NC1193: Using Behavioral and Environmental Tools to Identify Weight Related Factors Associated with Health in Communities of Young Adults
(Multistate Research Project)
NC1193: Using Behavioral and Environmental Tools to Identify Weight Related Factors Associated with Health in Communities of Young Adults
Duration: 10/01/2016 to 09/30/2021
Statement of Issues and Justification
STATEMENT OF THE PROBLEM
Excessive weight gain is associated with increased risk of developing many serious diseases, including cardiovascular disease, hypertension, and type 2 diabetes. Despite extensive efforts to promote weight management, these efforts only reach a small proportion of the population at risk and even effective programs promoting individual behavior change may have limited effectiveness in environments that promote weight gain. Furthermore, there are limited validated tools used to effectively assess the perception of the environment in which these individuals live. Using the ecological perspective to understand how different factors interact to influence food and physical activity behaviors, we can inform more tailored interventions that lead to lasting behavior change. Therefore research is needed to elucidate the combination of individual and environmental factors associated with unhealthy weight gain among our targeted population of young adults, including those in under-represented, low-income communities. Participants in this multi-state research group have applied theory-based behavioral constructs to design intervention programs to promote healthful eating and exercise behaviors in young adults with a goal of preventing unhealthy weight gain. Although these programs have been effective in improving dietary behavior, they did not prevent weight gain. Obesity currently affects 17 percent of children and adolescents and greater than 30% of adults in the United States . The socio-ecological framework is designed to account for the multiple societal levels that influence food and physical activity choices because the individual is studied in the context of interpersonal identity and support, organizations, community and public policy. Using the socio-ecological model to understand how different factors interact to influence food and physical activity behaviors is an important approach to understanding behavior change in this population. The previous five years of this multi-state research have been devoted to the development, validation and refinement of tools designed to: 1) evaluate the healthfulness of the environment, 2) evaluate the perceptions of the target community of the healthfulness of the environment, and 3) define the relationship between environmental and behavioral factors that influence excessive weight gain. The purpose of this renewal is to implement a newly developed model with consideration of cross-sector collaborations and to capture sustainability of change in environments, behavior and perception on college campuses and in low-income communities. Additionally, there will be continued effort on environment and behavioral instrument development, refinement, validation, and translation for under-represented or non-represented settings (e.g. low income communities who qualify for food assistance), as well as continued exploration of mechanisms of interaction between lifestyle behaviors and environmental factors in influencing healthy behaviors and health status of young adults using previous and ongoing work. This approach aligns with the U.S. Department of Agriculture’s focus on policy, systems, and environmental (PSE) approaches that address the outer levels of the socio-ecological model. It is also the intention of the PSE approach to supplement individual, group, and community-based educational strategies used by nutrition and physical activity educators in a multi-component program delivery model. It is argued that education in combination with PSE is more effective in tackling the prevention of overweight and obesity.
ISSUES AND JUSTIFICATION
Importance of work on college campuses. Since the numbers of young adults attending college has been increasing over the last 15 years  many young adults can be reached by targeting college campuses. Based on 2012 data, 41% of 18-24 year olds are enrolled in American colleges or universities . College students need health and nutrition information because they are in a transitional period of life, often referred to as “emerging adulthood.” As they grow in independence, they shift their support systems, expand those who are influential in their lives and form their own individual health behavior patterns  which set the stage for their future lives and health status. When their health choices include poor dietary and physical activity choices, excessive weight gain may be the consequence. Nelson and colleagues found that on average, during the first three to four months of college, undergraduate students gained 1.5 – 6.8 pounds, so that by the end of the first semester, the proportion of overweight or obese students had doubled. Arnold and colleagues reported that nearly one-third of college students are considered overweight or obese . It was reported some years ago, that being mildly or moderately overweight at age 20-22 years is linked with substantial incidence of obesity by age 35-37 years [7, 8]. College campuses, as microcosms of larger communities, provide excellent environments for making and/or advocating for changes in policies and function to support healthful lifestyles of young adults. The efficacy of diet, exercise, behavior change and environmental supports for healthful lifestyles and obesity prevention in this population group has yet to be demonstrated. Translating tools for under-represented or non-represented settings. Low-income audiences (those eligible for or on food assistance-related programs) are especially at risk for obesity because of extra barriers to adopting a healthful lifestyle and the strain on household resources. Various risk factors contribute to this increased risk for obesity, including limited access to healthful foods at an affordable cost, less money to spend on food, fewer opportunities to be physically active, more stressful life situations, and greater exposure to the marketing of nutrient-poor foods . Based on the REACH U.S. Risk Factor Survey of approximately 30 communities in the United States, residents in mostly minority communities continue to have greater barriers to health-care access, greater risks for, and burden of, disease compared with the general population living in the same county or state, as well as, lower socioeconomic status . Validated tools are needed to evaluate the food environment in low- income communities as part of a needs assessment for interventions designed to address obesity. Glanz and colleagues [11-15] published a series of articles on what is known about assessing the physical activity and food environments of communities. They called for combined approaches for effective research and policy efforts and the importance of community partnerships, as in community-based participatory research. Integrating Extension and Research. This multistate team, since its inception in 1990, has been