Health Education & Behavior

Background. Lower-income families in the United States are at increased risk for food insecurity and have higher rates of tobacco use. Many retailers accepting government food assistance benefits also sell tobacco products, whose marketing promotes smoking initiation and undermines quit attempts. We examined the presence of tobacco marketing in authorized retailers in the Supplemental Nutrition Assistance Program (SNAP) and/or Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), compared with nonauthorized retailers. Method. A nationally representative sample of tobacco retailers in the contiguous United States (N = 2,054) were audited for tobacco marketing in 2015. Using generalized estimating equations, we examined the association between WIC and SNAP authorization and presence of tobacco marketing, adjusted for store type and neighborhood demographics. Results. Both WIC-authorized (odds ratio [OR] 1.7, 95% confidence interval [CI] [1.1, 2.4]) and SNAP-authorized retailers (OR 2.3, 95% CI [1.7, 3.1]) had greater odds of displaying interior tobacco price promotions, compared with stores that were not WIC/SNAP authorized. SNAP-authorized stores (compared with nonauthorized) had almost 3 times greater odds of displaying interior tobacco advertisements (OR 2.9, 95% CI [1.9, 4.5]), while WIC-authorized retailers had 80% lower odds of displaying exterior tobacco advertisements (OR 0.2, 95% CI [0.1, 0.3]). Conclusion. Millions of lower-income American families may be disproportionately exposed to tobacco marketing at food retailers. Federal, state, and local policies could create healthier retail environments by restricting the marketing and availability of tobacco products and increasing promotions and access to healthy food options.

School enrollment, mobility, and occupation are each important factors to consider when examining HIV (human immunodeficiency virus) infection risk among youth in sub-Saharan Africa. Through an analysis of narrative life histories from 30 HIV-positive and 30 HIV-negative youth (aged 15-24 years), matched on gender, age, and village and purposively selected and interviewed from the Rakai Community Cohort Study, this article shows the complex connection between leaving school, mobility, and occupation with implications for HIV risk. We identified a pattern of risk factors that was present in many more HIV-positive than HIV-negative youth life stories. These HIV-positive youth shared a similar pathway during their transition to adulthood: After leaving school, they moved in search of occupations; they then engaged in risky occupations before eventually returning to their home village. Linking the lines of inquiry on school enrollment, mobility, and risky occupations, our findings have important implications for adolescent health research, practice, and policy in Uganda and across sub-Saharan Africa and the developing world.

Background. Prevention of both school dropout and teen pregnancy represent clear public health priorities for South Africa, yet their complex and potentially cyclical relationship has not been fully explored. Objective. To further understand how this relationship operates, we analyzed data from a randomized trial of young women aged 13 to 20 years enrolled in school in rural South Africa to estimate the association between pregnancy and subsequent dropout and between dropout and subsequent pregnancy. Method. We examined inverse probability (IP) of exposure-weighted survival curves for school dropout by pregnancy and for pregnancy by school dropout. We used weighted curves to calculate 1-, 2-, and 3-year risk differences and risk ratios. Additionally, we used an IP-weighted marginal structural cox model to estimate a hazard ratio (HR) for each relationship. Results. Dropout from school was associated with subsequent pregnancy (HR 3.58; 95% confidence interval [CI] [2.04, 6.28]) and pregnancy was associated with subsequent school dropout (HR 2.36; 95% CI [1.29, 4.31]). Young women who attended school but attended fewer days had a higher hazard of pregnancy than those who attended more school (HR 3.64; 95% CI [2.27, 5.84]). Conclusion. Pregnancy is both a cause and a consequence of school dropout. Consideration of school attendance and academic performance could ultimately enhance pregnancy prevention efforts in this population. Programs should be tailored differently for (1) girls who have dropped out of school, (2) those who are in school and at risk for pregnancy, and (3) those who are in school and become pregnant.

