningful interpretation of the fall-related risk factors.MethodsBaseline measures from a modified STEADI were used to predict self-reported falls over 4 years in 3170 respondents who participated in the 2011–2015 National Health and Aging Trends Study. A point method was then applied to find coefficient-based integers and 4-year fall risk estimates from the predictive model. Sensitivity and specificity estimates from the point method and the combined moderate and high fall risk STEADI categories were compared.ResultsThere were 886 (27.95%) and 387 (12.21%) respondents who were classified as moderate and high risk, respectively, when applying the stratification method. Falls in the past year (OR: 2.16; 95% CI: 1.61 to 2.89), multiple falls (OR: 2.94; 95% CI: 1.89 to 4.55) and a fear of falling (OR: 1.77; 95% CI: 1.45 to 2.16) were among the significant predictors of 4-year falls in older adults. The point method revealed integers that ranged from 0 (risk: 27.21%) to 44 (risk: 99.71%) and a score of 10 points had comparable discriminatory capacity to the combined moderate and high STEADI categories.ConclusionCoefficient-based integers and their risk estimates can provide an alternative interpretation of a predictive model that may be useful in determining fall risk within a clinical setting, tracking changes longitudinally and defining the effectiveness of an intervention.

Background Past mobile health (mHealth) efforts to empower type 2 diabetes (T2D) self-management include portals, text messaging, collection of biometric data, electronic coaching, email, and collection of lifestyle information. Objective The primary objective was to enhance patient activation and self-management of T2D using the US Department of Defense’s Mobile Health Care Environment (MHCE) in a patient-centered medical home setting. Methods A multisite study, including a user-centered design and a controlled trial, was conducted within the US Military Health System. Phase I assessed preferences regarding the enhancement of the enabling technology. Phase II was a single-blinded 12-month feasibility study that randomly assigned 240 patients to either the intervention (n=123, received mHealth technology and behavioral messages tailored to Patient Activation Measure [PAM] level at baseline) or the control group (n=117, received equipment but not messaging. The primary outcome measure was PAM scores. Secondary outcome measures included Summary of Diabetes Self-Care Activities (SDSCA) scores and cardiometabolic outcomes. We used generalized estimating equations to estimate changes in outcomes. Results The final sample consisted of 229 patients. Participants were 61.6% (141/229) male, had a mean age of 62.9 years, mean glycated hemoglobin (HbA1c) of 7.5%, mean BMI of 32.7, and a mean duration of T2D diagnosis of 9.8 years. At month 12, the control group showed significantly greater improvements compared with the intervention group in PAM scores (control mean 7.49, intervention mean 1.77; P=.007), HbA1c (control mean −0.53, intervention mean −0.11; P=.006), and low-density lipoprotein cholesterol (control mean −7.14, intervention mean 4.38; P=.01). Both groups showed significant improvement in SDSCA, BMI, waist size, and diastolic blood pressure; between-group differences were not statistically significant. Except for patients with the highest level of activation (PAM level 4), intervention group patients exhibited significant improvements in PAM scores. For patients with the lowest level of activation (PAM level 1), the intervention group showed significantly greater improvement compared with the control group in HbA1c (control mean −0.09, intervention mean −0.52; P=.04), BMI (control mean 0.58, intervention mean −1.22; P=.01), and high-density lipoprotein cholesterol levels (control mean −4.86, intervention mean 3.56; P Conclusions Our study produced mixed results with improvement in PAM scores and outcomes in both the intervention and control groups. Structural design issues may have hampered the influence of tailored behavioral messaging within the intervention group. Trial Registration ClinicalTrials.gov NCT02949037; https://clinicaltrials.gov/ct2/show/NCT02949037 International Registered Report Identifier (IRRID) RR2-10.2196/resprot.6993

IntroductionSeveral adipokines are implicated in the pathophysiology of gestational diabetes mellitus (GDM), however, longitudinal data in early pregnancy on many adipokines are lacking. We prospectively investigated the association of a panel of adipokines in early and mid-pregnancy with GDM risk.Research design and methodsWithin the National Institute of Child Health and Human Development (NICHD) Fetal Growth Studies-Singletons cohort (n=2802), a panel of 10 adipokines (plasma fatty acid binding protein-4 (FABP4), chemerin, interleukin-6 (IL-6), leptin, soluble leptin receptor (sOB-R), adiponectin, omentin-1, vaspin, and retinol binding protein-4) were measured at gestational weeks (GWs) 10–14, 15–26, 23–31, and 33–39 among 107 GDM cases (ascertained on average at GW 27) and 214 non-GDM controls. Conditional logistic regression was used to estimate ORs of each adipokine and GDM, controlling for known GDM risk factors including pre-pregnancy body mass index.ResultsThroughout pregnancy changes in chemerin, sOB-R, adiponectin, and high-molecular-weight adiponectin (HMW-adiponectin) concentrations from 10–14 to 15–26 GWs were significantly different among GDM cases compared with non-GDM controls. In early and mid-pregnancy, FABP4, chemerin, IL-6 and leptin were positively associated with increased GDM risk. For instance, at 10–14 GWs, the OR comparing the highest versus lowest quartile (ORQ4–Q1) of FABP4 was 3.79 (95% CI 1.63 to 8.85). In contrast, in both early and mid-pregnancy adiponectin (eg, ORQ4–Q1 0.14 (0.05, 0.34) during 10–14 GWs) and sOB-R (ORQ4–Q1 0.23 (0.11, 0.50) during 10–14 GWs) were inversely related to GDM risk. At 10–14 GWs a model that included conventional GDM risk factors and FABP4, chemerin, sOB-R, and HMW-adiponectin improved the estimated prediction (area under the curve) from 0.71 (95% CI 0.66 to 0.77) to 0.77 (95% CI 0.72 to 0.82).ConclusionsA panel of understudied adipokines including FABP4, chemerin, and sOB-R may be implicated in the pathogenesis of GDM with significant associations detected approximately 10–18 weeks before typical GDM screening.

