Recruiting a diverse group of middle school girls into the trial of activity for adolescent girls

Strategies for enhancing the implementation of school-based policies or practices targeting diet, physical activity, obesity, tobacco or alcohol use

BACKGROUND

Several school-based interventions are effective in improving child diet and physical activity, and preventing excessive weight gain, and tobacco or harmful alcohol use. However, schools are frequently unsuccessful in implementing such evidence-based interventions.

OBJECTIVES

1. To evaluate the benefits and harms of strategies aiming to improve school implementation of interventions to address student diet, physical activity, tobacco or alcohol use, and obesity. 2. To evaluate the benefits and harms of strategies to improve intervention implementation on measures of student diet, physical activity, obesity, tobacco use or alcohol use; describe their cost or cost-effectiveness; and any harms of strategies on schools, school staff or students.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search was between 1 September 2016 and 30 April 2021 to identify any relevant trials published since the last published review.

SELECTION CRITERIA

We defined 'Implementation' as the use of strategies to adopt and integrate evidence-based health interventions and to change practice patterns within specific settings. We included any trial (randomised controlled trial (RCT) or non-randomised controlled trial (non-RCT)) conducted at any scale, with a parallel control group that compared a strategy to implement policies or practices to address diet, physical activity, overweight or obesity, tobacco or alcohol use by students to 'no intervention', 'usual' practice or a different implementation strategy.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Given the large number of outcomes reported, we selected and included the effects of a single outcome measure for each trial for the primary (implementation) and secondary (student health behaviour and obesity) outcomes using a decision hierarchy. Where possible, we calculated standardised mean differences (SMDs) to account for variable outcome measures with 95% confidence intervals (CI). For RCTs, we conducted meta-analyses of primary and secondary outcomes using a random-effects model, or in instances where there were between two and five studies, a fixed-effect model. The synthesis of the effects for non-randomised studies followed the 'Synthesis without meta-analysis' (SWiM) guidelines.

MAIN RESULTS

We included an additional 11 trials in this update bringing the total number of included studies in the review to 38. Of these, 22 were conducted in the USA. Twenty-six studies used RCT designs. Seventeen trials tested strategies to implement healthy eating, 12 physical activity and six a combination of risk factors. Just one trial sought to increase the implementation of interventions to delay initiation or reduce the consumption of alcohol. All trials used multiple implementation strategies, the most common being educational materials, educational outreach and educational meetings. The overall certainty of evidence was low and ranged from very low to moderate for secondary review outcomes. Pooled analyses of RCTs found, relative to a control, the use of implementation strategies may result in a large increase in the implementation of interventions in schools (SMD 1.04, 95% CI 0.74 to 1.34; 22 RCTs, 1917 participants; low-certainty evidence). For secondary outcomes we found, relative to control, the use of implementation strategies to support intervention implementation may result in a slight improvement on measures of student diet (SMD 0.08, 95% CI 0.02 to 0.15; 11 RCTs, 16,649 participants; low-certainty evidence) and physical activity (SMD 0.09, 95% CI -0.02 to 0.19; 9 RCTs, 16,389 participants; low-certainty evidence). The effects on obesity probably suggest little to no difference (SMD -0.02, 95% CI -0.05 to 0.02; 8 RCTs, 18,618 participants; moderate-certainty evidence). The effects on tobacco use are very uncertain (SMD -0.03, 95% CIs -0.23 to 0.18; 3 RCTs, 3635 participants; very low-certainty evidence). One RCT assessed measures of student alcohol use and found strategies to support implementation may result in a slight increase in use (odds ratio 1.10, 95% CI 0.77 to 1.56; P = 0.60; 2105 participants). Few trials reported the economic evaluations of implementation strategies, the methods of which were heterogeneous and evidence graded as very uncertain. A lack of consistent terminology describing implementation strategies was an important limitation of the review.

AUTHORS' CONCLUSIONS

The use of implementation strategies may result in large increases in implementation of interventions, and slight improvements in measures of student diet, and physical activity. Further research is required to assess the impact of implementation strategies on such behavioural- and obesity-related outcomes, including on measures of alcohol use, where the findings of one trial suggest it may slightly increase student risk. Given the low certainty of the available evidence for most measures further research is required to guide efforts to facilitate the translation of evidence into practice in this setting.

Proactive and Reactive Recruitment of Black and Latino Adolescents in a Vaping Prevention Randomized Controlled Trial

The purpose of this study was to assesses the effectiveness of proactive and reactive methods in the recruitment of Black and Latino adolescents into a vaping-prevention randomized controlled trial (RCT). This study also assessed the characteristics of study participants by recruitment method. Proactive recruitment strategies included study presentations at community-based events (e.g., festivals, health fairs), school-based events (e.g., back-to-school events, after-school programs), and recreational centers (e.g., fitness centers, malls). Reactive recruitment strategies included study advertisements via social media (e.g., Facebook posts shared by local community-based organizations), word of mouth, and an academic-based research hub. Using proactive and reactive methods, in a 4-month period, 362 Black and Latino adolescents were successfully enrolled into the RCT. Compared to the proactive method, adolescents screened reactively were equally likely to be eligible but significantly more likely to enroll in the study. However, both proactive and reactive strategies made notable contributions to the overall recruitment effort. Moreover, proactive and reactive methods attracted adolescents with different characteristics (e.g., age, gender, sexual orientation, etc.). These findings suggest that both proactive and reactive recruitment strategies should be implemented for studies interested in recruiting a diverse sample of Black and Latino adolescents.

School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18

BACKGROUND

Physical activity among children and adolescents is associated with lower adiposity, improved cardio-metabolic health, and improved fitness. Worldwide, fewer than 30% of children and adolescents meet global physical activity recommendations of at least 60 minutes of moderate to vigorous physical activity per day. Schools may be ideal sites for interventions given that children and adolescents in most parts of the world spend a substantial amount of time in transit to and from school or attending school.

OBJECTIVES

The purpose of this review update is to summarise the evidence on effectiveness of school-based interventions in increasing moderate to vigorous physical activity and improving fitness among children and adolescents 6 to 18 years of age. Specific objectives are: • to evaluate the effects of school-based interventions on increasing physical activity and improving fitness among children and adolescents; • to evaluate the effects of school-based interventions on improving body composition; and • to determine whether certain combinations or components (or both) of school-based interventions are more effective than others in promoting physical activity and fitness in this target population.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, BIOSIS, SPORTDiscus, and Sociological Abstracts to 1 June 2020, without language restrictions. We screened reference lists of included articles and relevant systematic reviews. We contacted primary authors of studies to ask for additional information.

