Peer Reviewed: The YMCA/Steps Community Collaboratives, 2004-2008

Since the YMCA/Steps National Partnership began in 2004, the collaborative approach has built local synergy, linked content experts, and engaged national partners to concentrate on some of the most pressing health issues in the United States. Together, national and local partners used evidence-based public health programs to address risk factors such as poor nutrition, physical inactivity, and tobacco use. This article describes the YMCA/Steps National Partnership and focuses on the experiences and achievements of the YMCA/Steps Community Collaboratives, conducted with technical assistance from the National Association of Chronic Disease Directors between 2004 and 2008. We introduce some of the fundamental concepts underlying the partnership''s success and share evaluation results.     

Peer Reviewed: Effects of a Behavior-Based Weight Management Program Delivered Through a State Cooperative Extension and Local Public Health Department Network, North Carolina, 2008-2009

Introduction

Eat Smart, Move More, Weigh Less (ESMMWL) is an adult weight management program developed in response to North Carolina Obesity Plan recommendations to make weight management interventions accessible to underserved populations. ESMMWL was designed to be delivered through the North Carolina Cooperative Extension and North Carolina Division of Public Health. Program coursework included content on evidence-based eating and physical activity behaviors and incorporated mindful eating concepts. The objectives of this study were to describe participant changes in weight and behaviors and to document the effectiveness of the program.

Methods

In this prospective pilot study, courses were delivered and data collected from January 2008 through June 2009. Instructors provided feedback about implementation. For participants, height, weight, and waist circumference were measured at baseline and completion. Participants completed a questionnaire about changes in their eating and physical activity behaviors, changes in their confidence to engage in weight management behaviors, and their satisfaction with the course.

Results

Seventy-nine instructors delivered 101 ESMMWL courses in 48 North Carolina counties. Most of the 1,162 completers were white women. Approximately 83% reported moving toward or attaining their goal. The average weight loss was 8.4 lb. Approximately 92% reported an increase in confidence to eat healthfully, and 82% reported an increase in confidence to be physically active. Instructors made suggestions for program standardization.

Conclusion

This study demonstrated the effectiveness, diffusion, and implementation of a theoretically based weight management program through a state extension and local public health department network. Study of the sustainability of changes in eating and physical activity behaviors is needed.     

Peer Reviewed: All-Cause Mortality in Tianjin,China, 1999-2004

Introduction

We analyzed trends of major causes of death in Tianjin, China, from 1999 through 2004 to better inform disease prevention and control programs and policies.

Methods

To report all-cause deaths among Tianjin residents from 1999 through 2004, we standardized mortality rates to the world population in 2000. We analyzed age, sex, and geographic distribution of deaths from different causes and the leading causes of death in Tianjin.

Results

The 5 leading causes of death in Tianjin were cardiovascular disease, cerebrovascular disease, malignant neoplasm, chronic lower respiratory disease, and injuries and poisoning. Mortality in Tianjin declined from 0.60% in 1999 to 0.48% in 2004. Noncommunicable diseases accounted for more than 80% of all deaths. Infant and maternal mortality in Tianjin were low. Life expectancy of Tianjin residents increased every year but was consistently longer in women. When deaths from the main chronic diseases are not considered, life expectancy lengthens substantially.

Conclusion

Chronic diseases are the leading cause of death in Tianjin, China. China should commit additional resources to supporting chronic disease prevention and control programs, including proven special health promotion projects.     

Peer Reviewed: Vigorous Physical Activity Among Tweens, VERB Summer Scorecard Program, Lexington, Kentucky, 2004-2007

Introduction

Empirical examinations of the efficacy of community-based programs to increase and sustain physical activity among youth are lacking. This study describes changes in vigorous physical activity during a 3-year period among children aged 9 to 13 years (tweens) in Lexington, Kentucky, following introduction of the VERB Summer Scorecard (VSS) intervention.

