Heather J. Walter

Modification of risk factors for coronary heart disease: Five-year results of a school-based intervention trial

We conducted a study of the effectiveness of an educational intervention designed to modify risk factors associated with coronary heart disease among 3388 children in 37 schools in two demographically dissimilar areas (the Bronx and Westchester County) in and around New York City. Schools within each area were randomly assigned to either intervention or nonintervention groups. In schools targeted for intervention, children in the fourth through eighth grades were taught a teacher-delivered curriculum focusing on diet, physical activity, and cigarette smoking. Risk-factor levels were measured in all schools at base line and at four follow-up points. A total of 1769 of the children qualified for analysis of the intervention effect. After five years, the net mean change in plasma levels of total cholesterol was -1.7 mg per deciliter per year (-0.04 mmol per liter) (95 percent confidence interval, -2.7 to -0.7 mg per deciliter [-0.07 to -0.02 mmol per liter]) in the Westchester County schools, or -8.5 mg per deciliter (-0.22 mmol per liter) (5.1 percent) over a period of five years. In the schools in the Bronx, the net mean change was -1.0 mg per deciliter per year (-0.03 mmol per liter) (95 percent confidence interval, -2.3 to +0.3 mg per deciliter [-0.06 to +0.01 mmol per -2.3 to +0.3 mg per deciliter [-0.06 to +0.01 mmol per liter]), or -5.0 mg per deciliter (-0.13 mmol per liter) (2.9 percent) over a period of five years. Favorable trends in dietary intake and health knowledge were also observed, whereas the other targeted risk factors were not significantly altered. If these findings can be replicated, this will suggest that educational programs to modify coronary risk factors are feasible and may have a favorable (albeit small) effect on blood levels of cholesterol in children.

Self-Efficacy for AIDS Preventive Behaviors among Tenth Grade Students

To guide acquired immunodeficiency syndrome (AIDS) prevention program planning, 181 tenth grade students residing in or near an AIDS epicenter completed a survey measuring past year involvement in sexual intercourse and condom use, beliefs about self-efficacy for AIDS preventive behaviors, and beliefs about susceptibility to and severity of AIDS, and outcome efficacy of AIDS preventive actions. A degree of uncertainty existed for all areas of self-efficacy surveyed: refusing sexual intercourse under a variety of circumstances, questioning sex partners about past risky behaviors, and correct and consistent condom use. Students were most uncertain of their ability to refuse sex with a desirable partner, under pressure, or after drinking alcohol or using marijuana; to purchase condoms, or use them consistently after drinking alcohol or using marijuana; and to question partners about past homosexual history. Those students with lower self-efficacy for refusing sex were twice as likely to have had sexual intercourse. Similarly, those students with lower self-efficacy for correct, consistent condom use were five times less likely to have used condoms consistently. These associations remained even after adjusting for the influence of other AIDS-related beliefs. Implications of these findings focus on exploiting the link between self-efficacy and behavior by building a prevention program that emphasizes skills-building rather than the traditional knowledge-only approach.

Characteristics of users and nonusers of health clinics in inner-city junior high schools.

PURPOSE To compare the demographic, behavioral, psychosocial, and academic characteristics of users versus nonusers of inner-city junior high school-based health clinics. METHODS Students who used (n = 1344) and did not use (n = 2394) the health clinics based in four junior high schools in an economically disadvantaged, medically underserved New York City school district were compared on their responses to a health risk survey administered at the end of the 1991/92 academic year. RESULTS Compared to students who did not use the clinics, students who used the clinics were more likely to have had unprotected sexual intercourse, to have had suicide intentions or attempts, to be suspended from school for fighting, to be exposed to violence and the illicit drug culture, to hold beliefs favoring involvement in sexual intercourse and suicidality, and to have failed subjects in school. CONCLUSIONS Users of these junior high school-based health clinics are engaging in behaviors and hold beliefs that place them at risk for serious adverse health outcomes. School-based clinics have the potential to provide early intervention for these high risk adolescents.

Comparison of Three Theoretical Models of Substance Use among Urban Minority High School Students

OBJECTIVE This study compares the relative explanatory power of three theoretical models of substance use among urban minority high school students. METHOD A substance use survey was administered in the spring of 1991 to a randomly selected sample of classrooms in the ninth through twelfth grades of three public academic high schools in a New York City borough. Survey participants (N = 919) were 59% black and 34% Hispanic; the mean age was 16.4 years. RESULTS Substantial proportions of this sample of students reported experimental or occasional alcohol and cigarette use in the past year, and approximately one-tenth reported frequent use of these substances. Only small proportions of students reported past-year marijuana use, and few or no students reported past-year use of cocaine, crack or intravenous heroin. The socialization model of substance use was much more powerful than either the stress/strain or disaffiliation models in explaining past-year use of alcohol, cigarettes, and marijuana. However, certain variables derived from the stress/strain and disaffiliation models were important risk factors for the frequent use of these substances. CONCLUSIONS These findings suggest that the further elucidation of the social influence process among adolescents, and the development, implementation, and evaluation of especially intensive programs aimed at high-risk youths, should become adolescent substance use prevention research priorities.

Factors Associated with AIDS-Related Behavioral Intentions among High School Students in an AIDS Epicenter:

Using data from a cross-sectional survey of 531 predominantly black and Hispanic 10th graders in two New York City schools, the explanatory power of predictors of intentions to engage in sexual intercourse, to have multiple intercourse partners, and to use condoms was compared. Theoretically derived predictor variables (i.e., susceptibility, severity, benefits, barriers, self-efficacy, values, norms) were derived from the health belief model, social cognitive theory, and a model of social influence. One half of sampled students definitely intended to have sexual intercourse in the next year, one tenth definitely intended to have multiple partners, and two thirds definitely intended to use condoms. In multivariate analyses, variables derived from the model of social influence and from social cognitive theory were most strongly associated with the three investigated behavioral intentions; however, certain background and health belief variables also contributed to the explained variance in intercourse and multiple partner intentions.

