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PUBLIC HEALTH – SOCIAL AND BEHAVIORAL HEALTH Edited by Jay Maddock

Public Health – Social and Behavioral Health Edited by Jay Maddock

Published by InTech Janeza Trdine 9, 51000 Rijeka, Croatia Copyright © 2012 InTech All chapters are Open Access distributed under the Creative Commons Attribution 3.0 license, which allows users to download, copy and build upon published articles even for commercial purposes, as long as the author and publisher are properly credited, which ensures maximum dissemination and a wider impact of our publications. After this work has been published by InTech, authors have the right to republish it, in whole or part, in any publication of which they are the author, and to make other personal use of the work. Any republication, referencing or personal use of the work must explicitly identify the original source. As for readers, this license allows users to download, copy and build upon published chapters even for commercial purposes, as long as the author and publisher are properly credited, which ensures maximum dissemination and a wider impact of our publications. Notice Statements and opinions expressed in the chapters are these of the individual contributors and not necessarily those of the editors or publisher. No responsibility is accepted for the accuracy of information contained in the published chapters. The publisher assumes no responsibility for any damage or injury to persons or property arising out of the use of any materials, instructions, methods or ideas contained in the book. Publishing Process Manager Romina Skomersic Technical Editor Teodora Smiljanic Cover Designer InTech Design Team First published May, 2012 Printed in Croatia A free online edition of this book is available at www.intechopen.com Additional hard copies can be obtained from [email protected]

Public Health – Social and Behavioral Health, Edited by Jay Maddock p. cm. ISBN 978-953-51-0620-3

Contents Preface IX Section 1

Obesity, Food and Physical Activity 1

Chapter 1

The IDEFICS Intervention Toolbox – A Guide to Successful Obesity Prevention at Community Level 3 Vera Verbestel, Stefaan De Henauw, Staffan Marild, Stefan Storcksdieck genannt Bonsmann, Laura Fernández Celemín, Katharina Gallois, Holger Hassel and Ilse De Bourdeaudhuij

Chapter 2

Testing the Assumptions of Stage of Change for Fruit and Vegetable Consumption: A Naturalistic Study 41 Jay E. Maddock, Jodi D. Barnett, Carrie S. Marshall and Claudio R. Nigg

Chapter 3

Strategies for Cardiovascular Disease Prevention in Rural Southern African American Communities 59 Ralphenia D. Pace, Norma L. Dawkins and Melissa Johnson

Chapter 4

Gender Differences in Food Choice and Dietary Intake in Modern Western Societies 83 Claudia Arganini, Anna Saba, Raffaella Comitato, Fabio Virgili and Aida Turrini

Chapter 5

Iron Food Fortification for the Control of Childhood Anemia in Brazil Joel Alves Lamounier, Flávio Diniz Capanema and Daniela Silva Rocha

103

Chapter 6

Economic Stressors and Childhood Obesity: Differences by Child Age and Gender 115 Steven Garasky, Craig Gundersen, Susan D. Stewart, Joey C. Eisenmann and Brenda J. Lohman

Chapter 7

Critical Appraisal of Selected Body Composition Data Acquisition Techniques in Public Health 133 Steven Provyn, Aldo Scafoglieri, Jonathan Tresignie, Céline Lumé, Jan Pieter Clarys and Ivan Bautmans

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Contents

Chapter 8

Physical Activity, Inactivity, and Nutrition Behavior Among Children: Investigating Compensation and Transfer Effects Judith Väth, Katie Amato and Claudio R. Nigg

153

Chapter 9

U.S. Food Policy and Obesity 165 Julian M. Alston, Abigail M. Okrent and Joanna C. Parks

Section 2

Addictive Behaviors

185

Chapter 10

Alcohol Consumption Among Adolescents in Estonia 1994 – 2010 187 Kersti Pärna, Mariliis Tael, Inge Ringmets and Katrin Aasvee

Chapter 11

Public Health and Indigenous Australian Gambling: Risky Lifestyle or Harmless Recreation? 205 Helen Breen, Nerilee Hing and Ashley Gordon

Chapter 12

Self Medication, Drug Dependency and Self-Managed Health Care – A Review 223 A. O. Afolabi

Chapter 13

The Relationship Between Alcohol Consumption and Human Immunodeficiency Virus Infection and Risk Behaviour: A Systematic Literature Review of High-Risk Groups, with a Focus on South Africa 243 Manuela G. Neuman, Michelle Schneider, Radu M. Nanau, Charles Parry and Matthew Chersich

Section 3 Chapter 14

Chapter 15

Emerging Methods 293 Challenges in Healthcare in Multi-Ethnic Societies: Communication as a Barrier to Achieving Health Equity Emine Kale and Bernadette Nirmal Kumar Public Health Research and Action: Reflections on Challenges and Possibilities of Community-Based Participatory Research S. Lazarus, B. Duran, L. Caldwell and S. Bulbulia

309

Chapter 16

Nature Therapy and Preventive Medicine 325 Juyoung Lee, Qing Li, Liisa Tyrväinen, Yuko Tsunetsugu, Bum-Jin Park, Takahide Kagawa and Yoshifumi Miyazaki

Chapter 17

How Can the Empowerment Role of Public Health Nurses (PHNs) Be Fostered? A Review of an Exploratory Research Study Conducted in Ireland and Current Evidence 351 Teresa Cawley

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Contents

Chapter 18

Disseminating an Evidence-Based Disease Self-Management Program for Older Americans: Implications for Diversifying Participant Reach Through Delivery Site Adoption 385 Matthew Lee Smith, Basia Belza, Mary Altpeter, SangNam Ahn, Justin B. Dickerson and Marcia G. Ory

Chapter 19

Strategy and Practice of Support for Families with Multiple Births Children: Combination of Evidence-Based Public Health (EBPH) and Community-Based Participatory Research (CBPR) Approach 405 Syuichi Ooki and Kiyomi Hiko

Section 4

Special Populations and Settings

Chapter 20

TB Control in Prisons J. Noeske

Chapter 21

Social Determinants of Health in Deaf Communities Scott R. Smith and Nancy P. Chin

431

433

449

Chapter 22

Anxiety and Emotional Discomfort in the School Environment: The Interplay of School Processes, Learning Strategies, and Children’s Mental Health 461 L. Tramonte and J. D. Willms

Chapter 23

Re-Emergence of HIV Infection and Syphilis Among Men Who Have Sex with Men 477 Maria Antonella Di Benedetto, Nino Romano and Alberto Firenze

Chapter 24

Gun Violence in the United States: A Public Health Epidemic Amy J. Thompson

501

Chapter 25

The Public Health Intervention of Skin Care for All: Community Dermatology 523 Terence J. Ryan, Steven J. Ersser and Lucinda Claire Fuller

Chapter 26

Addressing Asthma from a Public Health Perspective 537 Adam Davis and Mindy Benson

Chapter 27

An Integrated Theoretical Framework to Describe Human Trafficking of Young Women and Girls for Involuntary Prostitution Thozama Mandisa Lutya and Mark Lanier

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VII

Preface Human health is greatly influenced by the daily behaviors and patterns that make up our lives. Tobacco use, physical inactivity, poor nutrition, immoderate alcohol use, drug use, violence, unsafe sexual practices and other risky behaviors account for a large proportion of premature morbidity and mortality worldwide. Over the last couple of decades, the role of the social sciences in influencing and changing human behaviors has become more prominent. Psychology, sociology, political science, economics, anthropology, communications and political science have all played an important role in health counseling, group based interventions, social marketing and policy change. A student being trained in a Master’s of Public Health program in Health Promotion needs to be versed in all of these areas to be effective at changes population level behaviors. This book provides an overview of the influence of the social and behavioral sciences to many public health issues that confront us today. In the first section, the chapters explore the growing problem of obesity and the related behavioral factors of physical inactivity and poor nutrition. Chapters examine the effects of food policies including iron fortification of foods, psychological theory testing to improve health, gender differences, the effect of stress on obesity and strategies to prevent childhood obesity and reach rural communities. In the second section, the chapters explore the effects of addictive behaviors. Issues around alcohol use, drugs and gambling are explored both in comprehensive reviews and in county level analyses. The third section examines a variety of different approaches and methods to changing health behaviors. These include evidence-based public health, community-based participatory research, empowerment, communication and dialog and even nature therapy. The final section reviews a variety of at-risk populations including prisoners, men who have sex with men, school children, deaf persons, school children and young women involuntarily participating in prostitution. Reviews of important but often neglected public health areas such as gun violence, skin care for all and asthma are also presented. This book exemplifies the global nature of public health. All six inhabited continents are represented by authors in this book. The home country of the authors include Australia, Estonia, South Africa, Nigeria, Brazil, Canada, Korea, Finland, Japan, Great Britain, Ireland, USA, Belgium, Sweden and Italy. This trans-national list of authors provides an important view of the future of public health and the increased need to

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Preface

collaborate with public health professionals across the world to address the myriad of public health issues. I hope you enjoy reading the following chapters. I find them to be insightful and to provide an excellent collection of the ways that the social and behavioral health sciences are being used to protect and promote the public’s health. Aloha.

Prof. Jay Maddock Department of Public Health Sciences, University of Hawai‘i at Mānoa USA

Section 1 Obesity, Food and Physical Activity

1 The IDEFICS Intervention Toolbox – A Guide to Successful Obesity Prevention at Community Level Vera Verbestel1, Stefaan De Henauw1, Staffan Marild2, Stefan Storcksdieck genannt Bonsmann3, Laura Fernández Celemín3, Katharina Gallois4, Holger Hassel4,5 and Ilse De Bourdeaudhuij1 1Ghent

University, Ghent, of Public Health and Community Medicine, Gothenburg, 3European Food Information Council (EUFIC), Brussels, 4University of Bremen, Bremen, 5Hochschule Coburg, University of Applied Sciences, Coburg, 1,3Belgium 2Sweden 4,5Germany

2Department

1. Introduction The chapter provides an overview of the IDEFICS (Identification and prevention of Dietaryand lifestyle-induced health EFfects In Children and infantS) intervention and its general content and structure, including the core set of intervention modules, communication strategies and corresponding standard operating procedures for use in preschools, primary schools and other settings and dissemination channels. The chapter does not present information on the development of the IDEFICS intervention but aims to provide practical guidance and recommendations for local policy makers and/or local public health authorities who wish to implement the intervention in their cities or communities. Every authority or institution wishing to implement the intervention will have to adapt all the intervention modules to account for local and/or culture-specific constraints. This can be done on the basis of qualitative research or equally valid sources of relevant information. General aspects of the IDEFICS project and the development of the IDEFICS community-oriented intervention programme have been described in detail elsewhere (Ahrens et al., 2006; Ahrens et al., 2011; De Henauw et al., 2011; Pigeot et al., 2010; Verbestel et al., 2011). 1.1 Timing of the IDEFICS intervention activities The timeline of the IDEFICS intervention is divided into three parts, referring to the classical phasing of establishing interventions (see Table 1): intervention adoption phase,

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intervention implementation phase and intervention dissemination phase. The intervention adoption phase was proceeded by a one-year preparation phase. Intervention preparation phase (Year 1) The implementation of a culturally adapted version of the IDEFICS intervention needs to be planned in advance. Therefore, local authorities or institutions aiming to implement the intervention, are recommended to consider a preparation phase of at least one year. During this period, necessary arrangements can be made for the start of the adoption phase. One of the most important arrangements that needs to be made during the preparation phase is to build a local intervention team. A local intervention team is a group of people that is preferably composed by the local authority or institution that aims to implement the intervention. It should consist of local experts in the field of health promotion and/or representatives of the respective authority or institution. The local intervention team needs to be able to prepare the adoption phase of the intervention and to support and supervise the implementation of the intervention during the first year. This support and supervision will gradually decrease so that local structures (community, family and schools) can independently continue the health-promoting efforts initiated by the intervention. The role of the local intervention team throughout the phases of the intervention is described in more detail below. First intervention period = Adoption phase (Year 2) Assuming that a school year starts in September, this phase should cover the period from September to August of Year 2 and starts right after the preparation phase (Year 1). During this period, the intervention will be launched and installed in the community, family and schools. This period is characterised by the continuous provision of material and logistic input, support and supervision from the local intervention team.

Year 1 Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul

Preparation phase

Year 2

Year 3

Year 4 and onwards

Intervention Intervention Intervention implementation dissemination adoption phase phase phase (support and (only (no support, no supervision) supervision) supervision)

Aug Table 1. Timeline of the IDEFICS intervention activities

The IDEFICS Intervention Toolbox – A Guide to Successful Obesity Prevention at Community Level

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Second intervention period = Implementation phase (Year 3) This phase covers the period from September to August of Year 3 and starts right after the adoption phase (Year 2). During this period, the intervention will be sustained and further progressed by the community, schools and families themselves without continuous material support from the local intervention team, but still with some degree of supervision. Third intervention period = Dissemination phase (Year 4 and onwards) This period starts in September of the school year after the implementation phase (Year 3) and aims at continuing the IDEFICS intervention without support and supervision of the local intervention team. 1.2 Dimensions of the IDEFICS intervention The development of the child has to be viewed from an interactive and contextual perspective. The ecological environment of a child includes the family and the school which are in turn situated in the community and the society at large. Interactions within and among these social contexts result in changes within, and influence the development of, the individual child (Davison & Birch, 2001).

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Recreation and fitness sector Sport and youth organisations Private actors (food companies, grocery stores)

-

-

Residents’ associations Organisations targeting persons with low socioeconomic status Social services and welfare sector Communication sector: local media

-

-

Local municipality (especially public health authorities) Local politicians Health care providers (paediatrician, family doctor, …)

Fig. 1. Dimensions of the IDEFICS intervention: the individual, the family, the school and kindergarten and the community level

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The community-based IDEFICS intervention takes a holistic approach associated with this contextual and interactive perspective of human development and is being executed on three intertwining levels: community level, school level and family level (Figure 1). Possible stakeholders in the community that can have an impact on the prevention of obesity are illustrated. The local intervention team has to analyse its own intervention community and identify the key persons and stakeholders. 1.3 Behaviours targeted by the IDEFICS intervention The behaviours that were targeted by the IDEFICS intervention can be found in Table 2. From this point onwards, these target behaviours will be called the “key messages”. The selection of these key messages was based on the available evidence in the scientific literature. Detailed information on this selection process is outside the scope of this chapter and can be found elsewhere (Verbestel et al., 2011). Due to the complex nature of the problem, there is also scientific evidence available showing additional behaviours having an influence on the development of childhood obesity (e.g. portion sizes and snacking). This means that multi-topic interventions for the prevention of childhood obesity do not necessarily have to focus on the below mentioned key messages. Other behaviours can be chosen as the focus of the intervention, as long as they are supported by scientific evidence in the childhood obesity preventive literature.

Diet Stimulate daily consumption of water Stimulate daily consumption of fruit and vegetables

Physical activity

Stress, coping and relaxation

Reduce TV-viewing

Spend more time together

Stimulate daily physical activity

Ensure adequate sleep duration

Table 2. The six key messages targeted by the IDEFICS intervention 1.4 Overview of the IDEFICS intervention modules The identification and elaboration of the IDEFICS intervention modules was predominantly carried out during the first year of the project on the basis of literature reviews, expert consultations and focus group research (Verbestel et al., 2011). The modules have been developed as distinct sets of activities but it should be realised that some of these modules are partly overlapping and/or interacting with one another. Table 3 illustrates how different modules have been conceived within a grid of targeted behaviours and intervention levels. Some modules have a more general scope whereas others are much more specific and focusing on a particular intervention level or behavioural dimension. The general content and structure supplemented with a description of the core actions for all the IDEFICS intervention modules is provided in the sections below.

The IDEFICS Intervention Toolbox – A Guide to Successful Obesity Prevention at Community Level

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COMMUNITY

SCHOOL

FAMILY

INDIVIDUAL

DIET

Module 1 Module 2 Module 3

Module 4 Module 8 Module 9

Module 10

Module 5

PHYSICAL ACTIVITY

Module 1 Module 2 Module 3

Module 4 Module 6 Module 7

Module 10

Module 5

Module 1 Module 2 Module 3

Module 4

Module 10

Module 5

STRESS, COPING AND RELAXATION

Module 1: Involvement of community partners Module 2: Long-term media campaign and public relations strategy Module 3: Lobbying for community environmental and policy interventions Module 4: Building partnerships Module 5: Education of children Module 6: Environmental changes related to physical activity – The Active Playground Module 7: Health-related physical education curricula Module 8: Environmental changes and school policy related to water consumption Module 9: Environmental changes and school policy related to fruit and vegetables Module 10: Education of parents Table 3. Overview of the IDEFICS modules by behavioural focus and intervention level

2. IDEFICS intervention modules at community level 2.1 Module 1: Involvement of community partners All the community partners will be engaged in the intervention by means of a community platform, i.e. a working group on meta (community) level in which all relevant stakeholders need to be represented. The local intervention team is an essential leading actor in the implementation of this module as it is responsible for triggering and coordinating the establishment and the operation of the community platform. This means that the implementation quality of this intervention module strongly depends on the leadership capacity of the local intervention team. Objectives -

-

Create involvement and commitment of all relevant sectors of the community. Make it possible to implement the intervention at community level by the combination of support from the intervention team in the early phase followed by a gradually increasing independence of the stakeholders in the community. Stimulate the community to develop, organise and promote programmes and structural changes that encourage the healthy behaviours targeted in the intervention. Prepare the dissemination phase of the community-based intervention.

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Establishment and composition of the community platform -

-

The community platform has to be established, organised and coordinated by a local intervention team. Preferably, one community platform is created in the community. When it is obvious that the creation of a single community platform is not feasible, it can be envisaged to create more than one community platform (e.g. when different communities are part of a larger intervention region). If a community already has a community platform, it is recommended to integrate the IDEFICS platform within the existing one. Every community platform has to include at least one representative from all important stakeholders in the community: each local intervention team has to analyse their own community to identify such key persons within these stakeholders. Stakeholders are perceived important when they are able to reach vulnerable groups, persons with low(er) socio-economic status or migration groups and/or if they can contribute significantly to the prevention of (childhood) obesity.

Task and responsibilities of the community platform The community platform is responsible for the development and implementation of all the intervention modules at community level, i.e.: -

Module 2: Long-term media campaign and public relations strategy Module 3: Lobbying for community environmental and policy interventions

Within this section, the tasks and responsibilities of the community platform are briefly outlined. More detailed and concrete descriptions can be found in the relevant module sections. Because of the ecological perspective associated with the IDEFICS intervention, interactions within and among the different contexts in the community - as illustrated in Figure 1 above are essential. The community platform is therefore expected to support the implementation of modules at other levels: -

Module 5: Education of children (school level) Module 10: Education of parents (family level)

The community platform will not be responsible for the intervention modules at the school level. The implementation of these modules will be organised by a working group at the school level (see module 4). Regarding module 5 and 10, the community platform will mainly provide logistic and reinforcing support (e.g. the provision of posters to the school working group). This support is explained in more detail within the appropriate module sections. Operation of the community platform during the intervention adoption phase (Year 2) The first part of the adoption phase (September – June, Year 2) is dedicated to building the infrastructure for implementing the intervention modules: -

All the participants of the community platform will receive instructions and guidelines about the modules that have to be implemented in the community. The community platform will work closely with the local intervention team in order to implement the community-level modules.

The IDEFICS Intervention Toolbox – A Guide to Successful Obesity Prevention at Community Level

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-

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The local intervention team will be in charge and will coordinate the community platform. If possible, the local intervention team is recommended to appoint a local coordinator from the beginning of the platform. The local coordinator is a person from the community (e.g. the chair of an already existing platform) who will be responsible for chairing the platform the year afterwards. The local intervention team and the community platform should preferably meet once a month. These meetings make it possible to evaluate the implementation of the modules and to discuss and solve practical problems that have occurred or possibly will occur.

Guidelines for the meetings of the community platform -

During the first meeting: • make an inventory of the local initiatives related to the prevention of obesity in the different sectors involved in the platform. During all the meetings: • always write a meeting report, as these reports can be used to analyse the implementation process of the intervention. • evaluate the aspects of the intervention modules that have been executed and provide strong support for the implementation of the (parts of the) modules that still have to be performed. • do not only discuss and evaluate the aspects of the intervention that have been successful but also address any challenges or failures. • continuously observe and detect what is going on inside the community related to the prevention of childhood obesity. • do not ignore but take notice of new initiatives that are proposed by the community platform members.

The second part of the adoption phase (July – August, year 2) is the transition period between the intervention adoption phase and the intervention implementation phase. This transition period is an intermediate stage between the intensively supported operation and the supervised operation of the community platform. During the transition period, following actions are recommended: -

-

In cooperation with the local intervention team, the community platform can search and appoint a local coordinator who can continue the responsibilities of the local intervention team. This local coordinator becomes the person in charge and will be responsible for coordinating the community platform. The local intervention team is responsible for the transfer of information to the local coordinator. It is essential that local coordinators can start their activities at the beginning of Year 3 (see Table 3).

Operation of the community platform during the intervention implementation phase (Year 3) The community platform is expected to continue with the activities and to work out new initiatives with minimal supervision and without continuous support of the local intervention team. From September of Year 3 onwards, the local intervention team no longer participates in the monthly meetings of the community platform. Starting from this moment, the local coordinator (of the community platform) has to be able to take over the role of the local intervention team.

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The local intervention team must keep itself informed about the initiatives of the community platform. For this reason, the local intervention team and the community platform are recommended to meet 3 times during the intervention implementation phase, i.e. once between September and December of Year 3 and twice between January and August of Year 3. Between the obligatory meetings, the community platform should have the possibility to keep in touch with the local intervention team in order to solve practical problems or get advice if necessary. Operation of the community platform during the intervention dissemination phase (Year 4 onwards) From year 4 onwards, the community platform is expected to operate completely independently, without any support or supervision from the local intervention team. 2.2 Module 2: Long-term media campaign and public relations strategy A first topic in the long-term media campaign and public relations strategy is the overall approach by which the intervention will become well known and the key messages will be spread in the community. A second issue in module 2 is the specific promotion campaign for the key messages by means of a slogan intervention. 2.2.1 Multimedia and public relations campaign (overall strategy) Objectives -

Facilitate cooperation of the stakeholders and community members with the IDEFICS intervention team. Avoid objection and resistance against the intervention. Inform all stakeholders and community members about the intervention. Attract funding or sponsoring.

The local intervention team can develop its own public relations strategy and timing, depending on the local needs and resources. Some examples of multimedia and public relation instruments that can be useful to fulfil the objectives of the overall strategy are leaflets (newsletters), information events, posters and a website in the local language. It is also recommended to not only rely on contacts and infrastructure of universities or health institutions but to establish own local media relations by developing for example a media kit (including press kit, contact list, media server) and/or organise media briefings (e.g. local kick-off event in September of Year 2). 2.2.2 Promotion campaign for the key messages (slogan intervention) Objectives -

Make the community aware of the key messages. Promote the key messages as important components of long-term health.

Window and street posters as a promotion campaign for the key messages Window and street posters can be used to promote the key messages within the community:

The IDEFICS Intervention Toolbox – A Guide to Successful Obesity Prevention at Community Level

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Recommended characteristics of the window and street posters are described in Table 4 below. The following guidelines are recommended for the development of the window and street posters: • The local intervention team is recommended to develop 3 posters: 2 posters about physical activity and diet (one key message of each theme combined on each poster) and 1 poster about sleep duration. • The window and street posters should reflect the same message. The street poster should be a bigger copy of the window posters. • The posters should be simple and attractive: the message should be readable and understandable in a couple of seconds and the text should be a short, striking and attractive slogan. • Multi-colour printing is very expensive and may distract the attention of the message. Black and white printing is much cheaper and more clearly visible. A message in black and white printing (can be printed on coloured paper) has the reputation to be very effective.

Dimensions of the poster

Window posters Minimum A3-format (maximum 50 - 70 cm, however, this size can already be a barrier to hang up the poster)

Street posters Minimum 50 – 70 cm

Target groups

Pedestrians, cyclists and car drivers

Pedestrians, cyclists and car drivers

Preferred places

Very suitable to hang up in public places, supermarkets and grocery stores, libraries, houses of residents, …

On the street site, preferably on places where a lot of people have to stop (e.g. traffic lights)

Table 4. Recommended characteristics of the window and street posters Because the visibility of the window and street posters will be synchronised with the integration of the key messages in the school curriculum (see module 5), the turnover of the posters is recommended to be set at 4 months for physical activity and diet and at 3 months for stress, coping and relaxation. The timing and turnover of the window posters during Year 2 of the IDEFICS project are shown in Table 5. Intervention adoption phase (Year 2) Oct

Nov

Dec

Jan

Window (and street) poster related to physical activity and diet (1st poster)

Feb

Mar

Apr

May

Window (and street) poster related to physical activity and diet (2nd poster)

Jun

Jul

Aug

Window (and street) poster related to sleep duration (3rd poster)

Table 5. Timing and turnover of the window (and street posters) in Year 2 of the IDEFICS project

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The window posters that were used in the IDEFICS intervention, are displayed below. These posters are available in the languages of those countries where the IDEFICS intervention was tested for its effectiveness (Belgium, Cyprus, Estonia, Germany, Hungary, Italy, Spain and Sweden).

Tasks and responsibilities of the community platform -

-

-

The distribution of the window and street posters is a task of the community platform. The community platform is responsible for the distribution of the posters at the right time in the different sectors of the community (see stakeholders). For example: the school is an important and easy setting to distribute the window posters to the residents of the community. Thus, the community platform also has to take care that the schools received the window posters in time. It is important that the community platform not only distributes the posters but also checks if the posters are in actual fact displayed. The community platform is responsible for encouraging the concerned institutions and/or persons to make the posters visible. The community platform is recommended to carry out a sample survey: this means that it has to register how many houses of the selected streets there is a poster in the window (the sample survey can be used for assessing the process of implementation of this module).

2.3 Module 3: Lobbying for community environmental and policy interventions Module 3 requires the community platform to lobby for improving the community environment and for policy interventions to prevent obesity in the community. This task consists of four separated parts: 1. 2. 3. 4.

Community environmental interventions to promote physical activity Community environmental interventions to promote the consumption of water A short-term perspective of community-based prevention of obesity A long-term perspective of community-based prevention of obesity

The IDEFICS Intervention Toolbox – A Guide to Successful Obesity Prevention at Community Level

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The community environmental interventions to promote physical activity and the consumption of water are strongly recommended to be put on the agenda of the community platform and should be implemented during the adoption phase. The short-term perspective of community-based prevention of childhood obesity requires efforts of the community platform to undertake actions/activities that contribute to the prevention of obesity within the adoption phase. The long-term perspective of the intervention aims at triggering new initiatives during the intervention adoption phase. Therefore, the community platform should start to advocate for environmental and policy interventions as soon as possible but the implementation of these interventions is not intended to be accomplished in the intervention adoption phase. 2.3.1 Community environmental interventions to promote physical activity: establishment of ‘play streets’ and community playgrounds Objective -

Provide opportunities and possibilities for outdoor activity and outdoor play to the children in the community areas at risk (= areas without opportunities/possibilities to play outdoors).

Concept of play streets Because the time children spend outdoors is positively correlated with higher physical activity levels in children (Ferreira et al., 2007), it is important that all children in the community at least have the possibility to be active outside. Community playgrounds are very important and the most favourable way to promote playing outside among young children. However, the establishment of community playgrounds is not possible everywhere. In such cases, play streets can provide children with safe opportunities to be active outside the home and attract children to different recreational activities. Play streets are spaces within neighbourhoods where road space is made available for children's play on weekend days and/or holidays (streets are closed for traffic during that time). The organisation of play streets is mostly focused on specific areas in the community with few options for leisure activities and/or opportunities to spend active time outdoor. It is supposed that families with a low(er) socio-economic status live in neighbourhoods with busy streets and no gardens, thus lack safe structures to play outside. Play streets are an easy way to remedy this situation. Identification of the concept of play street in the community The local intervention team has to identify if the concept of play streets already exists in the community. In some countries, the concept of play streets is already well known. -

If the concept DOES exist in the community, the standard operating procedure should be used. If the concept DOES NOT exist in the community, the local intervention team and the community platform are responsible for launching the play streets in the community in strong cooperation with the local municipalities.

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Identification of the community areas “at risk” The community platform has to identify the areas in the community where children have no or not enough opportunities to spend time outdoors. This can be done by identifying the number of community playgrounds, their location and condition (in areas where children have enough opportunities for outdoor activity) and by identifying the areas in the community where play streets need to be established (in areas with no or not enough places for outdoor activity). Guidelines for the establishment of the play streets or safe playgrounds in the selected areas -

-

Inform residents in the selected streets about the concept of play streets. Try to convince them to organise a play street in the street that they live. Motivate one resident to be the person in charge for a specific play street: one resident of the street has to act as an intermediary between the community platform and the residents of the street. If it is not possible to establish a play street in a certain area, try to use a public place (e.g. parking grounds) as a play street and promote this initiative in the neighbourhood. Play streets could be organised on weekends (Sundays) and particularly during vacation periods and holidays, throughout the intervention period and beyond. Advocate for the restoration of existing community playgrounds to a reasonable condition. For regions without any possibility for outdoor activity, advocate for new community playgrounds.

2.3.2 Community environmental interventions to promote the consumption of water: installation of water fountains in public places Objective -

Provide the residents of the community with opportunities to drink water in public places.

Tasks and responsibilities of the community platform -

The community platform is responsible for the availability and the promotion of water fountains in public places in the community. The community platform has to advocate for the placement of water fountains/dispensers in public places (e.g. public library, sports centres, squares). The community platform has to advertise the water fountains/dispenser in the community so that people are encouraged to use them (e.g. promote it on the website of the community, in the school and/or community paper, in the local newspapers).

2.3.3 Short-term perspective of community-based prevention of childhood obesity Every stakeholder represented in the community platform should try to undertake activities related to the prevention of obesity during the intervention adoption phase. Table 6 is a nonexhaustive list of possibilities that can be pursued by the stakeholders of the community. It is recommended that the stakeholders make efforts to realise some of these or similar initiatives.

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Stakeholder

Possible actions - Provide water and fruit and/or vegetables during internal meetings Local (e.g. meetings of the town council) and public meetings (e.g. assembly municipality of political parties). (public health - Stimulate the employees of the local authorities to drink water and authorities) provide free water during working hours. and local - Stimulate the employees of the local authorities to eat fruit and/or politicians vegetables as a snack during working hours. - Organise shopping tours, grocery tastings, cooking demonstrations, nutrition labelling. Private sector - Promote water and healthy food products such as fruit and vegetables. (food - Provide easy recipes with fruit and/or vegetables that are typical for a companies, certain season. grocery stores) - Provide ideas to drink water in several ways (e.g. with mint leaves, pieces of apple, …). - Organise extracurricular physical activity programmes. - Distribute information about sports and recreation programmes in the Working community. groups of the schools/kinder- - Enable sports and recreation programmes to make use of the school gartens facilities outside the school hours. - Organise active after-school programmes. - Provide and promote free water during the activities. - Stimulate the children to not bring sugar-sweetened beverages. Sport and - Stimulate the children to bring fruit and/or vegetables instead of less youth healthy snacks. organisations - Organise activities in which the family of the children can participate (family events). - Provide assessment, counselling and referral on physical activity, diet, stress, coping and relaxation as part of health care. Health care providers - Encourage parents to be role models for their children in the field of physical activity, diet, stress, coping and relaxation. Table 6. List of possible actions that can be undertaken by the stakeholders of the community as part of the short-term perspective of community-based prevention of childhood obesity 2.3.4 Long-term perspective of community-based prevention of childhood obesity In addition to the short-term perspective, the IDEFICS intervention also considers a longterm perspective in the prevention of childhood obesity. The start of the intervention is the best moment to start this process. The community platform should advocate for environmental and policy interventions that contribute to the prevention of childhood obesity. Based on the examples provided by Crawford & Jeffery (2005), Table 7 provides a list of possible initiatives that can be accomplished within the long term. These initiatives are linked to three different actors in the community which potentially have the ability to execute these proposals. The community platform should decide on the number of initiatives and trigger their execution by working with the relevant actors.

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Stakeholder

Possible initiatives -

Local municipality (public health authorities) and local politicians -

Private sector (food companies, grocery stores) Working groups of the schools and kindergartens -

-

Identify national obesity prevention plans and provide a significant contribution. Take initiatives that enable children to have access to sports and recreation programmes and the equipment and supplies that are needed to participate in such programmes. Promote indoor activities instead of screen-based activities (e.g. ice-skating, indoor swimming, …). Organise and promote programmes that stimulate walking, cycling, and the use of sports and recreation facilities in the community. Promote local activities that provide options for (un)structured play for children in a safe environment and at minimal cost. Enable the local public transport system to stop at the local swimming pool so that children can get there without any risk and additional cost. This applies also to other sports infrastructures. Develop safe roads in the municipality, especially those leading to schools. Safe roads are those that have safe pavements, bicycle paths, trails, and crosswalks that facilitate walking and cycling. Provide physical activity equipment into neighbourhoods that do not have access to physical activity and recreation facilities. Include healthy alternatives in the menus that are specifically available for children (e.g. include fruit as a dessert). Provide and promote healthy foods (e.g. fruits and vegetables). Make healthy foods available, accessible and attractive in the school environment. Create price incentives or use cross-subsidies to facilitate and promote healthy food. Remove sugar-sweetened beverages from vending machines in the school environment and replace them with water and/or other healthy options, or water dispensers. Create a school nutrition policy that promotes a healthy diet. Prohibit food advertising at school (e.g. sports sponsorships, exclusive marketing contracts to sell food and beverages) and do not start industry-sponsored collaborations. Promote, enable and facilitate active commuting to schools (e.g. organise walk/bike to school days, organise walking school buses or bicycle trains, provide safe bicycle sheds). Take care that adult and trained crossing guards are available at important and busy intersections around the school so that children can safely cross the streets on and from their way to school.

Table 7. Overview of possible initiatives for the long-term perspective of community-based prevention of childhood and adult obesity (Crawford & Jeffery, 2005)

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3. IDEFICS intervention modules at school and kindergarten level 3.1 Module 4: Building partnerships Building partnerships in the participating schools and kindergartens contains three levels of action: 1. 2. 3.

Alerting the staff members of the schools and kindergartens to the intervention Creation of a school working group Creation of a school platform at community level

By means of the first part of module 4, the local intervention team will aim for teachers to take part in the intervention and to support the overall content of the project in the schools and kindergartens. The second part of module 4, the creation of a school working group, is intended to create involvement and commitment among staff members and to facilitate the implementation of the intervention. Good cooperation with all staff members in all participating schools is the basic principle of this module. The creation of a school platform makes it possible to gather all school working groups. This third part of module 4 creates a structure in which the schools can exchange knowledge and experiences, share a collective opinion and together elaborate on and start new initiatives to prevent childhood obesity. 3.1.1 Alerting staff members of the schools and kindergartens to the IDEFICS intervention Objectives -

Inform the employees about the community-based intervention and particularly about the intervention that will take place at school level (aim, content, manual, guidelines). Increase awareness of the health behaviours which are advocated in the intervention. Motivate and encourage staff members to take part in the intervention and specifically in the school working group (explained in the second part of module 4).

Get in contact with the principals of the schools -

Inform them about the aim and content of the intervention. Receive an agreement for participation in the intervention. Make a first appointment with the schools which agree to participate or with schools which need some time for reflection and want more practical and concrete information.

Inform coordinating school organisations If several different schools are gathered in a coordinating school organisation, it is suggested to inform this organisation that the local intervention team will contact each of their schools individually. Make ample use of coordinating school organisations because they can play an important role in stimulating and supporting their schools during the implementation of the intervention. Additionally, they can be a starting point and negotiation partner in order to set up a school platform at community level.

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Organise a first appointment with the principals -

Explain the intervention (receive an agreement for participation in the intervention if still necessary). Discuss possibilities to organise a meeting for staff members during which they will be informed about the intervention. You can use an introduction booklet as an incentive to stimulate the schools. An overview of the possible content of this booklet is provided in Table 8 below.

Documents Brief overview of the intervention Manuals for each module prepared by the local intervention team PowerPoint Presentation Article for the school newspaper

Aim and content of the documents Document which describes the aim and content of the project and which puts the project in a broader social context. The manuals provide, for each module, the culturally adapted ideas which can be used by the school working groups in order to work out the intervention modules in their school. A presentation based on the document which briefly outlines the intervention. This presentation can be used by the school to inform parents or a third party about the intervention. An example of an article that can be used to include in the school newspaper. This article informs the parents about the fact that the school participates in the intervention.

Table 8. Possible content of the introduction booklet that can be used during the first contacts with the schools Organise a meeting for all staff members of a participating school After having informed the school principals, it is important to alert the staff members of the schools or kindergartens. Therefore, the local coordinating team has to organise an information session for all employees of each school or kindergarten that will participate in the intervention. The following guidelines can be used for the organisation of this meeting: -

-

Organise the first meeting in April or May of Year 1 at the latest (assuming that the school year starts in September). Organise the meeting in strong cooperation with the school board to make clear that the school board supports the project. The information session for the staff members should be a promotion campaign for participation in the school working group and must trigger the successful formation of the group (detection of staff members that are interested in participating in the school working group). During the meeting, the staff members must receive explanations about the communitybased intervention and the intervention activities that will take place at school level (aim, content, manual, guidelines).

3.1.2 Creation of a school working group Objectives -

Involve staff members in the implementation of the school-based intervention modules. Implement the school intervention by combining a certain degree of support from the local intervention team and a certain independence from the school or kindergarten.

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Encourage the school or kindergarten to develop, organise and promote programmes that support the health behaviours advocated in the intervention. Lay the foundation of the dissemination phase of the intervention in the schools and kindergartens.

Establishment and composition of the school working group The following strategy, guidelines and recommendations can be used to set up a school working group in every participating school/kindergarten. General recommendations -

-

-

-

A school working group must be established in every participating school/ kindergarten. It is the responsibility of the local intervention team to initiate the establishment of the school working groups. When a school or kindergarten already has a school working group, try to cooperate with it. Motivation of the staff members should not be the sole criteria when selecting participants for the school working group. Potential impact of the staff member (position in the organisation, ability to implement actions advocated by the intervention, power) should also be considered. Every school working group should contain the following representatives: • Representative(s) of the school board (most important link) • Teachers whose field of study is related to the content of the intervention • Educator(s): persons who are responsible for supervision during free time and recess • Representative(s) of the parents’ council • Representative(s) of staff members who have the ability to reach children at risk of developing excessive body fatness (especially those with obese parents and low(er) socio-economic status) Every school working group has to consist of at least 2 persons (local coordinator not included)

Inventory of motivated staff members who wish to participate in the school working groups After the meeting, all staff members of the school receive an information letter describing the aim and content of the intervention and the responsibilities of a person engaging in the school working group. This letter should be formulated by the local intervention team in cooperation with the school board. The letter has to make clear that staff members can also engage in the school working group as a co-worker. Co-workers are contact persons for the school working group which can be asked for the organisation or support of certain activities related to the intervention. Staff members who are motivated to participate in the school working group or as a co-worker can present themselves to the principal of the school. Appointment of a project leader in the school The school working group is responsible for the implementation of the intervention. With the implementation and dissemination phase of the intervention in mind, it is advisable

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that someone, besides the local intervention team, takes the lead in the entire process. For this reason it is suggested to appoint a project leader in every participating school. It is up to the principal to decide who will be the project leader in the school. -

-

-

This person has to compose the school working group with staff members who wish to engage in implementing the IDEFICS intervention. It is not expected from the local intervention team to take the lead in the organisation of the school working groups in every participating school. The school project leader can be a person from an existing working group, another staff member or the principal him- or herself. It is important that this person is in close contact with the school, school board, staff members and children. The school project leader will be the contact person for the local intervention team.

Despite the fact that the school working group will be composed by the school project leader, the local intervention team is expected to stay in close contact with the school project leader in order to stimulate/support the organisation and composition of the school working group. If the kindergarten and primary school are gathered in the same school and thus both belong to the same school board, it is recommended to set up two project leaders and two school working groups. This is necessary to be able to implement an intervention which is adapted to the different age groups that are part of the intervention. Tasks and responsibilities of the school working group The school working group will be responsible for the organisation of a cooking and activity competition in their own kindergarten or school and the implementation of all the intervention modules at school level. The school working group will therefore be responsible for the implementation of the following modules: -

Module 5: Education of children Module 6: Environmental changes related to physical activity (active playground) Module 7: Health-related physical education curricula Module 8: Environmental changes and school policy related to water consumption Module 9: Environmental changes and school policy related to fruit and vegetables

In the relevant modules, the task and responsibilities are explained in more detail. 3.1.3 Operation of the school working group After setting up the school working groups, it is essential that local intervention teams start to talk with the school working groups as soon as possible in order to make a final decision on how the different modules will be implemented in the school. As soon as the school working groups are set up, they have to act as a team. It must be avoided that the school project leader has to work out the whole project. For this reason a guideline has to be developed which supports the school project leader to implement the intervention. This guideline will include a well-defined description of the tasks of the school project leader, members and co-workers of the school working group, time table and description of the

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cooperation with local intervention teams andother useful information for the implementation of the intervention. Operation of the school working group during the intervention adoption phase (Year 2) During the first part of the adoption phase (September – June Year 2), the implementation of the intervention modules will be strongly supported by the local intervention team: -

-

All the participants of the school working group will receive instructions and guidelines about the modules that must be implemented in the schools/kindergartens. The school working group will work together with the local coordinator in order to implement the modules that will be imposed in the schools and kindergartens. The local coordinator has a coordinating role in the school working group and serves as the link to the community platform. The local coordinator and the school working group should meet on a regular basis and at least 4 times a year. Between these 4 meetings, the school working group can organise internal meetings whenever needed without the local coordinator. All these meetings make it possible to evaluate the implementation of the modules and to discuss and solve practical problems that have occurred or are expected. During the first meeting with the school working group, it is recommended to make an inventory of existing initiatives related to the prevention of obesity in the school or kindergarten. The following guidelines can be used during all the other meetings: • Produce a meeting report with the main points discussed and decisions taken. These reports can be used to analyse the implementation process of the intervention. • Discuss and evaluate the aspects of the intervention modules that have been executed as well as the ones forthcoming. Highlight things that went well (to be repeated), but also challenges (to find solutions) and things that went wrong (to try to avoid them happening again in the future). Provide strong support to the implementation team. • Continuously monitor activities going on inside the school or kindergarten related to preventing childhood obesity. • Do not ignore but take notice of new initiatives that are proposed by the school working group members. • Use the meeting as an opportunity to ensure the communication to all staff members of the school/kindergarten by publishing a newsletter or newsflash in the school paper.

The second part of the adoption phase (July – August, Year 2) is the transition period between the strongly supported and the supervised operation of the school working group. During the transition period, the following actions are recommended: -

-

The school working group should appoint a person in charge of the school working group (school working group coordinator) who will relay the local coordinator in his/her responsibilities with regard to the school working group. The school working group should start its activities at the beginning of September of year 3. The school working group coordinator should be invited to the community platform meetings.

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Operation of the school working group during the intervention implementation phase (Year 3) The school working group is expected to continue the activities and to work out new initiatives with minimal supervision and without continuous support of the local intervention team. From September of Year 3 onwards, the local coordinator no longer participates in the meetings of the school working group. From that moment, the school working group coordinator should fully take over the tasks of the local coordinator. The local coordinator must be kept informed about the initiatives of the school working group. For this reason, the local coordinator and the school working group or the school working group coordinator should meet at least twice during the intervention implementation phase, i.e. once between September and January of Year 3 and once between February and June of Year 3. Between these meetings, if needed, the school working group can keep in touch with the local coordinator in order to solve practical problems or get advice. Operation of the school working group during the intervention dissemination phase (September of Year 4 onwards) The school working group is expected to operate completely independently, without any support or supervision from the local intervention team. 3.1.4 The creation of a school platform at community level A school platform is a committee in which the school working groups of all the schools in the community can be represented. Objectives -

Create a structure in which the schools can exchange knowledge and experiences, and start new initiatives for the prevention of childhood obesity. Enable all school working groups in the community to express a collective opinion and be considered as an important and full member of the community platform.

General recommendations -

For guidelines about the establishment and operation of the school platform, it is recommended to use the guidelines for the community platform (see module 1). The school platform should be the one being represented in the community platform, instead of all school working groups separately.

3.2 Module 5: Education of children Objectives -

Integrate the key messages in the class curriculum. Increase knowledge, skills and self-efficacy in children. Promote key messages in the schools and kindergartens.

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Concept of module 5 Module 5 includes the integration of the key messages in the class curriculum and the promotion of the key messages in the entire school. The key messages have to be integrated in the framework of (classroom) health education and not as part of obesity prevention to avoid stigmatisation of affected children. To integrate the key messages in the class curriculum and to promote the key messages in the school, every participating school has to organise the Healthy Weeks: these are weeks in which a specific key message will be highlighted (with different exposures for primary schools and kindergartens). Organisation of the Healthy Weeks during the adoption phase (Year 2) -

-

-

9 Healthy Weeks should be organised during the intervention adoption phase, i.e. 4 Healthy Weeks about physical activity, 4 Healthy Weeks about diet and one additional Healthy Week about adequate sleep duration. The key message about spending time together (stress, coping and relaxation) will not be handled in a Healthy Week. This message should be systematically repeated and integrated within the other Healthy Weeks. As an example, Table 9 below shows how the Healthy Weeks can be planned during one school year. The planning of the Healthy Weeks can be culturally adapted, depending on the start of the school year and the local situation. However, it is recommended to maintain the alternation of the Healthy Weeks about physical activity and diet. Intervention adoption phase (Year 2) Month of Year 2 Oct

Theme of the Healthy Week

Key message to be highlighted

Physical activity

Stimulating daily physical activity

Nov

Diet

Stimulating daily consumption of fruit and vegetables

Dec

Physical activity

Reduce TV-viewing

Jan

Diet

Stimulating the daily consumption of water

Feb

Physical activity

Stimulating daily physical activity

Mar

Diet

Stimulating daily consumption of fruit and vegetables

Apr

Physical activity

Reduce TV-viewing

May

Diet

Stimulating the daily consumption of water

Jun

Stress, coping and relaxation

Ensure adequate sleep duration

Jul Aug

Vacation period: No Healthy Weeks

Table 9. Themes of the Healthy Weeks per month during the intervention adoption phase (Year 2)

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The themes of the Healthy Weeks have to be synchronised with the themes of the window posters (module 2) and the themes of the educational folders (see later module 10). Table 10 shows how the Healthy Weeks can be synchronised with the window posters and the educational folders, respectively. Intervention adoption phase (Year 2) Window and street posters Oct Nov Dec

Window poster related to physical activity and diet (1st poster)

Jan Feb Mar Apr

Jul Aug

Physical Activity Diet Physical Activity

Folders Distribution of folders related to physical activity and diet

Diet Window poster related to physical activity and diet (2nd poster)

May Jun

Theme of the Healthy Weeks

Physical Activity Diet Physical Activity

Distribution of folders related to physical activity and diet

Diet Window posters related to sleep duration (3rd poster)

Sleep duration Vacation period

Distribution of folders related to sleep duration

Table 10. Synchronisation between the Healthy Weeks (module 5), the window posters (module 2) and the educational folders (module 10) during the intervention adoption phase (Year 2) Tasks and responsibilities of the school working group and teachers to organise the Healthy Weeks The school working group should: -

Display the window posters with the related key message in the school building. Communicate to the parents about the Healthy Weeks in the newsletter of the school.

The teachers should: -

Hang the window poster with the related key message in the classroom. Give the intervention package to the children: a folder (see module 10) and a window poster for the parents about the handled key message. Integrate the handled key message in the class lessons (instructions later on in this chapter). The exposure time of the Healthy Week in the classroom differs for the kindergarten and the primary school:

The IDEFICS Intervention Toolbox – A Guide to Successful Obesity Prevention at Community Level

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Kindergarten: every day of the Healthy Week has to be in the theme of the handled key message. Primary school: teachers have to spend 1 class hour per Healthy Week for a total of 9 Healthy Weeks.

Tasks and responsibilities of the local intervention team -

-

Every school that participates in the intervention should be offered a manual for the organisation of the Healthy Week. This education manual should enable the schools and teachers to implement this module. The education manual has to be written by the local intervention team by following the guidelines described below.

Tasks and responsibilities of the school working group -

Distribution of the education manual to the relevant teachers. Communication to the teachers about the content of the education manual. Members of the school working group have to be approachable about practical problems related to this module (e.g. try to help the teachers with their problems or discuss them during the meetings).

Development of an education manual for the organisation of the Healthy weeks Table 11 below provides possibilities and ideas that can be used for the development of the education manuals. These examples can count as a guideline but have to be worked out by the local intervention team, which implies an adaptation to the culture and the specific kindergarten and school structure in each country. It is not always necessary to develop new materials, and local intervention teams should also search for and select existing materials that can be included in the education manuals and that are able to fulfil the objectives of this module. Practical guidelines to develop the education manuals -

-

-

-

The education manual has to contain educational strategies for the teachers to use in designing their lessons. • The ideas have to be concrete, original and age-adapted. • The information provided in the manual has to be ready to use. The education manual must provide the teacher with a practical answer to the question of how to handle the key messages in the classroom. When developing the education manual, always keep in mind that the educational strategies must aim to fulfil the following objectives for every key message: • Increase awareness and knowledge • Increase self-efficacy • Increase skills in children Because the content of the lessons will differ according to the age of the children, it is suggested to create a different education manual for the kindergarten and the primary school. Note: Education manuals are available for those countries where the IDEFICS intervention was tested for its effectiveness (Belgium, Cyprus, Estonia, Germany, Hungary, Italy, Spain and Sweden).

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-

Awareness

-

-

Skills -

Self-efficacy -

Interactive communication between teacher and children in combination with education material (posters, photographs, …):  What does being physically active mean?  What are the advantages of being physically active?  When can you be physically active at home and at school?  How much physical activity should we be getting each day? Self report activities in class or for homework: children can fill in the physical activities they performed the day before on an attractive education worksheet, they can make a collage in which they present their physical activities or they can report their activities by assigning pictures (depending on the age). Compare the self reports with the daily recommendation related to physical activity. Teach children to set physical activity goals.  Communicate interactively (what are physical activity goals, what are the most important characteristics, …) and discuss some examples (case study).  Provide educational worksheets on which children can report their physical activity goals at school and at home (“My accomplishment plan”).  In a next step, the children have to report which activities they actually have done (review of the accomplishment plan).  Performance against physical activity goals can be associated with a game: a child can gain a stamp or a sticker if they performed an activity goal. Teach children how to motivate themselves to get physically active and how to maintain the motivation. For example: organise an interactive communication about “talking to yourself”.  Are the following sentences examples of positive or negative things that you can say to yourself?  What are your feelings about …?  How can you change negative sentences into positive sentences? Play easy activity games in class (especially for toddlers and the youngest pre-school children) in order to teach locomotive skills. Help students to set realistic and challenging goals related to physical activity (see above). Compliment children on the skills they have developed (positive feedback). Encourage students to use effort as an explanation for failure, and the skills they have developed as an explanation for success. Do not attribute poor performance to lack of ability (and caution parents to avoid it as well). Help children recognise the skills they are acquiring: make the children aware of what they have learned. Success in the past is the best way to build confidence for future success: help children recognise their progress.

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Let the children make an individual line graph of their progress. Give students frequent opportunities to update their progress. Provide a monthly calendar to record their daily progress. However, avoid class charts where individual progress is displayed because children will compare their progress in relationship to others. This will have a detrimental effect on the self-efficacy of those who do not progress as fast as others. Children have to learn to compare with themselves. Use peer modelling during the lessons by working in small groups (this has an important influence on children’s self-efficacy during skill acquisition). REDUCE TV VIEWING   

-

-

Awareness

Skills -

Self-efficacy

-

Interactive communication between teacher and children:  Which TV shows did you watch yesterday?  When did you start watching? When did you stop?  How many hours can we watch a day? Is it good to watch TV? Self report activities in class or for homework:  Encourage group reporting about time spent watching TV.  Self report activities by means of an attractive education worksheet (did you watch TV while eating supper? Did you turn on the TV before school? Did you turn on the TV when you came home from school?, …). Compare the self reports with the daily recommended limit of TV viewing. Have students brainstorm a list of fun alternatives to watching TV Teach children how to watch TV selectively (for example: select the programmes you want to see and turn off the TV afterwards, help your parents in the kitchen during commercial breaks, …) Teach self-monitoring techniques to children (for example: children make a diary in which they can report the amount of hours they watched TV, the programmes watched, …) See guidelines provided for daily physical activity and use them for the activities related to the key message about TV viewing. DAILY CONSUMPTION OF FRUIT AND VEGETABLES

-

Awareness

-

-

Interactive communication between teacher and children in combination with education material (posters, photographs, …):  What is good about eating fruits and vegetables?  How many fruit and vegetables should we be eating each day?  Where can we buy and eat fruits and vegetables?  How can we eat fruits and vegetables? Self report activities in class or for homework: children can fill in the amount of fruit and vegetables they ate the day before on an attractive education worksheet (or report it by making a collage or assigning pictures). Compare the self reports with the daily intake recommendation for fruits and vegetables. Visit a local fruit and vegetable farmer, grocery stores.

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-

Skills -

Self-efficacy

Taste/preference -

Prepare fruits and vegetables in the class: show how to cut vegetables and how to peel fruit and provide the opportunity to practice in small groups (you can also provide an action plan that visualises the different steps in cutting a certain vegetable). Organise a recipe competition in which children can use their preparation skills. Organise recognition games. See guidelines provided for daily physical activity and use them for the activities related to the key message about fruit and vegetables. As an extra, help children to serve as their own model.  If a video camera is available, tape the children while they are participating in the preparation of fruit and vegetables and allow to view themselves being successful (or take photographs of the activity). While showing the tape or photographs, give positive feedback about the skills that the children acquired and were demonstrating. Organise tasting activities and games in the class. Provide fruits and vegetables that children have not tasted before on repeated occasions. Teachers have to be role models: taste the fruits and vegetables in front of the children and show that you like them. DAILY CONSUMPTION OF WATER

-

Awareness

-

Skills

-

Self-efficacy

Interactive communication between teacher and children in combination with education materials (posters, photographs, …):  What are the advantages of drinking water? Why should I give preference to water over other drinks?  How much water should we be drinking each day?  Where can we drink water? In which forms can we drink water? Self report activities in class or for homework: children can fill in the amount of water they drank the day before on an attractive education worksheet (or report it by making a collage or assigning pictures). Compare the self reports with the recommended daily consumption of water. Show the children how to prepare flavoured water (e.g. with mint leaves, pieces of apple or strawberry). Teach children how to deal with the daily recommended intakes (always fill your favourite cup with water and try to empty it while doing homework, always take a bottle of water with you, …). See guidelines provided for daily physical activity and use them for the activities related to the key message about the consumption of water.

Table 11. Ideas for the content of the education manuals

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3.3 Module 6: Environmental changes related to physical activity - The Active Playground Objectives -

Increase time spent in moderate to vigorous physical activities during recess. Provide an opportunity to help children reach the recommended physical activity level (contribute to the daily recommended norm of physical activity).

Possibilities to create an active playground The creation and the promotion of an active playground is part of improving the school environment with the aim to stimulate the children to be physically active while at school. The local intervention team has the opportunity to create an active playground in the schools and kindergartens by means of one or a combination of the following strategies: Change the physical design of the playground Redesign the playground, using multicolour playground markings (e.g. hopscotch) and physical structures (e.g. soccer goal posts, basketball hoops). This is found to be a sufficient stimulus for increasing children's school physical activity levels during recess and is also a method that is low in cost (Stratton & Mullan, 2005; Ridgers et al., 2007). Provide attractive play tools in the playground Providing game equipment during recess (e.g. balls, ropes, small bikes) is found to be effective in increasing children's physical activity levels. These findings suggest that promoting physical activity through game equipment provision during recess can contribute to reaching the daily recommended activity levels in children (Verstraete et al., 2006). Structural changes related to recess period The playground space available for children (number children/m²) during recess periods is found to be an important predictor of children’s physical activity levels (Cardon et al.,2008). Therefore, structural changes that reduce the number of children on the same surface area can be an inexpensive way to increase physical activity levels during recess: e.g. divide all children in two groups and let them have playtime at different moments. In addition to the environmental and structural possibilities to create an active playground, as described above, it is strongly recommended to combine one or more of these strategies with the following actions: -

Promotion of an active playground in the school. Coaching of teachers/educators to supervise the playground in an active way. They have an important role in stimulating children to be active in the playground.

Development of a manual for the creation of the active playground Every school participating in the intervention should be offered a manual for the creation of an active playground. This school manual should enable the schools to implement this module. Because the content of the manual will differ according to the age of the children, it

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is suggested that a different manual be prepared for the kindergarten and the primary school. The school manual can be written by the local intervention team on the basis of the following guidelines: Provide ideas to change the physical design of the playground -

Provide country-specific ideas to change the physical design of the playground. Integrate guidelines for the schools (e.g. if coloured marks are painted on the playground, they have to stay visible and thus have to be repainted on a regular basis). It is of special importance that the ideas are age-adapted: try to propose different ideas for the kindergarten and the primary school and even within the primary school. Castles, dragons, clock faces, mazes, fun trails, dens, hopscotch, letter scares, snakes and ladders, and various animals are popular in early primary schools. Markings for netball, football and short tennis, and targets for games-related skills are rather preferred in late primary schools (Stratton & Mullan, 2005). The ideas also have to reach both boys and girls.

Provide ideas for materials that can be provided in the playground -

Integrate different country-specific kinds of materials and play tools for the playground (e.g. sports balls or a (suit)case with circus materials). It is of special importance that the ideas are age-adapted (different for the kindergarten and the primary school) and that they reach both boys and girls. Integrate guidelines for the schools.

Provide suggestions on how the active playground can be promoted in the school -

-

Teachers have to inform the children about the possibilities to be active during break times (at the beginning of the school year and during the school year – e.g. by means of the school newspaper). The physical education teacher can instruct all students on proper use and all possibilities of the playground equipment. Just before the break, the teacher can remind the kids about the possibilities to be physically active. Ask the children after the break what they have done in the playground.

Include information about the importance of active supervision and coaching by teachers and/or educators -

Integrate guidelines for teachers/educators on how they should supervise/coach the children in the playground (e.g. encourage the students to walk when they talk instead of sitting on the bench, help the students to start a game or play along with them, and continue to encourage the students while they are being active and for other students to join in, challenge the children by setting goals e.g. how many times can you skip the rope in one minute, how many baskets can you score in one minute?).

Tasks and responsibilities of the school working group -

Distribution of the education manual to the relevant teachers. Communication to the teachers about the content of the education manual.

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Members of the school working group have to be approachable about practical problems related to this module (e.g. try to help the teachers with their problem or discuss them during the meetings).

3.4 Module 7: Health-related physical education curricula Objectives -

Keeping all children active as much as possible during physical education classes (trying to reach a high activity level during the lessons). Development of knowledge, social attitudes and skills, and movement skills in children, which are necessary to lead an active lifestyle. Building children’s confidence in their physical abilities.

Manual for the optimisation of physical education classes -

-

Every school participating in the intervention should be offered a manual which provides guidelines and tools for teachers, educators and nurses on how they can organise health-related physical education classes in primary school and how they can increase physical activity during time spent at the kindergarten. The manual should enable teachers, educators and nurses to implement this module. Because the content of the manual will differ according to the age of the children, it is suggested to create a different manual for the kindergarten and the primary school. The school manual can be written by the local intervention team on the basis of following guidelines (Bagby & Adams, 2007; SPARK, 2011):

Inform teachers, educators and/or nurses about the basic characteristics of health-related physical education curricula and emphasise them in the manual -

Aim to reach a high activity level for all the children during physical education classes. Develop the knowledge, attitudes, and social and movement skills, in children, which are necessary to lead an active lifestyle. Aspire to give every child positive experiences. Use activities with a high transfer value (i.e. activities children can also do in the playground and/or at home, e.g. rope skipping, Frisbee, …).

Integrate guidelines for teachers, educators and/or nurses to fulfil the basic characteristics of health-related physical education curricula -

Provide guidelines on how to increase the activity rate of children during physical education classes (e.g. restrict waiting time for children). Provide guidelines on which activities contribute to a higher physical activity level in children. Provide guidelines on how to create a pleasant lesson that stimulates the physical activity rate.

Provide strategies to integrate the guidelines in practice -

It is important that the teachers, educators or nurses verify which guidelines they are implementing already and how frequently. For example: a teacher, educator or nurse can focus on guidelines to reach a high activity level during one week. They verify

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which guidelines they already apply and which ones are new. The teacher, educator or nurse tries the new ones and evaluates the effect. Over the next weeks, the teacher, educator or nurse can then focus on other guidelines. Note: Such a manual is available for those countries where the IDEFICS intervention has been tested for its effectiveness (Belgium, Cyprus, Estonia, Germany, Hungary, Italy, Spain and Sweden). Tasks and responsibilities of the school working group -

Distribution of the education manual to the relevant teachers. Communication to the teachers about the content of the education manual. Members of the working group have to be approachable about practical problems related to this module (e.g. try to help the teachers with their problem or discuss them during the meetings).

3.5 Module 8: Environmental changes and school policy related to water consumption Objectives -

Create a school environment that discourages the consumption of sugar-sweetened beverages. Create a school environment that stimulates the consumption of water.

Possibilities to increase the daily water consumption in schools and kindergartens The local intervention team can increase the daily water consumption in schools and kindergartens by means of one or a combination of the following strategies: Permanently provide free water during breaks, play time and/or lessons -

Provide water fountains in the playground (environment). Provide free water at the table during dinner (environment). Allow drinking water during theory lessons: children can have a water bottle on their desk (school policy). Allow drinking water during physical education classes and stimulate the teacher to integrate a “water drinking moment” (school policy).

It is of special importance that the provision of water facilities is in proportion to the number of children in the school and adapted to the student population (location, height, hygiene, …). It is for example better to allow drinking cups in the kindergarten whereas the placing of water fountains is rather recommended in primary schools. The provision of water should also be clearly communicated to the students and the staff members: when, where, how, … Reorientation of the beverage supply in the school (changing the environment and/or the school policy) Favour water as the main drink supply in school. This reorientation will require clear regulations about the consumption of sugar-sweetened beverages and water and possibly a change to the school policy. If it is possible to change the school policy or to set regulations about the consumption of sugar-sweetened beverages, this should be clearly communicated to the children, staff members and parents.

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Examples of how the beverages supply can be changed: -

Remove vending machines in which sugar-sweetened beverages are offered (environment – school policy). Do not remove all vending machines but replace sugar-sweetened beverages by water or other healthier options (environment – school policy). Do not allow the sale and consumption of sugar-sweetened beverages in the school (regulations – school policy)

Promote the availability of water and clearly communicate about the regulations It is strongly recommended to promote all the initiatives to the children, parents and staff members of the school. It is also essential to communicate to the children, parents and staff members about the regulations related to the consumption of water. Examples of how the availability of water can be promoted: -

Describe the water initiatives and regulations in the school paper. Teachers can ask children to make an advertisement about the consumption of water and make them visible in the school. Provide recyclable cups or tins for water (sponsorship can be used to finance this initiative).

3.6 Module 9: Environmental changes and school policy related to fruit and vegetables Objective -

At least once a week, make fruit and vegetables available in the school environment during the breaks.

Possibilities to increase the consumption of fruit and vegetable in schools and kindergartens The local intervention team can increase the daily consumption of fruit and vegetables in schools and kindergartens by means of one or a combination of the following strategies: Availability and accessibility of fruit and vegetables in the school (make environmental changes) The working group of the school can make a contract with a local fruit and vegetable trader or merchant who can deliver at least once a week fresh and seasonable fruit and/or vegetables to the school. Practical implications -

Try to provide fresh seasonal fruit. Try to provide fruit that is easy to eat for the children. Make the fruits and vegetables accessible, especially for the youngest children: involve for example volunteering (grand)parents to prepare the fruits and vegetables at school. Sponsorship can be used to finance the fruit and vegetable project. Without sponsorship, a child can participate in the fruit and vegetable project when parents have paid a financial contribution to the school at the beginning of the school year.

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The day on which the fruits and vegetables are delivered can become a dedicated ‘fruit and vegetable day’ for the rest of the school year.

Other possibilities -

Organise: “bring your own fruits and vegetables to school”. Organise an additional “fruit and vegetable day”: children can only bring fruit and/or vegetables instead of less healthy snacks. School gardens (children grow vegetables at school). Organise the calendar game: every child that brings a piece of fruit or gets a sticker in their agenda.

Reorientation of the food supply in the schools (changing the environment and/or the school policy) Change the food supply in the school to include fruits and vegetables as an alternative to less healthy snacks. This reorientation will require clear regulations and possibly a change to the school policy. If it is possible to change the school policy or to set regulations about the consumption of less healthy snacks and fruits and vegetables, this should be clearly communicated to the children, staff members and parents. Examples of how the food supply can be changed: -

Remove the vending machines in which less healthy snacks are represented. Restrict the time that vending machines with (less healthy) snacks are available. Increase the price of high-energy snacks and lower the price of fruits and vegetables. Do not sell less healthy snacks but replace them by fruit and/or vegetables.

Promote the availability/accessibility of fruit and vegetables and clearly communicate about the regulations It is strongly recommended to promote all the initiatives to the children, parents and staff members of the school. It is also essential to communicate to the children, parents and staff members about the regulations related to the consumption of water. Examples of how the availability/accessibility of fruit and vegetables can be promoted: -

Describe the initiatives and regulations related to fruits and vegetables in the school newspaper. Inform the parents in particular about the fruit and vegetables initiatives and try to involve them. Teachers can ask children to make an advertisement about the consumption of fruit and vegetables and make them visible in the school.

4. IDEFICS intervention modules at family level 4.1 Module 10: Education of parents Objectives -

Increase behavioural skills in parents in order to increase social support and accessibility and availability of fruit and vegetables at home. Increase awareness in parents. Increase self-efficacy in parents.

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Concept of module 10: educational folders and videos for parents Parents should receive educational folders and videos to learn about parenting strategies that can remove barriers and facilitate them in their ability to create health-promoting family environments. Educational folders The local intervention team can develop 3 folders: 1 folder about diet, 1 folder about physical activity and 1 folder about sleep duration. The key message about spending more time together has to be integrated in these folders. The educational folder about physical activity that was used in the IDEFICS intervention, is displayed below. All of the folders are already available in the languages of those countries where the IDEFICS intervention was tested for its effectiveness (Belgium, Cyprus, Estonia, Germany, Hungary, Italy, Spain and Sweden).

Guidelines for the development of the folders Four aspects of parenting can be the focus of the educational folders and can provide a framework for the development of the educational materials, i.e. beliefs and knowledge of the parents, parental modelling, availability and/or accessibility and shaping. For a detailed description of these aspects of parenting, references are made to Crawford and Jeffery (2005). Based on the examples provided by Crawford and Jeffery (2005), Table 12 offers an overview of strategies that can help parents in their ability to create family environments that promote and encourage a healthy lifestyle.

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DAILY PHYSICAL ACTIVITY

Beliefs and knowledge

-

Modelling

-

Availability and/or accessibility

-

Shaping

-

Use the daily recommended norm related to physical activity as a guideline. Believe in the ability of your children to be physically active. Be physically active yourself and together with the family. Include physical activity into the leisure time of the family (e.g. hiking or cycling with the entire family). Plan and participate in physically active family activities (e.g. walking or cycling instead of driving, playing outside) and include physical activity in family events such as birthday parties, picnics, and vacations. Provide activity-related equipment in the home environment (e.g. balls, bicycles). Visit sports and recreation facilities with your children where they can be physically active (e.g. community playgrounds, sports organisations). Identify outdoor activities and perform them together with your child. Identify indoor activities other than screen-based activities and perform them together with your child. Use fun physical activities as a reward for behaviours with positive outcome. Do not use physical activity as a punishment for behaviours with negative outcome. REDUCE TV VIEWING

Beliefs and knowledge Modelling

Availability and/or accessibility

Shaping

-

Use the daily recommended norm related to watching television as a guideline.

-

Reduce your own TV viewing time. Switch off the TV while you, your children or the entire family is eating.

-

Set clear rules regarding TV viewing time (e.g. your children can select one or more programmes, they can watch these programmes but the TV should be switched off before and after the selected programmes). Do not put a TV or a computer in your children’s bedroom. Provide active and fun alternatives to TV viewing.

-

Do not use watching TV as a reward for behaviours with positive outcome.

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DAILY CONSUMPTION OF WATER

Beliefs and knowledge Modelling

-

Use the daily recommended norm related to water as a guideline.

-

Limit your own intake of less healthy beverages and model the consumption of water at every moment of the day. Show your child that you like water and that water is tasty. Do not show your own dislike for water.

-

Availability and/or accessibility

-

Shaping

-

Provide water during meals. Provide sometimes alternatives for clear water, for example flavoured water with mint leaves or pieces of strawberry, apple, … Provide your child with a nice tin or their favourite cup which is always filled with water and accessible to take. Set rules about the consumption of less healthy beverages: e.g. only one can of soft drink a week, only on weekends, only at parties, … Do not use sugar-sweetened beverages or similar drinks as a reward for behaviours with positive outcome. Do not use drinking water instead of sugar-sweetened beverages as a punishment for a behaviour with negative outcomes. DAILY CONSUMPTION OF FRUIT AND VEGETABLES

Beliefs and knowledge

Modelling

-

Use the daily recommended norm related to fruit and vegetables as a guideline.

-

Eat fruits and vegetables yourself and show your children that you like them. Involve your children in the selection and preparation of fruit and vegetables.

-

Availability and/or accessibility

-

Shaping

-

Make fruits and vegetables easy available and accessible in the home environment and during family trips. Provide fruits and vegetables that your child never has tasted before. Provide fruit and vegetables in a form that is easy and ready to eat (e.g. pre-cut vegetables and/or peeled fruit). Try to do this in the home environment, during family trips and/or to provide it to your child as a snack at school (instead of less healthy snacks). Do not use fruits and vegetables as a punishment for behaviours with negative outcome. Do not use unhealthy snacks and foods as a reward for behaviours with positive outcome.

Table 12. Examples of parenting strategies for diet and physical activity (Crawford & Jeffery, 2005)

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Distribution of the folders -

-

The community platform is responsible for the dissemination of the folders at the right moment in all the different sectors of the community (see stakeholders). For example: the school is an important and easy setting to distribute the folders to the residents of the community. Thus, the community platform also has to take care that the schools receive the folders in time. The distribution of these folders will be synchronised with the distribution of the window and street posters and the integration of the key messages in the class curriculum (see Table 10): use the folders that handle the same key message as highlighted on the window poster and in the Healthy Weeks.

Educational videos A media agency could develop scenarios for the educational videos based on the content and ideas provided in this intervention manual.

5. Conclusion The fundamental idea of the IDEFICS project was that obesity prevention should be triggered by local policy makers or local public health authorities and supported by initiatives taken by local stakeholders in the community. As part of this project, a community-based intervention for the prevention of childhood obesity was developed and tested for its effectiveness. The content and the implementation strategy of the IDEFICS intervention are now available and provide local policy makers and public health authorities with the opportunity to explore a model for obesity prevention in Europe. This chapter was written in a way that local policy makers or local public health authorities have the necessary guidance and recommendations at their disposal to implement the intervention in their local city or community. The major advantage of the intervention framework is that it can be culturally adapted to the local needs and requirements which increases the feasibility of implementation in European countries.

6. Acknowledgements This work was done as part of the IDEFICS Study (www.idefics.eu). We gratefully acknowledge the financial support of the European Community within the Sixth RTD Framework Programme Contract No. 016181 (FOOD).

7. References Ahrens, W., Bammann, K., Siani, A., Buchecker, K., De Henauw, S., Iacoviello, L., Hebestreit, A., Krogh, Vittorio, L., Lauren, M., Staffan, Molnar, D., Moreno, L.A., Pitsiladis, Y., Reisch, L.A., Tornaritis, M., Veidebaum, T., Pigeot, I., on behalf of the IDEFICS consortium (2011). The IDEFICS cohort: Design, characteristics and participation in the baseline survey. Int J Obes, 35 (Suppl.1):S3 - S15.

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Ahrens, W., Bammann, K., De Henauw, S., Halford, J., Palou, A., Pigeot, I., Siani, A., Sjöström, M. (2006). Understanding and preventing childhood obesity and related disorders–IDEFICS: a European multilevel epidemiological approach. Nutr Metab Cardiovasc Dis, 16, 302-308. Bagby, K. & Adams, S. (2007). Evidence-based practice guideline: increasing physical activity in schools--kindergarten through 8th grade. J Sch Nurs, 23, 137143. Cardon, G., Van Cauwenberghe, E., Labarque, V., Haerens, L., & De Bourdeaudhuij, I. (2008). The contribution of preschool playground factors in explaining children's physical activity during recess. Int J Behav Nutr Phys Act, 26, 5:11. Crawford, D. & Jeffery, R. W. (2005). Obesity Prevention and Public Health. Oxford University Press. Davison, K.K. & Birch, L.L. (2001). Childhood overweight: a contextual model and recommendations for future research. Obes Rev, 2, 3. De Henauw, S., Verbestel, V., Marild, S., Barba, G., Bammann, K., Eiben, G., Hebestreit, A., Iacoviello, L., Gallois, K., Konstabel, K., Kovacs, É., Maes, L., Molnar, D., Moreno, L.A., Reisch, L., Siani, A., Tornaritis, M., Williams, G., Ahrens, W., De Bourdeaudhuij, I., Pigeot, I. (2011). The IDEFICS Community-Oriented Intervention Program: A new model for childhood obesity prevention in Europe? Int J Obes (Lond), 35 Suppl 1:S 16-23. Ferreira, I., van der, H. K., Wendel-Vos, W., Kremers, S., van Lenthe, F. J., & Brug, J. (2007). Environmental correlates of physical activity in youth - a review and update. Obes Rev, 8, 129-154. Pigeot, I., De Henauw, S., Foraita, R., Jahn, I., Ahrens, W. (2010). Primary prevention from the epidemiology perspective: Three examples from the practice. BMC Med Res Meth, 10 (10). Ridgers, N. D., Stratton, G., Fairclough, S. J., & Twisk, J. W. (2007). Long-term effects of a playground markings and physical structures on children's recess physical activity levels. Prev Med., 44, 393-397. Sports, Play and Activity Recreation for Kids (SPARK) (2011). Pre-developed curricula specifically designed to increase levels of physical activity in children during physical education class. http://www.sparkpe.org/ Stratton, G. & Mullan, E. (2005). The effect of multicolor playground markings on children's physical activity level during recess. Prev Med., 41, 828-833. Verbestel, V., De Henauw, S, Maes, L, Haerens, L., Mårild, S., Eiben, G., Lissner, L., Moreno, L.A., Lascorz Frauca, N., Barba, G., Kovács, É., Konstabel, K., Tornaritis, M., Gallois, K., Hassel, H., De Bourdeaudhuij, I. (2011). Using the intervention mapping protocol to develop a community-based intervention for the prevention of childhood obesity in a multi-centre European project: the IDEFICS intervention. Int J Behav Nutr Phys Act, 8, 82.

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Verstraete, S. J., Cardon, G. M., De Clercq, D. L., & De Bourdeaudhuij, I (2006). Increasing children's physical activity levels during recess periods in elementary schools: the effects of providing game equipment. Eur J Public Health, 16, 415-419.

2 Testing the Assumptions of Stage of Change for Fruit and Vegetable Consumption: A Naturalistic Study Jay E. Maddock*, Jodi D. Barnett, Carrie S. Marshall and Claudio R. Nigg

Department of Public Health Sciences University of Hawai‘i at Mānoa, USA

1. Introduction Chronic disease now accounts for 7 of every 10 deaths in the United States and 60% of the nation’s health expenditures [1]. Poor nutrition is a substantial contributor to the chronic disease burden, accounting for over $33 billion in medical costs and $9 billion in lost productivity per year [1]. Fortunately, many detriments of chronic disease, such as increased risk for heart disease [2-4], stroke [5, 6], diabetes [7, 8], osteoporosis [9], and cancer [10, 11], can be prevented through adoption of a healthy diet. Fruit and vegetables are an integral part of a healthy diet, and they provide many nutrients that may reduce the risk for some types of cancers and chronic disease [12-16]. To achieve this protective effect, disease prevention guidelines recommend that individuals consume at least five servings of fruits and vegetables a day [17, 18]. However, data from the 50 US states indicates that 70-80% of US adults fall short of these recommendations [19]. The substantiated link between poor diet and the epidemic prevalence of chronic disease in America necessitates population-based interventions aimed at increasing fruit and vegetable consumption. Explanatory theories of behavior change, such as the Transtheoretical Model (TTM), can help guide intervention programs in developing the most effective strategies for promoting and sustaining change in a population. Over the past two decades, the central organizing construct of the TTM, the stages of change has experienced widespread use as well as pointed criticisms [20]. The model postulates that people move through a series of five stages of change in their attempts to modify their problem behaviors [21]. As people change stages, they employ mediating processes such as self-efficacy and decisional balance, differentially making each stage unique. Five stages of change have been identified: precontemplation (no intention to change behavior in the foreseeable future, or denial of need to change); contemplation (intention to change within the next 6 months); preparation (serious intention to change in the next 30 days); action (initiation of overt behavioral change); and maintenance (sustaining behavioral change for 6 months or more) [21]. *

Corresponding Author

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Although the TTM was originally developed as a framework for smoking cessation, it has gained widespread use over the past two decades as the basis of formalized treatment programs and population-based interventions for over a dozen health-related behaviors. The TTM has been adapted to many areas of behavior change including eating behaviors [22], exercise adoption [23], condom use [24], and several others [25]. With the great popularity of the stages of change construct in particular, careful measurement work has not always been conducted when adapting the construct to a new behavior. Over the past few years, several research papers have examined the crosssectional relationship between the stages of change for fruit and vegetable intake and other related variables [26-31]. Research on self-change in naturalistic populations is necessary to assess the efficacy of stage of change models. While the vast majority of the literature is cross-sectional, a longitudinal approach is “more in line with the temporal nature of the model” because it can expose processes and patterns of change at the individual level that may be masked by a cross-sectional, population-based design [32]. Weinstein and colleagues (1998) have outlined four properties of a stage theory of health behavior [33]. The first is a classification system to place individuals into discrete stages. The second characteristic is an ordering of the stages. It is assumed here that although people can move both forward and backward between the stages they are most likely to move to adjacent stages in their attempts to change. It is also predicted that on a population level the closer a stage is to action, the more likely those people are to move into action in the future. The final two characteristics of a stage theory are common barriers to change facing people in the same stage and different barriers to change in different stages. For instance, the TTM postulates that experiential processes are important for early stage changes such as precontemplation to contemplation, while behavioral processes are important for later stage changes for example preparation to action [21]. Two alternatives also exist to the interpretation of a stage model: pseudostages created from a continuous variable, for instance motivation (linear pseudostage), and pseudostages created from a general algebraic equation, including interactions and limits on variables (non-linear pseudostage) [33]. Four research designs have been developed for testing the efficacy of stage models [33]. The first and most common design is to examine cross-sectional comparisons of people in different stages. In this approach, an analysis of variance is typically conducted to assess differences across the stages of change for certain variables which are predicted to differ by stage. While the largest body of research is conducted in this area it provides a weak test of stage model which cannot rule out a non-linear pseudostage [33]. The second design for testing the stage of change construct is the examination of stage sequences. This requires longitudinal data and often predicts movement between pre-action stages to action [34]. The prediction is that people who start in stages closer to action will be more likely to move to action over time. Stage transitions across more than two time points can also be examined to assess if changes are more likely to occur to adjacent stages. However, data collection periods can often miss transitions in stage. This also does not rule out either pseudostage. The third design is the longitudinal prediction of stage transitions. This design tests the assumption that different constructs are important for different stage transitions. For instance, behavioral processes are more important for the transition from preparation to action than from the transition from precontemplation to contemplation. This data helps

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establish that motivation is not a continuum but that real quantitative differences occur between the stages, supporting the stage model and the non-linear pseudostage model [33]. The final design is an experimental study of matched and mismatched interventions, where participants are randomized to either a stage appropriate intervention or a non-stage appropriate intervention. This method provides the best test of the stage model by formally testing the assumptions that a stage matched intervention is superior to a mismatched intervention [33]. In this study, we will examine three of Weinstein and colleagues (1998) tests of a stage model [33], summarized in Table 1. First, cross-sectional comparisons of people in different stages will be assessed by behavior and related psychosocial variables. Then stage sequences will be examined over three time points. Finally, longitudinal prediction of stage transitions by baseline behaviors and related psychosocial variables will be conducted.

1.

Cross-sectional comparisons of people in different stages

Supports a stage theory if: a.

Attributes of people differ across stages

b.

The patterns of differences across stages vary from one attribute to another

2. Examination of Stage Sequences Supports a stage theory if: a.

Successive stages follow the hypothesized sequence

3. Longitudinal Predictions of Stage Transitions Supports a stage theory if: a.

Predictors of stage transition vary from stage to stage

Table 1. Research Designs for Testing Stage Theories 2. Methods 2.1 Data collection A longitudinal survey using random digit dialing of Hawaii’s non-institutionalized adult population was conducted from February to April of 2002 [34]. The person over 18 who had the last birthday was asked to complete the interview to provide randomization within household. Informed consent was obtained over the phone. The survey took approximately 20 minutes to complete. All procedures were approved by the University of Hawaii Committee on Human Subjects. Interviewers were trained on the survey in small group settings for 6 hours in both classroom and live phone settings. Interviewers were assisted by a computer aided telephone interview (CATI) system designed specifically for the survey. Skip patterns and out of range responses were automatically controlled by the system. Follow-up surveys were conducted at 6 and 12 months post-baseline.

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During the follow-up, at least five attempts were made to contact the participants. Respondents were also given the option to callback at their convenience. Primary reasons for non-completion included disconnected phone numbers, no longer living at current number, no callback by participants, and no answer. 2.2 Measures Participants were asked a series of demographic questions, including age, sex, height, weight, education attained, income level, marital status, ethnic identification, language spoke at home, and perceived health. Participants were then asked about behaviors and other variables related to fruit and vegetable consumption. Fruit and Vegetable Intake was assessed using a short “all day” assessment developed by the National Cancer Institute [35]. This instrument has been shown to have good reliability compared to actual intake and is recommended for population based research [35]. Stage of Change relative to consumption of fruits and vegetables was assessed. The instrument (Figure 1) inquired about participants’ fruit and vegetable intake followed by their intentions to consume five or more servings per day. Participants were classified into one of five stages; (1) Precontemplation – Do not eat 5-a-day with no intentions to do so in the next 6 months; (2) Contemplation – Do not eat 5-a-day but intend to do so in the next six months; (3) Preparation – Do not eat 5-a-day but intend to in the next month; (4) Action – Currently eating 5-a-day, but for less than six months; (5) Maintenance - Currently eating 5a-day for more than six months [36].

Fig. 1. Stage of Change Instrument

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45

Self-Efficacy for eating 5-a-day was assessed with a 10-point continuous scale from (1) Not at all confident to (10) Very confident; “How confident are you that you can eat 5 or more servings of fruits and vegetables per day?” Intentions, subjective norm, perceived behavioral control and attitude from the Theory of Planned Behavior were also assessed [37]. Subjective Norm was measured using three continuous 10-point scale items from (1) strongly disagree to (10) strongly agree. Satisfactory alpha levels for this scale were α = .82 and .86 at baseline and 1 year. Questions included: “Most people who are important to me think I should be eating 5-a-day on a regular basis”; “People in general approve of eating 5-a-day”; and “Most people who are important to me would like me to eat 5-a-day”. Perceived Behavioral Control was measured using three continuous 10-point scale items. The higher the score meant the greater the endorsement of the item. Satisfactory alpha levels for this scale were α = .76 and .79 at baseline and 1 year. Questions included: “If I wanted to I could easily eat 5-a-day on a regular basis” (1) strongly disagree to (10) strongly agree; “How much control do you have over the number of times you eat 5-a-day” (1) very little control to (10) complete control; and “For you to eat 5-a-day on a regular basis is……” (1) extremely difficult to (10) extremely easy. Attitudes were measured using four continuous 10-point scale items. Satisfactory alpha levels for this scale were α = .83 and .84 at baseline and 1 year. One question was asked followed by four different response sets: “Eating 5-a-day regularly is….” (1) harmful to (10) beneficial; (1) foolish to (10) wise; (1) unenjoyable to (10) enjoyable; and (1) unpleasant to (10) pleasant. 2.3 Analysis The SPSS System for Windows version 11.5.0 was used for all data analyses [38]. For all analyses, only individuals who completed both the baseline and 12 month assessment were included. T-tests and chi-square analyses were used to assess differential dropout between baseline and the 12 month follow-up. Mean differences in behavior, self-efficacy, intentions, subjective norm, perceived behavioral control and attitudes for fruit and vegetable consumption were examined across stages of change at baseline using an analysis of variance (ANOVA). Longitudinal stability of the stages of change was examined using the Cohen’s kappa test of inter-rater reliability. Stage transitions were examined descriptively by examining the pattern of stage transition across baseline, 6 months and 12 months. For this analysis, the contemplation and preparation stages were combined as were the action and maintenance stages. This was done due to very small sample sizes in both contemplation and action. Patterns of change were assessed using similar categories to Prochaska and colleagues (1991). They included: 1. Stable – in the same stage all three time points; 2. Progressing – moving forward at least one stage with no setbacks; 3. Relapse – moving backward at least one stage without returning to the original stage; 4. Mixed inverted V pattern – participants first increased and then decreased their stage, for example moving from contemplation to action and then back to contemplation; 5. Mixed V pattern – participants first decreased and then increased their stage, for example moving from action to contemplation and then back to action [39].

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Baseline differences in behavior and the related psychosocial variables were examined as possible stage change predictors by looking at each baseline stage of change and assessing which stage the individual moved into at 12 months. One-way ANOVAs with follow-up Tukey tests were used to assess significant differences by baseline stage. 3. Results 3.1 Sample characteristics A total sample of n=3,519 respondents completed baseline surveys (22.8% response rate), with n=2,390 (67.9%) completing the six month follow-up, and N=1,978 completing the 12 month follow-up (56.2% of baseline). At baseline, the mean age was 46.3 years, with a mean of 14.9 years of education, and a median income of $40,000 to $50,000 per year. A greater percent of females participated in the study (62.0%). The sample was ethnically diverse with 86% of the sample comprised of Caucasian, Japanese, Filipino, Chinese, and Native Hawaiians. A mean of 3.1 fruits and vegetables were consumed per day by participants. All demographic variables are displayed in Table 2. 3.2 Attrition analysis Differential attrition rates by demographic variables and behavior were analyzed. No significant differences were found across gender and fruit and vegetable consumption. Small but significant differences existed across age, income level, education, and ethnicity, p < .001. Those less than 35 years of age, a household income of less than $40,000, and no college education experienced a higher rate of attrition. Those of Japanese ethnicity showed the greatest percent of retention as compared to other ethnicities. The main reason for nonresponse was an inability to contact the participant (63.3%) after five attempts. Demographic characteristics of participants who completed the study and those who dropped out are presented in Table 2. 3.3 Missing data analysis Missing data was assessed for all of the variables of interest including stage of change, fruit and vegetable consumption, intentions, self efficacy, attitudes, subjective norms and perceived behavioral control. None of these variables had more than 10% missing data across both baselines, 6 months and 12 months. With the low level of missing data and the large sample size, no corrections were made for missing data and the case was eliminated from the analysis. 3.4 Stage distributions First, the stage distributions were examined across both time points, individually. Almost identical results were found with 39.2% in precontemplation (38.2% at 12 months), 5.4% in contemplation (4.2% at 12 months), 34.8% in preparation (36.7% at 12 months), 2.2% in action (1.9% at 12 months) and 18.4% in maintenance at baseline (18.9% at 12 months).

