Multilevel correlates of household anthropometric typologies in Colombian mothers and their infants.

BACKGROUND: The aim of this study was to establish the association of maternal, family, and contextual correlates of anthropometric typologies at the household level in Colombia using 2005 Demographic Health Survey (DHS/ENDS) data. METHODS: Household-level information from mothers 18-49 years old and their children <5 years old was included. Stunting and overweight were assessed for each child. Mothers were classified according to their body mass index. Four anthropometric typologies at the household level were constructed: normal, underweight, overweight, and dual burden. Four three-level [households (n = 8598) nested within municipalities (n = 226), nested within states (n = 32)] hierarchical polytomous logistic models were developed. Household log-odds of belonging to one of the four anthropometric categories, holding 'normal' as the reference group, were obtained. RESULTS: This study found that anthropometric typologies were associated with maternal and family characteristics of maternal age, parity, maternal education, and wealth index. Higher municipal living conditions index was associated with a lower likelihood of underweight typology and a higher likelihood of overweight typology. Higher population density was associated with a lower likelihood of overweight typology. CONCLUSION: Distal and proximal determinants of the various anthropometric typologies at the household level should be taken into account when framing policies and designing interventions to reduce malnutrition in Colombia.

Evaluation of an online training for improving self-reported evidence-based decision-making skills in cancer control among public health professionals.

OBJECTIVES: The purpose of this evaluation was to assess the effect of the online evidence-based cancer control (EBCC) training on improving the self-reported evidence-based decision-making (EBDM) skills in cancer control among Nebraska public health professionals. STUDY DESIGN: Cross-sectional group comparison. METHODS: Previously developed EBDM measures were administered via online surveys to 201 public health professionals at baseline (comparison group) and 123 professionals who took part in the training. Respondents rated the importance of and their skill level in 18 EBCC skills. Differences were examined using analysis of variance models adjusted for gender, age, years at agency, and years in position, and stratified by respondent educational attainment. RESULTS: Among professionals without an advanced degree, training participants reported higher overall skill scores (P = .016) than the baseline non-participant group, primarily driven by differences in the partnerships and collaboration and evaluation domains. No differences in importance ratings were observed. Among professionals with advanced degrees, there were no differences in skill scores and small differences in importance scores in the expected direction (P < .05). Respondents at baseline rated the following facilitators for EBDM as important: expectations from agency leaders and community partners, high priority placed on EBDM by leadership, trainings, and positive feedback. They also reported using a variety of materials for making decisions about programs and policies, though few used individual scientific studies. CONCLUSIONS: EBCC led to improved self-reported EBDM skills among public health professionals without an advanced degree, though a gap remained between the self-reported skills and the perceived importance of the skills. Further research on training content and modalities for professionals with higher educational attainment and baseline skill scores is needed.

Worksite nutrition supports and sugar-sweetened beverage consumption.

OBJECTIVE: This study examined the link between worksite environmental supports for nutrition behaviours and sugar-sweetened beverage (SSB) consumption and offers insight into potential intervention points for reducing SSB consumption and combatting overweight and obesity. METHODS: Perceived worksite supports for healthy nutrition and self-reported SSB consumption were analysed for 2,015 working adults in the state of Missouri using a subset of questions from the Supports at Home and Work for Maintaining Energy Balance (SHOW-ME) study. RESULTS: Employees' use of vending facilities and the availability of water coolers/water bottles was significantly associated with increased SSB consumption, while use of cafeterias was significantly associated with decreased SSB consumption. Symbols or signs to identify healthy alternatives were significantly associated with sports drink consumption. CONCLUSIONS: This study supports previous work indicating the worksite as a necessary environment for nutrition interventions. When choices (vending and cafeteria) are provided, employees report making healthier decisions. For worksites without cafeterias, alternatives should be explored including mobile food trucks and farmer's markets.

Accessing evidence to inform public health policy: a study to enhance advocacy.

