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Support provided by the US Food Stamp Program (FSP) is intended to promote health. The objective of this qualitative study was to examine food security for low-income Hawaii residents. A sample of low-income Hawaii residents (n = 86) were recruited to participate in a series of focus group discussions. Most participants were female (73.5%), Native Hawaiian/Pacific Islander (61.6%), ages 18-39 (62.7%), high school educated (80.5%), low-income (50.6% < $10,000), used food stamps (73.5%), and had 4.07 ± 2.89 persons per household. At 2 hour focus groups, participants received a healthy meal and a monetary incentive. Audio recordings were transcribed verbatim and analyzed using NVivo. Over 50% indicated FSP assistance was not enough. When this happened, most participants had alternatives including food banks, churches, friends and family members. Shopping strategies included budgeting, buying in bulk, or smarter shopping practices. Several participants were concerned about high living costs. Food insecurity should be addressed for FSP participants in Hawaii, with many residents not being able to meet nutritional and economic needs on their own. [ABSTRACT FROM AUTHOR]

A reliable two-factor instrument measuring appearance motivation attitudes for sun protection was developed using a longitudinal sample of beachgoers. At baseline, data on sun protection and appearance motivation attitudes were collected on 2324 individuals. Principal components analyses (PCA) indicated a two-factor solution measuring attitudes toward tan attractiveness and skin protection with only 2 items loading on the skin protection factor. At 12-months, the instrument was revised and shortened but including 3 new skin protection items. Split-half analyses were conducted to further refine and develop the instrument. PCA on half of the sample revealed a two-factor solution, which was confirmed using structural equation modeling on the remaining half. This resulted in a two correlated-factor, 10-item measure. Each factor was summed to create two scales. Both scales were internally consistent and demonstrated good external validity, correlating with sun protection specific Transtheoretical model variables. The tan attractiveness attitudes scale significantly improved prediction of sun protection outcomes over 24 months, over and above TTM variables. [ABSTRACT FROM AUTHOR]

PURPOSE: Investigate physical activity and related psychosocial factors reported by new mothers. METHODS: Women (N = 79) were surveyed to determine their physical activity patterns before and after childbirth. Barriers and facilitators of physical activity were also identified. FINDINGS: Most women (63%) were ethnic minorities, mean age was 31.8 +/- 5.5 years, and their infants' mean age was 8.2 +/- 3.8 months. Combining women's reported physical activity before their pregnancy and after childbirth resulted in four significantly different groups: (1) 21.5% were inactive before and after birth; (2) 22.7% were active before and after; (3) 12.6% were inactive before, but active after birth; and (4) 43.0% were active before but inactive or irregularly active postpartum (p < .0003). Barriers to physical activity included personal issues, including lack of support from a spouse, and parenting duties. Facilitators to being active included social support for exercise and availability of childcare. CONCLUSIONS: New mothers are at high risk for inactivity and reductions in previously established levels of physical activity. They also have specific barriers and facilitators to being physically active. Future research should develop effective methods for increasing physical activity in mothers of infants. [ABSTRACT FROM AUTHOR]

Purpose: This study examined correlates of park-based physical activity (PA) among children in neighborhood parks.Design: Direct observation was used to assess PA among children.Setting: Public parks in Tampa, Florida (n=10), and Chicago, Illinois (n=18), from low income and high income and racially/ethnically diverse communities. Subjects. Children (n=3410), coded as anyone who appeared to be 10 years or younger, observed at parks in Tampa and Chicago.Measures: Physical activity was measured by a modified version of the System for Observing Play and Leisure Among Youth (SOPLAY).Analysis: Descriptive statistics and multilevel regression models were used in data analysis.Results: At the activity observation level, children's PA was positively related to temperature and unstructured activities in Tampa and Chicago parks. Among park activity area predictors, type of activity area was significantly related to PA. In Tampa, more PA was observed on courts, and less PA was observed in shelter areas compared with open space areas. In Chicago, less PA was observed on courts and fields compared with open space areas. Neighborhood income was associated with lower PA in Tampa parks. Neighborhood race/ethnicity was not a significant predictor of children's PA in either city.Conclusions: Children's PA was linked to modifiable social and environmental features within parks. Strategies to increase PA among children in parks should promote courts, playgrounds, informal activities, and free play. [ABSTRACT FROM AUTHOR]

