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BACKGROUND: The US Affordable Care Act (ACA) energy posting mandate requires restaurant chains to disclose information on the energy content of their food items. Assessments of the effect of menu energy labeling on dietary choices have reported inconsistent findings. OBJECTIVE: This study examines the impact of menu energy labeling on food items purchased by college students after the mandate was enacted nationally. STUDY DESIGN AND SETTING: Student food sales data from purchases made at three fast-food restaurants during the 2017/2018 and 2018/2019 academic years at a university campus were used for the analysis. The total sample included 1,662 students on the university meal plan; these students generated 145,295 food transactions at the restaurants over the study period. We utilized a difference-in-differences (DiD) empirical strategy, comparing changes in transaction-level energy purchases at two fast food restaurants (FFRB and FFRC - treatment groups) that posted energy information in the summer of 2018 with another fast food restaurant (FFRA - control group) that began posting energy information before the study period. RESULTS: We observed increases in the average energy content per transaction after implementing the menu labeling policy. The DiD estimates found an increase of 20.6 in the average calories of energy purchased per transaction at the treatment restaurants relative to the control restaurant. In the subgroup analyses, the DiD estimates indicate calories of energy increased: 18.7 for female students, 20.5 for male students, 23.5 for non-Hispanic Black students, 30.2 for students eligible for federal financial aid, and 19.9 for students not eligible for federal financial aid. CONCLUSION: The results suggest that the ACA energy menu labeling policy led to an increase in the energy content per transaction by students at a public university. This paper highlights the need for more research to better understand the determinants of food choice among college students.

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BACKGROUND: While the retail food environment has been well studied, research surrounding the university food environment is still emerging. Existing research suggests that university food environments can influence behavioral outcomes such as students' dietary choices, which may be maintained long-term. Despite a growing interest in assessing university food environments, there is no standardized tool for completing this task. How researchers define "healthy" when assessing university food environments needs to be clarified. This paper describes the protocol for systematically reviewing literature involving university food environment assessments. OBJECTIVE: This paper aimed to describe the protocol for a systematic review of the assessments of university food environments. The review will summarize previously used tools or methods and their implications. METHODS: Electronic databases, including PubMed (NLM), Cochrane Library (Wiley), Web of Science (Clarivate), APA PsycINFO (EBSCO), CINAHL (Cumulative Index to Nursing & Allied Health) Complete (EBSCO), ProQuest Nursing and Allied Health, and Google Scholar were searched for papers published between 2012 and 2022 using combinations of related medical subject headings terms and keywords. The electronic databases were supplemented by reviewing the reference list for all included papers and systematic reviews returned with our search results. The review will include all study types, including randomized controlled trials, observational studies, and other pre-post designs. Papers that examine at least 1 aspect of the university food environment, such as cafeterias, campus convenience stores, and vending machines, were considered for inclusion. A total of 2 reviewers will independently screen titles and abstracts, complete a full-text review, extract data, and perform a quality assessment of included papers, with a third reviewer resolving any conflicts. The Quality Assessment for Diverse Studies (QuADS) tool was used to determine the methodological quality of selected studies. A narrative and tabular summary of the findings were presented. There will not be a meta-analysis due to the methodological heterogeneity of the included papers. RESULTS: The initial queries of 4502 records have been executed, and papers have been screened for inclusion. Data extractions were completed in December 2023. The results of the review were accepted for publication in May 2024. The systematic review generated from this protocol will offer evidence for using different assessment tools to examine the campus food environment. CONCLUSIONS: This systematic review will summarize the tools and methods used to assess university food environments where many emerging adults spend a significant part of their young adult lives. The findings will highlight variations in practice and how "healthy" has been defined globally. This review will provide an understanding of this unique organizational food environment with implications for practice and policy. TRIAL REGISTRATION: PROSPERO CRD42023398073; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=398073. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/54955.

