Implementation of a multilevel, multicomponent intervention for obesity control in Native American communities (OPREVENT2): challenges and lessons learned.

OPREVENT2 was a multilevel, multicomponent (MLMC) adult obesity prevention that sought to improve access and demand for healthier food and physical activity opportunities in six Native American communities in the Southwest and Midwest. OPREVENT2 worked with worksites, food stores, schools (grades 2-6), through social media and mailings, and with a local community action committee (CAC), in each of the three intervention communities, and was implemented in six phases. We conducted a process evaluation to assess implementation of each intervention component in terms of reach, dose delivered and fidelity. Implementation of each component was classified as high, medium or low according to set standards, and reported back at the end of each phase, allowing for improvements. The school and worksite components were implemented with high reach, dose delivered and fidelity, with improvement over time. The school program had only moderate reach and dose delivered, as did the social media component. The CAC achieved high reach and dose delivered. Overall, study reach and dose delivered reached a high implementation level, whereas fidelity was medium. Great challenges exist in the consistent implementation of MLMC interventions. The detailed process evaluation of the OPREVENT2 trial allowed us to carefully assess the relative strengths and limitations of each intervention component.

Partnering with carryouts: implementation of a food environment intervention targeting youth obesity.

Youth obesity is a major public health problem in the United States, especially among urban-based, minority youth. The B'More Healthy Communities for Kids (BHCK) trial worked at multiple levels of the food environment, including carryouts, to increase access to and demand for healthy, affordable foods. The objective of this article is to describe the development and implementation of BHCK's carryout intervention. Process evaluation was conducted to assess intervention reach (number of interactions with youth and adults either in person or on social media), dose delivered (number of food samples and promotional materials distributed, social media posts and meetings with owners) and fidelity (availability of promoted items). Overall, the carryout intervention showed moderate to optimal reach, moderate to optimal dose delivered and moderate to optimal fidelity. These findings demonstrate a successfully implemented carryout intervention in a low-income urban setting. Lessons learned about new methods for engaging the community and increasing demand for healthy food can be used to inform future studies and programs to improve the food environment.

Implementation of B'More Healthy Communities for Kids: process evaluation of a multi-level, multi-component obesity prevention intervention.

B'More Healthy Communities for Kids was a multi-level, multi-component obesity prevention intervention to improve access, demand and consumption of healthier foods and beverages in 28 low-income neighborhoods in Baltimore City, MD. Process evaluation assesses the implementation of an intervention and monitor progress. To the best of our knowledge, little detailed process data from multi-level obesity prevention trials have been published. Implementation of each intervention component (wholesaler, recreation center, carryout restaurant, corner store, policy and social media/text messaging) was classified as high, medium or low according to set standards. The wholesaler component achieved high implementation for reach, dose delivered and fidelity. Recreation center and carryout restaurant components achieved medium reach, dose delivered and fidelity. Corner stores achieved medium reach and dose delivered and high fidelity. The policy component achieved high reach and medium dose delivered and fidelity. Social media/text messaging achieved medium reach and high dose delivered and fidelity. Overall, study reach and dose delivered achieved a high implementation level, whereas fidelity achieved a medium level. Varying levels of implementation may have balanced the performance of an intervention component for each process evaluation construct. This detailed process evaluation of the B'More Healthy Communities for Kids allowed the assessment of implementation successes, failures and challenges of each intervention component.

Using the theory of normative social behavior to understand compliance with a smoke-free law in a middle-income country.

Smoke-free laws, which ban smoking in public venues, can be effective in protecting public health, but it has been difficult to achieve compliance with these laws in low- and middle-income countries. This study was conducted to understand the social norms around public smoking and learn how to improve compliance in Bogor, the first Indonesian city to pass a comprehensive smoke-free law. Eleven stratified focus groups were conducted (n = 89). Data were analyzed using the theory of normative social behavior, which posits that the influence of descriptive norms (perceptions about what other people do) on behavior is moderated by injunctive norms (perceptions about what one is expected to do), outcome expectations and group identity. The findings showed that participants perceived smoking in public to be common for men (descriptive norm). Public smoking is acceptable except in places with air conditioning and around children or pregnant women (injunctive norms). Men smoke without penalty of social or legal sanctions (outcome expectations) and may feel affiliation with other smokers (group identity). Together, these factors support public smoking and inhibit compliance with the smoke-free law. Theory-based communication and policy remedies are suggested that may bolster compliance with Bogor's smoke-free law given the current pro-smoking norms.

