Lucia A. Leone

A qualitative study of perceived barriers to fruit and vegetable consumption among low-income populations, North Carolina, 2011

Introduction Obesity is the leading preventable cause of illness and a major contributor to chronic disease. Eating fresh fruits and vegetables can help manage and prevent weight gain and reduce the risk of chronic diseases. Low-income communities often lack stores that sell fresh fruit and vegetables and have instead stores that sell foods low in nutritional value. The objective of this study was to understand perceived community-level barriers to fruit and vegetable consumption among low-income people. Methods We conducted 8 focus groups involving 68 low-income participants in 2 North Carolina counties, from May 2011 through August 2011. The socioecological model of health guided data analysis, and 2 trained researchers coded transcripts and summarized findings. Four focus groups were conducted in each county; 1 was all male, 5 all female, and 2 mixed sexes. Most participants were black (68%), most were women (69.1%), and most had a high school education or less (61.8%). Almost half received support from either the Supplemental Nutrition Assistance Program or another government assistance program. Results We identified 6 major community-level barriers to access to fruits and vegetables: cost, transportation, quality, variety, changing food environment, and changing societal norms on food. Conclusion Policymakers should consider supporting programs that decrease the cost and increase the supply of high-quality fruits and vegetables in low-income communities.

Reach, Usage, and Effectiveness of a Medicaid Patient Navigator Intervention to Increase Colorectal Cancer Screening, Cape Fear, North Carolina, 2011

Introduction Screening for colorectal cancer can reduce incidence and death, but screening is underused, especially among vulnerable groups such as Medicaid patients. Effective interventions are needed to increase screening frequency. Our study consisted of a controlled trial of an intervention designed to improve colorectal cancer screening among Medicaid patients in North Carolina. Methods The intervention included a mailed screening reminder letter and decision aid followed by telephone support from an offsite, Medicaid-based, patient navigator. The study included 12 clinical practices, 6 as intervention practices and 6 as matched controls. Eligible patients were aged 50 years or older, covered by Medicaid, and identified from Medicaid claims data as not current with colorectal cancer screening recommendations. We reviewed Medicaid claims data at 6 months and conducted multivariate logistic regression to compare participant screening in intervention practices with participants in control practices. We controlled for sociodemographic characteristics. Results Most of the sample was black (53.1%) and female (57.2%); the average age was 56.5 years. On the basis of Medicaid claims, 9.2% of intervention participants (n = 22/240) had had a colorectal cancer screening at the 6-month review, compared with 7.5% of control patients (n = 13/174). The adjusted odds ratio when controlling for age, comorbidities, race, sex, and continuous Medicaid eligibility was 1.44 (95% confidence interval, 0.68–3.06). The patient navigator reached 44 participants (27.6%). Conclusion The intervention had limited reach and little effect after 6 months on the number of participants screened. Higher-intensity interventions, such as use of practice-based navigators, may be needed to reach and improve screening rates in vulnerable populations.

Promoting fruit and vegetable consumption among members of Black Churches, Michigan and North Carolina, 2008-2010

Introduction Evidence-based health promotion programs that are disseminated in community settings can improve population health. However, little is known about how effective such programs are when they are implemented in communities. We examined community implementation of an evidence-based program, Body and Soul, to promote consumption of fruits and vegetables. Methods We randomly assigned 19 churches to 1 of 2 arms, a colon cancer screening intervention or Body and Soul. We conducted our study from 2008 through 2010. We used the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework to evaluate the program and collected data via participant surveys, on-site observations, and interviews with church coordinators and pastors. Results Members of 8 churches in Michigan and North Carolina participated in the Body and Soul program. Mean fruit and vegetable consumption increased from baseline (3.9 servings/d) to follow-up (+0.35, P = .04). The program reached 41.4% of the eligible congregation. Six of the 8 churches partially or fully completed at least 3 of the 4 program components. Six churches expressed intention to maintain the program. Church coordinators reported limited time and help to plan and implement activities, competing church events, and lack of motivation among congregation members as barriers to implementation. Conclusions The RE-AIM framework provided an effective approach to evaluating the dissemination of an evidence-based program to promote health. Stronger emphasis should be placed on providing technical assistance as a way to improve other community-based translational efforts.