composed of faculty bridging Extension and research with a strong focus on behavior change and nutrition education intervention. Extension provides non-formal education and learning activities to people throughout the country. It emphasizes taking knowledge gained through research and education and bringing it directly to the people to create positive changes. Young adults, 18-24, have been the focus, primarily those in college, because of their vulnerability due to life changes and independent decision-making, which sets the stage for their own health and the health of current and future generations. From 2001-2005, this Extension-Research team used the Transtheoretical Model/Stages of Change to tailor educational materials to increase fruit and vegetable intake in low-income young adults . The partnership has continued through two USDA funded projects, iCook: A 4-H Program to Promote Culinary Skills and Family Meals for Obesity Prevention, 2012-2017 , based in the Social Cognitive Theory, and the more recent “Get Fruved”: a peer-led, train-the-trainer social marketing intervention to increase fruit and vegetable intake and prevent childhood obesity, 2014-2019 , based in social marketing. Both of these projects are using community-based participatory research principles to foster Extension and target population partnerships. This multistate team recognizes the need for environmental changes to support tailored behavior change, and over the last five years, has been developing and testing tools to measure environmental supports for healthful lifestyle on college campuses. This work, aligning with the U.S. Department of Agriculture’s focus on policy, systems and environmental (PSE) change strategies, leads naturally to communities outside college campuses, and specifically to target populations of under-represented, low-income audiences who are at increased risk for unhealthful lifestyles, food insecurity, and reliance on assistance programs. Policy, Systems, and Environmental (PSE) Change Strategies. Strategies and interventions designed with policy, system, and environmental approaches support the individual by facilitating healthful options. These approaches have become the hallmark of multi-level interventions. The Centers for Disease Control and Prevention (CDC) and the Institute of Medicine believe that these strategies will have a much broader population impact and be less costly, more sustainable, and less prone to stigmatize individuals who are overweight or obese than programs focused on individual behavior change . PSE strategies are intended to supplement individual, group, and community-based educational strategies used by nutrition and physical activity educators in a multi-component program delivery model. Education combined with PSE is more effective than either strategy alone for preventing overweight and obesity . Environmental Factors and Obesity. The impact of the built environment on risk for obesity is pervasive in the obesity literature. The built environment encompasses a variety of components including, but not limited to, neighborhood walkability, access to parks, safety, cleanliness, and traffic flow . These factors influence the ability and desire for people to be physically active. A review by Renalds et al. identified factors of the built environment that influenced physical activity . More lights, fewer intersections and traffic, and better scenery all encouraged physical activity, while poor security and poor neighborhood maintenance discouraged physical activity. The authors concluded that neighborhoods that encouraged walking had more physically active residents with lower incidence of overweight. Many researchers have reported a positive association between some aspect of the built environment and obesity [22-25], possibly because of barriers to physical activity. In their review on obesity and the built environment, Booth et al. noted that biological, psychological, behavioral, and social factors do not fully account for the current obesity epidemic, which provides support for the evaluation of the effect of the built environment . Increasing the ability for neighborhoods to promote physical activity may translate into a reduced risk for obesity but may be a challenge in socially disadvantaged neighborhoods where physical activity is lower for a variety of reasons [26-28]. More affluent neighborhoods tend to have higher levels of physical activity, which may provide more protection against certain diseases in these communities . Currently there are few published studies documenting the effect a change in the built environment has had on the community. McCreedy and Leslie described a city-wide initiative in Orlando, Florida, called Get Active Orlando that brought together a multidisciplinary team of community partners passionate about changing the culture of their city to encourage physical activity . With a grant from the Robert Wood Johnson’s “Active Living by Design” initiative, researchers designed and implemented a community-wide campaign that encouraged healthful lifestyle changes. After establishing baseline data by surveying their target low socioeconomic status neighborhood, researchers developed programs designed to increase physical activity such as bike giveaways, safe bike rides, free bike repair, a senior walking program, and a community garden. These programs were successful in getting the community involved and physically active. The program successes have led to policy changes for development projects in the community intended to make the city more active. Their website (www.getactiveorlando.com) provides information as well as a Design Standards Checklist to be used by developers to promote physical activity in developments. A similar program in Somerville, Massachusetts, described by Burke et al, also achieved positive results . Although it is premature to determine if changes in the built environment will lead to a decrease in obesity, Orlando and Somerville can serve as models for community promotion of physical activity for the health benefit of residents. Another environmental factor is the food environment. According to Hill and Peters (1998) “one way in which the current environment promotes obesity is by providing more frequent opportunities for the consumption of large quantities of food. A variety of highly palatable, inexpensive foods is available nearly everywhere” . A cross-sectional survey of rural adults indicated that frequency of eating at establishments that promote excessive food consumption such as buffets, cafeterias and fast food was positively associated with obesity . Young adults in the Coronary Artery Risk Development in Young Adults (CARDIA) study who ate at fast food restaurants more than twice a week had a significantly higher weight gain during the 15 year study period than those who ate fast food less than once a week . Despite these findings, Giskes and colleagues reported insufficient evidence to support an association between fast food consumption and obesity based on their 2007 review of literature, and stated that more studies are needed . Upscale of Approach from Young Adult Population. Identifying evidence-based approaches and