Testing the Assumptions of Stage of Change for Fruit and Vegetable Consumption: A Naturalistic Study

47

6 Months

12 Months

Dropout

Retain

Dropout

Retain

(n = 1129)

(n = 2390)

(n=1541)

(n=1978)

% Male

41.4

38.9

41.9

38.0

% Female

58.6

61.1

58.1

62.0

42.8 (16.4)

**48.0 (16.0)

43.1 (16.4)

**48.8 (15.8)

% Caucasian

32.5

35.0

33.2

35.0

% Hawaiian / partHawaiian % Japanese

18.7

17.6

19.3

16.9

15.5

20.7

14.9

22.2

% Filipino

10.8

8.7

11.0

8.2

% Other

22.5

18.0

21.7

17.7

14.2 (3.0)

**14.9 (3.1)

14.4 (3.0)

**14.9 (3.2)

< $40,000

49.8

39.3

47.4

39.0

$40,000-$49,999

11.9

11.2

12.2

10.9

> $49,999

38.3

49.5

40.4

50.1

3.0 (1.83)

3.1 (1.82)

3.1 (1.9)

3.1 (1.8)

Demographics Gender

Age Mean (SD) in yrs Ethnicity1,2

Education Mean yrs (SD) Income1,2

Behavior Mean fruit and vegetable intake

** Significant t-test (p < .001) 1 = Significant Chi-Square Test at 6 months (p < .001) 2 = Significant Chi-Square Test at 12 months (p < .001)

Table 2. Attrition comparison by baseline demographics at 12 months 3.5 Behaviors and related constructs by stages of change Differences in behavior and related constructs for fruit and vegetable consumption were examined across stages of change at baseline for self-efficacy, intention, subjective norms, perceived behavioral control, and attitude. Significant differences in behavior and all related constructs were observed across stages of change, p < .001 (Table 3). The largest effect sizes were found across stages of change for behavior, intentions and self efficacy; η2 = .624,

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η2=.310 and η2=.304 respectively. These three variables showed significant differences across almost all of the stage transitions. Attitudes and subjective norms were important for differentiating between precontemplation and the other stages and perceived behavioral control was significant in differentiating between maintenance and the other stages. Behavior

Self-

Attitudes

Efficacy

Subjective

Perceived

Norm

Behavioral Control

N = 1884

N = 1917

N = 1890

N = 1791

N = 1891

Precontemplation

2.09 (1.02)

5.32 (2.92)

8.23 (1.83)

6.45 (2.64)

6.69 (2.30)

Contemplation

2.51 (1.14)

6.65 (2.52)

8.57 (1.68)

7.40 (2.30)

7.22 (2.23)

Preparation

2.73 (1.00)

7.94 (2.00)

9.02 (1.47)

7.82 (2.34)

7.97 (1.86)

Action

5.53 (0.91)

8.19 (1.76)

9.23 (1.08)

8.02 (1.87)

7.91 (2.01)

Maintenance

5.87 (1.44)

9.27 (1.37)

9.55 (0.98)

8.34 (1.95)

9.20 (1.19)

F-value

F(4,1879)

F(4,1912)

F(4,1885) =

F(4,1786) =

F(4,1886) =

= 780.39,

= 209.03,

49.97,

45.50,

103.97,

p < .000

p < .000

< .000

.000

< .000

.624

.304

.096

.092

.181

PC < All

PC < All

PC<

PC < All

PC< P,A,M

C < A,M

C < P,A,M

P,A,M

C
C < P,M

P < A,M

P,A < M

C
P
P,A < M

eta2 Tukey post-hoc test1

p

p<

p

PC = Precontemplation, C = Contemplation, P = Preparation, A = Action, M = Maintenance.

Table 3. Behavior and mediators by stage of change at baseline 3.6 Examination of progression to action/maintenance While a high level of stability in stages of change was found cross-sectionally, longitudinal results yielded a small yet significant Cohen’s kappa correlation at κ = .246, indicating a low level of stability from baseline to 12 months, p < .001 (Table 4). Less than half of those in maintenance at baseline remained after 12 months. Precontemplators showed the greatest level of stability at 59.2%. Baseline stage of change was a significant predictor of action and

Testing the Assumptions of Stage of Change for Fruit and Vegetable Consumption: A Naturalistic Study

49

maintenance status at 1 year with only 8.0% of precontemplators reaching action or maintenance compared to 7.9% of contemplators, 22.1% of individuals in preparation, 38.1% of individuals in action and 49.1% of individuals in maintenance (p < .01). Table 4 displays the stage transitions from baseline to 12 months. Stage at 6 Months n = 2390 PC (%)

C (%)

P (%)

A (%)

M (%)

Precontemplation

58.8

4.9

27.4

2.4

6.6

Contemplation

36.0

16.2

33.3

3.6

10.8

Preparation

25.3

4.8

49.6

2.1

18.2

Action

14.6

2.1

41.7

2.1

39.6

Maintenance

15.3

1.1

26.5

4.6

52.5

Baseline1

Stage at 12 months n = 1978 PC (%)

C (%)

P (%)

A (%)

M (%)

Precontemplation

59.2

5.1

27.7

0.8

7.2

Contemplation

37.3

8.8

46.1

2.0

5.9

Preparation

26.9

3.7

47.3

2.6

19.5

Action

14.3

7.1

40.5

4.8

33.3

Maintenance

18.4

1.7

30.7

2.3

46.8

Baseline2

Stage at 12 months n = 1831 PC (%)

C (%)

P (%)

A (%)

M (%)

Precontemplation

66.3

5.1

22.6

0.2

5.9

Contemplation

34.5

8.3

48.8

4.8

3.6

Preparation

26.5

2.7

54.0

2.7

14.1

Action

24.5

8.2

32.7

2.0

32.7

Maintenance

11.9

3.5

26.8

2.7

55.1

6

Months3

1 = Cohen’s kappa; κ = .289, p < .001 2 = Cohen’s kappa; κ = .246, p < .001 3 = Cohen’s kappa; κ = .349, p < .001

Table 4. Longitudinal stability of stage of change for 5-a-day over 6 and 12 months

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3.7 Examination of stage sequence Stage sequence was then assessed across the 3 time points. Stable patterns were the most common for individuals in precontemplation (43.3%) and maintenance (32.5%) at baseline. The contemplation stage was very unstable with only 3.7% of respondents who began in contemplation remaining there for all three time points. Overall, more than a third (34.5%) of participants remained in the same stage over the three time points. Over the 12 month time period, about one-quarter (24.6%) of respondents progressed without relapse through the stages and one-fifth (19.3%) relapsed without progress. Precontemplators (40.4%) and contemplators (34.6%) were the most likely to progress, while maintainers (45.6%) were the most likely to relapse. Mixed patterns of change were also common with 11.7% of respondents showing the mixed inverted V pattern and 9.9 showing the mixed V pattern. Table 5 shows the patterns of stage transitions for all of the stages. Precontemplation

N

%

Stable

290

43.3

Progressing

270

40.4

(n = 669)

Relapse

N/A

Mixed inverted V Mixed V

109

16.3

N/A

Contemplation

N

%

Stable

3

3.7

Progressing

28

34.6

Relapse

18

22.2

Mixed inverted V

19

23.5

Mixed V

13

16.0

N

%

Stable

181

30.3

Progressing

115

19.3

Relapse

129

25.0

Mixed inverted V

66

11.1

Mixed V

86

14.4

(n = 81)

Preparation (n = 597)

Testing the Assumptions of Stage of Change for Fruit and Vegetable Consumption: A Naturalistic Study

Action

51 N

%

Stable

0

0

Progressing

9

23.1

Relapse

15

38.5

Mixed inverted V

6

15.4

Mixed V

9

23.1

N

%

116

35.6

(n = 39)

Maintenance (n = 326) Stable Progressing Relapse

N/A 149

Mixed inverted V Mixed V

45.7

N/A 61

18.7

N

%

Stable

590

34.5

Progressing

422

24.6

Relapse

331

19.3

Mixed inverted V

200

11.7

Mixed V

169

9.9

Overall (n = 1712)

Note: 1. Stable – in the same stage all three time points; 2. Progressing – moving forward at least one stage with no setbacks; 3. Relapse – moving backward at least one stage without returning to the original stage; 4. Mixed inverted V pattern – participants first increased and then decreased, for example moving from contemplation to action and then back to contemplation; 5. Mixed V pattern – participants first decreased and then increased, for example moving from action to contemplation and then back to action.

Table 5. Stage sequences across 3 time points 3.8 Longitudinal prediction of stage transitions Longitudinal prediction of stage transitions was then assessed by stage for behavior and the related psychosocial variables over the 12 month time period. All of the variables significantly predicted change across time except for subjective norms and behavior which did not predict relapse among people in action and maintenance at baseline. Self efficacy was the strongest predictor of relapse. Behavior was the strongest predictor of movement

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from contemplation and preparation to action or maintenance. Intention was the strongest predictor of change out of precontemplation. For transitions into stages, attitude and subjective norm predicted change from precontemplation to contemplation/preparation and perceived behavioral control predicted change from preparation to action/maintenance. All of the longitudinal predictors of stage transition are displayed in Tables 6 and 7.

Baseline PC

PC 1.99 (0.99)

Stage at 6 months C/P A/M Behavior 2.19 (0.99)1 2.71 (1.05)2,3

C/P

2.53 (1.05)

2.59 (1.05)

3.15 (0.87)2,3

A/M

5.78 (2.00)

5.61 (1.14)

5.99 (1.35)3

PC

8.03 (1.88)

Attitude 8.57 (1.67)1 8.60 (1.75)2

C/P

8.61 (1.68)

9.01 (1.36)1

9.38 (0.98)2,3

A/M

9.25 (1.15)

9.48 (0.88)

9.61 (0.99)2

PC

6.19 (2.70)

Subjective Norm 6.76 (2.68)1 6.47 (2.44)

C/P

7.20 (2.47)

7.97 (2.17)1

8.07 (2.22)2

A/M

7.98 (2.04)

8.15 (1.95)

8.44 (1.82)

PC

6.41 (2.33)

C/P

7.33 (2.15)

7.96 (1.82)1

8.43 (1.65)2,3

A/M

8.67 (1.68)

8.85 (1.40)

9.39 (1.01)2,3

PC

4.83 (2.88)

Self Efficacy 5.72 (2.66)1 5.75 (3.00)2

C/P

7.43 (2.21)

7.74 (2.08)

8.49 (1.85)2,3

A/M

8.86 (1.77)

9.04 (1.50)

9.45 (1.11)2,3

Perceived Behavioral Control 6.91 (2.28)1 7.12 (2.33)2

F value

η2

F(2,853) = 19.02 p < .001 F(2,888) = 22.93 p < .001 F(2,485) = 3.45 p < .05

.045 .052 .014

F(2,858) = 9.60 p < .001

.022

F(2,895) = 15.92 p < .001 F(2,481) = 3.92 p < .05

.036 .016

F(2,814) = 3.96 p < .05 F(2,859) = 10.26 p < .001 F(2,438) = 2.07 p = ns

.010

F(2,860) = 5.97 p < .01 F(2,896) = 17.96 p < .001 F(2,481) = 14.10 p < .001

.014

F(2,869) = 10.61 p < .001 F(2,907) = 14.12 p < .001 F(2,484) = 7.74 p < .001

.024

.024 ----

.040 .059

.031 .032

Note: PC = Precontemplation, C = Contemplation, P = Preparation, A = Action, M = Maintenance. 1 = C/P > PC for Tukey post-hoc test (p < .05) 2 = A/M > PC for Tukey post-hoc test (p < .05) 3 = A/M > C/P for Tukey post-hoc test (p < .05)

Table 6. Baseline behavior and mediator score by 12 month stage of change

Testing the Assumptions of Stage of Change for Fruit and Vegetable Consumption: A Naturalistic Study

Baseline PC

PC 1.98 (1.00)

Stage at 1 Year C/P A/M Behavior 2.18 (1.08)1 2.57 (1.06)2,3

C/P

2.43 (1.04)

2.68 (1.02)1

3.18 (0.83)2,3

A/M

5.70 (1.95)

5.64 (1.04)

6.00 (1.34)

PC

7.97 (1.87)

Attitude 8.63 (1.70)1 8.56 (1.73)2

C/P

8.64 (1.82)

9.02 (1.40)1

9.32 (1.18)2

A/M

9.03 (1.28)

9.63 (0.66)1

9.61 (1.04)2

PC

6.19 (2.71)

Subjective Norm 6.74 (2.52)1 6.83 (2.48)

C/P

7.30 (2.51)

8.03 (2.24)1

7.81 (2.20)

A/M

7.97 (2.02)

8.44 (1.77)

8.33 (2.00)

PC

6.47 (2.32)

C/P

7.37 (2.13)

7.95 (1.86)1

8.49 (1.59)2,3

A/M

8.30 (1.95)

9.00 (1.26)1

9.40 (0.95)2,3

PC

4.97 (2.96)

Self Efficacy 5.75 (2.83)1 5.98 (2.64)2

C/P

7.47 (2.15)

7.72 (2.17)

8.31 (1.84)2,3

A/M

8.26 (2.13)

8.98 (1.44)1

9.64 (0.83)2,3

Perceived Behavioral Control 6.80 (2.32) 7.51 (1.98)2

53

F value

η2

F(2,719) = 9.83, p < .001 F(2,739) = 26.1, p < .001 F(2,389) = 2.8, p = .06

.028

F(2,721) = 11.5, p < .001 F(2,746) = 9.8, p < .001 F(2,384) = 10.2, p < .001

.031

F(2,689) = 3.9, p < .05 F(2,712) = 6.6, p < .001 F(2,353) = 1.3, p = ns

.011

F(2,722) = 5.8, p < .01 F(2,746) = 15.7, p < .001 F(2,385) = 19.1, p < .001

.016

F(2,733) = 7.5, p < .001 F(2, 757) = 7.4, p < .01 F(2,388) = 28.1, p < .001

.020

.066 ----

.026 .051

.018 ----

.041 .091

.019 .127

Note: PC = Precontemplation, C = Contemplation, P = Preparation, A = Action, M = Maintenance. 1 = C/P > PC for Tukey post-hoc test (p < .05) 2 = A/M > PC for Tukey post-hoc test (p < .05) 3 = A/M > C/P for Tukey post-hoc test (p < .05)

Table 7. Baseline behavior and mediator score by 12 month stage of change 4. Discussion This study examines the psychometric properties of the stage of change construct for fruit and vegetable consumption following three of the four research designs for testing stage models outlined by Weinstein and colleagues (1998) [33]. First, stage distribution was

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assessed. Over one-third of respondents were in the preparation stage of change. While this is unusual for most proactively recruited samples [25] it is consistent with other fruit and vegetable staging results [40, 27]. Next, cross-sectional comparisons of individuals in different stages showed significant differences for fruit and vegetable consumption and self efficacy as well as related constructs from the Theory of Planned Behavior including attitude, intention, subjective norm and perceived behavioral control. Attitude, self efficacy and intention all varied linearly across the stage of change. Perceived behavioral control showed a non-linear relationship with no increase between preparation and action and a large increase between action and maintenance. Attitude and subjective norms showed significant differences in the early stage with little difference between contemplation, preparation and action. Fruit and vegetable intake increased dramatically between preparation and action due to the definition of action requiring consumption of five servings of fruit and vegetables a day. These findings support the ability of stage to differentiate between related psychosocial constructs among people at different stages and support both a true stage model and the non-linear pseudostage model over the linear pseudostage model. Stage of change was then examined longitudinally. Stage membership varied greatly over the year with less than half of respondents remaining in the same stage of change. However, the construct did show predictive validity with individuals in preparation almost three times as likely to reach action and maintenance than those in precontemplation at baseline. The preparation stage was also reached by 18% more contemplators than precontemplators at 12 months. Individuals who began the study in maintenance were also the most likely to be in maintenance at the end of the study. Participants in preparation, action and maintenance at baseline were more likely to be in action or maintenance at 12 months than those who started at precontemplation or contemplation. This supports the assumption that the stage of change for fruit and vegetable consumption are temporally ordered, with preparation the closest to action [33]. Next, we looked at patterns of change across the three time points. Stable patterns were the most common for individuals in precontemplation and maintenance. This is consistent with finding with stage of change for smoking [39]. Overall, we saw about one-third of participants remaining stable in their stage, one-quarter linearly progressing, one-fifth linearly regressing and one-fifth showing unstable patterns. With little longitudinal data available of stage transitions for fruits and vegetables it is difficult to compare or contrast these results to other studies. Although Weinstein et al (1998) recommend the examination of stage sequences even they admit that, “labeling a changing pattern of transition probabilities as gradual or abrupt is somewhat subjective, so sequence data may not be very conclusive” [33]. This appears to be the case here, with the stage transition data neither supporting nor refuting the stage model. The six month time point is probably too long for what appears to be a fairly unstable behavior. Finally, we examined the longitudinal prediction of stage transitions. All of the variables showed some predictive validity, although the effect sizes were small. According to the TTM, cognitive strategies are important for early stage progress, while behavioral processes are important for later stage progress [21]. While this study did not examine the processes of change it does contain both experiential (attitude, subjective norm) and behavioral (perceived behavioral control) psychosocial constructs. We would therefore expect that attitude and subjective norm predict change from precontemplation to

Testing the Assumptions of Stage of Change for Fruit and Vegetable Consumption: A Naturalistic Study

55

contemplation/preparation and perceived behavioral control predicts change from preparation to action/maintenance. Similar to our cross-sectional findings, the data does appear to support this assumption. 5. Conclusions Overall, the stage of change measure for fruit and vegetable consumption is well supported by these analyses. The measure differentiates between individuals cross-sectionally, provides prediction for progress to action, and does appear to show properties relevant to an actual stage model over a linear pseudostage model. These analyses do not settle the debate between stage models and a non-linear pseudostage model, since matched and mismatched interventions are needed to examine this difference. They do, however validate the utility of the stage of change measure as an important tool for designing population interventions to increase fruit and vegetable intake. Stage of change is widely used in practice due to its utility in interventions. Stage-based expert system technology has been shown to be an important tool in reaching [41, 42]. However, Weinstein and colleagues (1998) last test of matched and mismatched interventions are still uncommon, with two small studies in physical activity and smoking not supporting improved efficacy of a stagematched intervention [43, 44]. This study has several limitations. We did not use all of the constructs from the Transtheoretical Model including decisional balance and the processes of change. Instead several constructs from the Theory of Planned Behavior were used. Although this is not entirely consistent with the TTM, since it is a trans-theoretical model it is not surprising that the constructs showed similar relationships across stage to the ones postulated by Prochaska and DiClemente (1983) [45]. This approach also follows what other authors have shown, with non-Transtheoretical Model constructs varying by stage of change including attitude and expectancies [46, 47]. Also differential dropout occurred across several demographic categories. However, this appeared to be related to a younger, more mobile population rather than active refusals. To our knowledge, this is the largest study of the fruit and vegetable staging construct to examine Weinstein and colleagues (1998) first three research designs and one of the only studies for any behavior to examine the longitudinal predictors of stage transition [33]. Several questions still need to be addressed to further improve the stage of change instrument. The most important is probably the 30 day criteria for precontemplation and the 6 month criteria for maintenance. These timeframes have been applied almost universally to every behavior that stage of change has been applied to with little rationale except historical precedence. For fruit and vegetable intake, the preparation stage is endorsed by over 40% of the population yet only 22% of these individuals were in action or maintenance after one year. This might be an area where additional examination is needed since action for an acquisition behavior is very different than from cessation of an addictive behavior. Finally, intervention research testing matched and mismatched groups is needed for fruit and vegetable intake to assess the feasibility of the stage model compared to the non-linear pseudostage model. 6. Competing interests The authors declare that they have no competing interests.

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7. Authors’ contributions JM conceptualized the paper, conducted the study, and wrote a large section of the manuscript. JB conducted the statistical analysis. CM drafted sections of the manuscript. As co-investigator, CN also participated in the conception and design of the study and provided comments on the manuscript. 8. Acknowledgements This study was funded by the Tobacco Settlement Special Fund through a contract with the Hawaii State Department of Health. Special thanks also go to QMark Research and Polling for completing the survey interviews. 9. References [1] National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention. Physical Activity and Good Nutrition: Essential Elements to Prevent Chronic Diseases and Obesity. [www.cdc.gov/nccdphp/overview.htm] [2] Brousseau ME, Schaefer EJ. Diet and coronary heart disease: clinical trials. Curr Atherosclerosis Reports 2000; 2: 487-493. [3] Hu, FB, Willett WC. Diet and coronary heart disease: findings from the Nurses’ Healthy Study and Health Professionals Follow-up Study. J of Nutr, Health, and Aging 2001, 5(3): 132-128. [4] Kromhout D, Menotti A, Kesteloot H, Sans S. Prevention of coronary heart disease by diet and lifestyle: Evidence from prospective cross-cultural, cohort, and intervention studies. Circulation 2002, 105; 893-898. [5] Boden-Albala B, Sacco RL. Lifestyle factors and stroke risk: exercise, alcohol, diet, obesity, smoking, drug use, and stress. Curr Atherosclerosis Reports 2000, 2(2): 160166. [6] Renaud SC. Diet and stroke. J of Nutr, Health, & Aging 2001, 5(3): 167-172. [7] Dyson PA. The role of diet and exercise in type 2 diabetes prevention. J of Prof Nurs 2003, 18(12): 690-692. [8] Steyn NP, Mann J, Bennett PH, Temple N, Zimmet P, Tuomiletho J, Lindstrom J, Louheranta A. Diet, nutrition and the prevention of type 2 diabetes. Pub Health Nutr 2004, 7(1A): 147-165. [9] Prentice A. Diet, nutrition, and the prevention of osteporosis. Pub Health Nutrition 2004, 7(1A): 227-43. [10] Key TJ, Schatzkin A, Willett WC, Allen NE, Spencer EA, Travis RC. Diet, nutrition, and the prevention of cancer. Pub Health Nutr 2004, 7(1A): 187-200. [11] Willet WC. Diet, nutrition, and avoidable cancer. Env Health Persp 1995, 103 (Suppl 8): 165-170. [12] Bazzano LA, Serdula MK, Liu S. Dietary intake of fruits and vegetables and risk of cardiovascular disease. Curr Atherosclerosis Rep 2003, 5(6): 492-499. [13] Feldman EB. Fruits and vegetables and the risk of stroke. Nutrition Rev 2001, 59(1): 2427. [14] Ness AR, Powles JW. Fruit and vegetables, and cardio-vascular disease: a review. Int J of Epi 1997, 26(1): 1-13.

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[15] Van’t Veer P, Jansen MC, Klerk M, Kok FJ. Fruits and vegetables in the prevention of cardiovascular disease and cancer. Pub Health Nutr 2000, 3(1): 103-107. [16] World Cancer Research Fund and the American Institute for Cancer Research. Food, Nutrition and the Prevention of Cancer: A Global Perspective. Washington, DC: American Institute for Cancer Research; 1997. [17] US Department of Agriculture: USDA’s Food Guide Pyramid. Washington, DC: US Government Printing Office; 1992. [18] US Department of Health and Human Services: The Surgeon General’s Report on Nutrition and Health. Washington, DC: US Government Printing Office; 1988. [19] Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System Online Prevalence Data, 1995-2002. [www.cdc.gov/brfss] [20] Prochaska JO, Redding CA, Evers KE. The Transtheoretical Model and Stages of Change. In Health Behavior and Health Education, 3rd edition. Edited by Glanz K, Rimer BK, Lewis FM. San Francisco, CA: John Wiley and Sons Inc; 2002. [21] Prochaska JO, DiClemente CC, Norcross JC. In search of how people change: Applications to addictive behaviors. Am Psych 1992, 47(9): 1102-1112. [22] Glanz K, Patterson RE, Kristal AR, Feng Z, Linnan L, Heimendinger J, Hebert JR. Impact of work site health promotion on stages of dietary change: the Working Well Trial. Health Ed Beh 1998, 25(4): 448-463. [23] Schumann A, Nigg CR, Rossi JS, Jordan PJ, Norman GJ, Garber CE, Riebe D, Benisovich SV. Construct validity of the stages of change of exercise adoption for different intensities of physical activity in four samples of differing age groups. Am J of Health Prom 2002, 16: 280-287. [24] Bowen, AM, Trotter, R. HIV risk in intravenous drug users and crack cocaine smokers: predicting stage of change for condom use. J of Consulting & Clinical Psych 1995, 63(3): 238-248. [25] Prochaska JO, Velicer WF, Rossi JS, Goldstein, MG, Marcus BH, Rakowski W, Fiore C, Harlow LL, Redding CA, Rosenbloom D, Rossi SR. Stages of change and decisional balance for 12 problem behaviors. Health Psych 1994, 13: 39-46. [26] Brug J, Glanz K, Kok G. The relationship between self-efficacy, attitudes, intake compared to others, consumption and stages of change related to fruit and vegetables. Am J of Health Prom 1997, 12: 25-30. [27] Campbell MK, Symons M, Demark-Wahnefried W, Polhamus B, Bernhardt JM, McClelland JW, Washington C. Stages of change and psychosocial correlated of fruit and vegetable consumption among rural African-American church members. Am J of Health Prom 1998, 12: 185-191. [28] Ma J, Betts NM, Horacek T. Measuring stages of change for assessing readiness to increase fruit and vegetable intake among 18- to 24-year-olds. Am J of Health Prom 2001, 16: 88-97. [29] Sorensen G, Stoddard A, Macario E. Social support and readiness to make dietary changes. Health Ed & Beh 1998, 25: 586-598. [30] Van Duyn MAS, Heimendinger J, Russek-Cohen E, DiClemente CC, Sims LS, Subar AF, Krebs-Smith SM, Pivonka E, Kahle LL. Use of the Transtheoretical Model of Change to successfully predict fruit and vegetable consumption. J of Nutr Ed 1998, 30: 371-380.

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[31] Van Duyn, MAS, Kristal AR, Dodd K, Campbell MK, Subar AF, Stables G, Nebling L, Glanz K. Association of awareness, intrapersonal and interpersonal factors and dietary change with fruit and vegetable consumption: a national survey. Am J of Health Prom 2001, 16: 69-78. [32] Povey R, Conner M, Sparks P, James R, Shepherd R. A critical examination of the application of the Transtheoretical Model’s stages of change to dietary behavior. Health Ed Res 1999, 14(5): 641-651. [33] Weinstein ND, Rothman AJ, Sutton SR. Stage theories of health behavior: conceptual and methodological issues. Health Psych 1998, 17(3): 290-9. [34] Waksberg, J. Sampling methods for Random Digit Dialing. J of the Am Stat Assn 1978, 73: 40-46. [35] Thompson FE, Subar AF, Smith AF, Midthune D, Radimer KL, Kahle LL, Kipnis V. Fruit and vegetable assessment: performance of 2 new short instruments and a food frequency questionnaire. JADA 2002, 102: 1764-1772. [36] Greene GW, Clark P, Prochaska JO, Riebe D, Nigg CR. Stage-based health promotion with the elderly. NCI, 2nd meeting of the HPRB Nutrition Behavior Grantees. Washington, DC; 2000. [37] Montano DE, Kasprzyk D. The Theory of Reasoned Action and the Theory of Planned Behavior. In Health Behavior and Health Education, 3rd edition. Edited by Glanz K, Rimer BK, Lewis FM. San Francisco, CA: John Wiley and Sons Inc; 2002. [38] SPSS (version 11.5.0). Chicago: SPSS, Inc; 2002. [39] Prochaska JO, Velicer WF, DiClemente CC, Guadagnoli E, Rossi JS. Patterns of change: Dynamic typology applied to smoking cessation. Multivariate Beh Res 1991, 26(1): 83-107. [40] Frame CJ, Green CG, Herr DG, & Taylor ML. A 2-year stage of change evaluation of dietary fat and fruit and vegetable intake behaviors of cardiac rehabilitation patients. Am J of Health Prom 2003, 17: 361-368. [41] Prochaska JO, DiClemente CC, Velicer WF, Rossi JS. Standardized, individualized, interactive and personalized self-help programs for smoking cessation. Health Psych 1993, 12: 399-405. [42] Redding CA, Prochaska JO, Pallonen UE, Rossi JS, Velicer WF, Rossi SR, Greene G, Meier K, Evers K, Plummer BA, Maddock JE. Transtheoretical individualized multimedia expert systems targeting adolescents’ health behaviors. Cognitive & Beh Prac, 1999, 6: 142-151. [43] Blissmer B, McAuley E. Testing the requirements of stages of physical activity among adults: the comparative effectiveness of stage-matched, mismatched, standard care, and control interventions. Ann of Beh Med 2002, 24: 181-189. [44] Quinlan KB, McCaul KD. Matched and mismatched interventions with young adult smokers: testing a stage theory. Health Psych 2000, 19: 165-171. [45] Prochaska and DiClemente. Stages and processes of self-change of smoking: Toward an integrative model of change. J of Consulting & Clinical Psych 1983, 51: 390-395. [46] Jordan PJ, Nigg CR, Norman GJ, Rossi JS, Benisovich SV. Does the Transtheoretical model need an attitude adjustment? Integrating attitude with decisional balance as predictors of stage of change for exercise. Psych of Sport & Exercise 2002, 3: 65-83. [47] Noar SM, Laforge RG, Maddock JE, Wood MD. Rethinking positive and negative aspects of alcohol use: Suggestions from a comparison of alcohol expectancies and decisional balance. J on Studies on Alcohol 2003, 64: 60-69.

3 Strategies for Cardiovascular Disease Prevention in Rural Southern African American Communities Ralphenia D. Pace, Norma L. Dawkins and Melissa Johnson Tuskegee University USA

1. Introduction Cardiovascular disease (CVD) is a commonly recognized umbrella term encompassing conditions, disease or disorders of the heart and/or blood vessels that may result in impairment of optimal cardiovascular functioning. CVD is the leading cause of morbidity and mortality in the United States, as well as in both developed and developing nations. Although the risk for CVD in the United States may vary according to and fluctuate within certain demographic, educational, behavioral and socio-economic characteristics, disparities in CVD prevention and treatment continue to ensue, particularly within minority populations. This gap in CVD disparity is further increased in regard to African American women living in rural southern communities. Demographic, socioeconomic and neighborhood characteristics are suggested to converge within rural African American communities to additively influence CVD risk. Efforts to prevent CVD have often involved the use of diet and nutrition, nutrition education, physical activity modifications and behavioral-based strategies. The higher rate of disparities in CVD prevalence, mortality, preventive and treatment services in rural regions warrants an aggressive approach in addressing this issue to improve public health. The use of prevention strategies, exploiting specific aspects of the above mentioned strategies may prove useful in mitigating CVD risk disparities among African Americans living in rural southern communities. This chapter will investigate CVD risk, prevention and treatment, with an emphasis on African Americans living in rural southern communities. Additionally, several strategies employing an integrative multi-disciplinary approach to preventing CVD in rural southern African American communities will be provided.

2. Definitions and classification of CVD CVD is an umbrella term encompassing conditions such as: high blood pressure (HBP); coronary heart disease, including myocardial infarction and angina pectoris; heart failure, stroke and congenital cardiovascular defects (Lloyd-Jones et al., 2009). Classifications of CVD include, but are not limited to: atherosclerosis, cardiomyopathy, cerebrovascular disease (stroke), congenital heart disease, coronary heart disease, hypertension, heart failure, and transient ischemic attack. Ideally to achieve and maintain cardiovascular health several

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anthropometrical (e.g. body mass index), behavioral (e.g. physical activity), dietary (e.g. healthy diet score) and clinical (e.g. total cholesterol, blood pressure and fasting plasma glucose) objectives should be met (Lloyd-Jones et al., 2010). 2.1 CVD prevalence in the United States Cardiovascular disease (CVD) has been recognized as a public health problem for nearly a century in the United States, whereas in previous years contagious diseases such as typhoid disease, smallpox, diphtheria, rheumatic fever and tuberculosis posed a particular threat to public health (Griswold, 1927). Over one-third of adults living in the United States over the age of 20 years have high blood pressure, one of the most common types of CVD (Roger et al., 2011). Among these individuals the highest prevalence of hypertension is observed among African Americans- particularly those living in the rural South (Danaei et al., 2010). Further, these individuals also exhibit greater disparities in smoking, elevated blood glucose and adiposity. It is predicted that nearly half of individuals living in the United States will exhibit some form of CVD by 2030 (Heidenreich et al., 2011). The financial burden associated with the costs of CVD treatment, morbidity and mortality are projected to reach over $800 billion during this time. An estimated 1 in 3 American adults are predicted to possess one or more forms of CVD, the most common of which is hypertension or high blood pressure (HBP) (Lloyd-Jones et al., 2009). Although the prevalence of heart disease is slightly less in African Americans compared to Whites (10.2% vs. 11.4%), a significantly greater number of African Americans have high blood pressure (31.7% in African Americans vs. 22.2% in Whites). Individuals living in the southern region of the United States referred to as the “stroke belt” have the highest rates of high blood pressure (Hajjar & Kotchen, 2002). Further, high blood pressure increases the risk for cerebrovascular disease or stroke, which is the third leading cause of death among Americans (Lloyd-Jones et al., 2010). Although stroke-related deaths have declined in recent years, individuals living in the southeastern region of the United States exhibit the highest rates of stroke and related hospitalizations. 2.2 CVD prevalence in rural southern African American communities As mentioned previously, individuals living in the stroke belt, a cluster of communities in Arkansas, Louisiana, Mississippi, Alabama, Georgia, South Carolina, North Carolina, Virginia, Tennessee, Kentucky and Indiana, exhibit stroke death rates higher than the national average. In comparison to other regions of the United States, CVD prevalence is elevated among individuals living in rural southern communities, particularly African American women (Taylor et al., 2002). The highest rates of CVD mortality are often observed among those who are poor and live in rural regions (Cooper et al., 2000). 2.3.1 Demographic and socioeconomic characteristics of rural communities Rural communities are generally composed of individuals who are older, have lower educational attainment and lower socioeconomic status (Johnson, 2006). Persistent sluggish economies and lower income brackets have contributed to the continual presence of poverty across generations observed in rural America (Brown & Warner, 1991). Although a vast majority of non-Hispanic Whites occupy rural communities, rural communities in the southeastern United States are heavily populated by African Americans.

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Although younger residents (21 to 35 years of age) of rural communities demonstrate greater knowledge regarding the general relationship between diet and CVD risk, these individuals were also found to express less immediate concern in developing adverse health outcomes (Pace et al., 2008). Nevertheless with knowledge of the relationship between a specific dietary component (i.e. fat) and CVD risk, came dietary behaviors that may reduce the risks associated with CVD (i.e. consumption of low-fat dairy products). Among 18 to 26 year old African Americans living in rural communities, females and greater educational attainment were associated with greater CVD risk knowledge (Winham & Jones, 2011). Although rural African American women may perceive themselves at risk for hypertension, barriers such as income, lack of insurance, medical expenses, neighborhood environment and family support/characteristics may inhibit them from actively seeking CVD prevention and/or treatment measures (Ford et al., 2009). 2.3.2 Rural African American neighborhood/community resources In comparison to urban communities, rural communities have limited access to fruits and vegetables (Hosler et al., 2008). Research indicates that neighborhood characteristics influence the affordability of fresh fruit and vegetables, with African American rural residents paying more for these items (Dunn et al., 2011). Perceptions regarding self-efficacy, the neighborhood (i.e. community) and home (i.e. consumer) nutrition environment and family support among rural Georgia residents indicate positive associations between these variables and healthy dietary behaviors (Hermstad et al., 2010). Components of the neighborhood nutrition environment include food accessibility as influenced by the number, type and location of grocery/convenience stores and restaurants. Conversely, the home nutrition environment includes the presence, cost and quality of healthy food items in the neighborhood, which influence consumer nutrition behaviors such as shopping at supermarkets versus convenience stores and dining out at a sit-down versus a fast-food establishment. The home nutrition environment and consumer nutrition behavior were positively associated with dietary behaviors that facilitate dietary fat intake among rural women. Senior citizens living in rural communities are at risk for inadequate fruit and vegetable intake as well. Older women reported consuming more servings of fruit and vegetables, although both men and women reported consuming comparable servings of fruit and vegetables in rural Texas (Sharkey et al., 2010). Likewise, fruit and vegetable consumption among these individuals was influenced by supermarket location, produce variety and produce quality. Consequently, the diet quality of rural residents is compromised. Data collected on the diet quality of older adults living in the rural southern United States revealed that less than 2% met the dietary guidelines (Savoca et al., 2009). Although overall diet quality was inadequate, dietary intakes of dark green and orange vegetables were sufficient. In comparison to American Indians and in some instances non-Hispanic whites, rural African Americans reported consuming greater quantities of total and whole fruit, grains and meat. Sanderson et al (2003) found that nearly two-thirds of African American women living in rural Greene, Lowndes and Wilcox counties of Alabama were either “insufficiently inactive” (46%) or “inactive” (15%). Contributing to their current level of physical activity or inactivity were participation in regular religious services, observing others engaging in physical activity (i.e. exercise), interacting with others engaging in physical activity and more positive feelings and perceptions regarding participation in physical activity. In addition, an

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immense sense of community related to neighborhood characteristics such as quality, safety and neighbor support contributed to more personal positive feelings and perceptions regarding physical activity. Rural women who viewed their neighborhood as safe and observed the presence of sidewalks were more likely to engage in regular physical activity (Wilcox et al., 2003). Glover et al (2011) found rural South Carolina female children to be significantly more likely to engage in physical activity than their male counterparts. Among these children less than half (42%) indicated that they consume fewer than the recommended daily servings of fruit and vegetables. 2.4 Racial/ethnic disparities in CVD Racial and socioeconomic distinctions between CVD risk among women living in the rural southern region of the United States have been noted by researchers (Appel et al., 2002). Women with lower education levels exhibited the greatest risk for CVD, as augmented by inadequate physical activity, smoking, elevated cholesterol levels and a family history of CVD. In comparison to White women, African American women living in rural communities had significantly lower education and income levels. Among these women the prevalence of hypertension and diabetes was greater among African American women. Although deaths from CVD have declined in individuals living in rural regions, those in the southern and Appalachian regions of the United States are still at an amplified risk for premature death from CVD (Pearson and Lewis, 1998; Barnett & Halverson, 2000; Barnett et al., 2000). National rates of death in the United States from heart disease were the second highest in southern rural counties; among men the highest percentage of deaths related to CVD were observed in these counties (Eberhardt et al., 2001). Disparities in access to medical treatment facilities in rural areas are believed to contribute to the increased risk of premature death from CVD among rural residents. In comparison to urban communities, rural communities are more likely to have inadequate access to and quality of health care services (Reschovsky & Staiti, 2005). Minorities (i.e. African Americans and Hispanic Americans) living in rural regions have disproportionately limited access to health care compared to their White counterparts (Mueller et al., 1999). African American women living in rural areas are particularly vulnerable (Cort et al., 2001). Significant disparities in access to facilities that provide treatment for acute cases of CVD (i.e. stroke) have been observed when comparing urban to rural communities, with significantly fewer rural communities having access to acute care facilities (Khan et al., 2011). Disparities in stroke prevalence have also been observed with African Americans being more likely to report having a stroke, compared to other ethnic groups; African Americans were also more likely to report being hypertensive (McGruder et al., 2004; Lloyd-Jones, 2009). Among these individuals, black non-Hispanic females with less than a high school education, living above or equal to the poverty line with an annual income <$20,000 and unemployed were more likely to have a stroke. Racial/ethnic disparities in CVD risk in regard to the presence of other co-morbidities such as diabetes, insulin resistance and hypertension have also been observed (Brown, 2006). Zuniga et al (2003) suggest that disparities in CVD among rural Americans may be augmented due to certain behavioral characteristics and attitudes. Lower educational attainment, socioeconomic status and standards of living among individuals in rural communities may contribute to behaviors that increase CVD risk; poor dietary patterns,

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smoking, physical inactivity and the failure to manage other co-morbidities such as hypertension and diabetes contribute to this increased risk (Cooper et al., 2000). 2.5 Classical and novel assessments of CVD risk CVD clinical risk assessment has customarily been assessed based on an individual’s lipid profile. Generally, the risk for CVD is amplified due to the risk for and presence of other comorbidities. In addition to the more common physiological manifestations of CVD risk, novel assessments of CVD include the presence of more recently recognized proteins and cytokines that influence CVD risk. It has been suggested that acute phase proteins such as C - reactive protein (CRP), fibrinogen, homocysteine and lipoprotein (a) may be useful as novel assessment parameters of CVD risk (Hackman & Anand, 2003). Conventional risk factors for CVD risk assessment include biological (e.g. genetic predisposition, physiological (e.g. inflammatory disorders, hypertension, hyperlipidemia, diabetes), behavioral (e.g. cigarette smoking, physical inactivity) (Khot et al., 2003), dietary (e.g. inadequate fiber and antioxidant nutrients, high fat composition) and demographic (e.g. age, race, sex, education, income) (Figure 1). Indirect CVD risk may be assessed based on the presence of other co-morbidities as certain disease states increase the risk for developing CVD. For example, persistent elevations in blood glucose as seen in diabetes mellitus may increase the risk for hypertension. As indicated earlier in regard to racial/ethnic disparities in CVD risk, hypertension typically afflicts African Americans earlier in life and with greater severity.

Biological genetic predisposition Neighborhood

Physiological inflammation, co-morbidities

food access, housing, rural, safety, services, toxin exposure

Novel

CVD risk

Sociocultural beliefs, perceptions, stressors

Behavioral physical activity, smoking

Dietary fat, dietary fiber, antioxidants

Demographic age, race, sex, education, income

Fig. 1. Conventional and novel influencers of CVD risk.

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The assessment of CVD risk in African Americans is elusive in that generational non-genetic trajectories not commonly observed among other subgroups ensue in the African American population. Because African Americans typically exhibit lipid profiles within the “normal” range, an assessment of CVD risk (or other co-morbidities) based solely on lipid profile may not be sufficient to determine the level of true risk (Sumner et al., 2005a). While African Americans may display normal triglyceride levels even in the presence of insulin resistance, these individuals may have increased lipoprotein activity, which serves to attenuate increases in postprandial triglyceride levels (Sumner et al., 2005b). Although triglyceride levels may be used as a clinical diagnostic tool for insulin resistance, the demonstration of normal triglyceride levels among African Americans with insulin resistance (Sumner & Cowie, 2008), suggest that the identification of this disorder, as well as CVD, based solely on these variables may be insufficient. The integration of several specific biomarkers for disease risk as well as socioeconomic and demographic characteristics that influence disease risk may prove useful in the assessment of CVD risk among African Americans. Research findings suggest that socioeconomic characteristics may influence and/or mediate the manifestation of certain physiological processes, which may increase the risk of adverse cardiovascular outcomes (Muennig et al., 2007; Aiello & Kaplan, 2009). Further, chronic socioeconomic conditions may transcend generations and result in persistent inflammatory and immunologic responses that increase CVD risk. Lower socioeconomic characteristics during childhood have been associated with CVD in adulthood (Galobardes et al., 2006). Lower socioeconomic status has been found to be positively associated with inflammatory biomarkers such as fibrinogen and C - reactive protein (Wilson et al., 1993; Tabassum et al., 2008). Predictors of socioeconomic status and certain biomarkers related to CVD risk include employment/occupational status, educational attainment and income (Yarnell et al., 2005; Muennig et al., 2007; Ranjit et al., 2007; Rosvall et al., 2007). Of the predictors of socioeconomic status (i.e. education, income and occupation), education was significantly associated with decreased blood pressure, decreased total cholesterol and increased highdensity lipoprotein cholesterol (HDL-C) (Winkleby et al., 1992). Albert et al (2006) found education and income to function as novel assessments of CVD risk, with education and income being inversely associated with CVD risk.

3. Global perspective of CVD Cardiovascular disease (CVD) is caused by disorders associated with the heart and blood vessels, which include heart attack (coronary heart disease), stroke, hypertension, peripheral artery disease, rheumatic heart disease, congenital heart disease, and heart failure (WHO, 2011). According to the World Health Organization (WHO) report, 17.3 million people died from CVD in 2008. Of those deaths, 7.3 million resulted from coronary heart disease and 6.2 million from stroke. Low and middle income regions are disproportionally affected with over 80% of the deaths occurring in these locations. It is projected by 2030 that approximately 23.6 million people will die from CVD, which will remain the leading cause of death (WHO, 2011). Despite the declines in CVD over the past few decades, it still remains the leading cause of death in the United States. In 1992, more than 816,000 Americans died from some form of CVD, compared to 631,636 in 2006. In this same year heart disease was the major cause of death among various ethnic groups as well as for the general population. African Americans had the highest death rates

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compared to Asian and Pacific Islanders, Native Americans or Alaskan natives and Hispanics. In general heart disease was highest in Mississippi, a Black Belt state characterized by a population density of African Americans (CDC, 2010). It was estimated that in 2010 heart disease would cost the United States 316.4 billion dollars. This cost includes: healthcare services, medications, and lost productivity (CDC, 2010). Many Black Belt states exhibit higher prevalence of CVD, hypertension or high blood pressure (HBP) and obesity that exceed the national average (Table 1). It is estimated that 9 out of ten individuals with heart disease have at least one risk factor. Modifiable risk factors high blood pressure, high cholesterol, diabetes, smoking, overweight and obesity, poor diet, physical inactivity and alcohol use, are associated with lifestyle behaviors (Fakiri et al., 2006). Awareness of modifiable risk factors can lead to positive improvement in the health of individuals. 3.1 Stroke, hypertension and obesity African Americans are disproportionally affected by CVD, and are more likely to have two or more risk factors (Gillum, 2001). Furthermore research studies have shown that AfricanAmerican children have an increased relative stroke risk of 2.12 compared to Whites (Fullerton 2003). Also death rates for stroke was 48.1 for White males compared with 73.9 for African-American males; the disparities followed similar trends for White females, with a rate of 47.4 compared to 64.9 for African-American females per 100,000 (Fullerton, 2003). In general African Americans have been shown to be at risk 70% more than whites for stroke hospitalization (Kennedy, 2002). The severity, disability and mortality from stroke for African Americans are greater compared to Whites. African Americans develop hypertension at an earlier age than Whites and Mexican Americans (CDC, 2010; Ong et al., 2007). Among African Americans more females (44.1%) than males (42.2%) tend to develop hypertension. The percent affected by hypertension is higher for African-Americans males and females 42.2% and 44.1% compared to the general population 31.8 and 30.3, respectively. The prevalence of hypertension in African Americans in the United States is among the highest in the world (Hertz, 2005). Hypertension is a major risk factor for heart disease, stroke, congested heart failure and kidney failure (CDC, 2010). Within the African American community, rates of hypertension vary substantially. Those with the highest rates are more likely to be middle aged or older, less educated, overweight or obese, physically inactive, and have diabetes mellitus (Collins, 2002). In the past four decades the prevalence of obesity among U. S. adults increased from 13 to 32%. Presently, 66% of adults are overweight or obese; 16% of children and adolescents are obese and 34% are overweight. Overweight adolescents have a 70% chance of becoming overweight or obese adults and this number increases to 80% if one or both parents are obese (Kaufman, 20007). It is projected that by 2015, 75% of adults will be overweight and 41% will be obese (Wang and Beydoun, 2007). According to the Centers for Disease Control and Prevention none of the states in the United States of America met the Healthy People 2010 ‘s goal to reduce obesity prevalence to 15%. Furthermore, the number of states with an obesity prevalence of 30% or more increased to 12 states in 2010 (CDC, 2011). In general the states where African Americans are present in the highest concentrations, They tend to have higher rates of obesity. Additionally, higher rates of obesity are found among groups with low educational and income levels, racial and ethnic minorities, rural and high poverty

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areas. Obesity is a risk factor for CVD and other chronic diseases and disproportionally affects African Americans of all ages (Odgen et al., 2006). The rate of obesity is higher in rural areas, due in part to poor nutrition, physical inactivity, and low educational levels (Jackson, Doescher, Jerant & Hart, 2005). In Table 1 below, the prevalence of CVD is illustrated in the Black Belt States.

Alabama Arkansas Georgia Florida Louisiana Mississippi North Carolina South Carolina Tennessee

CVD1(%) 4.0 5.2 3.8 4.1 5.0 3.9 4.2 4.1 4.0

HBP (%) 34.0 32.5 31.7 28.3 34.3 36.2 30.4 31.0 30.6

Obesity (%) 32.2 30.1 29.6 25.6 31.0 34.0 27.8 31.5 30.8

National

4.5

29.7

33.8

Table 1. CVD, HBP and obesity

prevalence1 in

adults across the Black Belt States.

3.2 Rural communities defined Because there are different characterizations of rural areas, there is no single preferred definition that suits all policy requirements. The US Census Bureau defines an urbanized area asan area that includes a central city and the surrounding densely settled territory that together have a population of 50,000 or more and a population density generally exceeding 1,000 people per square mile. The Office of Management Bureau designates areas as metro; Economic Research Service/United States Department of Agriculture (USDA) uses ruralurban continuum codes to distinguish metro counties by size and non-metro counties by their degree of urbanization or proximity to urban areas. USDA uses codes zero to three as metro; four to nine as non-metro. An urban population with a designation of four has 20,000 inhabitants or more adjacent to a metro area and a code of nine signifies completely rural or urban with a population of fewer than 2,500 not adjacent to a metro area (USDA National Agricultural Library, 2008). 3.2.1 Rural African American communities For the purpose of this text rural areas/communities are smaller towns or cities with low population density; where most of the land is devoted to agriculture. This definition better describes the communities inhibited by a vast majority of African Americans. The Black Belt region is characterized by rural socioeconomic decline, inadequate programs, acute problem of poverty, poor health, substandard housing and underemployment. This region includes the southern most states with a high percentage of African Americans/Blacks (Webster & Bowman, 2008; Wimberly & Morris 1997). A large segment (54.8%) of the African American 1

Coronary Heart Disease Prevalence

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population resides in this region compared to 17.5%, 18.8%, 8.7% in the northeast, Midwest, and West, respectively (US Census Bureau 2000). For example, in the state of Alabama there are 17 Black Belt counties which include Barbour, Bullock, Butler, Choctaw, Dallas, Greene, Hale, Lowndes, Macon, Marengo, Montgomery, Perry, Pike, Russell, Sumter, and Wilcox (Figure 1). The total population in this region is close to 600,000 or about 13 percent of the 4.5 million in the State. The percent of poverty ranges from 26.8% to 40% within the Black belt counties (Federal Statistics, 2004). The per capita income for the State of Alabama is estimated at $33,945, but is much lower in selected Black Belt counties with median incomes ranging from $24,969 to $30,370. Furthermore, median incomes for non-Black Belt counties in Alabama ranged from $41,770 to $64,371. When compared with other Alabama counties, Black Belt counties in Alabama have disproportionate greater rates of heart disease, cancer, hypertension and diabetes. CVD mortality rates are higher in Black Belt counties compared to non-Black Belt counties in Alabama (Table 1). Similar trends exist in the Delta region. In general CVD mortality rates are higher, the rate in Alabama is 235, Mississippi is 267.6 and South Carolina is 306 (from 2004 report)compared to the national average of190 per 100,000.

Fig. 2. Alabama black belt counties.

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Black Belt States Alabama Arkansas Georgia Florida Louisiana Mississippi North Carolina South Carolina Tennessee Virginia

Income 33,945 33,150 35,490 39,272 38,446 31,186 35,638 33,163 35,307 44,762

National

40,584

Table 2. Per capita personal income (2010) of households in the Black Belt States. Health Ranking*

Median Income

High School Graduation Rate

CVD Mortality Rate**

61 67 31 62

27,011 24,969 30,370 28,530

57.6 65.9 53.5 48.3

373 323 295 400

Non-Black Belt Lee Shelby Jefferson Alabama

2 1 29

41,770 64,371 43,279

69.2 76.2 60.8

178 145 265 235

National

-

50,221

84.6

191

County Black Belt Macon Bullock Barbour Lowndes

*County Health Ranking 1= best performance and 67 = worst performance.

**CVD mortality rate per 100,000 Taken from "Selected Indicators of Health Status in Alabama”, AL Rural Health Association and Alabama Department of Public Health, 2007 Table 3. Comparison of Four Targeted Black Belt Counties and Non Black Belt Counties in Alabama on Selected Health Measures Americans living in rural areas are disadvantaged as it relates to healthcare. These rural residents have to travel long distances to reach a healthcare facility, have less access to specialized care and are less likely to receive preventive care (Larson and Fleishman, 2003). Data showed that rates were higher (176.3) among rural African Americans admitted for uncontrolled diabetes without complications compared to metropolitan Whites and Blacks 13.8 vs. 76.7, respectively (AHRQ, 2005). In general pre-mature mortality is greater among rural residents than among urban/metropolitan or suburban. The age-adjusted death rate among individuals aged 1-24 who lived in rural counties was 31% higher than those living

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in urban counties and 65% higher than individuals living in suburban counties. Similar trends exist for more mature adults living in rural counties when compared to their urban counterparts. Death rates from CVD and cancer are higher in rural areas within certain regions. The mortality rate from heart disease was highest in the South (Eberhardt et al., 2001); furthermore, it was 25% higher than the rate among Southern suburban residents. The gap becomes wider for African American women where a 10-fold difference was observed; and the highest rates were among residents who lived in rural areas in the Mississippi Delta region (Taylor, Hughes & Garrison, 2002). Stroke is also higher among rural African Americans (Gillum, 1997). In Mississippi 80% or more of the counties have no physicians who specialize in CVD. Furthermore there is a lack of medical care resources for coronary care unit beds and cardiac rehabilitation units as well as limited action for intervention and treatment. Additionally, an analysis of services to Medicare beneficiaries revealed that the level of cardiology services for rural Medicare recipients was 40% lower than the urban beneficiaries as a result of the lower number of doctor service per beneficiary (15%) (Taylor, 2002). Furthermore, there is an increasing body of research that supports the presence of physical bias on race/ethnicity, economic status and in some cases gender (Fincher et al., 2004). 3.3 CVD interventions The Department of Health and Human Service in 1990 established the Healthy 2000 National Health Promotion and disease Prevention objectives, a strategy for improving the health of Americans. In 2000, the 2010 objectives were launched, as “a comprehensive nationwide promotion and disease prevention agenda. There were 467 objectives designed to serve as a frame work for improving the health of all people in the United States. In December of 2010 the Healthy People 2020 was delivered which continues to build and expand goals and objectives established two decades earlier (CDC, 2011). The objectives relating to reducing health disparities in African Americans was partially met; for example diabetes prevalence, diabetes-related deaths and lower extremity amputations. However, fetal alcohol syndrome increases and the gap widened (CDC, 2002). Disparities among African Americans generally continue in all aspects of their lives. The Healthy People indicated that community-based intervention is an important method for achieving health objectives. Community-based partnerships have effectively changed health related issues such as establishing requirements for smoke free schools and labeling of heart healthy foods (Brownson, 1996). Large community based interventions have addressed both individual and community wide changes with emphasis on CVD prevention. These large interventions include: the North Karelia project, Finland, Stanford Five-City Project, and Pawtucket Heart health Program. The projects in the US reported favorable results except for the Minnesota Heart Study, where significant progress in reduction of risk factors were not realized. Unfortunately none of these large scale cardiovascular studies were focused on African Americans or rural populations (Brownson et al., 1996). Interventions targeting African Americans are sparse, however smaller intervention projects focused on the rural African American population have demonstrated promising results. Significant reductions in body weight, total cholesterol, diastolic and systolic blood pressure among African Americans who participated in a Nutrition Education Program in rural Alabama were observed (Qian et al., 2005). Increased folate intake among rural AfricanAmerican men at risk for CVD was also reported after 12 weeks of nutrition education.

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Furthermore, fruits and vegetable consumption increased among rural and inner city participants (O’Loughlin, 1999; Brownson et al., 1996; Joshu et al., 2003; Resnicow et al., 2004). In the Bootheel Heart Project, an intervention focused on improving lifestyle factors related to CVD among at-risk African Americans, noted improvements for each of the five risk factors associated with CVD (i.e. leisure physical activity, smoking status, consumption of five fruits and vegetables daily, weight status and cholesterol levels). The Bootheel project was a physical activity intervention that focused on African Americans at risk for CVD as a result of physical inactivity and other lifestyle factors. Increasing physical activity in the rural African American population is a major factor in partially addressing CVD health disparities issues. For physical activity intervention strategies to be effective, barriers and limitations must be identified and addressed. The most often cited reason for physical inactivity is the lack of facilities. In the rural areas, there are no designated walking trails or sidewalks. Safety is sometimes cited (Carter, 2009 unpublished data). Eyler et al (2003) reported positive outcome in physical activity levels among African American women involved in a cardiovascular Health Network project. In one study although an increased use of the walking trail was reported a significant change in walking rates was not evident (Brownson et al., 2004) A Faith-based Institution engaged in physical activity programs has seen a 54% increase in churches implementing such programs. Physical activity is an important factor for CVD prevention (Wilcox et al., 2006). It will require creative approaches to engage rural African Americans in physical activity and other life changing habits that are sustainable to achieve desired goals in CVD disparity reduction 3.4 CVD prevention among African Americans The reasons for disparities observed among the African American population are complex and often interrelated. They are associated with low socioeconomic status, inequalities in work, income, education, limited access to health care and overall standard of living. African Americans living in the South and specifically the Black Belt/ Lower Mississippi Delta region have the highest CVD rates in the nation. Much effort has focused on pharmacologic management of CVD, although these treatments have proven benefit, they are costly and may have side effects and may require additional medical intervention. As noted earlier there are many rural areas without physicians; and access to cardiac physicians is a limitation for this segment of the population. CVD prevention programs for African Americans especially in the rural areas should be established upon the community-based participatory research model. Community-based participatory model is a constructive research paradigm use to promote active community involvement that shapes the research and intervention strategies as well as implementation of the study. It is an interactive process, incorporating, research, reflection, and dynamic action involving individuals from all levels (community leaders, participants). There are several facts that drive the need for culturally sensitive prevention strategies that are region and community specific. The approach should elucidate information on nutritional and physical activity behaviors, group support, self efficacy, socialization patterns, willingness to participate in long term lifestyle modification etc. A holistic approach is warranted which will include changes at the systems levels, to include policy changes as it related to federal appropriation and implementation of these policies. It is important to increase awareness and engage African Americans in culture specific activities, broaden their perceptions and bring light to the disparities and action that will reduce these anomalies.

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4. Disease prevention strategies for rural African Americans African Americans living in rural America would benefit most from disease prevention program strategies within their communities since in comparison to other ethnic groups they are disproportionately affected by CVD, particularly hypertension, when compared to their White counterparts. They are also a group with less access to overall health care. Rural communities in Black Belt states (AL, FL, GA, LA, NC, SC, MS, TN and AR) throughout the US generally have higher ratesof CVD per 100, 000, often exceeding the national rate. These statistics obviously show the need for intervention within these communities. Place of geographical residence has also been implicated as a factor in determining health status. In an evaluation among rural, urban and suburban residence, individuals living in the most urban and most rural areas were the most disadvantaged relative to health measures (Eberhardt & Pamuk, 2004). In a study conducted by Mainous III et al (2004) in Charleston, South Carolina, a Black Belt state, on race, rural residence and control of hypertension, the results strongly suggested that among patients with diagnosed hypertension, 11% of rural Whites, 13% of urban Whites, 20% of urban African Americans, and 23% of rural African Americans had diastolic blood pressures greater than 90 mmHg (P<0.01). In addition to risks for disparities in health, living in rural communities creates other disadvantages such as availability and accessibility to healthier food selections. Food availability and accessibility factors were evaluated in two contrasting cities in Tuskegee, AL (located in Macon County, a Black Belt County) and Auburn, AL. Thirty retail outlets were evaluated for the availability of selected foods in Macon County. More healthy food selections such as frozen, low-sodium or dark-green, yellow vegetables, low-fat milk or yogurt, low-sodium and low-fat cheese were often unavailable in convenience stores; none of the supermarkets in the same location stocked low-sodium vegetables (Bovell-Benjamin et al., 2008). Similar findings on availability and accessibility were found in a South Los Angeles restaurant relative to African Americans having healthy food options, both in food selections and in food preparation. Restaurants in economically disadvantaged poorer rural communities heavily promoted unhealthy food options to residents compared to residents living in more affluent areas (Lewis et al., 2005). 4.1 Diet and nutrition prevention strategies Many disease prevention strategies for cardiovascular exist with varied results. The main stream intervention strategies emphasize the importance of nutrition education using several social theories to enhance the change process. Diet has also been implicated as a tool to reduce or prevent selected types of CVD. Consumption of diets rich in fruits and vegetables, containing significant amounts of antioxidants, high dietary fiber, low saturated and trans fat and a balance in other essential nutrients are recommended to reduce the risk for CVD. Sweet potato greens and purslane, two novel foods, and several traditional foods included in the African-American diet such as butter beans, purple hull peas, muscadine grapes, collards, butter peas, figs, okra, mustard greens, green onions, rutabagas, and eggplant are examples of foods that contain significant levels of antioxidants (Huang et al., 2007a, 2007b, 2008, 2009). In an article by Johnson and Pace (2010),the nutritional characteristics of sweetpotato (Ipomoea batatas) leaves were reviewed in terms of health promotion and disease prevention. The supply an abunadnce of vitamins, minerals, antioxidants, dietary fiber and essential fatty acids.

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Additionally, the bioactive compounds contained in this vegetable occupy a role in promoting health by improving immune function, suppressing cancer cell growth and reducing oxidative stress and free radical damage, which are associated with the development of cardiovascular and other chronic diseases. Currently sweet potato leaves are consumed in Asian and African countries; limited consumption occurs in the United States. Additionally, the articleexamined the nutritional characteristics and bioactive compounds within sweetpotato leaves that contribute to health promotion and disease prevention. Dawkins et al (2010) found that purslane (Portulaca oleracea ) contained relatively high amounts of omega-3 fatty acids, protein and dieary fiber and low amounts of total fat. High dietary fiber and low dietary fat are synergistic in the reduction and prevention of cardiovascular disease. However, for all of these foods,theirhealth benefits are not well known nor have their nutrient value been emphasized as excellent foods for consumptionto prevent diseases in the African American community. 4.2 Other CVD prevention strategies After one year of participation in one of three churched-based intervention strategies, a standard behavioural group intervention, the standard intervention supplemented with spiritual strategies, or self-help strategies, 529 African American women from 16 different churches who participated in the intervention exhibited significant improvements in body weight, waist circumference, systolic blood pressure, total dietary fat and sodium intake. The self help group did not show improvement. The improvements in the intervention group suggest that theyreduced their CVD risk profiles one year after the initiation of the program. Further suggested from this research is that church-based programs can significantly benefit the cardiovascular health of African American women (Yanek et al., 2001) 4.2.1 Rural CVD prevention strategies Nutrition, Health and Physical Activity Fairs (NHPAFs) are often used to provide information to the community to create awareness, education, and action to reduce CVD risk factors in individuals attending the fair. The NHPAFs, hosted in Macon County, AL in 2008, 2009, 2010 and 2011 were community nutrition outreach activities with residents from other neighboring counties participating. Other counties included: Bullock, Montgomery, Chambers, and Lee. These nutrition fairs were sponspored by the Department of Food and Nutritional Sciences, Tuskegee University, Tuskegee, AL. At the NHPAFs, participants most unique experience allowed them to have onsite nutrition assessments, clinical evaluations measurements of blood pressure, glucose and cholesterol, percent body fat, waist and hip circumference, hydration level, weight, vision, hearing, as well as foot health and care and breast self-examination. Consultation with nutritionists, physicians, nurse practitioners and diabetic educators were also available for interpretation of clinical measurements. Additionally, participants were exposed to gardening and herb displays, NUTRIFOODs (sweet potato leaves, purslane, butter beans, purple hull peas, muscadine grapes, collards, butter peas, figs, okra, mustard greens, green onions, rutabagas, and eggplant) tasting. Data collected at these fairs showed that individuals with scores higher than 10 (determined from a 25-question instrument where lower scores are better) were good candidates for nutrition counseling. The mean score was 18 among those 14 to 80 years old. Other outcome measures showed significant positive associations (P <0.05) between weight and blood glucose,

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and body mass index (BMI) and systolic blood pressure; BMI was positively and significantly (P <0.01) associated with blood glucose, diastolic blood pressure, and percent body fat. High nutrition scores correlated with increased risk for chronic disease (NHPAF, 2007). Often in small rural communities with limited health resources, nutrition and health fairs can be used to assess the health status of residents. Twenty-two men, 45 women and six children participated in a one-day health fair sponsored by a school of nursing, University of Alabama. The results indicated that participants need assistance with health promotion in several areas: weight loss/obesity, blood sugar control, lowering cholesterol levels, vision and hearing follow-up, etc. (Lyons et al., 2001). 4.3 Effective social models and compliance tools for disease prevention in African Americans The traditional social models, e.g. Social Cognitive Theory, Health Belief Model, and the Transtheoretical Model for Change etc. are commonly used to promote sustained behavioral change. Social Cognitive Theory variables (e.g. social support, self-efficacy, outcome expectations andself-regulation) are often used to reinforce desired behaviors. The question of whether all behavior is the same in African Americans compared to Whites living in rural or urban American communities remains unanswered. In a university-neighborhood health care center intervention to promote the Dietary Approaches to Stop Hypertension (DASH) diet study, 82 low-income African American adults with poorly controlled blood pressure participated (12 to 15 participants per group) in the study for eight weeks for one to two hours weekly. The intervention followed constructs of Social Cognitive Theory and featured dinners developed using the DASH diet plan. Following the dietary intervention, blood pressure was significantly decreased (P < 0.05) among participants who did not miss more than 2 of 8 sessions (Rankins et al., 2005). Through the 12-week Tuskegee University Nutrition Outreach Program (TUNOP), the effects of a church-based nutrition education and lifestyle intervention, utilizing the Transtheoretical Model for Change, on blood lipid profile and risks for CVD in African Americans were investigated (Qian et al., 2007). Eighty-nine African Americans aged 35-75 years, 15 men and 74 women) at CVD risk participated in the program. Lipid profiles (triacylglycerols, low density lipoprotein cholesterol [LDL-C], high density lipoprotein cholesterol [HDL-C], and total cholesterol) and plasma high-sensitivity C-reactive protein (hs-CRP) concentrations were monitored before and after nutrition education intervention. Results showed a 3% reduction in body weight (P <0.01);BMI (kg/m2) was reduced by 3.2% (P <0.01). Hip circumference was reduced from baseline by 1.22% (P <0.05). Other reductions includedan 8.8% reduction (P <0.05) in triacylglycerols; a 5.1% increase was measured (P <0.01) in HDL-C. The decreased hs-CRP level, a 68.5% reduction (P <0.05) indicated that nutrition education did reduce the inflammatory processes within the human body, which might have a beneficial effect on disease reduction. A meta analysis (386 articles) aimed at determing the effectiveness of health programs on healthy outcomes in faith-based organizations were evaluated at approximately 200 eligible institutions. Significant reduction (P <0.05) in cholesteol and blood pressure levels and weight were measured. Therefore, such programs focused on primary prevention, general health maintenance and cardiovasuclar health (DeHaven et al., 2004) can bring about improvements in overall health and reduce the risk for CVD.

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Lack of exercise also negatively impacts hypertension. Martin et al (2007) evaluated the characteristics of insufficiently active hypertensive African-American women using a social cognitive theory and the Transtheoretical Model to identity positive resources and areas of need to improve activity levels. According to the Transtheoreticl Model stages of change, 88.52 % of the sample was in the contemplation state. Women reported moderate levels of confidence to overcome barriers, a moderate level of confidence to use self-motivation, and reported that barriers rarely interfered with their ability to be physiclly active. The researchers concluded that physical activity interventions should focus on developing social support networks and teaching a variety of behavior strategies important to the adoption of an active lifestyle. The same group of researchers in an effort to further determine the relationship of health behavior theories with self-efficacy among insufficiently active hypertensive African-American women identified correlates associated with self-efficacy which included: overcoming barriers to physical activity; making time for activity and sticking with physical activity. The results suggested that self-efficacy is behavior specific and each measure likely provides specific information (Martin et al., 2008). 4.4 Recommended integrative CVD prevention strategies The obvious cardiovascular disparities existing between African Americans and Whites as well as African Americans living in rural versus urban areas, clearly suggest that an integrative strategy to reduce these racial and geographical disparities is needed. An integrated strategy (addressing the entire needs of the community) for African Americans living in rural communities must take into consideration programs that will address specific demographical, geographical, cultural, educational and socioeconomic characteristics in order to be effective in reducing high blood pressure, weight and other risk factors for CVD. Sustaining change must be a part of any program aimed at improving the lives of African Americans living in the rural South. Barriers to cardiovascular health faced by African Americans living in the rural South include: lack of food availability and accessibility, inadequate intake of fruits and vegetables and other foods, lack of knowledge about the good quality of foods already in their diet, physical inactivity and lack of the resources needed to access what is needed. These barriers must and should be overcome if we are ever to close the gap relative to health disparities. Prevention strategies should be tailored to be culturally and regionally specific to meet the needs of each community.

5. Conclusion CVD is of public health concern particularly among African Americans living in rural communities in the southern region of the United States. African American women living in rural communities are at a particularly elevated risk for CVD. Risk for CVD increased by limited education, income and neighborhood resources, which act in concert to further widen the gap in health disparities. CVD prevention within these communities requires an integrative, culturally sensitive strategy that identifies, evaluates and optimizes demographic, environmental, food, and social factors that contribute to health promotion and disease prevention. Nutrition-based strategies should consider the context of the food environment and promote the increased consumption of more healthful foods already present in the diet. Behavior based strategies should consider the potential lack of sidewalks and other facilities that may hinder physical activity. Finally, social models and compliance

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tools should consider the unique family and community environments, which may be passed down from one generation to the next and how this influences sustained behavior and ultimately cardiovascular health. Preventing CVD and ultimately mitigating CVD disparities in rural communities necessitates an integrative approach encompassing an open and honest dialogue between community residents and leaders, health care professionals and federal health agencies.

6. Acknowledgment The authors would like to acknowledge the Tuskegee University Department of Food and Nutritional Sciences, College of Agriculture, Environment and Nutrition Sciences and the Tuskegee University USDA/NIFA George Washington Carver Experiment Station.

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4 Gender Differences in Food Choice and Dietary Intake in Modern Western Societies Claudia Arganini, Anna Saba, Raffaella Comitato, Fabio Virgili and Aida Turrini INRAN - Istituto Nazionale di Ricerca per gli Alimenti e la Nutrizione (National Research Institute for Food and Nutrition), Rome, Italy “Sexual difference is probably the issue in our time which could be our 'salvation' if we thought it through.” Luce Irigaray 1. Introduction A significant “male oriented” bias in science is a matter of fact (Marino et al., 2011), even though the number of women majoring in science has increased dramatically (Yokoo, 1996). Considering people graduated in mathematics, science and technology per 1,000 of population aged 20-29, since 1993 up to 2009 (EUROSTAT, 2011), proportion of women is 4.4% vs. 3.4% of men. Interestingly, 4 out of 5 authors of this paper are women. It is justifiable to ask the reason for this gender bias. We can advocate two “reasonable” reasons: the first one has mainly sociologic concern in that different aspects of the human society still present an odd distribution. Research is not an exception and even though the proportion of women within professionals involved in public and private research has reached and possibly overtaken the other gender, the target of scientific investigations is still to be actually considered somehow unbalanced in favour of one gender. The second one has an exquisitely pragmatic origin: in the majority of cases, and unless your research is not to be focused on events strictly connected to females (pregnancy, lactation, few organ specific disease), males are a simpler and cheaper experimental model than females. No needs to carefully evaluate risk factors bound to pregnancy and lactation, to consider hormonal cycle, no sharp changes of tissue functionality associated with ageing. It is a matter of fact that in science, and nutritional science is not an exception, there is a widely accepted overlapping between the terms “human” and “male”, while the term female (or woman in the case of the specie H. Sapiens) strictly refers to “not males”. At the same time, the majority of us would agree in defending the evidence that both the biochemistry and the physiology significantly differ between genders, even independently on the most evident female physiological characteristics of presenting a specific and cyclic exposure to hormones flux. These differences are consistent with a gender-specific genetic set up, and result in a specific capacity to relate to and cope with the environmental challenge.

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Recent literature (Marino et al., 2011) has highlighted that nutrition could differently influence the health of male and female individuals. It is widely accepted that nutrition is not only “just a fuel” but is the most significant part of the environment that we actually introduce into our body and eating patterns are a relevant component of the cultural reference models (Harris, 1985). Driven by the above considerations this chapter will present and discuss available data emerging from an extensive literature review addressing differences and similarities between genders in food choice and food consumption patterns in modern western societies. An original elaboration of data on food consumption profiles according to gender will also be presented and critically evaluated under the perspective of nutrients intake and fulfilment of nutritional requirements at population level. In the preparation of this overview, we have undertaken a bibliographical search limited to social and scientific literature published in English. The search, informed by a strongly limited selection of words, included databases of peer-reviewed literature (SCOPUS) from 1995 to 2011. A ‘snowball procedure’ was employed whereby the references cited in each article were browsed for further relevant research. An original elaboration of data on food consumption profiles according to gender will also be presented and critically evaluated under the perspective of nutrients intake and fulfilment of nutritional requirements.

2. Key determinants in food choice: A gender perspective Food choices is an area in which research has revealed consistent behavioural gender differences. Food choice is dependent on a wide spectrum of factors, which affect human behaviour in different ways, resulting alternatively in the choice of some specific products and in the rejection of others. The study of food choice is mostly dealing with one question: “why do people eat the foods they eat?” Food plays an important part in all our lives in a variety of ways. The choices people make among foods determine which nutrients enter the body. However, in modern societies, food is more than mere sustenance. What people choose to eat is not solely based on their biological needs, their choice also addresses many psychological and/or emotional issues (Conner & Armitage, 2002). After all, a person does not necessarily have to be hungry to eat, does not always choose his/her most preferred food, and some of the influences in food choice might be unconscious. Generally speaking, food choice is a complex human behaviour and consequently is influenced by many interrelating factors ranging from biological mechanism and genetic profiles to social and cultural factors. Many studies have explored selected aspects of food choices from an ample variety of disciplines and perspectives (Axelson & Brinberg, 1989; Booth, 1994; Glanz et al., 1992; Mennell et al., 1992; Murcott, 1983; Shepherd, 1990, 2005; Thompson, 1988). Recent notions generally split the factors influencing food choice into those related to the food, to the person making the choice and to the external economic and social context in which the choice is made (Booth and Shepherd, 1988; Randall and Sanjur, 1981). There are chemical components and physical properties of the food which are likely to have an impact on choice, via sensory perception. However, perceiving a sensory attribute in a food does not necessarily means that a person will choose to consume that food. It is the person’s liking for that specific attribute in that food which influences choice. Psychological differences between people,

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such as personality, may also influence food choice. In addition to factors associated with the person and the food, there are also other many factors in the context within which the choice is made that can be important in food choice. These include marketing and economic variables as well as social, cultural, religious or demographic variable. Food choices are made by individuals from alternatives available in a certain use situation. They are made repetitively, every day in various use situations: what to buy and take home for the family, what to eat at the canteen and which dishes to choose from a menu when eating out at a restaurant. Food choice may also be characterized by the context, a situation determined by the time, place, and company. In Western societies the abundance and variety of foods to choose is extensive. Anthropological and sociological work has emphasized the meaning of food and eating in self and cultural definition (Berbesque, 2009; Counihan, 1999; Murcott, 1983; Vartaniana et al., 2007). This literature indicates that, as mentioned above, the importance of food and eating extends well beyond a the need of covering “physiological needs”, playing a role in identity expression, communication, social interactions, as well as in delineating status and gender roles. Eating behaviour is therefore likely to be vulnerable to various social influences, including the desire to respond in a socially-desirable manner (Herman et al., 2003). Studies by Lindeman and colleagues (Lindeman & Sirelius, 2001; Lindeman & Stark, 1999, 2000) suggest that food choice is a means by which one expresses one’s own philosophy of life. In addition, the current emphasis on dieting and slimness in Western cultures promotes norms describing “what and when” one should eat, as well as what one should look like. Taken together, these considerations suggest that what one eats has important implications for social judgments. In addition, social changes such as the increased participation of women in the workforce lead to reduced time available for food selection and meal preparation, which further complicates food choice. Contemporary consumers have fears and conflicts involving food and health (Mennell et al., 1992; Rozin et al., 1999), and social norms about foods and meal composition, that guided previous generations, appear to be eroding, leaving people with a lack of structure related to food and eating behaviour (Fischler, 1980). A body of literature has consistently found that many variables may influence eating behaviour, but their interrelations make their effect difficult to distinguish. In addition, the analysis of the effects of single or multiple factors is further complicated by the fact that eating behaviour is not a constant phenomenon, but will change with differing circumstances and experiences of the individual. Studies conducted in modern western societies report consistent associations between gender and specific foods, where meat (especially red meat), alcohol, and hearty portion sizes are associated with masculinity, while vegetables, fruit, fish and sour dairy products (e.g., yogurt, cottage cheese) are associated with femininity (Jensen & Holm, 1999; Sobal, 2005). The results of a study conducted on the Hazda, a tribe of human foragers living in Tanzania, also showed a sex differences in food preferences, with males preferring meat more and females preferring berries more (Berbesque, 2009). Overall, the most relevant differences according to gender in food choices in modern western societies, emerging from our literature review, were in the relationship between eating habits and health consciousness, and between eating behaviour and weight control. Those topics will be discussed in the following sections.

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2.1 Eating habits and health consciousness In general, women have been frequently reported to engage in far more health-promoting behaviours than men and have healthier lifestyle patterns (Courtenay, 1998, 2000; Gough & Conner, 2006; Kandrack et al., 1991; Lonnquist et al., 1992; Roos et al., 2001). Men usually talk about eating as habitual and routine, and as necessary activity to “fuel” their “fleshes”. Although they are aware of “healthy eating guidelines”, they often show skepticism and resistance to nutrition education messages, and frequently perceive healthy eating as monotonous and unsatisfying. Some men do express interest in food, cooking, and health, and indicate that they are reducing their consumption of red meat and increasing consumption of vegetables (Sobal, 2005). These alternative experiences with food are more commonly expressed by “high educational levels”, such as engineers, than by “blue-collars workers, such as carpenters or drivers, suggesting that social class may mediate associations between “masculinity” and food (Roos et al., 2001; Sobal, 2005). With regard to eating habits, a large number of reports indicate that in general, women are more aware about diet and health-diet relationship implications and also embrace suggested dietary changes to a greater degree than men (Barker et al., 1995; Courtenay, 2000; Friel et al., 1999; Girois et al., 2001; Thiele & Weiss, 2003). Data on a representative survey in the Norwegian population (Fagerli & Wandel, 1999) shows that women considered health aspects and chose accordingly the foods they consider to be healthy, more often than men when selecting foods for an everyday dinner. Accordingly, their reported changes more often are in line and agree with dietary guidelines. The same study also reported consistent associations of healthier food behaviours with increased age, higher education, and female gender. These findings are similar to the observations resulting from the analyses from a population data set conducted in 114 worksites in the USA, overall employing 37,291 workers who were engaged in a variety of activities (Hunt et al., 1997). Also in this study, female gender was associated with food choices closest to the recommendations to increase fiber, fruits and vegetables and to reduce fat. A single exception was in found the adherence to follow the recommendation to increase consumption of beans and lentils for which male gender were associated with greater consumption. In a Pan-EU survey of 14331 subjects, female respondents perceived that “quality/freshness”, “price”, “trying to eat healthy” and “family preferences” were the most important influences affecting food choice, whereas “taste” was the most frequently selected factor affecting food choice of male respondents (Lennenäs et al., 1997). In a different study, females have been reported to be more likely than males to mention more vegetables or less fat or balance as a part of a healthy diet (Margetts et al., 1997). Another factor contributing to food choices is the persuasion by others or by specific circumstances. More women than men reported that influence of other people can prevent them from eating healthier (Lappalainen et al., 1997). It has also been shown that men give lower priority to health compared to other considerations, such as taste and convenience, in making their food choices (Steptoe et al., 2002; Wardle and Griffith, 2001) and that they feel more ambivalent about healthy dietary choices (Povey et al., 2001; Sparks et al, 2001). Earlier studies have found significant gender differences in opinions and behaviour with regard to different health aspects. For instance they reported that men choose fewer high-fiber foods, eat fewer fruits and vegetables and low-fat foods, and consume more soft drink that women

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(Beardsworth et al., 2002; Beer-Borst et al., 2000; Fulkerson et al., 2004;Li et al., 2000; Liebman et al., 2001; Pollard et al., 2002; Prättälä et al., 2007; Wardle et al., 2000). The International Health and Behaviour survey (IHBS) examined a range of health behaviours in a total of 19298 university students from 23 different countries utilizing a study approach based on a self-report questionnaire (Wardle et al, 2004). In almost all of the 23 countries a higher percentage of women reported to avoid high fat-foods, to eat fiber-rich foods, to eat fruit daily. Differences in salt intakes were less consistent but nevertheless a significant female advantages in 6 countries was observed. Similarly, in a study on 1024 UK adults, women reported to consume a larger number of portion of fruit and vegetables, than men (Baker & Wardle, 2003). A research carried out in the UK, the Netherlands and in Finland documents that women are more interested than men in eating healthily and natural products (Roininen et al., 2001). The food choice motivations of a representative sample of 9339 Polish respondents depended mostly on gender and age (Wadolowska et al., 2008). The study confirmed the findings of other authors about the role of females and its correlation with health-concerned attitudes, inclination to comply with dietary recommendations and readiness to gain new nutrition knowledge. In a nationally representative sample of Irish adults (n=1256), it has been observed that young lowest social class, primary level education males, were the subgroup most likely to have negative attitudes or motivation towards healthy eating (Kearney et al.,2001). Studied conducted in Ireland reported that women were generally more prone to make conscious efforts to try to eat a healthy diet 'most of the time', while men were three times more likely to 'hardly ever' make such conscious efforts to eat a healthy diet (Kearney et al., 2001; Hearty et al. 2007). Data from a representative sample of 98733 Canadians (Canadian Community Health Survey) indicates that gender plays an important role in determining food choices. Women are more likely than men to choose or avoid foods following to concerns about health and, accordingly, choose or avoid foods due to their contents (Ree et al. 2008). In general, women have been shown to be more thoughtful about food and health issues and they seem to have more moral and ecological misgivings about eating certain foods than men, who are more confident and demonstrate a rather uncritical and traditional adherence to eating profiles and pattern (Beardsworth et al., 2002; Teratanavat & Hooker, 2006; Verbeke & Vackier, 2004). There has been a great deal of interest over recent years in the protective effect of fruit and vegetables against a number of diseases, and there is convincing evidence that high intakes of vegetables and fruit are associated with lower risk of chronic diseases (Colgan et al., 2004; Liu et al., 2000; Sargeant et al., 2001). International and national health organisations (NHMRC, 2002; WHO, 2003) have recommended to increase the consumption of vegetables and fruit as an important health and nutrition priority. In the Health Education Authority‘s Health and Lifestyle Survey of 1993 it was found that the main demographic characteristics that distinguished between low and high fruit and vegetable consumers were age, gender and smoking status (Thompson et al. 1999). These demographic characteristics perhaps result in the strongest variations in intakes of fruit and vegetables, with women reporting higher preference for eating vegetables than men (Thompson et al., 1999; Wardle et al., 2004). However, men reported to like fruit slightly more than women and there was no significant gender difference in attitudes towards fruit and vegetables, although women’s attitudes were slightly more positive (Wardle et al., 2004).

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One possible mechanism for the gender-specific patterns of healthy food choices might be related to nutritional knowledge. A number of studies have reported gender differences in the knowledge nutritional information (Crawford & Baghurst, 1990; Parmenter et al., 2000; Tate & Cade, 1990), supporting the hypothesis that differences in awareness could contribute to gender differences in intake. Gender, level of education and occupational social class were found to have significant independent effect on level of nutrition knowledge scores. In particular, women demonstrated superior knowledge regarding all the areas of nutrition, as confirmed by the majority of studies dealing with the evaluation of nutritional knowledge (Butriss, 1997; Parmenter et al., 2000). Food-related activities, such as shopping, cooking and eating are conventionally presented as female-centered (Caplan et al., 1998; Warde & Hetherington, 1994). Given women’s traditional role in purchasing, preparing and providing food, it is not surprising that men know less about the health benefits of specific food items (Nutrition Forum, UK, 2003). The rise in the number of people living alone together with the decline in the number of traditional family units, where the husband earns and the wife is responsible for shopping and cooking, has raised new concerns. In fact, it appears that even though there is an increasing number of men cooking for themselves and fewer relying on women to make decisions about their diets, this novel activity is not accompanied by a significant increase in nutrition knowledge. However, the significance of nutrition knowledge as an determinant in food choices has been questioned in the light of evidence from research in the field of fat and fiber intake showing no more than small correlations between nutrition knowledge and dietary quality (Shepherd and Towler, 1992; Lappalainen et al., 1997). However, a recent study found substantial associations between knowledge and fruit and vegetable intake, possibly because, unlike the situation for fat intake, overall levels of public awareness are low (Wardle et al., 2000). Fewer men than women knew the current recommendations for fruit and vegetable intake, and fewer were aware of the links between fruit and vegetable consumption and disease prevention. The evidence that men have a lower knowledge about nutrition, or accord lower priority to nutrition in making their food choices, could result in lower intakes of fruit and vegetables. However, only in four member states (Austria, Belgium, Finland and Italy) within the Pan-Europe survey, more men than women reported lack of knowledge as a barrier towards healthy eating (Lappalainen et al., 1997). Even though methodological differences in assessing food choices might have been in part generated slightly different results on gender-specific food choice, all the observations reported here are consistent in concluding that women generally make slightly healthier food choices. If women report healthier practices (or at least attempt to make healthier choices) all over the world, then this would suggest that any explanations for the differences are more likely to indicate underlying behavioural characteristics of men and women than local cultural effects. 2.2 Eating behaviour and weight control A factor that could contribute to gender differences in food choice is women’s greater concern about weight control and their higher frequency of dieting. There is a consistent body of recent literature (Afifi et al., 2002; Johnson & Wardle, 2005; Kostanski et al., 2004; Liebman et al, 2001; Wardle et al., 2000; Wardle & Griffith, 2001) that clearly indicates that there are important gender differences in weight concern and body self-perception.

