Advancing School and Community Engagement Now for Disease Prevention (ASCEND)

PURPOSE

To compare two intensity levels (standard vs. enhanced) of a nutrition and physical activity intervention vs. a control (usual programs) on nutrition knowledge, body mass index, fitness, academic performance, behavior, and medication use among elementary school students.

DESIGN

Quasi-experimental with three arms.

SETTING

Elementary schools, students' homes, and a supermarket.

SUBJECTS

A total of 1487 third-grade students.

INTERVENTION

The standard intervention (SI) provided daily physical activity in classrooms and a program on making healthful foods, using food labels. The enhanced intervention (EI) provided these plus additional components for students and their families.

MEASURES

Body mass index (zBMI), food label literacy, physical fitness, academic performance, behavior, and medication use for asthma or attention-deficit hyperactivity disorder (ADHD).

ANALYSIS

Multivariable generalized linear model and logistic regression to assess change in outcome measures.

RESULTS

Both the SI and EI groups gained less weight than the control (p < .001), but zBMI did not differ between groups (p = 1.00). There were no apparent effects on physical fitness or academic performance. Both intervention groups improved significantly but similarly in food label literacy (p = .36). Asthma medication use was reduced significantly in the SI group, and nonsignificantly (p = .10) in the EI group. Use of ADHD medication remained unchanged (p = .34).

CONCLUSION

The standard intervention may improve food label literacy and reduce asthma medication use in elementary school children, but an enhanced version provides no further benefit.

A Multicomponent Intervention Helped Reduce Sugar-Sweetened Beverage Intake in Economically Disadvantaged Hispanic Children

PURPOSE

This study aimed to examine the effect of a multicomponent intervention program on consumption of sugar-sweetened beverages (SSBs), and lifestyle factors associated with SSB intake, in Hispanic children from low-income families.

DESIGN

A five-wave longitudinal study using a quasi-experimental design was conducted.

SETTING

Five elementary schools in West Texas served as the setting.

SUBJECTS

Participants included 555 predominantly Hispanic children (ages 5-9 years) from low-income families and their parents (n = 525).

INTERVENTION

A multicomponent intervention program was implemented.

MEASURES

Children's anthropometric measures were obtained. Their weight status was determined based on body mass index for age and gender. Parents responded to a demographic questionnaire, a shelf inventory, an acculturation scale, and a family survey.

ANALYSIS

Growth curve analyses were used to test differences between intervention and comparison participants' SSB intake and to examine potential covariates.

RESULTS

Comparison group children's daily SSB intake significantly increased over time (B = 1.06 ± .40 ounces per month, p < .01), but this linear increase of SSB was slowed down by the intervention (B = -.29 ± .12, p < .05). More daily TV time, more fast food intake, and more types of SSBs available at home were associated with higher SSB intake.

CONCLUSION

Risk factors of childhood obesity were associated with each other. The intervention program produced a modest reduction in SSB consumed by economically disadvantaged and predominantly Hispanic children.

Making Healthy Eating Policy Practice: A Group Randomized Controlled Trial on Changes in Snack Quality, Costs, and Consumption in After-School Programs

PURPOSE

The aim of this study was to evaluate an intervention designed to assist after-school programs (ASPs) in meeting snack nutrition policies that specify that a fruit or vegetable be served daily and sugar-sweetened beverages/foods and artificially flavored foods eliminated.

DESIGN

The study used a 1-year group-randomized controlled trial.

SETTING

The study took place in ASPs operating in South Carolina, United States.

SUBJECTS

Twenty ASPs serving over 1700 children were recruited, match-paired postbaseline on enrollment size and days fruits/vegetables were served per week, and randomized to either intervention (n = 10) or control (n = 10) groups.

INTERVENTION

The study used Strategies To Enhance Practice for Healthy Eating (STEPs-HE), a multistep adaptive intervention framework that assists ASP leaders and staff to serve snacks that meet nutrition policies while maintaining cost.

MEASURES

Direct observation of snacks served and consumed and monthly snack expenditures as determined by receipts were used.

ANALYSIS

The study used nonparametric and mixed-model repeated measures.