Methods

A community coalition, guided by a marketing plan that addressed motivators for tweens to participate in physical activity, designed and implemented VSS. Youth used a scorecard to monitor their physical activity, which was verified by adults. There were 3,428 students surveyed in 2004; 1,976 in 2006; and 2,051 in 2007 (mean age for 2004, 2006, and 2007, 12 y). For each year, we performed Χ ² tests and computed summary statistics for age, sex, and grade. Chi-square tests and cumulative logit models were used to analyze physical activity trends among VSS participants, VSS nonparticipants, and a reference group.

Results

The proportion of youth who reported frequent vigorous physical activity increased from 32% in 2004 to 42% in 2007. The proportion of VSS participants with moderate or high levels of vigorous physical activity increased by approximately 17 percentage points, more than twice the proportion of nonparticipants.

Conclusion

Interventions such as VSS may empower communities to take action to encourage greater physical activity among youth.     

Peer Reviewed: Body Weight Dissatisfaction Among Israeli Jewish and Arab Women With Normal or Overweight-Obese Body Mass Index,Israeli INHIS-1, 2003-2004

Introduction

In Israel, 58.9% of Jewish and Arab Israeli women aged 25 to 64 years are overweight or obese (body mass index ≥25 kg/m²). The objective of this analysis is to describe body weight dissatisfaction differences between Jewish and Arab Israeli women with normal or overweight-obese body mass index.

Methods

This analysis included 1,393 Jewish and Arab women who participated in the Israeli National Health Interview Survey, 2003-2004. The survey covered a random sample of the Israeli general population aged 21 years or older. All variables were based on self-report. Body weight dissatisfaction was a multiple-choice question in the survey that offered the following responses: very satisfied, satisfied, reasonably satisfied, not satisfied, or very unsatisfied. Univariate and multivariate analyses were conducted.

Results

Overall, 39.1% of Jewish women reported body weight dissatisfaction, compared with 29.1% of Arab women. Older overweight-obese Arab women had a lower prevalence of body weight dissatisfaction than Jewish women of the same age group, which indicates cultural differences in body weight dissatisfaction among older overweight-obese women. However, cultural differences do not appear to influence body weight dissatisfaction among younger Jewish and Arab women of normal weight.

Conclusion

This study suggests that Jewish and Arab women differ in their perceptions of body weight. Interventions tailored to each group are needed to promote healthy dietary and physical activity behaviors.     

Peer Reviewed: Trends in Incidence Rates of Tobacco-Related Cancer, Selected Areas, SEER Program, United States, 1992-2004

Introduction

Recent trends in incidence rates for tobacco-related cancers may vary geographically because of variation in socioeconomic status and in history of comprehensive state tobacco control programs (starting with California in 1989). Recent trends in risk factors are likely to affect cancer incidence rates at the youngest ages.

Methods

Trends in age-adjusted incidence rates for cancers most strongly associated with tobacco (ie, lung, oral cavity-pharynx, and bladder cancers) were analyzed for 1992 through 2004 in 11 areas (the states of Connecticut, Hawaii, Iowa, Utah, and New Mexico, and the metropolitan areas of Atlanta, Georgia; Detroit, Michigan; Los Angeles County, California; San Francisco-Oakland, California; San Jose-Monterey, California; and Seattle-Puget Sound, Washington) in the Surveillance, Epidemiology and End Results (SEER) Program. The 8 states differed in poverty rate of the population and in history of statewide tobacco control efforts as measured by an initial outcomes index (IOI) for the 1990s and a strength of tobacco control (SoTC) index for 1999 through 2000. Annual percentage change (APC) in incidence rate was calculated for whites and blacks separately and by sex for each SEER area.

Results

Among whites, the largest declines for lung cancer were in the 3 SEER areas of California, which were the only areas with significant (negative) APCs for oral cavity-pharynx cancer (but not for bladder cancer). For blacks, significant (negative) APCs for both lung and oral cavity-pharynx cancers were found in 4 of 5 areas with useful data but only 1 of 3 areas for bladder cancer. The strongest correlations of APCs for whites were for lung and oral cavity-pharynx cancers with the IOIs for the early 1990s and with the SoTC (due to the influence of California, which had the highest SoTC).

