Southwest Cardiovascular Curriculum Project: Study Findings for American Indian Elementary Students

Attitudes toward Alzheimer's disease and dementia caregiving and health outcomes: Racial and ethnic differences

This study aimed to explore racial/ethnic differences in the attitudes toward Alzheimer's Disease (AD) and dementia caregiving among midlife women who were family caregivers of persons living with AD (MWPLAD) in the U.S. and examine the associations of the attitudes to their health outcomes. This was a cross-sectional online survey study among 172 MWPLAD. The instruments included: the Attitude toward AD and Related Dementias Scale, the Questions on Attitudes toward AD Caregiving, the Social Readjustment Rating Scale, the EQ-5D-5L and the Midlife Women's Symptom Index. Multiple linear regression analyses were conducted. There were significant racial/ethnic differences in caregivers' attitudes toward dementia caregiving, health-related quality of life, and total severity scores of symptoms (p < .01). Controlling for covariates including race/ethnicity, caregivers' positive attitudes toward dementia caregiving were significantly associated with their health outcomes (p ≤ .05). Interventions for MWPLAD need to consider racial/ethnical differences in their attitudes toward dementia caregiving.

Decreasing menopausal symptoms of Asian American breast cancer survivors through a technology-based information and coaching/support program

OBJECTIVE

One of the most prevalent and distressing symptoms after breast cancer treatment is menopausal symptoms. Asian American breast cancer survivors have lower quality of life and often receive inadequate management of menopausal symptoms compared to other racial/ethnic groups. Technology-based programs could be a solution to fill the gap in care. The purpose of this study was to test the efficacy of a technology-based information and coaching/support program on menopausal symptoms of Asian American breast cancer survivors.

METHODS

This study adopted a randomized pretest/post-test group design among 91 Asian American breast cancer survivors (42 in an intervention group who used the program and the American Cancer Society Web site and 49 in a control group who used only the American Cancer Society Web site). The intervention was a theory-driven and culturally tailored intervention program that aimed to provide information and coaching/support using computers and mobile devices. Multiple instruments were used to measure background characteristics and menopausal symptoms at pretest, post 1-month, and post 3 months. An intent-to-treat linear mixed-model growth curve analysis was used to analyze the data.

RESULTS

The intervention group showed a significant decrease in the distress scores of menopausal symptoms over time: physical (β = -0.07, P = 0.08), psychological (β = -0.13, P = 0.05), psychosomatic (β = -0.17, P = 0.06), and total symptoms (β = -0.19, P = 0.01). Theory-based variables including attitudes, social influences, and self-efficacy partially mediated the impact of the intervention on the distress scores of menopausal symptoms (P < 0.10).

CONCLUSIONS

The program was effective in alleviating menopausal symptoms of Asian American breast cancer survivors.

Improving menopausal symptoms through promoting physical activity: a pilot Web-based intervention study among Asian Americans

OBJECTIVE

Based on previous studies, a Web-based physical activity promotion program with educational modules on menopausal symptoms and physical activity has been developed for Asian American midlife women to reduce their menopausal symptoms through increasing their physical activity. The purpose of this pilot randomized intervention study was to determine the efficacy of the Web-based program in improving menopausal symptom experience of Asian American midlife women.

METHODS

This was a randomized repeated measures pretest/posttest (pretest, post 1 month, and post 3 months) control group study among 29 Asian American midlife women. Multiple instruments were used, including the Midlife Women's Symptom Index and the Kaiser Physical Activity Survey. The data were analyzed using a mixed-model growth curve analysis.

RESULTS

Over time, total severity scores decreased for the control group (-0.53, P < 0.10), whereas they did not exhibit a meaningful change for the intervention group. Both study groups experienced improvement in active living habits over time, but such an improvement was greater for the intervention group (β = 0.29, P < 0.001) than for the control group (β = 0.08, P < 0.10). The time × group interactions for total severity scores were not statistically significant anymore after controlling for physical activity (-0.34 for the control group, P = 0.10).

CONCLUSIONS

The findings supported the feasibility of a 3-month Web-based intervention for menopausal symptom management among Asian American midlife women and the preliminary efficacy of the program in increasing their physical activity.

Community engagement to reduce inequalities in health: a systematic review, meta-analysis and economic analysis

Background

Community engagement has been advanced as a promising way of improving health and reducing health inequalities; however, the approach is not yet supported by a strong evidence base.

Objectives

To undertake a multimethod systematic review which builds on the evidence that underpins the current UK guidance on community engagement; to identify theoretical models underpinning community engagement; to explore mechanisms and contexts through which communities are engaged; to identify community engagement approaches that are effective in reducing health inequalities, under what circumstances and for whom; and to determine the processes and costs associated with their implementation.

Data sources

Databases including the Cochrane Database of Systematic Reviews (CDSR), The Campbell Library, the Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment (HTA) database, the NHS Economic Evaluation Database (NHS EED) and EPPI-Centre’s Trials Register of Promoting Health Interventions (TRoPHI) and Database of Promoting Health Effectiveness Reviews (DoPHER) were searched from 1990 to August 2011 for systematic reviews and primary studies. Trials evaluating community engagement interventions reporting health outcomes were included.

