Abby C. King - US grants

Cardiovascular disease (CVD) remains the nation's major killer and largest single source of health expenditures. The impact of CVD mortality and morbidity is particularly notable with advancing age. Included among the factors identified as contributory to risk is the level of regular physical activity individuals engage in. The association between physical activity and CVD has been noted for older as well as younger populations. The identification of physical activity as a plausible method for positively influencing physiological as well as behavioral and psychological responses to stress presents one potential mechanism through which the association between regular activity and CVD risk may be at least partly mediated. While the relatively few controlled studies of the effects of aerobic activity on stress-related response are encouraging, a number of dimensions remain virtually unexplored, including the study of responses in the natural environment and the use of promising home-based activity interventions for generating sustained exercise adherence. In addition to cardiovascular disease, a relationship between physical activity and stress-related response has implications for issues related to enhancement of daily function and quality of life in older adults. Yet to undertake a comprehensive inquiry of the effects of physical activity on stress-related response, an understanding of biomedical as well as behavioral and psychological processes associated with each is needed. The purpose of the proposed course of training and research is to take advantage of the unique resources at Stanford University in obtaining systematic training in biomedical areas of particular relevance to the exercise and stress fields. Stanford faculty with expertise in cardiovascular function and assessment, exercise physiology, neuroendocrinology, carbohydrate metabolism, and aging will serve as specialty advisors in directing the course of the training. This training will then be applied in the development and piloting of physiological, behavioral, and psychological measures of stress-related response, occurring in both laboratory and natural settings, in an older adult population (ages 50-70). The specific aims of the pilot work are to develop laboratory-based stress-related stimulus conditions that are relevant for and acceptable to an older population; to pilot laboratory- based and natural setting protocols for measuring the 3 modalities of stress-related response in older adults; and to determine effect sizes for the measures under investigation with respect to the target population. The testing and measurement procedures developed during this proposal will subsequently be applied in a larger project proposal aimed at assessing the short- and longer-term effects of physical activity on physiological, behavioral, and psychological responses to stress in this population.

Chronic stress has been implicated as a contributing factor underlying a range of chronic and infectious disease processes, as well as more immediate aspects of daily function and quality of life in the aging adult. Given this, the development of nonpharmacologic approaches that may improve psychological health as well as mitigate stress-induced aberrations in cardiovascular, neuroendocrine, and immune responses related to disease remains a critical area for systematic study. Regular physical activity has been identified as a promising, though little studied, method for positively influencing both physiological and psychological responses to stress in older adults. While the relatively few controlled studies of the effects of aerobic activity on stress-related response are encouraging, a number of dimensions remain virtually unexplored, including the effects of exercise on immune response and other physiological parameters in older adults; and the use of promising home-based activity interventions in chronically stressed older populations, such as family caregivers, who could particularly benefit from physical activity interventions but whose circumstances typically prohibit attendance at traditional class-based programs. To undertake a comprehensive, state-of-the-art inquiry of the effects of physical activity on stress-related response in family caregivers, an understanding of the array of biomedical as well as behavioral and psychological processes associated with each is needed. The current proposal represents a 2-year extension of a 3-year Special Emphasis Research Career Award in Behavioral Geriatrics focused on the study of physical activity and stress in older adults. The first three years of this award were dedicated to obtaining systematic training in methods of measuring cardiovascular, neuroendocrine, and endocrine responses to stress in both the laboratory and the field. The purpose of the current proposal is to: (1) extend these systematic training experiences to the area of immune function, which represents a critical dimension of the body's physiological response to stress, and (2) conduct a controlled feasibility study investigating the role of regular physical activity in influencing stress-related response in a sample of older women caregivers. The proposed course of interdisciplinary educational experiences takes advantage of the unique resources at Stanford University, as well as the expertise of three of the top research teams in psychoneuroimmunology in the U.S. The proposed training and research goals are designed to extend current knowledge related to the objective assessment of levels of physical demand and functioning in caregivers, and the development of optimal physical activity training regimens for enhancing physical and psychological function and quality of life in this important population segment. The procedures and results from this proposal will subsequently be applied in a larger-scale investigation of the effects of physical activity on stress-related response in this population.

aerobic exercise; human therapy evaluation; cardiovascular disorder prevention; lifestyle; longitudinal human study; information systems; heart disorder; health care quality; disease /disorder proneness /risk; clinical trials; body weight; blood pressure; physical fitness; health care cost /financing; blood lipoprotein; behavior modification; handbook; blood chemistry; human subject;

This is a Shannon Award providing partial support for research projects that fall short of the assigned institute's funding range but are in the margin of excellence. The Shannon award is intended to provide support to test the feasibility of the approach; develop further tests and refine research techniques; perform secondary analysis of available data sets; or conduct discrete projects that can demonstrate the PI's research capabilities or lend additional weight to an already meritorious application. Further scientific data for the CRISP System are unavailable at this time.

