Lisa K. Staten

Provider Counseling, Health Education, and Community Health Workers: The Arizona WISEWOMAN Project

BACKGROUND The Arizona Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) project used provider counseling, health education, and community health workers (CHWs) to target chronic disease risk factors in uninsured, primarily Hispanic women over age 50. METHODS Participants were recruited from two Tucson clinics participating in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). Women were randomly assigned into one of three intervention groups: (1) provider counseling, (2) provider counseling and health education, or (3) provider counseling, health education, and CHW support. At baseline and 12 months (1998-2000), participants were measured for height, weight, waist and hip circumference, and blood pressure. Blood tests were conducted to check blood glucose, cholesterol, and triglyceride levels. At each time point, participants also completed 24-hour dietary recalls and questionnaires focusing on their physical activity levels. RESULTS A total of 217 women participated in baseline and 12-month follow-up. Three fourths were Hispanic. All three intervention groups showed an increase in self-reported weekly minutes of moderate-to-vigorous physical activity, with no significant differences between the groups. Significantly more women who received the comprehensive intervention of provider counseling, health education, and CHW support progressed to eating five fruits and vegetables per day, compared with participants who received only provider counseling or provider counseling plus health education. CONCLUSIONS All three interventions increased moderate-to-vigorous physical activity but not fruit and vegetable consumption. The intervention group with provider counseling, health education, and CHW support significantly increased the number of women meeting national recommendations for fruit and vegetable consumption.

Formative Research in School and Community-Based Health Programs and Studies: “State of the Art” and the TAAG Approach

Formative research uses qualitative and quantitative methods to provide information for researchers to plan intervention programs. Gaps in the formative research literature include how to define goals, implementation plans, and research questions; select methods; analyze data; and develop interventions. The National Heart, Lung, and Blood Institute funded the Trial of Activity for Adolescent Girls (TAAG), a randomized, multicenter field trial, to reduce the decline in physical activity in adolescent girls. The goals of the TAAG formative research are to (a) describe study communities and schools, (b) help design the trial’s interventions, (c) develop effective recruitment and retention strategies, and (d) design evaluation instruments. To meet these goals, a variety of methods, including telephone interviews, surveys and checklists, semistructured interviews, and focus group discussions, are employed. The purpose, method of development, and analyses are explained for each method.

Validation of the Arizona Activity Frequency Questionnaire using doubly labeled water.

PURPOSE Physical activity questionnaires (PAQs) are considered the most cost-efficient method to estimate total energy expenditure (TEE) in epidemiological studies. However, relatively few PAQs have been validated using doubly labeled water (DLW) in women or in samples with diverse ethnic backgrounds. This study was conducted to validate the Arizona Activity Frequency Questionnaire (AAFQ) for estimation of TEE and physical activity energy expenditure (PAEE) over 1 month using DLW as a reference method. METHODS Thirty-five relatively sedentary women completed the AAFQ before participating in an 8-d DLW protocol to measure TEE. TEE and PAEE were estimated from the AAFQ by calculating resting metabolic rate (RMR) using the equation of Mifflin et al. (AAFQmif), by measuring RMR using indirect calorimetry (AAFQic), and using MET conversion (AAFQmet). A predictive equation for TEE was generated. RESULTS The mean +/- SD for TEE and PAEE from DLW were 9847 +/- 2555 kJ x d(-1) and 5578 +/- 2084 kJ x d(-1), respectively. Formulas using RMR to calculate the TEE and PAEE from the AAFQ tended to underestimate TEE and PAEE, whereas those that included only weight tended to overestimate TEE and PAEE. On the basis of the Mifflin et al. equation, the AAFQ tends to underestimate PAEE by 13%. This underestimation may be explained by the low lean body mass of the sample population and by effectiveness of the METs/RMR ratio in the obese. The following predictive equation was calculated: TEE (kJ x d(-1)) = (86.0 * average total daily METs) + (2.23 * RMRmif) - 6726. When the predictive equation is used, TEE calculated from the AAFQ is highly correlated with DLW TEE (adjusted r(2) = 0.70, P < 0.001). CONCLUSION The AAFQ is an effective tool for the prediction of TEE and PAEE in epidemiological studies.