Background: Modifiable cardiovascular risk factors constitute a significant cause of cardiovascular disease and mortality among patients with cancer. Recent studies suggest a potential link between neighborhood walkability and favorable cardiovascular risk factor profiles in the general population., Objectives: This study aimed to investigate whether neighborhood walkability is correlated with favorable cardiovascular risk factor profiles among patients with a history of cancer., Methods: We conducted a cross-sectional study using data from the Houston Methodist Learning Health System Outpatient Registry (2016-2022) comprising 1,171,768 adults aged 18 years and older. Neighborhood walkability was determined using the 2019 Walk Score and divided into 4 categories. Patients with a history of cancer were identified through International Classification of Diseases-10th Revision-Clinical Modification codes (C00-C96). We examined the prevalence and association between modifiable cardiovascular risk factors (hypertension, diabetes, smoking, dyslipidemia, and obesity) and neighborhood walkability categories in cancer patients., Results: The study included 121,109 patients with a history of cancer; 56.7% were female patients, and 68.8% were non-Hispanic Whites, with a mean age of 67.3 years. The prevalence of modifiable cardiovascular risk factors was lower among participants residing in the most walkable neighborhoods compared with those in the least walkable neighborhoods (76.7% and 86.0%, respectively). Patients with a history of cancer living in very walkable neighborhoods were 16% less likely to have any risk factor compared with car-dependent-all errands neighborhoods (adjusted OR: 0.84, 95% CI: 0.78-0.92). Sensitivity analyses considering the timing of events yielded similar results., Conclusions: Our findings demonstrate an association between neighborhood walkability and the burden of modifiable cardiovascular risk factors among patients with a medical history of cancer. Investments in walkable neighborhoods may present a viable opportunity for mitigating the growing burden of modifiable cardiovascular risk factors among patients with a history of cancer., Competing Interests: The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2024 The Authors.)

Introduction: Time spent in nature provides myriad physical and mental health benefits for both adults and children. Despite these benefits, most people spend too little time in nature to realize the maximal effect. Different types of childhood experiences may have differential influence on adult time in nature. This study assessed the influences of different kinds of childhood outdoor experiences on time spent in nature as an adult. The first aim was to utilize 20 childhood nature experience items to construct summative scales. The second aim was to examine the influence of each scale and other factors on adult time in nature., Methods: A 2-factor scale measuring wild and domesticated childhood nature experiences was developed using principal and confirmatory factor analyses. An online study of 2,109 American adults was conducted. Multiple linear regression examined the influences of the 2 childhood nature experiences scales, attitude and self-efficacy scales, and sex and age covariates on adult time spent in nature., Results: Significant predictors of adult time in nature were wild childhood nature experiences (β=0.279, p <0.001), positive attitudes about nature (β=0.12, p <0.05), negative attitudes about nature (β= -0.23, p <0.001), and self-efficacy (β=0.71, p <0.001)., Conclusions: Wild childhood nature experiences (e.g., camping, hiking, and fishing) that include skill building, that are immersive and engaging, and that involve opportunity for social interaction may translate better into adult nature activities. Programs that introduce and support wild experiences may increase lifelong time spent in nature., (© 2024 The Authors.)

In this cross-sectional study, we examined the impact of access to nature on mental health utilization in urban neighborhoods using Texas outpatient encounters data merged with NatureScore TM (0-100; low to high nature levels) and US census data (household income, education, employment, poverty, and insurance coverage) at the zipcode level. Our sample size included 61 million outpatient encounters across 1169 zipcodes, with 63% women and 30% elderly. A total of 369,344 mental health encounters were identified, with anxiety/stress and depression encounters representing 68.3% and 23.6%, respectively. We found that neighborhoods with a NatureScore of 60+ had lower overall mental health utilization than those below 40 (RR 0.51, 95%CI 0.38-0.69). This relationship persisted for depression, bipolar disorder, and anxiety/stress and in neighborhoods with a NatureScore above 80 ( p < 0.001). Compared to neighborhoods with a NatureScore below 40, those above 80 had significantly lower depression (aRR 0.68, 95%CI 0.49-0.95) and bipolar (aRR 0.59, 95%CI 0.36-0.99) health encounters after adjusting for demographic and socioeconomic factors. This novel approach, utilizing NatureScore as a proxy for urban greenness, demonstrates the correlation between a higher NatureScore and reduced mental health utilization. Our findings highlight the importance of integrating nature into our healthcare strategies to promote well-being and mental health.

Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: There has been limited research on college campus' green spaces and their benefits to students. This study aimed to identify relationships between a Texas campus's green spaces and students' knowledge of their health benefits and their perception of their health compared to the campus' indoor built environments., Methods: Photovoice was utilized to answer this study's research questions. Participants were instructed to take a photograph inside a building on campus and one outdoors anywhere on campus. Participants answered a questionnaire containing health-related questions, demographics, and nature relationship questions. Additionally, there was an in-class analysis and discussion to characterize overarching themes, knowledge, and evoked emotions. Frequencies, percentages, and a paired t-test were utilized to investigate the hypothesis that through the application of photovoice, participants would display more knowledge of nature's health benefits and a better perception of areas providing emotional, mental, physical, and social health benefits when in these green spaces compared to the indoor built environments on campus., Results: 122 students took photographs and answered the questionnaire. 91 students participated in the in-class discussion. Most students felt more positive (80%) and perceived better health with their outdoor location compared to their indoor. They also responded higher to having more positive overall health benefits (63%) outdoors than indoors., Conclusions: These findings further solidified nature improves overall mood, there is a positive relationship between health and nature, and people are aware of it. Future studies should attempt to identify barriers accessing campus green spaces and develop interventions to encourage students to utilize these spaces., (© 2023. The Author(s).)