Healthy Foods North improves diet among Inuit and Inuvialuit women of childbearing age in Arctic Canada.

BACKGROUND: Healthy Foods North (HFN) is a community-based intervention designed to promote a healthy diet and lifestyle of Inuit and Inuvialuit populations in Arctic Canada. The objective of the present study was to determine the effects of HFN on the nutrient intake of women of childbearing age. METHODS: Six communities in Nunavut (n = 3) and the Northwest Territories (n = 3) were selected for programme implementation; four received a 12-month intervention and two served as controls. Quantitative food frequency questionnaires were used to assess dietary intake at baseline and 1 year post-intervention. Among women participants aged 19-44 years (n = 136), 79 were exposed to the intervention and 57 were not. Mean daily energy and nutrient intake and density were determined. Dietary adequacy was assessed by comparing the women's daily nutrient intakes with dietary reference intakes (DRI). RESULTS: Main outcomes were the pre- to post-intervention changes between intervention and control groups for energy and selected nutrient intakes, nutrient density and dietary adequacy. Among the participants, the intervention had a beneficial effect on vitamin A and D intake. The percentage of individuals with nutrient intakes below the DRI increased from pre- to post-intervention for vitamin A and D in the control group but only for vitamin A in the intervention group. The programme did not have a significant impact on calorie, sugar, or fat consumption. CONCLUSIONS: The HFN programme is effective in mitigating some of the negative impacts of the nutrition transition on dietary adequacy among Inuit and Inuvialuit women of childbearing age.

Utility of non-high-density lipoprotein cholesterol in assessing incident type 2 diabetes risk.

AIMS: Traditional lipid indices have been associated with type 2 diabetes, but limited data are available regarding non-high-density lipoprotein (non-HDL) cholesterol. In view of recent guidelines for the clinical management of dyslipidemia recommending the monitoring of non-HDL cholesterol as a secondary target after achieving the low-density lipoprotein (LDL) cholesterol goal, we aimed to assess the association of non-HDL cholesterol with incident type 2 diabetes and compare its utility as a risk predictor with traditional lipid variables in Aboriginal Canadians. METHODS: Of 606 diabetes-free participants at baseline, 540 (89.1%) returned for 10-year follow-up assessments. Baseline anthropometry, blood pressure, fasting insulin and serum lipids were measured. Fasting and 2-h postload glucose were obtained at baseline and follow-up to determine the incidence of type 2 diabetes. RESULTS: The cumulative incidence of type 2 diabetes was 17.5%. Higher non-HDL cholesterol, total-to-HDL cholesterol ratio, apolipoprotein B, triglyceride and LDL cholesterol and lower HDL cholesterol concentrations were individually associated with incident type 2 diabetes in univariate analyses (all p < 0.05). Non-HDL cholesterol was a superior determinant of incident diabetes compared with LDL cholesterol (comparing C-statistics of univariate models p = 0.01) or HDL cholesterol (p = 0.004). With multivariate adjustment including waist circumference, non-HDL cholesterol remained associated with incident diabetes [odds ratio (OR) 1.42 (95% confidence interval, CI 1.07-1.88)], while LDL cholesterol and HDL cholesterol became non-significant. CONCLUSIONS: Non-HDL cholesterol was associated with incident type 2 diabetes and was superior to LDL cholesterol as a risk predictor in this population. Further studies are required to establish the utility of non-HDL cholesterol in non-Aboriginal populations.

Healthy food intentions and higher socioeconomic status are associated with healthier food choices in an Inuit population.

