Integrating Civic Engagement Into a Lifestyle Intervention for Rural Women - A Mixed Methods Process Evaluation.

PURPOSE: The present study aimed to evaluate the implementation of a civic engagement curriculum (HEART Club) designed to catalyze positive environmental change in rural communities. DESIGN: The HEART Club curriculum was integrated into a six-month community-based health behavior intervention to reduce cardiovascular disease risk. SETTING: Participants were recruited from eight rural towns in Montana and New York. SUBJECTS: 101 midlife and older women. INTERVENTION: Participants worked to address an issue related to their local food or physical activity environment and establish progress monitoring benchmarks. METHOD: Evaluation components included after-class surveys, program leader interviews (n = 15), participant focus groups (n = 8), and post-intervention surveys. RESULTS: Intervention sites reported high fidelity (78%) to the curriculum. Average attendance was 69% and program classes were rated as highly effective (4.1 out of 5). Despite positive participant feedback, low readiness for civic engagement and insufficient time were implementation challenges. The majority of HEART Club groups had accomplished two or more benchmarks post-intervention. Facilitators of progress included community support, effective leadership, and collective effort. Participants also indicated that trying to affect community change while simultaneously making personal health improvements likely stalled initial progress. CONCLUSION: These findings highlight the potential and challenges associated with civic engagement within the context of rural lifestyle interventions. Future implementation efforts should focus on reframing civic engagement as an approach to support and maintain behavior change.

Facilitators, Barriers, and Best Practices for In-Person and Telehealth Lactation Support During the COVID-19 Pandemic.

OBJECTIVE: To explore the perspectives of lactation support providers delivering breastfeeding education via in-person and telehealth consultations and assess the impact of COVID-19 on the provision of breastfeeding education. DESIGN: Qualitative descriptive study using purposive sampling. SETTING: Massachusetts-based lactation support providers who provided in-person and/or telehealth consultations in various practice settings (e.g., inpatient; outpatient; private practice; and the Special Supplemental Nutrition Program for Women, Infants, and Children). PARTICIPANTS: Fourteen Massachusetts-based lactation support providers, ages 36 to 68 years. MEASUREMENTS: Participants completed an online demographic and employment characteristics survey and virtual key informant interviews, from which six main themes were defined. RESULTS: The six main themes included Common Questions Asked by Clients, Prenatal and Postpartum Consultation Topics, Facilitators for Telehealth Versus In-Person Consultations, Barriers for Telehealth Versus In-Person Consultations, Best Practices, and COVID-19 Adaptations. From participant interviews, common subthemes emerged. The primary adaptation due to COVID-19 was shifting to telehealth. Content in lactation consultations was similar via in-person and telehealth sessions. Typical content areas included breast pumping and mother's milk supply. A notable difference was the lack of physical examinations for women and newborns in telehealth sessions. Scheduling flexibility was a key facilitator of telehealth consultations, whereas the inability to provide hands-on assistance and chaotic home environments were common barriers. In-person facilitators included weighing newborns to assess feeding success and insurance billing coverage, whereas unsupportive family members were noted as a barrier. Diversity, equity, and inclusion-related barriers (e.g., language barriers, lack of reflective diversity, lack of stable Internet access) were observed in both settings. Best practices for in-person and telehealth consultations included meeting mothers where they are and focusing on mothers' goals. CONCLUSION: Practice adaptations adopted during the pandemic and best practice recommendations may be useful for lactation support providers and other health care professionals caring for breastfeeding dyads.

Practical, Evidence-Based Approaches to Nutritional Modifications to Reduce Atherosclerotic Cardiovascular Disease: An American Society For Preventive Cardiology Clinical Practice Statement.

Despite numerous advances in all areas of cardiovascular care, cardiovascular disease (CVD) is the leading cause of death in the United States (US). There is compelling evidence that interventions to improve diet are effective in cardiovascular disease prevention. This clinical practice statement emphasizes the importance of evidence-based dietary patterns in the prevention of atherosclerotic cardiovascular disease (ASCVD), and ASCVD risk factors, including hyperlipidemia, hypertension, diabetes, and obesity. A diet consisting predominantly of fruits, vegetables, legumes, nuts, seeds, plant protein and fatty fish is optimal for the prevention of ASCVD. Consuming more of these foods, while reducing consumption of foods with saturated fat, dietary cholesterol, salt, refined grain, and ultra-processed food intake are the common components of a healthful dietary pattern. Dietary recommendations for special populations including pediatrics, older persons, and nutrition and social determinants of health for ASCVD prevention are discussed.

