Health promotion practice and the road ahead: addressing enduring gaps and encouraging greater practice-to-research translation.

A decade ago, Lancaster and Roe described four critical gaps (i.e., communications, accessibility, credibility, and expectations) between research and practice in health education and health promotion that formed the framework for this department. Despite considerable attention and some progress, these gaps persist and are barriers to interaction and translation between health promotion and health education research and practice. Looking to the next several years as the new Associate Editors for this department, we renew the department's commitment toward addressing these enduring gaps around which we frame new questions and invite continued dialogue.

Lunchtime practices and problem behaviors among multiethnic urban youth.

Research has begun to show associations between adolescents' mealtime practices and their engagement in problem behaviors. Few studies have addressed this longitudinally and/or examined lunchtime practices during the school day. This study tests for associations between urban multiethnic middle school students' (N = 1498) lunchtime practices in the sixth grade and their engagement in problem behaviors by eighth grade. Positive associations were found between not eating lunch at school in the sixth grade and increased drug use and delinquency by eighth grade. Eating lunch outside of school was found to be significantly associated with smoking and marijuana use only. Gender differences in associations between lunchtime practices and problem behaviors were suggested. Implications for school policy and prevention efforts are discussed.

Measurement of perceived school climate for active travel in children.

OBJECTIVES: To describe the development of an original scale that measures perceived school climate for active travel in fourth- and fifth-grade girls and boys. METHODS: The data were analyzed using confirmatory factor analysis (CFA) to provide evidence of factorial validity, factorial invariance, and construct validity. RESULTS: The CFA supported the fit of a 3-factor (encouragement, praise, and importance) correlated model for the school climate for active travel measure. This hierarchical model was invariant between sex and across a 7-month time period, and initial evidence for construct validity was provided. CONCLUSIONS: School climate for active travel is a measurable construct, and preliminary evidence suggests relationships with more support for active travel from friends and family.

Girls' perception of physical environmental factors and transportation: reliability and association with physical activity and active transport to school.

BACKGROUND: Preliminary evidence suggests that the physical environment and transportation are associated with youth physical activity levels. Only a few studies have examined the association of physical environmental factors on walking and bicycling to school. Therefore, the purpose of this study was (1) to examine the test-retest reliability of a survey designed for youth to assess perceptions of physical environmental factors (e.g. safety, aesthetics, facilities near the home) and transportation, and (2) to describe the associations of these perceptions with both physical activity and active transport to school. METHODS: Test and retest surveys, administered a median of 12 days later, were conducted with 480 sixth- and eighth-grade girls in or near six U.S. communities. The instrument consisted of 24 questions on safety and aesthetics of the perceived environment and transportation and related facilities. Additionally, girls were asked if they were aware of 14 different recreational facilities offering structured and unstructured activities, and if so, whether they would visit these facilities and the ease with which they could access them. Test-retest reliability was determined using kappa coefficients, overall and separately by grade. Associations with physical activity and active transport to school were examined using mixed model logistic regression (n = 610), adjusting for grade, race/ethnicity, and site. RESULTS: Item-specific reliabilities for questions assessing perceived safety and aesthetics of the neighborhood ranged from 0.31 to 0.52. Reliabilities of items assessing awareness of and interest in going to the 14 recreational facilities ranged from 0.47 to 0.64. Reliabilities of items assessing transportation ranged from 0.34 to 0.58. Some items on girls' perceptions of perceived safety, aesthetics of the environment, facilities, and transportation were important correlates of physical activity and, in some cases, active transport to school. CONCLUSION: This study provides some psychometric support for the use of the questionnaire on physical environmental factors and transportation for studying physical activity and active transport to school among adolescent girls. Further work can continue to improve reliability of these self-report items and examine their association of these factors with objectively measured physical activity.

A typology of middle school girls: audience segmentation related to physical activity.

The Trial of Activity for Adolescent Girls (TAAG) combines social ecological and social marketing approaches to promote girls' participation in physical activity programs implemented at 18 middle schools throughout the United States. Key to the TAAG approach is targeting materials to a variety of audience segments. TAAG segments are individuals who share one or more common characteristic that is expected to correlate with physical activity. Thirteen focus groups with seventh and eighth grade girls were conducted to identify and characterize segments. Potential messages and channels of communication were discussed for each segment. Based on participant responses, six primary segments were identified: athletic, preppy, quiet, rebel, smart, and tough. The focus group information was used to develop targeted promotional tools to appeal to a diversity of girls. Using audience segmentation for targeting persuasive communication is potentially useful for intervention programs but may be sensitive; therefore, ethical issues must be critically examined.

