Health Education Research

This Article Abstract FREE Full Text (PDF) E-letters: Submit a response Alert me when this article is cited Alert me when E-letters are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My Personal Archive Download to citation manager Search for citing articles in: ISI Web of Science (18) Request Permissions Disclaimer Google Scholar Articles by Peterson, K. E. Articles by McCormick, M. C. Search for Related Content PubMed PubMed Citation Articles by Peterson, K. E. Articles by McCormick, M. C. Social Bookmarking          What's this?

Health Education Research, Vol. 17, No. 5, 531-540, October 2002
© 2002 Oxford University Press

Design of an intervention addressing multiple levels of influence on dietary and activity patterns of low-income, postpartum women

K. E. Peterson^1,2, G. Sorensen³, M. Pearson⁴, J. R. Hebert⁵, B. R. Gottlieb¹ and M. C. McCormick¹

¹ Departments of Maternal and Child Health, and ² Nutrition, Harvard School of Public Health, Boston, MA 02115, ³ Center for Community-based Research, Dana Farber Cancer Institute, Boston MA 02115, ⁴ Department of Nutrition, University of Massachusetts, Amherst, MA 01003 and ⁵ Department of Epidemiology and Biostatistics, University of South Carolina School of Public Health, Columbia, SC 29208, USA

	Abstract

Top Abstract Rationale Purpose Theoretical approach Study methods Intervention approach Analysis Conclusion References

 
Low-income, multi-ethnic women are at elevated risk for obesity and chronic diseases, yet influences at different levels may act as barriers to changing risk behaviors. Following the birth of a child, childrearing and social isolation can exacerbate these influences. The social ecological framework integrates behavior-change strategies at different levels, providing a strong theoretical base for developing interventions in this high-risk population. The primary purpose of this randomized controlled trial is to test the efficacy of an educational model delivered by community-based paraprofessionals in improving diet, activity and weight loss among new mothers over a 12-month postpartum period and a 6-month maintenance period. This model fosters institutional change to support behavior changes influenced at intrapersonal and interpersonal levels, through collaboration with federal programs for low-income families: the Special Supplemental Food Program for Women, Infants and Children (WIC), and the Expanded Food and Nutrition Education Program (EFNEP). Participants are randomized to the Usual Care, e.g. WIC nutrition and breastfeeding education, or Enhanced EFNEP intervention arm, consisting of Usual WIC Care plus a sustained, multi-component intervention including home visits, group classes and monthly telephone counseling. If shown to be efficacious, this program will be readily sustainable through existing federal agencies.

	Rationale

Top Abstract Rationale Purpose Theoretical approach Study methods Intervention approach Analysis Conclusion References

 
Dietary and physical activity behaviors are risk factors for preventable illnesses among the leading causes of premature deaths, including Type 2 diabetes, coronary heart disease, stroke and certain cancers (USDHHS, 1996, 2000; AICR, 1997; USDA/USDHHS, 2000; Krebs-Smith, 2001). An imbalance between dietary intake and energy expenditure can result in obesity, further contributing to incidence of chronic disease (Visscher and Seidell, 2001). Disparities in diet and activity behaviors and their outcomes underscore the need for effective interventions in low-income, multi-ethnic groups (USDHHS, 1996; Flegal et al., 1998; USDA/USDHHS, 2000). Prospective studies have shown dramatic reductions in chronic disease risk with adherence to a low-risk health behavior profile (Stampfer et al., 2000; Hu et al., 2001) meeting public health guidelines for weight status, diet and physical activity. Addressing risk behaviors in concert can maximize the efficacy of interventions, because change in one behavior can serve as a gateway for change in others (Marcus et al., 1991; Pirie et al., 1992; Emmons et al., 1994).

The postpartum period represents a time for establishing a behavioral pattern contributing to long-term risk of chronic disease among women. Childrearing demands coupled with fatigue, depression, multiple physical symptoms and social isolation (McCormick et al., 1992) can exacerbate unhealthy diet and activity patterns. Obesity prevalence rises with age and with the number of pregnancies (Brown et al., 1992; Williamson et al., 1994). This constellation of risks also supports conceptualization of the postpartum period as a window of opportunity to modify health practices (Stover and Marnejon, 1995). Efficacy of behavior-change interventions will depend, however, on addressing multiple influences in the social context of low-income, multi-ethnic women that may constrain diet and physical activity behaviors (Crockett et al., 1992; Eyler et al., 1998; Townsend et al., 2001).

	Purpose

Top Abstract Rationale Purpose Theoretical approach Study methods Intervention approach Analysis Conclusion References

 
A social ecological framework integrating theories of behavior change at different levels of influence is well suited to address systematically determinants of dietary intake and physical activity patterns in population groups at greatest risk of chronic disease. This project is designed to test the efficacy of an educational model delivered by community-based paraprofessionals in the US Department of Agriculture’s (USDA) Expanded Food and Nutrition Education Program (EFNEP) in improving health behaviors of low-income, multi-ethnic women following birth of a child. New mothers are recruited from the Special Supplemental Food Program for Women, Infants and Children (WIC), also administered by the USDA, or through medical providers in community health centers where WIC programs are co-located. The primary purpose is to evaluate whether the Enhanced EFNEP model produces greater change in dietary intake, physical activity and pregnancy-related weight changes in the first 12 months postpartum and after 6 months of maintenance, compared with WIC care alone. Community-based federal programs provide important channels for reaching low-income, multi-ethnic women. By collaborating with USDA programs already providing nutrition education to low-income families, we foster institutional change to maximize behavioral influences at individual and interpersonal levels.

