Publications by authors named "Kathleen J Porter"

22 Publications

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Advancing engagement and capacity for rural cancer control: a mixed-methods case study of a Community-Academic Advisory Board in the Appalachia region of Southwest Virginia.

Res Involv Engagem 2021 Jun 22;7(1):44. Epub 2021 Jun 22.

Department of Public Health Sciences, University of Virginia, School of Medicine, P.O. Box 800717, Charlottesville, VA, 22908, USA.

Background: The objectives are to: 1) describe engagement processes used to prioritize and address regional comprehensive cancer control needs among a Community-Academic Advisory Board (CAB) in the medically-underserved, rural Appalachian region, and 2) detail longitudinal CAB evaluation findings.

Methods: This three-year case study (2017-2020) used a convergent parallel, mixed-methods design. The approach was guided by community-based participatory research (CBPR) principles, the Comprehensive Participatory Planning and Evaluation process, and Nine Habits of Successful Comprehensive Cancer Control Coalitions. Meeting artifacts were tracked and evaluated. CAB members completed quantitative surveys at three time points and semi-structured interviews at two time points. Quantitative data were analyzed using analysis of variance tests. Interviews were audio recorded, transcribed, and analyzed via an inductive-deductive process.

Results: Through 13 meetings, Prevention and Early Detection Action Teams created causal models and prioritized four cancer control needs: human papillomavirus vaccination, tobacco control, colorectal cancer screening, and lung cancer screening. These sub-groups also began advancing into planning and intervention proposal development phases. As rated by 49 involved CAB members, all habits significantly improved from Time 1 to Time 2 (i.e., communication, priority work plans, roles/accountability, shared decision making, value-added collaboration, empowered leadership, diversified funding, trust, satisfaction; all p < .05), and most remained significantly higher at Time 3. CAB members also identified specific challenges (e.g., fully utilizing member expertise), strengths (e.g., diverse membership), and recommendations across habits.

Conclusion: This project's equity-based CBPR approach used a CPPE process in conjunction with internal evaluation of cancer coalition best practices to advance CAB efforts to address cancer disparities in rural Appalachia. This approach encouraged CAB buy-in and identified key strengths, weaknesses, and opportunities that will lay the foundation for continued involvement in cancer control projects. These engagement processes may serve as a template for similar coalitions in rural, underserved areas.
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June 2021

Low Health Literacy Is Associated With Energy-Balance-Related Behaviors, Quality of Life, and BMI Among Rural Appalachian Middle School Students: A Cross-Sectional Study.

J Sch Health 2021 Aug 6;91(8):608-616. Epub 2021 Jun 6.

Professor, School of Medicine, Department of Public Health Sciences, University of Virginia, 16 E. Main Street, Christiansburg, VA, 24073., USA.

Background: Many studies document associations between low health literacy (HL) and poor health behaviors and outcomes. Yet, HL is understudied among adolescents, particularly from underserved, rural communities. We targeted rural adolescents in this cross-sectional study and explored relationships between HL and (1) energy-balance-related health behaviors and (2) body mass index (BMI) and quality of life (QOL).

Methods: Surveys were administered to 7th graders across 8 middle schools in rural Appalachia. HL was assessed using the Newest Vital Sign. Energy-balance-related behaviors and QOL were assessed using validated instruments. Height and weight were objectively measured. Analyses were conducted using the Hodges-Lehmann nonparametric median difference test.

Results: Of the 854 adolescent students (mean age = 12; 55% female), 47% had limited HL. Relative to students with higher HL, students with lower HL reported significantly lower frequency of health-promoting behaviors (water, fruit and vegetable intake, physical activity, sleep), higher frequency of risky health behaviors (sugar-sweetened beverages, junk food, screen time), and had higher BMI percentiles and lower QOL (all p < .05).

Conclusions: Low HL is associated with energy-balance-related behaviors, BMI, and QOL among rural, Appalachian adolescents. Findings underscore the relevance of HL among rural middle school students and highlight implications for school health.
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August 2021

A Novel Behavioral Intervention for Rural Appalachian Cancer Survivors (weSurvive): Participatory Development and Proof-of-Concept Testing.

JMIR Cancer 2021 Apr 12;7(2):e26010. Epub 2021 Apr 12.

Department of Public Health Sciences, School of Medicine, University of Virginia, Christiansburg, VA, United States.

Background: Addressing the modifiable health behaviors of cancer survivors is important in rural communities that are disproportionately impacted by cancer (eg, those in Central Appalachia). However, such efforts are limited, and existing interventions may not meet the needs of rural communities.

Objective: This study describes the development and proof-of-concept testing of weSurvive, a behavioral intervention for rural Appalachian cancer survivors.

Methods: The Obesity-Related Behavioral Intervention Trials (ORBIT) model, a systematic model for designing behavioral interventions, informed the study design. An advisory team (n=10) of community stakeholders and researchers engaged in a participatory process to identify desirable features for interventions targeting rural cancer survivors. The resulting multimodal, 13-week weSurvive intervention was delivered to 12 participants across the two cohorts. Intervention components included in-person group classes and group and individualized telehealth calls. Indicators reflecting five feasibility domains (acceptability, demand, practicality, implementation, and limited efficacy) were measured using concurrent mixed methods. Pre-post changes and effect sizes were assessed for limited efficacy data. Descriptive statistics and content analysis were used to summarize data for other domains.