BACKGROUND Past mobile health (mHealth) efforts to empower type 2 diabetes (T2D) self-management include portals, text messaging, collection of biometric data, electronic coaching, email, and collection of lifestyle information. OBJECTIVE The primary objective was to enhance patient activation and self-management of T2D using the US Department of Defense’s Mobile Health Care Environment (MHCE) in a patient-centered medical home setting. METHODS A multisite study, including a user-centered design and a controlled trial, was conducted within the US Military Health System. Phase I assessed preferences regarding the enhancement of the enabling technology. Phase II was a single-blinded 12-month feasibility study that randomly assigned 240 patients to either the intervention (n=123, received mHealth technology and behavioral messages tailored to Patient Activation Measure [PAM] level at baseline) or the control group (n=117, received equipment but not messaging. The primary outcome measure was PAM scores. Secondary outcome measures included Summary of Diabetes Self-Care Activities (SDSCA) scores and cardiometabolic outcomes. We used generalized estimating equations to estimate changes in outcomes. RESULTS The final sample consisted of 229 patients. Participants were 61.6% (141/229) male, had a mean age of 62.9 years, mean glycated hemoglobin (HbA1c) of 7.5%, mean BMI of 32.7, and a mean duration of T2D diagnosis of 9.8 years. At month 12, the control group showed significantly greater improvements compared with the intervention group in PAM scores (control mean 7.49, intervention mean 1.77; P=.007), HbA1c (control mean −0.53, intervention mean −0.11; P=.006), and low-density lipoprotein cholesterol (control mean −7.14, intervention mean 4.38; P=.01). Both groups showed significant improvement in SDSCA, BMI, waist size, and diastolic blood pressure; between-group differences were not statistically significant. Except for patients with the highest level of activation (PAM level 4), intervention group patients exhibited significant improvements in PAM scores. For patients with the lowest level of activation (PAM level 1), the intervention group showed significantly greater improvement compared with the control group in HbA1c (control mean −0.09, intervention mean −0.52; P=.04), BMI (control mean 0.58, intervention mean −1.22; P=.01), and high-density lipoprotein cholesterol levels (control mean −4.86, intervention mean 3.56; P CONCLUSIONS Our study produced mixed results with improvement in PAM scores and outcomes in both the intervention and control groups. Structural design issues may have hampered the influence of tailored behavioral messaging within the intervention group. CLINICALTRIAL ClinicalTrials.gov NCT02949037; https://clinicaltrials.gov/ct2/show/NCT02949037 INTERNATIONAL REGISTERED REPORT RR2-10.2196/resprot.6993

Mobile applications and interactive websites are an increasingly used method of telemedicine, but their use lacks evidence in digestive diseases. This study aims to explore digestive disease studies that use telemedicine to effectively manage disease activity, help monitor symptoms, improve compliance to the treatment protocol, increase patient satisfaction, and enhance the patient-to-provider communication. EBSCO, PubMed, and Web of Science databases were searched using Medical Subject Headings and other keywords to identify studies that utilized telemedicine in patients with digestive disease. The PRISMA guidelines were used to identify 20 research articles that had data aligning with 4 common overlapping themes including, patient compliance (n = 13), patient satisfaction (n = 11), disease activity (n = 15), and quality of life (n = 13). The studies focused on digestive diseases including inflammatory bowel disease (n = 7), ulcerative colitis (n = 4), Crohn’s Disease (n = 1), irritable bowel syndrome (n = 6), and colorectal cancer (n = 2). From the studies included in this systematic review, patient compliance and patient satisfaction ranged between 25.7–100% and 74–100%, respectively. Disease activity, measured by symptom severity scales and physiological biomarkers, showed improvements following telemedicine interventions in several, but not all, studies. Similar to disease activity, general and disease-specific quality of life showed improvements following telemedicine interventions in as little as 12 weeks in some studies. Telemedicine and mobile health technology may be effective in managing disease activity and improving quality of life in digestive diseases. Future studies should explore both gastrointestinal and gastroesophageal diseases using these types of interventions.

The purpose of this study was to examine the relationship between parental BMI and the family environment and determine if differences exist in child diet and physical activity related parenting behaviors by parental BMI in a community sample of families recruited through elementary schools in a local school district. We found an association between parental BMI category and family nutrition and physical activity (FNPA) score. Families with an underweight or normal weight parent had a larger proportion (64.3%) of high (indicating a healthier family environment) FNPA scores and families with an overweight or obese parent had a smaller proportion (45.2%) of high FNPA scores (χ 2 = 5.247, P = 0.022). Families with a parent who was overweight or obese had 2.18 times the odds (95% CI 1.11–4.27) of being in the low FNPA (“less healthy” environment) group. Further, underweight/normal weight parents reported higher levels of monitoring of child diet (Z = −3.652, P

