A Mixed-Methods Examination of the Impact of the Partnerships to Improve Community Health Produce Prescription Initiative in Northeastern North Carolina

OBJECTIVE

To conduct a mixed-methods examination of the impact of the Partnerships to Improve Community Health produce prescription initiative in northeastern North Carolina.

DESIGN

Quantitative surveys were conducted among participants before and after the distribution of produce prescription vouchers. Univariate statistics were used to describe the participant population, and paired t tests were used to examine change in fruit and vegetable intake. Qualitative, in-depth telephone interviews were conducted among participants, health educators, and food retailers and coded for themes.

SETTING

Eight health promotion programs, 2 food pantries, and 11 food retailers.

PARTICIPANTS

In each health promotion program or food pantry, between 6 and 97 participants were enrolled.

INTERVENTION

Produce prescription vouchers were distributed to participants and redeemed at local food retailers.

MAIN OUTCOME MEASURE S

An increase in local fruit and vegetable purchasing and consumption.

RESULTS

Of the produce prescription participants who completed the baseline survey (n = 93), 86% were female, 64% were African American, and 68% were food insecure. The voucher redemption rate was 18%. The majority of participants indicated that they visit farmers' markets more now than before the produce prescription initiative, that shopping at the farmers' market made it easy to include more fresh produce in their family's diet, and that they tried a new farmers' market because of the produce prescription initiative. All health educators and food retailers who participated felt that the initiative benefited their program or operation and were willing to partner with the program again.

CONCLUSIONS

While redemption rates were lower than anticipated, the produce prescription initiative had positive impacts on participants' local fruit and vegetable purchasing and consumption. Because of COVID-19, the initiative was not implemented until late in the North Carolina produce season. Moving forward, the program will start earlier and work with local food retailers to connect with their communities to increase redemption rates.

Health Literacy Among Adults With Multiple Chronic Health Conditions

Low health literacy (HL) is associated with poorer health outcomes. We examined HL among adults with multiple chronic conditions (CCs), using 2016 Behavioral Risk Factor Surveillance System data. Health literacy was measured by 3 subjective questions about difficulty with the following tasks: (1) obtaining health information or advice; (2) understanding spoken health information; and (3) understanding written health information. We estimated the prevalence of low HL (difficulty with ≥1 HL tasks) and used multiple logistic regression analysis to examine associations between HL and number of CCs. The prevalence of low HL was 13.8% overall and increased with the number of CCs from 10.6% among those with no CC to 24.7% among those with 3 or more CCs, with the latter having more than twice the adjusted odds of low HL compared with the former (adjusted odds ratio = 2.65; 95% confidence interval, 2.36-2.97). Efforts to improve HL in this population are needed.

Trends and Rural-Urban Differences in Participation in Diabetes Self-management Education Among Adults in North Carolina: 2012-2017

PURPOSE

This study aimed to report recent trends in self-reported diabetes self-management education (DSME) participation rates among adults in North Carolina and to compare these rates between rural and urban residents.

METHODS

Data for this analysis were obtained from the NC Behavioral Risk Factor Surveillance System (BRFSS) for the years 2012, 2013, 2015, and 2017, when the survey included the diabetes module. Respondents were classified as having participated in DSME if they answered "Yes" to the question, "Have you ever taken a course or class in how to manage your diabetes yourself?" We used the Rural Urban Continuum Code to classify urban and rural residence. The study sample included 4368 adults 18 years or older with self-reported diabetes. We assessed the changes in DSME participation from 2012 to 2017. We used multiple logistic regression modeling to assess the association between rural residence and DSME participation. All analyses were conducted in Stata 14 and accounted for the survey design of the BRFSS. Statistical significance was set at P < .01.

RESULTS

Overall, the DSME participation rates decreased slightly in the study period, from 55.8% in 2012 to 55.6% in 2013 to 56.5% in 2015 to 52.1% in 2017. By rural-urban residence, the rates were 52.3% versus 57.8% in 2012, 54.0% versus 56.5% in 2013, 48.8% versus 62.0% in 2015, and 46.7% versus 56.1% in 2017. The multiple logistic regression model results showed that rural residents were less likely to have participated in DSME (adjusted odds ratio = 0.78; 95% confidence interval, 0.64-0.94) than urban residents. Adults with higher income and education levels were also more likely to have participated in DSME (P < .01).

CONCLUSIONS

The recent BRFSS data showed that the DSME participation rate declined slightly in North Carolina. There were persistent rural-urban disparities in DSME participation, with rural residents showing lower rates, and the gaps seemed to be widening.

IMPLICATIONS FOR POLICY OR PRACTICE

Continuous efforts are needed to bring more American Diabetes Association/American Association of Diabetes Educators programs to rural communities and assist persons with diabetes to participate in DSME training to reduce the burden of diabetes. Furthermore, those in rural areas may need additional support.

Willingness to Get a COVID-19 Vaccine and Reasons for Hesitancy Among Medicare Beneficiaries: Results From a National Survey

OBJECTIVES

To assess (1) the willingness to get a COVID-19 vaccine among Medicare beneficiaries, (2) the associated factors, and (3) the reasons for vaccine hesitancy.

METHODS

Data were taken from the Medicare Current Beneficiary Survey (MCBS) 2020 Fall COVID-19 Supplement, conducted October-November 2020. Willingness to get a COVID-19 vaccine was measured by respondents' answer to whether they would get a COVID-19 vaccine when available. We classified responses of "definitely" and "probably" as "willing to get," and responses "probably not," "definitely not," and "not sure" as "vaccine hesitancy." Reasons for vaccine hesitancy were assessed by a series of yes/no questions focusing on 10 potential reasons. The analytical sample included 6715 adults 65 years and older. We conducted a logistic regression model to assess demographic factors and other factors associated with the willingness to get a COVID-19 vaccine. All analyses were conducted in Stata 14 and accounted for the complex survey design of MCBS.