Social competence among urban minority youth entering middle school: relationships with alcohol use and antisocial behaviors.

Social competence is increasingly multidimensional during adolescence as young people encounter a variety of new social situations and can respond with a broad range of appropriate behaviors. However, research on social competence has focused more on children than adolescents. The present study examined the relationships between components of social competence (e.g., assertiveness and social confidence) and adolescent problem behaviors including alcohol use and antisocial behaviors (e.g., aggression and delinquency). A survey was administered to 6th grade students (N=2411) entering 20 New York City public and parochial middle schools and again a year later in the 7th grade. Findings indicated that verbal aggression was reported most frequently among students (93%), followed by physical aggression (69%), delinquent behaviors (53%), and alcohol use (16%). Structural equation modeling indicated that while assertiveness was protective in terms of adolescent problem behaviors, social confidence--the level of confidence that students had in initiating social interactions including dating--was associated with greater alcohol use and antisocial behavior both cross-sectionally and longitudinally. Additional analyses revealed that social confidence related to the initiation of dating (e.g., asking someone out for a date or having a conversation with a member of the opposite sex) was most strongly correlated with each problem behavior outcome. These findings suggest that social confidence, particularly as it relates to precocious dating behavior during early adolescence, is a risk factor for the early initiation of alcohol use and antisocial behavior.

Self-management strategies mediate self-efficacy and physical activity.

BACKGROUND: Self-efficacy theory proposes that girls who have confidence in their capability to be physically active will perceive fewer barriers to physical activity or be less influenced by them, be more likely to pursue perceived benefits of being physically active, and be more likely to enjoy physical activity. Self-efficacy is theorized also to influence physical activity through self-management strategies (e.g., thoughts, goals, plans, and acts) that support physical activity, but this idea has not been empirically tested. METHODS: Confirmatory factor analysis was used to test the factorial validity of a measure of self-management strategies for physical activity. Next, the construct validity of the measure was tested by examining whether self-management strategies mediated the relationship between self-efficacy and self-reported physical activity, independently of several social-cognitive variables (i.e., perceived barriers, outcome expectancy value, and enjoyment), among cross-sectional samples of 6th grade (n=309) and 8th grade (n=296) girls tested between February 14 and March 17, 2002. Data were analyzed in 2004. RESULTS: Consistent with theory, self-efficacy had direct effects on the social-cognitive variables. The primary novel finding is that self-management strategies mediated the association of self-efficacy with physical activity in both samples. CONCLUSIONS: The measure of self-management strategies for physical activity yields valid scores among adolescent girls and warrants experimental study as a mediator of the influence of efficacy beliefs on physical activity.

Predictors of violent behavior in an early adolescent cohort: similarities and differences across genders.

The authors assessed a cohort of 2,335 students from the Minneapolis, Minnesota, area to identify predictors of violent behavior and to determine whether the predictors varied by gender. The sample was 76% White; boys and girls were equally represented. The majority lived with two parents. A measure of violent behavior collected at the end of the eighth-grade year (2000) was entered into Poisson regression against baseline data collected at the beginning of the seventh-grade year (1998). Predictors of violent behavior influencing both boys and girls included depressive symptoms, perceived invulnerability to negative future events, paternal nonauthoritative behavior, and drinking alcohol. Additional predictors of violent behavior specific to girls included both risk and protective factors.

Scale development for perceived school climate for girls' physical activity.

OBJECTIVES: To test an original scale assessing perceived school climate for girls' physical activity in middle school girls. METHODS: Confirmatory factor analysis (CFA) and structural equation modeling (SEM). RESULTS: CFA retained 5 of 14 original items. A model with 2 correlated factors, perceptions about teachers' and boys' behaviors, respectively, fit the data well in both sixth and eighth graders. SEM detected a positive, significant direct association of the teacher factor, but not the boy factor, with girls' self-reported physical activity. CONCLUSIONS: School climate for girls' physical activity is a measurable construct, and preliminary evidence suggests a relationship with physical activity.

Naturally occurring changes in physical activity are inversely related to depressive symptoms during early adolescence.

OBJECTIVE: We examined the relationship between naturally occurring changes in physical activity and depressive symptoms across a 2-year period among adolescent boys and girls. METHODS: Participants (N = 4594) reported their frequency of physical activity outside of school and completed the Center for Epidemiological Studies Depression scale in the Fall of 1998 (beginning of 7th grade; baseline data), Spring of 1999 (end of 7th grade; interim data), and Spring of 2000 (end of 8th grade; follow-up data). RESULTS: Latent growth modeling indicated that a 1 SD unit change in the frequency of leisure-time physical activity was inversely related to a.25 SD unit change in depressive symptoms. This relationship was attenuated but remained statistically significant when simultaneously controlling for the confounding variables of sex, socioeconomic status, smoking, alcohol consumption, and the value participants placed on their health, appearance, and achievement. CONCLUSIONS: Naturally occurring changes in physical activity were negatively related with changes in depressive symptoms. The results encourage randomized controlled trials to experimentally determine whether an increase in physical activity reduces depression risk among adolescent boys and girls.