	Theoretical approach

Top Abstract Rationale Purpose Theoretical approach Study methods Intervention approach Analysis Conclusion References

 
Within a social ecological framework (McLeroy et al., 1988), we focus intervention development on three levels: intrapersonal, interpersonal and organizational. This project will not directly alter community influences, e.g. access to healthy foods and safe, low-cost ways to increase daily physical activity. The intervention model incorporates strategies addressing these constraints through program activities at other levels of influence.

A limited number of diet and activity interventions developed for low-income, multi-ethnic women have been evaluated in controlled trials. Effective models have largely focused on single behaviors, e.g. fruit and vegetable intake (Havas et al., 1998a; Campbell et al., 1999a; Anderson et al., 2001), dietary fat consumption (Campbell et al., 1999b), weight loss (French et al., 1998a) or physical activity (Chen et al., 1998). Few physical activity interventions in comparable study populations have been implemented in combination with weight loss or dietary components (Avila and Hovell, 1987; Lasco et al., 1987). Studies that have described the theoretical basis for intervention development in low-income minority groups (Havas et al., 1998a; Chen et al., 1998) have drawn upon Social Cognitive Theory (SCT) (Bandura, 1977), the Stages of Change Transtheoretical Model (TM) (Prochaska and DiClemente, 1982) and social support models (Israel, 1985). Campbell designed a church-based intervention to increase fruit and vegetable consumption within an ecologic framework, addressing these intra- and interpersonal theories of behavior change as well as community influences (Campbell, 1999a). Nutrition education intervention trials successful in improving dietary intake also documented significant changes in relevant mediating variables, self efficacy, knowledge and social support (Havas et al., 1998a; Campbell et al., 1999a). Chen et al. found significant increases in walking among low-income, multi-ethnic women participating in both arms of an 8-week mail and telephone intervention, but did not report changes in mediating variables (Chen et al., 1998).

Individual behavior change is the primary focus at the intrapersonal level of the social ecological framework, integrating perspectives from Social Learning Theory, expectancy value theories and learning models. Common among these theories is the supposition that behavior change is a function of attitudes, perceived norms and perception of one’s ability to initiate and maintain change. The TM provides a strong basis for understanding the sequential process of behavior change and adapting intervention approaches to an individual’s level of readiness (Prochaska and DiClemente, 1982). Behavioral choice theory complements the TM, also emphasizing approaches to enhance motivation. Recent research in this area points to the utility of multiple alternatives as a means of enhancing intrinsic motivation and increasing perceived control as a means of maintaining behavior change (Epstein et al., 1991, 1995; Gortmaker et al., 1999). Application of this theory among low-income populations, whose choices may be limited by financial and social circumstance, requires that these aspects be considered in intervention design. To our knowledge, behavioral choice theory has not been incorporated in multi-risk factor reduction trials addressing intrapersonal influences on diet and activity among adults.

On the interpersonal level, we rely upon literature describing the impact of social support and social networks on health status and behaviors (Israel, 1985; Berkman and Syme, 1979). Families and friends can provide a range of support, and people who are isolated are more likely to engage in high-risk behaviors. The clustering of a number of behavioral characteristics in families points to the importance of addressing household influences in individualizing plans and goals for diet and activity changes (Sallis and Nader, 1988; Sallis et al., 1988). We elected to focus on two domains of social support—an assessment of network size and function related to emotional, instrumental, informational and appraisal support (House, 1981), and supportive behaviors directed toward diet and activity change.

We also aim to build organizational support for health behavior change. Our approach to intervention development at this level is guided by literature on the diffusion of innovations (Steckler et al., 1992) and organizational change (Kaluzny and Hernandez, 1988). In a limited number of interventions implemented in low-income and minority populations, recruitment and/or participation was scheduled in conjunction with WIC or Food Stamp certification appointments (Chen et al., 1998; Havas et al., 1998a; Campbell et al., 1999b; Anderson et al., 2001). These studies did not, however, address and maximize organizational influences on potential efficacy of the educational model. By contrast, Campbell et al. used an ecologic approach to implement educational sessions and other group activities to increase fruit and vegetable intake of older African-Americans through a range of organizational, e.g. church-based, channels and coalitions with grocers and farmers (Campbell et al., 1999a). At the level of the organization, the process of intervention development and testing relies on a strong partnership with EFNEP. The active involvement of individuals at all levels of the organization allows for greater ‘ownership’ of the program and future sustainability, maintenance of interventions, change in organization as a result of participating in the programs, and individual change, including knowledge and resources (Altman, 1995).

	Study methods

Top Abstract Rationale Purpose Theoretical approach Study methods Intervention approach Analysis Conclusion References

 
This is a randomized controlled trial comparing the effectiveness of Usual WIC Care to the Enhanced EFNEP program. A total of 700 postpartum women from two urban areas who are WIC-eligible or current participants will be enrolled into the study. Racial/ethnic distribution varies across urban areas. Boston-area WIC participants are approximately 75% Hispanic, 14% black, 9% white, and 1% Asian and Portuguese. In WIC programs located in two adjacent cities in western Massachusetts, participants range from 45 to 77% Hispanic, 4 to 21% black, 18 to 30% white and 1 to 4% Asian. After completing informed consent procedures and a baseline evaluation, participants are randomized into one of two treatment arms. We use a stratified randomization procedure to ensure equal distribution across condition by BMI ± 27 and Spanish or English language. We do not stratify sampling within racial/ethnic group, due to high diversity in the WIC population and the infeasibility of sampling sufficient numbers to test intervention effects within strata.

