Abstract
Objectives:
To examine the association between frequency of seeing people walk within sight of home and neighborhood social cohesion among adults, and whether this association varies by race/ethnicity.
Methods:
We used cross-sectional 2015 National Health Interview Survey data on Latino, non-Latino White, non-Latino Black, and non-Latino Asian adults (N = 33,099). Multinomial logistic regression models were used to estimate the associations.
Results:
Seeing people walk every day and every 2-3 days were significantly more likely to report medium levels of neighborhood social cohesion, relative to low. The association between seeing people walk and neighborhood social cohesion varied by race/ethnicity.
Conclusions:
Higher frequency of seeing others walk may contribute to higher levels of neighborhood social cohesion.
Keywords: social cohesion, seeing people walk, race/ethnicity, epidemiology, neighborhood
Engaging in physical activity can lead to positive health outcomes such as maintaining a healthy weight and preventing chronic diseases such as cardiovascular disease, type 2 diabetes, and cancer.1 Previous research has suggested that seeing others exercise influences physical activity outcomes,2-6 and that this association varies by race/ethnicity.3 For example, findings from a study among women showed that frequency of seeing others exercise was only significantly related to physical activity among African-American women.3 However, less is known about the contribution of seeing people exercise to other social environment factors, such as neighborhood social cohesion.
Neighborhood social cohesion is defined as the connectedness and solidarity that is shared within a group.7, 8 Previous research has suggested that neighborhood social cohesion varies by race/ethnicity.9-11 For example, in a study by Almeida et. al (2009), Mexican Americans reported lower social cohesion compared with non-Latino Whites. Further, higher levels of neighborhood social cohesion have been associated with a lower risk of adverse health outcomes such as hypertension, and stroke mortality,12, 13 and with favorable health behavior outcomes such as higher levels of physical activity and meeting physical activity recommendations.14, 15 Given the various health outcomes associated with neighborhood social cohesion, research is warranted to obtain further insight into the factors that contribute to neighborhood social cohesion. However, to the authors’ knowledge, no studies to date have examined the association of seeing people walk with neighborhood social cohesion, and whether this association varies by race/ethnicity.
Using data from a nationally representative sample of US adults we examined (1) the association between frequency of seeing people walk within sight of home and neighborhood social cohesion and (2) whether the association between seeing people walk and neighborhood social cohesion varied by race/ ethnicity (ie, Latinos, non-Latino Whites, non-Latino Blacks, and non-Latino Asians). We hypothesized that higher frequency of seeing people walk is associated with higher levels of neighborhood social cohesion among all adults. Further, we also hypothesized that there would be variation in this association by race/ethnicity. For example, we hypothesized that seeing people walk every day or every 2–3 days, compared with less than once a week, would be associated with medium or high levels of neighborhood social cohesion for some racial/ethnic groups, but not all.
METHODS
We used data from the 2015 National Health Interview Survey (NHIS), a cross-sectional survey that is conducted annually employing a multistage probability sample survey design to gather a nationally representative sample of the non-institutionalized US civilian population. The NHIS obtains information on health and demographics from all family members. An adult of 18 years of age or older within each family is selected at random and interviewed to collect additional information. Additional NHIS survey details can be found elsewhere.16
Of the 33,243 participants who met the inclusion criteria of our study analyses (ie, ≥18 years of age, and identifying as Latino, non-Latino White, non-Latino Black, or non-Latino Asian) those with missing data on variables of interest were excluded (N = 144). The final analytic sample was based on data from 33,099 participants with complete data on the variables of interest.
Measures
Seeing people walk within sight of home.
Participants were asked “how often are there people walking within sight of your home?” to measure the frequency with which they see individuals walk within sight of their home. Participant responses were categorized as every day, every 2–3 days, about once a week, and less than once a week.
Neighborhood social cohesion.
Participants were asked questions related to their perceived neighborhood social cohesion. Individuals were asked whether they agreed or disagreed with the following 4 statements: 1) “People in this neighborhood help each other out”; 2) “There are people I can count on in this neighborhood”; 3) “People in this neighborhood can be trusted”; and 4) “This is a close-knit neighborhood”. We reverse coded the original response scales for all neighborhood social cohesion items and created a neighborhood social cohesion sum score of the 4 items with higher levels of neighborhood social cohesion indicated from a higher score. From the sum score, we used approximate tertiles of neighborhood social cohesion to develop categories of low, medium, and high neighborhood social cohesion. Previous research has utilized these 4 items assessing neighborhood social cohesion and have demonstrated high internal consistency.15
Covariates.
