Sandra M. Coulon

An overview of the Positive Action for Today's Health (PATH) trial for increasing walking in low income, ethnic minority communities

BACKGROUND Ethnic minorities and lower-income adults have among the highest rates of obesity and lowest levels of regular physical activity (PA). The Positive Action for Todays Health (PATH) trial compares three communities that are randomly assigned to different levels of an environmental intervention to improve safety and access for walking in low income communities. DESIGN AND SETTING Three communities matched on census tract information (crime, PA, ethnic minorities, and income) were randomized to receive either: an intervention that combines a police-patrolled-walking program with social marketing strategies to promote PA, a police-patrolled-walking only intervention, or no-walking intervention (general health education only). Measures include PA (7-day accelerometer estimates), body composition, blood pressure, psychosocial measures, and perceptions of safety and access for PA at baseline, 6, 12, 18, and 24 months. INTERVENTION The police-patrolled walking plus social marketing intervention targets increasing safety (training community leaders as walking captains, hiring off-duty police officers to patrol the walking trail, and containing stray dogs), increasing access for PA (marking a walking route), and utilizes a social marketing campaign that targets psychosocial and environmental mediators for increasing PA. MAIN HYPOTHESES/OUTCOMES: It is hypothesized that the police-patrolled walking plus social marketing intervention will result in greater increases in moderate-to-vigorous PA as compared to the police-patrolled-walking only or the general health intervention after 12 months and that this effect will be maintained at 18 and 24 months. CONCLUSIONS Implications of this community-based trial are discussed.

Formative Process Evaluation for Implementing a Social Marketing Intervention to Increase Walking Among African Americans in the Positive Action for Today’s Health Trial

OBJECTIVES Evaluating programs targeting physical activity may help to reduce disparate rates of obesity among African Americans. We report formative process evaluation methods and implementation dose, fidelity, and reach in the Positive Action for Todays Health trial. METHODS We applied evaluation methods based on an ecological framework in 2 community-based police-patrolled walking programs targeting access and safety in underserved African American communities. One program also targeted social connectedness and motivation to walk using a social marketing approach. Process data were systematically collected from baseline to 12 months. RESULTS Adequate implementation dose was achieved, with fidelity achieved but less stable in both programs. Monthly walkers increased to 424 in the walking-plus-social marketing program, indicating expanding program reach, in contrast to no increase in the walking-only program. Increased reach was correlated with peer-led Pride Strides (r = .92; P < .001), a key social marketing component, and program social interaction was the primary reason for which walkers reported participating. CONCLUSIONS Formative process evaluation demonstrated that the walking programs were effectively implemented and that social marketing increased walking and perceived social connectedness in African American communities.

A Systematic, Multi-domain Review of Mobile Smartphone Apps for Evidence- Based Stress Management

CONTEX Chronic stress presents a growing, pervasive burden in healthcare, and mobile smartphone applications (apps) have the potential to deliver evidence-based stress management strategies. This review identified and evaluated stress management apps across domains of (1) evidence-based content; (2) transparency in app development; and (3) functionality of the app interface. EVIDENCE ACQUISITION The iOS App Store was systematically searched. Apps with descriptions indicating that they targeted the intended audience and included evidence-related terminology, at least one evidence-based stress management strategy, and behavior change components were downloaded and evaluated by two independent raters across the three domains of evidence-based content, transparency, and functionality. EVIDENCE SYNTHESIS A total of 902 apps were identified based on 21 searches. Of these, 60 met study criteria and were downloaded and evaluated between April and June 2015. Twenty (33%) ultimately did not deliver an evidence-based strategy. Of the delivered strategies, the most common were mindfulness and meditation (73%) and diaphragmatic breathing (25%). On average, apps addressed half of the transparency criteria, and nearly all (85%) were acceptable across usability criteria. A total of 32 apps included both evidence-based content and exhibited no problems with usability or functionality; apps affiliated with a non-profit, research-engaged institution comprised 31% of these. CONCLUSIONS This review evaluated 60 iOS apps for stress management across domains of evidence-based content, transparency, and functionality; these apps have the potential to effectively supplement medical care. Findings further indicate that a comprehensive, multi-domain approach can distinguish apps that use evidence-based strategies from those that do not.