OBJECTIVES: Improving population health often involves policy changes that are the result of complex advocacy efforts. Information exchanges among researchers, advocates, and policymakers is paramount to policy interventions to improve health outcomes. This information may include evidence on what works well for whom and cost-effective strategies to improve outcomes of interest. However, this information is not always readily available or easily communicated. The purposes of this paper are to describe ways advocates seek information for health policy advocacy and to compare advocate demographics. STUDY DESIGN: Cross-sectional telephone survey. METHODS: Seventy-seven state-level advocates were asked about the desirable characteristics of policy-relevant information including methods of obtaining information, what makes it useful, and what sources make evidence most reliable/trustworthy. Responses were explored for the full sample and variety of subsamples (i.e. gender, age, and position on social and fiscal issues). Differences between groups were tested using t-tests and one-way analysis of variance. RESULTS: On average, advocates rated frequency of seeking research information as 4.3 out of five. Overall, advocates rated the Internet as the top source, rated unbiased research and research with relevancy to their organization as the most important characteristics, and considered information from their organization as most reliable/believable. When ratings were examined by subgroup, the two characteristics most important for each question in the total sample (listed above) emerged as most important for nearly all subgroups. CONCLUSIONS: Advocates are a resource to policymakers on health topics in the policy process. This study, among the first of its kind, found that advocates seek research information, but have a need for evidence that is unbiased and relevant to their organizations and report that university-based information is reliable. Researchers and advocates should partner so research is useful in advocating for evidence-based policy change.

Family-based models for childhood-obesity intervention: a systematic review of randomized controlled trials.

Effective interventions are needed to address the growing epidemic of childhood obesity. In the past 35 years, family-based approach has gradually developed as a preferred intervention. This review aimed to examine the methodological rigour and treatment effectiveness of family-based interventions according to intervention types and theoretical orientations. A total of 15 randomized controlled trials (RCTs) of family-based lifestyle interventions for children and adolescents aged 2-19 years were included. The adapted Methodological Quality Rating Scales (MQRS) and a four-grade qualitative scoring scheme were adopted to evaluate the methodological rigour and the effectiveness of treatment, respectively. The average MQRS score was 7.93 out of 14 points. Ten of the 15 RCTs had well aligned their research questions with appropriate research methods. The overall short-term outcome of the15 RCTs were satisfactory with an average score of 3.1. Family-based interventions rooted in behaviour theory achieved better results than those theoretically connected to family systems theory in terms of treatment effectiveness. Results suggest future studies to improve the methodological design and continue to explore the potential of the family systems approach.

Communicating evidence-based information on cancer prevention to state-level policy makers

Opportunities exist to disseminate evidence-based cancer control strategies to state-level policy makers in both the legislative and executive branches. We explored factors that influence the likelihood that state-level policy makers will find a policy brief understandable, credible, and useful.

Personal, neighbourhood and urban factors associated with obesity in the United States.

INTRODUCTION: Growing evidence suggests the built environment impacts obesity within urban areas; however, little research has investigated these relationships across levels of urbanisation in diverse and representative populations. This study aimed to determine whether personal and neighbourhood barriers differ by the level of urbanisation and the relative importance of personal barriers, neighbourhood barriers and land-use development patterns measured by a county-level sprawl index. METHODS: Population-based, cross-sectional telephone survey data were collected on 1818 United States adults of diverse ethnicity and income level. Primary analyses were stratified by the level of urbanisation at the county level (large metropolitan, small metropolitan, non-metro, rural). Associations between obesity and neighbourhood and personal barriers were estimated with logistic regression, controlling for demographic variables. Within metropolitan areas, the association between body mass index (BMI) and county-level sprawl was estimated using hierarchical linear modelling, controlling for individual-level neighbourhood and personal barriers and demographic variables and then assessing cross-level interaction. RESULTS: The prevalence of neighbourhood, but not personal, barriers differed widely across levels of urbanisation. Specific neighbourhood (eg traffic, unattended dogs) and personal (eg time, injury) barriers differentially correlated with obesity across strata. The impact of sprawl on BMI (B = -0.005) was consistent with previous findings; standardised coefficients indicate that personal (beta = 0.10) and neighbourhood (beta = 0.05) barriers had a stronger association than sprawl (beta = -0.02). Furthermore, the effect of sprawl on BMI increased by -0.006 with each additional personal barrier. CONCLUSIONS: Future intervention planning and policy development should consider that personal barriers and built environment characteristics may interact with each other and influence obesity differently across urbanisation levels.