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Weight control/body perception are known to influence food choice decisions, mainly in women (Glanz et al., 1998; Goode et al., 1995; Rozin et al., 1999). In many studies of attitudes to body weight or dieting, women reported more dissatisfaction with their weight and make more attempts to control weight than men (Beardsworth et al., 2002; Bellisle et al., 1995; Wardle & Griffith, 2001;). Numerous research on body image have shown that women are more likely than men to perceive themselves as overweight and to express discontentment with their body shape (McElhone et al., 1999; Neumark-Sztaine et al., 1999). Concern with adhering to a slimming diet has been found to be significantly more widespread among women than men (Germov & Williams, 1996; Sobal et al., 1995). A PanEU survey on 15239 subjects (European Communities, 1999), reported a strong gender difference in the percentage of people who are content with their body weight. A consistent majority of males was comfortable with their current body weight compared with females. Conversely, a far higher proportion of females wished to be lighter or considerably lighter compared with males. The relative proportion choosing dieting as the strategy for losing weight compared with other methods was highest in the group wishing to be considerably lighter, especially among females (European Communities, 1999). On the other hand, it has been observed that men generally prefer to select physical exercise than dieting as a means for body weight control, while women were more inclined to select dieting, restrained eating and daily checking of body weight (Clark et al., 2009). Moreover, in women, the frequency of dieting is often associated with difficulties in eating behaviour. Restrained eating behaviour, cognitive control and eating disorders are mainly seen as behavioural phenomena more common in women. Men, on the other hand, have fewer problems with their eating behaviour, and their attitude to food is generally uncomplicated and enjoyable, even though they are more frequently overweight and have higher risk of associated disease (Kiefer et al., 2005). Problems with eating behaviour have a strong female prevalence emerging in childhood and adolescence(Afifi-Soweid et al., 2002). Girls often eat less and pay attention to calories, sugar and fat intake under the pressure of “feeling obliged” to be slim. Consequently, in part due to a specific social pressure, girls are more likely than boys to develop eating disorders (i.e., anorexia, bulimia, binge eating disorder). Women affected by certain eating disorders are likely to experience a constant internal conflict between the desire of being slim or slimmer, and the drive for certain “forbidden” food. Women are more often affected by the problem of craving (i.e., the strong willing for certain foods) than man, being more likely to be wishful for sweet foods. This attitude results in a difficulty in sticking to a weight reducing-slimming diet (Lafay, et al, 2001). Extensive research showed that women often experience the so called “carbohydrate craving” and there is an association between the wish for sugar- and fat-rich foods (like chocolate and other sweets) and menstrual cycle (Bruinsma and Taren, 1999, Rozin et al., 1991, Smith & Souter, 1969; Yen at al., 2010). Recent findings showed that the wish for sweet food regresses in women with increasing age (Kiefer et al., 2005). In connection with the craving for particular foods, women more frequently report negative feelings, in contrast to men who describe positive feelings (Lafay et al., 2001). Women also eat more than usual in stressful situations more frequently than men (Kandiah et al., 2006).

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A study dealing with the emotional triggers of “comfort” food consumption indicate that in women this eating behaviour was triggered by negative feelings, whereas in men was motivated by positive emotions (Dubè et al., 2005). Differences in preference towards “comfort“ foods across gender were investigated in a survey conducted in North America on 1416 people (Wansink et al., 2003). The findings of this study are consistent with other research showing that females preferred “comfort” foods within the category of snacks, such as chocolate, candy and ice cream. Indeed, one research on “chocolate addiction” reported that 70 of the 72 self-selected “addicts” were female (Tuomisto et al., 1999) and in another study the 92% of the surveyed sample selfidentified as “chocolate addicts” were female (Hetherington & MacDiarmid, 1993). Wansink et al. (2003) reported that males preferred more substantial, warm, hearty- meal related comfort foods such as meat dishes, pizza or pasta, casserole and soup. On the other hand side it emerged that when women indulged in high-calories sweets like candy or ice cream often felt guilty afterwards – while men who chose foods other than sweets and snacks, didn’t (Wansink et al., 2003).

3. Gender differences in nutrients intake In order to detect any gender-associated trend in nutrients intake, we have analysed the nutritional profiles estimated at population level within the context of nationwide individual dietary surveys. We considered the database of dietary intakes of 22 European Countries, partners of the European and Health Report (ENHR II), the most suitable source of data on the basis of the number of countries involved and the approach utilized to collect the indicators (Elmadfa, 2009). Data from this report have been therefore processed to highlight possible differences between males and females population groups concerning the percentage contribution to the average daily energy intake by carbohydrates, proteins, fats, fatty acids, and mean daily intake of minerals and vitamins. Data were then grouped by nutrients, by gender, country, and age-class and graphically plotted in order to detect similarities and differences associated to gender. Overall, no significant differences were observed in the percentage contributions of macronutrients to the daily energy intake. Minimum and maximum values (ranges) observed in average per-capita daily intakes in females per each country overlap those of males. These findings are in agreement with data obtained in previous studies (Flynn et al., 2009 ; Reynolds at al., 1999). In the European Health and Nutrition report (ENHR II, Elmafda, 2009), solely for carbohydrates were found differences in the percentage of the average daily energy intake equal or higher than 5% among adults (10% in Estonia, and Lithuania; 9% in Czech Republic; 8% in Austria, Poland, Denmark, and Germany; 7% in Hungary, Portugal, and Finland; 5% in Latvia; less than 5% resulted in Greece, Sweden, France, Spain, The Netherlands, United Kingdom, Romania, Norway, and Italy), and elderly (10% United Kingdom and Denmark; 9% Germany; 7% in Hungary and Romania; 5% Poland and Greece; less than 5% France, Finland, The Netherlands, Sweden, Ireland, Spain, and Italy). The gap is due to the fact that the group of adult and elderly males tends to replace carbohydrates with alcohol. In two cases, differences higher than 10% were found for fats among adolescents in Norway (11% males vs. females) and Dutch (19% females vs. males). Percentage of energy from proteins did not show differences in absolute value higher than 1%.

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4-6 years Mineral Sodium (g) Potassium (g) Calcium (mg)

7-9 years

Age class 10-14 15-17 years years

18-64 years

65+ years

Gender min Male 1,8

max

min

max

min

max

min

max

min

Max

min

max

3,4

2,2

4,2

2,3

5,0

2,9

6,5

2,6

7,3

2,3

7,0

Female 1,7

6,0

3,4

1,9

3,7

2,2

4,8

2,2

4,5

1,7

5,6

1,8

6

0

16

14

5

4

32

44

53

30

28

17

2,0

2,8

1,9

3,0

1,9

4,0

2,4

4,4

2,7

4,4

2,2

3,8

Female 1,9

2,7

1,8

2,9

1,7

4,0

1,2

3,3

2,3

3,6

2,2

3,7

Δ% Male Δ% Male

5 4 6 3 12 0 100 33 17 22 0 3 604 1103 732 1207 701 1381 806 1447 687 1171 627 1071

Female 606 1024 631 1126 600 1238 645 1040 508 1047 533 Δ% Male

Phosphorus Female (mg) Δ% Male Magnesium Female (mg) Δ% Male Iron Female (mg) Δ% Male Zinc Female (mg) Δ% Male Iodine Female (mg) Δ% Male Copper Female (mg) Δ% Male Manganese Female (mg) Δ% Male Selenium Female (μg) Δ%

0

8

16

7

17

12

25

39

35

12

18

959 12

882 1284 960 1455 964 1704 1413 1705 1264 1778 1059 1576 900 1183 851 1295 807 1636 962 1356 1017 1422 959 1404 -2 171

9 267

13 204

12 303

19 200

4 503

47 260

26 467

24 256

25 465

10 221

12 403

166

267

166

301

181

429

186

369

197

372

179

348

17

40

27

30

25

3

0

23

1

10

23

16

7,3

10,6

8,4

11,8

9,2

19,4 10,2

19

10,6 26,9

10

25,2

6,8

10,6

7,7

11,8

7,7

14,8

7,8

14

8,2

22,2

8,5

20,9

7 6,0

0 9,2

9 7,0

0 10,9

19 7,0

31 14,6

31 9,3

36 15,2

29 8,6

21 14,6

18 7,5

21 12,3

5,3

8,9

6,4

9,4

6,1

13,9

6,4

11,0

6,7

10,7

6,7

11,2

13

3

9

16

15

5

45

38

28

36

12

10

69

223

73

203

102

209

93

221

67

264

107

226

70

198

73

179

85

171

115

182

48

200

97

190

-1 0,7

13 2,2

0 0,9

13 2,8

20 0,9

22 2,9

-19 1,2

21 3,4

40 1,1

32 2,3

10 1,1

19 1,9

0,7

2,0

0,8

2,6

0,7

2,8

0,8

2,1

0,1

2,2

0,9

1,9

0

10

13

8

29

4

50

62

1000

5

22

0

1,4

3,3

1,7

3,7

1,8

4,6

2,5

6,1

2,0

5,0

2,2

4,9

1,3

3,0

2,0

3,0

1,7

4,1

1,9

4,4

2,2

5,0

2,0

5,0

8 23

10 61

-15 27

23 41

6 29

12 110

32 39

39 59

-9 36

0 73

10 39

-2 62

24

61

20

50

28

104

30

38

31

54

34

55

-4

0

35

-18

4

6

30

55

16

35

15

13

Table 1. Minerals ranges of mean daily intake by age-class, and gender calculated starting from values observed in 22 European Countries (ENHR II partners).

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4-6 years

7-9 years

Age class 10-14 15-17 years years

18-64 years

65+ years

Vitamin

Gender

min

max

min

max

Vitamin A(g)

Male

0,4

1,1

0,4

1,3

Female

0,4

1,2

0,4

1,1

0

-8

0

18

33

4

33

13

0

10

25

9

β-carotene (g)

Δ% Male

1,2

3,8

1,6

4,1

1,1

4,8

1,2

4,7

1,4

5,3

1,3

4,8

Female

1,1

3,4

1,6

4,0

1,1

5,2

1,0

4,7

1,4

5,6

1,3

5,0

Vitamin D (μg)

Δ% Male

9 1,8

12 5,8

0 1,5

2 6,4

0 1,5

-8 4,8

20 1,8

0 7,5

0 1,6

-5 10,9

0 0,7

-4 15,0

Female

1,5

6,5

1,5

5,1

1,2

4,5

1,5

7,1

1,2

10,1

0,7

12,9

20

-11

0

25

25

7

20

6

33

8

0

16

Vitamin E (mg)

Δ% Male

5,3

9,8

6,3

11,2

5,9

14,5

6,8

20,8

3,3

17,4

6,3

13,7

Female

5,1

9,8

5,9

13,3

5,6

18,1

6,0

15,5

4,2

16,1

6,7

13,7

Thiamin (mg)

Δ% Male

4 0,8

0 1,4

7 0,9

-16 1,6

5 0,9

-20 2,3

13 1,3

34 2,3

-21 1,1

8 2,3

-6 0,9

0 2,1

Female

0,8

1,3

0,8

1,4

0,8

1,9

1,0

1,9

0,9

2,1

0,9

1,4

0

8

13

14

13

21

30

21

22

10

0

50

Riboflavin (mg)

Δ% Male

1,3

2,1

1,2

2,0

1,2

2,9

1,5

2,6

1,4

2,4

1,2

3,2

Female

1,2

1,8

1,1

1,7

1,1

2,8

1,2

2,3

1,2

2,8

1,2

2,6

Niacin (mg)

Δ% Male

8 17 9 18 15,7 24,9 18,7 29,9

9 8,7

4 25 13 40,4 12,2 43,3

17 9,2

-14 41,3

0 8

23 37,9

Female

14,4 24,6 16,2 26,3

6,9

32,5

6,4

30,6

6,7

31,9

min

max

min

max

min

max

min

max

0,4

2,4

0,4

1,8

0,5

2,2

0,5

2,5

0,3

2,3

0,3

1,6

0,5

2,0

0,4

2,3

7,3

30,5

9

1

15

14

26

24

67

42

44

35

19

19

Vitamin B6 (mg)

Δ% Male

1,3

1,8

1,2

2,5

1,2

2,8

1,5

3,1

1,6

3,5

1,2

3,0

Female

1,0

1,9

1,1

1,9

1,1

2,7

1,2

2,5

1,3

2,1

1,2

2,9

Folates (μg)

Δ% Male

30 150

-5 256

9 144

32 290

9 149

4 428

25 190

24 365

23 203

67 494

0 139

3 343

Female

109

199

133

264

140

360

154

298

131

392

121

335

38

29

8

10

6

19

23

22

55

26

15

2

Cobalamin (μg)

Δ% Male

2,7

5,3

3,6

5,5

3,2

11,8

4,9

7,5

1,9

9,3

3,1

8,2

Female

2,6

5,0

2,2

5,3

2,2

11,1

3,5

5,2

1,0

8,8

2,5

7,5

Vitamin C (mg)

Δ% Male

4 60

6 170

64 63

4 172

45 73

6 197

40 71

44 201

90 64

6 153

24 59

9 142

Female

61

157

57

172

77

222

67

205

62

153

60

160

Δ%

-2

8

11

0

-5

-11

6

-2

3

0

-2

-11

Table 2. Vitamins ranges of mean daily intake by age-class, and gender calculated starting from values observed in 22 European Countries (ENHR II partners).

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To complete the analysis ranges of average daily intake of minerals and vitamins intake across the 22 European countries were compared (table 1-2), confirming males having higher intakes in general, in almost all age-gender groups looking at both the minimum and the maximum value of intake observed in the 22 countries. Exceptions for minerals (Table 1): calcium and phosphorus (minimum in 4-6 years old), iodine (minimum in 4-6 and 15-17 years old), manganese (minimum 7-9 years old, 18-64 and maximum in 65+ years old), and selenium (minimum in 4-6 years old, maximum in 15-17 years old) (Elmadfa, 2009). Vitamins intake showed higher variability than minerals intake (Table 2). Males had higher or equal per-capita average daily intakes both for minimum and maximum in all age-gender groups for niacin, folate, cobalamine, and thiamine only. In all other cases at least one age group showed either the minimum or the maximum value The similarities in the percentage of energy provided by macronutrients and the overlapping of ranges for minerals and vitamins evidenced above indicate that the overall quality of diet does not differ substantially between males and females in all classes of ages and throughout Europe. A further remarks concerns dietary fibre, being highly associated with the mean energy intake, then increasing with the age (Elmadfa, 2009).

Fig. 1. Ranges of per-capita average daily intake (MJ) by age- class and gender Overall, the level of energy intake was the main difference found when comparing the average per-capita dietary intakes of males vs. females (Elmadfa, 2009). As expected, men consume more energy than women (Figure 1), similarly to what is reported in other studies like a cross-country comparison (Flynn et al. 2009), or a cross-studies analysis (Reynolds et al. 1999). This difference occurs even though men and women show a similar food volume consumption (Marti-Henneberg et al. 1999).

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In other words, the quantity of food does not seem the main component concurring to the energy intake. The combination of food categories characterizing the diet according to gender therefore plays a central role in determining the amount of energy consumed. 3.1 Dietary profiles and nutrient intakes In order to explore more in depth the relation between food consumption and nutrients intake, we investigated the available literature reporting studies addressing gender specific dietary profiles. According to Kiefer and co-authors (Kiefer et al., 2005) children, adolescents and adults males consume more energy, fat, and cholesterol but less carbohydrates and fibre than females. Fibre intake was found higher in females also in most studies reported by Reynolds et al. (1999). Data from The National Health and Nutrition Examination Survey (NHANES II) on the US population from 1976-1980, indicate that males consume more calories and fats than females (Block et al., 1988). A research conducted in the US (Courtenay, 2000) showed that males of all ages consume more saturated fat and dietary cholesterol than females. Cholesterol intake of males was substantially higher that recommended levels, while dietary cholesterol of most females of all ages fell within the recommended range for classes of age (Courtenay, 2000). One study (Wardle et al., 2004) showed that gender differences in food consumption do not always reflect differences in the proportion of energy consumed as fats or fibre intake, but this might be due to gender difference in alcohol consumption, which is likely to add a substantial amount of energy as “drink calories”. Once adjusted for energy intake, the dietary micronutrients profile of women tend to be higher than in men. In general, the diets of females were more nutrient-dense, with the exception of milk-derived calcium, and also higher in dietary fibre, phytochemicals, and various micronutrients (Liebman et al., 2003). Among school children, girls were found to consume much less energy than boys and also have a reduced micronutrient intakes. Pre-school children did not show significant gender differences in dietary profiles (Backstrand et al., 1997). These observations corroborate the importance of differences associated to gender in food choices in determining the quality of the diet, at individual level. According to Chung & Hoerr (2005) , women seem more predisposed to meet the minimum recommended number of servings of fruit. Moreover, men have been shown to consume less carotenoid-rich foods, such as carrots, spinach, broccoli and other greens than women (Courtenay, 2000). In agreement with the study by Chung & Hoerr (2005) and Wardle and co-workers (2004) showed that women eat more fruit than men. Several studies have reported that in various western countries women eat more fruits, vegetables, cereals, cereal products, milk, dairy products and whole grain products than men. On the other hand, the consumption of red meat, eggs, alcohol, soft drinks, high sucrose food, as well as various high starch foods such as potatoes and bread is higher in men (Beer-Borst et al., 2000; Fraser et al., 2000; Kiefer, 2005; Prättälä et al., 2007; Wardle, 2004). The differences associated with gender were similar in all countries, throughout age and educational groups, and in rural and urban areas (Prättälä et al., 2007). A study on gender

Gender Differences in Food Choice and Dietary Intake in Modern Western Societies

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differences in food intake conducted on1556 older people living in Britain (Fraser et al., 2000), also indicated that women eat more butter, full-fat milk and certain beverages, cakes, apples, pears and bananas, whereas men consume more eggs, sugar and meat products. Men also consume more alcoholic drinks, more frequently and in higher amounts than women (Bates et al., 1999; Fraser et al., 2000;Liebman et al., 2003). Similar trends have been found in two British national surveys, the Health and Lifestyle Survey (Cox et al., 1993), and the National Dietary and Nutritional Survey (Gregory et al., 1990) . These observations are also in agreement with data obtained in studies conducted in the United States (Wirfalt & Jeffrey, 1997) and Australia (Baghurst et al., 1994). On the whole, the studies reported here strongly suggest that a higher intake of fruit and vegetables is one of the elements characterizing women’s dietary profiles. The results of the present analysis on gender differences in nutrients and foods intake lead to figure out that fruit and vegetables consumption is a suitable indicator for dietary characterization. This remark suggests to include this relatively novel quantitative variable in future population studies as a tool to analyse gender specific eating behaviour. Moreover, a composite methodological design linking food choice and dietary intake approaches could help to deepen the knowledge of eating behaviour in the population. Gender is usually considered in the Nutritional recommendations published by European countries (Pavlovic et al., 2007), even though a conceptual bias, might occur when scientific evidences are collected on males and then extrapolated to women (Tarnopolsky, 2003). Nutritional recommendations at international level are developed by gender and age when addressing specific nutrient requirements (World Health Organization [WHO] 2010a, thereafter (WHO, 2010a) whereas this does not occur in the formulation of nutritional goals for the general population (WHO 2010a, 2010b, 2010c). Further investigations should be carried out to analyse the appropriateness of including gender specific statements in internationals nutrition policy guidelines.

4. Conclusions All reported data are consistent with the view that in modern Western Societies women generally show a tendency to perform healthier food choices and are much more concerned about the importance of food choice and eating behaviour to stay in a good physical shape than men. This attitude is also reflected by dietary profiles in terms food intake pattern, showed consistent trends according to gender. In conclusion, the “take home message” extrapolated from this systematic review, in strong accordance with other recent studies (Berbesque, 2009; Marino et al., 2011), is to stress the importance of considering a gender specific approach, both in terms of behaviour and of physiology, when addressing nutrition issues in research and in policy making. As a matter of fact, a more detailed informative basis would help the formulation of suitable monitoring programs in the research side, and an increasing effectiveness of policy interventions in respect of different population groups. Acknowledgment. The present review was performed within the project PALINGENIO supported by the Italian Ministry of Agriculture, Food and Forestry Policy.

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5 Iron Food Fortification for the Control of Childhood Anemia in Brazil Joel Alves Lamounier1, Flávio Diniz Capanema2 and Daniela Silva Rocha3 1Universidade

Federal de São João Del Rei, Campus Centro Oeste (UFSJ), Divinópolis, Minas Gerais, 2Children and Adolescents Health Nucleun, Faculdade da Saúde e Ecologia Humana (FASEH), Vespasiano, Minas Gerais, 3Universidade Federal da Bahia, Vitoria da Conquista, BA, Brazil

1. Introduction Iron deficiency anemia represents a serious nutritional problem worldwide, and it especially affects children and pregnant women in developing countries. According to Global Health Burden Disease Report of World Health Organization, anemia is considered the most prevalent public health problem in the World (World Health Organization [WHO], 2008), which requires public policies to combat iron deficiency and anemia. In Brazil, the National Survey of Demography and Health of Children and Women - PNDS - showed 20.9% prevalence of anemia among children 6 to 59 months, with the highest prevalence in the northeast (Brazilian Institute of Geography and Statistics [IBGE], 2010). Studies conducted between 1996 and 2007, involving children less than 5 years in different regions of the country, showed very high rates of anemia. The prevalences were 47.8-63.7% in south, 10.477.8% in southern, 55.1-84% in north, 35.7-89.1% in northeast, and 31-63.1% in midwest of Brazil (Jordão et al., 2009). A meta-analysis study which included articles published in the last 10 years, the prevalence of anemia was higher than 40.0% in children under seven years old (Andrade, 2004). Also in day care centers iron deficiency anemia is considered the most common nutritional deficiency in childhood, with high prevalence (Capanema et al., 2008; Castro et al., 2011; Matta et al., 2005; Morais et al., 2005; Neves et al., 2005) The magnitude of nutritional anemia in Brazil represents a serious public health problem, specially the short and long term affects anemia can have on growth in at-risk groups. Thus, as a result of this problem, various intervention approaches are being adopted in attempts to control and prevent anemia. One possible intervention measure, which has shown to be successful in reducing anemia in at-risk groups, is the iron fortification of foods made available to children. Food fortification is highlighted as one of the most cost-effective health solutions to fight malnutrition among children and anemia deficiencies among women. Fortification of staple foods improves micronutrient status by delivering small amounts of micronutrients on a

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daily basis. In addition, some other options, such as drinking water for consumption also has been a good alternative. Staple food fortification is routinely practiced around the globe in developed countries and contributed for decreasing childhood anemia. In developing countries, anemia is still a public health problem in a large number of these. Therefore, food fortification with iron have been considered, since it requires no change in eating habits and delivers benefit through the consumption of fortified staple foods or drinking water. In this chapter this issue was discussed as a Brazilian experience to control and reduce anemia in childhood using the iron fortification strategy. The use of food vehicles, iron salts and their costs, as well as recent works on iron fortification of foods in Brazil are reviewed.

2. General aspects of iron fortification of infant foods The fortification of foods consists in the addition of complementary nutrients to foods in natura. A concern with nutritional deficiencies in populations and a utilization of fortification as an intervention measure were extensively documented throughout the twentieth century. In 1910, for example, in Denmark, due to concern over vitamin A deficiency, which affected large numbers of children, health officials initiated large scale industrial fortification of margarine with vitamin A, resulting in the elimination of xerophthalmia in the population (Nilson & Piza, 1998). Once foods are enriched with micronutrients, such as iron, large, at-risk populations will be reached over long periods without the need of effective individual cooperation (Tuma et al., 2003; WHO, 1989). Therefore, food fortification is considered highly effective and flexible, is socially acceptable and furthermore, it does not interfere with the population’s dietary habits. In addition, the risk of side effects and toxicity are minimal due to reduced doses of micronutrients added to foods (Tuma et al., 2003) Food fortification is a public health measure, and in order to be successful, several considerations should be kept in mind. First, the food vehicle of choice must be consumed regularly and in large scale by the targeted population. In addition, the selected food vehicle should be evaluated for potent absorption inhibitors, and if the added iron compound will have an impact on the iron status of the consumer. Secondly, it is important that the selected iron compound does not cause unacceptable changes in color and flavor when added to foods. Additionally, the food vehicle should be sufficiently stable during long periods of storage and during cooking in order to guarantee that true food consumption may be quantitatively capable of contributing significantly to the nutritional requirements of the population. Finally, the food vehicle must be centrally produced and proper technology is available for industrial-scale fortification (Andrade, 2004; Cardoso & Penteado, 1994). The objective of iron food fortification programs is to increase the dietary mineral in foods to prevent and control iron-deficiency in at-risk groups (Andrade, 2004). The fortification of foods with iron is a preferred strategy advocated by the World Health Organization. Iron added to foods has been shown to be the most efficient options to control iron-deficiency, and studies have shown improvements over a period of one to three months in people suffering from this deficiency (Nilson & Piza, 1998). In Europe, some countries have adopted a policy of distribution of infant formula and fortified cereals, which resulted in decreasing the prevalence of iron deficiency in last decades (Hercberg, 2001). In the United States, in a cross-sectional study using data from the Centers

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for Disease Control and Prevention's (CDC), five American States found that the prevalence of anemia among children dropped by more than 50% in the last two decades and was attributed to better nutritional conditions related to large-scale consumption of fortified foods and possibly better iron bioavailability in some products (Sherry et al., 2001). The prevalence of anemia (NHANES III - conducted between 1988 to 1994) in the U.S. was 3% and 9% in children aged one to two years and less than 1% and 3% for children aged three to five years with anemia iron deficiency and iron deficiency, respectively (Looker, 1997). In Chile the prevalence of iron deficiency anemia is low in infants, preschoolers, school children, adolescents, adult men and women of childbearing age. Only pregnant women are still highly prevalent. It is likely that this low prevalence is due to fortification of flour with iron and B vitamins. The National Program for Complementary Alimentación (PNAC) distributes milk to children since 1952, while since 1970, this is enriched with iron. Through studies, the composition of output has been modified and now provides the program for infants and pregnant women milk powder fortified with iron, zinc, copper and ascorbic acid (Nilson & Piza, 1998). In Panama, children receive free via Alimentación Complementary Program (CAP) cereal fortified with vitamins and minerals. School-age children receiving iron-fortified milk and biscuits since 2006 that are offered to students in the country have also been fortified with iron and other vitamins and minerals, with coverage in difficult areas (Fontes, 2007). Cuba also adopted as a strategy to combat anemia food fortification, and the flours are enriched with iron and other vitamins and minerals since 1999. Children under two years are a priority for action, and more than 95% of the nation's children receive at subsidized prices, a pope fruit enriched with iron and vitamin C (since 2001). Milk fortified with iron is distributed, also at subsidized prices, to children under one year since 2005, and the program has covered 98% (Herrera, 2007). For children under one year, the most appropriate strategy seems to be the fortification of child foods at home. Fortification of complementary foods (weaning foods targeted to children age) is an alternative to targeted supplementation. Commercially-prepared complementary foods typically reach higher income, more urbanized households and this tends to have been left more to the market as an initiative. Zlotkin and colleagues at the Hospital for Sick Children, University of Toronto (Canada) developed a less costly alternative of the provision of micronutrients which an be added to infant foods. It was named "home fortification" and used sprinkles, the multiple-micronutrient sachet. The biological efficacy, bioavailability, safety and acceptability of Sprinkles were tested in various scenarios, including countries such as Bangladesh, Benin, Bolivia, China, Canada, Ghana, Guyana, Haiti, India, Indonesia, Kyrgyzstan, Mexico, Mongolia, Pakistan, Vietnam (Sprinkles Global Health Initiative, 2009). Bolivia was the first country that has documented the use of home fortification with intervention at the level of public health. In 2005, the country's data pointed to 70% prevalence of anemia among children 6 to 24 months. The country adopted the strategy of distributing sachets containing iron, vitamin A, vitamin C, folic acid and zinc for all children. Each child receives one sachet per day in one meal. Some recent studies look at the costs and potential impacts of sprinkles and conclude that the benefit: cost ratio of sprinkles interventions, containing iron as well as other micronutrients, can be as high as 37:1 if one assumes that a course of intervention for four months between the ages of 6 months and one year largely protects an infant against anemia throughout childhood (Sharieff et al., 2006).

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In Latin and South America, food fortification is widely practiced and can be classified in three program types: mandatory fortification of foods commonly consumed in large part by the population, such as wheat flour and corn meal; fortification targeting specific groups as in the example of foods consumed by infant and children populations, in this case cereal, powdered milk, biscuits and other industrialized products; and voluntary fortification, in which the food industry adds iron and other micronutrients to industrialized foods. The direct costs of food fortification are extraordinarily low when compared to the high social costs of micronutrient deficiencies. In most cases, according to the World Bank, the cost of fortification is less than one dollar per year to protect an individual against vitamin A, iron and iodine deficiencies. The cost to prevent an iron-deficiency alone has been estimated to be less than US$ 0.10 per year (Nilson & Piza, 1998).

3. Wheat and corn flour iron fortification In Brazil, since 2001 the Ministry of Health made mandatory the addition of iron [30% Recommended Nutritional Intake (RNI) or 4.2 mg/100 g] and folic acid (70% RNI or 150 µg) to milled wheat and corn flour. Federal law now dictates mandatory fortification of iron instead of voluntary fortification by the grain industry. This measure has as its core objective of increasing the accessibility of milled cereal grains with iron and folic acid consumed by the Brazilian population to reduce the prevalence of iron-deficiency and neural tube defects in Brazil (National Agency of Sanitary Surveillance, 2006). However, iron-fortified wheat flour is not always available, or it is consumed in small quantities to be affective by poor children 6 to 60 months of age (Beinner & Lamounier, 2003). Fortification of specific foods, as part of a complementary diet, has shown to be more effective for the control and prevention of iron-deficiency among infants (Andrade, 2004). In addition, and according to Hurrell (1997) it is likely that the low levels of elemental iron added to wheat flour (40 mg/Kg) would have little impact on iron nutrition, but the much higher levels added to commercial infant cereals (200-550 mg/Kg) together with vitamin C, could contribute substantially to the prevention of iron deficiency anemia. However, this measure becomes questionable in relation to infants, age of greatest risk for anemia due to the fact that these foods are not recommended and regularly consumed in sufficient quantities to meet the iron needs of this particular group. Moreover, it is likely that the low level of elemental iron (40mg/kg) added to wheat flour has little impact on nutritional status of children. No effect of flour fortification was observed in hemoglobin levels of children under five years in the city of Pelotas. Fact can partly be explained both by insufficient consumption of flour and also by the low bioavailability of dietary iron. The study was conducted between May and June 2004, prior to the mandatory fortification of flour and 12 and 24 months after the implementation of the action which occurred between 2005 and 2006 (Assunção et al., 2007). Moreover, in Brazil, there is not a monitoring program of mandatory fortification of flour.

4. Fortification of milk The Brazilian Pediatrics Society has recommended the use of infant formula supplemented with iron for infants until the age of two as supplementary feeding with breastfeeding. However, cow's milk is an important food consumed by children especially those families of low socioeconomic status. Cow´s milk presents low bioavailability of iron, and consumption of excessive amounts of fresh or pasteurized cow’s milk may be associated with occult

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intestinal blood loss during infancy, which may also contribute towards increasing the occurrence of anemia in infancy (Torres et al., 2000). The use of cow’s milk, due to socialeconomic and cultural practices, is used frequently in Latin America, including Brazil, during infancy, and iron fortification of this vehicle is an inexpensive alternative to increasing iron levels in children (Torres et al., 1995). Torres et al. (1995) studied the impact using powdered whole milk fortified with 9 mg of iron and 65 mg of vitamin C per 100 g during six months in 107 children in municipal daycare facilities, and another 228 children at public health clinics in the city of São Paulo. At baseline intervention, 66.4% and 72.8% of the children attending public daycare and public health clinics were diagnosed with anemia, respectively. At six months post study, the percentage of children still anemic decreased to 20.6% in daycare and 18% in children seen at health clinics. In a later study, Torres et al. (2000) evaluated the use of 3 mg of amino acid chelate in pasteurized cow’s milk (3 mg/L). During the 12-month study, 239 children 6 to 42 months of age received, daily, one liter of fortified cow’s milk. The mean hemoglobin levels at baseline for children less than 12 months, 12 to 23 months, 24 to 35 months, and 36 months of age, and older were 10.2 ± 1.3, 10.1 ± 1.6, 11 ± 1.3 and 11.8 ± 1.3 g/dl, respectively. At baseline, anemia prevalence was evaluated at 62.3%, and at six months, the percentage of children still anemic decreased to 41.8% and 26.4% after 1-year, respectively. Mean hemoglobin levels at 12 months were 11.1 ± 1.3, 11.6 ± 1.1, 12 ± 1.2, and 12.1 ± 1.0 g/dl, for 11, 12 to 23, 24 to 35, and 36 months of age, respectively. The increases were significant for the first three age groups, but not for the last group (36 months and older). Braga (1996) evaluated 102 children aged two to six years of age from a low, socio-economic community, enrolled in municipally funded daycare facilities in the city of São Paulo. Using an infant formula, 14 mg of iron and 100 mg of ascorbic acid were added to 200 ml of formula daily during 180 days. At the conclusion of the study, significant increases were observed in anthropometric indices (not shown here), mean hemoglobin (Hb) levels and hematocrit (Htc) values at baseline (Hb: 12.1 ± 0.66 g/dl; Htc: 35.7 ± 1.9) and post study (Hb: 12.7 ± 0.66 g/dl; Htc: 37.9 ± 1.9) showed improvements. The authors concluded that the preschool children could benefit in the control and prevention of anemia with a permanent iron-fortification program of foods in daycare facilities. In another study to evaluate iron fortification of infant formula, Ferreira (2000) randomly assigned 111 children, between the ages of four and six months, to two intervention groups during six months: the experimental group (68 infants) received iron fortified (1.8 mg ferrous sulfate/200 ml) milk formula and a control group (43 infants) received milk formula (0.7 mg iron/200 ml). At baseline, anemia prevalence in groups 1 and 2 was 63.2% and 67.4%, respectively. Mean hemoglobin levels in group 1 increased from 10.6 g/dl to 11.3 g/dl, however, in group 2, mean Hb actually decreased from 10.6 g/dl to 10.1 g/dl at six months. Similar significant results were seen for mean ferritin values: at baseline, ferritin values increased from 34.8 to 44.8 mcg/dl, but in group 2, mean ferritin values decreased from 41.8 to 26.1 mcg/dl. Hb and ferritin status were significantly improved in iron fortified group. Overall, the anemia prevalence decreased from 63.2% to 33.8% in group 1, and increased from 67.4% to 72.1% in group 2. It should be noted that effectiveness of iron fortified fresh or pasteurized cow’s milk and milk formulas will depend on several factors such as iron compounds, quantity, bioavailability, iron enhancers and inhibitors likely to affect bioavailability, and overall added cost to the targeted consumer.

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5. Iron fortification of biscuits and bread rolls Some studies were conducted on the effect of bovine hemoglobin-fortified cookies on the hemoglobin levels of 16 iron-deficient preschool children in northeast Brazil (Nogueira et al., 1992). Each child was offered five cookies per day containing 1.25 mg of iron over three months as part of their normal school meal program. An evaluation of the total nutrients offered to the children showed an iron intake of just 4.0 mg/day. Baseline mean hemoglobin was 9.4 ± 2.6 g/dl, and after three months, mean hemoglobin increased to 13.2 ± 0.2 g/dl. Initial anemia prevalence was 73% and disappeared at three months post intervention. With the addition of bovine hemoglobin-fortified cookies to the children’s diet, total iron intake increased to an average of 8.3 mg (83% of iron RDA – Recommended Daily Allowance) at a total cost of US$ 0.50 per child, with no measurable side effects or taste alterations reported. A project developed with 1500 children from daycare centers in the city of Barueri, Sao Paulo, using cookies and breads fortified with iron aminoquelato at a dose of 2 mg / day, showed reduced levels of anemia from 32% to 11% in a period of 2 months of intervention, with positive change for the weight / height and height / age (Fisberg et al., 1996). Giorgini et al. (2001) evaluated 89 preschool children during six months in a study using iron bisglycinate chelate. Children received two sweet rolls twice daily each fortified with 2 mg iron bis-glycinate (4 mg/day) five days a week. At baseline, 28% of the children had hemoglobin levels less than 11.0 g/dl, and at six months end study, nine percent of the children continued to be anemic. Mean hemoglobin at baseline was 11.5 g/dl, and at end, 12.6 g/dl. Mean hemoglobin increased 1.1 g/dl in non-anemic children and 1.4 g/dl in anemic ones. At the start of the study, mean ferritin level was 11.3 µg/l, and upon conclusion, mean ferritin increased significantly to 20.2 µg/l. Anthropometric indicators for weight/age and height/age also increased significantly. However, the problem of fortification of breads and crackers is that these foods are not consumed in sufficient quantities to meet the needs of infants, and often not even part of the food habits of this age group at highest risk for anemia. Despite the universal assumption that biscuits and sweet rolls are consumed by almost everyone, biscuits and sweet rolls consumption by infants, toddlers and school children are quite different. As a consequence, the fractional iron intake contribution would be too low in a flour-based fortification program for infants. But these two vehicles – biscuits and sweet rolls complement each other, resulting in a significant reduction of the population below the iron RDAs (Vellozo et al., 2003).

6. Iron fortification of potable drinking water The addition of iron to potable drinking water is one alternative to the control and prevention of iron deficiency and anemia. This rather simple method can reach a large part of the Brazilian population at each level of the social-economic stratum by the use of drinking water on a daily basis. Drinking water, other than used for drinking, is commonly used for preparation of foods, which may contribute even more towards increasing iron ingestion (Ferreira et al., 1991). Dutra de Oliveira et al. (1994) evaluated 31 preschool children aged two to six years enrolled in daycare facilities in Ribeirao Preto, Sao Paulo. During eight months, children consumed iron-fortified drinking water (20 mg Fe/Liter) which resulted in a significant decrease in the prevalence of anemia. At baseline, anemia prevalence was diagnosed in 58% of subjects. At four months 16% continued anemic, but at eight months post-study intervention anemia

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virtually disappeared since anemia was present in only 3% of subjects. Mean hemoglobin levels at baseline (10.6 ± 1.1 g/dl) increased significantly to 12.1 ± 1.4 g/dl at four months, and 13 ± 1.1 g/dl at end study. In a later study, Dutra de Oliveira et al.(2002) studied lowincome families during four months in which 21 families with children aged one to six years where divided into experimental and control groups. In the experimental group, family members consumed iron-fortified drinking water containing 10 mg of ferrous sulfate plus 60 mg of ascorbic acid per liter of water. The control group consumed their drinking water without the addition of iron or ascorbic acid. Results were very promising and showed that hemoglobin levels in children increased from 10.9 ± 1.1 g/dl to 11.7 ± 1.1 g/dl after four months of fortification intervention. Similar results were observed in the experimental adult group in which hemoglobin levels increased (12.9 ± 1.7 g/dl to 13.7 ± 1.7 g/dl). Results for ferritin were also positive in the experimental group in which ferritin levels increased in children, and significantly in adults. According to the authors, the iron fortification of drinking water is an effective, feasible alternative and practical way to distribute iron to low-income families, is technically inexpensive and has the promising potential for the control and prevention of anemia in Brazil and in other countries. In another study, 160 preschool children from eight municipal daycare facilities benefited from daily consumption of iron (12 g element iron/L) plus ascorbic acid (90 mg/L) prepared in 20-L plastic water jugs (Beinner et al., 2005). Mean Hb at baseline and after eight months of intervention increased significantly from 11.8 ± 1.3 g/dl to 12.4 ± 0.93 g/dl, respectively. The prevalence of iron deficiency determined by hemoglobin levels decreased from 43.2% to 21% at eight months post intervention. Significant (p< 0.05) anthropometric growth indicators- weight/age, height/age and weight/height were also observed during the study. Fundamentally important to the success of this study was education of the targeted population, which resulted in behavior change and a greater awareness of the importance of combating iron deficiency and anemia by the use of iron-fortified drinking water. The use of drinking water as a vehicle for the control and prevention of iron deficiency and anemia is an effective and efficient model, which can be used in targeting preschool children enrolled at daycare facilities, and/or at the household level, which will include all family members. Consumption of drinking water fortified with iron can contribute to increasing iron-intake to meet minimal Recommended Nutrient Intake (RNI) allowance of bioavailable iron acceptable to preschool children aged 6 to 59 months of age. Other then adding ironconcentrate to the appropriate number of liters of drinking water, it is easy to distribute and can be easily monitored. In children attending daycare centers in Belo Horizonte city, southern of Brazil, a longitudinal study was conducted to evaluate the effectiveness of fortification of drinking water with iron and vitamin C in the reduction of the anemia as well as to identify the prevalence of anemia. It was evaluated 380 children aged six to 74 months. Since 55 did not participate in the second evaluation, a total of 312 children assessed before and at the end of the intervention. To study the identification of risk factors, it was evaluated only children under five years old, the group with the highest risk for anemia. A questionnaire was applied to parents or responsible for the children, containing information socioeconomic, maternal and related to the children's health. Anthropometric measurements (weight and height) and fingerstick blood samples occurred in two periods: before and after five months of fortification. Children were considered as anemic with hemoglobin < 11.0 g / dl for the group aged 6 to 59 months, and values < 11.5 g/dL for those aged 60 to 74 months. Multivariate analysis was performed to evaluate the association between these variables and anemia. The total number of children evaluated before and after

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the fortification was 318, being 52.2% male, with average of 45.4 ± 15.8 months. The prevalence of anemia decreased significantly from 29.3% before the fortification, to 7.9% at the end of the study (p< 0,001). Considering the prevalence by age group, a reduction of 62.5%, 75% and 78.8% was found for children of 24 months, 24 to 48 months and > 48 months, respectively. The hemoglobin median increased 10.2%: from 11.8 g/dL to 13 g/dL, with a significant increase in all age groups. There was improvement in height-for-age and weight-for-age, however, only the first measurement showed a significant difference. For the study of the risk factors of anemia, the prevalence of anemia in this population was 30.8%, and the prevalence was 71.1% in children aged ≤ 24 months. The risk factors of anemia were age ≤ 24 months (OR: 9.08 CI: 3.96 to 20.83), and height-for- age < -1 z score (OR: 2.1, CI: 1.20 to 3.62). The fortification of water with iron and vitamin C significantly reduced the prevalence of anemia in children attending daycare centers, as well as it improved the nutritional status of them, being considered an important strategy to control this nutritional deficiency (Rocha, 2010)

7. Iron fortification of bean and rice In southeastern state of São Paulo, Brazil, studies were carried out, during four months, to evaluate bean flour enriched with iron in 85 anemic children two to five years of age. Results demonstrated a non-significant increase in anthropometric measurements and a significant reduction in the prevalence of anemia, which at baseline, was 13%, and at end study, anemia had disappeared in subjects that had received the iron-fortified bean flour (Fisberg et al., 2003). Unfortunately, milled bean flour represents a greater cost burden, and in addition, is not widely consumed throughout Brazil. Rice is another alternative for food fortification. One study was conducted in four nurseries in Rio de Janeiro (RJ), with children in the intervention group (n = 180) attending two nurseries and the control group (n = 174) in the other two nurseries. It was observed an increase in hemoglobin concentration in both groups, with the reduction in the prevalence of anemia in the intervention group was 37.8% to 23.3% and for the control group was 45.4% for 33, 3%, with no difference in reduction between the groups. According to the authors, the total amount of iron available was not sufficient to achieve more significant results in the intervention group, after four months of study (Bagni et al., 2009). The other study was conducted with families in the metropolitan area of Belo Horizonte. A group of 84 children received iron-fortified rice (23 mg Fe / day) and another group received ferrous sulfate (25 g Fe / L). After five months of intervention, there was a reduction in the prevalence of anemia in both groups, with an initial prevalence of 100% in both groups, decreasing to 61.9% for the group receiving the fortified rice and 85.6% for the group receiving ferrous sulfate, with a significant difference between groups (Beinner et al., 2009). Regarding rice, more studies are needed to evaluate the timing and dose required fortification of that vehicle, to achieve preventive effects and / or significant curative as well as assess the effect of simultaneous use with other supplements containing iron

8. Other iron fortified foods Orange juice fortification studies shown improvement in childhood anemia. In ongoing studies with iron fortification of foods, De Paula & Fisberg (2001) evaluated the use of 20 g of iron fortified sugar added to orange juice offered to 93 preschool children during six months. Children were divided into two groups: group 1 received 10 mg of iron per kilo of sugar, and group 2 received 100 mg of iron per kilo of sugar, both in the form of ferrous tris-

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glycinate. Anemia prevalence in both groups evaluated at baseline was 38.1% and 29.4%, respectively. At six months post study intervention, anemia prevalence in both groups decreased to 19.7% and 19.6%, respectively (p = 0.01). Mean hemoglobin levels increased to 0.4 g/dl; in anemic children alone, mean Hb increased greatly to 1.3 g/dl and 1.5 g/dl in groups 1 and 2, respectively (p < 0.001). According to ferritin results, there was a positive trend towards normalization of ferritin values in iron-deficient children. It was suggested, in terms of cost, that use of 10 mg iron/Kg be used when compared with 100 mg/Kg, as same results were observed. In yet another study using orange juice as an iron vehicle, Almeida et al. (2003) evaluated iron fortification of this widely produced fruit rich in vitamin C, which greatly facilitates iron absorption. Fifty preschool children consumed orange juice with iron (10 mg ferrous sulfate per 100 ml of concentrated orange juice) twice daily during four months. Anemia prevalence decreased from 60% to 20% at end study, and mean hemoglobin level increased from 10.5 ± 1.7 to 11.6 ± 1.1 g/dl (p = 0.00). The use of iron fortified orange juice is a promising strategy as a complimentary vehicle for ingestion of iron in children. Orange juice is widely consumed by all levels of the social strata in Brazil. An iron compound can be added during processing without provoking organoleptic changes (i.e., color, flavor, and consistency), and even allow for much higher quantities of iron- from 3 to 10 times morethan in other targeted or mandatory foods. The added cost can be absorbed through advertising and processing. The manioca flour enriched with ferrous bis-glycinate was studied during four months in 80 preschool children enrolled in a philanthropic institution in the city of Manaus. Anemia prevalence decreased significantly from 22.7% to 8% after four months of intervention (p < 0.05). According to the authors, mandioca flour is widely consumed in the North region of the country and can be considered a promising food vehicle in the control and prevention of iron deficiency and anemia (Tuma et al., 2003) Studies on fortification showed a positive response, both in relation to acceptance of fortified food, and prevention, as in the recovery of hemoglobin levels in both groups (Hertrampf, 1990; Torres et al., 1995; Vitolo et al., 1998). The food industries have used the enrichment of their products as a commercial appeal, focused on creating a quality attribute to further enhance the marketing of their products. However, there is no data in Brazil to assess the impact of these foods, fortified voluntarily by industry, in the prevalence of anemia.

9. Conclusion Studies on iron fortification of foods, over the last twenty years, have shown promising results in the control and prevention of iron deficiency and anemia in infant and child populations. Unfortunately, only a small number of efficacy and effectiveness trails of iron fortification of foods and liquids conducted in Brazil have been published. Researchers have used various types of food vehicles as well as different iron compounds in attempt to reduce nutritional deficiency, particularly an iron deficiency. The high prevalence of iron deficiency and anemia in infancy in most regions of Brazil have called attention to an inadequate nutrition making this a serious public health problem leading to eventual losses in terms of future growth and productivity at all stages of human development. State and federal governmental health agencies must move forward to

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prioritize national nutrition agenda that will draft mandatory fortification of food staples for mass consumption. Finally, fortified food is made available to vulnerable populations when industry is motivated to develop the logistics needed to fortify their products and when government is motivated to change policy requiring fortification.

10. References Agência Nacional de Vigilância Sanitária. Ferro e ácido fólico enriquecem farinha. Available from: http://www.anvisa.gov.br/divulga/noticias/2004/180604.htm. Accessed in 2006 (Dec 18). Andrade, KC. (2004) A fortificação de alimentos com ferro no controle da anemia ferropriva. Revista Brasileira de Ciências da Saúde, Vol.II, No.3, pp. 50-5. Assao TY, Silva DG, Ribeiro LC, Devincenzi MU, Sigulem DM. (2004) A importância do ferro na saúde e nutrição do grupo materno-infantil. Compacta Nutrição, Vol.5, No.3, pp. 7-22. Assunção MC, Santos IS, Barros AJ, Gigante DP, Victora CG. (2007) Efeito da fortificação de farinhas com ferro sobre anemia em pré-escolares, Pelotas, RS. Rev Saúde Pública, Vol.41, No.4, pp. 539-48. Bagni UV, Baião MR, Santos MMAS, Luiz RR, Veiga GV. (2009) Efeito da fortificação semanal do arroz com ferro quelato sobre a frequência de anemia e concentração de hemoglobina em crianças de creches municipais do Rio de Janeiro, Brasil. Cad. Saúde Pública, Vol.25, No.2, pp. 291-302. Beinner MA, Lamounier JA. (2003) Recent experience with fortification of foods and beverages with iron for the control of iron-deficiency anemia in Brazilian children. Food Nutr Bull. Vol.24, No.3, pp. 268-74. Beinner MA, Lamounier JA, Tomaz C. (2005) Effect of iron-fortified drinking water of daycare facilities on the hemoglobin status of young children. Journal of the American College of Nutrition, Vol.24, No.2, pp. 107-114. Beinner MA,Velasquez-Melendez G, Pessoa MC, Greiner T. (2009) Iron-fortified Rice is as efficacious as supplemental iron drops in infants and Young children. Journal of Nutrition, Vol.4, pp. 1-5. Braga JAP. Avaliação do estado nutricional de crianças submetidas a intervenção nutricional com um suplemento lácteo fortificado com ferro. [These] São Paulo (SP): Universidade Federal de São Paulo; 1996 Capanema FC, Lamounier JA, Rocha DS, Tonidandel WC, Drumond CA, Maia LS, Gomes CMA. (2008) Prevalência de anemia em crianças pertencentes a creches de Belo Horizonte – MG. Revista da Fundação Ezequiel Dias, Vol.2, No.1, pp. 75-82. Cardoso MA, Penteado MVC. (1994) Intervenções nutricionais na anemia ferropriva [Nutritional strategies for controlling iron deficiency anemia]. Cad Saúde Pública = Rep Public Health.,Vol.10, No.2, pp. 231-40. Castro TG et al. (2011) Anemia e deficiência de ferro em pré-escolares da Amazônia Ocidental brasileira: prevalência e fatores associados. Cad. Saúde Pública, Vol. 27, No. 1, pp. 131-42. de Paula RA, Fisberg M. (2001) The use of sugar fortified with iron tris- glycinate chelate in the prevention of iron deficiency anemia in preschool children. Arch Latinoam Nutr.; Vol.51, Suppl 1, pp. 54-9.

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de Almeida CAN, Crott GC, Ricco RG, Del Ciampo LA, Dutra-de-Oliveira JE, Cantolini A. (2003) Control of iron-deficiency anaemia in Brazilian preschool children using iron-fortified orange juice. Nutrition Research, Vol. 23, No. 1, pp. 27-33. Dutra-de-Oliveira JE, Ferreira JB, Vasconcellos VP, Marchini JS. (1994) Drinking water as an iron carrier to control anemia in preschool children in a day-care center. J Am Coll Nutr, Vol. 13, No. 2, pp. 198-202. Dutra-de-Oliveira JE, de Almeida CA. (2002) Domestic drinking water--an effective way to prevent anemia among low socioeconomic families in Brazil. Food Nutr Bull., Vol. 23, (3 Suppl), pp. 213-6. Ferreira AMA. Prevenção da anemia ferropriva em lactentes que freqüentam creches do município de São Paulo, através de uma fórmula láctea infantil fortificada com ferro.[These] São Paulo (SP): Universidade Federal de São Paulo; 2000. Ferreira JF, Aranda RA, Bianchi MLP, Desai ID, Dutra-de-Oliveira JE (1991) Utilização da água potável como veiculo de nutrientes: estudos experimentais com ferro [Use of drinking water as a vehicle of nutrients: experimental studies with iron]. Arch Latinoam Nutr., Vol. 41, No. 3, pp. 400-8. Fisberg M, Velloso EP, Ribeiro RMS, Zullo M, Braga JAP, Soraggi C, Kliamca PE, Chedid EA, Schuch M, Valle J, Cardoso R, Krumfli M, Graziani E. (1996) - Projeto Barueri. Pediatr. Atual, Vol. 11, No. 4, pp. 19-26. Fisberg M, Lima AM, Naufel C, Rodrigues C, Rhein SO, Oliveira S. (2003) Feijão enriquecido com ferro na prevenção de anemia em pré-escolares. Nutrição em Pauta, Vol. 59, No. 11, pp. 10-18. Fontes F. (2007) Politicas de combate de carencias de micronutrientes em Panamá. Rev Méd de Minas Gerais, Vol. 17, pp. S74-9. Giorgini E, Fisberg M, De Paula RAC, Ferreira AMA, Valle J, Braga JAP. (2001) The use of sweet rolls fortified with iron bis-glycinate chelate in the prevention of iron deficiency anemia in preschool children. ALAN, Vol.51, 1 Suppl, pp. 48-52. Herrera MP. (2007) Estrategias y acciones para combatir la anemia y la deficiencia de hierro: la experiência de Cuba en la fortificación de alimentos con hierro. Rev Méd Minas Gerais, Vol.17, pp. S86-9. Hertrampf E, Olivares M, Walter T, Pizarro F. (1990) Anemia ferropriva en el lactante: erradicación con leche fortificada con hierro. Rev Méd Chile.; Vol.118, pp. 1330-7. Hurrell RF. (1997) Preventing iron deficiency through food fortification. Nutr Rev., Vol.55, No. 6, pp. 210-22. Instituto Brasileiro de Geografia e Estatística – IBGE Pesquisa de Orçamentos Familiares 2008-2009 Antropometria e Estado Nutricional de Crianças, Adolescentes e Adultos no Brasil, 2010. Jordão RE, Bernardi JLD, Filho AAB. (2009) Prevalence of iron-deficiency anemia in Brazil: a systematic review. Rev Paul Pediatr, Vol.27, No. 1, pp. 90-8. Looker AC, Dallman PR, Carroll MD, Gunter EW, Johnson CL. (1997) Prevalence of iron deficiency in the United States. Prevalence of iron deficiency in the United States. J Am Med Assoc., Vol.277, No. 12, pp. 973-6. Matta IEA, Veiga GV, Baião MR, Santos MMAS, Luiz RR. (2005) Anemia em crianças menores de cinco anos que freqüentam creches públicas do município do Rio de Janeiro, Brasil. Rev. Bras. Saúde Matern. Infant., Vol.5, pp. 349-57. Morais MB, Alves GM, Fagundes-Neto U. (2005) Nutritional status of Terena indian children from Mato Grosso do Sul, Brazil: follow up of weight and height and current prevalence of anemia. J Pediatr, Vol.81, pp. 383-9.

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Neves MBP, Silva EMK, Morais MB. (2005) Prevalence and factors associated with iron deficiency in infants treated at a primary care center in Belém, Pará, Brazil. Cad. Saúde Pública, Vol.21, No. 6, pp. 1911-18. Nilson A, Piza J. (1998) Food fortification: a tool for fighting hidden hunger. Food and Nutrition Bulletin, Vol.19, No. 1, pp. 49-60. Nogueira NN, Colli C, Cozzolino SMF. (1992) Controle da anemia ferropriva em préescolares por meio da fortificação de alimento com concentrado de hemoglobina bovina: estudo preliminar [Iron deficiency anemia control in pre-school children by food fortification with bovine hemoglobin: preliminary study]. Cad Saúde Pública = Rep Public Health. Vol.8, No. 4, pp. 459-65. Rocha DS. Efetividade da fortificação da água com ferro e vitamina c na prevalência de anemia e no estado nutricional em crianças assistidas em creches De Belo Horizonte-MG, 2010. Doutorado [These] - Universidade Federal de Minas Gerais Sharieff W, Horton S, Zlotkin S. (2006) Economic Gains of a home fortification program: evaluation of “Sprinkles” from provider’s perspective. Canadian Journal of Public Health, Vol.97, No. 1, pp. 20-23. Sherry B, Mei Z, Yip R. (2001) Continuation of the decline in prevalence of anemia in lowincome infants and childrens in five states. Pediatrics, Vol.107, No. 4, pp. 677-82. Sprinkles Global Health initiative: about sprinkles.[cited 2009 May]. Available from: . The Global Burden of Disease: 2004 updated. Part 3: Disease incidence, prevalence and disability. World Health Organization Press, Switzerland, 2008. Pags 31-32. Available from: http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update _full.pdf Torres MAA, Souza Queiroz S. (2000) Prevenção da anemia ferropriva em nível populacional: uma revisão da literatura dos últimos quinze anos [Prevention of iron deficiency anemia in public health: a fifteen years review of the literature]. Nutrire. Vol.19, No. 20, pp. 145-64. Torres MAA, Sato K, Lobo NF, Queiroz SS. (1995) Efeito do uso de leite fortificado com ferro e vitamina C sobre os níveis de hemoglobina e condição nutricional de crianças menores de 2 anos [Effects of vitamin C and iron-fortified milk use on hemoglobin levels and nutritional condition of children cared for in day]. Rev Saúde Pública = J Public Health, Vol.29, No.4, pp. 301-7. Tuma RB, Yuyama LKO, Aguiar JPL, Marques HO. (2003) Impacto da farinha de mandioca fortificada com ferro aminoácido quelato no nível de hemoglobina de pré-escolares [Impact of cassava flour fortified with iron amino acid chelate on the hemoglobin level in pre-schools]. Rev Nutr, Vol.16, No.1, pp. 29-39. Vellozo EP, Silva R, Fagioli D. (2003) Pão enriquecido com ferro na prevenção da anemia de crianças matriculadas em creches da Prefeitura do Município de São Paulo. Nutrição em Pauta. Vol.63, pp. 32-42. Vitolo MR, Aguirre NC, Kondo MR, Giuliano Y, Ferreira N, Lopez FA. (1998) Impacto do uso de cereal adicionado de ferro sobre os níveis de hemoglobina e a antropometria de pré-escolares. Rev Nutr.; Vol.11, No.2, pp. 163-71. World Health Organization. Preventing and Controlling Iron Deficiency Anaemia through Primary Health Care. A guide for health administrators and programme managers. Geneve: WHO; 1989.

6 Economic Stressors and Childhood Obesity: Differences by Child Age and Gender Susan D.

Stewart3,

Steven Garasky1, Craig Gundersen2, Joey C. Eisenmann4 and Brenda J. Lohman3 1IMPAQ

International, LLC, of Illinois, 3Iowa State University, 4Michigan State University USA 2University

1. Introduction Childhood obesity is a public health challenge in the United States (U.S.) and elsewhere in the world. Additionally, those who are obese are heavier than in the past (Anderson & Butcher, 2006). In the U.S., one in three children is overweight or obese (Ogden et al., 2010), a prevalence that has tripled since 1970 (Anderson & Butcher, 2006; Kumanayika & Grier, 2006; Wang & Zhang, 2006). In response to this public health issue, Healthy People 2010 (US/DHHS, 2000) and President Obama (US/Office of the President, 2010) have identified childhood obesity as a national health priority as it has immediate consequences for a child’s physical and psychological health (Puhl & Latner, 2007; Raman, 2002; Strauss, 1999; US/DHHS, 2000), as well as implications for future health (Freedman et al., 2007; Raman, 2002; Strauss, 1999; US/DHHS, 2000). Beyond negative health outcomes, there are also economic costs (e.g., greater need for health care) associated with childhood obesity (Marder & Chang 2006; Skinner et al., 2008). Thus, identifying factors related to childhood obesity not only has implications for the health and quality of life of children, but it also has important implications for family expenditures and health care costs. It is commonplace to focus on physical inactivity and dietary factors as the cornerstones of the childhood obesity epidemic, but stress is another common feature of the landscape facing American families today. Stress manifests itself across numerous dimensions at both the individual and family level. While stress can be managed successfully by many individuals and families, in some cases stress can become severe enough to lead to serious health consequences. A vast literature has demonstrated the effects of stress on numerous health outcomes for children and adults (e.g., Dearing et al., 2006; Evans & English, 2002; Gee & Walsemann, 2009; Kort-Butler, 2009; Schilling et al., 2008), including childhood obesity (Eisenmann, 2006; Garasky et al., 2009; Gundersen et al., 2008; Lohman et al., 2009). While this work has provided policymakers with important insights, a central issue related to this research must be addressed. Through regression analyses this work has found positive associations between stress and childhood obesity after controlling for a host of potential confounding factors, but it has not ascertained whether unobserved factors

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correlated with stress (e.g., a child’s ability to cope with adverse conditions) may be the cause of the association. That is, these studies have implicitly assumed that time invariant unobserved factors were similar between different children and have ignored the possibility that children in households experiencing stress are different in unobserved ways from children in households not experiencing stress. To address this issue, the current study examined panel data using fixed effects models that controlled for time-invariant differences between children by using only within-individual variation to estimate the regression coefficients (Allison, 2005). We examined data from the first two waves of the Child Development Supplement (CDS) of the Panel Study of Income Dynamics (PSID). Our results indicated that exposure to housingrelated economic stressors leads to a higher probability of a child being obese and to higher levels of obesity, especially for younger females. Other forms of stress examined here (financial and neighborhood) were not related to child weight status. These findings were robust across a range of model specifications and suggest that efforts to reduce housing stress may also lead to reductions in childhood obesity.

2. Background 2.1 Theoretical framework Child health is an important aspect of family well-being. The ecological theory of human development identifies four levels of influence faced by families attempting to maximize their well-being (Bronfenbrenner & Morris, 1998). These levels are the microsystem (e.g., individuals and families), the mesosystem (e.g., neighborhoods and social networks), the exosystem (e.g., community), and the macrosystem (i.e., larger cultural context). Theoretical work on the “stress process” defines stress as a negative physiological response and stressors as the external factors that cause this negative response (e.g., Aneshensel, 1992; Boss, 1988; Chrousos & Gold, 1992; Pearlin, Menaghan, Lieberman & Mullan, 1981; Pearlin, Schieman, Fazio & Meersman, 2005). While genetic factors have consistently been shown to be central to whether a child is obese (e.g., Crossman et al., 2006; Gibson et al., 2007), environmental factors at the microsystem and mesosystem levels such as family, parental, and economic influences matter as well (e.g., Anderson et al., 2003; Cutler et al., 2003; Dietz & Robinson, 2008; Loureiro & Nayga, 2005). Environmental factors combined with a biological predisposition toward obesity provide the conditions for one’s propensity for obesity to come to fruition (Anderson et al., 2003). 2.2 Stress and health Stress is an environmental factor that often leads to reduced psychological and physiological health. One of the most common consequences of stress exposure is psychological distress, especially depression (e.g., Brooks et al., 2002; Kort-Butler, 2009; Schilling et al., 2008). Daily hassles and chronics stressors are the typical antecedents to depressive symptoms with stress leading to anxiety and aggression (Evans & English, 2002; Krause et al., 2003; Kort-Butler, 2009). Physiologically, higher levels of stress have been associated with higher levels of selfreported illness (Gee & Walsemann, 2009; Goodman, 1999; Larson et al., 2008). Early and chronic exposure to stressors has been linked with cardiovascular disease and obesity.

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Specifically, the psychosocial stressors that provoke exaggerated cardiovascular reactivity may also trigger overeating (Marniemi et al., 2002; Siervo et al., 2009). Indeed, research has found that stress exposure leads to increased cortisol levels, which enhances appetite and decreases leptin resistance, which increases the risk of obesity (Bjorntorp, 2001; Koch et al., 2008; Siervo et al., 2009). The effects of economic stressors on health and well-being have been examined under a range of headings including economic stress, financial stress, economic hardship, economic strain, economic pressure, and material hardship (e.g., Fletcher et al., 2005; Kim & Garman, 2003; Kim et al., 2006). Lower income children are at an elevated risk of exposure to varied forms of these stressors (Gershoff et al., 2007; Pearlin et al., 2005; Wickrama et al., 2007) and may have more severe health consequences stemming from stress due to their greater exposure and vulnerability (Sampson et al., 1997; Spencer, 2001). Recently, scholars have shown an association between household- and individual-level indicators of stress and childhood obesity (Garasky et al., 2009; Gundersen et al., 2008; Lohman et al., 2009). 2.3 Stress and childhood obesity Recent evidence suggests that stress faced by family members may lead to childhood obesity. Gundersen et al. (2008) found using data from the National Health and Nutrition Examination Survey (NHANES) that higher values of an index measuring cumulative stress exposure led to higher probabilities of obesity for food secure children in comparison to food insecure children. This result held for younger children, but the effect was statistically insignificant for older children. Lohman et al. (2009) found using data from the Three-City Study that higher levels of individual stress experienced by a child between the ages of 10 and 15 were statistically significantly associated with higher probabilities of childhood obesity. In contrast to Gundersen et al. (2008), they found that food insecure children with higher levels of maternal stress had higher probabilities of childhood obesity in comparison to food secure children. In should be noted that Gundersen et al. (2008) and Lohman et al. (2009) examined data from different surveys and employed different protocols for measuring food insecurity and stress which may have led to their finding somewhat conflicting results. Garasky et al. (2009) found using data from the PSID that stress was associated with childhood obesity, but the type of stress had differential effects for younger and older children. For younger children, lack of cognitive stimulation and emotional support in the household were associated with higher probabilities of obesity. However, for older children, mental and physical health problems and financial strain in the household were associated with higher probabilities of obesity. Finally, van Jaarsveld et al. (2009) conjectured that perceived stress in pre-adolescence may set adiposity trajectories, with no accentuation of differences due to perceived stress in adolescence, when they did not find an association between perceived stress and weight gain among British adolescents. Important to this research, few studies have investigated whether associations between stressor exposure and weight status differ between females and males, nor have they examined whether the associations differ by gender within age groups (an exception being van Jaarsveld et al. (2009) who examined potential differences among adolescents by gender). Among adolescents, boys and girls have the same likelihood of being overweight (Anderson et al., 2003) with no differences in the effect of perceived stress on weight gain (van Jaarsveld et al., 2009). However, some research indicates that girls and boys cope with

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stress differently (e.g., Frydenberg & Lewis, 2004; Rudolph, 2002), although others have found no gender differences in adolescent coping (Wadsworth & Compas, 2002). Different coping styles for boys and girls may affect their risks of obesity. For example, eating-related responses to stress differ for boys and girls (Mikolajczyk et al., 2009) with adolescent girls being more likely than boys to suffer from disordered eating (Hepworth, 2004). Additionally, greater consumption of sweets and fast food consistent with higher rates of “emotional eating” has been found among women relative to men (Larsen et al., 2006). The current study expanded on previous work by considering three types of economic stressors most commonly examined in the literature and most relevant to the home environments of children – housing, financial and neighborhood stressors – within a fixed effects framework. We examined separate groups of younger and older children and, given the mixed results by age and gender discussed above, compared the relationship between stress and obesity for girls versus boys within each age group. Previous studies did not systematically examine the potential effects of these economic factors on a child’s propensity to be obese in this way. Additionally, previous work concentrated on binary measures of obesity (an exception being van Jaarsveld et al. (2009)). We utilized the obesity gap (Garasky et al., 2009; Jolliffe, 2004) to depict the extent of a child’s obesity. A central advantage to using the gap measure is that it addresses a key disadvantage associated with binary measures of child weight status. A binary measure of obesity treats all children with a body mass index (BMI) ≥ 95th percentile for age and sex the same. With the obesity gap, these children are treated differently within the context of the models. From a policy perspective, these additional analyses are important as one may be especially interested in children with relatively high levels of obesity (US/Office of the President, 2010).

3. Methods We controlled for time invariant unobserved factors through the following fixed effects model: OBitα = γIit + λYit + μi + εit

(1) α

where i denotes a child, t denotes the interview wave (t=1 or 2), OBit denotes the measures of the weight status of the child (in manners described below), I is a vector of the three economic stressor indices described below, Y is a vector of time varying covariates, μ is a child-specific fixed effect, and ε is an error term. We estimated logit fixed effects models for the binary specification of weight status and linear regression fixed effects models for our continuous (i.e., gap) measure. With respect to the direction of the influence of the economic stressors on childhood obesity, these models implicitly assumed that the stressors affected weight status. While in theory the relationship between the economic stressors and weight status could be bidirectional, our model was consistent with the vast majority of research in this area and every study discussed above. 3.1 Data Our analyses were conducted with data from the first two waves of the Child Development Supplement (CDS-I and CDS-II) of the PSID. The PSID, begun in 1968, is a longitudinal study of a nationally representative sample of U.S. individuals and the families in which they reside. In 1997, a refresher sample of post-1968 immigrant families and their adult children was introduced to keep the study representative of the U.S. population (PSID, 2005). Currently, PSID interview waves are conducted biannually.

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The CDS, a research component of the PSID focusing on children age 0-12 years in PSID families was introduced in 1997. The CDS examines a range of developmental outcomes within the context of family, neighborhood, and school environments. Assessments of cognition, behavior, and health status are obtained from a variety of sources including the child and the child’s primary caregiver. The multi-method CDS survey design includes computer-assisted personal interviews (CAPI) and audio computer-assisted self-interviews (ACASI) (PSID, 2008b). Trained personnel measure the child’s height without shoes using a rafter’s square and tape measure. The child’s weight is measured using a digital scale (PSID, 2008a). In 2002-2003, interviewers recontacted families that participated in CDS-I and remained active in the PSID as of 2001. Of those families, 91% were successfully reinterviewed (PSID, 2008b). Information from CDS-I and CDS-II constituted the basis of our study. We supplemented these data with income and household composition data from contemporaneous PSID interview waves. Together, these data were well-suited for this analysis as they provided a large sample of households and detailed longitudinal information on child characteristics, family stressors, and relevant covariates. This data set had other strengths as well. In particular, the use of directly measured child height and weight strengthened this study as other large, national studies (e.g., Youth Risk Behavior Survey; National Longitudinal Survey of Youth) tend to rely on less reliable self-report or parental-report methods. Our analytic sample consisted of 1,263 youths who at the time of the CDS-I interview were between 2 and 14 years of age. This research examined the full analytic sample, as well as two age-based subsamples. Consistent with other research, the full sample was split at age 8 years at the time of the CDS-I interview. Children less than 8 years of age (i.e., 24-95 months of age) at the time of the CDS-I interview were the younger sample (n = 677 children). Children at least 8 years of age (i.e., 90-167 months of age) at the time of the CDS-I interview comprised the older sample (n = 586 children). Youths under age 2 years (less than 24 months) at the time of the CDS-I interview and over age 18 years (over 228 months) at the time of the CDS-II interview were removed. Also, youths classified as underweight (body mass index < 5th percentile for age and gender as defined below) at either their CDS-I or CDS-II interview were removed from the sample since underweight children were not the focus of the referent group (i.e., normal weight youth). 3.2 Variables and descriptive statistics 3.2.1 Dependent variables The measures used to delineate child weight status began with the calculation of a child’s body mass index (BMI, kg/m2). The BMI for each child was then mapped into a percentile based on age (in months) and gender using the Centers for Disease Control and Prevention (CDC) growth charts for the United States (e.g., Kuczmarski et al., 2002; Ogden et al., 2002). Our measures of obesity (OBBIN and OBGAP) were derived from these BMI percentiles and employed the definitions of the American Academy of Pediatrics (Barlow, 2007). That is, we set the obesity cutoff at the 95th percentile for age and gender. Our binary measure of child weight status (OBBIN) was defined as follows: OBBIN = 1 if BMIPER ≥ 95 OBBIN = 0 otherwise

(2)

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where BMIPER was the child’s BMI percentile for age and gender. Our measure of obesity severity (OBGAP, the obesity gap measure) was defined as follows: OBGAP = [(BMIPER – 95) / 5] if BMIPER ≥ 95 OBGAP = 0 otherwise

(3)

To better understand how OBBIN and OBGAP were defined, consider three children who have BMI percentiles for age and gender of 50, 96 and 99, respectively. Regarding OBBIN, the first child, and any child with a BMIPER below the 95th percentile, will have OBBIN set equal to 0. For the second and third child, and any child with BMIPER ≥ 95th percentile, OBBIN will equal 1. As for OBGAP, the first child, and any child with a BMIPER below the 95th percentile, OBGAP will be set to 0 as well. Key to these analyses is that the second and third children, both of whom are classified as obese, will have different values for OBGAP. OBGAP will equal 0.2 for the second child, while OBGAP will equal 0.8 for the third child. That is, children with more severe obesity (higher BMI percentiles for age and gender) will have higher obesity gap scores.

Variables Dependent Variables Obese

All Children 2 to 14 yrs CDS-I CDS-II

Younger Children 2 to <8 yrs CDS-I CDS-II

Older Children 8 to 14 yrs CDS-I CDS-II

0.200

0.210

0.241

0.230

0.154

0.186

0.130 (0.291)

0.120 (0.268)

0.170 (0.330)

0.136 (0.283)

0.084 (0.228)

0.101 (0.249)

Housing stressors (range = 0-4)

0.245 (0.514)

0.196 (0.484)

0.270 (0.554)

0.225 (0.507)

0.217 (0.463)

0.164 (0.453)

Financial stressors (range = 0-10)

1.451 (1.529)

1.182 (1.496)

1.539 (1.530)

1.205 (1.513)

1.348 (1.522)

1.155 (1.479)

0.299 (0.584)

0.295 (0.592)

0.298 (0.575)

0.301 (0.609)

0.300 (0.595)

0.289 (0.573)

4.154 (1.200)

4.064 (1.217)

4.049 (1.216)

4.165 (1.133)

4.275 (1.171)

3.947 (1.299)

50.565 (54.930)

70.725 (106.238)

47.144 (44.570)

65.316 (71.196)

54.516 (64.687)

76.974 (135.712)

Obesity gap Stressor Indices

Neighborhood stressors (range = 0-2) Control Variables Number of persons in household Annual total family income ($1000) Number of respondents

1263

677

586

a Percent of sample reported for categorical measures. Means with standard errors reported in parentheses for continuous measures. Children are classified as ‘younger’ or ‘older’ based on their age at the time of the CDS-I interview. Obese (BMI ≥ 95th percentile).

Table 1. Summary statistics: Variables in multivariate regressions.a

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Summary statistics for the variables in the multiple regressions for each wave are reported in Table 1 with changes in the variables across interviews reported in Table 2. About onefifth of the analytic sample was categorized as obese in each wave. The group of younger children had a higher proportion that was obese compared to the older children. About onefourth (22.7%) of all of the children experienced a change in weight status between interviews with a higher percentage of younger children (28.5%) experiencing change compared to the older children (15.9%). Older children, however, were more likely to become obese (9.6%) between interviews than to no longer be obese (6.3%) at the second interview. Younger children slightly more frequently became non-obese between waves (13.7% became obese, 14.8% were no longer obese at CDS-II). By definition, there was more change in weight status when status was assessed via the obesity gap (31.8% for all children, 37.8% for younger children, and 24.9% for older children) than when obesity was assessed through the standard binary measure.

Variables

All Children 2 to 14 yrs Increase Decrease

Younger Children 2 to <8 yrs Increase

Decrease

Older Children 8 to 14 yrs Increase Decrease

Dependent Variables Obesea

11.8

10.9

13.7

14.8

9.6

6.3

Obesity gap

17.0

14.8

18.0

19.8

15.9

9.0

Housing stressors

10.4

15.5

11.7

15.8

8.9

15.0

Financial stressors

25.7

36.9

25.4

39.3

26.1

34.1

Neighborhood stressors

13.3

13.1

12.9

12.9

13.8

13.5

Number of persons in household

22.3

28.9

29.8

21.0

13.7

38.1

Annual total family income ($1000)

78.4

21.1

77.7

21.9

79.2

20.3

Stressor Indices

Control Variables

Number of respondents

1263

677

586

Children are classified by their age at the time of the CDS-I interview. Obese (BMI ≥ 95th percentile). a Increase defined as becoming obese between CDS-I and CDS-II interviews. Decrease defined as no longer being obese at CDS-II interview.

Table 2. Summary statistics: Change in variables in multivariate regressions from CDS-I to CDS-II (% of children).

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3.2.2 Economic stressors Stress is a difficult concept to measure. Both subjective (i.e., directly asking individuals how much stress they feel from a given stressor) and objective (i.e., observing stressors within an individual’s environment or assessing physiologic markers such as cortisol) assessments of stress have been used in research. For example, Gottholmseder et al. (2009) examined the effect of commuting on perceived stress via a survey question asking “How do you feel when you arrive at your place of work (under normal traffic conditions)?” van Jaarsveld et al. (2009) when examining the link between stress and weight gain among adolescents assessed perceived stress with four questions that focused on stress and coping over the preceding month (e.g., “How often have you felt that you could not control the important things in your life?”). On the other hand, Kim et al. (2006) linked the stress caused by excessive debt (an objective financial stressor) to a higher likelihood of workplace absenteeism. This study employed objective measures of stress for three categories of economic stressors (housing, financial and neighborhood). Consistent with individuals experiencing “stress pile-up” as a result of dealing with multiple stressors at once (McGuigan, 1999; White & Klein, 2002) and aggregate economic risk being a more important correlate than any single economic risk (MacFadyen et al., 1996), a stressor index was calculated for each category by summing the dichotomous response values for the variables in the category. Housing stressors. Economic stressors related to housing were measured via four variables. CDS respondents when asked about economic problems in the last 12 months were asked three questions about housing experiences. “Did they move to cheaper living quarters?” “Did they move in with other people?” “Did they send one or more of the children to live with someone else?” A ‘yes’ response to any of these items was considered an indicator of housing-related economic stress. The last housing indicator regarded mortgage and rent expenditures. Respondents were queried about monthly first mortgage, second mortgage and rent payments. An indicator of economic stress was calculated by summing these payments and multiplying by 12 to arrive at an annual housing expenditure. The annual housing expenditure was divided by annual family income to determine the share of annual income spent on housing. If the share of income spent on housing was greater than 30 percent, an amount commonly considered to represent a household that is housing cost burdened (US/HUD, 2007), we considered this to be an indicator of economic stress. The housing stressors index ranged in value from 0 to 4. Financial stressors. Economic stressors related to finances were measured via ten variables. Respondents were asked a series of questions regarding possible financial problems they may have experienced in the past 12 months. Specifically, respondents were asked: Have you done any of the following or have any of the following happened as a result of economic problems in the last 12 months?: (1) Sold possessions or cashed in life insurance; (2) Postponed major purchases; (3) Postponed medical care; (4) Borrowed money from friends or relatives; (5) Filed for or taken bankruptcy; (6) Fallen behind in paying bills; (7) Had a creditor call or come to see you to demand payment; (8) Had your wages attached or garnished by a creditor; (9) Had a lien filed against your property because you could not pay a bill; and (10) Had your home, car or other property repossessed. For each question, a

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‘yes’ response was considered an indicator of economic stress. The financial stressors index ranged in value from 0 to 10. Neighborhood stressors. Economic stressors related to the household’s neighborhood were measured via two variables. Respondents were asked to rate their neighborhood as a place to raise children on a five-point scale ranging from ‘excellent’ to ‘poor.’ Families residing in neighborhoods self-assessed as being a ‘fair’ or ‘poor’ place to raise children were considered to be experiencing neighborhood-related economic stress. Respondents also were asked how safe it was to walk around alone in their neighborhood after dark. Responses ranged from ‘completely safe’ to ‘extremely dangerous.’ Families residing in neighborhoods self-assessed as being ‘somewhat dangerous’ or ‘extremely dangerous’ also were considered to be experiencing neighborhood-related economic stress. The neighborhood stressors index ranged in value from 0 to 2. One-third (31.20%) of the respondents reported they had experienced some aspect of housing stress (had an index value > 0) at one or both CDS interviews. Similarly, about onethird (33.57%) reported experiencing some facet of neighborhood stress during the study. It was more common to experience an aspect of financial stress. Three-fourths (74.43%) of the respondents indicated they had experienced an element of financial stress during one or both of the CDS interviews. As seen in Table 1, the mean values for each of the three stressor indices decreased from CDS-I to CDS-II for all children. Housing fell from 0.245 (out of 4) to 0.196; financial decreased from 1.451 (out of 10) to 1.182; neighborhood declined from 0.299 (out of 2) to 0.295. Index values declined across age groups as well, except for neighborhood stressors increasing between interviews from 0.298 to 0.301 for younger children. As seen in Table 2, some children experienced change in these measures. The most change occurred with financial stressors with over 60 percent of the sample experiencing a change. In contrast, about one-fourth of all children in the analytic sample experienced a change in their level of housing or neighborhood stressors. 3.2.3 Time varying covariates Two time varying covariates were included in these analyses. These were the number of persons in the household and annual total family income. As seen in Table 1, there were about four members on average in each household. The slight mean decrease in household size between waves stemmed from three times as many of the households of older children experiencing a decrease in size versus an increase in size (38.1% and 13.7%, respectively). Mean annual income increased from $50,565 at CDS-I to $70,725 at CDS-II with approximately three-fourths of the sample gaining income between waves.

4. Results Results from our estimation of equation (1) on the samples of all children, younger children and older children are displayed in Table 3. The columns in each table reflect results for the full analytic sample (columns 1-2), the younger children (columns 3-4) and the older children (columns 5-6) for the various specifications of weight status (OB). In columns (1), (3) and (5), we set α=0 in equation (1) (i.e., the binary measure of obesity) and estimated logit fixed effects models. In columns (2), (4) and (6), we set α=1 (i.e., the obesity gap). We estimated linear regression fixed effects models for the obesity gap analyses.

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All Children

Younger Children

2 to 14 yrs

Older Children

2 to 8 yrs

8 to 14 yrs

Obese

Obesity Gap

Obese

Obesity Gap

Obese

Obesity Gap

(1)

(2)

(3)

(4)

(5)

(6)

0.4618**

0.0407***

0.4308*

0.0563**

0.8376*

0.0171

(0.1999)

(0.0144)

(0.2213)

(0.0218)

(0.5021)

(0.0173)

Stressor Indices Housing stressors Financial stressors Neighborhood stressors

-0.0165

-0.0051

-0.0929

-0.0069

-0.1842

-0.0023

(0.0786)

(0.0057)

(0.0902)

(0.0089)

(0.1633)

(0.0066)

-0.0058

-0.0042

0.0557

0.0118

-0.2718

-0.0189

(0.1819)

(0.0143)

(0.2115)

(0.0232)

(0.3730)

(0.0158)

-0.1442

-0.0049

0.0198

0.0039

-0.4937**

-0.0131

(0.1041)

(0.0081)

(0.1295)

(0.0131)

(0.1991)

(0.0091)

-0.0022

-0.0001

-0.0025

-0.0003

-0.0022

-0.0001

(0.0001)

(0.0034)

(0.0003)

(0.0033)

Control Variables Number of household members Annual total family income ($1000) Constant Number of observations/ respondents

(0.0023)

(0.0001)

0.1500***

0.1480**

0.1550***

(0.0355)

(0.0582)

(0.0389)

2526 / 1263

1354 / 677

1172 / 586

Estimated coefficients with standard errors in parentheses. Obese (BMI ≥ 95th percentile). Superscripts of *, **, and *** indicate that the p-value of the coefficient is less than 0.10, 0.05, or 0.01, respectively.

Table 3. Effects of stressor indices and time varying covariates on weight status and gap measures. The housing stressors index was significantly, positively related to the likelihood of being obese across both specifications of weight status for all children. With respect to the magnitude of the relationship, a one unit increase from the average value of the housing stressors index across both interview waves (from 0.221 to 1.221) led to a 10.7 percentage point increase in the probability of being obese from a mean probability of 20% at CDS-I, and 32.6% increase in the depth (obesity gap) of obesity for those who were obese. (Derived from Tables 1 and 3.) We found no evidence of a relationship between the other forms of economic stressors –financial and neighborhood stressors – and child weight status.

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Economic Stressors and Childhood Obesity: Differences by Child Age and Gender Obese

Obesity Gap

Obese

Obesity Gap

(1)

(2)

(3)

(4)

Younger Children: 2 to 8 yrs Females Housing stressors Financial stressors Neighborhood stressors

Males

0.8029**

0.0810***

0.1895

0.0245

(0.3983)

(0.0279)

(0.2949)

(0.0346)

-0.1547

-0.0038

-0.0559

-0.0094

(0.1534)

(0.0125)

(0.1154)

(0.0128)

0.0034

0.0055

0.0787

0.0105

(0.3349)

(0.0351)

(0.2899)

(0.0314)

Number of observations/ respondents

628 / 314

726 / 363 Older Children: 8 to 14 yrs

Females Housing stressors Financial stressors Neighborhood stressors Number of observations/ respondents

Males

20.0090

0.0231

0.3925

0.0120

(4476.3590)

(0.0217)

(0.5196)

(0.0271)

-0.3554

-0.0053

-0.1170

0.0008

(0.2932)

(0.0077)

(0.2217)

(0.0112)

-1.1994

-0.0392**

0.2019

0.0008

(0.7814)

(0.0194)

(0.5651)

(0.0251)

590 / 295

582 / 291

Estimated coefficients with standard errors in parentheses. Obese (BMI ≥ 95th percentile). Superscripts of *, **, and *** indicate that the p-value of the coefficient is less than 0.10, 0.05, or 0.01, respectively. The coefficients on the time varying covariates are suppressed for brevity.

Table 4. Effects of stressor indices and time varying covariates on weight status and gap measures, by age group and gender. The relationships between economic stressors and child weight status were considered for younger (age 2 to 8 years at the CDS-I interview) and older (age 8 to 14 years) children separately and are reported in Table 3, as well. For younger children, exposure to housing stressors was positively and significantly related to obesity. Examining the magnitude of the relationships as above, a one unit increase in the housing stressors index led to a 10.7 percentage point increase in the probability of being obese. The percent increase for the obesity gap measure was 36.9%. While the percentage point increases in the probability of being obese were the same for all children and only the younger children, the magnitude of the association for the depth of obesity for those who were obese was larger for the sample of younger children than for all children. Unlike younger children, for older children the housing stressors index was significantly positively associated with weight status for only

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the binary obesity measure. This result indicated that a one unit increase in the housing stressor index was associated with a 9.5 percentage point increase in the likelihood of being obese for older children. The other two measures of economic stress were statistically insignificant for both age groups. Table 4 provides additional depth to the age-based analyses by examining the relationships between the three economic stressors and weight status by the gender of the child. These analyses revealed that the significant relationship between housing stressors and weight status for younger children was confined to females. For younger females, a one unit increase in the housing stressors index increased the likelihood that a younger female was obese by 19.3 percentage points. The percentage increases in the depth (obesity gap) of obesity for those young females who were obese stemming from a unit increase in the housing stressor index was 57.9. The relationship between housing stressors and weight status for younger males was statistically insignificant. The remaining results were generally consistent with those reported in Table 3. Financial and neighborhood stressors were not related to weight status for younger females or males. For older females and males, none of the stressor indices were related to weight status except for exposure to neighborhood stressors unexpectedly being negatively associated with weight status for older females in the obesity gap examinations.