Background. The gateway behavior hypothesis posits that change in a health behavior targeted for modification may promote positive changes in other untargeted health behaviors; however, previous studies have shown inconsistent results. Aims. To examine the patterns and predictors of change in untargeted health behaviors in a large health behavior change trial. Method. Using repeated-measures latent class analysis, this study explored patterns of change in untargeted physical activity, alcohol consumption, and smoking behavior during the first year of the Women’s Health Initiative dietary modification trial that targeted total fat reduction to 20% kcal and targeted increased fruit and vegetable intake. Participants were healthy postmenopausal women who were randomly assigned to either the low-fat dietary change intervention (n = 8,193) or a control (n = 12,187) arm. Results. Although there were increases in untargeted physical activity and decreases in alcohol consumption and smoking in the first year, these changes were not consistently associated with study arm. Moreover, although the results of the repeated-measures latent class analysis identified three unique subgroups of participants with similar patterns of untargeted health behaviors, none of the subgroups showed substantial change in the probability of engagement in any of the behaviors over 1 year, and the study arms had nearly identical latent class solutions. Discussion and Conclusion. These findings suggest that the dietary intervention did not act as a gateway behavior for change in the untargeted behaviors and that researchers interested in changing multiple health behaviors may need to deliberately target additional behaviors.

Background. Evidence suggests that children and adolescents growing up in low-income families and those with underrepresented ethnocultural backgrounds tend to have high prevalence rates of obesity and more difficulty adhering to childhood obesity interventions. However, less is known about how intergenerational, family-based approaches to lifestyle interventions for childhood obesity support sustained behavior change. Aims. The aim of this study was to explore the perspectives of health care providers regarding family adherence and behavior change in a childhood obesity program that served ethnoculturally diverse and low-income families. Method. Semistructured in-person interviews were conducted with 18 providers at one of three hospitals participating in a Canadian family-based childhood obesity program. Data were thematically analyzed using a constant comparative approach. Results. The following key themes emerged as challenges from the provider’s perspective for family adherence and behavior modification in the childhood obesity program: divergent views about obesity, complicated lives and logistical priorities, parental role modeling, and intergenerational tensions. Discussion and Conclusion. This examination of providers’ perspectives on family adherence and behavior modification relevant to the management of childhood obesity highlight the importance of tailoring childhood obesity programs to the complex and diverse needs of families from diverse backgrounds. Recommendations include methods of service delivery that address logistical challenges and are better suited to extended families, particularly grandparents.

Many researchers and authorities have recognized the important role that sports clubs can play in public health. In spite of attempts to create a theoretical framework in the early 2000s, a thorough understanding of sports clubs as a setting for health promotion (HP) is lacking. Despite calls for more effective, sustainable, and theoretically grounded interventions, previous literature reviews have identified no controlled studies assessing HP interventions in sports clubs. This systematic mapping review details how the settings-based approach is applied through HP interventions in sports clubs and highlights facilitators and barriers for sports clubs to become health-promoting settings. In addition, the mapped facilitators and barriers have been used to reformulate previous guidelines of HP in sports clubs. Seven databases were searched for empirical research published between 1986 and 2017. Fifty-eight studies were included, principally coming from Australia and Europe, describing 33 unique interventions, which targeted mostly male participants in team sports. The settings-based approach was not yet applied in sports clubs, as more than half of the interventions implemented in sports club targeted only one level of the socio-ecological model, as well as focused only on study participants rather than the club overall. Based on empirical data, the analysis of facilitators and barriers helped develop revised guidelines for sports clubs to implement settings-based HP. This will be particularly useful when implementing HP initiatives to aid in the development of sports clubs working with a whole setting approach.

Background/Aim. Increased knowledge, attitudes, and beliefs about a topic and behavioral capability and self-efficacy for healthy eating are often a precursor to behavior change. The purpose of this study is to determine the effectiveness of the multicomponent school-based program on children’s healthy eating knowledge, attitudes, and self-efficacy for healthy eating, and on their eating habits over time. Method. Quasi-experimental (4 treatment, 2 comparison) in a metropolitan area using a pretest–posttest method. Participants were 628 fifth-grade youth (377 treatment, 251 comparison) with a mean age of 9.9 years. The Building Healthy Communities (BHC) program is an 8-month school-wide healthy school transformation program and includes six main components. Outcome measures include children’s healthy eating knowledge, attitudes, self-efficacy, and behavior. Missing data were imputed, confirmatory factor analysis tested scale factor structure, and path analysis determined a parsimonious path explaining behavior change. Results. The Student Attitudes and Self-Efficacy (SASE) scale had good measurement model fit. BHC group’s healthy eating knowledge and behaviors increased significantly, while SASE remained moderate. For both groups, the students’ knowledge and SASE significantly predicted their healthy eating behaviors; however, the intervention group accounted for a greater amount of variance (35% vs. 26%). Discussion. The BHC program was effective in improving healthy eating knowledge and behavior among youth, and the relationship between variables did not vary by group. Healthy eating knowledge is a significant predictor of both future knowledge and behavior.