SELECTION CRITERIA

Eligible interventions were relevant to public health practice (i.e. were not delivered by a clinician), were implemented in the school setting, and aimed to increase physical activity among all school-attending children and adolescents (aged 6 to 18) for at least 12 weeks. The review was limited to randomised controlled trials. For this update, we have added two new criteria: the primary aim of the study was to increase physical activity or fitness, and the study used an objective measure of physical activity or fitness. Primary outcomes included proportion of participants meeting physical activity guidelines and duration of moderate to vigorous physical activity and sedentary time (new to this update). Secondary outcomes included measured body mass index (BMI), physical fitness, health-related quality of life (new to this update), and adverse events (new to this update). Television viewing time, blood cholesterol, and blood pressure have been removed from this update.  DATA COLLECTION AND ANALYSIS: Two independent review authors used standardised forms to assess each study for relevance, to extract data, and to assess risk of bias. When discrepancies existed, discussion occurred until consensus was reached. Certainty of evidence was assessed according to GRADE. A random-effects meta-analysis based on the inverse variance method was conducted with participants stratified by age (children versus adolescents) when sufficient data were reported. Subgroup analyses explored effects by intervention type.

MAIN RESULTS

Based on the three new inclusion criteria, we excluded 16 of the 44 studies included in the previous version of this review. We screened an additional 9968 titles (search October 2011 to June 2020), of which 978 unique studies were potentially relevant and 61 met all criteria for this update. We included a total of 89 studies representing complete data for 66,752 study participants. Most studies included children only (n = 56), followed by adolescents only (n = 22), and both (n = 10); one study did not report student age. Multi-component interventions were most common (n = 40), followed by schooltime physical activity (n = 19), enhanced physical education (n = 15), and before and after school programmes (n = 14); one study explored both enhanced physical education and an after school programme. Lack of blinding of participants, personnel, and outcome assessors and loss to follow-up were the most common sources of bias.  Results show that school-based physical activity interventions probably result in little to no increase in time engaged in moderate to vigorous physical activity (mean difference (MD) 0.73 minutes/d, 95% confidence interval (CI) 0.16 to 1.30; 33 studies; moderate-certainty evidence) and may lead to little to no decrease in sedentary time (MD -3.78 minutes/d, 95% CI -7.80 to 0.24; 16 studies; low-certainty evidence). School-based physical activity interventions may improve physical fitness reported as maximal oxygen uptake (VO₂max) (MD 1.19 mL/kg/min, 95% CI 0.57 to 1.82; 13 studies; low-certainty evidence). School-based physical activity interventions may result in a very small decrease in BMI z-scores (MD -0.06, 95% CI -0.09 to -0.02; 21 studies; low-certainty evidence) and may not impact BMI expressed as kg/m² (MD -0.07, 95% CI -0.15 to 0.01; 50 studies; low-certainty evidence). We are very uncertain whether school-based physical activity interventions impact health-related quality of life or adverse events.

AUTHORS' CONCLUSIONS

Given the variability of results and the overall small effects, school staff and public health professionals must give the matter considerable thought before implementing school-based physical activity interventions. Given the heterogeneity of effects, the risk of bias, and findings that the magnitude of effect is generally small, results should be interpreted cautiously.

A school-based, peer-led programme to increase physical activity among 13- to 14-year-old adolescents: the GoActive cluster RCT

Background

Adolescent physical activity levels are low and are associated with rising disease risk and social disadvantage. The Get Others Active (GoActive) intervention was co-designed with adolescents and teachers to increase physical activity in adolescents.

Objective

To assess the effectiveness and cost-effectiveness of the school-based GoActive programme in increasing adolescents’ moderate-to-vigorous physical activity.

Design

A cluster randomised controlled trial with an embedded mixed-methods process evaluation.

Setting

Non-fee-paying schools in Cambridgeshire and Essex, UK (n = 16). Schools were computer randomised and stratified by socioeconomic position and county.

Participants

A total of 2862 Year 9 students (aged 13–14 years; 84% of eligible students).

Intervention

The iteratively developed feasibility-tested refined 12-week intervention trained older adolescents (mentors) and in-class peer leaders to encourage classes to undertake two new weekly activities. Mentors met with classes weekly. Students and classes gained points and rewards for activity in and out of school.

Main outcome measures

The primary outcome was average daily minutes of accelerometer-assessed moderate-to-vigorous physical activity at 10 months post intervention. Secondary outcomes included accelerometer-assessed activity during school, after school and at weekends; self-reported physical activity and psychosocial outcomes; cost-effectiveness; well-being and a mixed-methods process evaluation. Measurement staff were blinded to allocation.

Results

Of 2862 recruited participants, 2167 (76%) attended 10-month follow-up measurements and we analysed the primary outcome for 1874 (65.5%) participants. At 10 months, there was a mean decrease in moderate-to-vigorous physical activity of 8.3 (standard deviation 19.3) minutes in control participants and 10.4 (standard deviation 22.7) minutes in intervention participants (baseline-adjusted difference –1.91 minutes, 95% confidence interval –5.53 to 1.70 minutes; p = 0.316). The programme cost £13 per student compared with control. Therefore, it was not cost-effective. Non-significant indications of differential impacts suggested detrimental effects among boys (boys –3.44, 95% confidence interval –7.42 to 0.54; girls –0.20, 95% confidence interval –3.56 to 3.16), but favoured adolescents from lower socioeconomic backgrounds (medium/low 4.25, 95% confidence interval –0.66 to 9.16; high –2.72, 95% confidence interval –6.33 to 0.89). Mediation analysis did not support the use of any included intervention components to increase physical activity. Some may have potential for improving well-being. Students, teachers and mentors mostly reported enjoying the GoActive intervention (56%, 87% and 50%, respectively), but struggled to conceptualise their roles. Facilitators of implementation included school support, embedding a routine, and mentor and tutor support. Challenges to implementation included having limited school space for activities, time, and uncertainty of teacher and mentor roles.

Limitations

Retention on the primary outcome at 10-month follow-up was low (65.5%), but we achieved our intended sample size, with retention comparable to similar trials.

Conclusions

A rigorously developed school-based intervention (i.e. GoActive) was not effective in countering the age-related decline in adolescent physical activity. Overall, this mixed-methods evaluation provides transferable insights for future intervention development, implementation and evaluation.

Future work

Interdisciplinary research is required to understand educational setting-specific implementation challenges. School leaders and authorities should be realistic about expectations of the effect of school-based physical activity promotion strategies implemented at scale.