Review methods

Study eligibility criteria: published after 1990; outcome, economic, or process evaluation; intervention relevant to community engagement; written in English; measured and reported health or community outcomes, or presents cost, resource, or implementation data characterises study populations or reports differential impacts in terms of social determinants of health; conducted in an Organisation for Economic Co-operation and Development (OECD) country. Study appraisal: risk of bias for outcome evaluations; assessment of validity and relevance for process evaluations; comparison against an economic evaluation checklist for economic evaluations. Synthesis methods: four synthesis approaches were adopted for the different evidence types: theoretical, quantitative, process, and economic evidence.

Results

The theoretical synthesis identified key models of community engagement that are underpinned by different theories of changes. Results from 131 studies included in a meta-analysis indicate that there is solid evidence that community engagement interventions have a positive impact on health behaviours, health consequences, self-efficacy and perceived social support outcomes, across various conditions. There is insufficient evidence – particularly for long-term outcomes and indirect beneficiaries – to determine whether one particular model of community engagement is likely to be more effective than any other. There are also insufficient data to test the effects on health inequalities, although there is some evidence to suggest that interventions that improve social inequalities (as measured by social support) also improve health behaviours. There is weak evidence from the effectiveness and process evaluations that certain implementation factors may affect intervention success. From the economic analysis, there is weak but inconsistent evidence that community engagement interventions are cost-effective. By combining findings across the syntheses, we produced a new conceptual framework.

Limitations

Differences in the populations, intervention approaches and health outcomes made it difficult to pinpoint specific strategies for intervention effectiveness. The syntheses of process and economic evidence were limited by the small (generally not rigorous) evidence base.

Conclusions

Community engagement interventions are effective across a wide range of contexts and using a variety of mechanisms. Public health initiatives should incorporate community engagement into intervention design. Evaluations should place greater emphasis on long-term outcomes, outcomes for indirect beneficiaries, process evaluation, and reporting costs and resources data. The theories of change identified and the newly developed conceptual framework are useful tools for researchers and practitioners. We identified trends in the evidence that could provide useful directions for future intervention design and evaluation.

Funding

The National Institute for Health Research Public Health Research programme.

School-based programmes for preventing smoking

BACKGROUND

Helping young people to avoid starting smoking is a widely endorsed public health goal, and schools provide a route to communicate with nearly all young people. School-based interventions have been delivered for close to 40 years.

OBJECTIVES

The primary aim of this review was to determine whether school smoking interventions prevent youth from starting smoking. Our secondary objective was to determine which interventions were most effective. This included evaluating the effects of theoretical approaches; additional booster sessions; programme deliverers; gender effects; and multifocal interventions versus those focused solely on smoking.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Tobacco Addiction Group's Specialised Register, MEDLINE, EMBASE, PsycINFO, ERIC, CINAHL, Health Star, and Dissertation Abstracts for terms relating to school-based smoking cessation programmes. In addition, we screened the bibliographies of articles and ran individual MEDLINE searches for 133 authors who had undertaken randomised controlled trials in this area. The most recent searches were conducted in October 2012.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) where students, classes, schools, or school districts were randomised to intervention arm(s) versus a control group, and followed for at least six months. Participants had to be youth (aged 5 to 18). Interventions could be any curricula used in a school setting to deter tobacco use, and outcome measures could be never smoking, frequency of smoking, number of cigarettes smoked, or smoking indices.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed studies for inclusion, extracted data and assessed risk of bias. Based on the type of outcome, we placed studies into three groups for analysis: Pure Prevention cohorts (Group 1), Change in Smoking Behaviour over time (Group 2) and Point Prevalence of Smoking (Group 3).

MAIN RESULTS

One hundred and thirty-four studies involving 428,293 participants met the inclusion criteria. Some studies provided data for more than one group.Pure Prevention cohorts (Group 1) included 49 studies (N = 142,447). Pooled results at follow-up at one year or less found no overall effect of intervention curricula versus control (odds ratio (OR) 0.94, 95% confidence interval (CI) 0.85 to 1.05). In a subgroup analysis, the combined social competence and social influences curricula (six RCTs) showed a statistically significant effect in preventing the onset of smoking (OR 0.49, 95% CI 0.28 to 0.87; seven arms); whereas significant effects were not detected in programmes involving information only (OR 0.12, 95% CI 0.00 to 14.87; one study), social influences only (OR 1.00, 95% CI 0.88 to 1.13; 25 studies), or multimodal interventions (OR 0.89, 95% CI 0.73 to 1.08; five studies). In contrast, pooled results at longest follow-up showed an overall significant effect favouring the intervention (OR 0.88, 95% CI 0.82 to 0.96). Subgroup analyses detected significant effects in programmes with social competence curricula (OR 0.52, 95% CI 0.30 to 0.88), and the combined social competence and social influences curricula (OR 0.50, 95% CI 0.28 to 0.87), but not in those programmes with information only, social influence only, and multimodal programmes.Change in Smoking Behaviour over time (Group 2) included 15 studies (N = 45,555). At one year or less there was a small but statistically significant effect favouring controls (standardised mean difference (SMD) 0.04, 95% CI 0.02 to 0.06). For follow-up longer than one year there was a statistically nonsignificant effect (SMD 0.02, 95% CI -0.00 to 0.02).Twenty-five studies reported data on the Point Prevalence of Smoking (Group 3), though heterogeneity in this group was too high for data to be pooled.We were unable to analyse data for 49 studies (N = 152,544).Subgroup analyses (Pure Prevention cohorts only) demonstrated that at longest follow-up for all curricula combined, there was a significant effect favouring adult presenters (OR 0.88, 95% CI 0.81 to 0.96). There were no differences between tobacco-only and multifocal interventions. For curricula with booster sessions there was a significant effect only for combined social competence and social influences interventions with follow-up of one year or less (OR 0.50, 95% CI 0.26 to 0.96) and at longest follow-up (OR 0.51, 95% CI 0.27 to 0.96). Limited data on gender differences suggested no overall effect, although one study found an effect of multimodal intervention at one year for male students. Sensitivity analyses for Pure Prevention cohorts and Change in Smoking Behaviour over time outcomes suggested that neither selection nor attrition bias affected the results.

