Sleep Disturbance Mediates the Associations Between HIV Stigma and Mental and Physical Health Among Black Adults with HIV.

OBJECTIVES: Black Americans have been disproportionally affected by the HIV epidemic, and experience significant disparities in sleep health, mental health, and physical health domains. Using longitudinal data from a sample of Black adults with HIV, the current study examined the associations between stigma and mental and physical health outcomes and how sleep disturbance may play a mediating role. METHODS: Data were drawn from a recent randomized controlled trial. Questionnaires were used to examine internalized and anticipated HIV stigma, perceived discrimination (enacted stigma) based on multiple social identities (i.e., HIV-serostatus, race, sexual orientation), sleep disturbance, mental health problems (depressive and posttraumatic stress disorder [PTSD] symptoms), and mental and physical health-related quality of life (HRQOL) at baseline, 7-month follow-up, and 13-month follow-up assessments. Linear mixed modeling was used to examine main effects of stigma on health outcomes; causal mediation analysis was used to estimate indirect paths through sleep disturbance. RESULTS: Internalized and anticipated HIV stigma and multiple discrimination were associated with more sleep disturbance, more depressive and PTSD symptoms, and poorer mental and physical HRQOL. Results also indicated significant indirect paths (i.e., mediation) through greater sleep disturbance between HIV-related stigma and discrimination and mental health and health-related quality of life. CONCLUSIONS: Results support that sleep disturbance is a mediating pathway through which different forms of stigmas impact health outcomes. Sleep may be an intervention target to help improve mental and physical well-being and reduce health disparities among racial and ethnic minority people with HIV.

Food Insecurity Among Aging SNAP Participants and Eligible Nonparticipants in Two Predominantly Low-Income Black Neighborhoods: Implications for SNAP Enrollment and Outreach for Older Adults.

BACKGROUND: The Supplemental Nutrition Assistance Program (SNAP) plays a critical role in alleviating poverty and food insecurity. Despite these benefits, many older Americans who are eligible for SNAP do not participate in the program. Few studies have explored household factors and food insecurity outcomes associated with nonparticipation among older Black Americans. OBJECTIVES: The study aim was to explore changes in food insecurity and related financial hardship outcomes between 2020 and 2021 among SNAP participants, eligible nonparticipants, and ineligible nonparticipants; compare reasons for not participating in SNAP; and to compare household factors associated with SNAP nonparticipation. METHODS: Longitudinal design examining data from 2020 and 2021 to assess changes in food insecurity over the course of the coronavirus disease 2019 pandemic. PARTICIPANTS/SETTING: Participants were 528 adults (aged 30 to 97 years) in households randomly selected from a listing of all residential addresses in two predominantly Black neighborhoods with lower incomes in Pittsburgh, PA, and surveyed between March to May 2020 and May to December 2021. MAIN OUTCOME MEASURES: Food security was measured using the validated 6-item US Department of Agriculture Adult Food Security Survey Module. STATISTICAL ANALYSES PERFORMED: Findings are based on a descriptive analysis of food security and related indicators. Statistical testing was performed to assess differences between SNAP participation status and individual characteristics, food security, and financial hardship using Wald F test for continuous measures and Pearson χ2 test for categorical measures. A multivariable linear model was used to assess the association of SNAP participation and eligibility status with change in food insecurity. RESULTS: In cross-sectional analyses of 2021 data, no differences were observed between SNAP participants and eligible nonparticipants for food insecurity, food bank use, mean weekly food spending per person, and difficulty paying for basics. However, with respect to changes in food insecurity over the course of the pandemic, SNAP participants experienced a greater improvement in mean food security scores between 2020 and 2021 (-0.52 reduction in mean food insecurity score or a 16% improvement in food security; P ≤ 0.05) relative to SNAP-eligible nonparticipants. Perceived ineligibility (71.3%) and perceived lack of need (23%) were the most common reasons for not participating in SNAP. CONCLUSIONS: More than one-third of SNAP participants and eligible nonparticipants experienced food insecurity and financial hardship. However, there were differences in the changes in food insecurity between these groups.

Association of Place With Adolescent Obesity.

