Meredith L. Graham

The Theory, Development, and Implementation of an e-Intervention to Prevent Excessive Gestational Weight Gain: e-Moms Roc

BACKGROUND Gaining more weight during pregnancy than is recommended by the Institute of Medicine is prevalent and contributes to the development of obesity in women. This article describes the development and use of e-Moms of Rochester (e-Moms Roc), an electronic intervention (e-intervention), to address this health issue in a socioeconomically diverse sample of pregnant women. MATERIALS AND METHODS Formative research in the form of intercept interviews, in-depth interviews, and focus groups was conducted to inform the design of the e-intervention. The Web site continuously tracked each participants use of e-intervention features. RESULTS An e-intervention, including Web site and mobile phone components, was developed and implemented in a randomized control trial. Formative research informed the design. Participants in all arms accessed blogs, local resources, articles, frequently asked questions, and events. Participants in the intervention arms also accessed the weight gain tracker and diet and physical activity goal-setting tools. Overall, 80% of women logged into the Web site and used a tool or feature at least twice. Among those in the intervention arm, 70% used the weight gain tracker, but only 40% used the diet and physical activity goal-setting tools. CONCLUSIONS To maximize and sustain potential usage of e-Moms Roc over time, the e-intervention included customized reminders, tailored content, and community features such as blogs and resources. Usage was comparable to those in other weight studies with young adults and higher than reported in a published study with pregnant women. This e-intervention specifically designed for pregnant women was used by the majority of women.

How an Online Intervention to Prevent Excessive Gestational Weight Gain Is Used and by Whom: A Randomized Controlled Process Evaluation

Background Online interventions have emerged as a popular strategy to promote healthy behaviors. Currently, there is little agreement about how to capture online intervention engagement. It is also uncertain who engages with weight-related online interventions and how engagement differs by demographic and weight characteristics. Objective The objectives of this study were to (1) characterize how pregnant women engaged with features of an online intervention to prevent excessive gestational weight gain, (2) identify demographic and weight status subgroups of women within the sample, and (3) examine differences in use of intervention features across the demographic and weight status subgroups. Methods A sample of racially and socioeconomically diverse pregnant women from a northeastern US city was assigned to the intervention group in a randomized controlled trial to prevent excessive gestational weight gain (n=1014). The intervention website included these features: weight-gain tracker, health-related articles, blogs, physical activity and diet goal-setting tools, and local resources. Engagement variables were created to capture the amount, consistency, and patterns of feature use across pregnancy using latent class analysis. Demographic/weight status subgroups were also created using latent class analysis. Differences in engagement across the demographic/weight status subgroups were examined using chi-square analysis. Results Six engagement patterns emerged: “super-users” (13.02%, 132/1014), “medium-users” (14.00%, 142/1014), “consistent weight-tracker users” (14.99%, 152/1014); “almost consistent weight-tracker users” (21.99%, 223/1014), “inconsistent weight-tracker users” (15.98%, 162/1014), and “non-users” (20.02%, 203/1014). Four demographic/weight status subgroups emerged: three minority and one white. There were different engagement patterns by demographic/weight status subgroups. Super-users were more likely to be in the white subgroup, while non-users were more likely to be in the minority subgroups. However, around a third of women in minority subgroups were consistently or almost consistently engaging with the weight-tracker (black, young women, 32.2%, 67/208; black, heavier women, 37.9%, 50/132; Hispanic women, 27.4%, 32/117). Conclusions While white and higher income women had higher engagement in general, depending on the measure, there was still considerable engagement by the minority and low-income women. Trial Registration Clinicaltrials.gov: NCT01331564; http://clinicaltrials.gov/ct2/show/NCT01331564 (Archived by WebCite at http://www.webcitation.org/6Rw4yKxI5).

eMoms: Electronically-mediated weight interventions for pregnant and postpartum women. Study design and baseline characteristics

BACKGROUND The influence of childbearing in the development of obesity is situated within two different but related contexts: pregnancy-related weight gain and weight gain prevention and control in young adult women. Pregnancy related weight gain contributes to long-term weight retention in childbearing women. OBJECTIVE To present the study design, data collection procedures, recruitment challenges, and the baseline characteristics for the eMoms of Rochester study, a randomized clinical trial testing the effect of electronically-mediated behavioral interventions to prevent excessive gestational weight gain (GWG) and postpartum weight retention among women aged 18-35 years of diverse income and racial/ethnic backgrounds in an urban setting. DESIGN Randomized double blind clinical trial. A total of 1722 women at or below 20 weeks of gestation were recruited primarily from obstetric practices and randomized to 3 treatment groups: control arm; intervention arm with access to intervention during pregnancy and control at postpartum (e-intervention 1); and intervention arm with access to intervention during pregnancy and postpartum (e-intervention 2). Enrollment and consent were completed via study staff or online. Data were collected via online surveys, medical charts, and measurement of postpartum weights. The primary endpoints are gaining more weight than recommended by the Institution of Medicine guidelines and weight retained at 12 months postpartum. CONCLUSION This study will provide evidence on the efficacy of behavioral interventions in the prevention of excessive GWG and postpartum weight retention with potential dissemination to obstetric practices and/or health insurances. ClinicalTrials.gov #NCT01331564.

