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Effects of interactive multimedia for the prevention of obesity on self-efficacy, beliefs about physical activity, and social influence

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Effects of interactive multimedia for the prevention of obesity on self-efficacy, beliefs about physical activity, and social influence

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Content EFFECTS OF INTERACTIVE MULTIMEDIA FOR THE PREVENTION
OF OBESITY ON SELF-EFFICACY, BELIEFS ABOUT PHYSICAL
ACTIVITY, AND SOCIAL INFLUENCE
by
Susan K. Chung
A Dissertation Presented to the
FACULTY OF THE ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION
August 2004
Copyright 2004 Susan K. Chung
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UMI Number: 3145183
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ACKNOWLEDGMENTS
I would like to first and foremost acknowledge
God— to Him be the glory for being my rock and my
foundation, allowing me to know that I can do all
things through Jesus Christ who strengthens me.
Also, my deepest gratitude goes to my family: To
my husband (or fiance at the time) for his amazing
patience and gentle encouragement. To my father, for
always being on my side and having confidence in my
abilities. And to my mother, for her constant and
never-ending support.
Finally, this dissertation would not have been
possible without the expert guidance of my esteemed
advisor, Dr. Robert Rueda. Not only was he readily
available for me, as he so generously is for all of
his students, but he always read and responded to the
drafts of each chapter of my work more quickly than I
could have hoped. Although he is not a man of many
words, his oral and written comments are always
extremely perceptive, helpful, and appropriate. I am
also very grateful for having an exceptional doctoral
ii
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committee and wish to acknowledge Dr. Edward
Kazlauskas and Dr. Maurice Hitchcock for their
continual support and encouragement.
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TABLE OF CONTENTS
ACKNOWLEDGEMENTS ................ ii
LIST OF TABLES........................................ vi
ABSTRACT..............................................vii
Chapter
1 . THE PROBLEM.......................................1
The Problem Situation............................2
Purpose of the Study....... 7
Importance of the Study......................... 8
Research Questions and Hypothesis.............10
Conceptual Assumptions......................... 11
Delimitations....................................11
Limitations......................................12
Organization of this Study.....................12
2. REVIEW OF RELEVANT LITERATURE..................15
Health Significance of Childhood Obesity 15
Need for Effective Health Education ........ 19
Previous Studies Relating to
the Prevention of Obesity...................21
Review of Epidemiological Studies:
Physical Activity............................24
Review of Intervention Studies:
Physical Activity............................34
Theoretical Basis of Behavioral
Intervention................................. 54
Social Learning Theory and
Social Cognitive Theory.....................55
Potential Use of Interactive Multimedia
on Obesity....................................57
Summary.......................................... 68
iv
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3. METHODS AND PROCEDURES........................... 71
Design............................................71
Sample 7 3
Measures ......... 7 4
Procedures.......................................78
Data Analysis....................................81
Methodological Assumptions.....................82
4. RESULTS............................................ 84
Analysis of Findings............................84
The Effect in Relation to Self-efficacy
Measures Regarding Physical Activity.......88
The Effect in Relation to Beliefs About
Physical Activity Measures
Regarding Physical Activity.................93
The Effect in Relation to Social Influence
Measures Regarding Physical Activity.......94
5. SUMMARY, DISCUSSION, AND RECOMMENDATIONS.......96
Summary.......................................... 96
Discussion....................................... 99
Recommendations................................ 102
SELECTED REFERENCES................................. 106
APPENDIX DATA COLLECTION MATERIALS............... 123
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LIST OF TABLES
Table
1. Physical Activity Epidemiological Studies
in Elementary and Middle School-aged
Children.......................................... 25
2. Physical Activity Intervention Studies:
Elementary and Middle
School-Aged Interventions....................35
3. Multimedia Intervention Studies: CD-ROM
Interventions for Children...................58
4. Demographics...................................... 75
5. Self-efficacy Measures: Pre-test
Versus Post-test Using a McNemar's Test ....86
6. Beliefs About Physical Activity Measures:
Pre-test Versus Post-test Using
a McNear's Test............................... 89
7. Social Influence Measures: Pre-Test
Versus Post-Test Using a McNemar's Test .... 91
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ABSTRACT
Obesity and overweight are important public
health concerns associated with a variety of
physiological, psychological, and social consequences
in children. Obesity-related diseases are one of the
leading causes of death, only second to tobacco-
related diseases. In the United States, more than $70
billion annually is spent on health-care costs
associated with obesity. Current data suggest that
25% of the children that live in the United States are
overweight. Obesity that begins in early life can
persists into adulthood and result in serious
illnesses. Obesity can result in higher risk for
heart disease, stroke, diabetes, hypertension, some
forms of cancer, gall bladder, and joint diseases.
Obesity can lead to bowing of the legs and pain
in the hip joints due to excess weight on the bones
and joints. Obese children may develop severe
headaches which can even lead to loss of vision. They
may suffer from daytime sleepiness or breathing
difficulty during sleep. Obese females may develop a
condition called "polycystic ovary disease" which can
vii
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lead to excess hair over the body and problems with
the menses (Cohen, 2001).
