Psychosocial correlates of sun-protective practices of preschool staff toward their students.

The skin cancer rate in the US has been increasing faster than that for other cancers. Most skin cancers are related to sun exposure and the majority of exposure occurs before adulthood. Thus, children are an important target group to study and preschools can be useful avenues for delivering sun-protection messages. The current study examines the behaviors of preschool staff in protecting students from sun exposure and investigates factors related to sun-protective practice. Preschool staff (n = 245) were surveyed about their sun-protective practices toward students as the cross-sectional baseline measurement for a larger project. The primary aim of this study was to investigate correlates of staff's sun-protective behavior toward students. A theoretical model of psychosocial constructs that combined components of the Theory of Planned Behavior and Social Cognitive Theory was evaluated using structural equation modeling. Self-efficacy and perceived norms were the strongest correlates of behavior. A hypothesized link between expectancy and behavior was not supported. The roles of self-efficacy and perceived norms in the preschool context are discussed as they relate to staffs behavior.

Effects of the CATCH physical education intervention: teacher type and lesson location.

BACKGROUND: Substantial differences exist in how and where physical education (PE) is conducted in elementary schools throughout the United States. Few effectiveness studies of large-scale interventions to improve PE have been reported. DESIGN: Multicenter randomized trial. SETTING/ PARTICIPANTS: The Child and Adolescent Trial for Cardiovascular Health (CATCH) was implemented in PE classes in 96 schools (56 intervention, 40 control) in four study centers: California, Louisiana, Minnesota, and Texas. INTERVENTION: The 2.5-year PE intervention consisted of professional development sessions, curricula, and follow-up consultations. MAIN OUTCOME MEASURES: Intervention effects on student physical activity and lesson context in PE were examined by teacher type (PE specialists and classroom teachers) and lesson location (indoors and outdoors). RESULTS: Differential effects by teacher type and lesson location were evidenced for both physical activity and lesson context. Observations of 2016 lessons showed that intervention schools provided more moderate-to-vigorous physical activity (p=0.002) and vigorous physical activity (p=0.02) than controls. Classroom teachers improved physical activity relatively more than PE specialists, but PE specialists still provided longer lessons and more physical activity. Classroom teachers increased lesson length (p=0.02) and time for physical fitness (p=0.03). CONCLUSIONS: The intervention improved PE of both specialists' and classroom teachers' lessons. States and districts should ensure that the most qualified staff teaches PE. Interventions need to be tailored to meet local needs and conditions, including teacher type and location of lessons.

Schoolwide effects of a multicomponent HIV, STD, and pregnancy prevention program for high school students.

Few studies have tested schoolwide interventions to reduce sexual risk behavior, and none have demonstrated significant schoolwide effects. This study evaluates the schoolwide effects of Safer Choices, a multicomponent, behavioral theory-based HIV, STD, and pregnancy prevention program, on risk behavior, school climate, and psychosocial variables. Twenty urban high schools were randomized, and cross-sectional samples of classes were surveyed at baseline, the end of intervention (19 months after baseline), and 31 months afterbaseline. At 19 months, the program had a positive effect on the frequency of sex without a condom. At 31 months, students in Safer Choices schools reported having sexual intercourse without a condom with fewer partners. The program positively affected psychosocial variables and school climate for HIV/STD and pregnancy prevention. The program did not influence the prevalence of recent sexual intercourse. Schoolwide changes in condomuse demonstrated that aschool-based program can reduce the sexual risk behavior of adolescents.

Health care professionals' skills, beliefs, and expectations about screening for domestic violence in a border community.

This article describes domestic violence education of health professionals and determines association between screening behavior and preparedness, outcome expectations, and beliefs about how and when to screen. A survey was mailed to all primary care physicians, dentists, and nurse practitioners in El Paso, Texas (n = 561). Return rate was 34.4%. Using linear regression, differences (p < 0.05) were found between dentists and others in percentage of patients screened, education, preparedness, and beliefs. Education had a positive association (p < 0.001) with preparedness, beliefs about when to screen, and outcome expectations, and a negative association with beliefs about how to screen. Preparedness, beliefs, and realistic outcome expectations had a positive association (p < 0.02) with percentage of female patients screened. Education about domestic violence is important in increasing preparedness and influencing beliefs about when to screen and what outcomes can be expected. Educational programs should include not only information, but also skills training to increase perceptions of preparedness.

Impact of a computer-assisted education program on factors related to asthma self-management behavior.