Trial registration

Current Controlled Trials ISRCTN31583496.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 6. See the NIHR Journals Library website for further project information. This work was additionally supported by the Medical Research Council (London, UK) (Unit Programme number MC_UU_12015/7) and undertaken under the auspices of the Centre for Diet and Activity Research (Cambridge, UK), a UK Clinical Research Collaboration Public Health Research Centre of Excellence. Funding from the British Heart Foundation (London, UK), Cancer Research UK (London, UK), Economic and Social Research Council (Swindon, UK), Medical Research Council, the National Institute for Health Research (Southampton, UK) and the Wellcome Trust (London, UK), under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged (087636/Z/08/Z; ES/G007462/1; MR/K023187/1). GoActive facilitator costs were borne by Essex and Cambridgeshire County Councils.

Dietary behaviors and poor sleep quality among young adult women: watch that sugary caffeine!

PURPOSE

Associations of dietary patterns with sleep quality have not been sufficiently studied, particularly among young adults. Studying factors associated with sleep quality among young adults are especially important given the significant life changes they are experiencing, which can influence not only sleep quality but also dietary behaviors.

METHODS

We examined the cross-sectional association of sleep quality among 462 women at age 23 years. We used the Pittsburg Sleep Quality Index (PSQI) to define sleep quality. Intake over the previous 7 days of fruits and vegetables, soda, sports drinks, other sweetened drinks, and coffee drinks was assessed by a self-report questionnaire. Linear regression analysis examined the association between PSQI scores and dietary intake.

RESULTS

About 47% of participants were White, 25% Black, 10% Hispanic, and 18% Other. Almost ½ (45%) reported poor sleep quality. Compared with participants reporting consuming no energy drinks, participants who reported consuming any energy drinks had PSQI scores that were 0.84 points higher (7.08 ± 0.51 vs 6.24 ± 0.39; p=0.04) (indicating poorer sleep quality). Participants who reported drinking one or more high-calorie coffee drinks had PSQI scores that were 1.00 points higher compared with those reporting drinking no high-calorie coffee drinks (7.14 ± 0.51 vs 6.14 ± 0.42; p=0.02). Fruit or vegetable intake was not associated with PSQI score.

CONCLUSIONS

Poor sleep quality is prevalent among young women. Young women with poor sleep quality should consider their sugary caffeine use to determine if it may be associated with their sleep.

Strategies for enhancing the implementation of school-based policies or practices targeting risk factors for chronic disease

BACKGROUND

A number of school-based policies or practices have been found to be effective in improving child diet and physical activity, and preventing excessive weight gain, tobacco or harmful alcohol use. Schools, however, frequently fail to implement such evidence-based interventions.

OBJECTIVES

The primary aims of the review are to examine the effectiveness of strategies aiming to improve the implementation of school-based policies, programs or practices to address child diet, physical activity, obesity, tobacco or alcohol use.Secondary objectives of the review are to: Examine the effectiveness of implementation strategies on health behaviour (e.g. fruit and vegetable consumption) and anthropometric outcomes (e.g. BMI, weight); describe the impact of such strategies on the knowledge, skills or attitudes of school staff involved in implementing health-promoting policies, programs or practices; describe the cost or cost-effectiveness of such strategies; and describe any unintended adverse effects of strategies on schools, school staff or children.

SEARCH METHODS

All electronic databases were searched on 16 July 2017 for studies published up to 31 August 2016. We searched the following electronic databases: Cochrane Library including the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; MEDLINE In-Process & Other Non-Indexed Citations; Embase Classic and Embase; PsycINFO; Education Resource Information Center (ERIC); Cumulative Index to Nursing and Allied Health Literature (CINAHL); Dissertations and Theses; and SCOPUS. We screened reference lists of all included trials for citations of other potentially relevant trials. We handsearched all publications between 2011 and 2016 in two specialty journals (Implementation Science and Journal of Translational Behavioral Medicine) and conducted searches of the WHO International Clinical Trials Registry Platform (ICTRP) (http://apps.who.int/trialsearch/) as well as the US National Institutes of Health registry (https://clinicaltrials.gov). We consulted with experts in the field to identify other relevant research.

SELECTION CRITERIA

'Implementation' was defined as the use of strategies to adopt and integrate evidence-based health interventions and to change practice patterns within specific settings. We included any trial (randomised or non-randomised) conducted at any scale, with a parallel control group that compared a strategy to implement policies or practices to address diet, physical activity, overweight or obesity, tobacco or alcohol use by school staff to 'no intervention', 'usual' practice or a different implementation strategy.

DATA COLLECTION AND ANALYSIS

Citation screening, data extraction and assessment of risk of bias was performed by review authors in pairs. Disagreements between review authors were resolved via consensus, or if required, by a third author. Considerable trial heterogeneity precluded meta-analysis. We narratively synthesised trial findings by describing the effect size of the primary outcome measure for policy or practice implementation (or the median of such measures where a single primary outcome was not stated).

MAIN RESULTS

We included 27 trials, 18 of which were conducted in the USA. Nineteen studies employed randomised controlled trial (RCT) designs. Fifteen trials tested strategies to implement healthy eating policies, practice or programs; six trials tested strategies targeting physical activity policies or practices; and three trials targeted tobacco policies or practices. Three trials targeted a combination of risk factors. None of the included trials sought to increase the implementation of interventions to delay initiation or reduce the consumption of alcohol. All trials examined multi-strategic implementation strategies and no two trials examined the same combinations of implementation strategies. The most common implementation strategies included educational materials, educational outreach and educational meetings. For all outcomes, the overall quality of evidence was very low and the risk of bias was high for the majority of trials for detection and performance bias.Among 13 trials reporting dichotomous implementation outcomes-the proportion of schools or school staff (e.g. classes) implementing a targeted policy or practice-the median unadjusted (improvement) effect sizes ranged from 8.5% to 66.6%. Of seven trials reporting the percentage of a practice, program or policy that had been implemented, the median unadjusted effect (improvement), relative to the control ranged from -8% to 43%. The effect, relative to control, reported in two trials assessing the impact of implementation strategies on the time per week teachers spent delivering targeted policies or practices ranged from 26.6 to 54.9 minutes per week. Among trials reporting other continuous implementation outcomes, findings were mixed. Four trials were conducted of strategies that sought to achieve implementation 'at scale', that is, across samples of at least 50 schools, of which improvements in implementation were reported in three trials.The impact of interventions on student health behaviour or weight status were mixed. Three of the eight trials with physical activity outcomes reported no significant improvements. Two trials reported reductions in tobacco use among intervention relative to control. Seven of nine trials reported no between-group differences on student overweight, obesity or adiposity. Positive improvements in child dietary intake were generally reported among trials reporting these outcomes. Three trials assessed the impact of implementation strategies on the attitudes of school staff and found mixed effects. Two trials specified in the study methods an assessment of potential unintended adverse effects, of which, they reported none. One trial reported implementation support did not significantly increase school revenue or expenses and another, conducted a formal economic evaluation, reporting the intervention to be cost-effective. Trial heterogeneity, and the lack of consistent terminology describing implementation strategies, were important limitations of the review.