Introduction: ASCO is actively developing CancerLinQ (CLQ), a rapid learning system for oncology care. The purpose of this study was to explore providers’ opinions and concerns related to implementation of CLQ, including ethical issues. Methods: Twenty key informant oncologists were recruited for individual in-depth interviews through ASCO contacts, purposively selected to represent a wide variety of cancer specialties as well as different levels of familiarity with CLQ (familiar v unfamiliar). Qualitative data analysis was completed by a three-member team using an inductive narrative approach. Themes were examined by participants familiar and unfamiliar with CLQ, and quotations exemplifying each theme are provided. Results: Participants’ opinions centered on three main themes: (1) general attitudes regarding learning health care systems, (2) optimal approach to patient consent, and (3) appropriateness of data use. There was clear support for the use of big data in clinical decision making for patients and in research. Unfamiliar participants expressed concerns regarding system protections against patient identification, and both familiar and unfamiliar participants discussed the dilemma of including genetic information. Respondents were in agreement with notifying patients early; however, there was debate over whether patients should opt in or opt out. Overall, there was great concern regarding sharing data with drug companies and insurers. Conclusion: Understanding oncologists’ perspectives regarding the ethical implications of CLQ implementation is critical to its success. More research is needed on the impact of rapid learning systems on providers, patients, health systems, and the ultimate effect on cancer care.

The purpose of this study was to investigate the eating behaviors and social cognitive factors that affect fruit and vegetable consumption. Strategies to change, pros & cons, enjoyment, family support, and peer influence were measured in children ages 8–10 years both pre- and post- Zest Quest® program (pre: n = 82; post: n = 80). Children for a comparison group were selected from comparable elementary schools and pre- and post- measures were evaluated (pre: n = 92; post: n = 87). Chi-squared analyses were conducted on individual measures and Spearman correlations & linear regression were used for composite variables with fruit and vegetable consumption as the dependent variable. Results from the study demonstrated significant moderate correlations for fruit change strategies pre- (rs = 0.39) and post-intervention (rs = 0.33) and vegetable change strategies pre-intervention (rs = 0.42) in the Zest Quest® group. Peer influence (rs = 0.33) and enjoyment (rs = 0.38) showed significant moderate correlations with fruit intake in the comparison group. The regression analysis showed pros (β = 0.24, p value 0.05) and cons (β = 0.14, p value 0.05) to be significant predictors for fruit intake post-intervention in the Zest Quest® group. Prior to the intervention, strategies to change (β = 0.10, p value 0.02) was a significant predictor for fruit intake and cons (β = 0.15, p value = 0.03) for vegetable intake in this group. Family support and peer influence were not significant in the regression models, but demonstrated significance in the crude model. Eating behaviors and social cognitive factors may have an effect on fruit and vegetable consumption, but these measures are difficult to capture. Future research should continue exploring the impact of family support and peer influence on fruit and vegetable intake.

BACKGROUND Heart failure (HF) causes significant economic and humanistic burden for patients and their families, especially those with a low income, partly due to high hospital readmission rates. Optimal self-care is considered an important nonpharmacological aspect of HF management that can improve health outcomes. Emerging evidence suggests that self-management assisted by smartphone apps may reduce rehospitalization rates and improve the quality of life of patients. We developed a virtual human–assisted, patient-centered mobile health app (iHeartU) for patients with HF to enhance their engagement in self-management and improve their communication with health care providers and family caregivers. iHeartU may help patients with HF in self-management to reduce the technical knowledge and usability barrier while maintaining a low cost and natural, effective social interaction with the user. OBJECTIVE With a standardized systematic usability assessment, this study had two objectives: (1) to determine the obstacles to effective and efficient use of iHeartU in patients with HF and (2) to evaluate of HF patients’ adoption, satisfaction, and engagement with regard to the of iHeartU app. METHODS The basic methodology to develop iHeartU systems consists of a user-centric design, development, and mixed methods formative evaluation. The iterative design and evaluation are based on the guidelines of the American College of Cardiology Foundation and American Heart Association for the management of heart failure and the validated “Information, Motivation, and Behavioral skills” behavior change model. Our hypothesis is that this method of a user-centric design will generate a more usable, useful, and easy-to-use mobile health system for patients, caregivers, and practitioners. RESULTS The prototype of iHeartU has been developed. It is currently undergoing usability testing. As of September 2018, the first round of usability testing data have been collected. The final data collection and analysis are expected to be completed by the end of 2019. CONCLUSIONS The main contribution of this project is the development of a patient-centered self-management system, which may support HF patients’ self-care at home and aid in the communication between patients and their health care providers in a more effective and efficient way. Widely available mobile phones serve as care coordination and “no-cost” continuum of care. For low-income patients with HF, a mobile self-management tool will expand their accessibility to care and reduce the cost incurred due to emergency visits or readmissions. The user-centered design will improve the level of engagement of patients and ultimately lead to better health outcomes. Developing and testing a novel mobile system for patients with HF that incorporates chronic disease management is critical for advancing research and clinical practice of care for them. This research fills in the gap in user-centric design and lays the groundwork for a large-scale population study in the next phase. INTERNATIONAL REGISTERED REPOR DERR1-10.2196/13502