An overview of the Families Improving Together (FIT) for weight loss randomized controlled trial in African American families

BACKGROUND The Families Improving Together (FIT) randomized controlled trial tests the efficacy of integrating cultural tailoring, positive parenting, and motivational strategies into a comprehensive curriculum for weight loss in African American adolescents. The overall goal of the FIT trial is to test the effects of an integrated intervention curriculum and the added effects of a tailored web-based intervention on reducing z-BMI in overweight African American adolescents. DESIGN AND SETTING The FIT trial is a randomized group cohort design the will involve 520 African American families with an overweight adolescent between the ages of 11-16 years. The trial tests the efficacy of an 8-week face-to-face group randomized program comparing M + FWL (Motivational Plus Family Weight Loss) to a comprehensive health education program (CHE) and re-randomizes participants to either an 8-week on-line tailored intervention or control on-line program resulting in a 2 (M + FWL vs. CHE group) × 2 (on-line intervention vs. control on-line program) factorial design to test the effects of the intervention on reducing z-BMI at post-treatment and at 6-month follow-up. INTERVENTION The interventions for this trial are based on a theoretical framework that is novel and integrates elements from cultural tailoring, Family Systems Theory, Self-Determination Theory and Social Cognitive Theory. The intervention targets positive parenting skills (parenting style, monitoring, communication); cultural values; teaching parents to increase youth motivation by encouraging youth to have input and choice (autonomy-support); and provides a framework for building skills and self-efficacy through developing weight loss action plans that target goal setting, monitoring, and positive feedback.

Associations among environmental supports, physical activity, and blood pressure in African-American adults in the PATH trial

High blood pressure disproportionately affects African-American adults and is a leading cause of stroke and heart attack. Engaging in recommended levels of physical activity reduces blood pressure, and social and physical environmental supports for physical activity may increase engagement in physical activity. Based on social cognitive theory within a bioecological framework, the present study tested hypotheses that perceived peer social support for physical activity and neighborhood walkability would be positively associated with physical activity, and that physical activity would mediate their relation with blood pressure. Baseline data were collected with 434 African-American adults in underserved communities (low income, high crime) participating in the Positive Action for Todays Health (PATH) trial. Perceived peer social support for physical activity and neighborhood walkability were measured with validated surveys. Physical activity was assessed with 7-day accelerometry (moderate-to-vigorous physical activity, min/day) and with a 4-week recall of walking. Three blood pressure assessments were taken by trained staff using standard protocols, with values from the second and third assessments averaged. The sample was predominantly female (63%), overweight (mean body mass index = 30.9, SD = 8.4), and had slightly elevated blood pressures with a mean systolic blood pressure of 132.4 (SD = 17.9) and a mean diastolic blood pressure of 81.4 (SD = 11.0). Results demonstrated that peer social support for physical activity (B = 2.43, p = .02) and neighborhood walkability (B = 2.40, p = .046) were significantly related to average daily moderate-to-vigorous physical activity. Neighborhood walkability was also significantly associated with self-reported average daily walking (B = 8.86, p = .02). Physical activity did not mediate their relation with blood pressure and no significant direct effects of these variables on blood pressure were found. The positive influence of social and physical environmental supports on physical activity in underserved African-American communities may guide intervention efforts and contribute to our understanding of physical activity and related health outcomes.

Imputational modeling of spatial context and social environmental predictors of walking in an underserved community: the PATH trial.

BACKGROUND This study examined imputational modeling effects of spatial proximity and social factors of walking in African American adults. PURPOSE Models were compared that examined relationships between household proximity to a walking trail and social factors in determining walking status. METHODS Participants (N=133; 66% female; mean age=55 years) were recruited to a police-supported walking and social marketing intervention. Bayesian modeling was used to identify predictors of walking at 12 months. RESULTS Sensitivity analysis using different imputation approaches, and spatial contextual effects, were compared. All the imputation methods showed social life and income were significant predictors of walking, however, the complete data approach was the best model indicating Age (1.04, 95% OR: 1.00, 1.08), Social Life (0.83, 95% OR: 0.69, 0.98) and Income <

Multilevel Associations of Neighborhood Poverty, Crime, and Satisfaction With Blood Pressure in African-American Adults

10,000 (0.10, 95% OR: 0.01, 0.97) were all predictors of walking. CONCLUSIONS The complete data approach was the best model of predictors of walking in African Americans.