RESULTS

Overall, 61.0% (95% confidence interval [CI], 59.1-63.0) of Medicare beneficiaries would be willing to get a vaccine when available. Among those who were hesitant, more than 40% reported that mistrust of the government and side effects as the main reasons. Logistic regression model results showed that non-Hispanic Blacks (adjusted odds ratio [AOR] = 0.33; 95% CI, 0.24-0.44) and Hispanics (AOR = 0.60; 95% CI, 0.47-0.77) were less willing to get a vaccine than non-Hispanic Whites; beneficiaries with an income of less than $25 000 (AOR = 0.71; 95% CI, 0.62-0.81) were less willing to get the vaccine than those with an income of $25 000 or more; those who did not think that the COVID-19 virus was more contagious (AOR = 0.53; 95% CI, 0.41-0.69) or more deadly (AOR = 0.51; 95% CI, 0.41-0.65) were also less willing to get the vaccine than those who thought that the virus was more contagious or more deadly than the influenza virus.

CONCLUSIONS

The 2020 MCBS survey data showed that close to 40% of Medicare beneficiaries were hesitant about getting a COVID-19 vaccine, and the hesitancy was greater in racial/ethnic minorities. Medicare beneficiaries were concerned about the safety of the vaccine, and some appeared to be misinformed. Evidence-based educational and policy-level interventions need to be implemented to further promote COVID-19 vaccination.

Rural-urban differences in uptake of diabetes self-management education among Medicare beneficiaries: Results from the 2016 to 2018 Medicare Current Beneficiary Survey

PURPOSE

To assess rural-urban differences in participation rates of diabetes self-management education and associated factors among Medicare beneficiaries with type 2 diabetes (T2DM).

METHODS

Data were from the 2016 to 2018 Medicare Current Beneficiary Survey (MCBS). Participation in diabetes self-management education was self-reported. The study sample included 3,799 beneficiaries aged 65 years and older with self-reported T2DM. Logistic regression was used to assess the association of participation in diabetes self-management education and residential location. Sampling weights embedded in the MCBS were incorporated into all analyses.

FINDINGS

Overall, the participation rate of diabetes self-management education was 46.8% (95% CI: 44.4%-49.2%). The rate was 40.3% for beneficiaries in rural areas, 48.0% for suburban areas, and 47.3% for urban areas. About 31% of beneficiaries newly diagnosed with diabetes did not participate within the past year. Controlling for other covariates, beneficiaries in rural areas were less likely to have participated in diabetes self-management education (AOR = 0.73, 95% CI: 0.55-0.95) than those living in urban areas. Asian Americans were less likely to have participated (AOR = 0.49, 95% CI: 0.28-0.84) than Whites. Those who were older, with lower education, and lower income levels were less likely to have participated (P < .05).

CONCLUSIONS

Recent MCBS data indicate that more than half of Medicare beneficiaries with T2DM did not participate in diabetes self-management education, and the participation rate in rural areas was 7 percentage points lower than that ​in urban areas. The study findings highlight challenges to maximize the benefits of participating in diabetes self-management education, particularly in rural areas.

A four-year observational study to examine the dietary impact of the North Carolina Healthy Food Small Retailer Program, 2017-2020

BACKGROUND

The North Carolina (NC) Healthy Food Small Retailer Program (HFSRP) was passed into law with a $250,000 appropriation (2016-2018) providing up to $25,000 in funding to small food stores for equipment to stock healthier foods and beverages. This paper describes an observational natural experiment documenting the impact of the HFSRP on store food environments, customers' purchases and diets.

METHODS

Using store observations and intercept surveys from cross-sectional, convenience customer samples (1261 customers in 22 stores, 2017-2020; 499 customers in 7 HFSRP stores, and 762 customers in 15 Comparison stores), we examined differences between HFSRP and comparison stores regarding: (1) change in store-level availability, quality, and price of healthy foods/beverages; (2) change in healthfulness of observed food and beverage purchases ("bag checks"); and, (3) change in self-reported and objectively-measured (Veggie Meter®-assessed skin carotenoids) customer dietary behaviors. Differences (HFSRP vs. comparison stores) in store-level Healthy Food Supply (HFS) and Healthy Eating Index-2010 scores were assessed using repeated measure ANOVA. Intervention effects on diet were assessed using difference-in-difference models including propensity scores.

RESULTS

There were improvements in store-level supply of healthier foods/beverages within 1 year of program implementation (0 vs. 1-12 month HFS scores; p = 0.055) among HFSRP stores only. Comparing 2019 to 2017 (baseline), HFSRP stores' HFS increased, but decreased in comparison stores (p = 0.031). Findings indicated a borderline significant effect of the intervention on self-reported fruit and vegetable intake (servings/day), though in the opposite direction expected, such that fruit and vegetable intake increased more among comparison store than HFSRP store customers (p = 0.05). There was no significant change in Veggie Meter®-assessed fruit and vegetable intake by customers shopping at the intervention versus comparison stores.

CONCLUSIONS

Despite improvement in healthy food availability, there was a lack of apparent impact on dietary behaviors related to the HFSRP, which could be due to intervention dose or inadequate statistical power due to the serial cross-sectional study design. It may also be that individuals buy most of their food at larger stores; thus, small store interventions may have limited impact on overall eating patterns. Future healthy retail policies should consider how to increase intervention dose to include more product marketing, consumer messaging, and technical assistance for store owners.

Diabetes Self-Care and Clinical Care Among Adults With Low Health Literacy

OBJECTIVE

Low health literacy has been associated with unfavorable health outcomes. We examined diabetes self- and clinical care measures among adults with diabetes by 3 dimensions of health literacy.

DESIGN/SETTING

Questions about health literacy were available for optional use in the 2016 Behavioral Risk Factor Surveillance System. We analyzed 2016 Behavioral Risk Factor Surveillance System data from 4 states and the District of Columbia that had included both the Health Literacy and Diabetes optional modules.

PARTICIPANTS

Respondents who participated in the 2016 Behavioral Risk Factor Surveillance System in Alabama, Louisiana, Mississippi, Virginia, and Washington, District of Columbia, and completed both modules (n = 4397).

MAIN OUTCOME MEASURES

Health literacy was measured by level of difficulty (easy, difficult) with 3 health literacy tasks: getting health advice or information, understanding health information delivered orally by health professionals, and understanding written health information. Diabetes care measures included physical activity, self-monitoring blood glucose, self-checking feet, hemoglobin A1c testing, professional foot examination, flu vaccination, professional eye examination, dental visits, and diabetes self-management education.