Feasibility of a yoga intervention to decrease pain in older women: a randomized controlled pilot study.

BACKGROUND: A significant proportion of older women suffer from chronic pain, which can decrease quality of life. The objective of this pilot randomized study was to evaluate the feasibility of a flow-restorative yoga intervention designed to decrease pain and related outcomes among women aged 60 or older. METHODS: Flow-restorative yoga classes were held twice weekly for 1 hour and led by a certified yoga instructor. Participants randomized to the intervention group attended the yoga classes for 12 weeks and received supplemental materials for at-home practice. Those randomized to the control group were asked to maintain their normal daily routine. Feasibility was evaluated using recruitment and retention rates, class and home practice adherence rates, and participant satisfaction surveys. Outcome measures (self-reported pain, inflammatory markers, functional fitness, quality of life, resilience, and self-reported physical activity) were assessed at baseline and post-intervention. Paired t-tests or Wilcoxon signed-rank tests were used to examine changes in outcome measures within treatment groups. RESULTS: Thirty-eight participants were recruited and randomized. Participants were primarily white, college-educated, and higher functioning, despite experiencing various forms of chronic pain. Attendance and retention rates were high (91 and 97%, respectively) and the majority of participants were satisfied with the yoga program (89%) and would recommend it to others (87%). Intervention participants also experienced reductions in pain interference and improvements in energy and social functioning. CONCLUSIONS: This pilot study provides essential data to inform a full scale randomized trial of flow-restorative yoga for older women with chronic pain. Future studies should emphasize strategies to recruit a more diverse study population, particularly older women at higher risk of disability and functional decline. TRIAL REGISTRATION: Clinicaltrials.gov , NCT03790098 . Registered 31 December 2018 - Retrospectively registered.

Web-Based Dissemination of a Civic Engagement Curriculum to Promote Healthy Eating and Active Living in Rural Towns: The eHEART Study.

Civic engagement interventions aimed at improving food and physical activity environments hold promise in addressing rural health disparities, but ensuring feasible and sustained dissemination remains a challenge. The present study aimed to evaluate the feasibility of a civic engagement curriculum adapted for online dissemination (Healthy Eating and Activity in Rural Towns (eHEART)). The eHEART curriculum and website were developed based on feedback from local health educators and community members. eHEART groups were facilitated by local Extension educators across three rural towns in three U.S. states (Montana, Wisconsin, and Alaska). Implementation feasibility was assessed through monthly project reports and interviews with educators. All eHEART groups successfully completed curriculum activities and met their project goals after nine months (November 2018 to July 2019). Groups ranged in size from 4 to 8 community residents and implemented varied strategies to improve aspects of their local food and/or physical activity environments. Facilitators of implementation included clear guidance on facilitating curriculum activities and the flexible and community-driven nature of eHEART projects. Recommended changes included more guidance on evaluating projects and contacting stakeholders as well as providing online tools and support for project management. Findings from this work have important implications for creating healthier rural environments. Local health educators and other community groups can feasibly use the eHEART curriculum to foster environmental changes that support healthy eating and active living.

Caregiver involvement in interventions for improving children's dietary intake and physical activity behaviors.