Background: The growth of urban dwelling populations globally has led to rapid increases of research and policy initiatives addressing associations between the built environment and physical activity (PA). Given this rapid proliferation, it is important to identify priority areas and research questions for moving the field forward. The objective of this study was to identify and compare research priorities on the built environment and PA among researchers and knowledge users (e.g., policy makers, practitioners)., Methods: Between September 2022 and April 2023, a three-round, modified Delphi survey was conducted among two independent panels of international researchers (n = 38) and knowledge users (n = 23) to identify similarities and differences in perceived research priorities on the built environment and PA and generate twin 'top 10' lists of the most important research needs., Results: From a broad range of self-identified issues, both panels ranked in common the most pressing research priorities including stronger study designs such as natural experiments, research that examines inequalities and inequities, establishing the cost effectiveness of interventions, safety and injuries related to engagement in active transportation (AT), and considerations for climate change and climate adaptation. Additional priorities identified by researchers included: implementation science, research that incorporates Indigenous perspectives, land-use policies, built environments that support active aging, and participatory research. Additional priorities identified by knowledge users included: built environments and PA among people living with disabilities and a need for national data on trip chaining, multi-modal travel, and non-work or school-related AT., Conclusions: Five common research priorities between the two groups emerged, including (1) to better understand causality, (2) interactions with the natural environment, (3) economic evaluations, (4) social disparities, and (5) preventable AT-related injuries. The findings may help set directions for future research, interdisciplinary and intersectoral collaborations, and funding opportunities., (© 2023. Crown.)

Background: Rural residents generally lack adequate physical activity to benefit health and reduce disparities in chronic diseases, such as cardiovascular disease and certain cancers. The Socioecological Model describes physical activity as involving a dynamic and reciprocal interaction between individual, social, and community factors. Community group-based walking programs and civic engagement interventions aimed at enhancing physical activity have been successful in rural communities but have not targeted all three socioecological levels. Public libraries can act as innovative public health partners in rural communities. However, challenges remain because rural libraries often lack the capacity to implement evidence-based health promotion programming. The goals of this study are (1) build the capacity for rural libraries to implement evidence-based health promotion programs, (2) compare changes in physical activity between a group-based walking program and a combined group-based walking and civic engagement program with rural residents, and (3) conduct an implementation evaluation., Methods: We will conduct a comparative effectiveness study of a group-based walking (standard approach) versus a group-based walking plus civic engagement program (combined approach) aimed at enhancing walkability to increase physical activity among rural adults. Key mediators between the program effects and change in outcomes will also be identified. Finally, we will evaluate program implementation, conduct a cost effectiveness evaluation, and use a positive deviance analysis to understand experiences of high and low changers on key outcomes. Twenty towns will be matched and randomized to one of the two conditions and our aim is to enroll a total of 350-400 rural residents (15-20 per town). Study outcomes will be assessed at baseline, and 6, 12, and 24 months., Discussion: This study will build the capacity of rural libraries to implement evidence-based walking programs as well as other health promotion programs in their communities. The study results will answer questions regarding the relative effectiveness and cost effectiveness of two multilevel physical activity interventions targeting rural communities. We will learn what works and how these multilevel interventions can be implemented in rural populations., Trial Registration: ClinicalTrials.gov Identifier: NCT05677906., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Successful recruitment into randomized trials and interventions is essential to advance scientific knowledge to improve health. This rapid assessment study explored how the COVID-19 pandemic affected participant recruitment overall, identified how it exacerbated existing challenges to recruit hard-to-reach populations, and described how NIH-funded Principal Investigators (PIs) responded to COVID-era recruitment challenges. A cross-sectional survey of NIH-funded PIs conducting interventions and trials related to health behaviors was conducted in 2022. The survey was completed by 52 PIs, most of whom were highly experienced in this type of research. Eighteen PIs reported it was very difficult to recruit participants now (39.1%) compared to before COVID-19 when only one did (2.2%). PIs reported changing recruitment and data collection methods (29.4%), increasing staff dedicated to recruitment (29.4%), and increasing participant compensation (23.5%). Recruitment methods shifted from in-person activities to social media and other electronic communications. Barriers to recruitment included reluctance to participate in research, COVID-19 protocols and precautions, overwhelmed community partners, staff burnout and turnover, and limited access to technology for some populations that were already hard to reach. Facilitators to recruitment consisted of increased access and ability to use remote technologies, use of social media, strong community ties, and wanting to be part of something positive. PIs perceived recruitment as much more difficult after the onset of COVID-19, though research teams were able to pivot to more online and remote options. These tools may have a lasting impact in modernizing recruitment, data collection, and intervention techniques in future trials., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Little is known about pandemic-related impacts on participant recruitment into community-based health studies during the COVID-19 pandemic. The aim of this report was to summarize lessons learned from principal investigators (PIs) of NIH-funded community-based health behavior studies that were scheduled to recruit during the COVID-19 pandemic. We report on findings from three open-ended questions that were part of a 50-question online survey conducted from December 2022 - January 2023, completed by 52 PIs. Four categories of lessons emerged to optimize recruitment into studies: formalize relationships with community partnerships; focus on study operations; recruitment is a science and an art; and reduce participant burden and increase participant benefit. Taken together, these recommendations will require longer and more complex recruitment plans. To implement these plans, researchers and funders will need to allocate more time, thoughtful attention, and financial resources to support formal community partnerships, additional staff time and training, real-time monitoring and refinement of multiple strategies throughout recruitment, and increased attention to participant benefit., Competing Interests: Conflict of Interest: None declared.