5. Conclusions Although efforts to prevent and treat obesity have traditionally emphasized physical activity and diet, it is now becoming more widely recognized that the causes of childhood obesity are complex and multifactorial (Dietz & Robinson, 2008; Eisenmann, 2006). In this paper, we considered the impacts of economic stressors on childhood obesity. Employing an ecological theoretical framework (Bronfenbrenner & Morris, 1998), we considered factors within the microsystem and mesosystem associated with childhood obesity. Specifically, we examined the relationships between economic stress and obesity during childhood and adolescence. In contrast to previous work on this topic, we explicitly controlled for the effects of time invariant unobserved factors (e.g., a child’s ability to cope with adverse conditions) which may be correlated with stress through the estimation of fixed effects models. Additionally, we included measures that portray the incidence of obesity. After controlling for these factors, we found statistically significant effects of economic stress on childhood obesity. Consistent with others (e.g., Garasky et al. (2009)), we found that the relationships between economic stressors and child weight status differed across age groups. More specifically, experiencing housing stress was significantly positively associated with a younger girl’s probability of being obese, and the depth of her obesity. The differing associations between stressors and child weight by age groups can be considered within either a developmental family process framework or a developmental neuropsychoendocrine perspective (i.e., maturation of the stress systems). Younger children are more dependent on their caregivers. Middle childhood youth and early adolescents (ages 8 to 14 years in this study) may have additional/alternative sources of support such as peers, coaches, teachers and romantic partners to whom they may turn in times of stress. Additionally, we conjecture that housing stressors may be more apparent to younger children than other stressors. Compared to the other sources of economic stress considered here (financial and neighborhood stressors), housing-related stress may have the most

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serious ramifications in terms of altering a child’s day-to-day routine. There is evidence, for example, showing that frequent moves are negatively related to the well-being of children (Astone & McLanahan, 1994; Tucker et al., 1998). Children and families experiencing the types of housing stress examined here may have less control over their food choices and physical activities. Girls in particular are less physically active (Sallis et al., 2000), are more susceptible to stress (Rudolph, 2002), and are more likely to use food as a coping mechanism (Larsen et al., 2006.) We offer five recommendations for future research based on the results of this study. First, other indicators of economic stress should be considered. For example, families often contend with finding adequate and affordable child care which may impact the health and well being of their children, especially their younger children. Second, although examining the mechanisms underlying the relationship between economic stressors and obesity was outside the scope of this study, several potential pathways could be examined. One possibility is parenting. Several studies suggest that economic pressure is associated with lower marital quality, lower parenting quality, and higher levels of depression in children’s caretakers, each of which is associated with worse child outcomes (e.g., Kalil & Dunifon, 2007; Robila & Krishnakumar, 2006). Third, our models implicitly assumed that exposure to economic stressors affected child weight status, but that child weight status did not affect the economic stress experienced in the child’s household. While the consensus in the literature is that our models reflect the appropriate direction of the relationship when considering economic stressors, future research may want to consider whether the direction of the relationship is reversed when examining non-economic stressors. For example, parents with overweight children may become stressed due to the stigmatization and discrimination associated with weight in our society (e,g., Puhl & Brownell, 2006) or may experience stress as a result of negative perceptions of their appearance (Kraig & Keel, 2001). Fourth, researchers may wish to investigate the effects of longer-term economic shifts within families on child weight status using the longitudinal study design employed here. For example, the effects of income volatility, changes in family structure, and job loss could be considered. Similarly, longer term exposure to stressors could be examined. Lastly, while this article has not examined the effect of the social safety net on childhood obesity, future research may wish to consider how the numerous assistance programs in the U.S. interact to help families mitigate economic challenges and stress. Dietz and Robinson (2008) contend that it is unlikely that the problem of obesity will respond to a single intervention. A clear policy implication from this research is the identification of a new avenue for reducing the likelihood that a child will be obese. Based on our findings, reductions in housing stress will lead to reductions in the extent and depth of childhood obesity. From a policy perspective, efforts to address housing stress such as the provision of rent vouchers and current programs targeting families facing foreclosure may have a potential added benefit of reducing childhood obesity and associated health care costs to U.S. government programs such as Medicaid and State Child Health Insurance Programs.

6. Acknowledgment We wish to thank Yemisi Kuku for tremendous research assistance.

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7 Critical Appraisal of Selected Body Composition Data Acquisition Techniques in Public Health Steven Provyn, Aldo Scafoglieri, Jonathan Tresignie, Céline Lumé, Jan Pieter Clarys and Ivan Bautmans

Vrije Universiteit Brussel Belgium

1. Introduction Human body composition (BC) may be the most typical health-related discipline that enables both “easy indexes” and “complicated technology” for the same purpose, e.g. measuring quantities of adipose tissue, muscle, skin, bone and its minerals to predict health risks. Human BC may also be the most confusing health-related discipline because of the mixture of apparent corresponding and analogue terminology. Fat versus adipose tissue, fat-free mass versus lean-body mass versus adipose-tissue -free mass, visceral fat versus internal fat or abdominal fat. For the non-expert, who is often the clinical user, this is very confusing, especially because experts themselves do not always differentiate as they should between fat and adipose tissue. Methods for assessing human body composition are applied in many fields. In particular, the assessment or prediction of ‘total body fat’ is a common, popular and, at the same time, important element of public health, physical anthropology, sport and exercise sciences and, more specifically, of kinanthropometry, physiology, biomechanics, auxology and ergonomics. It is also general knowledge that monitoring adiposity is a dominant factor in analysing body composition, and that skinfold (SF) measurements (and quantities derived from them) play a key role in the prediction of adiposity. In addition, skinfolds have specific applications in occupational biomechanics, human hydrodynamics, drug quantification, diabetes, coronary heart disease, nutrition, endocrinology, hypertension, anorexia nervosa and in many epidemiological and human growth studies. Consequently, the SF is also a central factor in adipose tissue patterning, in ‘fat’ distribution studies, in somatotyping and in commercialised systems for monitoring adiposity and proportional mass (Edwards, 1951; Garn, 1955; Heath and Carter, 1967; Garn et al., 1971; Duquet et al., 1977; Mueller and Stallones, 1981; Jurimae et a l., 2005; Jurimae et al., 2007; Tafeit et al., 2007). Given the easy accessibility of the subcutaneous layer and its non-invasive nature, this interest in skinfolds has led to a proliferation of SF applications and formulae. In the literature, there are over 1000 articles dealing directly with SF measurement, both in applied and fundamental research. Altogether, more than 600 equations have been developed to

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predict body fat from skinfolds (Lohman, 1981; Martin et al., 1985; Clarys et al., 1987; Clarys et al., 1999; Provyn et al. 2010, 2011). Body fat or adipose tissue prediction formulae can be subdivided into regression equations based on anthropometric variables called anthropometric-based formulae (ABF) and into equations, once again based on anthropometric variables, but initially estimating density from which BF or AT are calculated in a second phase. These formulae will be called density-based formulae (DBF), and thereafter %AT is obtained with the Siri (1956) or Brozek (1963) conversion formulae according to the original publication. The accuracy of population-specific equations was improved with the addition of breadths and girths in combination with SFs and the use of populations of varied ages and degrees of body adiposity. It is well known, however, that the major weakness of population-specific equations is partly due to their inability to account for ageing and the non-linear relationship between subcutaneous AT and body density (Daniel et al., 2003). Due to its popularity and oversupply, the choice of a suitable equation is not evident. When selecting the most appropriate equation, using your common sense is advisable and generally accepted, if your selection is based on the characteristics of the population on which the equation was originally validated. In reality its application is not guaranteed. Studies comparing anthropometry with reference body composition techniques conducted on large samples of different ages are necessary (Rolland-Cachera and Brambilla, 2005). We know that the tissue distribution is different among men and women in particular adipose tissue and muscle tissues. (Clarys et al., 1984; Clarys et al., 1999) With reference to public health issues, there is a rising demand to improve the performance of techniques and systems while, at the same time, increasing clinical precision. Related research issues require that we consider whether or not we are studying what we think we are and whether or not the measuring techniques we use are consistent. Deeper insight into failures and how to prevent them can be gained by comparing and contrasting the reliability of systems with differing characteristics: electromechanical machinery, bioelectrical analysers, scanners and imaging equipment, etc. The user, e.g. the researcher, physician, clinician, or therapist depends on this system reliability. In addition to this reliability, other quantities are necessary to ensure field or user reliability of the system. This chapter will give a critical appraisal of common used body composition data acquisition techniques such as, Anthropometry and prediction equations.

2. Anthropometry Anthropometry refers to the measurement of proportions of the human body in an easy way, and is probably the best-known and most widely used technique for estimating BC both in the laboratory as well as in rural or urban field situations. Beside measuring weight and height, which do not provide any information about a nutritional status, other techniques are used to measure the size and proportion of body segments, (e.g. skinfolds , bone breadth and lengths, circumference and segment depths). It is known that SF is a central factor in AT patterning and ‘fat’ distribution studies (Edwards, 1951; Garn et al., 1971; Mueller and Stallones, 1981), in somatotyping (Heath and Carter, 1967), and in various BC issues (Martin et al., 1985). Clarys et al. indicated that its use is not without criticism, herewith referring to compressibility, lack of tissue constancies,

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skin-thickness-induced errors and not in the least to the examiner’s skill level (Clarys et al., 1987; Clarys et al., 2005). The interest in skinfolds, given the easy accessibility of the subcutaneous layer and its noninvasive nature, has led to a proliferation of SF applications and formulae. Prediction equations have been developed using either linear (population specific) or quadratic (generalised) regression models. Generally speaking, equations have been developed for relatively homogeneous populations and are assumed to be valid only for individuals with similar characteristics, e.g. gender, ethnicity, age or levels of physical activity. Besides this, anthropometric measurements are suitable for measurement error. Their accuracy depends not only on the prediction ability of the used formulae but also on the measurement skills, subject-related factors (e.g. obesity, age, etc.) and the type of calliper (Lohman et al., 1984). 2.1 Quality control and reliability of the panniculus adiposus calliper – A critical appraisal of the all-round skinfold measure This section describes the state of the art of an on-going critical search of the skinfold based on experimental anatomy over two decades (Clarys et al., 1984; Martin et al., 1985; Martin et al., 1994; Clarys et al., 1999; Marfell-Jones et al., 2003; Martin et al., 2003; Clarys et al., 2005). The SF-calliper measurement has become a routine laboratory and field method for so many years, that it has obtained the status of ‘a tradition’. In other words, this method has become too normal, almost too obvious to be analysed. Hägar (1991) stated that “two important assumptions must be made in the calculation of body SF measurements: 1. 2.

Subcutaneous fat constitutes a constant proportion of total body fat over all ranges of body weight; and Measurement sites are representative of all subcutaneous fat.“

This statement is, at best, doubtful (Hägar, 1991). What is really being measured is the thickness of a double skinfold and compressed subcutaneous adipose tissue (Figure 1).

Fig. 1. Schematic representation of a double skinfold and compressed subcutaneous AT with application of a calliper To infer the mass of fat in the body from this measurement requires another series of assumptions whose validity has never been seriously challenged (Clarys et al., 1987). In order to review the assumptions associated with calliper adiposity transformations, our ‘step-by-step’ model (Marfell-Jones et al., 2003; Clarys et al., 2005; Clarys et al., 2009) is

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relevant. The transformation from calliper reading to total body adiposity can be divided into a number of steps. The thickness of a compressed double layer of skin and subcutaneous AT should be representative of the uncompressed single layer of adipose tissue. This should indicate the total subcutaneous adiposity from which internal and whole-body adiposity can be predicted. Based on a pooled cadaver data, Brussels Cadaver Analysis Study (BCAS), (N=51), we have reviewed again the facts, assumptions and hazards to be taken into account in the transformation of SFs to whole-body AT mass. Figure 2 presents a flow chart of the systematic step-by-step reasoning behind the calliper reading with its associated seven assumptions. Each of these steps and assumptions is considered separately in chronological order:

Fig. 2. Flow chart of the transformation from skinfold to total body adiposity; eight possible steps (left) and possible assumptions (right) (Clarys et al., 2009) 2.1.1 Assumption I (constant compressibility) A calliper produces a constant SF compressibility. Most users of the calliper adopt some strategy to standardise the calliper reading in spite of its dynamic characteristics. Some wait “for all needle movements to cease” before taking the reading, while others record after “an initial rapid phase of the movement” or take the reading after two or four seconds of

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applying pressure. In addition to the dynamic compressibility, there is also a static element. Even after standardising the timing of the calliper reading, similar thicknesses of AT may yield different calliper values due to different degrees of tissue compressibility. Since the BCAS data include both SF thickness and the direct depth measurement (after incision) of the thickness of the subcutaneous adipose tissue layer, skinfold compressibility could be obtained for each site (Marfell-Jones et al., 2003). However, it was found that SF compressibility is by no means constant. 2.1.2 Assumption II (skin thickness negligible or a constant fraction of skinfold) Skin thickness is a negligible part or a constant fraction of the skinfold. All SF measurements contain a double layer of skin of unknown thickness. If this is very small in comparison to the SF measurement, its influence may be negligible. Data on skin thickness are sparse. Comprehensive skin thickness and surface data are to be found in various literature (Clarys et al., 1988; Verbraecken et al., 2006; Clarys et al., 2008). The site where the effect of skin thickness was most marked was the subscapular, where skin thickness accounted for 28.1% of the SF reading (34.0% for males, 23.9% for females). The subscapular and triceps sites are most commonly used for predicting whole-body values but have quite different proportions of skin (Clarys et al., 1987; Clarys et al., 2005). Consequently, on the basis of skin thickness, the subscapular skinfold should be a poorer predictor than SFs at arm and leg sites. 2.1.3 Assumption III (fixed adipose tissue patterning) Adipose tissue patterning is fixed (equal) all over the body. “Fat patterning” refers to differences in the anatomical placement of AT (Mueller, 1985) and therefore should be referred to more accurately as “adipose tissue patterning”. The patterning of subcutaneous AT is known to exhibit very large variations between individuals (Mueller and Stallones, 1981; Clarys et al., 1988; Martin et al., 2003; Clarys et al., 2005). To assess the value of various sites as predictors of subcutaneous adiposity, correlations have been determined between calliper and incision thickness with the dissected subcutaneous adipose tissue mass (Clarys et al., 1987). An unexpected finding is the high correlation for lower limb sites. Of the six best sites, all but one were on the lower limbs. The triceps, a highly favoured site for ‘fat’ prediction and considered to be the single indicator of AT (e.g. in digitised commercial devices) ranked a poor eleventh. The best predictors were front thigh, medial calf, rear thigh and supra-spinal. To summarise, under no circumstances is adipose tissue patterning divided equally over the body. 2.1.4 Assumption IV (constant or fixed proportion of fat in adipose tissue) Predicting human body fat is conditional on the knowledge of the fat content of, or in, AT. Even if the exact mass of subcutaneous adipose tissue is known, the prediction of subcutaneous fat mass requires some assumptions concerning the fat content of AT. Reported values range from 5.2 to 94.1% but are generally in the range 60 - 85%. In addition, the fat content of adipose tissue increases with increasing adiposity. Taking into account these considerations, which are compounded by the fact that ‘fat’ is ether extractable, whereas ‘adipose tissue’ is an anatomical – morphological – entity, confusion over the two (which occurs too often) should be avoided by eliminating ‘fat’ terminology from all morphologically based predictions of adiposity (Clarys et al. 1987).

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2.1.5 Assumption V (Linear relation between internal, external and total adipose tissue) A high correlation between internal, external and total AT obtained from skinfolds is essential. From evidence based on cadaver studies, it is assumed that, both in male and female subjects, any excess of adipose tissue is piled up subcutaneously, intramuscularly and internally, mostly in the trunk. The amount of intramuscular fat in the obese should not be underestimated and should therefore be considered as a third component. However, in the cadaver analysis, the intramuscular amount was allocated to the internal AT. SF callipers are only able to estimate subcutaneous adiposity. In order to estimate total body adiposity, some assumptions must be made about the relationship between internal and subcutaneous (external) adipose tissue. Figures 3 and 4 confirm a (very) good relation between whole body AT and both internal and external AT for men and women.

Fig. 3. Total adipose tissue mass versus internal adipose tissue mass (Clarys et al., 2005)

Fig. 4. External (subcutaneous) versus total body adipose tissue (Clarys et al., 2005)

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If, in these circumstances, internal adiposity stores are proportional to subcutaneous adiposity, this relationship provides a rationale for use of skinfold callipers. Alternatively, the internal AT may be negligible when compared with subcutaneous adipose tissue, once again providing some justification for the use of callipers. If, however, there is no significant relationship between internal and subcutaneous AT masses, and/or internal adiposity stores are far from negligible, then there cannot be any evidence-based prediction of total body adiposity and, concomitantly, there is no justification for using calliper measurements if these do not correlate with the above. Data indicate a good correlation between external and internal mass in both men (r=0.72) and women (r=0.86) (Figure 5). Almost all the assumptions necessary to convert SF calliper readings to percentages of ether-extractable fat are clearly unfounded, which supports our lack of confidence in the correctness of any whole-body fat prediction that depends on such assumptions. For this reason, once again we recommend the complete rejection of using the term 'fat', in favour of the term 'adipose tissue', which is, in fact, what is actually being measured by SF callipers.

Fig. 5. External (subcutaneous) versus internal (visceral + intermuscular adipose tissue) (Clarys et al., 2005) 2.1.6 Assumption VI (linear relation sum of skinfolds and subcutaneous adipose tissue) Skinfolds relate to (external) subcutaneous and total AT in men and women. Having rejected the concept of body fat prediction, we then considered whether total body adiposity could be confidently predicted from skinfolds. To achieve this, SF measurements would need to predict subcutaneous adipose tissue mass adequately, and there would have to be a strong relationship between the latter and total body adiposity. The most commonly used sites for SF measurements (in a variety of combinations) are triceps, subscapular, biceps, iliac crest, supraspinale, abdominal, front thigh and medial calf. The use of all of these sites gives an achievable, reasonably comprehensive coverage of the body’s subcutaneous AT deposition.

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For this reason, the relationship between the sum of these eight skinfolds and the subcutaneous adipose tissue masses of all those BCAS subjects for whom these data were available (n=20) was examined. Figure 6 shows a strong significant correlation between these entities in men (r=0.82), but a rather poor relationship in women (r=0.56).

Fig. 6. Sum of skinfolds (8) vs. external (subcutaneous) adipose tissue (Clarys et al., 2005) 2.1.7 Assumption VII (Relation sum of skinfolds and total adipose tissue equal in men and women) The important difference in basic relations as seen in assumption VI with the results of figure 6 jeopardise the use of SF measurements e.g. SF for men only seems somewhat hazardous. The reason for this gender difference are not be found in the direct relation between external (subcutaneous) AT and whole body AT. Figure 4, for that matter, indicate perfect correlations. If, however, the relation of the sum of skinfolds, for both genders would relate well with the direct whole body AT. The findings as described in assumption VI would be overruled. Unfortunately this is not the case. A r=0.48 in female against r=0.86 in men rejects the idea of equal relations between gender. Because of the difference in BC tissue distribution between men and women (e.g. AT and muscle mass), the use of skinfolds in whatever combination will remain hazardous in women (Clarys et al., 2005; Clarys et al., 2009)

3. Quality control and suitability of age, ethnicity and activity-matched prediction formulae for adiposity In order to investigate the validity in terms of quality for application in other groups and individuals. Density- and anthropometry-based equations for the determination of %AT have been selected for a sample of white female adults with a broad age-range and different lifestyles. For this purpose, DXA was used as a comparative measure. 3.1 Methodology One hundred and twenty eight subjects, from the Merseyside, United Kingdom, were recruited through a notice placed on the Liverpool John Moores university website, at health promotion sites used by Liverpool City Council, and at adjacent academic institutions. The subjects' characteristics and profile are shown in Table 1.

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Female

Male

Mixed N=54

Actives N=27

Non actives N=27

Mixed N=74

Actives N=55

Non actives N=19

x ± SD

x ± SD

x ± SD

x ± SD

x ± SD

x ± SD

Âge (years)

30.9 ± 8.5

30.4 ± 9.1

31.5 ± 7.9

Height (cm)

164.7 ± 5.8 163.3 ± 5.9 166.1 ± 5.5 178.9 ± 7.1 179.2 ± 6.6 178.1 ± 8.6

Paramètres

Weight (kg) BMI (kg/m²)* Underweight (N) Waist/Hip ratio Normal weight (N) Waist/Hip ratio Overweight (N) Waist/Hip ratio Obese (N) Waist/Hip ratio DXA % BF Hours sport/week

63.4 ± 11.1 60.7 ± 7.1 66.1 ± 13.6 23.3 ± 3.4 22.7 ± 1.9 23.9 ± 4.3 2 2 0.70 ± 0.02 0.70 ± 0.02 40 24 16 0.73 ± 0.04 0.73 ± 0.04 0.74 ± 0.04 9 3 6 0.79 ± 0.05 0.80 ± 0.06 0.78 ±0.05 3 3 0.84 ± 0.04 0.84 ± 0.04 28.0 ± 6.2 26.1 ± 4.8 29.9 ± 6.9 4.5 ±4.3 7.7 ± 3.7 1.2 ± 1.2

34.4 ± 14.1 35.4 ± 14.5 31.5 ± 13.1 80.3 ± 9.6 81.1 ± 9.9 78.1 ± 8.5 23.3 ± 3.4 25.3 ± 3.0 24.6 ± 2.2 41 30 11 0.83±0.04 0.84 ± 0.04 0.81 ± 0.03 29 22 7 0.89±0.05 0.89 ± 0.05 0.87 ±0.06 4 3 1 0.92±0.07 0.89±0.04 1.0 16.9 ± 4.6 16.7 ± 4.8 17.3 ± 4.3 6.6 ±4.7 8.2 ± 4.3 1.8 ± 1.2

BF = body fat; BMI= body mass index; DXA= dual energy X-ray absorptiometry; SD= standard deviation; *=BMI classification according to the World Health Organisation: underweight=BMI<18.5; normal weight=18.5
Table 1. Characteristics / profile of the participating subjects; All subjects received a full written and verbal explanation of the nature of the study before providing informed written consent. Approval for this study was obtained from the University’s Research Ethics Committee. Participants presenting osteosynthetic materials (e.g. screws, endoprotheses) or who were pregnant were excluded from the study. After explaining the measurement procedure, the participants were assessed for anthropometry (number of variables corresponding with the ad hoc %AT constituents) and a DXA scan on the same visit. Participants were asked to refrain from consuming alcohol for 24 hours and food and beverages (except water) for three hours prior to the test session. Participants wore lightweight clothing without zips, buttons or any other metal and removed all jewellery prior to the test protocol. The amount of activity per week was deducted from self-reported information. To separate daily and work-related activity from defined sport participations an arbitrary threshold of four hours was chosen. Less than four hours activity corresponded to "low active" and more than four hours activity per week was considered "high active". The rationale of this choice is a subjective interpretation of daily/weekly activity e.g. undefined walking and house hold activities as against all defined supplementary activity. Subjects were subdivided into three groups: i) high active group (≥4 hour's exercise/week), ii) low active (≤ 4 hours exercise/week) and iii) all subjects (regardless of their physical activity level).

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Since anthropometry is an anatomical derivative and because DXA produce value levels that are morphological rather than chemical, all outcomes were labelled as AT instead of BF from here onwards (Clarys et al., 2005; Bolotin, 2007; Provyn et al., 2008). The research personnel for DXA and anthropometry respectively remained the same throughout the entire examination period. In order to exclude bias due to inter-observer variation, the order in which subjects were assessed was randomised. 3.1.1 Anthropometry Ninety one (91) formulae corresponded to the inclusion criteria (e.g. gender = female or male, ethnicity = white, age range between 18 and 75 years), among which 34 ABF and 57 DBF fitted within the criteria (Table 2).

Observed Number of population range in N years equations x + SD Wilmore & 3 18-48 21,4 ± 3,8 128 Behnke 1970 3 18-48 21,4 ± 3,8 128 Katch & Mc 1 17-24 20,3 ± 1,8 69 Ardle 1973 Durnin & 15 16-68 272 Womersley 15 17-72 209 1974 Pollock et al. 18-22 19,7 ± 1,5 95 7 1976 40-55 44,9 ± 4,8 48 1 16-83 708 Deurenberg 1 21-66 238 et al. 1991 1 16-83 946 8 18-64 39,9 ± 14,1 84 Lean et al. 8 18-64 39,9 ± 14,1 84 1996 8 17-65 40,1 ± 13,1 63 8 17-65 40,1 ± 13,1 63 3 14-83* 48,8 ± 17,6 225 Gallagher et 3 10-86 48,8 ± 19,2 192 al. 2000 3 10-86 417 Equation reference

Evans et al.2005

1 1 1

18-25 18-34 18-34

20,6 ± 1,9 20,9 ± 2,4 20,8 ± 2,3

Total

91

(= 34 ABF + 57 DBF)

102 30 132

♀/♂

Activity level

Concept of estimation

♀ ♀

NM NM



Gymnast

A D D

♀ ♂

Mixed Mixed

D D

♂ ♂ ♀ ♂ ♀/♂ ♀ ♀ ♂ ♂ ♀ ♂ ♀/♂

NM NM NM NM NM NM NM NM NM NM NM NM

D D A A A A D A D A A A

♀/♂ ♀/♂ ♀/♂

Athletes Athletes Athletes

A A A

N=number of subjects for whom the original formulae were developed. NM = not mentioned; Mixed= active + sedentary; Y = age in years; ABF = Anthropometry-based formulae; DBF = Density-based formulae

Table 2. Selected adiposity equations applicable on the target population;

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With the detailed information of all the necessary variables available, the measurements battery was completed. Measurements were taken from the right side of the body at different locations and included all the sites and measures necessary to calculate the estimation of %AT using all the selected equations. These anthropometric measurements included: •





Fourteen skinfolds : 1) triceps, 2) subscapular, 3) scapular (oblique fold lateral and downward at the inferior angle of the scapula), 4) biceps, 5) forearm 1 (vertical fold at maximum girth, lateral aspect with hand supinated), 6) forearm 2 (vertical fold at max girth, anterior aspect with hand supinated), 7) chest (vertical fold on the midaxillary line at the level of the xiphoid process), 8) iliac crest horizontal, 9) iliac crest vertical, 10) supraspinale, 11) abdominal, 12) front thigh, 13) thigh (vertical fold on the anterior aspect midway between superior aspect of the patella and the anterior superior iliac spine), 14) medial calf. Fourteen girths: 1) neck, 2) arm girth relaxed, 3) arm girth flexed and tensed, 4) forearm, 5) wrist, 6) chest, 7) waist, 8) waist 1 (midway between inferior margin of the last rib and the crest of the ilium in a horizontal plane and around the pelvis), 9) waist 2 (while standing at umbilical level), 10) gluteal, 11) mid-thigh, 12) knee, 13) calf, 14) ankle. Four breadths: 1) bi-epicondylar humerus, 2) bi-styloid ulna/radius, 3) bi-epicondylar femur, 4) ankle bi-malleolar.

All anthropometric measurements were taken exactly as described by the respective authors of the selected formulae. If no repeatable descriptions were mentioned, the protocol as described by Martin and Saller (1957), with instructions from The International Society for the Advancement of Kinanthropometry (ISAK)(Norton et al., 1996) was followed. Anthropometric measurements were taken by a qualified criterion anthropometrist (ISAK Level IV). Body mass was measured to the nearest 0.05 kg with a digital scale (SECA 220, seca gmbh & co, Hamburg, Germany) and stretched stature was measured to the nearest 0.1 cm using a stadiometer with the head in Frankfort plane. Skinfold thicknesses were measured with a Harpenden calliper (Harpenden skinfold calliper, Baty international, West Sussex, England), girths with a flexible Lufkin steel anthropometric tape (Lufkin W606PM, cooper industries, Ohio, United States) and breadths with a small sliding calliper (Rosscraft Campbell 10 small bone Calliper, Rosscraft Inc., Surrey, Canada) to the nearest 0.1 cm. Each measurement was taken twice and the mean was calculated. If the difference between the first and the second measure was >5% for skinfold, >1% for girths or breadths, a third measurement was taken and the mean of the two nearest measurements was calculated as the final value. 3.1.2 Dual energy X-ray absorptiometry The percentage AT is part of the data acquisition from the whole-body DXA scan. Although the data protocol mentions BF, its resulting value level corresponds to anatomical AT values (Nagy and Clair, 2000; Snijder et al., 2002; Bolotin, 2007). All scans were measured according to standard operating procedures using a fan beam dual energy X-ray absorptiometry scanner (Hologic QDR series Delphi A, Bedford, Massachusetts). The scans were analysed

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using system Hologic QDR software for Windows version 11.2. (© 1986-2001 Hologic inc.). The literature has reported a coefficient of variation for %AT from 1.8 to 6.9% (Madsen et al., 1997; Bachrach, 2000; Nagy and Clair, 2000; Wallace et al., 2005). Each whole-body scan lasted approximately four minutes. All scans were performed by the same experienced examiner who was blinded for the anthropometrical measurements. The DXA was calibrated daily using the anthropometric spine phantom supplied by the manufactures to assess the stability of the measurements. The DXA was also calibrated weekly for body composition using a step phantom (Hologic QDR series Delphi A, Bedford, Massachusetts), that claims the correction of errors related to skin thickness (beam hardening). 3.1.3 Statistical analysis The percentage of adiposity is part of the data acquisition of the whole body DXA scan. Statistical analysis was conducted using SPSS 19.0 for Windows (© SPSS Inc., Chicago, IL). All variables showed normal distribution (Kolmogorov Smirnov Goodness of Fit test; p>0.05). For each equation, the estimated %AT was calculated according to the population for which the formula was developed in the first place and according to age and hours of sports activity per week. The %AT estimated by equations were compared with the %AT as assessed by DXA, using Pearson correlation coefficients and paired sample t-tests. A correlation coefficient higher or equal to 0.70 was chosen as a cut-off value. Significance was set a priori at p<0.05. Agreement between %AT using different methods with a correlation in concordance with the previous settings was determined by means of Bland-Altman plots. 3.2 Results Prediction equations to estimate %AT have been described for different populations according to age and sports participation. To meet with these conditions, the subjects studied were divided into three groups high active (HA), low active (LA) and the combined group (CG), based on the self-reported hours of sport activity per week. For illustrative purposes only we have subdivided our participants into BMI categories, according to the WHO classifications, and according to their waist/hip ratio (Table 1). The percent of AT was calculated for the 91 analysed formulae. Three equations only displayed no significantly different (p>0.05) results with DXA (Table 3). Author Wilmore and Behnke 1970 Pollock et al. 1976 Lean et al. 1996

Formula LBW = 8.629 + 0.680 weight – 0.163 subscapular SF – 0.100 triceps SF – 0.054 thigh SF D = 1.07660 – 0.00098 pectoral SF – 0.00053 chest SF %BF (AT) = 1.31 triceps SF + 0.430 age – 9.16

LBW=Lean Body Weight; SF=Skinfold; %BF= percentage Body Fat.

Table 3. Remaining equations predicting percentage adipose tissue not significantly different from DXA. Within this selection of formulae, the Wilmore and Behnke (1970) and Pollock et al (1976; for the age group 40 to 55 years) equations overestimate %AT (Table 4). As concerns the equations of Lean et al. (1996) and Pollock et al (1976; for the age group 18 to 22 years), overestimate %AT (Table 4).

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Critical Appraisal of Selected Body Composition Data Acquisition Techniques in Public Health Age range target N ♀/♂ population 18-48

52



18-22

14



40-55

18



17-65

69



Anthropometric equations (reference) Wilmore et Behnke 1970 FBA Pollock et al. 1976 FBD Pollock et al. 1976 FBD Lean et al. 1996 FBA

%AT DXA ( x ± SD)

%AT formulae ( x ± SD)

Difference DXA-formulae

Pearsons'r

28,17 ± 6,24

27,59 ± 3,90

0,58 ± 4,16

0,76**

14,20 ± 3,29

14,92 ± 1,96

-0,72 ± 1,59

0,93**

18,51 ± 3,78

17,89 ± 2,88

0,62 ± 2,17

0,82**

16,25 ± 4,06

17,85 ± 8,89

-1,60 ± 6,68

0,70**

N= Number of subjects; FBA= Anthropometric based formula; FBD= Density based formula; %TA= Percentage adipose tissue; x ̅= Mean; SD= Standard Deviation; ICC= Intraclass correlation

Table 4. Validity of estimated % body adiposity; Further analysis with Bland and Altman plots for both ABF and DBF show acceptable to very good mean differences with DXA (from -1.9% up to 1.8%) (Figure 7).

A= Anthropometric based formula of Wilmore & Behnke (1970); B= Anthropometric based formula of Lean et al. (1996); C =Density based formula of Pollock et al. (1976) applied on males aged from 18 to 22 years; D= Density based formula of Pollock et al. (1976) applied on males aged from 40 to 55 years.

Fig. 7. Bland & Altman plots of the selected prediction equations;

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The anthropometric based formula of Wilmore and Behnke (1970) (Figure 7A) has a mean/average difference with DXA close to zero (x ̅ = 0.6) but shows limits of acceptance (between -7.6% and 8.7%). On the graph, we see that this formula tends to overestimate the percentage of body fat compared to DXA for women whose average is less than ± 29% AT and underestimate for women with a body fat percentage greater than 29%. Conversely, the anthropometric based equation of Lean et al. (1996) (Figure 7B) underestimates the percentage of body fat for men with an average AT% below 17 and tends to overestimate for subjects with an average AT% more than 17. The density based formula of Pollock et al. (1976) (Figure 7C) for men between 18 and 22 years, defines an average calculated at -0.7 and limits of agreement between -3.8 and 2.4. On the graph, the majority of differences between the two techniques is within the confidence interval for almost all of male subjects included in this formula. Therefore, the results obtained with the formula are relatively close to those obtained with DXA When this same formula is applied to men with an age between 40 to 55 years (Figure 7D), the limits of agreement are between -3.6 and 4.9 and the average 0.6%AT. The dispersion of values is limited, indicating a close relationship between the results of the equation and those of DXA. 3.3 Discussion Prediction equations for estimating body fat have been described since 1921 (Matiegka, 1921) and by means of density since 1951 (Brozek and Keys, 1951). Over the years many formulae have been developed in different populations with different characteristics. Today more than 600 prediction equations available to estimate %BF or %AT (e.g. ABF and DBF). The selection of the most appropriate equation for the purpose can be a major concern and must be based on the characteristics of the population on which the chosen equation was validated, realizing that the predictive accuracy of equations remains limited. This indirect approach to BC is automatically exposed to measurement error. In addition the absence of a single gold standard method for obtaining in vivo reference measurements for BC leads to the limited predictive accuracy of field methods in general (Heyward, 1998; Clarys et al., 1999; Clarys et al., 2005). This study has verified the quality of the predictive accuracy and the applicability of prediction formulae for estimating %AT. Ninety one formulae were retained and applied to a population within different categories of BMI, waist/hip ratio and physical activity level. All formulae were specific to the population at hand and thus a similar outcome of each formula per subject was to be expected. However, such a similarity cannot be confirmed by the results found in this study. Prediction equations that presented a negative estimation of %AT were excluded. Only 3 out of the original set of > 600 formulae were retained for further analysis with Bland and Altman plots (Figures 7). The plots for all formulae showed an good and acceptable mean/average difference with the DXA result. However the 95% limits of agreement reported in the current study between DXA and the equations are too large. According to Lohman (1986), a 2% accuracy of estimations for %BF is ideal, while a difference in estimated %BF cannot exceed 4.5% (Lohman, 1992). Taking this into consideration, the

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formulas investigated in this study provide both clinically and biologically unacceptable estimations of %AT. Several authors mentioned previously that prediction equations tend to be inaccurate if the population to which they are applied is different from the one from which the equations were derived (Wilmore and Behnke, 1970; Katch and McArdle, 1973; Sinning, 1978; Vansant et al., 1994; Wong et al., 2000). Brodie et al. (1998) also warns for errors that occur in the calculation of predicted density and its subsequent interpretation as a fat (or correctly termed AT) percentage when using body density as a variable. The welldocumented limitations associated with skinfold measurements such as the inability to palpate the fat/muscle interface and the difficulty in obtaining interpretable measurements in obese subjects (Brozek and Kinzey, 1960; Himes et al., 1979; Fanelli and Kuczmarski, 1984) cannot be ignored. Even in a matched population (age, gender, ethnicity, activity level, etc.), the results indicate that formulae are not reliable tools for predicting %BF nor %AT. This lack of observer reliability may be explained on the one hand by the failure of previous studies to report the BMI (underweight, normal weight, overweight, obese), waist/hip ratio distribution categories, as well as by a good definition for athletes (number of hours of sport per week) within a population. On the other hand, many of the formulae studied, have been initially developed against indirect techniques such as hydrodensitometry, bioelectrical impedance analysis, plethysmography, etc. It can be assumed that errors related to the reference standard used has influenced the difference with DXA. The use of DXA for assessing BC is not new. Since the seventies total body scans have measured whole-body fat and lean masses in addition to total-body bone mineral content. Lately there has been an increasing usage of DXA as a research tool. This study must make reservation for the DXA comparison. Several studies have shown possible evidence to warn against misinterpretations of DXA data, and it has been suggested that there is insufficient confidence in the ability of DXA to accurately measure the variables it claims to measure (Bolotin, 1998; Bolotin, 2001; Bolotin and Sievanen, 2001; Bolotin et al., 2003; Bolotin, 2004; Bolotin, 2007; Provyn et al., 2008). This lack of confidence has focused principally on the inaccuracies inherent to the surface body density, bone mineral content and the doubtful DXA interpretation of what should be lean body mass (Bolotin, 2001; Bolotin, 2007). Provyn et al. (2008) validated DXA against an in-vitro (dissection) technique and concluded that DXA is a good predictor of %AT, although also warning about the lack of its accuracy when measuring %AT. Because of this critical appraisal, this study has avoided using the wording of “reference standard or golden standard” terminology but has instead referred to a “comparison measure” in the absence of any possible direct measure. Therefore, the choice of an appropriate method and an appropriate prediction equation to precisely assess %AT in individuals remains a challenging task for health and nutrition professionals taking into account that there is no significant difference (p>0.05) between the average predicted %AT and the average relative comparison measure.

4. General conclusion As the result of strong variations in human BC related to age, gender, race, tissue composition and lifestyle, the application of these equations in both men and women, in a clinical setting is questionable (Lohman, 1986; Ortiz et al., 1992; Wong et al., 2000; Clarys et

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al., 2005). In particular equations resulting from hydrodensitometry-based data collection are subject to some hazards (Scafoglieri et al 2010). Skinfold compressibility is by no means constant; skin thickness varies with location, females have thinner skin than males and there are significant gender differences in adipose and muscle tissue patterning. Thus, an identical thickness of adipose tissue does not necessarily contain the same concentrations of fat. Despite this variability, a relationship was demonstrated between aggregate skinfold measurements and subcutaneous adipose tissue mass (as opposed to subcutaneous fat) (Clarys et al., 2005). Prediction equations provide a relatively easy method for the estimation of body adiposity in the context of various health status approaches. The practical “easiness” is due to the use of anthropometry, skinfold thicknesses in particular. Skinfold measurements have been proven adequate (Martin et al., 2003) and thus also the use of a calliper device, which has become a routine laboratory and field instrument that has obtained the status of “tradition” (Martin et al., 1985; Clarys et al., 1987; Clarys et al., 2005). Martin et al. (1985) and Clarys et al. (1987; 2005) showed however that the use of such a skinfold calliper is not without any criticism. Almost all assumptions necessary to convert skinfold calliper readings to percentage ether-extractable fat are clearly unfounded, which means that any whole-body fat prediction that depends on such assumptions cannot be trusted. Having rejected the concept of the prediction of body fat, the next consideration is whether total body adiposity could be confidently predicted from skinfolds instead. To achieve this, SF measurements need to predict subcutaneous adipose tissue adequately, which has been confirmed by a strong relationship between the latter and total body adiposity (Clarys et al., 1999). To preempt the question whether equations with anthropometric variables and/or density based on volumes, can predict %BF or %AT, it should repeatedly be made clear that all previously developed formulae produce AT values. In previously publications, several DBF have shown negative values for %AT in both men and women (Durnin and Womersley 1974; Jackson et al. 1980). In this study, the same phenomenon was observed. These formulae used the Siri equation for predicting %AT and the negative values are a direct consequence of calculated whole-body densities greater than 1.100 g/ml. The occurrence of such values would be a clear indication and confirmation of violation of the assumption of constant density for the FFM. Unrealistic values for %AT (less than 2%), by using the Siri equation, were already reported by Pollock et al. (1977). It can be assumed that many studies encountered negative AT values but probably considered them as erroneous and thus they were never reported. Subjects were also divided into groups (active and non-active), based on self-report. This method of assessing activity level is questionable due to its subjectivity and the lower ability of adolescents to record their activities. Furthermore, physical activities are generally characterised by irregular bouts of activity of short duration and varied intensity, making it even more difficult to obtain accurate data. In both men and women, prediction equations cannot be used for individual diagnosis but only to give an idea of the BC of an age-, ethnicity-, gender- and activity-matched population. This study on white females and males confirms that the majority of formulae are not valid for practical use on age-matched individuals. However 5% of the ABF group (e.g. one of the Wilmore and Behnke (1970) formulae and one of the Lean et al. (1996) formulae), has been

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proven valid on a population corresponding to the original. Of the density derived %AT formulae (DBF), 2% of the developed equations are applicable on similar populations to the original e.g. Pollock et al. (1976 for the age category 18-22y and 40-55y) (Table 4). Although projects of this kind are time consuming and cumbersome, it is advisable to repeat the same exercise for men and for different ethnic groups for whom whole-body %AT formulae have been developed.

5. References Bachrach, LK. (2000). "Dual energy X-ray absorptiometry (DEXA) measurements of bone density and body composition: promise and pitfalls." J Pediatr Endocrinol Metab,13 Suppl 2, pp. 983-8. Bolotin, HH. (1998). "Analytic and quantitative exposition of patient-specific systematic inaccuracies inherent in planar DXA-derived in vivo BMD measurements." Med Phys 25(2), pp. 139-51. Bolotin, HH. (2001). "Inaccuracies inherent in dual-energy X-ray absorptiometry in vivo bone mineral densitometry may flaw osteopenic/osteoporotic interpretations and mislead assessment of antiresorptive therapy effectiveness." Bone 28(5), pp. 548-55. Bolotin, HH. (2004). "The significant effects of bone structure on inherent patient-specific DXA in vivo bone mineral density measurement inaccuracies." Med Phys 31(4), pp. 774-88. Bolotin, HH. (2007). "DXA in vivo BMD methodology: an erroneous and misleading research and clinical gauge of bone mineral status, bone fragility, and bone remodelling." Bone 41(1), pp. 138-54. Bolotin, HH. & Sievanen, H. (2001). "Inaccuracies inherent in dual-energy X-ray absorptiometry in vivo bone mineral density can seriously mislead diagnostic/prognostic interpretations of patient-specific bone fragility." J Bone Miner Res 16(5), pp. 799-805. Bolotin, HH.; Sievanen, H. & Grashuis, JL. (2003). "Patient-specific DXA bone mineral density inaccuracies: quantitative effects of nonuniform extraosseous fat distributions." J Bone Miner Res 18(6), pp. 1020-7. Brodie, D.; Moscrip, V.; & Hutcheon, R. (1998). "Body composition measurement: a review of hydrodensitometry, anthropometry, and impedance methods." Nutrition 14(3), pp. 296-310. Brozek, J.; Grande, F.; Anderson, JT. & Keys, A (1963). "Densitometric analysis of body composition: Revision of some quantitative assumptions." Ann N Y Acad Sci, 110, pp. 113-40. Brozek, J. & Keys, A. (1951). "The evaluation of leanness-fatness in man; norms and interrelationships." Br J Nutr, 5(2), pp. 194-206. Brozek, J. & Kinzey, W. (1960). "Age changes in skinfold compressibility." J Gerontol 15, pp. 45-51. Clarys, JP.; Martin, A. & Drinkwater, D. (1988). "Physical and structural distribution of human skin." Human Biology Budapest, 18, pp. 55-63. Clarys, JP.; Martin, AD. & Drinkwater, DT. (1984). "Gross tissue weights in the human body by cadaver dissection." Hum Biol, 56(3), pp.: 459-73. Clarys, JP.; Martin, AD.; Drinkwater, DT. & Marfell-Jones, MJ. (1987). "The skinfold: myth and reality." J Sports Sci , 5(1), pp. 3-33.

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Clarys, JP.; Martin, AD.; Marfell-Jones, MJ.; Janssens, V.; Caboor, D. & Drinkwater, DT. (1999). "Human body composition: A review of adult dissection data." Am J Hum Biol, 11(2), pp. 167-174. Clarys, JP.; Provyn, S.; Marfell-Jones, M. & Van Roy, P. (2006). "Morphological and constitutional comparison of age-matched in-vivo and post-mortem populations." Morphologie, 90(291), pp. 189-96. Clarys, JP.; Provyn, S. & Marfell-Jones, MJ. (2005). "Cadaver studies and their impact on the understanding of human adiposity." Ergonomics, 48(11-14), pp. 1445-61. Clarys, JP.; Provyn, S.; Wallace, J.; Scafoglieri, A. & Reilly, T (2008). Quality controle of fan beam scanning data processing with in vitro material. Transaction of 2008 IEEE International Conference on industrial engineering and engineering management, Singapore. Clarys, JP.; Scafoglieri, A.; Provyn, S. & Sesboüé, B. (2009). "The hazards of hydrodensitometry." Biom Hum et Anthropol, 27(1-2), pp. 69-78. Daniel, M.; Martin, AD.; Drinkwater, DT.; Clarys, JP. & Marfell-Jones, MJ. (2003). "Waist-tohip ratio and adipose tissue distribution: contribution of subcutaneous adiposity." Am J Hum Biol, 15(3), pp. 428-32. Deurenberg, P.; van der Kooy K.; Leenen R.; Weststrate J.A. & Seidell J.C. (1991). Sex and age specific prediction formulas for estimating body composition from bioelectrical impedance: a cross-validation study. Int J Obes, 15(1), pp. 17-25. Duquet, W.; Van Gheluwe, B. & Hebbelinck, M. (1977). "Computer program for calculating Health-Carter anthropometric somatotype." J Sports Med Phys Fitness, 17(3), pp. 255-62. Durnin, JV. & Womersley, J. (1974). "Body fat assessed from total body density and its estimation from skinfold thickness: measurements on 481 men and women aged from 16 to 72 years." Br J Nutr, 32(1), pp. 77-97. Edwards, DA. (1951). "Differences in the distribution of subcutaneous fat with sex and maturity." Clin Sci (Lond), 10(3), pp. 305-15. Evans, EM.; Rowe DA.; Misic MM.; Prior BM. & Arngrimsson SA. (2005). Skinfold prediction equation for athletes developed using a four-component model. Med Sci Sports Exerc, 2005. 37(11), pp. 2006-11. Fanelli, MT. & Kuczmarski, RJ. (1984). "Ultrasound as an approach to assessing body composition." Am J Clin Nutr, 39(5), pp. 703-9. Gallagher, D.; Heymsfield SB.; Heo M.; Jebb SA.; Murgatroyd PR. & Sakamoto Y. (2000). Healthy percentage body fat ranges: an approach for developing guidelines based on body mass index. Am J Clin Nutr, 72(3), pp. 694-701. Garn, SM. (1955). "Relative fat patterning: an individual characteristic." Hum Biol 27(2), pp. 75-89. Garn, SM.; Rosen, NN. & McCann, MB. (1971). "Relative values of different fat folds in a nutritional survey." Am J Clin Nutr, 24(12), pp. 1380-1. Hägar, A. (1991). Estimation of body fat in infants, children and adolecents. Adipose tissue in childhood. Bonnet, P. Florida USA, CRC Press Boca Raton, pp. 49-56. Heath, BH. & Carter, JE. (1967). "A modified somatotype method." Am J Phys Anthropol, 27(1), pp. 57-74. Heyward, VH. (1998). "Practical body composition assessment for children, adults, and older adults." Int J Sport Nutr, 8(3), pp. 285-307. Himes, JH.; Roche, AF. & Siervogel, RM. (1979). "Compressibility of skinfolds and the measurement of subcutaneous fatness." Am J Clin Nutr, 32(8), pp. 1734-40.

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Jurimae, T.; Jurimae, J.; Wallner, SJ.; Lipp, RW.; Schnedl, WJ.; Moller, R. & Tafeit, E. (2007). "Relationships between body fat measured by DXA and subcutaneous adipose tissue thickness measured by Lipometer in adults." J Physiol Anthropol, 26(4), pp. 513-6. Jurimae, T.; Sudi, K.; Jurimae, J.; Payerl, D.; Moller, R. & Tafeit, E. (2005). "Validity of optical device lipometer and bioelectric impedance analysis for body fat assessment in men and women." Coll Antropol, 29(2), pp. 499-502. Katch, FI. & McArdle, WD. (1973). "Prediction of body density from simple anthropometric measurements in college-age men and women." Hum Biol, 45(3), pp. 445-55. Lean, ME.; Han, TS. & Deurenberg, P. (1996). "Predicting body composition by densitometry from simple anthropometric measurements." Am J Clin Nutr, 63(1), pp. 4-14. Lohman, TG. (1981). "Skinfolds and body density and their relation to body fatness: a review." Hum Biol, 53(2), pp. 181-225. Lohman, TG. (1986). "Applicability of body composition techniques and constants for children and youths." Exerc Sport Sci Rev, 14, pp. 325-57. Lohman, TG. (1992). Advances in body composition assessment, Champaign, Ill.: Human Kinetics Publishers. Madsen, OR.; Jensen, JE. & Sørensen, OH. (1997). "Validation of a dual energy X-ray absorptiometer: measurement of bone mass and soft tissue composition." Eur J Appl Physiol Occup Physiol, 75(6), pp. 554-8. Marfell-Jones, M.; Clarys, JP.; Alewaeters, K. & Martin, AD. (2003). "The hazards of whole body adiposity prediction in men and women." Biom Hum et Anthropol, 21(1-2), pp. 103-17. Martin, AD.; Daniel, M.; Clarys, JP. & Marfell-Jones, MJ. (2003). "Cadaver-assessed validity of anthropometric indicators of adipose tissue distribution." Int J Obes Relat Metab Disord, 27(9), pp. 1052-8. Martin, AD.; Daniel, MZ.; Drinkwater, DT. and Clarys, JP. (1994). "Adipose tissue density, estimated adipose lipid fraction and whole body adiposity in male cadavers." Int J Obes Relat Metab Disord, 18(2), pp. 79-83. Martin, AD.; Janssens, V.; Caboor, D.; Clarys, JP. & Marfell-Jones, MJ. (2003). "Relationships between visceral, trunk and whole-body adipose tissue weights by cadaver dissection." Ann Hum Biol, 30(6), pp. 668-77. Martin, AD.; Ross, WD.; Drinkwater, DT. & Clarys, JP. (1985). "Prediction of body fat by skinfold caliper: assumptions and cadaver evidence." Int J Obes, 9 Suppl 1, pp. 31-9. Martin, R. and Saller, K. (1957). Lehrbuch der anthropologie I, In systematischer darstellung mit besonderer berücksichtigung der anthropologischen methoden. Stuttgart, Gustav Fischer Verlag. Matiegka, J. (1921). "The testing of physical efficiency." American Journal of Physical Anthropology, 4, pp. 223-30. Mueller, WH. (1985). Biology of human fat paterning. London, Ciba foundation. Mueller, WH. & Stallones, L. (1981). "Anatomical distribution of subcutaneous fat: skinfold site choice and construction of indices." Hum Biol, 53(3), pp. 321-35. Nagy, TR. & Clair, AL. (2000). "Precision and accuracy of dual-energy X-ray absorptiometry for determining in vivo body composition of mice." Obes Res, 8(5), pp. 392-8. Norton, K.; Whittingham, N.; Carter, L.; Kerr, D.; Gore, C. & Marfell-Jones, M. (1996). International Standards for Anthropometric Assessment. Underdale, SA, Australia, International Society for the Advancement of Kinanthropometry.

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Ortiz, O.; Russell, M.; Daley, TL.; Baumgartner, RN.; Waki, M.; Lichtman, S.; Wang, J.; Pierson, RN. Jr. & Heymsfield, SB. (1992). "Differences in skeletal muscle and bone mineral mass between black and white females and their relevance to estimates of body composition." Am J Clin Nutr, 55(1), pp. 8-13. Pollock, ML.; Gettman, LR.; Jackson, A.; Ayres, J.; Ward, A. & Linnerud, AC. (1976). "Body composition of elite class distance runners." Ann N Y Acad Sci, 301, pp. 361-70. Provyn, S.; Clarys, JP.; Wallace, J.; Scafoglieri, A. and Reilly, T. (2008). "Quality control, accuracy, and prediction capacity of dual energy X-ray absorptiometry variables and data acquisition." J Physiol Anthropol, 27(6), pp. 317-23. Provyn, S.; Scafoglieri A.; Tresignie J.; Bautmans I. ; Reilly T. & Clarys JP. (2011) Quality control of 157 whole body adiposity prediction formulae in age and activity matched men. J Sports Med Phys Fitness, Sep;51(3), pp.426-34. Provyn, S.; Wallace J. ; Scafoglieri A. ; Sesboüé B. ; Marfell-Jones M. ; Bautmans I. & Clarys JP. (2010), Formules de prédiction de l’adiposité chez la femme – contrôle de qualité Original Research Article, Science & Sports, Volume 25, Issue 6, December , pp.291-303 Rolland-Cachera, MF. & Brambilla, P. (2005). "Reference body composition and anthropometry." Int J Obes (Lond), 29(8), pp. 1010. Scafoglieri A.; Provyn S.; Bautmans I.; Wallace J.; Sutton L.; Tresignie J.; Louis O.; De Mey J. & Clarys JP. (2010). Critical Appraisal of Data Acquisition in Body Composition: Evaluation of Methods, Techniques and Technologies on the Anatomical Tissue-System Level, Data Acquisition, Michele Vadursi (Ed.), ISBN: 978-953-307-193-0, InTech, Sinning, WE. (1978). "Anthropometric estimation of body density, fat, and lean body weight in women gymnasts." Med Sci Sports, 10(4), pp. 243-9. Siri, WE. (1956). "The gross composition of the body." Adv Biol Med Phys, 4, pp. 239-80. Snijder, MB.; Visser, M.; Dekker, JM.; Seidell, JC.; Fuerst, T.; Tylavsky, F.; Cauley, J.; Lang, T.; Nevitt, M. & Harris, TB. (2002). "The prediction of visceral fat by dual-energy Xray absorptiometry in the elderly: a comparison with computed tomography and anthropometry." Int J Obes Relat Metab Disord, 26(7), pp. 984-93. Tafeit, E.; Moller, R.; Jurimae, T.; Sudi, K. & Wallner, SJ. (2007). "Subcutaneous adipose tissue topography (SAT-Top) development in children and young adults." Coll Antropol, 31(2), pp. 395-402. Vansant, G.; Van Gaal, L. & De Leeuw, I. (1994). "Assessment of body composition by skinfold anthropometry and bioelectrical impedance technique: a comparative study." JPEN J Parenter Enteral Nutr, 18(5), pp. 427-9. Verbraecken, J.; Van de Heyning, P.; De Backer, W. & Van Gaal, L. (2006). "Body surface area in normal-weight, overweight, and obese adults. A comparison study." Metabolism, 55(4), pp. 515-24. Wallace, J.; George, K. and Reilly, T. (2005). "Validation of dual-energy x-ray absorptiometry for segmental body composition analysis." Journal of Sports Sciences, 11/12(23), pp. 1165-6. Wilmore, JH. & Behnke, AR. (1970). "An anthropometric estimation of body density and lean body weight in young women." Am J Clin Nutr 23(3), pp. 267-74. Wong, WW.; Stuff, JE.; Butte, NF.; Smith, EO. & Ellis, KJ. (2000). "Estimating body fat in African American and white adolescent girls: a comparison of skinfold-thickness equations with a 4-compartment criterion model." Am J Clin Nutr, 72(2), pp. 348-54.

8 Physical Activity, Inactivity, and Nutrition Behavior Among Children: Investigating Compensation and Transfer Effects 1Institute

Judith Väth1, Katie Amato2 and Claudio R. Nigg2

for Sport and Sport Sciences, University of Karlsruhe, Karlsruhe 2Department of Public Health Sciences, University of Hawai‘i at Mānoa, Honolulu, HI 1Germany 2USA 1. Introduction The increasing prevalence of overweight children is an important public health problem in the United States. Nearly 1/3 of children are considered to be at risk for being overweight and currently more than 9 million children over 6 years of age are considered obese (Ogden et al. 2002; Koplan et al. 2005). Obesity and being overweight is a risk factor for several diseases: type 2 diabetes, cardiovascular disease, hypertension, osteoporosis, and certain types of cancer (Eaton et al. 2006). Both physical activity (PA) and nutrition behaviors have been shown to be an important and effective method to reduce weight. Physical activity expends energy and can lead to a reduction in weight loss. A meta-analysis showed that there is a small to moderate relationship between body fat and activity in children (Rowlands, Ingledew and Eston 2000). But to reduce adiposity in children and adolescents of normal weight an intense level of PA for a longer duration is needed (Barbeau and Litaker 2003; Eliakim et al. 2000). Time spent in vigorous and hard activity correlated significantly with percentage of body fat but not with BMI in 5-10.5 year-olds (Abbott and Davies 2004). Physical activity not only positively influences physiological factors, but also has a positive effect on psychological aspects. Regular PA can increase the ability to cope with stress and lead to an improved health perception and quality of life (Röthlosberger, Calmonte and Seiler 1997). Strong et al. (2005) emphasized many other beneficial effects of PA, such as better cardiovascular health and self-esteem. Most research examining physical inactivity focuses on television (TV) viewing. Some crosssectional studies found positive associations between TV viewing and obesity. An analysis of the CDC 1999 Youth Risk Behavior Survey demonstrated a significant association between overweight and viewing TV more than 2 hours per day (Lowry et al. 2002). Also, eating meals in front of the TV may influence energy intake because it is associated with lower fruit, vegetable, and juice intake and greater intake of salty snacks, pizza, soft drinks, and red meat (Proctor 2003; Coon et al. 2001).

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Some clinical evidence shows that receiving advice to increase fruit and vegetable consumption is an effective strategy for weight management as fruits and vegetables have a low energy density, are high in fiber, and may cause satiety. In addition, consumption of fruits and vegetables could also displace consumption of less healthy and higher energydense foods (Sherry 2005). Children and adolescents in the US have not consumed the recommended 5 servings of fruits and vegetables per day (Cavadini, Siega-Rizz and Popkin 1996). Studies report that only 18% of girls and 14% of boys consume the recommended number of servings of fruits and vegetables (American Dietetic Association 2004; Enns, Mickle and Goldmann 2003). Relationships between PA, inactivity, and nutrition behavior are consistently shown in studies on elementary school children (Sallis, Prochaska and Taylor 2000; Driskell et al. 2008; Pearson and Biddle 2011). For example, in a comprehensive review of PA correlates among children Driskell et al. (2008) found that healthy diet, intention to be active, and PA preferences (among others) cluster with PA. Traditionally, PA and nutrition interventions have focused on influencing single behaviors. However, recent research suggests that multiple behavior change interventions may have a greater impact than single behavior change interventions (Nigg, Allegrante and Ory 2002; Emmons et al. 1994). Because these behaviors are associated in individuals; combined PA, inactivity, and nutrition interventions hold promise for effectively influencing multiple outcomes. In a PA and healthy eating intervention evaluation on adults, a multiple behavior intervention was 3 times as successful as a single behavior intervention (Johnson et al. 2008). In another study on children, a combined nutrition and PA group scored significantly better than a control group on measures of nutrition knowledge. Results of single- and multiple behavior change interventions imply that future investigation of how changes in PA, inactivity, and nutrition may impact each other is warranted (Warren et al. 2003). Physical activity, inactivity, and nutrition behaviors may act as gateway behaviors. Gateway behaviors are those which when changed lead to a positive change in another health behavior (Nigg et al. 2009). Depending on the interaction of the behaviors, change in more than one behavior may be due to transfer or compensation effects. Borrowed from learning and teaching research (Barnett and Ceci 2002), transfer effects describe the translation of knowledge and confidence in one health behavior to another. Research on transfer effects is inconclusive: some studies report null results (Ussher, Taylor and Faulkner 2008; Wilcox et al. 2000), while others provide support (Nigg et al. 2009; Fleig et al. 2011). Transfer effects may depend on the 1) co-occurrence of behaviors 2) similarity of health behavior domains (Flay and Petraitis 1994), and 3) individual ability to transfer skills to another domain (Perkins and Saloman 1994). Because PA, inactivity, and nutrition are associated and naturally co-occur, transfer effects may explain the success of behavior change interventions. To date, transfer effects in these domains have not yet been investigated in children. Research on single behavior interventions measuring other behaviors has found support for transfer effects between PA and nutrition in adults. One study found that self-efficacy in exercise served as a gateway to healthy diet (Tucker and Reicks 2002). Additionally, a recent exercise intervention found PA transfer effects on fruit and vegetable intake (Fleig et al. 2011). Combined PA and nutrition interventions evaluating transfer effects are few. One intervention comparing single versus multiple behavior interventions that targeted PA and fat intake found that success at

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improving both behaviors was not associated with intervention condition (Vandelanotte et al. 2008). Results suggest that participants who successfully changed both behaviors in the single behavior change intervention experienced transfer effects. In contrast to transfer effects, the opposite interaction effect may occur where individuals may compensate for their risk behavior by performing another health behavior (see Compensatory Health Belief Model, Knauper et al. 2004). For example, it has been shown that smokers are more physically active in order to compensate for their unhealthy lifestyle (Xu 2002). Less literature is available on compensation effects of PA, inactivity, and nutrition. One study exploring the effects of a PA intervention on adult’s nutrition found that PA was not a gateway behavior for fruit and vegetable consumption. Instead, they found that increases in PA activity were associated with increases in fat intake (Dutton et al. 2008) suggesting that participants may have compensated for increased fat intake with increased PA. Both transfer and compensation effects of PA, inactivity, and nutrition behavior may have important intervention implications, but they have not yet been explored in children. Therefore, the purpose of the current study is to compare PA, inactivity, and nutrition behavior, their influence on each other in children, and to determine if there are compensation or transfer effects.

2. Methods Twenty-one schools in the state of Hawaii (the islands of Oahu, Hawaii, and Maui) participating in Fun 5 were randomly selected and stratified by afterschool care provider, year joined, and county. Fun 5 is a nutrition and PA program aimed at reducing obesity through increasing fruit and vegetable consumption and PA (Battista et al. 2005). Parental consent and student surveys containing PA, inactivity, and nutrition behavior questions were sent to the site coordinators with instructions for distribution, administration, and return of completed materials. One site did not return any surveys and 7 sites did not get parental permission. A significant portion of sites’ student surveys (N= 250) were obtained without consent and destroyed. In the final analysis, only students from 13 sites were evaluated. There were two measurement points: one at the beginning of the school year (Fall 2005 – baseline T1); and the other at the end of the school year (Spring 2006 – follow-up T2). The University of Hawaii Committee on Human Subjects approved this research. 2.1 Participants Participants were enrolled in Hawaii’s A-Plus public elementary after-school program (A+). A+ is a state mandated after-school program for children in public elementary schools that begins immediately after the end of the school day until the last child is picked-up (2pm~5:30pm). The program includes snack time, homework time, PA, and enrichment activities such as arts and crafts. At T1, 188 student surveys from 13 sites were available for analysis (53.2% female; grade 4= 39%; grade 5= 34%; and grade 6= 27%). At T2, 137 students (56.7% female; grade 4= 37%; grade 5= 37%; and grade 6= 26%) completed the survey from the same 13 sites. For the analysis, only children who took part on both measurement points are included. Table 1 shows the sample of those participants that completed T2 and those that did not complete T2.

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Variable Strenuous PA (min/wk) Moderate PA (min/wk) Mild PA (min/wk) Inactivity (hrs/day) Fruit (serv/day) Vegetable (serv/day)

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Completed (N= 137) mean Std.

Not completed (N= 51) mean Std.

df

sig.

202.28

135.86

213.14

137.18

185

.628

147.45

125.47

152.24

137.72

184

.823

119.48

140.75

136.67

141.08

181

.469

4.47

3.252

3.88

3.090

186

.268

4.69

2.950

4.32

2.622

180

.438

3.77

2.825

3.82

2.561

179

.915

t-test

Note: PA – physical activity; min – minutes; wk – week; hrs – hours; serv – servings Std. – Standard deviation; df – difference; sig – significance; N – numbers.

Table 1. Mean, standard deviation and significance of PA, inactivity, and nutrition variables at T1 (completed or not completed T2) 2.2 Measures The student survey included measures on demographics (grade and gender), PA, inactivity, and fruit and vegetable consumption. An adaptation of Godin & Shephard's Leisure-Time Physical Activity Questionnaire (Godin and Shepard 1985) indicates how many days during an average week people are engaged in strenuous, moderate, and mild PA during their free time. Strenuous PA is defined as "heart beats rapidly, sweating” examples are: running, jogging, soccer, squash, cross country skiing, judo, roller skating, vigorous swimming, vigorous long distance bicycling, vigorous aerobic dance classes, and/or heavy weight training. Moderate PA is defined as "not exhausting, light sweating” examples are: fast walking, baseball, tennis, easy bicycling, volleyball, badminton, easy swimming, popular, folk and / or hula dancing. Mild PA is defined as "minimal effort, no sweating, e.g. easy walking, yoga, archery, fishing, bowling, lawn bowling, shuffleboard, horseshoes, and/ or golf. For a sample of adults (Godin and Shepard 1985) aged 18-65 years, two-week testretest reliabilities of .94, .46, and .48 were reported for strenuous, moderate, and mild PA respectively. Strenuous PA was significantly associated with maximum oxygen intake (VO2max; r = .38) and percentage of body fat (r = .21). The instrument was found to be significantly related to caloric accelerometer readings (r = .32), metabolic equivalents (METs; r = .36), treadmill PA time (r = .57), percentage of body fat (r = -.43), VO2max (r = .56), and the stages of PA across populations (Jacobs et al. 1993; Lee et al. 2001; Schumann et al. 2002). A second set of questions reflects the minutes (in 10 min increments) that participants spent in each activity level each day. This allows a calculation of min/week of PA for each intensity level. For sedentary behavior one question addressed how many hours the student watched TV or played video games on an average day (Buckworth and Nigg 2004). Validity of this item has shown a small negative correlation in PA with children (Nigg 2005).

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Participants reported how many servings of fruits and how many servings of vegetables they ate each day. A serving was described as: ½ cup of cooked vegetables = size of 2 pingpong balls; 1 cup of salad = size of 1 baseball; 1 piece of fruit = size of 1 baseball; or ¾ cup of 100% fruit juice = 6 ounces. The single items addressing the average number of fruits and the average number of vegetables eaten each day have documented validity and reliability in adolescents (Prochaska 2000). 2.3 Analysis Data analysis was conducted via SPSS 14.0 (2005, SPSS Worldwide Headquarters, Chicago, IL). Three variables represent PA level in min/week (strenuous, moderate, mild), one variable measures the inactivity (TV watching or videogame playing), and two variables address healthy nutrition behavior (fruit and vegetable consumption). For the measurement of strength and direction of cross-sectional relationships Pearson Correlations were conducted. Cohen’s guidelines (1988) for interpretation of the correlation coefficient were used: small ranging from │.10│ - │.29│; medium ranging from │.30│ - │.49│; and large ranging from │.50│ – │1.0│. A linear regression was conducted to assess the longitudinal relationship between a dependent variable, independent variables, and a random term. Independent variables were all the behaviors at T1. For example, strenuous PA, moderate PA, mild PA, inactivity, fruit and vegetables at T1 were used to predict one dependent variable at T2 (e.g., strenuous PA).

3. Results A t-test was conducted to compare those who completed T2 with those who did not complete T2. Means and standard deviations are represented in Table 1 and show for all six variables that there is no significant difference between both groups (p > .05). Only the 137 participants who completed T1 and T2 were included in the analysis. Cross-sectional analysis with all the participants at T1 did not alter any conclusions (results not shown). Table 2 shows the mean and standard deviation of all variables across time. There were no significant differences between T1 and T2 (p > .05).

Variable Strenuous PA (min/wk) Moderate PA (min/wk) Mild PA (min/wk) Inactivity (hrs/day) Fruit (serv/day) Vegetable (serv/day)

T1 (Fall 2005) mean std. 202.3 135.9 147.4 125.5 119.5 140.7 4.47 3.252 4.69 2.950 3.77 2.825

T2 (Spring 2006) mean Std. 214.2 134.8 147.1 127.0 126.1 142.0 4.26 3.094 4.18 2.784 3.77 2.577

t-test df 133 135 132 135 125 124

Sig. .430 .971 .530 .606 .111 .842

Note: PA – physical activity; min – minutes; wk – week; hrs – hours; serv – servings Std. – Standard deviation; df – difference; sig – significance

Table 2. Mean, standard deviation and significance of PA, inactivity, and nutrition variables The correlations between the variables of PA, inactivity, and nutrition behavior of T1 are represented in Table 3 and Table 4 shows the same correlations for T2. Regarding T1: there is a small correlation between strenuous PA and fruit consumption (r= .256**), between mild

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PA and inactivity (r= .181*), between mild PA and fruit consumption (r= .229*) and also between mild PA and vegetable consumption (r= .248*). A medium correlation could be found between strenuous and mild PA (r= .366**), between moderate and mild PA (r= .419**), between moderate PA and fruit consumption (r= .370**), between vegetable consumption and strenuous PA (r= .337**) and moderate PA (r= .379**). Large relationships between strenuous and moderate PA (r= .558**) and between fruit and vegetable consumption (r= .624**) were found.

Pearson’s correlation

Strenuous Moderate Mild PA Inactivity Fruit Vegetable PA PA (min/wk T1) (hrs/day T1) (serv/day T1)(serv/day T1) (min/wk T1) (min/wk T1)

Strenuous PA (min/wk T1) Moderate PA (min/wk T1) Mild PA (min/wk T1) Inactivity (hrs/day T1) Fruit (serv/day T1) Vegetable (serv/day T1)

.558**

.366**

-.003

.256**

.337**

.419**

.084

.370**

.379**

.181*

.229*

.248*

.069

.008 .624**

**. Correlation is significant at the 0.01 level (2-tailed) *. Correlation is significant at the 0.05 level (2-tailed) Note: PA – physical activity, min – minutes, wk – week, hrs – hours, serv – servings

Table 3. Correlation between PA, inactivity, and nutrition variables of T1

Pearson’s Strenuous PA Moderate PA Mild PA Inactivity Fruit Vegetable Correlation (min/wk T2) (min/wk T2) (min/wk T2) (hrs/day T2) (serv/day T2) (serv/day T2) Strenuous PA (min/wk T2) Moderate PA (min/wk T2) Mild PA (min/wk T2) Inactivity (hrs/day T2) Fruit (serv/day T2) Vegetable (serv/day T2)

.304** .

.274**

-.081

.288**

.163

.520**

-.044

.020

.006

.043

.052

.054

.062

-.129

**. Correlation is significant at the 0.01 level (2-tailed) *. Correlation is significant at the 0.05 level (2-tailed) Note: PA – physical activity, min – minutes, wk – week, hrs – hours, serv - servings

Table 4. Correlation between PA, inactivity, and nutrition variables of T2

.538**

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Regarding T2: there is a small relationship between mild and strenuous PA (r= .274**), between strenuous PA and fruit consumption (r= .288**). A medium correlation is evidenced for strenuous and moderate PA (r= .304**). A large relationship was found between moderate and mild PA (r= .520**) and between fruit and vegetable consumption (r= .538**).

Moderate Strenuous Mild PA Inactivity Fruit Vegetable PA PA (min/wk T2) (hrs/day T2) (serv/day T2) (serv/day T2) (min/wk T2 ) (min/wk T2) (r2= .112) Independent (r2= .156) (r2= .263) (r2= .180) (r2= .174) (r2=.104) Dependent

Strenuous PA (min/wk T1) Moderate PA (min/wk T1) Mild PA (min/wk T1) Inactivity (hrs/day T1) Fruit (serv/day T1) Vegetable (serv/day T1)

.186 .081 .226 .062 -.055 .569 -1.035 .777 3.371 .505 -4.574 .403

.298 .002 .017 .879 .168 .057 -3.884 .250 2.794 .543 -11.346 .022

-.015 .894 .238 .062 .189 .070 1.765 .655 1.394 .794 -.976 .865

.000 .921 -.004 .108 .002 .393 .312 .000 .168 .139 -.182 .133

.000 .823 -.004 .107 .001 .629 .050 .483 .611 .000 -.235 .027

.003 .179 -.004 .100 .000 .953 .083 .244 .056 .576 .336 .002

Note: PA – physical activity, min – minutes, wk – week, hrs – hours, serv - servings

Table 5. Linear Regression of PA, inactivity, and nutrition variables (unstandardized Coefficient B, significance) The outcomes of the linear regression analyses (see Table 5) show that there is no significant (p> .05) relationship of T2 strenuous PA and of T2 mild PA with all the T1 predictors. However, T2 strenuous PA is marginally (p≤ .10) significant with T1 strenuous PA and T1 moderate PA. T2 mild PA is also marginally (p≤ .10) significant with T1 moderate PA and T1 mild PA. There is a significant (p≤ .05) relationship between T2 moderate PA and T1 strenuous PA (unstandardized coefficient B= .298) and marginally with T1 mild PA (unstandardized coefficient B= .168). Also, a significant negative relationship was found between T2 moderate PA and T1 vegetables (unstandardized coefficient B= -11.346). For T2 fruit consumption there is a significant negative relationship with T1 vegetable consumption (unstandardized Coefficient B= -.235). T2 vegetable consumption and inactivity are only significant predictors of themselves at T1.

4. Discussion The purpose of the current study was to compare PA, inactivity, nutrition behaviors, and their influence on each other in children to determine if there are compensation or transfer effects between the different domains of behavior. According to the Compensatory Health Belief Model, individuals can compensate their risk behavior by performing another health behavior (Knauper et al. 2004).The opposite effect occurs when individuals transfer their knowledge and experiences from one behavior change to another (Barnett and Ceci 2002).

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The results of the cross-sectional analyses show that PA behavior relates to itself and it relates to fruit and vegetable consumption. Students that are strenuously active are more likely to be moderately active. This may be because they warm-up with a moderate intensity activity. Students that are mildly active are also moderately active but are less strenuously active. Regarding the relationship between PA and nutrition behavior, the outcomes of T1 show a strong relationship between moderate PA and fruit and vegetable consumption. Also, strenuous PA is related to fruit and vegetable consumption. The results support a transfer effect because very active children are also more likely to eat more fruits and vegetables. Regarding the relationship between PA and fruit and vegetable consumption of T2, there is only a small correlation between strenuous PA and fruit consumption. This result also points to a transfer effect. The longitudinal results are weaker: they confirm the transfer effect within PA intensities but not for the transfer to fruit and vegetable consumption. Cross-sectional and longitudinal analysis shows an independence of the inactivity variable both from PA and from the nutrition variables. Similarly, Anderson et al. (1998) and Nigg et al. (2002) did not find any meaningful relationship between TV watching and PA. Olivares et al. found no association between nutritional status and television viewing (Olivares et al. 2004). However, studies have shown that TV viewing may contribute to a decline in fruit and vegetable consumption among adolescents. Boynton-Jarrett et al. (2003) documented that the fruit and vegetable consumption was negatively associated with hours of TV viewing. Their prospective analyses indicated that both baseline television viewing and change in television viewing independently predicted a reduction in fruit and vegetable consumption. Cross-sectional and longitudinal results of fruit and vegetable consumption show an expected transfer effect within fruits and vegetables as both variables represent eating behaviors. There is also cross-sectional indication of transfer effects between fruit and vegetable consumption and PA; however, this was not confirmed by the longitudinal analysis. There were no predictive relationships with PA or inactivity. As expected, the relationship is weaker over time as people change their behavior. The longitudinal results also show a negative prediction of fruits by vegetables. This negative relationship between the two nutrition variables has statistical reasons and points to a suppression effect. A statistical suppression means that instead of the drop that we would see from the direct effect of the same behavior on the outcome when vegetable variable is introduced, the opposite happens. The testing of suppression should be evidenced on a priori assumptions about the theoretical relation between the variables and the role of the second predictor variable as a suppressor. 4.1 Limitations There are some limitations that need to be considered when interpreting the outcomes of this study. First, data was collected by self-report only and thus, the outcomes could possibly be influenced by social desirability. Second, the survey only included questions concerning PA of 10 minutes or more of continuous activity. Corbin and Pangrazi (1998) noted that children normally exercise in short bouts of activity rather than being constantly active. Third, the sample size (N= 137) did not allow for subgroup analysis (e.g., gender). With decreasing numbers the chance of random distortion of the results increases (Boes,

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Haensel and Schott 2000). Lastly, the large amount of students who did not provide data influenced the representativeness. However, as we were interested in variable relationship and not prevalence we do not deem this a serious limitation.

5. Conclusion In conclusion, there seems to be no compensation effect between PA, inactivity, and nutrition behavior in children. Inactivity does not seem to be related to PA or nutrition. However, there are important transfer effects between different PA intensities and between nutrition behaviors in children. These outcomes support growing evidence that multiple behavior interventions have the potential for a greater impact on public health than single behavior interventions. More research is needed to understand the mechanisms and moderations (e.g., gender) of the influence and relationship between PA, inactivity, and nutrition behavior. Finally, intervention research should investigate how to capitalize and promote the important transfer effects.

6. Acknowledgements This research was funded by the Hawaii Medical Service Association, an independent licensee of the Blue Cross and Blue Shield Association. We would like to thank the valuable contributions of: Marisa Yamashita, Jo Ann Chang, Richard Chung, Cynthia Ross, Paula Adams, Phoebe Hwang, Michele Hamada, and Jessica Westling; the private providers (Kama’aina Kids, YMCA, and the Hawaii State Department of Education) and the participating sites.

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9 U.S. Food Policy and Obesity 1Department

Julian M. Alston1, Abigail M. Okrent2 and Joanna C. Parks1

of Agricultural and Resource Economics, University of California, Davis, CA, 2USDA Economic Research Service, Washington, DC, USA

1. Introduction The obesity epidemic has been identified as the most critical public health issue facing the United States today, but it is not confined to the United States or even to high-income countries. It is a global phenomenon that reaches the entire spectrum of the income distribution, and particularly the poorest individuals within rich countries and the middleand high-income individuals in the poorest countries. Many policies have been proposed to counter obesity, and some of those proposed policies focus on altering the food system—to influence food consumption habits and thus nutrition and obesity by changing the choices available to consumers or by changing the incentives to choose. Indeed, some jurisdictions have already introduced policies restricting the sale of certain food items in schools and others have introduced taxes on certain caloric beverages. This chapter reviews what is known about the causal links between food policies and obesity and presents new evidence about the likely efficiency and effectiveness of particular proposed policies as remedies for obesity. We begin with a discussion of the economic rationale for government intervention in the economy to reduce the prevalence of obesity. While we note the ‘public health’ rationale and related arguments and instruments, our work is concerned with economic arguments and policies that work through the market for food. The economic rationale for obesity policy is based on the presence of externalities in health care (public and private) (e.g., Bhattchayra and Sood 2011; Finkelstein, Fiebelkorn, and Wang 2003; Finkelstein et al. 2009), and myopic preferences whereby individuals discount utility in distant future periods at a higher rate than in the near term (Cutler, Glaeser and Shapiro 2003; Freebairn 2010). We conclude that a basis for some such intervention exists, beyond paternalism, because some of the costs of one person’s obesity are borne by others through the public health-care system. The issue then, for economists, is what is the appropriate form of market intervention? Using food policies as obesity policy is an inherently ‘second-best’ approach because the economic distortion does not stem from a distortion in the price of food. For example, obese individuals may create a negative externality for non-obese individuals through health insurance because of pooling of heterogeneous risk groups. In this case, a ‘first-best’ solution may be to charge obese individuals greater health care premiums. However, it seems likely that many people would find such a solution unacceptable, making it politically infeasible. Hence, some current policies addressing rising obesity rates have targeted changing the inputs to obesity (i.e., food consumption and physical activity).

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The next major part of the chapter reviews and assesses evidence on the effects of current food policies that, according to some writers, have contributed to increasing or reducing obesity. Included in this set of policies are farm subsidies, agricultural research and development (R&D), public food and nutrition assistance programs, nutrition and health education programs, and regulations. We present evidence to show that farm subsidies have had negligible impacts on obesity (if anything, the net effect of farm support has been to increase the cost of food and thus reduce obesity), and that the Food Stamp Program (a large food assistance program), likewise, has had insignificant effects, on obesity rates. On the other hand, agricultural R&D has contributed to significant movements in the relative prices of food commodities and has most likely contributed to obesity while also yielding great benefits to society through reducing food costs for both rich and poor, thin and fat alike, and reducing pressure on natural resource stocks. In addition, we review a significant literature on the effects of nutrition labels on food for consumption in the home or away from home, the implications of changing nutrition education in schools, and the potential impacts of restrictions on what may be sold in schools. We present an up-to-date assessment of the main findings from this contemporary literature. The third main part of this chapter presents an assessment of the likely impacts and potential usefulness of a long list of policy instruments that have been proposed—or, in some cases, adopted—to reduce the prevalence and social costs of obesity. This assessment consists of a synthesis of results from the literature and our own work in the area. One set of policies to be considered are taxes on particular foods, farm commodities as ingredients of food (e.g., sugar), or nutrients (e.g., trans fats) that affect obesity. Such policies generally are found to have small effects on food consumption, obesity and overall nutrition and health; to be regressive; and to enhance government revenue but sometimes with large social welfare costs (e.g., Kuchler, Tegene, and Harris 2004; Chouinard et al. 2007). However, Okrent and Alston (2012) found that taxes on calories would be comparatively efficient as a means of reducing obesity, and would yield significant net social benefits. Some have proposed changes to food and nutrition programs, to limit the use of food stamps (SNAP benefits) to certain types of ‘healthy’ foods, but economic arguments suggest that such changes may introduce more problems than they would solve (Alston et al. 2009). Other policies have been suggested, including some directed to reducing food deserts (Ver Ploeg et al. 2009) and others to do with banning advertising of fast food or otherwise regulating the food industry. These policies are also discussed briefly. The chapter concludes with a brief synopsis of the main issues addressed and some central findings regarding the potential roles for food policy as obesity policy, which food policy instruments are potentially worthwhile, and how well they compare with other types of policies directed towards reducing obesity. Our presentation and evidence is centered on the United States, and specific to U.S. policies and institutions, but the general arguments and findings are more broadly applicable. 2. The rationale for government intervention to address obesity The existence of large social costs of obesity alone does not justify any response by the government (Philipson and Posner 1999; Philipson and Posner 2003; Cawley 2004). Economic justifications for policies aimed at reducing obesity could rest on the existence of externalities or other economic distortions that mean the costs of being obese are not all

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borne by the obese individual. For instance, heavier people take up more space and impose costs on others who have to share space with them in planes, trains, automobiles, and elevators. Absent appropriate pricing policies, these costs are shared without compensation. Perhaps more serious is the phenomenon of pooling health-care system costs, both through private insurance and through Medicare and Medicaid. However, such cost pooling alone might not involve significant distortions in behavior or in total costs of obesity, and therefore it might not justify intervention by the government on economic efficiency grounds. Bhattacharrya and Sood (2011) found that the extent of moral hazard in this context—whereby the fact that costs of obesity are pooled induces responses that result in greater social costs of obesity—is quite modest. Furthermore, Bhattacharya and Sood (2011) found that the incremental health-care costs associated with obesity are passed on to obese workers with employer-sponsored health insurance in the form of lower cash wages. If this is true, some other justification for intervention is required. Freebairn (2010) proposed two other sources of spillover effects of obesity that could be used to provide a public-goods argument to justify government intervention. First, some health-care costs are borne by government expenditure, and the use of general taxation measures to raise revenues to finance such expenditures entails deadweight losses (mainly from distortions in the labor market) such that the marginal social cost of government spending is likely to be in the range of $1.20 per dollar. Second, people who are obese are less productive than others, and have more days lost to illness, and consequently contribute less in income taxation to the total pool of government revenue available for spending on public goods. Parks, Alston, and Okrent (2011) estimated that a one pound per person increase in average adult body weight in the United States would add $749 million to annual U.S. public health expenditure. This is a lower bound estimate of the marginal social cost of the obesity externality. A different kind of public goods argument for intervention relates to the economics of information: the government could play a role in the provision of information about the health consequences of diet to the extent that the private sector does not have sufficient incentive to do so, or in the design of appropriate regulations over the labeling of products with respect to their nutritional characteristics. The appropriate place to draw the line in such roles is far from clear, given that the private sector has some incentive to provide information that consumers demand. To some extent at least, the arguments for government intervention related to obesity rest on paternalism—that individuals do not know what is best for them, or are unable for some reason or other to act in ways that are in their best interest, and that the state can help them make happier choices. To many people, the notion that the government could play a role in individual consumption choices—even with respect to the nutrition of infants and children—may be anathema. But this is a complex and difficult issue, an area of life in which many people are clearly unhappy with the ultimate cumulative and enduring consequences of their individual consumption choices, presumably made freely and willingly. The psychological and the biophysical linkages between food consumption, other behavior, and obesity are complicated and dynamic, and not fully understood. To some extent, a propensity for obesity can be inherited genetically. But also, as with addictive substances like nicotine and alcohol, a propensity for obesity can be acquired through experience, beginning in infancy, or even in the womb. Such dynamic complexities, in which the daily

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choices made by parents can have lifelong implications for the opportunities faced by their children, are not confined to obesity; and, like other elements of child health and education, this aspect of the obesity problem may be seen by some people as a justification for policy intervention. Obesity policy is easily justified if the policy results in a Pareto improvement in societal well-being, i.e., if the policy makes some people better off and leaves everyone at least as well off as they were before the implementation of the policy. A less stringent criterion is the Kaldor-Hicks criterion, of a potential Pareto improvement: a case where some people are made worse off by a policy change but the beneficiaries could afford to compensate the losers and still be better off. It is referred to as a potential Pareto improvement in that the compensation need not take place. This criterion for a net national benefit from a policy change is implicit in most economic discussions. Policies that effectively reduce the rate of obesity in the population would improve the health of the individuals who lose weight, benefiting them directly, and at the same time would reduce the external costs they impose on others. Such obesity policy is worthwhile, according to the Kaldor-Hicks criterion, so long as the societal benefits outweigh the costs (Deaton 2002; Just, Hueth, and Schmitz 2004, p. 32). An alternative rationale for government intervention is the ‘public health’ rationale: health is a public good and the mission of public health is “fulfilling society’s interest in assuring conditions in which people can be healthy” (Institute of Medicine 1988). The philosophy of social justice forms the foundation of the public health mission, that is, the public health system aims to overcome the societal barriers that prevent the equal distribution of health burdens and benefits across the population (Turnock 2004). Public health tools include the “Let’s Move” campaign, increased monitoring of obesity prevalence, and stricter school food regulations. Given that low-income individuals in the United States experience more extreme obesity (BMI > 35) than higher-income individuals, and that some of this disparity may be attributable to the societal conditions associated with living in poverty (e.g., lack of health insurance and access to fresh fruits and vegetables), there is a social justice or public health argument for public policy to reduce obesity (Jolliffe 2010).1 While we acknowledge this alternative rationale for policy, in this chapter we focus on policies that operate through markets for food, for which the relevant rationale must be an economic one. 3. Effects of past and current food policies on obesity The increased prevalence of obesity in the United States has been attributed to past and current policies directed at both producers and consumers of food. Policies directed at improving the welfare of farmers (i.e., farm subsidies and investment in agricultural R&D) and low-income families (i.e., food and nutrition assistance programs) may have inadvertently contributed to increased consumption of food, calories and body weight. In addition, policies directed at providing better health and nutrition information (including food labels) to consumers so as to help them make better-informed consumption decisions, may have been ineffective. This section examines the literature on the effects of past and current food policies on obesity, with an emphasis on U.S. policies. 1 In the United States the most common definition of low-income is an individual or household that has an income at or below 130 percent of the federal poverty line.