RESULTS

Among those with self-reported diabetes, 5.9% found it difficult to get health advice or information, 10.7% found it difficult to understand information health professionals told them, and 12.0% found it difficult to understand written health information. Those who found it difficult to get health advice or information had 44% to 56% lower adjusted odds of A1c testing, professional foot examinations, and dental visits; those who found it difficult to understand written health information had lower odds of self-monitoring glucose and self-checking feet. Difficulty understanding both oral and written health information was associated with never having taken a diabetes self-management class.

CONCLUSIONS

Our results suggest that problems with health literacy may be a barrier to good disease management among adults with diabetes and that health care providers should be attentive to the needs of patients with low health literacy, especially for diabetes-specific specialty care.

Rural, Suburban, and Urban Differences in Chronic Pain and Coping Among Adults in North Carolina: 2018 Behavioral Risk Factor Surveillance System

Introduction

Our study aimed to examine the prevalence of chronic pain, its severity, its causes, and coping mechanisms that are used by North Carolina adults in rural, suburban, and urban areas.

Methods

We analyzed data from the Behavioral Risk Factor Surveillance System’s first chronic pain module in 2018, representing 3,598 respondents. Self-reported chronic pain was defined as the affirmative response to the question, “Do you suffer from any type of chronic pain, that is, pain that occurs constantly or flares up often?” We computed prevalence of chronic pain and use of coping mechanisms by rural, suburban, or urban residential status. We used multiple logistic regression to assess the association between chronic pain and residential location, adjusting for demographic characteristics, employment, and health insurance.

Results

In 2018, an estimated 27.5% (95% confidence interval [CI], 25.6%–29.3%) of North Carolina adults experienced chronic pain. Prevalence of chronic pain in rural areas (30.9%) and suburban areas (30.8%) was significantly higher, compared with urban areas (19.6%). Compared with urban residents with chronic pain, those with chronic pain in suburban areas (adjusted odds ratio [AOR], 0.44; 95% CI, 0.26–0.76) and in rural areas (AOR, 0.39; 95% CI, 0.24–0.65) were less likely to use nonmedication therapies (eg, acupuncture, physical therapy, yoga) and were less likely to use 3 or more types of chronic pain treatment (suburban AOR, 0.47; 95% CI, 0.25–0.88; rural AOR, 0.53; 95% CI, 0.29–0.95).

Conclusion

Our results indicate that persons living in rural and suburban areas may be more likely to have chronic pain and less likely to use nonmedication treatments than those in urban areas.

Associations between shopping patterns, dietary behaviours and geographic information system-assessed store accessibility among small food store customers

OBJECTIVE

To examine associations between geographic information systems (GIS)-assessed accessibility to small food stores, shopping patterns and dietary behaviours among small food store customers.

DESIGN

Residential addresses and customer shopping patterns (frequency of shopping, and previous purchase of fruits and vegetables) were gathered through customer intercept surveys. Addresses were geocoded, and GIS-assessed distance and driving time from the participants' residence to the store were calculated. Dietary status and behaviours were assessed using an objective non-invasive measure of skin carotenoids, the National Cancer Institute Fruit and Vegetable Screener, and items to assess sugary beverage intake. Associations between distance and driving time, demographics, shopping frequency, prior reported purchase of fruits and vegetables at the store and dietary behaviours were examined.

SETTING

Small food stores (n 22) across North Carolina.

PARTICIPANTS

Cross-sectional convenience samples of English-speaking customers aged 18 years or older (n 692).

RESULTS

Participants living closer to the small store had lower income and formal education, were more likely to be Black, more likely to have previously bought fruits and vegetables at the store and more frequently shopped at the store. In adjusted models, skin carotenoids (n 644) were positively associated with distance to the store from home in miles (P = 0·01).

CONCLUSIONS

Customers who lived closer to the stores were more frequent shoppers and more likely to have previously purchased fruits and vegetables at the store yet had lower skin carotenoids. These results support continued efforts to examine how to increase the availability and promotion of healthful foods at small food retail stores.

Geofencing: Mobile Technology as a Health Promotion Tool to Raise Awareness of a Dental Clinic in Rural North Carolina

PURPOSE

The purpose of the study was to assess the use of geofence technology to raise awareness of a dental clinic in rural North Carolina.

METHODS

The catchment area of the dental clinic was defined by ZIP Codes. A geofence was identified, and cell phones within the perimeter were targeted for oral health message drops to occur over 3 months from April to June 2017. Surveys conducted twice, pre- and postintervention (message drop), evaluated change in community awareness of services available at the dental clinic. A cross-sectional analysis was used to measure the effect of the exposure to the geofence technology in survey respondents.

FINDINGS

The survey included 200 participants (100 pre- and 100 postintervention). There were no significant differences in race or age for pre- and postintervention survey groups. The majority of respondents were American Indians (47.0% pre, 58.6% post) or black (28.8% pre, 25.5% post). There was a statistically significant improvement in awareness of the dental clinic (P = .045) from pre- to postintervention. A significant increase was also observed in the question related to dental visits by the respondent or family member of the respondent (from 6.5% to 15.0%, P = .04). A more modest improvement was found in questions related to the cost of dental care, type of insurance accepted, and services provided.

CONCLUSION

Geofencing has the potential to increase awareness of health care services and ultimately increase the number of patients receiving care.

Health Literacy and Health Behaviors Among Adults With Prediabetes, 2016 Behavioral Risk Factor Surveillance System

OBJECTIVES

Evidence is needed for designing interventions to address health literacy-related issues among adults with prediabetes to reduce their risk of developing type 2 diabetes. This study assessed health literacy and behaviors among US adults with prediabetes and the mediating role of health literacy on health behaviors.

METHODS

We used data from the 2016 Behavioral Risk Factor Surveillance System (BRFSS) (N = 54 344 adults). The BRFSS health literacy module included 3 questions on levels of difficulty in obtaining information, understanding health care providers, and comprehending written information. We defined low health literacy as a response of "somewhat difficult" or "very difficult" to at least 1 of these 3 questions. Respondents self-reported their prediabetes status. We included 3 health behavior indicators available in the BRFSS survey-current smoking, physical inactivity, and inadequate sleep, all measured as binary outcomes (yes/no). We used a path analysis to examine pathways among prediabetes, health literacy, and health behaviors.