Interactive Multimedia for the Promotion of
Physical Activity, an obesity prevention program for
fourth-grade children, includes a CD-ROM, classroom,
and family/homework sessions that promote physical
activity. The interactive multimedia intervention
focuses on individual, behavioral, and environmental
factors, and merges constructs from Social Cognitive
Theory (SCT). The focus of this study was to examine
Interactive Multimedia for the Promotion of Physical
Activity (IMPACT) to evaluate the psychosocial
correlates of physical activity, specifically focusing
on self-efficacy, beliefs about physical activity, and
social influences.
viii
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CHAPTER 1
THE PROBLEM
Obesity among children and adolescents has
experienced an alarming increase in the United States.
Most available treatments for obese children have
yielded only modest, unsustained effects.
Consequently, prevention is considered to hold the
greatest promise. Unfortunately, most prevention
programs that specifically attempt to reduce fat and
energy intake and increase physical activity have been
ineffective at changing body composition. As a result,
there is a need for innovative approaches to prevent
obesity. Schools have access to large numbers of
children in an environment that has the potential to
support healthy behavior and is favorable for the
delivery of health promotion programs. Primary
schools are particularly suitable for interventions as
children in this age group are responsive to health
messages and behavioral changes may be maintained into
adolescence and adulthood.
1
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The Problem Situation
Obesity, defined as a body weight greater than
120% of ideal body weight, is now considered a disease
of epidemic proportions. Obesity can result in higher
risk for heart disease, stroke, diabetes, hypertension
some forms of cancer, and gall bladder and joint
diseases. Research indicates that these health risks
apply not only to obese and overweight adults but
children and adolescents as well (Birch & Fisher,
1998). Obesity that begins early in life persists
into adulthood (Abraham, Collins, & Nordsieck, 1970;
Charney, Goodman, MacBride, Lyon, & Pratt, 1976; Stark
Atkins, Wolff, & Douglas, 1981), and increases the
risk of obesity-related morbidity later in life (Must,
Jacques, Dallal, Bajema, & Dietz, 1992). Obesity can
lead to bowing of the legs and pain in the hip joints
due to excess weight on the bones and joints. Obese
children may develop severe headaches, which can even
lead to loss of vision. They may suffer from daytime
sleepiness or breathing difficulty during sleep.
Obese females may develop a condition called
"polycystic ovary disease" which can lead to excess
2
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hair over the body and problems with the menses (Cohen
2001).
Obesity currently affects 25% of children in the
United States (U.S.) and this number is likely to be
higher when more recent estimates become available
(Troiano, Flegal, & Kuczmarski, 1995). In adolescents
data demonstrates that the national prevalence of
obesity has risen from 15% (for the period 1976-1980)
to 21% (for the period 1988-1991). An analysis of
secular trends suggests a clear upward trend for body
weight and adiposity in children by 0.2 kg per year
between 1973 and 1994 (Freedman, Srinivansan, & Valdez
1997). In addition, childhood obesity is more
prevalent among minority sub-groups of the population.
A local school in Birmingham, Alabama reports the
prevalence of obesity at age 10 is 21% in Caucasian
boys and girls, 26% in African-American boys, and 38%
in African-American girls (Figueroa-Colon, Franklin, &
Lee, Aldridge, & Alexander, 1997). The higher
prevalence of obesity in African Americans, and
particularly among women, may explain why the
mortality rate from cardiovascular disease in African-
3
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American women is two to four times higher than
Caucasian women (Morrison, Payne, Barton, Khoury, &
Crawford, 1994; The National Heart, Lung, and Blood
Institute (NHLBI) Growth and Health Study Research
Group, 1992). Children are at increased risk for the
development of obesity during adolescent growth (Diet
1994), and during adiposity rebound (the age at which
body mass index reaches a low point) at age 5-6 years
(Whitaker, Pepe, Wright, Seidel, & Dietz, 1998).
There have been two studies which provide clear
indication of the epidemiological impact of childhood
obesity on overall health risk. First, offspring of
parents with coronary heart disease were found to be
more overweight during childhood and also developed an
adverse lipid risk profile at a faster rate (Bao,
Srinivasan, Valdez, Greenlund, Wattigney, & Berenson,
1997). Second, the incidence of type 2 diabetes,
typically thought of as an adult disease, has
increased 10-fold in children in recent years, and
this increase is most apparent among obese children
(Pinhas-Hamiel, Dolan, Daniels, Standiford, Khoury, &
Zeitler, 1998).
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Health education is an integral part of the total
education of the child and virtually every state,
district, and school in the United States requires
physical education for students. Quality health
education programs are needed to increase the physical
competence, health-related fitness, self-esteem, and
enjoyment of physical activity for all students so
that they can be physically active for a lifetime.
Knowing that physical activity promotes health is not
enough. Students must be given opportunities to gain
the knowledge and skills needed to adopt active
lifestyles. Physical education teaches students how
to add the habit of physical activity into their daily
lives by aligning instruction with the National
Standards for Physical Education (National Council for
Accreditation of Teacher Education, 2001), and by
providing content and learning experiences that
develop the skills and desire to be active for life.