Objectives: In Africa and Asia, 190 million preschoolers are vitamin A deficient. This study examined the social determinants of intake of vitamin A supplementation (VAS) among children aged 6-59 months during three different time periods in Kenya to identify those most vulnerable to vitamin A deficiency and highlight the varied targeting and outreach efforts; before the onset of a national restructuring and targeted distribution of VAS in children below 5 years through a twice-yearly door-to-door campaign called Child Health Weeks, during the implementation period, and several years later., Methods: The cross-sectional, national Demographic and Health Surveys were administered in Kenya in 2003, 2008-09, and 2014. Bivariate and multivariable logistic regression analyses were used to assess variables associated with VAS among children (n = 28,239)., Results: An overall two-fold increase in VAS was recorded between 2003 (31.8%) and 2014 (67.5%). In 2008-09, children aged 6-11 months were the most likely to receive VAS. In 2003 and 2014, geographical regions and settings, birth order of the child, educational level of the mother, religion, wealth index, number of antenatal visits, and access to a radio were identified as being significantly associated with VAS, in at least one of the years. These determinants were not significant in 2008-09 during the initial Child Health Weeks promotion campaign. The determinants of VAS varied during the three study periods, particularly in 2008-09 when the Child Health Weeks was first implemented., Conclusion: As efforts to increase VAS continue, addressing child-specific determinants will be essential to reduce health disparities., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

This is the first study to investigate the relationship between neighborhood walkability and cardiovascular (CV) risk factors in the United States using a large population-based database. Cross-sectional study using data from 1.1 million patients over the age of 18 in the Houston Methodist Learning Health System Outpatient Registry (2016-2022). Using the 2019 WalkScore, patients were assigned to one of the 4 neighborhood walkability categories. The burden of CV risk factors (hypertension, diabetes, obesity, dyslipidemia, and smoking) was defined as poor, average, or optimal (>3, 1-2, 0 risk factors, respectively). We included 887,654 patients, of which 86% resided in the two least walkable neighborhoods. The prevalence of CV risk factors was significantly lower among participants in the most walkable neighborhoods irrespective of ASCVD status. After adjusting for age, sex, race/ethnicity, and socioeconomic factors, we found that adults living in the most walkable neighborhoods were more likely to have optimal CV risk profile than those in the least walkable ones (RRR 2.77, 95% CI 2.64-2.91). We observed an inverse association between neighborhood walkability and the burden of CV risk factors. These findings support multilevel health system stakeholder engagements and investments in walkable neighborhoods as a viable tool for mitigating the growing burden of modifiable CV risk factors., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Rural communities are at higher risk for physical inactivity, poor dietary behaviors, and related chronic diseases and obesity. These disparities are largely driven by built environment, socioeconomic, and social factors. A community-based cluster randomized controlled trial of an intervention, the Change Club, aims to address some of these disparities via civic engagement for built environment change. Baseline data collection began in February 2020, only to be paused by the COVID-19 pandemic. In this context, the investigators evaluated multiple approaches for collecting data when the study resumed, focusing on Life’s Simple 7, and additional anthropometric, physiologic, and behavioral outcomes in rural and micropolitan (<50,000 population) communities in Texas and New York. Life’s Simple 7 includes fasting blood glucose, total cholesterol, blood pressure, weight, physical activity, diet, and smoking. Rigor and feasibility were considered across a variety of in-person versus at-home measurement options. After a comprehensive input from participants, partners, staff, researchers, and the funding liaison, the study team chose self-measurement and use of validated questionnaires/surveys to measure the Life’s Simple 7 components. This case provides an example of how a study team might adjust data collection protocol during unexpected and acute events while giving consideration to rigor, feasibility, stakeholder views, and participants’ health and safety.

Background: Physical inactivity is a risk factor for numerous adverse health conditions and outcomes, including all-cause mortality. Aging rural women are at particular risk for physical inactivity based on environmental, sociocultural, and psychosocial factors. This study reports on changes in physical activity and associated factors from a multicomponent community-engaged intervention trial., Methods: Strong Hearts, Healthy Communities 2.0 (SHHC-2.0) was a 24-week cluster (community) randomized controlled trial building on the results from the previous trial of SHHC-1.0. Rural women (n = 182) aged 40 and over living in 11 rural communities in upstate New York were recruited. The intervention consisted of twice-weekly experiential classes focused on exercise, nutrition, and civic engagement. Physical activity outcomes included accelerometry and self-report as well as related psychosocial measures at midpoint (12 weeks) and post-intervention (24 weeks). Data were analyzed using multilevel linear regression models with the community as the random effect., Results: Compared to participants from the control communities, participants in the intervention communities showed a significant increase in objectively measured moderate to vigorous intensity physical activity: at 12 weeks (increase of 8.1 min per day, P < 0.001) and at 24 weeks (increase of 6.4 min per day; P = 0.011). Self-reported total MET minutes per week also increased: at 12 weeks (increase of 725.8, P = 0.003) and 24 weeks (increase of 955.9, P = 0.002). Several of the psychosocial variables also showed significant positive changes., Conclusions: The SHHC-2.0 intervention successfully increased physical activity level and related outcome measures. Modifications made based upon in-depth process evaluation from SHHC-1.0 appear to have been effective in increasing physical activity in this at-risk population., Trial Registration: Clinicaltrials.gov: NCT03059472. Registered 23 February 2017., (© 2022. The Author(s).)