A schematic for focusing on youth in investigations of community design and physical activity.

This paper provides a first step in addressing special considerations for youth in a relatively new area of physical activity research. After reviewing the urgent need for novel approaches to increasing physical activity, the growing interest in the effects of community design are discussed. Although most discussion on this topic has focused on adults, there are important differences between youth and adults that warrant a special focus on youth and need to be accounted for This article presents a schematic that accounts for how and where youth spend their time, decomposing the day into time spent in travel and time spent at destinations, and identifying portions of those times that are spent engaged in physical activity. By focusing on both spatial and behavioral dimensions of youth time, the schematic may help organize and advance scientific inquiry into the relationships between community design and physical activity specifically for youth.

Are differences in exposure to a multicomponent school-based intervention associated with varying dietary outcomes in adolescents?

Multicomponent interventions are recommended for health behavior change among adolescents. However, it is difficult to disentangle the effects of multiple intervention components. This article reports outcomes associated with varying levels of exposure to a school-based nutrition intervention. Teens Eating for Energy and Nutrition at School (TEENS). Four incremental exposures were possible: (1) control group, (2) school environment interventions only, (3) classroom plus environment interventions, and (4) peer leaders plus classroom plus environment interventions. Pattems suggesting dose response were observed, with peer leaders reporting the largest increases in fruit, vegetable, and lower fat food consumption. Students exposed to classroom plus environment interventions also improved, whereas students exposed only to school environment interventions showed trends toward choosing lower fat foods and declining fruit intake and no change in vegetable intake. Control students' choices remained stable. Future studies may investigate mechanisms for peer leaders' changes, maximizing curriculum effectiveness, and improving environmental interventions.

Assessing intervention effects in a school-based nutrition intervention trial: which analytic model is most powerful?

This article compares four mixed-model analyses valid for group-randomized trials (GRTs) involving a nested cohort design with a single pretest and posttest. This study makes estimates of intraclass correlations (ICCs) available to investigators planning GRTs addressing dietary outcomes. It also provides formulae demonstrating the potential benefits to the standard error of the intervention effect (sigma(delta)) from adjustments for both fixed and time-varying covariates and correlations over time. These estimates will allow other researchers using these variables to plan their studies by estimating a priori detectable differences and sample size requirements for any of the four analytic options. These methods are demonstrated using data from the Teens Eating for Energy and Nutrition at School study. Mixed-model analyses of covariance proved to be the most powerful analysis in that data set. The formulae may be applied to any dependent variable in any GRT given corresponding information for those variables on the parameters that define the formulae.

School-based approaches to affect adolescents' diets: results from the TEENS study.

This article reports on the outcomes of the Teens Eating for Energy and Nutrition at School (TEENS) study, a 2-year intervention study conducted in 16 middle schools with a goal of increasing students' intakes of fruits, vegetables, and lower fat foods. Despite positive interim results for students randomized to intervention schools, the positive effects of the intervention were not seen for the primary outcomes at the end of the 2nd year. Positive effects were seen only for a food choice score (suggesting that the students usually choose lower versus higher fat foods) and not for measures of food intake. Future studies may need to take a step back toward more controlled efficacy studies in working with this age-group. In addition, future work may consider the use of peer leaders, more intensive teacher training, ongoing formative assessment, and the testing of more powerful environmental change intervention strategies.

Assessing the most powerful analysis method for school-based intervention studies with alcohol, tobacco, and other drug outcomes.

This article compares four mixed-model analyses valid for group-randomized trials (GRTs) involving a nested cohort design with a single pretest and a single posttest, the most common design used in GRTs. This study makes estimates of intraclass correlations (ICCs) available to investigators planning GRTs with alcohol, tobacco, and other drug measures as the outcomes of interest. It also provides formulae demonstrating the potential benefits to the standard error of the intervention effect of both adjustments for fixed and time-varying covariates, as well as correlations over time. These estimates will allow other researchers using these variables to plan their studies by performing a priori power analyses for any of four common analytic options.

Associations between perceived family meal environment and parent intake of fruit, vegetables, and fat.

