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Background: Religious institutions play a crucial role in health promotion and hold significant influence in the public health field. Aim: The aim of this review is to examine outcomes of health-promoting interventions involving the use of mosques as the intervention venue, its role in promoting health behavior change, and the role of theory in each intervention. Methods: A scoping review was conducted across 17 databases for relevant publications published up to and including August 2023 that involved the use of mosques as the intervention venue. Fourteen articles met inclusion criteria and were reviewed. Results: The studies featured a wide range of interventions. However, only eight of these studies integrated theoretical frameworks into their approaches, indicating a need for more structured guidance in this field. These theoretical frameworks included Participatory Action Research (PAR), the theory of planned behavior, behavior-change constructs, the patient-centered outcomes research (PCOR) framework, and prolonged exposure techniques within Islamic principles. The review identified three main health-focused intervention categories: mental health, prevention, and communication, each providing valuable insights into initiatives within Muslim communities. Conclusions: This review underscores the significance of inclusive and culturally sensitive health interventions, emphasizing the effectiveness of faith-based approaches in improving health outcomes, promoting positive health behaviors, and addressing communication and cultural barriers. The reviews findings stress the need for further research that incorporates theoretical frameworks and tailored interventions to meet the specific cultural needs of these communities, ultimately contributing to enhanced well-being within them.

In the field of artificial intelligence-based fitness apps, the effective integration of behavior change techniques (BCTs) is critical for promoting physical activity and improving health outcomes. However, the specific BCTs employed by apps and their impact on user engagement and behavior change are not explored sufficiently. This study investigates the Freeletics fitness app through a mixed-methods approach to evaluate the use of BCTs. In the quantitative analysis, fifteen unique BCTs were identified based on the Behavior Change Technique Taxonomy (V1). In the qualitative analysis, user reviews (n=400) were examined to understand perspectives on the app's effectiveness in promoting behavior change. Goal setting, action planning, self-monitoring of behavior, and social support were among the most prevalent BCTs identified in the Freeletics app, and their effectiveness in enhancing user engagement and promoting behavior change was also highlighted by user reviews. Among the areas of improvement identified in the study were the need for simplifying personalization options and addressing user concerns regarding the specificity of feedback. The study underscores the importance of integrating BCTs effectively within AI-based fitness apps to drive user engagement and facilitate behavior change. It contributes valuable insights into the design and implementation of BCTs in fitness apps and offers recommendations for developers, emphasizing the significance of goal setting, feedback mechanisms, self-monitoring, and social support. By understanding the impact of specific BCTs on user behavior and addressing user concerns, developers can create more effective fitness apps, ultimately promoting healthier lifestyles and positive behavior change.

Background. Health-promoting behaviors and positive lifestyle changes are crucial for effective stroke prevention. However, individuals at high risk of stroke exhibit poor health behavior due to a deficiency of individual motivation. Moreover, there are only a few studies on health-promoting behaviors that have applied behavior change theories in individuals at high risk of stroke. Objective. This study aimed to use the theory of the planned behavior (TPB) model to investigate determinants of health-promoting behaviors for stroke prevention and control. Method. In this cross-sectional study, 263 participants were recruited from five community health centers in Qingdao. Confirmatory factor analysis was performed to assess the reliability and validity of the constructs, and structural equation modeling was used to analyze the proposed relationships between the TPB-related variables. Results. The attitudes, subjective norms, and perceptions of behavioral control positively influenced behavioral intention. The behavioral intention had a positive effect on health-promoting behaviors. Attitudes, subjective norms, and perceived behavioral control were influenced primarily by the mediating variable behavioral intention to affect health-promoting behaviors. Stroke knowledge was an influential facilitator of behavioral attitudes, subjective norms, and perceived behavior control. Conclusion. The TPB-based model is suitable for explaining health-promoting behaviors in individuals at risk of stroke and for guiding the development of effective health management programs. A comprehensive person-centered motivation behavior strategy that is based on health education and complemented by social support and health resource optimization is critical in promoting health behavior motivation and health promotion behaviors in stroke high-risk groups.

Telephone-based services are a practical and effective behavioral support for smoking cessation, yet no in-depth analyses of this counseling have been conducted. Understanding the general content of Quitline conversations can help to improve current practices and may inform future interventions. Therefore, we aimed to independently explore conversation themes, topics, and client questions during Quitline counseling sessions with Quitline clients in Queensland, Australia. A purposive sample of 30 recorded counseling sessions, completed between January and March 2019, were de-identified, transcribed, and thematically analyzed. Seven themes, encompassing 35 topics, were derived from 26 initial calls and four follow-up calls: (1) Client details and building rapport; (2) Client history and motivation to quit; (3) Pharmacotherapy; (4) Behavioral aspects of quitting and relationship with smoking; (5) Understanding nicotine dependence and other important considerations; (6) Additional support and smoking cessation resources; and (7) Planning, goal setting and follow-up. Three themes emerged from 18 client questions including: (1) Pharmacotherapy safety and contraindications; (2) Pharmacotherapy instructions and mechanism of action; and (3) Physiology of nicotine dependence. This is the first qualitative analysis of the content of Quitline counseling sessions in Australia. Counselors collect and deliver a breadth of information to provide tailored, evidence-based health care, while building rapport and trust. Findings may be translatable into personalized self-help interventions that are more accessible or appealing to people reluctant to contact Quitline. Harnessing educational opportunities regarding pharmacotherapy adherence and misconceptions can improve client confidence in the product and smoking cessation outcomes. Further research will map conversations to motivational interviewing and behavior change techniques.

Poor mental well-being has been associated with negative student success outcomes among college students. Health and wellness coaching programs have been implemented in college campuses to address gaps in well-being support services. This pilot study evaluated a health and wellness coaching program at a large, urban university. A total of 499 students expressed interest in the program with 120 responding to a retrospective survey about their experience. Findings revealed that most students attended coaching for issues related to time and stress management or factors that commonly influence stress. Overall, students who participated in coaching were successful at improving their self-efficacy toward behavior change, changing their behavior, and achieving their goals. Students reported attending an average of four sessions with number of sessions attended being associated with increased confidence and motivation. In addition, autonomy, competence, and relatedness felt within the relationship with the coach were correlated with increased motivation, confidence, and readiness for behavior change. There was some relapse in terms of goal attainment observed with 17.4% of students who met their goals being unable to maintain progress. The program participants appeared to have enjoyed the process with 96% of students saying they would recommend the program to a friend. Health and wellness coaching programs may alleviate the burden of stress and other subclinical mental health concerns as well as decrease the number of students requiring services from more intensive mental health resources on campus.

We examined the prevalence and correlates of anticipated responses to hypothetical cigar price increases. Data are from a 2021 representative sample of U.S. adults who reported past-30-day cigar use (n = 454; mean age = 39.8 years). Weighted multivariable logistic regressions assessed the correlates of behavior change responses. If cigar price increased, 77.2% intend to pay more, 44.7% intend to reduce use, and 39.9%, 37.7%, and 17.1% intend to use other tobacco, cannabis, and cheaper cigars, respectively. Those who smoked cigarillos (vs. other cigars) had higher odds of intending to pay more (adjusted odds ratio [AOR] = 2.73; 95% confidence interval [CI] = [1.41, 5.29]) and use other tobacco (AOR = 2.35; 95%CI = [1.26, 4.36]). Those who smoked within 5 min of waking (vs. > 60 min) had higher odds of intending to use cheaper cigars (AOR = 5.19, 95%CI = [1.38, 19.46]). Almost half of U.S. adults who report past-30-day cigar use may reduce cigar smoking in response to price increases, though behavioral response may depend on cigar type smoked and tobacco dependence.