Results: Participants reported high program satisfaction (acceptability). Indicators of demand included enrollment of cancer survivors with various cancer types and attrition (1/12, 8%), recruitment (12/41, 30%), and attendance (median 62%) rates. Dietary (7/12, 59%) and physical activity (PA; 10/12, 83%) behaviors were the most frequently chosen behavioral targets. However, the findings indicate that participants did not fully engage in action planning activities, including setting specific goals. Implementation indicators showed 100% researcher fidelity to delivery and retention protocols, whereas practicality indicators highlighted participation barriers. Pre-post changes in limited efficacy outcomes regarding cancer-specific beliefs and knowledge and behavior-specific self-efficacy, intentions, and behaviors were in desired directions and demonstrated small and moderate effect sizes. Regarding dietary and PA behaviors, effect sizes for fruit and vegetable intake, snacks, dietary fat, and minutes of moderate-to-vigorous activity were small (Cohen d=0.00 to 0.32), whereas the effect sizes for change in PA were small to medium (Cohen d=0.22 to 0.45).

Conclusions: weSurvive has the potential to be a feasible intervention for rural Appalachian cancer survivors. It will be refined and further tested based on the study findings, which also provide recommendations for other behavioral interventions targeting rural cancer survivors. Recommendations included adding additional recruitment and engagement strategies to increase demand and practicality as well as increasing accountability and motivation for participant involvement in self-monitoring activities through the use of technology (eg, text messaging). Furthermore, this study highlights the importance of using a systematic model (eg, the ORBIT framework) and small-scale proof-of-concept studies when adapting or developing behavioral interventions, as doing so identifies the intervention's potential for feasibility and areas that need improvement before time- and resource-intensive efficacy trials. This could support a more efficient translation into practice.
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April 2021

Using the Socio-ecological Model to Explore Facilitators and Deterrents of Tobacco Use Among Airmen in Technical Training.

Mil Med 2021 Feb 26. Epub 2021 Feb 26.

Department of Public Health Sciences, University of Virginia, School of Medicine, Charlottesville, VA 29903, USA.

Introduction: Military personnel have some of the highest rates of tobacco use in the USA. Within the Air Force, a common point of Airmen's (re-)initiation of tobacco use is during technical training once the tobacco ban has been lifted. Unfortunately, little is known about what factors facilitate and deter tobacco use during technical training. The socio-ecological model, which emphasizes multiple levels of influence on behavior (e.g., personal, intrapersonal, and environmental), provides a strong and comprehensive basis for which to explore factors that may impact tobacco use during technical training.

Materials And Methods: Twenty-two focus groups were conducted among Airmen (n = 10), Military Training Leaders (MTLs, n = 7), and Technical Training Instructors (TTIs, n = 5). Semi-structured focus group protocols were developed based on the socio-ecological model and included questions intended to elicit factors that facilitated and deterred tobacco use during technical training. Focus groups were transcribed and then coded using a hybrid deductive-inductive process.

Results: At the personal level, five factors were identified that influenced tobacco use: choice, fit with lifestyle, associations with the tobacco experience, association with military job outcomes, and association with health outcomes. Three interpersonal level factors were identified: peer influence, leadership influence, and normative beliefs. There were two influential environmental level factors: pricing and promotion and access to tobacco. Except for normative beliefs, all personal, interpersonal, and environmental-level factors were discussed as having aspects that could either facilitate or deter tobacco use. Normative beliefs, an interpersonal-level factor, were only discussed as a facilitator of tobacco use.

Conclusions: Taken together, study findings can be used to enhance the effectiveness of tobacco prevention and cessation programs for Air Force Technical Trainees. Specific strategies to support the reduction of tobacco use among Airmen are presented.
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February 2021

Applying the socio-ecological model to understand factors associated with sugar-sweetened beverage behaviours among rural Appalachian adolescents.

Public Health Nutr 2021 Aug 11;24(11):3242-3252. Epub 2021 Jan 11.

Department of Public Health Sciences, UVA Cancer Center Research and Outreach Office, University of Virginia, 16 East Main Street, Christiansburg, VA24073, USA.

Objective: The objective of the current study was to identify factors across the socio-ecological model (SEM) associated with adolescents' sugar-sweetened beverage (SSB) intake.

Design: This cross-sectional study surveyed adolescents using previously validated instruments. Analyses included descriptive statistics, ANOVA tests and stepwise nonlinear regression models (i.e., two-part models) adjusted to be cluster robust. Guided by SEM, a four-step model was used to identify factors associated with adolescent SSB intake - step 1: demographics (i.e., age, gender), step 2: intrapersonal (i.e., theory of planned behaviour (attitudes, subjective norms, perceived behavioural control, behavioural intentions), health literacy, media literacy, public health literacy), step 3: interpersonal (i.e., caregiver's SSB behaviours, caregiver's SSB rules) and step 4: environmental (i.e., home SSB availability) level variables.

Setting: Eight middle schools across four rural southwest Virginia counties in Appalachia.

Participants: Seven hundred ninety seventh grade students (55·4 % female, 44·6 % males, mean age 12 (sd 0·5) years).

Results: Mean SSB intake was 36·3 (sd 42·5) fluid ounces or 433·4 (sd 493·6) calories per day. In the final step of the regression model, seven variables significantly explained adolescent's SSB consumption: behavioural intention (P < 0·05), affective attitude (P < 0·05), perceived behavioural control (P < 0·05), health literacy (P < 0·001), caregiver behaviours (P < 0·05), caregiver rules (P < 0·05) and home availability (P < 0·001).