Importance: Despite strong evidence linking place and obesity risk, the extent to which this link is causal or reflects sorting into places is unclear. Objective: To examine the association of place with adolescents' obesity and explore potential causal pathways, such as shared environments and social contagion. Design, Setting, and Participants: This natural experiment study used the periodic reassignment of US military servicemembers to installations as a source of exogenous variation in exposure to difference places to estimate the association between place and obesity risk. The study analyzed data from the Military Teenagers Environments, Exercise, and Nutrition Study, a cohort of adolescents in military families recruited from 2013 through 2014 from 12 large military installations in the US and followed up until 2018. Individual fixed-effects models were estimated that examined whether adolescents' exposure to increasingly obesogenic places over time was associated with increases in body mass index (BMI) and probability of overweight or obesity. These data were analyzed from October 15, 2021, through March 10, 2023. Exposure: Adult obesity rate in military parent's assigned installation county was used as a summary measure of all place-specific obesogenic influences. Main Outcomes and Measures: Outcomes were BMI, overweight or obesity (BMI in the 85th percentile or higher), and obesity (BMI in the 95th percentile or higher). Time at installation residence and off installation residence were moderators capturing the degree of exposure to the county. County-level measures of food access, physical activity opportunities, and socioeconomic characteristics captured shared environments. Results: A cohort of 970 adolescents had a baseline mean age of 13.7 years and 512 were male (52.8%). A 5 percentage point-increase over time in the county obesity rate was associated with a 0.19 increase in adolescents' BMI (95% CI, 0.02-0.37) and a 0.02-unit increase in their probability of obesity (95% CI, 0-0.04). Shared environments did not explain these associations. These associations were stronger for adolescents with time at installation of 2 years or longer vs less than 2 years for BMI (0.359 vs. 0.046; P value for difference in association = .02) and for probability of overweight or obesity (0.058 vs. 0.007; P value for difference association = .02), and for adolescents who lived off installation vs on installation for BMI (0.414 vs. -0.025; P value for association = .01) and for probability of obesity (0.033 vs. -0.007; P value for association = .02). Conclusion and Relevance: In this study, the link between place and adolescents' obesity risk is not explained by selection or shared environments. The study findings suggest social contagion as a potential causal pathway.

Examining the Cross-sectional Association Between Neighborhood Conditions, Discrimination, and Telomere Length in a Predominantly African American Sample.

Disproportionate exposure to adverse neighborhood conditions and greater discrimination may contribute to health disparities among African Americans (AAs). We examined whether adverse neighborhood conditions, alone or in conjunction with discrimination, associate with shorter leukocyte telomere length among a predominantly AA cohort. The sample included 200 residents from two low-income neighborhoods (96% AA; mean age = 67 years). Perceived neighborhood conditions and discrimination were surveyed in 2018, and objective neighborhood conditions (total crime rate, neighborhood walkability, ambient air pollution (PM2.5, black carbon)) were collected in 2017/2018. Relative telomere length (T/S; ratio of telomeric DNA to a single-gene copy) was assessed from blood samples. Linear regression models estimated the main effects of each neighborhood condition and discrimination and their interactions on the T/S ratio. Less walkable neighborhoods were associated with shorter telomeres. Higher air pollution (PM2.5) was associated with shorter telomeres among those experiencing greater discrimination. Findings highlight the importance of understanding the intersecting influences of historic and contemporary sources of systemic racism and how they contribute to accelerated aging among adults.

Longitudinal associations between sleep and BMI in a low-income, predominantly Black American sample.