Diabetes and heart disease are among the leading causes of death and disability in the United States, and these conditions are especially prevalent in the South. South Carolina's persistent racial and socioeconomic disparities in chronic disease outcomes are well-documented, yet little is known about how health care practices in medically underserved areas are addressing these challenges. Data were collected through a cross-sectional survey as part of two complementary 5-year cooperative agreements between the Centers for Disease Control and Prevention and the Division of Diabetes and Heart Disease Management (the Division) at the South Carolina Department of Health and Environmental Control. The Division fielded a survey to (a) assist in determining which Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) were best poised to implement specific strategies as part of these cooperative agreements and (b) provide data to establish the baseline for performance measures. FQHCs and RHCs in the top 25% of counties with the highest diabetes and heart disease burden were surveyed about eight domains: staffing/services, electronic health records, team-based care policies, lifestyle change programs, medication therapy management, telehealth, quality improvement collaboratives, and patient demographics. Data representing 71 practices revealed contrasts between RHCs and FQHCs and opportunities for improvement. For example, while most practices reported they were not implementing evidence-based lifestyle change programs (e.g., the National Diabetes Prevention Program), most RHCs and FQHCs expressed interest in starting such programs. Findings are being used to guide efforts to improve diabetes and heart disease prevention and management in South Carolina.

Given the COVID-19 pandemic's disproportionate impact on Hispanic individuals in the United States, research examining modifiable psychosocial correlates of COVID-19 preventive behaviors in this population is warranted. Prior research highlights health literacy and health consciousness as integral for the establishment of health-promoting behaviors. Notwithstanding, very little research has validated theory-based measures for health literacy and health consciousness and no research has investigated their relative importance in explaining behaviors that prevent COVID-19 illness among Hispanic individuals. This information is necessary for informing behavioral interventions seeking to promote the well-being of Hispanic people during the current pandemic and in future ones. This study provides a psychometric evaluation of the General Health Literacy Scale (GHLS) and the Health Consciousness Scale (HCS) and further examines their association with conventional COVID-19 preventive behaviors. Confirmatory factor analyses evaluated the psychometric properties of GHLS and HCS. Four separate hierarchical linear regressions, followed by dominance analyses, estimated the relative importance of health literacy and health consciousness on COVID-19 preventive behaviors, adjusting for sociodemographic characteristics. Both GHLS and HCS achieved adequate psychometric criteria, and holding constant sociodemographic characteristics, positively related to COVID-19 preventive behaviors. Although both health literacy and health consciousness were more important than sociodemographic characteristics in explaining COVID-19 preventive behaviors, health consciousness was most important, exceeding the explanatory power of health literacy in all regressions. COVID-19 public health campaigns that seek to raise health awareness among Hispanic people might prove more effective than campaigns that only seek to improve their health literacy.

Prevention-focused parenting education programs (P-FPEPs) provide knowledge and support to parents to strengthen parent-child relationships, enhance parental and family well-being, and promote healthy child development. The positive impact of such programs on child health and development is well documented. Yet, how P-FPEPs influence parents remains unclear. The objective of this study was to explore parental perceptions of changes associated with participation in a P-FPEP. We analyzed data using interpretive description with qualitative responses from 459 parents who participated in nine different P-FPEPs in a large Canadian city. Participation in a P-FPEP changed parents' relationships with themselves, their children, their partners, and their community. Participants' relationship with themselves as parents changed as they recognized the value of self-care without guilt, gained knowledge of typical child development, and developed greater confidence in their parenting. Positive changes in participants' relationships with their children were facilitated by better understanding the perspective of the child, improving communication, feeling more connected to their child, and changing parenting behavior. For many participants, the relationship with their partner improved when they learned about different parenting styles and began communicating more openly. Participants' relationships with the larger community were strengthened as they experienced a sense of normalization of their parenting experiences, developed connections with other parents, and learned about community resources. Independent of any specific program curriculum or structure, change associated with P-FPEPs focused on how a shift in understanding and attitudes changed relationships and consequently changed parenting behavior.

Research on behavioral and social science has demonstrated that transitions throughout a person's life course, as the life event of becoming a parent, represent an opportunity for dietary changes. However, research in this area has been mostly restricted to developed European and North American countries and has shown ambiguous results. The present work aimed to gain an in-depth understanding on the changes in eating habits caused by the transition to parenthood and to explore factors influencing those changes in Uruguay, a Latin American country. Forty-two in-depth interviews with Uruguayan parents from diverse social-economic backgrounds were conducted. The narrations by the interviewees evidenced mostly positive changes during three stages in the transition: pregnancy, the first months with the baby, and the beginning of complementary feeding. Most informants perceived changes mainly in terms of increased consumption of fruits, vegetables, and pulses; increased consumption of homemade meals; and decreased consumption of ultra-processed foods, fast foods, and fried foods. Reasons for these changes included adaptation of meals to the child's needs and schedule, feeling of responsibility for the child's health, and willingness to be a good role model. Factors influencing changes in eating habits were identified in some levels of the socioecological model and included socioeconomic status; price of fruits, vegetables, and fish; low accessibility of good quality fish; perceived time pressure; father's low interest on healthy eating; social support; and access to nutrition information. Findings suggest that parenthood represents a window of opportunity for favorable changes in eating habits. However, barriers constraining those changes should be addressed by stakeholders.

Background: Racial/ethnic minorities (REMs) continue to carry the burden of sexual health disparities in the United States, including increased health risks and lower proportions of preventative care. Community-based participatory research (CBPR) has been useful in developing interventions aimed at reducing these disparities. Specifically, partnership with the target group members has resulted in more culturally relevant intervention strategies. Aim: The purpose of this systematic review was to analyze the existing research on sexual health interventions targeting U.S. REMs that were developed using CBPR, to highlight the role target group members played in the development of these interventions, and to explore the benefits and outcomes of these partnerships. Method: Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guided the search of 46 thesauri terms for CBPR, sexual health, and REMs across six databases. Results: The initial search yielded 805 identified studies. After applying limiters, reviewing abstracts, and doing a full-text review, 24 appropriate studies were retained. The key findings indicated significant intervention outcomes such as increased health knowledge, attitude change, and behavioral intention that could reduce sexual risk-taking behaviors. Twelve studies detailed the methods for partnering with target group members to formulate interventions, highlighting the benefits related to recruitment, retention, and cultural relevance. Discussion: CBPR is well-positioned to address sexual health disparities among REMs. While community partnership strategies vary, the findings yield evidence that CBPR addressing sexual health disparities is achievable, can influence the effectiveness of interventions, and should be considered as an orientation in future sexual health research.

Background: There is little understanding of men's weight loss outcomes and behaviors in self-directed contexts, such as digital commercial mobile weight management programs. This is an especially pressing question given that men often express disinterest in weight management programs and it is unknown how that manifests in self-directed environments. Aims: Two studies fill this gap by retrospectively observing how men lose weight and engage in weight loss behaviors (Study 1) and their perceptions of improvements and gained knowledge (Study 2) when participating in the full length of a commercial mobile behavior change program called Noom. Method: In Study 1, repeated-measures linear mixed modeling was used to examine whether weight loss was statistically significant from baseline to 16 weeks and how engagement behaviors predicted weight in a sample of 7,495 male Noom users. In Study 2, 971 male Noom users completed an exploratory survey on the impact of the behavior change education in the program. Results: In Study 1, men who remained in the full length of the program lost statistically significant weight from baseline to 16 weeks. 63% achieved clinically meaningful (5% or more) weight loss. Engagement in weight loss behaviors on the program predicted the amount of weight lost. In Study 2, men reported learning most about practical application and psychological aspects relating to food and psychology. Discussion and Conclusion: This is the first study to observe men's weight loss outcomes, behaviors, and perceptions of what they learned in a self-directed behavior change program. Our findings have important implications for more effective health promotion for the many men who choose to self-direct their weight loss.