Multivariable models included age, sex, education, race/ethnicity, and perceived neighborhood safety. Age was modeled continuously, and educational attainment was categorized into 4 education levels (ie, less than high school, high school graduate, some college or college graduate). Race/ethnicity was categorized as Latino, non-Latino White, non-Latino Black, and non-Latino Asian. To measure perceived neighborhood safety, we used the following 3 items: 1) “Does traffic make it unsafe to walk”; 2) “Does crime make it unsafe to walk”; and 3) “Do dogs or other animals make it unsafe to walk”. Participant responses were categorized as yes and no.
Statistical Analysis
Unadjusted means or frequencies and standard errors of participant characteristics (ie, demographics, neighborhood safety, frequency of seeing people walk, and neighborhood social cohesion) were computed by race/ethnicity. Multinomial (polytomous) logistic regression models were used to estimate the adjusted odds ratios (OR) of the likelihood of medium or high neighborhood social cohesion, relative to low neighborhood social cohesion, and their associations with frequency of seeing people walk within sight of home. Model 1 estimates were unadjusted, and in Model 2 we adjusted for age, sex, race/ethnicity, and neighborhood safety. We also formally tested whether the association between frequency of seeing people walk and neighborhood social cohesion varied by race/ethnicity by including a race/ethnicity and frequency of seeing people walk interaction term in the fully adjusted model.
SAS 9.4 survey procedures (SAS Institute Inc., Cary, NC) were used in all analyses to account for survey weights and the complex sampling design of NHIS.
RESULTS
Table 1 presents the distribution of the participant demographics, neighborhood safety, frequency of seeing people walk, and neighborhood social cohesion by race/ethnicity. Among Latinos, approximately 32% reported having attained less than a high school education, while less than 14% of non-Latino White, non-Latino Black, and non-Latino Asian reported having less than a high school education. The proportion of individuals that reported traffic making it unsafe to walk was similar across all racial/ethnic groups. However, Latinos and non-Latino Blacks had greater proportions of individuals that reported that crime and dogs or other animals make it unsafe for them to walk in their neighborhood. Across all racial/ethnic groups a high proportion of participants indicated that they see people walk within sight of their home every day, with the higher proportions among Latinos, non-Latinos Blacks, and non-Latino Asians (75.24%, 78.71%, and 78.96%, respectively), compared with non-Latino Whites (70.92%). Between 25–30% of non-Latino Whites and non-Latino Asians reported low neighborhood social cohesion, while approximately 40% of Latinos and non-Latinos Blacks reported low neighborhood social cohesion.
Table 1.
Participant Characteristics by Race/ethnicity: National Health Interview Survey 2015
| Total Sample (N = 33099) |
Latinos (N = 5550) |
Non-Latino White (N = 21017) |
Non-Latino Black (N = 4588) |
Non-Latino Asian (N = 1944) |
|
|---|---|---|---|---|---|