BACKGROUND: Changing food behaviours amongst Canadian Inuit may contribute to rising chronic disease prevalence, and research is needed to develop nutritional behaviour change programmes. The present study examined patterns of food acquisition and preparation behaviours amongst Inuit adults in Nunavut and associations with psychosocial and socioeconomic factors. METHODS: Developed from behavioural theories and community workshops, Adult Impact Questionnaires were conducted with adult Inuit (≥19 years) from randomly selected households in three remote communities in Nunavut, Canada, to determine patterns of healthy food knowledge, self-efficacy and intentions, frequencies of healthy and unhealthy food acquisition and healthiness of preparation methods. Associations between these constructs with demographic and socioeconomic factors were analysed using multivariate linear regressions. RESULTS: Amongst 266 participants [mean (SD) age 41.2 (13.6) years; response rates 69-93%], non-nutrient-dense foods were acquired a mean (SD) of 2.9 (2.3) times more frequently than nutrient-dense, and/or low sugar/fat foods. Participants tended to use preparation methods that add fat. Intentions to perform healthy dietary behaviours was inversely correlated with unhealthy food acquisition (ß=-0.25, P<0.001), and positively associated with healthy food acquisition (ß=0.22, P<0.001) and healthiness of preparation methods (ß=0.15, P=0.012). Greater healthy food knowledge and self-efficacy were associated with intentions (ß=0.21, P=0.003 and ß=0.55, P<0.001, respectively). Self-efficacy was associated with healthier preparation (ß=0.14, P=0.025) and less unhealthy food acquisition (ß=-0.27, P<0.001), whilst knowledge was associated with acquiring healthy foods (ß=0.13, P=0.035). Socioeconomic status was positively associated with healthy preparation and food acquisition behaviours. CONCLUSIONS: Interventions to improve diet in Nunavut Inuit should target healthy food intentions, knowledge and self-efficacy. Behaviour change strategies emphasising economic benefits of a healthy diet should be employed to target individuals of low socioeconomic status.

Addressing the public health burden caused by the nutrition transition through the Healthy Foods North nutrition and lifestyle intervention programme.

Dietary inadequacies, low levels of physical activity, excessive energy intake and high obesity prevalence have placed Inuit and Inuvialuit populations of the Canadian Arctic at increased risk of chronic disease. An evidence-based, community participatory process was used to develop Healthy Foods North (HFN), a culturally appropriate nutrition and physical activity intervention programme that aimed to reduce risk of chronic disease and improve dietary adequacy amongst Inuit/Inuvialuit in Nunavut and the Northwest Territories. HFN was implemented over the course of 12 months in a series of seven phases between October 2008 and 2009 (Nunavut) and June 2008 and 2009 (Northwest Territories). Combining behaviour change and environmental strategies to increase both the availability of healthful food choices in local shops and opportunities for increasing physical activity, HFN promoted the consumption of traditional foods and nutrient-dense and/or low energy shop-bought foods, utilisation of preparation methods that do not add fat content, decreased consumption of high-energy shop-bought foods, and increased physical activity. Messages identified in the community workshops, such as the importance of family eating and sharing, were emphasised throughout the intervention. Intervention components were conducted by community staff and included working with shops to increase the stocking of healthy foods, point of purchase signage and promotion in shops and community settings, pedometer challenges in the workplace and use of community media (e.g. radio and cable television advertisements) to reinforce key messages. HFN represents an innovative multilevel approach to the reduction of chronic disease risk factors amongst Inuit and Inuvialuit, based on strong collaboration with local agencies, government and institutions.

Impact of the changing food environment on dietary practices of an Inuit population in Arctic Canada.