Dental caries is a chronic oral condition that disproportionately affects low-income women. The aim of this research was to investigate relationships between dental nutrition knowledge, socioecological factors, and prevalence of dental caries in low-income women. This quantitative cross-sectional study involved 220 women who were recruited from Central Texas. Participants completed demographics, the Dental Nutrition Knowledge Competency Scale, United States Adult Food Security Survey Module, and the Multidimensional Home Environment Scale. Two dentists measured dental caries via the Decayed, Missing, Filled Teeth Index. Regression models were conducted to test the effects of dental nutrition knowledge and Multidimensional Home Environment Scale factors on dental caries. Finally, mediation analysis explored relationships between dental nutrition knowledge and dental caries, adjusting for Multidimensional Home Environment Scale scores. Results showed that dental nutrition knowledge and Multidimensional Home Environment Scale score were significantly associated with dental caries. Subscales of self-efficacy for eating healthy, oral hygiene practices, emotional eating, availability of unhealthy foods at home, and social support were related to dental caries. The relationship between dental nutrition knowledge and caries was mediated by Multidimensional Home Environment Scale scores. This research emphasizes the role of dental nutrition knowledge and socio-ecological factors on prevalence of dental caries. Public health interventions to reduce dental caries should involve strategies that increase dental nutrition knowledge and encourage behavior change in low-income populations.

Clinics and community-based organizations (CBOs) are priority settings for implementing the evidence-based National Diabetes Prevention Program (DPP). Both program settings present theoretical advantages and disadvantages for engaging and helping populations most at risk for diabetes achieve lifestyle change goals. To date, few studies have compared implementation across them. The present study describes participant characteristics and lifestyle change outcomes across a sample of clinic- and community-based National DPPs which delivered services in Los Angeles during 2015 to 2018 (two clinics, two CBOs, combined n = 265 participants). Analyses examined participant gender, age, race/ethnicity, baseline body mass index, and program attributes such as screening method and language of instruction. Negative binomial regression models tested for differences in program attendance, mean weekly physical activity, and percent change in body weight by setting. Overall, participants were largely Hispanic/Latinx (81.51%) and female (90.19%). Programs operated by CBOs engaged other race/ethnic groups including Black participants more frequently than those operated by clinics (20.56% vs. 0%); the latter engaged more men (15.29% vs. 7.22%). Few participants in any setting met the National DPP's weight loss goal (clinic: 15.29%, CBO: 20.00%). Participating in a community-based program was initially associated with higher attendance and mean weekly physical activity, but associations were not significant after adjusting for covariates. Study results have practice implications for National DPP implementation and can help inform future efforts to scale and spread the program in Los Angeles and nationally.

Skin cancers are the most common malignancy in Australia. Regular sunscreen use can reduce the incidence of cutaneous squamous cell carcinomas and actinic keratoses and has been associated with reducing the incidence of basal cell carcinomas and melanomas. However, sunscreen effectiveness is limited by the failure of the population to use it routinely. Interventions that promote the daily application of sunscreen may reduce the morbidity, mortality, and economic burden associated with skin malignancies. We reviewed the literature that examines the effectiveness of interventions to increase routine sunscreen use and found that no one strategy has been shown to be clearly effective in adults and that relatively few studies have aimed to increase routine use in groups at extreme skin cancer risk. Future research should consider how interventions can be best designed and how sunscreen use is measured so that cost-effective, feasible strategies that result in improved sunscreen use in adults can be established.

Empowerment is a core construct in health behavior and an emerging trend in pediatrics. Although it has been suggested as an approach that may promote the person's participation in health care decisions and positive outcomes, little is known about the nature and effectiveness of interventions to support empowerment in families and preschool-age children. The aim of this review is to identify, appraise, and synthesize the evidence on health interventions explicitly using empowerment as an orienting concept with families and their preschool-age children. We identified randomized controlled trials (RCTs) through systematic searches of eight databases for articles published between 1986 and January 2019 and included RCTs that addressed empowerment as a health intervention approach or outcome and that studied families with 3- to 5-year-old children. The application of empowerment theory, the family and child involvement, and the use of behavior change techniques (BCTs) were assessed through appropriate frameworks. Ten interventions were identified, and 50% of them showed positive outcomes. Most studies claimed a theoretical base. However, the studies provided limited details on theory application in intervention planning, implementation, and evaluation, and the children's involvement in the interventions was generally scarce. The most commonly applied BCT was "instruction in how to perform the behavior." We identified 16 potentially effective BCTs. The evidence was not sufficiently robust to determine the effectiveness of empowerment interventions with families and preschool-age children. Additional high-quality studies are needed to produce clearer conclusions. Our results are useful for the design and evaluation of future interventions.

Background: Low levels of physical activity (PA) in adolescents highlight the necessity for effective intervention. During adolescence, peer relationships can be a fundamental aspect of adopting and maintaining positive health behaviors. Aim: This review aims to determine peer-led strategies that showed promise to improve PA levels of adolescents. It will also identify patterns across these interventions, including training provided and the behavior change techniques (BCTs) employed. Method: Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, PubMed, PsychINFO, and Scopus were searched using key concepts of peer, PA and adolescent for articles that examined interventions that had a peer-led component and reported on at least one PA outcome in 12- to 19-year-olds. Following title and abstract screening of 1,509 studies, and full text review stage, 18 progressed to data synthesis. Methodological quality was assessed using an adapted scale. Results: Quality assessment identified 11 studies as high quality. Half of the included studies (n = 9) reported improved PA outcomes in the school setting. The most prominent behavioral change techniques were social support, information about health consequences, and demonstration of the behavior. Older adolescents leading younger peers and younger adolescents leading those of the same age showed potential. Seldom have older adolescents been targeted. Gender-specific interventions showed the most promise. Conclusion: Peer leadership requires careful planning and in the school setting can be a resourceful way of promoting adolescent PA.

Background: Research on coaction suggests improvements in physical activity and emotional eating will occur in a reciprocal manner. Aims: To determine if changes in body satisfaction mediate relations between physical activity and emotional eating changes and if age affects degree of change in those variables. Method: Groups of early adult (n = 43) and middle-age (n = 52) women participants of a community-based obesity treatment were assessed on behavioral and psychological variables over 3 and 6 months. Results: Improvements in physical activity, anxiety-related emotional eating, body satisfaction, anxiety, and exercise self-efficacy were significant overall. Early adults demonstrated greater reductions in emotional eating. Physical activity increase over 3 months significantly predicted 6-month reduction in emotional eating but not vice versa. Body satisfaction change significantly mediated the physical activity--emotional eating relationships. Changes in anxiety and exercise self-efficacy moderated activity [right arrow] emotional eating and body satisfaction [right arrow] physical activity relationships, respectively. Conclusion: Findings can inform both theory and behavioral obesity interventions.

