Empiric validation of a process for behavior change.

Most behavior change trials focus on outcomes rather than deconstructing how those outcomes related to programmatic theoretical underpinnings and intervention components. In this report, the process of change is compared for three evidence-based programs' that shared theories, intervention elements and potential mediating variables. Each investigation was a randomized trial that assessed pre- and post- intervention variables using survey constructs with established reliability. Each also used mediation analyses to define relationships. The findings were combined using a pattern matching approach. Surprisingly, knowledge was a significant mediator in each program (a and b path effects [p<0.01]). Norms, perceived control abilities, and self-monitoring were confirmed in at least two studies (p<0.01 for each). Replication of findings across studies with a common design but varied populations provides a robust validation of the theory and processes of an effective intervention. Combined findings also demonstrate a means to substantiate process aspects and theoretical models to advance understanding of behavior change.

Healthy Team Healthy U: A Prospective Validation of an Evidence-Based Worksite Health Promotion and Wellness Platform.

OBJECTIVE: To evaluate the effects of a research-tested, team-based health promotion and wellness program combined with digital technologies and implemented in a diverse worksite setting among hospital, clinic, and university employees. METHODS: A prospective cohort study of employees completing biometrics and questionnaires before and after the initial 12-session wellness program and its 12-session booster, 1 year later. RESULTS: After both the initial intervention and booster, blood pressure and weight were reduced, with greater reductions among employees with pre-hypertension and hypertension and those with a body mass index ≥25. After both the initial intervention and booster, there was a significant increase in (1) daily intake of fruit and vegetable servings, (2) days/week of ≥30 min of exercise, (3) days/week of strength training, and (4) levels of moderately vigorous and vigorous daily physical activity. Self-reported indices of both depression and work-related stress were reduced, while participants reported increased happiness. Post booster, average sleep quality, and sleep duration increased among higher risk employees reporting ≤6 h of daily sleep. Employees reported receiving encouragement from co-workers to engage in healthful diet and physical activities, and exercised together more, and indicated that they would recommend the program to other employees. Longitudinal analysis revealed the durability of the initial intervention outcomes with further beneficial effects after the booster. CONCLUSION: A research tested, comprehensive team-based health promotion and wellness program, combined with digital technologies, improved employee health behaviors, mood, sleep, elements of co-worker cohesion, and biometrics among a diverse multi-site workforce. Positive program effects were durable, with enhanced results after the booster.

The safety and health improvement: enhancing law enforcement departments study: feasibility and findings.

This randomized prospective trial aimed to assess the feasibility and efficacy of a team-based worksite health and safety intervention for law enforcement personnel. Four-hundred and eight subjects were enrolled and half were randomized to meet for weekly, peer-led sessions delivered from a scripted team-based health and safety curriculum. Curriculum addressed: exercise, nutrition, stress, sleep, body weight, injury, and other unhealthy lifestyle behaviors such as smoking and heavy alcohol use. Health and safety questionnaires administered before and after the intervention found significant improvements for increased fruit and vegetable consumption, overall healthy eating, increased sleep quantity and sleep quality, and reduced personal stress.

Impact of implementation and conduct of the HEALTHY primary prevention trial on student performance.

PURPOSE: To determine whether a school-wide intervention program to reduce risk factors for type 2 diabetes (T2D) affected student achievement, rates of disciplinary actions, and attendance rates. DESIGN: The HEALTHY primary prevention trial was designed to evaluate a comprehensive school-based intervention to reduce factors for T2D, especially overweight and obesity. Students were followed up from beginning of sixth grade (Fall 2006) through end of eighth grade (Spring 2009). SETTING: Forty-two middle schools at seven U.S. sites. SUBJECTS: Schools were randomized in equal numbers at each site to intervention (21 schools, 2307 students) or control (21 schools, 2296 students). Intervention . An integrated school-wide program that focused on (1) foods and beverages, (2) physical education, (3) classroom-based behavior change and education, and (4) social marketing communication and promotional campaigns. MEASURES: Aggregate (grade- and school-wide) test performance (passing rate), attendance, and referrals for disciplinary actions. ANALYSIS: Descriptive statistics and tests of intervention versus control using mixed linear models methods to adjust for the clustering of students within schools. RESULTS: There were no differences between intervention and control schools in test performance for mathematics (p = .7835) or reading (p = .6387), attendance (p = .5819), or referrals for disciplinary action (p = .8671). CONCLUSION: The comprehensive HEALTHY intervention and associated research procedures did not negatively impact student achievement test scores, attendance, or referrals for disciplinary action.

Digital video technology and production 101: lights, camera, action.