AUTHORS' CONCLUSIONS

Pure Prevention cohorts showed a significant effect at longest follow-up, with an average 12% reduction in starting smoking compared to the control groups. However, no overall effect was detected at one year or less. The combined social competence and social influences interventions showed a significant effect at one year and at longest follow-up. Studies that deployed a social influences programme showed no overall effect at any time point; multimodal interventions and those with an information-only approach were similarly ineffective.Studies reporting Change in Smoking Behaviour over time did not show an overall effect, but at an intervention level there were positive findings for social competence and combined social competence and social influences interventions.

Fifteen Years of Promise in School-Based Physical Activity Interventions: A Meta-Analysis

Increasing physical activity among children and adolescents continues to be a public health priority (Glickman et al., 2012), with a focus on evidence-based physical activity in school settings. While individual studies report benefits from school-based physical activity interventions, no data-based analysis of these interventions has been published. This meta-analysis examined the outcomes of 12 school-based interventions that reported data from both treatment and intervention groups. The design of each study was unique; including one or more of 19 dependent variables representing physical activity, knowledge, body composition, and cardiovascular measures, and one or more component of the Coordinated School Health Model (CSHM). Generally the benefits from the intervention were small and not significant; health knowledge was the exception. Interventions including more components of the CSHM and interventions of greater duration (e.g., more minutes) were associated with enhanced outcomes and explained 89% of the variance. Weaknesses in the design and analysis of some interventions were inappropriate experimental unit (individual rather than school), multiple analyses on the same data without correction (e.g., Bonferroni), multiple publications of the same data, and the inclusion of all students regardless of whether the student needed to increase physical activity/ftness or reduce body mass/fat.

School-based programmes for preventing smoking

BACKGROUND

Smoking rates in adolescents are rising in some countries. Helping young people to avoid starting smoking is a widely endorsed goal of public health, but there is uncertainty about how to do this. Schools provide a route for communicating with a large proportion of young people, and school-based programmes for smoking prevention have been widely developed and evaluated.

OBJECTIVES

To review all randomized controlled trials of behavioural interventions in schools to prevent children (aged 5 to12) and adolescents (aged 13 to18) starting smoking.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Tobacco Addiction Group's Specialized Register, MEDLINE, EMBASE, PsyclNFO, ERIC, CINAHL, Health Star, Dissertation Abstracts and studies identified in the bibliographies of articles. Individual MEDLINE searches were made for 133 authors who had undertaken randomized controlled trials in this area.

SELECTION CRITERIA

Types of studies: those in which individual students, classes, schools, or school districts were randomized to the intervention or control groups and followed for at least six months.

TYPES OF PARTICIPANTS

Children (aged 5 to12) or adolescents (aged 13 to18) in school settings. Types of interventions: Classroom programmes or curricula, including those with associated family and community interventions, intended to deter use of tobacco. We included programmes or curricula that provided information, those that used social influences approaches, those that taught generic social competence, and those that included interventions beyond the school into the community. We included programmes with a drug or alcohol focus if outcomes for tobacco use were reported. Types of outcome measures: Prevalence of non-smoking at follow up among those not smoking at baseline. We did not require biochemical validation of self-reported tobacco use for study inclusion.

DATA COLLECTION AND ANALYSIS

We assessed whether identified citations were randomized controlled trials. We assessed the quality of design and execution, and abstracted outcome data. Because of the marked heterogeneity of design and outcomes, we computed pooled estimates only for those trials that could be analyzed together and for which statistical data were available. We predominantly synthesized the data using narrative systematic review. We grouped studies by intervention method (information; social competence; social influences; combined social influences/social competence; multi-modal programmes). Within each group, we placed them into three categories (low, medium and high risk of bias) according to validity using quality criteria for reported study design.

MAIN RESULTS

Of the 94 randomized controlled trials identified, we classified 23 as category one (most valid). There was one category one study of information-giving and two of teaching social comeptence. There were thirteen category one studies of social influences interventions. Of these, nine found some positive effect of intervention on smoking prevalence, and four failed to detect an effect on smoking prevalence. The largest and most rigorous study, the Hutchinson Smoking Prevention Project, found no long-term effect of an intensive eight-year programme on smoking behaviour. There were three category one RCTs of combined social influences and social competence interventions: one provided significant results and one only for instruction by health educators compared to self-instruction. There was a lack of high quality evidence about the effectiveness of combinations of social influences and social competence approaches. There was one category one study providing data on social influences compared with information giving. There were four category one studies of multi-modal approaches but they provided limited evidence about the effectiveness of multi-modal approaches including community initiatives.