Conclusions: SSB intake among adolescents in rural Appalachia was nearly three times above national mean. Home environment was the strongest predictor of adolescent SSB intake, followed by caregiver rules, caregiver behaviours and health literacy. Future interventions targeting these factors may provide the greatest opportunity to improve adolescent SSB intake.
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August 2021

Using a Socioecological Approach to Identify Factors Associated with Adolescent Sugar-Sweetened Beverage Intake.

J Acad Nutr Diet 2020 09 22;120(9):1557-1567. Epub 2020 Apr 22.

Background: Adolescents are among the highest consumers of sugar-sweetened beverages (SSBs) in the United States. More research is needed to understand the relationship of multiple levels of influence on adolescent SSB intake across the socioecological model in a nationally representative sample.

Objective: This secondary analysis of cross-sectional data aims to explain variance in adolescent SSB intake by exploring the associations of adolescent demographic (ie, age, race/ethnicity, and parent socioeconomic status), intrapersonal (ie, behavioral intention, self-efficacy, and media perception), interpersonal (ie, social norms and perceived parenting practices), and home availability variables.

Design: This study included 1,560 adolescents who participated in the 2014 National Cancer Institute-sponsored cross-sectional Family, Life, Activity, Sun, Health, and Eating study. Descriptive statistics, analyses of variance, and stepwise multiple linear regression models were used to explore factors associated with SSB intake. In the stepwise regression, a 4-step model was analyzed with each subsequent step adding variables from different socioecological model levels.

Results: The final step that included 14 variables individually associated with SSB intake significantly predicted 16.5% of the variance in SSB intake. Four variables were associated with higher SSB intake in the final step when controlling for all other variables: male sex (β=.066), non-Hispanic black vs non-Hispanic white (β=.123), adolescent's report of having parents allow them to have SSBs on a bad day (β=.150), and home SSB availability (β=.263). Race/ethnicity other than Hispanic and/or non-Hispanic black vs non-Hispanic white was associated with lower intake (β= -.092).

Conclusions: When considering potential targets for multilevel behavioral interventions aimed at reducing adolescent SSB intake, emphasis on reducing SSB availability at home may be especially important. Furthermore, although adolescence is a period of increasing independence, parent influence on adolescent's health behaviors may also be a key intervention target. Home and parental SSB factors may be more important than targeting intrapersonal factors and social norms among adolescents.
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September 2020

Predictors of engagement and outcome achievement in a behavioural intervention targeting sugar-sweetened beverage intake among rural adults.

Public Health Nutr 2020 02 4;23(3):554-563. Epub 2019 Dec 4.

Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA 22908, USA.

Objective: To describe relationships among baseline characteristics, engagement indicators and outcomes for rural participants enrolled in SIPsmartER, a behavioural intervention targeting sugar-sweetened beverage (SSB) intake.

Design: A secondary data analysis. Bivariate analyses determined relationships among baseline characteristics (e.g. age, gender, race, education, income), engagement indicators (completion of 6-month health screening, class attendance, call completion) and SSB outcomes (SSB ounce reduction (i.e. US fluid ounces; 1 US fl. oz = 29·57 ml), reduced ≥12 ounces, achieved ≤8 ounce intake). Generalized linear models tested for significant effects of baseline characteristics on engagement indicators and of baseline characteristics and engagement indicators on SSB outcomes.

Setting: South-west Virginia, USA, a rural, medically underserved region.

Participants: Participants' (n 155) mean age was 41 years; most were female (81 %), White (91 %) and earned ≤$US 20 000 per annum (61 %).

Results: All final models were significant. Engagement models predicted 12-17 % of variance, with age being a significant predictor in all three models. SSB outcome models explained 5-70 % of variance. Number of classes attended was a significant predictor of SSB ounce reduction (β = -6·12, P < 0·01). Baseline SSB intake significantly predicted SSB ounce reduction (β = -0·90, P < 0·001) and achieved ≤8 ounce intake (β = 0·98, P < 0·05).

Conclusions: The study identifies several participant baseline characteristics that may impact engagement in and outcomes from a community-based intervention targeting SSB intake. Findings suggest greater attendance of SIPsmartER classes is associated with greater reduction in overall SSB intake; yet engagement variables did not predict other outcomes. Findings will inform the future implementation of SIPsmartER and research studies of similar design and intent.
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February 2020

SIPsmartER delivered through rural, local health districts: adoption and implementation outcomes.

BMC Public Health 2019 Sep 18;19(1):1273. Epub 2019 Sep 18.

Department of Public Health Sciences, University of Virginia, School of Medicine, 16 East Main Street, Christiansburg, VA, 24073, USA.

Background: SIPsmartER is a 6-month evidenced-based, multi-component behavioral intervention that targets sugar-sweetened beverages among adults. It consists of three in-person group classes, one teach-back call, and 11 automated phone calls. Given SIPsmartER's previously demonstrated effectiveness, understanding its adoption, implementation, and potential for integration within a system that reaches health disparate communities is important to enhance its public health impact. During this pilot dissemination and implementation trial, SIPsmartER was delivered by trained staff from local health districts (delivery agents) in rural, Appalachian Virginia. SIPsmartER's execution was supported by consultee-centered implementation strategies.

Methods: In this mixed-methods process evaluation, adoption and implementation indicators of the program and its implementation strategy (e.g., fidelity, feasibility, appropriateness, acceptability) were measured using tracking logs, delivery agent surveys and interviews, and fidelity checklists. Quantitative data were analyzed with descriptive statistics. Qualitative data were inductively coded.