Conclusion

Lung and oral cavity-pharynx cancer incidence rates among whites aged 15 to 54 years declined more in California than in other areas, possibly because of comprehensive state tobacco control efforts. The different trends for bladder cancer vs other cancers could reflect the influence of risk factors other than tobacco. The greater geographic uniformity of trends among blacks than among whites for lung and oral cavity-pharynx cancers requires further study, particularly in relation to state tobacco control efforts.     

Peer Reviewed: Sociodemographic and Health Characteristics Associated With Attempting Weight Loss During Pregnancy

Introduction

Approximately 40% of women of childbearing age report that they are attempting to lose weight. No professional medical organization recommends attempting to lose weight during pregnancy because of the possible risks to both mother and baby. Since half of all pregnancies are unintended, women may attempt to lose weight before they know they are pregnant, and some women may continue or initiate weight loss attempts even after they know they are pregnant. This study examines the extent to which pregnant women report attempting to lose weight and associated sociodemographic and health characteristics.

Methods

We used aggregated multiple-year data (1996-2003) from the Behavioral Risk Factor Surveillance System to assess the prevalence of attempting to lose weight among pregnant women and the extent to which sociodemographic and health characteristics are associated with the behavior.

Results

The prevalence of attempting to lose weight during pregnancy was 8.1%. Attempting to lose weight during pregnancy was associated with age 35-44 years, Hispanic ethnicity, obesity, alcohol consumption, and mental distress during the previous month.

Conclusion

A substantial proportion of pregnant women attempt to lose weight. Preconception and prenatal care should include counseling women to achieve a healthy weight before becoming pregnant, to maintain healthy weight during pregnancy, and not to attempt weight loss during pregnancy. Further research should be conducted to understand how attempting weight loss during pregnancy translates into dietary change and weight loss and associated maternal and fetal outcomes.     

Peer Reviewed: Using the RE-AIM Framework to Evaluate a Physical Activity Intervention in Churches

Introduction

Health-e-AME was a 3-year intervention designed to promote physical activity at African Methodist Episcopal churches across South Carolina. It is based on a community-participation model designed to disseminate interventions through trained volunteer health directors.

Methods

We used the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework to evaluate this intervention through interviews with 50 health directors.

Results

Eighty percent of the churches that had a health director trained during the first year of the intervention and 52% of churches that had a health director trained during the second year adopted at least one component of the intervention. Lack of motivation or commitment from the congregation was the most common barrier to adoption. Intervention activities reached middle-aged women mainly. The intervention was moderately well implemented, and adherence to its principles was adequate. Maintenance analyses showed that individual participants in the intervention''s physical activity components continued their participation as long as the church offered them, but churches had difficulties continuing to offer physical activity sessions. The effectiveness analysis showed that the intervention produced promising, but not significant, trends in levels of physical activity.

Conclusion

Our use of the RE-AIM framework to evaluate this intervention serves as a model for a comprehensive evaluation of the health effects of community programs to promote health.     

Peer Reviewed: Diabetes Self-Management Education in South Auckland,New Zealand, 2007-2008

Introduction

Self-management education programs seek to help patients realize that they are their own principal caregivers and that health care professionals are consultants who support them in this role. The aim of this study was to evaluate a diabetes self-management education program implemented as part of a district-wide approach in South Auckland, New Zealand, which has some of the highest prevalence rates for diabetes and is one of the most ethnically diverse and deprived regions of New Zealand.

Methods

Self-management attitudes and behaviors were monitored with the use of questionnaires before and after program implementation. Clinical outcomes such as hemoglobin A1c, body mass index, and blood pressure were also tracked before the program began and 3 months after the program ended. Participant focus groups and facilitator interviews were conducted to explore perceptions of the program.

Results

Participants showed improvement in attitudes toward their own ability to manage their diabetes; in diet, physical activity, and foot care; and in hemoglobin A1c levels 3 months after the end of participation. Participants also reduced their sense of isolation when dealing with their diabetes. However, catering to the needs of a multiethnic community is extremely resource-intensive because of the need to provide adequate language and cultural interpretation.

Conclusion

Self-management education can work in multiethnic, high-needs communities in New Zealand. Programs must ensure they enable the appropriate mechanisms and have appropriate resources to support the community''s needs.     