Chronic diseases and impaired function related to physical inactivity are major factors in the disability, diminished quality of life, and burgeoning health care costs facing older women. Although the growing number of older women serving as family caregivers could especially benefit from the physical and psychological effects of regular, moderate- intensity endurance exercise, their life circumstances typically make it difficult to attend classes regularly away from home. While supervised home-based physical activity has proven to be effective in producing long- term physical and mental health benefits in community samples of older adults, a critical next step is to determine its effectiveness in such at- risk subgroups for whom it is particularly indicated. The objectives of this study are to: (1) determine the initial (6 months) and longer-term (12 months) effectiveness of a home-based moderate- intensity physical activity program in promoting significant increases in physical performance and functioning in older women caregivers; (2) evaluate the efficacy of the physical activity regimen for promoting initial and longer-term changes in a broad array of day-to-day functioning and well-being (quality of life) variables; (3) use the study as an opportunity to evaluate the effects of family caregiving on ambulatory blood pressure and heart rate responses as indicators of stress in the natural setting, as well as an opportunity to enhance knowledge with respect to the measurement of physical activity among older women. The study design is a one-year randomized trial in which women ages 50-75 years serving as primary caregivers for a relative with dementia will be randomly assigned to one of three conditions: supervised home-based physical activity training; music/relaxation training; or general support/instruction. All programs are designed to enhance long-term participation. Data will be collected at baseline and at 6 and 12 months using age-relevant physical performance tests, a comprehensive set of rated functioning and well-being scales, and several promising measures of physical activity. Our primary research hypotheses are that subjects assigned to physical activity training will demonstrate significant increases in physical functioning and performance, maintained through 12 months, relative to the non-exercise control conditions. Additional major questions of interest focus on the comparative changes in rated functioning and psychological well-being for the three conditions across the 12-month period; whether preliminary data suggesting significant negative effects of family caregiving on blood pressure responses in the natural setting are verified in a larger, more representative sample of caregivers; and the extent to which blood pressure and heart rate responses in the natural setting are influenced, both acutely and over time, by the different intervention regimens. This study will contribute important information with respect to the development of effective, potentially low-cost strategies for preventing caregiver disability and maintaining caregiver health, functioning, and well-being.

Low income ethnic minority women, many with reduced literacy skills, are at elevated risk for cardiovascular disease (CVD) and non-insulin- dependent diabetes mellitus. Recent NHANES data showed more women than men, especially Mexican-American women (46 percent), reported no leisure time physical activities. Exceedingly little research has been conducted evaluating methods for enhancing adherence to current physical activity recommendations in this highly sedentary and underserved population. This proposal is designed to encourage sustained increases in physical activity (PA) in a multiethnic, low income population of 180 health women (mean age 31 years). Women attending adult education classes will be recruited for the study. Twelve classes from 3 adult education sites will be randomly allocated to receive the intervention or to participate in an assessment-only control group. The intervention will combine class-based and home-based approaches to improve PA knowledge, attitudes, and PA levels. Participants will attend 8, one-hour weekly preparatory classes held in conjunction with their existing adult education courses (e.g., GED, job training). These classes, based on our previous experience with a similar population, will include didactic lectures, interactive discussions, group activities, and resource materials tailored to the women's literacy, social, and economic circumstances. The classes will teach behavioral skills that prepare women to increase their PA. At the end of the preparatory class, women from the class will be randomized to one of two home-based interventions. Women in the usual care intervention will receive standard print materials for initiating and maintaining physical activity. The experimental intervention will include telephone counseling and mailed materials that provide feedback on progress and incentives for initiating, increasing, and maintaining PA. Evaluation will consist of baseline and follow-up assessment at 10 weeks, 6 months, and 12 months. The primary outcomes will be measured on-site at the adult education sites. They will include reported PA levels and heart rate during a submaximal exercise test. Secondary outcomes include adherence to the exercise regimens, body mass index, blood pressure, waist-to-hip ratio, fasting serum lipids, and fasting glucose. Portable heart rate/activity monitors will be worn to validate adherence. This study will serve as a model for the design and dissemination of risk reduction programs for underserved populations in this and similar community settings.

Sleep complaints are one of the most common health problems facing middle- and older-aged adults, resulting in significant medical utilization along with reduced psychological well-being and quality of life. In light of the cost and potential adverse effects accompanying long-term use of sedative-hypnotic medications, the development of alternative strategies for improving sleep in older populations is strongly indicated. One such potentially efficacious strategy is regular physical activity, a health behavior that typically diminishes with age. Although results from the first randomized, controlled trial evaluating the effects of increases in physical activity on sleep quality among healthy older adults with initial sleep complaints were promising, the study suffered from several methodological constraints that require further investigation. The objectives of this study are to: (1) determine the initial (6 months) and longer-term (12 months) effectiveness of a moderate-intensity physical activity program in promoting significant improvements in subjectively and objectively measured sleep quality in older adults with moderate sleep complaints; (2) evaluate the efficacy of the physical activity regimen for promoting initial and longer-term changes in a broad array of psychological and physical functioning (quality of life) variables; and (3) investigate a selected set of potential mediators and moderators of the physical activity/sleep relationship. The study design is a one-year randomized trial in which 120 sedentary women and men ages 55 years and older with moderate sleep complaints will be randomly assigned to one of two conditions: moderate-intensity physical activity training, or an attention-control (health education) condition. Both programs are designed to enhance long-term participation. Data will be collected at baseline and at 6 and 12 months using age-relevant physical performance and physical activity instruments, self-rated and objective sleep quality measures collected in the natural environment, and a comprehensive set of psychological and physical functioning scales. Our primary hypotheses are that subjects assigned to physical activity training will demonstrate significant increases in sleep quality along with other quality of life measures, maintained through 12 months, relative to the non-exercise control condition. This study will contribute important information with respect to the development of effective nonpharmacologic approaches to improving sleep quality among the large segment of healthy, community-dwelling older adults with sleep complaints.