programs at a targeted, local level that can be scaled-up and adapted for diverse populations is necessary to win the war against obesity. Using previous work completed by this multistate team, a new model will be tested to capture the sustainability of our work. In Objective 1, we will forecast and capture the upscale evolvement of the programs we implement and the community impact via a dissemination and implementation model called eB4CAST (evidence-Based Forecasting). This model, adapted from the RE-AIM model , incorporates cross-sector engagement to capture the cultivating change in behavior and the environment. To support further scaling-up of our approach our multistate team will capture data that demonstrates trends in positive impact generated by sustainable community capacity-building and empowerment. Benefits of this project. This proposed research will reach young adults on college campuses and in low-income communities by using the socio-ecological model to ultimately impact policies, systems, and environments that will improve health and well-being. Research investigators will continue to work side-by-side as partners with young adults in diverse populations to understand, develop, create, and tailor interventions. Grant funding will be pursued for this research, as well as smaller state/local-specific projects. The ultimate outcome of this work will be tailored intervention strategies and environmental support approaches that meet audience needs in their acquisition of healthful eating behavior to prevent excessive weight gain. The collective power of the multiple states collaborating throughout the entire participatory process will significantly contribute to the understanding of how to best meet the needs of the priority population as they strive to prevent weight gain and adopt healthful habits. The outcomes from this work address health promotion priorities of USDA and other agencies such as National Institutes of Health and the Institute of Medicine. Need for cooperative work. Because of the multidimensional etiology of obesity and the equally multidimensional intervention designs needed to reduce incidence of obesity, significant large-scale progress toward weight management is unlikely to be achieved by a single investigator or University location, as acknowledged by the National Institutes of Health. Thus, a multi-state research team approach will increase diversity of expertise, environmental locations, and population demographics. The procedures outlined in this proposal require an enormous amount of work and a diverse set of research skills, all factors that this research team can provide. Furthermore, the limitations of previous studies on how environmental factors affect diet quality and health have suffered from regional bias that restricts ability to generalize findings. By using multiple communities to address specific objectives, this research team will be able to not only increase the power of analyses, but also enhance applicability of the findings and resolve regional disparities. This effective collaborative research relationship is demonstrated through a strong publication record with multiple authors from different institutions. This multi-state research team has a strong record of collaborative research (NC200, NC219, NC219R, NC1028, and NC1193 multi-state research) that will allow diversity needs to be met. Additionally, this research collaborative has successfully secured USDA grant funding, including an Initiative for Future Agriculture and Food Systems (IFAFS) grant, two National Research Initiative (NRI) grants and two Agriculture and Food Research Initiative (AFRI) grants.
Related, Current and Previous Work
RELATED, CURRENT AND PREVIOUS WORK
This current proposed research builds on more than 20 years of collaborative multi-state research, which was rooted in the community based participatory research (CBPR) approach and addressed eating and physical activity behaviors. Although most of the multi-state research team interventions have been focused on the college level, the researchers involved have a wide breadth of knowledge and experience developing, implementing, and evaluating healthy weight management and obesity prevention interventions with participants ranging in age from preschool to young adult college to non-college low-income audiences. We have examined and explored young adult behaviors, perceptions, and environments through the Stage-Tailored Multi-Modal Intervention Study, WebHealth, Project YEAH and currently in the Fruved Study. We have developed the Healthy Campus Environmental Audit and the Behavior, Environment, and Changeability Survey. We have made progress on a college environmental perceptions survey. The Stage-Tailored Multi-Modal Intervention Study. (S. Nitzke, PI) This USDA/IFAFS study was designed to assess effectiveness of an intervention to improve fruit and vegetable consumption in economically disadvantaged young adults. The study was a randomized treatment-control, pre-post, follow-up design conducted in 10 states through a researcher-Extension partnership. Young adults (n = 2024, ages 18–24) were recruited from non-college venues; 1255 (62%) completed assessment interviews at 0, 4 and 12 months. Assessment calls determined two measures of fruit and vegetable intakes, demographics and stage of change, plus treatment participants' decisional balance, processes, and self-efficacy. The intervention included a series of mailed materials and two educational calls in 6 months. Controls received a mailed pamphlet. Based on repeated measure analysis of variance, intent-to-treat, ?2, and logistic regression, at follow-up, participants in the experimental group had higher intakes of fruit and vegetables than controls (perceived daily intakes of 4.90 vs. 4.60 servings per day, F = 3.49, p < .05 and 4.31 vs. 3.92 servings/day via 5-A-Day Screener, F =4.78, p <.01) and greater progression to action or maintenance stages (66% progress in fruit for intervention vs. 55% progress in fruit for controls; 47% vs. 32% progress for vegetables, p =.0080 and .0001, respectively). Lower education, non-White ethnicity, male gender, living with children, and experimental group assignment predicted attrition (X26df = 288, p < .001, Cox R2 = .132). The researchers determined that tailored educational messages and research-Extension partnerships were advantageous for improving fruit and vegetable intakes of young adults . Web Health. (Geoffrey Greene, P.I. ) This USDA/NRI Integrated Project was designed to test the impact of a non-dieting online intervention for college students on biological and psychosocial indicators of health using a randomized, controlled design. It was hypothesized that young adults enrolled in a 10-lesson, web-based program receiving a non-diet intervention would gain less weight and improve intermediary outcomes related to eating competence, increase fruit and vegetable consumption, and physical activity to a greater extent than those in a non-intervention control condition. This sample of 1689 college students from 8 universities was relatively young (age 18-24 years), primarily in first and second years, living on campus, most self-reported ethnicity as white and 71% were in the normal weight range. A total of 1144 students (67.7%) completed the study. There was a significant multivariate time by group interaction (Wilkes ?