OBJECTIVE: Black individuals and those experiencing socioeconomic disadvantage are at increased risk for sleep problems and obesity. This study adds to the limited extant literature examining longitudinal associations between objectively measured sleep and changes in body mass index (BMI) in Black Americans. DESIGN: We focused on individuals with at least 1 observation of sleep and BMI at 1 of 3 study time points (2013, 2016, and 2018). We modeled longitudinal trends in BMI as a function of time, average of each sleep variable across assessments, and within-person deviations in each sleep variable over time. SETTING: Data were collected via interviewer-administered at-home surveys and actigraphy in Pittsburgh, PA. PARTICIPANTS: Our sample comprised 1115 low-income, primarily Black adults, including 862 women and 253 men. MEASUREMENTS: Sleep measures included actigraphy-measured total sleep time, sleep efficiency, and wakefulness after sleep onset, as well as self-reported sleep quality. We also included objectively measured BMI. RESULTS: In models adjusted for age, gender, and other sociodemographic covariates (eg, income, marital status), there were no significant longitudinal associations between total sleep time, sleep efficiency, wakefulness after sleep onset, or subjective sleep quality and changes in BMI. CONCLUSIONS: This study provides further evidence that, among a sample of low-income Black adults, sleep problems are not longitudinally predictive of BMI. Although ample cross-sectional evidence demonstrates that sleep problems and obesity commonly co-occur, longitudinal evidence is mixed. Better understanding the overlap of sleep and obesity over time may contribute to prevention and intervention efforts.

Randomized Controlled Trial of Rise, A Community-Based Culturally Congruent Counseling Intervention to Support Antiretroviral Therapy Adherence Among Black/African American Adults Living with HIV.

Structural inequities have led to HIV disparities, including relatively low antiretroviral therapy adherence and viral suppression rates among Black Americans living with HIV. We conducted a randomized controlled trial of Rise, a community-based culturally congruent adherence intervention, from January 2018 to December 2021 with 166 (85 intervention, 81 control) Black adults living with HIV in Los Angeles County, California [M (SD) = 49.0 (12.2) years-old; 76% male]. The intervention included one-on-one counseling sessions using basic Motivational Interviewing style to problem solve about adherence, as well as referrals to address unmet needs for social determinants of health (e.g., housing services, food assistance). Assessments included electronically monitored adherence; HIV viral load; and baseline, 7-month follow-up, and 13-month follow-up surveys of sociodemographic characteristics, HIV stigma, medical mistrust, and HIV-serostatus disclosure. Repeated-measures intention-to-treat regressions indicated that Rise led to significantly (two-fold) higher adherence likelihood, lower HIV stigmatizing beliefs, and reduced HIV-related medical mistrust. Effects on HIV viral suppression, internalized stigma, and disclosure were non-significant. Moreover, Rise was cost-effective based on established standards: The estimated cost per person to reach optimal adherence was $335 per 10% increase in adherence. Interventions like Rise, that are culturally tailored to the needs of Black populations, may be optimal for Black Americans living with HIV (ClinicalTrials.gov #NCT03331978).

RESUMEN: Las desigualdades estructurales han dado lugar a disparidades relacionadas con el VIH, incluyendo la relativamente baja adherencia a la terapia antirretroviral (TAR) y las tasas de supresión viral entre los afroamericanos que viven con el VIH. Conducimos una prueba controlada aleatoria de Rise, una intervención de adherencia culturalmente congruente basada en la comunidad, desde Enero de 2018 hasta Diciembre de 2021 con 166 (85 intervención, 81 controlada) adultos afroamericanos que viven con el VIH en el condado de Los Ángeles, California [M (SD) = 49.0 (12,2) años; 76% de hombres]. La intervención incluyó sesiones de asesoramiento individualizadas, usando el estilo básico Motivacional para las entrevistas, para resolver los problemas de adherencia como también referencias para confrontar sus necesidades insatisfechas de los determinantes sociales de la salud (por ejemplo, servicios de vivienda y asistencia de alimentos). Las evaluaciones incluyeron la adherencia monitoreada electrónicamente; la carga viral del VIH; y encuestas de referencia, seguimiento a los 7 meses y seguimiento a los 13 meses sobre características sociodemográficas, el estigma del VIH, la desconfianza médica y divulgación del estado serológico respecto al VIH. Los efectos sobre la supresión viral del VIH, el estigma interiorizado y la revelación de información no fueron significativos. Además, Rise fue rentable según los estándares establecidos: El costo estimado por persona para alcanzar la adherencia óptima fue de 335 dólares por cada 10% de aumento en la adherencia. Las intervenciones como Rise, que se adaptan culturalmente a las necesidades de las poblaciones afroamericana, podrían ser óptimas para los estadounidenses afroamericanos que viven con el VIH.