DESCRIPTION (adapted from investigator's abstract): The high prevalence of physical inactivity among middle- and older-aged adults is related to a number of chronic diseases and decreased quality of life. Counselor-directed physical activity programs may enhance extrinsic motivation (social influence theory) and promote physical activity. However, social influence may undermine long- term intrinsic motivation (cognitive evaluation theory), contributing to physical activity relapse once counselor-initiated contact ends. In contrast, programs that diminish the socially evaluative and controlling aspects of the counseling interchange may promote intrinsic motivation and foster long-term maintenance of physical activity, even when counselor-initiated contact ceases. The proposed study compares these alternative theoretical perspectives by conducting a randomized controlled clinical trial examining a 12-month telephone-administered counseling program delivered either by a person (social influence enhancement) or computer (cognitive evaluation enhancement) on one-year participation in and 18-month maintenance of physical activity in older sedentary adults. Outcome measures include physical activity and performance measures, as well as quality of life. Possible moderators and mediators of the response to intervention will be explored, as will costs associated with each intervention program.

DESCRIPTION (provided by applicant): Despite the recognized benefits of regular physical activity, older adults remain among the most inactive segments of the U.S. population. Over the past two decades, effective telephone-based counseling approaches to promote and sustain physical activity among older adults have been developed and validated. The next step in this line of research is to systematically evaluate methods for extending the reach and applicability of the telephone model for physical activity promotion through use of trained peer volunteers. No systematic evaluation of peer- vs. health educator-based delivery of physical activity counseling currently exists. The objective of this study is to conduct a randomized controlled trial to evaluate the effects of a 12-month telephone-supervised, home-based physical activity intervention, delivered via health educators versus supervised, trained peers, on physical activity patterns. Inactive men and women ages 50 years and older (N = 180) will be randomly assigned to one of these two programs or to an attention-control arm. The three arms will be matched with respect to the amount of counselor contact. Data will be collected at baseline, 6, and 12 months using age-appropriate physical activity, physical performance, and quality of life measures. Our primary hypotheses are that persons assigned to either experimental arm will show greater 12-month improvement in physical activity levels relative to controls, and both arms will show 12-month physical activity levels that are significantly above baseline levels. Additional questions of interest involve evaluation of potential mediators and moderators (including environmental influences) as well as the costs of the two physical activity interventions, and intervention-related effects on physical functioning and health-related quality of life. This study will contribute important public health information related to methods for expanding the scope and potential impact of the telephone model to a larger segment of the older adult population.

DESCRIPTION (provided by applicant): Older adults, particularly those caring for impaired loved ones (family caregivers), are at substantial risk for inactivity and sub-optimal dietary patterns. The physiological impact and resultant reductions in chronic disease risk obtained by enhancing both of these key health behaviors have been increasingly recognized. Yet, the best methods for combining the two to optimize behavioral success, with respect to sustained improvements in physical activity and healthful dietary intake, remain unclear. Two general temporal approaches have been utilized to date: a Sequential approach that emphasizes shaping of positive experiences in one health behavior prior to introducing the second behavior (learning theory perspective); and a Simultaneous approach that focuses on the benefits that can be more rapidly gained by introducing both behaviors concurrently (a 'life change' perspective). No systematic comparison of these two approaches in influencing sustained physical activity and dietary change currently exists. The objective of this study is to compare these alternative approaches by conducting a randomized controlled trial to evaluate the effects of a 12-month telephone-supervised, home-based physical activity + dietary intervention, conducted in either a sequential or simultaneous fashion, on physical activity and dietary patterns. Older adult caregivers (N=240) who are under-active and have sub-optimal diets, will be randomly assigned to one of three programs or to an attention-control arm. The four arms will be matched with respect to amount and type of staff contact. Data will be collected at baseline, 4, 8, and 12 months using appropriate physical activity, dietary, physical performance, and quality of life measures. Our primary hypotheses are that (1) caregivers assigned to the experimental arms will show greater 12-month improvement in both behaviors than controls, and (2) those randomized to one of the two Sequential exercise + diet programs will show greater improvements in the two behaviors relative to adults assigned to the Simultaneous program, due to the greater mastery and lower level of stress engendered by this 'smaller steps' approach. Additional questions of interest include evaluation of potential mediators and moderators of the interventions, and intervention related effects on physical functioning and health-related quality of life. This study will contribute important theoretical and public health information concerning how best to combine physical activity and dietary behaviors to optimize sustained adherence and promote desirable health outcomes.

DESCRIPTION (provided by applicant): Despite the recognized benefits of regular physical activity for older adults, adults over the age of 65 years remain among the most inactive segments of the U.S. population. Efforts to understand the factors influencing physical activity in this important group have been limited primarily to demographic and psychosocial domains. Although the importance of the neighborhood environment in influencing a host of health, behavioral, and psychosocial outcomes has been recognized, to date, no systematic investigation of the relationship between objective and subjective environmental factors and objectively measured physical activity levels among older adults has been undertaken. The primary objective of this observational study is to investigate whether seniors living in neighborhoods conducive to walking are more physically active, after adjusting for socioeconomic status (SES), than those living in neighborhoods less conducive to walking for transportation and recreational purposes as well as other forms of physical activity. Additional questions of interest concern the moderating effects of physical function, as well as the proportion of seniors living nearby, on the environment/physical activity relationship. The proposed project takes advantage of the sampling, recruitment, and data collection methods of an ongoing NIH-funded research project aimed at integrating public health and urban planning frameworks in studying the impacts of environmental factors on physical activity levels in younger adults. Population-based sampling methods will be used to recruit adults over 65 years of age living in high walkable versus less walkable neighborhoods of varying SES levels in two regions, Seattle, WA (n = 600) and Baltimore, MD (n = 600). In addition to objectively measured physical environment (using GIS) and physical activity levels (using accelerometry), self-reported neighborhood environment, physical activity, and quality of life variables of particular relevance to older adults will be assessed twice during a 12-month period. This study, which takes advantage of the expertise of a multi-disciplinary team, will contribute important conceptual and public health information that can lead to empirically based recommendations for modifying neighborhood environment characteristics to promote physical activity and other health and quality of life outcomes among older adults.