Physical activity improves muscular strength and
endurance, flexibility, and cardiovascular endurance,
as well as serves as a vehicle that helps children
establish self-esteem and strive for achievable,
5
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personal goals. Moderate physical activity can
substantially reduce the risk of developing or dying
from heart disease, diabetes, colon cancer, and high
blood pressure. The U.S. Department of Health and
Human Services (1991) recommends that all children
aged 5 years or older should engage in at least 30
minutes of daily physical activity at a moderate
intensity, and vigorous physical activity for 30
minutes at least 3 days per week.
Physical education is mandated for the health and
well-being of students but due to the standards-based
reform, the reality is that less than 35% of schools
offer daily physical education (Harsha, 1995). This
may even include their lunch and recess time where
students can choose to remain inactive. Physical
education budgets are being cut, which means less
teachers and facilities. In the United States, high
school gym attendance was 42% in 1991 and decreased to
25% in 1995. The standards-reform movement has forced
teachers to utilize their instruction time to focus on
the subject areas in which students will be tested.
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Physical education is an essential part of the
core curriculum and, as such, deserves equal priority
in■scheduling with other curricular areas.
Unfortunately, many other administrators express the
view that, while acknowledging that physical education
is important to child development and school
activities, they consider it to be an enrichment
activity unworthy of high priority, especially if a
school's goal is improving poor academic performance.
Purpose of the Study
Interactive Multimedia for the Promotion of
Physical Activity, an obesity prevention program for
fourth grade children, includes CD-ROM, classroom, and
family/homework sessions that promote physical
activity. The interactive multimedia intervention,
developed through collaboration of researchers,
teachers, script writers, and production team members,
focuses on individual, behavioral, and environmental
factors and merges constructs from Social Cognitive
Theory (SCT). The focus of this study is to examine
Interactive Multimedia for the Promotion of Physical
7
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Activity (IMPACT) to evaluate the psychosocial
correlates of physical activity specifically focusing
On self-efficacy, beliefs about physical activity, and
social influences.
Importance of the Study
Only a few interactive multi-media tools have
been developed for nutrition and health-related
education in children, but none are based on a
theoretical approach and have been tested for their
outcome effects for behavior change. Also, there is
no information on interactive multi-media tools
relating to the promotion of physical activity in
children.
Schools are an extremely important and useful
site for instituting obesity prevention programs since
the majority of children attend school and a great
deal of a child's eating and exercise is carried out
in this setting. School-based programs that encourage
physical activity are important for increasing
children's energy expenditure, because children are
less likely to participate in physical activity in the
8
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absence of adult supervision (Sallis, McKenzie,
Alcaraz, Kolody, Hovell, & Nader, 1993). These
programs may also create expectations for regular
physical activity that may persist into adulthood. In
order to increase physical activity among children
regardless of their athletic abilities, the Center for
Disease Control (1994) recommends daily physical
education classes that emphasize health-related
fitness activities over activities reguiring specific
athletic abilities. However, in 2001 only half of
high school students participated in physical
education classes and less than one third of students
had physical education daily. In addition to
requiring physical education, other opportunities for
schools to increase energy expenditure include
encouraging physical activity during recess and
providing after-school sports and health-related
fitness programs (Center for Disease Control and
Prevention, 1994).
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Research Questions and Hypothesis
This study sought to answer the following questions:
1. After participating in an interactive multimedia
obesity prevention program, to what extent, if
any, were fourth grade students affected in
relation to their self-efficacy regarding
physical activity?
2. After participating in an interactive multimedia
obesity prevention program, are fourth grade
students' beliefs about the nature of physical
activity significantly changed?
3. After participating in an interactive multimedia
obesity prevention program, are there significant
changes in relation to social influence of peers
on physical activity in fourth grade students?
The hypothesis investigated in this study was
that fourth grade students who were involved in a
theory-based interactive obesity prevention program
will demonstrate a significantly greater improvement
in self-efficacy, beliefs about physical activity, and
social influence than students given tradition
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interactive multimedia programs during their computer
lab time.
Conceptual Assumptions
1. This particular multimedia tool can have an
effect on psychosocial measures through a school-
based intervention program.
2. Behavior is influenced through a combined
interaction of events at the environmental,
behavioral, and individual levels.
Delimitations
1. The schools from which the sample is drawn are
limited to those which have access to computer
facilities.
2. The study sample was limited to subjects whose
school districts voluntarily agreed to
participate in the study.
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Limitations
1. The intervention was performed on whole schools
rather than having individuals separately
randomized to different treatments.
2. The study would have to be replicated across many
similar schools randomly chosen and assigned to
each of the two experimental groups either within
paired similar schools.
Organization of this Study
This research study is organized into five
chapters. Chapter 1 describes the background and
significance of the problem investigated, and offers
brief descriptions of the relevant research questions
and hypothesis. In addition, this chapter gives the
limitations, delimitations, and assumptions inherent
in this study.
Chapter 2 contains a review of the literature
relevant to the issues under investigation, and is
separated into several sections. Discussions include
significant research on obesity and the risks to
overall health. There is a focus on the need for
12
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effective health education, with an emphasis on
physical activity and diet as the main factors in
preventing obesity. Also in this chapter is a review
of previous studies relating to the prevention of
obesity, concentrating on the school education
programs as being the most attractive site for
prevention. A theoretical basis is included for
behavioral interventions, concentrating on the Social
Cognitive, which is used for this study. The chapter
concludes with a description of the potential use of
interactive multimedia and provides a review of
previous intervention studies that have used
interactive multimedia.