| Mean or % (SE) | Mean or % (SE) | Mean or % (SE) | Mean or % (SE) | Mean or % (SE) | |
| Demographics | |||||
| Age, years (mean) | 47.14 (0.18) | 41.03 (0.29) | 49.32 (0.23) | 44.39 (0.37) | 44.58 (0.51) |
| Male, % | 48.21 (0.37) | 49.82 (0.89) | 48.53 (0.49) | 45.14 (0.92) | 46.61 (1.28) |
| Education | |||||
| Less than high school, % | 12.57 (0.27) | 31.92 (0.78) | 8.03 (0.28) | 13.92 (0.65) | 9.24 (0.98) |
| High school graduate, % | 24.76 (0.35) | 28.21 (0.87) | 24.31 (0.45) | 28.03 (0.97) | 13.74 (1.04) |
| Some college, % | 31.06 (0.37) | 25.86 (0.84) | 32.21 (0.47) | 36.07 (0.90) | 21.53 (1.14) |
| College graduate, % | 31.62 (0.46) | 14.01 (0.71) | 35.46 (0.58) | 21.99 (0.85) | 55.49 (1.59) |
| Neighborhood Safety | |||||
| Does traffic make it unsafe to walk, % | |||||
| Yes | 23.51 (0.43) | 23.60 (0.86) | 23.54 (0.55) | 24.58 (0.97) | 20.59 (1.32) |
| No | 76.49 (0.43) | 76.40 (0.86) | 76.45 (0.55) | 75.42 (0.97) | 79.41 (1.32) |
| Does crime make it unsafe to walk, % | |||||
| Yes | 12.35 (0.29) | 19.35 (0.81) | 8.60 (0.30) | 23.54 (0.93) | 13.21 (1.03) |
| No | 87.65 (0.29) | 80.65 (0.81) | 91.40 (0.30) | 76.46 (0.93) | 86.79 (1.03) |
| Do dogs or other animals make it unsafe to walk, % | |||||
| Yes | 10.46 (0.28) | 13.88 (0.80) | 8.26 (0.30) | 18.82 (0.86) | 9.06 (1.00) |
| No | 89.54 (0.28) | 86.12 (0.67) | 91.74 (0.30) | 81.18 (0.86) | 90.94 (1.00) |
| Frequency of people walking within sight of home | |||||
| Less than once a week, % | 13.19 (0.39) | 9.83 (0.58) | 15.22 (0.52) | 9.30 (0.79) | 7.10 (0.85) |
| About once a week, % | 4.93 (0.19) | 5.43 (0.43) | 5.00 (0.24) | 4.16 (0.45) | 4.48 (0.67) |
| Every 2-3 days, % | 8.88 (0.25) | 9.50 (0.53) | 8.87 (0.34) | 7.84 (0.60) | 9.47 (0.90) |
| Every day, % | 73.00 (0.49) | 75.24 (0.92) | 70.92 (0.62) | 78.71 (1.08) | 78.96 (1.33) |
| Neighborhood Social Cohesion | |||||
| Low, % | 29.31 (0.41) | 39.03 (0.88) | 25.09 (0.50) | 39.72 (1.00) | 29.39 (1.22) |
| Medium, % | 33.18 (0.38) | 35.76 (0.84) | 31.62 (0.47) | 35.05 (0.97) | 38.94 (1.58) |
| High, % | 37.57 (0.45) | 25.21 (0.82) | 43.29 (0.58) | 25.23 (0.93) | 31.67 (1.45) |
SE=standard error.
Table 2 displays the results from the multinomial logistic regression analyses examining the associations between frequency of seeing people walk and neighborhood social cohesion among adults. Individuals that reported seeing people walk within sight of their home every day and every 2–3 days were significantly more likely to report medium neighborhood social cohesion, relative to low social cohesion (Odds Ratio [OR]: 1.17; 95% Confidence Interval [CI]: 1.03–1.33, OR: 1.47; 95% CI: 1.21–1.78, respectively). After adjustment for demographics and neighborhood safety, seeing people walk every day and every 2–3 days remained significantly associated with medium neighborhood social cohesion (OR: 1.16; 95% CI: 1.02–1.33, OR: 1.46; 95% CI: 1.20–1.78, respectively).
Table 2.
Associations of Frequency of Seeing People Walking Within Sight of Home with Neighborhood Social Cohesion among Adults: National Health Interview Survey 2015
| Model 1a | Model 2b | |||
|---|---|---|---|---|
| Neighborhood Social Cohesion | Neighborhood Social Cohesion | |||