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Objective: The Exercise is Medicine® On Campus (EIM-OC) international campaign leverages university resources (e.g., health centers, recreation, and kinesiology departments) to encourage students, faculty, and staff to integrate physical activity into campus culture. This involves evaluating student physical activity levels during health visits and establishing referral systems for exercise prescriptions. EIM-OC allows universities to earn tiered recognition (Gold, Silver, or Bronze) based on their on-campus physical activity promotion and integration. For Gold recognition, schools must incorporate routine physical activity assessments into their health system, ultimately connecting healthcare providers with health/fitness professionals (HFPs, e.g., campus recreation professionals, kinesiology professors). This research worked to uncover pivotal factors driving EIM-OC on-campus collaborations through HFPs' perspectives. Methods: HFPs (n = 11) working full-time at a Gold-level institution (n = 10 in United States) participated. Semi-structured, Zoom-recorded interviews with a generic qualitative research design were completed between June and September 2022. Results: Major thematic findings included the importance of tangible support (e.g., personnel), encounters with both trust and tension cross-campus, positive student development opportunities, and variations in outcome reporting and program evaluation. Faculty and staff emphasized the need for methods to obtain and sustain program funding. Participants also expressed the importance of interdisciplinary collaboration to increase the collective impact of EIM-OC on student health and overall collegiate success. Conclusion: HFPs expanded on their EIM-OC experiences and program sustainment or growth requirements. With increased interdisciplinary collaboration, rigor in outcome reporting, and tangible resources, the collective impact of EIM-OC on student health outcomes and overall collegiate success could be greatly perpetuated.

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The availability, promotion, and price of healthy foods within the university food environment may impact students' dietary choices. This systematic review summarizes the tools and methods used to assess the healthfulness of university food environments where many students spend a significant portion of their emerging adulthood. Thirty-six global studies published between 2012 and 2022 were sourced from PubMed (NNLM), Cochrane Library (Wiley), Web of Science (Clarivate), APA PsycInfo (EBSCO), CINHAL Complete (EBSCO), ProQuest Nursing, and Allied Health, following PRISMA 2020 guidelines. Of the included studies, 58% were institutional-level audits, 17% examined individual-level perceptions, and 25% combined both. Most institutional-level audits focused on one aspect of the food environment (e.g., eateries, vending machines). For studies examining multiple spaces within the campus environment (38%), comprehensive assessments were limited, and most studies had to employ a combination of assessment tools. Surveys were most often used to gather individual perceptions about the food environment. The Nutrition Environment Measures Survey (NEMS) was the most commonly used tool across all studies. This review highlights the need for a standardized tool, method, or a "healthy" benchmark for specific use at universities to improve methodological rigor and comparability of findings across institutions.

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Most early maternal deaths are preventable, with many occurring within the first year postpartum (we use the terms "maternal" and "mother" broadly to include all individuals who experience pregnancy or postpartum and frame our recognition of need and policy recommendations in gender-neutral terms. To acknowledge limitations inherent in existing policy and the composition of samples in prior research, we use the term "women" when applicable). Black, Hispanic, and Native American individuals are at the most significant risk of pregnancy-related death. They are more commonly covered by Medicaid, highlighting likely contributions of structural racism and consequent social inequities. State-level length and eligibility requirements for postpartum Medicaid vary considerably. Federal policy requires 60 days of Medicaid continuation postpartum, risking healthcare coverage loss during a critical period of heightened morbidity and mortality risk. This policy position paper aims to outline urgent risks to maternal health, detail existing federal and state-level efforts, summarize proposed legislation addressing the issue, and offer policy recommendations for legislative consideration and future study. A team of maternal health researchers and clinicians reviewed and summarized recent research and current policy pertaining to postpartum Medicaid continuation coverage, proposing policy solutions to address this critical issue. Multiple legislative avenues currently exist to support and advance relevant policy to improve and sustain maternal health for those receiving Medicaid during pregnancy, including legislation aligned with the Biden-Harris Maternal Health Blueprint, state-focused options via the American Rescue Plan of 2021 (Public Law 117-2), and recently proposed acts (HR3407, S1542) which were last reintroduced in 2021. Recommendations include (i) reintroducing previously considered legislation requiring states to provide 12 months of continuous postpartum coverage, regardless of pregnancy outcome, and (ii) enacting a revised, permanent federal mandate equalizing Medicaid eligibility across states to ensure consistent access to postpartum healthcare offerings nationwide.

