Charles E. Basch

Focus Group Interview: An Underutilized Research Technique for Improving Theory and Practice in Health Education

The purpose of this article is to increase awareness about and stimulate interest in using focus group interviews, a qualitative research technique, to advance the state-of- the-art of education and learning about health. After a brief discussion of small group process in health education, features of focus group interviews are presented, and a theoretical framework for planning a focus group study is summarized. Then, litera ture describing traditional and health-related applications of focus group interviews is reviewed and a synthesis of methodological limitations and advantages of this tech nique is presented. Implications are discussed regarding: need for more inductive qualitative research in health education; utility of focus group interviews for research and for formative and summative evaluation of health education programs; appli cability of marketing research to understanding and influencing consumer behav ior, despite notable distinctions between educational initiatives and marketing; and need for professional preparation faculty to consider increasing emphasis on qualita tive research methods.

Review and Analysis of Evaluation Measures Used in Nutrition Education Intervention Research

The purpose of this review is to provide a summary of the kinds of evaluation measures used in 265 nutrition education intervention studies conducted between 1980 and 1999 and an analysis of psychometric issues arising from such a review. The data are summarized in terms of tables for interventions with each of six key population groups: preschool children, school-aged children, adults, pregnant women and breast-feeding promotion, older adults, and inservice preparation of professionals and paraprofessionals. Measures evaluating knowledge and skills or behavioral capabilities were most widely used in studies with preschool, school-aged, and inservice populations (50%-85%) and less widely used in studies with the other groups, particularly breast-feeding promotion (5%). Measures of potential psychosocial mediators or correlates of behavior such as outcome expectancies, self-efficacy, or behavioral intention were used in 90% of behaviorally focused studies with school-aged children and in about 20% of studies with adults. Dietary intake measures were used in almost all studies, primarily food recalls, records, and quantitative food frequency questionnaires. Short frequency instruments involving only foods targeted in the intervention such as fruits and vegetables are increasingly being used. Measures of specific observable behaviors are also increasingly being used. Physiologic parameters were used in about 33% of behaviorally focused interventions with school-aged children and adults, 20% with older adults, and 65% with pregnant women and/or their infants. Criterion validity of newly developed intake instruments and content validity of instruments measuring mediating variables were reported in the majority (range 50%-90%) of studies. Reliability and stability of measures of mediating variables were reported in 50% to 75% of studies, with reliability coefficients mostly about .6 to .7. Two major conclusions from this review are that evaluation measures should be appropriate to the purpose, duration, and power of the intervention and that measures should have adequate validity and reliability in relation to both the outcomes and characteristics of the target audience. Major implications are that considerable preliminary work needs to be done before any intervention study to develop and test evaluation instruments so that they are appropriate and have adequate psychometric properties, and cognitive testing of published instruments with each new target audience is essential. We will then be better able to make judgments about the effectiveness of nutrition education.

Body Image, Weight, and Food Choices of Latina Women and Their Young Children

OBJECTIVE To investigate body image perceptions of women about themselves and their young children and their relationship to their food choices and those of their children. DESIGN Descriptive and correlational study. PARTICIPANTS AND SETTING 187 low-income, Latina women and their children, ages 5 to 7 years and 52% female, in New York City. VARIABLES MEASURED Body image, food frequency, body mass index (BMI) of mothers and children, and food choice criteria of mothers for their children. ANALYSIS Descriptive statistics and correlations. RESULTS All of the women selected a relatively thin body image as the most desirable, attractive, fit, and healthy (about 2.5 on a scale of 1-7). Body size dissatisfaction or wish to be thinner was significantly associated with more healthful diets. Tertiles (thirds) of children at the 50th and 75th mean BMI-for-age percentiles were thought to be too thin to be attractive or healthy and the third of children with a mean above the 97th percentile only barely too large. Mothers with the highest body mass indices may make the least healthful choices for their children. CONCLUSIONS AND IMPLICATIONS These Latina women preferred a thin figure for themselves but a plumper figure for their children. Culturally competent nutrition education incorporating body image issues needs to assist mothers in understanding the health consequences of childhood obesity, recognizing when their children are overweight, and understanding the importance of healthful food choices for their children.

A Review of Five Major Community-Based Cardiovascular Disease Prevention Programs. Part II: Intervention Strategies, Evaluation Methods, and Results

Major community-based cardiovascular disease prevention programs have been conducted in North Karelia, Finland; the state of Minnesota; Pawtucket, Rhode Island; and in three communities and more recently in five cities near Stanford, California. The main hypothesis is that community intervention will reduce the prevalence of cardiovascular disease risk factors and consequently reduce cardiovascular disease incidence, morbidity, and mortality. Intervention strategies include community mobilization, social marketing, school-based health education, worksite health promotion, screening and referral of those at high risk, education of health professionals, direct education of adults, and modification of physical environments. Formative evaluation provides short-term feedback to program managers about immediate effects of intervention strategies. Outcome evaluation examines the effects of intervention on longitudinally sampled cohorts and compares cardiovascular risk status and morbidity and mortality in intervention and comparison communities. Results from North Karelia and the Stanford Three Community Study indicate that this model is efficacious and cost-effective. The National Heart, Lung, and Blood Institute biomedical research spectrum envisions research in knowledge transfer and innovation diffusion as the last link in the causal chain whereby research affects the health of the population, but research in this area remains undeveloped compared to other aspects of cardiovascular disease prevention. This is Part II of a two part article; Part I appeared in Volume 4, Number 3.

