Purpose. Little research on the association of neighborhood environment with physical activity in resource-poor communities has been done. This study assessed changes in perceptions of the neighborhood environment and the association between the neighborhood environment and physical activity in a population-based Mexican American cohort from the U.S.-Mexico border in a community that embarked on enhancing pedestrian and cycling infrastructure and programming.
Methods. We analyzed data from a population-based sample of Mexican American individuals on the Texas-Mexico border. Longitudinal questionnaires were interviewer-administered. Heat map analysis assessed changes in the positive response rate reflecting perceptions of the neighborhood environment over time, and multivariate-adjusted logistic regression assessed how perceptions of neighborhood environment elements predicted meeting physical activity guidelines.
Results/findings. The sample (n=1036) was mostly female (71%), born in Mexico (70%), had no health insurance (69%). We saw improvements in the perceptions of several neighborhood environment attributes from 2008-2018, though we saw different longitudinal trajectories in these perceptions based on an individual’s longitudinal physical activity patterns. By 2014-2018, we saw significantly higher positive perceptions of the neighborhood environment for those who consistently met physical activity guidelines compared to those who did not (Adjusted Rate Ratio=1.12, p=0.049).
Conclusions. We found that perceptions of many neighborhood environment attributes improved between 2008 to 2018, and that overall positive perceptions were associated with consistently meeting physical activity guidelines over time.

Purpose: Policies aiming to increase reach and use of public transit have promise for improving population health by supporting active transportation and access to affordable, healthy food and other healthy opportunities. This quasi-experimental study evaluated the impact of a citywide zero-fare (free) bus transit policy on bus ridership relative to comparison cities with no fare changes.

Methods: Bus ridership data were collected from the transit agency in Kansas City, Missouri USA (486K residents, 40K monthly riders) and seven non-zero-fare comparison USA cities with similar population and transit characteristics (mean=665K±206K residents, mean=46K±25K monthly riders). Data spanned 2018-2022, reflecting two years before and three years after Kansas City’s zero-fare policy started in March 2020, coinciding with the start of the COVID-19 pandemic. Ridership was computed for the early (January-June) and late (July-December) half of each year and standardized relative to ridership in the first half of 2018 in each respective city. Changes in ridership in Kansas City were compared to average changes in ridership across the comparison cities.

Results/findings: In late 2019, just before the start of zero-fare, ridership levels were similar to early 2018 levels in Kansas City and on average across the comparison cities (within cities, changes were -9% to +16%). Ridership decreased dramatically in early 2020 when the pandemic and zero-fare started, by 22% in Kansas City and 41% across the comparison cities (within cities, decreases were 30% to 56%). In early 2021, many cities reached their lowest ridership levels, down 31% in Kansas City and 55% across the comparison cities. By late 2022, Kansas City ridership was back within 11% of early 2018 levels, whereas ridership in the comparison cities was only within 37% of early 2018 levels (ranging from within 18% to within 50%). 2023 data are still being collected.

Conclusions: Although the pandemic led to reduced bus ridership in all cities, ridership decreased much less in the zero-fare city, Kansas City, than in the comparison cities. Future research is needed to evaluate whether the higher ridership levels associated with free public bus transit translate to increases in active transportation, healthy eating, and related health markers.

Purpose: The Centers for Disease Control and Prevention’s (CDC) National Center for Chronic Disease Prevention and Health Promotion’s, Islands Program currently funds a 6-year cooperative agreement (DP19-1901) to prevent and control tobacco use, diabetes, and cardiovascular disease in the US Affiliated Pacific Islands, the US Virgin Islands, and Puerto Rico. The Islands Program conducted an evaluation to identify perceived social determinants of health (SDOH) addressed by the cooperative agreement, factors that affected the implementation of the cooperative agreement, and suggestions for working with the islands. These are critical to understanding and improving health outcomes of island populations. Culturally responsive, community-based participatory research methods were used.
Methods: The Islands Program conducted a process/implementation evaluation using the Participatory Action Research framework. Telephone interviews were conducted between November 2022-January 2024. A total of 23 individuals completed interviews. These individuals included representation from all eight islands awarded cooperative agreement funds and all CDC staff that have served as part of the Islands Program. Transcripts were coded using thematic analysis in NVivo. Inter-rater agreement reached Kappa ≥ .80.
Results: Over half of respondents (n=12) stated that diabetes, diseases caused by tobacco and betel nut use, and obesity were the biggest health issues in the islands. The top SDOHs were related to quality, affordable healthcare/insurance (n=15), food (15), transportation (n=14), and education (n=9). Implementation was affected by 15 internal or external factors. Respondents reported that staff recruitment/hiring/maintenance (n=15), capacity (n=14), funding (n=12), COVID-19/disease outbreaks (n=11), funder-specific policies (n=9), and infrastructure (n=9) impacted implementation effectiveness. In addition to funding and training, technical support from funders/partners is critical to overcoming these challenges. Designing program strategies that build on the current work and partnerships in the islands, focus on policy approaches, and aim at root causes of chronic disease will yield more positive impacts on the islands’ program and health outcomes (n=13).
Conclusions: Researchers and funders should use collaborative approaches with key stakeholders to understand underlying factors that facilitate and impede implementation effectiveness of program activities. Tailored approaches that incorporate these factors yield more impactful outcomes among island populations.