Background. Highly processed foods are inexpensive and abundant in our food supply, nutritionally poor, and disproportionately marketed to minority youth. This study is part of a curriculum development project to develop, implement, and evaluate the In Defense of Food (IDOF) curriculum designed to increase intake of whole/minimally processed foods and decrease intake of highly processed foods in youth. Aims. This pilot outcome evaluation was undertaken to assess initial effectiveness and to provide an in-depth understanding of changes in behavioral outcomes and psychosocial mediators. Methods. We used an explanatory mixed method approach, including a single-arm pretest–posttest of intervention effect, followed by a food rules assessment and in-depth interviews to describe participant responses to the intervention in more detail. The study was conducted in three afterschool classrooms in urban low-income neighborhoods with 32 multiethnic middle-school youth, receiving 10 weekly 2-hour sessions. Results. Two weeks postintervention, there was a large positive significant increase in whole/minimally processed food intake (p < .01; d = 0.59) and a small decrease in consumption of highly-processed foods (p = ns; d = 0.06), compared with baseline. Significant increases in psychosocial mediators: Self-efficacy and positive outcomes expectations were seen; others were not significant but changed in the desired direction. Qualitative assessments suggest that the intervention promoted skill building, but environmental barriers made these difficult to use. Discussion. The IDOF curriculum may be most effective for promoting consumption of fruits and vegetables, rather than decreasing intake of highly processed foods. In addition, in this young age-group, short actionable food rules may support self-regulation and behavior change. Conclusion. Among adolescent students in low-income urban neighborhoods, the IDOF afterschool curriculum may help promote self-efficacy and positive outcome expectancies and increase fruit and vegetable intake. Focusing on food processing and using “Food Rules” may be promising to elicit behavior change in youth; however, greater supports are needed to overcome social and environmental barriers.

Background. Compared with other occupations, long-haul truck drivers (LHTD) engage in excessively unhealthy behaviors and experience disproportionately poor health outcomes. Health promotion efforts targeting LHTDs focus on improving individual-level behaviors; however, this occupation is replete with adverse work organization characteristics, high job stress, and compromised sleep health, which are hypothesized to cause poor health behaviors and outcomes among LHTDs. Therefore, the purpose of this study was to explore the connections between work characteristics, job stress, and sleep outcomes, and health behaviors and physical and mental health outcomes among LHTDs. Method. This was a cross-sectional study, using interviewer-administered surveys with LHTDs (n = 260). Bivariate correlation analysis was used to explore the associations among work organization, job stress, sleep health, and health behaviors and outcomes. Logistic regression analyses were used to determine whether these work organization, job stress, and sleep factors predicted health behaviors and outcomes. Results. Long work hours of more than 11 hours daily (odds ratio [OR] = 2.34) resulted in increased odds of high caffeine consumption. High job stress (OR = 0.48) and poor sleep quality (OR = 0.42) led to decreased odds for spending at least 1 hour daily for cooking/eating. Low sleep duration, less than 7 hours daily (OR = 2.55), led to increased odds of a physical health diagnosis. Both high job stress (OR = 3.58) and poor sleep quality (OR = 2.22) resulted in increased odds of a mental health diagnosis. Conclusion. Health promotion efforts targeting LHTDs need to be coupled with upstream policy, environmental, and systems-level change, especially at the governmental and trucking industry levels.