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3.1 Farm subsidies The United States has a long history of agricultural policy and many commentators— including prominent economists, nutritionists, journalists, and politicians—have claimed that American farm subsidies have contributed significantly to the ‘obesity epidemic.’ They argue that farm subsidies have made fattening foods relatively cheap and abundant, and that reducing these subsidies will go a long way towards solving the problem. These commentators often treat the point as self-evident, and do not present details on the mechanism by which farm subsidies are supposed to affect obesity, nor evidence about the size of the likely impact. In particular, Pollan (2003, 2007) has claimed that subsidies on commodities such as corn and wheat have led to lower prices of high-calorie, processed foods. As proof of this effect, Pollan has pointed to the correlation between increased subsidies to corn farmers and rising obesity rates in the United States between 1970 and 2005. Likewise, Nestle (2002), Tillotson (2004), Muller, Schoonover and Wallinga (2007), Ludwig and Pollak (2009) and Popkin (2010) have attributed the growth in U.S. obesity rates to agricultural policies, and advocated a reorientation of government spending away from corn and wheat to fruits, vegetables and whole grains. Farm commodity programs can affect the rate of obesity by changing the relative prices of food commodities and thus retail foods, and hence, the composition of food consumption. However, several studies have demonstrated that the magnitude of this effect in the United States is likely to have been small and ambiguous (Alston, Sumner, and Vosti 2006; Alston, Sumner, and Vosti 2008; Beghin and Jensen 2008; Miller and Coble 2007; Rickard, Okrent, and Alston 2011; Schmidhuber 2004; Senauer and Gemma 2006). This finding has several elements. It is true that farm subsidies have resulted in lower U.S. prices of some commodities such as food and feed grains, and consequently, lower costs of producing cereals and bakery products and meats. However, the price-depressing effects of subsidies has been contained (or even reversed) by the imposition of additional policies like acreage set-asides that restrict production. In addition, since 1996, about half of the total subsidy payments have become decoupled from production and based on historical rather than current acreage and yields (Alston, Sumner and Vosti 2008; Sumner 2005; Beghin and Jensen 2008). Reflecting these facts about the policies, complete elimination of U.S. commodity subsidies would have minimal effect on corn, wheat or rice production and hence prices: 9–10 percent decrease in price of corn, 4–6 percent decrease in price of rice and 6–8 percent decrease in price of rice (Sumner 2005). Conversely, some farm commodity programs have actually increased the prices of commodities. Trade barriers on sugar, dairy and orange juice have increased the cost of these commodities to U.S. buyers and the U.S. food industry. The combination of subsidies for some commodities and trade barriers for others makes the story complicated at times. A case in point is the market for caloric sweeteners. Corn is often the target of criticism as a contributor to obesity, especially because of its use to make high fructose corn syrup (HFCS), which is used as a caloric sweetener in many foods and beverages. The use of HFCS as a sweetener has been encouraged by U.S. sugar policy that made sugar much more expensive and gave food manufacturers an economic incentive to substitute HFCS for sugar. So, farm subsidies are responsible for the growth in the use of corn to produce HFCS as a caloric sweetener, but not in the way that is often suggested. The culprit here is not corn

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subsidies; rather, it is sugar policy that has restricted imports, driven up the U.S. price of sugar, and encouraged the replacement of sugar with alternative caloric sweeteners. Combining the sugar policy with the corn policy, the net effect of farm subsidies has been to increase the price of caloric sweeteners generally, and to discourage total consumption while causing a shift within the category between sugar and HFCS. In this context, the subsidy policies effectively increase the overall price of caloric sweeteners; removing policies applied to sweeteners would lead to an overall increase in consumption of sweeteners (Alston, Rickard, and Okrent 2010). 3.2 Agricultural R&D Other agricultural policies may have had more significant effects on obesity. Alston, Sumner and Vosti (2006, 2008) suggested that productivity gains resulting from agricultural research and development (R&D) have been much more important than commodity subsidies as a determinant of food prices. In real terms agricultural commodity prices trended down significantly during the past 50 years, reflecting growth in supply of agricultural products outstripping growth in demand that was fueled by increases in population and per capita incomes. Alston, Beddow and Pardey (2009) attributed these trends in prices primarily to growth in farm productivity, which they ascribed primarily to public and private investments in agricultural R&D. Likewise, Miller and Coble (2007, 2008) estimated that increases in total factor productivity contributed more to lowering prices of retail food products, and thus, the portion of income spent on food, than did subsidies to farmers in the United States and across OECD countries. Beghin and Jensen (2008) also attributed substantial declines in the price of corn, and hence, HFCS and food products that use HFCS to technical change rather than subsidies. 3.3 Public food and nutrition programs Several studies have investigated the effects of participation in Food and Nutrition Programs (FANPs) on obesity (e.g., see Ver Ploeg, Mancino, and Lin 2007). This section emphasizes the three main programs: the Food Stamp Program (FSP), which in 2008 was revised and renamed the Supplemental Nutrition Assistance Program (SNAP); the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); and the National School Lunch Program (NSLP).2 The FSP has been much studied, with much of the research based on analysis of data from large national surveys, and mainly concerning impacts on household food expenditures, household nutrient availability, and individual dietary intakes. The research suggests that, participation in the FSP increases household availability of energy and protein and perhaps some vitamins and minerals. Less evidence is available about the impacts on individuals’ dietary intakes. Fox, Hamilton, and Lin (2004a, b) concluded that results were mixed and 2 While the FSP (or SNAP), WIC, and NSLP are by far the largest and most widely available FANPs, other FANPs are important for different subsets of the population. For example, the School Breakfast Program (SBP) serves about 10.6 million children per day, compared to the NSLP’s 31.3 million. The Child and Adult Care Food Program (CACFP) serves about 1,831.1 million meals a year to children in day care, and 64.2 million meals a year to adults, with about 3.3 million participants a day receiving a meal. Together, the SBP and the CACFP cost $5.1 billion per year, compared with $10 billion for the NSLP in 2009. The other seven smaller programs together cost only $1.2 billion annually.

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collectively inconclusive concerning impacts of the FSP on several other nutrition- and health-related outcomes (such as birth weight, height, weight, nutritional biochemistries, and general measures of health status). Although the findings are mixed, the balance of the evidence (weighing those studies that have done a better job of addressing the perennial econometric challenges) indicates that women who participate in the FSP are more likely to be obese, with estimated probabilities ranging from 6 to 9 percent (Gibson 2003; Chen, Yen and Eastwood 2005; Meyerhoefer and Pylypchuk 2008). However recent work by Fan (2010) found no effect of long- or short-run FSP participation by women on obesity once preparticipation weight and other socio-economic and demographic factors were taken into account. More-recent research by Parks (2011) demonstrated that low-income women who participated in the FSP at some point in the previous year did not gain significantly more weight over the past year then eligible women who did not participate. Studies of the impact of WIC have emphasized impacts on health-and nutrition-related outcomes of participants, which is the primary goal of WIC, unlike the other FANPs. Among others, obesity and abnormal gestational weight gain are both considered nutritional risk factors that qualify women for participation in WIC. The available evidence suggests that WIC participation increases the intakes by pregnant women of most of the target nutrients; less clear is whether it has led to a greater prevalence of adequate intakes, and little evidence is available on whether the dietary intakes of WIC participants are more-closely aligned with the Dietary Guidelines for Americans. Likewise, very little compelling evidence is available on the impacts of WIC on dietary intakes of participating children or on their nutrition and health characteristics. However, a range of evidence indicates that WIC has had significant impacts on dietary intake of infants, including particular nutrients that are largely associated with the consumption of cow’s milk versus formula and the introduction of solid foods. In particular, WIC has significantly reduced the prevalence of anemia among low-income American children. Children from households with WIC participants also tended to have better general health status, more so for the lowest-income children, and a higher probability of having up-to-date immunizations. Some writers have suggested that the NSLP and other school meals programs may have contributed to rising rates for obesity among school children.3 Ralston, Newman, Clauson, Guthrie and Buzby (2008) provided a comprehensive discussion of the NSLP, including historical trends, participant characteristics, and challenges facing administrators of the program, including tradeoffs between nutritional quality of foods served, costs, and participation—which they refer to as a school meals ‘trilemma’—as well as between program access and program integrity. The authors reported that program participation has had little if any measurable impact on caloric intake or obesity; that participants derive important nutritional benefits from participating in the program, including higher intake of key nutrients and under-consumed foods and lower intake of sweets, but also have high intakes of fat and sodium. A significant part of the problem of nutritional quality is associated with costs. Many schools depend on revenues from ‘competitive foods,’ even though such foods have been found to contribute to overconsumption of calories, increased plate waste of nutritionally balanced NSLP lunches, and decreased intakes of nutrients by students. 3 Other factors contributing to obesity related to eating at school include the availability of dispensers for candy, sodas, or fast foods, and the proximity of fast-food restaurants.

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3.4 Nutrition and health education (including food labels) Consumers make decisions on what foods to purchase based on information on prices and attributes of foods (e.g., convenience, healthiness, and so on). If individuals do not have a clear understanding of the health attributes of foods and how foods affect body weight, or they are unaware of the connection between obesity and higher risks of chronic illnesses, then individuals may be inadvertently choosing foods that cause their weight to deviate from the medically ideal body weight. Two types of information on diet and nutrition are relevant: (i) information on the negative health aspects of obesity, and (ii) information on how food consumption translates into personal weight gain or loss. In the United States, studies find that many individuals do not have a clear understanding of the diet-disease connection. Some evidence shows that increases in individual diet-disease knowledge significantly decrease the probability that an individual is obese and suggests that new policies to increase diet-disease health knowledge should lead to decreases in the incidence of obesity (Nayga 2000; Falba and Busch 2005). For example, Nayga (2000) estimated that complete acquisition of diet-disease knowledge could reduce the likelihood of an individual being obese to roughly 20%. This estimate of the impact of information is large and most likely overstated because of endogeneity between diet-disease knowledge and BMI: individuals who are more knowledgeable about the connection between diet and risk of disease are more likely to be those who have made weight management a priority for reasons that are unobserved, and not controlled for in estimation. The second type of information concerns individual understanding of the translation from current food consumption into future weight outcomes. Nutritional labeling increases the ability of an individual to predict the effect of food consumption on future weight. In the United States, many studies that examine the effect of nutritional labels on grocery store purchases utilize variation between 1992 and 1999, before and after the passage of the National Labeling and Education Act (NLEA). Labels existed before the NLEA under the voluntary labeling rules established by the Food and Drug Administration (FDA) in 1975, but they were not on all packaged foods and were not standardized. Mojduszka and Caswell (2000) examined labeling information on packages in 33 food product categories and concluded that incentives for voluntary disclosure of nutritional content by food processing firms prior to the NLEA did not generally result in reliable and consistent nutrition information being made available to consumers. Mathios (2000) found that prior to the NLEA, all low-fat salad dressings had a nutrition label, while the majority of higher-fat dressings did not, and sales for those with the highest fat levels declined significantly after the NLEA. Variyam and Cawley (2007) compared the change in body weight, after the implementation of NLEA, among those who use labels when food shopping to that among those who do not use labels. They found that non-Hispanic white women benefited the most from nutritional labeling, with an estimated 3.36 percent reduction in obesity associated with label use, whereas the new labels had no effect on the body weight of white men and black women and were actually associated with an increase in the body weight of black men. Variyam (2005) noted that the NLEA exempts much of the food consumed at restaurants from mandatory labeling regulations. Because consumers are less likely to be aware of the ingredients and nutrient content of restaurant foods than of foods prepared at home, public health advocates have called for mandatory nutrition labeling for major sources of these foods, such as fast-food restaurants and chain restaurants. Recent studies have begun to examine the effect of mandatory calorie postings on restaurant menus in New York City. Downs et al.

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(2009) utilized receipts collected from patrons outside two burger restaurants and a coffee shop in New York City before and after the mandate, and found little evidence of any effect of calorie postings on consumption. Elbel et al. (2009) also utilized receipts collected from patrons outside 14 chain restaurants in New York City and five chain restaurants in Newark, New Jersey. Similar to Downs, Loewenstein and Wisdom (2009) they found little evidence to suggest that the labels had any effect on consumption. However, Bollinger, Leslie and Sorensen (2010) found that mandatory calorie posting influenced consumer behavior at Starbucks, resulting in a 6% decrease in the average calories per transaction (down from 247 to 232 calories per transaction). Almost all of the observed effect was related to food purchases, where average food calories per transaction fell by 14%. Interestingly, they also found that calorie postings did not result in any statistically significant change in Starbucks’ total revenue. 3.5 Regulation The majority of evidence indicates that unregulated food marketing to children has contributed to the obesity problem. Concern has been expressed about the consequences of marketing food and other goods to children since the 1970s, but no progress has been made in establishing regulations that the government would enforce. Rather, the United States has relied on the food industry to regulate itself (Wilde 2009). Children under the age of approximately 8 (and possibly as old as 11) are especially vulnerable to food advertising because they cannot distinguish the content in a television program from the content in a commercial, or comprehend that the purpose of an advertisement is to persuade. The research summarized by the American Academy of Pediatrics (2006) and the Institute of Medicine (IOM)(2005) showed that television advertising—which only accounts for a fraction of the total advertising children are exposed to—strongly affects food preferences, short-term consumption (versus ‘usual dietary intake’), and purchase requests in 2–11 year olds. Some evidence suggests that advertising affects beliefs about foods and beverages and usual dietary intakes among children 2–11 and 2–5 years of age, respectively (American Academy of Pediatrics 2006; IOM 2005)4. In 2005, the IOM called on the U.S. food industry to self-regulate and reduce the prominence of energy-dense and nutrient-poor foods in advertisements aimed at children. However, the IOM also noted that, if self-regulation failed to achieve this goal, Congress should step in and enact policy that would mandate the changes in marketing to children (Institute of Medicine 2005; Wilde 2009). 4. Proposed and potential food policies Rising (or just high) rates of obesity, especially among children, have attracted the attention of governments worldwide. The issue is significant in the United States. Food and nutrition policy that was once devoted to issues of food security and inadequate nutrition must now confront the modern malnutrition paradox: poor people having poor dietary quality and food insecurity while at the same time experiencing the health consequences of overeating and sedentary lifestyles. Many proposals for policies to address this situation have been Usual dietary intake refers to the long-term dietary intake patterns of an individual, i.e., the average daily intakes of different dietary components over a year. Short-term consumption refers to consumption during a specific time frame following a particular stimulus or event, e.g., the number of potato chips and apple slices consumed after exposure to a potato chip advertisement (IOM 2005).

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suggested, including changes to existing food and nutrition programs, as well as other policies that also work through changing the effective prices or availability of food generally, or particular foods. Some such policies have already been introduced in some places (e.g., 35 states had a sales tax on soda in 2011).5 4.1 Food taxes and subsidies Economists have modeled and measured the potential impacts of various taxes and subsidies as instruments for reducing obesity. Some studies suggest that taxation or subsidization of certain foods would be effective as means of reducing average body weight in the United States and in other developed countries (Smith, Lin, and Lee 2010; O’Donoghue and Rabin 2006; Cash, Sunding, and Zilberman 2005; Sacks et al. 2011). A tax on a class of foods that are energy dense and deemed ‘unhealthy’ (e.g., soda and chips) would make ‘unhealthy’ foods more expensive relative to ‘healthy’ foods such that consumers would substitute away from consumption of ‘unhealthy’ foods and into consumption of ‘healthy’ foods. Others have argued that such pricing policies would have little effect on food consumption, and hence obesity and may also be regressive (Schroeter, Lusk, and Tyner 2007; Kuchler, Tegene and Harris 2004; Gelbach, Klick, and Strattman 2007; Allais, Bertail, and Nichèle 2010). It has also been suggested that even if a tax on a particular food is ineffective at reducing consumption of ‘unhealthy’ foods, the tax revenues that are generated from the tax could be used to fund public information programs and other obesity-reducing strategies (Jacobson and Brownell 2000; Kuchler, Tegene, and Harris 2005; Brownell and Frieden 2009). An alternative to taxing a particular ‘unhealthy’ food is subsidizing a food deemed to be ‘healthy.’ Many nutritionists recommend eating more fruits and vegetables as a weightcontrol strategy because fruits and vegetables are low-calorie, high-fiber foods that have been found to be more filling and satisfying than low-fiber foods (Tohill 2004). Guthrie (2004) and Lin and Guthrie (2007) argued that policies that make retail fruits and vegetables products cheaper would help reduce obesity by causing consumers to substitute away from more energy-dense foods. Evidence in support of this argument is mixed. While fruit and vegetable subsidies may cause individuals to consume more healthfully, they may also consume more calories not only from fruits and vegetables, but from goods that are complements to fruits and vegetables (Okrent and Alston 2012). Rather than taxing a food group or product, a tax on a nutrient (i.e., total fat or saturated fat), on an ingredient (e.g. added-sugars), or on the energy content of a food could be used to address obesity. Chouinard et al. (2007) estimated that taxing the fat content of dairy products by 10 percent in the United States would decrease fat consumption but would lead to a reduction in weight by less than one pound per person per year, holding all other determinants of weight constant. They also found that the consumer welfare losses from the fat tax on dairy products would be slightly more than the revenue generated (–$4.48 billion versus $4.45 billion) and the tax would be highly regressive. Miao, Beghin and Jensen (2010) reported similar findings for taxing the sugar content of foods. Okrent and Alston (2012) developed a model of the U.S. farm and food industry expressly designed for analyzing such questions. Key findings from this work are in keeping with Information on soda taxes is taken from the Bridging the Gap Program at the University of Illinois at Chicago; available at: http://www.impacteen.org/obesitystatedata.htm#01. 5

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economic intuition. Given that obesity is caused by an energy imbalance—an excess of calories consumed over calories expended—a tax on food according to its caloric content is likely to be a relatively efficient instrument (having the lowest total social cost per unit of impact on obesity). Taxes applied to particular nutrients (e.g., taxes on food products based on their sugar content or fat content) are likely to be less efficient than a tax on calories; taxes on particular foods (e.g., caloric beverages or sodas) are likely to be even less efficient. Many such instruments are likely also to be regressive, in the sense that the burden will be borne disproportionately by the poor. Economic tools like ‘fat taxes’ and ‘thin subsidies’ could be used both to influence consumption habits and raise revenue to offset excessive medical public medical expenditures engendered by obesity. Small taxes and subsidies have been found to have little effect on the consumption of categories of foods deemed ‘unhealthy’ and the overall caloric content of foods. Even if such taxes or subsidies were enacted, at what level of the food processing chain should they be applied? Would a subsidy for research and development into farm production of fruits and vegetables lower the price of those commodities and thereby encourage substitution from unhealthy foods to ‘healthy’ foods? Or would a tax on fast food be more effective? 4.2 Changes to farm subsidies or the emphasis of agricultural R&D Many people blame federal farm subsidies for the current obesity problems (e.g., Pollan 2003, 2007, 2008). It may seem obvious that subsidies must make certain foods cheaper, therefore contributing to overconsumption, but U.S. farm policies have had generally modest and mixed effects on prices and quantities of farm commodities. The overall effect on the prices paid by U.S. consumers for food has been negligible and, consequently, eliminating farm policies would have a tiny influence on dietary patterns and obesity (Alston, Sumner and Vosti 2008; Miller and Coble 2008; Alston, Rickard and Okrent 2010; Rickard, Okrent, and Alston 2012). U.S. farm policies might well be seen as unfair and inefficient. But whether we like these policies or not for other reasons, their effects on obesity are negligible. In fact, eliminating all farm subsidies, including those provided indirectly by trade barriers, may, if anything, lead to an increase in annual per capita consumption of calories and an increase in body weight.6 In contrast, agricultural R&D has had substantial impact on the abundance and relative prices of farm food commodities. Since 1949, the overall price of farm commodities in the United States has fallen by over 60 percent relative to the GDP deflator. This decline in the real prices of food commodities is attributable largely to agricultural productivity growth, mostly due to agricultural R&D, a significant share of which was funded (and in some cases performed) by the U.S. government, mainly through the USDA. If cheap and abundant food has contributed to obesity, then R&D from the USDA is partly to blame. Does this mean the USDA should have done less research or different research? The evidence from studies of 6 Similar results have been found for the case of sugar policy in the European Union. The EU uses a combination of price floors, import duties, export subsidies and quotas to support domestic sugar farmers. The elimination of these policies would reduce the price of sugar by 36% over a 4-year period. Bonnet and Requillart (2010) found that this 36% reduction in price in France would increase consumption of regular soft drinks by 1 liter per year per person and the consumption of added sugar by 124 grams per person per year. See, also, Schmidhuber (2004).

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the returns to research indicates that the United States has persistently underinvested in agricultural R&D. Marginal benefit-cost ratios in the range of 20:1 and higher indicate that the extent of the underinvestment has been significant (e.g., see Alston, Andersen, James, and Pardey 2010). These measures did not account for the contributions of agricultural R&D to the social cost of obesity, but it does not seem likely that taking those costs into account would change the picture appreciably. Nor does it seem likely that taking the impacts on costs of obesity into account would imply a significant change in the emphasis of the national benefitmaximizing research portfolio, to increase the share of funding going to research on specialty crops (e.g., see Alston and Pardey 2008). It is likely that better-targeted instruments can be found for reducing social costs of obesity, rather than reducing support for agricultural R&D generally (which is already underfunded) or sharply changing the mix to reduce research on commodities such as livestock and grains in favor of ‘healthy’ foods like fruits and vegetables (a change that might substantially reduce the returns to the portfolio as a whole without much appreciable impact on obesity). But the precise terms of this tradeoff are not clear and further work is needed before we can make more-specific claims. 4.3 Changes to food and nutrition assistance programs With respect to both the FSP and the NSLP discussions have emphasized the role of the cost advantages of foods and ingredients that are relatively energy dense in highly budgetconstrained dietary choices. Revisions to the programs have been suggested with a view to disallowing certain types of foods. Meanwhile, the question remains somewhat open as to what is the size of the effect, if any, of program participation on obesity rates, what is the social cost of that effect, which should be charged against the programs, and what adjustments to the programs may be appropriate to reduce those costs and thereby enhance the efficiency of the programs. In light of the observation that many of the poor are also obese, it has been suggested that the FSP could be modified to encourage participants to eat healthier diets. This idea may have been encouraged by findings that the FSP may have contributed to obesity among participants, but does not rest on that possibility. Under the FSP, participants may redeem their coupons for almost any food items. Some have suggested changing the program to restrict food stamp purchases to exclude certain foods deemed to be ‘unhealthy,’ e.g., sugar sweetened beverages (Brownell and Frieden 2009; Brownell and Ludwig 2011). Economic analysis (e.g., Guthrie et al. 2007; Alston, Mullally, Sumner, Townsend and Vosti 2009) suggests such restrictions would be ineffective or counterproductive because they would (i) have no impact on food consumption choices by many participants, (ii) would discourage program participation by some others, (iii) if effective in changing consumption choices, would result in relative price changes that would have opposite effects on some groups, and (iv) would increase administrative costs of the program as the food industry would redesign foods to meet the criteria in the restrictions. Another proposal would give coupons greater purchasing power if applied to particular categories of foods (e.g., fresh fruits and vegetables) than others (see Guthrie et al. 2007). Such a modification may be more effective than restricting the list of items eligible for purchase with food stamps, though it would have some of the same drawbacks. Both of these ideas would use a single instrument, the FSP, to pursue two targets: (i) assuring adequate nutrition intakes in populations deemed at risk of under-nutrition (to be achieved by an expanded food budget constraint for the poor); and (ii) reducing the prevalence of

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obesity. Modifying the FSP to pursue the second objective would almost surely diminish its effectiveness in relation to the first.7 Moreover, the problem of obesity is not confined to food stamp participants, and other instruments will be necessary if the government means to address the broader problem. If such other instruments are applied more broadly, it may make less sense to modify the FSP as well. Congress regularly reauthorizes federal school meal and child nutrition programs. However, the Healthy, Hunger-Free Kids Act of 2010 includes several notable changes in child meal program nutritional standards, access, and funding, as well increased school accountability and monitoring for meal quality. The new legislation provides the largest increase in funding and reimbursement rates for the school lunch program in decades, makes it easier for qualified children to receive free school meals, extends after-school meals to more at-risk children, and provides additional technical assistance to local school food-service providers. The Healthy, Hunger-Free Kids Act will increase access by improving and simplifying application procedures and expanding universal eligibility in high-poverty neighborhoods. The legislation also allows for the elimination of soda and other junk foods from schools nationwide. The USDA Food and Nutrition Service proposed new Nutrition Standards for the NSLP and SBP in mid-January 2011.8 The recommended changes to NSLP and SBP nutrition standards include increased servings of fruits, vegetables, and whole grains, a ban on trans fat, and reduced sodium content, as well as, for the first time ever, a maximum allowable calorie content per meal (the nutrition standards already include a calorie minimum). The Healthy, Hunger-Free Kids Act also raises nutritional standards for childcare centers participating in the Child and Adult Care Food Program, and provides funding for training, technical assistance and tools to assist child-care providers in complying with new standards and promoting better nutrition wellness among young children. 4.4 Changes to nutrition and health education Several studies have found that differences in health knowledge account for some variation in current obesity rates and that the introduction of nutrition labels has been somewhat effective in changing the food consumption patterns of individuals. However, strategies aiming to improve the state of nutrition knowledge of individuals (e.g., nutrition education programs and food labelling regulations) have been relatively ineffective, and policymakers have suggested several changes. Since the 1990 enactment of NLEA, the FDA has required packaged foods to list the amounts of various nutrients per serving along with a definition of serving size. This requirement has had some effects on consumer purchasing behavior but the actual use of the labels is much less than what is typically reported, fewer consumers are using the labels than in the past, and labels often leave shoppers confused and misinformed (Cowburn and 7 Conversely, some would favor expanding the scope of the FSP to include among the eligible purchases food away from home, including fast food, at least for certain groups in society (such as homeless) as a way of better achieving its primary purpose of providing a food income safety net. Such a proposal was debated in the New York Times http://www.nytimes.com/roomfordebate/2011/09/27/expand-theuse-of-food-stamps?nl=todaysheadlines&emc=thab1 8 The complete list of proposed nutrition standards is available at: http://www.fns.usda.gov/cnd/governance/regulations/2011-01-13.pdf.

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Stockley 2005; Todd and Variyam 2008). New forms of food labeling, and front-of-the package nutrient postings have been cited as potential tools for improving the nutrition of the population (Nestle and Jacobson 2000). In particular, many developed countries have begun to investigate whether ‘traffic-light’ nutrition labels with symbols on packages that indicate high, medium or low levels of a few specific nutrients or energy will help consumers make more healthful food choices. The evidence of whether traffic-light labels work is mixed. First, most of the front-of-the-package labeling has been self-regulated by the food industry—the ‘Smart Choices’ program in the United States, the ‘Choices’ logo in the Netherlands, and the ‘Multiple Traffic Light’ in the United Kingdom. Roberto et al. (2011) found that 60 percent of the foods that had the ‘Smart Choices’ label did not meet standard nutritional criteria for a healthy food based on the Nutrient Profile Model (a non-industrydeveloped and validated national standard). Second, even though most of these programs have been found to help consumers identify which foods are healthy, very little evidence is available on whether the programs actually caused consumers to purchase healthier foods (Grunert and Wills 2007). Garson and Engelhard (2007) found that sales of foods in vending machines at the University of Virginia labeled with a red light (i.e., highest in fat and calories) decreased 5.3 percent, while those labeled with a yellow light or green light increased by 30.7 and 16.5 percent, respectively. Similarly, Vyth et al. (2010) found some support for the claim that the Choices logo motivated healthy food choices in the Netherlands. Alternatively, Sacks, Rayner and Swinburn (2009) found little evidence that the introduction of the Multiple Traffic Light labels in the United Kingdom on ready meals and sandwiches had any impact on the relative healthfulness of consumer purchases. Hence, even if the new labels clarify whether a food is healthy, it is not clear the consumers will be induced by the information to change behavior and eat less calories. The Healthy, Hunger-Free Kids Act establishes important reforms for the national food stamp nutrition education program (SNAP-Ed), expanding the program’s focus to include obesity prevention and allowing the use of community and public health approaches to improve the diets of low-income families with the Nutrition Education and Obesity Prevention Grant Program. The provision requires that nutrition education activities be evidence-based and focused on specific nutrition or health outcomes. It also requires that schools that participate in the NSLP or SBP implement a ‘school wellness plan,’ with physical activity and nutrition education goals, plus nutrition guidelines for foods available on campus, by the 2011-12 school year. 4.5 Food marketing regulations When parental supervision declines at home, children are left vulnerable to environmental stimuli that can affect consumption patterns. For example, food marketers target the youth demographic by advertising during periods of the day when children watch television, which could induce children to choose less-healthy, but heavily advertised foods. Rashad, Grossman and Chou (2005) explained that a brand’s advertising acts as a complementary good such that consumers derive more utility from consuming a more-advertised good. For example, a child may value the toys associated with commercials more than a toy that is not advertised. Their results show a strong positive effect of exposure to fast-food restaurant advertising on the BMI for children and adolescents; a complete ban on fast-food television advertising during children’s programming hours would reduce the number of overweight children and adolescents by 10 percent and 12 percent, respectively.

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The Omnibus Reconciliation Act of 2009 called on the Federal Trade Commission, the USDA, the Centers for Disease Control and Prevention (CDC), and the FDA to jointly create the Interagency Working Group on Food Marketed to Children (Working Group) and produce a set of standards for the advertising of foods to children and adolescents. In April 2011 the Working Group released for public comment a set of proposed industry guidelines for self-regulation. The Working Group proposed two main nutrition principles, labeled principles A and B, that foods marketed to children should meet, as well as a definition of “marketing targeted at children and adolescents.” Nutrition principle A indicates that food products marketed predominantly to children (ages 2–17) should “make a meaningful contribution to a healthful diet.” Nutrition principle B calls on the industry to develop and reformulate food products marketed predominantly to children and adolescents to minimize the proportion of nutrients that could have unwanted effects on body weight (e.g., added sugars, salt, and trans fats) or health of children. Lastly, the Working Group adopted the FTC definition of “marketing targeted at children and adolescents” (ages 2–17), and requested that the industry adhere to the Nutrition Principles in 20 different categories of targeted advertising and promotional activities including movies, video games, magazines, and specific websites based on the share of the audience represented by children (Interagency Working Group 2011). 5. Conclusion Government intervention in the food industry with the aim of reducing the incidence of obesity can be justified, economically, if obesity entails externalities and if the benefits from the intervention exceed the costs. Food policy is a second-best obesity policy, but some of the policies considered in this chapter could pass this benefit-cost test, given that first-best policies are not feasible. Various policies have been proposed that would counter obesity by making relatively unhealthy foods relatively expensive. Some of the policies that are commonly discussed would be ineffective or inefficient. These include (i) limiting food stamps to only healthy foods, (ii) taxing foods according to their fat or sugar content, (iii) taxing caloric beverages, (iv) eliminating farm subsidies, or (v) reducing funding for agricultural R&D. Most of these policies would be ineffective relative to the objective of reducing obesity, and may be counterproductive relative to the safety-net purpose in that almost any such policy is likely to be regressive, falling disproportionately heavily on the poor. All of these policies would be inefficient in the sense that other policies could be devised that would have the same benefit (in terms of impact on obesity) at lower social cost. A relatively efficient policy would be to tax foods according to their individual caloric content, but this policy too might not be very effective unless accompanied by other instruments directed towards other elements of this very complex social problem. A combination of incentives through tax and subsidy policies, selective regulation, and educational programs seems likely to be more efficient than taxes alone. And the design of such policies bears careful consideration and analysis. Discussions of obesity tax policies tend to emphasize the demand side—taking the food product choices as given, and focusing on the use of incentives for consumers to choose differently from among the given choices. But given the large and increasing role of prepared foods and food away from home, the supply side may offer greater scope for substitution away from energy-dense foods, through innovations in food processing and manufacturing. Hence, in designing any such policy it is desirable to have in mind the potential impact on the food industry, through incentives to

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innovate in manufacturing and produce and promote consumption of foods that are attractive to consumers while having socially desirable nutritional characteristics. Calorie taxes could be introduced based on economic efficiency alone, but they might be based partly on paternalism, which is a potentially dangerous policy path. On the other hand, FANPs themselves are paternalistic, and it seems perfectly reasonable to require that FANPs do not encourage the poor or their children to eat unhealthy foods. This argument implies a basis for adapting the programs that provide specific foods (such as WIC, NSLP, SBP) and eliminating junk foods from schools, as entailed under the Health, Hunger-Free Kids Act of 2010. It is less useful relative to the SNAP program given its generic purpose as a food safety net. 6. References Allais, O., Bertail, P. and Nichele, V. (2010). "The Effects of a Fat Tax on French Households’ Purchases: A Nutritional Approach." American Journal of Agricultural Economics 92(1): 228-245. Alston, J.M. (2009). "Efficiency of Income Transfers to Farmers through Public Agricultural Research—Theory and Evidence from the United States." American Journal of Agricultural Economics 91(5): 1281-1288. Alston, J.M., Andersen, M.A., James, J.S. and Pardey, P.G. (2010). Persistence Pays: U.S. Agricultural Productivity Growth and the Benefits from Public R&D Spending. New York: Springer. Alston, J.M., Beddow, J.M. and Pardey, P.G. (2009). "Mendel versus Malthus: Research, Productivity and Food Prices in the Long Run." Department of Applied Economics Staff Paper No. P09-1. St. Paul, MN, University of Minnesota. Alston, J.M., Mullally, C., Sumner, D.A., Townsend, M. and Vosti, S.A. (2009). "Likely Effects on Obesity from Proposed Changes to the U.S. Food Stamp Program." Food Policy 34: 176-184. Alston, J.M. and Pardey, P.G. (2008). "Public Funding for Research into Specialty Crops." HortScience 43(5): 1461-1470. Alston, J.M., Rickard, B.J. and Okrent, A.M. (2010). "Farm Policy and Obesity in the United States." Choices 3rd Quarter 2010. Alston, J.M., Sumner, D.A. and Vosti, S.A. (2006). "Are Agricultural Policies Making Us Fat? Likely Links Between Agricultural Policies and Human Nutrition and Obesity, and their Policy Implications." Review of Agricultural Economics 28(3): 313-322. Alston, J.M., Sumner, D.A. and Vosti, S.A. (2008). "Farm Subsidies and Obesity in the United States: National Evidence and International Comparisons." Food Policy 33(6): 470-479. American Academy of Pediatrics Committee on Communications (2006). "Children, Adolescents, and Advertising." Pediatrics 118(6): 2563-2569. Beghin, J. and Jensen, H. (2008). "Farm Policies and Added Sugars in US Diets." Food Policy 33: 480-488. Bhattacharya, J. and Sood, N. (2011). "Who Pays for Obesity?" Journal of Economic Perspectives 25(1): 139-158. Bollinger, B., Leslie, P. and Sorensen, A. (2010). "Calorie Posting in Chain Restaurants." NBER Working Paper Series No. 15648. National Bureau of Economic Research. Bonnet, C. and Requillart, V. (2011). "Does the EU Sugar Policy Reform Increase Added Sugar Consumption? Empirical Evidence on the Soft Drink Market." Health Economics 20(9): 1012-1024.

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Brownell, K.D. and Frieden, T. (2009). "Ounces of Prevention--The Public Policy Case for Taxes on Sugared Beverages." The New England Journal of Medicine 360(18): 1-4. Brownell, K.D. and Ludwig, D.S. (2011). "The Supplemental Nutrition Assistance Program, Soda, and USDA Policy: Who Benefits?" Journal of the American Medical Association 306(12): 1370-1371. Cash, S.B., Sunding, D.L. and Zilberman, D. (2005). "Fat Taxes and Thin Subsidies: Prices, Diet, and Health Outcomes." Acta Agriculturae Scandinavica Section C 2: 167-174. Cawley, J. (2004). "An Economic Framework for Understanding Physical Activity and Eating Behaviors." American Journal of Preventive Medicine 27(3S): 117-125. Chen, Z., Yen, S.T. and Eastwood, D.B. (2005). "Effects of Food Stamp Participation on Body Weight and Obesity." American Journal of Agricultural Economics 87(5): 1167-1173. Chouinard, H.H., Davis, D.E., LaFrance, J.T. and Perloff, J.M. (2007). "Fat Taxes: Big Money for Small Change." Forum for Health Economics & Policy 10(2). Cowburn, G. and Stockley, L. (2005). "Consumer Understanding and Use of Nutrition Labeling: A Systematic Review." Public Health Nutrition 8(1): 21-28. Cutler, D.M., Glaser, E.L., and Shapiro, J.M. (2003). "Why Have Americans Become More Obese?" Journal of Economic Perspectives 17(3): 93-117. Deaton, A. (2002). "Policy Implications of the Gradient of Health and Wealth." Health Affairs 21(2): 13-30. Downs, J.S., Lowenstein, G. and Wisdom, J. (2009). "The Psychology of Food Consumption: Strategies for Promoting Healthier Food Choices." American Economic Review: Papers and Proceedings 99(2): 159-164. Elbel, B., Kersh, R., Brescoll, V.L. and Dixon, L.B. (2009). "Calorie Labeling and Food Choices: A First Look at the Effects on Low-Income People in New York City." Health Affairs 28(6): w1110-w1121. Falba, T. and Busch, S. (2005). "Survival Expectations of the Obese: Is Excess Mortality Reflected in Perceptions?" Obesity Research 13(4): 754-761. Fan, M. (2010). "Do Food Stamps Contribute to Obesity in Low-Income Women? Evidence from the National Longitudinal Survey of Youth 1979." American Journal of Agricultural Economics 92(4): 1165-1180. Finkelstein, E.A., Fiebelkorn, I.C. and Wang, G. (2003). "National Medical Spending Attributable to Overweight and Obesity: How Much, and Who’s Paying?" Health Affairs W3: 219-226. Finkelstein, E.A., Trogdon, J.G., Cohen, J.W. and Dietz, W. (2009). "Annual Medical Spending Attributable to Obesity: Payer-and Service-Specific Estimates." Health Affairs 28(5): w822-w831. Fox, M.K., Hamilton, W. and Lin, B.-H. (2004). "Effects of Food Assistance and Nutrition Programs on Nutrition and Health: Volume 3 Literature Review." Food Assistance and Nutrition Research Report No. 19-3 Food and Rural Economics Division, Economic Research Service, U.S. Department of Agriculture. Fox, M.K., Hamilton, W. and Lin, B.-H. (2004). "Effects of Food Assistance and Nutrition Programs on Nutrition and Health: Volume 4, Executive Summary of the Literature Review." Food Assistance and Nutrition Research Report No. 19-4 Food and Rural Economics Division, Economic Research Service, U.S. Department of Agriculture. Freebairn, J. (2010). "Taxation and Obesity?" The Australian Economic Review 43(1): 54-62. Garson, A. and Engelhard, C.L. (2007). "Attacking Obesity: Lessons from Smoking." Journal of the American College of Cardiology 49(16): 1673-1675.

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Gelbach, J., Klick, J. and Stratmann, T. (2007). "Cheap Donuts and Expensive Broccoli: The Effect of Relative Prices on Obesity." FSU College of Law, Public Law Research Paper 261. Florida State University. Gibson, D. (2003). "Food Stamp Program Participation is Positively Related to Obesity in Low Income Women." Journal of Nutrition 133: 2225-2231. Grunert, K.G. and Wills, J.M. (2007). "A Review of European Research on Consumer Response to Nutrition Information on Food Labels." Journal of Public Health 15: 385-399. Guthrie, J.F. (2004). "Understanding Fruit and Vegetable Choices: Economic and Behavioral Influences." Agriculture Information Bulletin No. 792. U.S. Department of Agriculture Economic Research Service. Guthrie, J.F., Frazao, E., Andrews, M. and Smallwood, D. (2007). "Improving Food Choices - Can Food Stamps Do More?" Amber Waves 5(2): 22-28. Institute of Medicine (2002). The Future of The Public's Health in the 21st Century. Washington, D.C.: The National Academies Press. Institute of Medicine and The National Academy of Sciences (1988). The Future of Public Health. Washington, DC: National Academy Press. Institute of Medicine Committee on Food Marketing and the Diets of Children and Youth (2005). "Food Marketing to Children and Youth: Threat or Opportunity?" Washington, D.C., Institute of Medicine. Interagency Working Group on Food Marketed to Children (2011). "Preliminary Proposed Nutrition Principles to Guide Industry Self-Regulatory Efforts: Request for Comments." CDC, FTC, FDA, and USDA. Jacobson, M.F. and Brownell, K.D. (2000). "Small Taxes on Soft Drinks and Snack Foods to Promote Health." American Journal of Public Health 90(6): 854-857. Jolliffe, D. (2010). "Overweight and Poor? On the Relationship between Income and Body Mass Index." IZA Discussion Paper No. 5366 Bonn, Germany, Institute for the Study of Labor (IZA). Just, R.E., Hueth, D.L. and Schmitz, A. (2004). The Welfare Economics of Public Policy. Cheltenham, UK: Edward Elgar Publishing Limited. Kuchler, F., Tegene, A. and Harris, J.M. (2004). "Taxing Snack Foods: Manipulating Diet Quality or Financing Information Programs?" Review of Agricultural Economics 27(1): 4-20. Lin, B.-H. and Guthrie, J.F. (2007). "How Do Low-Income Households Respond to Food Prices." Economic Information Bulletin No. 29-5. U.S. Department of Agriculture Economic Research Service. Ludwig, D.S. and Pollack, H.A. (2009). "Obesity and the Economy: From Crisis to Opportunity." Journal of the American Medical Association 301(5): 533-535. Mathios, A.D. (2000). "The Impact of Mandatory Disclosure Laws on Product Choices: An Analysis of the Salad Dressing Market." Journal of Law and Economics 43: 651-677. Meyerhoefer, C.D. and Pylypchuk, Y. (2008). "Does Participation in the Food Stamp Program Increase the Prevalence of Obesity and Health Care Spending?" American Journal of Agricultural Economics 90(2): 287-305. Miao, Z., Beghin, J.C. and Jensen, H.H. (2010). "Taxing Sweets: Sweetener Input Tax or Final Consumption Tax?" Selected paper prepared for presentation at the Agricultural & Applied Economics Association 2010 AAEA, CAES & WAEA Joint Annual Meeting, Denver, Colorado, July 25-27, 2010. Miller, J.C. and Coble, K.H. (2007). "Cheap Food Policy: Fact or Rhetoric?" Food Policy 32: 98-111. Miller, J.C. and Coble, K.H. (2008). "An International Comparison of the Effect of Government Agricultural Support on Food Budget Shares." Journal of Agricultural and Applied Economics 40(2): 551-558.

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Mojduszka, E.M. and Caswell, J.A. (2000). "A Test of Nutritional Quality Signaling in Food Markets Prior to Implementation of Mandatory Labeling." American Journal of Agricultural Economics 82: 298-309. Muller, M., Schoonover, H. and Wallinga, D. (2007). "Considering the Contribution of U.S. Food and Agricultural Policy to the Obesity Epidemic: Overview and Opportunities." Minneapolis, MN, Institute for Agricultural and Trade Policy. Nayga, R. (2000). "Schooling, Health Knowledge and Obesity." Applied Economics 32: 815-823. Nestle, M. (2002). Food Politics. Berkeley, CA: University of California Press. Nestle, M. and Jacobson, M.F. (2000). "Halting the Obesity Epidemic: A Public Health Policy Approach." Public Health Reports 115: 12-24. O'Donoghue, T. and Rabin, M. (2006). "Optimal Sin Taxes." Journal of Public Economics 90: 1825-1849. Okrent, A. and Alston, J.M. (2012). "The Effects of Farm Commodity and Retail Food Policies on Obesity and Economic Welfare in the United States." American Journal of Agricultural Economics, forthcoming. Parks, J.C. (2011). "The Effects of the Food Stamp Program on Energy Balance and Obesity." Dissertation, Department of Agricultural and Resource Economics Davis, CA, UC Davis. Parks, J.C., Alston, J.M. and Okrent, A.M. (2011). "The Marginal Social Cost of Obesity: Measures of the Impact of Changes in Obesity Rates on Public Health-Care Costs." Unpublished Working Paper Davis, CA, Department of Agricultural and Resource Economics, University of California, Davis. Philipson, T.J. and Posner, R.A. (1999). "The Long-Run Growth in Obesity as a Function of Technological Change." NBER Working Paper Series No. 7423. National Bureau of Economic Research. Philipson, T.J. and Posner, R.A. (2003). "The Long-Run Growth in Obesity as a Function of Technological Change." Perspectives in Biology and Medicine 46(Number 3 Supplement): S87-S107. Pollan, M. (2003). "The (Agri)Cultural Contradictions of Obesity." The New York Times. New York, NY, October 12. Pollan, M. (2007). "You Are What You Grow." The New York Times Magazine. New York, NY, April 22. Pollan, M. (2008). "Farmer In Chief." The New York Times. New York, NY, October 9. Popkin, B. (2010). The World is Fat. New York, NY: Avery. Ralston, K., Newman, C., Guthrie, J. and Buzby, J. (2008). "The National School Lunch Program: Background, Trends, and Issues." Economic Research Report No. 61. U.S. Department of Agriculture Economic Research Service. Rashad, I., Grossman, M. and Chou, S.-Y. (2005). "The Super Size of America: An Economic Estimation of Body Mass Index and Obesity in Adults." NBER Working Paper No. 11584. National Bureau of Economic Research. Rickard, B.J., Okrent, A. and Alston, J.M. (2011). "How Have Agricultural Policies Influenced Caloric Consumption Patterns in the United States?" Health Economics, forthcoming. Roberto, C.A., Bragg, M.A., Livingston, K.A., Harris, J.L., Thompson, J.M., Seamans, M.J. and Brownell, K.D. (2012). "Choosing Front-of-Package Labelling Nutritional Criteria: How Smart were ‘Smart Choices’?" Public Health Nutrition 16: 1-6. Sacks, G., Rayner, M. and Swinburn, B. (2009). "Impact of Front-of-Pack ‘Traffic-Light’ Nutrition Labeling on Consumer Food Purchases in the UK." Health Promotion International 24: 344-352.

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Sacks, G., Veerman, J.L., Moodie, M. and Swinburn, B. (2011). "‘Traffic-Light’ Nutrition Labeling and ‘Junk-Food’ Tax: A Modeled Comparison of Cost-Effectiveness for Obesity Prevention." International Journal of Obesity 35: 1001-1009. Schmidhuber, J. (2004). "The Growing Global Obesity Problem: Some Policy Options to Address It." Electronic Journal of Agricultural and Development Economics 12: 272-290. Schroeter, C., Lusk, J. and Tyner, W. (2008). "Determining the Impact of Food Prices and Income on Body Weight." Journal of Health Economics 27(1): 45-68. Senauer, B. and Gemma, M. (2006). "Why Is the Obesity Rate So Low in Japan and High in the US? Some Possible Economic Explanations." Paper presented at the Conference of the International Association of Agricultural Economists, Gold Coast, Australia, August 12-18, 2006 Smith, T.A., Lin, B. and Lee, J. (2010). "Taxing Caloric Sweetened Beverages: Potential Effects on Beverage Consumption, Calorie Intake, and Obesity." Economic Research Report No. 100. U.S. Department of Agriculture Economic Research Service. Sumner, D.A. (2005). "Boxed In: Conflicts Between U.S. Farm Policies and WTO Obligations." Trade Policy Analysis No. 1632. Washington, DC, Cato Institute. Swiburn, B., Gill, T. and Kumanyika, S. (2004). "Obesity Prevention: A Proposed Framework for Translating Evidence Into Action." Obesity Reviews 6: 23-33. Tillotson, J.E. (2004). "America’s Obesity: Conflicting Public Policies, Industrial Economic Development and Unintended Human Consequences." Annual Review of Nutrition 24: 617-643. Todd, J.E. and Variyam, J.N. (2008). "The Decline in Consumer Use of Food Nutrition Labels, 1995–2006." ERS Research Report No. 63. Washington DC, U.S. Department of Agriculture Economic Research Service. Tohill, B.C. (2004). "Dietary Intake of Fruit and Vegetables and Management of Body Weight." Background paper for Joint FAO/WHO Workshop on Fruit and Vegetables for Health, September 1–3, 2004. Turnock, B.J. (2004). Public Health: What It Is and How It Works. Sudbury, Massachusetts: Jones and Bartlett. Variyam, J.N. (2005). "Nutrition Labeling in the Food-Away-From-Home Sector: An Economic Assessment." Economic Research Report No. 4. Washington, DC, U.S. Department of Agriculture Economic Reseach Service. Variyam, J.N. and Cawley, J. (2007). "Nutrition Labels and Obesity." NBER Working Paper Series No. 11956. National Bureau of Economic Research. Ver Ploeg, M., Breneman, V., Farrigan, T., Hamrick, K., Hopkins, D., Kaufman, P., Lin, B.-H., Nord, M., Smith, T., Williams, R., Kinnison, K., Olander, C., Singh, A. and Tuckermanty, E. (2009). "Access to Affordable and Nutritious Food—Measuring and Understanding Food Deserts and Their Consequences: Report to Congress." AP036. Washington, DC, U.S. Department of Agriculture Economic Research Service. Ver Ploeg, M., Mancino, L. and Lin, B.H. (2007). "Food and Nutrition Assistance Programs and Obesity: 1976-2002." Economic Research Report No. 48. Washington, DC, U.S. Department of Agriculture Economic Research Service. Visscher, T.L.S. and Seidell, J.C. (2001). "The Public Health Impact of Obesity." Annual Review of Public Health 22: 355-375. Vyth, E.L., Steenhuis, I.H.M., Vlot, J.A., Wulp, A., Hogenes, M.G., Looije, D.H., Brug, J. and Seidell, J.C. (2010). "Actual Use of a Front-of-Pack Nutrition Logo in the Supermarket: Consumers’ Motives in Food Choice." Public Health Nutrition 13(11): 1882-1889. Wilde, P.E. (2009). "Self-Regulation and the Response to Concerns About Food and Beverage Marketing to Children in the United States." Nutrition Reviews 67(3): 155-166.

Section 2 Addictive Behaviors

10 Alcohol Consumption Among Adolescents in Estonia 1994 – 2010 Kersti Pärna1, Mariliis Tael2, Inge Ringmets1 and Katrin Aasvee2 1Department

of Public Health, University of Tartu Institute for Health Development Estonia

2National

1. Introduction Estonia is the smallest of the three Baltic countries on the east coast of the Baltic Sea with an area of approximately 45 215 square kilometres and a population of 1.34 million (01.01.2011) (Statistics Estonia, 2011) which was an independent state in 1918–1940. Estonia regained its independence in August 1991 after the collapse of the Soviet Union. This had enormous implications for health and for the political and economic transition during the succeeding years. In 2004, Estonia became a member of the European Union associated with introduction to the common European market and general pressure towards convergence in many policy areas. The years 1991–1994 represented the period of transition. In terms of economic development, the year 1994 was characterized by significant unemployment (7.6%) and the relatively low gross domestic product (GDP) at current prices (1370 Euros per person) (Statistics Estonia, 2011). In the period of economic growth unemployment was the lowest (4.7% in 2006) and GDP the highest (12 161 Euros per person in 2008). During the following economic downturn unemployment increased to 16.9% and GDP decreased to 10 674 Euros in 2010 (Statistics Estonia, 2011). It is estimated that alcohol consumption is responsible for about 4% of the total disease burden in the world (WHO, 2007). While regular light to moderate alcohol intake is associated with some reduction in total mortality (Di Castenuovo et al., 2006; Rehm et al., 2009), heavy drinking has been regarded as an important contributor to the high premature mortality rates in central and eastern Europe, particularly in the countries of the former Soviet Union (Chenet et al., 1998; Leinsalu, 2002; Leon et al., 1997; McKee et al., 2000; Popova et al., 2007). Alcohol consumption per capita (based on legal sale) increased from 5.6 litres of pure alcohol in 1994 to 15.2 in 2007 and thereafter decreased to 12.8 in 2009 in Estonia (Estonian Institute of Economic Research, 2008, 2010). Since 2006, the estimations were made about the quantity of alcohol beverages that tourists consume in Estonia and export from Estonia. Hence, the consumption of alcohol by Estonian inhabitants was 12.6 in 2007 and 10.2 in 2009 (Estonian Institute of Economic Research, 2010). In 1996–2006, alcohol consumption increased especially among men in Estonia. The proportion of men drinking more than

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280 g pure alcohol per week increased from 7.4% to 16.2%, and the proportion of women drinking more than 140 g pure alcohol per week increased from 2.7% to 4.7% between 1996 and 2006 (Pärna et al., 2010). In 2006, prevalence rate of non-beverage alcohol consumption was 2.3% among men (Pärna & Leon, 2011). In Estonia alcohol-related mortality was the lowest in 1988–1991 (3.5% of all deaths) and increased to 9.1% in 2002–2005 (Rahu & Pärna, 2009). At the same time, in Estonia age-standardized mortality rates of alcoholic liver cirrhosis increased from 9.7 to 37.5 per 100 000 men and from 2.2 to 16.1 per 100 000 women aged 25–64 in 1996–2006 (Pärna & Rahu, 2010). Although the vast majority of alcohol-related deaths occur in middle-aged and elderly people, alcohol consumption behaviour is undeniably established in adolescence. Early adolescence is a critical time, where behavioural habits (including alcohol consumption) are developing (Lintonen et al., 2000). Moreover, individuals who begin alcohol consumption at a younger age have an increased risk of becoming regular alcohol drinkers in adulthood. According to schoolchildren’s self-estimation, they consume alcohol due to boredom, stress and desire to fit in the group (Milgram, 2001). The use of alcohol may become a means of escaping from situations that youth feel powerless to change (United Nations, 2005). As among adults, alcohol consumption among adolescents is associated with road accidents, suicides, depression, memory problems, fighting, rape and unprotected sexual intercourse which could increase the risk of getting infected with HIV and other sexually transmitted diseases (Williams & Knox, 1987). Alcohol consumption may cause decrease of learning ability, which in turn causes learning difficulties due to which adolescent might fall out of school (Scheier et al., 2000). In addition, the existing evidence about the relationship between adolescent drinking behaviour and family related factors are inconsistent and even contradictory. While some studies have identified a higher risk of excessive adolescent drinking behaviour among lower socio-economic groups (Geckova et al., 2002; Lintonen et al., 2000; Lowry et al., 1996), others have found no or even inverse social gradients in schoolchildren’s alcohol consumption (Shucksmith et al., 1997). Living in non-intact families and bad family relationships have been risk factors for alcohol drinking among adolescents (Challier et al., 2000; Shucksmith et al., 1997). The aim of this chapter is to describe trends in the prevalence of alcohol consumption and episodes of drunkenness and to analyze associations between alcohol consumption, episodes of drunkenness and demographic and family related factors among schoolchildren in Estonia in 1994–2010.

2. Material and methods 2.1 Setting and sampling This study was based on international survey of health behavior among school-aged children (HBSC survey) conducted among 11-, 13- and 15-year-old schoolchildren in 1993/1994, 1997/1998, 2001/2002, 2005/2006 and 2009/2010 academic year in Estonia. To ensure the clarity of work results, hereafter the end year of the study (1994, 1998, 2002, 2006, 2010) was used while referring to the academic year. HBSC survey is a World Health Organization collaborative study, in 2010 43 countries participated in the survey. The main objective of HBSC survey is to collect high-quality

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internationally comparable data on schoolchildren’s health behavior, health and wellbeing in their social context (Roberts et al., 2007). The target groups of the survey are 11-, 13- and 15-year-old adolescents, in Estonia respectively schoolchildren from grades 5, 7 and 9. Schoolchildren fill an anonymous questionnaire in classroom during one school hour. A person outside from school is present, schoolchildren who miss the class are left out from the survey. The questionnaires are sealed in envelopes in front of schoolchildren to ensure the confidentiality of data (Aasvee et al., 2007; Maser, 2004). Methods used in this survey are the same in all participating countries and this gives a chance to monitor the changes in schoolchildren health, health behavior and social environment over years in different countries (Aasvee et al., 2007). HBSC survey has been conducted in Estonia in the following periods: February 1994 (King et al., 1996), February– March 1998 (Currie et al., 2000), November–December 2001 (Maser, 2004), February–March 2006 (Currie et al., 2008), February–April 2010. 2.2 Participants Databases from Statistics Estonia were used to compile the sample. Estonian counties were divided into 12 stratums according to language of instruction and urbanization. Sample sizes were calculated according to the number of children in grades 5, 7 and 9 in 12 stratums (Aasvee et al., 2007). In HBSC survey it is required that the number of schoolchildren in each age group is approximately 1500 (Roberts et al., 2007). To ensure equal inclusion probabilities the selection was made in two phases. In the first phase schools were selected. Inclusion probabilities were equal to the total number of grades 5, 7 and 9 in the selected school. This means that schools having more classes of these grades had higher probability to get into the sample. In second phase one class from each parallel was randomly chosen. While compiling the age groups, 90% of schoolchildren had to be within ±6 months of the mean age for each age group and remaining 10% no more than 12 months from the mean age. In chosen schools the school board decided whether they wanted to participate in the survey or not. Schoolchildren had the right to refuse filling the questionnaire if they themselves or their parents wanted that way. Over years the non-participation rate has been below 0.5% of the whole sample. Data files from countries that have participated in the survey have been checked and cleaned in Norwegian Social Science Data Services, where international database was created and is preserved (Aasvee et al., 2007). This chapter focuses on 13- and 15-year-old adolescents self-assessed alcohol consumption and episodes of drunkenness in 1994–2010. 2.3 Measures 2.3.1 Alcohol consumption Frequency of alcohol consumption variable was based on different alcoholic drinks (beer, wine, strong alcohol, liqueur, cider, light alcoholic beverages, alcopops) consumption

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question. Possible answers were ‘yes, every day’, ‘yes, every week’, ‘yes, every month’, ‘yes, less than once a month’ and ‘no, never’, ‘For the purposes of analysis, schoolchildren were categorised as drinking at least weekly (weekly alcohol consumption) or less often. 2.3.2 Drunkenness Frequency of drunkenness was assessed by asking whether schoolchildren had ever had so much alcohol that they were really drunk. Possible answers were ‘no, never’, ‘yes, once’, ‘yes, 2–3 times’, ‘yes, 4–10 times’, and ‘yes, more than 10 times’. Responses to this question were grouped into two categories: drunkenness never or only once in life and at least two episodes of drunkenness. 2.3.3 Demographic factors Sex, age and nationality were used as demographic factors. In accordance with age groups, schoolchildren were either 13- or 15-year-old, from grades 7 and 9 respectively. According to ethnicity two groups were formed: Estonians and non-Estonians (mainly Russians). 2.3.4 Family related factors Family structure, family wealth, family affluence scale and family relationships were used as family related factors, that influence health and health behaviour of schoolchildren. Based on family structure, schoolchildren were divided into four groups: 1) two biological parents; 2) one parent; 3) one parent and one step-parent; 4) other combinations (i.e. parent and grandparent, foster home etc.). Based on family wealth, schoolchildren responses were distributed into three groups: 1) bad (very bad and bad); 2) average; 3) good (very good and good). Family affluence scale (FAS) was calculated on the basis of four items 1) does your family own a car (0, 1, 2 or more), 2) how many times did you travel away on holiday with your family during the past 12 months (0, 1, 2, 3 or more), 3) do you have your own bedroom for yourself (0, 1) and 4) how many computers does your family own (0, 1, 2, 3 or more). A composite FAS score was calculated by summing the responses to these four items ranging from 0 to 9 (Richter et al., 2006). The scores were subsequently recoded into tertiles and respondents were divided into three groups respectively. In 2010 the FAS tertiles were as follows: low (0–4 points); middle (5–6 points); high (7–9 points) (Currie et al., 2008). Family relationships were evaluated on an 11 item scale, where 0 meant very bad relationships and 10 very good ones. Based on the scale, schoolchildren were divided into three groups: bad relationships (0–3); 2) average relationships (4–6); 3) good relationships (7–10). 2.4 Statistical analysis Prevalence of alcohol consumption and episodes of drunkenness were calculated separately for 13- and 15-year-old boys and girls. Logistic regression analysis was applied to assess the

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associations between weekly alcohol consumption, at least two episodes of drunkenness and demographic and family related factors among 13- and 15-year-old schoolchildren. Weekly alcohol consumption (I model) and at least two episodes of drunkenness (II model) were used as binary variables and demographic and family related factors were used as independent variables in logistic regression analysis models. Odds ratios (OR) and corresponding 95% confidence intervals (CI) were computed for both models. OR that equals 1 refers to the base comparison group. OR’s of weekly alcohol consumption and at least two episodes of drunkenness were adjusted to all demographic and family related factors in logistic regression analysis. The present analysis is based on 13- and 15-year-olds (N=12244), 5861 boys and 6383 girls through the study waves (Table 1). Questionnaires, where the correspondents hadn’t answered about their age (10 questionnaires) and alcohol consumption (99 questionnaires) were left out from the analysis. Questionnaires that lacked information about episodes of drunkenness were left out from the drunkenness analysis (62 questionnaires). Additional questionnaires that lacked information about questions related to demographic and family related factors were excluded from logistic regression analysis. Statistical analysis was conducted with Stata 10 (Hills & Stravola, 2007).

1994 Age group 13-year old 15-year old Total 13-year old 15-year old Total Total

N

1998 %

523 49.0 545 51.0 1068 100 622 626 1248 2316

49.8 49.2 100 100

N

2002 %

367 59.4 251 40.6 618 100 444 333 777 1395

57.1 42.9 100 100

N

2006 %

Boys 689 52.7 619 47.3 1308 100 Girls 734 53.1 648 46.9 1382 100 2690 100

N

2010 %

N

%

721 47.4 799 52.6 1520 100

688 51.1 659 48.9 1347 100

738 783 1521 3041

718 737 1455 2802

48.5 51.5 100 100

49.3 50.7 100 100

Table 1. Number of respondents by gender, age and study year, HBSC Survey, Estonia 1994–2010

3. Results 3.1 Demographic and family related characteristics of respondents In 2010, the number of 13- and 15-year-old adolescents studied was almost equal (Table 2). There was about 77% of Estonian and nearly one fourth non-Estonian schoolchildren. About 63% of adolescents were living with both biological parents, approximately 20% with one parent, 15% with parent and a step-parent, and 2% had some other family structure. Almost half of the schoolchildren evaluated their family wealth to be good, 46% found it was average and about 4% said it was bad. Approximately 38% of schoolchildren had high, one third middle and 27% low FAS. About 77% of adolescents evaluated their family relationships good, 19% average and 3% bad.

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Variables Age 13-year old 15- year old Ethnicity Estonian non-Estonian missing Family structure two parents one parent parent and step-parent other missing Family wealth good average bad missing Family affluence scale low middle high missing Family relationships good average bad missing

Boys (n=1347) %

Girls (n=1455) %

Total (n=2802) %

51.1 48.9

49.4 50.7

50.2 49.8

76.8 22.5 0.7

77.6 22.1 0.4

77.2 22.3 0.5

65.8 18.6 13.1 2.2 0.4

60.6 21.0 15.8 2.1 0.5

63.1 19.8 14.5 2.1 0.4

51.8 44.0 3.1 1.1

47.4 47.6 4.5 0.6

49.5 45.9 3.8 0.8

24.4 32.6 40.2 2.8

29.5 33.4 35.7 1.4

27.1 33.0 37.9 2.0

80.5 16.6 2.4 0.5

73.8 21.9 4.1 0.2

77.0 19.4 3.3 0.4

Table 2. Distribution of demographic and family related factors among 13- and 15-year-old schoolchildren by gender, HBSC Survey, Estonia, 2010 3.2 Alcohol consumption Prevalence rate of alcohol consumption has been quite high among Estonian adolescents over study years. After 2006 the prevalence rate decreased in all age groups. Among 13-year-old boys the alcohol drinking in 2010 (54.8%) was almost on the same level as in 1994, when it was 52.4% (Table 3). Compared to year 2006 the prevalence rate decreased 22.5%. Although alcohol consumption rate among 13-year-old girls decreased 10.5% after 2006, it was more than 20% higher in year 2010 than in 1994. Also for the first time, alcohol consumption of girls was higher compared to boys in 2010 (64.3% and 54.8%, respectively).

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Alcohol consumption

1994 N

1998 %

N

Yes every day every week every month seldom No Total

274 2 35 54 183 249 523

52.4 0.4 6.7 10.3 35.0 47.6 100

266 5 21 47 193 101 367

Yes every day every week every month seldom No Total

260 1 8 38 213 362 622

41.8 0.2 1.3 6.1 34.2 58.2 100

279 4 10 38 227 165 444

2002 %

Boys 72.5 1.4 5.7 12.8 52.6 27.5 100 Girls 62.8 0.9 2.3 8.6 51.1 37.2 100

N

2006 %

N

2010 %

N

%

520 19 82 116 303 169 689

75.5 2.8 11.9 16.8 44.0 24.5 100

557 19 66 131 341 164 721

77.3 2.6 9.2 18.2 47.3 22.8 100

377 15 39 84 239 311 688

54.8 2.2 5.7 12.2 34.7 45.2 100

482 5 50 83 344 252 734

65.7 0.7 6.8 11.3 46.9 34.3 100

552 9 47 103 393 186 738

74.8 1.2 6.4 14.0 53.3 25.2 100

462 4 53 107 298 256 718

64.3 0.6 7.4 14.9 41.5 35.7 100

Table 3. Distribution of alcohol consumption among 13-year-old schoolchildren by gender, HBSC Survey, Estonia, 1994–2010

1994 %

1998

Alcohol consumption

N

Yes every day every week every month seldom No Total

428 6 68 108 246 117 545

78.5 1.1 12.5 19.8 45.1 21.5 100

213 10 44 66 93 38 251

Yes every day every week every month seldom No Total

468 5 25 85 353 158 626

74.8 0.8 4.0 13.6 56.4 25.2 100

281 3 32 78 168 52 333

N

2002 N % Boys 84.9 541 87.4 4.0 19 3.1 17.5 177 28.6 27.0 136 22.0 37.1 209 33.8 15.1 78 12.6 100 619 100 Girls 84.4 569 87.8 0.9 7 1.1 9.6 122 18.8 23.4 163 25.2 50.5 277 42.8 15.6 79 12.2 100 648 100 %

2006 N

2010 %

N

%

716 1 195 202 300 83 799

89.6 2.4 24.4 25.3 37.6 10.4 100

535 12 121 164 238 124 659

81.2 1.8 18.4 24.9 36.1 18.8 100

700 7 130 231 332 83 783

89.4 627 0.9 4 16.6 95 29.5 213 42.4 315 10.6 110 100 737

85.1 0.5 12.9 28.9 42.7 14.9 100

Table 4. Alcohol consumption distribution among 15-year-old schoolchildren by gender, HBSC Survey, Estonia, 1994–2010

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Alcohol consumption among 15-year-old boys in 2010 (81.2%) was quite similar compared to 1994 (78.5%) (Table 4). The prevalence rate increased until 2006 and then dropped by 8.4% from 89.6% to 81.2% in 2010. Alcohol consumption among 15-year-old girls increased from 1994 to 2006, when it reached 89.4% and then dropped by 4.3%. For the second time during the study period the prevalence rate of alcohol consumption was higher among girls compared to boys: first in 2002, when difference was 0.4% and then in 2010, when difference was 3.9%. Prevalence rate of weekly alcohol consumption mostly decreased since 2002, except among 13-year-old girls (Figure 1). The prevalence rate among 13-year-old girls increased from 1.5% in 1994 to 7.9% in 2010. Among 13-year-old boys weekly alcohol consumption prevalence rate decreased from 14.7% in 2002 to 7.9% as among 13-year-old girls in 2010. In 2002 31.7% of 15-year-old boys and 20.0% of the same aged girls consumed alcohol weekly. The prevalence rate decreased from 2002 to 2010, 11.5% among 15-year-old boys and 6.6% among 15-year-old girls.

Fig. 1. Prevalence rates of weekly alcohol consumption among 13- and 15-year-old schoolchildren by gender, HBSC Survey, Estonia, 1994–2010 3.3 Drunkenness The prevalence rate of at least one episode of drunkenness mostly increased from 1994 to 2006 and then decreased. Compared to boys, prevalence rate among girls was only slightly lower in 2010 (Table 5). Among 13-year-old boys the prevalence rate of at least one episode of drunkenness more than doubled in the period of 1994–2006 and after that decreased 11.5% from 45.9% to 34.4%. Among 15-year-old girls the prevalence rate increased since 1994, the difference between years 1994 and 2010 was five-fold (6.9% in 1994 and 31.1% in 2010).

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Episodes of drunkenness

1994 N

1998 %

N

2002 %

Yes >10 times 4–10 times 2–3 times once No Total

96 5 6 24 61 423 519

18.5 1.0 1.2 4.6 11.8 81.5 100

122 3 11 41 67 244 366

Yes >10 times 4–10 times 2–3 times once No Total

43 2 2 8 31 577 620

6.9 0.3 0.3 1.3 5.0 93.1 100

66 2 2 13 49 377 443

N

Boys 33.3 309 0.8 37 3.0 33 11.2 100 18.3 139 66.7 380 100 689 Girls 14.9 209 0.5 16 0.5 17 2.9 60 11.1 116 85.1 525 100 734

2006

2010

%

N

%

N

%

44.8 5.4 4.8 14.5 20.2 55.2 100

329 40 43 102 144 387 716

45.9 5.6 6.0 14.3 20.1 54.1 100

234 28 29 66 111 446 680

34.4 4.1 4.3 9.7 16.3 65.6 100

28.5 2.2 2.3 8.2 15.8 71.5 100

219 15 28 72 104 519 738

29.7 2.0 3.8 9.8 14.1 70.3 100

221 24 29 69 99 490 711

31.1 3.4 4.1 9.7 13.9 68.9 100

Tabel 5. Distribution of episodes of drunkenness among 13-year-old schoolchildren by gender, HBSC Survey, Estonia, 1994–2010

Episodes of drunkenness Yes >10 times 4–10 times 2–3 times once No Total

1994 N 256 30 29 81 116 289 545

1998 % 47.0 5.5 5.3 14.9 21.3 53.0 100

2002

N

%

N

150 31 31 48 40 99 249

Boys 60.2 12.5 12.5 19.3 16.1 39.8 100

460 152 76 123 109 159 619

132 12 16 49 55 201 333

Girls 39.6 3.6 4.8 14.7 16.5 60.4 100

2006 %

74.3 24.6 12.3 19.9 17.6 25.7 100

N 566 164 110 181 111 230 796

2010 %

71.1 20.6 13.8 22.7 13.9 28.9 100

N 445 99 97 119 130 213

% 67.6 15.1 14.7 18.1 19.8 32.4 100

658 Yes >10 times 4–10 times 2–3 times once No Total

160 4 7 50 99 465 625

25.6 0.6 1.1 8.0 15.8 74.4 100

387 55 64 153 115 260 647

59.8 8.5 9.9 23.7 17.8 40.2 100

487 60 77 192 158 294 781

62.4 7.7 9.9 24.6 20.2 37.6 100

428 66 76 167 119 307 735

Table 6. Distribution of episodes of drunkenness among 15-year-old schoolchildren by gender, HBSC Survey, Estonia, 1994–2010

58.2 9.0 10.3 22.7 16.2 41.8 100

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Among 15-year-old boys the prevalence rate of at least one episode of drunkenness increased from 1994 (47.0%) to 2002 (74.3%) and then decreased (Table 6). Compared to year 1994, in 2010 the rate was higher by 20.6%. Among 15-year-old girls the prevalence rate increased from 1994 (25.6%) to 2006 (62.4%) and then decreased by 4.2%. The prevalence rate has more than doubled over the whole period. The prevalence rate of at least two episodes of drunkenness decreased after 2006 among 13and 15-year-old boys (Figure 2). The prevalence rate among 13-year-old boys in 2006 was 25.8% and in 2010 18.1%. Among 15-year-old boys the rate decreased from 57.2% in 2006 to 47.9% in 2010. Among 13-year-old girls the rate increased since 1994, when it was 1.9%, to 17.2% in 2010. Among 15-year-old girls the rate was stable since 2002, when it was 42.0%. However, compared to year 1994 the rate increased approximately 4 times from 9.8% to 42.0% in 2010.

Fig. 2. Prevalence rates of at least two episodes of drunkenness among 13- and 15-year-old schoolchildren by gender, HBSC Survey, Estonia, 1994–2010 3.4 Alcohol consumption and drunkenness by demographic and family related factors In 2010, weekly alcohol consumption and repeated drunkenness were higher among 15-year-olds (versus 13-year-olds) and among Estonian (versus non-Estonian) boys and girls (Table 7). Family structure was not associated with drinking alcohol weekly. Compared to schoolchildren living with both parents, odds for repeated drunkenness was higher among girls living with one parent, and among boys and girls living with parent and step-parent. Family wealth and FAS were associated with alcohol consumption and drunkenness only among girls. Odds to drink alcohol weekly and to have at least two episodes of drunkenness was higher among girls living in families with lower perceived wealth, but having higher FAS. Compared to adolescents with the good family relationships, odds to consume alcohol weekly and to have at least two episodes of drunkenness was higher among boys and girls with average and bad family relationships.

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Variables

Weekly alcohol consumption (I model) Boys Girls

AOR (95% CI) Age 13-year old 1 15- year old 2.78 (1.95–3.96) Ethnicity non-Estonian 1 Estonian 2.63 (1.58–4.36) Family structure two parents 1 one parent 1.21 (0.79–1.88) parent and step1.05 (0.64–1.71) parent other 1.73 (0.62–4.79) Family wealth good 1 average 0.83 (0.58–1.18) bad 1.13 (0.46–2.75) Family affluence scale low 1 middle 0.74 (0.46–1.19) high 1.41 (0.91–2.20) Family relationships good 1 average 1.71 (1.14–2.58) bad 3.82 (1.65–8.88)

Repeated drunkenness (II model) Boys Girls

AOR (95% CI)

AOR (95% CI)

AOR (95% CI)

1 1.62 (1.14–2.31)

1 4.14 (3.18–5.39)

1 3.47 (2.69–4.48)

1 2.23 (1.31–3.80)

1 2.45 (1.74–3.45)

1 2.03 (1.46–2.83)

1 1.33 (0.85–2.09) 1.32 (0.83–2.09)

1 1.32 (0.95–1.87) 1.72 (1.19–2.49)

1 1.55 (1.13–2.13) 1.45 (1.04–2.03)

1.20 (0.39–3.70)

2.01 (0.82–4.90)

2.65 (1.19–5.92)

1 1.16 (0.80–1.69) 2.38 (1.15–4.92)

1 0.89 (0.67–1.16) 1.12 (0.53–2.36)

1 1.44 (1.10–1.87) 1.96 (1.07–3.57)

1 1.35 (0.84–2.17) 2.05 (1.27–3.32)

1 1.12 (0.79–1.60) 1.35 (0.95–1.92)

1 1.29 (0.93–1.78) 1.95 (1.39–2.73)

1 2.27 (1.54–3.35) 3.30 (1.68–6.47)

1 1.76 (1.26–2.46) 3.43 (1.53–7.71)

1 1.85 (1.38–2.48) 2.47 (1.36–4.47)

Table 7. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) for weekly alcohol consumption (I model) and for at least two episodes of drunkenness (II model) pending on demographic and family related factors among 13- and 15-year-old schoolchildren by gender, HBSC Survey, Estonia, 2010

4. Discussion The present chapter focused on alcohol consumption among adolescents in Estonia in 1994–2010. 4.1 Limitations and strength of the survey Before discussing the results, one has to consider the limitations of the survey. Limitations are mainly related to questionnaire survey and its validity. Some studies have demonstrated that there is tendency to under-report when asking questions on such a sensitive risk taking behaviour like alcohol consumption (Newell et al., 1999). To deal with this potential bias of self-reporting all possible efforts to guarantee anonymity of responses were made. Despite of some limitations, this study provides basic data and several inferences can be drawn.

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Strength of this survey is related to the possibility to make cross-national comparisons as standard approach was employed according to the study protocol to use the same questions in each participating country. 4.2 Trends in alcohol consumption and drunkenness Weekly alcohol consumption increased from 1994 to 2002 and thereafter decreased among boys and girls in Estonia. Only among 13-year-old girls drinking alcohol weekly increased during the whole study period. Nevertheless, compared to the year 1994, prevalence of weekly drinking was much higher in 2010. In 1994–2002, similar increasing trend of alcohol consumption was found among adolescents in neighbouring countries Latvia and Lithuania (Zaborskis et al., 2006). Similar pattern emerged with drunkenness. Prevalence of at least two episodes of drunkenness increased from 1994 to 2006 and thereafter slightly decreased among boys and girls. Among 13-year-old girls weekly alcohol consumption increased during the whole study period. Throughout the study period prevalence of drunkenness increased more among girls. Again, compared to the year 1994, prevalence of weekly alcohol consumption was much higher in 2010. At the same time, Simons-Morton et al. (2009) reported world-wide cross-cultural patterns in alcohol consumption. The Northern European countries showed a declining trend, but Eastern European countries (including Estonia) experienced increasing trend in alcohol consumption and drunkenness. The variability of trends by country might reflect alcohol and marketing policy differences by country. Estonia has experienced significant political and economic changes during the last two decades. A lot of effects on alcohol related issues in Estonia could be associated with economic changes of the former Soviet Union as well as with the joining the European Union in 2004. Gender differences in alcohol consumption among adolescents were pronounced. Throughout the study period, drinking and drunkenness remained higher among boys compared to girls, but the gap between boys and girls declined and girls appeared to be catching up with boys especially among 13-year-olds. Also, gender gap was shrinking in almost all countries participating in HBSC Survey (Simons-Morton et al., 2009). The variability in trends by gender in Estonia could be due to increased effectiveness of contemporary marketing practices or relative ineffectiveness of policies and programs with girls. However, these changes in prevalence could also be due to changes in the social roles of women, allowing girls greater autonomy and wider range of social options (Rahav et al., 2006). Prevention of alcohol consumption among adolescents is very important because it prevents problems among adults in the future (Hingson et al., 2006). It has been found that the most effective prevention measures are those that are targeted to schoolchildren and to their parents at the same time (Smit et al., 2008; Wu et al., 2003). However, it has to be taken into account that every country needs it’s own implementation of a specific program due to cultural differences (Koning et al., 2010). Simons-Morton et al. (2010) compared alcohol consumption of adolescents in USA, Canada and Netherlands and found that there were higher odds to consume alcohol and get drunk in the Netherlands, where minimum age to purchase alcohol is 16 compared to Canada (minimum age 19) and USA (minimum age 21).

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4.3 Alcohol consumption and drunkenness by demographic and family related factors Weekly alcohol consumption and repeated drunkenness were associated with demographic factors like gender and age as described above. In addition, compared to non-Estonian adolescents alcohol drinking was more pronounced among Estonians. At the same time, weekly alcohol consumption was higher, but the amount of pure alcohol consumed per week was lower among adults of ethnic majority in Estonia (Pärna et al., 2010). However, in Lithuania, in schools with Lithuanian teaching language, Polish and Russian adolescents were more exposed to alcohol consumption (Šumskas et al., 2010). Drunkenness, but not weekly alcohol consumption was associated with family structure among boys and girls. Living in non-intact families was a risk factor for repeated drunkenness. Also, Bjarnason et al. (2003) reported that schoolchildren living with both biological parents engaged less frequently in heavy alcohol consumption than those living in other arrangements. According to world-wide literature, higher supervision in intact families and supportive family environment might be associated with lower alcohol consumption among adolescents in these families (Cookston, 1999; Shucksmith et al., 1997). Similar association was found between alcohol consumption, repeated drunkenness and family wealth among girls. Lower family wealth was a risk factor for heavy alcohol use among girls in Estonia. Zaborskis et al. (2006) found inverse relationship between alcohol consumption and the perceived family wealth in all three Baltic countries. In 1994–2002, girls in Estonia, but boys in Latvia and Lithuania from the families perceived by them as wealthy were more likely to drink weekly as compared to adolescents from the families perceived by them as not wealthy. This inconsistency in these findings might be explained by time difference in these studies (they were conducted in different years). Weekly alcohol consumption as well as repeated drunkenness was associated with family affluence scale among girls, but not among boys. At the same time, there was not found any relationship between repeated drunkenness and FAS among 11–15-year-olds in Estonia in 2002 (Richter et al., 2006). Again, this inconsistency in these results might be explained with different age groups and study years used in these studies. Moreover, Richter et al. (2006) found very limited evidence for a close consistent relationship between episodes of drunkenness and parental FAS in almost all other participating countries (27) in the same study. Kuntsche et al. (2004) have pointed out that while adults problem drinking seems to be more common in less affluent groups, this direction might be reversed for adolescents, where accessibility to financial resources is more limited. Also, higher FAS as well as family wealth might be not directly associated with higher education. Inconsistency in association of alcohol drinking with family wealth and FAS could be explained by the fact, that distribution of perceived family wealth among adolescents is quite different as compared to FAS. Adolescents who estimated the family wealth ‘not so well-off’ or ‘not at all well-off’ was in 2010 survey 3.2%, by FAS tertiles low economic situation was in 27% of students. Evidently, FAS shows more objectively the financial situation of the family. In addition, there might be other factors during adolescence, which may have a greater impact on drinking behaviour than family related factors and parental socioeconomic status. For instances, the specific character of adolescence as a stage of experimenting with behaviours associated with adult status (Richter et al., 2006) or situations that youth feel powerless to change (United Nations, 2005).

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Weekly alcohol consumption and repeated drunkenness were associated with worse family relationships among boys and girls in this study. According to world-wide literature, a supportive family environment (Shucksmith et al., 1997) and parent-child communication is associated with lowered prevalence of alcohol consumption (Luk et al., 2010). 4.4 Alcohol policy in Estonia During 1996–2006 alcohol policy was virtually nonexistent in Estonia. There was a national alcoholism and drug abuse prevention programme for 1997–2007, which was continued since 2004 under national drug abuse prevention strategy (1994–2012). This programme mainly focused on the creation of a nationwide information system to evaluate the damage caused by alcohol and drug abuse. In 1996–2006 the prices of alcoholic beverages increased in Estonia (1.3 times for domestically produced beer and 1.4 times for vodka). However, the average price increase has been slower than the increase in the consumer price index, as well as slower than the income increase of inhabitants, which most likely has also contributed to the increase of alcohol consumption (Estonian Institute of Economic Research, 2008). Compared to the 2004 level, excise tax increased 45% by the beginning of 2010. The highest tax increases (30% altogether) occurred in 2008 when the economic crisis started to affect the Estonian economy (Lai & Habicht, 2011). This was the first time when affordability of alcoholic beverages decreased after many years. A nation-wide restriction on the time of off-premise sales of alcoholic beverages was introduced in the summer of 2008. Currently, off-premise sale of alcoholic beverages is prohibited from 10 p.m. to 10 a.m. throughout Estonia. There is still wide availability of alcohol sales outlets: 198 alcohol retail shops per 100 000 inhabitants in Estonia in 2010, while 6.5 in Finland and 4.5 in Sweden (Estonian Institute of Economic Research, 2010). Since 2008 advertising of alcoholic beverages on television and radio has been prohibited from 7 a.m. to 9 p.m. in Estonia. Before, prohibition of TV advertisement ended at 8 p.m. for alcoholic beverages other than spirits (Lai & Habicht, 2011). Interventions on a personal level such as alcohol counselling have had very low focus in Estonia. A pilot study to evaluate the methods of early identification of risk drinking and counselling in the primary health care was carried out in the beginning of 2010. It was found that early identification of risk drinking and counselling are feasible. Continuous practical training, considering the specificity of primary health care, is necessary in order to promote the counselling skills of primary health care specialists (Saame et al., 2011). In Estonia, further alcohol policy actions should include the reduction of the density of alcohol outlets, more comprehensive advertisement bans, clearer separation of alcoholic beverages from other goods in retail stores and full implementation of brief alcohol interventions in primary health care (Lai & Habicht, 2011). In addition to previously mentioned policy actions, there should be an alcohol consumption prevention program targeted to adolescents and their parents. Higher price for light alcoholic beverages and consistently asking for ID-card while selling alcohol would lower

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alcohol consumption among adolescents. Root beer (0.5% and 0.8%) and non-alcoholic cider (1.2%) should be considered as alcoholic beverages. Also raising the minimum age to purchase alcohol from 18 to 21 would be an effective preventive measure.

5. Conclusion Alcohol consumption among adolescents in Estonia is a serious public health problem. Demographic and family related factors influence alcohol use of adolescents, especially among girls. The results of this study may guide the development of policy and interventions tackling alcohol consumption among adolescents in Estonia. Additional research is needed on the nature of differences in drinking attitudes and patterns among boys and girls and their parents. Also, it might be interesting to look at the alcohol consumption within the context of other, possibly more relevant factors such as peer or school influence and other parental factors.

6. Acknowledgment This study was carried out in the framework of the Health Behaviour in School-aged Children (HBSC) Survey, WHO/EURO collaborative international study. This chapter reports data from Estonia (Principal Investigator Katrin Aasvee). The International HBSC Coordinator is Candace Currie (University of St Andrews School of Medicine, St Andrews, Scotland). The Data Management Centre Manager is Oddrun Samdal (University of Bergen, Bergen, Norway). For details, see www.hbsc.org. This study was supported by the Estonian Ministry of Education and Science (target funding SF0180060s09) and the Estonian Ministry of Social Affairs (Strategy of Prevention of Cardiovascular Diseases 2005–2020).

