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.

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.

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.

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.

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.

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.

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.

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.

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.

Program characteristics and organizational factors affecting the implementation of a school-based indicated prevention program.

Reconnecting Youth (RY) is a school-based drug prevention program designed to address academic, substance use and mood management goals among youth at risk of dropping out of high school. This paper presents the organizational factors and RY program characteristics that either promoted or hindered the implementation of the program during a randomized controlled effectiveness trial in 10 schools in two school districts in the United States. Data were collected using surveys and interviews from teachers and school and district staff who participated in the implementation of the RY program in these schools. Results suggest that certain RY program characteristics made it difficult to implement. Small class size, resource-intensive procedures for student selection and recruitment and special training, qualities and skills needed to be an effective RY teacher meant that schools had to significantly change their usual practices to implement the program. Organizational barriers included a lack of financial resources and leadership support for program implementation, and low priority for non-academic courses for high-risk students. Transient student populations, staff turnover and district-wide scheduling and curriculum changes all resulted in high levels of organizational turbulence at most schools, further hindering program implementation.

Implementation examined in a health center-delivered, educational intervention that improved infant growth in Trujillo, Peru: successes and challenges.

Process evaluation was used to examine the implementation of a randomized, controlled trial of an education intervention that improved infant growth in Trujillo, Peru. Health personnel delivered the multi-component intervention as part of usual care in the government health centers. Quantitative and qualitative methods were used to examine process indicators, which included the extent of delivery (dose), fidelity to intervention protocol, barriers to implementation and context. Results demonstrated that most intervention components were delivered at a level of 50-90% of expectations. Fidelity to intervention protocol, where measured, was lower (28-70% of expectations). However, when compared with existing nutrition education, as represented by the control centers, significant improvements were demonstrated. This included both improved delivery of existing educational activities as well as delivery of new intervention components to strengthen overall nutrition education. Barriers to, and facilitators of, implementation were explored with health personnel and helped to explain results. This study demonstrates the importance of examining actual versus planned implementation in order to improve our understanding of how interventions succeed. The information gained from this study will inform future evaluation designs, and lead to the development and implementation of more effective intervention programs for child health.

Fidelity of implementation in a treatment effectiveness trial of Reconnecting Youth.

In 'a treatment effectiveness trial', a program is evaluated in a real-world setting, with an emphasis on achieving high implementation fidelity. Through fidelity assessment, the link between program implementation and outcomes is systematically evaluated and ultimately leads to a greater understanding of program success or failure. This paper reports the results of an implementation fidelity study of the 'Reconnecting Youth' (RY) prevention program. The research questions were (i) was the program implemented with fidelity? and (ii) did better fidelity predict better outcomes? RY is an indicated drug abuse prevention program for high school students that seeks to 'reconnect' high-risk youth to school before they drop out. The results reported here were part of a randomized controlled effectiveness trial of the RY prevention program conducted in two urban school districts in which 15 teachers taught 41 RY classes. Overall, implementation fidelity was high with an average 90% of core lessons being taught. Unexpectedly, increased quality of implementation predicted increased alcohol use and anger. Adherence (teaching more of the curriculum) predicted increased marijuana use, while exposure (student attendance) significantly increased bonding to high-risk peers, alcohol use and anger.

A description of the social-ecological framework used in the trial of activity for adolescent girls (TAAG).

Social-ecological (SE) models are becoming more widely used in health behavior research. Applying SE models to the design of interventions is challenging because models must be tailor-made for each behavior and population, other theories need to be integrated into multi-level frameworks, and empirical research to guide model development is limited. The purpose of the present paper is to describe a SE framework that guided the intervention and measurement plans for a specific study. The trial of activity for adolescent girls (TAAG) is a multi-center study of interventions to reduce the decline of physical activity in adolescent girls. The TAAG framework incorporates operant learning theory, social cognitive theory, organizational change theory and the diffusion of innovation model in a multi-level model. The explicit and practical model developed for TAAG has already benefited the study and may have elements that can generalize to other health promotion studies.

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.

Feasibility of screening adolescents for suicide risk in "real-world" high school settings.

OBJECTIVES: We evaluated the feasibility of a population-based approach to preventing adolescent suicide. METHODS: A total of 1323 students in 10 high schools completed the Suicide Risk Screen. Screening results, student follow-up, staff feedback, and school responses were assessed. RESULTS: Overall, 29% of the participants were rated as at risk of suicide. As a result of this overwhelming percentage, school staffs chose to discontinue the screening after 2 semesters. In further analyses, about half of the students identified were deemed at high risk on the basis of high levels of depression, suicidal ideation, or suicidal behavior. Priority rankings evidenced good construct validity on correlates such as drug use, hopelessness, and perceived family support. CONCLUSIONS: A simpler, more specific screening instrument than the Suicide Risk Screen would identify approximately 11% of urban high school youths for assessment, offering high school officials an important opportunity to identify young people at the greatest levels of need and to target scarce health resources. Our experiences from this study show that lack of feasibility testing greatly contributes to the gap between science and practice.