WIC serves pregnant and breastfeeding women, infants and children under 5 years living in households less than 185% of federal poverty guidelines, and who present with ‘physical or epidemiological signs that their health was at risk due to poor nutrition’ (IOM, 1996; USDA, 2001). Participants receive nutrition-risk assessment and education, food vouchers, and may participate in the WIC Farmers Market Nutrition Program. EFNEP serves adults in households below 125% of poverty guidelines or WIC eligible (Randall et al., 1989), offering classes in meal planning, food shopping and budgeting, food safety and child feeding (Brink and Sobal, 1994). Qualifications of EFNEP paraprofessionals include fluency in the clients’ language, a high school diploma or GED, knowledge of community resources, experience working with low-income learners, and a social and economic background similar to program participants.

The Control Condition, Usual WIC Care, consists of nutrition-risk appropriate counseling and breastfeeding consultation at the first postpartum and follow-up visits up to 12 months from delivery. WIC nutritionist staff conduct dietary assessments and provide nutrition education in accordance with Massachusetts WIC Program guidelines. EFNEP paraprofessionals and intervention staff affiliated with the study do not interact with participants in the control arm. The Enhanced EFNEP intervention condition consists of Usual WIC Care plus a multi-component intervention. Enhanced EFNEP participants receive three standardized intervention components over the 12-month intervention period: five home visits and four group classes from EFNEP paraprofessionals, and monthly motivational telephone calls from program staff. Printed materials, including recipes and cards to record personal diet and activity goals, supplement the three educational components. Intervention participants also receive bi-monthly telephone calls during a maintenance period from 12 to 18 months after delivery of their infant.

We hypothesize that improvements in primary outcomes (fruit and vegetable intake, saturated fat consumption, and total moderate-to-vigorous activity) will be significantly greater at 12 months postpartum among women participating in the intervention. The specific aims are to (1) determine if the Enhanced EFNEP educational model for multiple risk factor reduction yields greater mean improvements in primary outcomes, compared to Usual WIC Care, (2) determine the effect of the intervention on secondary outcomes (BMI and indicators of fat mass and distribution) compared with Usual WIC Care, and (3) assess the extent of implementation using an intervention tracking system. The statistical analysis, described below, will explore the role of mediating and modifying variables outlined in the conceptual framework (Figure 1). To minimize respondent burden, study personnel will obtain outcome data from control and intervention participants in conjunction with WIC visits at baseline (2–6 weeks postpartum), final (12 months) and after 6 months of maintenance (18 months). Project data collectors, WIC and community health center personnel are unaware the treatment assignment of study participants. We assess dietary outcomes using a Food Frequency Questionnaire (Willett et al., 1985) and physical activity through a 7-day recall (Blair et al., 1985; Sallis, 1998). Surveys are interviewer-administered in English or Spanish. In addition to measures of weight and height usually obtained at WIC visits, study personnel have been trained, and measurement techniques standardized to obtain mid-upper arm and waist circumferences and triceps skinfolds at three certification visits (2–6 weeks, and 12 and 18 months) following accepted procedures (WHO, 1995). In a random subsample of 20% of participants, we will obtain 7 days of accelerometer data at three time points as an independent measure of change in moderate-to-vigorous activity, and three 24-h dietary and physical activity recalls at baseline, and 12 and 18 months.

View larger version (28K): [in this window] [in a new window]   Fig. 1. Conceptual model: reducing disease risk in low-income, postpartum women.

 

	Intervention approach

Top Abstract Rationale Purpose Theoretical approach Study methods Intervention approach Analysis Conclusion References

 
The intervention model is designed for low-income women and operationalized at each level of influence described in the theoretical model. Each of the three intervention components—home visits, group classes and telephone sessions—addresses multiple levels of influence: intrapersonal, interpersonal and organizational. Strategies to address community influences on diet and physical activity behaviors have been incorporated into educational approaches at the other three levels.

Design rationale
We selected a three-part intervention delivered by paraprofessionals to build systematically social support, and extend formal and informal networks of low-income, postpartum women using organizational resources available to this population. We considered several factors in electing to develop a sustained, intensive multiple-component intervention, rather than a minimal or single-component approach. Physical activity changes have been documented with mail and phone interventions that minimize logistic constraints in similar populations (Chen et al., 1998). Self-help or one-time dietary interventions, however, changed knowledge and perceptions, but not behavior (French et al., 1998; Campbell, 1999b). Significant dietary effects were demonstrated only in multi-component interventions of at least 6 months duration, including group classes offered by peer or lay advisors, supplemented by recipes and mailings (Havas et al., 1998a) and other community activities (Campbell et al., 1999a). Furthermore, a single-component intervention is unlikely to be effective in changing a multi-risk behavior pattern. Preliminary data on women receiving OB/GYN services at participating Boston health centers indicated 35–45% did not attend scheduled postpartum visits in the 2–6 weeks following delivery (Gottlieb, unpublished). These data and documented childrearing demands and the social isolation among postpartum women (McCormick et al., 1992) mandated interactions through home visits. Because low-intensity interventions may more likely be accepted by busy young mothers (Chen et al., 1998), we incorporated bi-monthly motivational telephone counseling from 12 to 18 months postpartum to inform the utility of a low-intensity approach to maintenance following a sustained, intensive intervention.