Factors that affect physical activity (PA) behavior change are well established. Behavioral intention is a strong psychological predictor of behavior; however, there is less research on the factors that affect the "intention" to increase PA participation specifically, especially among adults in mid and later life who are inactive. Using data from the Canadian Community Health Survey, which was informed by the transtheoretical model (TTM), this study investigated the relationships between a range of demographic and biopsychosocial factors with the intention to become physically active among 1,159 inactive adults aged 40 years and older. Comparisons were made between participants reporting the intention to begin PA in the next 30 days (TTM Preparation; n = 610), 6 months (TTM Contemplation; n = 216), or not at all (TTM Precontemplation; n = 333). First, multinomial logistic regression identified age, sex, ethnicity, education, restriction of activities, self-perceived health, and community belonging as factors significantly associated with 30-day PA intention, while age and ethnicity were significantly associated with 6-month PA intention, compared with those reporting no intention. Second, binary logistic regression revealed that education was the only factor that differentially associated with intention timeframe as participants with lower levels of education were less likely to report PA intention in 30 days compared with 6 months. Findings demonstrate key demographic, biopsychosocial, and temporal factors that warrant consideration for tailored PA promotion programs that aim to effectively address the constraints and barriers that negatively influence PA intention among middle-aged and older adults.

Recent research shows personal financial debt is an important socioeconomic determinant of health, but the mechanisms through which it operates are not well understood. This article uses data from a mixed-methods study to explore how changes in spending and behavior that result from debt have salient health consequences in a cross-sectional sample of Boston area adults (n = 286). Findings show that a large majority of respondents had skipped medical care, housing payments, or consumer purchases at least once because of their debt. Controlling for multiple sociodemographic characteristics, each of these measures of debt-related behavior change was associated with worse self-rated health, and higher depressive symptoms, anxiety, and perceived stress. In models including all three measures, skipped medical care was associated with worse health across all outcomes, while skipped consumer purchases were associated with higher perceived stress and depression. These findings suggest that altered spending and care-seeking behaviors are potential pathways through which financial debt can negatively affect health and suggest areas in need of additional research.

Communication campaigns are expected to contribute to increase the efficacy of nutritional warnings. In this context, the aims of the present work were (a) to evaluate how citizens perceive different types of messages for a communication campaign and (b) to determine if personal characteristics such as gender, age, and educational level, as well socioeconomic and nutritional status, moderate how citizens perceive such campaign messages. A series of graphic pieces were designed for each of the following three types of messages: promotion of informed food choices; raising awareness of the negative health consequences of excessive consumption of sugar, fat, and sodium; and promotion of healthy food choices. An online study was conducted with 774 participants, who were randomly assigned to one of the three types of messages. The participants' self-reported perception of the graphic pieces was evaluated using 7-point Likert-type scales. After completing the evaluation task, the participants proceeded to a series of choices. This was implemented to evaluate whether exposure to different types of messages affected hypothetical food choices. Results revealed that messages related to the promotion of healthy eating were perceived as the most adequate as part of a communication campaign and had the potential to encourage more healthful hypothetical choices in the experimental task. However, gender, age, and nutritional status moderated the influence of the type of message on the participants' perception, meaning that different groups perceived different types of messages as the most adequate. The results from the present work stress the need to include different types of messages in a communication campaign to target individuals with different motivations and characteristics.

Background: Mobile health platforms can facilitate social support and address HIV (human immunodeficiency virus) stigma but pose challenges for intervention design and participant engagement. Giddens's structuration theory, that individuals are shaped by--and shape--their communities through rules and resources that give them power to operate within these environments, provides a useful analytic framework for exploring these dynamic intervention spaces. Method: Data were drawn from an online randomized controlled trial intervention (HealthMpowerment) for young Black men who have sex with men to reduce condomless anal intercourse. We applied a conversational analysis informed by structuration theory to 65 user-generated conversations that included stigma content. We aimed to understand how the interdependent relationship between the intervention space and participants' contributions might contribute to behavior change. Results: Thirty five intervention participants contributed to the analyzed conversations. Our analysis identified three types of conversational processes that may underlie behavior change: (1) Through intervention engagement, participants established norms and expectations that shaped their discussions; (2) participants used anecdotes and anonymity to reinforce norms; and (3) intervention staff members sought to improve engagement and build knowledge by initiating discussions and correcting misinformation, thus playing an integral role in the online community. Conclusions: The lens of structuration theory usefully reveals potential behavior change mechanisms within the social interactions of an online intervention. Future design of these interventions to address HIV stigma should explicitly characterize the context in which individuals (study staff and participants) engage with one another in order to assess whether these processes are associated with improved intervention outcomes.

Background: Malawi is a malaria-endemic country. A national malaria communication strategy was adopted to disseminate malaria messages with the aim of improving knowledge and adoption of malaria interventions. Objective: To examine the effect of maternal exposure to malaria messages and the medium through which such messages are delivered on insecticide-treated net (ITN) use and malaria infection among children under 5 years of age in Malawi. Methodology: Utilizing the data from the 2017 Malawi Malaria Indicator Survey, 2,055 children (aged under 5 years) and 1,886 children (aged 6-59 months) were analyzed for ITN use and malaria infection outcomes, respectively. Components of exposure to malaria messages were tested for association with ITN use and malaria infection outcomes using multiple logistic regression models. Results: Children whose mothers had reported hearing any malaria-related message in the past 6 months were more likely to sleep under an ITN and less likely to have malaria infection compared with those whose mothers had not heard any malaria-related message. Region and sex of the child were effect modifiers on the relationship between exposure to any malaria-related message and malaria infection. Knowledge regarding cause or protection methods partially mediated the relationship between exposure to any malaria message and malaria infection. Discussion and Conclusion: Health workers were an effective communication channel. Strengthening topic-specific malaria messages and building the capacity of health workers while alternately strengthening other message outlets may prove vital for effective malaria communication.

Nudging is increasingly used in public health interventions in Western societies to produced health-promoting behavior changes; however, there is lack of clarity as to what constitutes a nudge, scant knowledge of the effectiveness of nudging techniques in public health lifestyle interventions and a number of ethical and value-based concerns. The aim of this review is to address these research lacunae and identify the characteristics of nudges in empirical research on public health interventions intended to induce healthy lifestyle changes, including whether they are effective. We conducted systematic searches for relevant articles published between January 2008 and April 2019 in three databases, PubMed, CINAHL and PsycINFO, and combined this with a metasynthesis to construct interpretative explanations. A total of 66 original studies met the inclusion criteria. The findings of the systematic review showed that most nudging interventions involved diet/nutrition, most were carried out as single experiments, and the majority had the intended effects. Specific nudging techniques were identified with respect to the broader nudging categories of accessibility, presentation, using messages and pictures, technology-supported information, financial incentives, affecting the senses, and cognitive loading; several studies included more than one nudging technique. Although many nudging techniques had the intended effects, it is unclear whether they would work outside the study setting. The synthesis revealed that the studies lacked critical reflection on the assumptions about health that were implicit in nudging interventions, the cultural acceptability of nudges, the context-free assumptions of nudging theory, and the implications of these aspects for the public health context.

Mobile health applications (apps) are increasing in popularity to assist in health behavior change and maintenance. Drawing from constructs outlined within the social cognitive theory by Bandura, we explored how frequently users of a popular health app achieved their health-related goals. Participants reportedly used the MyFitnessPal (MFP) app within the past year completed an online survey on how often they used MFP, their self-efficacy for healthy eating (SE-HE), and achievement of nutrition-related goals. Findings suggest that higher levels of SE-HE and greater use of MFP predicted greater goal achievement. One important finding was that greater use of MFP related to increased reports for goal achievement when SE-HE was lower but not when participants showed high level of SE-HE. The results from this study suggest that MFP may be the most helpful for those who find it more difficult to meet their nutrition-related goals.