Chapter 3 contains a detailed design of the study,
including time frames, methods of data collection,
treatment variables, instrumentation, and statistical
tests utilized.
Chapter 4 contains a description of the data
collected during the study and statistical analysis of
the data.
13
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Chapter 5 includes a discussion of the
statistical results of the study, conclusions that may
be drawn, and implications for further research.
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CHAPTER 2
REVIEW OF RELEVANT LITERATURE
This chapter provides a brief review of the
literature on obesity and school-based prevention
programs relevant to this study. This chapter is
organized within five main sections: (a) Health
significance, (b) need for effective health prevention
strategies, (c) previous studies relating to the
prevention of obesity, (d) theoretical basis of
behavioral intervention, and (e) the potential use of
interactive multi-media in prevention interventions.
Health Significance of Childhood Obesity
Twenty-five percent of children in the United
States are affected by obesity or excess body weight
and these numbers are likely to be higher as recent
estimates become available (Troiano, Flegal, &
Kuczmarski, 1995). There has been a dramatic rise in
overweight and obesity in the past few decades, which
has been well documented in the literature (Strauss &
Pollack, 2001; U.S. Department of Health and Human
15
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Services, 1996). Among 6- to 11-year old youth, the
prevalence of overweight rose from 11.3% in 1994 to
15.3% in 2000. Among 12 to 19 year olds, overweight
prevalence increased from 10.5% in 1994 to 15.5% in
2000 (Ogden, Flegal, Carroll, & Johnson, 2002) .
In.addition, childhood obesity is more prevalent
among minority sub-groups of the population. The
higher prevalence of obesity in African Americans, and
particularly among women (Morrison, et al., 1994), may
explain why the mortality rate from cardiovascular
disease in African-American women is two to four times
higher than Caucasian women (U.S. Department of Health
and Human Services, 1996). The increase in obesity is
most marked in African Americans, Hispanics and low-
income populations (Strauss & Pollack, 2001). From
1986 to 1998, obesity increased 120% in African-
American and Hispanic children (ages 4 to 12), and
more than 50% among Caucasian children (Strauss &
Pollack, 2001).
Obesity is now considered a disease of epidemic
proportions. Even during childhood, obesity is
closely related to increased risk of cardiovascular
16
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disease and non-insulin dependent diabetes mellitus
(NIDDM) (Hubert, Feinleib, McNamara, & Castelli, 1983)
psycho-social concerns (Neumark-Aztainer, Story,
French, Hannan, Resnick, & Blum, 1997)) and increased
risk of some forms of cancer (Ballard-Barbarsh, 1994))
Children are at increased risk for the development of
obesity during adolescent growth (Deitz, 1994), and
during adiposity rebound (the age at which body mass
index reaches a low point) at age 5-6 years (Whitaker,
et al., 1998).
Obesity that begins early in life persists into
adulthood (Charney, et al., 1976), and increases the
risk of obesity-related morbidity later in life (Must,
Jacques, Dallal, Bajema, & Dietz, 1992). As
previously mentioned, obesity can result in higher
risk for heart disease, for stroke, diabetes,
hypertension, some forms of cancer, gall bladder, and
joint diseases. Obesity can lead to bowing of the
legs and pain in the hip joint due to excess weight on
the bones and joints. Obese children may develop
severe headaches which can even lead to loss of vision
They may suffer from daytime sleepiness or breathing
17
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difficulty during sleep. Obese females may develop a
condition called as "polycystic ovary disease" which
can lead to excess hair over the body and problems
with the menses (Cohen, 2001). The relationship of
childhood overweight to Type 2 diabetes mellitus,
cardiovascular disease, and some types of cancer has
been well established (Grundy, Blackburn, Higgins,
Lauer, Perri, & Ryan, 1999; Hubert, Feinleib, McNamara,
& Castelli, 1983; Must, Spadano, Coakley, Field,
Colditz, & Diet, 1999; Visscher & Seidell, 2001) .
There is indication of the epidemiological impact
of childhood obesity on overall health. Offspring of
parents with coronary heart disease were found to be
more overweight during childhood and also developed an
adverse lipid risk profile at a faster rate (Bao, et
al., 1997). Also incidence of Type 2 diabetes NIDDM
(typically thought of as an adult disease, has
increased 10-fold in children, and this increase is
most apparent among obese children (Pinhas-Hamiel, et
al., 1998).