Do social isolation and neighborhood walkability influence relationships between COVID-19 experiences and wellbeing in predominantly Black urban areas?

Black Americans have been disproportionately affected by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or COVID-19) pandemic. Since the pandemic's start, we have observed compounded health, social, and economic impacts for communities of color, fueled in part by profound residential segregation in the United States that, for centuries prior to the pandemic, created differences in access to opportunity and resources. Based on a longitudinal cohort of Black residents living in two racially isolated Pittsburgh neighborhoods, we sought to: 1) describe the experiences of behavioral responses to COVID-19 conditions (e.g., closures of businesses, schools, government offices) and illness experiences reported by residents within these disinvested, urban areas and 2) determine if these experiences were associated with perceptions of risk, negative mental health outcomes, and food insecurity; and 3) examine whether any of the associations were explained by social isolation or modified by neighborhood walkability. We found direct associations between residents' experience with COVID-19-related closures and with the illness, with perceived risk, and change in psychological distress, sleep quality, and food insecurity from pre-COVID-19 levels. Social isolation was a statistically significant mediator of all of these associations, most strongly mediating the pathway to psychological distress. We found neighborhood walkability to be a significant moderator of the association between closure experiences and sleep quality. The results suggest that experiences of COVID-19 closures and illness were associated with serious threats to public health in Black, disinvested, urban neighborhoods, beyond those caused directly by the virus. Outcomes of the pandemic appear very much dependent on the extent to which social and physical resources are available to meet the demands of stress.

Trends In Home Care Versus Nursing Home Workforce Sizes: Are States Converging Or Diverging Over Time?

There is strong preference among people with disabling conditions to receive care at home rather than in an institutional setting. Differences in state policies may make this more feasible in some states than others. Yet no study to date has examined trends in the long-term care workforce across states. Using state-level data on direct care workers from the period 2009-20, we examine trends in the sizes of the nursing home and home care workforces. We show that since 2009 most states have increased the size of their home care workforces and decreased the size of their nursing home workforces, but there is substantial variation across states in the magnitude of these changes. In addition, the gap between leading and lagging states in home care workforce size has grown over time. This suggests that more targeted efforts may be needed to ensure that people with disabling conditions can have their needs met in their desired setting across the nation.

Neighborhood Food Environment Associated with Cardiometabolic Health among Predominately Low-income, Urban, Black Women.

OBJECTIVES: This study sought to: 1) understand how the perceived food environment (availability, accessibility, and affordability) is associated with cardiometabolic health outcomes in predominately low-income Black residents in urban neighborhoods with limited healthy food access; and 2) examine the association of shopping at specific store types with cardiometabolic health outcomes. METHODS: We report on cross-sectional data from 459 individuals participating in the Pittsburgh, PA Hill/Homewood Research on Neighborhoods and Health (PHRESH) study. Mean participant age was 60.7 (SD=13.9); 81.7% were female. We used logistic regression to examine associations between three factors (perceived fruit and vegetable availability, quality, and price; primary food shopping store characteristics; and frequency of shopping at stores with low or high access to healthy foods) and cardiometabolic and self-rated health. RESULTS: Adjusting for sociodemographic characteristics, participants with higher perceived fruit and vegetable accessibility (AOR:.47, 95%CI: .28-.79, P=.004) and affordability (AOR:.59, 95%CI: .36-.96, P=.034) had lower odds of high blood pressure. Shopping often (vs rarely) at stores with low access to healthy foods was associated with higher odds of high total cholesterol (AOR:3.52, 95%CI: 1.09-11.40, P=.035). Finally, primary food shopping at a discount grocery (vs full-service supermarket) was associated with lower odds of overweight/obesity (AOR:.51, 95%CI: .26-.99, P=.049). CONCLUSIONS: These results suggest that both perceived accessibility and affordability of healthy foods are associated with reduced cardiometabolic risk factors in this urban, low-income predominantly Black population. Additionally, discount grocery stores may be particularly valuable by providing access and affordability of healthy foods in this population.