Peer Reviewed: Intention to Seek Care for Symptoms Associated With Gynecologic Cancers, HealthStyles Survey, 2008

Introduction

Women with ovarian cancer typically experience symptoms before diagnosis; such symptoms for other gynecologic cancers have not been systematically studied. We investigated which symptoms of gynecologic cancers prompt intention to seek care among women and whether demographic differences in intention exist. This study was undertaken, in part, to inform development of the Centers for Disease Control and Prevention''s campaign, Inside Knowledge: Get the Facts About Gynecologic Cancer.

Methods

We analyzed the 2008 HealthStyles dataset (n = 2,991 women), an annual, cross-sectional, national mail survey. We calculated weighted percentages of women who indicated an intention to seek care for symptoms (defined as intention to call or see a doctor) by demographic characteristics and level of concern about developing a gynecologic cancer. We evaluated independent predictors of intention to seek care for each symptom.

Results

For most symptoms, more than 50% of women reported an intention to seek care. Greater percentages of women indicated an intention to seek care for symptoms clearly gynecologic (eg, 91%, postmenopausal bleeding) than for symptoms not clearly gynecologic (eg, 37%, feeling full after eating a small amount). For most symptoms, after adjustment, black women, postmenopausal women, and women with greater concern about developing gynecologic cancers were more likely than their counterparts to intend to seek care.

Conclusion

Intention to seek care differed by race, menopausal status, and level of concern about developing a gynecologic cancer. These findings will help in developing messages to educate women about the array of gynecologic and nongynecologic cancer symptoms.     

Peer Reviewed: Implementing and Disseminating an Evidence-Based Program to Prevent Falls in Older Adults,Texas, 2007-2009

Introduction

Falls are a public health problem for the growing population of older adults. We describe a statewide effort to implement and disseminate A Matter of Balance/Volunteer Lay Leader model, an evidence-based fall-prevention program.

Methods

We analyzed 2 secondary databases: 1) a centralized administrative data set to document implementation processes and structures for delivering the program and 2) a common set of outcome measures for assessing the effect of the program on older Texans. We used multivariate analyses to examine changes on key outcome variables, controlling for major covariates.

Results

From 2007 through 2009, we reached 3,092 older Texas residents. Program capacity was built by certifying 98 master trainers and 402 lay leaders and delivering the program in 227 classes through the Area Agency on Aging network. Immediate outcome results were positive, which indicates a pathway to promote more successful aging: 1) increases in falls efficacy, 2) improvements in overall physical activity levels, and 3) reductions in interference with everyday normal routines.

Conclusion

Widespread dissemination of a program to prevent falls can promote active aging among people who would otherwise be at risk for a downward cycle of health and functionality. Creating partnerships among different delivery sectors is needed for building community infrastructure to enhance the health of older adults.     

Peer Reviewed: School and Student Characteristics Associated With Screen-Time Sedentary Behavior Among Students in Grades 5-8, Ontario,Canada, 2007-2008

Introduction

We examined school and student characteristics associated with screen-time sedentary behavior.

Methods

We analyzed data collected from 2,449 students in grades 5 through 8 who attended 30 elementary schools in Ontario, Canada. We used multilevel logistic regression to examine the student- and school-level factors associated with moderate and high screen-time sedentary behavior.

Results

Moderate screen time did not vary significantly across schools. Student characteristics significantly associated with moderate screen time were sex, number of friends who are active, and parental encouragement of physical activity. High screen time did vary significantly across schools; school-level differences accounted for 12% of the variability in the odds of a student reporting high screen time. Students who attended a school in the more advanced phase of emphasizing participation in physical activity through school programs were less likely to report high screen time compared with students who attended schools in the earlier phase for this school-level indicator. Student characteristics significantly associated with high screen time were sex, parental encouragement of physical activity, parental support of physical activity, and race/ethnicity.

Conclusions

High levels of screen-time sedentary behavior are associated with both student characteristics and the characteristics of the school a student attends. Developing a better understanding of the school characteristics associated with sedentary behavior will be valuable for guiding the development of interventions to reduce sedentary behavior among youth populations.     