AUTHORS' CONCLUSIONS

There is one rigorous test of the effects of information-giving about smoking. There are well-conducted randomized controlled trials to test the effects of social influences interventions: in half of the group of best quality studies those in the intervention group smoke less than those in the control, but many studies failed to detect an effect of the intervention. There are only three high quality RCTs which test the effectiveness of combinations of social influences and social competence interventions, and four which test multi-modal interventions; half showed significant positive results.

Reducing obesity and related chronic disease risk in children and youth: a synthesis of evidence with 'best practice' recommendations

Childhood obesity is a global epidemic and rising trends in overweight and obesity are apparent in both developed and developing countries. Available estimates for the period between the 1980s and 1990s show the prevalence of overweight and obesity in children increased by a magnitude of two to five times in developed countries (e.g. from 11% to over 30% in boys in Canada), and up to almost four times in developing countries (e.g. from 4% to 14% in Brazil). The goal of this synthesis research study was to develop best practice recommendations based on a systematic approach to finding, selecting and critically appraising programmes addressing prevention and treatment of childhood obesity and related risk of chronic diseases. An international panel of experts in areas of relevance to obesity provided guidance for the study. This synthesis research encompassed a comprehensive search of medical/academic and grey literature and the Internet covering the years 1982-2003. The appraisal approach developed to identify best practice was unique, in that it considered not only methodological rigour, but also population health, immigrant health and programme development/evaluation perspectives in the assessment. Scores were generated based on pre-determined criteria with programmes scoring in the top tertile of the scoring range in any one of the four appraisal categories included for further examination. The synthesis process included identification of gaps and an analysis and summary of programme development and programme effectiveness to enable conclusions to be drawn and recommendations to be made. The results from the library database searches (13,158 hits), the Internet search and key informant surveys were reduced to a review of 982 reports of which 500 were selected for critical appraisal. In total 158 articles, representing 147 programmes, were included for further analysis. The majority of reports were included based on high appraisal scores in programme development and evaluation with limited numbers eligible based on scores in other categories of appraisal. While no single programme emerged as a model of best practice, synthesis of included programmes provided rich information on elements that represent innovative rather than best practice under particular circumstances that are dynamic (changing according to population subgroups, age, ethnicity, setting, leadership, etc.). Thus the findings of this synthesis review identifies areas for action, opportunities for programme development and research priorities to inform the development of best practice recommendations that will reduce obesity and chronic disease risk in children and youth. A lack of programming to address the particular needs of subgroups of children and youth emerged in this review. Although immigrants new to developed countries may be more vulnerable to the obesogenic environment, no programmes were identified that specifically targeted their potentially specialized needs (e.g. different food supply in a new country). Children 0-6 years of age and males represented other population subgroups where obesity prevention programmes and evidence of effectiveness were limited. These gaps are of concern because (i) the pre-school years may be a critical period for obesity prevention as indicated by the association of the adiposity rebound and obesity in later years; and (ii) although the growing prevalence of obesity affects males and females equally; males may be more vulnerable to associated health risks such as cardiovascular disease. Other gaps in knowledge identified during synthesis include a limited number of interventions in home and community settings and a lack of upstream population-based interventions. The shortage of programmes in community and home settings limits our understanding of the effectiveness of interventions in these environments, while the lack of upstream investment indicates an opportunity to develop more upstream and population-focused interventions to balance and extend the current emphasis on individual-based programmes. The evidence reviewed indicates that current programmes lead to short-term improvements in outcomes relating to obesity and chronic disease prevention with no adverse effects noted. This supports the continuation and further development of programmes currently directed at children and youth, as further evidence for best practice accumulates. In this synthesis, schools were found to be a critical setting for programming where health status indicators, such as body composition, chronic disease risk factors and fitness, can all be positively impacted. Engagement in physical activity emerged as a critical intervention in obesity prevention and reduction programmes. While many programmes in the review had the potential to integrate chronic disease prevention, few did; therefore efforts could be directed towards better integration of chronic disease prevention programmes to minimize duplication and optimize resources. Programmes require sustained long-term resources to facilitate comprehensive evaluation that will ascertain if long-term impact such as sustained normal weight is maintained. Furthermore, involving stakeholders in programme design, implementation and evaluation could be crucial to the success of interventions, helping to ensure that needs are met. A number of methodological issues related to the assessment of obesity intervention and prevention programmes were identified and offer insight into how research protocols can be enhanced to strengthen evidence for obesity interventions. Further research is required to understand the merits of the various forms in which interventions (singly and in combination) are delivered and in which circumstances they are effective. There is a critical need for the development of consistent indicators to ensure that comparisons of programme outcomes can be made to better inform best practice.

Pathways curriculum and family interventions to promote healthful eating and physical activity in American Indian schoolchildren

BACKGROUND

Pathways, a multisite school-based study aimed at promoting healthful eating and increasing physical activity, was a randomized field trial including 1704 American Indian third to fifth grade students from 41 schools (21 intervention, 20 controls) in seven American Indian communities.

METHODS

The intervention schools received four integrated components: a classroom curriculum, food service, physical activity, and family modules. The curriculum and family components were based on Social Learning Theory, American Indian concepts, and results from formative research. Process evaluation data were collected from teachers (n=235), students (n=585), and families. Knowledge, Attitudes, and Behavior Questionnaire data were collected from 1150 students including both intervention and controls.