Examining the diagnostic validity of the Berlin Questionnaire in a low-income Black American sample.

STUDY OBJECTIVES: Black individuals and individuals of low socioeconomic status are at increased risk for obstructive sleep apnea (OSA). The Berlin Questionnaire is one of the most widely used screening tools for OSA; however, there is limited research on its diagnostic accuracy in low-income Black populations. METHODS: This study analyzed data from an ongoing study taking place among a cohort from 2 predominantly Black neighborhoods in Pittsburgh, Pennsylvania (96.3% Black, 79.6% female). The sample included 269 individuals without a prior diagnosis of OSA who completed the Berlin Questionnaire and also participated in a home sleep apnea test. An apnea-hypopnea index ≥ 15 events/h was used to identify individuals with moderate or severe OSA. RESULTS: 19.3% of individuals met criteria for moderate to severe OSA based on home sleep apnea test, while 31.2% of participants screened as high risk for OSA based on the overall Berlin index. Using apnea-hypopnea index ≥ 15 events/h as the reference standard, the Berlin Questionnaire had a sensitivity of 46.2%, specificity of 72.4%, positive predictive value of 28.6%, and negative predictive value of 84.9% among this sample. Analyses stratified by sex suggested that the Berlin Questionnaire had better diagnostic validity in women than men. CONCLUSIONS: The Berlin Questionnaire has lower sensitivity and positive predictive value in our sample than those observed in general population samples. The measure performed better among women, though a higher proportion of men fell into the moderate or severe OSA range based on the home sleep apnea test. Given the significant downstream consequences of OSA, utilizing screening tools that better detect OSA in Black communities is key. CITATION: Holliday SB, Haas A, Dong L, et al. Examining the diagnostic validity of the Berlin Questionnaire in a low-income Black American sample. J Clin Sleep Med. 2021;17(10):1987-1994.

Violent crime, police presence and poor sleep in two low-income urban predominantly Black American neighbourhoods.

OBJECTIVE: To examine violent crime in relation to sleep and explore pathways, including psychological distress, safety perceptions and perceived police presence, that may account for associations. METHODS: In 2018, 515 predominantly Black American (94%) adults (Pittsburgh, Pennsylvania, USA) provided survey data: actigraphy-assessed sleep duration and wakefulness after sleep onset (WASO). We estimated pathways from violent crime (2016-2018) to sleep through psychological distress, perceptions of safety and perceived adequacy of police presence. RESULTS: WASO was most strongly associated with violent crimes that were within 1/10 mile of the participant's home and within the month preceding the interview. Violent crimes were associated with lower perceived safety (ß=-0.13 (0.03), p<0.001) and greater WASO (ß=5.96 (2.80), p=0.03). We observed no indirect associations between crime and either WASO or sleep duration through any of the tested mediators. Crime was not associated with sleep duration. CONCLUSIONS: We demonstrated that more proximal and more recent violent crimes were associated with reduced perceived safety and worse WASO. Differential exposure to violent crime among Black Americans may contribute to health disparities by reducing residents' perceived safety and sleep health.

An audit tool for longitudinal assessment of the health-related characteristics of urban neighborhoods: implementation methods and reliability results.