Recruitment of Hispanic women to the Women's Health Initiative: the case of Embajadoras in Arizona

This study examined the use of lay advocates (i.e., women enrolled in a study who advocate to others) to improve recruitment among Hispanic women in the Arizona recruitment sites for a large-scale, national prevention study, the Womens Health Initiative (WHI). We examined whether trained, Hispanic lay advocates (called Embajadoras) brought more women into the study than a matched group of Hispanic and Anglo enrollees in the WHI who were supplied with brochures. Fifty-six Hispanic participants in the WHI were randomized to receive training or no training on advocacy, and continued to meet quarterly for 18 months. Also, 42 Anglo women were assigned to control. All groups received brochures to use for advocating the WHI. The number of women referred and enrolled was tracked as well as other factors expected to influence outcomes. Embajadoras were more successful at referral and enrollment than untrained Hispanic women and more successful at enrollment than untrained Anglo controls. Embajadoras were also found to distribute significantly more brochures than control groups. Therefore, a culturally aligned training program to encourage current Hispanic participants in a clinical trial to advocate the study to others may be an effective way to boost referrals and enrollments. Other potential influences on enrollment or referral success could not be determined due to the small sample size. Further study is needed to examine the best methods to encourage enrollment for women referred to the study.

Living on the edge: dietary strategies of economically impoverished women in Cali, Colombia.

Economically impoverished women in Cali, Colombia, have restricted access to food in a city where food is abundant. Ethnographic observations, interviews and 2 day food records were used to better understand the coping strategies used by a group of these women (n = 85) to maintain adequate levels of energy intake. Anthropometric indicators of nutritional status were normal for the group. Interview data revealed that the ability to purchase food was a concern for 58% of the women. When faced with a restricted ability to purchase food, the women indicated they made compromises in meal composition, reduced portion sizes, and/or reduced the number of meals. They also relied on relatives, friends, neighbors, store credit, or local government programs for access to food. Changes in meal composition were identified in 17.1% of all diet records (n = 509). Low energy intake (defined as energy intake < or = 1.27 x BMR) was identified in 17.1% of all diet records. Carbohydrate consumption was significantly greater on low-energy intake days. The adequate nutritional status of this group of women suggests that their coping strategies are usually adequate to maintain energy intake, but the presence of uncertainty, the frequency of compromises in diet composition, and the frequency of low-energy intake days suggest that these women are at risk for undernutrition.

Gastrointestinal parasitic infection, anthropometrics, nutritional status, and physical work capacity in Colombian boys.

This article tests the hypothesis that the presence of gastrointestinal parasites in Colombian boys is negatively associated with anthropometric characteristics, physical work capacity, blood hemoglobin (Hb) levels, and nutritional status. Anthropometric, Hb, V̇O2 max, and parasite load data were collected on 1,016 boys in Cali, Colombia. The boys were classified as lower socioeconomic class (SEC) from either urban or rural environments, and upper SEC from an urban environment. Sixty‐three percent of the boys were infected with gastrointestinal parasites and, of the infected boys, 80–95% had light parasite loads. Parasites found included Necator americanus, Ascaris lumbricoides, Entamoeba histolytica, Trichuris trichiura, Giardia spp., and Enterobius vermicularis. Infected boys had significantly lower weight, stature, weight‐for‐height (among 6–9‐year‐old boys), Hb levels, and V̇O2 max (ANCOVA, controlling for age and SEC). In terms of nutritional status, infected boys were 1.47 times more likely to be classified as iron deficient than noninfected boys (chi‐square, P < 0.001), and 1.61 times more likely to be classified as stunted (P < 0.001). Infection was not associated with wasting in any SEC group. In conclusion, light to moderate gastrointestinal parasite loads were associated with significantly lower weight, stature, weight‐for‐height (in 6–9‐year‐old boys), Hb levels, and V̇O2 max, and a significantly higher frequency of IDA and stunting. These data suggest that comprehensive analyses of the nutritional status of populations in regions endemic for parasitic infection should include testing for the presence of infection. Am. J. Hum. Biol. 11:763–771, 1999.