7. References Aasvee, K., Poolakese, A., Minossenko, A. & Kurbatova, A. (2007). Eesti kooliõpilaste tervisekäitumise uuring, 2005/2006. õppeaasta. Tabelid (tulemused kaalutud andmete alusel). [Health behaviour of school-aged children among adolescents in Estonia, 2005/2006. Tables (results based on weighted data)]. Tallinn, Estonia Bjarnason, T., Andersson, B., Choquet, M., Elekes, Z., Morgan, M. & Rapinett, G. (2003). Alcohol culture, family structure and adolescent alcohol use: multilevel modeling of frequency of heavy drinking among 15–16 year old students in 11 European countries. Journal of Studies on Alcohol, Vol.54, No.2, pp. 200–208 Challier, B., Chau, N., Predine, R., Choquet, M. & Legras, B. (2000). Associations of family environment and individual factors with tobacco, alcohol, and illicit drug use in adolescents, European Journal of Epidemiology, Vol.16, No.1, pp. 33–42 Chenet, L., Leon, D., McKee, M. & Vassin, S. (1998). Deaths from alcohol and violence in Moscow: socio-economic determinants. European Journal of Population, Vol.14, No.1, pp. 19–37 Cookston, J.T. (1999). Effects on adolescent problem behaviors. Journal of Divorce & Remarriage, Vol.32, No.1/2, pp. 107–122

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Currie, C., Hurrelmann, K., Settertobulte, W., Smith, R. & Todd, J. (Eds). (2000). Health and health behaviour among young people. Health behaviour in school-aged children: a WHO cross-national study (HBSC) international report. Health policy for children and adolescents. No. 1. Copenhagen, Denmark Currie, C., Gabhainn, S.N., Godeau, E., Roberts, C., Smith, R., Currie, D., Picket, W., Richter, M., Morgan, A. & Barnekow, V. (Eds). (2008). Inequalities in young people's health: international report from the HBSC 2005/06 survey. Health policy for children and adolescents, No. 5.Copenhagen, Denmark Di Castelnuovo, A., Costanzo, S., Bagnardi, V., Donati, M.B., Iacoviello, L. & de Gaetano, G. (2006). Alcohol dosing and total mortality in men and women: an updated metaanalysis of 34 prospective studies. Archives of International Medicine, Vol.166, No.22, pp. 2437–2445 Estonian Institute of Economic Research. (2008). Alkoholi turg, tarbimine ja kahjud Eestis. Aastaraamat 2008. [Alcohol market, consumption and harms in Estonia. Yearbook 2008]. Tallinn, Estonia Estonian Institute of Economic Research. (2010). Alkoholi turg, tarbimine ja kahjud Eestis. Aastaraamat 2010. [Alcohol market, consumption and harms in Estonia. Yearbook 2010]. Tallinn, Estonia Geckova, A., van Dijk, J.P., Groothoff, J.W. & Post, D. (2002). Socio-economic differences in health risk behaviour and attitudes towards health risk behaviour among Slovak adolescents. Sozial und Praventivmedizin, Vol.47, No.4, pp. 233–239 Hills, M. & Stravola, B. (2007). A short introduction to Stata for biostatistics: updated to Stata 10, Timberlake Consultants, ISBN-10 978-0-9557076-1-2, London, United Kingdom Hingson, R.W., Heeren, T. & Winter, M.R. (2006). Age at drinking onset and alcohol dependence. Archives of Pediatrics & Adolescent Medicine, Vol.160, No.7, pp. 739–746 King, A., Wold, B., Tudor-Smith, C. & Harel, Y. (1996). The health of youth: a cross-national survey. European Series, No.69. Copenhagen, Denmark Koning, I.M., van den Eijnden, R.J.J.M., Engels, R.C.M.E., Verdurmen, J.E.E. & Vollebergh, W.A.M. (2010). Why target early adolescents and parents in alcohol prevention? The mediating effects of self-control, rules and attitudes about alcohol use. Addiction, Vol.106, No.3, pp. 538–546 Kuntsche, E., Rehm, J. & Gmel, G. (2004). Characteristics of binge drinkers in Europe. Social Science & Medicine, Vol.59, No.1, pp. 113–127 Lai, T. & Habicht, J. (2011). Decline in alcohol consumption in Estonia: combined effects of strengthened alcohol policy and economic downturn. Alcohol and Alcoholism, Vol.46, No.2, pp. 200–203 Leinsalu, M. (2002). Social variation in self-rated health in Estonia: a cross-sectional study. Social Science & Medicine, Vol.55, No.5, pp. 847–861 Lintonen, T., Rimpelä, M., Vikat, A. & Rimpelä, A. (2000). The effect of societal changes on drunkenness trends in early adolescence. Health Education Research, Vol.15, No.3, pp. 261–269 Lowry, R., Kann, L., Collins, J.L. & Kolbe, L.J. (1996) The effect of socioeconomic status on chronic disease risk behaviors among US adolescents. Journal of the American Medical Association, Vol.276, No.10, pp. 792–797 Luk, J.W., Farhat, T., Iannotti, R.J. & Simons-Morton, B.G. (2010). Parent-child communication and substance use among adolescents: do father and mother communication

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play a different role for sons and daughters? Addictive Behaviour, Vol.35, No.5, pp. 426–431 Maser M. (2004). Kooliõpilaste tervisekäitumine. 2001/2002. õppeaasta uuring. [Health behaviour of school-aged children, 2001/2002 survey]. Tallinn, Estonia McKee, M., Pomerleau, J., Robertson, A., Pudule, I., Grinberga, D., Kadziauskiene, K., Abaravicius, A. & Vaask, S. (2000). Alcohol consumption in the Baltic Republics. Journal of Epidemiology and Community Health, Vol.54, No.5, pp. 361–366 Milgram, G.G. (2001). Alcohol influences: the role of family and peers. In: Learning about drinking, E. Houghton, & A.M. Roche, (Eds.), 85–108, Taylor and Francis, Philadelphia, USA Newell, S.A., Girgis, A., Sanson-Fisher, R.W. & Savolainen, N.J. (1999). The accuracy of selfreported health behaviors and risk factors relating to cancer and cardiovascular disease in the general population: a critical review. American Journal of Preventive Medicine, Vol.17, No.3, pp. 211–229 Popova, S., Rehm, J., Patra, J. & Zatonski, W. (2007). Comparing alcohol consumption in central and eastern Europe to other European countries. Alcohol and Alcoholism, Vol.42, No.5, pp. 465–473 Pärna, K. & Leon, D.A. (2011). Surrogate alcohol drinking in Estonia. Alcoholism: Clinical and Experimental Research, Vol. 35, No. 8, pp. 1454–1457 Pärna, K. & Rahu, K. (2010). Dramatic increase in alcoholic liver cirrhosis mortality in Estonia in 1992–2008. Alcohol and Alcoholism, Vol.45, No.6, pp. 548–551 Pärna, K., Rahu, K., Helakorpi, S. & Tekkel, M. (2010). Alcohol consumption in Estonia and Finland: Finbalt survey 1994–2006. BMC Public Health, Vol.10 (May 19), 261. Rahav, G., Wilsnack, R., Bloomfield, K., Gmel, G. & Kuntsche, S. (2006). The influence of societal level factors on men's and women's alcohol consumption and alcohol problems. Alcohol and Alcoholism Supplement, Vol.41, No.1, pp. i47–i55 Rehm, J., Mathers, C., Popova, S., Thavorncharoensap, M., Teerawattananon, Y. & Patra, J. (2009). Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet, Vol.373, No.9682, pp. 2223–2233 Richter, M., Leppin, A. & Gabhainn SN. (2006). The relationship between parental socioeconomic status and episodes of drunkenness among adolescents: finding from a cross-national survey. BMC Public Health, Vol.6 (November 28), 289 Roberts, C., Currie, C. & Samdal, O. (2007). Measuring the health and health behaviours of adolescents through cross-national survey research: recent developments in the Health Behaviour in Schoolaged Children (HBSC) study. Journal of Public Health, Vol.15, No.3, pp. 179–186 Saame, I., Gluškova,N., Viilmann, K. & Kalda, R. (2011). Prooviuuring alkoholi liigtarvitamise varajase avastamise ja nõustamise metoodika hindamiseks Eesti perearstisüsteemis. [Pilot project to evaluate the methods of early identifi cation of risk drinking and counselling in the primary health care system in Estonia]. Eesti Arst, Vol.90, No.5, pp. 216–224 Scheier, L.M., Botvin, G.J., Griffin, K.W. & Diaz, T. (2000). Dynamic growth models of selfesteem and adolescent alcohol use. Journal of Early Adolescence, Vol.20, No.2, pp. 178–209

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Shucksmith, J., Glendinning, A. & Hendry, L. (1997) Adolescent drinking behaviour and the role of family life: a Scottish perspective. Journal of Adolescence, Vol.20, No.1, pp. 85– 101 Simons-Morton, B.G., Farhat, T., ter Bogt, T.F., Hublet, A., Kuntsche, E., Gabhainn, S.N., Godeau, E. & Kokkevi, A. (2009). Gender specific trends in alcohol use: crosscultural comparisons from 1998 to 2006 in 24 countries and regions. International Journal of Public Health, Vol.54, Suppl2, pp. 199–208 Simons-Morton, B.G., Pickett, W., Boyce, W., ter Bogt, T.F., Vollebergh, W. (2010). Crossnational comparison of adolescent drinking and cannabis use in the United States, Canada, and the Netherlands. International Journal of Drug Policy, Vol.21, No.1, pp. 64–69 Smit, E., Verdurmen, J., Monshouwer, K. & Smit, F. (2008). Family interventions and their effect on adolescent alcohol use in general populations; a meta-analysis of randomized controlled trials. Drug and Alcohol Dependence, Vol.97, No.3, pp. 195– 206 Statistics Estonia. (2011). Available from www.stat.ee (14.06.2011) Šumskas, L., Lenciasukiene, I. & Zaborskis, A. (2010). Health behaviour inequalities among Lithuanian, Polish and Russian school-aged children in Lithuania. Central European Journal of Medicine, Vol.5, No.1, pp. 97–107 Tuinstra, J., Groothoff, J.W., van den Heuvel, W.J. & Post, D. (1998) Socio-economic differences in health risk behavior in adolescence: do they exist? Social Science & Medicine, Vol.47, No.1, pp. 67–74 Zaborskis, A., Šumskas, L., Maser, M. & Pudule, I. (2006). Trends in drinking habits among adolescents in the Baltic countries over the period of transition: HBSC survey results, 1993–2002. BMC Public Health, Vol.6 (March 15), 67 United Nations. (2005). World Youth Report 2005: Today and in 2015. New York, USA Williams, F.G. & Knox, R. (1987). Alcohol abuse intervention in a university setting. Journal of American College Health, Vol.36, No.2, pp. 97–102 World Health Organization. (2007). WHO Expert Committee on problems related alcohol consumption.WHO technical report series 944. Second report. World Health Organization, Geneva: Switzerland,. Available from http://www.who.int/substance_abuse/expert_committee_alcohol_trs944.pdf

11 Public Health and Indigenous Australian Gambling: Risky Lifestyle or Harmless Recreation? Helen Breen, Nerilee Hing and Ashley Gordon

Centre for Gambling Education and Research, School of Tourism and Hospitality Management, Southern Cross University, Lismore NSW Australia 1. Introduction Gambling and particularly gambling-related problems give rise to a complex range of issues. Understanding gambling issues has tended to focus on the individual and their behaviour in the past but is increasingly being recognised as a public health concern (Blaszczynski & Nower, 2007; Shaffer & Korn, 2002). The public health perspective generally considers gambling behavior as a continuum from recreational gambling to low risk and moderate risk gambling and then problem gambling. This perspective focuses attention on the prevention of gambling problems, on minimization of gambling harms and on treatment for those suffering severe gambling problems (Productivity Commission, 2010). A public health view of gambling invites examination of its influences and impacts on populations and communities. Thus the focus of this chapter is on gambling by Indigenous Australians from several communities but belonging to one tribal group in regional Australia.1 This chapter also draws on a model of gambling derived from the public health literature to analyse risk and protective factors associated with gambling within these communities. The usefulness of public health concepts and models to the study of gambling are demonstrated in this chapter. As well, it makes an empirical contribution to a little studied area.

2. Background Gambling has long been recorded as a recreational activity in many cultures. Over 300 years ago, regular visits by Macassan fishermen and traders to northern parts of Australia brought card gambling to Indigenous Australians (Breen, 2008). Card gambling remains a widespread and popular form of contemporary recreation in many Indigenous communities, while the expansion of commercial forms of gambling such as poker machines, casinos, lottery-type products, sports betting and wagering has broadened Indigenous participation in gambling (McMillen & Donnelly, 2008). However, there is limited knowledge about Indigenous gambling or gambling-related problems (Belanger, 1 Being aware of the debate around titles used to describe Aboriginal and Torres Strait Islander Australians, in this chapter we use the terms Indigenous Australian and Aboriginal interchangeably depending on source.

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2006, 2011). Internationally, various Indigenous populations appear to have a higher prevalence of problem gambling than the general population (Conner & Taggart, 2009; Dyall, 2010; Williams, Stevens & Nixon, 2011). While research in Australia is limited, results suggest higher problem gambling rates among Indigenous Australians compared to nonIndigenous Australians, although prevalence rates have not been rigorously measured (Stevens & Young, 2009). Nevertheless, Indigenous Australians are considered an at-risk group for gambling problems, given their social and economic disadvantage. Lower socio-economic groups, particularly those who experience poverty, unemployment, welfare dependence, homelessness and low education, usually have higher rates of gambling-related problems than the general population (Shaffer & Korn, 2002; Volberg & Abbott, 1997). Further, gamblers on low incomes suffering from problems with their gambling experience losses that are borne disproportionately (Shaffer & Korn, 2002). In New Zealand, people in lower socio-economic groups, especially Maori and Pacific Island peoples, tend to experience higher rates of problem gambling (Ministry of Health, 2009). A variety of socio-economic factors negatively affect the health and welfare of some Indigenous Australians. Indigenous Australians generally have a lower life expectancy, higher unemployment records, lower education levels, live with poverty and experience higher levels of psychological distress compared to non-Indigenous Australians (Australian Bureau of Statistics (ABS), 2010; Holland, 2011). Livingstone and Adams (2010) maintain that Australian gaming taxation mainly draws from disadvantaged groups of gamblers, adding to their financial hardship and marginalisation. Thus structural deficiencies and inequalities aligned with individual life circumstances may accumulate and impact on gambling issues for Indigenous Australians. Given that little research has been conducted into gambling by Indigenous Australians, research on identifying and explaining underlying risk factors that contribute to gambling problems appears to be a useful addition to the sparse knowledge in this field. Additionally, research into protective factors, those that assist gamblers in controlling their gambling appears to make a similar contribution, adding balance to this topic. In this research, problem gambling is defined as ‘difficulties in limiting money and/or time spent on gambling which leads to adverse consequences for the gambler, others, or for the community’ (Neal, Delfabbro & O’Neil, 2005, p. i). 2.1 Theoretical approach Risk and protective factors associated with gambling can arise from multiple influences. Identifying and analysing risk factors contributing to gambling-related problems form a major component of public health gambling research (Perese, Bellringer & Abbott, 2005). Risk factors, those that exacerbate negative gambling consequences and encourage further gambling (Thomas & Jackson, 2008), are largely unknown for Indigenous gamblers (Breen, Hing & Gordon, 2010). The situation is similar for protective factors, those that protect or reduce gamblers’ exposure to harmful gambling consequences (Breen, 2011). Once identified, risk factors can be appropriately targeted for early intervention and prevention even if causal relationships are not established. Additionally, protective factors, those that assist gamblers to make decisions to protect them from harmful outcomes, can potentially inform appropriate public health promotion and education strategies.

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The Model of Influences on Gambling Behaviours and Outcomes has been developed specifically to examine influences on the behaviour of gamblers and the consequences of their gambling activities (Thomas & Jackson, 2004). Three important elements of gambling uptake are integral to this model. These elements are the propensity to gamble, the influence of gambling products and services on gambling behaviour and the consequences of gambling behaviour. Each of these three elements has accompanying risk, moderating and protective factors. Leaving aside moderating factors, risk and protective factors may vary according to the propensity to gamble by different populations and by the nature and availability of different forms of gambling. Risk and protective factors associated with gambling outcomes may encourage further gambling for some gamblers but not for others. Thus, designing appropriate public health strategies to address problematic gambling requires a sound understanding of the risk and protective factors associated with gambling by the targeted population. For a depiction of this model, see Figure 1.

Fig. 1. Model of influences on gambling behaviours and outcomes (Thomas & Jackson, 2004:44) A variety of influences contribute to gambling uptake and to gambling-related problems. Thomas and Jackson (2004, 2008) propose that behavioural characteristics, sociological and cultural factors strongly influence gambling uptake. In considering gambling uptake and the influence of risk and protective factors associated with it, risks relating to the propensity to gamble might include a faulty understanding about the nature of chance and random events underpinning many forms of gambling, boredom, social isolation, depression and a variety of cultural and ethnic issues (Korn & Shaffer, 1999; Thomas & Jackson, 2004, 2008). Gambling risks relating to the nature of the gambling products and services may include access to gambling, gaming venue characteristics, the nature of the games and the nature of rewards offered (Hing & Haw, 2010; Productivity Commission 1999, 2010). Risk factors potentially affecting gambling outcomes and thus encouraging further gambling might

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include financial problems, legal troubles, relationship breakdown, depression and/or suicide (Korn & Shaffer, 1999; Thomas & Jackson, 2008; Productivity Commission 1999). In contrast, protective factors affecting gambling uptake might arise through the propensity to gamble to socialise and relax with others and enjoy any economic outcomes (Korn & Shaffer, 1999; Shaffer & Korn, 2002). For gambling products and services, the influence of responsible gambling strategies publicised by signs and information in the gaming venues, through self-exclusion from venues and from media messages may be protective (QLD Treasury, 2004). For gambling outcomes, having adequate assets to budget for gambling and to provide a buffer against gambling losses (Thomas & Jackson, 2004; Productivity Commission, 1999, 2010) and having family support to help reduce or cease gambling if gambling problems arise (McMillen & Bellew, 2001) may be protective. Any or all of these potential risk and protective factors depend on personal, social, economic and cultural contexts. More risk factors have been identified in prior research than protective factors. In order to provide some balance in this analysis of gambling, the purpose of this chapter is to analyse risk and protective factors associated with gambling by Indigenous Australians in one region of New South Wales (NSW) Australia in order to inform public health measures directed at problem gambling.

3. Methods An appropriate research design should be culturally sensitive as well as methodologically sound. An interpretative qualitative research design (Guba & Lincoln, 1989) was seen as being culturally appropriate (Martin, 2008). Being based on respectful communication and mutual cooperation, this approach provided rich in-depth data and valuable information. After consultations and discussions, permission was sought and granted by Indigenous Elders in this region and by a university ethics committee for this research to be carried out. For the setting, in northern New South Wales the eastern corner is comprised of six adjoining local government areas (LGAs). Each LGA has a different geographic, social and economic profile but the Indigenous people of the six LGAs make up one tribal group. To request appropriate permissions for interviews and gather support for the research, we visited the six LGAs several times to explain the project. From an initial list of contacts of Indigenous people and organisations already known, each person interviewed was asked if they could identify other organisations and people relevant to the research. This sampling method, often called snowball sampling, was brokered by someone already known. It was useful in developing confidence and trust between people over time. Snowball sampling was used until all locations were visited and saturation was reached (Creswell, 2007). This process yielded interviews with 169 Indigenous Australians, 21 non-Indigenous Australian gaming venue managers and 10 non-Indigenous Australian gambling counsellors. On average, 30 Indigenous Australians were interviewed in each LGA, although only 20 were interviewed in one LGA where the population was small and widely dispersed. Semistructured interviews (single or in small groups of two or three) were mainly conducted in workplaces, community and health centres and coffee shops. The three researchers, one Indigenous man and two non-Indigenous women, conducted the one hour interviews in pairs, depending on cultural and gender issues. All interview notes and recordings were transcribed, then coded with N’Vivo software and analysed using thematic analysis (Braun & Clarke, 2006). The data were coded and analyzed

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within the larger constructs of the Thomas and Jackson (2004) model for the propensity to gamble, the use of gambling products and services and the consequences of gambling on gambling behaviour. These results are provided below.

4. Results For the results, risk factors, those that exacerbate and intensify adverse consequences of gambling, are presented first. These are followed by protective factors, those that assist people in making informed choices to protect them from harmful gambling consequences. Please note: all quotations are from Indigenous Australians unless described otherwise. 4.1 Risk factors for indigenous australian gambling Using the Thomas and Jackson (2004) model, risk factor results were analysed by propensity to gamble, by the use of gambling products and services and by gambling outcomes and consequences. 4.1.1 Propensity to gamble Risk factors including personal, family, financial, historical and cultural risks were identified by the research participants as increasing the propensity to gamble. Personal risks were seen as gambling to escape from grief and loss, from boredom, due to peer pressure, after consuming alcohol or drugs, from being unemployed and having time to gamble, from having literacy and numeracy problems, and to obtain relief from abuse. Explaining escape from historical grief and cultural loss, some respondents said ‘memories come up from the past and people push the memories down ... people turn to something, drinking, drugs, gambling, when the old memories surface’. Escape sometimes meant looking for some time away from stressful situations, either at home or at work. Several people mentioned escape in terms of ‘time out alone’ or a break away from heavy responsibilities. Other respondents saw that boredom was a gambling risk especially when people were unemployed, had plenty of free time to gamble and where alternative entertainment options were very limited. Risks arising from peer pressure were explained as ‘(some friends) won’t talk to you unless you’re with them when playing the (poker) machines’. Similar remarks were ‘(I) go to a venue with friends, and the next thing they are all on (poker) machines. If I want to talk to them I have to go over to the (poker) machines too. Then next thing you are putting money in too’. The use of alcohol and drugs with gambling was described as ‘a cycle involving low selfesteem that leads to drink and drugs’. Some gamblers were seen as being ‘vulnerable to making poor choices, but most want to get out of the cycle’. Several people commented that ‘Aboriginal people are used to being broke and having no money, so when gambling and the money is gone they do not seem to worry’. For some people it was ‘acceptable to be poor in Aboriginal community, where some learnt to live in Struggle Street, used to having nothing’. Explaining budgeting problems and gambling, one person felt many people had ‘not learned to control things in the welfare cycle, they need to learn skills ... need to learn to budget’. Family risks were said to include generational exposure to gambling, normalisation of youth gambling and a lack of education generally. Gambling was reported to be learnt from

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parents, family and grandparents where young people learn from exposure and experience. Childhood exposure to gambling and gamblers was apparent to some participants. ‘Kids learn the behaviour from parents and older generations ... when it’s generational it is very hard to break the cycle’. Some people stated that gambling experiences started early. ‘Generations, kids learn to drink and gamble from their parents … then these kids have their own kids and their habits continue’. In one location numeracy and literacy problems were high with one person claiming that not everyone can ‘read or write, cannot read signs in the pub (hotel)’. This was further explained as a consequence of some parents not being home to send children to school regularly. Financial risks were reported as gambling to increase income and to repay debts; and being used to being poor so gambling losses made no great difference to a life of poverty and a cycle of dependency for some. Gambling to increase incomes and reduce financial pressures ‘has gone down from generation to generation. It’s not dealt with, it’s on-going’. Being financially pressed can exacerbate gambling problems leading to ‘desperation for money, hoping to win the big jackpot one day’. Some gamblers were reported to believe that a big win would help solve their financial problems, assist them to repay debts and remove the need to borrow from family and friends. Linking gambling to social and economic disadvantage some participants explained ‘gambling is linked to unemployment, they have more time to gamble but getting a job is hard’. This can affect self-esteem. ‘People think that they are not good enough to get a job, you need experience and no-one gives Indigenous a go’. Summarising financial risks associated with gambling, an Indigenous respondent commented ‘Aboriginal people are always broke and are always looking for a quick fix even if they have only $5 left’. A major theme identified by participants was concern about financial risks. Historical risks were said to include the longevity of gambling as an Indigenous recreation activity and borrowing money for gambling from family and kin. An overwhelming risk was reported thus: ‘If you hang out with others at the venue, then you either gamble or are asked for money to support others gambling, especially younger people ... cultural values fall away with alcohol consumption and drugs and gambling’. Cultural risks were believed to be a loss of Indigenous values, respect and discipline and a deterioration of traditional reciprocity when used for gambling. Cultural losses were seen as diminishing leadership. ‘Aboriginal men had a role in society, now they don’t ... lost their way’. Others felt there was a ‘lack of leadership, there is a struggle to find great leaders in the community, Elders’. Many participants were saddened by the loss of Elders. ‘A whole generation of Elders died early, some people have never had Elders to nurture them’. Keeping Indigenous values and culture alive was hard where ‘there are less numbers of Elders to get advice’. Thus, risks associated with propensity to gamble reported by these participants included many personal characteristics, family and cultural factors. More structural risks were linked to financial and historical factors. 4.1.2 Gambling products and services Risks reported to be associated with gambling products and services were a variety of physical and sensory experiences connected to gambling. These included the sound, light

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and visual features of poker (slot) machines, their attractive marketing and promotion, and the emotional attachment some people have to a lucky machine or favourite form of gambling. Access to the gambling environment was reported as usually easy and free services enhanced the appeal of staying in a venue to gamble. Social access and acceptance were also risks for some gamblers. The attraction and risk of using poker machines was explained as ‘Aboriginal people like the features of the machines, such as free spins ... like the noise, lights and jackpots’. Others saw attachment to poker machines as being a risk. ‘People like to go to the same machines for luck because they think they know what features are needed to win’. Faulty beliefs were evident. ‘People believe you win money on machines after a win, that is, have a win and believe it’s easy to win (again) so they keep playing’. Superstitious beliefs were apparent when gamblers ask ‘What did you come and talk to me for? I was winning; now I have stopped winning because you started talking to me’. As one person explained, ‘People don’t know the probability of a machine to pay and don’t understand the outcomes of losing money’. Marketing risks were described as ‘Clubs always have marketing stuff to keep you in there ... venue advertisements, things you can win, free coffee’. Gambling advertising was seen as ‘very attractive and is in your face all the time’. Others reported acceptance as a risk: ‘People get sucked in by lights and surroundings of a comfortable venue … air conditioned … no hassles’. Access to gaming venues, such as hotels or pubs and clubs in urban areas, was generally easy. They provided food, drinks and a variety of hospitality and sports services. Many respondents agreed risks included attractive venue characteristics saying ‘(Gaming) venues are appealing because you can drink and socialise ... it’s all there … meeting place, alcohol, food, gambling’ and ‘poker machines in the indoor/outdoor area for smokers, very easy to get access’. Therefore, participants reported risks associated with the use of gambling products and services as physical and sensory features linked to gambling as well as freely available physical and social access to gambling. 4.1.3 Consequences of gambling Risk factors relating to addressing problematic consequences of gambling largely were found to be barriers faced in addressing gambling-related problems. These barriers seemed to fall naturally into two groups, intrinsic or personal barriers and extrinsic or external barriers. Intrinsic barriers were identified as shame, denial, depression and social and cultural norms. In the majority of interviews shame, denial and a subsequent loss of selfesteem were mentioned as barriers. People seemed to ‘find it hard to admit … a problem with gambling’. Some gamblers were said to be too ashamed to ask for help and become defensive about their problems. This was partly due to pride and partly because of historical discrimination suffered by Indigenous Australians. ‘Ways to resolve problems and arguments were removed in the oppression of our culture; it was not replaced, left with no way to resolve problem’. For other gamblers, ‘depression, schizoid and paranoid’ comorbidities arose as barriers to their seeking gambling help. People with depression were seen to have limited ability to cope with pressure from gambling-related problems. Indigenous gambling was very much seen as a social and cultural norm. ‘Gambling is seen as a normal thing to do. For many people it’s a routine to be going down to the pub or club’.

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These norms were associated with all age groups. ‘Gambling is seen as a common activity for young and older Aboriginal people to do’. One person summarised this risk by saying ‘Gambling, a lot of people don’t think it’s a problem because it’s a social thing’. Some Indigenous gamblers were said to be ‘comfortable living with low incomes’. Further, based on traditional obligations to share with those asking for help, some gamblers relied on ‘extended families who take on the role of feeding kids’. This meant that ‘the gambler is not challenged’ and that gambling problems were extended by family and cultural norms. Extrinsic barriers were reported by participants to include a lack of knowledge regarding gambling help services, poor access to gambling help, a lack of culturally appropriate gambling help services, a lack of gambling education and awareness, concern about confidentiality of gambling help services, and a lack of knowledge about self-exclusion from gaming venues. Several participants said there was ‘no awareness in community of gambling problems ... no programs in place for alcohol, drugs and gambling’. Additionally, other people maintained that many gamblers would not know where to get gambling help because they personally did not know of any gambling help services in their location. Many participants remarked that there were ‘no gambling education and awareness programs to let people know about services’. Logistical problems with isolation and a lack of transport made it even more difficult for some gamblers to access gambling help. For access to gambling help telephone services, a couple of participants noted that many Indigenous people ‘don’t want to talk about it (gambling) on the phone’ and ‘would not ring any support for help’. A lack of ‘culturally appropriate gambling help services’ was seen as a barrier. A key issue raised was Indigenous people do not like seeing non-Indigenous people for help. ‘They don’t like going to non-Aboriginal services’. Additionally, they are ‘not comfortable with a non-Aboriginal counsellor’. One person felt this was particularly the case for ‘the older ones (who) really like Aboriginal services with Aboriginal staff’. Commenting on the lack of services, participants said generally ‘there are not enough services (Aboriginal and nonAboriginal) to help people with gambling problems’. Many respondents noted that ‘Mainstream organisations are not addressing Aboriginal issues … are not culturally appropriate ... not capable of addressing Aboriginal gambling issues’. Regarding confidential services, Indigenous gamblers were concerned about trust. ‘(We) won’t go into non-Indigenous services because confidentiality is a problem’. Gambling help seeking is hindered because Aboriginal people are ‘naturally a shy race’ said one nonIndigenous gambling counsellor. ‘Aboriginal people do not like to talk to people about their problems ... through history they are told to keep their problems to themselves’. Thus, some people feel unable to share their problems resulting in hiding their gambling problems until a crisis occurred. Thus, intrinsic risks associated with gambling outcomes and consequences were said to be the personal risks facing some gamblers who were experiencing gambling-related problems but were unable to admit this because of their shame, their depression and social and cultural norms encouraging gambling. Extrinsic risks were reported to be the lack of awareness about and availability of gambling help services, a lack of provision of culturally appropriate gambling help services and counsellors, and concern about confidentiality and possible retribution.

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4.2 Protective factors for indigenous gambling Using the Thomas and Jackson (2004) model, protective factor results were analysed in relation to the propensity to gamble, the use of gambling products and services and gambling consequences. 4.2.1 Propensity to gamble Protective factors identified in relation to the propensity to gamble were grouped into personal, family, financial and cultural themes. Personal protective factors were seen as selfcontrol in controlling gambling activities, self-respect, having a purpose in life and high aspirations, being employed and earning money, learning from experience and religious beliefs. Several themes emerged from the interviews in relation to personal protective factors. Some of these were linked to having ‘high values’ including self-respect and respect for others. Having respect and self-control meant having the willpower to ‘control ... set limits’ for gambling. Similarly, holding high aspirations, including working for a living, was considered a protective factor reducing the propensity to gamble. ‘People who work, learn to control their money ... people who do not work hard to earn their money don’t value it as much as someone who works for it’. Thus, ‘people who work more tend not to be the regular gamblers. They value their money more than others’. Others also commented that people who are aware of themselves and have a purpose in life ‘don’t want to waste their money in the poker machines’. People had also learnt not to gamble through past experience because ‘people see what’s destroyed’. Some spoke about their childhood and how they ‘don’t want that for my kids, gambling and drinking, as seen in my parents’ behaviour’. In two locations, a couple of people spoke about how ‘the church and religion plays a big role’ as a protective factor for gambling. One person found strength through attending church services, saying ‘I’ve been going to church since I was little’ and that ‘church is strong here’. Family protective factors were reported to include having strong family influences, family values upheld and positive extended family or kin relationships. Having family around you was also considered a protective factor, mentioned in over half the interviews. This occurred because ‘a partner pulls you up’ and because ‘some families pull one another into line’. Other people talked about the importance of family values. ‘Kids, family help people see things that are more important ... different home life and values’. Family responsibilities took precedence for many: ‘family and kids, put money towards them first’. One person said ‘people learn to spend on important things like kids, food ... they budget’. Another said that ‘children change your life as a number one priority’. In addition, the extended family was also identified as being involved ‘maybe an aunt or uncle who takes a bit of time’ and ‘everyone is there to help each other out’ and were also seen as protective factors for gambling. Some respondents advocated alternative family activities. ‘To do something else, have an open mind, spend time with family, social outings, education and parenting classes’. That is, ‘Aboriginal people should look to replace gambling with something else – other options to relax, escape when bored’. Financial protective factors were said to be education and skills in financial management and small stakes betting. The importance of budgeting skills and money management was discussed in terms of paying bills first before gambling and also setting a gambling budget.

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‘I set myself a limit of $20 then and still stick to it now’ and ‘I set a limit, pay bills first and only gamble with what is left over’. Using strategies to control expenditure included ‘leaving the key (debit and credit) card at home to limit the money spent’ and another was ‘(to) give his money to his dad who helps him budget’. Other people set up automatic deductions from their welfare pension to ensure essential items were paid first and then spent the remaining amounts as discretionary spending. One person commented ‘I just don’t like losing money … when you weigh up the odds and how many times people win and how many times people don’t, it doesn’t add up’. Thus, being able to prioritise spending through effective money management helped people ‘(to) decide to put money to good use, know how to do this’. Financial education and management was recognised as being important. Cultural protective factors were believed to be Indigenous Elders acting as role models and people respecting and adhering to traditional Elders’ example, cultural cohesion and cultural values. As a source of power and wisdom, ‘Elders play an important role as a source of advice and authority’. As role models, Elders were reported as ‘leaders and role models, able to correct people who stray off the path’. With good role models ‘kids grow up to value hard work and money, education, good food, have a vehicle, employment’. Cultural cohesion was considered to be very important and there was a strong Elders’ presence in several communities which was not so evident in others. In locations where Elders authority was respected and heeded, ‘cultural values were held by both men and women’. Some people were said to ‘come back to [the] community to get help, get advice from Elders … Elders point people in the right direction to get help’. Here, it was said ‘[we] look after our own’. 4.2.2 Gambling products and services There were very few protective factors seen as being relating to gambling products and services and those that were mentioned were only suggestions, not really part of people’s experience. Some participants mentioned that developing an understanding of the odds of winning would be protective. A few others saw tighter legal controls over gambling spending and reduced attractiveness of poker machines as potentially protective. For example, some participants said that it was protective to ‘learn more about how you don’t win on a poker machine’, although another disagreed, saying that ‘knowing the odds wouldn’t help much as people still want to escape’. A few people acknowledged that ‘legislation really helps with limits on spending and this should be tighter’. Another suggested that ‘making (poker) machines less attractive … reduce visual stimuli’. In many ways, these protective factors were potential interventions for reducing gambling risks. 4.2.3 Gambling consequences Protective factors relating to the consequences of gambling were reported to include factors that facilitated people to be able to address their gambling-related problems. Protective factors were identified as the provision of culturally appropriate gambling help services and counsellors, provision of gambling education and awareness specifically for Indigenous people, encouragement of male role models as community leaders, and a combination of Indigenous community strength and support for people who need assistance. Like gambling products and services, protective factors associated with gambling consequences were mainly seen as being potentially protective because very few had been experienced by these participants.

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Most participants raised concerns regarding a lack of Indigenous gambling help services and Indigenous counsellors. They commented ‘people did not go to non-Indigenous services before now ... need more Indigenous services’. Some felt it was important to provide a ‘non-judgemental service that needs to be in an appropriate place and service’. Then Indigenous gamblers may attend ‘if people knew about it and it was culturally appropriate’. In regards to community education about gambling and its impacts, it was contended that the ‘Aboriginal population needs to be informed about health promotion. Intervention services could be promoting this on family days and (at) public health events’. Additionally, some suggested ‘group awareness sessions would be good, as when it’s individual (sessions) they think they are being singled out’. Many participants agreed that Indigenous people ‘need education about gambling ... money matters … financial education’. Another way to inform Indigenous gamblers was said to be through ‘clubs and pubs … like the smoking campaigns … they could do something similar’. Where gambling was seen as somewhat problematic in two locations, one facilitator seen to strengthen the community was having strong male role models. Several people said ‘men are missing from … this community’. There were ‘very few men here as role models’. Men were missing due to young deaths, accidents and incarceration with ‘some young boys, teens are in juvenile detention centre’. While very capable women Elders were leading one community, there was a ‘need for community leaders (to) build culture’ for men to balance the leadership roles and to make up the ‘loss of (male) culture’. The need for male role models was seen as one way to strengthen communities and provide young males with aspirations to become Elders. Another facilitator for addressing gambling problems raised in the interviews was said to be Indigenous community strength and support. Community strength would facilitate group solutions. ‘Community groups get together and work together. Get all groups together, talk about issues and target problems early to stop problems’. An example of support was recounted as a gambler who ‘tried to kick the habit and came to live here and gave it up’. In this case the influence of a strong community helped this person because they ‘dealt with this at a community level’. Some of these protective factors were potentially helpful interventions for reducing gambling risks. These included the provision of culturally appropriate gambling help services and counsellors and the provision of gambling education and awareness specifically for Indigenous people. More general protective factors such as the encouragement of male role models as community leaders and Indigenous community strength to support for people who need assistance were more general protective factors which could be related to any issues. 4.3 Suggested interventions to address gambling issues Of the numerous suggestions for potential gambling interventions, the most important and frequently mentioned appeared to be the need for relevant and appropriate community education and awareness programs about gambling, for culturally appropriate gambling help services and trained Indigenous counsellors, and Indigenous specific responsible gambling resources. Indigenous role models were seen as assisting in these processes providing people were trained. Many participants remarked it was important to ‘make the community aware and educate them about gambling’. A starting point involved first

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recognising gambling as being a problem for some Indigenous people and ‘start talking about gambling and the problems it can cause’. Some suggestions to facilitate community awareness and education included having ‘fun days, barbeques, that’s where people talk ... in workshops in the schools’. Other suggestions were ‘a big youth forum for the community’ and ‘use (Aboriginal) Lands Council to spread community awareness about gambling’. In regards to the provision of culturally appropriate gambling help services, many participants stressed the need for these by saying ‘people shy away from non-Indigenous services’; ‘some need to speak to Indigenous help’; ‘you need more Aboriginal people there, whether it’s psychologists or mental health workers’; and, ‘we need more Aboriginal counsellors’. A participant asked rhetorically ‘why won’t our people ring that (free hot line) number, because it’s got no Aboriginal staff’. Some people had a fear of being stigmatised. Highlighting the effects of historical discrimination, one person said ‘got to be Indigenous way, not colonial way’. Several participants made the point that non-Indigenous workers and counsellors should undergo cultural awareness training and that this ‘should be compulsory, Blackfellas access community services, therefore these services need to be able to help, therefore they need awareness training’. Indigenous specific responsible gambling resources were seen as being ‘Aboriginal advertising campaigns for gambling’; ‘Aboriginal specific signs and messages in (gaming) venues’ and ‘an Indigenous gambling help line’. A few participants commented that there were ‘not enough Aboriginal workers in hospitality who could raise gambling issues for Aboriginal gamblers’. It was felt that the gaming industry and governments ‘can provide much more awareness of gambling that is more focused and appropriate to Aboriginal people’. Governments were expected to take the lead in addressing these issues if they were genuinely serious about reducing harm for Indigenous gamblers.

5. Discussion Clearly in this chapter, more risk than protective factors have been identified and described as being associated with gambling. Risk and protective factors are now discussed using three fundamental elements of the Thomas and Jackson (2004) model, the propensity to gamble, the use of gambling products and services and the consequences of gambling. 5.1 Risk and protective factors associated with the propensity to gamble Risks that increased the propensity to gamble included personal, family, financial, historical and cultural risks. Personal risk factors centred on gambling to escape (from grief and loss, violence and abuse), and gambling to alleviate disadvantaged structural conditions (unemployment and a lack of education) and gambling under the influence of alcohol or drugs. The desire to escape was a risk factor that affected some gamblers more than others. For those removed from their families as children and raised in institutions with no access to their homeland and culture, gambling appeared to provide an escape from harsh experiences and hurtful memories. Indigenous Australian researcher Atkinson (2002) agrees that growing up with long-lasting and traumatic effects of discrimination, marginalisation and disadvantage is reflected in illness, dysfunction and dependency for Indigenous Australians. Experiencing lengthy stress and anxiety, Atkinson (2002:91) noted, ‘people

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begin to feel like losers’. Using gambling to escape appeared as a risk associated with gambling by some gamblers. Gambling was also used by some Indigenous Australians to try to alleviate their disadvantaged structural conditions such as a lack of education and employment, and by inference, living in poverty. Similarly, Dickerson et al. (1996) found that being younger, single, having a low income, not having full-time work, and having fewer resources to fall back on were multiple risks linked to Indigenous Australian gambling-related problems. Supporting evidence was also reported in New Zealand and Canada regarding gambling by Maori, Pacific and First Nation peoples (Ministry of Health, 2009; Williams et al., 2011) Thus, a lack of education and subsequent unemployment opportunities, underemployment and time to gamble were recognised in the current study as risk factors which increased the propensity for gambling. Previous research has noted that Indigenous gambling-related risks are heightened when alcohol is a significant problem (Aboriginal and Medical Research Council of New South Wales (AHMRC), 2007). The link between alcohol and drug consumption, Indigenous gambling and negative life events was established by Stevens and Young (2009). A sense of loneliness and internalisation of shame and guilt contribute to some Indigenous people’s use of alcohol and gambling in order to reduce their disadvantage (AHMRC, 2007). Selfprotective mechanisms can be used by people vulnerable to risk (Dyall, 2010). The comorbidity between gambling and alcohol use was not unique to this research. In contrast, personal protective factors appeared to be mainly centred on control, respect and religious beliefs. Similarly, self-control and informal group control protected Indigenous gamblers in north Queensland by reducing their propensity to gamble (Breen 2010). This often included a general agreement on money stakes, on pooled stakes, low denomination gambling and shared winnings. These gamblers regulated their gambling in a healthy, collective way. There was similar evidence of informal group control and selfmanagement found in this current research. Religious beliefs were found to help people make decisions to abstain from gambling or to gamble in a controlled way. Some people had experienced adverse consequences from earlier gambling and their religious faith helped them resist repeating those experiences. In this research, as in north Queensland (Breen 2010), religious beliefs appeared to provide non-gamblers and reformed gamblers with protection through their beliefs, values and involvement in religious activities. Family risk factors said to be associated gambling focused on generational issues and normalisation of youth gambling. Family and adult gambling has previously been seen as a model for gambling by younger Indigenous Australians (AHMRC, 2007; McDonald & Wombo, 2006). A family history of gambling is important for linking social relationships with gambling. Maori mothers and grandmothers were said to be role models for their children, socialising them into gambling (Morrison, 1999). Indigenous youth appeared to follow social norms for gambling in family circles. Thus, unhealthy gambling activity by adult gamblers provides an example to others, especially youth, which may reinforce this risky behaviour. However, protective factors were identified as strong family values and positive relationships. In north Queensland, Breen (2010) found role models to be parents, grandparents, extended family members and siblings. They assisted some gamblers to

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manage their gambling by advice and substitution of activities, such as fishing. Role models and strong family ties also helped shield some Indigenous people from pressure to gamble. Some gamblers were said to face financial risks and create a cycle of dependency in their efforts to increase income and alleviate poverty through gambling. This was exacerbated by having few skills in budgeting and financial management. Prior research has also found that Indigenous gamblers on low incomes are more likely to experience problems with their gambling because they can least afford to lose money (AHMRC, 2007). Stevens and Young (2009) found that Indigenous gambling problems were linked to low individual and household income, uncertain housing tenure and cash flow problems. Using gambling to try to increase resources is an unreliable and high risk strategy which may result in gambling with borrowed money. Gambling to make money was a risk associated with gambling. Conversely, a financial protective factor used by some gamblers in the current study was limiting gambling activities to small stakes betting and having some understanding of the odds of winning. Such limits generally protect against problem gambling, that is, gambling characterised by difficulties in limiting money and/or time spent on gambling which leads to adverse consequences for the gambler, others and the community (Neal et. al. 2005:125). A further protective factor was identified as education and skills in financial management, with some gamblers reporting that they pay their bills first and only gamble with discretionary funds. Historical and cultural risks were reported to be centred on the longevity of Indigenous activities (cultural acceptance) and a loss of traditional values and respect. Similarly, some gamblers in north Queensland also found it difficult or nearly impossible to avoid gambling activities by virtue of a history of gambling within their families and kin folk (Breen, 2010). When a cycle of gambling losses resulted in debts and loans incurred by chasing losses, the ripple effect of gambling losses was felt by others as gamblers borrowed money, food and other essentials. Reciprocity traditionally supported others in times of genuine need, but was found to be a risk for some gamblers when used to extend their gambling. However, protective factors included respect for cultural values and Elders’ authority. Engagement with culture and spirituality, Atkinson (2002) maintained, are the foundations of health and healing for those traumatised Indigenous Australians seeking escape through highly addictive behaviours. Indigenous role models, particularly the example of Elders in certain communities, were protective by providing cultural leadership when acting in ways that were positive, balanced and respectful of Indigenous values. 5.2 Risk and protective factors associated with the use of gambling products and services Risks associated with gambling products and services were reported by participants as including the physical and sensory experiences tied to gambling, use of ‘lucky’ poker machines, marketing and the gambling environment. Poker machine appeals include fast games, recognisable artwork and graphics, enjoyable sounds, pleasing music, free spins, intermittent payouts, cash prizes and jackpot prizes (Productivity Commission 2010). The participants’ mentioned a variety of attractive features making poker machine gambling a very popular form of commercial gambling here. Poker machine gambling has been linked to a heightened risk of developing gambling problems

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generally and particularly for Indigenous women gamblers (AHMRC 2007). Some gamblers here, both male and female, appeared to be captured by poker machines and were reluctant to stop gambling when other gamblers are unaffected. A favourable view of gambling was found to be supported by marketing and venue appeal. In research in the Northern Territory, increased Indigenous participation in commercial gambling has been attributed to the socially inclusive nature of the gaming venues (McDonald & Wombo 2006). Similarly, the use of Maori cultural symbols and traditions for marketing gambling businesses, Dyall (2009) argued, encourages Maori gambling. Some marketing and promotional activities were perceived as risk factors by participants in this research. Easy physical and social access was seen to increase the appeal of gambling, especially if life at home was tense or over-crowded. Gaming venues with comfortable facilities made it easy to stay in a venue and gamble, a finding also noted by the AHMRC (2007). Similarly, in New Zealand, Morrison (2004) found that Maori women sought glamour and comfort in gaming venues as well as an escape from stress. While few protective factors were found associated with the use of gambling products and services, our risk factor results are confirmed by the literature for Indigenous gamblers here. 5.3 Risk and protective factors associated with the consequences of gambling As noted earlier, risk factors relating to the consequences of gambling were mainly expressed here in terms of barriers to addressing a gambling problem, while protective factors related to facilitators to addressing a gambling problem. A most important intrinsic barrier centred on shame. Similarly, an important extrinsic barrier focused on a lack of culturally appropriate gambling help services. Shame experienced with gambling-related problems was recognised as a source of pain for Indigenous gamblers in the past (Breen, 2010; McDonald & Wombo, 2006). The main barriers for Indigenous people in help-seeking for gambling problems were shame and some unwillingness to trust the confidentiality of counselling services (AHMRC, 2007). In contrast, Dickerson et al. (1996) reported that, in New South Wales, Indigenous gamblers with gambling-related problems sought help for their gambling at five times the rate of nonIndigenous gamblers with similar problems. However, the type of help sought was not identified. Denial and concealment were reported here as preventing Indigenous gamblers from seeking help and a lack of appropriate gambling help services exacerbated this risk. In contrast, facilitators suggested by participants were personal recognition of a gamblingrelated problem. This depends on having a sufficient understanding of gambling and its related effects to recognise signs of a gambling problem and knowing where to seek help. Mainstream research has also shown that gamblers with family and social support have heightened capacity to address gambling-related problems (Thomas & Jackson, 2004). For Indigenous gamblers, supportive attitudes and assurance of family help have also been identified as important facilitators for help-seeking (Breen, 2010). A lack of culturally appropriate gambling help services was an important extrinsic barrier to seeking help for a gambling problem. Uncertainty was raised about culturally unfamiliar operational processes of the gambling help services, a variety of communication styles, unequal power relationships and the gender of the counsellors. These barriers to help-

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seeking have been raised previously (McMillen & Bellew, 2001). Facilitators to reduce these barriers included the provision of a range of gambling help services, including culturally appropriate community education and awareness, gambling counselling, trained Indigenous counsellors and for a few, rehabilitation. To reduce gambling risks and improve protection, the location of gambling help services within Indigenous health services could assist gamblers to access help without feeling shame. Although this research was undertaken in one area of New South Wales and does not represent the state population of Indigenous Australians, it does reveal information on risk and protective factors associated with gambling that has not previously been identified or documented. The qualitative interviews conducted here have brought to light numerous risk and protective factors that deserve further investigation, possibly using quantitative methods to allow for generalisability.

6. Conclusions The application of a public health model to investigate gambling by Indigenous Australians in one area, northern New South Wales, has highlighted the complexities of Indigenous gambling motivations, behaviours, consequences, risk factors and protective factors. Importantly, this research has pointed out the opportunity for potential interventions to develop culturally sensitive and inclusive responsible gambling strategies and practices reported to be appropriate for Indigenous Australians here. These strategies and practices, developed in cooperation with Indigenous Australians, could filter down into other communities, heightening protection of Indigenous gamblers through the active participation of Indigenous collaborators. It is hoped that this research has provided a useful platform from which such actions can proceed.

7. Acknowledgement This project and subsequent authorship of this article was funded by Gambling Research Australia. We acknowledge and thank the Indigenous Australians involved in this research for their generous cooperation and consideration.

8. References Aboriginal Health & Medical Research Council of New South Wales (AHMRC). (2007). Pressing problems, gambling issues and responses for NSW Aboriginal communities, AHMRC, Sydney. Australian Bureau of Statistics. (ABS). (2010). The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples, No. 4704.0. ABS, Canberra. Belanger, Y. (2006). Gambling with the Future, The evolution of Aboriginal Gaming in Canada, Purich Pubishing Ltd., Saskatoon. Belanger, Y. (2011). (Ed.). First Nations gambling in Canada: Current trends and issues, University of Manitoba Press, Winnipeg. Blaszczynski, A. & Nower, L. (2007). Research and measurement issues in gambling studies: Etiological Models. In G. Smith, D. Hodgins & R. Williams (Eds.). Research and

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measurement issues in gambling studies, pp. 323-344, Academic Press, Burlington, MA. Braun, V. & Clarke, V. (2006). Using thematic analysis in psychology, Qualitative research in psychology, vol. 3, pp. 77-101. Breen, H. (2008). Visitors to Northern Australia: Debating the history of Indigenous gambling. International Gambling Studies, Vol.8, No.2, pp. 137-150. Breen. H. (2010). Risk and protective factors associated with Indigenous gambling in north Queensland. Unpublished PhD thesis, Southern Cross University, Lismore. Breen, H. (2011). Risk and protective factors associated with gambling consequences for Indigenous Australians in north Queensland. International Journal of Mental Health and Addiction. DOI: 10.1007/s11469-011-9315-8 Published Online First 26.2.2011, Retrieved from http://www.springerlink.com/content/l152j81274544p52/ (17 October 2011) Breen, H., Hing, N. & Gordon, A. (2010). Exploring Indigenous gambling: Understanding Indigenous gambling behaviour, consequences, risk factors and potential interventions. Gambling Research Australia, Melbourne. Conner, T. & Taggart, W. (2009). The impact of gaming on the Indian Nations in New Mexico, Social Science Quarterly, Vol.90, No.1, pp. 50-70. Creswell, J. (2007). Research design: Qualitative, quantitative and mixed methods approaches (2nd edition), Sage Publications, Thousand Oaks, CA. Dickerson, M., Allcock, C., Blaszczynski, A., Nicholls, B., Williams, J. & Maddern, R. (1996). A preliminary exploration of the positive and negative impacts of gambling and wagering on Aboriginal people in NSW, AIGR, Sydney. Dyall, L. (2007). Gambling, social disorganisation and deprivation. International Journal of Mental Health and Addiction, Vol.5, No.4, pp. 320-330. Dyall, L. (2010). Gambling: A poison chalice for Indigenous Peoples. International Journal of Mental Health and Addiction, Vol.8, pp. 205–213. Guba, E. & Lincoln, Y. (1989). Fourth Generation Evaluation. Sage Publications, Newbury Park, CA. Hing, N., Breen, H. & Gordon, A. (2010). Respecting Cultural Values: Conducting a Gambling Survey in an Australian Indigenous Community. Australian and New Zealand Journal of Public Health, Vol.34, No.6, pp. 547-553. (DOI: 10.1111/j.17536405.2010.00624.x) Hing, N. & Haw, J. (2010). Influence of venue characteristics on a player's decision to attend a gambling venue. Gambling Research Australia, Melbourne. Holland, C. (2011). Shadow Report, On Australian governments’ progress towards closing the gap in life expectancy between Indigenous and non-Indigenous Australians. Close the Gap Campaign Steering Committee, Canberra. Korn, D. & Shaffer, H. (1999). Gambling and the health of the public: Adopting a public health perspective. Journal of Gambling Studies, Vol.15, No.4, pp. 289-365. Livingstone, C. & Adams, P. (2010). Harm promotion: Observations on the symbiosis between government and private industries in Australasia for the development of highly accessible gambling markets. Addiction, Vol.106, pp. 3-8. Martin, K. (2008). Please knock before you enter, Aboriginal regulation of Outsiders and the implications for researchers. Post Pressed, Brisbane.

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McDonald, H. & Wombo, B. (2006). Indigenous gambling scoping study - Draft report. School for Social and Policy Research, Charles Darwin University, Darwin. McMillen, J. & Bellew, N. (2001). ACT needs analysis, gambling support services. AIGR, Sydney. McMillen, J. & Donnelly, K. (2008). Gambling in Australian indigenous communities: The state of play. Australian Journal of Social Issues, Vol.43, No.3, pp. 397-426. Ministry of Health. (2009). A Focus on Problem Gambling: Results of the 2006/07 New Zealand Health Survey. Ministry of Health, Wellington, New Zealand. Morrison, L. (1999). The good and the bad times: Maori women's experiences of gambling in Rotorua. Unpublished Master’s thesis, University of Waikato, New Zealand. Morrison, L. 2004, ‘Pokie gambling and Maori women: Friend or foe?’ eGambling: The Electronic Journal of Gambling Issues, Vol. 12, Retrieved from http://www.camh.net/egambling/issue12/jgi_12_morrison.html (15 October 2011) Neal, P., Delfabbro, P. & O’Neil, M. (2005). Problem gambling and harm: Towards a national definition, Gambling Research Australian, Melbourne. Perese, L., Bellringer, M. & Abbott, M. (2005). Literature review to inform social marketing and approaches, and behaviour change indicators, to prevent and minimise gambling harm, Health Sponsorship Council, New Zealand. Productivity Commission. (1999). Australia's gambling industries. Inquiry Report No. 10, Ausinfo, Canberra. Productivity Commission. (2010). Gambling. Report no. 50, Canberra. Shaffer, H., & Korn, D. (2002). Gambling and related mental disorders: A public health analysis. Annual Review of Public Health, Vol.23, pp. 171-212. Stevens, M. & Young, M. (2009). Reported Gambling Problems in the Indigenous and Total Australian Population. Gambling Research Australia, Melbourne. Thomas, S. & Jackson, A. (2004). Influences on gambling behaviors and outcomes: A model for the design of effective interventions. Gambling Research, Vol.6, No.2, pp. 40-51. Thomas, S. & Jackson, A. (2008) Risk and protective factors, depression and comorbidities in problem gambling, Report prepared for beyondblue, The Problem Gambling Research and Treatment Centre, Melbourne. Volberg, R., & Abbott, M. (1997). Gambling and problem gambling among indigenous peoples. Journal of Substance Use and Misuse, Vol.32, No.11, pp. 1525-1538. Williams, R., Stevens, R., & Nixon, G. (2011).Gambling and problem gambling in North American Aboriginal People. In Y. Belanger (Ed). First Nations gambling in Canada: Current trends and issues, pp. 166-194, University of Manitoba Press, Winnipeg.

12 Self Medication, Drug Dependency and Self-Managed Health Care – A Review A. O. Afolabi

Department of Dental Services, Federal Medical Centre, Owo, Ondo State Nigeria 1. Introduction Craving for medicine and self medication has been part of mankind from one generation to another. People generally hold the view that medicines should be used in the event of any sickness or discomfort1. Consumers are being called upon to assume more responsibility for their health promotion and disease prevention practices. This challenge has motivated them to embrace the concept of self medication. It is a common knowledge that there are not enough Doctors and Pharmacists in Africa and other developing countries to direct and guide everyone who become ill on the correct use of medications. Drug manufacturers have not helped matters as their chief concern is to promote the sale of their medicines without giving adequate information to the public on such drug if possible in the local language. This is compounded by high illiteracy level, poverty and inadequate health facilities and personnel. Self medication offers a way out as people begin to sense the positive benefits of multiplying their options in health care. In the developed countries with sufficient health manpower, many people still buy non-dangerous medications without a doctor’s prescription2,3. These are the over-the-counter (OTC) drugs whose sales statistics reflect the pattern of self medication4. Studies in Britain and United States show that on the average 50-75% of health care takes place within the realm of self medication5,6. This practice cuts across culture, gender, health and social status, race, occupation or any other sociodemographic or sociomedical state. A cost benefit study in the UK concluded that availability of OTC drugs to the public results in saving the General Practitioner’s time besides other benefits to the consumer since he /she can attend to other matters at the same time7. The total health expenditure within a country’s gross domestic product (GDP) strains the public purse to which increasing demand is made. One potential means of reducing this pressure within the health budget is a greater reliance on self health care. Self care users may visit the physician less often and stay fewer days in the hospital resulting in lower expenditure for the hospital and Physician services8. Self medication is however of public health concern because of the problem of drug misuse and abuse and its attendant medical (drug resistance and hypersensitivity), social (juvenile delinquency) and psychological (addiction and physical dependence) problems. In addition,

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lack of knowledge of possible side effects of self-administered medication and possibility of selling potentially dangerous drugs as over-the-counter in developing countries could have a deleterious effect on the general health of the public. This paper attempts to review existing information in the literature on the scope and distribution of self medication, its relationship with drug dependency and possible factors which might affect it. Recommendations are made on how self-medication can be effectively utilized in self managed health care.

2. Historical perspective Man has used drugs for various purposes from the dawn of history. Herbal and other plant derived remedies have been estimated by the World Health Organization (WHO) to be the most frequently used therapies worldwide. Plant-derived remedies can contain chemicals with potent pharmacologic and toxicologic properties9. From the ancient civilization of South America came cocaine obtained from the leaves of Erythroxylon coca which was chewed for pleasure and reduction of fatigue. Extracts of cacti and mushroom species, used for religious purposes among Central and North American Indians can be used as an hallucinogenic agent. In Africa, eserine, a component of miotic eyedrops develops from Calabar beans used in fetish practices. Bronchiodilatory effects of ephedra develops from ephedra plants species in ancients China while digitalis, a potent heart stimulant was developed from purple foxglove, an ingredient of herbal folk medicine in England10. Self medication had also been derived from other sources outside plants. In the southern United States of America, certain foods are used to reduce the excess volume of ‘blood’ which was believed to cause the illnesses; in Latin America, certain foods are used to counteract ‘hot’ or ‘cold’ illness and to restore the body equilibrium 11; in the majority of Xhosa speaking women of South Africa, indigenous healing practices are used for themselves and their babies because of the need to ‘strengthen’ the womb against sorcery, prevent childhood illness and to treat symptoms they perceive biomedical services would not be able to treat12.

3. Scope and distribution The concept of self medication, encouraging an individual to look after minor ailments with simple but effective remedies, has been adopted the world over. People hold the view that medicines should be used in the event of any sickness or discomfort12. In the United Kingdom, the government encourages self reliance while agencies like WHO promote individual family and community participation in primary health care13. Poor diagnostic ability compounded by a limited knowledge of appropriate management results in the increase of self medication and low rate of health care utilization14. People are more likely to seek care from Physicians for symptoms that are serious since it was perceived that Doctors do not have time for trivial complaints15. Hence, whenever they perceive a symptom as minor, self medication was usually used for treating themselves16. A survey conducted in Poland revealed that self medication, while widespread, does not imply a negative attitude towards health professionals or the existing system of medical care17. On the contrary, people began to sense the positive benefits of self care among which is its apparent

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contribution toward improvement of the efficiency of the over all health care system of themselves18. The basic knowledge about the proper way of dealing with drugs and potential dangers of self medication is both insufficient and under estimated. This can be seen from earlier19 and later20 studies conducted in Switzerland and Nigeria respectively which revealed that nearly one third of the population lacked sufficient drug knowledge. Lam and co-workers also showed that lack of knowledge was common with its side effects21. In spite of the above shortcomings in knowledge, individual attitude to self medication has not diminished as can be seen from various studies conducted worldwide which revealed prevalence which range from 60-90%22,23. For instance, Afolabi in a study of market women in a suburban community of Lagos, Nigeria reported 95-98%24; Omolase et al established that 79% of ophthalmic patients25 and 85% of patients in the general out patients clinic26 in Owo, Nigeria admitted self-medication and Servidoni et al in an Ear, Nose and Throat clinic in Brazil reported 83%27. Bamgboye et al, in a study of workers in a tertiary hospital in Nigeria reported a prevalence of 73%23, Onajole et al28 established in Lagos, Nigeria that 71% of their respondents admitted to drug misuse, Agbor and his co-worker29 reported 67.8% prevalence for oral health problems in Cameroun while three studies of different population groups in Sudan reported that 81.8%30, 79.5%31 and 73.9%22 respectively engaged in self medication without prescription or medical advice. However, other studies revealed a much lower prevalence for self-medication. For instance, it was 22% in a population-based study in Czechoslovakia32, 42% among dental outpatients in Nigeria33, 32.5% in a study among Hong Kong Chinese population21, 27.5% in a study conducted among Ethiopian populations34, 22% among ophthalmic patients in Ibadan, Nigeria35 and 31% of ear, nose and throat outpatients in Nigeria36. The extreme variation in figures might be due to the composition of the sample population, survey location and methods22. Majority of those who self medicated reported improvement of their symptoms and this could have accounted for the delay in presentation at the clinic/hospital22,23. This was confirmed by a Nigerian study of infants with acute respiratory tract infection which revealed that 32% had been treated with cough medicines, 42% with antipyretics, 5% with antibiotics and 10% with haematinics before they were brought to the clinic37. For chronic health problems, people device strategies of self care over months and years and apply them during flare-ups38. For instance, a study of asthmatics showed that while 80% of sufferers tended to reduce doses following improvement, 48% of these bought their drugs without prescription for prophylaxis and in case of flare-ups39. Among migraine sufferers, 42% self-treated themselves instead of consulting Physicians as most sufferers have learned to live with their condition40. This was further confirmed in a study of Canadian migraine sufferers where about 90% used OTC drugs to self-treat their ailments whenever they had an attack41. Pharmaceuticals can be bought without a Doctor’s prescription for self-treatment in most pharmaceutical shops in developing countries. It was 51% of drug sales in an Ecuadorian study 42, 66.3% from a study in the Phillipines 43 and 80% of drug purchases in a study across the U.S-Mexico border3. In countries where drug purchase is regulated like Portugal, a reduced prevalence of 26.2% was reported44.This emphasizes the importance of careful drug history for General Practitioners and Physicians so as to be aware of what patients are

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taking before treatment commence especially where subtherapeutic doses are involved. For instance, Bosch and co-workers reported self medication with subtherapeutic doses of the analgesics, aspirin and paracetamol even though full doses of diclofenac was prescribed by the physician45. The prevalence of self medication during pregnancy was low compared to the general population. This could be because drug use during pregnancy was mainly decided by the Obstetrician as revealed by the 5% prevalence rate from a multicentre study in Spain46. The rate was 10% among pregnant women of varying gestational ages in another Spanish study47. Self medication and traditional medicine dominate alternative health care strategies of child health in the tropics48. However, this practice is not limited to the tropics as a study in Spain showed that of children faced with acute illness, 86.6% previously self medicated for respiratory symptoms49. Babies are not spared as large number are given “gripe water” for no valid reason or for only trivial symptoms by their mothers50. Self medication could also account for why some fail to complete their hospital treatment especially for chronic illness. It was reported that 72.9% of the non-attenders at paediatric tuberculosis out-patient clinic self medicated with the antituberculosis drugs intermittently and beyond the period allowable51. In patients with sexually transmitted diseases (STD), the prevalence of self medication might actually be higher than reported. A study in a STD clinic in the United States showed that while only 14% admitted self medication with antimicrobial agents, urinary assay was positive for 60% of those using the agents52. Failure to tell the truth on the questionnaire might be due to the stigma attached to their ailment. Urinary assay for household drugs was also used to determine drugs available for self medication from a survey of urban and rural households in Zimbabwe53. Malaria is one of the major killers in developing countries. The use of antimalarias was not free from self medication as revealed by a hospital-based study in Tanzania where 72.7% of patients reported having used home kept antimalaria medication for suspected malaria fever54. People can also self-treat for malaria using herbal remedies or medications purchased from local shops as a study shows that 60% of malaria cases were self-treated through this means while only 18% received treatment at the local health centre55. People afflicted with chronic illness sparingly see a Doctor for their ailments as they learn to cope using self medication. It was reported that nearly six million Americans with selftreated arthritis never saw a Doctor for their condition even with severe limitation of activit56. This was also seen among migraine sufferers in Kenya where a study revealed that 56% resorted to self medication though 40% sought medical attention57. Among commercial sex workers, self medication with antibiotics was perceived as a potential means of protection against STD and acquired immune deficiency syndrome – AIDS58. In smokers, the practice may be used to self-treat negative effects with nicotine as evidenced by the occurrence of major depression in some who try to quit the smoking habit59. Health care providers are favourably disposed to self medication. It was reported that General Practitioners expected other Doctors to self-treat themselves rather than consult

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their fellow colleagues60. Tong and co workers reported a 60% “ever used” rate of self medication among pharmaceutical representatives probably due to their continuous exposure to drug samples of pharmaceutical companies61. Self medication with antibiotics is a common practice. Of medications consumed for self treatment in Nigeria, it accounted for 63.4% in an urban slum62, 44% among urinary tract attendees prior to hospital admission63, 39% among medical undergraduates64 and 24% for treating menstrual symptoms65. In addition, it accounted for a substantial percentage of diarrhoea treatment. A Nigerian study revealed that 53% of cases were self-treated with antibiotics while only 40% of cases were treated by prescriptions from the clinics66. The selftreated cases were usually associated with a higher risk of using inadequate medication or dosage. Bojali et al reported self medication with antibiotic for diarrhea in 37% of cases even though it is indicated in 5% of cases. It is noteworthy also that about 27% of cases used inadequate antibiotics in terms of duration and dose67 though previous study reported 67.7%68. Among market women, self medication with antibiotics accounted for 18% of all drugs used for this practice69. However, 90.4% of cases had incorrect knowledge about its dose and duration20. Possible explanation for this high prevalence of incorrect dose had to do with the time constraint in following the six hourly regimes of antibiotics for at least five days. This may seem laborious once the symptoms abate compared to single daily drug dosages which antihelmintics, laxatives/purgatives and sedative/hypnotics are known for. This might account for the latter’s correct dose which are easy to remember20. Self medication with analgesics is a common practice. The prevalence rate among market women was 31.3% of all drugs used in self medication20. A population-based study in Sweden revealed that 35% used a form of analgesics in the past two weeks due to selfperceived poor health and pain70. A study among the disabled with painful ailments reveals that about 50% self medicated with analgesics everyday71. Majority of people with acute episodic headache self medicated with OTC analgesics which was believed to be more adequate than if prescribed while those with chronic headache treat themselves with prescribed drugs from previous doctor’s visit72. In the dental profession, pain is the most likely symptom which could result in analgesic use without the Doctor’s prescription. Dentists are aware that patients with dental pain often use OTC analgesics on their own to alleviate symptoms or to avoid the need for dental attendance altogether29,33,73. A study revealed that the current use-rate was 52.9% among children with post-operative dental pain74. Apart from pharmaceutical products used by the majority, a minority patients use dangerous substances to alleviate dental pain such as battery water, local gin and ‘touch and go’ solution33, petrol and vinegar29. Drugs used for self medication in some countries are prohibited or strictly regulated in other countries. A study of some Mexican Pharmacies revealed that while 14.3% of drugs sold are strictly regulated, 51.4% of such drugs were obtained for self medication purposes75. Self medication with re-used needles and syringes for home injection of medications and vitamins may be a risk factor for transmission of HIV infection according to an exploratory study in the United States76. Apart from using prescribed drugs, natural medicines have also been used. For instance, 35% of women referred to a Gynaecologist admitted self medication with natural medicines77. Nutritional or dietary supplements like vitamins, minerals, herbal

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products, tissue extracts and protein solutions are also used by Americans as dietary supplements, for energy and immune system enhancement and cancer prevention78. Self medication has some life saving advantages. It has been shown that people self treating reflux oesophagitis with antacids had a low prevalence of pre-neoplastic and neoplastic pathologies while the use of alginate in 68% of cases relieves symptoms79.

4. Self medication and drug dependency The abuse of various self medication compounds for chronic illnesses may or frequently lead to a state of dependency. Aspirin, acetaminophen and caffeine were the most frequently abused among chronic headache sufferers80. Substance abuse and drug dependency have multiple causes ranging from poor instructions from the physician, improper diagnosis with gradual increase in amount consumed, a reinforcement mechanism and brain stimulation effects80. For instance, cocaine acts directly on the “pleasure centres” of the brain to release dopamine which triggers an intense craving for more of the drug otherwise a painful withdrawal symptom persist. It therefore produces pleasurable sensation of “reward” and physical dependence81. Nicotine, the psychoactive ingredient in cigarettes is an addictive agent that can stimulate and relax the user. Hence, some smokers self-treat negative moods with it59. Approximately, 30% of women from a study conducted in the United States, smoke cigarette during pregnancy despite its deleterious effect on the mother and foetus82.The beverage, alcohol (ethanol) was so commonly consumed that it is seldomly thought of as a drug. When consumed in small quantity, it induces a feeling of well being and relaxation while in large amounts, intoxication is produced. It can therefore be used as a form of self medication to achieve any of these states82. It may also be used to cope with perceived problem of sexuality83. The relationship between self medication and drug dependency was explained with the self medication hypothesis of addictive disorders defined by Khantzian as motivation of patients to seek a specific drug (reinforcement mechanism) for relief of a particular set of symptoms for adaptive purposes84. However, not all cases of drug dependencies follow this hypothesis because there are traits or symptoms which separate various groups of drug dependent individuals85,86. As a result, Khantzian87 revisited his theory in 2003 and stated that there was growing clinical support for the significant relationship between substance abuse disorders and psychiatric disorders as opposed to simple personality. Hence, people who are not receiving proper mental health treatment are attempting to selfmedicate for their disorders by using illicit substances.

5. Self medication – Sociodemographic and medical factors Despite a growing research interest in self medication, little information has been available about its major determinants. Individual self care in illness is shaped in the social environment – a major determinant of the type and amount of health care services used88. The sociodemographic determinants are age, gender, occupation, education, marital status, religion, race, income and culture. The sociomedical factors may be related to the female

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reproductive role (pregnancy, breast feeding, and menstruation), psychiatric disturbance, medical states like asthma, migraine and so on. The younger age group engaged in self medication than the older ones29,44,56,70,89,90. However, some studies revealed no association between age and self medication16,24,91,92. Women have above average knowledge about drugs and risks of self medication compared to men19. They also had a much higher probability of using supplements, OTC tranquilizers and analgesics for self medication than men who on the other hand commonly use more stimulants3,70,93,94. Self medication with drugs to relieve depressive symptoms was far more likely in men than women95. Factors related to general health status and women’s reproductive role influences gender differences in self medication96. During breastfeeding, self medication was dictated by the mother and her infant’s disorder. In addition, women with pre-menstrual symptoms use caffeine as a form of self medication to relieve the symptoms97. However, some studies revealed no association between gender and self medication16,91,92. Various studies consistently showed that self medication was associated with educational level. For instance, there is a positive correlation between level of education and self medication16,18,24,65,89,98,99. The trend of consulting patent medicine dealers for prescription decreases with acquisition of more formal education24,98,100. While studies showed no correlation between self medication and occupational status17,18, others revealed some association. For instance, employment status affected the pattern of OTC and prescription drugs96. Specialist in anaesthesiology, emergency medicine, general and family practice self medication than other medical specialist probably due to habitual overwork and unrestricted access to drugs101. The relationship between race and self medication had been documented from various studies. Non whites had a higher probability of using tranquilizers than whites94 and whites likely than blacks to consume supplements93. Among the elderly, fewer blacks reported the use of OTC medications than non-blacks102. While some studies found little or no association between self medication and social status17, others reported that among school aged subjects, social classes of parents has a direct relationship with drug consumption among their children103. The influence of culture is common in health related states and was related to female reproductive roles like childbirth, and in the treatment of morbidity and mortality in children104. Athletes consume sex hormones to alter their menstrual cycle so as not to disturb the training schedule and competitive programme while some use anabolic steroids to enhance their performance10.

6. Self medication – Commonest complaint responsible Usually, self medication is indicated for trivial symptoms perceived by the patient. It was favoured for skin condition, general health care, aches and pain, problems of the eye, mouth, gastrointestinal and respiratory tract105. Among adult patients with acute pathology, the most common complaints were pain and increase body temperature106. In a recent rural population study in Nigeria, it was in the order: malaria, gastrointestinal problems and urinary tract infections107. Among rural Japanese housewives it was headache, tiredness and gastrointestinal problems while in American and British housewives, it was emotional or

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psychological complaints108. Among children, respiratory symptoms common cold 92 with or without fever 109 were the commonest complaints.

49

especially for

With the use of antibiotics, the indication varies with different studies. The commonest complaints were for soft tissue, sexually transmitted diseases, upper respiratory and gastrointestinal tract infection110; upper respiratory tract infection91; respiratory infection38; throat, dental and urogenital infection111; respiratory tract infection and acute diarrhoea68,112 and diarrhoea, abdominal pain, fever and rashes20. For analgesics, the commonest complaints associated with its use are limb and back pain45; self perceived pain and poor health70; and body pain, headache, body weakness and fever5. Supplements are consumed for enhancement of diet, energy, immune system and for cancer prevention78.

7. Self medication – Commonly used medications Several medications have reportedly been used for this practice. This included antibiotics, analgesics and vitamins1, analgesics, vitamins and oral antibiotics among primary care patients16, while for OTC drugs, the commonly requested were for nervous system113, analgesics, cough or cold medications42. Among adult married women, the commonly used medications were vitamins and contraceptives114. Among market women surveyed in a sub-urban community in Nigeria, antipyretic analgesics, haematinics/vitamins, antibiotics, antimalarials and alternative or traditional medicines respectively were commonly consumed69. In an European study of those presenting with acute illness, the most commonly used medications were analgesics and antipyretics106 and among paediatric presentations were antipyretics, analgesics, antitussives and antibiotics49. In a community-based pharmacy study in Portugal, the main therapeutic groups used for self medications were in the order: throat, cough, cold, stomatological, laxative, analgesics and dermatological products respectively54; antibiotics and antimalarials for illness management107 and analgesics and antibiotics in dental outpatients20 from recent Nigerian studies; analgesics, cough, cold remedies, antiallergies, vitamin and energy tonic were the commonest OTC used as revealed from a recent review of selfmedication in India89. Orthodox medications were preferred to traditional African medicines for most common symptoms. However, some studies in developing countries revealed that people prefer traditional African medicines for diarrhea, vomiting, cough and cold115, rheumatic and neurological complaint100. Among Hong Kong Chinese, Chinese tonic was the most frequently used traditional medicine for self medication which was perceived as equally effective as western medicine21. The most commonly used supplement among Americans were minerals, multivitamins, vitamin C, calcium, vitamin E and A93 while the remaining percentage were for herbal products, megadose vitamins, protein and amino acid preparations78.

8. Self medication – Places where drugs are obtained and sources of drug knowledge The common places for drug supply were in the order: pharmacies, general medicine dealers, hospital/clinics, traditional sources, private practitioners and other sources115 like

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household medicine cabinet containing previous medical prescriptions which may not have been prescribed for the same condition116. Recent studies agreed that the pharmacy, roadside/patent medicine stores were the commonest places where drugs were obtained for selfmedication purposes. Other studies90,117 also agrees that family medicine cabinet were sources of self medication. However, the common sources of household stock are chemist, pharmacy, supermarket, hospital/clinics, friends and relatives118. In developing countries common sources of antimalarials used for self treatment were street and village shops and this could account for up to half of antimalarial drug distribution119. Recent studies in Nigeria and Cameroun24,29 agrees with the above showing that the hospital/pharmacy, patent /road side medicine dealers, and local hawkers/mobile drug vendors and native healers were the commonest sources. In choosing the most appropriate medicine to buy from the chemist shop, people relied on the advice of the sales clerk in the chemist shop1 , print media, family and friends24,29,120,121, pharmacist, general medicine dealers, general and private medical practitioners24. Among the young ones, sources of drugs knowledge include family members especially the mother (for therapeutic purposes), peer groups and illegal market (for intoxication purposes) 122. Among secondary school pupils in an Hong Kong study, the sources were in the following order: family members, previous illness experience, pharmacy shops, doctors or nurses, television or radio, newspaper or magazines, friends and teachers90. For painful condition, people self select drugs for self medication while small percentages were advised by the pharmacist or non-health professionals65,123. Since individuals suffering from sexually transmitted diseases often treat themselves with antibiotics, the common sources of drug supply were the medicine cabinet at home and the sources of drug knowledge were family members and friends. For dietary supplements, the principal source of drug information was the mass media52.

9. Self medication – How and when People who self medicated reported taking one or several medications and more often one or two medications were involved20,26,33,116. Individuals sometimes self administer medications via drug identification. Trade names were common means of identification and less frequently by generic names, action, color, shape and common usage names24,124. In painful complaints, the number of analgesics and duration of consumption was directly related to the intensity of the pain123. This was collaborated by a study among dental patients which revealed that the majority use analgesics within one week of presentation and only present when the pain did not resolve20. Self medication is commonly associated with subcurative doses. This can be seen from antimalaria therapy with chloroquine either administered orally or via injection98 and with antibiotic use where two-third of individuals used it for less than five days or in insufficient quantity20,68,112. Among pregnant women interviewed, over fifty types of symptoms necessitated self treatment47. In asthmatics, most of the sufferers tended to reduce their doses of medication following improvement of their symptoms39. Sometimes, consumption of household

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medications may be incorrectly volunteered but could only be confirmed by urine screening test for such medications53.

10. Self medication – Side effects and risk Although these medications are considered risk free and useful for the treatment of common health problems, their excessive use can also lead to serious side effects and unfavourable reactions89. For instance, the therapy may be poorly suited for the illness in question, delay diagnosis and the beginning of effective therapy, increased inorganic risk(s) due to inadequate drug therapy or of unnecessary expense116 and drug interaction between prescription and non prescription drugs99. The prevalence of side effects was associated with lack of knowledge about the drug prior to its usage21. Insufficient curative treatment with chloroquine (CQ) for individuals who treat themselves for suspected malaria fever could result in resistance to Plasmodium falciparum – the agent causing the ailment125,126. Chronic CQ toxicity was important in the causation of heart block in Africa, CQ retinopathy and abnormal ophtalmological findings, cardiac arrhythmia127,128. Stevens–Johnson syndrome following self medication with Fansidar has been reported129. With respect to OTC medications, reported risks associated with the improper use includes addiction, gastric irritation, liver toxicity, rebound headache syndrome41 , milk alkali syndrome130; dental caries from prolonged usage of self administered mineral supplement containing lactose131; liver toxicity/failure following prolonged use of analgesic containing paracetamol for dental pain132 ; peripheral neuropathy and subdermal vascular dermatosis following Vitamin B6 megatherapy133; cholinergic excess, loss of consciousness and seizure following cutaneous application of Diazinon, an organophosphate insecticide for pubic lice134. In addition, laxative abuse causing ammonium renal urate calculi, gastrointestinal fluid and electrolyte loss resulting in chronic extracellular volume depletion and intracellular acidosis had also been reported135. Simbi et al recently reported in-utero-ductal closure following near term maternal self medication with Nimesulide and Acetaminophen136. Self administered oral diuretics could result in pseudo-barter syndrome (hypokalaemia, metabolic alkalosis, hyperaldosteronism, hypomagnesimia, normocalcimia and hypocalcuria)137. Topical anaesthetic abuse of the cornea with subsequent fungal (candida) keratitis138 and severe toxic keratopathy139 had been reported. Sometimes, the side effect which could be dermatological tends to be the primary cause of drug intolerance. For instance, cutaneous manifestation of psoriatic arthritis could be exacerbated with ibuprofen self therapy140, fixed pigmented eruptions could be manifestation of such drugs, which if unrecognized, might be fatal if such a drug was repeated141. Among the elderly, adverse reaction to drugs are characteristically more frequent and severe as a result of factors including self medication142. In the case of substance abuse, depending on the substance used, it may result in organ damage, medical complications, vascular injury, less than satisfactory quality of life and depression80. Among alcoholics, male and female fertility can be interfered with82.

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Drug use before hospital admission is a source of potential drug toxicity and may obscure the diagnosis of infective illness and delay hospital stay143. It has been shown that the five most common adverse events following self medication related hospitalization were upper gastrointestinal bleeding144, skin rashes, hypoglycaemia, hypercorticism and hepatitis145.

11. Reasons for self medication The common reasons could be to cure an ailment24, suppress its cause indefinitely to give the body time to completely overcome it or for prevention, prophylaxis, palliation, convenience, postponing a natural event, out of habit or for special purposes10. In some cases, the main reasons could be triviality of the symptoms24,25,105, to save money and time16,24,33,120, lack of gravity to go and see a physician because they can take care of themselves117 or previous medical prescription for related symptoms21,109. In specific diseases like acute non specific diarrhea, people self medicated because the ailments were of short duration, can be treated symptomatically with non-prescription medications and adequate hydration and do not require a visit to the physician office146. In the case of chronic illnesses, it could be the cost of medication, patient’s psychological status, perceptions of the seriousness of their illness and vulnerability to complications147. For antimalarials, self medication with orthodox medication was greater than traditional remedies because of their efficiency, popularity, cheapness and availability98, distance and cost of seeking care from the formal health service99 and cultural beliefs148. Among market women, reasons given for self medication was in the order: for minor ailments, cheapness and because they know what to do24. Among dental patients, since the commonest complaint was pain, the main reason for self medication was to serve as a means of avoiding the need for dental attendance altogether73. Acute headache sufferers may treat themselves with OTC if they perceive it to be more adequate than prescribed drugs72. Reasons for using psychoactive drugs among the young people range from insomnia, worry or depression to intoxication122 while smokers may self treat negative effects like major depression with nicotine59.

12. Self managed health care Self medication is a necessary and important aspect of daily health care. It encourages self reliance for curative, preventive, promotive and rehabilitative care18. It appears to be substitute for, rather than supplements or stimuli for health service utilization149. In the Federal Republic of Germany and Switzerland, its importance in health care system had been recognized because of possibility of self treatment of minor illness and its health economic benefits150,151. Since individuals have a certain right to reasonable self mediation, an important aspect of a qualitative improvement of the practice was the information, education and counseling of the patient of which the pharmacist plays a major role152. In view of this, Ruegg reported that pharmacist in Switzerland had accepted this aspect of patient’s education and are adjusting their education to the problems of self medication150. This role of Pharmacist had also been suggested in a later study24,153,.

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In some cases, the practice is frequently and successfully used. An Australian-based study revealed that in only 2% of cases self treatment for minor ailments were the actions taken assessed as inappropriate and potentially harmful154. This agrees with a later study which showed that few, if any were consuming nutrient supplements in amount considered toxic93 and that most consumers used self medication preparations in a safe and proper way155. This agrees with other studies20,109. Hence, in some patients, self medication was recommended if they continue to have recurrences of a chronic infective process156. Further, because OTC drug sales statistics reflects pattern of self medication, it may be used to monitor the practice4. The above reflects the need for a liberal regulatory environment and comprehensive information package in consumer-oriented language. This could be achieved via consumeroriented advertisement and consumer product package leaflet. Advertisement gives consumers choice to determine what to buy. The government benefits since the consumers can buy OTC drugs with their own money and does not engage government health care budget for minor ailments157. Hence, one potential means of reducing pressure on the health budget of a country’s gross domestic product (GDP) is a greater reliance on self health care7. In a rehabilitative setting, patients could be actively involved in their medication program and be independent on the use of their medications when they leave hospital. A self medication program fulfills this role158,159. Therefore, during drug advertisement, advertising agencies should emphasize the possible side effects as they do for cigarette smoking. By this people are well informed as they read or hear it (especially if illiterate). Because the practice of self medication is worldwide, careful drug history by General Practitioners and Physicians is important to know what patients are taking before treatment commences especially when subtherapeutic doses are involved.

13. Conclusion Self medication is a necessary and important aspect of primary health care which if properly managed could be incorporated in the health care delivery system to reduce the burden on the secondary and tertiary level so that attention could be focused on the more serious health problems.

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[142] Bengaud S and Saint-Jean O. Properties of drug complications in elderly patients. Rev Prac 1990; 40(15): 1366-1370. [143] Martinez-De-Jesus F.R., Gallardo-Hernandez R., Morales-Guzman M., Peres-Morales A.G. Delay in hospitalization diagnosis and surgical intervention in acute appendicitis. Rev Gastroenteol Mex 1995; 60(1): 17-21. [144] Afolabi A.O, Adekanle O. Nonsteroidal Gastropathy in a Dental Patient: A case report. Nigeria Medical Practitioner 2008; 53(6):110-112. [145] Lin S.H and Lin M.S. A survey on drug related hospitalization in a community teaching hospital. Int J Clin Pharmacol Ther Toxicol 1993; 11(2): 66-69. [146] Brownlee H.J Jr. Family practitioner’s guide to patient self treatment of acute diarrhoea. Am J Med 1990; 88(6A): 275-295. [147] Cornelly C. An emperical study of a model self care in chronic illness. Clin Nurse Spec 1993; 7(5): 247-253. [148] Foster S. Treatment of malaria outside the formal health services. J Trop Med Hyg 1995; 98(1): 29-34. [149] Fleming G.V., Giachello A.L., Andersen R.M, Andrade P. Selfcare, substitute, supplement, or stimulus for formal medical care services. Med Care 1984; 22(10): 950-966. [150] Ruegg A. Contribution of the Pharmacist to safety of self medication. Soz Praventivmed 1986; 231(3): 160-164. [151] Beske F and Hanpft R. Status of self medication in West Germany. Soz Praventivmed 1986; 31(3): 156-159. [152] Meyer U. Thoughts on the qualitative improvement of self medication. Soz Praventivmed 1996; 31(3): 166-169. [153] Viberg N. Selling Drugs or Providing Health Care?: The role of private pharmacies and drugstores, examples from Zimbabwe and Tanzania. Pharm World Sci 2009; 29(1): 25-33 (Appendix XLV) Abstract. [154] Wilkinson I.F., Darby D.N., Mant A. Self care and medication. An evaluation of individual’s health care decision. Med Care 1987; 25(10): 965-978. [155] Cranz H. Over-the-counter drugs. The issues. Drug Saf 1990; 5 Suppl 1: 120-125. [156] Mulholland S. Guidelines for management of the problem patient. Urology 1988; 32(2 suppl 1): 28-31 [157] Reinstein J.A. OTC Advertising: In whose interest? The Manufacturer’s viewpoint. WHO Drug Information 1995; 9(1): 11-13. [158] Kelly J. Implementing a patient’s self-medication program. Rehabil Nurs 1994; 19(2): 8790, 95. [159] Love C.J., Raynor D.K., Coyrtney E.A., Purvis J., Teale C. Effects of self medication programs on knowledge of drugs and compliance with treatment in elderly patients. Br. Med. J 1995; 310(6989): 1229-1331.