Background: Heart failure (HF) causes significant economic and humanistic burden for patients and their families, especially those with a low income, partly due to high hospital readmission rates. Optimal self-care is considered an important nonpharmacological aspect of HF management that can improve health outcomes. Emerging evidence suggests that self-management assisted by smartphone apps may reduce rehospitalization rates and improve the quality of life of patients. We developed a virtual human–assisted, patient-centered mobile health app (iHeartU) for patients with HF to enhance their engagement in self-management and improve their communication with health care providers and family caregivers. iHeartU may help patients with HF in self-management to reduce the technical knowledge and usability barrier while maintaining a low cost and natural, effective social interaction with the user. Objective: With a standardized systematic usability assessment, this study had two objectives: (1) to determine the obstacles to effective and efficient use of iHeartU in patients with HF and (2) to evaluate of HF patients’ adoption, satisfaction, and engagement with regard to the of iHeartU app. Methods: The basic methodology to develop iHeartU systems consists of a user-centric design, development, and mixed methods formative evaluation. The iterative design and evaluation are based on the guidelines of the American College of Cardiology Foundation and American Heart Association for the management of heart failure and the validated “Information, Motivation, and Behavioral skills” behavior change model. Our hypothesis is that this method of a user-centric design will generate a more usable, useful, and easy-to-use mobile health system for patients, caregivers, and practitioners. Results: The prototype of iHeartU has been developed. It is currently undergoing usability testing. As of September 2018, the first round of usability testing data have been collected. The final data collection and analysis are expected to be completed by the end of 2019. Conclusions: The main contribution of this project is the development of a patient-centered self-management system, which may support HF patients’ self-care at home and aid in the communication between patients and their health care providers in a more effective and efficient way. Widely available mobile phones serve as care coordination and “no-cost” continuum of care. For low-income patients with HF, a mobile self-management tool will expand their accessibility to care and reduce the cost incurred due to emergency visits or readmissions. The user-centered design will improve the level of engagement of patients and ultimately lead to better health outcomes. Developing and testing a novel mobile system for patients with HF that incorporates chronic disease management is critical for advancing research and clinical practice of care for them. This research fills in the gap in user-centric design and lays the groundwork for a large-scale population study in the next phase. International Registered Report Identifier (IRRID): DERR1-10.2196/13502

Adverse selection predicts that individuals with lower health status would be more likely to sign up for health insurance. This hypothesis was tested among the long-term uninsured population in South Carolina (SC). This study used data from an in-person survey conducted from May 2014 to January 2015. Interviews were held with the long-term uninsured individuals at multiple sites throughout the state, using a multistage sampling method. SC residents aged 18 to 64 years who had had no health insurance for at least 24 consecutive months were eligible for the survey. The dependent variable is the participants’ attempt to obtain insurance coverage. Key independent variables are self-reported health status, hospitalization in the past year, use of emergency department in the past year, and presence of serious long-standing health problems. The analysis is stratified by the awareness of the Affordable Care Act (ACA)’s individual mandate while controlling for age, gender, race/ethnicity, and household income. Participants’ self-reported health status was not significantly associated with the attempt to sign up for health insurance in both groups (those aware and those unaware of the individual mandate). Being hospitalized in the previous year was significantly associated with their attempt to sign up for insurance in both groups. Participants with serious long-term health problems were more likely to have attempted to sign up for insurance among those who were not aware of the ACA. However, this association was statistically insignificant among those who had heard of ACA. Sicker people were more likely to attempt to sign up for insurance. However, being aware of the ACA’s individual mandate seemed to play a role in reducing adverse selection.

OBJECTIVES: Osteoarthritis (OA) is a common disease which significantly contributes to disability among older adults. Dietary factors are suggested to play a role in preventing OA, however, studies in this area spare. The objective of this study was to assess the association between adherence to the Dietary Approaches to Stop Hypertension (DASH) and OA in American adults. METHODS: This study included United States (US) adults (≥aged 20 years) who participated NHANES cycles 2007–2016. The Dietary Approaches to Stop Hypertension (DASH) score was calculated from nine food items with a higher DASH score indicating better adherence to the DASH dietary pattern. Multivariable logistic regression models adjusted for age, education, race/ethnicity, household income, smoking, alcohol consumption, and total energy intake were used to estimate the adjusted odds ratios (aOR) and 95% confidence intervals (CI) of DASH with OA. All analyses accounted for the complex survey design. RESULTS: Among the 17,349 participants included in this study, 9.05% reported OA. The DASH score was inversely associated with OA. The aOR (95% CI) were 1.00 (ref), 0.09 (0.70, 1.16), and 0.74 (0.58, 0.94) (P(trend) = 0.01) across the DASH score tertiles. When analyses were stratified by BMI categories (normal, overweight, obese) the magnitude of the association was stronger and remained significant only among obese participants (i.e., BMI ≥ 30 kg/m(2)). Among participants with an obese BMI, participants with a DASH score in the highest tertile compared to participants with a DASH score in the lowest tertile had a 17% lower likelihood of having OA (P = 0.009). CONCLUSIONS: In a representative sample of American adults, higher adherence to the DASH dietary pattern was associated with lower likelihood of having OA and this association was particularly evident among obese individuals. FUNDING SOURCES: N/A. SUPPORTING TABLES, IMAGES AND/OR GRAPHS

A multidisciplinary team developed and pilot-tested a curriculum, delivered by trained lay educators, to increase self-efficacy for physical activity among elderly food stamp recipients. Curriculum development was guided by a comprehensive literature review. Process evaluation was used to revise the curriculum and to assess lay educator training and pilot test fidelity. Three hundred sixteen low-income older adults participated in curriculum development and pilot-testing activities. One hundred twenty four participants completed pretest/posttest impact evaluation surveys. The average age of participants was 75 years old with 55.28% having less than high school education. Significant increases in self-efficacy regarding walking most days (p = .0022), using exercise bands (p