18
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Need for Effective Health Education
Only smoking related deaths outnumber the 300,000
preventable deaths per year in the United States that
could be attributed to diet and physical activity
factors (McGinnis & Foege, 1993). Heart disease
(accounting for 33% of annual deaths), cancer
(accounting for 23% of annual deaths), and
cerebrovascular disease (accounting for 7% of annual
deaths), are the three major causes of mortality in
the United States. In addition, other conditions such
as diabetes which currently afflicts 15.7 million
Americans, or 6% of the population, with an additional
800,000 new cases being diagnosed each year and
osteoporosis (afflicting 25 million Americans) are
major burdens on our health system. A significant
portion of these health risks can be averted by a
long-term commitment to primary prevention but are
difficult to treat. These conditions also have one
other feature in common. They have been recognized as
having a major involvement of lifestyle and, in
particular, to diet and physical activity. Thus,
there is a very strong link between lifestyle, disease
19
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prevention, health costs, and mortality. Public
health promotion is clearly the best way to treat the
increasing prevalence of obesity and lifestyle-related
chronic health conditions. Therefore the need for the
development of health promotion tools to improve the
diet and physical activity profile across the
diversity of the population is evident.
Recent metabolic and genetic research has
identified important pathways and deepened our
understanding of the physiological aspects of body
weight regulation. However, there is very little
evidence to support the concept that the current
epidemic of obesity and related diseases is explained
by acute metabolic and/or genetic defects. The more
likely explanation relates to sociological changes in
the environment which may promote the expression of an
obese phenotype (i.e., less requirement for physical
activity and greater abundance and availability of
food).
Studies support this concept since there has been
no major evidence found of a metabolic defect to
explain the etiology of obesity in growing pre-
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pubertal children (Trowbridge, Gower, Nagy, Hunter,
Treuth & Goran, 1997). Thus, obesity is the end-
result of the interaction of a normal metabolic/
genetic physiology with an obesity-promoting
environment and lifestyle (Ravussin & Swinburn, 1992).
Consequently, designating research into the
prevention of obesity was placed as its highest
priority by a task force on the prevention and
treatment of obesity (National Task Force on the
Prevention and Treatment of Obesity, 1994).
In order to achieve these goals, there is a clear
need to design school-based programs that are
culturally relevant and appropriate for the diversity
of school-aged children with regard to factors such as
ethnicity, gender, and socioeconomic status.
Previous Studies Relating to
the Prevention of Obesity
The two major lifestyle behaviors that are
clearly associated with the increased prevalence of
obesity and related disease risk in children are diet
(Gortmaker, Dietz, & Cheung, 1990) and physical
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activity (Dietz & Gortmaker, 1985), and probably an
interaction between the two. Despite the obvious
importance of promoting improved diet and increased
physical activity in children, and the potential of
the school environment to do so, only a few programs
have been designed and tested in controlled studies.
Less than 36% of elementary or secondary schools offer
daily physical education (Harsha, 1995). Even when
physical education is offered, previous studies have
been shown that many students spend the majority of
time being inactive. A study of a nationally
representative sample of 4,063 children (8-16 years)
during 1988-1991 showed that 20% of United States'
children do not get more than two bouts of vigorous
exercise per week (Silverman, 1991).
Television, along with other sedentary behaviors,
may contribute to obesity by competing with more
physically active behaviors, as well as setting the
occasion for eating (Gortmaker, Must, Sobol, Peterson,
Colditz, & Dietz, 1996). Sixty-seven percent of
children watch more than 2 hours of television per day,
with television viewing hours being linked to degree
22
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of obesity (Andersen, Crespo, Harriett, Cheskin, &
Pratt, 1998). Reducing sedentary behaviors represents
a potentially important -goal in childhood obesity
prevention and treatment. Watching television has
been proven to be a risk factor for the development of
obesity in children. The effect of reducing sedentary
behavior, in particular television watching, as a
component of a comprehensive obesity treatment program
has yet to be widely tested. A study was conducted on
90 families with obese children ranging in age 8-12
years. They were randomly assigned to groups that
were provided a comprehensive family-based behavioral
weight control program that included dietary and
behavior change information but differed in whether
sedentary or physically active behaviors were targeted
and the degree of behavior change required. Results
during 2 years showed that targeting either decreased
sedentary behaviors or increased physical activity was
associated with significant decreases in percent
overweight and body fat, and improved aerobic fitness.
23
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Review of Epidemiological Studies:
Physical Activity
Seven epidemiology studies of elementary school
youth physical activity were reviewed for this paper.
In these studies, the following was used to guide
their study design: two used Social Learning Theory,
five used Social Cognitive Theory, one used
Protection-Motivation Theory, and one used Theory of
Reasoned Action, which is a variant of the Social
Learning Theory. Four studies were cross-sectional
and three were longitudinal. The subjects of the six
U.S. studies ranged from fourth to ninth grades,
while the subjects in one British study were 11 and 12
years old. The measures in these studies included
physical activity (five self-report, two objective
measurement), questionnaire (six studies) and
interview (one study). The details of all seven
studies are presented in Table 1.
Ferguson's (Ferguson, Yersalis, Pomrehn, &
Kirkpatrick, 1989) cross-sectional study utilized the
Social Cognitive Theory using a 45-question survey and
measured attitudes towards exercise, attitudes towards
24
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Table 1
Physical Activity Epidemiological Studies in Elementary and Middle School-aged Children
Study Subjects
Research
Design
Measurement
Design
Proposed
Mediators
Dependent
Variables Results
(Ferguson,
Yersalis,
Pomrehn,
&
Kirkpatrick,
1989)
• 603 6th -8th grade
students
• 57% male
• 28% lived on farms
• no mean age provided
• nearly all students
white
• rural Iowa
Cross-sectional
Theory: SCT
45-question
survey, only
measured once,
as part of pilot
study
• Attitudes towards
exerase
• Attitudes towards
physical education
• Perceived athletic
ability
• Perceived self
esteem
• Perceived ability to
maintain
commitments
Frequency of PA
within an average
week outside of
gym class (self-
report)
Perceived benefits of PA, current
PA behavior, attitudes towards
PE, self-esteem, and gender
were all significant, independent
predictors of intention to engage
in PA.