RESULTS

About 1 in 5 (19.0%) adults with prediabetes had low health literacy. The rates of physical inactivity (31.0% vs 24.6%, P < .001) and inadequate sleep (38.8% vs 33.5%, P < .001) among adults with prediabetes were significantly higher than among adults without prediabetes. The path analysis showed a significant direct effect of prediabetes and health literacy on health behaviors. The indirect effect of prediabetes through health literacy on health behaviors was also significant.

CONCLUSION

BRFSS data from 2016 showed that rates of low health literacy and unhealthy behaviors were higher among adults with prediabetes than among adults without prediabetes. Interventions are needed to assist adults with prediabetes in comprehending, communicating about, and managing health issues to reduce the risk of type 2 diabetes.

Self-reported Health Literacy Among North Carolina Adults and Associations with Health Status and Chronic Health Conditions

BACKGROUND Low health literacy is a recognized contributor to health disparities. Significant proportions of the adult population, especially the underserved, have low health literacy. The purpose of this study was to examine health literacy and its associations with health status and chronic health conditions among North Carolina adults.METHODS The 2016 North Carolina Behavioral Risk Factor Surveillance System included health literacy questions that focused on accessing and understanding health information. Using these self-reported data, we estimated the prevalence of low health literacy and assessed its associations with general health status and chronic health conditions after adjusting for sociodemographic characteristics and health care access.RESULTS Overall, 4.8% of adults reported having difficulty getting health information or advice, 7.5% understanding oral information from health professionals, and 8.3% understanding written health information; 14.8% reported having difficulty with at least one of these tasks. The adjusted odds of low health literacy were moderately higher for those who had been diagnosed with the following conditions compared to those not diagnosed: heart attack, coronary heart disease, or stroke (AOR = 1.81, 95% CI=1.33, 2.47); COPD (AOR = 1.67, 95% CI = 1.19, 2.34); arthritis (AOR = 1.68, 95% CI = 1.32, 2.15); depression (AOR = 1.95, 95% CI=1.52, 2.50); and kidney disease (AOR = 1.62, 95% CI = 1.02, 2.60).LIMITATIONS All data were self-reported.CONCLUSIONS A notable segment of the North Carolina adult population has low health literacy, and those who do are particularly vulnerable to adverse health status. Targeted efforts are needed to identify strategies to improve health literacy and decrease health disparities.

Impact on Dietary Choices After Discount Supermarket Opens in Low-Income Community

OBJECTIVE

To examine (1) the association of a new supermarket opening with dietary intake and perceptions of healthy food availability, and (2) associations of distance to the primary food store and mean prices of fruits, vegetables, and sugary beverages with levels of consumption of these foods and body mass index in a low-income, southeastern community.

METHODS

The researchers used cross-sectional, self-administered questionnaire data and supermarket audit data collected in the supermarket community and comparison community before (2015) and after (2016) the supermarket opening. A difference-in-difference analysis employed propensity scores to compare pretest and posttest differences between communities.

RESULTS

There were no significant differences between communities on dietary behaviors. There was a significant cross-sectional, inverse association between distance to the primary food store and fruit and vegetable consumption among all respondents in 2016.

CONCLUSIONS AND IMPLICATIONS

The results suggest that adding a new discount supermarket is not necessarily associated with improvements in residents' fruit, vegetable, or sugary beverage consumption, or in their perceptions of the availability of healthy food in the neighborhood. However, distance to the store may be important.

The effects of traffic light labelling versus cartoon labelling on food and beverage purchases in a children's hospital setting

This study's purpose was to examine changes in healthy and unhealthy items purchased following the implementation of traffic light and cartoon labelling in a small retail food venue (Café Bay) in a children's hospital in eastern North Carolina. Between October 2015 and March 2016, daily food and beverage sales from Café Bay were obtained during baseline, traffic light labelling, a washout period, cartoon labelling (on healthy foods only) and a final washout period. Pearson chi-squared tests and multiple linear regressions were used to examine effects of labelling strategies, controlling for the holidays. In unadjusted analyses, traffic light labelling was associated with significant decreases in purchases of unhealthy items purchased, while cartoon labelling was associated with increases in unhealthy items purchased. In adjusted linear regression analysis, traffic light labelling was associated with fewer unhealthy purchases and thus may have potential to decrease the amount of unhealthy items purchased in a children's hospital food retail venue.

A possible dose-response association between distance to farmers' markets and roadside produce stands, frequency of shopping, fruit and vegetable consumption, and body mass index among customers in the Southern United States

BACKGROUND

The association between farmers' market characteristics and consumer shopping habits remains unclear. Our objective was to examine associations among distance to farmers' markets, amenities within farmers' markets, frequency of farmers' market shopping, fruit and vegetable consumption, and body mass index (BMI). We hypothesized that the relationship between frequency of farmers' market shopping and BMI would be mediated by fruit and vegetable consumption.

METHODS

In 15 farmers' markets in northeastern North Carolina, July-September 2015, we conducted a cross-sectional survey among 263 farmers' market customers (199 provided complete address data) and conducted farmers' market audits. To participate, customers had to be over 18 years of age, and English speaking. Dependent variables included farmers' market shopping frequency, fruit and vegetable consumption, and BMI. Analysis of variance, adjusted multinomial logistic regression, Poisson regression, and linear regression models, adjusted for age, race, sex, and education, were used to examine associations between distance to farmers' markets, amenities within farmers' markets, frequency of farmers' market shopping, fruit and vegetable consumption, and BMI.

RESULTS

Those who reported shopping at farmers' markets a few times per year or less reported consuming 4.4 (standard deviation = 1.7) daily servings of fruits and vegetables, and those who reported shopping 2 or more times per week reported consuming 5.5 (2.2) daily servings. There was no association between farmers' market amenities, and shopping frequency or fruit and vegetable consumption. Those who shopped 2 or more times per week had a statistically significantly lower BMI than those who shopped less frequently. There was no evidence of mediation of the relationship between frequency of shopping and BMI by fruit and vegetable consumption.