BACKGROUND: Improving the neighborhood environment may help address chronic disease and mortality. To identify neighborhood features that are predictors of health, objective assessments of the environment are used. Multiple studies have reported on cross-sectional assessments of health-related neighborhood features using direct observation. As study designs expand to better understand causation and predictors of change, there is a need to test whether direct observation methods are adequate for longitudinal assessment. To our knowledge, this is the first study to report on the reliability of repeated measurements of the neighborhood environment, and their stability, over time. METHODS: The Pittsburgh Hill/Homewood Research on Neighborhood Change and Health (PHRESH) study conducted longitudinal assessments in two low-income, African American neighborhoods at three waves (years 2012, 2015, 2017). The PHRESH audit tool is a modification of earlier validated tools, with an emphasis on environment features relevant for physical activity, sleep, and obesogenic behaviors. Trained data-collector pairs conducted direct observations of a 25% sample of street segments in each neighborhood. At each wave, we audited a sub-sample of street segments twice and assessed reliability using percentage inter-observer agreement and krippendorf's alpha statistics. Stability of these items was assessed as exhibiting moderate or high agreement at every time point. RESULTS: Across waves, a majority (81%) of the items consistently demonstrated moderate to high agreement except for items such as public/communal space, amount of shade, sidewalk features, number of traffic lanes, garden/flower bed/planter, art/statue/monument, amount of trash, and physical disorder. The list of items with poor agreement includes features that are easy to miss (e.g. flower bed/planter), hard to assess from outside (e.g. public/communal space), or may change quickly (e.g. amount of trash). CONCLUSION: In this paper, we have described implementation methods, reliability results and lessons learned to inform future studies of change. We found the use of consistent methods allowed us to conduct reliable, replicable longitudinal assessments of the environment. Items that did not exhibit stability are less useful for detecting real change over time. Overall, the PHRESH direct observation tool is an effective and practical instrument to detect change in the neighborhood environment.

Do investments in low-income neighborhoods produce objective change in health-related neighborhood conditions?

This study examined the effect of neighborhood investments on neighborhood walkability, presence of incivilities, and crime in two low-income, primarily African American neighborhoods in Pittsburgh, USA. During the study period, one of the neighborhoods (the intervention neighborhood) received substantially more publicly-funded investments than a demographically matched comparison neighborhood. Comparisons between the neighborhoods showed a significant difference-in-difference for all three outcomes. The intervention neighborhood experienced significantly more change related to improved walkability and decreased incivilities. However, the control neighborhood experienced better crime-related outcomes. Analyses that focused on resident proximity to investments found similar results. This highlights the nuances of neighborhood investment, which is important to consider when thinking about public policy.

Prevalence and correlates of obstructive sleep apnea in urban-dwelling, low-income, predominantly African-American women.

STUDY OBJECTIVES: The current study examined the prevalence and correlates of obstructive sleep apnea in a sample of low-income, predominantly African-American women using two waves of data. METHODS: Participants were adults from two urban neighborhoods who enrolled in the PHRESH Zzz Study (N = 828; Pittsburgh Hill/Homewood Research on Neighborhoods, Sleep, and Health). A subsample who reported never receiving OSA diagnosis completed home sleep apnea testing in 2016 (n = 269, mean age 55.0 years, 79.6% female) and again in 2018 (n = 135). Correlates of OSA tested included demographic and anthropometric variables, health behavior/conditions, psychological distress and general health, smoking status, actigraphy-measured sleep, and neighborhood factors measured at baseline. RESULTS: 18.0% of all 2016 participants reported receiving physician diagnoses of OSA. Among those who completed in-home assessment, 19.3% had AHI ≥15 and 33.8% had AHI ≥5 plus one or more sleep symptoms. Estimates of the prevalence of OSA in all 2016 participants were 33.8%-45.7% based on physician diagnoses and AHI results, depending on the criteria used. Age, gender, BMI, blood pressure, habitual snoring, neighborhood walkability, actigraphy-measured sleep characteristics, and smoking were concurrently associated with OSA in 2016. Changes in AHI categories from 2016 to 2018 were documented. CONCLUSIONS: Low-income African Americans, including women, are a high-risk group for OSA, but remain under-diagnosed and under-treated. The current findings show a high prevalence of OSA in African-American women and are among the first to demonstrate that both individual and neighborhood factors are implicated in OSA prevalence.

A novel approach to anthropometric assessment for geographically dispersed samples: A pilot study.

Measurements by trained personnel are the criterion standard for assessments of body mass index (BMI) and obesity. Yet, in-person measurements are less practical for studies of geographically dispersed samples. Recent advances in technology and the success of telehealth suggests that videoconferencing may be promising. We conducted a pilot study to examine the validity of videoconference-assisted measurements (VCAM) relative to in-person measurements by trained staff. We collected height, weight, percent body fat and waist circumference measurements using VCAM and staff measured in a convenience sample of 50 greater Los Angeles participants. We calculated relative standardized differences, and agreement between the two approaches using Pearson correlation and Bland-Altman plots. The small magnitude of differences (effect sizes <0.03), and high agreement suggested that the two approaches produce similar values. Thus, completing height and weight measurements through videoconference may be a valid and cost-effective approach, especially for geographically dispersed samples.

