The effect of a communications campaign on middle school students' nutrition and physical activity: results of the HEALTHY study.

The HEALTHY Study was a 3-year school-based intervention designed to change the behaviors of middle school students to reduce their risk for developing type 2 diabetes mellitus. This report examines the relation between exposure to communications campaign materials and behavior change among students in the HEALTHY intervention schools. Using data from campaign tracking logs and student interviews, the authors examined communications campaign implementation and exposure to the communications campaign as well as health behavior change. Campaign tracking documents revealed variability across schools in the quantity of communications materials disseminated. Student interviews confirmed that there was variability in the proportion of students who reported receiving information from the communication campaign elements. Correlations and regression analysis controlling for semester examined the association between campaign exposure and behavior change across schools. There was a significant association between the proportion of students exposed to the campaign and the proportion of students who made changes in health behavior commensurate with study goals. The results suggest that, in the context of a multifaceted school-based health promotion intervention, schools that achieve a higher rate of exposure to communication campaign materials among the students may stimulate greater health behavior change.

Barriers and facilitating factors among lay health workers and primary care providers to promote children's oral health in Chon Buri Province, Thailand.

This study explored the barriers and facilitating factors among lay health workers (LHWs) and primary care providers (PCPs) in implementing a multi-level program to promote children's oral health care in a rural Thai community. Twelve focus groups and 11 in-depth interviews were conducted with LHWs and PCPs who implemented the program from January 2008 to January 2009. The findings showed that the PCPs encountered the constraints of time and human resources, lack of ownership, and problem of coordination with the district hospital. The barriers among LHWs during home visits were related to their assumption of caregiver's knowledge, some conflicting beliefs, and limited counseling skills. The facilitating factors were the training program, caregivers' positive feedback, and available resources such as brochures and toothbrushes. The PCPs identified LHWs as the main facilitators of the program and indicated that policy should be developed for better integrating oral health services in local health Centers. This study provides a better understanding of the barriers and facilitating factors to promote children's oral health in rural Thai communities. While the barriers to integrating oral health activities to primary care are complex, the use of LHWs to promote the children's oral health was feasible and should be supported.

Promoting community practitioners' use of evidence-based approaches to increase breast cancer screening.

Many women do not get mammography screenings at the intervals recommended for early detection and treatment of breast cancer. The Guide to Community Preventive Services (Community Guide) recommends a range of evidence-based strategies to improve mammography rates. However, nurses and others working in community-based settings make only limited use of these strategies. We report on a dissemination intervention that partnered the University of North Carolina with the Susan G. Komen Triangle Affiliate to disseminate Community Guide breast cancer screening strategies to community organizations. The intervention was guided by social marketing and diffusion of innovation theory and was designed to provide evidence and support via Komen's existing relationships with grantee organizations. The present study reports the findings from a formative evaluation of the intervention, which included a content analysis of 46 grant applications pre- and post intervention and focus groups with 20 grant recipients.

Process evaluation results from the HEALTHY physical education intervention.

Process evaluation is an assessment of the implementation of an intervention. A process evaluation component was embedded in the HEALTHY study, a primary prevention trial for Type 2 diabetes implemented over 3 years in 21 middle schools across the United States. The HEALTHY physical education (PE) intervention aimed at maximizing student engagement in moderate-to-vigorous physical activity through delivery of structured lesson plans by PE teachers. Process evaluation data collected via class observations and interventionist interviews assessed fidelity, dose delivered, implementor participation, dose received and barriers. Process evaluation results indicate a high level of fidelity in implementing HEALTHY PE activities and offering 225 min of PE every 10 school days. Concerning dose delivered, students were active for approximately 33 min of class, representing an average of 61% of the class time. Results also indicate that PE teachers were generally engaged in implementing the HEALTHY PE curriculum. Data on dose received showed that students were highly engaged with the PE intervention; however, student misbehavior was the most common barrier observed during classes. Other barriers included teacher disengagement, large classes, limited gym space and poor classroom management. Findings suggest that the PE intervention was generally implemented and received as intended despite several barriers.

The evaluation of a multi-level oral health intervention to improve oral health practices among caregivers of preschool children.