This article describes the impact of an 8-week community program implemented by trained volunteers on the hypertension self-management of 185 patients who were batch randomized to intervention or wait-list control groups. Compared with control group participants, a higher proportion of treatment group participants moved from the cognitive to behavioral stages of motivational readiness for being physically active ( P < .001), practicing healthy eating habits ( P = .001), handling stress well ( P = .001), and living an overall healthy lifestyle ( P = .003). They also demonstrated a greater average increase in perceived competence for self-management, F(1.134) = 4.957, P = .028, η2 = .036, and a greater increase in mean hypertension-related knowledge, F(1.160) = 16.571, P < .0005, η2 = .094. Enduring lifestyle changes necessary for chronic disease self-management require that psychosocial determinants of health behavior are instilled, which is typically beyond standard medical practice. We recommend peer-led, community-based programs as a complement to clinical care and support the increasing health system interest in promoting population health beyond clinical walls.

Objective Develop scales to assess the impact of the Cooking with a Chef program on several psychosocial constructs. Methods Cross-sectional design in which parents and caregivers were recruited from child care settings (Head Start, faith-based, public elementary schools), and cooks were recruited from church and school kitchens. Analysis involved descriptive statistics, correlations, and exploratory factor analysis. Results Test-retest reliability coefficients ranged from r = 0.63 to r = 0.88. Exploratory factor analysis indicated a simple structure for 3 scales: Cooking Techniques Self-Efficacy, Negative Cooking Attitude, and Self-Efficacy Fruit and Vegetables and accounted for 85.0% of the total variance. Mean responses to each scale were not statistically different between parents and cooks. Conclusions and Implications Evidence of face validity and construct validity were provided through expert review, factor analysis, and scale correlations. Analyses presented constitute the first step in developing psychosocial scales for evaluating the Cooking with a Chef program and provide preliminary evidence that these scales work well with diverse groups.

Less than half of all US adults report meeting physical activity recommendations of 30 minutes or more of moderate to vigorous physical activity on at least 5 days per week. Thus, community-wide ecological initiatives are needed to create environments that support incorporating physical activity into residents' daily lives. In this article we describe an ongoing collaborative service-learning partnership between Clemson University, a community coalition, and a neighboring small rural town to address local social and physical environment supports for walking. Years 1 to 3 of this collaborative initiative were evaluated using a mixed-method approach to assess physical environment changes, social environment changes, community perceptions of support for walking, community perceptions of collaborating with university students, and students' skill development. Results revealed several key environmental changes such as mapping and marking 3 walking trails in the community, development of broad marketing efforts linked to the trails that promote community health and heritage, and annual community events to promote walking and the newly developed walking trails. Interview data with community leaders identified several key themes critical to facilitating and enhancing our university and community collaboration. Lastly, students developed skills in developing partnerships, mapping, advocacy, event planning, critical reflection, and qualitative and quantitative data collection and analysis. Through this process community members and students learn evidence-based public health skills for using data and planning frameworks to guide local initiatives, engage community members in decision making, and conducting evaluations.

The purpose was to assess the prevalence and correlates of complementary and alternative medicine use for weight control.A list-assisted random-digit-dialed telephone survey of adults was conducted in the fall of 2002 (n = 11,211). The focus of the study was complementary and alternative medicine (CAM) use, other than dietary supplements, in the previous 12 months.The sample of respondents was drawn from the total noninstitutionalized U.S. adult population residing in telephone-equipped locations.The sampling procedures were designed to obtain adequate representation of Hispanic and non-Hispanic black respondents. Data from the total sample of 11,211 were weighted to achieve an estimate of the U.S. population. Analyses focused on 372 people who had used CAM within the previous 12 months.Of the total, 3.3% (n = 372) had used a CAM therapy in the previous 12 months. Higher adjusted odds ratios for CAM use were found among respondents who were exercising for weight control; using a lower carbohydrate, higher protein diet; using a nonprescription weight-loss product(s); overweight; physically active; and not satisfied with one's body (adjusted for age, race, gender, education, and city size). The most often used therapies were yoga (57.4%), meditation (8.2%), acupuncture (7.7%), massage (7.5%), and Eastern martial arts (5.9%). CAM users used CAM therapies on their own (62.6%), in a group setting (26.8%) or with a CAM practitioner (10.6%).The use of CAM therapies other than dietary supplements for weight loss was relatively low. The most popular therapy was yoga, and the majority of CAM users used CAM therapies on their own. Persons who had used other weight loss methods had greater odds for using CAM in the previous 12 months, suggesting that CAM use is often added to other weight-loss strategies.

To better understand outcome expectations, barriers, and strategies for healthful eating, 5 structured focus groups were conducted with adolescents from low-income families (n = 48; 83% Black students; 10-14 years old). The focus group questions dealt with healthful eating in different settings: home, school, and other eating establishments. Results suggested that healthful eating is important to this population, but perceived barriers prevent the consistent consumption of healthful foods. Strategies suggested by participants to increase healthful eating (eg, parents and schools making healthy foods that look and taste good more available) should be considered when developing nutrition interventions for adolescents from low-income families.