RESULTS

By postassessment, intervention ASPs increased serving of fruits/vegetables to 3.9 ± 2.1 vs. 0.7 ± 1.7 d/wk and decreased serving sugar-sweetened beverages to 0.1 ± 0.7 vs. 1.8 ± 2.4 d/wk and sugar-sweetened foods to 0.3 ± 1.1 vs. 2.7 ± 2.5 d/wk compared to controls, respectively. Cost of snacks increased by $0.02/snack in the intervention ASPs ($0.36 to $0.38) compared to a $0.01 per snack decrease in the control group ($0.39 to $0.38). Across both assessments and groups, 80% to 100% of children consumed FVs.

CONCLUSIONS

The STEPs-HE intervention can assist ASPs in meeting nationally endorsed nutrition policies with marginal increases in cost.

Early Childhood Disadvantage for Sons of Mexican Immigrants: Body Mass Index Across Ages 2-5

PURPOSE

To distinguish the origins of higher weight status and determine when and why intra- and interracial/ethnic disparities emerge.

DESIGN

The study used a longitudinal analysis of the Early Childhood Longitudinal Study-Birth Cohort (ECLS-B).

SETTING

The study was conducted in the United States.

SUBJECTS

Participants were children of non-Hispanic white mothers and children of U.S.- and foreign-born mothers of Mexican origin from a nationally representative sample of children born in the year 2001 (N ≈ 3700).

MEASURES

The Centers for Disease Control and Prevention growth charts determined sex- and age-specific weight status. Covariates were obtained from birth certificate records and parent interviews.

ANALYSIS

Frequencies, growth curve trajectories, and ordinary least squares regression examined body mass index (BMI) and obesity across survey waves.

RESULTS

Compared to their peers with non-Hispanic white mothers, children of Mexican-heritage mothers have higher average BMI and greater rates of obesity. The BMI of boys with Mexican-born mothers is higher relative to whites and children of U.S.-born Mexican mothers across early childhood, increasing sharply at about age 4.5 years. This divergence is driven by increases in the BMI of boys, as girls do not show the same growth. A number of measures, including descriptors of children's nutritional intake, lifestyle factors, and acculturation, do not explain the increased obesity rates among sons of Mexican mothers.

CONCLUSION

Despite favorable perinatal health and weight, Mexican-American sons of foreign-born mothers show disadvantages in BMI that emerge close to the start of kindergarten.

A Reach, Effectiveness, Adoption, Implementation, Maintenance Evaluation of Weekend Backpack Food Assistance Programs

PURPOSE

The purpose of this study was to evaluate an ongoing statewide weekend backpack program through the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework.

DESIGN

Mixed-methods inquiry was used to explore the reach, effectiveness, adoption, implementation, and maintenance of backpack programs within Montana.

SETTING

Study participants completed audio-recorded one-on-one phone interviews.

PARTICIPANTS

Key informants (e.g., managers at food banks, staff at participating schools, policy makers) were purposively sampled (N = 20).

METHOD

Semistructured interviews were conducted to gather data to describe each RE-AIM dimension. Interviews were transcribed verbatim and deductively (i.e., using RE-AIM as themes) coded for meaning units, placed into higher-order categories, and summarized in narrative. Supporting quantitative data (e.g., the proportion of eligible students that joined the program, rate of school-level adoption) were calculated using descriptive statistics.

RESULTS

Backpack programs with a broad reach and evidenced effect may be appealing to adopt. Weekend food bags cost an average $3.87 (SD ± .94) and there were some positive (i.e., ease, protecting participants' privacy) and very few negative (logistical) components of implementation. Collaborators and community partners are necessary for long-term sustainability.

CONCLUSION

Backpack programs are widespread and have potential to relieve weekend hunger; however, more efforts need to be made to end childhood hunger.

Reliability and Validity of the Commitment to Physical Activity Scale for Adolescents

PURPOSE

To examine psychometric properties of a Commitment to Physical Activity Scale for Adolescents (CPASA).

DESIGN

Two test-retest studies and a prospective study, approved by a university institutional review board, were conducted in midwestern U.S. urban areas.

SETTING

The first test-retest study occurred in four community centers, the second test-retest study took place in a community school, and the prospective study occurred in eight middle schools.

SUBJECTS

To measure commitment at baseline and 1 week later, 51 girls in the first test-retest study completed an original 26-item scale, and 91 in the second test-retest study completed a revised 11-item scale. In the prospective study, 503 girls completed the 11-item scale.