Purpose. Increasing evidence supports the benefits of “Food is Medicine” intervention strategies that integrate food and nutrition into healthcare delivery. Among such strategies, medically tailored meal (MTM) interventions are particularly promising. MTMs are fully prepared, nutritionally tailored, home-delivered healthy meals for individuals living with diet-sensitive conditions, such as diabetes, heart failure, end-stage renal disease, HIV, and cancer. In Massachusetts, USA, a new policy resulted in the implementation of novel nutrition programs, including MTMs for high-risk patients, through Medicaid Accountable Care Organizations. The purpose of this study was to qualitatively assess the implementation of the MTM program to facilitate future uptake of these programs.

Methods. We interviewed 19 staff affiliated with four Accountable Care Organizations in Massachusetts, USA that had implemented an MTM intervention. Interviews were conducted in February-August 2023. The semi-structured interview guide was informed by the Health Equity Implementation Framework, and questions were about barriers to and facilitators of implementation, including the screening, referral, and enrollment process; perceptions about program logistics and sustainability; and perceptions about program impact. Interviews were conducted online via the Zoom videoconferencing app and lasted 50 minutes on average. The interviews were recorded, transcribed, and then coded using NVivo software. We used a directed qualitative content analysis approach.

Results. Staff perceived the MTM program as helping to improve the overall quality of care and appreciated the ability to provide tangible support to patients. Challenges to the screening and referral process were related to the food security criterion and included staff discomfort with discussing this issue as well as a mismatch between patient language and cultural factors and the screening tool. Logistical barriers included staff knowledge gaps about the MTM program and the time needed for recruitment and referral. Staff were concerned that patients would be unable to sustain benefits when the program ended.

Conclusions. Staff perceived many positive impacts of MTMs. In future programming, implementation may be improved by providing additional staff training. Language and culture may need to be better addressed, especially in the screening process, to help ensure that MTM programs are equitably implemented.

Purpose. Physical inactivity is a major health risk factor for multiple chronic diseases and early death but is rarely measured or promoted in primary care. Few studies have taken a comprehensive look at the relations between patient’s physical inactivity and health outcomes commonly included in patient’s electronic medical records (EMR). The purposes of this study were to: 1) compare EMR health outcomes between patients screened and not-screened for physical inactivity; and 2) to compare EMR health outcomes among screened patients identified as inactive, insufficiently active, and active. We hypothesized screened patients and unscreened patients would have similar health profiles but active patients would have superior health profiles compared to insufficiently active patients.

Methods. We conducted a cross-sectional study that included 40,706 adult patients treated at a large midwestern hospital between 11/1/2017 and 12/1/2022. Demographics, vital signs, visits and encounters, and disease diagnoses, were extracted from patient EMRs using the PCORnet Common Data Model (version 6.1). Chronic disease burden was calculated using the Elixhauser comorbidity index. Physical inactivity was measured among 7,261 adults coming in for annual wellness visits using the two-item Exercise Vital Sign (EVS) questionnaire. Screened patients were characterized as inactive (0 minutes/week), insufficiently active (1-149 minutes/week) and active (150+ minutes/week of moderate-vigorous of physical activity). Welch two sample t-tests were used to compare EMR health outcomes between screened and unscreened patients (N=33,445). Kruskal-Wallis rank sum test, Fisher’s exact test, or Pearson’s Chi-squared tests were conducted to compare EMR health outcomes between active, insufficiently active, and inactive patients.

Results. Patients screened for inactivity were younger (-1.7 years; p<0.001) and healthier than unscreened patients, presenting with superior cardiometabolic risk profiles and lower chronic disease burden (-0.27; p<0.001). Among patients screened for inactivity, active patients presented with superior cardiometabolic risk profiles and lower chronic disease burden (p<0.001). Active patients had a lower risk of 20 inactivity-related comorbid conditions compared to insufficiently active patients.

Conclusions. These findings illustrate the value of treating physical inactivity as a vital sign by screening patients for inactivity. Additional study is needed to identify best practice for providing inactive patients with effective resources to promote physical activity.

