Health Education & Behavior

Internet-based recruitment can be effective in reaching large numbers of geographically diverse individuals. Geosocial sexual networking apps on smartphones have emerged as the modal way in which men who have sex with men (MSM) meet sex partners, and as venues for sexual health research. We report on the performance of three types of ads—text-only, text with male figure (no face), and text with male figure (with face)—used on a geosocial sexual networking app to advertise free at-home HIV testing and to enroll in an online study. We ran five 2-week-long ads on a popular MSM geosocial app between fall 2017 and spring 2018 (~2.19 million impressions). Ads were evaluated in terms of the click-through rate (CTR = advertisement clicks/advertisement impressions), conversion rates (CR = number of enrolled participants/ad-generated clicks), cost per enrolled participant, and demographic composition of survey respondents. We enrolled n = 4,023 individuals, n = 2,430 of whom completed HIV testing—$6.21 spent on advertising per participant enrolled and $10.29 spent for everyone who completed HIV testing. Cost per enrolled participant was associated with the content of the ad used—ads featuring male figures (with or without a face shown) were more cost efficient than ads featuring text alone. These ads also outperformed text-only ads across a range of metrics, including responsiveness among younger MSM as well as MSM of color. Advertising materials that combine text with images may have greater appeal among priority populations.

Understanding the relationship between cognitive and behavioral processes and long-term behavior change is critical to developing behavior change maintenance interventions. We examined the relationship between cognitive and behavioral safer sex maintenance strategies and condomless vaginal/anal sex with clients among female sex workers (FSWs) in Mexico. We hypothesized a moderating effect of hazardous alcohol use, such that the relationship between the use of safer sex maintenance strategies and condomless sex would be weaker among FSWs who meet criteria for hazardous alcohol consumption. Data were gathered from 602 FSWs enrolled in a sexual risk reduction intervention with a text messaging maintenance component. Seven cognitive and behavioral strategies purported to be critical in sustaining long-term behavior change were measured (e.g., maintenance self-efficacy). The relationship between FSWs’ use of safer sex maintenance strategies and condomless vaginal/anal sex with clients was moderated by hazardous alcohol consumption. The association was weaker among FSWs who met criteria for hazardous alcohol consumption. Among FSWs who met criteria for hazardous alcohol consumption, maintenance self-efficacy was associated with fewer condomless sex acts with clients (b = −0.35, p < .001). Among FSWs who did not meet criteria for hazardous alcohol consumption, recovery self-efficacy (b = −0.21, p < .05) and self-monitoring (b = −0.34, p < .001) were associated with fewer acts of condomless sex. Results indicate the importance of examining the multidimensional nature of safer sex maintenance strategies and of exploring subgroup differences in their associations with behavioral outcomes. Interventions that address safer sex maintenance strategies in the context of alcohol treatment should be developed for this subgroup of FSWs.

As entertainment education (EE) becomes an increasingly popular medium for delivering health information, evaluation of EE is key to better understanding how it not only influences audiences but also how it can be better implemented. We suggest that EE evaluation has largely focused on impact while its implementation, specifically through narrative, characters, and genre, has remained unexplored. We propose drawing from theories and methods used in media studies to complement current approaches to understanding and evaluation of EE that can help improve EE for health education. East Los High serves as a case study, through which we examine the characters and the narrative demands of the telenovela genre to reveal a disproportional depiction of Latino men and women that ultimately replays familiar Latino stereotypes of criminality and exaggerated sexuality. We discuss the implications this has on the show’s ability to do public health work.

Sixty-eight young people contributed to a Design Thinking Challenge created to elicit a better understanding of their electronic image-sharing experiences, the helpful and harmful consequences of image-sharing to adolescent mental health and safety, and promising interventions that allow young people to make more positive decisions and minimize their risks when sharing images through electronic devices. Through this collaborative group-based process, each co-design group engaged in a four-phase process to discover, define, develop, and deliver an intervention that took the form of a paper-based mobile app prototype. Young people reported that they need information and advice to support their and others’ online decision making, help making situational decision-making skills for managing online interactions, and means to control information and images that can be accessed and distributed. Detailed app features that they required to address their decision-making needs are also discussed. These app intervention features highlight what young people need to make better-informed decisions when communicating through images electronically.