[unreadable] DESCRIPTION (provided by applicant): Despite the recognized benefits of regular physical activity (PA), mid-life and older ethnic minority adults are the most inactive segment of the U.S. population, putting them at increased risk for a number of chronic diseases and conditions including some forms of cancer and weight gain. Few interventions are available in low-income, ethnic minority communities due to cost, personnel, service delivery, and language/cultural barriers. Computer-based counseling programs that are culturally tailored, require minimal amounts of reading and computer literacy, and could be made available in trusted and regularly used community venues offer a promising though currently under-explored alternative for delivering health promotion advice and support to underserved groups. One such promising automated tool is the embodied conversational agent (ECA), an innovative computer-based communication medium that maximizes both visual and aural conversation elements while allowing for individualized message content and a user-friendly interface. The objective of this R-21 exploratory grant is to culturally adapt and pilot-test a theoretically-based, empirically supported ECA-PA program for use with older, low-income Latino adults, who represent the fastest-growing ethnic group in the U.S. Program delivery will occur at a trusted, frequently used community senior center. During Year 01, we will use participatory qualitative and quantitative research methods to culturally and linguistically adapt and pre-test the ECA-PA program with the target population. In Year 02, we will conduct an experimental 4-month pilot study to test the feasibility and preliminary efficacy of the ECA-PA program in promoting initial PA increases (documented via age- and language-appropriate questionnaires, logs, and accelerometry) in the target group. A total of 60 Latino adults ages 55 and over will be randomized to either the ECA-PA arm or a standard care control arm. We will follow those assigned to the ECA-PA program for an additional 4 months to ascertain preliminary behavioral maintenance effects of the program. As part of this study we will explore potentially important theoretically and empirically supported baseline moderators (e.g., health literacy, computer attitudes, acculturation, gender) and mediators associated with PA change (e.g., changes in PA self-efficacy, working alliance with the embodied conversational agent). The effect-size, process, and outcomes information generated by the feasibility study wlll inform a larger-scale trial aimed at evaluating the utility and cost-effectiveness of culturally adapted ECA programs as a means of promoting PA among a fast-growing though sedentary and under-served segment of the U.S. population. [unreadable] [unreadable] [unreadable]

Abstract

Davis - 0827384

Multi-scale modeling of health behavior choices: Water, sanitation, and child survival in Africa

This project integrates theory and methodologies from behavioral sciences, epidemiology, and microeconomics so as to better understand behavior change processes related to water, sanitation, hygiene and health. The broad research goal is to assess the extent to which, and the mechanisms by which, household-level information about risk for enteric illness (specifically water quality and hand cleanliness data) affect household perceptions and behavior related to water management, sanitation practices, and personal hygiene. The research approach includes (1) the collection of household and community information through repeated, structured surveys of households; (2) the collection and microbiological analysis of water and hand samples from household members; (3) the use of these water and hand rinse test results as personalized informational treatments that will be randomly assigned to clusters of households; (4) the modeling of observed changes in behavior, contamination levels, and/or health outcomes as a function of human, cultural, and physical environmental factors operating from the individual to the community scale; and (5) ?process tracing? in order to characterize specific causal mechanisms underlying observed changes. The field site for the project is in Tanzania, where one in six children dies before his/her fifth birthday, with diarrhea being the second leading cause of death after malaria. The project also seeks to inform research communities focused on decision making and behavior change related to health. Whereas the particular focus of the project relates to water, sanitation, and hygiene, the framework employed is relevant for many other areas of health research, particularly those in which both technology use and behavior change are involved.

DESCRIPTION (provided by applicant): Despite the recognized benefits of regular physical activity (PA), older adults are the most inactive segment of the U.S. population, putting them at increased risk for a number of chronic diseases and conditions including cardiovascular disease, diabetes, and weight gain. Efforts to understand the factors influencing physical activity in this important at-risk group have been limited primarily to demographic and psychosocial domains. While an increasing number of individually-adapted interventions have been developed for older adults, few systematic investigations have studied the impacts of objective and subjective environmental factors on physical activity increases within an intervention context. The proposed project takes advantage of the sampling, recruitment, and data collection methods of a recently completed NIH multi-site clinical trial aimed at evaluating the health-related impacts of a physical activity intervention in community-dwelling adults ages 70-89 years (LIFE-P trial). The primary objective of the proposed study is to investigate whether LIFE-P participants'systematic attempts to become more physically active were facilitated or impeded by the walkability of their neighborhood environments after adjusting for study site (San Francisco Bay area, CA, Dallas, TX, Pittsburgh, PA, Winston-Salem, NC) and other variables of interest. Additional questions of interest concern the moderating effects of physical function, SES, health status, and perceived neighborhood cohesion on the environment/ physical activity intervention relationship. The rich LIFE-P dataset includes multiple measurements of key health variables over a 12-month period (e.g., health status, objectively determined and perceived physical functioning, physical activity, quality of life). It will be combined with newly acquired data targeting stable elements of participants'neighborhood environments (including objective macro-scale and observed micro-scale built environment features, and perceived neighborhood variables). This study benefits from the expertise of a multi-disciplinary international team. It will contribute important conceptual and public health information that can inform intervention and policy decisions related to modifying neighborhood environment characteristics to promote physical activity and other health and quality of life outcomes among physically vulnerable older adults-- a group representing a prevalent, sedentary, and under-served segment of the U.S. population. PUBLIC HEALTH RELEVANCE: This study will contribute important conceptual and public health information that can inform intervention and policy decisions related to modifying neighborhood environment characteristics to promote physical activity and other health and quality of life outcomes among physically vulnerable older adults a group representing a prevalent, sedentary, and under-served segment of the U.S. population.