| Medium vs. Low | High vs. Low | Medium vs. Low | High vs. Low | |
| OR (95% CI) | OR (95% CI) | OR (95% CI) | OR (95% CI) | |
| Frequency of People Walking Within Sight of Home | ||||
| Every day | 1.17 (1.03-1.33) | 1.09 (0.95-1.26) | 1.16 (1.02-1.33) | 1.08 (0.94-1.25) |
| Every 2-3 days | 1.47 (1.21-1.78) | 1.12 (0.92-1.36) | 1.46 (1.20-1.78) | 1.10 (0.90-1.35) |
| About once a week | 1.06 (0.86-1.31) | 1.09 (0.87-1.37) | 1.04 (0.84-1.28) | 1.06 (0.85-1.34) |
| Less than once a week | 1.00 | 1.00 | 1.00 | 1.00 |
| Age | 1.01 (1.00-1.01) | 1.02 (1.02-1.02) | 1.01 (1.00-1.01) | 1.02 (1.02-1.02) |
| Male | 1.26 (1.16-1.36) | 1.08 (1.00-1.16) | 1.19 (1.09-1.29) | 0.99 (0.92-1.08) |
| Education | ||||
| Less than high school | 1.00 | 1.00 | 1.00 | 1.00 |
| High school graduate | 1.17 (1.02-1.36) | 1.33 (1.16-1.53) | 1.12 (0.97-1.30) | 1.25 (1.08-1.45) |
| Some college | 1.24 (1.08-1.41) | 1.43 (1.25-1.64) | 1.16 (1.01-1.33) | 1.31 (1.14-1.51) |
| College graduate | 1.62 (1.40-1.86) | 1.94 (1.68-2.24) | 1.46 (1.26-1.69) | 1.69 (1.45-1.95) |
| Race/Ethnicity | ||||
| Latino | 0.81 (0.72-0.90) | 0.47 (0.42-0.53) | 0.86 (0.76-0.96) | 0.51 (0.45-0.58) |
| Non-Latino White | 1.00 | 1.00 | 1.00 | 1.00 |
| Non-Latino Black | 0.75 (0.67-0.84) | 0.42 (0.37-0.48) | 0.83 (0.74-0.93) | 0.49 (0.43-0.56) |
| Non-Latino Asian | 1.02 (0.86-1.20) | 0.64 (0.55-0.76) | 1.06 (0.89-1.26) | 0.69 (0.58-0.82) |
| Neighborhood Safety | ||||
| Does traffic make it unsafe to walk, % | ||||
| Yes | - | - | 0.85 (0.77-0.95) | 0.78 (0.71-0.87) |
| No | - | - | 1.00 | 1.00 |
| Does crime make it unsafe to walk, % | ||||
| Yes | - | - | 0.48 (0.43-0.54) | 0.30 (0.26-0.34) |
| No | - | - | 1.00 | 1.00 |
| Do dogs or other animals make it unsafe to walk, % | ||||
| Yes | - | - | 0.97 (0.84-1.12) | 0.92 (0.79-1.08) |
| No | - | - | 1.00 | 1.00 |
OR=Odds Ratio.
Adjusted for age, sex, education, and race/ethnicity.
Adjusted for age, sex, education, ethnicity, and reporting unsafe to walk in neighborhood due to traffic, crime, and animals
We also examined if the association between seeing people walk within sight of home and neighborhood social cohesion varied by race/ethnicity (Table 3). We stratified analyses by race/ethnicity after formal tests for interaction indicated statistical significance (p for interaction= 0.0019). In adjusted models, among Latinos, seeing people walk every day was associated with medium and high neighborhood social cohesion (OR: 1.40; 95% CI: 1.05–1.88, OR: 1.58; 95% CI: 1.07–2.34, respectively), and seeing people walk every 2–3 days was associated with medium social cohesion (OR: 1.51; 95% CI: 1.01–2.26). Non-Latino Whites reporting seeing people walk every 2–3 days were more likely to have medium social cohesion (OR: 1.40; 95% CI: 1.09–1.79). Among non-Latino Blacks, seeing people walk every day was associated with medium social cohesion (OR: 1.56; 95% CI: 1.05–2.29), and seeing people walk about once a week was associated with high social cohesion (OR: 2.13; 95% CI: 1.13–4.03). There was no significant association between seeing people walk within sight of home and neighborhood social cohesion among non-Latino Asians.
Table 3.