AUTHORS' CONCLUSIONS

Given the very low quality of the available evidence, it is uncertain whether the strategies tested improve implementation of the targeted school-based policies or practices, student health behaviours, or the knowledge or attitudes of school staff. It is also uncertain if strategies to improve implementation are cost-effective or if they result in unintended adverse consequences. Further research is required to guide efforts to facilitate the translation of evidence into practice in this setting.

Development of a universal approach to increase physical activity among adolescents: the GoActive intervention

OBJECTIVES

To develop a physical activity (PA) promotion intervention for adolescents using a process addressing gaps in the literature while considering participant engagement. We describe the initial development stages; (1) existing evidence, (2) large scale opinion gathering and (3) developmental qualitative work, aiming (A) to gain insight into how to increase PA among the whole of year 9 (13-14 years-old) by identifying elements for intervention inclusion (B) to improve participant engagement and (C) to develop and refine programme design.

METHODS

Relevant systematic reviews and longitudinal analyses of change were examined. An intervention was developed iteratively with older adolescents (17.3 ± 0.5 years) and teachers, using the following process: (1) focus groups with (A) adolescents (n=26) and (B) teachers (n=4); (2) individual interviews (n=5) with inactive and shy adolescents focusing on engagement and programme acceptability. Qualitative data were analysed thematically.

RESULTS

Limitations of the existing literature include lack of evidence on whole population approaches, limited adolescent involvement in intervention development, and poor participant engagement. Qualitative work suggested six themes which may encourage adolescents to do more PA; choice, novelty, mentorship, competition, rewards and flexibility. Teachers discussed time pressures as a barrier to encouraging adolescent PA and suggested between-class competition as a strategy. GoActive aims to increase PA through increased peer support, self-efficacy, group cohesion, self-esteem and friendship quality, and is implemented in tutor groups using a student-led tiered-leadership system.

CONCLUSIONS

We have followed an evidence-based iterative approach to translate existing evidence into an adolescent PA promotion intervention. Qualitative work with adolescents and teachers supported intervention design and addressed lack of engagement with health promotion programmes within this age group. Future work will examine the feasibility and effectiveness of GoActive to increase PA among adolescents while monitoring potential negative effects. The approach developed is applicable to other population groups and health behaviours.

TRIAL REGISTRATION NUMBER

ISRCTN31583496.

Recruitment and retention of children in behavioral health risk factor studies: REACH strategies

BACKGROUND

Children are a common target group in behavioral health research. Yet their recruitment into community setting studies poses challenges to researchers and little guidance exists on recruitment and retention methods.

PURPOSE

This study aims to present successful strategies for the recruitment and retention of children into behavioral health risk factor studies.

METHOD

Firstly, a literature search in various databases was undertaken for papers published 1990-2012, focusing on recruitment and retention methods used in community-based studies with children aged 3-18 years. Secondly, a Delphi study was conducted in 2012 with 27 international experts in the fields of child-related behavioral health risk factors to gather expertise and consensus on successful recruitment and retention strategies applicable in children.

RESULTS

The literature review and Delphi study yielded a set of successful child recruitment and retention strategies, and examples for implementation. These are presented as strategies to Recruit, Engage and retAin Children in behavioral Health risk factor studies (REACH). Recognized strategies for successful recruitment and retention included building trustful relationships between researchers and study partners, parents, and children; having project champions; optimizing consent and follow-up procedures; offering incentives to study partners, children, and parents; minimizing participant burden; and designing feasible studies with cohesive research teams.

CONCLUSION

Using multiple REACH strategies is most promising for maximizing response rates and minimizing attrition of children in cross-sectional, longitudinal, and behavioral intervention studies in community settings such as schools, child care centers, and other youth-related organizations. Researchers can select the most suitable strategies based on their specific study design and requirements.

Recruitment and retention of urban schoolchildren into a randomized double-blind vitamin D supplementation trial

BACKGROUND

While rarely used for supplementation trials in the United States, schools present a practical alternative to a clinical setting.

PURPOSE

We describe the successful recruitment and retention of urban schoolchildren into a 6-month randomized, double-blind vitamin D3 supplementation trial.

METHODS

Boston-area urban schoolchildren, aged 8-15 years, were recruited in 2011-2012 through classroom and auditorium presentations. Informed consent forms in five languages were sent home to parents. Retention methods included regular telephone calls and gift cards for completed study visits.

RESULTS

In total, 691 schoolchildren enrolled. Their mean (standard deviation) age was 11.7 (1.4) years; 59% were racial/ethnic minorities and 68% qualified for free or reduced-price school meals. Multi-level, culturally sensitive, creative approaches contributed to success in recruitment and retention. Of 691 participants, 81% completed the 6-month intervention period. Reasons for attrition included missed appointments and fear of a blood draw. More children from households with higher incomes were retained than those from households with lower incomes (85% vs 79%, respectively, P = 0.04).

LIMITATIONS

The need for three fasting blood draws over the 6-month supplementation period was a limiting factor in the recruitment and retention of children in this study.

CONCLUSION

Recruitment of urban children into a school-based randomized controlled trial represents a feasible approach for a supplementation study. Particular attention to children of lower socioeconomic status may enhance participation and retention when conducting intervention studies among diverse populations.

The WHO Health Promoting School framework for improving the health and well-being of students and their academic achievement

BACKGROUND

The World Health Organization's (WHO's) Health Promoting Schools (HPS) framework is an holistic, settings-based approach to promoting health and educational attainment in school. The effectiveness of this approach has not been previously rigorously reviewed.

OBJECTIVES

To assess the effectiveness of the Health Promoting Schools (HPS) framework in improving the health and well-being of students and their academic achievement.