BACKGROUND: Poor diet and insufficient physical activity are major risk factors for non-communicable diseases. Developing healthy diet and physical activity behaviors early in life is important as these behaviors track between childhood and adulthood. Parents and other adult caregivers have important influences on children's health behaviors, but whether their involvement in children's nutrition and physical activity interventions contributes to intervention effectiveness is not known. OBJECTIVES: • To assess effects of caregiver involvement in interventions for improving children's dietary intake and physical activity behaviors, including those intended to prevent overweight and obesity • To describe intervention content and behavior change techniques employed, drawing from a behavior change technique taxonomy developed and advanced by Abraham, Michie, and colleagues (Abraham 2008; Michie 2011; Michie 2013; Michie 2015) • To identify content and techniques related to reported outcomes when such information was reported in included studies SEARCH METHODS: In January 2019, we searched CENTRAL, MEDLINE, Embase, 11 other databases, and three trials registers. We also searched the references lists of relevant reports and systematic reviews. SELECTION CRITERIA: Randomised controlled trials (RCTs) and quasi-RCTs evaluating the effects of interventions to improve children's dietary intake or physical activity behavior, or both, with children aged 2 to 18 years as active participants and at least one component involving caregivers versus the same interventions but without the caregiver component(s). We excluded interventions meant as treatment or targeting children with pre-existing conditions, as well as caregiver-child units residing in orphanages and school hostel environments. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures outlined by Cochrane. MAIN RESULTS: We included 23 trials with approximately 12,192 children in eligible intervention arms. With the exception of two studies, all were conducted in high-income countries, with more than half performed in North America. Most studies were school-based and involved the addition of healthy eating or physical education classes, or both, sometimes in tandem with other changes to the school environment. The specific intervention strategies used were not always reported completely. However, based on available reports, the behavior change techniques used most commonly in the child-only arm were "shaping knowledge," "comparison of behavior," "feedback and monitoring," and "repetition and substitution." In the child + caregiver arm, the strategies used most commonly included additional "shaping knowledge" or "feedback and monitoring" techniques, as well as "social support" and "natural consequences." We considered all trials to be at high risk of bias for at least one design factor. Seven trials did not contribute any data to analyses. The quality of reporting of intervention content varied between studies, and there was limited scope for meta-analysis. Both validated and non-validated instruments were used to measure outcomes of interest. Outcomes measured and reported differed between studies, with 16 studies contributing data to the meta-analyses. About three-quarters of studies reported their funding sources; no studies reported industry funding. We assessed the quality of evidence to be low or very low. Dietary behavior change interventions with a caregiver component versus interventions without a caregiver component Seven studies compared dietary behavior change interventions with and without a caregiver component. At the end of the intervention, we did not detect a difference between intervention arms in children's percentage of total energy intake from saturated fat (mean difference [MD] -0.42%, 95% confidence interval [CI] -1.25 to 0.41, 1 study, n = 207; low-quality evidence) or from sodium intake (MD -0.12 g/d, 95% CI -0.36 to 0.12, 1 study, n = 207; low-quality evidence). No trial in this comparison reported data for children's combined fruit and vegetable intake, sugar-sweetened beverage (SSB) intake, or physical activity levels, nor for adverse effects of interventions. Physical activity interventions with a caregiver component versus interventions without a caregiver component Six studies compared physical activity interventions with and without a caregiver component. At the end of the intervention, we did not detect a difference between intervention arms in children's total physical activity (MD 0.20 min/h, 95% CI -1.19 to 1.59, 1 study, n = 54; low-quality evidence) or moderate to vigorous physical activity (MVPA) (standard mean difference [SMD] 0.04, 95% CI -0.41 to 0.49, 2 studies, n = 80; moderate-quality evidence). No trial in this comparison reported data for percentage of children's total energy intake from saturated fat, sodium intake, fruit and vegetable intake, or SSB intake, nor for adverse effects of interventions. Combined dietary and physical activity interventions with a caregiver component versus interventions without a caregiver component Ten studies compared dietary and physical activity interventions with and without a caregiver component. At the end of the intervention, we detected a small positive impact of a caregiver component on children's SSB intake (SMD -0.28, 95% CI -0.44 to -0.12, 3 studies, n = 651; moderate-quality evidence). We did not detect a difference between intervention arms in children's percentage of total energy intake from saturated fat (MD 0.06%, 95% CI -0.67 to 0.80, 2 studies, n = 216; very low-quality evidence), sodium intake (MD 35.94 mg/d, 95% CI -322.60 to 394.47, 2 studies, n = 315; very low-quality evidence), fruit and vegetable intake (MD 0.38 servings/d, 95% CI -0.51 to 1.27, 1 study, n = 134; very low-quality evidence), total physical activity (MD 1.81 min/d, 95% CI -15.18 to 18.80, 2 studies, n = 573; low-quality evidence), or MVPA (MD -0.05 min/d, 95% CI -18.57 to 18.47, 1 study, n = 622; very low-quality evidence). One trial indicated that no adverse events were reported by study participants but did not provide data. AUTHORS' CONCLUSIONS: Current evidence is insufficient to support the inclusion of caregiver involvement in interventions to improve children's dietary intake or physical activity behavior, or both. For most outcomes, the quality of the evidence is adversely impacted by the small number of studies with available data, limited effective sample sizes, risk of bias, and imprecision. To establish the value of caregiver involvement, additional studies measuring clinically important outcomes using valid and reliable measures, employing appropriate design and power, and following established reporting guidelines are needed, as is evidence on how such interventions might contribute to health equity.

Process Evaluation of Strong Hearts, Healthy Communities: A Rural Community-Based Cardiovascular Disease Prevention Program.