As health professionals develop health communication for coronavirus disease 2019 (COVID-19), we implore that these communication approaches do not include fear appeals. Fear appeals, also known as scare tactics, have been widely used to promote recommended preventive behaviors. We contend that unintended negative outcomes can result from fear appeals that intensify the already complex pandemic and efforts to contain it. We encourage public health professionals to reevaluate their desire to use fear appeals in COVID-19 health communication and recommend that evidence-based health communication be utilized to address the needs of a specific community, help people understand what they are being asked to do, explain step-by-step how to complete preventative behaviors, and consider external factors needed to support the uptake of behaviors. To aid health professionals in redirecting away from the use of fear appeals, we offer a phased approach to creating health communication messages during the COVID-19 crisis.

Background: By defining what is "normal," appropriate, expected, and unacceptable, social norms shape human behavior. However, the individual-level mechanisms through which social norms impact population-level trends in health-relevant behaviors are not well understood. Aims: To test the ability of social norms mechanisms to predict changes in population-level drinking patterns. Method: An individual-level model was developed to simulate dynamic normative mechanisms and behavioral rules underlying drinking behavior over time. The model encompassed descriptive and injunctive drinking norms and their impact on frequency and quantity of alcohol use. A microsynthesis initialized in 1979 was used as a demographically representative synthetic U.S. population. Three experiments were performed in order to test the modelled normative mechanisms. Results: Overall, the experiments showed limited influence of normative interventions on population-level alcohol use. An increase in the desire to drink led to the most meaningful changes in the population's drinking behavior. The findings of the experiments underline the importance of autonomy, that is, the degree to which an individual is susceptible to normative influence. Conclusion: The model was able to predict theoretically plausible changes in drinking patterns at the population level through the impact of social mechanisms. Future applications of the model could be used to plan norms interventions pertaining to alcohol use as well as other health behaviors.

Understanding the relationship between cognitive and behavioral processes and long-term behavior change is critical to developing behavior change maintenance interventions. We examined the relationship between cognitive and behavioral safer sex maintenance strategies and condomless vaginal/anal sex with clients among female sex workers (FSWs) in Mexico. We hypothesized a moderating effect of hazardous alcohol use, such that the relationship between the use of safer sex maintenance strategies and condomless sex would be weaker among FSWs who meet criteria for hazardous alcohol consumption. Data were gathered from 602 FSWs enrolled in a sexual risk reduction intervention with a text messaging maintenance component. Seven cognitive and behavioral strategies purported to be critical in sustaining long-term behavior change were measured (e.g., maintenance self-efficacy). The relationship between FSWs' use of safer sex maintenance strategies and condomless vaginal/anal sex with clients was moderated by hazardous alcohol consumption. The association was weaker among FSWs who met criteria for hazardous alcohol consumption. Among FSWs who met criteria for hazardous alcohol consumption, maintenance self-efficacy was associated with fewer condomless sex acts with clients (b = -0.35, p < 0.001). Among FSWs who did not meet criteria for hazardous alcohol consumption, recovery self-efficacy (b = -0.21, p < 0.05) and self-monitoring (b = -0.34, p < 0.001) were associated with fewer acts of condomless sex. Results indicate the importance of examining the multidimensional nature of safer sex maintenance strategies and of exploring subgroup differences in their associations with behavioral outcomes. Interventions that address safer sex maintenance strategies in the context of alcohol treatment should be developed for this subgroup of FSWs.

The National Institutes of Health (NIH) has increasingly supported research in digital health technologies to advance research and deliver behavior change interventions. We highlight some of the research supported by the NIH in eHealth, mHealth, and social media as well as research resources supported by the NIH to accelerate research in this area. We also describe some of the challenges and opportunities in the digital health field and the need to balance the promise of these technologies with rigorous scientific evidence.

Background: Hookah is one of the most commonly used tobacco products among U.S. young adults due in part to widespread misperceptions that it is not harmful or addictive. There is growing evidence that hookah tobacco is associated with health harms and can lead to addiction. Research on interventions to address these misperceptions by communicating the harms and addictiveness of hookah use is needed. Aims: This study developed and pretested mobile multimedia message service (MMS) message content communicating the risks of hookah tobacco use to young adult hookah smokers. Method: Message content, delivery, and pretesting were tailored to participants' risk beliefs, hookah use frequency, and responses to simulated text message prompts. Participants viewed 4 of 12 core MMS messages randomized within-subjects and completed postexposure measures of message receptivity and emotional response (e.g., worry). Results: The sample included 156 young adult (age 18-30 years) hookah smokers; 31% smoked hookah monthly and 69% weekly/daily. Prior to viewing messages, a majority endorsed beliefs reflecting misperceptions about the risks of hookah tobacco. Postexposure measures showed participants were receptive to the messages and the messages evoked emotional response. As anticipated, messages produced similar receptivity and there were few differences in emotional response between the messages tested. Discussion: Young adult hookah tobacco smokers were receptive to tailored mobile MMS messages and messages evoked emotional response, two critical precursors to behavior change. Conclusion: Findings indicate that research testing the efficacy of tailored MMS messaging as a strategy for reducing hookah tobacco use in young adults is warranted.

The rapid growth and diffusion of digital media technologies has changed the landscape of market segmentation in the last two decades, including its use in promoting prosocial and behavior change. New, population-specific and culturally appropriate prevention strategies can leverage the potential of digital media to influence health outcomes, especially for the greatest users of digital technology, including youth and young adults. Health behavior change campaigns are increasingly shifting resources to social media, creating opportunities for innovative interventions and new research methods. This article examines three case studies of digital segmentation: (1) tobacco control from the Truth Initiative, (2) community-based public health programs from the Centers for Disease Control and Prevention, and (3) substance use (including opioids) and other risk behavior prevention from Public Good Projects. These case studies of recent digital segmentation efforts in the not-for-profit, government, and academic sectors show that it increases reach and frequency of messages delivered to priority populations. The practice of digital segmentation is rapidly growing, shows early signs of effectiveness, and may enhance future public health campaigns. Additional research could optimize its use and effectiveness in promoting prosocial and behavior change campaign outcomes.

Background: An adequate intake of fruits and vegetables (FVI) has shown benefits for reduced risk of manifesting chronic diseases. Thus, development of effective interventions to promote FVI is paramount. Aim: To assess the effectiveness of eHealth interventions for FVI targeted to healthy population, in comparison with control groups, and identify the moderators contributing to their effectiveness. Method: A database search was conducted in April 2016 and July 2018 using MEDLINE, PsycINFO, ERIC, Google Scholar, SciELO, and RISS, yielding 19 eligible studies. Risk of bias was assessed using Cochrane's Risk of Bias Tool. Random-effects model was used to calculate effect sizes (ES) by weighted standardized mean differences. Results: This meta-analysis includes 19 studies and 6,894 participants. The most common eHealth tool used was Internet-based interventions (n = 10). Most of studies were conducted in adults (n = 11), followed by children (n = 4), and adolescents (n = 4). The minimum number of behavior change techniques (BCTs) used was one, and the maximum seven. The overall ES was small (0.26, p < 0.001), favoring eHealth interventions. The between-studies heterogeneity was large (I[superscript 2] = 62.77%, p < 0.001). Subgroup analyses showed that the components with larger ES were tailored interventions (0.27, p < 0.001), computer-based interventions (0.44, p < 0.001), and use of =7 BCTs (0.42, p < 0.001). Discussion: All studies showed a positive ES favoring interventions. Large heterogeneity could be explained in part by the number of BCTs and type of eHealth tool used. Nonetheless, more concrete evidence regarding other intervention components effectiveness was limited by small sample size. Conclusion: The use of eHealth tools for the improvement of FVI showed to be more effective compared with nonintervention and interventions not using these technologies. Nonetheless, more research is needed to determine the specific combination of intervention components that could translate into larger effectiveness.