=.84, F 10, 617 =11.5, p<.001). Over 15 months, the treatment group had significantly higher FV intake (+0.5 cups/day) and physical activity participation (+270 MET-min/wk) than controls. For both intervention and control groups, anthropometric values and stress increased, while fitness levels decreased. There were no changes in eating competence. Gender differences were present for most variables. First year males and females gained more weight than participants in other school years. Among the 830 subjects in the intervention group, 697 (84%) completed all 10 lessons and 42 (5.1%) did not complete any lessons. Those completing all lessons spent an average of 7.8±4.7 min/lesson. In conclusion, this 10-week on-line nutrition and physical activity intervention to encourage competence in making healthful food and eating decisions, had positive and lasting effects on FV intake and maintained baseline levels of physical activity in a population that otherwise experiences significant declines in healthful behaviors . Project YEAH. (K. Kattelmann, PI) Multi-state researchers collaborated on a NRI-funded project called project YEAH (Young adults Eating and Active for Health) to develop a web-based intervention for obesity prevention among college and non-college young adults . The PRECEDE-PROCEED process of CBPR was used to identify and prioritize the problems of significance (quality of life/health/and environmental & behavioral determinants and predisposing/enabling and reinforcing factors) to young adults that were then linked to factors influencing weight gain. Young adults (n=1639) recruited from samples in 14 states were randomized into experimental or control groups. Participants in the experimental group received targeted online education and stage-of-change tailored email messages that encouraged healthy dietary and physical activity choices and effective stress management techniques. The experimental participants had significant improvements in cups of fruit and vegetable intake, minutes of vigorous physical activity in females, reduction in percentage of energy from fat, self-instruction and regulation for mealtime behavior, and hours of sleep at 6 months (post intervention) than control participants. There were also a significantly greater proportion of experimental participants in the action/maintenance stages than control participants for fruit and vegetable intake and physical activity . FRUVED. (S. Colby, PI) This five year (August 2014-2019) USDA, AFRI-funded project aims to increase fruit and vegetable intake and improve health outcomes through a peer-mentoring social marketing campaign. First year students (n=1800) on 8 campuses will be recruited in fall 2015 and followed each year with physical and behavioral survey assessments. The Healthy Campus Environmental Audit will be completed at baseline and designated time points throughout the grant. The control schools (AL, KS, ME, NY) will conduct assessments only. At the 4 treatment schools (FL, SD, TN, WV), during spring, 2015, sophomore students (n=256) participated in a newly developed undergraduate course and were trained on peer mentoring techniques. Students developed a social marketing campaign that will be implemented on the treatment campuses during the 2015-16 school year. In addition to the implementation of the developed intervention, peer mentors will be matched to the treatment first year participants. The peer mentors will not only keep the first year students connected to the social marketing campaign activities and social media events but will also provide individualized support to help them have the healthiest first year of college possible. Healthy Campus Environmental Audit. (T. Horacek, PI) The Healthy Campus Environmental Audit (HCEA) is an extensive campus environment tool that includes modules to assess the food and beverage environment, walkability/bikeability, recreational facilities, health policies and health initiatives. The modules are continuing to be refined using recently published literature and secondary data previously collected by this research team related to campus environments and student behavioral and health outcomes [41 – 50]. Data from our 2015 higher education environmental audit will be analyzed and published prior to the start of the proposed project. This environmental audit of campuses assessed the physical activity environment, food environments, obesity prevention building analysis, and campus policies. Behavior Environment Changeability Survey (BECS) assessed young adults’ perceptions and willingness to change predisposing and enabling factors affecting weight-related behaviors. The BECS consists of eight scales - Nutrition Changeability; Nutrition Behavior; Environmental Changeability; Program Importance and Changeability; Exercise Behavior; Sleep Behavior and Importance; Weight Loss; and Alcohol Intake. Internal consistency of the 8 scales ranged from ?=0.67 to 0.93 . College Environmental Perceptions Survey. The college environmental perceptions survey was designed to assess students’ perception of walkability/bikeability, recreation facilities, health policies, stress management, health initiatives/programs, and food environment on campuses. This survey has been piloted and results are being used to inform the further refinement of the next phase of survey development as the Behavioral Environment Perceptions Survey. Review of CRIS Database A review of multistate projects related to obesity prevention reveals that this is the only multistate project assessing individual and environmental factors influencing weight behavior decisions in young adults. There are other projects focused on obesity prevention; however, the age group or focus differs. The most closely related project is that of NC 1033 studying local food choices, eating patterns and population health. However, this multistate project differs in that it is specifically researching the food environment and food systems. Our multistate project, in addition to the food environment, is assessing the environmental support for physical activity .
Implement a new dissemination model (eB4CAST) to benchmark community-programing efforts for effectiveness in change and sustainability.
Continue environment and behavioral instrument development, refinement and validation of the Healthy Campus Environmental Audit and Behavior Environment Perceptions Survey for college campuses
Adapt and test the environment and behavior instruments in low-income communities.
Develop and pilot the novel and comprehensive Healthy Community Index on college campuses and adapt for use in low-income communities.
Continue exploration of mechanisms of interaction between lifestyle behaviors and environmental factors in influencing healthy behaviors and health status of young adults using existing datasets from this groupâ€™s previous and ongoing work.
The Healthy Campus Research Consortium (NC 1193) is functioning as an integrated research group and the members are expected to participate in all objectives.