DESCRIPTION (provided by applicant): This application addresses broad Challenge Area (06) Enabling Technologies, and Specific High-Priority Topic Area 06-OD(OBSSR)-101* "Using new technologies to improve or measure adherence". The chronic diseases that constitute the major killers of American adults, among them cardiovascular disease, cancer, and other diseases of aging, are inextricably linked with key health behaviors. These include regular physical activity and, more recently, sedentary behaviors such as prolonged television viewing that are associated with obesity, type-2 diabetes, and other hazardous health conditions. Unfortunately, regular adherence to healthful behavioral regimens remains poor across the majority of Americans. Recent advances in communication technologies such as 'smart phones'offer a potentially transformative platform for addressing common barriers to adherence through delivering convenient, sustainable, and contextually meaningful adherence strategies. The major objectives of this research are to develop and test theoretically based behavioral interventions, delivered via state-of-the-art mobile phone technology and aimed at increasing moderate-intensity physical activity (PA) and decreasing TV viewing among adults who could particularly benefit from such programs. During Year 01, participatory qualitative and quantitative research methods will be applied based on preliminary work to develop and formatively test the two mobile phone programs in the target population (i.e., adults ages 25 years and older who have low physical activity levels, watch greater than 14 hours of TV/week, and are overweight or obese). In Year 02, an experimental 4-month pilot study will be conducted to test the feasibility and preliminary efficacy of the two mobile phone programs. Up to 90 adults meeting eligibility criteria will be randomized to the mobile phone-PA, mobile phone-TV, or a mobile phone Control program. In light of the high prevalence of inactivity, overweight, and prolonged TV viewing among lower-income and midlife and older adults, study recruitment activities will particularly target those groups. Daily physical activity and TV viewing will be assessed through a combination of automated methods built or programmed into the phones (e.g., accelerometry, location 'aware'methods) along with user-provided information. Process variables (e.g., program satisfaction) will be assessed. Change in intermediate health outcomes (e.g., body weight, resting blood pressure and heart rate) and other relevant health behaviors (TV-related eating) will be assessed. The effect size, process, and outcomes information generated by this research will inform a subsequent larger trial evaluating the longer-term impacts and cost-effectiveness of the two mobile phone programs in promoting sustained behavioral adherence. The project will yield programs that, once evaluated in a larger trial, can be readily disseminated across the U.S. population at potentially low cost. The potential public health impacts are thus substantial. The project also will create new jobs, both within the context of the grant as well as in the private sector, if the types of technology innovations the project is aiming to create come to fruition. (According to the California Biomedical Industry, for every one employee of a biotechnology organization, another three to five will be employed in firms that service that industry.) Among the innovations of the proposed research are the focus on a state-of-the-art mobile technology platform that represents a convenient and increasingly available and acceptable means of reaching a substantial proportion of U.S. adults;intervention-specific applications of mobile phone technology that extend beyond the areas of assessment and monitoring where current research efforts have been aimed primarily;targeting of two different, highly prevalent health behaviors linked with chronic disease risk;and development, testing, and refinement of what, to our knowledge, will be the first intervention and monitoring technology aimed specifically at reducing TV viewing time among adults. In addition, we will utilize our collaborative relationship with the integrated consumer experience group at a large U.S. health insurance company (Humana) to explore potential translation and dissemination activities as well as subsequent funding mechanisms in furthering the technology evaluation and transfer activities stemming from the proposed research. Despite the recognized health benefits of increasing weekly levels of physical activity and reducing sedentary activities associated with obesity and other health problems, most American adults find it challenging to do so on an ongoing basis. This research aims to develop and evaluate effective, convenient, and easy to use behavioral programs, delivered by state-of-the-art mobile phone technologies, for increasing walking and decreasing prolonged television viewing. Such mobile phone-based programs represent an emerging, potentially cost-effective means for reaching a substantial proportion of Americans in a convenient, contextually meaningful, and ongoing fashion.