SEARCH METHODS

We searched the following electronic databases in January 2011 and again in March and April 2013: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, Campbell Library, ASSIA, BiblioMap, CAB Abstracts, IBSS, Social Science Citation Index, Sociological Abstracts, TRoPHI, Global Health Database, SIGLE, Australian Education Index, British Education Index, Education Resources Information Centre, Database of Education Research, Dissertation Express, Index to Theses in Great Britain and Ireland, ClinicalTrials.gov, Current controlled trials, and WHO International Clinical Trials Registry Platform. We also searched relevant websites, handsearched reference lists, and used citation tracking to identify other relevant articles.

SELECTION CRITERIA

We included cluster-randomised controlled trials where randomisation took place at the level of school, district or other geographical area. Participants were children and young people aged four to 18 years, attending schools or colleges. In this review, we define HPS interventions as comprising the following three elements: input to the curriculum; changes to the school's ethos or environment or both; and engagement with families or communities, or both. We compared this intervention against schools that implemented either no intervention or continued with their usual practice, or any programme that included just one or two of the above mentioned HPS elements.

DATA COLLECTION AND ANALYSIS

At least two review authors identified relevant trials, extracted data, and assessed risk of bias in the trials. We grouped different types of interventions according to the health topic targeted or the approach used, or both. Where data permitted, we performed random-effects meta-analyses to provide a summary of results across studies.

MAIN RESULTS

We included 67 eligible cluster trials, randomising 1443 schools or districts. This is made up of 1345 schools and 98 districts. The studies tackled a range of health issues: physical activity (4), nutrition (12), physical activity and nutrition combined (18), bullying (7), tobacco (5), alcohol (2), sexual health (2), violence (2), mental health (2), hand-washing (2), multiple risk behaviours (7), cycle-helmet use (1), eating disorders (1), sun protection (1), and oral health (1). The quality of evidence overall was low to moderate as determined by the GRADE approach. 'Risk of bias' assessments identified methodological limitations, including heavy reliance on self-reported data and high attrition rates for some studies. In addition, there was a lack of long-term follow-up data for most studies.We found positive effects for some interventions for: body mass index (BMI), physical activity, physical fitness, fruit and vegetable intake, tobacco use, and being bullied. Intervention effects were generally small but have the potential to produce public health benefits at the population level. We found little evidence of effectiveness for standardised body mass index (zBMI) and no evidence of effectiveness for fat intake, alcohol use, drug use, mental health, violence and bullying others; however, only a small number of studies focused on these latter outcomes. It was not possible to meta-analyse data on other health outcomes due to lack of data. Few studies provided details on adverse events or outcomes related to the interventions. In addition, few studies included any academic, attendance or school-related outcomes. We therefore cannot draw any clear conclusions as to the effectiveness of this approach for improving academic achievement.

AUTHORS' CONCLUSIONS

The results of this review provide evidence for the effectiveness of some interventions based on the HPS framework for improving certain health outcomes but not others. More well-designed research is required to establish the effectiveness of this approach for other health topics and academic achievement.

Comparison of enrollment rates of African-American families into a school-based tobacco prevention trial using two recruitment strategies in urban and rural settings

PURPOSE

This study evaluated similarities and differences of enrollment rates using two different recruitment strategies for a tobacco control trial in rural and urban African-American (AA) elementary school families.

DESIGN

A comparative study, nested within a larger randomized controlled trial, was used to test the effectiveness of two recruitment approaches on enrollment rates in rural and urban AA families.

SETTING

The study was conducted in 14 Title 1 elementary schools in the southeastern United States: 7 rural and 7 urban.

SUBJECTS

There were 736 eligible AA families, and 332 (45%) completed informed consent and were enrolled into the study.

INTERVENTION

The Facilitate, Open and transparent communication, Shared benefits, Team and tailored, Educate bilaterally, and Relationships, realistic and rewards (FOSTER) approach guided the two recruitment strategies: (1) written informational packets provided to fourth graders to take home to parents; and (2) proactive, face-to-face family information sessions held at schools.

MEASURES

Enrollment rates were based on responsiveness to the two recruitment strategies and completion of the informed consent process.

ANALYSIS

Chi-square, Cochran-Mantel-Haenszel, and Breslow-Day tests were performed.

RESULTS

Higher enrollment rates occurred during the family session for both rural and urban families (100% rural, 93.6% urban; p = .0475) than informational packets alone (28.7% rural, 22% urban; p < .0001). Rural family enrollment rates were overall higher than urban rates regardless of recruitment strategy (52.0% rural vs. 39.6% urban; p = .0008).

CONCLUSION

The findings suggest the FOSTER approach, although effective in both rural and urban settings, was more successful in recruiting rural families.

An innovative acupuncture treatment for primary dysmenorrhea: a randomized, crossover pilot study

CONTEXT

Dysmenorrhea, the occurrence of painful menstrual cramping of the uterus, is a major cause of activity restriction and absences from school and work among young women. Standard pharmaceuticals used to treat dysmenorrhea are not effective for all women and have side effects that limit their use. Studies elsewhere have shown beneficial effects for use of vitamin K1 as an acupoint treatment, but the acceptability of this treatment to women in the United States has been unknown.

OBJECTIVE

The study intended to examine the feasibility, acceptability, and preliminary effects of acupuncture point injection of vitamin K1 as an alternative treatment for primary dysmenorrhea among US women.

DESIGN

The research team conducted a pilot study using a blinded, randomized, crossover trial design.

SETTING

The study took place at the University of California, San Francisco (UCSF).

PARTICIPANTS

The study was conducted in the San Francisco Bay Area among women 18 to 25 y of age who had been diagnosed with primary dysmenorrhea. Fourteen women completed all of the study's visits.

INTERVENTION

Women with primary dysmenorrhea were randomized into 2 groups to receive bilateral injections of vitamin K1 in the Spleen-6 (SP-6) acupuncture point at the start of menstruation and then, following a 2-mo washout period, saline in a nonacupuncture point at the start of menstruation. One group received the vitamin K1 injection first, while the other group received the saline injection first.

OUTCOME MEASURE

Dysmenorrhea pain intensity was measured using a 0-10 numeric rating scale (NRS), before and after injections.

RESULTS

Women had an average 2.5-point decrease in pain after a vitamin K1 injection in the SP-6 acupoint (P < .001), as compared with a 1.8-point decrease after a saline injection (P < .001). Change scores for vitamin K1, as compared with a saline injection, approached statistical significance (P < .10). Intensity and duration of menstrual symptoms, as measured by the Cox retrospective symptom scale, also decreased following injections. After participating, 94% of the women remained agreeable to receiving the injection therapy, and 77% reported they would come every month were the treatment available.