A Typology of Middle School Girls: Audience Segmentation Related to Physical Activity

The Trial of Activity for Adolescent Girls (TAAG) combines social ecological and social marketing approaches to promote girls’ participation in physical activity programs implemented at 18 middle schools throughout the United States. Key to the TAAG approach is targeting materials to a variety of audience segments. TAAG segments are individuals who share one or more common characteristic that is expected to correlate with physical activity. Thirteen focus groups with seventh and eighth grade girls were conducted to identify and characterize segments. Potential messages and channels of communication were discussed for each segment. Based on participant responses, six primary segments were identified: athletic, preppy, quiet, rebel, smart, and tough. The focus group information was used to develop targeted promotional tools to appeal to a diversity of girls. Using audience segmentation for targeting persuasive communication is potentially useful for intervention programs but may be sensitive; therefore, ethical issues must be critically examined.

A pebble in the pond: the ripple effect of an obesity prevention intervention targeting the child care environment.

Through Steps to a Healthier Arizona, a unique partnership was developed to reach the culturally diverse, rural communities of Southern Arizona. This partnership included local, regional, and state agencies and coalitions focused on reducing the burden of chronic disease and health disparities. This article describes the success of a program aimed at preventing childhood obesity and diabetes. Partners in Yuma County worked with child care providers to implement organizational best practices which promote positive nutrition and physical activity behaviors in young children. As a result of this project, the number of child care centers in Yuma County implementing best practices increased. Additionally a ripple effect has reached beyond the individual child care setting, into broader local and state early childhood development systems. Taking place against the backdrop of state-wide initiatives in early childhood development and health, the Steps to a Healthier Arizonas NAP SACC program positioned stakeholders to integrate with these advances.Through Steps to a Healthier Arizona, a unique partnership was developed to reach the culturally diverse, rural communities of Southern Arizona. This partnership included local, regional, and state agencies and coalitions focused on reducing the burden of chronic disease and health disparities. This article describes the success of a program aimed at preventing childhood obesity and diabetes. Partners in Yuma County worked with child care providers to implement organizational best practices which promote positive nutrition and physical activity behaviors in young children. As a result of this project, the number of child care centers in Yuma County implementing best practices increased. Additionally a ripple effect has reached beyond the individual child care setting, into broader local and state early childhood development systems. Taking place against the backdrop of state-wide initiatives in early childhood development and health, the Steps to a Healthier Arizonas NAP SACC program positioned stakeholders to integrate with these advances.

Household headship and nutritional status: Female‐headed versus male/dual‐headed households

Approximately one‐third of all poor urban households in Latin America are headed by females. This study compares the nutritional status of women and children from female‐headed (FHH) and male/dual headed (MHH/DHH) households in economically disadvantaged neighborhoods in Cali, Colombia. Data collected included socioeconomic indicators, anthropometric dimensions, dietary intake, and interviews documenting household composition. Classification of household headship was based on the acknowledged head and the primary economic provider of the household. Of the households in this study, 81 (80%) were from MHH/DHHs and 20 (20%) from FHHs. FHHs had fewer material possessions and lived in houses made of less expensive materials compared to MHH/DHHs. However, there were no significant differences in the nutritional status of women or children in FHHs vs MHH/DHHs. Most women had BMIs within the normal range (19–29 kg/m2). The majority of children (95%) had weight‐for‐height z‐scores within ±2 of the NCHS references. These results suggest that while FHHs in Cali were economically poorer, the women studied appeared to have had access to sufficient food sources for themselves and their children. Am. J. Hum. Biol. 10:699–709, 1998.

ESTIMATING ENERGY INTAKE OF URBAN WOMEN IN COLOMBIA : COMPARISON OF DIET RECORDS AND RECALLS

As part of a larger study of energy-nutrition, we compared the performance of 24 h diet recalls with estimated diet records kept by trained observers. The subjects were economically disadvantaged women (n = 85) in the city of Cali, Colombia. A 24 h recall and an estimated diet record were collected for each woman at 0 and approximately 3 and 6 months. Energy intake obtained from the estimated dietary records was validated against energy expenditure and used as the reference method. Energy and macronutrient intake were calculated from published food composition tables and proximate analyses of common foods. The number of food items consumed per woman per day, total and in each of 16 food groups, was tabulated. Energy and macronutrient intakes were 11-13% lower in the 24 h recalls. The discrepancy energy could be largely accounted for by the lower number of food items in the recalls. The number of food items in eight of 16 food groups was significantly lower in the recalls compared to the records. Underreporting on the recalls was a general tendency in these subjects and not clearly related to average energy intake. We conclude that 24 h diet recalls underestimate energy and nutrient intake in this population and are not suitable for studies of human energetics.