Bayesian latent structure modeling of walking behavior in a physical activity intervention.

BACKGROUND African-American adults experience the highest rates of elevated blood pressure (BP), and this disparity may be linked to socioeconomic and neighborhood-related disadvantage. Based on a bioecological stress-buffering framework, relations of poverty and neighborhood environmental perceptions with BP were assessed using multilevel regression in at-risk African-American adults. METHODS This cross-sectional study used baseline data that were collected in 2008 as part of the Positive Action for Todays Health (PATH) trial (N = 409), a community-based intervention to increase walking in low-income, high-crime neighborhoods. BP and perceived neighborhood crime and satisfaction were investigated as individual-level indicators of health and neighborhood environment. Census block groups (N = 22) served as geographic proxies for neighborhoods, and poverty was obtained using 2010 U.S. Census data, to characterize the neighborhood-level socioeconomic environment. RESULTS There were no individual-level direct associations. Significant cross-product interactions demonstrated that with higher perceived crime, high satisfaction was associated with lower systolic (γ = 3.34) and diastolic (γ = -1.37) BP, but low satisfaction was associated with higher systolic (γ = 15.12) and diastolic (γ = 7.57) BP. Neighborhood-level poverty was associated with diastolic (γ = 11.48, SE = 4.08, P = 0.008) and systolic BP (γ = 12.79, SE = 6.33, P = 0.052). Variance in BP across block groups was low (intraclass correlation coefficients = 0.002-0.014) and there were no significant random effects. CONCLUSIONS Results supported hypotheses, with greater neighborhood satisfaction linked to lower systolic and diastolic BP when perceived crime was high. Neighborhood poverty was also linked to higher systolic and diastolic BP. Prevention efforts should further investigate whether attending to issues of poverty and related neighborhood perceptions reduces high BP in at-risk African-American communities.

Influence of Dietary Electrolytes on Childhood Blood Pressure

The analysis of walking behavior in a physical activity intervention is considered. A Bayesian latent structure modeling approach is proposed whereby the ability and willingness of participants is modeled via latent effects. The dropout process is jointly modeled via a linked survival model. Computational issues are addressed via posterior sampling and a simulated evaluation of the longitudinal model’s ability to recover latent structure and predictor effects is considered. We evaluate the effect of a variety of socio-psychological and spatial neighborhood predictors on the propensity to walk and the estimation of latent ability and willingness in the full study.

Neighborhood Social Predictors of Weight-related Measures in Underserved African Americans in the PATH Trial.

Although the prevalence of hypertension (HTN) is relatively low during childhood and adolescence (1), an estimated 2.6–3.4% of children and adolescents have hypertensive blood pressure (BP) levels and 5.7–13.6% have prehypertensive BP levels (2,3). BP patterns have been shown to track from childhood to the third and fourth decades of life (1,4), and elevated BP levels have been associated with increased risk of cardiovascular and renal diseases (5). Hypertension and cardiovascular risk also increase with increasing rates of overweight and obesity, and prevention programs are needed to reduce these risks in youth (5–7). Modifying intake of dietary electrolytes such as sodium and/or potassium has been shown to be an effective approach to BP reduction in adults (8–10), but there is less evidence for the benefit of this approach in children and adolescents (11). Current recommendations for primary prevention of HTN, published by The National High Blood Pressure Education Program Coordinating Committee (12), involve a population approach and an intensive strategy for targeting individuals who are at increased risk for developing HTN in early adulthood. The Committee outlines a number of approaches that have proven effective for prevention of HTN. Two of these approaches include reducing sodium intake and maintaining an adequate intake of potassium. Evidence also suggests that addressing obesity-related hypertension through weight reduction and maintenance programs may be more efficacious when physical activity is incorporated into the intervention, and regular aerobic activity is strongly recommended for improving BP (13–15).