Home visits
Participants receive five home visits from an EFNEP paraprofessional during the 12-month intervention period. Home visits are guided by a script, emphasizing one dietary or activity behavior at a single visit, but reinforcing other diet and activity outcomes.

At the intrapersonal level, behavior-change theories suggest that an effective intervention must target awareness, motivation and skills building (Sorensen et al., 1995, 1998). The home visits include an awareness component designed to foster knowledge of project goals, and the relationships between physical activity, diet and disease prevention. Motivational Interviewing techniques (Miller and Rollnick, 1991) have been adapted for home visits as one method for increasing awareness, enhancing motivation and self-efficacy, and building skills. The components of the Motivational Interview include: (1) rapport building, (2) identification of aspects the client does and does not like about each behavior, (3) personalized needs assessment; (4) discussion of how the behaviors fit into the client’s life and what changes the client would like to implement, and (5) goal setting. Emphasis on multiple behavioral alternatives also is consistent with behavioral choice theory. Feedback on the self-assessment is designed to help clients re-evaluate their health behaviors, increase perceived self-efficacy to make health behavior changes, help clients choose among behaviors and to set goals regarding changes.

The first home visit addresses interpersonal influences on health behavior by building rapport and social support provided by the EFNEP paraprofessional. The degree to which health education is received and accepted can be enhanced when it is provided by members of a social network who are respected and understand the social context in which the education is provided (Lacey et al., 1991; Eng and Young, 1992). During the remaining four home visits, the paraprofessional reviews the participant’s progress towards her goals, identifies and discusses solutions to barriers, provides information on diet and physical activity, and promotes attendance at group cooking and activity classes. Non-formal, interactive adult education strategies are well suited to EFNEP clientele (Hartman et al., 1994) and complement Motivational Interviewing techniques used to operationalize intrapersonal behavior-change theories. In focus groups with our study population, women indicated that facilitating behavior would include a ‘mentor’, not somebody who ‘nags’ or ‘stresses you out’, and wanted someone to walk with ‘to motivate me’ (Ebbeling, unpublished data). In order to provide support addressing community constraints on behavior choices, the paraprofessional asks the mother about participation in other assistance programs and household food insecurity.

Adoption of an innovation by an organization may follow several stages: (1) awareness of a problem and possible solution, (2) decision to adopt the innovation, (3) implementation, including redefining the innovation and modifying organizational structures to accommodate the innovation, and (4) institutionalization as an ongoing element in the organization’s activities (Kaluzny and Hernandez, 1988). In this study, the process of intervention development fosters organizational change through innovations to enhance established systems of communication and incorporate paraprofessionals’ skills into behavior-change strategies. EFNEP staff at all levels (executive, supervisory and paraprofessional) have participated actively in identifying needs, setting priorities and goals, and planning and pilot-testing protocols and intervention components. An Intervention Tracking Form (ITF) adapted from our previous work in these communities (Sorensen et al., 1998; Hunt et al., 2000) is used by both paraprofessionals and telephone counselors to document and communicate content of interactions with individual participants. In addition, monthly ‘grand rounds’ provide the opportunity for EFNEP paraprofessionals and supervisors, program and research staff to discuss progress and challenges using case examples, in order to improve quality of intervention delivery and support ongoing organizational development.

Group classes
Women in the intervention condition will participate in four group cooking and activity classes conducted by EFNEP paraprofessionals. Building on behavioral-change theories addressing both intrapersonal and interpersonal influences, classes reinforce project messages, offer demonstrations in food preparation, and emphasize social interaction with both the paraprofessional and other women. Skills are taught in group classes for those ready to change behavior.

Telephone counseling
During the 12-month intervention period, women in the Enhanced EFNEP program receive monthly motivational telephone calls from bilingual project personnel, trained in Motivational Interviewing (Miller and Rollnick, 1991). During the maintenance period, three calls will be made at bi-monthly intervals. About 15 min in duration, calls include a brief review of diet and activity themes, reinforce individuals’ diet and activity goals, review barriers, check for medical or other concerns, and review and provide community referrals and resources. These aspects of the call address each of the theories underlying change in intrapersonal, interpersonal and organizational influences on behavior, complementing and reinforcing home visit and group class components.

	Analysis

Top Abstract Rationale Purpose Theoretical approach Study methods Intervention approach Analysis Conclusion References

 
The conceptual model for hypothesized intervention effects on primary and secondary outcomes appears in Figure 1. Using generalized linear modeling methods, we will assess change from baseline to 12 and 18 months of follow-up in mean fruit and vegetable and saturated fat intakes and in MET-hours per day of total moderate-to vigorous activity. Secondary outcomes are mean BMI, triceps skinfold and waist circumference. The effect of the intervention will be evaluated using an intention-to-treat model, by the test of the treatment arm by time interaction in a regression of the form:

where Z = treatment group (0 = Usual WIC Care, 1 = Enhanced EFNEP) and T = time in years (0.12, 1.0 and 1.5).