BACKGROUND: Nutritional inadequacies and increasing chronic disease prevalence amongst Inuit in the Canadian Arctic highlight the need to address dietary practices. Research is needed to investigate the individual and environmental factors impacting diet to guide interventions. The present study aimed to explore multiple community perspectives of key factors affecting food choice and availability in Inuit communities in Nunavut, Canada. METHODS: Semi-structured in-depth interviews were conducted with Inuit adults (n=43) in two communities in Nunavut, Canada, and included community members, community leaders, elders, health staff and food shop staff. The interviewer transcribed the audio-taped interviews. Data were analysed using codes and the constant comparative method to determine categories and emergent themes. RESULTS: Thirty-three Inuit (27 females and six males) and 10 non-Inuit (four females and six males) adults participated. Traditional foods procured through hunting and gathering were considered the healthiest by community members, although multiple factors inhibited their procurement, including high petrol cost and decrease in traditional knowledge about hunting and gathering practices. Cost and quality were the main barriers to purchasing healthy foods at the shops. Community leaders and health staff identified multiple barriers to healthy eating in the community, such as skills to prepare some shop-bought foods. Shop managers identified several challenges to providing fresh produce and other perishable foods, such as long transportation routes that increase costs and harsh climatic conditions that may cause spoilage. They also cited factors influencing their decisions regarding whether to stock/discontinue certain foods, such as customers' requests, food cost and shelf-life. CONCLUSIONS: An intervention to reduce chronic disease risk and improve dietary adequacy amongst Nunavut Inuit may be effective by supporting individual behaviour modifications with food environment changes.

Important psychosocial factors to target in nutrition interventions to improve diet in Inuvialuit communities in the Canadian Arctic.

BACKGROUND: With increasing chronic disease amongst Inuvialuit in the Canadian Arctic, research on dietary behaviours and their determinants in this population is needed to develop nutritional behaviour change intervention strategies. The present study aimed to assess the knowledge, self-efficacy and intentions towards healthy eating and healthy eating behaviours of Inuvialuit adults in the Northwest Territories (NWT), Canada. METHODS: The Adult Impact Questionnaire was developed from behavioural theories and workshops held in the communities. It was conducted with adult Inuvialuit (≥19 years) from randomly selected households in three NWT communities to collect data on the psychosocial constructs of healthy food knowledge, self-efficacy and intentions, and the dietary behaviours of healthy and unhealthy food acquisition and preparation. Associations between demographic, socioeconomic, psychosocial constructs and behaviours were analysed using multivariate linear regression. RESULTS: The 228 participants [mean (SD) age 43.4 (13.6) years; response rates 65-85%] acquired non-nutrient-dense foods a mean (SD) of 2.7 (3.0) times more frequently than nutrient-dense, low sugar and low fat foods. Increased intention was associated with a greater frequency of acquiring healthy foods (ß=0.17, P=0.012) and a lower frequency of acquiring unhealthy foods (ß=-0.18, P=0.008). Overall, participants reported using food preparation methods that reduce fat content slightly more than methods that add fat [mean (SD) score 0.3 (1.9)]. Use of healthier food preparation methods was associated with higher levels of healthy food knowledge (ß=0.26, P<0.001), self-efficacy (ß=0.29, P<0.001) and intentions (ß=0.22, P=0.001). CONCLUSIONS: Healthy food intention was the construct most significantly associated with all three healthier dietary behaviours. Interventions that target intentions to change food choice and preparation may be effective strategies to improve dietary intake in Inuvialuit populations.

Awareness of chronic disease diagnosis amongst family members is associated with healthy dietary knowledge but not behaviour amongst Inuit in Arctic Canada.

BACKGROUND: The extent to which awareness of chronic disease (CD) diagnosis affects one's healthy food knowledge, self-efficacy and intentions or healthy dietary and physical activity (PA) behaviours remains unexplored among Inuit in Canada. METHODS: A food frequency questionnaire and an adult impact questionnaire were used in a cross-sectional study to collect self-reported data on daily energy and nutrient intake, PA and the diagnosis of hypertension, diabetes, heart disease and cancer amongst adult Inuit and their family members. Associations between awareness of personal and family CD status and healthy food knowledge, self-efficacy and intentions, percentage of energy consumed from non-nutrient-dense foods and PA were assessed via ordinal logistic regression. RESULTS: Of the 266 participants, those who self-reported CD for both themselves and their relative(s) were more likely to have high healthy food knowledge [odds ratio (OR)=2.45] than those who did not. Reporting hypertension and heart disease amongst only relatives increased the likelihood of high knowledge (OR=5.20) and intentions (OR=5.10) for healthy eating. Heart disease in both participants and their relatives was associated with high levels of PA (OR=12.24). However, there were no associations when only participants (but not their relatives) reported having CD. A joint effect between a high level of education and awareness of CD was positively related to high food knowledge (OR=38.93). An inverse association between awareness of CD and unhealthy eating was not observed. CONCLUSIONS: Awareness of a relative having a CD was a more important factor in increasing knowledge and, to a lesser degree, self-efficacy or intentions to eat healthy than participants' awareness of personal CD. However, awareness was not associated with lower non-nutrient-dense food intake.