DESCRIPTION (provided by applicant): 6-Year Study of Seniors'Neighborhood Environments, Physical Activity &Function Built environment changes has been recommended by the IOM, CDC, and others to improve physical activity (PA). Such changes may be most important for vulnerable groups like older adults who are least active and least studied. Scientists consistently call for prospective studies of built environment and PA. The proposed study is a 6-year follow-up of the Senior Neighborhood Quality of Life Study (SNQLS) cohort of 66+ year-old residents of neighborhoods selected to maximize variability in walk ability and income. Analyses of current data show neighborhood environments are related to PA and BMI. SNQLS is more methodologically advanced than other studies, with objective and perceived measures of both environments and PA, and a prospective follow-up can strengthen evidence of causality. A key innovation is re-assessment of the full range of PA-related environmental characteristics, including walk ability (GIS measured mixed use &street connectivity), microscale features (systematically observed and self-reported streetscape details such as sidewalk quality, safety of street crossings), and access to senior-relevant recreation facilities (GIS and reported). In addition to repeating accelerometer measures, we will add GPS assessment of mobility within neighborhoods. Aim 1, guided by ecological models, is to explain patterns of change in PA from 7-day accelerometry over 6 years by comprehensive measures of neighborhood environments and psychosocial variables. Secondary aims will assess moderators (e.g., physical function) of the relationship of 6-year change in PA with environmental measures and environmental correlates of 6-year changes in a validated measure of physical function, walking for transport and recreation, BMI, and sedentary time. Exploratory aims will assess the impact of changing residences and examine correlates of GPS-measured mobility and its health consequences. Based on pilot data, we expect to measure 70% (projected follow-up N=603) of the sample who participated at Time 1. The study will fill many gaps in knowledge about the relation of environments to multiple health outcomes in seniors. The interdisciplinary team will use results to advance the science of environments and health and develop evidence-based guidelines for designing neighborhoods that support healthy aging. PUBLIC HEALTH RELEVANCE: Relevance of this research to public health Physical inactivity is the 4th leading cause of death in the US, and older adults are the least active segment of the population. Cross-sectional studies, including our previous study, show that older adults living in neighborhoods where they can walk to nearby stores and have recreational opportunities are more active and less likely to be overweight. "Activity-supportive neighborhoods" may allow even older adults with limited function to retain their independence and be active. The proposed study will follow older adults over 6 years to examine whether neighborhood characteristics contribute to changes in physical activity, physical function, and risk of overweight, and overall health.

DESCRIPTION (provided by applicant): This grant will continue funding for a successful, 35-year training program in cardiovascular disease (CVD) prevention. The purpose of the program is to train behavioral and medical scientists to conduct interdisciplinary and translational research aimed at the prevention of CVD in communities. The training will be derived principally from direct research experience in an existing, excellent interdisciplinary research resource, the Stanford Prevention Research Center (SPRC), which includes community, policy, behavioral, and clinical research that totals $9 million annually. Current research includes studies examining a range of topics that include overweight/obesity and weight loss interventions (e.g., ethnic dance and screen time reduction in Latina girls; home-based nutrition intervention and play group exercise for low income Latinas; comparing case management environmental support in an under-served population; targeting overweight/obese adults with insomnia or asthma; comparing weight stabilization strategies) the built environment (e.g.,. neighborhood impact on physical activity in older adults; the effects of tobacco outlet density on teen smoking) as well as comparative treatments for smoking cessation, and improving physical activity assessment methodology through the use of new technologies. In addition, the SPRC is one of the clinical sites for the ongoing follow-up of the Women's Health Initiative. Working closely with 1-2 faculty, trainees develop an individual research project, join an ongoing research program for tailored training experiences, conduct data analyses, and publish 2-3 papers per year. Directed study, a weekly research seminar, regular career development seminars, participation in grant preparation, selected course attendance, and limited patient care and teaching round out the training. Physician trainees will enter a specific track that includes an optional 1-year MS degree in epidemiology or in clinical investigation. Trainee selection is based on interest in cardiovascular disease prevention, potential for an academic research career, and demonstrated excellence. We request eight postdoctoral positions for trainees who have either the M.D. or Ph.D. degree, or both. Of the 30 postdoctoral fellows completing training in the past 10 years (2001- 2010) 26 (87%) are currently in academic or other research positions; of the 39 postdoctoral trainees appointed in the past 10 years, 26 were women (67%) and 8 were under-represented minorities (21%; 2 Hispanic, 5 African-American, 1 Native American). Six of the eight are in academic positions, and two are still in training here.

6-Year Study of Seniors. Neighborhood Environments, Physical Activity & Function Built environment changes have been recommended by the IOM, CDC, and others to improve physical activity (PA). Such changes may be most important for vulnerable groups like older adults who are least active and least studied. Scientists consistently call for prospective studies of built environment and PA. The proposed study is a 6-year follow-up of the Senior Neighborhood Quality of Life Study (SNQLS) cohort of 66+ year-old residents of neighborhoods selected to maximize variability in walk ability and income. Analyses of current data show neighborhood environments are related to PA and BMI. SNQLS is more methodologically advanced than other studies, with objective and perceived measures of both environments and PA, and a prospective follow-up can strengthen evidence of causality. A key innovation is re-assessment of the full range of PA-related environmental characteristics, including walk ability (GIS measured mixed use & street connectivity), microscale features (systematically observed and self-reported streetscape details such as sidewalk quality, safety of street crossings), and access to senior-relevant recreation facilities (GIS and reported). In addition to repeating accelerometer measures, we will add GPS assessment of mobility within neighborhoods. Aim 1, guided by ecological models, is to explain patterns of change in PA from 7-day accelerometry over 6 years by comprehensive measures of neighborhood environments and psychosocial variables. Secondary aims will assess moderators (eg, physical function) of the relationship of 6-year change in PA with environmental measures and environmental correlates of 6-year changes in a validated measure of physical function, walking for transport and recreation, BMI, and sedentary time. Exploratory aims will assess the impact of changing residences and examine correlates of GPS-measured mobility and its health consequences. Based on pilot data, we expect to measure 70% (projected follow-up N=603) of the sample who participated at Time 1. The study will fill many gaps in knowledge about the relation of environments to multiple health outcomes in seniors. The interdisciplinary team will use results to advance the science of environments and health and develop evidence-based guidelines for designing neighborhoods that support healthy aging.