The statistical analysis will include explorations of the influence of mediating variables at different levels of influence through which the intervention may be effective, self-efficacy and stage of change, social networks and support, and health and nutrition program utilization and household food security. Modifying factors on study outcomes that may influence efficacy of the intervention on one or more primary or secondary outcomes include: perceived health status, smoking, television viewing, breastfeeding, acculturation/primary language, socioeconomic status, household size, and community access to nutrition and activity resources.

	Conclusion

Top Abstract Rationale Purpose Theoretical approach Study methods Intervention approach Analysis Conclusion References

 
Poor quality diets and a sedentary lifestyle are associated with preventable illnesses and premature death in the US. Low-income, multi-ethnic women are at elevated risk for these chronic diseases due to disparities in dietary and activity behaviors, and a greater prevalence of obesity. Influences at multiple levels posited by the social ecological model may act as barriers to adopting healthy dietary and activity patterns in this high-risk population. In the postpartum period, childrearing demands and lifestyle changes coupled with social isolation and poor health status also have the potential to exacerbate inappropriate dietary intake and low levels of moderate physical activity. The constellation of multiple risk factors for interrelated diet and activity behaviors affecting new mothers in low-income settings mandates a comprehensive theoretical framework integrating several behavior change strategies in intervention development. Pivotal features of the intervention model being tested in this study include:

1. The focus on the postpartum period as a ‘window of opportunity’ in terms of new mothers’ motivation and as an opportunity to improve a behavioral trajectory early in reproductive life.
   
2. A multi-risk factor approach addressing interrelated health behaviors.
   
3. A theoretically based model which uses a social ecological framework that incorporates a variety of behavior change approaches and addresses the social context in which these women live.
   
4. Building on an established system, by expanding the roles of paraprofessionals to address chronic disease risk through both diet and physical activity.
   
5. Strengthening linkages between existing federal programs and community health centers with postpartum women who are clients of these systems.
   
6. The formation of a partnership between behavior-change experts, intervention specialists and community-based paraprofessionals who bring a broad array of expertise and experience to intervention design and delivery.
   

This intervention model complements the limited number of diet and physical activity intervention trials in low-income, multi-ethnic women that have largely focused on application of intrapersonal (SCT and TM) and social support models to changing single behaviors. This intervention also incorporates behavioral choice theory into the design of intervention components addressing intrapersonal influences on multiple diet and activity behaviors, an approach used successfully in youth, but not evaluated in low-income, multi-ethnic adults. The change agent, the EFNEP paraprofessional, and educational techniques, Motivational Interviewing and non-formal education, are well suited to needs of a low-literacy population, as identified in qualitative research. Previous research conducted in WIC and other federal nutrition program settings serving a substantial proportion of low-income families in the US did not address the organizational level of influence on promoting and sustaining behavior change. Involvement of EFNEP collaborators and paraprofessionals in research design, testing and implementation ensures that learning is incorporated into the organization, directly supporting efforts of paraprofessionals in delivering intervention components to members of their own community. If shown to be efficacious, this program can be readily disseminated and sustained through the existing federal nutrition programs for low-income populations, in collaboration with well-established community health organizations.

	Acknowledgments

 
This study is supported by NICHD R01 HD37368 and NIH OBSSR RFA OD-98-002. The authors appreciate contributions to study design and proposal development from Michele Baltay, Candy Combe, Cara Ebbeling, Patty Freedson, Mary Kay Hunt, Jan Kallio, Abby King, Rachel Levine, Chuck Matthews, Louise Ryan and Judy Salkeld. We are grateful to Rebecca Mandell and Elizabeth Russo for editorial assistance, to Meridith Eastman for literature review and research coordination, and to Trish Lavoie, Laura Jay and Kate Crowley for administrative support.

	References

Top Abstract Rationale Purpose Theoretical approach Study methods Intervention approach Analysis Conclusion References

 
AICR (1997) Food, Nutrition and the Prevention of Cancer: A Global Perspective. AICR, Washington, DC.

Altman, D. G. (1995) Sustaining interventions in community systems: on the relationship between researchers and communities. Health Psychology, 14, 526–536.[Web of Science][Medline]

Anderson, J. V., Bybee, D. I., Brown, R., McLean, D. F., Garcia, E. M., Breer, M. L. and Schillo, B. A. (2001) 5-A-Day fruit and vegetable intervention improves consumption in a low income population. Journal of the American Dietetic Association, 101, 195–202.[Web of Science][Medline]

Avila, P. and Hovell, M. F. (1994) Physical activity training for weight loss in Latinas: a controlled trial. International Journal of Obesity, 18, 476–482.[Web of Science][Medline]

Bandura, A. (1977) Self-efficacy: toward a unifying theory of behavioral change. Psychological Review, 84, 191–215.[Web of Science][Medline]

Berkman, L. D. and Syme, S. L. (1979) Social networks, host resistance and mortality: a nine year follow-up of Alameda County residents. American Journal of Epidemiology, 109, 186–204.[Abstract/Free Full Text]

Blair, S., Haskell, W. L., Ho, P., Paffenbarger, R. S., Vranizan, K. M., Farquhar, J. W. and Wood, P. D. (1985) Assessment of habitual physical activity by a seven-day recall in a community survey and controlled experiments. American Journal of Epidemiology, 122, 794–804.[Abstract/Free Full Text]

Brink, M. and Sobal, J. (1994) Retention of nutrition knowledge and practices among adult EFNEP participants. Journal of Nutrition Education, 26, 74–78.