OBJECTIVE: To evaluate Watch, Discover, Think and Act (WDTA), a theory-based application of CD-ROM educational technology for pediatric asthma self-management education. DESIGN: A prospective pretest posttest randomized intervention trial was used to assess the motivational appeal of the computer-assisted instructional program and evaluate the impact of the program in eliciting change in knowledge, self-efficacy, and attributions of children with asthma. Subjects were recruited from large urban asthma clinics, community clinics, and schools. Seventy-six children 9 to 13 years old were recruited for the evaluation. RESULTS: Repeated-measures analysis of covariance showed that knowledge scores increased significantly for both groups, but no between-group differences were found (P: = 0.55); children using the program scored significantly higher (P: < 0.01) on questions about steps of self-regulation, prevention strategies, and treatment strategies. These children also demonstrated greater self-efficacy (P: < 0.05) and more efficacy building attribution classification of asthma self-management behaviors (P: < 0.05) than those children who did not use the program. CONCLUSION: The WDTA is an intrinsically motivating educational program that has the ability to effect determinants of asthma self-management behavior in 9- to 13-year-old children with asthma. This, coupled with its reported effectiveness in enhancing patient outcomes in clinical settings, indicates that this program has application in pediatric asthma education.

Safer choices: reducing teen pregnancy, HIV, and STDs.

OBJECTIVES: This study evaluated the long-term effectiveness of Safer Choices, a theory-based, multi-component educational program designed to reduce sexual risk behaviors and increase protective behaviors in preventing HIV, other STDs, and pregnancy among high school students. METHODS: The study used a randomized controlled trial involving 20 high schools in California and Texas. A cohort of 3869 ninth-grade students was tracked for 31 months from fall semester 1993 (baseline) to spring semester 1996 (31-month follow-up). Data were collected using self-report surveys administered by trained data collectors. Response rate at 31-month follow-up was 79%. RESULTS: Safer Choices had its greatest effect on measures involving condom use. The program reduced the frequency of intercourse without a condom during the three months prior to the survey, reduced the number of sexual partners with whom students had intercourse without a condom, and increased use of condoms and other protection against pregnancy at last intercourse. Safer Choices also improved 7 of 13 psychosocial variables, many related to condom use, but did not have a significant effect upon rates of sexual initiation. CONCLUSIONS: The Safer Choices program was effective in reducing important risk behaviors for HIV, other STDs, and pregnancy and in enhancing most psychosocial determinants of such behavior.

Dissemination and adoption of the Child and Adolescent Trial for Cardiovascular Health (CATCH): a case study in Texas.

The total impact of a health promotion program can be measured by the efficacy of the intervention multiplied by the extent of its implementation across the target population. The Child and Adolescent Trial for Cardiovascular Health (CATCH) was a school-based health promotion project designed to decrease fat, saturated fat, and sodium in children's diets, increase physical activity, and prevent tobacco use. This article describes the dissemination of CATCH in Texas, including the theoretical framework, strategies used, and lessons learned. To date (Fall 2000), CATCH materials have been adopted by more than 728 elementary schools in Texas.

Multilevel Models and Unbiased Tests for Group Based Interventions: Examples from the Safer Choices Study.

For many large-scale behavioral interventions, random assignment to intervention condition occurs at the group level. Data analytic models that ignore potential non-independence of observations provide inefficient parameter estimates and often produce biased test statistics. For studies in which individuals are randomized by groups to treatment condition, multilevel models (MLMs) provide a flexible approach to statistically evaluating program effects. This article presents an explanation of the need for MLM's for such nested designs and uses data from the Safer Choices study to illustrate the application of MLMs for both continuous and dichotomous outcomes. When designing studies, researchers who are considering group-randomized interventions should also consider the features of the multilevel analytic models they might employ.

Impact of HIV-positive speakers in a multicomponent, school-based HIV/STD prevention program for inner-city adolescents.

Qualitative and quantitative data from Safer Choices, a school-based multicomponent HIV prevention program, were examined to determine the impact of HIV-positive speakers on inner-city adolescents' HIV risk perception and empathy for people with HIV or AIDS. Inductive analyses were used to assess student reactions to speakers. Multilevel regression modeling techniques were used to analyze student survey data (n = 1,491) to determine the effect of speakers alone, as well as in combination with the multicomponent intervention, and a knowledge-based curriculum (comparison condition). Results showed that speakers were highly popular with students and teachers, and had a positive short-term impact on students' attitudes. Although not statistically significant, the combination of intervention and speakers had the greatest impact on outcome variables. Integrating HIV-positive speakers into multicomponent programs may have a positive impact on inner-city youth. Utilizing speakers without other educational components may have minimal effects. Strategies for training and utilizing HIV-positive speakers in school settings are included.