Background: Cardiovascular disease is the leading cause of death in the United States; however, women and rural residents face notable health disparities compared with male and urban counterparts. Community-engaged programs hold promise to help address disparities through health behavior change and maintenance, the latter of which is critical to achieving clinical improvements and public health impact., Methods: A cluster-randomized controlled trial of Strong Hearts, Healthy Communities-2.0 conducted in medically underserved rural communities examined health outcomes and maintenance among women aged ≥40 years, who had a body mass index >30 or body mass index 25 to 30 and also sedentary. The multilevel intervention provided 24 weeks of twice-weekly classes with strength training, aerobic exercise, and skill-based nutrition education (individual and social levels), and civic engagement components related to healthy food and physical activity environments (community, environment, and policy levels). The primary outcome was change in weight; additional clinical and functional fitness measures were secondary outcomes. Mixed linear models were used to compare between-group changes at intervention end (24 weeks); subgroup analyses among women aged ≥60 years were also conducted. Following a 24-week no-contact period, data were collected among intervention participants only to evaluate maintenance., Results: Five communities were randomized to the intervention and 6 to the control (87 and 95 women, respectively). Significant improvements were observed for intervention versus controls in body weight (mean difference: -3.15 kg [95% CI, -4.98 to -1.32]; P =0.008) and several secondary clinical (eg, waist circumference: -3.02 cm [-5.31 to -0.73], P =0.010; systolic blood pressure: -6.64 mmHg [-12.67 to -0.62], P =0.031; percent body fat: -2.32% [-3.40 to -1.24]; P <0.001) and functional fitness outcomes; results were similar for women aged ≥60 years. The within-group analysis strongly suggests maintenance or further improvement in outcomes at 48 weeks., Conclusions: This cardiovascular disease prevention intervention demonstrated significant, clinically meaningful improvements and maintenance among rural, at-risk older women., Registration: URL: https://www., Clinicaltrials: gov; Unique identifier: NCT03059472.

Background: Prior studies demonstrate associations between risk factors for obesity and related chronic diseases (e.g., cardiovascular disease) and features of the built environment. This is particularly true for rural populations, who have higher rates of obesity, cancer, and other chronic diseases than urban residents. There is also evidence linking health behaviors and outcomes to social factors such as social support, opposition, and norms. Thus, overlapping social networks that have a high degree of social capital and community cohesion, such as those found in rural communities, may be effective targets for introducing and maintaining healthy behaviors., Methods: This study will evaluate the effectiveness of the Change Club (CC) intervention, a civic engagement intervention for built environment change to improve health behaviors and outcomes for residents of rural communities. The CC intervention provides small groups of community residents (approximately 10-14 people) with nutrition and physical activity lessons and stepwise built environment change planning workshops delivered by trained extension educators via in-person, virtual, or hybrid methods. We will conduct process, multilevel outcome, and cost evaluations of implementation of the CC intervention in a cluster randomized controlled trial in 10 communities across two states using a two-arm parallel design. Change in the primary outcome, American Heart Association's Life's Simple 7 composite cardiovascular health score, will be evaluated among CC members, their friends and family members, and other community residents and compared to comparable samples in control communities. We will also evaluate changes at the social/collective level (e.g., social cohesion, social trust) and examine costs as well as barriers and facilitators to implementation., Discussion: Our central hypothesis is the CC intervention will improve health behaviors and outcomes among engaged citizens and their family and friends within 24 months. Furthermore, we hypothesize that positive changes will catalyze critical steps in the pathway to improving longer-term health among community residents through improved healthy eating and physical activity opportunities. This study also represents a unique opportunity to evaluate process and cost-related data, which will provide key insights into the viability of this approach for widespread dissemination., Trial Registration: ClinicalTrials.gov: NCT05002660 , Registered 12 August 2021., (© 2022. The Author(s).)