Peer Reviewed: Low Awareness of Overweight Status Among Parents of Preschool-Aged Children,Minnesota, 2004-2005

Introduction

Many studies have found that parents of overweight children do not perceive their child to be overweight. Little is known, however, about the extent to which such misperceptions exist among parents of preschool-aged children.

Methods

We analyzed data that were collected in 2004-2005 from parents of 593 preschool-aged children in 20 child care centers in the Minneapolis-St. Paul, Minnesota, metropolitan area. Parents were asked how they would classify their preschooler''s weight, and children''s height and weight were measured.

Results

Of the predominantly white, educated sample, most parents (90.7%) of overweight preschoolers classified their child as normal weight. An even higher percentage (94.7%) of children at risk for overweight were classified as normal weight by their parents. Most parents of normal-weight children classified their child''s weight as average. However, 16.0% classified their normal-weight child as underweight or very underweight.

Conclusion

Results indicate that parents are unlikely to recognize childhood overweight among preschool-aged children, which is concerning because parents of overweight children may be unlikely to engage in obesity prevention efforts for their child if they do not recognize their child''s risk status. A notable proportion of parents of normal-weight children perceived their child to be underweight, which suggests that parents of normal-weight children may be more concerned with undernutrition than overnutrition.     

Peer Reviewed: Physical Activity, Watching Television, and the Risk of Obesity in Students, Texas, 2004-2005

Introduction

The epidemic of childhood obesity has been well-documented. Prevalence of obesity among students in Texas is higher than the US prevalence. Our objective was to understand the combined influence of physical activity and television viewing on weight status of students in Texas.

Methods

Students in grades 4, 8, and 11 participated in the School Physical Activity and Nutrition survey during the 2004-2005 academic year. Multinomial logistic regression tested the associations between both being overweight and obese (vs underweight/normal weight) and the combined influence of physical activity and watching television, adjusting for age, grade, race/ethnicity, language spoken at home, and percentage of economically disadvantaged students in the school. We used 5 physical activity indicators to describe students'' physical activity.

Results

Girls who participated in less than 3 days of exercise per week to strengthen or tone muscles and watched 2 hours or less per day of television had increased odds of being obese (adjusted odds ratio, 1.8; 95% confidence interval, 1.1-3.0) compared with girls who participated in 3 or more days per week of exercise to strengthen or tone muscles and watched 2 hours or less per day of television. Boys in our study who watched 3 or more hours per day of television and did not meet physical activity recommendations had increased odds of being obese in all of our 5 physical activity indicators.

Conclusion

Although results varied by physical activity indicator and sex, our findings provide further evidence for the combined effect of high television watching and low physical activity engagement on the risk for obesity in children and adolescents.     

Peer Reviewed: The Incidence and Health Economic Burden of Ischemic Amputation in Minnesota, 2005-2008

Introduction

Critical limb ischemia (CLI) is the most severe manifestation of peripheral artery disease (PAD), is associated with high rates of myocardial infarction, stroke, and amputation, and has a high health economic cost. The objective of this study was to estimate the incidence of lower limb amputation, the most serious consequence of CLI, and to create a surveillance methodology for the incidence of ischemic amputation in Minnesota.

Methods

We assessed the incidence of ischemic amputation using all inpatient hospital discharge claims in Minnesota from 2005 through 2008. We identified major and minor ischemic amputations via the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure codes for lower limb amputation not due to trauma or cancer and assessed geographic and demographic differences in the incidence of ischemic amputation.

Results

The age-adjusted annual incidence of lower limb ischemic amputation in Minnesota during the 4-year period was 20.0 per 100,000 (95% confidence interval, 19.4-20.6). Amputations increased significantly with age, were more common in men and in people with diabetes, and were slightly more common in rural residents. The number of amputation-related hospitalizations was steady over 4 years. The median total charge for each amputation was $32,129, and cumulative inpatient hospitalization charges were $56.5 million in 2008.

Conclusion

The incidence of ischemic amputation is high and results in major illness and health economic costs. These data represent the first population-based estimate of ischemic amputation at the state level and provide a national model for state-based surveillance.