CONCLUSIONS

Findings suggested high acceptability for an acupuncture point injection of vitamin K1 as treatment for primary dysmenorrhea among young women in San Francisco. Pain decreased with both treatments, with a trend toward greater pain reduction for the vitamin K1/SP-6 injection. This finding is consistent with outcomes from the Obstetrics and Gynecology Hospital in Shanghai, China, where the protocol was developed.

The caloric calculator: average caloric impact of childhood obesity interventions

BACKGROUND

The childhood obesity epidemic reflects the daily accumulation of an "energy gap"-excess calories consumed over calories expended. Population-level interventions to reverse the epidemic can be assessed by the degree to which they increase energy expenditure and/or reduce caloric intake. However, no common metric exists for such comparative assessment.

PURPOSE

To develop a common metric, the Average Caloric Impact (ACI), for estimating and comparing population-level effect sizes of a range of childhood obesity interventions.

METHODS

An iterative, collaborative process was used to review literature from 1996 to 2012 and select illustrative interventions showing effects on youth diet and/or activity levels, energy balance, and weight. The ACIs of physical activity interventions were estimated based on program reach, frequency, duration, and intensity and mean body weight of the targeted age and gender group from the 2009-2010 National Health and Nutrition Examination Survey. ACIs of dietary interventions were based on reach and changes in foods and/or beverages consumed.

RESULTS

Fifteen interventions informed by 29 studies were included, ranging from individual behavioral to population-level policies. A web tool, the Caloric Calculator, was developed to allow researchers and policymakers to estimate the ACIs of interventions on target populations with reference to energy gap reductions required to reach the nation's Healthy People childhood obesity goals.

CONCLUSIONS

The Caloric Calculator and ACIs provide researchers and policymakers with a common metric for estimating the potential effect sizes of various interventions for reducing childhood obesity, providing a platform for evidence-based dialogues on new program or policy approaches as data emerge.

School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18

BACKGROUND

The World Health Organization (WHO) estimates that 1.9 million deaths worldwide are attributable to physical inactivity and at least 2.6 million deaths are a result of being overweight or obese. In addition, WHO estimates that physical inactivity causes 10% to 16% of cases each of breast cancer, colon, and rectal cancers as well as type 2 diabetes, and 22% of coronary heart disease and the burden of these and other chronic diseases has rapidly increased in recent decades.

OBJECTIVES

The purpose of this systematic review was to summarize the evidence of the effectiveness of school-based interventions in promoting physical activity and fitness in children and adolescents.

SEARCH METHODS

The search strategy included searching several databases to October 2011. In addition, reference lists of included articles and background papers were reviewed for potentially relevant studies, as well as references from relevant Cochrane reviews. Primary authors of included studies were contacted as needed for additional information.

SELECTION CRITERIA

To be included, the intervention had to be relevant to public health practice (focused on health promotion activities), not conducted by physicians, implemented, facilitated, or promoted by staff in local public health units, implemented in a school setting and aimed at increasing physical activity, included all school-attending children, and be implemented for a minimum of 12 weeks. In addition, the review was limited to randomized controlled trials and those that reported on outcomes for children and adolescents (aged 6 to 18 years). Primary outcomes included: rates of moderate to vigorous physical activity during the school day, time engaged in moderate to vigorous physical activity during the school day, and time spent watching television. Secondary outcomes related to physical health status measures including: systolic and diastolic blood pressure, blood cholesterol, body mass index (BMI), maximal oxygen uptake (VO2max), and pulse rate.

DATA COLLECTION AND ANALYSIS

Standardized tools were used by two independent reviewers to assess each study for relevance and for data extraction. In addition, each study was assessed for risk of bias as specified in the Cochrane Handbook for Systematic Reviews of Interventions. Where discrepancies existed, discussion occurred until consensus was reached. The results were summarized narratively due to wide variations in the populations, interventions evaluated, and outcomes measured.

MAIN RESULTS

In the original review, 13,841 records were identified and screened, 302 studies were assessed for eligibility, and 26 studies were included in the review. There was some evidence that school-based physical activity interventions had a positive impact on four of the nine outcome measures. Specifically positive effects were observed for duration of physical activity, television viewing, VO2 max, and blood cholesterol. Generally, school-based interventions had little effect on physical activity rates, systolic and diastolic blood pressure, BMI, and pulse rate. At a minimum, a combination of printed educational materials and changes to the school curriculum that promote physical activity resulted in positive effects.In this update, given the addition of three new inclusion criteria (randomized design, all school-attending children invited to participate, minimum 12-week intervention) 12 of the original 26 studies were excluded. In addition, studies published between July 2007 and October 2011 evaluating the effectiveness of school-based physical interventions were identified and if relevant included. In total an additional 2378 titles were screened of which 285 unique studies were deemed potentially relevant. Of those 30 met all relevance criteria and have been included in this update. This update includes 44 studies and represents complete data for 36,593 study participants. Duration of interventions ranged from 12 weeks to six years.Generally, the majority of studies included in this update, despite being randomized controlled trials, are, at a minimum, at moderate risk of bias. The results therefore must be interpreted with caution. Few changes in outcomes were observed in this update with the exception of blood cholesterol and physical activity rates. For example blood cholesterol was no longer positively impacted upon by school-based physical activity interventions. However, there was some evidence to suggest that school-based physical activity interventions led to an improvement in the proportion of children who engaged in moderate to vigorous physical activity during school hours (odds ratio (OR) 2.74, 95% confidence interval (CI), 2.01 to 3.75). Improvements in physical activity rates were not observed in the original review. Children and adolescents exposed to the intervention also spent more time engaged in moderate to vigorous physical activity (with results across studies ranging from five to 45 min more), spent less time watching television (results range from five to 60 min less per day), and had improved VO2max (results across studies ranged from 1.6 to 3.7 mL/kg per min). However, the overall conclusions of this update do not differ significantly from those reported in the original review.

AUTHORS' CONCLUSIONS

The evidence suggests the ongoing implementation of school-based physical activity interventions at this time, given the positive effects on behavior and one physical health status measure. However, given these studies are at a minimum of moderate risk of bias, and the magnitude of effect is generally small, these results should be interpreted cautiously. Additional research on the long-term impact of these interventions is needed.