OBJECTIVE: To evaluate the implementation of a community-based cardiovascular disease prevention program for rural women: Strong Hearts, Healthy Communities (SHHC). DESIGN: Mixed-methods process evaluation. SETTING/PARTICIPANTS: A total of 101 women from 8 rural towns were enrolled in the SHHC program; 93 were enrolled as controls. Eligible participants were aged ≥40 years, sedentary, and overweight or obese. Local health educators (n = 15) served as program leaders within each town. OUTCOME MEASURES: Reach, fidelity, dose delivered, dose received, and program satisfaction were assessed using after-class surveys, participant satisfaction surveys, interviews with program leaders, and participant focus groups. ANALYSIS: Descriptive statistics, chi-square tests of independence, and thematic analysis were employed. RESULTS: Intervention sites reported high levels of fidelity (82%) and dose delivered (84%). Overall reach was 2.6% and program classes were rated as effective (3.9/5). Participants were satisfied with their experience and reported benefits such as camaraderie and awareness of healthy eating and exercise strategies. Common recommendations included increasing class time and enhancing group discussion. CONCLUSIONS AND IMPLICATIONS: Implementation was good in terms of fidelity, dose delivered, and satisfaction, although low reach. Findings from this research have informed a second round of implementation and evaluation of the SHHC program in rural communities.

A Civic Engagement Approach to Encourage Healthy Eating and Active Living in Rural Towns: The HEART Club Pilot Project.

PURPOSE: To assess the feasibility and effectiveness of a civic engagement curriculum (encouraging Healthy Eating and Activity in Rural Towns [HEART] Club) designed to engage rural residents in improving their local food or physical activity environment. DESIGN: Pre-post surveys and focus groups. SETTING: Three rural Northeastern towns in the United States. PARTICIPANTS: Twenty-six rural residents (7-12 per town) recruited by local extension educators. MEASURES: Online surveys were used to assess outcomes related to feasibility (satisfaction) and effectiveness (knowledge, awareness, motivation, self-efficacy, and group efficacy for community change). Feasibility was also assessed through attendance logs, benchmark achievement records, and post-implementation focus groups. ANALYSIS: Participant characteristics and feasibility measures were summarized using descriptive statistics. Pre-post changes in effectiveness outcomes were assessed using Wilcoxon signed rank tests. Focus group data were thematically examined to identify barriers to and facilitators of HEART Club progress. RESULTS: Meeting attendance and program satisfaction were high (88% and 91%). Participants reported improvements in awareness; however, no other significant changes were observed. All HEART Clubs accomplished 3 or more project benchmarks after 6 months of implementation. Despite competing priorities and limited finances, groups effectively leveraged existing resources to achieve their goals. Important facilitators of success included stakeholder support, effective leadership, and positive group dynamics. CONCLUSION: These findings suggest that resident-driven initiatives that build upon local resources and establish feasible goals can successfully foster environmental change in rural communities.

Support and Sabotage: A Qualitative Study of Social Influences on Health Behaviors Among Rural Adults.

PURPOSE: Social environments exert an important influence on health behaviors, yet evidence from rural-specific contexts is limited. This study explored how social relationships influence health-related behaviors among midlife and older rural adults at increased risk of chronic disease. METHODS: Seventeen focus groups were conducted with 125 sedentary, overweight/obese adults (aged 40-91 years) residing in "medically underserved" rural Montana towns in 2014. Groups were stratified by age (40-64 and ≥65) and gender. Transcripts were examined thematically using NVivo software according to social influences on diet, physical activity, and tobacco use. Analyses were conducted in 2015-2016. RESULTS: Attitudes and actions of family members and friends were key influences on health behaviors, in both health-promoting and health-damaging ways. In these small, isolated communities, support from and accountability to family and friends were common facilitators of behavior change and maintenance. However, expectations to conform to social norms and traditional gender roles (eg, caregiving duties) often hindered healthy lifestyle changes. CONCLUSIONS: These findings suggest that health behavior interventions targeting adults in rural settings need to consider and, if possible, integrate strategies to address the impact of social relationships in both supporting and sabotaging behavior change and maintenance.

PGC-1α Promotes Breast Cancer Metastasis and Confers Bioenergetic Flexibility against Metabolic Drugs.