OBJECTIVE: To describe the family mealtime environment and assess associations with adult fruit, vegetable, and fat intake. DESIGN: Telephone survey. PARTICIPANTS: A convenience sample of 277 adults in the Minneapolis/St. Paul area were recruited through 4 schools. The sample was 85% female and 70% married. The mean number of children in the household was 2.6 (range 1 to 9). VARIABLES MEASURED: Adult fruit and vegetable intake, fat intake, and perceptions of the mealtime environment. ANALYSIS: Descriptive and mixed-model linear regression. RESULTS: Participants reported that the television was frequently on during dinner meals and almost one third felt that their family was too busy to eat dinner together. A higher frequency of television viewing during dinner was associated with lower fruit and vegetable consumption and higher fat consumption. Planning meals in advance was associated with higher fruit and vegetable consumption; however, 46% of the adults did not plan meals in advance. Arguments concerning eating behavior during dinner were associated with higher fat consumption. CONCLUSIONS AND IMPLICATIONS: The family meal environment is associated with adult eating patterns and should be considered when designing nutrition messages for families.

Predicting adolescents' intake of fruits and vegetables.

OBJECTIVE: To explore potential predictors of adolescents' fruit and vegetable intake by expanding on current theory and drawing from other adolescent research. DESIGN: This research reports on baseline and interim data from a school-based intervention study. Data were collected through surveys administered to students at the beginning and end of their 7th grade year. SETTING: The students attended 16 public schools in Minnesota. PARTICIPANTS: Data were collected on 3878 students; approximately half were female and 67% were white. All students in the 7th grade cohort were invited to participate in the surveys and over 94% completed both surveys. VARIABLES MEASURED: Our dependent variable, fruit and vegetable intake, was assessed by a validated fruit and vegetable food frequency scale. Predictive factors assessed included parenting style, spirituality/religiosity, depressive symptoms, and other commonly assessed predictors. ANALYSIS: Generalized linear mixed model regression. Omnibus test of association using P <.05 is reported. RESULTS: Subjective norms, barriers, knowledge, usual food choice, parenting style, spirituality/religiosity, and depressive symptoms were statistically significant predictors of intake. The model explained about 31% of the variance in fruit and vegetable consumption. CONCLUSIONS AND IMPLICATIONS: To better understand adolescents' fruit and vegetable intake, we must explore novel predictors. Our results need to be replicated, and more exploratory research in this field is needed.

Prevalence and correlates of depressive symptoms in young adolescents.

OBJECTIVES: To assess prevalence of elevated depressive symptoms in young adolescents and examine associations between symptoms and sociodemographic and behavioral factors. METHODS: Cross-sectional survey data from 3621 seventh grade students from 16 middle schools were analyzed. RESULTS: Elevated depressive symptoms were reported by 40% of girls and 30% of boys. Socioeconomic status, race/ethnicity, and age group were independently associated with depressive symptomatology. For girls, monthly alcohol use, monthly smoking, heavy drinking, and inhalant use were significant correlates. For boys, monthly alcohol use and inhalant use were significant. CONCLUSIONS: Elevated depressive symptomatology was a prevalent problem. Substance use was often associated with depressive symptoms, especially among girls.

Survey development for assessing correlates of young adolescents' eating.

OBJECTIVE: To describe the development and psychometric testing of a survey to assess multiple influences on young adolescents' eating behaviors. METHODS: A 204-item survey was piloted with middle-school students. We incorporated a broad view of determinants of eating behavior in an effort to expand the current field of predictors. RESULTS: The survey was reduced to 147 items and administered to 3,878 students. Internal consistencies were generally >0.70. Test-retest reliabilities were 0.30-0.98, mostly >0.60. CONCLUSIONS: We estimated psychometric properties for a range of measures in a diverse sample. This is important as the increasing demand for outcomes-based research expands the need for psychometrically sound survey measures.

Peer-led, school-based nutrition education for young adolescents: feasibility and process evaluation of the TEENS study.

Peer education has become a popular strategy for health promotion interventions with adolescents, but it has not been used widely in school-based nutrition education. This paper describes and reports on the feasibility of the peer leader component of a school-based nutrition intervention for young adolescents designed to increase fruit and vegetable intakes and lower fat foods. About 1,000 seventh-grade students in eight schools received the nutrition intervention. Of these, 272 were trained as peer leaders to assist the teacher in implementing the activities. Results from a multicomponent process evaluation based on peer leader and classroom student feedback, direct classroom observation, and teacher ratings and interviews are presented. Results show that peer-led nutrition education approaches in schools are feasible and have high acceptability among peer leaders, classroom students, and teachers.