Results: Delivery agents implemented SIPsmartER to the expected number of cohorts (n = 12), recruited 89% of cohorts, and taught 86% of expected small group classes with > 90% fidelity. The planned implementation strategies were also executed with high fidelity. Delivery agents completing the two-day training, pre-lesson meetings, fidelity checklists, and post-lesson meetings at rates of 86, 75, 100, and 100%, respectively. Additionally, delivery agents completed 5% (n = 3 of 66) and 10% (n = 6 of 59) of teach-back and missed class calls, respectively. On survey items using 6-point scales, delivery agents reported, on average, higher feasibility, appropriateness, and acceptability related to delivering the group classes (range 4.3 to 5.6) than executing missed class and teach-back calls (range 2.6 to 4.6). They also, on average, found the implementation strategy activities to be helpful (range 4.9 to 6.0). Delivery agents identified strengths and weakness related to recruitment, lesson delivery, call completion, and the implementation strategy.

Conclusions: In-person classes and the consultee-centered implementation strategies were viewed as acceptable, appropriate, and feasible and were executed with high fidelity. However, implementation outcomes for teach-back and missed class calls and recruitment were not as strong. Findings will inform the future full-scale dissemination and implementation of SIPsmartER, as well as other evidence-based interventions, into rural health districts as a means to improve population health.
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September 2019

Development and Pilot Testing of Text Messages to Help Reduce Sugar-Sweetened Beverage Intake Among Rural Caregivers and Adolescents: Mixed Methods Study.

JMIR Mhealth Uhealth 2019 07 30;7(7):e14785. Epub 2019 Jul 30.

Department of Public Health Sciences, University of Virginia, Christiansburg, VA, United States.

Background: A high consumption of sugar-sweetened beverages (SSBs) poses significant health concerns, particularly for rural adults and adolescents. A manner in which the health of both caregivers and adolescents can be improved is by developing innovative strategies that target caregivers as the agents of change. Sending text messages through mobile phones has been cited as an effective way to improve behavioral outcomes, although little research has been conducted in rural areas, particularly focusing on SSB intake.

Objective: By targeting rural caregivers, this 2-phase study aimed to (1) understand caregivers' perceptions and language preferences for SSB-related text messages to inform and refine message development and delivery and (2) evaluate the acceptability of text messages for SSB intake behavior change and examine short-term effects on SSB intake behavior.

Methods: A convergent mixed methods design was used to systematically develop and pilot-test text messages with caregivers in Southwest Virginia. In phase 1, 5 focus groups that included a card-sorting activity were conducted to explore advantages/disadvantages, language preferences (ie, tone of voice, audience, and phrase preferences), and perceived use of text messages. In phase 2, caregivers participated in a 5-week text message pilot trial that included weekly educational and personalized strategy messages and SSB intake assessments at baseline and follow-up. Before the focus groups and after completing the pilot trial, caregivers also completed a pre-post survey that assessed SSB intake, SSB home availability, and caregivers' SSB-related practices. Caregivers also completed individual follow-up telephone interviews following the pilot trial.

Results: In phase 1, caregivers (N=33) reported that text messages were convenient, accessible, and easy to read. In addition, they preferred messages with empathetic and authoritative tones that provided useful strategies and stayed away from using absolute words (eg, always and never). In the phase 2 pilot trial (N=30), 87% of caregivers completed baseline and 77% completed follow-up assessment, suggesting a high utilization rate. Other ways in which caregivers reported benefiting from the text messages included sharing messages with family members and friends (80%), making mental notes (57%), and looking back at messages as reminders (50%). Caregivers reported significant improvements in home environment, parenting practices, and rulemaking around SSB (P=.003, P=.02, and P=.04, respectively). In addition, the frequency of SSB intake among caregivers and adolescents significantly decreased (P=.003 and P=.005, respectively).

Conclusions: Spending time in the formative phases of text message development helped understand the unique perspectives and language preferences of the target population. Furthermore, delivering an intervention through text messages has the potential to improve caregiver behaviors and reduce SSB intake among rural caregivers and adolescents. Findings from this study were used to develop a larger bank of text messages, which would be used in a future study, testing the effectiveness of a text message intervention targeting SSB intake-related caregiver behaviors.
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July 2019

Kids SIPsmartER, a cluster randomized controlled trial and multi-level intervention to improve sugar-sweetened beverages behaviors among Appalachian middle-school students: Rationale, design & methods.

Contemp Clin Trials 2019 08 21;83:64-80. Epub 2019 Jun 21.

University of Virginia, Department of Public Health Sciences, UVA Cancer Center Research and Outreach Office, 16 East Main Street, Christiansburg, VA 24073, USA.