Prevalence of marked overweight and obesity in a multiethnic pediatric population: findings from the Child and Adolescent Trial for Cardiovascular Health (CATCH) study.

OBJECTIVE: Determine the prevalence of marked overweight and obesity among children in the Child and Adolescent Trial for Cardiovascular Health (CATCH), identify high risk groups, and compare findings to other recent studies. DESIGN: Cohort study. SUBJECTS/SETTING: Five thousand one hundred-six school children who were participants in CATCH at baseline (age approximately 9 years) during 1991 and 4,019 of those children who had follow-up data from 1994 (age approximately 1 years) available. METHODS: Body mass index (BMI), triceps and subscapular skinfolds, subscapular to triceps skinfold (S/T) ratio, and an estimate of body fat distribution from skinfolds was calculated. Findings were compared to population-based reference data from the First National Health and Nutrition Examination Survey, 1971 to 1973 (NHANES I), to data from the Bogalusa Heart Study, and to data from the Third National Health and Nutrition Examination Survey, 1988 to 1994 (NHANES III). RESULTS: Children in CATCH were markedly heavier and fatter than the NHANES I population and more comparable to the NHANES III population, especially those in the upper percentiles. The prevalence of obesity based on BMI and triceps skinfolds >95th percentile among CATCH children was higher in boys than in girls at both baseline (boys 9.1%, girls 8.6%) and follow-up (boys 11.7%, girls 7.2%). It was higher among African-Americans and Hispanics than whites for both sexes. S/T ratios did not differ appreciably from those observed in the NHANES I reference population, suggesting that body fat distribution was more stable over time than BMI and skinfolds. APPLICATIONS: Our findings support other recent reports that American children, especially African-American and Hispanic children, are becoming heavier and fatter. Preventive measures are warranted, especially for high-risk youth.

Watch, Discover, Think, and Act: a model for patient education program development.

In this report we describe the development of the Watch, Discover, Think and Act asthma self-management computer program for inner-city children with asthma. The intervention focused on teaching two categories of behaviors--asthma specific behaviors such as taking preventive medication and self-regulatory processes such as monitoring symptoms and solving asthma problems. These asthma self-management behaviors were then linked with empirical and theoretical determinants such as skills and self-efficacy. We then further used behavioral science theory to develop methods such as role modeling and skill training linked to the determinants. We matched these theoretical methods to practical strategies within the computer simulation and created a culturally competent program for inner-city minority youth. Finally, we planned a program evaluation that linked program impact and outcomes to the theoretical assumptions on which the intervention was based.

Watch, Discover, Think, and Act: evaluation of computer-assisted instruction to improve asthma self-management in inner-city children.

An interactive multimedia computer game to enhance self-management skills and thereby improve asthma outcomes in inner city children with asthma was evaluated. Subjects aged 6-17 were recruited from four pediatric practices and randomly assigned to the computer intervention condition or to the usual-care comparison. The main character in the game could match the subject on gender and ethnicity. Characteristics of the protagonist's asthma were tailored to be like those of the subject. Subjects played the computer game as part of regular asthma visits. Time between pre- and post-test varied from 4 to 15.6 months (mean, 7.6 months). Analysis of covariance, with pre-test scores, age, and asthma severity as covariates, found that the intervention was associated with fewer hospitalizations, better symptom scores, increased functional status, greater knowledge of asthma management, and better child self-management behavior for those in the intervention condition. Interactions with covariates were found and discussed in terms of variable efficacy of the intervention.

Sun Protection is Fun! A skin cancer prevention program for preschools.

Children and their caregivers are prime candidates for intervention to curb the rising incidence of skin cancer in the United States. Preschools provide a unique opportunity to influence the sun protection practices of parents and teachers on behalf of young children. Sun Protection is Fun!, a comprehensive skin cancer prevention program developed by The University of Texas M. D. Anderson Cancer Center in collaboration with The University of Texas-Houston Health Science Center School of Public Health, was introduced to preschools in the greater Houston area. The program's intervention methods are grounded in Social Cognitive Theory and emphasize symbolic modeling, vicarious learning, enactive mastery experiences, and persuasion. Program components include a curriculum and teacher's guide, videos, newsletters, handbooks, staff development, group meetings designed to encourage schoolwide changes to support the program, and sunscreen. The intervention map, including objectives for program development, implementation, and evaluation, is discussed.

Effectiveness of a social influence approach and boosters to smoking prevention.