(Biddle &
Armstrong,
1992)
• 72 middle school
students
• 11 and 12 years (12.2
±0.3)
• 51% male
• ethnic breakdown
unknown
• southwest England
Longitudinal
Theory: SCT
(Bandura is
referenced) &
PMT (Intrinsic &
extrinsic
motivation)
Heart rate
monitoring for 3
weekdays, the
Motivational
Orientation in
Sport Scale, the
Physical Self-
Perception Profile,
modified for use
with children
(includes sports
competence, body
attractiveness,
physical strength,
physical condition)
• Intrinsic motivation
(challenge,
curiosity, mastery,
judgment, criteria)
• Physical self
perception
Heart rate
monitoring to
assess physical
activity
Boys had a significantly higher
PA level than girls.
M: There was a significant
positive association between PA
and intrinsic motivation (e.g.,
mastery, personal control)
towards PE and sports.
F: There was a significant
positive association between PA
and extrinsic motivation (e.g.,
teacher’s opinion) towards PE
and sports.
t\J
Ol
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Table 1 (continued)
Study Subjects
Research
Design
Measurement
Design
Proposed
Mediators
Dependent
Variables Results
(Stucky-Ropp
& DiLorenzo,
1993)
• 242 5th and 6th grade
students;
• Mean age 11.2 ± 0.7
• 50% female
• 93% white
• middle-class
• Midwest
Cross-
sectional
Theory: SLT
mentioned
Physical Activity
Interview,
Children’s Physical
Activity
Questionnaire,
Parental Physical
Activity
Questionnaire
• Self-efficacy for PA
• Direct parental
modeling
• Friend and family
modeling/support
• Enjoyment of PA
• Home equipment
• Child’s exercise
knowledge
• Negative indicators of
PA (hrs watching TV/
video games)
MET values from
the Physical
Activity Interview
and Children’s
Physical Activity
Questionnaire
Boys: Child’s enjoyment of PA,
mother’s barriers to PA, and
mother’s report of family
support significantly associated
with PA
Girls: Child’s enjoyment of PA,
number of PA items in home,
barriers to PA, 6,h -8th and
parental modeling significantly
associated with PA
(Garcia,
Broda, Frenn,
Coviak,
Pender, &
Ronis, 1995)
• 286 4th , 6th, and 8th
grade students
• 52% female
• 30.4 % African-
American,
62.6 % Caucasian,
7% other race/ethnicity
Longitudinal
Theory: The
Health
Promotion
Model based
on SCT
In class
questionnaire
administration
10 weeks after
questionnaire
administration,
subjects filled out
the Child/
Adolescent
Exercise Log
• Cognitions (exercise
self-efficacy, exercise
self-schema, exercise
benefits / barriers
differential)
• Prior related behaviors
• Interpersonal variables
(exercise models,
exercise norms, social
support for exercise)
• Situational variables
(access to exercise
facilities / programs,
sedentary time)
Child/Adolescent
Exercise Log
consisting of 16
items of PA
frequency and
duration. Index
computed from
metabolic cost of
summed activities.
Male gender, index of
benefits/barriers to exercise,
and access to exercise
facilities associated with
increased exercise.
ro
< T \
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Table 1 (continued)
Study Subjects
Research
Design
Measurement
Design
Proposed
Mediators
Dependent
Variables Results
(DiLorenzo,
Stucky-
Ropp,
Vander Wal,
& Gotham,
1998)
(same study
as Stucky-
Ropp&
DiLorenzo,
1993)
Phase 1:
• 242 5t!,-6lt' graders
• Mean age 11.2 ±0.7
• 50% male
• Midwestern
• Predominantly
Caucasian
• Middle-class
Phase 2:
• 111 graders
• 54 girls, 57 boys
• Mean age 14.0 ± 0.7
Longitudinal
(Phase 1 5th -6lh
grade, Phase 2
8th -9th grade)
Theory: SLT
Physical Activity
Interview,
Children's
Physical Activity
Questionnaire,
Parental Physical
Activity
Questionnaire
• Self-efficacy for PA
• Direct parental
modeling
• Friend and family
modeling/support
• Enjoyment of PA
• Home equipment
• Child's exercise
knowledge
• Negative indicators
of PA (hrs watching
TV/ video games)
MET values from
the Physical
Activity Interview
and Children’s
Physical Activity
Questionnaire
Girls: In Phase 1 only child’s
enjoyment of PA was significant,
while in Phase 2 child’s exercise
knowledge, mother’s friend
modeling/support, child’s friend
and family modeling/support all
significantly predicted girls’ levels
of PA.