School Food and Beverage Availability and Children's Diet, Purchasing, and Obesity: Evidence From a Natural Experiment.

PURPOSE: Existing evidence on relationships between school food environments and children's in-school purchases, dietary behaviors, and body composition is based on observational studies that are vulnerable to residential selection bias. METHODS: This study leveraged exogenous variation in school environments generated by the natural experiment due to military parents' assignment to installations. We analyzed 1,010 child-wave observations from the Military Teenagers Environments, Exercise, and Nutrition Study collected during 2013-2015. Using multiple linear and logistic regression, we examined whether the number of competitive food and beverage (CF&B) items available for purchase in school, overall and by type (unhealthy, healthy, neutral), was associated with in-school food purchases, dietary behaviors, and body mass index (BMI) outcomes. Covariates included child and family characteristics and the healthiness of the home food environment. RESULTS: Unhealthy item availability was positively associated with purchasing any sweets (adjusted odds ratio [AOR], 1.30; p < .01), snacks (AOR, 1.23; p < .01), and sugar-sweetened beverages (AOR, 1.19; p = .01). However, there were no significant associations with overall food and beverage intake (e.g., sweets, soda) nor BMI outcomes. The home food environment was significantly associated with all outcomes. CONCLUSIONS: Access to unhealthy CF&B items may influence in-school purchases but does not appear to influence overall dietary behaviors and BMI outcomes. Substitution of caloric intake across locations within versus outside of school may play a role in explaining why purchases were associated with unhealthy CF&B availability but overall diet and downstream BMI were not.

Improved Street Walkability, Incivilities, and Esthetics Are Associated with Greater Park Use in Two Low-Income Neighborhoods.

Parks may provide opportunities for people to increase their physical activity and improve health. Yet, parks are generally less plentiful and underutilized in low-income urban neighborhoods compared with more advantaged neighborhoods. Renovations within and around parks may improve park utilization but the empirical evidence supporting this relationship is scarce. This study assessed the impact of greenspace, housing, and commercial investments on street characteristics (walkability, amenities, incivilities/poor esthetics) and park use by examining park use over time in two low-income neighborhoods in Pittsburgh, PA (n = 17 parks), before and after neighborhood-based renovations that were primarily centered in one neighborhood. We used systematic observation of parks, park use, and street blocks surrounding parks to examine the impact of neighborhood changes on park use. We used difference-in-differences to test whether park use and street characteristics surrounding the parks improved more in the intervention neighborhood than in the comparison neighborhood. We also used zero-inflated negative binomial regression with interactions by time to test whether changes in street characteristics were associated with changes in park use over time. We found that improved walkability, incivilities, and esthetics surrounding parks in socioeconomically disadvantaged neighborhoods were associated with greater park use and may help increase visits to underutilized parks.

Results from a natural experiment: initial neighbourhood investments do not change objectively-assessed physical activity, psychological distress or perceptions of the neighbourhood.