A Review of Five Major Community-Based Cardiovascular Disease Prevention Programs. Part I: Rationale, Design, and Theoretical Framework

Major community-based cardiovascular disease prevention programs have been conducted in North Karelia, Finland; the state of Minnesota; Pawtucket, Rhode Island; and in three communities and more recently in five cities near Stanford, California. These primary prevention programs aim to reduce cardiovascular disease incidence by reducing risk factors in whole communities. These risk factors are smoking, high blood cholesterol, diet high in cholesterol and saturated fat, hypertension, sedentary lifestyle, and obesity. This strategy may be contrasted with secondary prevention programs directed at patients who already have symptomatic cardiovascular disease and “high risk” primary prevention programs directed at individuals found through screening to have one or more risk factors. The design of the five major programs is similar in that intervention communities are matched for purposes of evaluation with nearby comparision communities. Underlying these programs are theories of community health education, social learning, communication, social marketing, and community activation, as well as more traditional biomedical and public health disciplines. This is Part I of a two-part article.

Telephone Outreach to Increase Colorectal Cancer Screening in an Urban Minority Population

OBJECTIVES We compared the effectiveness of a telephone outreach approach versus a direct mail approach in improving rates of colorectal cancer (CRC) screening in a predominantly Black population. METHODS A randomized trial was conducted between 2000 and 2003 that followed 456 participants in the New York metropolitan area who had not had recent CRC screening. The intervention group received tailored telephone outreach, and the control group received mailed printed materials. The primary outcome was medically documented CRC screening 6 months or less after randomization. RESULTS CRC screening was documented in 61 of 226 (27.0%) intervention participants and in 14 of 230 (6.1%) controls (prevalence rate difference=20.9%; 95% CI = 14.34, 27.46). Compared with the control group, the intervention group was 4.4 times more likely to receive CRC screening within 6 months of randomization. CONCLUSIONS Tailored telephone outreach can increase CRC screening in an urban minority population.

Promoting the selection of low-fat milk in elementary school cafeterias in an inner-city Latino community: evaluation of an intervention.

OBJECTIVES This study examined the effects of a school-based intervention designed to promote the consumption of low-fat white milk at lunchtime in 6 elementary schools in an inner-city, primarily Latino neighborhood. METHODS A multifaceted intervention based on social marketing techniques was delivered at 3 randomly selected schools. The school was the unit of assignment and analysis; 6902 children were involved in the study. Milk selection and consumption were measured by sampling discarded milk and/or tallying milk carton disappearance at baseline, immediately postintervention, and at 3 to 4 months follow-up. RESULTS Immediately postintervention, the mean proportion of sampled milk cartons that contained low-fat milk increased in the intervention schools, from 25% to 57%, but remained constant at 28% in the control schools. Differences between intervention and control schools remained significant at 3 to 4 months follow-up. The intervention was not associated with a decrease in overall milk consumption. CONCLUSIONS A school-based intervention can lead to significant increases in student consumption of low-fat milk.

Breakfast and the Achievement Gap Among Urban Minority Youth

OBJECTIVES To outline the prevalence and disparities of breakfast consumption among school-aged urban minority youth, causal pathways through which skipping breakfast adversely affects academic achievement, and proven or promising approaches for schools to increase breakfast consumption. METHODS Literature review. RESULTS On any given day a substantial proportion of American youth do not eat breakfast. On an average day, less than half (∼46%) of children participating in free or reduced-price lunch also participated in the School Breakfast Program for which they were also eligible. In a large study of 9-year-olds, 77% of White girls and 57% of Black girls consumed breakfast on all 3 days assessed; by age 19, the respective rates were 32% and 22%. Neuroscience research has identified the processes by which dietary behavior influences neuronal activity and synaptic plasticity, both of which influence cognitive functions. Participation in School Breakfast Programs has also been associated with reduced absenteeism. Universal School Breakfast Programs and allowing youth to eat breakfast in the classroom (vs cafeteria) are approaches that have been shown to increase participation. CONCLUSIONS Skipping breakfast is highly and disproportionately prevalent among school-aged urban minority youth, has a negative impact on academic achievement by adversely affecting cognition and absenteeism, and effective practices are available for schools to address this problem. Despite wide availability, the majority of American youth do not participate in School Breakfast Programs. High-quality universal breakfast programs that allow students to eat breakfast in the classroom are especially needed for youth who are not likely to get good nutrition the rest of the day.

The effect of health education on the rate of ophthalmic examinations among African Americans with diabetes mellitus.

OBJECTIVES This study evaluated a multicomponent educational intervention to increase ophthalmic examination rates among African Americans with diabetes. METHODS A randomized trial was conducted with 280 African Americans with diabetes, enrolled from outpatient departments of 5 medical centers in the New York City metropolitan area, who had not had a dilated retinal examination within 14 months of randomization (65.7% female, mean age = 54.7 years [SD = 12.8 years]). RESULTS After site differences were controlled, the odds ratio for receiving a retinal examination associated with the intervention was 4.3 (95% confidence interval = 2.4, 7.8). The examination rate pooled across sites was 54.7% in the intervention group and 27.3% in the control group. CONCLUSIONS The intervention was associated with a rate of ophthalmic examination double the rate achieved with routine medical care.

The availability of low-fat milk in an inner-city Latino community: implications for nutrition education.

Substitution of low-fat for whole milk is an important strategy for reducing saturated fat consumption, but intake of whole milk remains high among Latinos. To assess whether this is related to the unavailability of low-fat milk, we surveyed 251 grocery stores (bodegas) and 25 supermarkets in a predominantly low-income, urban Latino community. Low-fat milk was available in 73% of bodegas and 96% of supermarkets, but it constituted only 15% of total milk volume in bodegas and 37% of that volume in supermarkets. Since lack of availability was not a major obstacle to increasing low-fat milk consumption, public health nutrition campaigns should focus on increasing consumer demand.