The intake of sugar-sweetened beverages (SSB) is disproportionately high in Appalachia, including among adolescents whose intake is more than double the national average and more than four times the recommended daily amount. Unfortunately, there is insufficient evidence for effective strategies targeting SSB behaviors among Appalachian youth in real-world settings, including rural schools. Kids SIPsmartER is a 6-month, school-based, behavior and health literacy program aimed at improving SSB behaviors among middle school students. The program also integrates a two-way short message service (SMS) strategy to engage caregivers in SSB role modeling and supporting home SSB environment changes. Kids SIPsmartER is grounded by the Theory of Planned Behavior and health literacy, media literacy, numeracy, and public health literacy concepts. Guided by the RE-AIM framework (reach, effectiveness, adoption, implementation, and maintenance), this type 1 hybrid design and cluster randomized controlled trial targets 12 Appalachian middle schools in southwest Virginia. The primary aim evaluates changes in SSB behaviors at 7-months among 7th grade students at schools receiving Kids SIPsmartER, as compared to control schools. Secondary outcomes include other changes in students (e.g., BMI, quality of life, theory-related variables) and caregivers (e.g., SSB behaviors, home SSB environment), and 19-month maintenance of these outcomes. Reach is assessed, along with mixed-methods strategies (e.g., interviews, surveys, observation) to determine how teachers implement Kids SIPsmartER and the potential for institutionalization within schools. This paper discusses the rationale for implementing and evaluating a type 1 hybrid design and multi-level intervention addressing pervasive SSB behaviors in Appalachia. NCT03740113.
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August 2019

The reach and effectiveness of SIPsmartER when implemented by rural public health departments: a pilot dissemination and implementation trial to reduce sugar-sweetened beverages.

Transl Behav Med 2020 08;10(3):676-684

LENOWISCO and Cumberland Plateau Health District, Virginia Department of Health, Wise, VA, USA.

SIPsmartER is a theory-based, 6-month, multi-component health literacy intervention shown to improve sugar-sweetened beverages (SSB) behaviors among adults in rural, southwest Virginia. The objective of this pilot trial was to understand the reach and effectiveness of SIPsmartER when delivered by existing staff in public health practice settings. This pre-post research design was conducted in partnership with four medically underserved southwest Virginia Department of Health (VDH) districts. Validated measures and standardized data collection techniques were used. Analyses included descriptive statistics and multilevel mixed-effects linear regressions models. Of 928 individuals screened, 586 (63%) were eligible and 117 (20% of eligible) enrolled in SIPsmartER (79% retained). The sample was majority female (71%) and white (94%) and had ≤high school education (59%) and an annual income of approximately $12,500. Relative to the county population, the enrolled study sample was representative for age and race, yet underrepresented for men and overrepresented for low income and low educational attainment. Significant improvements from baseline to 6 months were observed for the primary SSB outcome (-403 [confidence interval [CI] = -528, -278] SSB kcals/day) (p < .001). SSB-related attitudes, perceived behavioral control, behavioral intentions, and media literacy also significantly improved (all p < .05). SIPsmartER appears to be promising for VDH and potentially other health departments in medically underserved areas. When compared to the previous effectiveness trial, existing VDH staff achieved similar reach and effectiveness for some, but not all, outcomes. Future work is needed on methods to support health departments in developing strategies to reach new participants and to integrate SIPsmartER into sustained practice.
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August 2020

Supporting maintenance of sugar-sweetened beverage reduction using automated versus live telephone support: findings from a randomized control trial.

Int J Behav Nutr Phys Act 2018 10 4;15(1):97. Epub 2018 Oct 4.

Department of Human Nutrition, Foods and Exercise, Virginia Tech, Blacksburg, VA, 24061, USA.

Background: Although reducing sugar-sweetened beverage (SSB) intake is an important behavioral strategy to improve health, no known SSB-focused behavioral trial has examined maintenance of SSB behaviors after an initial reduction. Guided by the RE-AIM framework, this study examines 6-18 month and 0-18 month individual-level maintenance outcomes from an SSB reduction trial conducted in a medically-underserved, rural Appalachia region of Virginia. Reach and implementation indicators are also reported.

Methods: Following completion of a 6-month, multi-component, behavioral RCT to reduce SSB intake (SIPsmartER condition vs. comparison condition), participants were further randomized to one of three 12-month maintenance conditions. Each condition included monthly telephone calls, but varied in mode and content: 1) interactive voice response (IVR) behavior support, 2) human-delivered behavior support, or 3) IVR control condition. Assessments included the Beverage Intake Questionnaire (BEVQ-15), weight, BMI, and quality of life. Call completion rates and costs were tracked. Analysis included descriptive statistics and multilevel mixed-effects linear regression models using intent-to-treat procedures.

Results: Of 301 subjects enrolled in the 6-month RCT, 242 (80%) were randomized into the maintenance phase and 235 (78%) included in the analyses. SIPsmartER participants maintained significant 0-18 month decreases in SSB. For SSB, weight, BMI and quality of life, there were no significant 6-18 month changes among SIPsmartER participants, indicating post-program maintenance. The IVR-behavior participants reported greater reductions in SSB kcals/day during the 6-18 month maintenance phase, compared to the IVR control participants (- 98 SSB kcals/day, 95% CI = - 196, - 0.55, p < 0.05); yet the human-delivered behavior condition was not significantly different from either the IVR-behavior condition (27 SSB kcals/day, 95% CI = - 69, 125) or IVR control condition (- 70 SSB kcals/day, 95% CI = - 209, 64). Call completion rates were similar across maintenance conditions (4.2-4.6 out of 11 calls); however, loss to follow-up was greatest in the IVR control condition. Approximated costs of IVR and human-delivered calls were remarkably similar (i.e., $3.15/participant/month or $38/participant total for the 12-month maintenance phase), yet implications for scalability and sustainability differ.

Conclusion: Overall, SIPsmartER participants maintained improvements in SSB behaviors. Using IVR to support SSB behaviors is effective and may offer advantages as a scalable maintenance strategy for real-world systems in rural regions to address excessive SSB consumption.