MEASURES

Commitment was measured via the CPASA. After completing the CPASA, girls in the prospective study wore ActiGraph GT3X-plus accelerometers that measured light, moderate, and vigorous physical activity (LMVPA) and moderate to vigorous physical activity (MVPA).

ANALYSIS

Internal consistency and test-retest reliability were estimated. Both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were conducted to cross-validate the factor structure.

RESULTS

For the 11-item CPASA, Cronbach α ranged from .81 to .82, and test-retest reliability was .88. Both EFA and CFA indicated a single factor. The scale was significantly correlated with LMVPA (r = .10) and MVPA (r = .11).

CONCLUSION

The 11-item CPASA demonstrated acceptable reliability and validity with girls.

Engaging Minority Youth in Diabetes Prevention Efforts Through a Participatory, Spoken-Word Social Marketing Campaign

PURPOSE

To examine the reach, efficacy, and adoption of The Bigger Picture, a type 2 diabetes (T2DM) social marketing campaign that uses spoken-word public service announcements (PSAs) to teach youth about socioenvironmental conditions influencing T2DM risk.

DESIGN

A nonexperimental pilot dissemination evaluation through high school assemblies and a Web-based platform were used.

SETTING

The study took place in San Francisco Bay Area high schools during 2013.

SUBJECTS

In the study, 885 students were sampled from 13 high schools.

INTERVENTION

A 1-hour assembly provided data, poet performances, video PSAs, and Web-based platform information. A Web-based platform featured the campaign Web site and social media.

MEASURES

Student surveys preassembly and postassembly (knowledge, attitudes), assembly observations, school demographics, counts of Web-based utilization, and adoption were measured.

ANALYSIS

Descriptive statistics, McNemar's χ² test, and mixed modeling accounting for clustering were used to analyze data.

RESULTS

The campaign included 23 youth poet-created PSAs. It reached >2400 students (93% self-identified non-white) through school assemblies and has garnered >1,000,000 views of Web-based video PSAs. School participants demonstrated increased short-term knowledge of T2DM as preventable, with risk driven by socioenvironmental factors (34% preassembly identified environmental causes as influencing T2DM risk compared to 83% postassembly), and perceived greater personal salience of T2DM risk reduction (p < .001 for all). The campaign has been adopted by regional public health departments.

CONCLUSION

The Bigger Picture campaign showed its potential for reaching and engaging diverse youth. Campaign messaging is being adopted by stakeholders.

Social Smoking and Mental Health Among Chinese Male College Students

PURPOSE

China has a high prevalence of smoking, but the characteristics of social smoking in Chinese college students have not been investigated. We examined the pattern of social smoking and explored the association between social smoking and personal cessation efforts and mental health factors among Chinese male college students.

DESIGN

Study design was a cross-sectional survey.

SETTING

P. R. China was the setting of the study.

SUBJECTS

Participants were a random sample of 1327 male college students.

MEASURES

All participants completed a self-administered questionnaire that examined their smoking behaviors and a group of specific mental health factors (loneliness, self-harm, suicide, depression, and anxiety).

ANALYSIS

Analysis was conducted using descriptive statistics, χ² analysis, and multivariate logistic regression.

RESULTS

Of a total of 207 current smokers, 102 (49.3%) were identified as social smokers. Compared with nonsmokers, social smokers had increased risks for depression (odds ratio, 1.74; 95% confidence interval, 1.15-2.65). Among daily smokers, social smokers were less likely to have an intention to quit smoking than nonsocial smokers (odds ratio, .08; 95% confidence interval, .01-.57).

CONCLUSION

This study reveals unique psychologic characteristics related to social smoking. College students are a particular group of interest because unhealthy behaviors initiated during adolescence may continue through adulthood. Our findings provide evidence for future tobacco control intervention among this population.

Adolescent and Young Adult Smokers Who Self-Identify as Nonsmokers: Relationship With Cigarette-Related Withdrawal and Cravings

PURPOSE

Examine the extent to which low-nicotine dependent daily smokers identify themselves as nonsmokers (smoking nonsmokers) over time, and examine the effect of nicotine-related withdrawal symptoms and cravings in predicting self-identified smoking status.

DESIGN

Longitudinal.

SETTING

National Youth Smoking Cessation Survey 2003-2005.