Brown, J. E., Kaye, S. A. and Folsom, A. R. (1992) Parity-related weight change in women. International Journal of Obesity, 16, 627–631.[Web of Science][Medline]

Campbell, M. K., Demark-Wahnefried, W., Symons, M., Kalsbeek, W. D., Dodds, J., Cowan, A., Jackson, B., Motsinger, B., Hoben, K., Lashley, J., Demissie, S. and McClelland, J. W. (1999a) Fruit and vegetable consumption and prevention of cancer: the Black Churches United for Better Health Project. American Journal of Public Health, 89, 1390–1396.[Abstract/Free Full Text]

Campbell, M. K., Honess-Morreale, L., Farrell, D., Carbone, E. and Brasure, M. (1999b) A tailored multimedia nutrition education pilot program for low-income women receiving food assistance. Health Education Research, 14, 257–267.[Abstract/Free Full Text]

Center for Nutrition Policy and Promotion (1998) Is Total Fat Consumption Really Decreasing? US Department of Agriculture, Washington, DC.

Chen, A. H., Sallis, J. F., Castro, C. M., Lee, R. E., Hickmann, S. A. Williams, C. and Martin, J. E. (1998) A home-based behavioral intervention to promote walking in sedentary ethnic minority women: Project WALK. Women’s Health Research, Gender and Behavior Policy, 4, 19–39.

Council on Ethical and Judicial Affairs (1990) Black–white disparities in health care. Journal of the American Medical Association, 263(17), 2344–2346.[Abstract/Free Full Text]

Cox, J. L. (1989) Postnatal depression: a serious and neglected postpartum complication. Baillier’s Clinical Obstetrics and Gynaecology, 3, 439–455.

Crockett, E. G., Clancy, K. L. and Bowering, J. (1992) Comparing the cost of a Thrifty Food Plan (TFP) market basket in three areas of New York state. Journal of Nutrition Education, 24, 71S–78S.

Emmons, K. E., Marcus, B. H., Linnan, L., Rossi, J. S. and Abrams, D. B. (1994) Mechanisms in multiple risk factor interventions: smoking physical activity, and dietary fat intake among manufacturing workers. Preventive Medicine, 23, 481–489.[Web of Science][Medline]

Eng, E. and Young, R. (1992) Lay health advisors as community change agents. Journal of Family and Community Health, 15, 24–40.

Epstein, L. H., Smith J. A., Vara L. S. and Rodefer, J. S. (1991) Behavioral economic analysis of activity choice in obese children. Health Psychology, 10, 311–316.[Web of Science][Medline]

Epstein, L. H., Valoski, A. M., Vara, L. S., McCurley, J., Wisniewski, L., Kalarchian, M. A., Klein, K. R. and Shrager, L. R. (1995) Effects of decreasing sedentary behavior and increasing activity on weight change in obese children. Health Psychology, 14, 109–115.[Web of Science][Medline]

Eyler, A. A., Baker, E., Cromer, L., King, A. C., Brownson, R. C. and Donatelle, R. J. (1998) Physical activity and minority women: a qualitative study. Health Education and Behavior, 25, 640–652.[Abstract]

Flegal, K. M., Carroll, M. D., Kuczmarski, R. J. and Johnson, C. L. (1998) Overweight and obesity in the United States: Prevalence and trends, 1960–1994. International Journal of Obesity, 22, 39–47.[Web of Science][Medline]

French, S. A., Neumark-Sztainer, D., Story, M. and Jeffery, R. W. (1998) Reducing barriers to participation in weight-loss programs in low-income women. Journal of the American Dietetic Association, 98, 198–200.[Web of Science][Medline]

Gortmaker, S. L., Peterson, K., Wiecha, J., Sobol, A. M., Dixit, S., Fox, M. K. and Laird, N. (1999) Reducing obesity via school-based interdisciplinary intervention among youth: Planet Health. Archives of Pediatric and Adolescent Medicine, 153, 409–418.[Abstract/Free Full Text]

Haan, M., Kaplan, G. and Syme S. (1989) Socioeconomic status and health: old observations and new thoughts. In Bunker, D., Gomby, J. and Kehrer, B. (eds), Pathways to Health: The Role of Social Factors. Henry J. Kaiser Family Foundation, Menlo Park, CA, pp. 76–135.

Hartman, T., McCarthy, P. R., Park, R. J., Schuster, E. and Kushi, L. H. (1994) Focus group responses of potential participants in a nutrition education program for individuals with limited literacy skills. Journal of the American Dietetic Association, 94, 744–748.[Web of Science][Medline]

Havas, S., Anliker, J., Damron, D., Langenberg, P., Ballesteros, M. and Feldman, R. (1998) Final results of the Maryland WIC 5-A-Day promotion program. American Journal of Public Health, 88, 1161–1167.[Abstract/Free Full Text]

House, J. S. (1981) Work, Stress and Social Support. Addison-Wesley, Reading, MA.