RESULTS

There were significant increases in knowledge and cultural identity in children in intervention compared to control schools with a significant retention of knowledge over the 3 years, based on the results of repeating the third and fourth grade test items in the fifth grade. Family members participated in Family Events and take-home activities, with fewer participating each year.

CONCLUSION

A culturally appropriate school intervention can promote positive changes in knowledge, cultural identity, and self-reported healthful eating and physical activity in American Indian children and environmental change in school food service.

Pathways process evaluation results: a school-based prevention trial to promote healthful diet and physical activity in American Indian third, fourth, and fifth grade students

BACKGROUND

Pathways was a large-scale, multisite, 3-year, study testing a school-based intervention designed to lower percent body fat in American Indian children.

METHODS

At the 21 intervention schools process evaluation data were collected for training of school personnel; implementation of the classroom and physical activity curricula; implementation of the project's food service guidelines in the school cafeterias; adult participation in the family events; and, students' perceived exposure to the Pathways interventions.

RESULTS

Students received about 93% of the classroom curriculum lessons. The minimum requirement of physical education being taught three times per week for at least 30 minutes duration was achieved by the fifth grade. The implementation of the food service behavioral guidelines increased from 51% in the third grade to 87% in the fifth grade. The family events had lower than anticipated adult participation. The participation rates were 45% during the third grade, and 41 and 63% during the fourth and fifth grades, respectively. There was a significant difference between intervention and control students' perceived exposure to Pathways type interventions.

CONCLUSION

The Pathways interventions were successfully implemented with good reach, high extent, and fidelity.

Treatments for spit tobacco use: a quantitative systematic review

AIMS

Spit tobacco use is prevalent in the United States and is associated with adverse health consequences. Health-care providers have neither evidence summaries nor evidence-based guidelines to assist them in treating patients who use spit tobacco.

DESIGN

We completed a systematic review of the literature to determine the efficacy and safety of pharmacological and behavioral interventions for the treatment of spit tobacco use.

FINDINGS

We found six randomized controlled trials testing pharmacological interventions and eight testing behavioral interventions. Using random-effects meta-analyses,bupropion sustained-release (SR) increased point prevalence tobacco abstinence at 12 weeks [odds ratio (OR) 2.1; 95% confidence interval (CI), 1.0-4.2]. Nicotine replacement therapy with patch or gum increased point prevalence tobacco abstinence at 6 months (OR 1.3; 95% CI, 1.0-1.6). Behavioral interventions increased long-term (6 month)point prevalence tobacco abstinence (OR 1.7; 95% CI, 1.1-2.9). Studies including an oral examination followed by feedback to the patient had the highest treatment effect.

CONCLUSIONS

Behavioral interventions for ST users are effective for increasing ST abstinence rates. Bupropion SR is probably effective and nicotine replacement therapy may be effective. This evidence from randomized controlled trials provides health-care professionals with information necessary to effectively treat spit tobacco use.

Prevention of overweight and obesity in children: influences on the food environment

PURPOSE

There is an epidemic of pediatric overweight and obesity leading to type 2 diabetes in youth. The purpose of this review is to describe the multiple paths of influence on the food environment of youth and to identify diabetes education strategies focused on early prevention of overweight and obesity.

METHODS

A review of relevant professional literature was conducted.

RESULTS

Models of obesity prevention in youth need to address genetic factors that influence the development of food preferences in the young child, parenting influences on eating pattern development, and access and availability of foods in the physical environment of the child.

CONCLUSIONS

Early intervention with parents of young children is required to prevent the development of eating patterns that lead to pediatric obesity and type 2 diabetes in youth. Diabetes educators need to be able to inform parents of the multiple paths of influence on the food environment of the child and suggest strategies to encourage the development of positive food preferences and intake.

Designing effective nutrition interventions for adolescents

By altering dietary behaviors, nutrition interventions during adolescence have the potential of affecting children at that time and later in life. The majority of interventions implemented in the teen years have occurred in schools, but other intervention sites have included after-school programs, summer camps, community centers, libraries, and grocery stores. Programs with successful outcomes have tended to be behaviorally based, using theories for the developmental framework; included an environmental component; delivered an adequate number of lessons; and emphasized developmentally appropriate strategies. One planning method that can be used in the development of nutrition interventions is Intervention Mapping. The steps of Intervention Mapping include conducting a needs assessment, developing proximal program objectives, mapping appropriate strategies and methods to address the objectives, planning the program design, planning program adoption and implementation, and evaluation. The use of intervention-planning techniques, coordination of nutrition and physical education interventions, using technological advances such as CD-ROMs, incorporation of policy changes into intervention efforts, and dissemination of effective programs are all trends that will influence the future development of effective nutrition programs for adolescents.

School-based programmes for preventing smoking

BACKGROUND

Smoking rates in adolescents are rising. Helping young people to avoid starting smoking is a widely endorsed goal of public health, but there is uncertainty about how to do this. Schools provide a route for communicating with a large proportion of young people, and school-based programmes for smoking prevention have been widely developed and evaluated.

OBJECTIVES

To review all randomised controlled trials of behavioural interventions in schools to prevent children (aged 5 to12) and adolescents (aged 13 to18) starting smoking.

SEARCH STRATEGY

We searched The Cochrane Controlled Trials and Tobacco Review group registers, MEDLINE, EMBASE, Psyclnfo, ERIC, CINAHL, Health Star, Dissertation Abstracts and studies identified in the bibliographies of articles. Individual MEDLINE searches were made for 133 authors who had undertaken randomised controlled trials in this area.