Perceived and observed neighborhood indicators of obesity among urban adults.

OBJECTIVE: The global obesity epidemic has been partially attributed to modern environments that encourage inactivity and overeating, yet few studies have examined specific features of the physical neighborhood environment that influence obesity. Using two different measurement methods, this study sought to identify and compare perceived and observed neighborhood indicators of obesity and a high-risk profile of being obese and inactive. DESIGN: Cross-sectional telephone surveys (perceived) and street-scale environmental audits (observed) were conducted concurrently in two diverse US cities to assess recreational facility access, land use, transportation infrastructure and aesthetics. SUBJECTS: A total of 1032 randomly selected urban residents (20% obese, 32% black, 65% female). ANALYSIS: Bivariate and multivariate logistic regression analyses were conducted to estimate the association (adjusted prevalence odds ratio (aOR)) between the primary outcome (obese vs normal weight) and perceived and observed environmental indicators, controlling for demographic variables. RESULTS: Being obese was significantly associated with perceived indicators of no nearby nonresidential destinations (aOR=2.2), absence of sidewalks (aOR=2.2), unpleasant community (aOR=3.1) and lack of interesting sites (aOR=4.8) and observed indicators of poor sidewalk quality (aOR=2.1), physical disorder (aOR=4.0) and presence of garbage (aOR=3.7). Perceived and observed indicators of land use and aesthetics were the most robust neighborhood correlates of obesity in multivariate analyses. CONCLUSIONS: The findings contribute substantially to the growing evidence base of community-level correlates of obesity and suggest salient environmental and policy intervention strategies that may reduce population-level obesity prevalence. Continued use of both measurement methods is recommended to clarify inconsistent associations across perceived and observed indicators within the same domain.

A comparison of national estimates of obesity prevalence from the behavioral risk factor surveillance system and the National Health and Nutrition Examination Survey.

BACKGROUND: Obesity interventions are implemented at state or sub-state level in the United States (US), where only self-reported weight and height data for adults are available from the Behavioral Risk Factor Surveillance System (BRFSS). The prevalence estimates of overweight and obesity generated from self-reported weight and height from BRFSS are known to underestimate the true prevalence. However, whether this underestimation is consistent across different demographic groups has not been fully investigated. METHODS: In this study, we compared the prevalence estimates of obesity (body mass index (BMI) > or =30 kg/m(2)) and overweight (BMI > or =25 kg/m(2)) in different demographic groups in the US from the National Health and Nutrition Examination Survey (NHANES) and BRFSS during 1999-2000. We also compared the rank orders of the obesity and overweight prevalence across different demographic groups from the two data sources. RESULTS: Compared to NHANES, BRFSS underestimated the overall prevalence of obesity and overweight by 9.5 and 5.7 percentage points, respectively. The underestimation differed across different demographic groups: the underestimation of obesity and overweight prevalence was higher among women (13.1 and 12.2 percentage points, respectively) than among men (5.8 and -0.6 percentage points, respectively). The variation of underestimation was higher among men. A clear inverse association between educational attainment and obesity prevalence among non-Hispanic African American women was observed from BRFSS data. However, no such association was found from NHANES. While BRFSS can identify correctly the population with the highest obesity and overweight burden, it did not accurately rank the obesity and overweight prevalence across different demographic groups. CONCLUSION: Compared to NHANES, BRFSS disproportionately underestimates the prevalence of obesity and overweight across different gender, race, age, and education subgroups.

Strength of clean indoor air laws and smoking related outcomes in the USA.