Abstract. This study reports the effects of a pilot multi-level oral health intervention on caregivers' oral health practices and their determinants. Quasi-experimental, pretest-posttest evaluations using a comparison group design were employed to evaluate the effectiveness of a proposed intervention for promoting caregiver oral health behavior. The intervention consisted of three components: home visits by lay health workers (LHWs), enhancing oral health education and services at health centers, and community mobilization. These components were designed to target factors at intrapersonal, interpersonal, organizational and community levels based on a Social Ecological Model (SEM). Four oral health behaviors associated with early childhood caries (infant bottle feeding, tooth brushing, snack consumption and fluoride use), and multi-level determinants were assessed during pre- and post-tests. The one-year intervention demonstrated a positive effect on tooth brushing, using toothpaste, and fluoride supplements, but did not have a significant effect on bottle feeding and snack consumption among children. The intervention also had no effect on dental caries; in fact caries increased in both control and experimental groups. The caregiver knowledge, attitudes, outcome expectations, and self-efficacy towards these behaviors were significantly increased in the experimental group after intervention. Caregivers in the experimental group received greater social support by LHWs and health center staff than those in the control group (p < 0.001). The program had an impact on integrating oral health services at health centers and community participation in children's oral health. These findings confirm multi-level factors influence reported oral health behavior, but not outcomes in terms of caries. Process evaluation is needed to determine actual implementation levels, barriers and suggests for modification of the program in the future to improve outcomes in terms of caries.

Engaging key stakeholders to assess and improve the professional preparation of MPH health educators.

OBJECTIVES: We described the process of engaging key stakeholders in a systematic review of requirements for a master of public health (MPH) degree within the Department of Health Behavior and Health Education, University of North Carolina Gillings School of Global Public Health, and summarized resulting changes. METHODS: A benchmarking study of 11 peer institutions was completed. Key stakeholders (i.e., current students, alumni, faculty, staff, employers, and practicum preceptors) received online or print surveys. A faculty retreat was convened to process results and reach consensus on program revisions. RESULTS: MPH program changes included (1) improved advising and mentoring program, (2) elimination of research and practice track options, (3) increased elective and decreased required credit hours, (4) replacement of master's paper requirement with "deliverables" (written products such as reports, documents, and forms) produced as part of the required "Capstone" course, (5) extended community field experience to 2 semesters and moved it to year 2 of the program, and (6) allowed practica of either 200, 300, or 400 hours. CONCLUSIONS: Engaging key stakeholders in the program review process yielded important changes to the MPH degree program requirements. Others may consider this approach when undertaking curriculum reviews.

Ways of healthy aging: a case study of elderly people in a Northern Thai village.

This ethnographic study was conducted to explore ways of healthy aging and the influence of culture on health-related behaviors in a rural community in Northern Thailand. In-depth interviews, focus group discussions, participant observations and field notes were used to understand the lives of seven healthy Thai older adults aged 75 years and over. Data were collected from March 2007 to February 2008, with ongoing ethnographic analysis involving coding, identifying patterns, generalizing and making reflective notes to elucidate the cultural patterns of behavior. All informants perceived health as interrelated with their life styles, which was, in turn, closely related to their cultural roots, suggesting that culture influences the health of all members of smaller, closely knit communities, including the elderly, by integrating physical, social and spiritual health for older adults and their families.

Formative research in school and community-based health programs and studies: "state of the art" and the TAAG approach.

Formative research uses qualitative and quantitative methods to provide information for researchers to plan intervention programs. Gaps in the formative research literature include how to define goals, implementation plans, and research questions; select methods; analyze data; and develop interventions. The National Heart, Lung, and Blood Institute funded the Trial of Activity for Adolescent Girls (TAAG), a randomized, multicenter field trial, to reduce the decline in physical activity in adolescent girls. The goals of the TAAG formative research are to (a) describe study communities and schools, (b) help design the trial's interventions, (c) develop effective recruitment and retention strategies, and (d) design evaluation instruments. To meet these goals, a variety of methods, including telephone interviews, surveys and checklists, semistructured interviews, and focus group discussions, are employed. The purpose, method of development, and analyses are explained for each method.

Data to action: using formative research to develop intervention programs to increase physical activity in adolescent girls.

Formative research is used to inform intervention development, but the processes of transmitting results to intervention planners and incorporating information into intervention designs are not well documented. The authors describe how formative research results from the Trial of Activity for Adolescent Girls (TAAG) were transferred to planners to guide intervention development. Methods included providing oral and written reports, prioritizing recommendations, and cross-checking recommendations with intervention objectives and implementation strategies. Formative work influenced the intervention in many ways. For example, results indicated that middle schools offered only coeducational physical education and health education classes, so the TAAG intervention was designed to be appropriate for both sexes, and intervention strategies were developed to directly address girls' stated preferences (e.g., enjoyable activities, opportunity to socialize) and barriers (e.g., lack of skills, fear of injury) for physical activity. The challenges of using formative research for intervention development are discussed.

Qualitative comparison of dietary choices and dietary supplement use among older adults with and without a history of colorectal cancer.