Many maternal deaths happen within the first year postpartum and can be prevented. Black, Hispanic, and Native American mothers are at more risk for many reasons, including unfair systems and insufficient healthcare coverage from government insurance (Medicaid). Rules for getting Medicaid can be very different across states and in postpartum compared to pregnancy. The US government only requires states to continue providing Medicaid for 60 days postpartum, after which it is up to each state. If mothers are required to re-qualify for Medicaid shortly after giving birth, they could lose healthcare when they are at more risk of dying or getting sick. In this policy position paper, a team of maternal health researchers and clinicians reviewed and summarized recent research and current laws related to postpartum Medicaid to propose future laws that could address these issues. Some proposed laws would expand Medicaid coverage during postpartum, but lawmakers have not recently discussed them. This position paper recommends that lawmakers (i) consider laws that require states to provide 12 months of postpartum healthcare coverage and (ii) have the US government make the same rules to qualify for postpartum Medicaid across all states.

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BACKGROUND: Gestational weight gain (GWG) exceeding the recommendations of the Institute of Medicine (in the United States) is associated with numerous adverse maternal and infant health outcomes. While many behavioral interventions targeting nutrition and physical activity have been developed to promote GWG within the Institute of Medicine guidelines, engagement and results are variable. Technology-mediated interventions can potentially increase the feasibility, acceptability, and reach of interventions, particularly for pregnant women, for whom integration of interventions into daily life may be critical to retention and adherence. Previous reviews highlight GWG self-monitoring as a common intervention component, and emerging work has begun to integrate digital self-monitoring into technology-mediated interventions. With rapid advances in technology-mediated interventions, a focused synthesis of literature examining the role of digital self-monitoring tools in managing GWG is warranted to guide clinical practice and inform future studies. OBJECTIVE: The proposed review aims to synthesize the emerging research base evaluating digital GWG self-monitoring interventions, primarily focusing on whether the intervention is effective in managing GWG. Depending on the characteristics of the included research, secondary focus areas will comprise intervention recruitment and retention, feasibility, acceptability, and differences between stand-alone and multicomponent interventions. METHODS: This protocol was developed following the PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) guidelines for systematic review protocols. The proposed review would use a planned and systematic approach to identify, evaluate, and synthesize relevant and recent empirical quantitative studies (reported in English) examining the use of digital weight self-monitoring tools in the context of technology-mediated interventions to manage GWG in pregnant US adults, with at least 2 instances of data collection. Literature eligible for inclusion will have a publication date between January 2010 and July 2020. The Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies will be used to assess the methodological quality of included studies across various domains, and results will be synthesized and summarized per the synthesis without meta-analysis guidelines. RESULTS: The initial queries of 1150 records have been executed and papers have been screened for inclusion. Data extractions are expected to be finished by December 2023. Results are expected in 2024. The systematic review that will be generated from this protocol will offer evidence for the use of digital self-monitoring tools in the management of GWG. CONCLUSIONS: The planned, focused synthesis of relevant literature has the potential to inform the use of digital weight self-monitoring tools in the context of future technology-mediated interventions to manage GWG. In addition, the planned review has the potential to contribute as part of a broader movement in research toward empirically supporting the inclusion of specific components within more extensive, multicomponent interventions to balance parsimony and effectiveness. TRIAL REGISTRATION: PROSPERO CRD42020204820; https://tinyurl.com/ybzt6bvr. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/50145.

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The emergence of the COVID-19 pandemic significantly changed the prenatal care experience, specifically regarding medical appointments and social opportunities. It is critical to capture this change through the narratives of pregnant people, particularly those of marginalized populations, whose voices may often be underrepresented in the literature. This mixed-methods paper summarizes the experiences of 40 pregnant Black/African American (AA) women during the COVID-19 pandemic. A cross-sectional, online survey was administered between 2020 and 2021 to assess prenatal health and the impacts of the COVID-19 pandemic on patients' pregnancy experience. Coping behaviors during the pandemic were self-reported using the COPE-IS. Univariate analyses were conducted. An additional analysis of participants (n = 4) was explored through a week-long qualitative exercise using a photo documentation procedure. Photo-Elicitation Interviews (PEI) were conducted to capture and center their pandemic pregnancy experiences. Sources of stress during the pandemic varied, with the most common being financial concerns (n = 19, 47.5%). Over half of the sample (n = 18, 54.5%) self-reported increases in their positive coping behaviors during the pandemic, such as communicating with friends and family, talking to healthcare providers, listening to music, and engaging in spiritual practices-such as prayer. The four PEI study participants reflected on the impacts of social distancing on their prenatal experience and mentioned hospital and provider-related weariness due to their race. The findings of this study suggest that during the COVID-19 pandemic, Black/AA pregnant women in Charlotte, NC used social support, mindfulness practices, self-advocacy, and health literacy to navigate challenges present during their prenatal health experience. This paper highlights the personal, social, and structural experiences of pregnant women during a public health crisis so that responsive and effective programs or policies can be planned in the future.