The prevalence of NIDDM and associated risk factors in native Canadians.

OBJECTIVE: To determine the true prevalence of impaired glucose tolerance (IGT), NIDDM, and associated risk factors by age and sex in an isolated native community. RESEARCH DESIGN AND METHODS: A community-wide prevalence survey using a 75-g oral glucose tolerance test (OGTT) was undertaken in the remote native reserve of Sandy Lake, Ontario, Canada. Measurements for obesity included waist-to-hip circumference, BMI, and percentage body fat. RESULTS: A total of 728 individuals were enrolled, representing a community participation rate of 72%. The overall crude prevalence of NIDDM was 17.2% (18.1% females and 16.0% males) and increased to 26.1% overall (28.0% females and 24.2% males) when age-standardized. The prevalence of IGT was higher in females compared with males (age-standardized prevalence of 19.8 vs. 7.1%, respectively). Females had a higher prevalence of obesity, IGT, and NIDDM occurring at younger ages. Measures of obesity and fasting insulin levels were significantly associated with NIDDM in the 18-49 age-group. CONCLUSIONS: The prevalence rates of NIDDM in this study population are the highest reported to date in a Canadian native population and among the highest reported in the world. Females appear to be at much higher risk of developing obesity, IGT, and NIDDM and at a younger age. Due to the high prevalence rates of IGT and NIDDM in this young population, there is urgent need to develop culturally appropriate community-based public health intervention programs before the long-term complications of diabetes have a devastating effect on the residents.

Low-income African-American adults share weight status, food-related psychosocial factors and behaviours with their children.

OBJECTIVE: This study aims to examine the extent to which low-income African-American children's weight status, psychosocial characteristics and food-related behaviours are associated with that of their adult caregivers. METHODS: Cross-sectional data from baseline evaluation of B'More Healthy Communities for Kids obesity prevention trial were used. Outcomes of interest were children's overweight and/or obesity status, food-related self-efficacy, knowledge, intentions and healthier/less healthy food acquisition scores. The primary exposures were adult caregiver's overweight and/or obesity status, their psychosocial factors and food acquisition scores. Multiple logistic regression analyses were used to assess associations. RESULTS: Children had higher odds of overweight or obesity if they had an overweight/obese caregiver (odds ratio [OR] 4.04, 95% confidence interval [95%CI] 1.59-10.28) or an obese caregiver (OR 2.50, 95%CI 1.39-4.51). Having a caregiver in the highest quartile of self-efficacy, food intentions and healthy food acquisition patterns was associated with higher odds of their child also having a higher score on these factors (self-efficacy: OR 3.77 [95%CI 1.76-8.04]; food intentions: OR 1.13 [95%CI 1.01-1.27]; and healthy food acquisition: OR 2.19 [95%CI 1.05-4.54]). CONCLUSIONS: Child and adult caregiver weight status and psychosocial characteristics were positively associated in this low-income, urban population. These findings may help inform obesity treatment or prevention programmes and interventions aimed at parents and families.

Chronic low intakes of vitamin A-rich foods in households with xerophthalmic children: a case-control study in Nepal.