Background: Childhood obesity is a growing problem for children in the United States, especially for children from low-income, African American families. Objective: The purpose of this qualitative study was to understand facilitators and barriers to engaging in healthy lifestyles faced by low-income African American children and their families. Methods: This qualitative study used semi-structured focus group interviews with eight African American children clinically identified as overweight or obese (BMI > 85) and their parents. An expert panel provided insights in developing culturally appropriate intervention strategies. Results: Child and parent focus group analysis revealed eleven barriers and no definitive facilitators for healthy eating and lifestyles. Parents reported confusion regarding what constitutes nutritional eating, varying needs of family members in terms of issues with weight, and difficulty in engaging the family in appropriate and safe physical activities; to name a few themes. Community experts independently suggested that nutritional information is confusing and, often, contradictory. Additionally, they recommended simple messaging and practical interventions such as helping with shopping lists, meal planning, and identifying simple and inexpensive physical activities. Conclusions: Childhood obesity in the context of low-resource families is a complex problem with no simple solutions. Culturally sensitive and family-informed interventions are needed to support low-income African American families in dealing with childhood obesity.

OBJECTIVE: This study used focus groups to identify preferences for physical activity (PA) and motivational themes for increasing PA in underserved adolescents. METHODS: Fifty-one adolescents, on the free lunch program (25 males and 26 females; ages 10-13 years; 72% African-American, 19% white, and 9% other minorities) participated in focus groups (6-10 children per group; same gender). The data were transcribed and coded into themes. A content analysis was performed using QSR NVivo. RESULTS: Boys rated their favorite activities as playing basketball, football, soccer, and baseball. Girls rated their favorite activities as playing basketball, swimming, and roller-skating. For motivational themes, boys and girls most frequently stated that they would participate in PA if it was a fun, provided a health benefit, and if there were a variety of choices offered. Being involved with friends was also identified as important to both boys and girls. CONCLUSIONS: The findings from this qualitative study suggest that including components of choice and a variety of physical activities may be important elements for intervention programs in underserved adolescents. Language: en

Background Perceptions of the environment and physical activity have been associated using survey methods, yet little is known about the validity of environmental surveys. In this study, perceptions of the environment at neighborhood and community levels were assessed (1) to determine validity by comparing respondent perceptions to objective measures and (2) to determine test–retest reliability of the survey. Methods A telephone survey was administered to a stratified sample of Sumter County, South Carolina adults. Respondents' home addresses were mapped using a geographic information system (GIS) ( n =1112). As an indicator of validity, kappa statistics were used to measure agreement between perceptions and objective measures identified at neighborhood and community levels using GIS. A second survey in an independent sample ( n =408) assessed test–retest reliability. Results When assessing perceptions of environmental and physical activity in a defined geographic area, validity and reliability for neighborhood survey items were κ=−0.02 to 0.37 and rho=0.42 to 0.74, and for community survey items were κ=−0.07 to 0.25 and rho=0.28 to 0.56. Conclusions Although causality between perception of access and safety and actual physical activity level cannot be assumed, those meeting national physical activity guidelines or reporting some physical activity demonstrated greatest agreement with access to recreation facilities, while those not meeting the guidelines demonstrated greater agreement with safety of recreation facilities. Factors such as distance and behavior may explain differences in perceptions at neighborhood and community levels. Using local environments with short distances in survey methods improves validity and reliability of results.

Background: The potential of mHealth technologies in the care of patients with diabetes and other chronic conditions has captured the attention of clinicians and researchers. Efforts to date have incorporated a variety of tools and techniques, including Web-based portals, short message service (SMS) text messaging, remote collection of biometric data, electronic coaching, electronic-based health education, secure email communication between visits, and electronic collection of lifestyle and quality-of-life surveys. Each of these tools, used alone or in combination, have demonstrated varying degrees of effectiveness. Some of the more promising results have been demonstrated using regular collection of biometric devices, SMS text messaging, secure email communication with clinical teams, and regular reporting of quality-of-life variables. In this study, we seek to incorporate several of the most promising mHealth capabilities in a patient-centered medical home (PCMH) workflow. Objective: We aim to address underlying technology needs and gaps related to the use of mHealth technology and the activation of patients living with type 2 diabetes. Stated differently, we enable supporting technologies while seeking to influence patient activation and self-care activities. Methods: This is a multisite phased study, conducted within the US Military Health System, that includes a user-centered design phase and a PCMH-based feasibility trial. In phase 1, we will assess both patient and provider preferences regarding the enhancement of the enabling technology capabilities for type 2 diabetes chronic care management. Phase 2 research will be a single-blinded 12-month feasibility study that incorporates randomization principles. Phase 2 research will seek to improve patient activation and self-care activities through the use of the Mobile Health Care Environment with tailored behavioral messaging. The primary outcome measure is the Patient Activation Measure scores. Secondary outcome measures are Summary of Diabetes Self-care Activities Measure scores, clinical measures, comorbid conditions, health services resource consumption, and technology system usage statistics. Results: We have completed phase 1 data collection. Formal analysis of phase 1 data has not been completed. We have obtained institutional review board approval and began phase 1 research in late fall 2016. Conclusions: The study hypotheses suggest that patients can, and will, improve their activation in chronic care management. Improved activation should translate into improved diabetes self-care. Expected benefits of this research to the scientific community and health care services include improved understanding of how to leverage mHealth technology to activate patients living with type 2 diabetes in self-management behaviors. The research will shed light on implementation strategies in integrating mHealth into the clinical workflow of the PCMH setting. Clinical Trial: ClinicalTrials.gov NCT02949037. https://clinicaltrials.gov/ct2/show/NCT02949037. (Archived by WebCite at http://www.webcitation.org/6oRyDzqei) [JMIR Res Protoc 2017;6(3):e38]