Background. Little research has been conducted on relations between challenging working and living conditions and psychological distress in Latino migrant day laborers (LMDLs), a particularly marginalized Latino population in the United States. Aims. Consistent with a structural-environmental framework of LMDL vulnerability to health and mental health problems, this study tests a model of hypothesized pathways between working and living conditions and multiple forms of psychological distress. Method. Structural equation modeling was used to test the conceptual model with 344 LMDLs who participated in a cross-sectional survey in the San Francisco Bay Area. Results. As hypothesized, results reveal pathways between (1) working and living conditions; (2) working and living conditions and depression, as well as desesperación (desperation), the latter a Latino cultural idiom of distress frequently expressed by LMDLs; and (3) between living conditions and alcohol use. Discussion. Findings increase understanding regarding how challenging working and living conditions contribute to the same, as well as different, forms of psychological distress in LMDLs. Conclusions. Implications for mitigating structural vulnerability to psychological distress can be addressed at multiple social-ecological levels ranging from community-based support for enhancing LMDL employment (e.g., via day labor centers) to expanding the availability of work authorization for undocumented workers.

Evidence suggests that Hispanic and non-Hispanic White men (NHW) have comparable prevalence rates of alcohol use. However, Hispanic men consistently have higher prevalence rates of alcohol misuse compared with NHW men. Consequently, Hispanic men experience disproportionate levels of adverse health consequences of alcohol misuse when compared with NHW men. The aim of this study was to explore Hispanic male perspectives and opinions regarding alcohol use patterns that may lead to disparate rates of alcohol misuse in Hispanic males. Demographic data were collected with questionnaires. Twenty semistructured one-on-one interviews were completed in English and Spanish with Mexican-origin Hispanic men (age: 44.6 ± 11.3 years). A thematic analysis was conducted using a hybrid deductive–inductive strategy with an a priori codebook supplemented with iterative analysis of transcripts. Results suggest that alcohol misuse patterns in Hispanic males are influenced by an interaction between alcohol-related social norms and learned expressions of masculinity; a lack of knowledge of the alcohol-related health risks that further perpetuate the normalization of alcohol misuse; and expressions of masculinity and adaptive coping that lead to alcohol misuse as an escape from life stressors. Given the rapid expansion of the Hispanic population in the United States, and the disparate consequences of alcohol misuse in this population, it is imperative to consider the complex and often compounded impact of sociocultural norms and the social context on misuse-related behaviors. Viable prevention and treatment strategies should be addressed thought multicomponent, community-level strategies that more comprehensively address the complexities of alcohol misuse in this population.

Background. Associations between religious involvement and substance use are well established. However, limited research examines the effects of religious affiliation, informal participation, and network support on substance use among two distinct age cohorts. Objectives. This study aims to examine whether religious affiliation, informal participation, and network support are associated with alcohol, tobacco, and marijuana use among young and late middle-age adults. Method. The UC Berkeley Social Networks Study (Wave 1, 2015) offers novel cohort data on young (21-30 years old, n = 483) and late middle-age (50-70 years old, n = 673) adults. Poisson regression models were used to predict alcohol use, while logistic regression models were used to predict odds of smoking and marijuana use. Results. Among young adults, membership in a religious organization was associated with less alcohol, tobacco, and marijuana use. Conversely, participating in informal organizations was associated with more alcohol and marijuana use. Desiring more people to talk to and get together with were associated with more smoking and drinking, respectively. However, wishing more people to ask for help was associated with less substance use altogether. In a similar pattern, among older adults, religious involvement was associated with less alcohol and marijuana use. Desiring more people to ask for help was also related to less marijuana use. Conclusion. Younger adult participation in informal groups serves to encourage social substance use. In contrast, older people are more involved in religious groups, which support social behaviors that do not include substance use.

Introduction. Drinking alcohol has detrimental health consequences, and effective interventions to reduce hazardous drinking are needed. The self-regulation intervention of Mental Contrasting with Implementation Intentions (MCII) promotes behavior change across a variety of health behaviors. In this study, we tested if online delivery of MCII reduced hazardous drinking in people who were worried about their drinking. Method. Participants (N = 200, female = 107) were recruited online. They were randomized to learn MCII or solve simple math problems (control). Results. Immediately after the intervention, participants in the MCII condition (vs. control) reported an increased commitment to reduce drinking. After 1 month, they reported having taken action measured by the Readiness to Change drinking scale. When drinking was hazardous (Alcohol Use Disorders Identification Test ≥ 8, n = 85), participants in the MCII condition indicated a decreased number of drinking days, exp(β) = 0.47, CI (confidence interval) [−1.322, −.207], p = .02, and drinks per week, exp(β) = 0.57, CI [0.94, 5.514], p = .007, compared with the control condition. Discussion. These findings demonstrate that a brief, self-guided online intervention (Mdn = 28 minutes) can reduce drinking in people who worry about their drinking. Our findings show a higher impact in people at risk for hazardous drinking. Conclusion. MCII is scalable as an online intervention. Future studies should test the cost-effectiveness of the intervention in real-world settings.