Boys: In Phase 1 child's
enjoyment of PA, child's friend
and family modeling/support, and
mother’s perceived negative
family support all significantly
accounted for variance in child’s
level of activity. In Phase 2 child’s
self-efficacy for PA, child’s
exercise knowledge, direct
parental modeling (inversely
related) and child’s interest in
sports media all significantly
predicted child’s level of activity.
Comment: Different results for
Phase 1 from previous study -
smaller sample size.
NO
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Table 1 (continued)
Study Subjects
Research
Design
Measurement
Design
Proposed
Mediators
Dependent
Variables Results
(T rost, Pate,
Ward,
Saunders, &
Riner, 1999)
• 198 6th grade students
• 11.4 ±0.6 yrs
• 52% female
• 55.1% Black
• South Carolina
Cross-sectional
Theory: SCT
and Theory of
Reasoned
Action (TRA)
Questionnaires
administered in
the classroom,
and immediately
after were given
accelerometer to
wear for 7
consecutive days,
only to be taken
off when sleeping,
bathing or
swimming.
• PA self-efficacy
• PA social norms
• Beliefs about PA
outcomes
• Perceived PA of
parents and friends
• Access to
equipment at home
• Involvement in
community PA org.
• Participation in
community sports
teams
• Self-reported hrs of
TV / video games
Moderate physical
activity (MPA) and
vigorous physical
activity (VPA)
assessed using
CSA uniaxial
accelerometer
Significantly higher MPA
participation in boys than girls; no
gender differences in VPA.
M: PA self-efficacy significantly
correlated with VPA.
F: PA self-efficacy and outcome
expectancies significantly
correlated with both MPA and
VPA. Access to PA equipment
also significantly associated with
MPA.
(Sallis,
Prochaska,
Taylor, Hill,
& Geraci,
1999)
• 247 students grades 4-
6
• 76 % Caucasian,
14% African-American
(in sample of 1,504
parents and their
children in grades 4-
12)
• National sample
Cross-sectional
Theory: nothing
explicit,
includes SCT
Structured phone
interviews to
assess youth
physical activity
patterns
(averaged 34
minutes in length)
- random-digit dial
sampling method
- interviewed
parents and
children
Body satisfaction, enjoy
ment of PE, general
barriers to PA, time
barriers, use of afternoon
time, method of transport
to school, parent physical
activity index, importance
of child’s physical activity,
parent enjoyment of
activity, family support
index, social barriers,
access to play space,
play rules, supervised
programs, environmental
barriers
Child physical
activity level (11-
item global index
computed from
parent and child
self-report)
Boys: use of afternoon time, enjoy
PE, family support, importance of
child’s PA (to parent), Parent PA
were all statistically significant
and explained PA levels.
Girls: use of afternoon time, time
barriers, family support all
significantly contributed to
physical activity levels.
N3
co
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Table 1 (continued)
Legend:
PA = physical activity
PE = physical education
SCT = Social Cognitive theory
SLT = Social Learning theory
PMT = Protection Motivation theory
ro
CD
physical education, perceived athletic abilities,
perceived self-esteem, and perceived ability to
maintain commitments. Six hundred and three sixth-
eighth grade subjects were tested. The results of the
study were that all proposed mediators were
significant independent predictors of intention to
engage in physical activity.
Biddle's (Biddle & Armstrong, 1992) longitudinal
study also utilized the Social Cognitive Theory using
a heart rate monitor for three weekdays, the
motivational orientation in sport scale, and the
physical self-perception profile. This design
measured intrinsic motivation, such as challenge,
curiosity, mastery, and judgment, and physical self
perception. Seventy-two middle school students, ages
11 and 12, were tested. The results of the study were
that boys had a significantly higher physical activity
level than girls.
Stucky-Ropp and DiLorenzo's (Stucky-Ropp &
DiLorenzo, 1993) cross-sectional study utilized the
Social Learning Theory using a physical activity
interview and children/parent physical activity
30
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questionnaire to measure self-efficacy in physical
activity, direct parent modeling, friend and family
support/modeling, enjoyment of physical activity, home
equipment, child's exercise knowledge, and negative
indicators of physical activity (TV viewing/video
games). The results of this study were child's
enjoyment of physical activity, mother's barriers to
physical activity, and mother's report of family
support were significantly associated with physical
activity in males. In females, enjoyment of physical
activity, number of physical items in the home,
barriers to physical activity, and parental modeling
were significantly associated with physical activity.
Garcia (Garcia, Broda, Frenn, Coviak, Pender, &
Ronis, 1995) utilized the Health Promotion Model,
which is based on the Social Cognitive Theory to
design a longitudinal study using an in-class
questionnaire to test cognitions, prior related
behaviors, and situational variables. Two hundred and
eighty-six fourth, sixth, and eighth grade students
were tested. The results were that male subjects
31
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showed increase in exercise with benefits/barriers to
exercise and access to exercise facilities.