Socioeconomic status, ethnic origin, and risk factors for coronary heart disease in children

The associations between socioeconomic status, ethnic origin, and risk factors for CHD were studied in 2,591 white and black children from two socioeconomically dissimilar populations in the New York City area. The study subjects were selected from all fourth graders in 44 elementary schools. Blood pressure, plasma lipids, body mass index, and physical fitness were measured. In a random subsample of 353 subjects, a 24-hour dietary recall interview was performed. White children in the lower socioeconomic area had the most unfavorable risk factor profile. Differences between the groups in mean level of plasma total cholesterol primarily were associated with factors related to area of residence. Children in a lower socioeconomic environment may be considered to be candidates for especially intensive intervention strategies for the primary prevention of CHD.

A Pilot Demonstration of Comprehensive Mental Health Services in Inner-City Public Schools.

BACKGROUND National policy statements increasingly espouse the delivery of comprehensive mental health services in schools. In response to the limited evidence supporting this recommendation, the purpose of this study was to assess the need for, and feasibility, desirability, and outcomes of a full model of comprehensive mental health services in 2 public elementary schools in inner-city neighborhoods. METHODS The program, based upon a national model for comprehensive school mental health services, comprised universal and indicated preventive as well as clinical interventions designed to target needs identified in a baseline screening survey. The program was implemented over 1 school year by mental health professionals in collaboration with school teachers. Mental health outcomes comparing baseline to follow-up data were assessed in multiple domains among students and teachers. RESULTS After 1 year of intervention, students had significantly fewer mental health difficulties, less functional impairment, and improved behavior, and reported improved mental health knowledge, attitudes, beliefs, and behavioral intentions. Teachers reported significantly greater proficiency in managing mental health problems in their classrooms. School staff overwhelmingly endorsed satisfaction with the program. CONCLUSION If the observed favorable findings from this pilot demonstration can be replicated in methodologically rigorous studies, additional support would be garnered for national policy recommendations about comprehensive school mental health services.

Risk Factors for Substance Use among High School Students: Implications for Prevention

To identify salient risk factors for drug use that could be targeted for modification in prevention programs, a survey was administered to a sample of 1,091 urban and suburban 10th grade students. Substantial proportions of students reported alcohol alcohol and cigarette use in the past year, and around 10% reported heavy use of these substances. In general, the measured risk factors most strongly associated with the use of alcohol, cigarettes, and marijuana were those derived from the socialization model of substance use; however, certain factors derived from the stress/strain and disaffiliation models also were related to increased drug use risk.

Cardiovascular risk factors among black schoolchildren: Comparisons among four know your body studies

Baseline cardiovascular risk factor variables were obtained from 1,041 black District of Columbia children in Grades 4-6 as part of a Know Your Body evaluation project. Screening included height, weight, triceps skinfold measurements, systolic and diastolic blood pressures, step-test for fitness, serum cholesterol, high-density lipoprotein cholesterol and thiocyanate. Results were compared with those in three other Know Your Body studies, Bronx, New York, Westchester, New York, and Los Angeles, and indicated that District of Columbia black children are more likely to have high cholesterol levels and to fail the fitness test than black children in the other studies. In the District of Columbia, obese children had significantly higher total serum cholesterol, systolic, diastolic, and high-density lipoprotein levels, and were less fit than other District of Columbia children; almost three-fourths of all of the children had one or more risk factors. Socioeconomic status was negatively correlated with diastolic blood pressure, skinfold thickness, and cholesterol levels and was positively correlated with high-density lipoprotein cholesterol. Rates of obesity and diastolic blood pressure were consistent with Bronx and Westchester comparisons suggesting that socioeconomic status interacts with ethnicity to determine risk factor levels. The existence of children with multiple risk factors in all of the Know Your Body studies supports the need for early intervention.

Collaborative Care for Children With ADHD Symptoms: A Randomized Comparative Effectiveness Trial

OBJECTIVES: Although many attention-deficit/hyperactivity disorder (ADHD) care models have been studied, few have demonstrated individual-level symptom improvement. We sought to test whether complementing basic collaborative care with interventions that address common reasons for symptom persistence improves outcomes for children with inattention and hyperactivity/impulsivity. METHODS: We conducted a randomized comparative effectiveness trial of 2 care management systems for 6- to 12-year-old children being evaluated for ADHD (n = 156). All participants received care management with decision support. Care managers in the enhanced care arm also were trained in motivational and parent management techniques to help parents engage in their child’s treatment, address their own mental health needs, and manage challenging child behaviors. We used multivariable models to assess inattention, hyperactivity/impulsivity, oppositionality, and social skills over 1 year. RESULTS: Both treatment arms generated guideline concordant diagnostic processes in 94% of cases; 40% of children had presentations consistent with ADHD. For the entire sample, there were no differences in symptom trajectories between study arms; mean differences in change scores at 12 months were –0.14 (95% confidence interval –0.34 to 0.07) for inattention; –0.13 (–0.31 to 0.05) for hyperactivity/impulsivity; –0.09 (–0.28 to 0.11) for oppositionality; and 3.30 (–1.23 to 7.82) for social skills. Among children with ADHD-consistent presentations, enhanced arm participants experienced superior change scores for hyperactivity/impulsivity of –0.36 (–0.69 to –0.03), oppositionality –0.40 (–0.75 to –0.05), and social skills 9.57 (1.85 to 17.28). CONCLUSIONS: Among children with ADHD-consistent presentations, addressing barriers to engagement with care and challenging child behaviors has potential to improve the effectiveness of collaborative care.