Background. Despite the strong link between health literacy and cardiovascular health outcomes, health literacy measurements remain flawed and fragmented. There exists a gap in the knowledge when formulating a valid measurement to capture the broad concept of health literacy. The existence of various tools for health literacy measurement also hampers the availability of health literacy data. Additionally, little research is available on a valid measurement tool for cardiovascular health literacy. Objective. This study aims to provide an overview of the health literacy measurement tools used in the context of cardiovascular health. Method. A scoping review was conducted. Two electronic databases, Medline and Embase, were searched to identify studies that described a tool for the measurement of health literacy in the context of cardiovascular health. Results. After reviewing the available studies, 53 studies met the inclusion criteria. A total of 26 health literacy measurement tools were identified in the studies. Among the 26 tools, 16 used an objective measurement approach, 9 adopted a subjective approach, and 1 employed a mixed approach. Additionally, 28 studies used tools to measure print literacy, 15 studies measured print literacy and numeracy, and 5 studies measured print literacy, oral literacy, and numeracy. Conclusions. STOFHLA, TOFHLA, and REALM were the mostly commonly used tools in the selected studies. The majority of tools were based heavily on reading skills and word recognition. Researchers should focus on the development of more comprehensive and reliable health literacy measurement tool(s) specific to cardiovascular health to assist health care providers to more efficiently and accurately identify people with cardiovascular problems who have inadequate health literacy.

Despite the promise of incentive-based chronic disease prevention programs, comprehensive evidence on their accessibility among low-income populations remains limited. We adapted Aday and Andersen’s framework to examine accessibility and consumer satisfaction within the Medicaid Incentives for the Prevention of Chronic Disease (MIPCD) cross-site demonstration. MIPCD provided 10 states with 5-year grants to implement incentivized chronic disease prevention and management programs for low-income and/or disabled—Medicaid enrolled—Americans. We conducted 36 focus group discussions between July 2014 and December 2015 with Medicaid enrollees participating in the MIPCD programs. We assessed participants’ satisfaction by program type (i.e., diabetes prevention, diabetes management, hypertension reduction, smoking cessation, and weight management) related to three components: program enrollment and participation, staff courtesy, and program convenience. Based on Aday and Andersen’s framework, we conducted thematic analysis to determine similarities and differences across MIPCD programs by type. Participant feedback confirmed the importance of several features of the Aday and Andersen framework, particularly programs with easy enrollment and participation procedures, courteous and helpful staff, and those that are convenient and flexible for participants. Participants valued programming around the clock via telephone and flexible, in-person hours of operation as well as proximity of the program to reliable transportation. We observed that most participants, despite enrollment and participation barriers, perceived programs as accessible and were willing to engage and continue to participate. This finding may reflect behavior change theory’s perspective on personal readiness to change. Individuals in the preparation stage of change can effectively change health habits despite barriers they may encounter. In some cases, personal readiness to change was more impactful than consumer satisfaction at encouraging ongoing participation and perceived access to the programs. Thus, program developers may want to consider individual participant readiness to change and its impact on consumer satisfaction when designing, implementing, and evaluating behavior change initiatives.

Chronic pain is an increasing public health concern, with an associated poor quality of life. Social media platforms play an increasing role in health communication issues, but visual platforms such as Pinterest are understudied. This study analyzed 502 Pinterest posts for chronic pain–related variables, including health belief model constructs, as well as measures of social support and coping mechanisms. Most pins mentioned the high severity of chronic pain, and a third mentioned self-efficacy related to self-care, while almost 50% referred to cues to action related to self-care. This study positions Pinterest as a social media platform with the potential to both transfer knowledge and provide social support for patients with chronic pain. Health care and public health practitioners should consider participating in these conversations as well as providing quality information to ensure that reputably sourced information is available.