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In the United States, there is an opportunity to improve the nutritional health of university students through the campus food environment. This project used a content analysis approach to investigate whether healthy food standards and policies were incorporated into the contract agreements between North Carolina (NC) public universities and their food service management companies. Food service contracts were collected from 14 NC public universities using food service management companies on campus. Each contract was evaluated using the 35-item North Carolina Food Service Policy Guidelines Assessment to examine four elements of the campus food environment: Beverages, Packaged Snacks, Prepared Foods, and Other (e.g., strategic placement of healthier food). Five university food service contracts incorporated no North Carolina Food Service Policy Guidelines, three university contracts included one to five guidelines, and six university contracts included six to nine guidelines. Altogether, 13 of the 35 guidelines were incorporated into at least one university food service contract. This project presents a cost and time-effective assessment method for determining if evidence-based nutrition guidelines have been included in university food service contracts. This approach and findings may lead to contract revisions to improve the campus food environment and, subsequently, the nutritional health of college populations.

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Assessing resilience among alternative sexuality (alt-sex; e.g., kink, polyamory) community members is imperative as alt-sex individuals often face discrimination and possess intersecting marginalized identities. The Brief Resilience Scale (BRS) has extensive psychometric support; however, prior research indicates both a one- and two-factor (i.e., succumbing and resilience) structure. Further, the psychometric properties of the BRS have not been examined among alt-sex community members. As such, the current study examined the BRS factor structure among alt-sex individuals and measurement invariance across demographic groups (i.e., sexual orientation, gender identity, and sexual assault history). Confirmatory factor analyses and multi-groups invariance analyses were conducted. The two-factor BRS model demonstrated better fit to the data. Model fit did not differ by sexual orientation or gender identity. Measurement invariance was observed by lifetime sexual assault history, with higher factor loadings on succumbing items among alt-sex community members with a lifetime history of sexual assault. Our findings support use of the BRS to measure resilience among alt-sex individuals. Succumbing, or weakened resilience, is a salient factor for alt-sex community members who are sexual assault survivors, warranting further attention.

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Pregnancy embodiment describes the way a pregnant individual inhabits their body, including disconnection and connection, likely influencing both distress and well-being. Emerging work indicates that acceptance of pregnancy-related bodily change may support well-being, particularly when co-occurring with self-care behaviors. Yet, specific associations of pregnant embodiment and intentional, individualized self-care practices (mindful self-care; MSC) with well-being and distress remain unexamined. The present study tested independent and interactive associations between MSC and positive embodiment (body agency), and negative embodiment (body estrangement), respectively, with maternal distress and well-being in a sample of US pregnant women (N = 179; Mage = 31.3 years, aged 21-43; 85.6 % White, 4.9 % Hispanic/Latinx). Challenge and threat/harm appraisals of the COVID-19 pandemic were included in the model to represent responses to the unique sociohistorical context. Measurement-corrected path analytic models explained a substantial proportion of variation in well-being and a smaller proportion in prenatal distress. Among those with higher MSC, the association between body estrangement and prenatal distress was weaker. Results support mindful self-care as protective for pregnancy distress in the setting of body disconnection. Future individualized health promotion might consider how high-stress contexts influence application of self-care practices and impact distress and well-being during pregnancy.