The built environment can influence physical activity behavior. Walk Score is a widely used measure of the neighborhood built environment to support walking. However, studies of the association between Walk Score and accelerometer-measured physical activity are equivocal and no studies have examined this relationship among older adults. We analyzed data from a large, diverse sample of women (n = 5650) with a mean age of 79.5 (SD = 6.7) at time of accelerometry wear in the Women's Health Initiative Objective Physical Activity Cardiovascular Health Study in the United States to examine associations between neighborhood Street Smart Walk Score (SSWS) and accelerometer-measured physical activity. Participants wore triaxial accelerometers for seven days and SSWS was determined from home addresses. 67 % of the sample lived in "car-dependent" locations (SSWS 0-49 out of 100); only 3 % lived in "walker's paradise" locations (SSWS 90-100). The multivariable model indicated an association between SSWS and accelerometer-measured physical activity (steps/day) in the total sample. The association varied by neighborhood socioeconomic status; in high socioeconomic status neighborhoods, higher SWSS was associated with greater steps per day, while no significant association between SWSS and physical activity was observed in low socioeconomic neighborhoods. This study should catalyze furtherresearch regarding the utility of SSWS in determining neighborhood walkability for older women across different neighborhood settings and suggests other built environment factors must be considered when determining walkability. Future studies should examine what factors influence walkability and develop age-relevant methods to assess and characterize neighborhood walkability., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Authors.)

Competing Interests: Conflict of Interest We have no conflicts of interest to disclose.

Purpose: The purpose of this study was to develop and evaluate the reliability and validity of self-efficacy and intentions measures for time spent in nature (TSN). TSN is related to improvement in psychological well-being and health, yet most American adults spend very little time in such settings. Theory-based interventions have been effective in increasing physical activity, a related behavior, and may be one mechanism to increase TSN. Self-efficacy and intentions have been shown to be strong predictors of health behaviors and are used across several theories. However, scales to measure these factors have not yet been developed and are needed to facilitate effective interventions., Methods: TSN self-efficacy and intentions scales were developed using a sequential nine-step procedure: identification of the domain and item generation; content validity; pre-testing of questions; sampling and survey administration; item reduction; extraction of factors; tests of dimensionality; tests of reliability; and tests of validity. The 14-member multidisciplinary, researcher and practitioner investigative team generated 50 unique items for self-efficacy and 24 unique items for intentions. After subjecting items to content validity and pre-testing, item sets were reduced to 21 assessing self-efficacy and nine assessing intentions. A nationwide sample of 2109 adult participants (49.7% female, Mean Age = 58.1; 59.8% White, 18.4% Hispanic, 13.3% Black) answered these items via an on-line survey., Results: Using split-half measures, principal components analysis indicated a one-factor solution for both scales. The factor structure was upheld in confirmatory factor analyses and had high internal consistency (α = .93 self-efficacy; .91 intentions). The scales were moderately correlated with each other (r = .56, p < .001) and were strongly related to TSN with large effect sizes (eta 2  > .20)., Conclusions: The study resulted in reliable and valid self-efficacy (14 items) and intentions (8 items) scales that can be used to develop future theory-based interventions to increase TSN and thereby improve population health., (© 2022. The Author(s).)

Despite near universal health insurance coverage in China, populations with low incomes may still face barriers in access and utilization of affordable health care. We aimed to identify the likelihood of forgone medical care due to cost by surveying individuals from the community to assess: (1) The percent with forgone medical care due to cost; and (2) Factors associated with forgone medical care due to cost. Surveys conducted (2016-2017) in Mandarin included demographic and medical care utilization-related items. Theoretically-informed, fully-adjusted analyses were employed. Approximately 94% of respondents had health insurance, which is somewhat similar to national estimates. Overall, 24% of respondents resided in rural areas, with 18% having less than a high school education, and 49% being male. More than 36% reported forgone medical care due to cost in the past 12 months. In fully-adjusted analyses, having lower education, generally not being satisfied with the commute to the hospital, and being a resident of a province with a lower density of physicians were associated with forgone medical care. Cost-related disparities in the access and utilization of needed medical care persist, even with near universal health insurance, which may be due to one's satisfaction with travel time to healthcare and other community assets.

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 < 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.