Does Usage of an eHealth Intervention Reduce the Risk of Excessive Gestational Weight Gain? Secondary Analysis From a Randomized Controlled Trial

Background Excessive gestational weight gain (GWG) contributes to the development of obesity in mother and child. Internet-based interventions have the potential for delivering innovative and interactive options for prevention of excessive GWG to large numbers of people. Objective The objective of this study was to create a novel measure of Internet-based intervention usage patterns and examine whether usage of an Internet-based intervention is associated with reduced risk of excessive GWG. Methods The website featured blogs, local resources, articles, frequently asked questions (FAQs), and events that were available to women in both the intervention and control arm. Weekly reminders to use the website and to highlight new content were emailed to participants in both arms. Only intervention arm participants had access to the weight gain tracker and diet and physical activity goal-setting tools. A total of 1335 (898 intervention and 437 control) relatively diverse and healthy pregnant women were randomly assigned to the intervention arm or control arm. Usage patterns were examined for both intervention and control arm participants using latent class analysis. Regression analyses were used to estimate the association between usage patterns and three GWG outcomes: excessive total GWG, excessive GWG rate, and GWG. Results Five usage patterns best characterized the usage of the intervention by intervention arm participants. Three usage patterns best characterized control arm participants’ usage. Control arm usage patterns were not associated with excessive GWG, whereas intervention arm usage patterns were associated with excessive GWG. Conclusions The control and intervention arm usage pattern characterization is a unique methodological contribution to process evaluations for self-directed Internet-based interventions. In the intervention arm some usage patterns were associated with GWG outcomes. ClinicalTrial ClinicalTrials.gov; Clinical Trials Number: NCT01331564; https://clinicaltrials.gov/ct2/show/NCT01331564 (Archived by WebCite at http://www.webcitation/6nI9LuX9w)

Association between consistent weight gain tracking and gestational weight gain: Secondary analysis of a randomized trial

The effective components of interventions for reducing excessive gestational weight gain (GWG) remain to be identified. This study investigated the sociodemographic, physical, psychosocial, and environmental correlates of online GWG tracking and its independent association with GWG outcomes.

Barriers to weight‐related health behaviours: a qualitative comparison of the socioecological conditions between pregnant and post‐partum low‐income women

The association between socioecological factors and poor health outcomes for low-income women and their children has been the focus of disparities research for several decades. This research compares the socioecological conditions among low-income women from pregnancy to post-partum and highlights the factors that make weight management increasingly difficult after delivery. As part of the formative research for an online health intervention, group and individual interviews were conducted with low-income pregnant and post-partum women. Five pregnancy group interviews (n = 15 women), five post-partum group interviews (n = 23 women) and seven individual interviews with a total of 45 participants were conducted in Rochester, New York. All interviews were audio-recorded. The constant comparative method was used to code interview notes and identify emergent themes. Subjects faced many challenges that affected their attitudes, beliefs and their ability to maintain or improve healthy weight behaviours. These included unemployment, relationship issues, minimal social support, lack of education, limited health care access, pre-existing medical conditions and neighbourhood disadvantage. Compared with pregnant women, post-partum women faced additional difficulties, such as child illnesses and custody issues. The most striking differences between pregnancy and post-partum related to the familys medical problems and greater environmental constraints. Many factors detracted from womens capacity to engage in healthy weight behaviours post-partum, including challenges present prior to delivery, challenges present prior to delivery that worsen after delivery, and new challenges that begin after delivery. These additional post-partum challenges need to be considered in designing programmes, policies and interventions that promote healthy weight.