The aim of this study was to systematically review lay health worker (LHW)--led self-management interventions for adults with long-term conditions to see how the interventions have been implemented and to compose a synthesis of research findings, taking into consideration the intervention components that have been applied. We conducted systematic searches for articles published between January 2010 and December 2015 in five databases: Cochrane, MEDLINE, CINAHL, PsycINFO, and Web of Science. Forty original studies were found that met the inclusion criteria: self-management with diabetes (n = 29), cardiovascular diseases (n = 8), and those at risk of cardiovascular diseases (n = 3). These consisted of 22 randomized controlled trials and 18 other trials, with durations of 1 day to 24 months. The findings showed that the training of LHWs and the implementation of interventions varied widely. A synthesis of the implementation methods covers the background of the LHWs and the interventions as well as the components applied in each. Eight interventions had effects on physical activity and eight on nutrition behavior. The review also includes preliminary findings on intervention components effective in improving physical activity and nutrition behavior, including self-monitoring as a behavior change technique and group meetings as an intervention format. The same components and behavior change techniques were applied in effective and noneffective interventions. The review found that LHW-led interventions have potential in promoting self-management in long-term condition. In the future, a qualified and evidence-based structure for LHW-led interventions is suggested in order to improve the systematization of interventions and their effects.

Perceived social norms are routinely observed as positive predictors of indoor tanning. Past research has suggested that messaging interventions target normative perceptions to reduce indoor tanning behavior. Despite this call, little empirical research has investigated the utility of taking a social norms approach in behavioral interventions. The present study addresses this gap by conducting a quasi-experiment (N = 206) assessing the effect of an intervention message correcting normative misperceptions on indoor tanning intentions at different levels of tanning frequency. Results suggest that tailored normative intervention messages can successfully reduce tanning intentions among high-frequency tanners, those who scored at the 75th and 90th percentile of tanning frequency (f[supercript 2] for interaction = 0.015). These results provide preliminary empirical evidence to support previous theorizing on the efficacy of social norms interventions among high-frequency indoor tanners.

Policy, systems, and environmental change are now widely accepted as critical to sustaining improvements in community health. Evidence suggests that such systems-level change is most effective when driven by community-based partnerships. Yet, after more than three decades of building community-based partnership work, health inequities have continued to deepen. To address health inequities, current and historical distributions of power are increasingly recognized as important considerations in efforts to ensure all individuals have the opportunity to attain their full health potential (i.e., achieving health equity). Building on social determinants of health literature, social injustice and powerlessness are put forth as fundamental causes of health inequities. Focusing on power as a root cause of health and health equity through application of Wolff and colleagues' six principles requires substantial changes in contemporary public health practice. This case study uses document analysis of a single case, the Community Teams Program, to assess the evolution of a statewide public health leadership program's efforts to build the capacity of coalition-based teams to catalyze community change in line with Wolff and colleagues' principles. Deductive, selective coding of the materials surface four themes in the program adaptations: (1) the need to focus on power as a root cause, (2) shifting power through relationship building, (3) storytelling as a way to shift narrative, and (4) building mechanisms into the curriculum that hold coalitions accountable for applying and sustaining learned skills. The themes demonstrate philosophical, pedagogical, and organizational changes to center power building approaches in health promotion. Findings are triangulated by reflections from the program director and recorded reflections of participants captured in existing evaluation data.

Background: Highly processed foods are inexpensive and abundant in our food supply, nutritionally poor, and disproportionately marketed to minority youth. This study is part of a curriculum development project to develop, implement, and evaluate the "In Defense of Food" (IDOF) curriculum designed to increase intake of whole/minimally processed foods and decrease intake of highly processed foods in youth. Aims: This pilot outcome evaluation was undertaken to assess initial effectiveness and to provide an in-depth understanding of changes in behavioral outcomes and psychosocial mediators. Methods: We used an explanatory mixed method approach, including a single-arm pretest-posttest of intervention effect, followed by a food rules assessment and in-depth interviews to describe participant responses to the intervention in more detail. The study was conducted in three afterschool classrooms in urban low-income neighborhoods with 32 multiethnic middle-school youth, receiving 10 weekly 2-hour sessions. Results: Two weeks postintervention, there was a large positive significant increase in whole/minimally processed food intake (p < 0.01; d = 0.59) and a small decrease in consumption of highly-processed foods (p = ns; d = 0.06), compared with baseline. Significant increases in psychosocial mediators: Self-efficacy and positive outcomes expectations were seen; others were not significant but changed in the desired direction. Qualitative assessments suggest that the intervention promoted skill building, but environmental barriers made these difficult to use. Discussion: The IDOF curriculum may be most effective for promoting consumption of fruits and vegetables, rather than decreasing intake of highly processed foods. In addition, in this young age-group, short actionable food rules may support self-regulation and behavior change. Conclusion: Among adolescent students in low-income urban neighborhoods, the IDOF afterschool curriculum may help promote self-efficacy and positive outcome expectancies and increase fruit and vegetable intake. Focusing on food processing and using "Food Rules" may be promising to elicit behavior change in youth; however, greater supports are needed to overcome social and environmental barriers.

Background: Evidence suggests that children and adolescents growing up in low-income families and those with underrepresented ethnocultural backgrounds tend to have high prevalence rates of obesity and more difficulty adhering to childhood obesity interventions. However, less is known about how intergenerational, family-based approaches to lifestyle interventions for childhood obesity support sustained behavior change. Aims: The aim of this study was to explore the perspectives of health care providers regarding family adherence and behavior change in a childhood obesity program that served ethnoculturally diverse and low-income families. Method: Semistructured in-person interviews were conducted with 18 providers at one of three hospitals participating in a Canadian family-based childhood obesity program. Data were thematically analyzed using a constant comparative approach. Results: The following key themes emerged as challenges from the provider's perspective for family adherence and behavior modification in the childhood obesity program: divergent views about obesity, complicated lives and logistical priorities, parental role modeling, and intergenerational tensions. Discussion and Conclusion: This examination of providers' perspectives on family adherence and behavior modification relevant to the management of childhood obesity highlight the importance of tailoring childhood obesity programs to the complex and diverse needs of families from diverse backgrounds. Recommendations include methods of service delivery that address logistical challenges and are better suited to extended families, particularly grandparents.

Background: The gateway behavior hypothesis posits that change in a health behavior targeted for modification may promote positive changes in other untargeted health behaviors; however, previous studies have shown inconsistent results. Aims: To examine the patterns and predictors of change in untargeted health behaviors in a large health behavior change trial. Method: Using repeated-measures latent class analysis, this study explored patterns of change in untargeted physical activity, alcohol consumption, and smoking behavior during the first year of the Women's Health Initiative dietary modification trial that targeted total fat reduction to 20% kcal and targeted increased fruit and vegetable intake. Participants were healthy postmenopausal women who were randomly assigned to either the low-fat dietary change intervention (n = 8,193) or a control (n = 12,187) arm. Results: Although there were increases in untargeted physical activity and decreases in alcohol consumption and smoking in the first year, these changes were not consistently associated with study arm. Moreover, although the results of the repeated-measures latent class analysis identified three unique subgroups of participants with similar patterns of untargeted health behaviors, none of the subgroups showed substantial change in the probability of engagement in any of the behaviors over 1 year, and the study arms had nearly identical latent class solutions. Discussion and Conclusion: These findings suggest that the dietary intervention did not act as a gateway behavior for change in the untargeted behaviors and that researchers interested in changing multiple health behaviors may need to deliberately target additional behaviors.