Videos are powerful tools for enhancing the reach and effectiveness of health promotion programs. They can be used for program promotion and recruitment, for training program implementation staff/volunteers, and as elements of an intervention. Although certain brief videos may be produced without technical assistance, others often require collaboration and contracting with professional videographers. To get practitioners started and to facilitate interactions with professional videographers, this Tool includes a guide to the jargon of video production and suggestions for how to integrate videos into health education and promotion work. For each type of video, production principles and issues to consider when working with a professional videographer are provided. The Tool also includes links to examples in each category of video applications to health promotion.

Health promotion for adolescent childhood leukemia survivors: building on prevention science and ehealth.

Teenage survivors of childhood acute lymphoblastic leukemia (ALL) have increased morbidity likely due to their prior multicomponent treatment. Habits established in adolescence can impact individuals' subsequent adult behaviors. Accordingly, healthy lifestyles, avoiding harmful actions, and appropriate disease surveillance are of heightened importance among teenage survivors. We review the findings from prevention science and their relevance to heath promotion. The capabilities and current uses of eHealth components including e-learning, serious video games, exergaming, behavior tracking, individual messaging, and social networking are briefly presented. The health promotion needs of adolescent survivors are aligned with those eHealth aspects to propose a new paradigm to enhance the wellbeing of adolescent ALL survivors.

National Athletic Trainers' Association position statement: anabolic-androgenic steroids.

OBJECTIVE: This manuscript summarizes the best available scholarly evidence related to anabolic-androgenic steroids (AAS) as a reference for health care professionals, including athletic trainers, educators, and interested others. BACKGROUND: Health care professionals associated with sports or exercise should understand and be prepared to educate others about AAS. These synthetic, testosterone-based derivatives are widely abused by athletes and nonathletes to gain athletic performance advantages, develop their physiques, and improve their body image. Although AAS can be ergogenic, their abuse may lead to numerous negative health effects. RECOMMENDATIONS: Abusers of AAS often rely on questionable information sources. Sports medicine professionals can therefore serve an important role by providing accurate, reliable information. The recommendations provide health care professionals with a current and accurate synopsis of the AAS-related research.

Body mass index as a predictor of firefighter injury and workers' compensation claims.

OBJECTIVE: To determine the relationship between lifestyle variables including body mass index and filing a workers' compensation claim due to firefighter injury. METHODS: A cross-sectional evaluation of firefighter injury related to workers" compensation claims occurring 5 years after the original Promoting Healthy Lifestyles: Alternative Models' Effects study intervention. RESULTS: A logistic regression analysis for variables predicting filing a workers' compensation claim due to an injury was performed with a total of 433 participants. The odds of filing a compensation claim were almost 3 times higher for firefighters with a body mass index of more than 30 kg/m than firefighters with a normal body mass index (odds ratio, 2.89; P < 0.05). CONCLUSIONS: This study addresses a high-priority area of reducing firefighter injuries and workers' compensation claims. Maintaining a healthy body weight is important to reduce injury and workers' compensation claims among firefighters.

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.

Worksite wellness program implementation: a model of translational effectiveness.

Occupational health promotion programs with documented efficacy have not penetrated worksites. Establishing an implementation model would allow focusing on mediating aspects to enhance installation and use of evidence-based occupational wellness interventions. The purpose of the study was to implement an established wellness program in fire departments and define predictors of program exposure/dose to outcomes to define a cross-sectional model of translational effectiveness. The study is a prospective observational study among 12 NW fire departments. Data were collected before and following installation, and findings were used to conduct mediation analysis and develop a translational effectiveness model. Worker age was examined for its impact. Leadership, scheduling/competing demands, and tailoring were confirmed as model components, while organizational climate was not a factor. The established model fit data well (χ (2)(9) = 25.57, CFI = 0.99, RMSEA = 0.05, SRMR = 0.03). Older firefighters, nearing retirement, appeared to have influences that both enhanced and hindered participation. Findings can inform implementation of worksite wellness in fire departments, and the prioritized influences and translational model can be validated and manipulated in these and other settings to more efficiently move health promotion science to service.

The PHLAME (Promoting Healthy Lifestyles: Alternative Models' Effects) firefighter study: testing mediating mechanisms.

This paper examines the mechanisms by which PHLAME (Promoting Healthy Lifestyles: Alternative Models' Effects), a health promotion intervention, improved healthy eating and exercise behavior among firefighters, a population at high risk for health problems due to occupational hazards. In a randomized trial, 397 firefighters participated in either the PHLAME team intervention with their work shift or a control condition. Intervention sessions taught benefits of a healthy diet and regular exercise, and sought to improve social norms and social support from coworkers for healthy behavior. At posttest, team intervention participants had increased their fruit and vegetable consumption as compared to control participants. An increase in knowledge of fruit and vegetable benefits and improved dietary coworker norms partially mediated these effects. Exercise habits and VO2 max were related to targeted mediators but were not significantly changed by the team intervention. Partial support was found for both the action and conceptual theories underlying the intervention. Our findings illustrate how an effective program's process can be deconstructed to understand the underpinnings of behavior change and refine interventions. Further, fire stations may improve the health of firefighters by emphasizing the benefits of healthy diet and exercise behaviors while also encouraging behavior change by coworkers as a whole.