Metabolic adaptations play a key role in fueling tumor growth. However, less is known regarding the metabolic changes that promote cancer progression to metastatic disease. Herein, we reveal that breast cancer cells that preferentially metastasize to the lung or bone display relatively high expression of PGC-1α compared with those that metastasize to the liver. PGC-1α promotes breast cancer cell migration and invasion in vitro and augments lung metastasis in vivo. Pro-metastatic capabilities of PGC-1α are linked to enhanced global bioenergetic capacity, facilitating the ability to cope with bioenergetic disruptors like biguanides. Indeed, biguanides fail to mitigate the PGC-1α-dependent lung metastatic phenotype and PGC-1α confers resistance to stepwise increases in metformin concentration. Overall, our results reveal that PGC-1α stimulates bioenergetic potential, which promotes breast cancer metastasis and facilitates adaptation to metabolic drugs.

Development and testing of a community audit tool to assess rural built environments: Inventories for Community Health Assessment in Rural Towns.

Rural populations face unique challenges to physical activity that are largely driven by environmental conditions. However, research on rural built environments and physical activity is limited by a paucity of rural-specific environmental assessment tools. The aim of this paper is to describe the development and testing of a rural assessment tool: Inventories for Community Health Assessment in Rural Towns (iCHART). The iCHART tool was developed in 2013 through a multistep process consisting of an extensive literature search to identify existing tools, an expert panel review, and pilot testing in five rural US communities. Tool items represent rural built environment features that influence active living and physical activity: community design, transportation infrastructure, safety, aesthetics, and recreational facilities. To assess reliability, field testing was performed in 26 rural communities across five states between July and November of 2014. Reliability between the research team and community testers was high among all testing communities (average percent agreement = 77%). Agreement was also high for intra-rater reliability (average kappa = 0.72) and inter-rater reliability (average percent agreement = 84%) among community testers. Findings suggest that the iCHART tool provides a reliable assessment of rural built environment features and can be used to inform the development of contextually-appropriate physical activity opportunities in rural communities.

Neighborhood Walkability and Adiposity in the Women's Health Initiative Cohort.

INTRODUCTION: Neighborhood environments may play a role in the rising prevalence of obesity among older adults. However, research on built environmental correlates of obesity in this age group is limited. The current study aimed to explore associations of Walk Score, a validated measure of neighborhood walkability, with BMI and waist circumference in a large, diverse sample of older women. METHODS: This study linked cross-sectional data on 6,526 older postmenopausal women from the Women's Health Initiative Long Life Study (2012-2013) to Walk Scores for each participant's address (collected in 2012). Linear and logistic regression models were used to estimate associations of BMI and waist circumference with continuous and categorical Walk Score measures. Secondary analyses examined whether these relationships could be explained by walking expenditure or total physical activity. All analyses were conducted in 2015. RESULTS: Higher Walk Score was not associated with BMI or overall obesity after adjustment for sociodemographic, medical, and lifestyle factors. However, participants in highly walkable areas had significantly lower odds of abdominal obesity (waist circumference >88 cm) as compared with those in less walkable locations. Observed associations between walkability and adiposity were partly explained by walking expenditure. CONCLUSIONS: Findings suggest that neighborhood walkability is linked to abdominal adiposity, as measured by waist circumference, among older women and provide support for future longitudinal research on associations between Walk Score and adiposity in this population.

Changes in household food insecurity rates in Canadian metropolitan areas from 2007 to 2012.

OBJECTIVES: The socio-demographic characteristics of food-insecure households in Canada have been well characterized, but there is little understanding of what drives the prevalence rates. This study was undertaken to estimate the prevalence of household food insecurity by census metropolitan area (CMA), compare prevalence rates within CMAs and within provinces over time, and assess the effect of local area economic characteristics on changes in CMA food insecurity rates. METHODS: Data from the 2007-2012 annual components of the Canadian Community Health Survey were used to generate food insecurity rates for 33 CMAs and the corresponding nine provinces, and to compare changes in prevalence over time. Fixed-effects multiple linear regression analysis was applied to examine associations between changes in food insecurity and local area economic factors, considering peak unemployment rate, average number of Employment Insurance beneficiaries, vacancy rate, poverty rate and poverty gap. RESULTS: Food insecurity rates ranged from 19.9% in Halifax to 9.0% in Quebec City in 2011-2012. Rates within and between CMAs were much more variable than provincial rates. Between 2007-2008 and 2011-2012, the prevalence increased significantly in Halifax, Montreal, Peterborough, Guelph, Calgary and Abbotsford, but decreased in Hamilton. Among the economic characteristics examined, only rising peak unemployment rates were linked to increases in food insecurity in CMAs. CONCLUSIONS: Our results suggest that policy initiatives to expand employment opportunities, improve the quality and stability of employment, and increase benefits for disadvantaged workers could reduce the prevalence of food insecurity within CMAs.