OBJECTIVES: Environmental tobacco smoke (ETS) is often encountered in the workplace. There have been efforts to apply and enforce state laws limiting workplace smoking. There has been little study of the relative effectiveness of state and/or local laws in affecting both rates of workplace ETS exposure and adult smoking rates. This study investigates these hypotheses, as well as the effect of these laws on youth smoking. DESIGN: This is a secondary data analysis using sources including the Current Population Survey (CPS), Behavioral Risk Factor Surveillance System (BRFSS), Youth Risk Behavior Survey (YRBS), and the National Household Survey of Drug Abuse (NHSDA) between the years of 1996 and 1999. Linear regression models were used to investigate the effect of a state's clean indoor air (CIA) law (using a measure of extensiveness) on the overall amount of people who reported working in a smoke-free environment, youth smoking rates and adult smoking rates. RESULTS: The extensiveness of a state's CIA law was found to be a reliable predictor of the percentage of indoor workers who report a smoke-free work environment and the rates of youth smoking. State CIA laws were not conclusively associated with adult smoking rates. CONCLUSIONS: The extensiveness of a state's CIA law is strongly associated with a higher percentage of indoor workers reporting a smoke-free work environment. This study did not reveal a similar association between local laws and smoke-free work environments. Youth smoking rates, shown to be related to state CIA laws, may be further affected with more stringent CIA policy.

Differential correlates of physical activity in urban and rural adults of various socioeconomic backgrounds in the United States.

STUDY OBJECTIVES: Few studies have analysed the rates and correlates of physical activity in economically and geographically diverse populations. Objectives were to examine: (1) urban-rural differences in physical activity by several demographic, geographical, environmental, and psychosocial variables, (2) patterns in environmental and policy factors across urban-rural setting and socioeconomic groups, (3) socioeconomic differences in physical activity across the same set of variables, and (4) possible correlations of these patterns with meeting of physical activity recommendations. DESIGN: A cross sectional study with an over sampling of lower income adults was conducted in 1999-2000. SETTING: United States. PARTICIPANTS: 1818 United States adults. MAIN RESULTS: Lower income residents were less likely than higher income residents to meet physical activity recommendations. Rural residents were least likely to meet recommendations; suburban residents were most likely to meet recommendations. Suburban, higher income residents were more than twice as likely to meet recommendations than rural, lower income residents. Significant differences across income levels and urban/rural areas were found for those reporting neighbourhood streets, parks, and malls as places to exercise; fear of injury, being in poor health, or dislike as barriers to exercise and those reporting encouragement from relatives as social support for exercise. Evidence of a positive dose-response relation emerged between number of places to exercise and likelihood to meet recommendations for physical activity. CONCLUSIONS: Both income level and urban rural status were important predictors of adults' likelihood to meet physical activity recommendations. In addition, environmental variables vary in importance across socioeconomic status and urban-rural areas.

Application of a rating system to state clean indoor air laws (USA).

OBJECTIVE: To develop and implement a system for rating state clean indoor air laws. DESIGN: The public health interest of state clean indoor air laws is to limit non-smoker exposure to environmental tobacco smoke (ETS). Current estimates of health risks and methods available for controlling ETS provided a framework for devising a ratings scale. An advisory committee applied this scale to each of seven site specific smoking restrictions and two enforcement related items. For each item, a target score of +4 was identified. The nine items were then combined to produce a summary score for each state. A state that achieved the target across all nine items would receive a summary score of 36 points and be eligible to receive an additional 6 points for exceeding the target on six of the nine items, resulting in a maximum summary score of 42 points. Individual scores were also adjusted to reflect state level preemption measures. Each state's law was evaluated annually from 1993 through 1999. SETTING: USA. MAIN OUTCOME MEASURE: A summary score measuring the extensiveness of the state's clean indoor air law. RESULTS: State laws restricting smoking in the seven individual locations of interest were relatively weak. The overall mean score across the location restrictions ranged from 0.72 in 1993 to 0.98 in 1999. Mean scores were higher for the enforcement items than for the location restrictions. Summary scores ranged from 0 to 20 in 1993 and 0 to 31 in 1994 through 1999. Average summary scores ranged from 8.71 in 1993 to 10.98 in 1999. By the end of 1999, scores increased for 22 states; however, between 1995 and 1997 there were no changes in the summary scores. Three states scored zero points across all years. From 1993 through 1999, there was a 41% increase in the number of states that had in place state level preemption measures. CONCLUSION: The number of newly enacted state clean indoor air laws has remained relatively stagnant since 1995. With a few exceptions, as of the end of 1999, progress in enacting state laws to meet specified public health targets for reducing exposure to ETS was relatively low. Thus, state laws in the USA provide, on average, only minimal protection in specified areas and, given the increase in preemption, are increasingly undermining those passed in localities.