Worksite health promotion in six varied US sites: beta testing as a needed translational step.

BACKGROUND: Dissemination of health promotion interventions generally has followed an efficacy, effectiveness to full scale paradigm, and most programs have failed to traverse that sequence. OBJECTIVE: Report national dissemination of a health promotion program and juxtapose sequential case study observations with the current technology transfer literature. DESIGN: Multiple department-level case studies using contact logs, transcribed interactions, augmented with field notes and validated by respondent review; at least two investigators independently generated site summaries, which were compared to formulate a final report. RESULTS: Adoption was facilitated with national partners and designing branded materials. Critical site influences included departmental features, local champions, and liaison relationships. Achieving distal reach and fidelity required sequential process and program revisions based on new findings at each site. CONCLUSIONS: Beta testing to redesign program elements and modify process steps appears to be a needed and often ignored translational step between efficacy and more widespread dissemination.

The IGNITE (investigation to guide new insight into translational effectiveness) trial: Protocol for a translational study of an evidenced-based wellness program in fire departments.

BACKGROUND: Worksites are important locations for interventions to promote health. However, occupational programs with documented efficacy often are not used, and those being implemented have not been studied. The research in this report was funded through the American Reinvestment and Recovery Act Challenge Topic 'Pathways for Translational Research,' to define and prioritize determinants that enable and hinder translation of evidenced-based health interventions in well-defined settings. METHODS: The IGNITE (investigation to guide new insights for translational effectiveness) trial is a prospective cohort study of a worksite wellness and injury reduction program from adoption to final outcomes among 12 fire departments. It will employ a mixed methods strategy to define a translational model. We will assess decision to adopt, installation, use, and outcomes (reach, individual outcomes, and economic effects) using onsite measurements, surveys, focus groups, and key informant interviews. Quantitative data will be used to define the model and conduct mediation analysis of each translational phase. Qualitative data will expand on, challenge, and confirm survey findings and allow a more thorough understanding and convergent validity by overcoming biases in qualitative and quantitative methods used alone. DISCUSSION: Findings will inform worksite wellness in fire departments. The resultant prioritized influences and model of effective translation can be validated and manipulated in these and other settings to more efficiently move science to service.

Long-term effects of a worksite health promotion program for firefighters.

OBJECTIVE: To describe effects of 2 worksite health promotion programs for firefighters, both immediate outcomes and the long-term consequences for 4 years following the interventions. METHODS: At baseline, 599 firefighters were assessed, randomized by fire station to control and 2 different intervention conditions, and reevaluated with 6 annual follow-up measurements. RESULTS: Both a team-centered peer-taught curriculum and an individual motivational interviewing intervention demonstrated positive effects on BMI, with team effects on nutrition behavior and physical activity at one year. Most differences between intervention and control groups dissipated at later annual assessments. However, the trajectory of behaviors across time generally was positive for all groups, consistent with lasting effects and diffusion of program benefits across experimental groups within the worksites. CONCLUSIONS: Although one-year programmatic effects did not remain over time, the long-term pattern of behaviors suggested these worksites as a whole were healthier more than 3 years following the interventions.

A school-based intervention for diabetes risk reduction.

BACKGROUND: We examined the effects of a multicomponent, school-based program addressing risk factors for diabetes among children whose race or ethnic group and socioeconomic status placed them at high risk for obesity and type 2 diabetes. METHODS: Using a cluster design, we randomly assigned 42 schools to either a multicomponent school-based intervention (21 schools) or assessment only (control, 21 schools). A total of 4603 students participated (mean [+/- SD] age, 11.3 [+/- 0.6 years; 54.2% Hispanic and 18.0% black; 52.7% girls). At the beginning of 6th grade and the end of 8th grade, students underwent measurements of body-mass index (BMI), waist circumference, and fasting glucose and insulin levels. RESULTS: There was a decrease in the primary outcome--the combined prevalence of overweight and obesity--in both the intervention and control schools, with no significant difference between the school groups. The intervention schools had greater reductions in the secondary outcomes of BMI z score, percentage of students with waist circumference at or above the 90th percentile, fasting insulin levels (P=0.04 for all comparisons), and prevalence of obesity (P=0.05). Similar findings were observed among students who were at or above the 85th percentile for BMI at baseline. Less than 3% of the students who were screened had an adverse event; the proportions were nearly equivalent in the intervention and control schools. CONCLUSIONS: Our comprehensive school-based program did not result in greater decreases in the combined prevalence of overweight and obesity than those that occurred in control schools. However, the intervention did result in significantly greater reductions in various indexes of adiposity. These changes may reduce the risk of childhood-onset type 2 diabetes. (Funded by the National Institutes of Health and the American Diabetes Association; ClinicalTrials.gov number, NCT00458029.)