Background/Aim: Increased knowledge, attitudes, and beliefs about a topic and behavioral capability and self-efficacy for healthy eating are often a precursor to behavior change. The purpose of this study is to determine the effectiveness of the multicomponent school-based program on children's healthy eating knowledge, attitudes, and self-efficacy for healthy eating, and on their eating habits over time. Method: Quasi-experimental (4 treatment, 2 comparison) in a metropolitan area using a pretest-posttest method. Participants were 628 fifth-grade youth (377 treatment, 251 comparison) with a mean age of 9.9 years. The Building Healthy Communities (BHC) program is an 8-month school-wide healthy school transformation program and includes six main components. Outcome measures include children's healthy eating knowledge, attitudes, self-efficacy, and behavior. Missing data were imputed, confirmatory factor analysis tested scale factor structure, and path analysis determined a parsimonious path explaining behavior change. Results: The Student Attitudes and Self-Efficacy (SASE) scale had good measurement model fit. BHC group's healthy eating knowledge and behaviors increased significantly, while SASE remained moderate. For both groups, the students' knowledge and SASE significantly predicted their healthy eating behaviors; however, the intervention group accounted for a greater amount of variance (35% vs. 26%). Discussion: The BHC program was effective in improving healthy eating knowledge and behavior among youth, and the relationship between variables did not vary by group. Healthy eating knowledge is a significant predictor of both future knowledge and behavior.

Introduction: Drinking alcohol has detrimental health consequences, and effective interventions to reduce hazardous drinking are needed. The self-regulation intervention of Mental Contrasting with Implementation Intentions (MCII) promotes behavior change across a variety of health behaviors. In this study, we tested if online delivery of MCII reduced hazardous drinking in people who were worried about their drinking. Method: Participants (N = 200, female = 107) were recruited online. They were randomized to learn MCII or solve simple math problems (control). Results: Immediately after the intervention, participants in the MCII condition (vs. control) reported an increased commitment to reduce drinking. After 1 month, they reported having taken action measured by the Readiness to Change drinking scale. When drinking was hazardous (Alcohol Use Disorders Identification Test = 8, n = 85), participants in the MCII condition indicated a decreased number of drinking days, exp([beta]) = 0.47, CI (confidence interval) [-1.322, -0.207], p = 0.02, and drinks per week, exp([beta]) = 0.57, CI [0.94, 5.514], p = 0.007, compared with the control condition. Discussion: These findings demonstrate that a brief, self-guided online intervention ("Mdn" = 28 minutes) can reduce drinking in people who worry about their drinking. Our findings show a higher impact in people at risk for hazardous drinking. Conclusion: MCII is scalable as an online intervention. Future studies should test the cost-effectiveness of the intervention in real-world settings.

Background: Emotions are important in smoking-related communications, but the role of discrete positive and negative emotions in comparative risk messages about combusted and electronic cigarettes (e-cigarettes) is unclear. Method: In an online experiment, 1,202 U.S. adult current smokers or recent quitters were randomized to view one of six messages about comparative risk of e-cigarettes and cigarettes. Participants reported their feelings of hope, happiness, fear, guilt, disgust, and anger and risk perceptions and behavioral intentions about e-cigarettes and cigarettes. Results: Hope was associated with higher perceived absolute cigarette risk, lower perceived absolute and comparative e-cigarette risk, and stronger intentions to quit smoking, seek quit help, use nicotine replacement therapy (NRT), switch to e-cigarettes, and use e-cigarettes exclusively versus dual use. Happiness was related to stronger intentions to seek quit help, use NRT, and switch to e-cigarettes but higher perceived comparative risk of e-cigarettes. Fear was associated with stronger intentions to quit smoking, seek quit help, use NRT, and switch to e-cigarettes. Guilt was related to higher perceived absolute cigarette risk, lower perceived comparative e-cigarette risk, and stronger intentions to use NRT. Disgust was associated with higher absolute and comparative e-cigarette risk and stronger intentions to quit smoking, seek quit help, and use e-cigarettes exclusively versus dual use. Anger was related to lower perceived absolute cigarette risk, higher perceived comparative e-cigarette risk, and weaker intentions to quit smoking. Conclusion: Comparative risk messages about e-cigarettes that arouse hope, fear, and guilt and avoid anger might be particularly likely to have positive impact on smokers.

Faith-based settings offer opportunities for reaching populations at risk for chronic conditions and are optimal settings for dissemination and implementation (D&I) research. "Faith, Activity, and Nutrition" (FAN) is an evidence-based program designed to promote physical activity (PA) and healthy eating (HE) through church policy, systems, and environmental change. We report implementation fidelity for Phase 1 of the FAN D&I project, a countywide effort. The group randomized study included pre- and postintervention assessments of core PA and HE components. We compared implementation in early intervention (n = 35) versus delayed intervention (control, n = 19) churches; assessed individual church implementation; and examined the effects of level of implementation on church member outcomes. Implementation assessments were conducted with the FAN coordinator via telephone survey. Study outcomes were assessed with church members 8 to 12 months following baseline assessment via self-administered surveys. We found significantly higher levels of implementation for PA opportunities, PA and HE guidelines, PA and HE messages, and PA and HE pastor support in intervention versus control churches and showed church-level variation in PA and HE implementation. PA self-efficacy varied by level of implementation; high and low implementers did not differ in proportion of church members physically inactive, although low implementers had fewer members inactive than controls. The high level of implementation in intervention churches shows promise for broader dissemination of FAN.

Background: Behavioral interventions to prevent pediatric obesity have shown inconsistent results across the field. Studying what happens within the "black box" of these interventions and how differences in implementation lead to different outcomes will help researchers develop more effective interventions. Aim: To compare the implementation of three features of a phone-based intervention for parents (time spent discussing weight-related behaviors, behavior change techniques used in sessions, and intervention activities implemented by parents between sessions) with study outcomes. Methods: A random selection of 100 parent-child dyads in the intervention arm of a phone-based obesity prevention trial was included in this analysis. Sessions were coded for overall session length, length of time spent discussing specific weight-related behaviors, number of behavior change techniques used during the sessions, and number of intervention-recommended activities implemented by the parents between sessions (e.g., parent-reported implementation of behavioral practice/rehearsal between sessions). The primary study outcome, prevention of unhealthy increase in child body mass index (BMI) percentile, was measured at baseline and 12 months. Results: Overall session length was associated with decreases in child BMI percentile (b = -0.02, p = 0.01). There was no association between the number of behavior change techniques used in the sessions and decreases in child BMI percentile (b = -0.29, p = 0.27). The number of activities the parents reported implementing between sessions was associated with decreases in child BMI percentile (b = -1.25, p = 0.02). Discussion: To improve future interventions, greater attention should be paid to the intended and delivered session length, and efforts should be made to facilitate parents' implementation of intervention-recommended activities between sessions (ClinicalTrials.gov, No. NCT01084590).

The rising prevalence rate of obesity in the United States has accentuated concerns about obesity-related problems as a major public health issue, which has motivated widespread efforts to increase public knowledge and to motivate individuals to change their relevant behaviors. Although health campaign messages commonly include information about prevalence rates for obesity, the impact of obesity labeling and prevalence rate descriptions in such messages has been overlooked by researchers. This online framing experiment fills the research gap by investigating the effects of obesity labeling (disease vs. body type) and prevalence statistics (prevalence rates of obesity, extreme obesity, combined overweight-obesity, or no prevalence information). Our findings suggest that obesity perceptions deviate from reality and that participants use framed cues in the health message as reference points when making judgments related to the nature and prevalence of obesity. Moreover, this study shows that even accurate information might lead to inaccurate perceptions as a result of framing, and perceptions of the nature and prevalence of obesity mediate the effects of framing on behavioral intentions. Implications for obesity framing and the design of public health messages are discussed.