SELECTION CRITERIA

Types of studies: those in which individual students, classes, schools, or school districts were randomised to the intervention or control groups and followed for at least six months.

TYPES OF PARTICIPANTS

Children (aged 5 to12) or adolescents (aged 13 to18) in school settings. Types of interventions: Classroom programmes or curricula, including those with associated family and community interventions, intended to deter use of tobacco. We included programmes or curricula that provided information, those that used social influences approaches, those that taught generic social competence, and those that included interventions beyond the school into the community. We included programmes with a drug or alcohol focus if outcomes for tobacco use were reported. Types of outcome measures: Prevalence of non-smoking at follow-up among those not smoking at baseline. We did not require biochemical validation of self-reported tobacco use for study inclusion.

DATA COLLECTION AND ANALYSIS

We assessed whether identified citations were randomised controlled trials. We assessed the quality of design and execution, and abstracted outcome data. Because of the marked heterogeneity of design and outcomes, we did not perform a meta-analysis. We synthesised the data using narrative systematic review. We grouped studies by intervention method (information; social competence; social influences; combined social influences/social competence and multi-modal programmes). Within each category, we placed them into three groups according to validity using quality criteria for reported study design.

MAIN RESULTS

Of the 76 randomised controlled trials identified, we classified 16 as category one (most valid). There were no category one studies of information giving alone. There were fifteen category one studies of social influences interventions. Of these, eight showed some positive effect of intervention on smoking prevalence, and seven failed to detect an effect on smoking prevalence. The largest and most rigorous study, the Hutchinson Smoking Prevention Project, found no long-term effect of an intensive 8-year programme on smoking behaviour. There was a lack of high quality evidence about the effectiveness of combinations of social influences and social competence approaches. There was limited evidence about the effectiveness of multi-modal approaches including community initiatives.

REVIEWER'S CONCLUSIONS

There is no rigorous test of the effects of information giving about smoking. There are well-conducted randomised controlled trials to test the effects of social influences interventions: in half of the group of best quality studies those in the intervention group smoke less than those in the control, but many studies showed no effect of the intervention. There is a lack of high-quality evidence about the effectiveness of combinations of social influences and social competence interventions, and of multi-modal programmes that include community interventions.

Review and analysis of evaluation measures used in nutrition education intervention research

The purpose of this review is to provide a summary of the kinds of evaluation measures used in 265 nutrition education intervention studies conducted between 1980 and 1999 and an analysis of psychometric issues arising from such a review. The data are summarized in terms of tables for interventions with each of six key population groups: preschool children, school-aged children, adults, pregnant women and breast-feeding promotion, older adults, and inservice preparation of professionals and paraprofessionals. Measures evaluating knowledge and skills or behavioral capabilities were most widely used in studies with preschool, school-aged, and inservice populations (50%-85%) and less widely used in studies with the other groups, particularly breast-feeding promotion (5%). Measures of potential psychosocial mediators or correlates of behavior such as outcome expectancies, self-efficacy, or behavioral intention were used in 90% of behaviorally focused studies with school-aged children and in about 20% of studies with adults. Dietary intake measures were used in almost all studies, primarily food recalls, records, and quantitative food frequency questionnaires. Short frequency instruments involving only foods targeted in the intervention such as fruits and vegetables are increasingly being used. Measures of specific observable behaviors are also increasingly being used. Physiologic parameters were used in about 33% of behaviorally focused interventions with school-aged children and adults, 20% with older adults, and 65% with pregnant women and/or their infants. Criterion validity of newly developed intake instruments and content validity of instruments measuring mediating variables were reported in the majority (range 50%-90%) of studies. Reliability and stability of measures of mediating variables were reported in 50% to 75% of studies, with reliability coefficients mostly about .6 to .7. Two major conclusions from this review are that evaluation measures should be appropriate to the purpose, duration, and power of the intervention and that measures should have adequate validity and reliability in relation to both the outcomes and characteristics of the target audience. Major implications are that considerable preliminary work needs to be done before any intervention study to develop and test evaluation instruments so that they are appropriate and have adequate psychometric properties, and cognitive testing of published instruments with each new target audience is essential. We will then be better able to make judgments about the effectiveness of nutrition education.

Health outcomes of elementary school students in New Brunswick. The education perspective

With data from the New Brunswick School Climate Study (N = 6,883 students from 147 schools), this study examined individual differences in and school effects on health outcomes of students. Results of hierarchical linear modeling showed that females reported experiencing more physical health problems, eating less healthy food, and doing fewer exercises than males. Students of high socioeconomic status (SES) reported eating more healthy food and doing more exercises than students of low SES. Native students reported experiencing more physical health problems and eating less healthy food than nonnative students. Students of single parents reported eating more healthy food and exercising more than students of both parents. Schools showed effects on health outcomes over and above the effects of students. Students in schools with high SES and positive disciplinary climate reported fewer physical and mental health problems. Students in large schools reported less healthy food intake and fewer physical exercises.

Assessing food selection in a health promotion program: validation of a brief instrument for American Indian children in the southwest United States

OBJECTIVE

Brief dietary assessment instruments are needed to evaluate behavior changes of participants in dietary intervention programs. The purpose of this project was to design and validate an instrument for children participating in Pathways to Health, a culturally appropriate, cancer prevention curriculum.