Objective 1. Implement a new dissemination model (eB4CAST) to benchmark community-programing efforts for effectiveness in change and sustainability. Measuring and giving impact reports to the community to empower future change across all sectors, especially public health, relies on long-term evidence-based community research to design, implement, capture and report back trends. To our knowledge there is no current systematic technique over time to quantify the longevity and impact of the target population of community programming dissemination. One such model this research team is using to further understand impact is eB4CAST. eB4CAST was developed by this group using a modified framework of the RE-AIM model  to capture intervention/program adoption, usability, fidelity and future application in additional target populations. eB4CAST was built to document research findings to support the projected continuation and translation into current health practices. Direct and indirect collection of data factor into the projection of usability in ideal future dissemination sites. Prior to the implementation of a program, a community is given a report based on geographical location and other key data that are publicly available through indirect measures such as census, county and state databases. As the program is implemented, direct measures at four levels of the community are captured through surveys to state, county, local community, and individual levels, which then contribute to direct data. A footprint report that compiles all the direct and indirect data is then given to the local leaders to share current impact. This is repeated over time as the intervention/program is repeated. Combining the two levels (direct and indirect) allows eB4CAST to measure effectiveness during roll out of new program structure and adaptation. Data are organized into four sections of eB4CAST; Capture, Assemble, Suitability, and Timelessness: • Capture: captures information regarding individual and community environmental and socio-economic data. • Assemble: captures data regarding the function and effectiveness of the program, including fidelity measurements. • Sustainability: documents the impact of the program on the participants and community. • Timelessness: gathers direct feedback about participant feelings regarding program longevity and impact and the community’s capability and desire to continue supporting the program. There are eight steps from the initial identification of a community to the delivered end report: Step 1: eB4CAST community registration. Step 2: Pre-implementation report using indirect measures. Step 3: Report provided to community leader for sharing. Step 4: Intervention/Program implemented with direct data captured until completion of program. Capture-Environmental scan - Collect census data and/or enrollments for in campus and/or communities that plan to implement the Healthy Community Index (HCI), and input from key stakeholders in the implementation of the HCI; Assemble—implement the HCI in various campus and community settings. As the intervention is delivered data will be collected to determine the overall acceptance in the community as well as the unexpected costs of the study. Fidelity measures will be done to determine the effectiveness of the delivery. Suitability-post implementation will be determined through direct questionnaires and testimonies of leaders and participants on their perception of the intervention. Step 5: Last session or collection of intervention impact. Timelessness—post implementation will be determined through use of the Ripple Effect Mapping Tool  with a group of participants from the intervention implementation. Step 6: Footprint report compiled using direct and indirect data. Step 7: Report given to community and/or state leader. Step 8: Repeat and capture change referring to previous report that was generated in a single community over time. The ability to predict the continuous duration of community based programs sets eB4CAST apart from previously used monitoring tools that are meant to be managed in an electronic repository. The eB4CAST framework provides a systematic method to capture the future blueprint and “realness of impact” of the program in new untapped communities with potential results in positive health outcomes witnessing a shift in the general public’s health.
Objective 2. Continue environment and behavioral instrument development, refinement and validation of the Healthy Campus Environmental Audit and Behavior Environment Perceptions Survey for college campuses. This objective continues with work started in the previous multi-state project. During the 2015-2016 academic year, results of each state’s surveys will be provided to participatory campus committees and stakeholders. Feedback from committees and stakeholders will be used to modify audits or constructs assessed by surveys. In Year 1 (2016-17) the revised Healthy Campus Environmental Audit will be tested in a small sample (not all states will be required to participate) and revised accordingly. The Healthy Campus Environmental Audit (HCEA) is a comprehensive series of objective assessments to determine the environmental supports for health promotion and obesity prevention. The audit includes the most important evidence-based health promotion, food/dining, physical activity education and infrastructure environmental factors that might influence consumer behavior. The HCEA evaluates cafeteria/restaurants, convenience stores, vending, recreation programs/facilities, walkability/bike-ability, and initiatives and policies. The HCEA is applicable for a variety of campus types: worksites, schools, colleges/universities, hospitals, and communities. The extensiveness of the implementation of this audit is decided by the campus team. The HCEA can be used in its entirety to understand the full food/physical activity/health promotion environment, by evaluating a sampling of venues for each audit, or simply to evaluate one specific venue (e.g. a restaurant, a store, a vending machine, a recreation facility, etc.). The HCEA can be used to document, monitor, and advocate for health-facilitating campus environmental and policy supports and changes. Each Audit is composed of approximately 15-25 items, with criterion scored using a five-point semantic-differential scale ranging from limited to extensive healthfulness or environmental support/evidence. Each audit has been reviewed by experts, pilot-tested, and has acceptable inter-rater reliability. Institutional review board deemed all aspects of this study to be Exempt. Audits are continuing to be validated. Self-administered training tools are provided. Audits are administered via Qualtrics and work to develop mobile device data collection is ongoing. Campus results and comparative feedback are provided. Rutgers University is working to “automate” these audits such that data can be collected real-time in the field using a mobile devise . The Full Restaurant Evaluation Supporting a Healthy (FRESH) Dining Environment Audit evaluates the nutrition environment of dining establishments including restaurants (fast food, sit down, cafes), dining halls, cafeterias, buffets and food courts . The audit evaluates the food and preparation descriptions to determine healthfulness of menu items, rather than a nutrient analysis perspective, and the availability/extensiveness of other supports for