Background. Long-term continuous adherence to biennial screening mammograms as guidelines recommend remains low. Limited evidence suggests that reminder calls may increase short-term adherence as much as telephone counseling, but research is needed comparing the long-term effects of these two approaches. Purpose. To compare the impacts of two telephone outreach interventions and mailed reminders on 4-year continuous mammography adherence. Method. A cohort of 3,215 women, age 50 to 81 years, was selected from 30,160 women from a 4-year randomized trial of three interventions to promote biennial mammography: reminder letter only (LO), letter plus reminder call (RC), and two letters plus educational material and a counseling call (CC). Women selected remained eligible for the trial all 4 years and received annual interventions as needed. The proportion with a mammogram in the last 24 months was determined at baseline and four annual time points. Results. Continuous adherence at all four time points was higher in the RC (78.8%) and CC arms (78.8%) than in the LO arm (75.1%; p < .001). Multivariable analysis confirmed this finding: CC (odds ratio = 1.27; 95% confidence interval = [1.01, 1.61]) and RC (odds ratio = 1.23; 95% confidence interval = [0.98, 1.56]). Only 27.8% of women eligible for an initial counseling call actually received counseling. Conclusions. Compared with letters alone, outreach calls can modestly increase continuous mammography adherence among insured women with consistent primary care. Telephone counseling was no more effective than a reminder call, possibly due to limited acceptance of counseling calls by women who may find them unwelcome or unnecessary.

Background. Community health workers (CHWs), often called “health promotion volunteers” in Japan, are individuals who act as a natural helping resource in the community. Aim. This study tested the efficacy of a CHW-based intervention to improve dietary habits among community-dwelling older people in Japan, using a controlled, crossover design. Method. Seventy-eight people aged 65 to 74 years with poor dietary variety living in four administrative districts in Hikone City (Shiga Prefecture, Japan) were nonrandomly allocated to an immediate-intervened group (IIG; n = 41) or a delayed-intervened group (DIG; n = 37). Participants joined a biweekly, four-session program (120 minutes/session), comprising “CHW drama-style lectures,” “group discussion among participants and CHWs,” “tasting of dishes,” and “take-home practical activities.” For the initial 2-month period, the IIG received the intervention and the DIG did not. The groups were crossed over for the subsequent 2-month period. The primary outcome measure was participants’ dietary variety score (score range: 0-10). Results. The dietary variety score in the IIG significantly increased in the initial 2-month period compared with the DIG (effect size 1.60 points; 95% confidence interval: 0.75, 2.45). The intervention had a similar effect in the DIG in the subsequent 2-month period. Moreover, an analysis within the IIG showed that the intervention effects persisted for at least 2 months after the intervention. Conclusions. The CHW-based intervention improved dietary habits among older people. Our findings provide evidence that a CHW-based natural helping approach is a possible solution to promote healthy aging in the community.

Background. The National Council on Aging’s Aging Mastery Program (AMP) aims to help older adults implement health behavior and lifestyle changes to promote healthy aging and social engagement. The purpose of the present community-partnered evaluation was to test the effectiveness of AMP implementation in Los Angeles County to improve participants’ quality of life, global physical and mental health, and patient activation. Method. A modified randomized wait-list controlled trial design was used to examine experimental, quasi-experimental, and dose-response evidence in five senior centers. Participants completed questionnaires at baseline and after the 10-week intervention, self-reporting their overall quality of life, physical health, mental health, and patient activation. Results. Experimental, intention-to-treat analyses found AMP assignment did not affect any measured outcomes (n = 71). Quasi-experimental, “as treated” analyses (n = 106) controlling for study site and sociodemographic characteristics indicated that participants who attended AMP reported more positive changes in global mental health than the control group. Attending AMP was not associated with changes in quality of life, physical health, or patient activation. Dose-response analyses among AMP participants who attended at least one class (n = 75) found that attending more classes was not significantly associated with greater improvements in mental health. Conclusions. Experimental, intention-to-treat analyses did not support effectiveness of AMP on quality of life, physical or mental health, or patient activation; quasi-experimental analyses found attending AMP was associated with improvements in mental health. Recruitment challenges and participants’ nonadherence with condition assignment decreased our ability to detect effects. https://clinicaltrials.gov/ct2/show/NCT03342729?term=Aging+Mastery+Program&rank=1.