Associations of Frequency of Seeing People Walking Within Sight of Home with Neighborhood Social Cohesion among Adults by Race/Ethnicity: National Health Interview Survey 2015a
| Latino | Non-Latino White | Non-Latino Black | Non-Latino Asian | |||||
|---|---|---|---|---|---|---|---|---|
| Neighborhood Social Cohesion | Neighborhood Social Cohesion | Neighborhood Social Cohesion | Neighborhood Social Cohesion | |||||
| Medium vs. Low | High vs. Low | Medium vs. Low | High vs. Low | Medium vs. Low | High vs. Low | Medium vs. Low | High vs. Low | |
| OR (95% CI) |
OR (95% CI) |
OR (95% CI) |
OR (95% CI) |
OR (95% CI) |
OR (95% CI) |
OR (95% CI) |
OR (95% CI) |
|
| Frequency of People Walking Within Sight of Home | ||||||||
| Every day |
1.40 (1.05-1.88) |
1.58 (1.07-2.34) |
1.04 (0.89-1.23) |
1.00 (0.84-1.19) |
1.56 (1.05-2.29) |
1.25 (0.89-1.78) |
1.18 (0.69-2.04) |
0.76 (0.40-1.45) |
| Every 2-3 days |
1.51 (1.01-2.26) |
1.22 (0.72-2.08) |
1.40 (1.09-1.79) |
1.06 (0.82-1.35) |
1.64 (0.98-2.75) |
1.35 (0.82-2.22) |
2.00 (0.88-4.54) |
1.16 (0.47-2.85) |
| About once a week | 1.26 (0.77-2.04) |
1.42 (0.78-2.57) |
1.00 (0.76-1.33) |
0.95 (0.73-1.24) |
0.78 (0.44-1.36) |
2.13 (1.13-4.03) |
1.00 (0.41-2.46) |
0.46 (0.15-1.41) |
| Less than once a week | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
OR=Odds Ratio
Adjusted for age, sex, education, and reporting unsafe to walk in neighborhood due to traffic, crime, and animals.
DISCUSSION
Our study examined the association between frequency of seeing people walk within sight of home and neighborhood social cohesion, and whether this association varied by race/ethnicity. Our findings indicated that the frequency of seeing people walk is significantly associated with neighborhood social cohesion, and that this relationship varies by race/ethnicity. Specifically, confirming our study hypothesis, the results revealed that those who reported higher frequency of seeing others walk within sight of their home were more likely to report higher levels of neighborhood social cohesion. When we examined this association by race/ethnicity, our findings showed that seeing people walk every day was associated with high neighborhood social cohesion in Latinos. In Latinos and non-Latino Whites, seeing people walk every 2–3 days was associated with medium neighborhood social cohesion. Among non-Latino Blacks, seeing people walk every day was associated with medium social cohesion, and seeing people walk about once a week was associated with high social cohesion.
To our knowledge, the present study is the first to examine the association between the frequency of seeing people walk in sight of home and neighborhood social cohesion, and whether this association varies by race/ethnicity. Our findings suggest that seeing people walk within sight of home contributes to neighborhood social cohesion. There may be direct and indirect processes in the underlying mechanisms of these associations that promote neighborhood social cohesion. For example, higher frequency of seeing people walk within sight of the home may elicit feelings of safety and trust in neighbors, and in turn influence neighborhood social cohesion. Previous research has shown that individuals who perceive their neighborhood as safe report a higher sense of community.17 Further, presence and level of traffic within a neighborhood can negatively influence perceptions related to helpfulness, safety, and friendliness of an area.18 Another possible explanation for our findings is that higher frequency of seeing people walk within sight of home may be an indicator of a walkable neighborhood, which may promote social interaction. For instance, walkable neighborhoods could facilitate opportunities for individuals to interact and engage in the neighborhood, consequently fostering a sense of community.17, 19 Also, seeing neighbors while engaged in walking has been positively associated sense of community.20 Future research should consider examining other aspects of the social environment to obtain insight into the mechanisms through which seeing people walk within sight of home contributes to neighborhood social cohesion. For example, future studies should consider accounting for community type as geographical influences could play a role in frequency of seeing people walk and neighborhood social cohesion.
Our findings also showed that the association between seeing people walk and neighborhood social cohesion varied by race/ethnicity. Among Latinos, seeing people walk every day was associated with high neighborhood social cohesion. Similar patterns of seeing people walk every 2–3 days with medium levels of neighborhood social cohesion were observed among Latinos and non-Latino Whites. Among non-Latino Blacks, seeing people walk every day was associated with medium social cohesion, and seeing people walk about once a week was associated with high social cohesion. These differences may be partially explained by variations observed in neighborhood social cohesion, and in seeing people walk. Previous research has suggested that there is variation by race/ethnicity in neighborhood social cohesion,9-11 and seeing people walk in relation to physical activity,2-6 although our study is the first to examine the variation by race/ethnicity in the association between seeing people walk and neighborhood social cohesion. Another possible explanation for this variation by race/ethnicity could be explained by other neighborhood factors not included in our study, such as neighborhood ethnic composition. For example, research has shown that among Latinos, living in a more heterogeneous neighborhood is associated with higher social cohesion.9 Further research is needed to identify and understand the factors that contribute to the variation by race/ethnicity in the association between seeing people walk and neighborhood social cohesion.