DESCRIPTION (provided by applicant): Virtual Advisors for Physical Activity Promotion in Aging Latino Communities BACKGROUND: Aging Latino adults suffer disproportionately from a number of chronic conditions (e.g., diabetes, obesity) improved by increased physical activities (PA) such as walking. Due to language, education, computer, and health literacy barriers, older Latino adults often cannot readily access typical health promotion programs offered in-person or online in U.S. communities. Lay health advisors (promoters in Spanish) offer a nationally recognized, culturally tailored and cost-efficient health behavior change model for Latino communities. However, as with all human delivered health programs, they impose constraints on participant schedules, and, even with careful intervention fidelity procedures in place, some variability in program delivery across advisors is inevitable. Computer-based culturally tailored physical activity advisor programs can potentially reduce human- to-human scheduling and fidelity constraints and extend program reach. In a recently completed 4- month experiment, a computer-based bilingual Virtual Advisor with touch-screen interactivity (no keyboard or mouse needed) was housed in a community center and programmed to tailor PA advice to the needs and preferences of low-income, aging Latino adults. The Virtual Advisor program successfully increased regular walking levels in participants compared to a health education control. OBJECTIVE: The primary study aim is to conduct a comparative effectiveness trial evaluating the 12- month impacts of the community-based Virtual Advisor PA program relative to a proven Lay Advisor program in a broader population of aging Latino adults. The secondary aim is to determine the comparative cost effectiveness of the Virtual vs. Lay Advisor programs. DESIGN: The 12-month randomized trial will enroll inactive Latino adults ages 55 years and older living near 16 neighborhood community centers (n=265/arm; 530 total). The primary outcome is minutes of walking per week, and additional outcomes of interest include BMI, sedentary behavior, functional performance, and health- related quality of life. Additional areas of investigation are to evaluate theoretically based and empirically supported moderators and mediators of intervention success and determine the potential generalizability of the interventions. IMPACT: The study seeks to demonstrate that a computer-based Virtual Advisor tailored to the needs of aging Latino adults can provide an effective and potentially cost-efficien alternative to Lay Advisors in community settings frequented by this population. The potential extended reach of such programs for use in a range of community settings (e.g., clinics, pharmacies, libraries) provides substantial promise for positively impacting the current health disparities gap.

DESCRIPTION (provided by applicant): Latinos are the fastest growing ethnic group in the US and are disproportionately impacted by chronic conditions (e.g., overweight/obesity, diabetes) that can be mitigated by physical activity. While evidence-based programs are available to improve physical activity, dissemination is constrained by reliance on costly, limited resources. Short message service (SMS or text messaging) has strong potential as an intervention medium for Latinos, as they are dominant users of mobile phones and text messaging, including those with limited literacy and computer skills. We propose to develop a personalized, culturally-congruent and interactive SMS program to promote the adoption and maintenance of physical activity for overweight, underactive Latino adults and test it for comparable efficacy to an evidence-based telephone-based advising program that has been used successfully with Latinos. Grounded in Social Cognitive and Self-Determination Theories, both programs will include a core set of self-regulatory skill building, social support, and autonomous motivation enhancement, and will be tailored for cultural, linguistic and literacy appropriateness. Randomized at the individual level, 376 sedentary, overweight Latinos ages 45 years and older will be assigned to one of three arms: the SMS- delivered physical activity program, the Human-delivered physical activity program, or an attention-control arm of SMS-delivered basic healthful nutrition advice. They will receive their assigned program for 12 months, and then will be followed for a 6-month maintenance phase, with a final assessment at 18 months. Analyses will determine if the two physical activity programs result in equivalent efficacy in adoption and maintenance of clinically meaningful physical activity increases, and superiority over the attention-control arm at 12 and 18 months. The two physical activity interventions will also be compared for equivalency in prevention of weight gain and reduction in abdominal adiposity. We will explore the relative costs of the programs to determine which program increases physical activity for a lower cost. While health promotion programs delivered by professional staff may be more expensive than those delivered electronically, it is unclear if the automated version can produce more cost-efficient outcomes (i.e., comparable improvements in outcomes for significantly reduced cost). This study will determine if SMS is equivalent in efficacy to the traditional human-delivery channel in increasing physical activity and preventing weight gain, and if it results in a more cost-efficient program. If achieved, this research can significantly reduce health disparities associated with physical activity for Latinos by providing an efficacious tailored and culturally appropriate program poised for widespread dissemination and rapid uptake.

Project Summary/Abstract Background: Low-income midlife and older adults are disproportionately impacted by a range of chronic diseases and conditions that contribute to widening US health disparities and can be alleviated by regular physical activity (PA), yet are among the most inactive segments of the US population. Relatively few PA programs have been developed specifically with their needs in mind, most of these interventions remain primarily at the individual level of impact, and few such interventions take full advantage of the recognized impacts that built and social environmental factors have for increasing and sustaining daily PA. Objective: The major objective of this application is to enhance the potential scalability and sustainability of person-level PA interventions by leveraging the capacity of residents themselves as local data gatherers and solution generators for neighborhood environmental change. The primary aim of the proposed group-randomized trial is to systematically compare the sustained (two-year) multi-level impacts of a lay advisor-delivered, person-level PA intervention that has demonstrated efficacy and translatability (Active Living Every Day) [ALED Alone arm], versus the ALED program in combination with a novel neighborhood-level intervention, called Our Voice [ALED+Our Voice arm]. The Our Voice program teaches residents to use a simple mobile application to individually and collectively identify neighborhood barriers to daily PA. They then convey this information to local stakeholders and decision-makers in ways that can facilitate potentially sustainable neighborhood-level improvements in support of regular PA. Design: We propose to randomize 16 public housing sites serving low- income, ethnically diverse midlife and older adults to ALED Alone vs. ALED+Our Voice (n=265 participants per arm; total=530). We hypothesize that 2-year ALED+Our Voice participant PA, measured via accelerometry, will be higher than in ALED Alone. We also will evaluate the 2-year impacts of the two programs on neighborhood- level PA using a standardized PA observation tool (SOPARC-path form). Additional questions of interest include levels of PA change at intermediate measurement time points; exploration of intervention effects in relation to a set of putative multi-level mediators; and exploration of the relative costs of the two interventions in relation to PA changes. We will also explore, in both arms, ongoing participant communication with local stakeholders (i.e., local organizations, media) that can set the stage for continued social and built environment changes beyond the project period. IMPACT: If the preliminary evidence supporting the promise of the Our Voice community engagement program is confirmed, it will provide a means for expanding the impacts and reach of person-level PA interventions beyond participants themselves to the neighborhood setting. This can, in turn, provide a scalable means for potentially sustainable PA promotion across broader income groups of relevance to US health disparities.