making healthy dining decisions. The Convenience Store Supporting Healthy Environment for Life-promoting Food (SHELF) Audit evaluates the healthfulness of the food store environment of convenience stores, drug stores, dollar/discount stores, mini-marts, bodegas/corner stores, and food carts . The audit evaluates the presence of healthier foods and the availability/extensiveness of other environmental supports for making healthy food purchasing decisions. Healthfulness Vending Evaluation for Nutrient-Density (VENDing) Audit evaluates the nutrition environment of vending machines (snack, beverage and prepared foods) using nutrient density healthfulness scores and the availability of environmental supports for making healthy vending purchase decisions . Physical Activity Campus Environmental Supports (PACES) Audit evaluates the recreation facilities and programs for a campus environment and the availability and extensiveness of the environmental physical activity supports . Sneakers and Spokes Walkability/Bike-ability Audit is adapted from the Centers for Disease Control and Prevention’s (CDC’s) Healthier Worksite Initiative Walkability Audit  and evaluates the safety and quality features of walking/biking path segments on a campus. Healthy Environment Policies, Opportunities, Initiatives, Notable Topics Survey (POINTS) Audit evaluates and benchmarks the extensiveness and quality of health promotion/obesity prevention initiatives/interventions, programs, resolutions/pledges and policies for a campus environment . The audit surveys campus professionals with expertise who categorize the extensiveness of each health promotion/obesity prevention topic rather than recording/evaluating every specific initiative/program in the environment. Campus Environment Demographics Audit tracks the geographic, demographic and environmental variables necessary to describe, modify and compare campus results. Note: Syracuse University is the lead institution who developed and refined these tools. The work has been supported, pilot-tested and implemented by NC1193 Regional Researchers (15 states) to enhance our work and effectiveness with young adults. The original HCEA work started in 2008 and was revised in 2009; these versions were complex and difficult to use. The results have been published. In 2014, SU started over with each audit of the HCEA to create these simplified, easy to use audits. Validation studies for each of the HCEA components will be conducted in Year 1 (2016-17). Validation will include testing of the Qualtrics and/or the Rutgers automated versions and comparing each component of the HCEA to 1-2 existing environmental audits as a comparative measure. For example VENDing can be compared to NEMS-V ; Sneakers and Spokes Walkability/Bikeability compared to NEWS-A  and/or BEAT ; SHELF compared to CX3  and NEMS-S ; FRESH compared to NEMS-R  and Slim by Design. Each institution would be involved in validating 2-3 audit components. The process for the behavioral and perceptual assessment survey development will be more complex. The behavioral assessment component of the College Environmental Behavior and Perceptions Survey (CEBPS) is based on existing validated instruments and only needs minor refinement using items from a survey currently being used in the FRUVED study. However, the perceptual component of that instrument was developed to assess student perceptions of the healthfulness of their college environment with items mirroring areas assessed in the environmental audit (HCEA). This component, with 16 individual items, did not have an identifiable factor structure; thus, we need a new approach to develop a valid perception instrument. The perception section of the CEBPS will be revised using standard procedures [67, 68] with the objective of developing a psychometrically valid instrument called Behavioral Environmental Perceptions Survey (BEPS) for college student populations. The initial steps, which will occur during the final year of the current multi-state 2015-2016, will be to identify key constructs related to perceptions of the environment, review existing items from the College Environmental Behavior and Perceptions Survey (CEBPS) as well as the Behavior Environment Changeability Survey (BECS) surveys, generate additional items through brainstorming, and develop a prototype survey with approximately 100 items. Items will be reviewed by experts in the working group, tested for fit with constructs using Q-sort techniques, and reviewed by students in cognitive interviews. The prototype instrument will then be administered to a convenience sample of 300 students for initial factor analysis. Year 1 of this renewal (2016-2017) will focus on the development of the pilot Behavioral Environmental Perceptions Survey (BEPS) instrument to administer to a diverse group of 600 college students on selected campuses for exploratory and confirmatory analyses (not all states will be required to participate). In addition, cognitive validation procedures, similar to those used in developing the College Environmental Behavior and Perceptions Survey (CEBPS), will be conducted on additional selected campuses. Based on these results, refinements will be made for a final BEPS instrument. In Year 2 (2017-2018) all campuses will administer the refined versions of the environmental audit (HCEA) and the behavior-perceptions survey (BEPS) simultaneously.
Objective 3. Adapt and test the environment and behavior instruments in low-income communities. To accomplish Objective 3, Year 02 (2017-2018) will focus on adapting the Behavior Environmental Perceptions Survey (BEPS) for low-income populations. Selected universities will administer the survey to a convenience sample (n=400). Using exploratory analysis (exploratory factor analysis), the instrument will be refined to include items fitting into identifiable factors reflecting the breadth of constructs related to community perceptions of the environment. Decisions will be made to determine other constituents that should be included in data assessment, including demographic as well as behavioral items. In Year 03 (2018-2019), the instrument will be administered to a wider audience of diverse community members (n=2,400) with additional validation items. Confirmatory analyses (factor analysis, structural equation modeling, internal consistency) will validate the psychometric structure, and the instrument will be validated based on additional items. Additional validation analyses will compare the relationship between previously identified behaviors and perceptual scores. Similarly, behavioral items will be compared to previous data as a validation of these items. The end product will be a validated Behavioral Environmental Perceptions Survey for low-income communities (BEPS-Communities), which can be disseminated to other institutions and used as a component of the Healthy Community Index. In addition, during Year 02 (2017-2018) prototype audits of the HCEA will be pilot tested in low-income communities. In Year 03 (2018-2019), a pilot of the complete HCEA will be conducted by selected multi-state researchers. The modified HCEA will be administered validated in Year 04 (2019-2020). The end product will be a validated HCEA that can be disseminated to other institutions where low-income populations are targeted and used as a component of the Healthy Community Index (HCI) when assessing these population groups.