Young women's anterior cruciate ligament injuries: an expanded model and prevention paradigm.

Anterior cruciate ligament (ACL) injuries among young female athletes occur at rates three- to eight-times greater than in male competitors and, in general, females experience more sports injuries than males, when balanced for activity and playing time. ACL injuries are a particular concern, as they result in immediate morbidity, high economic costs and may have long-term adverse effects. While several closely monitored ACL injury preventive programmes have been effective, those efforts have not been uniformly protective nor have they achieved widespread use. To date, ACL injury prevention has focused on neuromuscular and anatomical factors without including issues relating more broadly to the athlete. Coincident with greater female sport participation are other influences that may heighten their injury risk. We review those factors, including early single sport specialization, unhealthy dietary behaviours, chronic sleep deprivation and higher levels of fatigue, substance use and abuse, and psychological issues. We augment existing models of ACL injury with these additional dimensions. The proposed expanded injury model has implications for designing injury prevention programmes. High school athletic teams are natural settings for bonded youth and influential coaches to promote healthy lifestyles, as decisions that result in better athletes also promote healthy lifestyles. As an example of how sport teams could be vehicles to address an expanded injury model, we present an existing evidenced-based sport team-centered health promotion and harm reduction programme for female athletes. Widening the lens on factors influencing ACL injury expands the prevention paradigm to combine existing training with activities to promote psychological well-being and a healthy lifestyle. If developed and shown to be effective, those programmes might better reduce injuries and, in addition, provide life skills that would benefit young female athletes both on and off the playing field.

A mediation analysis of the ATHENA intervention for female athletes: prevention of athletic-enhancing substance use and unhealthy weight loss behaviors.

OBJECTIVE: To explain, through mediation analyses, the mechanisms by which ATHENA (Athletes Targeting Healthy Exercise and Nutrition Alternatives), a primary prevention and health promotion intervention designed to deter unhealthy body shaping behaviors among female high school athletes, produced immediate changes in intentions for unhealthy weight loss and steroid/creatine use, and to examine the link to long-term follow-up intentions and behaviors. METHODS: In a randomized trial of 1668 athletes, intervention participants completed coach-led peer-facilitated sessions during their sport season. Participants provided pre-test, immediate post-test, and 9-month follow-up assessments. RESULTS: ATHENA decreased intentions for steroid/creatine use and intentions for unhealthy weight loss behaviors at post-test. These effects were most strongly mediated by social norms and self-efficacy for healthy eating. Low post-test intentions were maintained 9 months later and predicted subsequent behavior. CONCLUSIONS: ATHENA successfully modified mediators that in turn related to athletic-enhancing substance use and unhealthy weight loss practices. Mediation analyses aid in the understanding of health promotion interventions and inform program development.

Risk factors for type 2 diabetes in a sixth- grade multiracial cohort: the HEALTHY study.

OBJECTIVE: HEALTHY is a 3-year middle school intervention program designed to reduce risk factors for type 2 diabetes. The prevalence of diabetes risk factors at baseline in a cohort of 6,358 sixth-grade students is reported. RESEARCH DESIGN AND METHODS: Forty-two schools at seven U.S. sites were randomly assigned to intervention or control. Students participated in baseline data collection during fall of 2006. RESULTS: Overall, 49.3% of children had BMI >or=85th percentile, 16.0% had fasting blood glucose >or=100 mg/dl (<1% had fasting blood glucose >or=126 mg/dl), and 6.8% had fasting insulin >or=30 microU/ml. Hispanic youth were more likely to have BMI, glucose, and insulin levels above these thresholds than blacks and whites. CONCLUSIONS: Sixth-grade students in schools with large minority populations have high levels of risk factors for type 2 diabetes. The HEALTHY intervention was designed to modify these risk factors to reduce diabetes incidence.

Long-term Outcomes of the ATHENA (Athletes Targeting Healthy Exercise & Nutrition Alternatives) Program for Female High School Athletes.

Adolescence and emerging adulthood are critical windows for establishing life-long behaviors. We assessed long-term outcomes of a prospective randomized harm reduction/health promotion program for female high school athletes. The intervention's immediate beneficial effects on diet pill use and unhealthy eating behaviors have been reported; however, tobacco, alcohol and marijuana use were not immediately altered (Elliot et al, 2004). One to three years following graduation, positive benefits in those domains became evident, and intervention students reported significantly less lifetime use of cigarettes, marijuana, and alcohol. Sport teams may be effective vehicles for gender-specific interventions to promote competency skills and deter harmful actions, and those benefits may manifest when acquired abilities are applied in new environments following high school graduation.