Dietary patterns in 81 rural Nepali households with a 1-6-y-old child with a history of xerophthalmia were compared with dietary patterns of 81 households with an age-matched nonxerophthalmic control subject. Weekly food-frequency questionnaires were collected from case and control "focus" children, a younger sibling (if present), and the household 1-2 y after recruitment and treatment of cases. Control households and children were more likely than case households and children to consume vitamin A-rich foods during the monsoon (July-September) and major rice harvesting (October-December) seasons. Cases were less likely to consume preformed vitamin A-rich foods throughout the year [odds ratio (OR) = 1.2-4.5] with the strongest differences observed from October to December (OR = 2.0-4.2). Dietary risks were generally shared by younger siblings of cases, suggesting that infrequent intake of beta-carotene and preformed vitamin-A rich foods begins early in life and clusters among siblings within households, a pattern that is consistent with their higher risk of xerophthalmia and mortality. In developing countries where vitamin A deficiency is endemic, dietary counseling for children with xerophthalmia should be extended to their younger siblings. Moreover, dietary intake of preformed vitamin A may be as, or more, important as carotenoid-containing food consumption in protecting children and other members of households from vitamin A deficiency.

Overweight among children and adolescents in a Native Canadian community: prevalence and associated factors.

BACKGROUND: The prevalence of pediatric obesity in North America is increasing. Native American children are at especially high risk. OBJECTIVES: The objective was to evaluate the prevalence of pediatric overweight and associated behavioral factors in a Native Canadian community with high rates of adult obesity and type 2 diabetes mellitus. DESIGN: Height and weight were measured in 445 children and adolescents aged 2-19 y. Fitness level, television viewing, body image concepts, and dietary intake were assessed in 242 subjects aged 10-19 y. Overweight was defined as a body mass index > or =85th percentile value for age- and sex-specific reference data from the third National Health and Nutrition Examination Survey (NHANES III). Multiple logistic regression was used to examine factors associated with overweight, with adjustment for age and sex. RESULTS: The overall prevalence of overweight in subjects aged 2-19 y was significantly higher than NHANES III reference data [boys: 27. 7% (95% CI: 21.8, 34.5); girls: 33.7% (95% CI: 27.9, 40.1)]. In the subset aged 10-19 y, > or =5 h television viewing/d was associated with a significantly higher risk of overweight than was < or =2 h/d [odds ratio (OR) = 2.52; 95% CI: 1.06, 5.98]. Subjects in the third and fourth quartiles of fitness had a substantially lower risk of overweight than did those in the first quartile [third quartile compared with first quartile: OR = 0.24 (95% CI: 0.09, 0.66); fourth quartile compared with first quartile: OR = 0.13 (95% CI: 0.03, 0. 48)]. Fiber consumption on the previous day was associated with a decreased risk of overweight (OR = 0.69; 95% CI: 0.47, 0.99 for each 0.77 g/MJ increase in fiber intake). CONCLUSIONS: Pediatric overweight is a harbinger of future diabetes risk and indicates a need for programs targeting primary prevention of obesity in children and adolescents.

Low dietary fiber and high protein intakes associated with newly diagnosed diabetes in a remote aboriginal community.

The high prevalence of diabetes mellitus in North American aboriginal populations may be due to recent changes in lifestyle, including the adoption of a high-fat, low-fiber diet. To determine whether fat or fiber intakes were associated with new cases of diabetes, we studied 72% (728/1018) of residents aged > 9 y from a remote aboriginal community in northern Ontario using the 75-g oral-glucose-tolerance test and 24-h dietary recall. The mean fat intake of this population (36% of energy) was typical for North America, but fiber intake (1.2 g/MJ) was very low. Logistic-regression analysis, adjusted for age, sex, and body mass index, showed that a 1-SD increase in fiber intake reduced the risk of having diabetes by 39% (P = 0.026) whereas the same increase in protein intake increased the risk by 38% (P = 0.027). There was no significant effect of energy, fat, starch, or simple sugars. These data support Trowell's original dietary-fiber hypothesis that "... dietary fiber depleted starchy foods are conducive to the development of diabetes mellitus in susceptible human genotypes."

Multisite formative assessment for the Pathways study to prevent obesity in American Indian schoolchildren.