DESIGN

Validation of a brief food selection instrument, Yesterday's Food Choices (YFC), which contained 33 questions about foods eaten the previous day with response choices of yes, no, or not sure. Reference data for validation were 24-hour dietary recalls administered individually to 120 students selected randomly.

SUBJECTS

The YFC and 24-hour dietary recalls were administered to American Indian children in fifth- and seventh-grade classes in the Southwest United States.

STATISTICAL ANALYSES PERFORMED

Dietary recalls were coded for food items in the YFC and results were compared for each item using percentage agreement and the kappa statistic.

RESULTS

Percentage agreement for all items was greater than 60%; for most items it was greater than 70%, and for several items it was greater than 80%. The amount of agreement beyond that explained by chance (kappa statistic) was generally small. Three items showed substantial agreement beyond chance (kappa > or = 0.6); 2 items showed moderate agreement (kappa = 0.40 to 0.59) most items showed fair agreement (kappa = 0.20 to 0.39). The food items showing substantial agreement were hot or cold cereal, low-fat milk, and mutton or chile stew. Fried or scrambled eggs and deep-fried foods showed moderate agreement beyond chances.

CONCLUSIONS

Previous development and validation of brief food selection instruments for children participating in health promotion programs has had limited success. In this study, instrument-related factors that apparently contributed to poor agreement between data from the YFC and 24-hour dietary recall were inclusion of categories of foods vs specific foods; food knowledge, preparation, and vocabulary, item length, and overreporting of attractive foods. Collecting and scoring the 24-hour recall data may also have contributed to poor agreement. Further development of brief instruments for evaluating changes in children's behavior in dietary programs is necessary. Factors related to the YFC that need further development may be issues that are also important in the development of effective, brief dietary assessments for children as individual clients or patients.

Food Perceptions and Dietary Behavior of American-Indian Children, Their Caregivers, and Educators: Formative Assessment Findings from Pathways

Dietary findings from a school-based obesity prevention project (Pathways) are reported for children from six different American-Indian nations. A formative assessment was undertaken with teachers, caregivers, and children from nine schools to design a culturally appropriate intervention, including classroom curriculum, food service, physical education, and family components. This assessment employed a combination of qualitative and quantitative methods (including direct observations, paired-child in-depth interviews, focus groups with child caregivers and teachers, and semistructured interviews with caregivers and foodservice personnel) to query local perceptions and beliefs about foods commonly eaten and risk behaviors associated with childhood obesity at home, at school, and in the community. An abundance of high-fat, high-sugar foods was detected in children's diets described by caregivers, school food-service workers, and the children themselves. Although children and caregivers identified fruits and vegetables as healthy food choices, this knowledge does not appear to influence actual food choices. Frequent high-fat/high-sugar food sales in the schools, high-fat entrees in school meals, the use of food rewards in the classroom, rules about finishing all of one's food, and limited family resources are some of the competing factors that need to be addressed in the Pathways intervention.

Pathways family intervention for third-grade American Indian children

The goal of the feasibility phase of the Pathways family intervention was to work with families of third-grade American Indian children to reinforce health behaviors being promoted by the curriculum, food service, and physical activity components of this school-based obesity prevention intervention. Family behaviors regarding food choices and physical activity were identified and ranked according to priority by using formative assessment and a literature review of school-based programs that included a family component. The family intervention involved 3 primary strategies designed to create an informed home environment supportive of behavioral change: 1) giving the children "family packs" containing worksheets, interactive assignments, healthful snacks, and low-fat tips and recipes to take home to share with their families; 2) implementing family events at the school to provide a fun atmosphere in which health education concepts could be introduced and reinforced; and 3) forming school-based family advisory councils composed of family members and community volunteers who provided feedback on Pathways strategies, helped negotiate barriers, and explored ideas for continued family participation. For strategy 2, a kick-off Family Fun Night provided a series of learning booths that presented the healthful behaviors taught by Pathways. At an end-of-year Family Celebration, a healthy meal was served, students demonstrated newly learned Pathways activities, and certificates were presented in recognition of completion of the Pathways curriculum. Based on evaluation forms and attendance rosters, strategies 1 and 2 were more easily implemented and better received than strategy 3. Implications for developing family involvement strategies for intervention programs are discussed.

Multisite formative assessment for the Pathways study to prevent obesity in American Indian schoolchildren

We describe the formative assessment process, using an approach based on social learning theory, for the development of a school-based obesity-prevention intervention into which cultural perspectives are integrated. The feasibility phase of the Pathways study was conducted in multiple settings in 6 American Indian nations. The Pathways formative assessment collected both qualitative and quantitative data. The qualitative data identified key social and environmental issues and enabled local people to express their own needs and views. The quantitative, structured data permitted comparison across sites. Both types of data were integrated by using a conceptual and procedural model. The formative assessment results were used to identify and rank the behavioral risk factors that were to become the focus of the Pathways intervention and to provide guidance on developing common intervention strategies that would be culturally appropriate and acceptable to all sites.