Objective 4. Develop and pilot the novel and comprehensive Healthy Community Index on college campuses and pilot in low-income communities. Create a Healthy Community Index (HCI) with evidence-based scoring system. The final Index will be delivered via web-based interface and include appropriate feedback and suggestions for change. Development of the HCI will include the following steps: • Conduct literature search related to relevance (weighting) of food environment, physical activity, and policy to unhealthy weight gain. • Administer the Environmental Audit (HCEA) on 60 diverse campuses (i.e. traditional, two-year, technical schools and potentially Job Corp). To achieve a sample of 60, each of the 12 multi-state team members will administer the audit on their own campus and recruit 4 other sites for implementation of the audit. • Administer the Behavioral Environment Perceptions Survey (BEPS) on the same 60 diverse campuses (i.e. traditional, two-year, technical schools and potentially Job Corp). To achieve a sample of 60, each of the 12 multistate team members will administer the audit on their own campus and recruit 4 other sites for implementation of the audit. • Collect self-reported health outcomes in addition to behavioral items from BEPS such as self-reported BMI via online survey (e.g. visits to health care provider, quality of life) among selected students and employees (e.g. sophomores and juniors; employees with 1-2 years of service). • Compare results from the environmental audit (HCEA), behavioral items from BEPS and health outcomes at the 60 campuses to determine final Healthy Community Index and scoring system via statistical analyses. Objective 5. Continue exploration of mechanisms of interaction between lifestyle behaviors and environmental factors in influencing healthy behaviors and health status of young adults using existing datasets from this group’s previous and ongoing work. According to the PRECEDE-PROCEED planning model , etiological factors and determinants of health include genetics, behavioral patterns, and environmental factors. In previous work, we examined and explored young adult behaviors, perceptions, and environments through WebHealth, BECs, Project YEAH, CEBPS, the Healthy Campus Environmental Audit (HCEA) and the current project, Fruved. Exploration will continue on the associations among identified variables and their contributions to weight-related factors. These factors include, but are not limited to, diet and exercise behaviors, stress management, sleep, within-meal eating behavior, cognitions (cognitive restraint), susceptibility to emotional eating and external cues, personality, parental status, income level, and ethnicity.
Measurement of Progress and Results
- Direct and indirect data collection from communities will be analyzed and compiled into a report for community leaders to assess current impact of community programing. From the program implementation there will be two reports in the format of an infographic (one with indirect data at the beginning of the program and a second one post-program that will include both indirect and direct data collection). These reports can be used in multiple ways: to drive policy change, educate local community stakeholders about the status of the program, demonstrate program impact at the local and state level, and compete for further program and research funding.
- Data from Healthy Campus Environmental Audits (HCEA) and appropriate validation instruments will be assessed to determine validity of HCEA instruments. Data from the Behavioral Environment Perceptions Survey (BEPS) and appropriate validation instruments as well as cognitive interviews will be assessed to determine the validity of BEPS.
- Using exploratory and confirmatory factor analyses, a Behavioral Environmental Perceptions Survey (BEPS) will be refined to measure community perceptions of the environmentâ€™s support for healthful behaviors. Refinement of this survey can inform stakeholders in peer groups and in administration groups and allow them to target healthy behaviors to nudge in this age group in campus and non-campus environments.
- Compare results from the HCEA and health outcomes to determine final HCI and scoring system via statistical analyses. From creating a score with the environment an organization can strive to realign institution goals to improve their current score by learning where they are currently and how to make changes.
- Continue statistical exploration of the associations among the following weight related factors; dietary and exercise behaviors, coping with stress, sleep, within-meal eating behavior, susceptibility to emotional eating and external cues and cognitive restraint, personality, relationship with parents, current parental status, income level, and ethnicity. From the multi-state teams large data sets continued work and products can be derived from this big data approach.
Outcomes or Projected Impacts
- A systematic technique specific (eB4CAST) to community programing will be developed to quantify the impact and sustainability of the dissemination of the programing. Outcomes will be multi-layer and cross-sectional to give information and empowerment back to local and state stakeholders to use data and proof of program impact. This data reporting can result in improvements in funding secured for policy change, improvements in community health and social interaction.
- A Healthy Campus Environmental Audit (HCEA) and Behavioral Environmental Perceptions Survey (BEPS) can be used by communities (college and universities) to document and monitor campus environment, policy, and population support for facilitating health. Community development and improvement at university settings is paramount to draw potential incoming students and to retain them.
- The Healthy Campus Environmental Audit (HCEA) and Behavioral Environmental Perceptions Survey (BEPS) will be adapted and tested in low-income communities to measure and monitor the community environment, policy, and population support for facilitating healthful behaviors. Mirror effort of behavior and environment is highly valued in mission statements of institutions. The upscaling of work in one community and its demonstration and ease into another will be a model.
- A Healthy Community Index (HCI) with evidence-based scoring system will be developed for use by campus and community leaders to benchmark the environment for support of healthful behavior. The final Index will be delivered via web-based interface and include appropriate feedback and suggestions for change. An institution will be able to track a score that has been benchmarked and can then demonstrate their effort in improving that score over time. This claim will attract individuals seeking to live in a progressive environment of improving health parameters.
- Mechanisms of interaction between lifestyle behaviors and environmental factors in influencing healthy behaviors and health status of young adults will be determined and results disseminated for use in health and wellness programing. Big data merging and analysis is necessary to continue the work of large collaborating groups. By using our team research approach we can model how work on this scale can be done efficiently and cost-effectively.