We describe the formative assessment process, using an approach based on social learning theory, for the development of a school-based obesity-prevention intervention into which cultural perspectives are integrated. The feasibility phase of the Pathways study was conducted in multiple settings in 6 American Indian nations. The Pathways formative assessment collected both qualitative and quantitative data. The qualitative data identified key social and environmental issues and enabled local people to express their own needs and views. The quantitative, structured data permitted comparison across sites. Both types of data were integrated by using a conceptual and procedural model. The formative assessment results were used to identify and rank the behavioral risk factors that were to become the focus of the Pathways intervention and to provide guidance on developing common intervention strategies that would be culturally appropriate and acceptable to all sites.

Portion-size estimation training in second- and third-grade American Indian children.

Training in portion-size estimation is known to improve the accuracy of dietary self-reporting in adults, but there is no comparable evidence for children. To obtain this information, we studied 110 second- and third-grade American Indian schoolchildren (34 control subjects were not trained), testing the hypotheses that a 45-min portion-size estimation training session would reduce children's food quantity estimation error, and that the improvement would be dependent on food type, measurement type, or both. Training was a hands-on, 4-step estimation and measurement skill-building process. Mixed linear models (using logarithmic-transformed data) were used to evaluate within- and between-group differences from pre- to posttest. Test scores were calculated as percentage estimation errors by difference and absolute value methods. Mean within-group estimation error decreased significantly (P<0.05) from pre- to posttest for 7 of 12 foods (trained group) by both calculation methods, plus 3 additional foods by the difference method and one additional food by the absolute value method. Significant (P<0.05) between-group differences occurred for 3 foods, reflecting a greater decrease in estimation error for the trained group. Improvement was greatest for solid foods estimated by dimensions (P>0.05) or in cups (P<0.05), for liquids estimated by volume or by label reading (P<0.001), and for one amorphous food estimated in cups (P<0.01). Despite these significant improvements in estimation ability, the error for several foods remained >100% of the true quantity, indicating that more than one training session would be necessary to further increase dietary reporting accuracy.

Development of a questionnaire to assess knowledge, attitudes, and behaviors in American Indian children.

One aim of the Pathways study is to improve the knowledge, attitudes, and behaviors of American Indian children in grades 3-5 regarding physical activity and diet in. This article describes the development of a culturally sensitive, age-appropriate questionnaire to assess these variables. The questionnaire was designed to be administered in the classroom in two 30-min sessions. Questions were developed to assess 4 key areas: physical activity, diet, weight-related attitudes, and cultural identity. Potential questions were written after review of relevant literature and existing questionnaires. Numerous and extensive revisions were made in response to input from structured, semistructured, and informal data collection. Questions were pretested in 32 children in grades 3-5 by using semistructured interviews. Test-retest reliability and the internal consistency of scales were examined in 371 fourth-grade children and subsequently in 145 fourth-grade children. Questions were reviewed by American Indians from the communities involved in the Pathways study several times during the developmental process. The process described here serves as one model for the development of a culturally appropriate tool to assess knowledge, attitudes, and behaviors in American Indian children.

Process evaluation in a multisite, primary obesity-prevention trial in American Indian schoolchildren.

We describe the development, implementation, and use of the process evaluation component of a multisite, primary obesity prevention trial for American Indian schoolchildren. We describe the development and pilot testing of the instruments, provide some examples of the criteria for instrument selection, and provide examples of how process evaluation results were used to document and refine intervention components. The theoretical and applied framework of the process evaluation was based on diffusion theory, social learning theory, and the desire for triangulation of multiple modes of data collection. The primary objectives of the process evaluation were to systematically document the training process, content, and implementation of 4 components of the intervention. The process evaluation was developed and implemented collaboratively so that it met the needs of both the evaluators and those who would be implementing the intervention components. Process evaluation results revealed that observation and structured interviews provided the most informative data; however, these methods were the most expensive and time consuming and required the highest level of skill to undertake. Although the literature is full of idealism regarding the uses of process evaluation for formative and summative purposes, in reality, many persons are sensitive to having their work evaluated in such an in-depth, context-based manner as is described. For this reason, use of structured, quantitative, highly objective tools may be more effective than qualitative methods, which appear to be more dependent on the skills and biases of the researcher and the context in which they are used.