CONCLUSIONS

More work should be done to understand factors within farmers' markets that encourage fruit and vegetable purchases.

Assessment of personal protective equipment use among farmers in eastern North Carolina: a cross-sectional study

Agriculture consistently ranks among the top hazardous occupations, accounting for a significant number of injuries and fatalities in the workplace. Eastern North Carolina has a significant number of small, independent, family-run, owned, and operated farms. However, little is known about perception, behavior, training, accessibility, or purchasing personal protective equipment (PPE) for safety among farmers in the region. In this study, telephone interviews were conducted among participating farmers between March and June 2012 (N = 129). Univariate and bivariate analyses were conducted to examine associations between PPE behavior and workplace hazards, health-related concerns, and wearing and purchasing PPE. Findings indicated that personal behavior of wearing hearing protection devices (HPDs) and protection from the sun among farmers was low. However, a relatively high percentage of farmers reported wearing PPE when working with agricultural chemicals. Most farmers received training from agricultural extension offices. The findings indicate that, in general, farmers are well aware of the risks associated with occupational hazards and recognize concern for health and safety protection in the workplace. Transitioning these concerns into preventative action remains a challenge and priority for the agricultural health professional.

Preferred Healthy Food Nudges, Food Store Environments, and Customer Dietary Practices in 2 Low-Income Southern Communities

OBJECTIVE

To examine how food store environments can promote healthful eating, including (1) preferences for a variety of behavioral economics strategies to promote healthful food purchases, and (2) the cross-sectional association between the primary food store where participants reported shopping, dietary behaviors, and body mass index.

METHODS

Intercept survey participants (n = 342) from 2 midsized eastern North Carolina communities completed questionnaires regarding preferred behavioral economics strategies, the primary food store at which they shopped, and consumption of fruits, vegetables, and sugary beverages.

RESULTS

Frequently selected behavioral economic strategies included: (1) a token and reward system for fruit and vegetable purchases; and (2) price discounts on healthful foods and beverages. There was a significant association between the primary food store and consumption of fruits and vegetables (P = .005) and sugary beverages (P = .02).

CONCLUSIONS AND IMPLICATIONS

Future studies should examine associations between elements of the in-store food environment, purchases, and consumption.

Assessing Preliminary Impact of the North Carolina Community Transformation Grant Project Farmers' Market Initiatives Among Rural Residents

OBJECTIVE

Using the Social Determinants of Health as the study's theoretical underpinning, the authors examined the impact of the North Carolina Community Transformation Grant Project farmers' market initiatives on changes in awareness and use of farmers' markets, and fruit and vegetable consumption.

METHODS

During the farmers' market season, the researchers conducted a random digit-dial telephone survey among residents in 3 rural North Carolina counties to examine changes in farmers' market awareness, shopping, and fruit and vegetable consumption. They examined change over 1 year using t tests, chi-square tests, and propensity score matching.

RESULTS

In 1 county there were increases in farmers' market shopping and fruit and vegetable consumption, and in 1 county there were decreases in farmers' market shopping and fruit and vegetable consumption.

CONCLUSIONS AND IMPLICATIONS

The impact of farmers' market initiatives may be affected by county-specific socioeconomic contexts.

Associations between neighborhood-level factors related to a healthful lifestyle and dietary intake, physical activity, and support for obesity prevention polices among rural adults

We examined cross-sectional associations among neighborhood- and individual-level factors related to a healthful lifestyle and dietary intake, physical activity (PA), and support for obesity prevention polices in rural eastern North Carolina adults. We examined perceived neighborhood barriers to a healthful lifestyle, and associations between neighborhood barriers to healthy eating and PA, participants' support for seven obesity prevention policies, and dependent variables of self-reported dietary and PA behaviors, and measured body mass index (BMI) (n = 366 study participants). We then used participants' residential addresses and Geographic Information Systems (GIS) software to assess neighborhood-level factors related to access to healthy food and PA opportunities. Correlational analyses and adjusted linear regression models were used to examine associations between neighborhood-level factors related to a healthful lifestyle and dietary and PA behaviors, BMI, and obesity prevention policy support. The most commonly reported neighborhood barriers (from a list of 18 potential barriers) perceived by participants included: not enough bicycle lanes and sidewalks, not enough affordable exercise places, too much crime, and no place to buy a quick, healthy meal to go. Higher diet quality was inversely related to perceived and GIS-assessed neighborhood nutrition barriers. There were no significant associations between neighborhood barriers and PA. More perceived neighborhood barriers were positively associated with BMI. Support for obesity prevention policy change was positively associated with perceptions of more neighborhood barriers. Neighborhood factors that promote a healthful lifestyle were associated with higher diet quality and lower BMI. Individuals who perceived more neighborhood-level barriers to healthy eating and PA usually supported policies to address those barriers. Future studies should examine mechanisms to garner such support for health-promoting neighborhood changes.

Adoption of Evidence-Based Interventions in Local Health Departments: "1-2-3 Pap NC"

Descriptions of barriers and facilitators to adoption of evidence-based interventions in local health departments (LHDs) are limited. This study was conducted by the North Carolina Public Health Practice-Based Research Network to identify factors associated with adoption of an evidence-based human papillomavirus video intervention, "1-2-3 Pap NC," in North Carolina LHDs. A sequential mixed-method study design was used. Data from the 2013 National Profile of Local Health Departments were used to test associations between LHD characteristics and adoption of the intervention. Qualitative, key stakeholder interviews with LHD directors provided the context for quantitative data. Data collection and analysis continued from March 3, 2014, to September 15, 2014. Overall, 28% of North Carolina health jurisdictions (33 of 100 counties) implemented the intervention. Of the three channels used to deliver the intervention to clients, most LHDs opted to show the video in the exam room (42%), followed by website/other social media (36%) and video loop in the lobby/waiting room (22%). In logistic regression, gender of the director (female) was significantly and positively associated with adoption of the intervention (AOR=4.44, p<0.05). Being a first-time director was marginally significant (AOR=0.28, p=0.074), suggesting first-time directors were less likely to adopt. Qualitative results suggested that aspects of communication (awareness and positive attitudes) and agency directors' evaluation of resources, balanced against intervention complexity and flexibility, competing priorities, and mandates, influenced adoption. Adoption of evidence-based interventions by LHDs is critical to improve population health. Practice-based research can contribute to understanding facilitators and modifying barriers to this process.