Aims: To examine factors associated with undiagnosed diabetes in Namibia and South Africa., Methods: This study used the most recent Demographic and Health Surveys (DHS) from Namibia (2013) and South Africa (2016). This study focused on adults at 35-64 years old. Using Andersen's Behavioral Model, potential contributing factors were categorized into predisposing factors (sex and education), enabling factors (wealth, health insurance, and residence), and a need factor (age, BMI, and high blood pressure). Separate multivariable logistic regression models were used to examine factors associated with undiagnosed diabetes in Namibia (N = 242) and South Africa (N = 525)., Results: In Namibia, higher odds of having undiagnosed diabetes were associated with rural residence (adjusted odds ratio (aOR) = 2.21) and age younger than 45 years old (aOR = 3.20). In South Africa, odds of having undiagnosed diabetes were higher among the poorest-to-poorer group than it was in the richer-to-richest group (aOR = 2.33). In both countries, having high blood pressure was associated with lower odds of having undiagnosed diabetes (aOR = 0.31 in Namibia; aOR = 0.21 in South Africa)., Discussion: Different enabling and need factors were associated with undiagnosed diabetes in these two countries, which implies potentially-different mechanisms driving the high prevalence of undiagnosed diabetes, as well as the needs for different solutions., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Obesity is increasingly affecting Chinese adolescents due to trends in unhealthy eating, including lower fruit and vegetable consumption and increased consumption of processed foods. A cross-sectional study of adolescents was conducted in Wuhan, China, in October 2019 that included measurements of perceived social isolation, eating when anxious or depressed, diet composition, body weight, and height. Social isolation, eating when sad or anxious, and eating alone were significant predictors of processed food and sugar-sweetened beverage consumption, although only eating when sad or anxious was a significant predictor of fruit and vegetable consumption. Eating when anxious or depressed did not mediate these relationships. Social isolation was associated with consumption of processed foods and sugar-sweetened beverages by boys, but not by girls, and only eating home-cooked dinner was associated with fruit and vegetable consumption by female adolescents. Eating when sad or anxious, eating alone, and eating home-cooked meals were all associated with fruit and vegetable consumption among male adolescents. The effects of social isolation, anxiety, and depression could act to increase unhealthy eating through several mechanisms potentially mediated by chronic stress, while eating alone could also act to increase unhealthy eating due to effects of self-efficacy and food availability. The interplay between diet and outside factors, including environment, social factors, and personal psychology specific to Chinese adolescents needs to be better understood to develop comprehensive interventions for this population., Competing Interests: Conflicts of Interest M. Renée Umstattd Meyer served as the editor for this article in place of J. E. Maddock. No conflicts are declared by the authors., (© JHEAL, 2021.)

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., (© The Author(s) 2020. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.)

Bicycling holds promise as a healthy and sustainable means of transportation and physical activity. Despite the growing interest in community-based environmental approaches to promoting physical activity, bikeability has received relatively little attention. This paper provides a scoping review of the instruments developed to measure bikeability along with practice-based analyses of the tools related to user expertise, estimated cost, and required time to implement. The review summarizes the literature, identifies research gaps, and informs stakeholders with articles from EBSCO and transportation databases published after 2003 when the previous bikeability instrument review paper was published. Data extraction included the tool name, data collection method, study location, data collection scale, type of measure, and description. Two reviewers independently reviewed articles included in the full text review, and the inter-rater agreement exceeded 90%. The database search yielded 388 unique articles, and 17 met the inclusion/exclusion criteria. Most of the studies, 11 of 17, were applied to settings outside of the U.S. Five studies employed a self-report survey, and five studies examined bikeability using geospatial data, like GIS. Seven studies used a direct observation audit tool-one specifically using a mobile app and another using virtual observation techniques with Google Street View. Bikeability tools are useful for assessing communities and their supports for bicycling. Our primary finding is that advances in technology over the past two decades have driven innovative and useful methodologies, in a variety of disciplines, for assessing the environment, but more consensus is needed to provide a universal definition of bikeability.

Purpose: COVID-19 is largely spread through close contact with infected people in indoor spaces. Avoiding these spaces is one of the most effective ways to slow the spread. This study assessed who had engaged in risky travel and leisure behaviors before the availability of vaccines., Design: National cross-sectional on-line survey collected in November and December 2020. Setting: United States; Participants: 2589 adults representative by gender and race/ethnicity to the US population; Measures: The survey assessed if people had resumed 11 risky behaviors during the pandemic, prior to vaccines. Independent variables included age, race/ethnicity, region of the country, education, income, preexisting conditions, perceived severity and susceptibility, positive COVID diagnosis, and political ideology., Analysis: Univariate analysis and logistic regressions were used to assess demographic and psychological factors of those resuming these behaviors. Results: Most (60.3%) of people had resumed at least 1 behavior with eating inside of restaurants (33.2%) and visiting family and friends (37.5%) being the most prevalent. In the multivariate analyses, perceived susceptibility was significant across all behaviors. Young people, fiscal conservatives, and people with higher perceived severity were more likely to perform several of the behaviors. Preexisting conditions did not predict any of the behaviors., Conclusions: Travel and leisure behaviors vary by type of risk and may need specific tailored, prevention messages to promote risk reduction during future pandemics.

Background: Many countries have been trying to eliminate Mother-to-Child transmission of the Human Immunodeficiency Virus (HIV) and achieve the 90-90-90 target goals. The targets mean that 90% of People Living with HIV (PLWHIV) know their HIV status, 90% of those who are infected receive Antiretroviral treatment (ART), and 90% of those achieve viral suppression. Despite some progress, the goals have not been met in the Philippines, Myanmar, and Cambodia, countries with relatively high or growing HIV prevalence. This study identifies the sociodemographic determinants of testing among women in these countries so that better health education and stigma reduction strategies can be developed., Methods: Descriptive and multivariable analyses were conducted using Demographic and Health Survey data conducted in the Philippines (2017), Myanmar (2015/2016), and Cambodia (2014). The outcome variable was having ever been tested for HIV. Independent variables included knowledge and attitudes about HIV and social determinants of health., Results: A significant difference in testing rates among women was observed (the Philippines: 5%, Myanmar: 19%, Cambodia: 42%). In Myanmar and Cambodia, women who had more HIV knowledge and less stigma towards PLWHIV were more likely to get tested for HIV than those who did not. Marital status, education, wealth were strong predictors for HIV testing among women. Younger women aged 15-19 and those who live in the rural areas were less likely to get HIV tested than older and those living in urban areas. Employed women were less likely to seek an HIV test than the unemployed in Myanmar and Cambodia, whereas, in the Philippines, the opposite relationship was found., Conclusion and Global Health Implications: Women with less education and those less familiar with HIV should be targeted for HIV testing interventions. Stigma reduction and different testing strategies could facilitate early screening leading to improved HIV testing among women., Competing Interests: Conflicts of Interest: The authors declare no competing interests., (Copyright © 2021 Myint et al.)