Introduction. Physical activity (PA), particularly low-impact activities like bicycling, can improve health in older adults. However, bicycling rates are lower in the Midwest than other regions in the United States. Therefore, it is important to identify unique social, personal, and environmental factors that inhibit or promote bicycling, and how these are associated with PA. The influences of these factors were explored using the social ecological model. Method. A cross-sectional online survey was developed using previously validated local and national bicycling questionnaires, then distributed to Midwestern bicyclists 50 years and older. Exploratory factor analysis was conducted to understand the influences of social, personal, and environmental barriers and promoters on bicycling patterns. All models were conducted separately by gender, and accounted for age, race, education, marital status, income, and employment. Results. Social promoters (B = 0.386, p = .002), such as having friends/family that bicycle were associated with greater PA. Personal promoters (B = −0.311, p = .006) such as needing to lose weight were associated with reduced PA. Environmental factors had no associations with PA. However, individual environmental components, such as number of vehicles on the roads, were significantly associated with PA for both males and females. Females reported more barriers than males. The overall model accounted for 16.1% of the total variance in PA levels. Conclusion. Interventions to promote PA via bicycling in older adults should focus on social factors, while also reducing personal-level factors for males. Interventions for females could focus on reducing specific personal, social, and environmental barriers.

Settings-based approaches have become an increasing health promotion focus since the World Health Organization’s 1986 Ottawa Charter. While schools, cities, and prisons have implemented this approach, its development within sports environments is recent. Sports are a popular leisure-time activity, requiring validated tools to measure health promotion activity. This study’s aim was to develop a measurement tool based on international consensus that measures perceptions of health promotion within sports clubs. It is grounded in the settings-based approach and builds on theory from previous works expanding their context and knowledge. An online, three-round international Delphi study was conducted, inviting experts in sports and health fields to participate in designing the tool. Round 1 created a collaborative list of items; Round 2 validated items based on relevance, importance, and feasibility; and the final round classified items into one determinant category—social, cultural, environmental, or economic. Panelists (69 experts) from 13 countries participated, creating a final list of 62 items at 3 organizational levels; the sports club level included 23 items, the officials level retained 20 items, and the coaching level contained 19 items. This study provides several innovations: (1) applying the settings-based approach to health promotion within sports clubs, (2) defining each club level (sports club, official, coaching) and determinants (social, cultural, environmental, economic) within 3-levels, (3) creating a tool that measures perceptions of health-promotion activities per level and determinant, and (4) obtaining expert consensus on included items. These advancements allow further research on promoting health within sports clubs.

Most of the health interventions designed to increase athletes’ reporting of potential concussion symptoms have focused only on the individual athlete. Unfortunately, interventions targeted at athletes’ knowledge and understanding of concussion risk has not reliably increased their reporting behavior, leading to increased calls for “changing the culture of concussion reporting.” To date, no studies have examined the role of organizational safety climate has on concussion-symptom reporting behavior. We hypothesized that players’ perception of organizational safety climate would be indirectly related to their concussion symptom reporting intentions, via the influence of safety culture on supportive social norms and self-efficacy, two well-known predictors of concussion reporting intentions. We used structural equation modeling techniques to create robust latent measures of our model variables and then examined the indirect influence of football program safety climate on football players’ symptom reporting intentions. Surveys were completed by NCAA Division I football players (N = 223) before and after the 2017 football season. We tested a confirmatory factor analysis and hypothesized latent variable model with preseason data, made small adjustments to our model (adding correlated error terms), and then confirmed using postseason data. We also examined a competing, alternative model. Results support the indirect and influence of perceived safety climate on concussion reporting intentions primarily via the relationship between safety climate and social norms, and to a lesser extent between safety climate and self-efficacy. Discussion focuses on the importance of considering the addition of interventions aimed at systems-level influences to facilitate supportive social norms and athlete self-efficacy regarding concussion symptom reporting.