A cross-sectional study of stressors among farmers in Eastern North Carolina

BACKGROUND

Agriculture is a hazardous, stressful occupation that can adversely affect farmers' health. Identifying stressors among farmers may help health professionals improve health outcomes by developing targeted intervention strategies and services.

METHODS

Over a 4-month period, we conducted a cross-sectional study of 128 farmers in an economically disadvantaged, 29-county region of Eastern North Carolina. We used a modified version of the Farm Ranch Stress Inventory to measure farmers' self-reported reactions to potential stressors.

RESULTS

The majority of farmers surveyed were aged 40-59 years, had farmed for more than 20 years, and worked more than 40 hours per week on the farm. Large proportions of respondents identified the following factors as 'very stressful': concern about the weather (60.2%), concern over the future of the farm (29.7%), outsiders not understanding the nature of farming (25.2%), problems with machinery (23.4%), market prices for crops/livestock (45.3%), taxes (38.3%), health care costs (32.5%), and not having enough time to spend with family in recreation (13.3%). Experiencing 8 or more factors as "very stressful" was found to be positively associated with working more than 40 hours per week on the farm (P = .008) and with being a farm manager or a farm worker who does not operate equipment (P = .001).

CONCLUSIONS

Information about perceived stressors among farmers may help health professionals develop targeted interventions for reducing stress. More research is needed to better evaluate health outcomes, to reduce farm-related injuries, and to improve psychosocial well-being.

Farmers' market use is associated with fruit and vegetable consumption in diverse southern rural communities

Background

While farmers’ markets are a potential strategy to increase access to fruits and vegetables in rural areas, more information is needed regarding use of farmers’ markets among rural residents. Thus, this study’s purpose was to examine (1) socio-demographic characteristics of participants; (2) barriers and facilitators to farmers’ market shopping in southern rural communities; and (3) associations between farmers’ market use with fruit and vegetable consumption and body mass index (BMI).

Methods

Cross-sectional surveys were conducted with a purposive sample of farmers’ market customers and a representative sample of primary household food shoppers in eastern North Carolina (NC) and the Appalachian region of Kentucky (KY). Customers were interviewed using an intercept survey instrument at farmers’ markets. Representative samples of primary food shoppers were identified via random digit dial (RDD) cellular phone and landline methods in counties that had at least one farmers’ market. All questionnaires assessed socio-demographic characteristics, food shopping patterns, barriers to and facilitators of farmers’ market shopping, fruit and vegetable consumption and self-reported height and weight. The main outcome measures were fruit and vegetable consumption and BMI. Descriptive statistics were used to examine socio-demographic characteristics, food shopping patterns, and barriers and facilitators to farmers’ market shopping. Linear regression analyses were used to examine associations between farmers’ market use with fruit and vegetable consumption and BMI, controlling for age, race, education, and gender.

Results

Among farmers’ market customers, 44% and 55% (NC and KY customers, respectively) reported shopping at a farmers’ market at least weekly, compared to 16% and 18% of NC and KY RDD respondents. Frequently reported barriers to farmers’ market shopping were market days and hours, “only come when I need something”, extreme weather, and market location. Among the KY farmers’ market customers and NC and KY RDD respondents, fruit and vegetable consumption was positively associated with use of farmers’ markets. There were no associations between use of farmers’ markets and BMI.

Conclusions

Fruit and vegetable consumption was associated with farmers’ market shopping. Thus, farmers’ markets may be a viable method to increase population-level produce consumption.

Temporal and regional trends in the prevalence of healthy lifestyle characteristics: United States, 1994-2007

OBJECTIVES

We examined temporal and regional trends in the prevalence of health lifestyles in the United States.

METHODS

We used 1994 to 2007 data from the Behavioral Risk Factor Surveillance System to assess 4 healthy lifestyle characteristics: having a healthy weight, not smoking, consuming fruits and vegetables, and engaging in physical activity. The concurrent presence of all 4 characteristics was defined as a healthy overall lifestyle. We used logistic regression to assess temporal and regional trends.

RESULTS

The percentages of individuals who did not smoke (4% increase) and had a healthy weight (10% decrease) showed the strongest temporal changes from 1994 to 2007. There was little change in fruit and vegetable consumption or physical activity. The prevalence of healthy lifestyles increased minimally over time and varied modestly across regions; in 2007, percentages were higher in the Northeast (6%) and West (6%) than in the South (4%) and Midwest (4%).

CONCLUSIONS

Because of the large increases in overweight and the declines in smoking, there was little net change in the prevalence of healthy lifestyles. Despite regional differences, the prevalence of healthy lifestyles across the United States remains very low.

Prevalence of work-related asthma in Michigan, Minnesota, and Oregon

INTRODUCTION

Adults who have asthma that is caused or aggravated by triggers at work experience a reduced quality of life. In this study, the authors sought to estimate the proportion of asthma that is associated with work using a state-based survey of adults with asthma.

METHODS

In 2005, Michigan, Minnesota, and Oregon piloted the Behavioral Risk Factor Surveillance System Adult Asthma Call-Back Survey, with sample sizes of 867, 469, and 1072, respectively. Six questions addressing work-related asthma (WRA) were analyzed to generate estimates of the proportion of adult asthma that is work-related and compare those with and without WRA.

RESULTS

Over half of all adults with asthma (53%) reported that their asthma was caused or made worse by any job they ever had, and among these respondents reporting WRA, only 21.5% to 25.1% reported ever telling or being told by a health professional that their asthma was work-related. Additionally, adults with WRA consistently reported poorer asthma control and higher health care utilization than adults with non-WRA.

CONCLUSIONS

WRA is a common but frequently unrecognized health problem, and this lack of recognition might contribute to poorer asthma control among adults with WRA. Because early recognition, treatment, and management of WRA are crucial for improving long-term prognosis, clinicians need to include assessment of workplace triggers in both their diagnostic and treatment plans for adult patients with asthma.