Approximately two thirds of those older than 60 years have a hypertension diagnosis. The aim of our program, Health Coaches for Hypertension Control, is to improve hypertension self-management among rural residents older than 60 years through education and support offered by trained community volunteers called Health Coaches. Participants received baseline and follow-up health risk appraisals with blood work, educational materials, and items such as blood pressure monitors and pedometers. Data were collected at baseline, 8 weeks, and 16 weeks on 146 participants who demonstrated statistically significant increases in hypertension-related knowledge from baseline to 8 weeks that persisted at 16 weeks, as well as significant improvements in stage of readiness to change behaviors and in actual behaviors. Furthermore, clinically significant decreases in all outcome measures were observed, with statistically significant changes in systolic blood pressure (−5.781 mmHg; p = .001), weight (−2.475 lb; p < .001), and glucose (−5.096 mg/dl; p = .004) after adjusting for multiple comparisons. Although 40.4% of participants met the Healthy People 2020 definition of controlled hypertension at baseline, the proportion of participants meeting this definition at 16 weeks postintervention increased to 51.0%. This article describes a university–community–hospital system model that effectively promotes hypertension self-management in a rural Appalachian community.

OBJECTIVE To examine the relationships between 2 parenting styles and family nutrition and physical activity. METHODS Parents of elementary/primary school children in the southeastern United States (N = 145) completed surveys regarding family relationships and health behaviors. RESULTS Parents exhibiting a laissez-faire parenting style reported lower levels of family nutrition and physical activity. In addition, parent BMI moderated the relationship between laissez-faire parenting and these health behaviors. CONCLUSIONS This study indicates that family-oriented nutrition and physical activity programs may benefit from including a focus on decreasing laissez-faire parenting, as well as helping overweight parents reduce their BMIs.

In developing recommendations for core measures/items for the evaluation of the Youth Expanded Food and Nutrition Education Program (EFNEP), three nutrition education curricula, implemented by land grant universities, were content analyzed. Selection criteria included the following: Curriculum content must include all EFNEP core content areas and must be implemented in more than one state with school children in third through fifth grades. Content analysis strategies were employed to identify and describe common areas/themes and mediators of behaviors addressed across the selected curricula. Content analysis coding was based on a list of behavioral mediators, which have empirical associations with nutrition, physical activity, and food safety. The most evident approaches identified across the three curricula were to enhance motivation, teach cognitive knowledge, and practice behavioral skills. The presence of self-regulation and environmental theory–based strategies was limited in all three curricula. In addition, multiple themes for nutrition, physical activity, and food safety were commonly addressed across curricula with multiple educational strategies. Based on these findings, recommendations for developing content appropriate measures and items for an outcome evaluation tool for Youth EFNEP are provided.

The Southeast United States has experienced rapid growth in the Latino population - mostly Mexican immigrants - with the number of Latinos in the region nearly quadrupling over the past decade. These states, known as new settlement areas, are not as well prepared to meet the health needs of Spanish-speaking immigrants compared to traditional settlement states like Florida, Texas, and California. Unfortunately for these families, immigration to the United States is often associated with becoming obese, or having children at a higher risk for obesity. Rates of obesity have risen dramatically among all racial and ethnic groups in the past few decades, however, Latinos of all ages have the highest rates of overweight and obesity compared to other racial and ethnic groups. One explanation is that although adjustment to a new environment and culture takes considerable time, the adoption of a more sedentary lifestyle and unhealthy diet occurs more rapidly, leading to significant increases in obesity between first and subsequent generations. Families are important referents in establishing health behaviors in children, and there are broader social and physical environmental factors that have strong associations with the development of obesity as well. Moreover, immigrant families must strive to be healthy while coping with acculturative stressors. Relationships between all of these factors are typically studied in isolation. This article explores obesity among new settlement Latino families and provides an integrated conceptual model anchored in the social ecological perspective.

Athletic injury risk in youth is known to be greater in organised sport, higher levels of competition, games, and tournaments, yet young athletes are often expected to participate in tournaments that involve multiple matches per day on consecutive days. In 2006 and 2008 injury rates were observed during a club youth soccer tournament that involved athletes aged 9-18 years playing three to four matches over two consecutive days, to determine if injury risk varied over the course of the event. The injury rate for day 1 was 7.91/1000 hours with a mean severity of 3.5 days missed versus a day 2 rate of 6.75 and severity of 2.3. The rate and severity for the first game in a day were 7.13 and 3.5 respectively compared to 7.9 and 2.5 for game 2. Further research is needed to determine if a high density match schedule increases injury risk for youth soccer players.

Background Although school-based behavioral interventions for increasing physical activity (PA) in children and adolescents have been conducted, little evidence suggests that these curriculum-based approaches lead to increases in overall activity outside of program days. The overall goal of the “Active by Choice Today” (ACT) trial is to expand the body of knowledge concerning the factors that influence long-term increases in PA in underserved adolescents (low socioeconmic status, minorities) during their middle school years. Design and setting An overview of the ACT study design, theoretical framework, process evaluation, and primary hypotheses is presented. The trial involves twenty-four middle schools (1560 6th graders) in South Carolina that are randomly assigned to one of two after-school programs (motivational and life skills intervention, or general health education). Intervention The intervention integrates constructs from Self-Determination and Social Cognitive Theories to enhance intrinsic motivation and behavioral skills for PA. The intervention targets skill development for PA outside of program days and the after-school program social environment (autonomy, choice, participation, belongingness, fun, enjoyment, support) is designed to positively impact cognitive mediators (self-efficacy, perceived competence), and motivational orientation (intrinsic motivation, commitment, positive self-concept). Main hypotheses/outcomes It is hypothesized that the 17-week motivational and life skills intervention will lead to greater increases in moderate-to-vigorous PA (based on 7-day accelerometry estimates) at post-intervention as compared to the general health education program. Conclusions Implications of this innovative school-based trial are discussed.