Environmental and policy determinants of physical activity in the United States.

OBJECTIVES: This study examined (1) descriptive patterns in perceived environmental and policy determinants of physical activity and (2) associations between these factors and behavior. METHODS: A cross-sectional study was conducted from 1999 to 2000 among US adults; individuals at lower income levels were oversampled. RESULTS: Availability of areas for physical activity was generally higher among men than among women. The 4 most commonly reported personal barriers were lack of time, feeling too tired, obtaining enough exercise at one's job, and no motivation to exercise. Neighborhood characteristics, including the presence of sidewalks, enjoyable scenery, heavy traffic, and hills, were positively associated with physical activity. There was a high level of support for health policy-related measures. Up to one third of individuals who had used environmental supports reported an increase in physical activity. CONCLUSIONS: An array of environmental and policy determinants, particularly those related to the physical environment, are associated with physical activity and should be taken into account in the design of interventions.

A prospective investigation of the impact of smoking bans on tobacco cessation and relapse.

BACKGROUND AND OBJECTIVES: To examine the long term impact of workplace smoking bans on employee smoking cessation and relapse. Over three years we studied a total of 1033 current or former smokers (intervention group) employed in smoke-free hospitals and 816 current or former smokers (comparison group) employed in non-smoke-free workplaces. The design of this natural experiment is a prospective cohort study. We randomly selected both hospitals and employees from 12 strata based on hospital size and state tobacco regulations, and sampled employees in the same communities. Main outcome measures were post-ban quit ratio and relapse rate. RESEARCH DESIGN: Between groups comparisons were conducted using the Cochran-Mantel-Haenszel statistic for general association, stratified Cox proportional hazards models, and the CMH analysis of variance statistic based on ranks. McNemar's test and the sign test were used to test for changes over time within each group. RESULTS: Differences in the post-ban quit ratio were observed between intervention and comparison groups (p < or = 0.02). For employees whose bans were implemented at least seven years before survey, the post-ban quit ratio was estimated at 0.256, compared with 0.142 for employees in non-smoke-free workplaces (p = 0.02). After controlling for a variety of factors, time to quit smoking was shorter for the hospital employees (p < 0.001), with an overall relative risk of quitting of 2.3. Contrary to expectations, relapse rates were similar between the groups. CONCLUSION: Employees in workplaces with smoking bans have higher rates of smoking cessation than employees where smoking is permitted, but relapse is similar between these two groups of employees. The results of this investigation have international applicability for policy makers, clinicians, employers, and employees. Countries should review smoking policies in workplaces in light of their own smoking patterns and efforts to deal with environmental tobacco smoke.

Physician advice and support for physical activity: results from a national survey.

BACKGROUND: It is increasingly well documented that physical activity (PA) is a key preventive behavior and that visits to a physician provide an important opportunity for advice and counseling. This paper reports on physician counseling behaviors regarding PA and other chronic disease risk factors from a national survey. METHODS: A diverse sample of U.S. adults (N=1818), with oversampling of lower-income households, was surveyed about their PA level as well as a host of social, environmental, and physician counseling issues. RESULTS: Overall, 28% of respondents reported receiving physician advice to increase their PA level. Of those who received advice, only 38% received help formulating a specific activity plan and 42% received follow-up support. Patients who received advice and support were more likely to be older, nonwhite, and to have more chronic illnesses and more contact with their doctor. CONCLUSIONS: Physician advice, counseling, and follow-up are important components of the social-environmental supports needed to increase population PA levels. Health system changes, including teaching communication skills, prompts to use those skills, and system changes to support attention to PA, are needed to extend promotion of PA to more patients.