Knowledge of Tissue Plasminogen Activator for Acute Stroke Among Michigan Adults

Background and Purpose— Although tissue plasminogen activator (tPA) is an effective therapy for acute ischemic stroke, treatment rates remain low. Efforts to address the underuse of tPA include public education to increase the recognition of stroke symptoms and the awareness of tPA treatment. Our objective was to determine the level of knowledge about tPA treatment for acute stroke among a representative sample of Michigan adults.

Methods— The Michigan Behavioral Risk Factor Survey (BRFS) is a random-digit-dial telephone survey of adults conducted annually as part of the national BRFS. Questions regarding tPA treatment for acute stroke were included in the 2004 Michigan BRFS. We examined the prevalence of awareness using χ 2 tests and generated multivariable logistic regression models.

Results— Among 4724 respondents, only 32.2% (95% CI=30.8 to 33.8%) were aware of the existence of tPA treatment for acute stroke, of whom 52.7% (50.0 to 55.4%) knew that it needed to be administered within 3 hours of symptom onset. Awareness of tPA was higher among middle aged adults, females, whites, and those with higher education and income. Awareness of the time window for tPA was higher among middle aged adults and whites.

Conclusions— In this population-based survey only a third of the public were aware of tPA as a treatment for stroke, and only 1 in 6 were aware that the treatment exists and needs to be given within 3 hours of symptom onset. Continuing efforts are necessary to increase public knowledge about tPA treatment for acute stroke.

Racial disparities in knowledge of stroke and heart attack risk factors and warning signs among Michigan adults

OBJECTIVE

To describe the level of knowledge regarding risk factors and warning signs for stroke and heart attack among White and African American adults in Michigan and to quantify racial disparities.

METHODS

Knowledge of stroke and heart attack risk factors and warning signs was assessed by using data from the 2004 Michigan Behavioral Risk Factor Survey. Prevalence estimates of knowledge were generated, and statistical differences in knowledge between Whites and African Americans were assessed. Adequate knowledge was defined as knowing 3 correct warning signs or risk factors. Logistic regression models were used to quantify the racial disparity in knowledge while controlling for potential confounding.

RESULTS

Whites had substantially higher levels of adequate knowledge of risk factors (stroke: 31.6% vs 13.8%; heart attack: 52.6% vs 24.3%) and warning signs (stroke: 30.0% vs 17.2%; heart attack: 29.3% vs 13.8%) compared with African Americans (all observed differences were significant at P < .05). The odds of adequate knowledge of risk factors (stroke: adjusted odds ratio [AOR] 2.9; heart attack: AOR 3.4) and warning signs (stroke: AOR 2.0; heart attack: AOR 2.4) were significantly higher for Whites than for African Americans.

CONCLUSION

A strong racial disparity in the knowledge of stroke and heart attack risk factors and warning signs exists among Michigan adults. Communitywide public education programs in conjunction with targeted interventions for at-risk populations are necessary to produce meaningful improvements in the awareness of stroke and heart attack risk factors and warning signs among Michigan adults.

Healthy lifestyle characteristics among adults in the United States, 2000

BACKGROUND

Many public health recommendations and clinical guidelines emphasize the importance of healthy lifestyles. Recent epidemiologic studies demonstrate that following a healthy lifestyle has substantial health benefits. The objectives of this study were to report on the prevalence of healthy lifestyle characteristics (HLCs) and to generate a single indicator of a healthy lifestyle.

METHODS

National data for the year 2000 were obtained from the Behavioral Risk Factor Surveillance System, which consists of annual, statewide, random digit-dialed household telephone surveys. We defined the following 4 HLCs: nonsmoking, healthy weight (body mass index [calculated as weight in kilograms divided by the square of height in meters] of 18.5-25.0), consuming 5 or more fruits and vegetables per day, and regular physical activity (> or =30 minutes for > or =5 times per week). The 4 HLCs were summed to create a healthy lifestyle index (range, 0-4), and the pattern of following all 4 HLCs was defined as a single healthy lifestyle indicator. We report prevalences of each HLC and the indicator by major demographic subgroups.

RESULTS

By using data from more than 153 000 adults, the prevalence (95% confidence interval) of the individual HLCs was as follows: nonsmoking, 76.0% (75.6%-76.4%); healthy weight, 40.1% (39.7%-40.5%); 5 fruits and vegetables per day, 23.3% (22.9%-23.7%); and regular physical activity, 22.2% (21.8%-22.6%). The overall prevalence of the healthy lifestyle indicator (ie, having all 4 HLCs) was only 3.0% (95% confidence interval, 2.8%-3.2%), with little variation among subgroups (range, 0.8%-5.7%).

CONCLUSION

These data illustrate that a healthy lifestyle-defined as a combination of 4 HLCs-was undertaken by very few adults in the United States, and that no subgroup followed this combination to a level remotely consistent with clinical or public health recommendations.

Proportion of trips made by walking: estimating a state-level baseline for Healthy People 2010 Objective 22-14

PURPOSE

The purpose of this study was to investigate the proportion of short trips made by walking among Michigan adults and barriers to walking for transportation.

METHODS

Four questions on walking for transportation were asked of 3808 respondents to the Michigan Behavioral Risk Factor Surveillance System (BRFSS) between January and December 2001.

RESULTS

Three quarters (74.3%) of Michigan adults were estimated to have made at least one short trip (.25-1 mile) in the previous week; however, only 36.2% of them walked even one of these trips. The mean proportion of short trips walked was 21.4%; less than 10% of all respondents walked five or more trips per week.

DISCUSSION

Our results provide a Michigan-specific baseline for Healthy People 2010 Objective 22-14 (i.e., increase the proportion of trips made by walking) and suggest the potential for these questions to be used to monitor active transportation via the BRFSS.

Seasonal variation in adult leisure-time physical activity

PURPOSE

To determine the effect of season on self-reported leisure-time physical activity (LTPA) behaviors of Michigan adults.

METHODS

Data were obtained from the 1996 Michigan Behavioral Risk Factor Survey conducted throughout the year. Survey respondents were considered active if they reported participating in at least one LTPA during the past month. Complete information regarding type, frequency, and duration of up to two LTPA was available on 2843 adults (1635 women and 1208 men). Four seasons were defined as winter (January-March; N = 677), spring (April-June; N = 759), summer (July-September; N = 760), and fall (October-December; N = 647). Total weekly leisure-time energy expenditure was quantified (kcal x kg-1 x wk-1) from MET intensities, duration, and frequency of activity sessions per week. Seasonal differences were identified using ANOVA.