Background—Previous studies have shown that choice and self-initiated behavior change are important for increasing intrinsic motivation and physical activity (PA), however, little of this research has focused on underserved adolescents. Purpose—This study examined the effects of a 4-week student-centered intervention on increasing PA in underserved adolescents. Methods—Twenty-eight students in the intervention school were matched (on race, percentage on free or reduced-price lunch program, gender, and age) with 20 students from another school who served as the comparison group (30 girls, 18 boys; ages 10–12 years; 83% African American; 83% on free or reduced-price lunch). The student-centered intervention was consistent with selfdetermination (motivation) theory and social cognitive theory in that it emphasized increasing intrinsic motivation and behavioral skills for PA. Intervention adolescents took ownership in selecting a variety of PA activities in which to participate, and they generated coping strategies for making effective PA behavior changes. Results—Intervention participants showed greater increases in accelerometer estimates of time spent in moderate PA, moderate-to-vigorous PA, and vigorous PA from baseline to Week 4 of the intervention than the comparison group. Intervention participants also showed greater increases in PA motivation and positive self-concept for PA than comparison adolescents. Conclusions—This study provides preliminary evidence that increasing adolescent involvement and choice of activities may be important in developing future PA interventions for underserved adolescents.

The use of a geographic information system (GIS) to study environmental supports for physical activity raises several issues, including acquisition and development, quality, and analysis. We recommend to public health professionals interested in using GIS that they investigate available data, plan for data development where none exists, ensure the availability of trained personnel and sufficient time, and consider issues such as data quality, analyses, and confidentiality. This article shares information about data-related issues that we encountered when using GIS to validate responses to a questionnaire about environmental supports for physical activity.

The importance of regular physical activity is well documented, yet according to epidemiological surveillance data, physical inactivity among all age groups persists. Past attempts to promote physical activity focused on individual-level changes; current approaches focus on environmental changes that will provide opportunities for whole communities to be active. The current ecological focus has led to an increase in funding and research regarding environmental supports of physical activity. As this is a new area of research, much work needs to be done to improve the ability to assess environmental features that support physical activity. This article describes a partnership between researchers and community members to develop and test an objective tool to measure sidewalk maintenance. Community members used data collected with the tool to increase awareness about sidewalk maintenance issues among local policy makers. Collaboration between researchers and community partners was critical for the success of this study.

Valid assessment of physical activity is necessary to fully understand this important health-related behaviour for research, surveillance, intervention and evaluation purposes. This article is the second in a companion set exploring the validity of pedometer-assessed physical activity. The previous article published in Sports Medicine dealt with convergent validity (i.e. the extent to which an instrument's output is associated with that of other instruments intended to measure the same exposure of interest). The present focus is on construct validity. Construct validity is the extent to which the measurement corresponds with other measures of theoretically-related parameters. Construct validity is typically evaluated by correlational analysis, that is, the magnitude of concordance between two measures (e.g. pedometer-determined steps/day and a theoretically-related parameter such as age, anthropometric measures and fitness). A systematic literature review produced 29 articles published sinceor =1980 directly relevant to construct validity of pedometers in relation to age, anthropometric measures and fitness. Reported correlations were combined and a median r-value was computed. Overall, there was a weak inverse relationship (median r = -0.21) between age and pedometer-determined physical activity. A weak inverse relationship was also apparent with both body mass index and percentage overweight (median r = -0.27 and r = -0.22, respectively). Positive relationships regarding indicators of fitness ranged from weak to moderate depending on the fitness measure utilised: 6-minute walk test (median r = 0.69), timed treadmill test (median r = 0.41) and estimated maximum oxygen uptake (median r = 0.22). Studies are warranted to assess the relationship of pedometer-determined physical activity with other important health-related outcomes including blood pressure and physiological parameters such as blood glucose and lipid profiles. The aggregated evidence of convergent validity (presented in the previous companion article) and construct validity herein provides support for considering simple and inexpensive pedometers in both research and practice.

Perceptions of the environment and physical activity have been associated using survey methods, yet little is known about the validity of environmental surveys. In this study, perceptions of the environment at neighborhood and community levels were assessed (1) to determine validity by comparing respondent perceptions to objective measures and (2) to determine test-retest reliability of the survey.A telephone survey was administered to a stratified sample of Sumter County, South Carolina adults. Respondents' home addresses were mapped using a geographic information system (GIS) (n =1112). As an indicator of validity, kappa statistics were used to measure agreement between perceptions and objective measures identified at neighborhood and community levels using GIS. A second survey in an independent sample (n=408) assessed test-retest reliability.When assessing perceptions of environmental and physical activity in a defined geographic area, validity and reliability for neighborhood survey items were kappa= -0.02 to 0.37 and rho=0.42 to 0.74, and for community survey items were kappa= -0.07 to 0.25 and rho=0.28 to 0.56.Although causality between perception of access and safety and actual physical activity level cannot be assumed, those meeting national physical activity guidelines or reporting some physical activity demonstrated greatest agreement with access to recreation facilities, while those not meeting the guidelines demonstrated greater agreement with safety of recreation facilities. Factors such as distance and behavior may explain differences in perceptions at neighborhood and community levels. Using local environments with short distances in survey methods improves validity and reliability of results.