Hu, F. B., Manson, J. E., Stampfer, M. J., Colditz, G. A., Liu, S., Solomon, C. G. and Willett, W. C. (2001) Diet, lifestyle and the risk of type 2 diabetes mellitus in women. New England Journal of Medicine, 345, 790–797.[Abstract/Free Full Text]

Hunt, M. K., Lederman, R., Stoddard, A., Potter, S., Phillips, J. and Sorenson, G. (2000) Process tracking results from the Treatwell 5-a-Day worksite study. American Journal of Health Promotion, 14, 179–187.[Web of Science][Medline]

Institute of Medicine (1996) WIC Nutrition Risk Criteria: A Scientific Assessment. National Academy Press, Washington, DC.

Israel, B. (1985) Social networks and social support: implications for natural helper and community level interventions. Health Education Quarterly, 12, 65–80.[Web of Science][Medline]

Kaluzny, A. P. and Hernandez S. R. (1988) Organizational change and innovation. In Shortell, S. M. and Kaluszny, A. D. (eds) Health Care Management: A Text in Organization Theory and Behavior. Wiley, New York, pp. 378–417.

Kant, A. K., Block, G., Schatzkin, A., Ziegler, R. G. and Nestle, M. (1991) Dietary diversity in the US population, NHANES II, 1976–1980. Journal of the American Dietetic Association, 91, 1526–1531.[Web of Science][Medline]

Krebs-Smith, S. M. (ed.) (2001) The Dietary Guidelines: surveillance issues and research needs. Journal of Nutrition, 131, Suppl. 2SI.

Lacey, L., Tukes, S., Manfredi, C. and Warnecke, R. (1991) Use of lay health educators for smoking cessation in a hard-to-reach community. Journal of Community Health, 16, 269–282.[Medline]

Lasco, R. A., Curry, R. H., Dickson, V. J., Powers, J., Menes, S. and Merritt, R. K. (1989) Participation rates, weight loss, and blood pressure changes among obese women in a nutrition–exercise program. Public Health Reports, 104, 640–646.[Web of Science][Medline]

McCormick, M. C., Brooks-Gunn, J., Holmes, J. H., Wallace, C. Y. and Heagarty, M. C. (1992) Maternal health status in the year after delivery among low-income women. Journal of Women’s Health, 1, 225–230.

McLeroy, K. R., Bibeau, D., Steckler, A. and Glanz, K. (1988) An ecological perspective on health promotion programs. Health Education Quarterly, 15, 351–377.[Web of Science][Medline]

Miller, W. and Rollnick, S. (1991) Motivational Interviewing; Preparing People to Change Addictive Behaviors. Guilford Press, New York.

Patterson, B. H. and Block G. (1988) Food choices and the cancer guidelines. American Journal of Public Health, 78, 282–286.[Medline]

Pirie, P. L., McBride, C. M., Hellerstedt, W. L., Jeffery, R. J., Hatsukami, D., Allen, S. and Lando, H. (1992) Smoking cessation in women concerned about weight. American Journal of Public Health, 82, 1238–1243.[Abstract/Free Full Text]

Prochaska, J. O. and DiClemente C. C. (1982) Transtheoretical therapy: toward a more integrative model of change. Psychotherapy: Theory, Research and Practice, 20, 161–173.[Web of Science]

Randall, M. J., Brink, M. S. and Joy, A. (1989) EFNEP: an investment in America’s future. Journal of Nutrition Education, 21, 276–279.

Sallis, J. F. (1998) A collection of physical activity questionnaires for health-related research: seven-day physical activity recall. Medicine & Science in Sports and Exercise, 29 (6 Suppl.), S89–S103.

Sallis, J. F., Patterson, T. L., Buono, M. J., Atkins, C. J. and Nader, P. R. (1988) Aggregation of physical activity habits in Mexican-American and Anglo families. Journal of Behavioral Medicine, 11, 31–41.[Web of Science][Medline]

Sorensen, G., Himmelstein, J. S., Hunt, M. K., Youngstrom, R., Hebert, J. R., Hammond, S. K., Palombo, R., Stoddard, A. and Ockene, J. K. (1995) A model for worksite cancer prevention: integration of health protection and health promotion in the Wellworks Project. American Journal of Health Promotion, 10, 55–62.[Web of Science][Medline]

Sorensen, G., Hunt, M. K., Cohen, N., Stoddard, A., Stein, E., Phillips, J., Baker, F., Combe, C., Hebert, J. and Palombo, R. (1998) Worksite and family education for dietary change: the Treatwell 5-A-Day Program. Health Education Research, 13, 577–591.[Abstract/Free Full Text]

Stampfer, M. J., Hu, F. B., Manson, J. E., Rimm, E. B. and Willett, W. C. (2000) Primary prevention of coronary heart disease in women through diet and lifestyle. The New England Journal of Medicine, 343, 16–22.[Abstract/Free Full Text]

Steckler, A., Goodman, R. M., McLeroy, K. R., Davis, S. and Koch, G. (1992) Measuring the diffusion of innovative health promotion programs. American Journal of Health Promotion, 6, 214–224.[Medline]

Stover, A. M. and Marnejon, J. G. (1995) Postpartum care. American Family Physician, 52, 1465–1472.[Web of Science][Medline]

Townsend, M. S., Peerson, J., Love, B., Achterberg, C. and Murphy, S. P. (2001) Food insecurity is positively related to overweight in women. Journal of Nutrition, 131, 1738–1745.[Abstract/Free Full Text]

USDA/USDHHS (2000) Nutrition and Your Health: Dietary Guidelines for Americans, 5th edn. Home and Garden Bulletin 232. US Government Printing Office, Washington, DC.