BACKGROUND: Few studies have assessed objectively measured physical activity (PA), active transportation, psychological distress and neighborhood perceptions among residents of a neighborhood before and after substantial improvements in its physical environment. Also, most research-to-date has employed study designs subject to neighborhood selection, which may introduce bias in reported findings. We built upon a previously enrolled cohort of households from two low-income predominantly African American Pittsburgh neighborhoods, matched on socio-demographic composition including race/ethnicity, income and education. One of the two neighborhoods received substantial neighborhood investments over the course of this study including, but not limited to public housing development and greenspace/landscaping. We implemented a natural experiment using matched intervention and control neighborhoods and conducted pre-post assessments among the cohort. Our comprehensive assessments included accelerometry-based PA, active transportation, psychological distress and perceptions of the neighborhood, with assessments conducted both prior to and following the neighborhood changes. In 2013, we collected data from 1003 neighborhood participants and in 2016, we re-interviewed 676 of those participants. We conducted an intent to treat analysis, with a difference-in-difference estimator using attrition weighting to account for nonresponse between 2013 and 2016. In addition, we derived an individual-level indicator of exposure to neighbourhood investment and estimated effect of exposure to investment on the same set of outcomes using covariate-adjusted models. RESULTS: We observed no statistically significant differences in activity, psychological distress, satisfaction with one's neighborhood as a place to live or any of the other measures we observed prior to and after the neighborhood investments between the intervention and control neighborhoods or those exposed vs not exposed to investments. CONCLUSIONS: Using this rigorous study design, we observed no significant changes in the intervention neighborhood above and beyond secular trends present in the control neighborhood. Although neighborhood investment may have other benefits, we failed to see improvement in PA, psychological distress or related outcomes in the low-income African American neighborhoods in our study. This may be an indication that improvements in the physical environment may not directly translate into improvements in residents' physical activity or health outcomes without additional individual-level interventions. It is also possible that these investments were not dramatic enough to spur change within the three year period. Additional studies employing similar design with other cohorts in other settings are needed to confirm these results. TRIAL REGISTRATION: Trial Registration is not applicable since we did not prospectively assign individuals to a health-related intervention.

The power of social networks and social support in promotion of physical activity and body mass index among African American adults.

Social support and social networks can elucidate important structural and functional aspects of social relationships that are associated with health-promoting behaviors, including Physical Activity (PA) and weight. A growing number of studies have investigated the relationship between social support, social networks, PA and obesity specifically among African Americans; however, the evidence is mixed and many studies focus exclusively on African American women. Most studies have also focused on either functional or structural aspects of social relationships (but not both) and few have objectively measured moderate-to-vigorous physical activity (MVPA) and body mass index (BMI). Cross-sectional surveys of adult African American men and women living in two low-income predominantly African American neighborhoods in Pittsburgh, PA (N = 799) measured numerous structural features as well as functional aspects of social relationships. Specifically, structural features included social isolation, and social network size and diversity. Functional aspects included perceptions of social support for physical activity from the social network in general as well as from family and friends specifically. Height, weight, and PA were objectively measured. From these, we derived Body Mass Index (BMI) and moderate-to-vigorous physical activity (MVPA). All regression models were stratified by gender, and included age, income, education, employment, marital status, physical limitations, and a neighborhood indicator. Greater social isolation was a significant predictor of lower BMI among men only. Among women only, social isolation was significantly associated with increased MVPA whereas, network diversity was significantly associated with reduced MVPA. Future research would benefit from in-depth qualitative investigations to understand how social networks may act to influence different types of physical activity among African Americans, as well as understand how they can be possible levers for health promotion and prevention.

Attitudes and Barriers to Healthy Diet and Physical Activity: A Latent Profile Analysis.

Healthy diet and physical activity (PA) prevent and reduce chronic disease. Social cognitive theory delineates multiple attitudes and barriers that influence these behaviors. Understanding covariation in these attitudes and barriers is complex. We examined whether individuals could be grouped into a small number of categories that are easier to study. Interviews were conducted with 982 adults from two low-income, predominantly African American neighborhoods in the same city. Social cognitive constructs, including self-efficacy, social norms, and internal and external barriers to diet and exercise, and walking were self-reported. We measured moderate to vigorous physical activity with accelerometers and diet with 24-hour recalls. We conducted a latent profile analysis of attitudes and barriers to diet and PA and identified four classes: (a) moderate diet and negative exercise attitudes, where participants were roughly average on dietary attitudes but reported exercise-related challenges, including lower social support, outcome expectancies, physical functioning, and self-efficacy; (b) few barriers and benefits of healthy diet and exercise, where participants reported fewer barriers and lower outcome expectancies for diet and PA; (c) moderate overall attitudes, where participants had average scores on most indicators but below-average exercise self-efficacy and slightly more exercise barriers; and (d) positive overall attitudes, characterized by more positive attitudes toward both diet and PA across most domains, particularly regarding self-efficacy to overcome exercise barriers. These profiles could inform efforts to tailor individual-level interventions for diet and PA of persons at high risk of chronic diseases.