Background. Parent-aimed guidance on the topic of processed foods may help limit highly processed foods in children’s diets, but little is known about parent understanding and perceptions of these products. Aims. To determine how parent perceptions of processing align with processing classification systems used in research, and to identify opportunities for future research in communicating information about processed foods. Method. Six focus groups with lower income, racial/ethnic minority and immigrant parents of fourth to sixth graders (n = 37) were conducted. Parents were asked to discuss their views on terminology related to food processing, classification of foods according to their processing level, the healthfulness of select foods, and criteria for choosing snacks for their children. Focus groups were guided by a thematic approach. NVivo 12 (QSR International) was used to facilitate analyses. Results. Thirty mothers and seven fathers participated. Two thirds (62%) were foreign-born; 38% identified as Hispanic. The term “processing” lacked consistent meaning among parents, with variation by immigrant status. Participants associated highly processed foods with convenience, packaging, and added ingredients; “less-processed” versions of foods (e.g., fresh; homemade) were perceived as healthier. Children’s preferences were the main criteria for choosing snacks. Foreign-born parents were more likely to associate processed foods with positive characteristics (e.g., properly cooked). Conclusion. The concept of food processing is an area of misconception among parents, providing an opportunity for education that may be extended to larger audiences. A universally accepted definition of food classification by processing level is necessary to effectively communicate the link between processing and healthfulness.

School-based health activities that involve parents are more likely to be effective for child health and well-being than activities without a parent component. However, such school-based interventions tend to recruit the most motivated parents, and limited evidence exists surrounding the involvement of hard-to-reach parents with low socioeconomic status (SES). Mothers remain responsible for the majority of family care; therefore, this study investigated mothers with low SES to establish the reasons and barriers to their involvement in school-based health activities and to propose strategies to increase their involvement in those activities. Interviews were conducted with mothers with low SES, who were typically not involved in school-based health activities (n = 16). An inductive–deductive approach to hierarchical analysis revealed that there are several barriers resulting in mothers being less involved, particularly due to issues surrounding the schools’ Parent Councils and the exclusivity of school-based events. Efforts made by the school to promote health activities and involve parents in such activities were revealed, alongside recommendations to improve on these practices. The findings offer multiple ways in which future school-based health interventions can recruit and involve mothers with low SES.

Latino adolescents face challenges to performing energy balance–related behaviors (EBRBs) to prevent childhood obesity, including healthy dietary intake, adequate physical activity, and limited screen time. Fathers are underrepresented in family-based obesity interventions but could be influential in shaping the EBRBs of Latino children. Three types of parenting practices (setting expectations/limits, role modeling, managing availability and accessibility) have shown relatively consistent positive relationships with children’s EBRBs in studies that have mostly involved mothers. The purpose of this study was to develop measures to assess Latino fathers’ parenting practices based on existing measurement instruments, focus groups and cognitive testing. Criterion validity of the measures (40 items) was examined with Latino fathers and their early adolescents (10-14 years old, n = 96 dyads) who were predominantly from low-income, two-parent households. Criterion validity was indicated by significantly higher intakes of fruit and vegetables; lower intakes of sugar-sweetened beverages, sweets/salty snacks and fast foods; more weekly physical activity hours; and fewer daily screen time hours among adolescents who reported high versus low levels/frequencies of supportive parenting practices. In addition, nearly all scales of adolescent-reported paternal behavioral modeling and availability/accessibility practices were significantly correlated with adolescents’ corresponding EBRBs (r = 0.22 to 0.54). However, poor validity and agreement with early adolescents’ reports were found for most father-reported parenting practices. Overall, this study indicated that the measures were acceptable for assessing adolescents’ report of Latino fathers’ parenting practices around EBRBs. The findings also indicate the importance of including early adolescents’ reports in measuring paternal parenting practices.

Background. Health insurance access and health literacy are critical components of “enabling resources” to encourage uptake of services. We sought to test whether health literacy boosts health services utilization in the context of expanded access to health insurance stemming from the Affordable Care Act. Method. We used individual-level data from 11 states included in the Behavioral Risk Factor Surveillance System 2016. We conducted a two-stage least squares instrumental variables analysis. We instrumented improved access to health insurance stemming from Affordable Care Act Medicaid expansion. As outcome variables, we examined cost as a barrier to needed care, having a personal doctor and receipt of routine health checkups, flu shots, Pap tests, mammograms, sigmoidoscopy/colonoscopy, and dental visits in the past year. We then tested whether the relation between improved health insurance access and health services utilization was moderated by health literacy. Health literacy was measured by a dichotomized scale comprising three items: difficulties obtaining advice or information about health, difficulties understating information from health professionals, and difficulties understanding written health information. Results. We found that improving health insurance access increased the likelihood of reporting a personal doctor while reducing the likelihood of reporting cost as a barrier to care. We also found an interaction effect between health insurance and health literacy on dental visits. However, there was no significant interaction effect between insurance access and health literacy for preventive services utilization. Conclusion. Health literacy did not explain why people fail to access preventive services even when they obtain access to insurance, with the sole possible exception of dental visits among individuals with high literacy.