USDA (2001) History of WIC 1974–1999: 25th Anniversary. FNS Online: http://www.fns.usda.gov/wic/MENU/NEW/WICHistory.PDF

USDHHS (1996) Physical Activity and Health: A Report of the Surgeon General. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA.

USDHHS (2000) Healthy People 2010, conference edn. US Government Printing Office, Washington, DC.

Visscher, T. L. and Seidell, J. C. (2001) The public health impact of obesity. Annual Reviews of Public Health, 22, 355–375.

WHO (1985) Physical Status: The Use and Interpretation of Anthropometry. WHO Technical Report Series 854. WHO, Geneva.

Williamson, D. F., Madans, J., Pamuk, E., Flegal, K. M., Kendrick, J. S. and Serdula, M. K. (1994) A prospective study of childbearing and 10-year weight gain in US white women 25 to 45 years of age. International Journal of Obesity, 18, 561–569.[Web of Science][Medline]

Willett, W. C., Sampson, L., Stampfer, M. J., Rosner, B., Bain, C., Witschi, J., Hennekens, C. H. and Speizer, F. E. (1985) Reproducibility and validity of a semiquantitative food frequency questionnaire. American Journal of Epidemiology, 122, 51–65.[Abstract/Free Full Text]

Received on February 14, 2001; accepted on December 31, 2001

CiteULike    Connotea    Del.icio.us    What's this?

This article has been cited by other articles:

				A. C. Lindsay, K. M. Sussner, M. L. Greaney, and K. E. Peterson Influence of Social Context on Eating, Physical Activity, and Sedentary Behaviors of Latina Mothers and Their Preschool-Age Children Health Educ Behav, February 1, 2009; 36(1): 81 - 96. [Abstract] [PDF]

				S. C. Wangberg An Internet-based diabetes self-care intervention tailored to self-efficacy Health Educ. Res., February 1, 2008; 23(1): 170 - 179. [Abstract] [Full Text] [PDF]

				H. M. Devlin, J. Desai, G. S. Holzman, and D. T. Gilbertson Trends and Disparities Among Diabetes-Complicated Births in Minnesota, 1993-2003 Am J Public Health, January 1, 2008; 98(1): 59 - 62. [Abstract] [Full Text] [PDF]

				T. Dubowitz, S. A. Smith-Warner, D. Acevedo-Garcia, S.V. Subramanian, and K. E. Peterson Nativity and Duration of Time in the United States: Differences in Fruit and Vegetable Intake Among Low-Income Postpartum Women Am J Public Health, October 1, 2007; 97(10): 1787 - 1790. [Abstract] [Full Text] [PDF]

				G. W. Greene, L. C. Nebeling, M. L. Greaney, A. C. Lindsay, C. K. Hardwick, D. J. Toobert, K. Resnicow, G. C. Williams, D. L. Elliot, T. Goldman Sher, et al. A Qualitative Study of a Nutrition Working Group Health Promot Pract, July 1, 2007; 8(3): 299 - 306. [Abstract] [PDF]

				C. B. Ebbeling, M. N. Pearson, G. Sorensen, R. A. Levine, J. R. Hebert, J. A. Salkeld, and K. E. Peterson Conceptualization and Development of a Theory-Based Healthful Eating and Physical Activity Intervention for Postpartum Women Who Are Low Income Health Promot Pract, January 1, 2007; 8(1): 50 - 59. [Abstract] [PDF]

				V. H. Barkauskas, S. L. Lusk, and B. L. Eakin Selecting Control Interventions for Clinical Outcome Studies West J Nurs Res, April 1, 2005; 27(3): 346 - 363. [Abstract] [PDF]

				M. G. Ory, P. J. Jordan, and T. Bazzarre The Behavior Change Consortium: setting the stage for a new century of health behavior-change research Health Educ. Res., October 1, 2002; 17(5): 500 - 511. [Abstract] [Full Text] [PDF]

This Article Abstract FREE Full Text (PDF) E-letters: Submit a response Alert me when this article is cited Alert me when E-letters are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My Personal Archive Download to citation manager Search for citing articles in: ISI Web of Science (18) Request Permissions Disclaimer Google Scholar Articles by Peterson, K. E. Articles by McCormick, M. C. Search for Related Content PubMed PubMed Citation Articles by Peterson, K. E. Articles by McCormick, M. C. Social Bookmarking          What's this?

Online ISSN 1465-3648 - Print ISSN 0268-1153

Copyright © 2009 Oxford University Press

Oxford Journals Oxford University Press

• Site Map
• Privacy Policy
• Frequently Asked Questions

Other Oxford University Press sites: Oxford University Press Oxford Journals China Oxford Journals Japan American National Biography Booksellers' Information Service Children's Fiction and Poetry Children's Reference Corporate & Special Sales Dictionaries Dictionary of National Biography Digital Reference English Language Teaching Higher Education Textbooks Humanities International Education Unit Law Medicine Music Online Products Oxford English Dictionary Reference Rights and Permissions Science School Books Social Sciences Very Short Introductions World's Classics