Recruitment and retention strategies for a community-based weight management study for multi-ethnic elementary school children and their parents

This article describes successful recruitment and retention strategies for a community-based weight management study in two school districts in North Carolina. Recruitment and retention on both district and school levels and child and parent levels are discussed. A total of 358 children and 358 parents from eight schools in rural North Carolina participated in a randomized controlled trial to test the effectiveness of a nutrition and exercise education, coping skills training, and exercise intervention. Recruitment and retention at the district and school level included meeting with superintendents and receiving a proper introduction to school principals and consistently clear communication throughout the study. At the school level, relationships were developed with the principal and other key personnel to keep lines of communication open during the study. Recruitment and retention strategies at the child and parent level included allowing adequate time for questions during consent and assent and providing a free nutrition and exercise program, a light meal, homework assistance, child care for other children who came to the program, and transportation vouchers if needed. Successful recruitment and retention strategies at the district and school levels and child and parent levels are important for conducting longitudinal community-based studies.

Knowledge, Skills, and Qualities for Effectively Facilitating an Adolescent Girls' Group

Nurses employed in a variety of school settings often rely on group-format approaches to support the health and well-being of adolescent girls. The process of selecting an effective facilitator, and evaluating the impact of a facilitator on intervention process and outcomes, is rarely described. The purpose of this article was to synthesize the literature regarding facilitator knowledge, skills, and qualities to provide school-based researchers and practitioners with a framework for selecting and evaluating group facilitators. Literature was reviewed between Fall of 2008 and Spring of 2011. Findings were synthesized into categories that provide the organization for this article (why groups, why a facilitator, and the knowledge, skills, and qualities of an effective girls' group facilitator). Nurses need to carefully identify, select, and equip those who serve as facilitators because group successes, evidenced in the ways girls grow and support each other in growth, are the result of a successful, well-matched facilitator-group participant experience.

Adolescent girls' and parents' views on recruiting and retaining girls into an after-school dance intervention: implications for extra-curricular physical activity provision

Background

Many adolescents are not sufficiently active and girls are less active than boys. Physical activity interventions delivered during curriculum time have reported weak effects. More sustained changes in physical activity may be obtained by facilitating participation in enjoyable activities. Dance is the favourite activity of UK girls but there is a shortage of dance provision. Dance sessions delivered after the school day could prove to be an effective means of engaging adolescent girls in physical activity. There is a lack of information about the factors that would affect girls' recruitment and retention in an after-school dance programme.

Methods

Focus groups were conducted with 65, Year 7 (11-12 year old) girls from 4 secondary schools in Bristol. In-depth phone interviews were also conducted with 16 (4 per school) of the girls' parents. Interviews and focus groups examined issues that would affect recruitment into the intervention, strategies that could be used to attract girls who have little or no previous experience in dance, any factors that would increase their interest in participating in an after-school dance programme and any factors that would affect retention in the programme. All interviews and focus groups were digitally recorded and thematically analysed.

Results

Girls reported that a taster session in which they had an opportunity to sample the intervention content and "word of mouth" campaigns by peers, who did not need to be their friends, would encourage them to participate in an after-school dance programme. Sessions that maximised enjoyment and facilitated socialisation opportunities would enhance retention. Parents reported that encouraging groups of friends to join the programme, and stressing the enjoyment of the session would increase participation.

Conclusions

Recruitment and retention campaigns that focus on enjoyment, socialisation, mastery, goal setting and relating to other girls may be effective strategies for recruiting and retaining girls in an after-school dance programme. These factors are consistent with well-established theories of individual behaviour change such as self-determination theory and social cognitive theory. Recruitment and retention campaigns that are targeted to address theoretically derived mediators of behaviour may be more effective than traditional approaches.

Project Wings, a coping intervention for Latina adolescents: a pilot study

The authors examined the feasibility and preliminary outcomes of Project Wings Girls' Groups, a school-based mental health promotion program designed to improve well-being in Latina adolescents, as observed in outcomes, including perceived stress, depressive symptoms, coping, and connectedness. This pilot randomized controlled trial compared outcomes over 9 months postintervention for 42 9th and 10th grade adolescents attending two urban high schools. Girls were randomized to Project Wings Girls' Groups, a 16-session facilitated curriculum, including sharing circles, mind-body exercises, and coping skills building or the attention control (i.e., similar format but focused on general health topics). Feasibility of retention and long-term follow-up data collection was demonstrated, with lessons learned for future study. Although not statistically powered, this trial demonstrated findings in the expected direction, including reduced perceived stress and depression and increased connectedness. A trial with sufficient power is warranted to examine Project Wings' effects on mental health problems among Latina adolescents.

Recruitment and retention strategies and methods in the HEALTHY study

HEALTHY was a 3-year middle school-based primary prevention trial to reduce modifiable risk factors for type 2 diabetes in youth. The study was conducted at seven centers across the country. This paper describes the recruitment and retention activities employed in the study. Schools and students were the focus of recruitment and retention. Each center was responsible for the recruitment of six schools; eligibility was based on ability to enroll a sufficient number of predominately minority and lower socioeconomic status students. Study staff met with district superintendents and school principals to verify the eligibility of schools, and to ascertain how appropriate the school would be for conducting the trial. Sixth grade students were recruited employing a variety of techniques; students and their parents did not know whether their school was randomized to the intervention or control arm. This cohort was followed through sixth, seventh and eighth grades. In the eighth grade, an additional sample of students who were not originally enrolled in the study was recruited in a similar manner to participate in data collection to allow for cross-sectional and dose-response secondary analyses. Parents signed informed consent forms and children signed informed assent forms, as per the needs of the local Institutional Review Board. Parents received a letter describing the results of the health screening for their children after data collection in sixth and eighth grades. Retention of schools and students was critical for the success of the study and was encouraged through the use of financial incentives and other strategies. To a large extent, student withdrawal due to out-migration (transfer and geographical relocation) was beyond the ability of the study to control. A multi-level approach that proactively addressed school and parent concerns was crucial for the success of recruitment and retention in the HEALTHY study.

Recruitment and retention strategies and methods in the HEALTHY study

HEALTHY was a 3-year middle school-based primary prevention trial to reduce modifiable risk factors for type 2 diabetes in youth. The study was conducted at seven centers across the country. This paper describes the recruitment and retention activities employed in the study. Schools and students were the focus of recruitment and retention. Each center was responsible for the recruitment of six schools; eligibility was based on ability to enroll a sufficient number of predominately minority and lower socioeconomic status students. Study staff met with district superintendents and school principals to verify the eligibility of schools, and to ascertain how appropriate the school would be for conducting the trial. Sixth grade students were recruited employing a variety of techniques; students and their parents did not know whether their school was randomized to the intervention or control arm. This cohort was followed through sixth, seventh and eighth grades. In the eighth grade, an additional sample of students who were not originally enrolled in the study was recruited in a similar manner to participate in data collection to allow for cross-sectional and dose-response secondary analyses. Parents signed informed consent forms and children signed informed assent forms, as per the needs of the local Institutional Review Board. Parents received a letter describing the results of the health screening for their children after data collection in sixth and eighth grades. Retention of schools and students was critical for the success of the study and was encouraged through the use of financial incentives and other strategies. To a large extent, student withdrawal due to out-migration (transfer and geographical relocation) was beyond the ability of the study to control. A multi-level approach that proactively addressed school and parent concerns was crucial for the success of recruitment and retention in the HEALTHY study.