SUBJECTS

One hundred thirty-two adolescents and young adults (16-24 years).

MEASURES

A questionnaire was used to assess smoking identity, withdrawal, cravings, and smoking intensity parameters.

ANALYSIS

Multivariable logistic regression analysis.

RESULTS

Among the 132 smoking nonsmokers at baseline, 45% remained smoking nonsmokers at the 2-year follow-up, with 55% transitioning to smoking (i.e., self-identified as smoking smokers in the interim). After adjustments, participants exhibiting greater restlessness and cravings over time, respectively, had 3.59 (p = .01) and 4.31 (p = .008) greater odds of being a smoking nonsmoker at baseline but then transitioning into a smoking smoker at 2-year follow-up.

CONCLUSION

These findings may have implications with respect to interventions emphasizing withdrawal and craving symptoms. Further, given that some youth smokers self-identify as nonsmokers, and do so over time, potential intervention efforts may be pointed toward cognitive-related strategies at improving self-perceptions.

Child and Caregiver Attitudes About Sports Drinks and Weekly Sports Drink Intake Among U.S. Youth

PURPOSE

To examine caregiver and youth attitudes about sports drinks (SDs) and the association of those attitudes with youth SD intake.

DESIGN

Study design was cross-sectional. The online YouthStyles survey was sent to youth (ages 12-17 years) whose caregivers completed the online Summer ConsumerStyles survey for adults.

SETTING

The 2011 Styles survey data comprised the setting.

SUBJECTS

The sample was composed of 815 U.S. caregiver-youth dyads.

MEASURES

The outcome variable is youth SD consumption, and exposure variables are youth and caregivers' attitudes that SDs are healthy for children, and caregivers' attitude that children need SDs for hydration. Covariates are youth demographic and physical activity variables.

ANALYSIS

Multivariable logistic regression was used to estimate adjusted odds ratios (ORs) for youth SD consumption one or more times per week after controlling for covariates.

RESULTS

About one in five youth consumed SDs one or more times per week. Caregiver attitudes about the healthfulness of SDs and children's need of SDs for hydration both significantly differed by race and caregiver education level. The odds of youth SD consumption one or more times per week were significantly higher among youth of caregivers who agreed that SDs are good, healthy drinks for children (OR, 2.72 vs. disagreed) and among youth of caregivers who agreed that children need SDs for hydration (OR, 3.15 vs. disagreed). Youth attitude about SD healthfulness was not associated with intake.

CONCLUSION

Caregivers, particularly minority and less educated caregivers, may need more education about SD use.

Association of Concurrent Healthy Eating and Regular Physical Activity With Cardiovascular Disease Risk Factors in U.S. Youth

PURPOSE

Examine whether concurrently consuming a healthy diet and regularly being physically active among U.S. youth is more favorably associated with cardiovascular disease (CVD) biomarkers than other physical activity and dietary patterns.

DESIGN

Cross-sectional.

SETTING

United States (National Health and Nutrition Examination Survey) 2003-2006.

SUBJECTS

Two thousand six hundred twenty-nine youth (6-17 years).

MEASURES

Healthy Eating Index (HEI), accelerometer-determined physical activity, biomarkers, and anthropometry. Four categories were created: consuming a healthy diet (top 40% of HEI) and active (sufficient to meet guidelines); unhealthy diet and active; healthy diet and inactive; and unhealthy diet and inactive.

ANALYSIS

Multivariable regression.

RESULTS

Children consuming a healthy diet and who were active had significantly lower waist circumference (β = -5.5, p < .006), C-reactive protein (CRP) (β = -.2, p < .006), and triglycerides (β = -27.9, p < .006) than children consuming an unhealthy diet and who were inactive. Children engaging in both healthy behaviors had significantly lower CRP (β = -.11, p < .001) and total cholesterol levels (β = -7.8, p = .004) than those only engaging in sufficient activity; there were no significant differences in biomarker levels among children engaging in both healthy behaviors and those only consuming a healthy diet. No associations were significant for adolescents.

CONCLUSION

Concurrent healthy eating and regular physical activity among children is favorably associated with CVD biomarkers when compared with unhealthy diet and inactivity.