Trial Registry:; NCT02193009 ; Registered 11 July 2014. Retrospectively registered.
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October 2018

A Participatory Process to Engage Appalachian Youth in Reducing Sugar-Sweetened Beverage Consumption.

Health Promot Pract 2019 03 24;20(2):258-268. Epub 2018 Mar 24.

University of Virginia School of Medicine, Charlottesville, VA, USA.

Children and adolescents consume excessive amounts of sugar-sweetened beverages (SSBs), which are associated with adverse health outcomes. We describe a yearlong participatory research study to reduce SSBs in Central Appalachia, where excessive consumption is particularly prevalent. This study was conducted in partnership with a community advisory board in Southwest Virginia. Nine "youth ambassadors," aged 10 to 13 years helped to systematically adapt SIPsmartER, an effective theory-based program for Appalachian adults, to be age and culturally appropriate and meet desired theoretical objectives. They then assisted with delivering the curriculum during a school-based feasibility study and led an advocacy event in their community. Satisfaction surveys and feedback sessions indicate that ambassadors found the program acceptable and important for other students. Validated surveys and focus groups suggested that theoretical objectives were met. Findings from these mixed methods sources informed curricular changes to further enhance acceptability and refine theoretical objectives. Participation in follow-up advocacy activities was tracked and described. Following the yearlong study, ambassadors reported having advocacy skills and motivation to continue reducing SSB intake in their community. Results, challenges, and lessons learned are presented to inform larger efforts to enhance acceptability of programs and inspire youth to take action to reduce health disparities in Appalachian communities.
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March 2019

Using the Clear Communication Index to Improve Materials for a Behavioral Intervention.

Health Commun 2019 06 8;34(7):782-788. Epub 2018 Feb 8.

a Department of Public Health Sciences , University of Virginia.

Ensuring that written materials used in behavioral interventions are clear is important to support behavior change. This study used the Clear Communication Index (CCI) to assess the original and revised versions of three types of written participant materials from the SIPER intervention. Materials were revised based on original scoring. Scores for the entire index were significantly higher among revised versions than originals (57% versus 41%, < 0.001); however, few revised materials ( = 2 of 53) achieved the benchmark of ≥90%. Handouts scored higher than worksheets and slide sets for both versions. The proportion of materials scored as having "a single main message" significantly increased between versions for worksheets (7% to 57%, = 0.003) and slide sets (33% to 67%, = 0.004). Across individual items, most significant improvements were in , with four-items related to the material having a single main message. Findings demonstrate that SIPER's revised materials improved after CCI-informed edits. They advance the evidence and application of the CCI, suggesting it can be effectively used to support improvement in clarity of different types of written materials used in behavioral interventions. Implications for practical considerations of using the tool and suggestions for modifications for specific types of materials are presented.
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June 2019

Why and How Schools Make Nutrition Education Programs "Work".

J Sch Health 2018 01;88(1):23-33

Department of Nutrition and Education, Teachers College Columbia University, 525 West 120th Street, Box 137, New York, NY 10025.

Background: There are many potential health benefits to having nutrition education programs offered by expert outside sources in schools. However, little is known about why and how schools initiate, implement, and institutionalize them. Gaining this understanding may allow the impact and reach of nutrition and other health education programs in schools to be extended.

Methods: A total of 22 school community members from 21 purposefully selected New York City public elementary schools were interviewed using a semistructured interview protocol about their schools' experiences initiating, implementing, and institutionalizing nutrition education programs. Interviews were audiotaped and transcribed. Chronological narratives were written detailing each school's experience and passages highlighting key aspects of each school's experience were identified. These passages (N = 266) were sorted into domains and themes which were regrouped, resorted, and adjusted until all researchers agreed the domains and themes represented the collective experiences of the schools.

Results: The interviews elicited 4 broad domains of action: building motivation, choosing programs, developing capacity, and legitimizing nutrition education. Within each domain, themes reflecting specific actions and thoughts emerged.

Conclusions: The identified domains of action and their themes highlight specific, practical actions that school health advocates can use to initiate, implement, and institutionalize nutrition education programs in schools.
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January 2018

Implementation of Media Production Activities in an Intervention Designed to Reduce Sugar-Sweetened Beverage Intake Among Adults.

J Nutr Educ Behav 2018 02 14;50(2):173-179.e1. Epub 2017 Aug 14.

Department of Public Health Sciences, School of Medicine, University of Virginia, Christiansburg, VA.

Objective: To inform the implementation of media production activities with adult populations by describing the construction of counter-advertisements (counter-ads) within a behavioral intervention.

Methods: SIPsmartER participants could create 2 types of counter ads during the intervention's media literacy lesson. Participants (n = 40) were from rural southwestern Virginia. Most were female (85%) and white (93%), and 28% were low health literate. Descriptive statistics and Fisher exact tests were used to compare completion rates, content, techniques used, and persuasive intent with counter ad type and health literacy status.

Results: Each participant produced 2.1 (SD, 0.8) counter-ads. Ads included health risks (64%) and nutrition facts (16%). The majority used persuasive techniques (72%) and were persuasive for drinking fewer sugar-sweetened beverages (72%). There were differences by type but not health literacy status.

Conclusions And Implications: Findings suggested that counter-ads can be used in behavioral interventions for adults. Guidance is provided to support their implementation.
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February 2018

Kids SIP smartER: A Feasibility Study to Reduce Sugar-Sweetened Beverage Consumption Among Middle School Youth in Central Appalachia.

Am J Health Promot 2018 07 21;32(6):1386-1401. Epub 2017 Jul 21.