Purpose: Despite the existence and effectiveness of the National Diabetes Prevention Program (NDPP), rural populations that experience disparities in diabetes risk also have inequitable access to evidence-based diabetes prevention programs. A potential challenge for adoption and implementation of the NDPP in rural communities is that the intensity and content of the NDPP may not be compatible with rural community resources and capacity. The Cooperative Extension System (Extension), available in every state in the U.S., employs Family and Consumer Science (FCS) professionals to deliver health promotion programs and presents an opportunity for NDPP delivery in rural settings. The purpose of this exploratory study was to identify strategies to support the adoption and implementation of the NDPP based on potential barriers and facilitators to delivery within Extension.

Methods: Guided by the Consolidated Framework for Implementation Research (CFIR), individual semi-structured interviews were conducted in the Fall of 2022 with Kansas State Research and Extension (KSRE) FCS agents (n = 11) to acquire information on nutrition and physical activity program implementation experience in rural communities that could be applied to NDPP adoption and implementation. Data were analyzed thematically using a deductive and inductive approach.

Findings: Identified strategies—development of a formal implementation blueprint for participant recruitment and tailoring implementation for remote delivery—addressed specific barriers related to the CFIR implementation process domain of engaging with the innovation (i.e., NDPP) or program reach. Specifically, two primary barriers emerged from the interviews: 1.) difficulty in engaging participants due to a lack of systematic recruitment processes and 2.) difficulties for participants related to the time/location of program, program relevance, and competing family demands.

Conclusions: These results led to the design of a type II hybrid-effectiveness trial where two remote delivery methods of the NDPP will be assessed for reach, retention, and effectiveness (weight loss) when delivered through KSRE. Further, a formal implementation blueprint for participant recruitment, including a population health management approach through rural medical clinics where potential participants are identified through electronic health records (active), will be compared to traditional recruitment methods such as flyers, media, word of mouth, etc. (passive) on participant yield, retention, and participant demographics.

Purpose: Poor diet quality is associated with elevated chronic disease risk and the rising cost of US healthcare. Having enough healthy food, or “Nutrition Security” (NS), is cited as a barrier to eating healthy in families experiencing food insecurity (FI). Recently, the Gretchen Swanson Center for Nutrition (GSCN) has developed a tool to measure NS. This tool presents a promising evaluation approach for “Food As Medicine” (FAM) interventions, which aim to improve healthy food access, diet quality, and diet-related chronic disease risk. The objective of this research is to report on the feasibility of the GSCN NS tool and explore the impact of a FAM intervention on NS and FI.

Methods: Data were collected from a cohort of participants enrolled in an ongoing longitudinal Produce Prescription intervention (PRx) between February 2023 and February 2024. Adult caregivers who screened positive for FI were recruited by clinicians during clinic visits for their children aged 0-18 years old. Enrolled families received 8 pounds of produce and virtual nutrition education twice-monthly for 6 months. Adults completed self-report surveys at baseline and post-intervention, including GSCN measures of NS, Healthfulness Choice (HC), Dietary Choice (DC), and the 6-item USDA Household Food Security Survey (FI). We report the relationship between NS, HC, DC, and FS scores at pre- and post-intervention and the pre-post change in scores. Correlations were tested with Spearman Rank, and longitudinal change in scores was tested by paired T-tests.

Results: One-hundred twenty-six adults provided baseline data and 53 provided post-intervention data. At baseline, NS and DC were correlated with FI (R=-0.60 and R=-0.50, respectively, p<0.001) and at post-intervention, NS was correlated with FI (R=-0.60, p<0.001). There was a significant pre-post increase in NS scores (t=-0.27, p<0.05) and decrease in FI scores (t=3.15, p<0.01). There was also a significant relationship between change in NS and change in FI (R=-0.36, p<0.05).

Conclusions: Participation in a PRx was associated with an increase in NS and reduction in FI severity and these changes were significantly correlated. Use of the NS tool in FAM program evaluation was feasible and provided novel insight into the impact of a FAM intervention.

Purpose: Family physical activity may improve health outcomes and kindergarten readiness in young children from economically disadvantaged backgrounds to promote health equity. The purpose of this abstract is to describe the process and outcomes of engaging with community leaders to develop the Families Moving Together intervention for female caregivers and their preschool-aged children who receive housing assistance.
Methods: Five action planning meetings (one hybrid and 4 virtual) were held with community leaders who had expertise in physical activity, early learning, or family engagement. The PRACTical planning for Implementation and Scale-up (PRACTIS) Guide provided a framework for each meeting to consider implementation and sustainability barriers and facilitators during the design process. The Framework Analysis method was used to analyze qualitative data using inductive and deductive coding to describe participant perspectives and action planning processes. Two research team members coded each transcript and the final themes were discussed by four research team members who were involved in the analysis.
Results/Findings: Action planning participants (N=19) were aged 50 ± 13.4 years, primarily female (89%), and worked across several community organizations in an urban city in Central Kentucky. There were three core themes identified from analyzing the transcripts. First, participants approached the action planning process with shared values, such as respect, access, and equity. Second, these core values provided a foundation for creating coordinated, collaborative, and sustainable solutions to address community challenges. Finally, participants described program design elements to remove barriers and increase facilitators for participation and impact. The final outcome, a community-based family physical activity intervention, Families Moving Together, was co-developed with action planning meeting participants. During this process, community leaders identified other partners and resources to support the design and implementation of the intervention.
Conclusions: Community leaders engaged with the research team in an iterative process using the PRACTIS guide to design strategies to increase physical activity and kindergarten readiness that could be implemented and sustained in the community. Participants prioritized the voice of community members and collaborative approaches to design and sustain programs. This process could be replicated in other under resourced settings to create sustainable partnerships that facilitate community health.