OBJECTIVE: To explore colorectal cancer survivors' beliefs about diet, dietary supplements, health, and cancer in relation to beliefs of a similar group without colorectal cancer. DESIGN: In-depth, semistructured, open-ended interviews were used to examine perceptions. PARTICIPANTS: Twenty-two participants (10 colorectal cancer survivors and 12 from a comparison group) from the North Carolina Strategies for Improving Diet, Exercise, and Screening Study. ANALYSIS: Verbatim interview transcripts were coded and analyzed. Comparisons were made between colorectal cancer survivors and the comparison group. RESULTS: Three main themes emerged: the influence of significant life events on dietary change, concerns about contaminants in the food supply, and a lack of physician guidance in dietary supplement selection. CONCLUSION AND IMPLICATIONS: The experience of colorectal cancer is significant and may lead to dietary change among some survivors, but these findings do not suggest that it is necessarily more influential than other life events. Participants sought to control diet (for coping or survival) and also felt that diet cannot be controlled (due to the contamination of the food supply). Although many lacked guidance from physicians about dietary supplements, they were comfortable making their own decisions to self-treat. Enhanced understanding of the themes that guide selection of diet and dietary supplements can provide a context for dietitians in practice and researchers conducting behavioral interventions.

Community-based approach for prevention and control of dengue hemorrhagic fever in Kanchanaburi Province, Thailand.

An action research design was conducted in two villages of Mueang District, Kanchanaburi Province to assess the effectiveness of a community-based approach program. Knowledge, perceived susceptibility, self-efficacy, and regular larval survey behavior were measured for program outputs. Container Index (CI), House Index (HI), and Breteau Index (BI) were used to confirm program outcomes. Key community stakeholders in the experimental village were identified and empowered through active learning in the village. Monthly meetings with the key stakeholders were used to share experiences learned, to reflect on the program outputs and outcomes as well as to plan for the next cycle of program activities. The program was quite successful. Knowledge, perception, self-efficacy, and larval survey practices in the experimental group were significantly higher than before the experiment, and higher than the comparison group. CI, HI, and BI were decreased sharply to better than the national target. Community status as community leaders was the best predictor for larval survey behavior at the first survey. Participating in the study program activities was the best predictor at the end of the program. The results from this study suggest that the dengue hemorrhagic fever (DHF) prevention and control program at the sub-district health level should be more proactive and emphasized at the village level. Monitoring the disease control program outputs and outcomes should be performed regularly during monthly meetings. Finally, local health officers need to be empowered for these matters.

The North Carolina Youth Empowerment Study (NCYES): a participatory research study examining the impact of youth empowerment for tobacco use prevention.

This article describes the North Carolina Youth Empowerment Study (NC YES), a 3-year participatory evaluation of youth programs addressing tobacco use prevention. The study goals of NC YES were to (1) convene an advisory board comprised of lay youths and adults in a participatory research process, (2) document the characteristics of youth programs for tobacco use prevention and control in North Carolina, and (3) track the role of youth involvement in initiating and implementing 100% tobacco-free policies in local school districts. The NC YES Statewide Advisory Board helped guide the evaluation process, reviewed study protocols and data collection instruments, and helped interpret preliminary findings. Both quantitative and qualitative methods(e.g., telephone interviews and written questionnaires) were used to gather data from youth and adult leaders to achieve these aims. Lessons learned about the process of conducting participatory evaluation approaches and summary findings about the role of youths in policy advocacy efforts are presented.

Passage of 100% tobacco-free school policies in 14 North Carolina school districts.

Though comprehensive tobacco-free school policies constitute an important component of state tobacco control efforts, little research exists about their adoption process. In the past two years, efforts occurred in North Carolina to increase the number of school districts adopting 100% tobacco-free school policies. As part of the North Carolina Youth Empowerment Study (NC-YES), researchers developed a school tobacco policy interview guide to conduct interviews with 40 key people (e.g., school board member, principal, etc.) in each of 14 school districts that adopted a 100% tobacco-free school policy by the end of 2001. Results showed seven districts adopted their school policy in the past two years. Seven themes emerged: 1) Catalysts: Local adult and youth "champions" facilitated policy change; 2) Process of Adoption: Most school policies were adopted with an administrator or other adult initiating the change, but youth involvement increased in recent years; 3) Methods of Adoption: Advocates personalized health concerns by focusing on children and role modeling by adults; 4) Political Leadership: Governors of North Carolina, through letters to school districts and a policy summit, played an important role in stimulating policy change; 5) Barriers to Adoption: Concerns expressed before policy adoption, about teacher attrition or inability to enforce the policy, did not occur as feared; 6) Enforcement Issues: A key to policy enforcement involved being consistent, supportive, and firm; and 7) Economics of Tobacco Farming/Manufacturing: Though a local tobacco economy did little to influence policy adoption, districts that adopted policies were not located in counties with heavy tobacco production. Public health advocates may use this information to encourage school districts to adopt 100% tobacco-free school policies.

Health education leadership development: a conceptual model and competency framework.

