5-a-day Power Plus: process evaluation of a multicomponent elementary school program to increase fruit and vegetable consumption.

The 5-a-Day Power Plus program targeted multiethnic fourth- and fifth-grade students in 10 intervention and 10 control urban elementary schools in St. Paul, Minnesota, to increase fruit and vegetable consumption. The intervention included behavioral curricula in classrooms, parental involvement, school food service changes, and food industry support. Process evaluation was conducted by using surveys and classroom and lunchroom observations to assess the characteristics of teachers and food service staff, the degree the intervention was implemented as intended, and exteral factors that may have affected the program results. Results showed high levels of participation, dose, and fidelity for all of the intervention components, with the exception of parental involvement. The process evaluation findings help explain why the increase in fruit and vegetable consumption occurred mostly at school lunch and not at home. Future intervention research should focus on creating new and potent strategies for parental involvement and for increasing the appeal and availability of vegetables.

Patterns in child and adolescent consumption of fruit and vegetables: effects of gender and ethnicity across four sites.

OBJECTIVES: Few studies have examined the association of gender and ethnicity with fruit and vegetable consumption. We examined these associations using baseline data from four school-based sites funded under the National Cancer Institute's 5 A Day for Better Health Program. METHODS: Diet was measured using 24-hour recalls at three sites and seven-day food records at one site. Demographics were obtained via self-report or school records. Regression analyses for clustered data were employed with fruit and vegetables combined and fruit and vegetables separately. RESULTS: Girls ate more fruit, more vegetables and more fruit and vegetables combined than boys at the Georgia site. Ethnicity was significant in two sites: In Georgia, African-Americans ate more fruit and more fruit and vegetables combined than European-Americans; in Minnesota, Asian-American/Pacific Islanders and African-Americans ate more fruit than European-Americans, and European-Americans and African-Americans ate more vegetables than Asian-Americans. No significant effects were found at the Alabama or Louisiana sites. CONCLUSIONS: Ethnicity was related to fruit and vegetable consumption in Georgia and Minnesota. Consistent with prior studies, gender was related to fruit and vegetable consumption, with girls consuming more servings than boys; however, this was observed at one site only, Georgia. Consumption levels were similar to national estimates for children and varied by region. Further studies are needed using a single methodology to facilitate regional comparisons.

Is having a regular provider of diabetes care related to intensity of care and glycemic control?

BACKGROUND: We investigated whether having a regular health care provider for diabetes was related to the intensity of care, use of preventive services, or glycemic control in a well-defined population of adults with diabetes. METHODS: Adults with diabetes who were continuously enrolled in a health maintenance organization (HMO) for 1 year were identified by diagnostic and pharmacy databases (estimated sensitivity = 0.91, positive predictive value = 0.94). In a stratified random sample, 1828 patients were sent a survey by mail that had a corrected response rate of 85.6%. Further data on utilization of services and glycosylated hemoglobin values were obtained from administrative databases and linked to survey responses. RESULTS: HMO members who reported having a regular health care provider (RP) for their diabetes (N = 1243) were comparable with those (N = 144) who denied having such a provider (NRP) in age, race, sex, comorbidity, and years of education, but had longer-duration diabetes (10.9 years vs 8.3 years; P = .002). After adjusting for age, sex, education level, duration of diabetes, and type of HMO clinic (owned vs contracted), RP subjects were more likely than NRPs (all P < .001) to follow a special diet for patients with diabetes (55% vs 33%), regularly monitor glucose levels at home (68% vs 47%), have greater frequency of glycosylated hemoglobin (Hb A1c) testing (65% vs 38%), have more foot examinations (42% vs 17%), have recommended cholesterol checks (77% vs 63%), and have had a recent preventive examination (86% vs 68%). Smaller differences favoring having a regular provider were noted for insulin use (48% vs 33%, odds ratio [OR] = 1.71, P = .013), for an influenza immunization within 1 year (65% vs 51%, P = .029), and for dilated retinal examinations (64% vs 51%, P < .027). No differences between groups were noted for dental checkups (69% vs 67%, P = .724) or likelihood of endocrinology referral (17% vs 10%, P = .104). Mean Hb A1c level was 8.2% (normal is < 6.1%) in the RP group and 8.6% in the NRP group (P = .182). Twelve percent of RPs and 24% of NRPs had an Hb A1c level of greater than 10% (chi 2 = 3.7, OR = 0.48, P = .05) after adjusting for age, sex, duration of diabetes, and education level. CONCLUSIONS: After adjustment for case mix, patients with diabetes who identified a regular primary health care provider for their diabetes were more likely to receive most recommended elements of diabetes care and to have better glycemic control than patients without such a provider. This effect was partially, but not completely, mediated by a higher number of clinic visits for those with a regular health care provider. Innovators seeking to improve diabetes care should be mindful of the relationship between having a regular primary health care provider and the quality of diabetes care.

Changing fruit and vegetable consumption among children: the 5-a-Day Power Plus program in St. Paul, Minnesota.