2 Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA.

Purpose: To test the feasibility of Kids SIP smartER, a school-based intervention to reduce consumption of sugar-sweetened beverages (SSBs).

Design: Matched-contact randomized crossover study with mixed-methods analysis.

Setting: One middle school in rural, Appalachian Virginia.

Participants: Seventy-four sixth and seventh graders (5 classrooms) received Kids SIP smartER in random order over 2 intervention periods. Feasibility outcomes were assessed among 2 teachers.

Intervention: Kids SIP smartER consisted of 6 lessons grounded in the Theory of Planned Behavior, media literacy, and public health literacy and aimed to improve individual SSB behaviors and understanding of media literacy and prevalent regional disparities. The matched-contact intervention promoted physical activity.

Measures: Beverage Intake Questionnaire-15 (SSB consumption), validated theory questionnaires, feasibility questionnaires (student and teacher), student focus groups, teacher interviews, and process data (eg, attendance).

Analysis: Repeated measures analysis of variances across 3 time points, descriptive statistics, and deductive analysis of qualitative data.

Results: During the first intervention period, students receiving Kids SIP smartER (n = 43) significantly reduced SSBs by 11 ounces/day ( P = .01) and improved media ( P < .001) and public health literacy ( P < .01) understanding; however, only media literacy showed between-group differences ( P < .01). Students and teachers found Kids SIP smartER acceptable, in-demand, practical, and implementable within existing resources.

Conclusion: Kids SIP smartER is feasible in an underresourced, rural school setting. Results will inform further development and large-scale testing of Kids SIP smartER to reduce SSBs among rural adolescents.
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July 2018

Dietary quality changes in response to a sugar-sweetened beverage-reduction intervention: results from the Talking Health randomized controlled clinical trial.

Am J Clin Nutr 2017 04 1;105(4):824-833. Epub 2017 Mar 1.

Departments of Human Nutrition, Foods, and Exercise and.

The reduction of sugar-sweetened beverage (SSB) intake may be beneficial for weight management and other related health conditions; however, to our knowledge, no data exist regarding the spontaneous changes in other dietary components or the overall dietary quality after an SSB-reduction intervention. We explored longitudinal changes within and between an SSB-reduction intervention (SIPsmartER) and a physical activity intervention (MoveMore) with respect to spontaneous changes in ) energy intake and macronutrients and micronutrients, ) dietary quality [Healthy Eating Index-2010 (HEI)], and ) beverage categories. Participants were enrolled in a 6-mo, community-based behavioral trial and randomly assigned into either the SIPsmartER ( = 149) intervention group or the MoveMore ( = 143) matched-contact comparison group. Dietary intake was assessed through a mean of three 24-h dietary recalls at baseline and 6 mo. Dietary recalls were analyzed with the use of nutritional analysis software. A multilevel, mixed-effects linear regression with intention-to-treat analyses is presented. SIPsmartER participants showed a significant reduction in total SSBs (mean decrease: -366 mL; ≤ 0.001). Several spontaneous changes occurred within the SIPsmartER group and, compared with the MoveMore group, included significant HEI improvements for empty calorie, total vegetable, and total HEI scores (mean increases: 2.6, 0.3, and 2.6, respectively; all ≤ 0.01). Additional positive changes were shown, including significant decreases in total energy intake, fat, added sugars, and total beverage energy (all ≤ 0.05). Few dietary changes were noted in the MoveMore group over the 6-mo intervention. Intervention of the single dietary component SSB resulted in additional spontaneous and beneficial dietary changes. Interventions that target a single dietary change, such as limiting SSB intake to <240 mL/d (<8 fl oz/d), may improve the overall dietary quality health and provide motivation to make additional dietary changes. This trial was registered at as NCT02193009.
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April 2017

Predicting sugar-sweetened behaviours with theory of planned behaviour constructs: Outcome and process results from the SIPsmartER behavioural intervention.

Psychol Health 2017 05 6;32(5):509-529. Epub 2017 Feb 6.

d Department of Health Promotion, Social and Behavioral Health , 986075 Nebraska Medical Center, University of Nebraska Medical Center , Omaha , NE 68198-6075 , USA.

Objective: Guided by the theory of planned behaviour (TPB) and health literacy concepts, SIPsmartER is a six-month multicomponent intervention effective at improving SSB behaviours. Using SIPsmartER data, this study explores prediction of SSB behavioural intention (BI) and behaviour from TPB constructs using: (1) cross-sectional and prospective models and (2) 11 single-item assessments from interactive voice response (IVR) technology.

Design: Quasi-experimental design, including pre- and post-outcome data and repeated-measures process data of 155 intervention participants.

Main Outcome Measures: Validated multi-item TPB measures, single-item TPB measures, and self-reported SSB behaviours. Hypothesised relationships were investigated using correlation and multiple regression models.

Results: TPB constructs explained 32% of the variance cross sectionally and 20% prospectively in BI; and explained 13-20% of variance cross sectionally and 6% prospectively. Single-item scale models were significant, yet explained less variance. All IVR models predicting BI (average 21%, range 6-38%) and behaviour (average 30%, range 6-55%) were significant.

Conclusion: Findings are interpreted in the context of other cross-sectional, prospective and experimental TPB health and dietary studies. Findings advance experimental application of the TPB, including understanding constructs at outcome and process time points and applying theory in all intervention development, implementation and evaluation phases.
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May 2017

Development and Evaluation of the Sugar-Sweetened Beverages Media Literacy (SSB-ML) Scale and Its Relationship With SSB Consumption.