A qualitative study of factors related to cardiometabolic risk in rural men

BackgroundRural men are known to have poor health behaviors, which contribute to their elevated burden of cardiometabolic disorders in the United States. Although regular physical activity, healthy eating, and avoiding tobacco can reduce cardiometabolic risk, little is known about how to engage rural men in health promotion programs. To bridge this gap in evidence, we investigate knowledge of modifiable cardiometabolic risk factors among rural men in the western United States, identify their concerns related to heart health and motivation to reduce risk, and explore individual, social, and community-level influences on heart-healthy behaviors, specifically diet, physical activity, and tobacco use.MethodsWe conducted seven focus groups with 54 sedentary, overweight/obese men (mean body mass index [BMI] = 31.3 ± 4.6) aged 43–88 residing in government-designated “medically underserved” rural Montana towns in September and October 2014. All sessions were audio-recorded and transcribed verbatim. Transcripts were coded and analyzed thematically using Nvivo software. Participants also completed a brief questionnaire about personal characteristics and health behaviors. These data were explored descriptively.ResultsDespite being classified as overweight/obese and sedentary, no participants reported to be in poor health. Many men described health relative to self-reliance and the ability to participate in outdoor recreation; concern with health appeared to be related to age. Participants were generally knowledgeable of heart-healthy behaviors, but many felt fatalistic about their own risk. Catalysts for behavior change included a serious medical event in the household and desire to reduce aging-associated functional decline. Barriers to adopting and maintaining healthy eating and physical activity habits and abstaining from tobacco included normative beliefs around masculinity and individual liberty, the limited social universe of small towns, winter weather, time constraints, and preferences for unhealthy foods. Facilitators included behavioral self-monitoring, exercising with a partner, and opportunities for preferred activities, such as hunting and team sports.ConclusionsThese findings provide important insight about influences on rural men’s health behaviors and provide guidance for possible intervention strategies to promote cardiometabolic health.Trial registrationClinicalTrials.gov NCT02499731. Registered 1 July 2015.

Determinants of Pregnant Women's Online Self-Regulatory Activities for Appropriate Gestational Weight Gain.

This study examined psychosocial and sociodemographic factors associated with pregnant women’s use of Web-based tools to set and monitor personal goals for healthy diet and physical activity. These tools were made available to women participating in a randomized trial testing a Web-based intervention to promote appropriate gestational weight gain. We used data from a baseline survey of pregnant women assigned to the intervention group and log data on women’s use of various intervention features (N = 873). Women who believed that appropriate gestational weight gain would lead to healthy outcomes for their child were more likely to engage in online goal-setting and self-monitoring. Less positive outcome expectancy beliefs about the relationship between their own weight and baby’s health partially explains why some at risk subpopulations (e.g., African-American women) were less likely to utilize online self-regulatory tools. This study specifies key psychosocial and motivational factors that guide the construction and monitoring of goals among pregnant women. These findings offer guidance for the design of interventions to promote self-regulatory techniques by identifying groups for whom those features are most likely to be useful, as well as psychological determinants of their use.

Effects of Online Self-Regulation Activities on Physical Activity Among Pregnant and Early Postpartum Women

Physical and psychological changes that occur during pregnancy present a unique challenge for womens physical activity. Using a theory-based prospective design, this study examines the effects of pregnant womens (a) physical activity cognitions (self-efficacy, outcome expectancy, and safety beliefs) and (b) online self-regulation activities (goal-setting and self-monitoring) on subsequent changes in their physical activity intentions and behavior during pregnancy and immediately postpartum. The authors used data from three panel surveys administered to pregnant women enrolled in a web-based intervention to promote healthy pregnancy and postpartum weight, as well as log data on their use of self-regulatory features on the intervention website. Perceived self-efficacy and perceived safety of physical activity in pregnancy enhanced subsequent intentions to be physically active. Repeated goal-setting and monitoring of those goals helped to maintain positive intentions during pregnancy, but only repeated self-monitoring transferred positive intentions into actual behavior. Theoretically, this study offers a better understanding of the roles of self-regulation activities in the processes of goal-striving. The authors also discuss practical implications for encouraging physical activity among pregnant and early postpartum women.

Environmental Influences on Physical Activity among Rural Adults in Montana, United States: Views from Built Environment Audits, Resident Focus Groups, and Key Informant Interviews

Rural populations in the United States have lower physical activity levels and are at a higher risk of being overweight and suffering from obesity than their urban counterparts. This paper aimed to understand the environmental factors that influence physical activity among rural adults in Montana. Eight built environment audits, 15 resident focus groups, and 24 key informant interviews were conducted between August and December 2014. Themes were triangulated and summarized into five categories of environmental factors: built, social, organizational, policy, and natural environments. Although the existence of active living features was documented by environmental audits, residents and key informants agreed that additional indoor recreation facilities and more well-maintained and conveniently located options were needed. Residents and key informants also agreed on the importance of age-specific, well-promoted, and structured physical activity programs, offered in socially supportive environments, as facilitators to physical activity. Key informants, however, noted that funding constraints and limited political will were barriers to developing these opportunities. Since building new recreational facilities and structures to support active transportation pose resource challenges, especially for rural communities, our results suggest that enhancing existing features, making small improvements, and involving stakeholders in the city planning process would be more fruitful to build momentum towards larger changes.