Drug manufacturers are expected to provide labeling information needed to yield safe and effective product use. However, it is not clear that consumers dose sunscreen, an over-the-counter drug, appropriately; in fact, existing evidence suggests underdosing as a common phenomenon. The objective of this study was to evaluate the effect of dispensing device and labeling on self-administered doses of sunscreen in young adults. To investigate those effects, a 2 × 2 factorial laboratory experiment crossing dispensing device (two levels) with labeling treatment (two levels) was conducted. Participants applied sunscreen from each of the four treatments; dosing concentration, measured in mg/cm², served as the response variable. Participants (n = 94) were recruited on the campuses of Michigan State University (East Lansing, MI) and California Polytechnic State University (San Luis Obispo, CA). Each participant applied sunscreen from each unique treatment to sites on their arms and legs (four applications). Postapplication, a survey was completed to characterize demographics, risk perception, and sunscreen use patterns. Results indicate participants applied approximately 30% less sunscreen from the pump bottles than the squeeze bottles (difference estimate of 0.3059 mg/cm², standard error = 0.0607, p < .0001); there was no evidence of a difference based on label treatments. Post hoc recognition tests indicated only 55% of participants were able to recognize the two experimental labels they had viewed immediately following sunscreen application. Sunscreen application density was directly related to level of worry regarding skin cancer and frequency of sunscreen use (α = .05). Our results suggest the dispensing device used to deliver sunscreen impacts the dosage amount consumers apply.

Background. Getting a sufficient amount of sleep is an important component of living a healthy lifestyle. Consequently, it is important for researchers to identify the factors that influence sleep duration. Aims. The current study has a twofold objective. The first is to see if two types of social support are associated with sleep duration. The second objective is to see if meaning in life and depressive symptoms serve as indirect pathways in the relationship between social support and sleep. Method. The data come from an internet survey of a random probability sample of adults who reside in the United States (N = 2,287). Questions were administered on received support, satisfaction with support, meaning in life, depressive symptoms, and sleep. Results. The findings indicate that the amount of support that is received is associated with satisfaction with support, greater satisfaction with support is associated with a stronger sense of meaning in life, a stronger sense of meaning is related to fewer depressive symptoms, and fewer depressive symptoms is significantly associated with the likelihood of getting the recommended number of hours of sleep. Discussion and Conclusions. Instead of merely showing that social support is associated with sleep, our findings take a modest step toward explaining how this relationship arises (i.e., through an increased sense of meaning in life and, in turn, reduced depressive symptoms). This theoretical specificity is helpful for devising interventions to improve sleep habits.

Background. John Henryism is defined as a measure of active coping in response to stressful experiences. John Henryism has been linked with health conditions such as diabetes, prostate cancer, and hypertension, but rarely with health behaviors. Aims. We hypothesized that reporting higher scores on the John Henryism Scale may be associated with poorer medication adherence, and trust in providers may mediate this relationship. Method. We tested this hypothesis using data from the TRUST study. The TRUST study included 787 African Americans with hypertension receiving care at a safety-net hospital. Ordinal logistic regression was used to examine the relationship between John Henryism and medication adherence. Results. Within our sample of African Americans with hypertension, lower John Henryism scores was associated with poorer self-reported adherence (low, 20.62; moderate, 19.19; high, 18.12; p < .001). Higher John Henryism scores were associated with lower trust scores (low John Henryism: 40.1; high John Henryism: 37.9; p < .001). In the adjusted model, each 1-point increase in the John Henryism score decreased the odds of being in a better cumulative medication adherence category by a factor of 4% (odds ratio = 0.96, p = .014, 95% confidence interval = 0.93-0.99). Twenty percent of the association between medication adherence and John Henryism was mediated by trust (standard deviation = 0.205, 95% confidence interval = 0.074-0.335). Discussion. This study provides important insights into the complex relationship between psychological responses and health behaviors. It also contributes to the body of literature examining the construct of John Henryism among African Americans with hypertension. Conclusion. The findings of this study support the need for interventions that promote healthful coping strategies and patient–provider trust.