A National Public Health Education Leadership Institute was developed through collaboration among national health education professional organizations, the Centers for Disease Control and Prevention, and a school of public health. The institute provides health educators in leadership positions throughout the country access to a 15-month integrated and sequential professional leadership development program. This article presents a conceptual model and competency framework for that program. The model contains elements considered critical for design of leadership programs in public health and can be used by both professional development and academic programs to shape their design of leadership curricula.

School factors as barriers to and facilitators of a preventive intervention for pediatric type 2 diabetes.

School-based interventions are essential to prevent pediatric obesity and type 2 diabetes. School environmental factors influence implementation of these interventions. This article examines how school factors acted as barriers to and facilitators of the HEALTHY intervention. The HEALTHY study was a cluster-randomized trial of a multicomponent intervention implemented in 21 schools. Interview data were analyzed to identify barriers and facilitators. Barriers included teacher frustration that intervention activities detracted from tested subjects, student resistance and misbehavior, classroom management problems, communication equipment problems, lack of teacher/staff engagement, high cost and limited availability of nutritious products, inadequate facility space, and large class sizes. Facilitators included teacher/staff engagement, effective classroom management, student engagement, schools with direct control over food service, support from school leaders, and adequate facilities and equipment. Contextual barriers and facilitators must be taken into account in the design and implementation of school-based health interventions.

Strategies to Promote Physical Activity During Pregnancy: A Systematic Review of Intervention Evidence.

Physical activity during pregnancy has been associated with significant health benefits, however most women in the United States do not meet current guidelines. This systematic review evaluates evidence for interventions to improve physical activity during pregnancy in order to identify best practices and inform future research. Electronic databases (PubMed, CINAHL, SportDISCUS, Embase, ERIC, Psych Info and ISI Web of Science) were searched in July 2011 for peer-reviewed journal articles. Studies were included if they were English-language randomized control trials that measured the efficacy of an intervention targeted to pregnant women and designed to change physical activity as a primary or secondary outcome. Out of 777 studies identified through the systematic search, nine interventions were identified for inclusion by multiple reviewers. Data was abstracted using an abstraction form modeled after the "Guide to Community Preventive Services." Of the nine interventions included in the review, three reported statistically significant positive results for physical activity. While interventions included a variety of strategies and techniques, none were uniquely associated with positive outcomes. Overall this review suggests that little is known about the efficacy of interventions for physical activity during pregnancy. We provide several recommendations for future research and intervention design.

Shifts in BMI category and associated cardiometabolic risk: prospective results from HEALTHY study.

OBJECTIVES: To evaluate shifts across BMI categories and associated changes in cardiometabolic risk factors over 2.5 years in an ethnically diverse middle school sample. METHODS: As part of HEALTHY, a multisite school-based study designed to mitigate risk for type 2 diabetes, 3993 children participated in health screenings at the start of sixth and end of eighth grades. Assessments included anthropometric measures, blood pressure, and glucose, insulin, and lipids. Students were classified as underweight, healthy weight, overweight, obese, or severely obese. Mixed models controlling for school intervention status and covariates were used to evaluate shifts in BMI category over time and the relation between these shifts and changes in risk factors. RESULTS: At baseline, students averaged 11.3 (±0.6) years; 47.6% were boys, 59.6% were Hispanic, and 49.8% were overweight or obese. Shifts in BMI category over time were common. For example, 35.7% of youth who were overweight moved to the healthy weight range, but 13% in the healthy weight range became overweight. BMI shifts were not associated with school intervention condition, household education, or youth gender, race/ethnicity, pubertal status, or changes in height. Increases in BMI category were associated with worsening of cardiometabolic risk factors, and decreases were associated with improvements. Boys who increased BMI category were more vulnerable to negative risk factor changes than girls. CONCLUSIONS: There are substantial shifts across BMI categories during middle school that are associated with clinically meaningful changes in cardiometabolic risk factors. Programs to promote decreases in BMI and prevent increases are clearly warranted.

Evaluating nurses' implementation of an infant-feeding counseling protocol for HIV-infected mothers: The Ban Study in Lilongwe, Malawi.

A process evaluation of nurses' implementation of an infant-feeding counseling protocol was conducted for the Breastfeeding, Antiretroviral and Nutrition (BAN) Study, a prevention of mother-to-child transmission of HIV clinical trial in Lilongwe, Malawi. Six trained nurses counseled HIV-infected mothers to exclusively breastfeed for 24 weeks postpartum and to stop breastfeeding within an additional four weeks. Implementation data were collected via direct observations of 123 infant feeding counseling sessions (30 antenatal and 93 postnatal) and interviews with each nurse. Analysis included calculating a percent adherence to checklists and conducting a content analysis for the observation and interview data. Nurses were implementing the protocol at an average adherence level of 90% or above. Although not detailed in the protocol, nurses appropriately counseled mothers on their actual or intended formula milk usage after weaning. Results indicate that nurses implemented the protocol as designed. Results will help to interpret the BAN Study's outcomes.