Predictors of the Existence of Congregational HIV Programs: Similarities and Differences Compared With Other Health Programs

PURPOSE

Identify and compare predictors of the existence of congregational human immunodeficiency virus (HIV) and other health programs.

DESIGN

Cross-sectional study.

SETTING

United States.

SUBJECTS

A nationally representative sample of 1506 U.S. congregations surveyed in the National Congregations Study (2006-2007).

MEASURES

Key informants at each congregation completed in-person and telephone interviews on congregational HIV and other health programs and various congregation characteristics (response rate = 78%). County-level HIV prevalence and population health data from the Robert Wood Johnson Foundation's 2007 County Health Rankings were linked to the congregational data.

ANALYSIS

Multinomial logistic regression was used to assess factors that predict congregational health programs relative to no health programs; and of HIV programs relative to other health activities.

RESULTS

Most congregations (57.5%) had at least one health-related program; many fewer (5.7%) had an HIV program. Predictors of health vs. HIV programs differed. The number of adults in the congregation was a key predictor of health programs, while having an official statement welcoming gay persons was a significant predictor of HIV programs (p < .05). Other significant characteristics varied by size of congregation and type of program (HIV vs. other health).

CONCLUSION

Organizations interested in partnering with congregations to promote health or prevent HIV should consider congregational size as well as other factors that predict involvement. Results of this study can inform policy interventions to increase the capacity of religious congregations to address HIV and health.

Reliability and validity of the Turkish version of the situational self-efficacy scale for fruit and vegetable consumption in adolescents

PURPOSE

The purpose of this research was to examine the psychometric properties of the Turkish version of the situational self-efficacy scale for vegetable and fruit consumption in adolescents.

DESIGN

This was a methodological study.

SETTING

The study was conducted in four public secondary schools in Istanbul, Turkey.

SUBJECTS

Subjects were 1586 adolescents.

MEASURES

Content and construct validity were assessed to test the validity of the scale. The reliability was assessed in terms of internal consistency and test-retest reliability.

ANALYSIS

For confirmatory factor analysis, χ(2) statistics plus other fit indices were used, including the goodness-of-fit index, the adjusted goodness-of-fit index, the nonnormed fit index, the comparative fit index, the standardized root mean residual, and the root mean square error of approximation. Pearson's correlation was used for test-retest reliability and item total correlation. The internal consistency was assessed by using Cronbach α.

RESULTS

Confirmatory factor analysis strongly supported the three-component structure representing positive social situations (α = .81), negative effect situations (α = .93), and difficult situations (α = .78). Psychometric analyses of the Turkish version of the situational self-efficacy scale indicate high reliability and good content and construct validity.

CONCLUSION

Researchers and health professionals will find it useful to employ the Turkish situational self-efficacy scale in evaluating situational self-efficacy for fruit and vegetable consumption in Turkish adolescents.

Effect of a park-based after-school program on participant obesity-related health outcomes

PURPOSE

The objective of this study was to examine the effect of a structured after-school program housed in a large county parks system on participant health and wellness outcomes.

DESIGN

Longitudinal cohort study over one school year (fall 2011-spring 2012).

SETTING

A total of 23 county parks in Florida.

SUBJECTS

Children ages 5 to 16 (N = 349, 55% non-Hispanic black, 40% Hispanic, mean age 8.9 years).

INTERVENTION

An after-school program called Fit-2-Play that integrates daily standardized physical activity and health and wellness education components.

MEASURES

Preintervention (August/September 2011) and postintervention (May/June 2012) anthropometric, systolic/diastolic blood pressure, fitness, and health and wellness knowledge measurements were collected.

ANALYSIS

Comparison of pre-post outcome measure means were assessed via general linear mixed models for normal-weight (body mass index [BMI] <85th percentile for age and sex) and overweight/obese (BMI ≥85th percentile for age and sex) participants.

RESULTS

The overweight/obese group significantly decreased their mean (1) BMI z score (2.0 to 1.8, p < .01) and (2) subscapular skinfold measurements (19.4 to 17.5 mm, p < .01) and increased (1) mean laps on the Progressive Aerobic Cardiovascular Endurance Run test (10.8 to 12.5, p = .04) and (2) percentage with normal systolic blood pressure (58.1% to 71.0%, p = .03) from pretest to posttest. On average, participants significantly improved their health and wellness knowledge over the school year (p < .01). Normal-weight participants maintained healthy BMI ranges and significantly increased fitness levels.