Purpose. Women who reside in rural areas are at higher risk for maternal morbidity and mortality compared to women residing in urban areas. Emerging evidence indicates that differences in dietary intake may contribute to rural health disparities in the general population; however, less is known about rural-urban dietary differences during pregnancy. The purpose of this study is to characterize differences in dietary intake between rural and urban women during pregnancy. We hypothesize that rural women will have worse diet quality across pregnancy compared to urban women.
Methods. Women (N=333) participating in the ongoing Pregnancy 24/7 cohort study from Iowa and West Virginia were included in analyses. The study includes three assessments, one each trimester of pregnancy. Participants provided their home address and completed a diet screener at each assessment. Rural status was determined using the rural-urban commuting area (RUCA) code based on the participant’s address, with RUCA codes of 4-10 considered rural and 1-3 considered urban. Diet was assessed using the National Cancer Institute’s Diet Screener Questionnaire (DSQ), providing estimated dietary intakes for fruits and vegetables, whole grains, dairy, fiber, calcium, and added sugars. Mixed effects models analyzed the association between rural status and dietary intake, after adjustment for study site, age, race and ethnicity, education, income, trimester, relationship status, and parity.
Results. We included 91 pregnant women from rural areas and 242 from urban areas. Fruit/vegetable and fiber intakes were lower in rural women vs. urban women (2.2 vs. 2.4 cups/day, p=0.006 and 14.3 vs. 15.2 grams/day, p=0.002). Rural participants also consumed more added sugar (18.4 vs. 17.3 tsp/day, p=0.025) and greater grams of sugar from sugar-sweetened beverages (9.2 vs. 7.8 tsp/day, p=0.004), than urban participants. No other significant differences were observed.
Conclusions. Dietary differences were observed across pregnancy in our sample, with those residing in rural areas consuming less fruits, vegetables, and fiber and more added sugars compared to those in urban areas. These findings illustrate a need for dietary interventions in rural populations during pregnancy. In subsequent analyses, we plan to examine if the observed differences in dietary intake partly explain rural disparities in maternal-child health outcomes.

Purpose: To evaluate associations between corporate social responsibility (CSR) commitments and the nutritional quality of menu offerings in 66 top-selling restaurant chains from 2012 to 2018.
Methods: Data on restaurant CSR commitments and the nutrition content of menu offerings were abstracted from the Internet Archive database of restaurant websites and the New York City Department of Health’s MenuStat database, respectively. Nutritional quality scores of restaurant menu offerings were determined via a modified Nutrition Environment Measures Study-Restaurants (NEMS-R) tool. Generalized linear mixed models with a random effect for restaurant were used to evaluate differences in NEMS-R score and in the nutrition content of menu items (kcal, total fat, saturated fat, sugar, fiber) between restaurants with and without CSR commitments. For all models, the effect of CSR overall and by year was tested. Sensitivity analyses were conducted using health-related CSR commitments identified by qualitative coding in a random subsample of web text sections (n=4,096) versus CSR commitments identified by keywords (health and non-health-related) in all the web text sections (n=10,615).
Results: Almost one fifth of restaurants (19%) in 2012 had CSR commitments; and just under one half of restaurants (48%) in 2018 had CSR commitments. There were no differences in the nutritional quality of menus (NEMS-R score) or the nutrition content of menu items in restaurants with versus without CSR commitments, overall or over time. Sensitivity analyses suggest modest changes in the nutrition content of menu items at restaurants with CSR commitments both overall and by year. Specifically, there was a modest decline in per-item calories offered each year (-3.4 kcals per year 95%CI: -7.0, -0.4) but a slightly higher amount of total fat and saturated fat overall by restaurants with CSR commitments vs. those without (0.09 g of fat 95%CI: 0.0, 2.1 and 0.4 g saturated fat 95%CI: 0.0, 1.1, respectively). There were small declines in saturated fat over time (-0.1 g saturated fat per year 95%CI: -0.2, 0.0) in restaurants with CSR commitments vs. those without.
Conclusions: CSR commitments did not translate into nutritional changes to restaurant menus that would meaningfully impact health.