Health Commun 2017 10 3;32(10):1310-1317. Epub 2016 Oct 3.

b Department of Human Nutrition, Foods, and Exercise , Virginia Tech.

Understanding how adults' media literacy skill sets impact their sugar-sweetened beverage (SSB) intake provides insight into designing effective interventions to enhance their critical analysis of marketing messages and thus improve their healthy beverage choices. However, a media literacy scale focusing on SSBs is lacking. This cross-sectional study uses baseline data from a large randomized controlled trial to (a) describe the psychometric properties of an SSB Media Literacy Scale (SSB-ML) scale and its subdomains, (b) examine how the scale varies across demographic variables, and (c) explain the scale's concurrent validity to predict SSB consumption. Results from 293 adults in rural southwestern Virginia (81.6% female, 94.0% White, 54.1% receiving SNAP and/or WIC benefits, average 410 SSB kcal daily) show that overall SSB-ML scale and its subdomains have strong internal consistencies (Cronbach's alphas ranging from 0.65 to 0.83). The Representation & Reality domain significantly predicted SSB kilocalories, after controlling for demographic variables. This study has implications for the assessment and inclusion of context-specific media literacy skills in behavioral interventions.
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October 2017

Effects of a behavioral and health literacy intervention to reduce sugar-sweetened beverages: a randomized-controlled trial.

Int J Behav Nutr Phys Act 2016 Mar 22;13:38. Epub 2016 Mar 22.

Department of Health Promotion, Social & Behavioral Health, University of Nebraska Medical Center, Omaha, NE, 68198-4365, USA.

Background: Despite excessive consumption of sugar-sweetened beverages (SSB), little is known about behavioral interventions to reduce SSB intake among adults, particularly in medically-underserved rural communities. This type 1 effectiveness-implementation hybrid RCT, conducted in 2012-2014, applied the RE-AIM framework and was designed to assess the effectiveness of a behavioral intervention targeting SSB consumption (SIPsmartER) when compared to an intervention targeting physical activity (MoveMore) and to determine if health literacy influenced retention, engagement or outcomes.

Methods: Guided by the Theory of Planned Behavior and health literacy strategies, the 6 month multi-component intervention for both conditions included three small-group classes, one live teach-back call, and 11 interactive voice response calls. Validated measures were used to assess SSB consumption (primary outcome) and all secondary outcomes including physical activity behaviors, theory-based constructs, quality of life, media literacy, anthropometric, and biological outcomes.

Results: Targeting a medically-underserved rural region in southwest Virginia, 1056 adult participants were screened, 620 (59%) eligible, 301 (49%) enrolled and randomized, and 296 included in these 2015 analyses. Participants were 93% Caucasian, 81% female, 31 % ≤ high-school educated, 43% < $14,999 household income, and 33% low health literate. Retention rates (74%) and program engagement was not statistically different between conditions. Compared to MoveMore, SIPsmartER participants significantly decreased SSB kcals and BMI at 6 months. SIPsmartER participants significantly decreased SSB intake by 227 (95% CI = -326,-127, p < 0.001) kcals/day from baseline to 6 months when compared to the decrease of 53 (95% CI = -88,-17, p < 0.01) kcals/day among MoveMore participants (p < 0.001). SIPsmartER participants decreased BMI by 0.21 (95% CI = -0.35,-0.06; p < 0.01) kg/m(2) from baseline to 6 months when compared to the non-significant 0.10 (95 % CI = -0.23, 0.43; NS) kg/m(2) gain among MoveMore participants (p < 0.05). Significant 0-6 month effects were observed for about half of the theory-based constructs, but for no biological outcomes. Health literacy status did not influence retention rates, engagement or outcomes.

Conclusions: SIPsmartER is an effective intervention to decrease SSB consumption among adults and is promising for translation into practice settings. SIPsmartER also yielded small, yet significant, improvements in BMI. By using health literacy-focused strategies, the intervention was robust in achieving reductions for participants of varying health literacy status.

Trial Registration:; ID: NCT02193009 .
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March 2016

Accuracy of self-reported energy intake in weight-restored patients with anorexia nervosa compared with obese and normal weight individuals.

Int J Eat Disord 2012 May 23;45(4):570-4. Epub 2012 Jan 23.

Eating Disorders Research Unit, Department of Psychiatry, College of Physicians and Surgeons of Columbia University/New York State Psychiatric Institute, New York, NY, USA.

Objective: To compare self-reported and measured energy intake in weight-restored patients with anorexia nervosa (AN), weight-stable obese individuals (OB), and normal weight controls (NC).

Method: Forty participants (18 AN, 10 OB, and 12 NC) in a laboratory meal study simultaneously completed a prospective food record.

Results: AN patients significantly (p = .018) over-reported energy intake (16%, 50 kcal) and Bland-Altman (B-A) analysis indicated bias toward over-reporting at increasing levels of intake. OB participants significantly (p = .016) under-reported intake (19%, 160 kcal) and B-A analysis indicated bias toward under-reporting at increasing levels of intake. In NC participants, NS (p = .752) difference between reported and measured intake was found and B-A analysis indicated good agreement between methods at all intake levels.

Discussion: Self-reported intake should be cautiously interpreted in AN and OB. Future studies are warranted to determine if over-reporting is related to poor outcome and relapse in AN, or under-reporting interferes with weight loss efforts in OB.
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May 2012