A decade after the first health app became available, the field of digital health has produced a range of health behavior insights and an expanding product portfolio. Despite sustained interest and growth fueled by academic and industry interests, the impact of digital health on health behavior change and related outcomes has been limited. This underperformance relative to expectations may be partially attributed to a gap between industry and academia in which both seek to develop technology-driven solutions but fail to converge around respective, unique strengths. An opportunity exists for new and improved collaborative models of research, innovation, and care delivery that disrupt the field of behavioral medicine and benefit academic and industry interests. For those partnerships to thrive, recognizing key differences between academic and industry roles may help smooth the path. Here we speak specifically to concerns particular to academics and offer suggestions for how to navigate related challenges.

Background: Hand washing is an effective way to prevent transmission of infectious diseases. Education and promotional materials about hand washing may change individuals' awareness toward hand washing. Infectious disease outbreak may also affect individuals' awareness. Aims: Our study aimed to examine associations between hand-washing education and self-reported hand-washing behaviors among Korean adults during the year of the Middle East respiratory syndrome (MERS) outbreak. Methods: Data from the 2015 Community Health Survey were used for this study. The total study population comprised 222,599 individuals who were older than 20 years of age. A multiple linear regression model was used to investigate associations between hand hygiene education and self-reported hand-washing behaviors. Subgroup analyses stratified by age, sex, income, and MERS outbreak regions were also performed. Results: Individuals who received hand-washing education or saw promotional materials related to hand washing had significantly higher scores for self-reported use of soap or sanitizer (ß = 0.177, P < 0.0001) and self-reported frequency of hand washing (ß = 0.481, P < 0.0001) than those who did not have such experiences. The effect of hand-washing education on self-reported behavior change was greater among older adults, women, and lower income earners. The effect of hand hygiene education on self-reported use of soap or sanitizer was similar regardless of whether the participants lived in MERS regions. Conclusion: Our findings emphasize the importance of education or promotions encouraging hand washing, especially for older adults, women, and lower income earners. In addition, MERS outbreak itself affected individuals' awareness of hand-washing behaviors. Well-organized campaigns that consider these factors are needed to prevent infectious diseases.

Background: Physical activity exerts cancer-protective effects, yet most Americans are inactive, especially in the South, where cancer incidence rates are generally higher. Telephone-based approaches can help overcome physical activity intervention barriers in this region (literacy, costs, lack of transportation/technology, distance from facilities) and can be automated via interactive voice response (IVR) systems for improved reach and cost-effectiveness. Aims: To evaluate the Deep South IVR-supported Active Lifestyle (DIAL) intervention. Method: A pilot randomized controlled trial was conducted among 63 underactive adults in Birmingham, Alabama, from 2015 to 2017. Results: Retention was 88.9% at 12 weeks, and =75% adherence (IVR contact on at least 63 out of 84 days) was noted among 62.5% of intervention participants. Intervention participants reported larger increases in self-reported minutes of moderate-to-vigorous intensity physical activity from baseline to 12 weeks than the wait-list control arm (median change = 47.5 vs. 5.0 minutes, respectively, p = 0.09). Moreover, the intervention produced significantly greater increases in physical activity self-regulation (p < 0.001) and social support from family (p = 0.001) and friends (p = 0.009) from baseline to 12 weeks, compared with the wait-list control. Significant decreases in self-reported sleep disturbance also were found in the intervention arm but not among the controls, p < 0.05. Overall, intervention participants reported being satisfied with the DIAL program (71.4%) and would recommend it to friends (92.9%). Discussion: Findings support the feasibility, acceptability, and preliminary efficacy of the DIAL intervention. Conclusion: Next steps include intervention refinement in preparation for a fully powered efficacy trial and eventual dissemination to rural counties.

Background: Tobacco use contributes to an estimated 14.6% of male and 5.7% of female deaths in Bangladesh. Aims: We examine the determinants of tobacco-related quit attempts among Bangladeshis with and without awareness of the synergized "People Behind the Packs" (PBTP) communication campaign used to support the introduction of pack-based graphic warning labels (GWLs) in 2016. Method: Data from 1,796 adults were collected using multistage sampling and a cross-sectional face-to-face survey. Analyses used a normalized design weight to ensure representativeness to the national population of smokers within Bangladesh. Results: For the overall sample, the multivariable logistic regression model revealed quit attempts were associated with having seen the pack-based GWLs, recalling =1 PBTP campaign message, higher levels of self-efficacy to quit, and recognizing more potential side-effects associated with using tobacco products. Conversely, the likelihood of quitting attempts were lower among dual tobacco users (relative to smokers) and those using tobacco at least daily (vs. less than daily). The hierarchical multivariable logistic regression model among those aware of =1 PBTP campaign message indicated quitting attempts were positively associated with recalling more of the campaign messages and discussing them with others. Conclusion: This national evaluation of pack-based GWLs and accompanying PBTP campaign within Bangladesh supports the efficacy of using synergized communication messages when introducing such labels. That quit attempts are more likely among those discussing PBTP campaign messages with others and recalling more PBTP campaign messages highlights the importance of ensuring message content is both memorable and engaging.

Background: We have demonstrated previously that patterns of behavioral adherence in the first 6 months of behavioral lifestyle interventions were associated with significant weight loss at 18 months. In this article, we extend this work to examine patterns of behavioral adherence over 18 months and to explore baseline demographic and psychosocial predictors. Method: Latent class analysis was applied separately to the Weight Loss Maintenance and PREMIER trials data to examine patterns of adherence to the following recommendations: (1) consuming =9 servings of fruits and vegetables per day, (2) =25% of energy from total fat, (3) =7% energy from saturated fat, and (4) =180 minutes of moderate-to-vigorous physical activity per week. Multinomial logistic regression was used to test demographic and psychosocial predictors of latent class membership. Results: Four distinct subgroups with common patterns of behavioral adherence were identified in each trial including, Behavioral Maintainers, who maintained adherence to all behavioral recommendations for 1 year, Nonresponders, who did not adhere to the recommendations at any time point, and latent classes that reflected patterns of adherence to one or two behaviors or behavioral relapse. A significantly higher proportion of Behavioral Maintainers sustained =5% weight loss for 1 year compared with Nonresponders. Participants with higher vitality scores at baseline were more likely to belong to a latent class with long-term adherence to one or more recommendations than the Nonresponders class. Conclusions: Regular assessment of health behaviors and psychosocial measures such as vitality may help identify nonresponders and inform treatment tailoring to improve long-term behavioral and weight outcomes.

Diet and physical activity are behavioral risk factors for many chronic diseases, which are among the most common health conditions in the United States. Yet most Americans fall short of meeting established dietary and physical activity guidelines. Faith-based organizations as settings for health promotion interventions can affect members at multiple levels of the social ecological model. The present study investigated whether change in the church social environment was associated with healthier behavior at church and in general at 1-year follow-up. Six churches received mini-grants and technical assistance for 1 year to support policy and environmental changes for healthy eating (HE) and physical activity (PA). Socioenvironmental (social support and social norms) and behavioral (HE and PA at church and in general) outcomes were derived from baseline and 1-year follow-up church member surveys (n = 258). Three of six churches demonstrated significant improvements in all three socioenvironmental aspects of HE. Two of five churches exhibited significant socioenvironmental improvements for PA at follow-up. Church social environmental changes were related to health behaviors at church and in general (p < .05). Change in social support for HE, social support for PA, and social norms for PA were each associated with three church-based and general behavioral outcomes. Social norms for healthy eating were related to two general behavior outcomes and social norms for unhealthy eating to one general behavioral outcome. Study findings demonstrate that socioenvironmental characteristics are essential to multilevel interventions and merit consideration in designing policy and environmental change interventions.