OBJECTIVES: A randomized school based trial sought to increase fruit and vegetable consumption among children using a multicomponent approach. METHODS: The intervention, conducted in 20 elementary schools in St. Paul, targeted a multiethnic group of children who were in the fourth grade in spring 1995 and the fifth grade in fall 1995. The intervention consisted of behavioral curricula in classrooms, parental involvement, school food service changes, and industry support and involvement. Lunchroom observations and 24-hour food recalls measured food consumption. Parent telephone surveys and a health behavior questionnaire measured psychosocial factors. RESULTS: The intervention increased lunchtime fruit consumption and combined fruit and vegetable consumption, lunchtime vegetable consumption among girls, and daily fruit consumption as well as the proportion of total daily calories attributable to fruits and vegetables. CONCLUSIONS: Multicomponent school-based programs can increase fruit and vegetable consumption among children. Greater involvement of parents and more attention to increasing vegetable consumption, especially among boys, remain challenges in future intervention research.

Using continuous quality improvement to improve diabetes care in populations: the IDEAL model. Improving care for Diabetics through Empowerment Active collaboration and Leadership.

BACKGROUND: The care of patients with chronic diseases, especially those with diabetes mellitus, has been less than ideal. However, despite clear national guidelines, various examples of better care models, and multiple attempts to improve care, an effective process for facilitating and replicating diabetes care improvements in typical primary care practices has been elusive. METHODS: On the basis of the approach and lessons from developmental work at the Minnesota Diabetes Control Program and a trial of continuous quality improvement for clinical preventive services (IMPROVE), a clinic-based intervention processes (IDEAL) has been developed to improve the system and process of care for patients with diabetes as a model for all chronic diseases. The intervention incorporates facilitation of leadership actions in support of change, training for the leader and facilitator of an intraclinic multidisciplinary continuous quality improvement (CQI) team, and consultative and networking support of the change process. Each element of this intervention emphasizes a seven-step process improvement approach and a system for care of patients with diabetes. This model is being developed and tested in a unique partnership between the Minnesota Department of Health and HealthPartners, a large managed care organization (MCO). RESULTS: A prepilot demonstration has succeeded in improving glycemic control, three primary care clinics affiliated with HealthPartners have succeeded in a pilot of the intervention, and an additional 13 clinics are participating in a randomized controlled trial of a refined intervention. CONCLUSIONS: The IDEAL model holds promise for substantial improvements in care, not only for diabetes but for all chronic diseases and for other settings.

Social support in worksite smoking cessation: qualitative analysis of the EASE project.

PURPOSE: Mobilize and study social support in EASE, a worksite smoking cessation program. DESIGN: Qualitative study of social support in two pilot and two test worksites. SETTING: Collaboration with American Lung Association of eastern Missouri to implement program in 12 companies between 1982 and 1985. SUBJECTS: Ninety-eight participants in cessation clinics at pilot and test sites and 350 randomly sampled respondents from among all 877 employees at test sites. INTERVENTION: Steering committees included representatives of management and line employees and tailored the program from plans and materials for program promotion, self-help manuals, and a standard curriculum for a Group Comprehensive Clinic. MEASURES: Implementation and participation from project records. Outcomes and perceptions of social support from surveys of employees. RESULTS: Twelve to 24 months after program initiation, smoking cessation among active participants ranged from 21% to 41%. Consistent with emphasis on promoting support for quitting throughout the worksite, 10% to 25% of nonparticipants were abstinent at follow-ups, exceeding national base rates. Surveys indicated greater importance of social support than of program's procedures or materials and greater benefits of social ties to nonsmokers than to others attempting to quit. Differences among companies in both reported social support for nonsmoking and cessation rates paralleled differences in Steering Committees' activities and organizational support for the program. CONCLUSION: Though limited by lack of experimental controls, this qualitative study of active program participants as well as random samples of all employees indicates social support can be a strength of worksite smoking cessation programs.

Implications for the practicing physician of the psychosocial dimensions of smoking.

The multifaceted nature of smoking includes its physiologic, social, and psychologic dimensions and its career features. It develops over time, through phases such as experimentation or conditioning. It also is given up over time, often after several unsuccessful attempts. Several repetitions of a sequence of considering cessation, attempting to quit, and relapsing are likely to precede permanent cessation. Those who are not ready to commit themselves to quitting may be reached by low-key information more than by too forceful exhortation. Those who are ready to quit may select from among a range of approaches, including group clinics, "self-help" manuals, and physician counseling. Maintenance requires as much attention as does cessation. Cooperation from those around the quitter, reminders to use skills for coping with stressors or temptations, and continued encouragement from the physician may all encourage long-term abstinence. Owing to the multifaceted nature of smoking and quitting and the multiple approaches to cessation and its maintenance, the physician may best be viewed as a catalyst for nonsmoking. If appropriate to his or her practice, this may include extended patient counseling, but those unable to provide this may still make great contributions through brief information on why it is important to quit, encouragement to do so, timely referral to other staff or to materials and programs available in the community, and continued expression of interest in the patient's efforts and/or success. All these may catalyze quitting without demanding excessive time or skills beyond those commonly employed by the physician. In catalyzing nonsmoking, the physician can also be an effective proponent of community or voluntary agency programs as well as institutional and governmental policies to limit smoking in health care facilities and public places. The American College of Chest Physicians' policy encouraging nonsmoking among its Fellows and in their offices is an excellent example of this catalyst role.