This paper presents the short-term and long-term results of a randomized smoking prevention trial. The purpose was to evaluate two smoking prevention programs, a social influence (SI) program and a SI program with an additional decision-making component (SI(DM)). Moreover, the contribution of boosters was assessed as well. Fifty-two schools were randomly assigned to the SI program, the SI(DM) program or a control group. Half of the treatment schools were randomly assigned to the booster condition; the other half did not receive boosters. Both programs consisted of five lessons, each lasting 45 min, and were given in weekly sessions in grades 8 and 9 of high schools in the Netherlands. The most successful program was the SI program with boosters which resulted in a significantly lower increase in smoking rates (5.6 and 9.7%, respectively) compared to the control group (12.6 and 14.9%, respectively) at both 12 and 18 months follow-up. The results suggest that boosters can be an effective tool for maintaining or increasing the effectiveness of smoking prevention programs. It is recommended that the SI program with the booster be implemented at the national level, since this intervention showed the greatest behavioral effects.

Psychosocial predictors of delay of first sexual intercourse by adolescents.

This investigation predicted adolescents' delay of intercourse onset from attitudes, social norms, and self-efficacy about refraining from sexual intercourse. Age, gender, ethnicity, and parental education were also examined as predictors and moderators of the relationships among the 3 psychosocial determinants and onset. The participants (N = 827), part of a cohort initially surveyed in the 9th grade, reported at baseline that they had never engaged in intercourse. The multivariable proportional hazards regression model suggested that adolescents with more positive attitudinal and normative beliefs, as well as those with a parent who graduated from college, were less likely to engage in intercourse in the follow-up period (up to approximately 2 years). Interventions that include an objective to delay onset may benefit from addressing psychosocial determinants, especially attitudes and norms about sexual intercourse.

PIP: This study predicted adolescent's delay of intercourse onset from attitudes, social norms, and self-efficacy about refraining from sexual intercourse. Age, gender, ethnicity, and parental education were also examined as predictors and moderators of the relationships among the three psychosocial determinants and onset. The longitudinal data for the study were obtained from 827 participants in the US who were part of a cohort initially surveyed in the 9th grade. These participants reported at baseline that they had never engaged in intercourse. Utilizing the multivariable proportional hazards regression model, findings suggested that adolescents with more positive attitudinal and normative beliefs were less likely to engage in intercourse in the follow-up period (up to approximately 2 years). This was also the case for those students with a parent who graduated from college. Attitudes and norms were the most robust predictors of intercourse. In addition, a relatively modest increase in either scale was predictive of a 30% reduction in the onset of future intercourse in the most conservative analytic model. Interventions that include an objective to delay onset may benefit from addressing psychosocial determinants, especially attitudes and norms about sexual intercourse.

Padres Trabajando por la Paz: a randomized trial of a parent education intervention to prevent violence among middle school children.

This paper reports the results of a randomized trial to test the effectiveness of a theoretically derived intervention designed to increase parental monitoring among Hispanic parents of middle school students. Role model story newsletters developed through the process of Intervention Mapping were mailed to half of a subsample of parents whose children participated in Students for Peace, a comprehensive violence prevention program. The results indicated that parents in the experimental condition (N = 38) who had lower social norms for monitoring at baseline reported higher norms after the intervention than the parents in the control condition (N = 39) (P = 0.009). Children of parents in the experimental group reported slightly higher levels of monitoring at follow-up across baseline values, whereas control children who reported moderate to high levels of monitoring at pre-test reported lower levels at follow-up (P = 0.04). These newsletters are a population-based strategy for intervention with parents that show some promise for comprehensive school-based interventions for youth.

Validity of scales measuring the psychosocial determinants of HIV/STD-related risk behavior in adolescents.

We examined the content, construct and concurrent validity of scales to assess beliefs and self-efficacy related to adolescents' sexual risk behavior. We addressed content validity in the scale development process by drawing on literature and theory, and by pre-testing items with focus groups. We used confirmatory factor analysis of two models, an intercourse involvement model and a condom use model, to assess construct validity. The final intercourse involvement model included three scales: norms about sexual intercourse, attitudes about sexual intercourse and self-efficacy in refusing sex. The final condom use model included five scales: norms about condoms, attitudes about condom use, self-efficacy in communicating about condoms, self-efficacy in buying/using condoms and barriers to condom use. After two alterations to the models, the chi 2 and other indices indicated that the data fit the models well. Supporting the concurrent validity of the scales, high school students who had never had sexual intercourse had more negative attitudes toward sexual intercourse among teenagers, perceived norms toward sexual intercourse among teenagers to be more negative and expressed greater self-efficacy in refusing sex than did those who had experienced sexual intercourse. Consistent condom users had more positive attitudes and norms about condoms, had higher self-efficacy in communicating about and buying/using condoms, and perceived fewer barriers to condom purchase and use than did inconsistent condom users.