Although associations were not significant among non-Latino Asians, a similar pattern of higher neighborhood social cohesion with higher frequency of seeing people walk within sight of home was observed. One possible explanation of this finding is that other neighborhood factors such as neighborhood immigrant composition, which was not assessed in our study, may be more important for neighborhood social cohesion than seeing people walk among non-Latino Asians. For instance, previous findings have shown that Chinese Americans residing in neighborhoods with a higher proportion of immigrants (ie, immigrant enclaves) reported lower social cohesion.21 Similarly, among Asian Americans, neighborhood ethnic density has been shown to be negatively associated with social cohesion.22 Also, although we did not find an association of seeing people walk with neighborhood social cohesion, previous research has suggested that other types of cohesion, such as family cohesion, relative to neighborhood social cohesion, may play a stronger role in the health of Asian Americans.23 Further, Asian Americans have been shown to have social networks and support that differ from other racial/ethnic groups.24 Future research further examining neighborhood factors that influence social cohesion and their role in the health of Asian Americans is warranted given the limited research in this area.
The strengths of our study should be considered despite the following limitations. Due to the cross-sectional nature of the NHIS data, our ability to draw causal inferences or directionality between the study variables cannot be ascertained. Also, all the measures in our study were based on self-reported data, which could lead to response bias and misrepresent the accuracy of the results. Lastly, we selected 4 items to measure neighborhood social cohesion, whereas prior studies have used 5 items for this measure.8 However, the 4 neighborhood social cohesion measures used in our study have demonstrated high internal consistency in previous research.15
Our study is the first to examine the relationship between the frequency of seeing others walk in sight of the home and neighborhood social cohesion. While previous studies have associated greater neighborhood social cohesion with favorable health outcomes, the association observed in our study adds to current research on factors that contribute to neighborhood social cohesion and highlights the importance of favorable neighborhood environments to promote health. As our findings suggest, seeing others walking within sight of the home may positively influence neighborhood social cohesion, and in turn, lead to positive health outcomes. However, it is important to continue to take into consideration the importance of the built environment given its role in promoting physical activity, such as walking. Our findings also suggest that the contribution of other neighborhood factors (eg, built and social environmental factors) to neighborhood social cohesion should be further explored.
IMPLICATIONS FOR HEALTH BEHAVIOR OR POLICY
Our results reveal that seeing others walk frequently within sight of the home may positively impact the levels of shared trust and connectedness experienced among neighbors. This finding, while highlighting the importance of being physically active (ie, walking) in neighborhoods, also sheds light on a factor that contributes to neighborhood social cohesion. Currently, there is a vast amount of research that demonstrates that neighborhood social cohesion influences health outcomes, but a lack of research on the factors that contribute to neighborhood social cohesion. We recommend that researchers further examine factors that may contribute to neighborhood social cohesion so we may better understand how we can influence neighborhood social cohesion and thereby promote health. By understanding the factors that influence neighborhood social cohesion, researchers can inform recommendations for developing neighborhood programs and policies that build on current knowledge of the various built and social environment factors within a neighborhood that impact health.
In efforts to reduce health disparities, it will be important for researchers and practitioners to consider the role of social and physical determinants of health, such as neighborhood-level factors. As a leading indicator topic in Healthy People 2020, having a deeper understanding of the influence of social determinants of health is especially important when designing programs among groups residing in communities burdened by unfavorable neighborhood factors that act as barriers to health. Further, the development of health interventions and health promotion programs that address health disparities that exist across various racial/ethnic populations and are exacerbated by residing in an neighborhood environment, remains critical. Thus, we recommend that researchers, practitioners, and policymakers work together to continue to identify the social and physical determinants that contribute to health disparities and translate research findings into programs and policies that support equitable communities.
Acknowledgments.
Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under award number P20CA221697–01 and P20CA221696–01. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Support for this study was provided in part by the University of Houston’s HEALTH Research Institute.
Footnotes
Human Subjects Approval Statement. All procedures were approved by the University of Houston Institutional Review Board.
Conflict of Interest Disclosure Statement. The authors have no competing interests pertaining to this research.
Contributor Information
Rosenda Murillo, University of Houston, Houston, TX..
Darleesa Doss, Indiana State University, Terre Haute, IN..
Jocelyn Yanez, University of Houston, Houston, TX..
Lily Ortega, University of Houston, Houston, TX..
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