Examination of perceived neighborhood characteristics and transportation on changes in physical activity and sedentary behavior: The Trial of Activity in Adolescent Girls

We examined the association between perceived neighborhood characteristics and transport and 2-year changes in accelerometer-determined nonschool MET-weighted moderate-to-vigorous physical activity (MW-MVPA) and sedentary behavior of adolescent girls. Reporting that children do not play outdoors in their neighborhood, that their neighborhood was well lit, and that there were trails in their neighborhood were each associated with significant decreases in nonschool MW-MVPA. None of the neighborhood or transportation measures was associated with changes in nonschool sedentary behavior. Further work is needed to understand the determinants of the decline in physical activity and the increase in sedentary behavior among adolescent girls.

Obesity and depressed mood associations differ by race/ethnicity in adolescent girls

Abstract Objectives. To evaluate bidirectional associations between obesity and depressed mood in adolescent girls, and determine if associations differed by racial/ethnic group. Methods. We analyzed data collected from 918 adolescent girls studied in 6(th) and 8(th) grades in the Trial of Activity for Adolescent Girls (TAAG). Racial/ethnic group was defined as non-Hispanic white, non-Hispanic black, and Hispanic. Height and weight were measured and obesity was defined as a body mass index-for-age ≥95(th) percentile. The Center for Epidemiologic Studies Depression Scale (CES-D) was used to measure depressive symptoms and depressed mood, defined as CES-D ≥24. Generalized estimating equations were used to examine associations between 6(th) grade obesity and 8(th) grade depressed mood, as well as 6(th) grade depressed mood and 8(th) grade obesity. Results. Racial/ethnic group was a statistically significant effect modifier in both directions of association (p<0.02). Among white girls, 6(th) grade obesity was associated with greater likelihood of depressed mood in 8(th) grade (odds ratio [OR]=2.47, 95% confidence interval [CI]: 1.85, 3.30), whereas for black and Hispanic girls this association was not observed (OR= 1.16 and 0.82, respectively). Also for white girls, 6(th) grade depressed mood was associated with greater likelihood of obesity in 8(th) grade (OR = 4.47, CI: 1.96, 10.24), whereas for black and Hispanic girls, OR=0.83 and 1.89, respectively. Conclusions. Associations between obesity and depressed mood may be most problematic among adolescent girls in the white racial/ethnic group. Our results are consistent both with depressed mood contributing to obesity and obesity contributing to depressed mood.

Mediators affecting girls' levels of physical activity outside of school: findings from the trial of activity in adolescent girls

BACKGROUND

Providing after school activities is a community level approach for reducing the decline in physical activity of girls as they reach early adolescence.

PURPOSE

The purpose of this study was to examine psychosocial, environmental, and behavioral factors as potential mediators of after school physical activity in adolescent girls.

METHODS

We assessed objectively measured levels of physical activity occurring outside of school and potential predictors and mediators of activity in girls participating in the Trial of Activity in Adolescent Girls (TAAG).

RESULTS

We found that the TAAG intervention had a statistically significant and positive effect on out of school activity in the 2006 cohort. Self-efficacy, friends' social support, total social support, and difficulty getting to and from community activities mediated the level of moderate to vigorous physical activity in girls.

CONCLUSIONS

Parents, communities, and schools should provide and enhance opportunities outside of the school day for adolescents to be active. Reducing transportation barriers and enlisting social support appear to be key.

Feasibility and acceptability of a school-based coping intervention for Latina adolescents

Latino girls (Latinas) experience disproportionate rates of emotional distress, including suicidal ideation, which may be indicative of inadequate coping abilities. Prevention of mental health problems, a U.S. public health priority, is particularly critical for Latina adolescents due to lack of access to mental health treatments. The purpose of this study was to examine the feasibility of Project Wings, a 14-session stress management/coping intervention. Latinas in school (ages 15-21) met weekly for 2-hr with two bilingual experienced facilitators to participate in sharing circles, relaxation exercise, and skill building. Intervention participation and post-intervention focus group data were analyzed. Fall semester intervention (n = 10) occurred during school (72% attendance rate); spring semester intervention (n = 11) was after school (84% attendance rate). Focus group data confirmed acceptability. Latina adolescents will participate in a school-based, group-based stress management/coping intervention. The findings offer insights about intervention recruitment and retention that are specifically relevant to school nurses. Future research includes intervention testing using a randomized study design.

Promoting physical activity in middle school girls: Trial of Activity for Adolescent Girls

BACKGROUND

Physical activity is important for weight control and good health; however, activity levels decline in the adolescent years, particularly in girls.

DESIGN

Group randomized controlled trial.

SETTING/PARTICIPANTS

Middle school girls with English-speaking skills and no conditions to prevent participation in physical activity in 36 schools in six geographically diverse areas of the United States. Random, cross-sectional samples were drawn within schools: 6th graders in 2003 (n=1721) and 8th graders in 2005 (n=3504) and 2006 (n=3502).

INTERVENTION

A 2-year study-directed intervention (fall 2003 to spring 2005) targeted schools, community agencies, and girls to increase opportunities, support, and incentives for increased physical activity. Components included programs linking schools and community agencies, physical education, health education, and social marketing. A third-year intervention used school and community personnel to direct intervention activities.

MAIN OUTCOME MEASURES

The primary outcome, daily MET-weighted minutes of moderate-to-vigorous physical activity (MET-weighted MVPA), was assessed using accelerometry. Percent body fat was assessed using anthropometry.

RESULTS

After the staff-directed intervention (pre-stated primary outcome), there were no differences (mean= -0.4, 95% CI= -8.2 to 7.4) in adjusted MET-weighted MVPA between 8th-grade girls in schools assigned to intervention or control. Following the Program Champion-directed intervention, girls in intervention schools were more physically active than girls in control schools (mean difference 10.9 MET-weighted minutes of MVPA, 95% CI=0.52-21.2). This difference is about 1.6 minutes of daily MVPA or 80 kcal per week. There were no differences in fitness or percent body fat at either 8th-grade timepoint.

CONCLUSION

A school-based, community-linked intervention modestly improved physical activity in girls.