13 The Relationship Between Alcohol Consumption and Human Immunodeficiency Virus Infection and Risk Behaviour: A Systematic Literature Review of High-Risk Groups, with a Focus on South Africa Manuela G. Neuman1,2,*,†, Michelle Schneider3,†, Radu M. Nanau1,2, Charles Parry3,4 and Matthew Chersich5,6 1Departments

of Pharmacology & Toxicology and International Health, University of Toronto, 2In Vitro Drug Safety and Biotechnology, MaRS, Toronto, ON, 3Alcohol & Drug Abuse Research Unit, South African Medical Research Council, Cape Town, 4Department of Psychiatry, Stellenbosch University, Cape Town, 5Centre for Health Policy, School of Public Health University of Witwatersrand, 6International Centre for Reproductive Health, Ghent University, Ghent, 1,2Canada 3,4South Africa 5,6Belgium 1. Introduction The most common mechanism for contracting the human immunodeficiency virus (HIV) is through unprotected sexual intercourse with an infected partner. Biological aspects in the acquisition of HIV such as biological susceptibility to HIV infection are also important, but infection with HIV cannot occur without the behavioural component of bodily fluids mixing between HIV-positive and HIV-negative individuals. This study will focus on the behavioural component of unprotected sexual activity and alcohol consumption in terms of risk for HIV infection. Physiologically, alcohol use loosens inhibitions and impairs cognitive functions, which may lead to unsafe sexual behaviour, essentially unprotected sex. The relationship between alcohol use and the contracting of HIV is complex, as other confounding variables such as certain personality traits or alcohol expectancies also have an effect on both risky sex and alcohol consumption. These confounding variables may explain or partially explain the observed association between alcohol consumption, unsafe sex and HIV infection. * †

Corresponding Author Contributed equally to this paper

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Alcohol has been implicated in the transmission of HIV via unsafe sex in many systematic reviews examining this association. These literature reviews and meta-analyses have varied foci. Cook and Clark (2005) examined the association between alcohol consumption and sexually transmitted infections (STIs). Baliunas (2010) looked at alcohol consumption and risk for incident HIV. Fischer (2007) and Kalichman (2007) conducted global-level systematic review studies in Africa and sub-Saharan Africa (SSA) respectively. Woolf-King and Maisto (2011) conducted a narrative literature review that included qualitative and quantitative literature on the link of alcohol and high-risk sexual behaviour in sub-Saharan Africa. Pithey and Parry (2009) conducted a descriptive literature review examining studies that quantified the association between alcohol consumption and HIV in SSA. The results included a highrisk group category of shebeen/beerhall patrons and bar and hotel workers. Braithwaite et al., (2007) showed that alcohol consumption impacts negatively on people living with AIDS (PLWA). These reviews and the Braithwaite study, while consistently indicating a strong association, do not provide sufficient epidemiological evidence of causality between alcohol use and HIV sero-conversion. They only demonstrate that alcohol is an important correlate of sexual risk behaviour in populations. However, event-level studies, such as the diary studies of Leigh (2008) and Room (2008), have provided less-convincing evidence than the aforementioned global-level studies for the link between alcohol use and HIV via unprotected sex. This can be attributed to the fact that event-level studies can better control for confounding variables. Conversely, Kiene (2008) showed in the first diary study in South Africa (SA) that moderate or higher drinking levels prior to sex increased the likelihood of unprotected sex. Overall, the lack of conclusive evidence of a causal link between alcohol consumption and the transmission of HIV does not justify taking no action (Hill, 1965; Phillips 2004). No action implies that alcohol interventions as HIV prevention or treatment measures are not implemented. In addition, there is evidence that indicates that alcohol consumption has a harmful impact on the pathogenesis of HIV. Alcohol reduces an individual’s immune response (Friedman et al., 2006), hence increasing the susceptibility of contracting HIV and other opportunistic infections. For an HIV-positive person on antiretroviral medication, alcohol has a negative effect on HIV treatment adherence (Hendershot et al., 2009). Furthermore, antiretroviral drugs (ARV) and alcohol are both metabolized by the liver. Long-term alcohol abuse can result in liver disease, which in turn affects the ability of the liver to metabolise the ARVs (Shuper et al., 2010). There is sufficient epidemiological evidence that alcohol consumption is linked to HIV progression (Parry et al., 2009). Furthermore, Rehm et al., (2009) and Gmel et al., (2011) modelled the impact of alcohol on ARV adherence and HIV mortality. In light of the above evidence, the nexus of alcohol misuse and HIV is an important research arena, especially in SA, a country with one of the highest rates of HIV infection globally, as well as one of the highest per drinker alcohol consumption rates (Fritz et al., 2010). Sexually transmitted diseases are the leading risk factor for death and disability in SA, with 98% of these disability adjusted life years (DALYs) due to HIV / AIDS (Johnson et al., 2009). High alcohol consumption rates also translate into an enormous disease burden attributable to alcohol itself (Schneider et al., 2007). It is estimated that 5.6 million people are living with AIDS in SA with the adult prevalence at 17.8% in 2009 (UNAIDS, 2010). As is the case in the rest of SSA, high proportions of the general population in SA abstain from drinking alcohol (Obot 2007; Parry et al. 2005). The per capita annual alcohol consumption in SA is estimated

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between 10.3 and 12.4 litres (Rehm 2004). However, those who do drink do so to intoxication, particularly during weekends (Parry et al., 2005). In SSA, the alcohol consumption per drinker is 19.5 litres alcohol (Roecke et al., 2008). This figure is slightly higher in SA, at 20 litres per drinker per annum (Rehm et al., 2003). These high alcohol consumption levels for those who drink together with the high background prevalence of HIV do not augur well for the containment of the HIV epidemic in SA. Alcohol consumption is a multi-dimensional variable that includes volume, consumption patterns, as well as the context of consumption. Although all these factors impact on the outcome of interest, in this case, unsafe sex, the context provides the platform for the physical and psychosocial factors to play out and interact, often synergistically, thus creating greater chances of contracting HIV. Chersich et al., (2010) points out that it is often the context of alcohol consumption that is particularly unsafe for adolescents, sex workers and migrant labourers in SA. These individuals tend to be generally more vulnerable to contracting HIV due to inexperience with alcohol and sex in the case of adolescents, or due to illegal or transient positions for the latter two groups, respectively. A worrisome trend is the high alcohol consumption in certain sub-populations in SA, particularly emerging adults, farm workers and mine workers. For example, Madu and Matla (2003) reported that 39.1% of emerging adults consume alcohol. Problem drinking in farm workers has been estimated to be in excess of 65% (London, 2000) and over a quarter (26.3%) of HIV-positive mine workers were found to be meeting criteria for alcohol abuse (Säll et al., 2009). Moreover, in a sample of migrant women, alcohol use was a direct predictor of HIV-positive sero-status (Zuma et al., 2003). In a recent South African report, the definition of most at-risk populations (MARPs) for HIV/AIDS was expanded to include persons who drink excessively (Shisana et al., 2009). Globally, there are two patterns on how the HIV epidemic presents in populations. In many SSA countries, there is a generalised epidemic, as opposed to other countries where it is concentrated in high-risk groups. SA is experiencing a so-called generalised HIV/AIDS epidemic, defined as having an HIV prevalence rate in the general population greater than 1%, with heterosexual intercourse being the predominant mode of HIV transmission. Sexual networking within the population is sufficient to sustain the epidemic, despite high-risk sub-populations that contribute disproportionately to the spread of the disease in SA (Ngom and Clark, 2003). Notwithstanding the above, in the present review, we discuss the link between alcohol consumption, risky sexual behaviour, and the risk of HIV infection in high risk groups worldwide, with a particular focus on SA. This study will add to the accumulating evidence for delineating the causal pathways of alcohol use and risky sex to HIV infection. Many of the mediating factors in the causal web of alcohol use, unsafe sex and HIV acquisition tend to be more potent and hence easier to ascertain in some of these high risk groups. An important focus for HIV prevention research is to examine the role of alcohol with respect to risky sex in high HIV risk sub-populations. Universally, sections of populations have higher HIV prevalence rates than the general population. HIV/AIDS MARPs usually include men who have sex with men (MSM), injecting drug users (IDUs) and sex workers. These high-risk groups have larger pooled odds ratios (ORs) of alcohol use and HIV-positive status than the general population (Fischer et al., 2007).

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Fig. 1. Depicts female sex workers (FSWs) as key determinants for sex-concurrency for their clients, who include MSM and heterosexual individuals, who can be migrant workers, army personnel, adolescents and/or IDUs. These high-risk groups engage in patterns of behaviour that carry elevated risk for HIV infection (Parry 2008a). A component of these lifestyles may include closed or interconnected social and sexual networks within these sub-populations with relatively high HIV sero-prevalence rates. In addition, “bridging” effects among individuals from these groups leads to a wider network of HIV transmission. Figure 1 is a model of a network of HIV transmission in the presence or absence of alcohol consumption among the selected high-risk groups reviewed in this paper.

2. Materials and methods We performed a systematic review of published literature using PubMed, searching for articles that contained information about alcohol drinking patterns and sexual risk behaviours. We limited the search to literature published in English. In order to obtain more focused results so that we could, where necessary, refer to South Africa, we also included the words “South Africa” for the search. However, we did not have “South Africa” as an exclusion criterion. We found over 4000 results using the key words “alcohol” and “HIV”, from which we selected 750 of the most recent publications (i.e. June 2008 to June 2010). Reading these articles, the majority were in vitro studies of alcohol or HIV, or were performed on animals, or they described molecular mechanisms or discussed only one of the risk factors; often sexual transmission and alcohol were referred to only once, in passing. For the period January 2008 to October 2010 there were 183 articles that pertained to humans. From the 183 articles, 107articles were selected. The main reason for discarding 76

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articles was that they did not discuss alcohol consumption and risky sexual behaviour; the two variables were not linked in any way. The 107 articles were allocated to one or more of the six high-risk groups selected for the study. (Figure 2) Particular attention was paid to those papers that provided an indication of the drinking pattern (e.g. binge drinking, continuous drinking, alcohol abuse and alcohol intoxication) and the amount of alcohol consumed. Where the relationship between alcohol consumption and unprotected sex was quantified in the individual articles, this was captured and reported on.

PubMed Search “alcohol & HIV” 750 results prior to October 2010

183 articles published mostly between January 2008 and October 2010 were read

107 articles characterized populations, patterns of alcohol consumption and unsafe sexual practices. The articles were further divided and analyzed 17 CSWs (Table 1a) and 6 clients of CSWs (Table 1b)

4 army personnel (Table 2a) 5 migrant workers (Table 2b)

33 heterosexual individuals (Table 3a Table 3c)

16 MSM (Table 4)

9 IDUs (Table 5)

17 emerging adults (Table 6a and Table 6b)

Fig. 2. Flow diagram of the systematic literature review We also discuss a limited number of relevant papers published prior to 2008, which were used to emphasize some of the points that were not well represented in the more recent publications. These additional papers were obtained via a manual search of the reference sections of the articles obtained from the PubMed search.

3. Results This section is divided into six subsections, corresponding to each of the six at-risk groups that are discussed in detail. 3.1 Female Sex Workers and their clients The alcohol and condom use patterns of commercial sex workers (CSW), particularly FSWs, are described in Table 1a. In addition, the alcohol and condom use patterns of clients of the CSWs are described in Table 1b.

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Sex with a customer is often accompanied by alcohol consumption, as shown by studies in Afghanistan (Todd et al., 2010), China (Rogers et al., 2002; Wang et al., 2010), India (Bowen et al., 2010; Go et al., 2010; Samet et al., 2010; Verma et al., 2010), Kenya (Chersich et al., 2007), Mongolia (Witte et al., 2010), the Philippines (Chiao et al., 2006; Morisky et al., 2010), Scotland (Thomas et al., 1990), South Africa (Wechsberg et al., 2005; Wechsberg et al., 2009), Tanzania (Fisher et al., 2008; Fisher et al., 2010), the United States (Nemoto et al., 2003), and Vietnam (Nemoto et al., 2008). Alcohol is also consumed by male clients of FSWs in India (Madhivanan et al., 2005; Rodríguez et al., 2010; Samet et al., 2010; Schensul et al., 2010; Verma et al., 2010), Scotland (Morgan Thomas et al., 1990), Sri Lanka (Dissabandara et al., 2009), Thailand (Havanon et al., 1993), and Zimbabwe (Fritz et al., 2002). In addition, FSWs often consume alcohol together with their clients, as observed in massage parlours and bars in Vietnam (Nemoto et al., 2008), the Philippines (Chiao et al., 2006), the United States (Nemoto et al., 2003), China (Wang et al., 2010), India (Rodríguez et al., 2010) and Tanzania (Fisher et al., 2008). An Indian study found that alcohol consumption for both FSWs and their male partners are above the national average for their respective genders (Samet et al., 2010). In a sample of 335 FSWs and 171 female non-SW in South Africa, FSWs were found to be more likely than females who were not sex workers to suffer from an alcohol abuse disorder (Wechsberg et al., 2009). Some women describe alcohol use as a way to please the partner, when this is what the partner wants (Witte et al., 2010). 3.2 Female Sex Workers A sample of 48 FSWs report that they used alcohol in large amounts in order to decrease inhibitions prior to sex work and to cope with the stigma, psychological distress and violence brought about by their sex life (Witte et al., 2010). Other reasons for alcohol use were to conform to norms of sex partners who preferred them to be intoxicated and would pay more in these situations (Witte et al., 2010). Other groups also report than some FSWs use alcohol to make sex easier (Wechsberg et al., 2005; Nemoto et al., 2008; Todd et al., 2010). Drinking before sex with a client is linked with life-long inconsistent condom use in 454 FSWs (Wang et al., 2010). However, Wang et al. (2010) did not find a direct link between alcohol consumption, condom use, and STD prevalence, supporting the theory by Fisher et al. (2010) that the negative influence of alcohol on condom use is event-specific, rather than global. In support of this, the Mongolian study referred to earlier found that inconsistent condom use also occurs as a result of a partner being willing to pay more for unprotected sex, rather than due to alcohol use per se (Witte et al., 2010). Generally FSWs who used alcohol before sex with a client, compared with those who did not, were more likely to use condom inconsistently and to be STD-positive (Wang et al., 2010). Eighty five percent of FSWs report that their clients sometimes refused to wear a condom. In a different study in a sample of 3412 FSWs alcohol consumption and HIV prevalence were found to be high whereas condom use was found to be very low suggesting an inverse relationship between alcohol and condom use (Verma et al., 2010). Alcohol use has a significant association with having a non-paying male partner and having sex with more than three partners per day in 63.7% of FSWs (Verma et al., 2010). Alcohol use prior to sex leads to inconsistent condom use for both male migrant workers as well as for FSWs. HIV/AIDS education and an increase in a sex worker’s ability to use a condom effectively have been linked with decreased alcohol consumption and more frequent

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condom use, particularly among those FSWs who are also IDUs (Fisher et al., 2008; Strathdee et al., 2009; Morisky et al., 2010). A direct correlation between decreasing daily alcohol consumption and increasing consistent condom use was found in a sample of 911 FSWs (Morisky et al., 2010). Studies conducted in India report inconsistent condom use among FSWs who consume alcohol (Bowen et al., 2010; Go et al., 2010; Rodríguez et al., 2010; Samet et al., 2010; Verma et al., 2010). The rate of inconsistent condom use was found to be very high and no significant differences were found between FSWs who consume alcohol (even in high quantities) and those who do not, in a sample of 211 HIV-positive FSWs (Samet et al., 2010). Fifty seven percent of women report to have used alcohol around the time when they first entered sex work (Bowen et al., 2010). The study in a sample of 220 FSWs (Bowen et al., 2010) found that alcohol and drug consumption has increased since the time these women entered into the sex trade industry. To complicate matters even further, Chiao et al. (2006) report that alcohol consumption with a customer was accompanied by a significantly higher willingness to use a condom in a sample of 1,114 FSWs. Not surprisingly though, condom failure was also high in intoxicated FSWs or FSWs with intoxicated customers, and STD prevalence was significantly higher in FSWs who had sex with intoxicated customers than in FSWs who did not have sex with intoxicated customers (Chiao et al., 2006). However, alcohol consumption by the FSW did not increase the STD risk any further in this case. Similarly, FSWs who were intoxicated prior to sex were more prone to have STDs than FSWs who were not intoxicated, regardless of the partner’s status (Chiao et al., 2006). In a sample of 159 FSWs (53 working in massage parlours, bars/clubs and the street respectively), massage parlour FSWs report that alcohol consumption was inevitable for them, as it was part of the job (Nemoto et al., 2008). Alcohol consumption was higher for massage parlour and bar/club FSWs, where alcohol was often consumed with customers. In addition, 30% of street-FSWs were also IDUs, using mainly heroin (Nemoto et al., 2008). No significant association was found between condom use and having sex with a customer while under the influence of alcohol. Condom use for vaginal sex with a primary partner was very low, with over 65% of subjects reporting never having used a condom in this situation. Sex under the influence of alcohol was highest for massage parlour FSW and lowest for street FSWs. The trend was the same between sex with casual partners and sex with primary partners (Nemoto et al., 2008). The risk of condom failure increased significantly if one or both of the partners had been drinking within two hours before sex (Fisher et al., 2010). Condoms are more likely to be used in unfamiliar places, with first-time partners, or if sex was transactional (Fisher et al., 2010). In addition, Fisher et al. (2010) observed that a condom is 10 times more likely to be used if the woman was involved in the decision. In support of this argument, an Indian study found that FSWs avoid using alcohol in order to remain alert throughout the encounter, and to decrease the risk of violence (Rodríguez et al., 2010). This corroborated findings by Go et al. (2010) who report that alcohol consumption before sex, by either the FSWs or her partner, is associated with forced sex in 522 FSWs. In 93 FSWs, Wechsberg et al. (2005) found that FSWs who have been sexually abused are more likely to use condoms inconsistently and to become HIV infected. Daily alcohol consumption was reported by 18% of this sample. Although not significant, women who have been physically abused were

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more likely to use alcohol daily than those who were never physically abused. In contrast, those women who have never been sexually abused were less likely to consume alcohol daily than those who were sexually abused (p<0.05) (Wechsberg et al., 2005). Another study found that binge drinking was statistically associated with sexual violence in 719 FSWs (Chersich et al., 2007). In a study of Thai army conscripts, several male respondents reported that they use alcohol as a socially-acceptable excuse to not use a condom, and they relied on the FSW to put on the condom (MacQueen et al., 1996). On the same note, Nemoto et al. (2008) explained their finding that condom use was lowest in FSWs working in bars and clubs as customers of these women insisted that a condom is not used. In the same study, one massage parlour FSW argued that she tried to convince her partner to wear a condom, but she sometimes agreed to have unprotected sex because the partner would pay better (Nemoto et al., 2008). Condom negotiation is often hindered by having an inebriated partner. Women often compromise as they have low bargaining power (Nemoto et al., 2008; Rogers et al., 2002). At the same time, fear of violence often diminishes the power of a woman to negotiate condom use (Witte et al., 2010). In comparison, a Chinese study found that 63% of FSWs refused to provide sexual services to partners who refused to wear a condom (Rogers et al., 2002). Not surprisingly, condom use is not the only determinant of HIV infection. Nemoto et al. (2008) found the highest HIV prevalence (18%) in street FSWs, the group that had the lowest rate of inconsistent condom use. Sex under the influence of alcohol was lowest for street FSWs, with either casual or main partners, and it was highest for massage parlour FSWs. Sex under the influence of alcohol was overall higher with main partner, and condom use was lower (Nemoto et al., 2008). Interestingly, sex under the influence of alcohol, at least with a main partner, was reported by 100% of massage parlour FSWs interviewed, yet none of these women were found to be HIV-positive (Nemoto et al., 2008). The same group also found no HIV-positive Asian masseuses in a sample of 100, although STD prevalence was quite high at 94% (Nemoto et al., 2003). In this case, condom use was higher among AsianAmerican masseuses, with both casual partners and the main partner (Nemoto et al., 2003). In contrast, a Philippine study reports that sex with an intoxicated customer was higher among street FSWs, and STD prevalence was high in these situations (Chiao et al., 2006). In India, Verma et al. (2010) found a significant association between alcohol use and having more than three partners per day, both paying and not paying. In these cases, condom use is minimal, and this problem is even more pronounced in migrant FSWs who travel greater distances (Verma et al., 2010). Greater alcohol consumption was associated with a higher number of sex partners in a sample of 1044 FSWs working in bars and hotels (Fisher et al., 2008). It appears to be alcohol consumption, rather than the pattern of drinking, that is linked with HIV risk factors (Chersich et al., 2007). Chersich et al. (2007) found lifetime alcohol consumption, rather than binge drinking, to be linked with being seropositive. At the same time, daily drinking and consuming more than the equivalent of 11 beers in one week are strongly associated with being HIV-positive (Fisher et al., 2008). In addition, HIV risk was positively correlated with the amount of alcohol consumed per drinking occasion, peaking for 3 drinks per occasion, which is less than the level necessary to qualify a woman as a binge drinker. Daily drinkers were nearly four times more likely to be HIV-positive when compared with non-drinkers (Fisher et al., 2008). Alcohol users are more likely to have multiple sex partners (bar and hotel patrons) and are more likely to be HIV-positive (Fisher

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et al., 2008). In addition, everyday alcohol consumption and binge drinking were significantly associated with inconsistent condom use (Chersich et al., 2007). Despite binging being associated with higher sex risk factors, it did not increase HIV prevalence. Furthermore, binge drinking is associated with sexual violence (OR 1.85, CI 1.27-2.71, p<0.001) and other STDs (OR 1.56, CI 1.00-2.41, p=0.048) (Chersich et al., 2007). Among lifelong alcohol abstainers, HIV prevalence was significantly lower than it was among FSWs who had ever consumed alcohol. However, the drinking pattern did not have any significant effect on the HIV status, as the study did not find an association between binge drinking and a higher chance of contracting HIV, than among those who had ever consumed alcohol (Chersich et al., 2007). 3.3 Clients of Commercial Sex Workers A study of 206 male and three female clients of CSWs found that over 55.0% of CSWs were perceived to be under the influence of alcohol by their clients (Thomas et al., 1990). Interestingly, alcohol consumption did not influence condom use when the CSW was a female, but was negatively associated with condom use with a male CSW (Thomas et al., 1990). Condom use is event-specific for FSWs (Fisher et al., 2010; Wang et al., 2010), and the same can be said for clients of FSWs. Havanon et al. (1993) report that visiting FSWs is a socially acceptable for married men in the Thai society. In a study of 181 male clients of FSWs, condom use was found to be influenced by the perceived “cleanliness” of the establishment and the FSW, as well as the perceived number of sex partner that she has had, rather than one’s state of inebriation. Condom use was higher for students (Havanon et al., 1993). Being drunk is not reported as a reason for not using condoms. In a sample of 84 single male drinkers (aged 18 to 29 years), lower condom use was observed when sex took place away from the brothel, or when a certain level of intimacy with the CSW was achieved. However, no association between alcohol consumption and condom use with a CSW was reported (Schensul et al., 2010). Sex with a FSW while under the influence of alcohol was high in a sample of 1741 men in an STD clinic. Ninety two percent reported sex with a FSW, with 66% having done so under the influence of alcohol (Madhivanan et al., 2005). Sex while under the influence of alcohol was associated with unprotected sex, anal sex, multiple FSW partners, and a history of STDs (Madhivanan et al., 2005). In a sample of 205 HIV-positive men 26% reported inconsistent condom use with a FSWs and this was found to be correlated with alcohol consumption (Samet et al., 2010). Condom use was slightly higher among younger individuals (Samet et al., 2010), which is similar to findings by Havanon et al. (1993) in Thailand. In a sample of 324 male drinkers, the number of drinking days was associated with the number of unprotected sex episodes with casual partners of CSWs, as well as having sex while intoxicated (Fritz et al., 2002). At least one episode of sex while intoxicated during the previous six months was reported by 31% of subjects. Sixty nine percent of these men reported doing so with casual partners or CSWs. Having sex while intoxicated was linked with a 20-fold higher chance of having unprotected sex with a casual partner, and a 27-fold higher chance with a CSW. The number of drinking days was correlated with the number of episodes of unprotected sex with casual partners, episodes of paying for sex, and having sex while intoxicated (Fritz et al., 2002). There was also a strong link between having sex while intoxicated and HIV sero-conversion. Of HIV-positive men, 35.7% report to have drunk to

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intoxication on more than 16 days in the past month. Having sex while intoxicated was associated with a positive HIV status in 37% of the male subjects interviewed. Having sex while intoxicated in the last 6 months was significantly associated with recent seroconversion (OR 4.5, CI 1.0-19.4) (Fritz et al., 2002). 3.4 Army personnel and migrant workers The alcohol and condom use patterns of army personnel and migrant workers are described in Table 2a and Table 2b, respectively. 3.4.1 Army personnel Alcohol abuse is a common problem in army personnel, both active personnel and veterans. Alcohol abuse in this population has been linked with non-monogamous heterosexual sex, including sex with CSWs (MacQueen et al., 1996; Brodine et al., 2003; Tavarez et al., 2010). In a study of 498 sexually-active male military personnel, alcohol abusers were found to be more prone to have multiple sex partners, have sex with CSWs, and use condoms inconsistently. Nineteen percent of individuals, mainly unmarried men, reported having sex with a CSW. The odds of having multiple sex partners were higher in individuals suspected of alcohol abuse. Nineteen percent of the sample reported sex with a CSW, while 93% of this subgroup was believed to suffer from probable alcohol abuse problems. Individuals with suspected alcohol abuse problems were twice as likely to engage in non-monogamous sex, with inconsistent use of condoms. Two hundred and sixteen individuals reported being in non-monogamous relationships, with inconsistent condom use; of these, 86.6% report probable alcohol abuse problems (Tavarez et al., 2010). In a small sample of 76 young male army conscripts, the majority of the subjects reported using alcohol in a social setting, where all the individuals in the group would drink. Alcoholic beverages were often consumed in brothels, where the subjects would also have access to FSWs. In this context, alcohol was used to decrease inhibitions when interacting with the women, and to increase sexual pleasure (MacQueen et al., 1996). On the other hand, condoms were reported by army personal to decrease sexual pleasure, and alcohol consumption provided a socially acceptable excuse not to use a condom (MacQueen et al., 1996). Brodine et al. (2003) argued that the types of HIV infections identified in a large cohort of 520 recently-infected HIV-positive military personnel reflected the areas of the world where the soldiers were deployed, providing evidence of unprotected sex, possibly with CSWs. For example, 488 patients were infected with HIV-1 subtype B. Individuals with non-subtype-B HIV were likely to be married, and they were likely to have contacted the virus from CSWs outside the USA. Forty four percent of these subjects were heavy alcohol users, this was higher than the overall HIV cohort (OR 2.3, CI 0.6-10.3) (Brodine et al., 2003). In 881 HIV-positive veterans, Conigliaro et al. (2003) found that hazardous drinking was common. Hazardous drinking was linked to disease progression, as well as the cooccurrence of other conditions such as hepatic co-morbidity and anaemia. Alarmingly, hazardous drinking predominated in younger individuals and those with detectable viral loads (Conigliaro et al., 2003).

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3.5 Migrant workers As is the case for army personnel, migrant and seasonal workers are another group of individuals who live away from their spouses. Gupta et al. (2010) differentiate between temporarily mobile individuals and permanently mobile individuals. In India for example, most migrants travel in order to provide better conditions for their families, and this may make these individuals less prone to risky sexual behaviour (Gupta et al., 2010). At the same time though, a positive association between the length of time that an individual is mobile for and the number of lifetime sexual partners, including paid sex, was found in a national survey of 124385 women (15 to 49 years) and 74369 men (15 to 54 years) (Gupta et al., 2010). Higher alcohol consumption and a high prevalence of STDs were observed in those migrants who were mobile for the longest periods of time, who used alcohol almost daily, and who engaged in risky sex such as sex with multiple partners and paid sex. A higher incidence of having more than two lifetime partners was found in individuals who used alcohol almost daily (OR 2.94, CI 2.67-3.22, p<0.001) (Gupta et al., 2010). Rodríguez et al. (2010) report that male migrant workers consume alcohol in order to build up the courage to seek out FSWs, overcome emotional distress and prolong the sexual encounter. Similar to the study on young army conscripts (MacQueen et al., 1996), the behaviour of inebriated clients mitigates against FSWs negotiating condom use. Fear of violence affected the negotiation of condom use, sometimes derailing it altogether (Rodríguez et al., 2010). There are also migrant populations that traditionally have low levels of condom use. Xiao et al. (2010) argue that migrants with a low level of education are unlikely to use a condom regardless of whether they use alcohol or not. While no association was found between alcohol consumption of any kind and condom use in migrants, overall alcohol consumption was high in migrant workers (Lin et al., 2005; Rhodes et al., 2010). In addition, a high number of sexual partners, buying or selling sex, and a history of STDs were common occurrences (Lin et al., 2005; Rhodes et al., 2010). In 2153 sexually experienced young ruralto-urban migrants (1425 male and 728 female), levels of intoxication were elevated among migrants compared to the general population (Lin et al., 2005). Intoxication was more prevalent among male migrants than among female migrants (p<0.001). Alcohol intoxication was associated with multiple sex partners (OR 3.07, CI 1.91-4.95) and buying sex (OR 5.46, CI 2.97-10.04) in males. Intoxicated respondents were significantly more likely to engage in premarital sex and have multiple sexual partners, as well as purchase and sell sex, compared to non-intoxicated respondents (Lin et al., 2005). In a sample of 100 Mexican migrant workers, 10 (40%) of 25 individuals who report having sex in the past 3 months had done so under the influence of alcohol (Rhodes et al., 2010). In 7602 male migrants, alcohol consumption was found to be linked to having a higher probability of contacting a FSW, and of engaging in unprotected sex (Verma et al., 2010). Those migrants who contacted FSWs were more likely to use alcohol before sex than other migrants. Both alcohol consumption and unprotected sex were higher for those migrants who were mobile for longer periods of time (Verma et al., 2010). Condom use was furthermore inconsistent when male migrants reported alcohol consumption prior to sex with casual partners (OR 0.7, CI 0.6-0.9, p<0.01). Even higher rates of unprotected sex were found when male migrants consumed alcohol and contacted FSWs (OR 2.7, CI 2.1-3.5). About 15% of the total sample of male migrant workers reported sex with FSWs in the last 12 months prior to the survey. The proportion of total male migrant workers who reported

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sex with both paid (including FSWs) and unpaid partners in the last year prior to the survey was significantly higher among alcohol users than among the non-users. Among the subsample of male migrant workers who are clients of FSWs, inconsistent condom use with non-paying casual partners is significantly higher if they used alcohol prior to sex than those who did not consume alcohol prior to sex (Verma et al., 2010). The number of alcoholic drinks per week was positively associated with unprotected intercourse acts with casual partners in the past 3 months (p=0.009) (Amirkhanian et al., 2010). 3.6 Heterosexual couples The alcohol and condom use patterns of at-risk heterosexual individuals are described in Table 3a, Table 3b and Table 3c. 3.6.1 Heterosexual couples in the United States with unknown HIV status Raj et al. (2009a) did not find the amount of alcohol consumed before sex to be important with regard to the likelihood of condom use in a sample of 617 at-risk African American men. Fifty three percent of the sample reported never using a condom with the main female partner, and 21% reported never using a condom with casual female partners. Forty nine percent (102) of the sample who reported drinking before sex and 49.1% (53) of the sample who reported drinking to intoxication before sex had unprotected sex. Binge drinking was furthermore found to be associated with sex trade involvement (OR 2.2, CI 1.4-3.5) (Raj et al., 2009a). In a sample of 301 high-risk males and females, mostly African-Americans living in poor neighbourhoods, binge drinking during the past 30 days was linked with unprotected and casual sex (Towe et al., 2010). However, O’Leary et al. (2006) argued that alcohol consumption is one of several contributors to the HIV epidemic affecting certain at-risk groups, particularly African-Americans. In a sample analyzing 56 sexual events experienced by 28 homeless women, condoms were used in 19 of these events (Ryan et al., 2009). Condom use was higher when the relationship was perceived as casual, as opposed to more serious. On the other hand, condom use appeared lower when the woman was under the influence of alcohol, however statistical significance could not be established due to the low number of cases investigated (Ryan et al., 2009). Higher condom use with casual partners than main partner was also reported by a sample of 221 incarcerated women (57% identified themselves as white) (Rosengard et al., 2005), as well as 2,864 women (80% African-American) living in high-risk communities throughout the country (Lauby et al., 2001). Binge drinking was reported to lower the intention of the respondents to use a condom at the next sexual encounter with a casual partner (Rosengard et al., 2005). Additionally, the frequency of binging, were negatively correlated with the likelihood of condom use (Lauby et al., 2001). Having exchanged sex for money or drugs was also negatively associated with condom use, particularly with a main partner (Lauby et al., 2001). In a sample of 136 low-income heterosexual women experiencing physical violence by a male partner (63.2% African-American), Cavanaugh et al. (2010) found that while intoxication did not bring about sexual abuse, it may have influenced the partner’s decision not to wear a condom, and 14.0% of the sample report that they were frightened to ask their

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partner to wear one (Cavanaugh et al., 2010). In a sample of 158 predominantly immigrant Hispanic adult females, the level of intoxication of both the woman and her male sex partner was linked to a younger age of oral sex debut and more life-time sex partners (Dillon et al., 2010). In contrast, Wilson et al. (2010) found that alcohol consumption 5 or more days a week was not linked to having more than 3 sex partners in the past year, but it was associated with all the other risk factors (i.e. having a same sex partner (p=0.01), sex with a CSW (p=0.002), higher prevalence of other STDs (p=0.002)) in a sample of 128 male Mexican immigrants. At the same time, while binge drinking was correlated with unprotected anal sex in 436 high-risk heterosexual females (70% black), it was only marginally correlated with a pastyear history of STDs, but not HIV (Jenness et al., 2011. A history of sexual coercion while under the influence of alcohol was, however, found to be linked with a low likelihood of condom use in 5857 heterosexually active women (67% white). Women who were given alcohol or drugs at coerced sex were more likely to have multiple sex partners and engage in substance abuse (Stockman et al., 2010). 3.6.2 HIV-positive heterosexual couples in the United States In a sample of 535 HIV-positive African-American couples, alcohol dependency, by either partner, was found to not affect condom use (The NIMH Multisite HIV/STD Prevention Trial for African American Couples Group, 2010). However, this ethnic group is still at risk of HIV infection due to the high number of concurrent sexual partners and concurrent sexual partnerships were found to be especially prevalent among females who scored positive for alcohol abuse (The NIMH Multisite HIV/STD Prevention Trial for African American Couples Group, 2010). While observing that alcohol use decreased the frequency of condom use in 326 AIDS patients, Gerbi et al. (2009) found that ethnicity does not influence this behavior. The frequency of alcohol use was correlated with a higher number of sex partners (p=0.003) and lower condom use (p=0.001) (Gerbi et al., 2009). In a sample of 187 sexually active HIV-positive women (aged 18–61) in ambulatory care, binge drinking was found to double the likelihood that a condom was not used at last vaginal sex. Twenty five percent of the sample was classified as binge drinkers (Theall et al., 2007). Sixty two percent of women were found to have used condoms inconsistently. Although alcohol consumption had no influence on the woman’s preference to use a condom, the partner has an easier time manipulating the woman into engaging in unprotected sex when the woman was under the influence of alcohol (Theall et al., 2007). In a predominantly white sample of 262 patients (i.e. only 23.7% of participants were African-American) alcohol use is still associated with a higher likelihood of having sex with multiple partners (Stein et al., 2005). In this sample, the negative effect of alcohol on condom use becomes more apparent. Both the likelihood of having any sex and that that sex was unprotected were associated with any alcohol use, number of alcohol use days, number of drinks per drinking day, number of binge drinking days, and hazardous drinking. (Stein et al., 2005). 3.6.3 Heterosexual couples outside of the United States In a sample of 1370 women in Tanzania, Kapiga et al. (1998) observed that 5.5% of their sample (3.8% of non-drinkers and 9.4% of drinkers) seroconverted during the period

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between baseline and follow-up (i.e. a period of 1 to 3 years). Even though condom use was comparable between alcohol drinkers and non-drinkers, sero-conversion risk was found to be higher for those who consumed alcohol (Kapiga et al., 1998). In a Tanzanian sample of men, Ghebremichael and Paintsil (2009) found condom use with a main partner to be low after alcohol consumption in a sample of 789 men, even though 6.5% of the subjects were identified to be HIV-positive. Alcohol abuse was associated with higher STD prevalence. Most of these individuals (88%) were in monogamous relationships, and condom use was therefore low. The only risk behaviour associated with HIV was numerous sex partners in the past 3 years (12% of population) (Ghebremichael and Paintsil, 2009). Alcohol may enable males to release repressed feelings brought about by social hardship (Emusu et al., 2009), and alcohol abuse by the male partner is a strong indicator of both physical and sexual violence in African countries, with rape being common in these situations (Phorano et al., 2005; Seedat et al., 2009). Since sex is often unprotected in these cases, both the perpetrator and the victim are in danger of acquiring HIV in the case of serodiscordant partnerships. Alcohol abuse by the male partners of 26 women was associated with sexual violence and the sexual abuse of women in this study (Emusu et al., 2009). In South Africa, sexual violence brought about by alcohol abuse was identified in a sample of 428 men with multiple concurrent female sexual partners. Again, condom use was found to be low in these episodes of sexual violence (Townsend et al., 2011). Alcohol consumption (55%, CI 49.3%-60.2%) and unprotected sex (76.5%, CI 71.5%-81.3%) were found to be HIV risk factors (Townsend et al., 2011). In a sample of 292 men and 219 women in STD care in South Africa, individuals with a drinking problem were also more likely than individuals without a drinking problem to also be IDUs and to share injection equipment (OR 6.3, CI 2.3 to 17.2, p<0.01), have had an IDU partner (OR 4.6, CI 2.1 to 10.2, p<0.01), have two or more sex partners in the past 3 months (OR 3.0, CI 1.9 to 4.4, p<0.01) and to exchange sex for money or a place to stay (OR 4.8, CI 2.4 to 9.2, p<0.01) (Kalichman et al., 2006). However, no association between problem drinking and engaging in MSM sex was found (Kalichman et al., 2006). Unprotected serodiscordant sex was identified in 1052 men and 679 women being treated in an STD clinic. While the likelihood of using a condom for each serodiscordant sex episode was high overall, alcohol consumption was significantly associated with an increased number of sexual partners, thus leading to a relatively high number of unprotected incidents (Kalichman et al., 2010). Alcohol use before sex was associated with HIV-positive individuals (12 of 34, 36%) and engaging in unprotected serodiscordant sex versus protected sex (31 of 184, 26%) (OR 2.1, CI 0.9-5.0, p>0.05) (Kalichman et al., 2010). In a sample of 2,618 primary care patients in South Africa (63.8% female and 36.2% male), the prevalence of risky sexual behavior was 26% (Avalos et al., 2010). Sexual risk taking was overall higher for younger individuals (18 to 24 years old), and for men. Among people reporting at least one sexual risk behavior, 51.9% reported hazardous alcohol consumption (p<0.001). Hazardous alcohol consumption was associated with five of the six sexual risk behaviours analyzed: having a partner who ever traded sex for drugs, transportation, or money; having a partner who used injection drugs; having a partner who had an STI; having multiple partners; or failing to use a condom at last intercourse (p<0.05 for all risk behaviours) (Avalos et al., 2010). Similar findings emerged from a study conducted on 488

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participants (Andersson et al., 2009). Again, male gender was significantly associated with more sex partners in the previous six months (p<0.001), more casual/anonymous partners (p<0.001) and more one-night stands (p<0.001). Perhaps most worrisome is the finding that males engaged in unprotected sex with known/suspected HIV-positive partners (Andersson et al., 2009). In another South African study of 395 participants (195 males and 200 females), Wong et al. (2008) observed that while alcohol abuse is still higher in men than in women (p=0.001), women who were recently abused (past 30 days) by their partner were more likely than not to suffer from problem drinking (OR 3.0, CI 1.5 – 5.9, p=0.0005) and depression (odds ratio 3.1, CI 1.5 – 6.2, p=0.005). No correlation between intimate partner violence and depression, alcohol abuse, and sexual risk behaviours were identified in men. Any 30 day alcohol use was only marginally associated with intimate partner violence (p=0.08). For men, intimate partner violence was however linked to the abuse of various drugs (p=0.02) (Wong et al., 2008). Lifetime and past 6 month exposure to intimate partner violence were both comparable between males and females. Lifetime exposure to intimate partner violence was very close to 100% for both genders. Also, rates of depression and sexual risk behaviour were comparable between men and women (Wong et al., 2008). In a sample of 112 women [60 Black and 52 Coloured (mixed race) persons], ethnic differences in terms of drinking patterns were observed, despite both groups reporting that they had sex while under the influence of alcohol (Wechsberg et al., 2008). For Black women, more alcohol consumption was linked to more frequent sex, although they often reported having only one partner. On the other hand, Coloured women were more likely to have multiple partners (1.53 partners in the past 30 days for Coloured women, vs. 0.98 for Black women) (Wechsberg et al., 2008). Hargreaves et al. (2002) found an interesting link between alcohol use, age, socio-economic status and HIV prevalence. In a sample of 622 males and 893 females, they observed that alcohol consumption increased with both age and socio-economic status, for both men and women (Hargreaves et al., 2002). Drinking alcohol in the last month was significantly associated with HIV infection for both males and females aged 25–49 years. For both males (OR 1.7, CI 1.0-2.8) and females (OR 1.8, CI 1.0-3.3), there was a high correlation between high alcohol consumption and HIV acquisition. There is also a correlation between noncondom use and HIV infection (OR 3.1, CI 1.3-7.4). Condom use was higher for younger individuals in general, and for women with a higher socio-economic status. Overall, Hargreaves et al., (2002) found that past month drinking was significantly associated with HIV infection in individuals 25-49 years of age. In a sample of 181 alcohol and/or drug-dependent men and women in India, binge drinking was found to be negatively associated with being HIV-positive, or also being an IDU (Raj et al., 2009b). Moreover 40% of the sample was also IDUs, and 70% of the entire sample reported two or more sex partners in the past three months. Raj et al. (2009b) argue that the effects of alcohol on HIV infection may be masked by the already low rate of condom use in their sample. In another study conducted in India, current alcohol consumption was found to be associated with higher odds of having premarital sex in a sample of 1,642 never married males and 778 never married females aged 15–24 years. This association was significant in males only (Kumar et al., 2010).

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Being under the influence of alcohol by the man was also reported as a reason for risky premarital and extramarital sex among samples of both HIV-positive (Thomas et al., 2009) and HIV-negative individuals in India (Berg et al., 2010). Condom use was very infrequent among males in the HIV-positive sample, comprising of 100 women and 77 men, and it was nonexistent among women. The women however did not blame alcohol consumption for their risky behaviour (Thomas et al., 2009). In an HIV-negative sample of 486 married men living with their wives, drinking was found to lead to domestic violence (Berg et al., 2010), similar to some of the African studies reviewed above. Drinking in public venues means that these men would also have access to FSWs, thus increasing both their and their spouses’ risk of HIV infection (Berg et al., 2010). In addition, a direct correlation between the level of alcohol consumption and the degree of domestic violence was found. Heavy drinkers (two or three times a week or more and have three or four drinks or more on a typical day when they are drinking) were 3.5 times and 6.5 times more likely to engage in this behaviour when compared to overindulgent (once a week or less and have three or four drinks or more on a typical day when they are drinking) drinkers and social drinkers (one or two drinks on days in which they drink), respectively (Berg et al., 2010). In a large sample of 12,617 subjects in India, alcohol consumption was linked to new HIV infections in men only (Dandona et al., 2008). For women, the only significant HIV risk factor was multiple male sex partners (OR 17.85, CI 4.20-75.84) (Dandona et al., 2008). The severity of the alcohol misuse shows a linear association with HIV risk taking in a sample 1137 males (Nayak et al., 2010). Compared to non-hazardous drinking, alcohol abuse (OR 2.35, p<0.05) and alcohol dependence (OR 3.55, p<0.001) were significantly associated with risk behaviour. Among 433 drinkers (38.1% of the entire sample), the prevalence of hazardous drinking was 56.4%. While condom use is not discussed, current drinking is associated with HIV risk factors in general (OR 6.15, CI 3.70-10.22, p<0.001) (Nayak et al., 2010). S.K. Singh et al., (2010) in a study conducted in India, found that married men find themselves in situations where they are expected to drink more and to have sex with partners other than their spouses, but at the same time they are expected to use condoms with these partners. As a consequence, condom use with casual partners was found to be 14 times higher than with main partners, regardless of whether the men were married or not (p<0.01) (S.K. Singh et al., 2010). 3.7 Men Who Have Sex with Men Using a large sample of 1,050 in-care HIV-positive individuals (496 MSM (47% of the entire sample)), Golin et al. (2009) found that binge drinking at least once a week and alcohol consumption before sex were more prevalent in MSM than they were in women and heterosexual men (Golin et al., 2009). The likelihood of having unprotected sex was higher for MSM than it was for men who have sex with females (MSW), but it was lower than it was for women. In addition, the proportion of MSM who reported that alcohol consumption made sex less safe was higher than the sample average (Golin et al., 2009). Alcohol, at all levels of use, was associated with increased sexual risk taking in a sample of 262 HIVpositive individuals (47 MSM). In a study of 166 sexually active individuals, 99 (59.6%) reported unprotected sex (Stein et al., 2005). Increased odds of having any form of sex, including unprotected sex, was associated with any use of alcohol, number of alcohol use days, number of drinks per drinking day, number of binge drinking days, and hazardous

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drinking. In this sample, MSM were identified as engaging in unprotected sex almost three times as often as any other group, including IDUs (p<0.05) (Stein et al., 2005). In general, hazardous drinkers were found to be 5.64 times more likely to have multiple partners and to engage in unprotected sex, when compared to non-hazardous drinkers (p<0.01). This was once again more pronounced in MSM (Stein et al., 2005). The number of drinks on a typical drinking day was positively associated with unprotected sex in 321 methamphetamineusing, HIV-positive MSM (p<0.05) (Semple et al., 2010). In a sample of 478 AIDS-positive MSM, Bouhnik et al., (2007) found that unprotected sex with casual partners was widespread, and it was even more frequent with main partners than it is with casual partners, putting the regular partner at risk of HIV-infection. In comparison to their American counterparts, French MSM are more prone to unprotected sero-discordant sex following binge drinking (Bouhnik et al., 2007). While protected sex is higher with casual partners than with regular partners, further evidence that alcohol consumption still lowers the likelihood of protected sex with a casual partner is provided by Folch et al. (2009). In a cohort of 850 MSM, alcohol use before sex was associated with unprotected sex with casual partners (Folch et al., 2009). Alcohol use before sex has been directly linked with HIV sero-conversion. In a large cohort of 4,295 initially HIV-negative MSM who were in a non-monogamous relationship with an HIV-negative partner, Koblin et al. (2006) attribute 29% of sero-conversions within a 48 month period to alcohol use. Overall, 72.1% of men reported using alcohol or drugs before having sex. Sero-conversion was achieved mainly through unprotected sex with a large number of sex partners. The highest risk of sero-conversion (32.3%) was associated with having four or more male partners (OR 2.84, CI 1.72 to 2.69) (Koblin et al., 2006). Problem drinking was associated with unprotected sex with a sero-discordant male partner, as well as unprotected vaginal or anal sex with female partners and transgender partners among 197 African-American MSM (Reisner et al., 2010). Problem drinking was also associated with unprotected sex with a transgender person (OR 5.23, CI 1.26-21.69, p<0.02) and unprotected vaginal or anal sex with a female (OR 3.25, CI 1.70-6.24, p<0.004) (Reisner et al., 2010). The link between education and alcohol abuse in MSM populations is unclear. While Reisner et al., (2010) in the US and Tripathi et al., (2009) in Estonia in a sample of 79 MSM report that alcohol being linked to unprotected sex is a more frequent problem among individuals without a university degree, Mackesy-Amiti et al., (2010) found alcohol dependence to be relatively high in a sample of 187 MSM made up predominantly of employed individuals with a college education or higher. Even in this sample of welleducated individuals, both receptive and insertive unprotected anal sex were reported by almost one third of the sample, and 32% reported sex with a partner whose HIV status was positive or unknown (Mackesy-Amiti et al., 2010). In a sample of 378 black MSM, higher monthly income, as well as purchasing and exchanging alcohol and drugs for sex were linked with a higher likelihood of being HIV-positive (Lane et al., 2009). The risky sexual behaviour of MSM is likely to have wider ramifications than the group itself, as 83.8% of a sample of 68 African-American MSM report concurrent sexual relations with both males and females (Operario et al., 2009). Alcohol consumption and sex while under the influence of alcohol were high in this population, as were concurrent unprotected

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relationships with both males and females. There was evidence for concurrent partnerships across gender groups as well as concurrent unprotected sex partners. Overall, 73.5% reported having had recent (3 month) concurrent sexual partnerships with more than one gender group (Operario et al., 2009). Alcohol consumption has been found to be associated with unprotected MSM in other countries as well. Studies from Canada (Lambert et al., 2009), Australia (Prestage et al., 2009), Spain (Folch et al., 2009), Estonia (Tripathi et al., 2009) and Mexico (Mendoza-Pérez et al., 2009) report this. In addition, Lambert et al., (2009) report alcohol consumption two hours before sex was higher when the partner was casual, than when the partner was in a stable relationship with the subject of the study in a sample of 965 MSM who reported having sex with a partner with whom they were not in a couple relationship at last sexual episode. Van Griensven et al., (2010) found that alcohol consumption led 823 MSM to have more frequent sex, as well as more unplanned sex, with both casual and male CSWs. At the same time, sex frequency was not linked to condom use (van Griensven et al., 2010). In a sample of 566 MSM, Tsui and Lau (2010) argue that the way in which an MSM picks his partner will determine the type of risk that he is willing to take, in terms of condom use, as well as the likelihood that they will consume alcohol prior to sex. To this avail, Chinese MSM who recruit their partners from public venues are more likely to consume alcohol and to have multiple sex partners, while MSM who recruit their partners through the internet are more likely to have unprotected sex, be infected with STDs, and buy or sell sex, independent of alcohol consumption (Tsui and Lau, 2010). 3.8 Injecting drug users Being an injecting drug user is a risk factor for HIV infection (Sander et al., 2010). In a large, longitudinal study of drug users (72% male, 90% African-American) IDUs were found to be at increased risk of greater alcohol consumption compared to non-IDUs. As greater alcohol consumption is further linked to having more sex partners, a greater risk of HIV infection exists among IDUs (Sander et al., 2010). Among IDUs, alcohol consumption and binge drinking in particular have been found to be associated with needle sharing (Arasteh and Des Jarlais, 2009; Matos et al., 2004; Poudel et al., 2010; Stein et al., 2000), multiple sex partners (Arasteh and Des Jarlais, 2009 Chan et al., 2010 Matos et al., 2004; Poudel et al., 2010), sex under the influence of alcohol and/or drugs (Chan et al., 2010), sex with CSWs (Arasteh and Des Jarlais, 2009), sex with a paying customer (Matos et al., 2004), unprotected sex (Arasteh and Des Jarlais, 2009; Chan et al., 2010; Jenness et al., 2010; Matos et al., 2004), and injecting three or more times a day (Matos et al., 2004). For example, the odds ratio for sharing needles while intoxicated (compared to being sober) was 2.1 (CI 1.1-4.3) in a sample of 557 IDUs (89.4% male) (Matos et al., 2004). In the same sample, alcohol intoxication is associated with exchanging sex for money or drugs (Matos et al., 2004). Increasing alcohol use and alcohol addiction was associated with more frequent needle sharing and increased HIV transmission in a population of 196 (68% male, 85% white) active IDUs in care (Stein et al., 2000). In this sample, alcohol abusers were more likely to share needles than non-abusers (OR 2.3, CI 1.2–4.4, p=0.01), and a direct correlation between increasing alcohol consumption and more frequent needle sharing was found (Stein et al., 2000). Condom use was higher when neither partner was intoxicated, and it was higher overall when the partner was deemed as casual, as opposed to a main partner in 1253 HIV-positive IDUs (81% male, 50% Hispanic, 36% African-American) (Arasteh and Des Jarlais, 2009).

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Using a large sample of 9,519 adolescent IDUs (71.6% male, 41.4% Caucasian), Chan et al. (2010) found that the degree of risk taking is comparable between male and female subjects. The most prevalent sexual risk behaviour was having multiple sexual partners (39.3% of the sample). Gender differences were still identified, with women reporting more unprotected sex than men as well as sex with more IDU partners, while men reported more sex partners than women (Chan et al., 2010). Moreover, women were more likely to be IDUs themselves, when compared with men. These women were also more likely to have sex while under the influence of alcohol or drugs, and to trade sex for money or drugs (Chan et al., 2010). About 7% of adolescents reported using alcohol or drugs to make sex last longer or hurt less. Older age was associated with higher risk taking in terms of sex while under the influence of alcohol or drugs, unprotected sex, and multiple sex partners (Chan et al., 2010). On the other hand, higher education, older age and female gender were both associated with lower alcohol consumption, particularly binge drinking, among IDUs (Sander et al., 2010). AfricanAmerican youth were less likely to engage in sexual activities after consuming alcohol or drugs, yet they were generally more likely to engage in sex with multiple partners. Additionally, there seems to be an association between the severity of substance abuse and the degree of risk taking leading to STDs (Chan et al., 2010). The overall risk of having an IDU partner among 601 at-risk, non-IDU heterosexuals (57.4% female, 78.5 Black) was 13.8%. Binge drinking at least once a week was associated with a significantly higher risk of having an IDU sexual partner (OR 1.73, CI 1.08–2.76, p=0.02) (Jenness et al., 2010). Partners of IDUs were found to abuse alcohol and non-injectable drugs, and to practice unprotected sex with multiple partners (Jenness et al., 2010). HIV prevalence was high in this cohort of heterosexual New York individuals, and higher odds of testing positive for HIV were found among older individuals, and among those who had IDU sex partners (Jenness et al., 2010). A high prevalence of HIV was reported in another study analyzing a cohort of 296 IDUs (Poudel et al., 2010). In this study, 59% of 213 sexuallyactive participants reported multiple sex partners (Poudel et al., 2010). In a sample of 240 IDUs, Parry et al. (2008a) found that needle sharing takes place primarily with close friends and less frequently with strangers. In addition, HIV-positive IDUs report being more responsible about their disposal practices (Parry et al., 2008a). Interestingly, Parry et al., (2008a) found that IDUs often have sex with CSWs and MSM, thus creating a “bridging” effect, where HIV can be spread among individuals from these three vulnerable groups. At the same time, IDUs can also be CSWs or MSM themselves. In a sample of 78 IDU MSM, drug use led to sexual risk taking and needle sharing, despite HIV risk knowledge being high (Parry et al., 2008a). Further “bridging” was observed in this study, as these MSM would have sex when high with both men and women (Parry et al., 2008a). 3.9 Emerging adults 3.9.1 United States The findings of studies looking at the link between alcohol and HIV risk behaviours are listed in Table xx. When looking at emerging adults in the United States, males seem to be the ones more likely to consume alcohol prior to sex (Apostolopoulos et al., 2003; Murphy et al., 2009, Alleyne et al., 2010; Nkansah-Amankra et al., 2010). The major risk factor associated with alcohol consumption was identified as having multiple sex partners

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(Alleyne et al., 2010; Nkansah-Amankra et al., 2010). Within a sample of 1,474 high school students (grades 9–12), Latino males were found to take the most risks in terms of sexual behavior (Nkansah-Amankra et al., 2010). These risks include low HIV education, high alcohol consumption, particularly current binge drinking, and a high number of sex partners (Nkansah-Amankra et al., 2010). Ethnicity has also been linked to risk taking for university students. For example, in a sample of 222 black students and 335 white students, Hou (2009) found that African-American students were safer in terms of condom use and alcohol consumption prior to sex, but at the same time were 1.71 times as likely to engage in vaginal sex as white students, and they start doing so at a younger age (Hou, 2009). Another study looking at a large sample of American adolescents also found a lower level of sexual abstinence among African-American subjects, but at the same time more individuals in this group indicated that they always or almost always used a condom. Values for white and Latino individuals were comparable (Murphy et al., 2009). Alcohol consumption was found to be lowest in African-American women within a sample of 425 undergraduate-students enrolled full-time (Randolph et al., 2009). Frequent drinking for non-African-American women and frequent binge drinking for older men were once again linked to a higher number of sex partners. At the same time, younger age and a better understanding of the HIV risk were associated with higher prevalence of condom use for both men and women (Adefuye et al., 2009; Randolph et al., 2009). In addition, certain personality traits, for example sensation seeking, impulsivity, and disinhibited behavvior due to alcohol consumption were indicators of unprotected sex in two samples (n=270 and n=490, respectively) of sexually-active college students (Sheer and Cline, 1995; Xiao et al., 2010). In a sample of 390 students, having consumed at least one drink in the past 30 days was associated with not using a condom in both males (OR 1.24, CI 0.57-2.72, p≤0.05) and females (OR 1.81, CI 1.06-3.10, p=0.04). Having consumed alcohol in the past 30 days was a predictor of no condom use for females, especially those over 30 years of age (OR 3.43, CI 1.33-8.86, p=0.01) (Adefuye et al., 2009). The implications of this finding must be considered in light of the fact that many of these women also report fewer partners, and condom use is overall low in monogamous relationships (Adefuye et al., 2009). No link between number of sexual partners and condom use was found (Sheer and Cline, 1995; Randolph et al., 2009). At the same time, planned sex (OR 1.28, CI 1.04–1.59) and sex with a casual partner (OR 3.84, CI 2.30-6.41) were linked with higher condom prevalence in a population of 112 adolescents (Morrison et al., 2003). While Morrison et al. (2003) did not find a link between either alcohol consumption or the amount of alcohol consumed before sex and condom use, Murphy et al. (2009) found a direct positive correlation between the amount of alcohol consumed and the degree of risk taking in a large sample of 8,208 youth. Unfortunately, the latter study failed to separate condom use from the number of sexual partners, when discussing high risk behaviour (Murphy et al., 2009). Two other at-risk categories of emerging adults have been identified: club goers and spring breakers. Binge drinking was associated with sex after drinking in a sample of 308 young adults at nightclubs (Wells et al., 2010). The number of drinking days, especially binge drinking days, was positively associated with sex after drinking, and white subjects indicated more frequent drinking. Younger club-goers were more likely to have sex after drinking than older respondents (OR 1.75, CI 1.01-3.03). Younger club-goers also reported less safe sex after drinking (OR 2.34, CI 1.22-4.50) (Wells et al., 2010). For this group, drinking frequency was associated with less safe sex, however the amount of alcohol

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consumed was not important, as no association between unsafe sex and binge drinking was found (Wells et al., 2010). In a sample of 532 spring breakers (321 female and 211 male), 49% of men and 38% of women reported having sex as a direct result of drinking (Apostolopoulos et al., 2003). In this group, one third of individuals report that alcohol consumption led them to have unprotected sex, and the ratios were comparable between males and females (Apostolopoulos et al., 2003). Alcohol drinking has been associated with dating violence in a population of 2438 high school students (grades 9 to 12) (Alleyne et al., 2010). Alcohol consumption during the last sexual experience was significantly higher in males than in females (p<0.01). At the same time, condom use (p<0.001) and multiple sex partners in the last 3 months (p<0.01) were also higher in males. Interestingly, men reported to have experienced more dating violence, but females have experienced more forced sex (Alleyne et al., 2010). In a study on undergraduate students in southern US, older respondents reported more frequent binge drinking episodes, but these are once again accompanied by a higher number of sex partners and a higher likelihood of condom use (Randolph et al., 2009). The group reporting the lowest alcohol use was African-American females (Randolph et al., 2009). 3.9.2 Outside of the United States Young individuals use alcohol “to have fun”. A study conducted among 490 sexually active college students in China revealed that despite knowing the risk associated with unprotected sex, alcohol consumption diminished condom use (Xiao et al., 2010). While there seems to be almost general consensus that alcohol consumption leads to sex, the link between alcohol use and condom use is less clear. For example, alcohol use was linked to sexual initiation in two samples of secondary school students. However, condom use was very high in a sample of 768 students (Tavares et al., 2009), while it was more inconsistent in a sample of 3,575 students (Campo-Arias et al., 2010). In the latter study, alcohol consumption was linked to risky sexual behaviour (OR 2.50, CI 95%, 1.3-5.1) (Campo-Arias et al., 2010). Tavares et al. (2009) attribute these differences to a better education and wider access to information regarding HIV/AIDS that was available to the students in their sample. Several African studies, particularly from South Africa, will be discussed below. In a sample of 511 individuals, Singh K. et al. (2010) found that the highest number of sexually-active teenagers was among those recruited from venues that served alcohol. Individuals recruited in the nightlife/drinking venues, particularly 15 to 24 year olds reported the greatest alcohol consumption. Among them particularly women with the highest number of sexual partners reported the riskiest sex. This sample does not report the highest condom use (Singh K. et al., 2010). In a large sample of 4,724 young women and 4029 young men (12–25 years), having ever used alcohol was significantly associated with a lower age of first sex for both men and women (McGrath et al., 2009). In a study on 661 grade 9 students, alcohol and HIV prevention education affected HIV-related risk factors (Karnell et al., 2006). While it did not have any effects on alcohol-related risk factors in those individuals who had already had sex before pre-test, fewer students who had not had sex prior to pre-test were likely to drink or to report that their partner drank prior to sex. Sexual activities while under the influence of alcohol were significantly reduced (p<0.05), and females increased their sex refusal selfefficacy (p<0.05) following intervention (Karnell et al., 2006). Perhaps worrisome is the

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finding by Morojele et al. (2006b) that some of the boys from a sample of 61 adolescents (12 to 17 years) stated that they could obtain a more positive status by having multiple sex partners, and by having unprotected sex. In addition, some boys enjoyed the thrill of having multiple sex partners (Morojele et al., 2006b).

4. Discussion It is difficult to summarise the findings across the studies within the selected high risk groups and more so across the high risk groups because of the varied study designs, the difficulty of accurate measurements of the variables and the complexity of the subject matter. Female commercial sex workers are a particularly vulnerable group for contracting HIV group as they experience additional risk for contracting HIV resulting from biological susceptibility and factors related to gender inequality that often involves economic dependence on sexual partners. However this designation, namely the most at risk of the high risk groups may not be that relevant as there are often, sexual partnerships across the high risk groups as well as between the high risk groups and the general population. 4.1 Female Sex Workers (Table 1a) The 17 selected studies in this group reflect a wide range of alcohol use patterns. HIV status is not reported in many of the studies. In general, alcohol use is more likely lead to inconsistent condom use. Chersich et al. (2007) in a study conducted in Mombasa, Kenya found that binge drinking was associated with inconsistent condom use (OR 1.59, CI 1.00-2.53, p=0.047). Furthermore, condom use appears to be a function of the situation in which a woman finds herself in, and the amount of control that she has over the situation. The use of alcohol by commercial sex workers and their clients also leads to more aggressive behaviour and sexual violence; the latter generally excludes condom use.

Study

Study Settings

Alcohol Use Pattern

Condom Use Pattern

HIV Status

Todd et al. 2010

Jalalabad, Kabul, and Mazar-I-Sharif, Afghanistan

Only 4.7% of 520 FSWs report having ever used alcohol

30.2% of FSWs had ever used a condom with a client Of these, 38.2% (60) report always using condoms with clients

Prevalence of HIV was 0.19%

Rogers et al. 2002

Beijing, China

42% of women and 32% of their clients report alcohol consumption during sex work

61% of women reported consistent condom use

Wang et al. 2010

Nanning, Guangxi Zhuang, China

29.4% of women reported having had sex with their clients after drinking alcohol

Inconsistent condom use over their life time was significantly associated with drinking alcohol before having sex with a client (p<0.05)

Bowen et al. 2010

Nagaland, India

Alcohol use is widespread 68.5% of FSWs interviewed were regularly using alcohol or other drugs

Condom were used 65.3% of times in the past week

Go et al. 2010

Chennai, Tamil Nadu, India

Women who had a strong tendency to drink alcohol before sex were more likely to have more partners and to have experienced forced sex

Women who reported >20 days of alcohol consumption in the last 30 days were more likely to have unprotected sex

The Relationship Between Alcohol Consumption and Human Immunodeficiency Virus Infection and Risk Behaviour: A Systematic Literature Review… Study

Study Settings

Samet et al. 2010

Mumbai, India

Verma et al. 2010

India

Chersich et al., 2007

Mombasa, Kenya

Alcohol Use Pattern Overall, 38% of FSWs drink 11% are alcohol dependent 32% are heavy alcohol consumers (>7 drinks per week or >3 drinks on a single occasion) 62.0% report alcohol consumption in the last month 53.8% report alcohol consumption prior to sex

33.0% were binge drinker 44.7% were non-binge drinkers 22.4% were abstainers

Condom Use Pattern

HIV Status

90% of women reported inconsistent condom use during transactional sex over the last year

HIV-positive

Overall, inconsistent condom use was reported 58.5% of times

Binge drinking was associated with inconsistent condom use (OR 1.59, CI 1.00-2.53, p=0.047)

92% of women consume alcohol on a typical day (19%, 1 to 2 drinks; Ulaanbaatar and 29%, 3 to 4 drinks; 27%, 5 to 6 Darkhan Uul, drinks; 4%, 7 to 9 drinks; 13%, 10 or Mongolia more drinks) 44% (n=21) consumed five or more drinks per day 19% had consumed alcohol before commercial sex 37% reported Southern Philippines engaging in sex with inebriated customers Education about HIV/AIDS Southern Philippines decrease the daily amount of alcohol consumed 18% of women reported daily Pretoria, South Africa alcohol use during the previous 30 days FSWs were more likely that female Pretoria, South Africa non-SWs to be diagnosed with an alcohol or drug abuse disorder

69% (n=33) reported using condoms inconsistently with paying partners 38% (n=18) reported being less likely to use a condom with a paying partner after using alcohol Alcohol consumption with a customer was significantly associated with condom use (p<0.01) Education about HIV/AIDS increases the likelihood that a condom would be used Sexual abuse was associated with a lower chance of using a condom (p<0.01)

Moshi, Tanzania

73.9% women in the cohort had consumed alcoholic beverages and the prevalence of problem drinking at baseline was 34.6%

Interestingly, non-drinkers were more likely to have not used a condom during their last sex

Fisher et al. 2010

Moshi, Tanzania

The greatest risk of condom failure (19.4%) occurred when the woman alone had been drinking (OR 14.05, CI 4.03-50.41)

Nemoto et al. 2004

San Francisco, California, United States

67% report some alcohol consumption during the past 30 days 14% report consuming alcohol with a customer

Chi Minh City, Vietnam

89% of participants report alcohol consumption in the past year A total of 71% of FSWs report having had sex under the influence of alcohol A total of 90% of FSWs report consuming alcohol with customers

Witte et al. 2010

Chiao et al. 2006

Morisky et al. 2010 Wechsberg et al. 2005 Wechsberg et al. 2009

Fisher et al. 2008

Nemoto et al. 2008

Table 1a. Female Sex Workers

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39.9% who had ever consumed alcohol were HIV-positive 37.3% (84/225) of binge drinkers 23.2% (36/155) of lifetime-alcohol abstainers

Not discussed

The use of a condom appears to be more a function of situational negotiation and the woman’s control over the outcome Condoms were used consistently 91% of times for vaginal sex. Only 17% of respondents report always using a condom with their main partner Inconsistent condom use was reported by 85% of bar/club FSWs, 72% of massage parlour FSWs, and 68% of street FSWs

19.0% were HIVpositive HIV prevalence was 22.4% among alcohol drinkers, and 9.5% among abstainers

No woman reported being HIV-positive

Prevalence among those who had an HIV test was 7%; 18% of the street FSWs tested positive; 7% of bar/club FSWs tested positive

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4.2 Clients of Commercial Sex Workers (Table 1b) In the 6 selected studies in this group many reported high levels of alcohol consumption. In one study by Havanon et al. (1993) in Thailand, 82% report that drinking accompanies commercial sex. Samet et al. (2010) for a study in Mumbai, India, shows heavy alcohol consumption was significantly associated with inconsistent condom use in male clients of FSWs (OR 2.40, CI 1.21-4.77, p=0.01). Not all selected studies in this group reported HIV status.

Study Settings

Alcohol Use Pattern

Condom Use Pattern

HIV Status

Gender and Sexual Orientation of Subjects

Madhivanan et al. 2005

Mumbai, India

Men who report sex with a FSW, they were more likely to have consumed alcohol before sex (OR 1.5, CI 1.2-1.9, p<0.001)

Men who report sex with a FSW were more likely to have had unprotected sex (OR 1.9, CI 1.4-2.6, p<0.001)

1683 subjects had an HIV test with HIV prevalence of 14%

Heterosexual males

Samet et al. 2010

Mumbai, India

44% of men were heavy alcohol users (>14 drinks per week or >4 drinks on a single sitting)

Heavy alcohol consumption was significantly associated with inconsistent condom use HIV-positive in male clients of FSWs (OR 2.40, CI 1.21-4.77, p=0.01)

Heterosexual males

Edinburgh, Scotland

Over 75% (sometimes) and 40% (regularly) of subjects consumed alcohol before contacting a CSW

Alcohol use was inversely associated with condom use with male CSWs (p=0.027), but not with FSWs

Mostly male subjects: 175 had contacted FSWs; 26 had contacted MSWs; 5 had contacted both FSWs and MSWs

Sri Lanka

54.5% used alcohol on a regular basis (weekly or more) 16.8% reported daily alcohol consumption

Of 67.3% of subjects who report having sex with a CSW, only 14.4% reported regular condom use

Heterosexual males

Thailand

82% report that drinking accompanies commercial sex, while 74% of them report to have been drunk

Nearly 50% of subjects usually use condoms, and students usually use condoms 77% of times

Males

Harare, Zimbabwe

84% of subjects identified themselves as alcohol drinkers

Sex while intoxicated was associated with 20 times more unprotected sex with casual partners and 27 times more unprotected sex for those paying for sex

Study

Thomas RM et al. 1990

Dissabandara et al. 2009

Havanon et al. 1993

Fritz et al. 2002

Overall, 96 subjects were HIV-positive

Male

Table 1b. Clients of Commercial Sex Workers 4.3 Army personnel (Table 2a) People who live for prolonged periods far from their home may be considered migrants. Among army personnel and migrant workers alcohol consumption is very high, leading to multiple sex partners, including CSWs. HIV status is provided in three of the four studies in this group. Studies on army personnel show inconsistent condom use coupled with alcohol consumption, with many in non-monogamous relationships (Brodine et al., 2003; MacQueen et al., 1996; Tavarez et al., 2010).

The Relationship Between Alcohol Consumption and Human Immunodeficiency Virus Infection and Risk Behaviour: A Systematic Literature Review… Study

Study Settings

Alcohol Use Pattern

Tavarez et al. 2011

Border-crossing zones on the western border of the Dominican Republic

Alcohol abuse is a predictor of sex with a CSW (OR 4.80, CI 2.00-11.30, p<0.001)

MacQueen et al. 1996

Phitsanuloke Province, Northern Thailand

Alcohol consumption is described as very high in this qualitative study

Brodine et al. 2003

United States

Conigliaro et al. 2003

Pittsburg, Pennsylvania

64% of the cohort reported moderate to heavy alcohol consumption, defined as five drinks per session, two to three times monthly 351 (40.40%) are present drinkers 289 (33.1%) are binge drinkers (≥6 drinks on 1 occasion) 310 (35.5%) were hazardous drinkers (binge drinkers or scored ≥8 on AUDIT)

Condom Use Pattern Alcohol abuse is an indicator of nonmonogamous, unprotected sex (OR 2.8, CI 1.7 -4.4) Alcohol virtually eliminates the willingness of the male to use a condom Overall, condom use was very limited, and this can be attributed to alcohol use during sex

HIV Status

267

Gender and Sexual Orientation of Subjects

Male

7% of men were HIVpositive

Heterosexual Males

HIVpositive

Heterosexual Males

HIVpositive

99% of the sample were male MSM made up 36% of the sample

Table 2a. Army Personnel 4.4 Migrant workers (Table 2b) There were five studies selected for this group. One study by Gupta (2010) showed that HIV prevalence was higher among migrants than it was among non-migrants (0.60% versus. 0.33%), particularly those who drank almost every day (1.36%). Xiao et al. (2010) argue that migrants with a low level of education do not use condoms whether they bring into play alcohol or not. Verma et al. (2010) illustrated greater alcohol consumption and higher rates of unprotected sex for migrants who were away from home for prolonged periods. This study, conducted in India, reported alcohol use prior to sex in general as significantly higher in highly mobile, male migrant workers (OR 1.5, CI 1.2-1.7). 4.5 Heterosexual couples 4.5.1 In the United States with unknown HIV status (Table 3a) Ten studies were selected for inclusion in this group. In a study by Cavanaugh et al., 2010, a woman’s alcohol problem was associated with unprotected sex with a non-monogamous primary partner. In an earlier study by Lauby et al., 2001 binge drinking correlates with low condom use with both main partner and casual partners (p<0.001) Condom use was lower overall with main partner than it was with casual partners. 4.5.2 HIV-positive heterosexual couples in the United States (Table 3b) Five studies were selected for this group. One by Theall et al. 2007 found that alcohol consumption was associated with the partner refusing to use a condom. Another, based on findings by The NIMH: Multi-site HIV/ STD-Prevention Trial for African AmericanCouples Group, 2010 showed that females were less likely to be alcohol dependant (9.09%) than males (14.96%), (OR 1.65, CI 1.15-2.36). Alcohol use correlated with a higher number of sex partners and lower condom use (Gerbi et al., 2009).

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Study

Study Settings

Alcohol Use Pattern

Condom Use Pattern

Lin et al. 2005

Beijing and Nanjing, China

34.6% of the participants had been intoxicated at least once during the previous month

No association between alcohol intoxication and condom use was found

Gupta et al. 2010

India

6408 (8.6%) of men drink once a week 2358 (3.2%) of men drink almost daily

Condom use with a paid partner was highest for those who used alcohol almost daily (p<0.001)

Verma et al. 2010

India

Alcohol use prior to sex in general is significantly higher in highly mobile male migrant workers (OR 1.5, CI 1.2-1.7)

Amirkhanian et al. 2010

St. Petersburg, Russia

Participants report consuming 4.3 drinks per week

Rhodes et al. 2010

North Carolina, United States

Nearly 10% of the sample reported drinking alcohol every day or nearly every day Nearly 58% reported binge drinking during the past year

Gender and Sexual Orientation of Subjects

HIV Status

Both males and females HIV prevalence was higher among migrants than it was among nonmigrants (0.60% vs. 0.33%), particularly those who drink almost every day (1.36%)

Approximately one third of men report inconsistent condom use with paid partners Mean percentage of condom use was 35.0%

Both males and females

Heterosexual males

Males

Alcohol consumption does not decrease condom use

Heterosexual males

Table 2b. Migrant Workers

Study

Study Settings

Binge drinking correlates with low condom use with both main partner and casual partners (p<0.001)

Condom use was lower overall with main partner than it was with casual partners

Heterosexual females

17.2% report weekly binge drinking

From 40% of women who report casual partners in the past 3 months, 47% of them report consistent condom use

Heterosexual females

There are significantly fewer lifelong drinkers in this region, particularly in the disproportionally-affected populations, such as AfricanAmerican individuals, and young African-American females

Not discussed

Heterosexual males and females

Ryan et al. 2009

Cavanaugh et al., 2010

New Haven, Connecticut

89.7% of women used alcohol in their life 50.7% of women have used alcohol to intoxication during the past 6 months

Miami, Florida

Alcohol intoxication before sex was associated with younger age of oral sexual debut Not discussed (p<0.01), as well as more sex partners (p<0.01)

Rosengard et al. 2005

O’Leary et al. 2006

Dillon et al. 2010

Gender and Sexual Orientation of Subjects

Condom Use Pattern

Philadelphia and Pittsburgh (Pennsylvania), Portland (Oregon), Oakland and San Francisco (California) Rhode Island Department of Corrections Women’s Division A representative sample of the United States population (census data), with particular focus on Georgia, Louisiana, Alabama, Florida, South Carolina, North Carolina and Mississippi Los Angeles county, California

Lauby et al. 2001

HIV Status

Alcohol Use Pattern

15 of 56 sexual events involved alcohol consumption

Condoms were used in 19 of 56 sexual events A woman’s alcohol problem was however associated with sexual risk behaviour (OR 1.24, CI 0.46-3.54); 11.0% of women report unprotected sex with a non-monogamous primary partner

Heterosexual females

Heterosexual females

Heterosexual females

The Relationship Between Alcohol Consumption and Human Immunodeficiency Virus Infection and Risk Behaviour: A Systematic Literature Review…

Alcohol Use Pattern

Condom Use Pattern

HIV Status

Gender and Sexual Orientation of Subjects

New York City, New York

41.7% were binge drinkers

Overall, 38% of women had unprotected anal intercourse 47.3% of those who had unprotected anal sex in the past year were binge drinkers

9% were HIV +

Heterosexual females

Nationallyrepresentative sample of the United States

Approximately 30% of women were given alcohol or drugs prior to sexual coercion

Among 1085 women with more than 1 male sex partner in the past year, 69.0% reported no condom use at last vaginal sex

Baltimore, Maryland

84% reported having unprotected sex during the Binge drinking during the past past 12 months 30 days is linked with Unprotected sex was higher unprotected sex (OR1.18, CI with a main partner (84%), 1.04-1.33, p=0.008) compared to a casual partner (63%)

Dallas, Texas

92.2% of the sample consume alcohol; 14.4% of those reporting alcohol consumption do so more than 5 times a week

Study

Study Settings

Jenness et al. 2011

Stockman et al. 2010

Towe et al. 2010

Wilson et al. 2010

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Heterosexual females

10 (3%) were HIV +

Of the 108 men who reported having had sex in the past year, 54% reported very limited or non-existent condom use. Only 17% report always using a condom

Heterosexual males and female

Heterosexual males

Table 3a. Heterosexual Couples in the United States with Unknown HIV Status

Study Authors

Study Settings

Alcohol Use Pattern

Condom Use Pattern

HIV Status

Subject-Gender and Sexual Orientation

Stein M. et al. 2005

Brown University, Providence Rhode Island

Hazardous drinking has a statistically higher association for having any sex compared to binge drinking (p=0.0001 vs. p=0.001)

A higher probability of unprotected sex was associated with any use of alcohol

HIVpositive

67% of patients were self-identified as heterosexual

Theall et al. 2007

New Orleans, Louisiana

Approximately 25% of the women were classified as bingers

Alcohol consumption was associated with the partner refusing to use a condom (OR 1.58, CI 1.30-8.41)

HIV+; 16% report that their last partner was also HIV +

Heterosexual females; 23% report more than one male partner in the last year

AIDSpositive

Heterosexual males and females

Gerbi et al. 2009

Montgo-mery, Alabama

Men were significantly more likely than women to drink alcohol before sex

Alcohol use before sex was correlated with lower condom use (74% of those who do not drink before sex vs. 43% of those who drink before sex report using condoms most of the time, p=0.0001)

Golin et al. 2009

Seven HIV clinics in six US cities

6% of the sample report always using alcohol before sex, and 63% never using alcohol before sex

12.3% of the sample report unprotected sex with an atrisk partners in the past 3 months

HIVpositive

Heterosexual males

The NIMH: Multisite HIV/ STDPrevention Trial for African AmericanCouples Group, 2010

Atlanta, Los Angeles, New York Philadelphia

Females were less likely to be alcohol dependant (9.09%) than males (14.96%) (OR 1.65, CI 1.15-2.36)

Condom protected sex was significantly lower in females (p=0.0018)

One partner in the couple was HIV +

Heterosexual males and females

Table 3b. HIV-positive Heterosexual Couples in the United States

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4.5.3 Outside of the United States (Table 3c) Eighteen studies were included for this group: An Indian study by Kumar et al, 2010, found that current consumption of alcohol is associated with premarital sex among males only (OR 3.5, CI 2.53-4.83, p<0.001).l The study also found that condom use in rural areas was lower than in urban areas however this was significant only for males. In SA, violence, often of a sexual nature, perpetrated by men under the influence of alcohol, against women is of particular concern (Seedat et al., 2009). In a Cape Town study condom use was found to be low in these episodes of sexual violence (Townsend et al., 2011).

Study

Study Settings

Alcohol Use Pattern

Condom Use Pattern

HIV Status

Gender and Sexual Orientation of Subjects

Dandona et al. 2008

Guntur district, Andhra Pradesh, India

Consuming alcohol before sex was associated with HIV in males only (OR 3.60, CI 2.08-8.22)

Not discussed

Not quantified

Heterosexual males and females

Thomas BE et al. 2009

Chennai, India

16.7% of men and 0% of women report alcohol consumption

More than 80% of men 100% of women reported that they did not use condoms

HIV-positive

Heterosexual males and females

Berg et al. 2010

Navi Mumbai, India

Drinking patterns ranged from social drinking to overindulgent and heavy drinking

Not discussed

Heterosexual males

Kumar et al. 2011

Guntur district, Andhra Pradesh, India

Current consumption of alcohol is associated with premarital sex among males only (OR 3.5, CI 2.53-4.83, p<0.001)

Condom use in rural areas was lower than in urban areas, however this was significant only for males

Heterosexual males and females

Not discussed

Heterosexual males

Nayak et al. 2010

Karnataka, India

Singh SK et al. 2010

Navi Mumbai, India

Hargreaves et al, 2002

Kisumu, Kenya

Raj A et al. 2009(b)

St. Petersburg, Russia

Kalichman et al. 2006

Cape Town, South Africa

Among drinkers, the mean quantity of alcohol consumed was 60 g (5 drinks) 15% of the sample used alcohol 4 or more times a week Mean thirty day mL of alcohol consumed was approximately 230 and less than 5% of drinkers, drank over 1000 mL a month For both men (48%) and women (15%), highest alcohol consumption in the past month was among those 25-49 years with a higher socio-economic status 72% reported alcohol consumption during the past 30 days 64% reported binge drinking – 93% of these were alcohol dependent Alcohol consumption in the context of sex was higher for individuals reporting a drinking problem (OR 24.4, CI 14.3-41.4, p<0.01) and for individuals whose partner reported a drinking problem (OR 5.1, CI 3.1-8.5, p<0.01)

High alcohol consumption correlates with high condom use (p<0.002) Condom use was higher among males (31.1%) and females (16.8%) 15-24 years, with a higher socioeconomic status 88% report unprotected sex with a main partner, while 76% report unprotected sex with a casual partner

No association between problem drinking and condom use was found

Heterosexual males

HIV prevalence was 19.8% in males and 30.2% in females

Heterosexual males and females

8% of binge drinkers and 28% of nonbinge drinkers were HIV+ (p<0.001)

Heterosexual males and females

Heterosexual males and females

The Relationship Between Alcohol Consumption and Human Immunodeficiency Virus Infection and Risk Behaviour: A Systematic Literature Review…

Study

Gender and Sexual Orientation of Subjects

Study Settings

Alcohol Use Pattern

Condom Use Pattern

Wechsberg et al. 2008

Cape Town, South Africa

At baseline, Black women report alcohol use on more days in the past month than Colored women (13.55 vs. 5.82, p<0.001)

Black women were more likely to use a condom (50% vs. 15%) and to have only one partner (main)

Heterosexual females

Wong et al. 2008

Cape Town, South Africa

High levels of problem drinking were found among both men (58%) and women (42%)

Not discussed

Heterosexual males and females

Soweto, South Africa

Males reported higher rates of heavy alcohol use (p<0.001)

Substance use and male gender predicted higher risk behaviours, including inconsistent condom use

Cape Town, South Africa

Hazardous alcohol use was reported by 12.6% of the entire sample

Multiple sex partners and inconsistent condom use were the two most common sexual risk behaviours reported

Kalichman et al. 2010

Cape Town, South Africa

In a multivariate analysis, alcohol use was significantly associated with unprotected sex with serodiscordant partners (OR 2.5, CI 1.0-6.5, p<0.05)

Condom use was generally high for HIV-positive individuals, however it was low when engaging in seroconcordant sex

Townsend et al. 2011

Cape Town, South Africa

Problem alcohol use was associated with both physical and sexual intimate partner violence, with inconsistent condom use

Physical intimate partner violence was associated with inconsistent condom use

Andersson et al. 2009

Avalos et al. 2010

HIV Status

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HIV-negative

Heterosexual males and females

Heterosexual males and females

1479 (85%) of the sample was tested for HIV 218 (12%) of those tested were HIV +

Heterosexual males and females

Heterosexual males

Kapiga et al. 1998

Dar es Salaam, Tanzania

29.5% of subjects consumed alcohol

Condom use was not different between drinkers and nondrinkers

All women started off HIVnegative Drinking was associated with risk of HIV (OR 2.43, CI 1.543.82)

Ghebremichael and Paintsil, 2009

Moshi district, Tanzania

About 33% of the participants were categorized as alcohol abusers

80% of subjects never used condoms in the past 12 months, and only 6% used them often

6.5% of men were HIVpositive

Heterosexual males

About half of the women were HIVnegative (and their male partners were HIV +), and the other half were HIV+ (and their male partners were HIVnegative)

Heterosexual females

Emusu et al. 2009

Kampala, Jinja and Mbale, Uganda

Alcohol abuse by HIVpositive male partners often Unprotected resulted in them perpetrating unprotected sex

Table 3c. Heterosexual Couples Outside of the United States

Heterosexual females

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4.6 Men Who Have Sex with Men (MSM) (Table 4) Drug and alcohol abuse is reported to be particularly high among men who have sex with men; this has implications for risky sexual practices. Eleven studies were selected for inclusion in this group, some studies included only HIV-positive and some HIV-negative participants. In one study by Koblin et al., 2006, of initially HIV-negative persons, 29% of sero-conversions in the cohort was attributed to alcohol use (odds ratio 2.54, CI 1.83 to 3.53). In one study, MSM were identified as engaging in unprotected sex almost three times as often as any other group, including IDUs (Stein et al., 2005). Like the American MSM, the French MSM are also more likely to engage in unprotected sero-discordant sex following binge alcohol consumption (Bouhnik et al., 2007). While protected sex is higher with casual partners than with regular partners for MSM, alcohol consumption further lowers the likelihood of protected sex with a casual partner Unprotected sex with casual partners is associated with a greater risk of frequent alcohol use before or during sex (OR 1.5, CI 1.032.24, p=0.037), (Folch et al., (2009))

Study

Alcohol Use Pattern

Condom Use Pattern

Australia

Drugs and alcohol are used to enhance the sexual experience in more 'adventurous' gay community subcultures

Having more than five drinks (OR 2.41, CI 1.34-4.33, p=0.003) was associated with unprotected anal intercourse with non-HIV seroconcordant partners

Montreal, Canada

Alcohol was used before sex 39.4% of the times when the partner was regular and 49.8% of the times when the partner was casual

Alcohol use was associated with unprotected anal sex at last sexual episode 12.2% of participants had unprotected anal sex at last sexual episode

Tallinn, Estonia

Mean alcohol consumption was 7.1 standard alcoholic drinks per week in the week preceding the study

Over 50% of the sample did not use a condom regularly in the past 12 months Higher alcohol consumption was negatively associated with use of condom during the last intercourse

Bouhnik et al. 2007

France

Alcohol consumption at least once a month, is associated with unprotected serodiscordant sex (OR 2.4, CI 1.2-4.9, p=0.003)

Unprotected sex was more prevalent within seroconcordant couples than it was in sero-discordant couples

Tsui and Lau, 2010

Hong Kong

Only 13.3% of subjects reported that they drank alcohol before sex

MSM who chose their sexual partners from the internet are more likely to engage in unprotected sex

MSM

MendozaPérez et al. 2009

Ciudad Juárez, Chihuahua, Mexico

29.6% report consuming alcohol more than twice a week

Alcohol consumption was associated with engaging in unprotected sex

MSM

Lane et al. 2009

87.9% report that they drank at least once per month 75.9% scored positive for Soweto, South Africa problem drinking 54.5% of subjects report 10 or more drinks on a typical day of drinking

Prestage et al. 2009

Lambert et al. 2009

Tripathi et al. 2009

Unprotected anal intercourse predicts HIV-positive status (28.0%, CI 21.9%-33.6%)

HIV Status

Gender and Sexual Orientation of Subjects

Study Settings

MSM

Self-reported HIV-negative or HIV statusunknown

MSM

MSM

AIDS-positive

HIV prevalence was estimated at 13.2% Problem drinking predicts HIVpositive status (75.9%, CI 70.0%-82.1%)

MSM

MSM

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Study Settings

Folch et al. 2009

Catalonia, Spain

van Griensven et al. 2010

Bangkok, Thailand

Stein M. et al. 2005

Providence, Rhode Island

Koblin et al. 2006

Golin et al. 2009

Operario et al. 2009

Boston (Massachusetts), Chicago (Illinois), Denver (Colorado), New York (New York), Seattle (Washington), San Francisco (California) Denver (Colorado), Kansas City (Missouri), Nashville (Tennessee), Brooklyn (New York), Chapel Hill (North Carolina) and Atlanta (Georgia)

Oakland, California

MackesyAmiti et al. 2010

Chicago, Illinois

Reisner et al. 2010

Massachusetts

Semple et al. 2010

San Diego, California

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Alcohol Use Pattern

Condom Use Pattern

HIV Status

Gender and Sexual Orientation of Subjects

19.6% of men were frequent users of alcohol 63.8% of men used alcohol and drugs at some time before or during sex 80.2% of MSM report alcohol consumption in the past 4 months Of these, 11.5% binge drank Alcohol use (OR 1.95, p<0.01) and hazardous alcohol use (OR 2.90, p<0.01) were associated with having sex

Unprotected sex with casual partners is associated with a greater risk of frequent alcohol use before or during sex (OR 1.5, CI 1.03-2.24, p=0.037)

24.3% of frequent alcohol users were HIVpositive

MSM

Always using a condom was reported by 43.7% of MSM, and this increased to 70.8% when the partner was paid

HIV-negative

MSM

Heterosexual males and females and MSM

Alcohol use (OR 2.30, p<0.01) and hazardous alcohol use (OR 2.66, p<0.01) were associated with unsafe sex

HIV-positive

72.1% of men reported using alcohol or drugs before having sex

69.1% report any unprotected anal intercourse

Initially HIVnegative, 29% of seroconversions in the cohort MSM was attributed to alcohol use (odds ratio 2.54, CI 1.83 to 3.53)

26% of MSM report binge drinking at least once a week 51% of MSM report drugs or alcohol use before sex in the past 3 months

23.0% of MSM report unprotected sex

HIV-positive

MSM

70.6% of subjects report alcohol use before sex in the past 30 days

33.8% to 51.5% had unprotected anal sex with a male Alcohol use was not linked to unprotected sex

17.6% reported being HIVpositive

MSM who report sexual relationships with females

Between 28% and 35% of the sample report unprotected anal intercourse

HIV-negative

MSM

93% individuals used alcohol 39% individuals showed signs of alcohol dependence Overall, 29% of the sample was found to abuse alcohol at the time of enrolment into the study The average number of drinks in a typical drinking day was 3.5

Problem drinking was linked to unprotected anal sex with a sero-discordant male partner (OR 3.22, CI 1.22-8.50, p<0.02) The average number of unprotected anal sex acts in the past 2 months was 10

MSM

HIV-positive

MSM

Table 4. Men Who Have Sex with Men 4.7 Injecting Drug Users (IDUs) (Table 5) For injecting drug users, alcohol consumption leads to needle sharing, unsafe sex and exchanging sex for money and drugs, opening the door for HIV transmission and reinfection. Nine studies were selected for this group with mixed HIV status. A study in

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Nepal conducted by Poudel et al. 2010 reported that 44% of non-drinkers share needles, as opposed to 55% of alcohol drinkers (OR 0.63, CI 0.38-1.03). For IDUs, condom use was higher when both partners were sober and it was higher overall when the partner was a casual partner, as opposed to a main partner (Arasteh and Des Jarlais, 2009). There also seems to be an association between the severity of substance abuse and the degree of risk taking resulting in contracting STDs (Chan et al., 2010). Study

Study Settings

Alcohol Use Pattern

Condom Use Pattern

HIV Status

Gender and Sexual Orientation of Subjects

Poudel et al. 2010

Kathmandu Valley, Nepal

44% of non-drinkers share needles, as opposed to 55% of alcohol drinkers (OR 0.63, CI 0.38-1.03)

Not discussed

21% of 202 participants who had taken an HIV test tested positive

Males

Vega Baja, greater San Juan, Puerto Rico

Alcohol intoxication during the last 30 days was reported by 18% of participants

Matos et al. 2004

Parry et al. 2008(a)

Parry et al. 2008(b)

Stein MD. et al. 2000

Cape Town, Durban and Pretoria, South Africa Cape Town, Durban and Pretoria, South Africa Providence, Rhode Island

Alcohol use is not mentioned

Those reporting alcohol intoxication were also more likely to report unprotected sex with a paying partner and with a casual partner Being high was a reason to not think about safe (have unprotected sex)

Alcohol is not mentioned

Drugs led to inconsistent condom use

60% had used alcohol in the last month 14% were at-risk alcohol abusers

Not discussed

35% of the sample were at-risk drinkers (defined as more than 14 drinks per week for males or 7 drinks per week for females) 35.2% of males and 44.8% of females (37.9% average) had sex while high on alcohol or drugs (p<0.001)

Arasteh and Des Jarlais, 2009

New York City, New York

Chan et al. 2010

67 cities in 29 states across the United States

Jenness et al. 2010

New York City, New York

34.5% of participants binged on alcohol at least weekly in the past year

Sander et al, 2010

Baltimore, Maryland

At study entry, 36% of participants were binge drinkers

At-risk drinkers report lower condom use than occasional or non-drinkers 33.3% of males and 44.3% of females (36.4% average) had sex without protection (p<0.001) IDU partnerships were associated with risky unprotected sex

Not discussed

Both males and females

28% of individuals who offered to be tested for HIV tested positive Among MSM who agreed to HIV testing, one-third tested positive 89% of subjects had been tested for HIV, and 4% of these subjects tested HIVpositive

HIV-positive

Mostly heterosexual male and female

Both heterosexual males and MSM

Males and females

Both males and females

Heterosexual males and females

Overall, 7.0% tested positive for HIV

Heterosexual males and females

HIV-negative at the start of the study

Predominantly heterosexual males and females (MSM was reported at 1% of visits)

Table 5. Injecting Drug Users 4.8 Emerging adults In emerging adult populations, alcohol is often consumed in the context of parties, with the potential for multiple sex partners, and unsafe sexual encounters.