Milestones(1):This milestone is an ongoing milestone and will continue through Year 5. -Analyze existing datasets to explore mechanisms of interaction between weight-related health, cognitive, behavioral, and environmental factors influencing body weight. -Prepare manuscripts. -Develop behavior-perception Behavioral Environment Perceptions Survey (BEPS) instrument and administer pilot at selected universities to a convenience sample (n=400). -Revise and validate Healthy Campus Environmental Audit (HCEA) with 6-8 universities. -Begin the dissemination and implementation of the eB4CAST model, including the environmental scan of existing local publically available data (indirect measures) and stakeholders in the community (direct measures) (Assess ability to Capture, Assemble, Sustain, Timeliness).
(2): This milestone will start in Year 1 and continue through Year 4. -Finalize development of (BEPS) instrument and administer on all campuses in all states (n=2400). -Test Healthy Campus Environmental Audit (HCEA) in relatively small sample of low-income communities for purposes of developing an audit for use in low-income communities. -Conduct final validation of the Healthy Campus Environmental Audit (HCEA) on campuses in all states. -Collect survey of self-reported health outcomes among selected students and employees with 1-2 years of service. -Capture and report environmental change and individual perception (eB4CAST).
(3): This milestone will start in Year 2 and continue through Year 4. -Test the prototype smaller instruments of the final version of the Behavioral Environment -Perceptions survey (BEPS) and the environmental audit (HCEA) for the low income populations. -Administer validated environmental audit on 60 diverse campuses. -Administer BEPS to 200 diverse community people (n=2400. -Validate BEPS and HCEA in low income and university settings. -Develop scoring system for Healthy Community Index. -Monitor and report environmental change and individual perception (eB4CAST).
(4):This milestone will start in Year 2 and continue through Year 5. -Assess Healthy Community Index self-scoring from targeted campus administrators and community stakeholders. -Develop web-based dissemination platform for Healthy Community Index. -Monitor and report environmental change and individual perception. (eB4CAST)
(5):This milestone will start in Year 4 and continue through Year 5. -Finalize Healthy Community Index to provide overall rating for communities with feedback for improvement. -Monitor and report environmental change and individual perception (eB4CAST). -Investigate feasibility of dissemination of Healthy Community Index using eB4CAST.
Projected ParticipationView Appendix E: Participation
It is expected that the outcomes from the development of the tools will be disseminated through presentations at local, regional and national meetings. Additionally, manuscripts will be submitted to appropriate peer reviewed journals. To facilitate the collaboration and sharing of data and costs among the group members, we have established as part of our multi-state policies and procedures manual a plan to facilitate the management of data and costs associated with the data management and analysis.
In addition, an important aspect of the work this five years is to develop the eB4CAST model, which will allow documentation of dissemination and sustainability of research endeavors. Both through this model and the Healthy Community Index, the multistate team will provide reports to stakeholders on campuses and in low-income communities. This type of evidence-based community research is instrumental in driving change in awareness, behavior and policy to impact our populations of interest for weight-related health promotion.
The NC1193 Multistate group has developed and adopted a policy and procedures manual that guides the functioning of the group. An Executive Committee (chair, chair-elect, and secretary) has the administrative oversight and organization for the multistate group. The chair, chair-elect, and secretary are elected by the members to serve for one-year terms. The term begins 1 Oct of each respective year. It is the responsibility of the chair to set the meetings, develop and post agendas and run the meetings. The chair-elect completes the duties in absence of the chair. The secretary maintains the minutes and posts on the multistate website. Additional administrative sub-committees with respective chairs and recorders have been developed to serve the research needs and functioning of the multi-state group. The Policies and Procedures Reports and Awards sub-committee is responsible for maintaining the policy and procedure manual, submitting the annual report, chair the renewal committee, and prepare additional documents such as awards submission. The Publications and Presentations subcommittee maintains a current list (including a copy of the document) of journal articles, abstracts, posters, and major presentations made by group members relevant to multi-state objectives. This group is also responsible for maintaining and approving the respective requests to use multistate data (ROOT & SHOOTS) forms. The Data Management subcommittee is responsible to oversee the quality, storage, access, dissemination, archiving and preservation of Healthy Campus Research Consortium (HCRC) datasets. The Program Planning sub-committee plans and arranges for the annual meeting. The multi-state members meet on a regular basis (monthly) via teleconference and annually face-to-face at a date and place that is selected by the entire group.
The maximum size of the multistate group is 15 members. Members are expected to actively participate in, collaborate, and contribute to the HCRC research and administrative activities. Each member will be on at least one subcommittee related to committee management and one subcommittee related to research activities, participate in regularly scheduled teleconferences, and lead state-specific research activities. Members who choose not to actively participate will be asked to resign from the HCRC group. Active participation is defined as participating in at least 50% of teleconference calls and contributing to the collaborative research and administrative activities. Consideration for termination of group membership due to inactive status will be presented on agenda and discussed by full group membership followed by a vote by the full membership at the next group meeting (face-to-face or teleconference). A protocol has been established for accepting new members. New members are voted upon by the current members and should have applicable expertise that strengthens the group research, at least one chapter of dissertation published, able to obtain independent funding for participation, and ability to establish a target population, community partners, and steering committee to participate in the group research. The best time to join the group is during the renewal process. Candidates must submit CV and documentation of how their skills meet the group research needs to the Chair. The group will review and vote upon the respective candidates.
Policies have been established on cost sharing, establishing research topics, data sharing, publications, presentations, and research procedures. All NC1193 publications and related materials should give credit to the multistate project and other relevant grants. A password protected website has been developed for archival of minutes and other documents used by the multi-state members. A list-serve is also maintained by one of the members to facilitate communication.
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