The 2nd edition of the Physical Activity Guidelines for Americans was released in November of 2018. This document contained specific guidelines for young children, children and adolescents, adults, older adults, pregnant and postpartum women, and adults living with chronic conditions and disabilities as well as safety recommendations. Given the complexity of the recommendations, the aim of this study was to assess which of the guidelines were covered by both print and broadcast media in the three months following the release of the guidelines. LexisNexis was searched for print media as well as transcripts of broadcast media. YouTube was used to search for broadcast television news stories. All retrieved stories (n = 34) were coded independently by two raters on which of the elements of the guidelines were covered. On average, stories covered less than half of the guidelines. Most stories reported aerobic guidelines for adults, children and adolescents and young children. Muscle strengthening and vigorous exercise were covered less frequently. No stories mentioned guidelines for pregnant or postpartum women or adults with disabilities. Print (M = 6.4, sd = 2.7) covered more recommendations than broadcast media (M = 4.0, sd = 1.9, p < .01). Coordinated national efforts are needed to ensure that Americans are aware of the new and complete guidelines., (© 2020 The Authors.)

Proactive health behavior change and maintenance are essential for preventing obesity and other lifestyle diseases. Few studies have examined the relationship between eating behavior and physical condition among multiethnic samples. In this study, ethnic differences were examined to obtain basic data on health education for improvement of obesity in Hawai'i. The intake of fruits and vegetables and exercise habits in each of the transtheoretical model stages of change were evaluated in the 4 most populous ethnic groups in Hawai'i in terms of how the participants' health behaviors were associated with obesity. The participants comprised 2795 white, Native Hawaiian, Filipino, and Japanese adults (age range, 18-55 years). There are 4 main findings of this study. First, there were differences in fruit and vegetable intake and exercise habits in each transtheoretical model stage among the ethnic groups. Second, there were differences in attitudes regarding nutrition and healthy food intake and self-efficacy regarding exercise in each ethnic group. Third, items that have the potential to improve obesity in the theory of planned behavior differed, particularly among men, in the 4 ethnic groups. Finally, a low percentage of participants recognized that the recommended number of servings of fruits and vegetables was 5 or more. Education for men may be particularly important. The findings indicate that modified health education approaches may be needed in accordance with the ethnicity of the population., Competing Interests: Neither of the authors identifies any conflict of interest., (©Copyright 2020 by University Health Partners of Hawai‘i (UHP Hawai‘i).)

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 < .05), high-income earners (OR = 3.71, p < .05), or reported lower life satisfaction (OR = 1.40, p < .05). Higher trust scores were associated with a lower likelihood of a serious response, including violence (OR = 0.80, p < .01)., 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.

Objectives: Childhood obesity rates remain high. The youth sports environment is an opportunity to combat obesity. The purpose of this study was to determine the types of beverages/ snacks provided at youth sports and determine associations between energy consumption and expenditure. Methods: This cross-sectional study observed 4 different sports in a youth sports league (N = 189). The System for Observing Fitness Instruction Time (SOFIT) was used to quantify physical activity. Food environmental scans were used to quantify caloric intake. A t-test was conducted to examine differences between energy consumption and expenditure. We conducted a separate analysis for games that did not offer snacks/beverages. Results: The average energy expenditure was 170.3 calories per game; males were more physically active than females. The average caloric content was 213.3 calories for games that did not offer snacks/beverages and average sugar provided was 26.4 grams per game. The majority of sugar came from sugar-sweetened beverages. Conclusions: Calorie intake was higher than expenditure. Children were consuming more sugar in one game than daily recommendations. Youth sports would benefit from an intervention aimed at the food environment.

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.

Objectives: Parks are more widely used by older adults in East Asia than in the United States. Parks are an important community asset for healthy aging; yet, little is known about park usage and features among older adults in China. Methods: The Community Park Audit Tool and the System for Observing Play and Recreation (SOPARC) were used to assess park features, PA levels and primary activities among 40,469 older adults in Nanchang, China. Results: None of the 8 parks observed had basketball courts or baseball fields and only one had a playground. Results indicated that about half of older adults were active in parks, with women, cooler temperatures, weekdays, and morning hours being related to higher levels of activity. Conclusions: Lessons from the construction of parks in China may be useful in increasing park use in older adults in western countries. Features such as exercise equipment, water features, and small exercise areas were common where western parks are often designed with features for teens and youth including basketball courts, baseball fields, and playgrounds.

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.