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The objective of this study was to explore the meal-related thought processes, planning, and purchasing behaviors of primary caregivers on weeknights. A mixed-methods study design was applied using a cross-sectional survey and qualitative interviews. Thirty-three primary caregivers from early childhood education centers were enrolled in the study. Descriptive statistics of sample characteristics were conducted and an a-priori thematic analysis of interview recordings was completed using NVivo Qualitative software. The following key themes were identified: satisfaction with dinner, feeding behaviors before the COVID-19 pandemic, regretful feeding experiences, meal planning, food purchasing, social support, and general feelings about dinner preparation and cooking. Important considerations for food purchasing included family satisfaction, price, convenience, and healthfulness. Satisfaction around dinner choices varied, with dissatisfaction often related to a bad workday, being stressed, or making meals that family members disliked. Findings demonstrate the need for more research and interventions around the topic of meal planning and preparation, specifically for working parents, that further examine tasks required for providing meals, the physical and cognitive time for meal preparation, and helpful means of support.

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BACKGROUND: Excessive gestational weight gain has increased over time and is resistant to intervention, especially in women living with overweight or obesity. This study described the process evaluation methods and findings from a behavioral lifestyle intervention for African American and white women living with overweight and obesity that spanned pregnancy (≤ 16 weeks gestation) through 6 months postpartum. METHODS: The Health in Pregnancy and Postpartum (HIPP) study tested a theory-based behavioral intervention (vs. standard care) to help women (N = 219; 44% African American, 29.1 ± 4.8 years) living with overweight or obesity meet weight gain guidelines in pregnancy and lose weight in postpartum. Participants completed process evaluation surveys at 32 weeks gestation (n = 183) and 6 months postpartum (n = 168) regarding their perceptions of most and least helpful aspects of the intervention. A database tracked delivery and receipt of intervention components (in-depth counseling session, telephone calls, podcasts). Descriptive statistics are used to report fidelity, dose, and participants' perceptions. We also tested whether dose of behavioral intervention components was associated with gestational weight gain and 6-month postpartum weight retention with linear regression models controlling for baseline age and gestational weeks, receipt of Medicaid, race, parity, and marital status. A content analysis was used to code and analyze responses to open-ended survey questions. RESULTS: Over 90% of participants (both groups) would recommend the program to a friend. Implementation fidelity was moderately high and greater in pregnancy than postpartum for all intervention components. Dose received and participants' ratings of the in-depth counseling session and telephone calls were more favorable than podcasts. The Facebook group was not perceived to be very helpful, likely because of low participant interaction. Although podcasts were created to reinforce call topics, this redundancy was viewed negatively by some. More calls completed and more podcasts downloaded related to lower gestational weight gain (p < .05). CONCLUSION: Study findings underscore challenges in engaging this important but busy population, especially during the postpartum period. TRIAL REGISTRATION: The study was registered at clinicaltrials.gov (NCT02260518) on 10/09/2014. https://clinicaltrials.gov/ct2/show/NCT02260518 .

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Birth doulas were deemed "non-essential" personnel during the COVID-19 pandemic and were generally excluded from attending hospital births in person. This study documents the impacts of pandemic-related contextual factors on birth doula care in the San Francisco Bay Area, examines how doulas adapted their services, and explores implications for policy and practice. We employed a contextually bound qualitative case study methodology driven by social action theory and conducted interviews with 15 birth doulas. The pandemic disrupted physical settings, the social environment, communication modalities, contractual arrangements, and organizational level factors. The historical context also amplified awareness of institutionalized racism in birth settings and highlighted birth doulas' advocacy role. Striking deficits exist in birth doulas' integration into US healthcare systems; this made their services uniquely vulnerable to the pandemic circumstances. Birth doulas' value ought to be more formally recognized within health policy, health insurance, and hospital systems as complementary care to that provided by medical providers to improve access to high-quality perinatal care.