Veggie Van Pilot Study: Impact of a Mobile Produce Market for Underserved Communities on Fruit and Vegetable Access and Intake

ABSTRACT We conducted a pilot evaluation of the Veggie Van, a mobile produce market that brings weekly boxes of reduced-cost locally grown fruits and vegetables (F&V) to lower-income communities and offers cooking and nutrition education to customers. We conducted surveys just prior to starting Veggie Van at each of 3 sites and again at 2–3 months. F&V intake was measured with a 2-question item and a 10-item food frequency questionnaire (FFQ) in a subset of participants. At baseline, average servings/day of F&V was 4.9 (SD = 2.6, n = 60). At follow-up, individuals who reported shopping at Veggie Van frequently (n = 32) increased their F&V consumption by 0.41 servings/day compared with a decrease of −1.19 for those who rarely/never used Veggie Van (n = 27), a total difference of 1.6 servings/day (P = .01). There were no statistically significant differences in F&V consumption between groups based on the FFQ measure. Frequent shoppers reported additional health improvements and increases in their ability to buy enough F&V. We conclude that offering weekly boxes of affordable F&V paired with education in underserved communities may improve F&V consumption for frequent program users.

Cluster Randomized Trial of a Church-Based Peer Counselor and Tailored Newsletter Intervention to Promote Colorectal Cancer Screening and Physical Activity Among Older African Americans

Action Through Churches in Time to Save Lives (ACTS) of Wellness was a cluster randomized controlled trial developed to promote colorectal cancer screening and physical activity (PA) within urban African American churches. Churches were recruited from North Carolina (n = 12) and Michigan (n = 7) and were randomized to intervention (n = 10) or comparison (n = 9). Intervention participants received three mailed tailored newsletters addressing colorectal cancer screening and PA behaviors over approximately 6 months. Individuals who were not up-to-date for screening at baseline could also receive motivational calls from a peer counselor. The main outcomes were up-to-date colorectal cancer screening and Metabolic Equivalency Task (MET)-hours/week of moderate–vigorous PA. Multivariate analyses examined changes in the main outcomes controlling for church cluster, gender, marital status, weight, and baseline values. Baseline screening was high in both intervention (75.9%, n = 374) and comparison groups (73.7%, n = 338). Screening increased at follow-up: +6.4 and +4.7 percentage points for intervention and comparison, respectively (p = .25). Baseline MET-hours/week of PA was 7.8 (95% confidence interval [6.8, 8.7]) for intervention and 8.7 (95% confidence interval [7.6, 9.8]) for the comparison group. There were no significant changes (p = .15) in PA for intervention (−0.30 MET-hours/week) compared with the comparison (−0.05 MET-hours/week). Among intervention participants, PA increased more for those who participated in church exercise programs, and screening improved more for those who spoke with a peer counselor or recalled the newsletters. Overall, the intervention did not improve PA or screening in an urban church population. These findings support previous research indicating that structured PA opportunities are necessary to promote change in PA and churches need more support to initiate effective peer counselor programs.

Colorectal Cancer Screening and Physical Activity Promotion Among Obese Women: An Online Evaluation of Targeted Messages

Obese women are at higher risk for several cancers, but are less likely than normal weight women to engage in cancer prevention behaviors such as screening and physical activity. Targeted health messages may help increase healthy behaviors among vulnerable groups such as obese women. Using findings from focus groups with obese women, the authors created targeted messages to promote colorectal cancer screening and physical activity among obese women. The messages addressed psychosocial constructs, such as benefits and barriers to colorectal cancer screening and exercise, which were relevant to the target population. Messages were tested online with women age 50 years and older (N = 181). Participants were stratified by weight (obese vs. nonobese) and randomized to review either 10 targeted (intervention) or 10 generic (control) messages. Study outcomes included elaboration about the messages, message relevance and trustworthiness, and behavioral intentions. The authors used moderation and subgroup analyses to determine whether the intervention messages were better received by certain women. They found no differences in elaboration, behavioral intentions, relevance, or trustworthiness between intervention and control for either weight group. However, exercise intentions increased more (p = .06) among inactive obese women who received intervention messages (+2.9) compared with those who were in the control group (+1.2). Intervention messages also produced more elaboration among women who viewed their weight as a barrier to screening or exercise. Tailoring intervention messages for obese women on the basis of behavior and barriers may improve outcomes more than giving the same messages to all obese women.

Obesity Predicts Differential Response to Cancer Prevention Interventions Among African Americans

Wellness for African Americans Through Churches was a randomized trial that tested the effectiveness of tailored print and video (TPV) and/or lay health advisors (LHA) at increasing recreational physical activity (RPA), fruit and vegetable (F&V) consumption, and colorectal cancer (CRC) screening in African American churches. Baseline data revealed lower screening and RPA rates among obese individuals but no weight-related differences in F&V consumption. This analysis examined if intervention effectiveness was also moderated by participant weight group. Regression analyses tested for interactions between intervention and weight group for screening and RPA. Weight group was found to be a moderator of intervention effectiveness (p = .02); normal and overweight individuals receiving the LHA intervention increased RPA more, whereas obese individuals responded better to TPV. For CRC screening, the interaction term was not significant; weight alone was related to screening at follow-up (p = .049), with obese individuals reporting less screening. These results suggest that weight tailoring may improve the effectiveness of behavior change interventions.