Stage of readiness to exercise in ethnically diverse women: a U.S. survey.

PURPOSE: To assess stage of readiness to exercise and readiness to be physically active in a national survey of women aged 40 yr and over from various racial/ethnic groups (the U.S. Women's Determinants Study). METHOD: The prevalence of each stage was determined and compared across race/ethnicity. In addition, the level of misclassification between self-report of stage of readiness to exercise/be physically active and self-reported participation in specific exercise behavior was evaluated. RESULTS: Data were collected from a total of 2912 U.S. women via telephone survey over a 1-yr period (black 26%, American Indians/Alaskan Natives 25%, Hispanics 23%, and whites 26%). Over half the total sample was staged as currently undertaking regular exercise (maintenance stage, 55%), 25% indicated they were in precontemplation, and 15% were in contemplation stage. Few women were in preparation and action stages. There were statistically significant differences between the minority groups. Specifically, black women (OR 0.53, 95% 0.31-0.91) were less likely to be in the active stages (e.g., preparation, action, maintenance) than Hispanics and Alaskan Native/American Native women, and this was true after controlling for important sociodemographic and health variables (age, education, BMI, and smoking). The additional analysis of a modified stage question developed to assess readiness to be more physically active (150 min.wk(-1)) may have provided inflated results (82% in maintenance), possibly due to the complexity of the questions. The level of misclassification between measures ranged from 5 to 20%. CONCLUSION: These results have important implications for the use of stage of change measures with populations of older ethnically diverse women particularly and the popularity of modifying stage questions to reflect "lifestyle" or moderate-intensity physical activity.

The relationship between parental modeling, eating patterns, and dietary intake among African-American parents.

OBJECTIVE: This article examines the relationship between the frequency with which African-American parents report modeling healthful dietary behaviors for their children and parental dietary intake. DESIGN: Cross-sectional, baseline data from a community-based dietary change study to reduce fat intake and increase fruit and vegetable consumption among African-American parents was analyzed to identify role-modeling behaviors. SUBJECTS/SETTING: Subjects were 456 African-American parents who participated in a dietary change study as part of a national parent education group. Participants completed the Parental Dietary Modeling Scale, an eating patterns questionnaire and a food frequency questionnaire. STATISTICAL ANALYSES PERFORMED: Descriptive statistics and stepwise multiple linear regression analyses were conducted. RESULTS: Parental modeling of healthful dietary behavior was associated with the performance low-fat eating patterns (r = 0.48; P < .001), lower dietary fat intake (r = -0.30; P < .001), and higher consumption of fruits and vegetables (r = 0.18; P < .001). APPLICATIONS: The frequency with which parents model healthful dietary behaviors may be associated with parental dietary intake and may have long-term implications for the development of childhood eating patterns. Dietetics professionals need to carefully assess parents' current dietary modeling behaviors and inform parents about how performance of these general behaviors may affect their child's ultimate nutrition health.

Correlates of overweight and weight-loss practices in Missouri.

OBJECTIVE: To examine potential correlates of overweight and weight-loss practices in Missouri. METHODS: Two probability surveys (n=3,010) were used to investigate the associations of sociodemographic and health-related factors with overweight and attempting, exercising, dieting, and desiring to lose weight. RESULTS: Race, gender, and receiving professional advice were strongly associated with being overweight. Gender, receiving professional advice, and leisure-time physical activity were positively associated with attempting and desiring to lose weight. CONCLUSIONS: Public health programs can utilize this knowledge to reduce the prevalence of overweight by encouraging professional advice and promoting regular exercise.

A community research partnership to improve the diet of African Americans.

OBJECTIVE: To describe a community research partnership in which a national parent education organization collaborated with academic institutions to develop a dietary change program for underserved African American parents. METHODS: Qualitative methods were used to characterize issues that impacted partnership operations. RESULTS: Data are reported on partnership activities including program development and implementation with African American parents. Lessons learned and strategies for improving the partnership are presented. CONCLUSIONS: Ongoing assessment and evaluation of how a partnership operates, especially in the context of multiple sites, are important to sustaining successful functioning.