CONCLUSION

Findings suggest that the Fit-2-Play after-school programs can be a significant resource for combating childhood obesity and instilling positive physical health in children, particularly among ethnic and socioeconomically diverse communities.

Nonresident African-American fathers' influence on sons' exercise intentions in the fathers and sons program

PURPOSE

To test the effects of a family-centered intervention for enhancing intentions to exercise among African-American boys with nonresident fathers.

DESIGN

Quasi-experimental, intervention study.

SETTING

Two Midwestern cities.

SUBJECTS

A total of 287 nonresident African-American fathers and their 8- to 12-year-old sons (n = 158 intervention dyads; n = 129 comparison dyads).

INTERVENTION

The Fathers and Sons Program is a 15-session family-based intervention focused on promoting the health of African-American boys by enhancing the parenting attitudes and behaviors of their nonresident fathers and positively influencing parent-child interactions.

MEASURES

Demographic information and intervention outcomes were assessed at baseline and follow-up via self-report.

ANALYSIS

Descriptive statistics, logistic regression, and structural equation modeling.

RESULTS

The intervention was successful in improving the exercise intentions of boys (B = .246; p = .005; B = .210; p = .012). The effect was not direct; increasing contact between fathers and sons (B = .154; p = .001), enhancing the quality of their relationship (B = .366; p < .001), and improving fathers' own intentions to exercise (B = .265; p = .001) were mediating factors.

CONCLUSION

Interventions aimed at improving exercise intentions among African-American boys with nonresident fathers should focus on relational factors.

Sex moderates associations between perceptions of the physical and social environments and physical activity in youth

PURPOSE

To determine if the sex of the child moderates the relationships between perceptions of the physical/social environments and moderate to vigorous physical activity (MVPA) in youth.

DESIGN

Cross-sectional.

SETTING

North Carolina.

SUBJECTS

A final sample of 711 children, 8 to 17 years of age, was available for analysis.

MEASURES

Self-reported presence of environmental factors previously identified to be associated with physical activity in youth was collected via survey. Daily MVPA was assessed via accelerometry for a minimum of 4 days.

ANALYSIS

Multilevel linear regression models were employed, adjusted for clustering at the county and individual level. MVPA was first regressed onto sex and environmental perception items while controlling for grade and race. The interaction term between sex and environmental perception was then added to the model.

RESULTS

A significant positive association was observed in the first models between MVPA and two items related to parent permission to (1) walk and (2) ride a bike in the neighborhood. These effects were fully moderated by sex, with males indicating "yes" on these items exhibiting 6.87 and 5.21 more minutes of MVPA (respectively) than males indicating "no."

CONCLUSION

Environmental perceptions appear to be related to MVPA, but this relationship is present only in males. Future research should be conducted to identify modifiable social and physical characteristics that are associated with MVPA in females.

Associations between childhood obesity and the availability of food outlets in the local environment: a retrospective cross-sectional study

PURPOSE

Examine whether individual-level childhood obesity is related to residential availability of fast food and healthy food outlets.

DESIGN

Retrospective cross-sectional study.

SETTING

Perth, Western Australia.

SUBJECTS

A total of 1850 children aged 5 to 15 years in 2005-2010 who participated in the Western Australian Health and Wellbeing Surveillance System survey.

MEASURES

Geographical Information Systems were used to calculate a range of measures of fast food and healthy food outlet access and availability. For example, distance to nearest and access and density measures within 800 m and 3 km of each child's residence were all tested.

ANALYSIS

Multivariate logistic regression analysis, controlling for individual-level sociodemographic factors and lifestyle behaviors.

RESULTS

An increasing number of healthy food outlets within 800 m of a child's home was associated with a significantly reduced risk of being overweight/obese in all models tested. After controlling for age, physical activity, time spent sedentary, weekly takeaway consumption, area disadvantage, and count of fast food outlets, each additional healthy food outlet within 800 m was associated with a 20% decrease in the likelihood of a child being overweight or obese (odds ratio: .800, 95% confidence intervals: .686-.933).

CONCLUSION

The local food environment around children's homes has an independent effect on child weight status. These findings highlight the importance of the built environment as a potential contributor towards child health, which should be considered when developing community health promotion programs.