Pathways: a culturally appropriate obesity-prevention program for American Indian schoolchildren

Pathways, a culturally appropriate obesity prevention study for third-, fourth-, and fifth-grade American Indian schoolchildren includes an intervention that promotes increased physical activity and healthful eating behaviors. The Pathways intervention, developed through a collaboration of universities and American Indian nations, schools, and families, focuses on individual, behavioral, and environmental factors and merges constructs from social learning theory with American Indian customs and practices. We describe the Pathways program developed during 3 y of feasibility testing in American Indian schools, with special emphasis on the activities developed for the third grade; review the theoretical and cultural underpinnings of the program; outline the construction process of the intervention; detail the curriculum and physical education components of the intervention; and summarize the formative assessment and the school food service and family components of the intervention.

Effects of physical activity interventions in youth. Review and synthesis

INTRODUCTION

Physical inactivity has been identified as an important public health concern for youth. School and community settings can be important infrastructures for promoting physical activity (PA). This paper reviews studies of physical activity in school and community settings among preschool through college-aged persons to determine characteristics and effects of interventions. Studies in progress are included.

METHODS

Studies from 1980 to 1997 testing physical activity interventions in schools and community settings were identified by computerized search methods and reference lists of published reviews. Studies needed to have used a quantitative assessment of PA, used a comparison or control group, included participants who were preschool through college age, and be conducted in the United States or foreign school or community settings. Significance of effects was examined overall and for various types of interventions.

RESULTS

Twenty-two school-based studies were reviewed, 14 completed and 8 in progress. Three studies were in countries other than the United States. The 8 studies in progress were all in the United States. Only 7 community studies were reviewed, all in the United States. Four studies were in progress. Several community studies involved a high percentage of African-American or Hispanic youth and their families. Studies showing the best results used randomized designs, valid and reliable measurements, and more extensive interventions. Some follow-up results showed PA was sustained after interventions ended.

CONCLUSIONS

The collection of school and community studies is limited for several age groups with none below third grade and only three at college age. There are few community studies. The most is known about upper-elementary-age-students, including the first multicenter randomized trial to report significant results for increasing moderate to vigorous physical activity (MVPA) in physical education (PE) and increase vigorous PA outside of school. A number of older study designs were weak and assessments less than optimal, but studies in progress are stronger. Special attention is needed for girls, middle schools, and community settings for all youth. More objective assessments are needed for measuring PA outside of school and in younger children, since they cannot provide reliable self-report.

Nutritional concerns in American Indian and Alaska Native children: transitions and future directions

The nutritional health of American Indian and Alaska Native children has changed dramatically over the past 30 years. The prevention and treatment of malnutrition (primarily undernutrition) was a major health issue until the mid to late 1970s. Now, a generation later, obesity in American Indian and Alaska Native children is a major health threat. In 1969, the National Institutes of Health sponsored a conference to review the nutritional status of North American Indian children and to set a national agenda to improve the nutritional health of Indian children. Subsequently, increased food availability; food assistance programs; and improved sanitation, transportation, and health care have eliminated undernutrition as a major health issue. However, the substantial reduction in undernutrition has been accompanied by a rapid increase in childhood obesity. The current epidemic of child and adult obesity and associated obesity-related morbidities, such as type 2 diabetes mellitus and other chronic diseases, has implications for the immediate and long-term health of young American Indians. This article reviews the current nutritional health of American Indian and Alaska Native children, the changes that have occurred the past 30 years, and the nutrition transition to increasing obesity and subsequent diabetes that is being seen in American Indians. Future directions to improve the health of American Indian and Alaska Native children are discussed, as is the urgent need for obesity prevention programs that are culturally oriented, family centered, and community- and school-based and that target healthful eating and physical activity beginning in childhood.

Heart healthy eating behaviors of children following a school-based intervention: a meta-analysis

The purpose of this meta-analysis was to estimate the effects of school-based interventions on heart healthy eating behaviors of fourth and fifth grade students. The overall effect size (d value) across 12 studies was .24. The 95% confidence interval ranged from .174 to .301. It can be concluded that the school-based cardiovascular health promotion programs had a significant effect on the heart healthy eating behaviors of student participants. Recommendations include identification of reliable measures and inclusion of culturally diverse populations in future studies.

The Kahnawake Schools Diabetes Prevention Project: intervention, evaluation, and baseline results of a diabetes primary prevention program with a native community in Canada

OBJECTIVES

Kahnawake Schools Diabetes Prevention Project is a 3-year community-based, primary prevention program for non-insulin-dependent diabetes mellitus in a Mohawk community near Montreal, Canada. Objectives are to improve healthy eating and encourage more physical activity among elementary school children.

METHODS

Intervention incorporates behavior change theory, Native learning styles, the Ottawa Charter for Health Promotion, and a health promotion planning model. Evaluation uses a mixed longitudinal and cross-sectional design to measure obesity, fitness, eating habits, and physical activity of elementary school children in the experimental and comparison communities. Intermediate variables are self-efficacy and perceived parental support. Process evaluation provides feedback to the intervention.

RESULTS

During 3 years, 63 distinct interventions that included a Health Education Program reinforced by school events, a new Community Advisory Board, a recreation path, and community-based activities promoting healthy lifestyles were implemented. Baseline consent rates were 87 and 71% in the experimental and comparison schools. As expected, anthropometric data increase with age. Between 9 and 10 years there are increased weight, height, BMI, and skinfold thicknesses; decreased fitness; and increased television watching.

CONCLUSIONS

Implementing a Native community-based diabetes prevention program is feasible through participatory research that incorporates Native culture and local expertise.