RESULTS

Average (+/-SEM) weekly leisure time energy expenditure was significantly greater (P < 0.001) during spring (17.5 +/- 0.8 kcal x kg-1 x wk-1) and summer (17.5 +/- 0.7 kcal.kg-1.wk-1) compared with winter (14.8 +/- 0.7 kcal x kg-1 x wk-1) and fall (15.0 +/- 0.7 kcal x kg-1 x wk-1). Duration of the first activity was significantly greater (P < 0.05) in summer (58.6 +/- 1.6 min) compared with winter (53.4 +/- 1.8 min). However, intensity (4.6 +/- 0.1 METs) and frequency (3.1 +/- 0.1 sessions per week) of the first activity did not differ among seasons. A second activity was performed by 1319 (46.4%) of active individuals and was more common in the spring (46.8%) and summer (54.5%) compared with fall (42.6%) and winter (39.4%) (chi2 = 31.0; P < 0.01). When both active and inactive subjects are considered, the Healthy People 2010 recommendation for moderate physical activity was met only during spring and summer.

CONCLUSION

Weekly leisure-time energy expenditure averaged approximately 15-20% higher during spring and summer. Much of this difference was due to active respondents participating in a second activity during these seasons.

Knowledge of stroke risk factors and warning signs among Michigan adults

OBJECTIVE

To assess the knowledge of stroke risk factors and warning signs in a representative statewide sample of Michigan adults.

METHOD

Respondents to the 1999 Michigan Behavioral Risk Factor Survey, a random-digit-dialed statewide survey of >2,500 adults, were asked to report up to three risk factors and warning signs for stroke. Predictors of inadequate knowledge (defined as not reporting any correct responses) of stroke risk factors and warning signs were identified using multiple logistic regression.

RESULTS

Eighty percent reported at least one correct risk factor for stroke, and 28% reported three. The most frequently mentioned risk factors were hypertension (32%), smoking (29%), and physical inactivity (26%). Sixty-nine percent reported at least one correct warning sign of stroke, but only 14% reported three. The most frequently mentioned warning signs were sudden weakness or numbness (46%) and sudden slurred speech, disorientation, or difficulty understanding (30%). Predictors for inadequate knowledge of both stroke risk factors and warning signs were similar and included age, race, sex, education, hypertension, and smoking.

CONCLUSIONS

Knowledge of stroke risk factors and warning signs was moderate at best. One in five respondents was not aware of any stroke risk factors, and almost one in three was not aware of any stroke warning signs. Stroke knowledge was poorest among groups that have the highest risk of stroke.

Physical activity patterns among walkers and compliance with public health recommendations

PURPOSE

Walking is the most common leisure-time physical activity (LTPA) among U.S. adults. The purpose of this study was to estimate the prevalence of walking for physical activity and the proportion of walkers who met current public health physical activity recommendations.

METHODS

We analyzed data from the 1998 Behavioral Risk Factor Surveillance System, a collection of state-based, random-digit-dialed telephone surveys of adults. Physical activity measures included the type, frequency, and duration of the two LTPAs in which respondents engaged most often during the previous month. We calculated the prevalence of walking and the prevalence of three physical activity patterns defined by combinations of walking duration and frequency. We also examined the effect on these patterns of participating in a second LTPA.

RESULTS

In 1998, an estimated 38.6% of U.S. adults walked for physical activity. Among walkers, 21.3% walked a minimum of 30 min five or more times per week. This approximates compliance with current physical activity recommendations. Compliance increased to 34.5% when the criteria were relaxed to include at least 150 min of walking per week accumulated over three or more occasions. Relaxing the criteria further to include a minimum of 150 min.wk(-1) regardless of frequency produced only a small increase in compliance (37.6%). However, compliance with each of these three activity patterns approximately doubled when a second LTPA was taken into account.

CONCLUSIONS

Less than 40% of walkers complied through walking with even our most liberal physical activity pattern (> or =150 min.wk(-1) regardless of frequency). For walkers to meet current public health recommendations, many need to walk more frequently and/or to engage in additional physical activities.

A healthy diet indicator: quantifying compliance with the dietary guidelines using the BRFSS

BACKGROUND

The Behavioral Risk Factor Surveillance System (BRFSS) monitors population prevalence of risk factors related to chronic disease through annual telephone surveys. The purpose of this study was to investigate the feasibility of using the BRFSS to estimate an indicator of overall diet quality among adults.

METHODS

The authors developed a brief set of dietary questions that were included in the 1997 Michigan BRFSS. Responses to these questions were analyzed to calculate the Michigan healthy diet indicator (MI-HDI), which was modeled after the U.S. Department of Agriculture's Healthy Eating Index.

RESULTS

Among 2,532 respondents, the mean MI-HDI was 55.7 points (maximum score = 100). The mean MI-HDI decreased consistently with declining self-rated eating habits, from 61.5 among those with excellent eating habits to 45.2 among those with poor habits. Diet quality, as measured by the MI-HDI, was higher among women than men and improved with age, education, and factors related to certain interactions with health professionals.

CONCLUSIONS

A BRFSS-based indicator can be a feasible and valuable tool for evaluating diet quality among adults using an established state-level surveillance system.

Validity of a household gun question in a telephone survey

The validity of self-reported data on the presence of guns in the home obtained in a telephone survey was assessed in samples of households where a hunting license had been purchased or a handgun registered. The survey was conducted among a random sample of Ingham County, MI, residents who had purchased a hunting license between April 1990 and March 1991 and among those registering a handgun during 1990. A third study sample was selected from the county's general adult population using a random digit dialing method. The interviews were conducted between November 1991 and January 1992. The proportion of respondents who reported that at least one gun was kept in their household was 87.3 percent among handgun registration households and 89.7 percent among hunting license households. In the survey of the general population of the county, approximately one-third of the respondents reported keeping a gun in the household, 67 percent of them for hunting and 23 percent for safety. Despite some limitations, the data indicate that a question on gun presence in a household can be used in a in a telephone survey.