Three-year maintenance of improved diet and physical activity: the CATCH cohort. Child and Adolescent Trial for Cardiovascular Health.

OBJECTIVE: To assess differences through grade 8 in diet, physical activity, and related health indicators of students who participated in the Child and Adolescent Trial for Cardiovascular Health (CATCH) school and family intervention from grades 3 through 5. DESIGN: Follow-up of the 4-center, randomized, controlled field trial with 56 intervention and 40 control elementary schools. PARTICIPANTS: We studied 3714 (73%) of the initial CATCH cohort of 5106 students from ethnically diverse backgrounds in California, Louisiana, Minnesota, and Texas at grades 6, 7, and 8. RESULTS: Self-reported daily energy intake from fat at baseline was virtually identical in the control (32.7%) and intervention (32.6%) groups. At grade 5, the intake for controls remained at 32.2%, while the intake for the intervention group declined to 30.3% (P<.001). At grade 8, the between-group differential was maintained (31.6% vs 30.6%, P = .01). Intervention students maintained significantly higher self-reported daily vigorous activity than control students (P = .001), although the difference declined from 13.6 minutes in grade 5 to 11.2, 10.8, and 8.8 minutes in grades 6, 7, and 8, respectively. Significant differences in favor of the intervention students also persisted at grade 8 for dietary knowledge and dietary intentions, but not for social support for physical activity. No impact on smoking behavior or stages of contemplating smoking was detected at grade 8. No significant differences were noted among physiologic indicators of body mass index, blood pressure, or serum lipid and cholesterol levels. CONCLUSION: The original CATCH results demonstrated that school-level interventions could modify school lunch and school physical education programs as well as influence student behaviors. This 3-year follow-up without further intervention suggests that the behavioral changes initiated during the elementary school years persisted to early adolescence for self-reported dietary and physical activity behaviors.

Short-term impact of safer choices: a multicomponent, school-based HIV, other STD, and pregnancy prevention program.

This study evaluated the effectiveness of the first year of Safer Choices, a theoretically based, multicomponent HIV, STD, and pregnancy prevention program for high school youth. The study featured a randomized trial involving 20 schools in California and Texas, with a cohort of 3,869 ninth-grade students. Students who completed both the baseline and the first follow-up survey approximately seven months later were included in the analysis (n = 3,677). Safer Choices enhanced 9 of 13 psychosocial variables including knowledge, self efficacy for condom use, normative beliefs and attitudes regarding condom use, perceived barriers to condom use, risk perceptions, and parent-child communication. Safer Choices also reduced selected risk behaviors. Specifically, Safer Choices reduced the frequency of intercourse without a condom in the three months prior to the survey, increased use of condoms at last intercourse, and increased use of selected contraceptives at last intercourse.

PIP: Safer Choices is a theoretically based, multicomponent HIV, sexually transmitted disease (STD), and pregnancy prevention program for high school youths. This study assessed the effectiveness of this program 1 year after its implementation. The study conducted a randomized trial involving 20 schools (10 from California and 10 from Texas), with a cohort of 3869 ninth-grade students. Five schools in each state were randomly assigned to the Safer Choices program while the other five were assigned to a comparison program. Baseline and follow up data were then collected using student self-report surveys. 3677 students (95%) in the final cohort were surveyed. The results showed significant differences, which favored the intervention schools. Safer Choices enhanced 9 of 13 psychosocial variables, including knowledge, self efficacy for condom use, normative beliefs and attitudes regarding condom use, perceived barriers to condom use, risk perceptions, and parent-child communication. Furthermore, Safer Choices reduced selected risk behaviors such as the frequency of intercourse without using condoms in the three months prior to the survey; increased use of condoms at last intercourse; and increased use of other contraceptives at last intercourse. Overall, the first year of Safer Choices was successful in changing most of the behavioral determinants under the study and in enhancing protective behaviors.

Intervention mapping: a process for developing theory- and evidence-based health education programs.

The practice of health education involves three major program-planning activities: needs assessment, program development, and evaluation. Over the past 20 years, significant enhancements have been made to the conceptual base and practice of health education. Models that outline explicit procedures and detailed conceptualization of community assessment and evaluation have been developed. Other advancements include the application of theory to health education and promotion program development and implementation. However, there remains a need for more explicit specification of the processes by which one uses theory and empirical findings to develop interventions. This article presents the origins, purpose, and description of Intervention Mapping, a framework for health education intervention development. Intervention Mapping is composed of five steps: (1) creating a matrix of proximal program objectives, (2) selecting theory-based intervention methods and practical strategies, (3) designing and organizing a program, (4) specifying adoption and implementation plans, and (5) generating program evaluation plans.