Abstract The goal of this project is to build a state-of-the-science regional center of research excellence in Colombia, known as the Stanford-Colombia Collaboratory on Chronic Disease (S-C3), whose focus is on the prevention of major non-communicable diseases (NCDs) facing Colombia and the region, including cancer, diabetes, cardiovascular disease, and depression. Physical inactivity is one of the most important contributors to the global burden of NCDs, responsible for ~6-10% of major NCDs worldwide. The prevalence of physical inactivity and sedentary behavior is increasing in LMICs and approaching levels of higher income countries. In Colombia, 47% of adults and 74% of adolescents do not meet physical activity recommendations. Multi-level approaches that promote physical activity at the individual, family, community, and societal levels hold substantial promise for effectively preventing and controlling the major NCDs. We and others have demonstrated effective strategies for increasing physical activity across the socioeconomic gradient using approaches that leverage widely available information technologies such as smartphone applications (apps), SMS/text messaging, interactive voice response systems, and culturally tailored virtual advisors. This grant application builds upon an existing productive collaboration between scientists from Stanford University and the Universidad de los Andes in Bogotá, Colombia. The S-C3 will enable scientists in the region to expand their expertise to include development and rigorous evaluation of behavioral interventions to promote physical activity that are effective and scalable. Our specific aims are the following: 1. Establish the necessary infrastructure to support a regional center of research excellence for NCD prevention in Colombia. The S-C3 will represent a partnership among key organizations in Colombia, including Universidad de los Andes, Universidad del Rosario, their partners from the sectors of Health, Sports and Recreation, as well as Transport and Urban Planning, and Stanford School of Medicine. 2. Build sustainable mechanisms for increasing research capacity aimed at developing and rigorously testing theory-based interventions that leverage culturally tailored, widely available technologies aimed at primary and secondary prevention of NCDs in Colombia. Capacity-building activities in Colombia will serve as a resource and a model for other Latin American countries. 3. Demonstrate the partnership's capability for engaging in cutting-edge behavioral intervention research to promote physical activity and prevent NCDs. We will conduct two initial pilot studies that target individual and community levels to increase physical activity in underserved populations. 4. Develop short-, mid-, and long-term trans-disciplinary research plans that focus on optimizing regional capacity for impactful change in the prevalence of NCD's in Colombia. We will leverage the partnership's expertise in creating effective physical activity interventions in diverse Latino populations.

Project Summary / Abstract The mission of the Stanford BSSR Pre-Doctoral Training Program at the Intersection of Data Sciences with Behavioral, Social, and Population Health Research is to develop a cross-campus collaborative training program to provide talented pre-doctoral students with advanced specialized training at the intersections of social and behavioral health science, social epidemiology, data science, and population health. We are building a new team that spans the Stanford campus including faculty from 6 schools and 11 departments. We will provide a transformative multi-disciplinary predoctoral training environment that draws mentors from diverse fields (health and social psychology, medical sociology, social epidemiology, communications, health economics, business, education, law) and quantitative disciplines (computer science, informatics, statistics). The graduates of our program will have rigorous training in their own scientific disciplines, combined with extensive expertise working on a broad range of innovative research projects that rely on data of primarily two types: (1) intensive or voluminous longitudinal data from mHealth, smartphone and sensor technologies or electronic health records, and/or (2) large and complex data from internet, commercial, health administrative records, large population databases, internet data and social media platforms, crowd sourcing, and citizen science data. Predoctoral trainees in their first or second year of graduate studies will be admitted from programs in health psychology, medical sociology, social/behavioral epidemiology, health economics or another social science discipline. We are requesting support for 5 pre-doctoral students per year whose training will last 2 or more years. They will emerge from the program with a thorough understanding of their own fundamental discipline combined with advanced expertise in cutting-edge statistical and computational methods for analyzing increasingly complex and multidimensional longitudinal sets. The training program components will include both department or discipline-specific training in addition to program-wide data science components including: (1) innovative curriculum, including specialized quantitative curriculum customized to the experience and background of each trainee; (2) a mentored research experience with a dual mentor model (one disciplinary mentor, one methodological mentor); (3) exposure to team science approaches to problem solving, including design thinking, cross-disciplinary collaborations, and team building; (4) experiential components, including availability of Stanford dry-lab rotations and short-term internships in Silicon Valley companies; (5) forums for intellectual exchanges; and (6) many opportunities to develop professional skills in grant writing and collaboration. BSSR graduates will have the capability to conduct cutting edge research on behavioral and social, and health issues, as well as prevention and treatment interventions that have the potential to reduce the risks of heart, lung, blood, and sleep (HLBS) disorders and improve outcomes among patients with these disorders.