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BACKGROUND: Mobile mental health systems (MMHS) have been increasingly developed and deployed in support of monitoring, management, and intervention with regard to patients with mental disorders. However, many of these systems rely on patient data collected by smartphones or other wearable devices to infer patients' mental status, which raises privacy concerns. Such a value-privacy paradox poses significant challenges to patients' adoption and use of MMHS; yet, there has been limited understanding of it. OBJECTIVE: To address the significant literature gap, this research aims to investigate both the antecedents of patients' privacy concerns and the effects of privacy concerns on their continuous usage intention with regard to MMHS. METHODS: Using a web-based survey, this research collected data from 170 participants with MMHS experience recruited from online mental health communities and a university community. The data analyses used both repeated analysis of variance and partial least squares regression. RESULTS: The results showed that data type (P=.003), data stage (P<.001), privacy victimization experience (P=.01), and privacy awareness (P=.08) have positive effects on privacy concerns. Specifically, users report higher privacy concerns for social interaction data (P=.007) and self-reported data (P=.001) than for biometrics data; privacy concerns are higher for data transmission (P=.01) and data sharing (P<.001) than for data collection. Our results also reveal that privacy concerns have an effect on attitude toward privacy protection (P=.001), which in turn affects continuous usage intention with regard to MMHS. CONCLUSIONS: This study contributes to the literature by deepening our understanding of the data value-privacy paradox in MMHS research. The findings offer practical guidelines for breaking the paradox through the design of user-centered and privacy-preserving MMHS.

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The relationship between political affiliations and diet-related discussions on social media has not been studied on a population level. This study used a cost- and -time effective framework to leverage, aggregate, and analyze data from social media. This paper enhances our understanding of diet-related discussions with respect to political orientations in U.S. states. This mixed methods study used computational methods to collect tweets containing "diet" or "#diet" shared in a year, identified tweets posted by U.S. Twitter users, disclosed topics of tweets, and compared democratic, republican, and swing states based on the weight of topics. A qualitative method was employed to code topics. We found 32 unique topics extracted from more than 800,000 tweets, including a wide range of themes, such as diet types and chronic conditions. Based on the comparative analysis of the topic weights, our results revealed a significant difference between democratic, republican, and swing states. The largest difference was detected between swing and democratic states, and the smallest difference was identified between swing and republican states. Our study provides initial insight on the association of potential political leanings with health (e.g., dietary behaviors). Our results show diet discussions differ depending on the political orientation of the state in which Twitter users reside. Understanding the correlation of dietary preferences based on political orientation can help develop targeted and effective health promotion, communication, and policymaking strategies.

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Marginalization causes gender diverse individuals to experience increased stress compared with cisgender individuals, such as social stigma and discrimination, which can lead to poor physical and mental health outcomes. This population uses various resources to cope with these challenges, including community social support. This qualitative research aimed to understand how gender diverse individuals perceive their community resilience. Supported by a community partner organization, we recruited N = 20 gender diverse participants for semi-structured interviews analyzed through inductive thematic qualitative analysis. The data revealed similarities with community resilience factors observed among other minority groups as well as novelty. Themes emerged on both individual and group levels and include strengths (e.g., opening to the group, role modeling for resilience, and group resources) and threats to community resilience (e.g., social anxiety, physical health conditions, and stigma). This paper informs the development of community resilience interventions in the context of gender diversity.

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Purpose: Pregnant women with elevated body mass index (BMI) are difficult to recruit into lifestyle studies. This article (1) summarized strategies to recruit pregnant women into a randomized trial, and (2) reported recruitment statistics and their correlates. Materials and Methods: African American and white women with BMI ≥25 and gestational age <16 weeks were recruited primarily through obstetric clinics into the Health in Pregnancy and Postpartum study. Women completed a brief screening form, and if initially eligible, a phone screening. We compared characteristics of those randomized versus not randomized. Results: Initially eligible pregnant women (N = 1578) were identified through direct recruitment by research staff, indirect recruitment by clinic staff at obstetric clinics, and self-referrals through advertisements. Of these women, 54.0% (850) were reached for further screening, and 43.5% (685) were fully eligible. Among eligible women, 58.8% (403) were scheduled for a baseline visit, and 33.3% (228) were randomized. The overall recruitment yield was 14.4%. Recruited participants were diverse (44% African Americans) and averaged 12.6 weeks gestation at baseline. Randomized (vs. nonrandomized) women were more likely to own a cell phone, have access to a computer with internet at home or work, and have downloaded a podcast. Conclusions: Although this study did not reach the recruitment goal, a relatively large and diverse sample of pregnant women were recruited early in pregnancy. Recruiting women with elevated BMI for a behavioral lifestyle intervention is challenging, particularly among women with characteristics, including less phone and internet access and limited experience in using podcasts. This study is registered at Clinicaltrials.gov: NCT02260518.