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In United States (Table 6a) Ten studies showed that outcome variables of interest differed across race, age and sex. (Hou, 2009) established that Black students were less likely to use alcohol before any type of sexual activity. However this group was more likely to use a condom during sex of any kind. Adefuye et al, (2009) found that condom use was higher in younger individuals when compared with older individuals. Alleyne et al., (2010) noticed that alcohol use at last sex was 18.0% overall, with 15.0% in females and 21.1% in males. Also males were more likely to have used a condom during their last sexual episode.

Study

Study Settings

Alcohol Use Pattern

Condom Use Pattern

Sheer and Cline, 1995

A large South-Eastern University, United States

Alcohol is often consumed at parties

No significant association was found between the number of sex partners and condom use

Apostolopoulos et al. 2003

Sample was representative of university students, United States

Alcohol or drugs influenced decisions involving sex

31% of males and 32% of females report that alcohol use prior to sex had a negative influence on their decision to use a condom

Morrison et al. 2003

Seattle, Washington

Most subjects had been drinking more than one or two drinks per occasion and most have been getting drunk at least several times per week

The odds of condom use were not associated with whether or not alcohol was consumed before sex. Condom use was marginally lower for females than it was for males (OR 0.30, CI 0.11-1.06)

Adefuye et al. 2009

An urban Midwestern university, United States

14.6% of individuals below the age of 19 report alcohol use before sex

Condom use was higher in younger individuals

Hou, 2009

Southern universities, United States

Black students were less likely to use alcohol before any type of sexual activity

Black students were more likely to use a condom during sex of any kind

Murphy et al. 2009

Data collected from the National Longitudinal Survey of Youth

Males were found to consume higher levels of alcohol

The highest alcohol consumption was associated with the group that showed the highest sexual risk tendencies in both males and females

Randolph et al. 2009

A Southern University, United States

62.9% of participants reported binge drinking

Condom use was greater among older participants. Higher perceived risk of HIV was also associated with greater condom use

Alleyne et al. 2010

Youth Risk Behavior Survey, Illinois

Alcohol use at last sex was 18.0% overall, with 15.0% in females and 21.1% in males

Males were more likely to have used a condom during their last sexual episode.

Nkansah-Amankra et al. 2010

Colorado Youth Risk Behavioral Survey, Colorado

Alcohol consumption was found to lead to sexual risk taking and multiple sex partners

Not discussed

Wells et al. 2010

New York, New York

62.9% reported to sex after use of alcohol

Not discussed

Table 6a. Emerging Adults in the United States Outside of the United States (Table 6b) HIV status is provided in two of the seven selected studies. Each of these seven studies provides valuable insight into the dynamics operating within this high-risk group relating to alcohol consumption and unsafe sex. A Chinese study (Xiao et al., 2010), showed that using alcohol diminished the likelihood of participants using condoms. In a South African study by McGrath et al., 2009, it was observed that for men, age at first sex was associated with having ever used alcohol (OR 1.89, CI 1.55-2.30, p<0.001).

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Study

Study Settings

Alcohol Use Pattern

Condom Use Pattern

Tavares et al. 2009

Santiago Island, Cape Verde

Alcohol consumption was associated with sexual initiation in males

84.72% reported having used a condom in their first sexual intercourse

Xiao et al. 2010

Hunan Province, China

Using alcohol diminished the likelihood of participants using condoms

Impulsivity was shown to be negatively correlated with condom use

Campo-Arias et al. 2010

Santa Marta, Colombia

Of 804 students with a history of sexual relationships, 18.4% reported sexual intercourse after alcohol consumption

33.7% informed inconsistent condom use

Karnell et al. 2006

Pietermaritzburg area, KwaZulu-Natal, South Africa

A greater willingness to use a condom during the next 3 At pre-test, almost half of the sample (both males months was reported by and females) were using alcohol students in the intervention group (p<0.01)

Morojele et al. 2006

Grade 8 and grade 11 students in Cape Town, South Africa

Some boys report that they supplied alcohol to girls in order to sleep with them. Some girls report that they consumed alcohol and other drugs voluntarily, and this made them more prone to engage in sexual acts

Some boys avoided condom use in order not to decrease sexual pleasure

McGrath et al., 2009

KwaZulu-Natal, South Africa

In men, age at first sex was associated with having ever used alcohol (OR 1.89, CI 1.55-2.30, p<0.001). The same trend was seen in women, although it was not statistically significant

Not discussed

Singh K et al., 2010

Hwange District, Zimbabwe

61% of individuals aged 15 to 19 that were found in nightlife/drinking venues report ever to have had sex – this was significantly higher than individuals in any other type of venue (p<0.01)

Condom use at last sex was 53.9% in the sample reporting the highest number of sexual partners

Table 6b. Emerging Adults Outside of the United States 4.9 Condom use Not all studies have consistent findings with regard to condom use and alcohol consumption. The first important criterion may have to do with how they are used, rather than merely whether condoms are used. The fact that condom use is documented does not automatically imply that the condom was used effectively, i.e. there were no accidents including breakage and spillage, and that a condom was used for every separate act of sexual intercourse that took place during a particular sexual encounter. Effective condom application for every act of sexual intercourse is a key means of limiting the spread of HIV. Condoms not only prevent HIV infection and other STIs but also prevent unplanned pregnancies. Condom use is recommended for monogamous couples if serodiscordant or both are infected. The number and sequencing of the sexual acts as well as the characteristics of the persons and nature of the sexual behaviour involved in the partnerships are not that relevant if there is adequate protection for contracting STIs. Information concerning condom use for protection against contracting HIV is known but not necessarily acted upon. Hence an important focus of public health efforts should be on addressing other intermediary risk factors for sexual HIV risk behaviour, particularly those risk factors resulting from the use of alcohol. Basic research on condom use and number of sexual partners is stymied by social desirability bias. The data obtained on safe-sex practices may be valid or there may be overestimates on condom usage as well as under or over-estimates on the number of sexual partners. Furthermore, it is necessary to refer to the mechanics of condom use when

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inebriated. A South African study by Townsend et al. (2010) attempted to answer the question: ‘‘Are condoms applied less effectively and consistently by men who drink heavily compared to those who do not?’’ The study replicated findings from other studies, (Kalichman et al, 2008; Simbayi et al. 2006) that heavy drinkers, if they use condoms, use them inconsistently. 4.10 Concurrency Johnson et al. (2009) applied a mathematical model that demonstrated that concurrency is a major driver of the HIV/AIDS epidemic in SA. Concurrency in sexual relationships refers to sexual encounters that overlap in time with different partners, usually two or more simultaneous relationships. The role of concurrency in the spread of HIV is not straight forward. Concurrency subsumes various other factors such as the levels of infectiousness of HIV, so it may be particularly relevant to the spread of HIV, for instance early on in the epidemic or for a newly infected person. According to Morris 2010 concurrency increases the risk of transmitting HIV not acquiring it. One may debate whether long term polygamous relationships or several monogamous relationships in quick succession have a greater impact on HIV transmission. Morris argues that as the connectivity in sexual networks is non–linear a small behavioural change can result in significant HIV prevention. She suggests that if 5% of those individuals who are sexually active have their partners serially rather than concurrently, without reducing the number of partners, this will impact positively on the HIV epidemic. The Townsend (2010) study referred to above showed high rates of problem drinking for men who have multiple, concurrent sexual partners (It should be noted that the figure from Townsend (2010) for problem-drinkers of 58.5% for men in urban contexts in the Western Cape (South Africa) is considerably higher than the 27.9 % of lifetime problem drinkers in the same region recorded in the first South African Demographic and Health Survey (Parry et al. 2005). Despite this finding, Townsend (2010) did not find that problem drinkers were more likely to have multiple partners than non-problem drinkers. Kalichman et al. (2007) however showed that greater frequency and quantities of alcohol use was related to a greater number of sexual partners. Furthermore, an interesting finding from the Townsend (2010) study is that the amount of alcohol consumed effects the choice of sexual partner, i.e. one who is more likely to drink alcohol and be unemployed; this in turn has additional implications for riskier sexual encounters. For example, with transactional sex there is less likelihood of condom use. The link between alcohol use, condom use and concurrency is not clear-cut; no pattern is discernable both within and between groups. A somewhat counter intuitive finding is that condoms are more likely to be used for casual partners, i.e. conferring protection against HIV infection. 4.11 Limitations of the study Overall, this study has limitations in that only English language papers were considered and comprised mainly of those published between 2008 and 2010. Furthermore, HIV status of the subjects was not always provided in the papers and alcohol use patterns were often loosely defined. The emerging adult high risk group may also include some studies that can

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be considered to constitute a separate high risk group, namely adolescents, for example, Morojele 2006b. Groups are not mutually exclusive, individuals within groups may also be part of other groups, for example men who classify themselves as heterosexual may also engage in sex with other men. Katz (2008) highlights that there are significant risk factors that are not captured from standard behavioural indicators, Katz also suggests that cumulative risk, that is, risk over an extended period is not captured by annual measures of sexual risk, such as the number of sexual partners in the past 12 months. These concerns impact on the adequacy of the measures of sexual risk behaviour and may explain why the demonstrated behavioural changes (Shisana et al., 2009) have not lead to the expected declines in HIV measures in SA. For example, despite evidence showing increased condom use there is an indication that condoms are not used consistently. 4.12 Models Epidemiological models combine epidemiological and statistical data, such as the probability of contracting HIV per sexual encounter, as well as behavioural data to help elucidate the spread and the control of HIV. Models are necessary to simulate complex sexual networks. For example, Wim Delva’s SIMPACT is a modeling tool used to simulate HIV epidemics in complex sexual networks. SIMPACT can model the effect of concurrency on the pathogenesis of HIV/AID. For example by “capturing the formation and dissolution of sexual relationships between individuals” it can demonstrate the impact of this interpersonal behaviour on HIV transmission. (Delva thesis. Page 120). Wim Delva argues that “the potential for epidemiological models to improve our understanding of the determinants of HIV spread and control may only be fully unlocked when questions about the sexual network structure and partnership dynamics are adequately addressed both by empirical studies and ensuing advances in model development.” (Delva thesis. Page 120) “SIMPACT is a rather flexible tool, so in principle it is indeed possible to model the effect of alcohol (reduction) on the transmission of HIV in the population. However, the effect of alcohol works indirectly through behavioural choices (primarily formation of sexual relationships and condom use). If data are available describing how alcohol impacts on sexual risk behaviour, SIMPACT will be able to simulate what the implications of these effects are in terms of enhanced HIV transmission.” (e-mail correspondence from Wim Delva)

5. Conclusion and recommendations This literature review again demonstrated the strong association between alcohol consumption and HIV transmission via unsafe sex; broadly defined as unprotected sexual intercourse. This literature review examined two HIV prevention strategies, condom use and concurrency with the additional behavioural component, namely, alcohol consumption at time of sexual encounter in selected high risk sub-populations. It shows that the link between drinking and unsafe sex, that is, inconsistent condom use and multiple sexual partners, is influenced by diverse factors such as the amount of alcohol consumed (generally but not always), the setting and power relations, among other variables and that this holds across the risk groups studied and in different countries. To a large extent this literature

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review substantiates the findings of previous reviews in this area. Although it does not close the question of whether alcohol use is causally related to unsafe sex, it does add more evidence to the established association. It extends the area of research in that it focuses on high risk groups globally. In so doing it indicates important future areas of research, namely a focus on vulnerable sub-populations and the necessity to intervene on alcohol consumption and its role in leading to risky sex and subsequent sero-conversion to HIV. In Africa and other countries where the HIV epidemic is mainly driven by unprotected sexual intercourse, focusing on factors influencing sexual risk behaviour is paramount in preventing new and re-infections of HIV. The focus on high-risk groups is not to further stigmatise certain groups that include drug users, sex workers and MSM. The focus on highrisk behaviours in these groups is vital in order to pinpoint group specific HIV prevention interventions. Specific recommendations for additional studies in SA in the identified high-risk groups from this review are the military and migrant workers in SA. The focus should be on alcohol consumption and risky sexual practices within these high-risk groups. The studies of the SA military should include SA peacekeepers in Africa on their return to SA. There is also a need for more studies on migrants to SA from the rest of Africa. Oscillating internal rural / urban migration was the cornerstone of Apartheid labour policies. Lurie (2010) suggests that labour migration early on in the HIV epidemic in SA, i.e. in the early 1990’s, was critical to the dissemination of the virus from urban to rural areas. However, in the light of evidence of HIV transmission in rural areas he questions the uni-directionality of the spread of HIV and recommends interventions aimed at migrants and their partners to limit the transmission of HIV. Another mobile population to target for HIV prevention measures are truck drivers and the CSWs at truck stops, Ramjee and Gouws, 2002 conclude that truckers may have facilitated the spread of HIV infection in southern Africa. Using condoms, HIV counselling and testing, and needle and syringe programs were all found to be effective and cost-effective techniques to prevent HIV infection among IDUs in a review of Thai literature (Pattanaphesaj and Teerawattananon, 2010). As for IDUs in SA, Parry (2010a) examines risk behaviour in both IDUs and non-injection drug use (NIDU), vulnerable populations at risk for HIV, to inform service delivery that includes prevention and harm reduction. Although the focus of this study is substance abuse that does not include alcohol, many of the recommendations apply equally to alcohol abuse. These include a specific recommendation that service delivery be more integrated, with HIV counselling and testing be provided at substance abuse centres, and that VCT address both substance abuse and sexual risk behaviours. An important recommendation that is pertinent to the current review is that VCT be more specific to sub-populations. In South Africa, sex work is illegal and this adds to the challenge of identifying and implementing HIV prevention interventions. It is important to identify places for HIV prevention programmes to be developed and implemented. For example, shebeens or township taverns are generally frequented by mixed social networks of mainly men who congregate to drink, socialise and find new, usually casual sexual partners (Morojele 2006a). An intervention in a bar with peer leaders has been shown to reduce risky sex for patrons in gay bars (Kelly et al. 1997). Furthermore, the type of research on reduced HIV risk needs to encompass alcohol and other substance

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abuse as well as poor mental health and social problems; particularly in vulnerable subpopulations. (Jewkes 2010a; Jewkes 2010b; Sikkema 2011). Parry et al. (2010b) states that in order to address poor health outcomes resulting from alcohol-related risky sex or non-adherence to antiretroviral regimens resulting from alcohol misuse, primary health care level personnel should use appropriate instruments to screen for problem alcohol use and if necessary provide brief interventions for substance abuse and VCT for HIV. The latter includes proper training of health and social services workers. Overall there should be greater emphasis on advocacy concerning the negative health outcomes from alcohol misuse. This includes educating people on the link of alcohol to unsafe sexual practices and the re-infection/infection with, transmission and progression of HIV/AIDS. Intervention research should include an examination of the efficacy and cost-effectiveness of Brief Interventions for problem alcohol use as HIV prevention. Epidemiological and operational research is needed specifically on the prevalence of alcohol problems in patients with HIV and the integration of alcohol and HIV services in the public health sector at primary health care level (Parry 2010b). The present review clearly shows that there are specific groups at higher risk of contracting HIV. These groups would benefit from improved risk-assessment information. To this end we suggest additional studies in this domain utilising meta-analyses and the modelling of data obtained for the specific groups to better summarise and utilise the information obtained. The statistical data from this review can be utilised as parameter values for modeling the spread of HIV in these sub-populations. In addition to the SIMPACT model there are others, including the STDSIM model (Habbema, 1996) that utilises different data sources to determine which prevention and intervention programmes for STIs are most cost effective. Evidence–based, cost effective HIV interventions for specific high risk groups are a priority. In order to be optimally effective these should take into account the norms and practices central to the particular sub-population. Broader structural problems, outside the public health ambit, such as gender inequality and poverty need to be addressed in the longer term, as they are the underlying, albeit more distal risks factors resulting in the spread of HIV in SA.

6. Acknowledgement We acknowledge the U.S. President’s Emergency Fund for AIDS Relief (PEPFAR) through the US Centers of Disease Control and Prevention (CDC) (PO S-SF750-06-M-0781), and the South African Medical Research Council for funding some of the activities that informed this manuscript. Its contents, however, are solely the responsibility of the authors and do not necessarily represent the official views of the CDC, PEPFAR or other organizations referred to above.

7. Abbreviations AIDS - acquired immune deficiency syndrome ARV - antiretroviral drugs

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CSW - commercial sex workers DALYs - disability adjusted life years FSW - female sex workers HIV - human immunodeficiency virus IDU - Injecting Drug Users MARPs- most at-risk populations MSM – men having sex with men SA - South Africa SSA - sub-Saharan Africa STDs –sexually transmitted disease STIs – sexually transmitted infections US – United States of America

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Stein M, Herman DS, Trisvan E, Pirraglia P, Engler P, and Anderson BJ. 2005. Alcohol use and sexual risk behavior among human immunodeficiency virus-positive persons. Alcohol Clin. Exp. Res. 29 (5): 837-843. Stein MD, Hanna L, Natarajan R, Clarke J, Marisi M, Sobota M, and Rich J. 2000. Alcohol use patterns predict high-risk HIV behaviors among active injection drug users. J Subst. Abuse Treat. 18 (4): 359-363. Stockman JK, Campbell JC, and Celentano DD. 2010. Sexual violence and HIV risk behaviors among a nationally representative sample of heterosexual American women: the importance of sexual coercion. J Acquir. Immune. Defic. Syndr. 53 (1): 136-143. Strathdee SA, Mausbach B, Lozada R, Staines-Orozco H, Semple SJ, Abramovitz D, FragaVallejo M, Torre AL, Amaro H, Martinez-Mendizabal G, Magis-Rodriguez C, and Patterson TL. 2009. Predictors of sexual risk reduction among Mexican female sex workers enrolled in a behavioral intervention study. J Acquir. Immune. Defic. Syndr. 51 Suppl 1: S42-S46. Tavares CM, Schor N, Franca I, Jr., and Diniz SG. 2009. Factors associated with sexual initiation and condom use among adolescents on Santiago Island, Cape Verde, West Africa. Cad. Saude Publica 25 (9): 1969-1980. Tavarez MI, Chun H, and Anastario MP. 2011. Correlates of sexual risk behavior in sexually active male military personnel stationed along border-crossing zones in the Dominican Republic. Am. J Mens. Health 5 (1): 65-77. The NIMH Multisite HIV/STD prevention Trial for African American Couples Group.(2010) The Contribution of Male and Female Partners’ Substance Use to Sexual Risks and STDs Among African American HIV Serodiscordant Couples. AIDS Behav. 14 (5): 1045-1054. Theall KP, Clark RA, Powell A, Smith H, and Kissinger P. 2007. Alcohol consumption, ART usage and high-risk sex among women infected with HIV. AIDS Behav. 11 (2): 205215. Thomas BE, Chandra S, Selvi KJ, Suriyanarayanan D, and Swaminathan S. 2009. Gender differences in sexual behaviour among people living with HIV in Chennai, India. Indian J Med. Res. 129 (6): 690-694. Thomas RM, Plant MA, and Plant ML. 1990. Alcohol, AIDS risks and sex industry clients: results from a Scottish study. Drug Alcohol Depend. 26 (3): 265-269. Todd CS, Nasir A, Stanekzai MR, Bautista CT, Botros BA, Scott PT, Strathdee SA, and Tjaden J. 2010. HIV, hepatitis B, and hepatitis C prevalence and associated risk behaviors among female sex workers in three Afghan cities. AIDS 24 Suppl 2: S69S75. Towe VL, Sifakis F, Gindi RM, Sherman SG, Flynn C, Hauck H, and Celentano DD. 2010. Prevalence of HIV infection and sexual risk behaviors among individuals having heterosexual sex in low income neighborhoods in Baltimore, MD: the BESURE study. J Acquir. Immune. Defic. Syndr. 53 (4): 522-528. Townsend L, Rosenthal SR, Parry CD, Zembe Y, Mathews C, and Flisher AJ. 2010. Associations between alcohol misuse and risks for HIV infection among men who have multiple female sexual partners in Cape Town, South Africa. AIDS Care 22 (12): 1544-1554. Townsend L, Jewkes R, Mathews C, Johnston LG, Flisher AJ, Zembe Y, and Chopra M. 2011. HIV risk behaviours and their relationship to intimate partner violence (IPV)

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Section 3 Emerging Methods

14 Challenges in Healthcare in Multi-Ethnic Societies: Communication as a Barrier to Achieving Health Equity Emine Kale and Bernadette Nirmal Kumar

Norwegian Centre for Minority Health Research, Oslo University Hospital

Norway

1. Introduction The main learning objectives of this chapter are to gain knowledge and a better understanding of: • • • • •

Health and migration Migration and the challenges for healthcare services Equity in healthcare services Barriers to communication The use of interpreters in healthcare

2. Health and migration Over 200 million people celebrated their last birthday outside their country of birth, characterizing the sheer scale, scope and extent of migration. The international migrant population (those living outside their country of birth) in 2010 was estimated at 214 million (3.1% of the global population), whereas UNDP has estimated that 740 million migrated within their country of birth. 75% of all international migrants are in 12% of all countries (IOM, 2002). Migration, globalization intensified by rapid transportation and communication technologies, and trade and commerce have all contributed to the evolving multicultural societies in nations all over the world. Modern day societies are characterized as being heterogeneous with increasing complexities of the heterogeneity. As a part of this global development, West European countries, including Scandinavian countries, have become increasingly multicultural over the last few decades. In Norway half a million immigrants account for 12.2 % of the total population. In Oslo, the immigrant population stands at 28 %, the highest proportion in Norway (Statistics Norway, 2012). A consequence of these demographic changes is the challenge host societies face in integrating non-Western immigrant groups into existing healthcare services; the language barrier is the primary challenge for meeting the healthcare needs of the immigrant population.

3. Challenges in healthcare in multi-ethnic societies Multicultural societies are often societies in transition that might be undergoing enormous changes. However, the changes are far from unidirectional, being positive and/or negative.

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When migrants and their offspring are compared with other groups, changing socioeconomic circumstances within and between generations in different migrant and ethnic groups can be linked to changing health patterns (Macbeth, 2001). This suggests that the health of adults might be related to exposures across their life course (Ben-Shlomo, 2004). The circumstances of migration and the social and health characteristics of resettlement are also key determinants of health (Wolffers, 2003). Post-migration determinants of health include the type of work migrants are expected to perform in the host country, the physical and housing conditions available to them, their language skills, remaining in contact with family, acquiring a new social network and their access to health and social services (Carballo M, 2004). A recent epidemiological study in Norway, “The Oslo Immigrant Health Study”, documents the health of migrants at the population level for the first time and indicates that the health of immigrant groups differs greatly compared to Norwegians and even more so with each other (Kumar, 2008). Only 30% of immigrant women from Pakistan and Turkey in the 59/60 year age group reported good health (Kumar, 2008). In all ethnic groups those with the highest education reported good health more frequently than others. Women reported more musculoskeletal disorders than men. However, men had higher proportions of myocardial infarction and stroke. Immigrant groups report mental distress more often than Norwegians, especially immigrant women (Kumar, 2008f) General obesity is a challenge for Turkish and Pakistani women in Oslo, as around 50% were obese (Body Mass Index >30). This is far higher than any of the other ethnic/gender groups. On the other hand, we found Vietnamese men and women with almost no obesity (3-4%). Children of migrants are often caught at the crossroads between the majority (host) and minority (immigrant) cultures. Ethnic adolescents, therefore, land in double jeopardy with persisting unhealthy habits from their minority cultures and acquiring unhealthy habits from the majority as well. This is well illustrated in the case of boys from the Indian subcontinent in Oslo with high consumption of both full fat milk and carbonated soft drinks (Kumar, 2004f). Often the ability of children of migrants to adapt and adopt the host language and culture creates a perceived gap between them and their parents. Their immigrant parents fear that they are distancing themselves from their native values and behavioural patterns. The intra familial stress and parent-child conflicts may be precursors to low self-esteem, feelings of guilt and psychosocial morbidity among children of migrants (Kumar, 2010). The poor health of immigrants is also reflected in their frequent use of health services. In the Oslo Immigrant Health Study, immigrants made a greater number of visits to the general practitioner (GP) and specialists compared to Norwegians. Turkish and Iranians visited the psychiatrist/psychologist most frequently. Emergency services were used most frequently by those from Turkey and least by the Norwegians (Kumar, 2008). Increased use of healthcare services may reflect: higher prevalence of mental distress related to lifestyle conditions among immigrants, reasons other than health problems cited when using health services or that their need for satisfactory healthcare is not met (FHI 2008). Particular challenges for migrants, such as language barriers, might be a contributing factor to ineffective communication and the increased use of healthcare services (Schyve, 2007).

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Further analysis of the situation is recommended to gain a better understanding of the causes of this situation and to devise strategies to cope with it.

4. Equity in health and healthcare 4.1 The concepts of equity Equity and equality are two concepts that are closely related, but not one and the same. While equality is well-defined, easily understood and measured, equity is not. Whitehead’s definition of inequity refers to differences in health that are unnecessary and avoidable, and unfair and unjust (1985). While situations defined as unfair and unjust will vary depending on the place and time one has to examine the cause and judge the unfairness of the situation within the context of that particular society. Equity in health thus means that every individual has a fair chance to attain their full health potential and, that no one should be disadvantaged from achieving this potential, if it can be avoided (p. 7) Therefore, the aim of policy for equity in health is to reduce or eliminate those health differences which result from factors which are considered to be both avoidable and unfair by creating equal opportunities for health and bringing health differentials down to the lowest level possible (Whitehead, 1985). Braveman and Gruskin define equity as the absence of disparities in health (or in the major social determinants of health) between social groups who have different levels of underlying social advantage/disadvantage - that is, different positions in the social hierarchy (P. 254 2003). Populations who are already socially disadvantaged or socially excluded (for example, persons who are unemployed, homeless or members of a disenfranchised racial, ethnic or religious group) are at a further disadvantage with respect to their health. Social disadvantage here refers to two important attributes: the lower social hierarchy and less economically privileged position (or deprivation which can be relative or absolute). Equity has an ethical aspect which is based on the principle of distributive justice and linked to human rights, and can be assessed by comparing health and its social determinants among different more or less advantaged social groups. 4.2 Equity in healthcare In practice equity means equal access to care, equal utilization for equal need and equal quality of care for all (Whitehead, 1985). Equal access to available care implies equal rights to the available services for everyone and a fair distribution of resources based on healthcare needs. Inequities in access arise when resources and facilities are unevenly distributed, for instance, greater availability in urban areas compared to scarce availability in deprived and rural areas. “Inconvenient” openings hour for clinics, communication barriers and large geographical distances and transport expenses can also be obstacles to equal access to health services. While studies have documented over- or under-utilization of health services, further studies are required to understand better why the utilization rates are different. The variations in the utilization of services are not only indicators of inequities, but also related to the quality of services.

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Equal quality of care for all means that providers must ensure that everyone gets the same high standard of professional care. However, when healthcare providers do not offer the same standards and quality of care to all individuals regardless of age, gender, religious belief or ethnic background, inequities will inevitably arise (Whitehead, 1985). Studies illustrating this phenomenon document negative health outcomes for the children of Spanish-speaking Latinos because of language barriers (Clemans-Cope et al., 2007). Language barriers preventing equal access to healthcare will be dealt with in further detail later in this chapter. 4.3 Equity in health policy Health policies must address social determinants of health, such as improving living conditions, unemployment and working conditions of underprivileged groups, in order to achieve equity in health and healthcare services. These policies need to acknowledge that some groups in society are more disadvantaged than others. Hence, they face greater restrictions in their lifestyle choices, e.g., inadequate income and/or lower levels of education, which in turn limits where and how people live. Therefore, policies should enable people to adopt healthier lifestyles by increasing access to healthier lifestyles. (Whitehead, 1985) An important aspect of achieving equity is to ensure user participation, involvement and empowerment, and to avoid a top down approach. This means that administrators need to make efforts to ensure that information is accessible to all, thereby making it easier for users to participate and influence the decision-making process. An important prerequisite in developing and improving equity is providing evidence by identifying the needs of different vulnerable groups. Research is also needed to monitor and evaluate the effectiveness of policies. An intersectoral approach is recommended as the determinants of inequities may be inherent in many other sectors in society (Shaw et al., 2006; Whitehead, 1985).

“What the scalpel is to the surgeon, words are to the clinicians… The conversation between doctor and patient is the hearth of the practice of medicine.”

Woloshin et al. 1995:72

5. Communication barriers preventing equity in healthcare The increasing number of immigrants from economically less privileged parts of the world to both Western Europe and Northern America, and the diversity this represents is often perceived as a challenge to existing healthcare services, which were traditionally organized to cover the needs of the native population. One of the most important challenges in

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healthcare is to be able to meet the needs of patients from immigrant backgrounds who are not proficient in the language used in the host country. It is not only language barriers which may represent a challenge in healthcare, but also cultural differences in the perception of health/sickness and the sickness role, experiences of illness, help-seeking behaviour and health literacy level. These differences should not go unnoticed or be under-recognized. A language difficulty is perhaps the easiest problem to detect because it is often the most obvious one. Even so, there are usually no common procedures for systematically assessing the need for language assistance and ensuring adequate help. The healthcare providers, who usually have little or no training in how to evaluate patients’ language abilities and often have no clear procedures for how to follow up after facing language barriers, seem often to be left alone to make the decisions themselves (Kale et al., 2010a). Even when a professional interpreter is attained, communication problems can arise due to lack of knowledge and skills on the part of healthcare provider regarding how to work together with the interpreter for optimal communication (Kale et al., 2010b). Healthcare institutions have responsibilities to ensure competency and procedures in their organizations in order to be able to give optimal health services to diverse populations for equal access and quality care for all. 5.1 Health literacy Along with language barriers to effective communication in healthcare there are other potential barriers. Inadequate health literacy of patients is one of the reasons for difficulties in communicating effectively the treatment procedures or prescriptions in consultations and non-compliance. Health literacy refers to a mismatch between the healthcare provider’s level of communication and the patient’s level of comprehension of the medical information given to them (Weiss, 2003). Health literacy is not the same as literacy and is described elsewhere as an individual’s ability to read, understand and use basic health information and services to critically evaluate the information and make appropriate health decisions. Health literacy requires a group of abilities like reading, understanding, remembering the information obtained, analysing and decision-making skills. For instance, the ability to read and understand prescription instructions, understanding informational materials and brochures, filling out forms and so on. We do not have any statistics in Scandinavia, but according to the first large scale assessment done in 2003 in the USA, 21% of the adult population have basic and 14% below basic health literacy, while the majority (53 %) had intermediate health literacy (Kutner et al., 2006). In this study White and Asian/Pacific Islander adults had higher average health literacy than Black, Hispanic American Indian/Alaska Native and Multiracial adults. It has been shown that patients with low health literacy have less awareness of preventive health knowledge, less knowledge of their medical status and self-care instructions compared to people who are more literate (Weiss, 2003). This is an especially crucial issue for immigrant patients who are in a vulnerable position because of difficulties in getting the information they need in a language they can comprehend. In fact, elderly people, people with low socioeconomic status, unemployed people, minority ethnic groups and individuals who have recently immigrated and do not speak the majority language or have the majority language as their second language are in the risk group for low health literacy (Weiss, 2003)

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(Ref: http://talk.onevietnam.org/vietnamese-americans-and-health-literacy-ready/ 5.2 Language barriers There are many models of how human communication proceeds between people from the simplistic and mechanical transmission model where a message is sent to f.exp. verbally from the so called “encoder” or sender to the “decoder” or receiver, to a more complex linear model of the Sender-message-Channel-Receiver Model (SMCR) of communication. There are also models which use a constructivist point of view in which communication is perceived as a collaborative and joint activity where reciprocally in the interaction is emphasized (Clark, 2007). When analysing communication, regardless of which communication model one employs to conceptualize the communication between people, one can still think of plenty of reasons why barriers to effective communication between the patient and healthcare provider arise in addition to lack of a common language, for instance, message overload (when a person receives too many messages at the same time) and message complexity and misunderstanding due to language-related factors (semantic or syntactical) and different perspectives because of cultural differences between the participants (Montana et al., 2008).

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Cultural barriers might arise in meetings with migrants depending on what patients bring to the consultations such as their personality, earlier experiences, habits, attitudes, beliefs and prejudices. To a large extent these characteristics are shaped both by the society they belong to and are currently part of and therefore will be an integral part of the ongoing communication and thus also influence the future course of action. It is also about what the healthcare provider has in terms of personal cultural baggage, e.g., the professional culture he/she belongs to, as well as the organizational or institutional culture in which the interactions are embedded (Helman, 2001). There has been increasing awareness about that the attitudes of therapists from majority populations with regard to various minorities and how this may influence diagnostic practices and the quality of the treatment provided (IOM 2002, ACP 2010). These reports document that minority patients have less access to necessary health services than White patients from the majority. Relatively significant differences in the treatment of various diseases were pointed out, for example, with regard to cancer, cardiovascular diseases, diabetes and psychiatric disorders among minorities, to the disadvantage of these patients. It is assumed that several factors could explain these differences, including health service organizations and consultation practices, of which the clinical uncertainty of physicians, caused by limited information/time constraints and negative attitudes to minority patients, may have a decisive impact. It is essential that healthcare providers and patients communicate effectively to ensure that patients get proper help. Effective communication is defined as communication that is “comprehended by both participants; it is usually bidirectional between participants, and enables both participants to clarify the intended message” (Schyve & The Joint Commission, 2007, p.360) and requires a vast repertoire of skills in interpersonal processing like listening, observing, speaking, analysing and evaluating, all of which enable collaboration and cooperation. “In the absence of comprehension, effective communication does not occur; when effective communication is absent, the provision of health care proceeds only with errors, poor quality, and risks to patient safety” (p.360). Ideally communication should be in the same language to be able to communicate efficiently and when not possible with qualified language assistance (i.e., using professional interpreters). Doctors view culture, ethnicity and language difficulties as barriers to both effective physician-patient communication and a satisfying working alliance (Johnson et al., 2004; Laveist et al., 2002; Meeuwesen et al., 2006). Immigrant patients living in Scandinavia report similar experiences in the existing studies. They complain about not being understood because of language problems and cultural differences, not having enough time to explain their problem and the doctors not being interested in their worries and concerns (Grønseth, 2006; Nielsen, 2005) For many years the communication between physicians and patients has been made a topic in studies from different perspectives (Zimmermann et al., 2007; Kale et al., 2011). In a review article based on selected peer-reviewed studies of communication between physicians from majority populations and patients from a non-Western background, Schouten & Meeuwesen (2006) conclude that the research results obtained to date indicate considerable communication problems. Research also shows that healthcare workers underestimate the negative impact of language barriers and underuse interpreter services (Bischoff et al., 2010; Kale et al., 2010a).

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The negative consequences of language-based obstacles in intercultural communication in healthcare are documented to some extent, but far less than adequately and seldom systematically (Divi et al., 2007). In Scandinavia, the consequences of poor communication between healthcare professionals and minority patients have only to some extent been discussed. For instance Essen (2001) examined stillbirths among women from Somalia, Ethiopia and Eritrea and found a lower quality of prenatal care in immigrant populations compared with the majority population. She pointed out the infrequent use of interpreters in the delivery ward as one of the most important reasons for the reduced quality of care. Divi et al. (2007) point exactly to this lack of interest researchers have shown in this issue by referring to what Johnstone and Kanitsaki said in their article from 2004: ‘…there is a paucity of literature specifically addressing the critical relationship that exists between culture, language, and patient safety, and the particular risks that patients from minority racial, ethno-cultural, and language backgrounds face when being cared for by healthcare professionals who do not know about, share, or understand either their culture or language’ In order to fill this knowledge gap to some extent, Divi et al. (2007) studied the type and frequency of adverse events experienced by patients with Limited English Proficiency (LEP) and English-speaking patients in six U.S. hospitals. The findings showed that LEP hospital patients are more likely than their English-speaking counterparts to experience adverse events that result in harm, and the severity of that harm is often greater. Among 251 adverse events involving patients with LEP, 130 (52%) were related to communication problems whereas 36% of adverse events with English–speaking patients were related to communication problems. •

Misunderstandings and difficulties in uncovering misunderstandings



Problems with giving preventive health information and in getting informed consent



Difficulties with involving patients in their treatment and decision-making



Inadequate comprehension of diagnoses and treatment



Increased risk of misdiagnosis - both over- or under-diagnosis



Inappropriate treatment or lack of treatment



Over or underuse of healthcare services



Increased use of unnecessary diagnostic resources



Less adherence



Frustrations and less satisfaction on both sides

Box 1. Potential negative effects of language barriers in healthcare (Jacobs et al., 2004; Moreno & Morales, 2010; Flores, 2003; 2005; Ngo-Metzer, 2003) 5.3 The use of interpreter services in order to overcome language problems There is general agreement that a desirable way to overcome language barriers is the use of a professional interpreter. The widespread practice of using non-professionals, family members or friends, or bilingual staff on an ad hoc basis as interpreters has been

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discouraged (Frederics, 1996; Jareg et al., 2006). This is because emotional ties between the patient and their family and friends can interfere with the interpretation. Furthermore, nonprofessional interpreters cannot be expected to have adequate knowledge of medical terminology or a good enough command of both languages needed in order to impart the correct information. The patient’s right of confidentiality and privacy may be breached if the patient feels forced to accept the presence of a family member as interpreter. Further, their presence can inhibit discussions regarding sensitive issues such as domestic violence, sexual abuse, psychiatric illness and other sensitive health problems like sexually transmitted diseases (Flores, 2003; 2005). Moreover, the use of a patient’s minor-aged children in planned or acute consultations would be especially unethical and professionally irresponsible, not least towards the child, with regard to the child’s best interests. This can even be against the principles of the conventions on the Rights of Children (Jareg & Pettersen, 2006) 5.3.1 “We take what we have”: A questionnaire-based survey about the use of interpreters in Oslo This title is an answer from one of the healthcare providers which describes the situation quite well considering what they usually do when language assistance is encountered with their patients. Although communication and language barriers between healthcare workers and patients have recently received attention internationally, in Scandinavia few studies have documented what healthcare workers do when they encounter language obstacles, the expectations they have of the interpreters and their evaluation of their own needs. Therefore, a questionnaire-based survey using a cross-sectional design was conducted with healthcare providers working at hospitals in Oslo as participants during 2004-2005. Even though the immigrant’s right to have a professional interpreter in encounters with the public health sector can be considered weakly anchored in existing legislation in several countries, there has been an increased emphasis on patient rights and the legal strengthening of these rights in Scandinavia, as well as in other Western countries. For instance according to the Patient Rights Law in Norway (1999), the patient has the right to contribute to or facilitate the consultation with the healthcare worker and the right to contribute to the choice of the available examinations and treatment methods. In order to be able to contribute, it is stated that information should be adapted to the patient’s individual conditions, such as age, maturity, experience, culture and language background. In addition, healthcare workers are to ensure, to the best of their ability, that the patient has understood the content and meaning of the information. The fact that responsibility is placed on the healthcare workers to evaluate the need for a professional interpreter emphasizes the importance of investigating the associated factors and situations related to this evaluation process and describe the common practices among healthcare workers. With that aim a cross-sectional survey study was conducted using a structured questionnaire in Oslo a few years ago. The survey was distributed to all general practitioners (GPs) at the primary care clinics in the three city districts in Oslo that have the highest percentage of non-Western immigrants. In addition, healthcare professionals in three hospitals that offer specialized health services to these city districts were included. Even though the response rate was low in this study some interesting tendencies were uncovered. The study, in parallel with earlier studies, indicated that professional

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interpreters were underutilized in the health sector, considering the frequency of the language barriers experienced by providers in the study. Further, the answers indicated that the use of interpreters as a working method was not sufficiently embedded in the healthcare services as a standardized and quality assured procedure. Therefore, the use of interpreters seemed to be somehow incidental and dependent on the health provider’s own knowledge and initiative. Responses indicated that situations where healthcare workers did not use interpreters, even though the patient’s understanding of Norwegian was insufficient, occurred quite often (in 28.8% of cases with doctors and 41.5% of cases with nurses). Further 25.3% of respondents indicated that they had often conducted the first conversation with a patient without knowing whether the patient’s understanding of Norwegian was adequate. How do conversations take place when there is a language barrier and how does this affect the health outcomes? This survey did not give an answer to these questions. Well-known impacts when facing language barriers is the feeling of defeat, vulnerability and perhaps helplessness on the part of the patient, but also on the part of the health provider. From clinical experiences, it is known that patients can blame themselves for not being able to speak the majority language better and often feel ashamed about this. Sometimes they do not concede that they have language difficulties, instead pretending to understand. In this study, a large percentage of the respondents answered that they often tried to communicate with the patient without an interpreter (33%) in acute situations. This is thought-provoking considering that such situations might involve life-threatening conditions. Further findings indicated that healthcare providers had a tendency to resort to solutions that are most easily available, for example, using family or friends as interpreters or trying to communicate with the patient in spite of language barriers. More than half of the physicians and nurses responded that they often communicated with the patient through family member(s) or friends. What were the reasons for not using professional language assistance? The healthcare workers stated often that the reasons for not arranging an interpreter were impracticality, it being too time-consuming and poor access to interpreter services. Further, a considerable percentage of the survey participants expressed dissatisfaction with both their own methods of working with interpreters and with the interpreter's qualifications. 5.3.2 Implications of this study for healthcare services One of the implications of this study is that the existing practices can have negative consequences for equal access to healthcare services for patients with limited majority language proficiency and inadequate health literacy. The Patient Rights Law in Norway places the responsibility on healthcare workers and healthcare institutions to guarantee the patient’s right to information and input by providing optimal communication with patients. The healthcare providers, who usually have no training in how to evaluate patients’ language abilities, seem often to be left alone to make the decisions. A newly conducted study indicates that healthcare providers and patients might evaluate quite differently whether or not a language barrier exists (Le C, 2011). Therefore, it is important that administrators at healthcare services and healthcare policy makers are aware of their responsibility to secure the knowledge base and procedures necessary to fulfil the intention of the laws.

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Better routines and procedures in the workplace for the effective organization of work with interpreters and a higher awareness and competence at the institutional level about which measures should be taken in order to adapt healthcare services for patients with limited majority language proficiency and inadequate health literacy are recommended. Before the consultation • Prefer professional interpreters rather than ad hoc solutions with for example family members • Set up time to meet the interpreter to explain the goal of the consultation • Check if the interpreter’s background characteristics and position in the community might affect the relationship between interpreter and the patient negatively • Explain the field in which the interpretation is needed and some specifics aspects of the topic which the interpreter should be aware of and prepared for • Inform the interpreter briefly about your methods and approaches • Agree upon a cooperation model During the consultation • Sit in a triangle such that you face the patient and the interpreter is sitting beside both of you • Ensure that the interpreter always explains his/her role and gives information about the confidentiality rule at the beginning of the consultation • Look at the patient when the interpreter speaks • Use direct speech (e.g., “you” instead of “tell her/him that…)” • Avoid long sentences and jargon • Be aware of signals from the patient and the interpreter about the quality of the communication and interaction • To secure effective communication ask control question to the patient, for example, ask what he/she understood of the information/instructions you have just given • Do not involve the interpreter as a cultural broker or mediator, unless he/she has a defined role as such • Be aware that mediated communication is different than direct immediate communication, and has its own limits After the consultation • Give a debriefing to the interpreter if it has been a difficult consultation emotionally • Evaluate the cooperation and give feedback • Use the same interpreter if possible to assist in developing a professional working alliance being established between you and the interpreter, as well as between the patient and the interpreter this can be especially important in mental health services

Box 2. Some recommendations for working with interpreters in medical settings

6. Conclusions • •

With over 200 million migrants in the world today, steadily increasing migration is a key driver of multiethnic societies. Multi-ethnic societies multiply the challenges for healthcare and these range from varying health behaviours, beliefs and attitudes, diseases, communication, language and cultural barriers, requirements based on religion, lack of information, personal biases, stereotyped views, individual racism to institutional (health system) bias and enforcement of laws requiring equal opportunities in employment and other walks of public life.

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Unless there is a focus on health inequities disadvantaged groups will not have a fair opportunity to attain their full health potential. Health equity should not only be seen in the light of rights, laws and at the macro level of health systems, but also in access and quality of care and equal utilization for equal need. Communication in healthcare is influenced by many factors. Language barriers and inadequate health literacy can, among other things, influence communication negatively in healthcare encounters. It seems that the influence of these factors on communication and health outcomes are often underestimated by healthcare providers and policy makers. Existing legislation in several countries has increased emphasis on patient rights and the legal strengthening of these rights. This implies that healthcare workers and healthcare institutions have the responsibility to guarantee the patient’s right to information by providing optimal communication with patients and communication should be adapted to patient needs. An optimal way to overcome language barriers is to ensure the assistance of professional interpreters, but studies mentioned above indicate that the decisionmaking of healthcare providers regarding whether or not professional language assistance is needed is often influenced by hectic working conditions, making the providers resort to solutions that are most easily available, but not necessarily optimal. These practices can have negative consequences for equal access to healthcare services for patients with limited majority language proficiency and inadequate health literacy. Finally, given that multi-ethnic societies are here to stay, further operational research and development, and implementation of good practices are critical to both tackling health inequities and overcoming barriers in communication.

7. References American College of Physicians. Racial and Ethnic Disparities in Health Care, Updated 2010. Philadelphia: American College of Physicians; 2010: Policy Paper. (Available from American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106) Baker D, Parker R, Williams M, Coates WC & Pitkin K. (2006). Use and effectiveness of interpreters in an emergency department. J Amer Med Assoc, 275:783–788. Ben-Shlomo Y & Kuh D. (2004). A Life Course Approach to Chronic Disease Epidemiology. 2 ed. New York: Oxford University Press. Bischoff A & Hudelson P. (2010). Communicating with foreign language-speaking patients: is access to professional interpreters enough? J Travel Med, 17:15–20. Braveman P & Gruskin S. (2003). Defining equity in health. J Epidemiol Community Health. 57:254-258. Carballo M, Smajkic A, Zeric D, Dzidowska M, Gebre-Medhin J & Van Halem, J. (2004). Mental health and coping in a war situation: the case of Bosnia and Herzegovina. J Biosoc Sci. Jul;36(4):463-77. Clark, HH. (1996). Using Language. Cambridge University Press.UK. Clemans-Cope & Kenney G. (2007). Low income parents' reports of communication problems with health care providers: effects of language and insurance. Public Health Rep. Mar-Apr; 122(2):206-16.

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Divi C, Koss R G, Schmaltz SP & Loeb JM. (2007). Language Proficiency and Adverse Events in U.S. Hospitals: A Pilot Study, Inter Journal for Quality in Healthcare, April 19(2):60–67. Essen B. (2001). Prenatal morality among immigrants from Africa’s Horn. The importance of experience, rationality, and tradition for risk assessment in pregnancy and childbirth. Scientific treatise. Medical faculty, University of Lund, Malmø, Sweden. FHI (2008). Norwegian Inst. for Public Health. The Oslo immigrant profile. Oslo. Flores G, Laws MB, Mayo SJ, et al. (2003). Errors in medical interpretation and their potential clinical consequences in pediatric encounters. Pediatrics.111:6-14. Flores G. (2005). The impact of medical interpreter services on the quality of health care: a systematic review. Med Care Res Rev. 62:255-299. Frederics C. (1996). Using non-professional interpreters in a multiethnic primary care clinic. University of Malaya, Malaysia. (Accessed 24 January, 2005, at http://www.criticallink.org/ journalsc12/10.htm.). Grønseth, AS. (2006). Lost selves and lonely persons. Experiences of illness and well-being among Tamil refugees in Norway. PhD dissertation at NTNU. Helman CG. (2001). Culture, Health and Illness. (Fourth edition) Arnold, London. International Organization for Migration (2010). World Migration Report 2010 – the future of migration: Building capacities for change. Geneva: IOM. Institute of Medicine (IOM) (2002). Unequal Treatment: Confronting racial and Ethnic Disparities in Healthcare. Washington, DC: National Academies Press. Jacobs E, Shepard D, Suaya J & Stone E. (2004). Overcoming language barriers in healthcare: Costs and benefits of interpreter services. American Journal of Public Health.94:866–869. Jareg K & Pettersen Z. (2006).Tolk og tolkebruker – to sider av samme sak. [The interpreter and the interpreter’s user - two aspects of the same issue] Bergen/Oslo: Fagbokforlaget/NAKMI. Johnson RL, Roter D, Powe NR & Cooper LA. (2004). Patient Race/Ethnicity and Quality of Patient–Physician Communication During Medical Visits. American Journal of Public Health: Vol. 94, No. 12, pp. 2084-2090. Kale E & Syed HR. (2010 a). Language barriers and the use of interpreters in the public health services. A questionnaire-based survey. Patient Educ Couns. 81, 187-191. Kale E, Ahlberg N & Duckert F. (2010 b). Hvordan håndterer helsepersonell språklige barrierer? En undersøkelse av tolkebruk i helsevesenet (How do healthcare providers deal with language barriers?) Tidskrift for Norsk Psykologforening, 47, 818823. Kale E, Finset A, Eikeland HL & Gulbrandsen P. (2011). Emotional Cues and Concerns in Hospital Encounters with Non-Western Immigrants as compared with Norwegians. An Exploratory Study. Patient Educ Couns, 84, 325-331. Kazzi B, Cooper C. (2003). Barriers to the use of interpreters in emergency room pediatric consultations. J Pediatric Child Health.39:259–263. Kumar, BN, G. Holmboe-Ottesen NL & Wandel M.(2004). Ethnic Differences in Body Mass Index and Associated Factors of Adolescents From Minorities in Oslo, Norway: A Cross-Sectional Study. Public Health Nutrition 7(8): 999–1008. Kumar BN, Grøtvedt L, Meyer HE, Sogaard AJ, Strand BH. (2008). The Oslo Immigrant Health Profile. Oslo. Nasjonalt folkehelseinstitutt (7). Kumar BN, Viken B. (2010). (Eds). Folkehelse i et migrasjonsperspektiv. Bergen: Fagbokforlaget. Kutner M., Greenberg E., JinY., and Paulsen C. (2006). The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006–483).U.S.

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Department of Education. Washington, DC: National Center for Education Statistics. Le, C. (2011). Tolkebruk i helsetjenesten (Use of interpreters in health services), Master thesis. UIO. Lov 1999-07-02 nr. 63: Lov om pasientrettigheter. [Act relating to the rights of patients] Laveist TA & Nuru-Jeter A. (2002). Is doctor-patient race concordance associated with greater satisfaction with care? J Health Soc Behav. 4:296-306 Macbeth H & Shetty PS. (2001). Health and ethnicity. London: Taylor & Francis Meeuwesen L, Harmsen JA, Bernsen RM, et al. (2006). Do Dutch doctors communicate differently with immigrant patients than with Dutch patients? Soc Sci Med; 63: 2407–17. Meyer B. (1998). Interpreter-mediated doctor-patient communication: The performance of non-trained community interpreters. Seminar: Second international conference on interpreting in legal, health, and social service settings, Vancouver, Canada, 19-23. (Accessed 8 September, 2005, at http://www.criticallink.org/English/criticallink2_papers.htm.) Montana P J. & Charon, B H. (2008). Management. 4th ed. New York. Barron's Educational Series, Inc. Moreno G. & Morales LS. (2010). Hablamos Juntos (together we speak): Interpreters, provider communication, and satisfaction with care. J Gen Intern Med. Dec; 25(12):1282–8. Morales LS, Cunningham WE, Brown JA, Liu H & Hays RD. (1999). Are Latinos less satisfied with communication by health-care providers? J Gen Intern Med. 14: 407417. Nielsen AS. (2005). Smertelige erfaringer (Painfull experiences). PhD. dissertation, København Universitet. Ngo-Metzger Q, Massagli MP, Clarridge BR, Manocchia M et al. (2003). Linguistic and cultural barriers to care. J Gen Intern Med. 18:44–52. Pöchhacker F. (2000). The Community Interpreter’s Task: Self-Perception and Provider Views. R P.Roberts, S E.Carr, D.Abraham & A. Dufour A (Eds.), The Critical Link 2: Interpreters in the community. 49-65. John Benjamins Publishing Schyve PM. (2007). Language Differences as a Barrier to Quality and Safety in Health Care: The Joint Commission Perspective. J Gen Intern Med. 2007 November; 22(Suppl 2): 360–361. Shaw M, Dorling, D & Smith GD. (2006). Poverty, social exclusion and minorities. Marmot M & Wilkinson R G. (Eds), Social determinants of Health. 2. Ed. Oxford University Press, New York. Weiss BD. (2003). Health Literacy. A manual for clinicians. American Medical Association Foundation and American Medical Association. Accessed 21. Januar 2012 http://www.acibademsaglik.com/upload/pdf/literatur40.pdf) Whitehead M. (1992). The concepts and principles of equity in health. Int J Health Serv 22:429–445. (First published with the same title from: Copenhagen: World Health Organisation Regional Office for Europe,1990 [EUR/ICP/RPD 414]) Woloshin S, Schwartz LM, Katz SJ & Welch HG. (1997). Is language a barrier to the use of preventive services? J Gen Intern Med. 12:472-477. Wolffers I, Verghis S, Marin M. (2003).Migration, human rights, and health. Lancet. Dec; 362(9400):2019-20. Zimmermann C, Del Piccolo L, Finset A. (2007).Cues and concerns by patients in medical consultations: a literature review. Psychol Bull 133:438–63.

15 Public Health Research and Action: Reflections on Challenges and Possibilities of Community-Based Participatory Research S. Lazarus1,2,3, B. Duran4, L. Caldwell5,6,7 and S. Bulbulia1 1Safety and Peace Promotion Research Unit (SAPPRU) for Social and Health Sciences, University of South Africa 3Faculty of Education, University of the Western Cape 4Indigenous Wellness Research Institute (IWRI), University of Washington, Seattle 5University of Nebraska, Lincoln, Rhodes College 6University of Memphis 7Annie E. Casey Foundation 1,2,3South Africa 4,5,6,7USA 2Institute

1. Introduction Research has an important role to play in public health, providing new knowledge which is generally used to inform application in all areas of health. In addition to the traditional role of research in health, where the focus is on applied knowledge production, research can also be used as a form of action, and therefore is a recognised area of activities which, in itself, can be a form of intervention (Springett & Wallerstein, 2008). As will be come clear below, there are various terms given to this type of research, and there are varied interpretations of what this kind of activity entails. The main focus, however, is generally on both knowledge production, and action in community or social affairs (Lazarus, 2007). Within the context of action or intervention research, the element of participation is sometimes included as a central principle and characteristic. The emphasis in participatory forms of research is on facilitating various levels of participation of the ‘researched’ in the study. In this chapter, the focus is on the utilisation, possibilities and challenges of CommunityBased Participatory Research (CBPR) as a tool for both research and action in public health. This chapter makes some important contributions to public health in general, and research more specifically. First, it emphasises the value of research as a public health intervention. Second, it emphasises the importance of participation in public health research. Third, it provides an important critical lens to public health research, drawing on social critical perspectives which highlight power dynamics in research endeavours. Fourth, it provides important insights from the authors’ collective experiences of working in marginalised communities, in the USA (specifically American Indian/Alaska Native (AIAN), and African American contexts), and in South Africa.

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The chapter commences with an overview of CBPR as a particular approach, and locates this approach within broader meta-theoretical paradigmatic frameworks. Drawing on both literature and personal experiences of the authors, the next section focuses on the utility, possibilities and potential outcomes of CBPR. Key challenges often faced in this kind of activity are then identified. The authors then draw on their own experiences to provide some suggestions for how some of these challenges can be addressed.

2. CBPR as an approach to research and action in public health Community-engaged research is labeled in different ways, including the following terms: Community-Based Participatory Research (CBPR) (Israel, 2005; Minkler & Wallerstein, 2008), Participatory Action Research (PAR) (Cornwall & Jewkes, 1995), Action Research (Reason & Bradbury, 2001, 2008), and Research Practice Networks (Green & Hickner, 2006; Westfall, Mold & Fagnan, 2007), amongst others. Community engagement, a term currently commonly used in university circles in South Africa, is also often used in this context, although it goes beyond only research activities, including various levels of community participation. The following definitions of CBPR are useful. Israel et al. (2005) state that CBPR refers to a partnership approach to research that equitably involves community members, organisation representatives, and researchers in all aspects of the research process. According to the Kellogg Foundation’s Community Scholars Programme, CBPR is a collaborative approach to research that equitably involves all partners in the research process and recognizes the unique strengths that each brings. CBPR begins with a research topic of importance to the community with the aim of combining knowledge and action for social change to improve the community. In contrast to an instrumental research approach, CBPR constitutes a worldview reflected through an applied approach or process which includes the following specific characteristics: • • • • • •

The Community as the unit of identity, solutions and practice (Israel, Schulz, Parker & Becker, 2001; Schulz et al., 2002) Community engagement at all levels of the research, from problem identification and theory development to sustainability A multi-level focus of change, including individual, community and social determinants (Hawe, Shiell & Riley, 2009) Epistemological diversity in theory and methods; including indigenous decolonizing approaches, empowerment, feminist, queer, systems theory and other critical approaches (Wallerstein & Duran, 2008) Research that includes clearly outlined mutual benefits and co-learning between partners (Israel et al., 2001, Schulz et al., 2002) A long term process and commitment to sustainability (Israel, 2005; Minkler & Wallerstein, 2008)

This approach is in line with general community engagement approaches which include the following key characteristics (Attree & French, 2007; Herbertson, Ballesteros, Goodland & Munilla, 2009; Popay, 2006; Rifkin, Lewando-Hundt & Draper, 2000): • •

Understanding the history and current dynamics of the community, and respecting its uniqueness Aligning community engagement with the community’s own plans and agenda for community development

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Strengthening and sustaining communities Establishing appropriate structures and processes to elicit and represent community views, and ensuring that they are accountable to the community Working with and through a range of groups and organisations, not just formal channels Fostering participation of the community in all key steps

The community engagement approach aligns with CBPR in its focus on the relationship between the ‘university and community’, with CBPR emphasizing the need for shared control, thus emphasizing the power relations in the process. Historically, the CBPR approach has been informed by action research, led by Kurt Lewin in the 1940s. Lewin’s action research approach included cycles of action, reflection, problemsolving and decision-making for new actions, with organisational change being a major focus (Lewin, 1938, 1951, 1997; Lewin & University of Michigan Research Center for Group Dynamics, 1975). In the 1970s, participatory research became popular, as a result of radical critiques of research traditions by social scientists from Asia, Africa, and Latin America in particular. Orlando Fals-Borda, most notably, combined scientific research, adult education and political action that aimed to: (a) raise levels of consciousness (b) empower class and group interests to organize, and (c) evaluated by concrete benefits to communities, not abstractions (Fals-Borda & Rahman, 1991). This included critiques of structural underdevelopment and the need to redistribute inequitable structures, challenges to academic distance from communities, and the development of new academic discourses of feminism, post-colonialism, post structuralism (Wallerstein & Duran, 2008). Much of the above is aligned with the principles of empowerment (Fetterman & Wandersman, 2005) where capacity building, community ownership and democratic participation, within a, social justice framework, are emphasized. This incorporates a key indigenous principle which states: “Don’t plan about us, without us!” (NACCO, 2001). It is important to note that the principle of participation is central to this approach and that not all collaboration meets standards of CBPR. One way to view community engagement is on a continuum from minimal participation to full participation of the community concerned. These different positions on the continuum can be seen as either consultation, involvement, or engagement (Hashagen, 2002). • •



Consultation suggests simply providing information to the community and requesting feedback, and carries no undertaking that there is to be a shift in what is done or how it is done. Involvement carries a stronger message, implying that the academic institution decides on the structures and decision-making processes, and that the community needs to be encouraged to become involved in them. The community has no part in deciding on the suitability of those structures or processes. Engagement suggests a different sort of relationship which avoids making assumptions about communities, asks for a dialogue, and implies that the development of the relationship itself will need to be a focus of attention.

Community research in general draws on a variety of research methodologies, which can be viewed on a continuum of control over phenomena <------> collaboration Heller et al. (1984). Specific research methods used include: participant observation, ethnographic approach,

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network analysis, studies of community populations, and social indicators (measures of social and community well-being), action research, simulation, field experiments, quasiexperimental approaches, and time-series designs. Some examples of different methods used in public health include: participatory community case studies, including random community trials (RCT) (Pokorny et al., 2004); epidemiological research including both science and community participation (TorresHarding et al., 2004); participatory project-based research, where both scientific standards and maximum impact are considered important (Stoeker, 2005); participatory rural appraisal (including historical mapping and inventory asset mapping (Stoeker, 2005); participatory or empowerment evaluation linked to public health interventions, where “participatory evaluation is a health-promoting intervention in itself” (Springett and Wallerstein, 2008, p. 205); and community-driven asset identification, referred to as “barefoot epidemiology” by Minkler and Hancock (2008), which uses a variety of traditional and innovative methods. Community asset mapping is used as a tool for identifying community resources, promoting community pride and eliciting community-embedded knowledge (Minkler & Hancock, 2008). Health promotion research, which usually includes some form of programme development, implementation and evaluation (Reddy et al., 2003), targets populations, communities or settings, and is oriented towards community change; draws on the strengths of the community; takes the sociocultural context into account; and is usually community-based, emphasizing “empowering people through mediating structures, networks, and community institutions” (Revenson & Schiaffino, 2000, p. 473). CBPR could use any of the above methods, but the process is guided by the values and principles outlined above, with community participation and ownership being central. This approach to research is generally located within a participatory paradigm (Guba & Lincoln, 2005), but draws from a number of research paradigms such as post-positivist, constructivist and transformative perspectives (Mertens, 2005), including both hermeneutic and critical traditions (Springett & Wallerstein, 2008). The participatory paradigm reflects holistic, systemic, and relational worldviews (Bradbury & Reason, 2008; Guba & Lincoln, 2005), where knowledge is generated as partners (Springett & Wallerstein, 2008). The participatory paradigm outlined in Guba and Lincoln’s (2005, p. 195-199) updated version of ‘basic beliefs of alternative inquiry paradigms’ focuses on the generation of a participative reality, cocreated by mind and cosmos; a critical subjectivity, favouring experiential, propositional and practical knowing, and co-created findings; political participation in collaborative action inquiry, within a language grounded in shared experiential contexts; pursued in communities of practice; focusing on transforming the world in the service of human flourishing; including self-reflective action; drawing on voices through narrative, movement, song, dance and other presentational forms; and pursued by co-researchers who learn through active engagement in the process, using democratic qualities and skills.

3. Utility, possibilities and potential outcomes of CBPR Why should we use a CBPR approach? Some of the reasons are briefly outlined below. •

There is a increasing interest in health disparities which are appropriately addressed by this approach.

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There is an increasing community and funder demand for community-driven research. There have been disappointing results in intervention research Complex health and social problems are ill-suited to “outside expert” research. It supports implementation and research dissemination. It supports the principle of democracy, and addresses issues of power and domination. It builds capacity and reduces dependency on “professional outsiders”. It ensures cultural and local competence. It facilitates sustainability. It enhances fit and productivity of programmes. It produces more valid research. Ethical considerations are well addressed.

Minkler and Baden (2008) argue that CBPR often results in more effective research. It is externally valid in terms of utility, and internally valid because people are likely to be more honest and willing to participate, resulting in more accurate data. The development of local knowledge is facilitated, and CBPR methods contribute to better translation of research and practice by facilitating community-academic communication and flows of knowledge. The potential outcomes of this approach are clear. As Wallerstein’s (2008, 2010) Interactive CBPR Conceptual Model (refer Figure 1 below) outlines, at the system level, capacities are developed, policies and practices are improved, and sustained interventions can be developed. At the broadest level of meeting the goal of improving health and addressing disparities, this approach contributes to social justice.

Source: Wallerstein, 2008, p. 177; Wallerstein, 2010, p. 131

Fig. 1. Conceptual Logic Model of Community-Based Participatory Research: Processes to Outcomes

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Since 2009, the Indigenous Wellness Research Institute, the University of New Mexico Center for Participatory Research, and the National Congress of American Indians Policy Research Center have collaborated as investigators to better understand how Community Based Participatory Research (CBPR) works to improve health and health equity. Their NIH project (“Research for Improved Health: A National Study of Community-Academic Partnerships,” funded for 2009-2013) aims to (a) better understand CBPR practice variability across contexts, conditions and populations, including American Indian/Alaska Native communities, communities of colour and others which face health disparities; (b) identify promoters and inhibitors of CBPR partnership success; (c) better understand CBPR pathways and promising partnership practices that lead to improved health status; and (d) further develop appropriate research/evaluation measurement tools and methods to assess CBPR partnership effectiveness. The Interactive CBPR Conceptual Model which is being developed by this research team is available as a web tool, allowing users to download surveys (instruments) and individual items measures (variables), with associated information useful for evaluating CBPR partnerships and assessing partnership characteristics.

4. Key challenges of community-based participatory research The following set of challenges linked to conducting research within a CBPR approach has been identified in the literature. There are various tensions inherent in this approach to research. These tensions include (a) science <---> community participation, (b) science/research <---> practical goals/action, and (c) control over phenomena <---> collaboration continuum. These tensions are described in more detail below. Issues of control are central to challenges experienced in CBPR. In particular, nonrandomized designs, which are often favoured in this kind of research, raise a number of challenges in CBPR (Farquhar and Wing, 2008: Heller et al., 2004; Springett & Wallerstein, 2008; Stoeker, 2005). This means that (a) you cannot randomly assign people, resulting in selection bias, (b) the research often cannot be replicated as communities are different, (c) disparities in programmes means you cannot generalize findings, (d) external, intervening events create bias, (e) uncontrollability is exacerbated if there is too much discretion and community choice across sites, and (f) you cannot clearly attribute effects to interventions because of these ‘interferences’. One of the ‘interferences’ is the actual participation and partnership which is acknowledged as having an effect on the interventions and outcomes of the research (Springett & Wallerstein, 2008). It is clear that validity requirements are an ongoing challenge, given the ‘messiness’ of community-engaged research. Although this remains an area of contestation in mainstream research circles, particularly within medical arena, many researchers have found ways to address the concerns usually raised (e.g. Bradbury & Reason, 2008; Mertens, 2005; TorresHarding et al., 2004). These strategies are described below. In addition to the various methodological challenges identified above, community research has political inherency (Mertens, 2005) and is messy, requiring longer time-frames and high levels of flexibility. Historical abuse of research, and political agendas and dynamics in the community, can also hamper the research (Farquhar & Wing, 2008).

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Springett and Wallerstein (2008) raise further specific challenges: • • • • • • •

Pre-existing goals of the research can constrain issue selection. It often involves a great deal of time and resources which need to be built into research protocols and funding grants. Funders hold back on funding unpredictable processes and outcomes. Researchers often lack all the skills required, and the community does not always think ‘critically’. The larger the reach of a project, the more difficult it is to ensure a democratic process. It is difficult to control the ‘coming and going’ of people in the project. The relationship between researcher and researched, the balance between expert and lay involvement, and insider/outsider dynamics are all challenges.

A further area of concern for many in public health and other circles is that of ongoing colonisation through research and knowledge production. Foucault’s theory of “governmentality” (Foucault, 1980) describes the powerful conditions that influence individuals and populations to actively self-regulate their own behavior in alignment with scientific and evidence based prescription of health. This insight unveils the hidden mechanism of power in standard approaches to community engagement. Through the privileging of evidence-based interventions, health becomes an “ethical imperative”, requiring individuals to regulate their behavior and reshape their selves in keeping with new biomedical and public health knowledge. Those who acquire these science sanctioned behaviours earn the status of sanitary citizens (Briggs & Mantini-Briggs 2003), individuals deemed to possess modern medical understandings of the body, health, and illness, practice hygiene, and depend on doctors and nurses when they are sick (Briggs, 2001; Ong, 1987). People who are assumed to be incapable of accepting this modern medicalised relationship to the body, hygiene, illness, and healing—or who reject this subjectivity—become unsanitary subjects (Briggs, 2005). These terms incorporate what have been referred to as biomedical citizens (Ong 1995, Shah 2001) and, at the same time, draw attention to the broader moral, social, political, and cultural meanings that shape how social responsibility is defined in terms of health. These discursive mechanisms are a return to the historical uses of medicine and public health in colonisation. The literature consulted revealed that researchers working within this paradigm have found a variety of strategies to address the challenges highlighted above (Bradbury & Reason, 2008; Farquhar & Wing, 2008; Flicker et al., 2008; Mertens, 2005; Minkler & Baden, 2008; Springett & Wallerstein, 2008;). This includes: • • • • • • • •

Ensuring that the community’s needs and agenda’s are addressed Developing and utilising participatory leadership skills Facilitating optimal participation during each step of the research process Balancing the various tensions in this type of research Using rigorous tools and techniques, using locally and culturally appropriate methods and instruments Using multiple methods Developing different kinds of validity measures that cover the requirement for rigour and quality Working within a strict code of conduct for ethics purposes

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Translating the research for both dissemination and utilization purposes, in languages and formats relevant to the people concerned

Springett and Wallerstein (2008) stress the need to balance the requirements of participation, the use of rigorous tools and techniques, and the practical demands of the real world, while retaining the values of social action. They argue that this requires good participatory leadership skills to hold the project. As mentioned earlier, a number of researchers have found ways to address the concerns usually raised around validity (e.g. Bradbury & Reason, 2008; Mertens, 2005; TorresHarding et al., 2004). This includes emphasizing that there are different kinds of validity (e.g. methodological validity, interpersonal validity, consequential validity, and multicultural validity) which need to be taken into account. Bradbury and Reason (2008) argue for the alternative use of the term quality which is linked to relational praxis, reflexive or practical outcome, plurality of knowing, conceptual and theoretical integrity, extending ways of knowing, methodological appropriateness, and engaging in significant work. With regard to addressing the participation challenges in each of the research steps, Minkler and Baden (2008) make the following suggestions: • • • • • •

Research question selection: The question needs to meet the needs from both sides Instrument and research design: Community input is necessary and one often needs to forego an emphasis on ‘control’ Ethical review and informed consent: This needs to fit the local culture Data collection: Methods need to be developed with the community and adjusted where needed Data analysis and interpretation: Involvement of community in analysis is not always possible or appropriate, but it is optimal and can be very successful Dissemination and use of findings: Various methods, including public approaches, need to be pursued for dissemination, and the focus on ‘action’ can create tensions between academics and community because researchers generally do not get involved in the ‘action’.

Flicker et al. (2008) provide a very useful framework for ethical considerations in CBPR research, providing guidelines for CBPR ethics boards, based on an analysis across 30 schools of public health in the USA. They argue that, in addition to normal ethics guidelines (e.g. autonomy, nonmaleficence, beneficence, justice), the principles of CBPR must also be made visible. This includes ensuring that there is a clear Terms of Reference or Memorandum of Understanding between the research partners. They also argue that the process of the research needs to be documented.

5. Reflections on CBPR challenges in practice The following challenges have been found to be particularly relevant to the authors based on their varied experiences in marginalised and historically oppressed communities. Many of these challenges can be located within researcher-community relationship dynamics, particularly in relation to participation and community consent, knowledge and power, resources and privilege, general community dynamics, and specific research considerations.

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5.1 Knowledge and power Challenges relating to knowledge and power include the following key issues: • •





Researchers and communities usually have different interests in knowledge production, with the latter usually being more interested in solving particular practical problems. Academic researchers are usually viewed as being the experts who have ‘scientific knowledge’, and this creates imbalances in power relations. This perceived academic expertise may silence others’ voices. These imbalances are supported by government and other powerful structures which favour academic language and a particular form of scientific knowledge that reflects an Anglo-Euro-American worldview. There is generally a lack of acknowledgement and honouring of all kinds of knowledge systems.

5.2 Resources and power Challenges relating to resources, which are linked to access to power in society, include the following: •

• •

There is clearly inequitable access to all resources relating to research, with local communities having minimal, if any, access to the required financial and skillresources. Academic researchers usually have access to the resources for the research, and therefore the balance of power. The role and interests of funders play a key role, often overtly or covertly guiding the community research agenda.

5.3 Participation and power Who is involved in the research, and how, is a key consideration when conducting CBPR. Some of the key challenges relating to participation are listed below. • •





On a practical level, the question of who initiates the project is an important one as it often reflects and perpetuates imbalanced power relations in the research partnership. A related question is ‘whose research agenda’ is on the table. A challenge for communitybased researchers is accepting that everything that has statistical significance may not be relevant to community outcomes. Community based researchers are often confronted with meaningful findings from mixed method studies that could advance the communities objectives but not their respective fields. Similarly researchers are challenged with the tensions between community capacity (e.g. empowerment) and professional outcomes (i.e. publication). The question of who is involved in the research process is also an important question. This includes challenges relating to identifying the ‘right’ people, and then including them fully in the process. Once one has all the relevant people ‘around the table’, a central challenge relates to facilitating optimal participation. This includes mediating ongoing power dynamics and tensions. It is important to note that the levels of participation and control are never

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static, and expectations of levels of participation vary by levels of ownership. Furthermore, power and control shifts with function and content. 5.4 Community dynamics Challenges relating to community dynamics are always present. This includes the following issues: • • • •







Conducting research in and with the community always involves formal and informal political dynamics which can interfere with the research process. This includes challenges relating to cultural diversity which is a reality in any modern community. It is necessary to understand the current power dynamics, including a historical and contemporary analysis of positions and other forms of power. The challenge of understanding one’s own position of power in these dynamics is crucial. This relates to the challenge of reflexivity – self-reflection on one’s position within power relations. The community’s possible history of oppression (a reality in all the contexts of practice of the authors of this paper) needs to be understood and healed and utilised for the purposes of both personal and political empowerment. The collective memory of oppression is often transmitted inter-generationally through folklore, fables, or direct instruction and serves as the foundation for cultural mistrust that influences health behaviour. Researchers rarely take the time to hear the stories of marginalisation, exploitation, and often terror that serve as determinants to a community’s health behaviours. Balancing historical realities with contemporary outcomes often challenges researchers who exist in a “pseudo objective” scientific bubble. Communities approach researchers with an ascribed set of characteristics based on previous exposure to exploitation. There are many challenges relating to community empowerment. This includes both fostering personal and collective agency, and managing an understandable but often destructive reaction of entitlement. Sustainability relating to community development is also a key challenge. Many of the above mentioned challenges relate to this issue.

5.5 Research methodology challenges Challenges relating to the actual research methodology employed in a CBPR project are real, and need to be addressed. • • • •

Challenges relating to control have been well articulated in the literature briefly discussed above. The tensions of control have to be managed in an ongoing way. Acknowledgement of the messiness of this approach to research is also important. This includes being aware of the need to be flexible in the process of the research. Challenges relating to research translation include ensuring that the action envisaged actually happens, and is sustained in some way within the community concerned. The urgency that communities face to find solutions to challenges usually do not fit within the timeframe of the research process. Researchers often enjoy the privilege of

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exploration because their wellbeing is often not intrinsically dependent on the answer to a research question. Time to think deeply and employ systematic methods to answering questions is a privilege that researches take for granted. The challenge is for researchers to respect the cultural and pragmatic function of time when participating in research with communities. The suggestions of ways of addressing these challenges identified in the literature (refer the previous section) are relevant in the varied contexts of practice of the authors of this paper. In addition to the points raised by others, the following important considerations and recommendations are offered, based on reflections of our own practices in historically oppressed communities that are still marginalised in one way or another. It should be noted that most of these recommendations relate directly to the challenges of power highlighted in the previous section. Given the historical (and contemporary) realities of these communities, this is not surprising. • •

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Given the power dynamics relating to knowledge generation, researchers should engage community stakeholders in a dialogue that genuinely honours the different forms of knowledge ‘around the table’. This includes decolonising knowledge systems, and honouring and providing opportunities to engage with different knowledge systems and research approaches. In meeting these challenges it is important to honour both academic and community-bedded or indigenous knowledges in order to realign the power dynamics. With regard to the privileging of academic knowledge, it is important to create spaces for postcolonial and hybrid knowledge production, and including culturally supported interventions, indigenous theories, and decolonising methodologies. With regard to incompatible discourses between academia and community, we need to broaden the discourse to include ‘life world’ cultural and social meanings. We need to shift power between universities and communities through bidirectional learning, shared resources, collective decision making and outcomes beneficial to the community, including the co-discovery and promotion of community scholarship. A researcher’s ability to acknowledge privilege and share power in community settings is a powerful tool in CBPR. Effective engagement with communities requires the shedding of the formal academic training which over emphasizes individual contributions in favour of a more ecological perspective of community health. Shifting paradigms to more collective strength-based approaches is probably one of the most important methods of addressing the challenges to CBPR. Our collective experience has highlighted the important of reflexivity. This self-reflective process is discussed in more detail in a forthcoming publication (Duran, Lazarus, Caldwell & Bulbulia). For the purpose of this paper, it is important to emphasise that we need to start with ourselves, examining our own interests and position in the research process and community dynamics. This includes constantly reflecting on ‘whose research agenda’ is being promoted and pursued, ensuring that community interests are always at the forefront. Acknowledgement of cultural diversity is central to working with the inevitable differences in any community. Dealing with these differences includes advocating for inclusive, accountable and transparent processes, and promoting ongoing facilitated dialogue which, at times, may require various conflict management strategies.

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Facilitating empowerment requires employing strategies to foster both personal and collective agency, within the context of collective accountability. Engagement requires addressing various gaps. This includes general gaps in accessing resources, including information and knowledge. It is therefore important to redress current inequalities relating to accessing information and knowledge, as well as access to inclusive processes in knowledge construction. Sustainability relating to community development is a challenge which has to be addressed. It is important to build this capacity during project development. All CBPR project should be guided by general community development principles which have been developed over time, in our own and other similar contexts. To ensure that research translation does occur, that is, that the action proposed is followed through, it is important that appropriate forms of research dissemination are developed. This includes ensuring that knowledge dissemination and production is mutually owned and respected. Proper ‘follow through’ also means that resources must be allocated to ‘action’ phases of the research intervention. This means that researchers have to consider their commitment to the community(ies) concerned beyond normal academic requirements!

A central challenge in CBPR is to conduct rigorous research that is both culturally responsive and scientifically sound. Putting these two aspects together requires creative and innovative strategies, and fundamentally, a deep respect for diverse ways of seeing and doing, and embracing different knowledge systems. Research needs to be demystified and decolonized and made accessible, appropriate and relevant to the community context. 6. In conclusion No matter how ignorant a person is, there is one thing he / she knows better than anybody else, and that is where the shoes pinch his / her own feet, and because it is the individual that knows his / her own troubles even if he / she is not literate or sophisticated in other respects, every individual must be consulted in such a way, actively, not passively, that he himself / herself, becomes a part of the process of authority, of the process of social control, that his / her needs and wants have a chance to be registered in a way that they count in determining social policy (John Dewey) Central to the arguments in this discussion on CBPR as a research and action strategy within public health is the need for respect. Engaging with this value and principle, within ourselves and with our research partners, provides a firm basis for the development of related values and principles which should guide our research practice. Reflection on ourselves and our practice, emphasised in this chapter, must include an honest engagement with our position in the various dynamics of power within the research relationship. We are all challenged to recognise that our individual and collective development and liberation is a joint journey which requires us to walk and talk together in mutual respect and wonder. If you have come to help me, you are wasting your time, but if you have come because your liberation is bound to mine, then let us work together (Lila Watson: Aboriginal woman leader)

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7. References Attree, P. & French, B. (2007). Testing theories of change associated with community engagement in health improvement and health inequalities reduction. Report prepared for NICE (Available on request from [email protected]). Bradbury, H. & Reason, P. (2008). Issues and choice points for improving the quality of action research. In Minkler, M. & Wallerstein, N. Community-based participatory research for health: From process to outcomes. San Francisco, Jossey-Bass. Briggs, C. L. (2001). Modernity, Cultural Reasoning, and the Institutionalization of Social Inequality: Racializing. Comparative Studies in Society & History, 43(4), 665. Briggs, C. L. (2005). Communicability, Racial Discourse, and Disease. Annual Review of Anthropology, 34(1), 269-291. Cornwall, A. & Jewkes, R. (1995). What is participatory research? Soc Sci Med, 41(12), 16671676. Durlak et al (2004). In Jason, L.A., Keys, C.B., Suarez-Balcazar, Y.S., Taylor, R.R. & Davis, M.I. (2004). Participatory community research: Theories and methods in action. Washington: APA. Fals-Borda, O., & Rahman, M. A. (1991). Action and knowledge: Breaking the monopoly with participatory action research. New York/London: Apex Press Intermediate Technology Publications. Farquhar, S.A. & Wing, S. (2008). Methodological and ethical considerations in communitydriven environmental justice research. In Minkler, M. & Wallerstein, N. Communitybased participatory research for health: From process to outcomes. San Francisco: JosseyBass. Felner, D., Felner, T.Y. & Silverman, M.M. (2000). Prevention in mental health and social intervention: Conceptual and methodological issues in the evolution of science and practice of prevention. In J. Rappaport & E.