DiLorenzo's (DiLorenzo, Stuckiy-Ropp, Vander Wal,
& Gotham, 1998) longitudinal study had 242 fifth-sixth
graders that were between 11 and 12 years old. The
Social Learning Theory was utilized to measure self-
efficacy, direct parent modeling, friend and family
modeling/support, enjoyment of physical activity, home
equipment, child's exercise knowledge, and negative
indicators of physical activity. The results of this
study show that female students' enjoyment of physical
activity, child's exercise knowledge, mother's friend
modeling/support, child's friend and family
modeling/support all significantly predicted girls'
levels of physical activity.
The results for male subjects were that enjoyment
of physical activity, child's friend and family
modeling/support, and mother's perceived negative
family support all significantly accounted for
variance in child's level of activity. Also, child's
self-efficacy for physical activity, child's exercise
knowledge, direct parental modeling (inversely
32
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related) and child's interest in sports media all
significantly predicted child's level of activity.
Trost's (Trost, Pate, Ward, Saunders, & Riner,
1999) cross-sectional study, consisting of 198 sixth
grade students utilized the Theory of Reasoned Action,
which is a variant of the Social Cognitive Theory.
The measurement design was a questionnaire
administration in the classroom to test self-efficacy,
social norms, beliefs about physical activity,
perceived physical activity of parents and friends,
access to equipment at home, involvement in the
community physical activity organizations,
participation in sports teams, and self-reported hours
of TV viewing/video games. The results of this study
were that there was a significant correlation with
self-efficacy and vigorous physical activity in males
and females.
Sallis' (Sallis, Prochaska, Taylor, Hill, &
Geraci, 1999) cross-sectional study consisted of 247
fourth-sixth grade students and utilized structured
phone interviews to assess youth physical activity
patterns. The proposed mediators included body
33
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satisfaction, enjoyment of physical education, general
barriers to physical activity, and use of afternoon
time. In males, the results were use of afternoon
time, enjoy PE, family support, and parent physical
activity. There were all statistically significant.
In females, use of afternoon time, time barriers,
family support all significantly contributed to
physical activity levels.
Review of Intervention Studies:
Physical Activity
The most common site for intervention studies
with elementary and middle-school-aged children is in
the school. Many of the intervention studies targeted
nutrition along with physical activity. Most of the
school-based interventions modified physical education
(PE) classes. Many studies succeeded in increasing
activity in PE. Some studies increased activity
outside of physical education classes and/or outside
of school, while some did not. Thirteen intervention
studies of elementary school youth physical activity
were reviewed for this paper. Table 2 details the 13
34
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Table 2
Physical Activity Intervention Studies: Elementary and Middle School-Aged Interventions
United States: Urban, Peri-urban, and Suburban
Study Subjects Research Design
Measurement
Design
Proposed
Mediators
Dependent
Variables Results
Know Your
Body
Program, Los
Angeles
(Marcus,
Wheeler,
Cullen, &
Crane, 1987)
• 1,488 Students
• 18 elementary Schools in LA
• Multi-Ethnic
• Boys & girls
• Grades 4,5
Quasi-
experimental,
cohort design
Theory: Social
Influences & SCT
3 Intervention
Groups and 1
Control Group
• 1 -1 health ed
curriculum
and clinical
screening
• I-2 clinical
screening
only
• I-3 health ed
curriculum
only
Group-administered
pre-test
questionnaires
February 1981:
• Health
knowledge
• Health beliefs/
attitudes
• Self-reported
health
behaviors
Group administered
post-test
questionnaires
March 1982
• Knowledge
• Beliefs
• Attitudes
• Self-report
knowledge
• Self-report
beliefs
• Self-report PA
• I-3 increased on
knowledge scales
• i-3 increased on
PA
co
cn
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Table 2 (continued)
Study Subjects Research Design
Measurement
Design
Proposed
Mediators
Dependent
Variables Results
Go for Health
(Parcel,
Simons-
Morton,
O'Hara,
Baranowski, &
Wilson, 1989;
Simons-
Morton,
Parcel,
Baranowski,
Forthofer, &
O'Hara, 1991)
• 409 Students
• 4 Schools
• Texas
• 62.3% Caucasian, 20.9%
Hispanic, 14.8% African-
American, 2% Asian
American and American
Indian
• Boys & girls
• Grades 3,4
Quasi-
experimental,
cohort
• 2 schools
intervention
group
• 2 schools
control group
• 2 years long
Theory: SLT &
Organizational
change
Intervention:
• Curriculum
• Changes in
PE Classes
• Changes in
school lunch
Pre- and post-test
assessments
• Behavioral
capability for
healthful eating
and exercise
• Expectations for
healthful eating
and exercise
• Self-efficacy for
healthful eating
and exercise
• Survey of
knowledge,
attitudes & seif-
efficacy
• Observation of
PA in PE
classes
• Self-report PA
• Increased PA
knowledge
• Increased PA self-
efficacy
• Increased
moderate-vigorous
PA in PE
• No increase in out-
of-school PA
u>
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Table 2 (continued)
Study Subjects Research Design
Measurement
Design
Proposed
Mediators
Dependent
Variables Results
Class of 1989
(an ancillary
study of the
Minnesota
Heart Health
Program)
(Kelder, Perry,
& Klepp,
1993)
• 2,376 students
• 7 schools, Minnesota, North
Dakota, South Dakota
• 90% white
• Girls and boys
• 6th grade (followed through
12th grade)
Longitudinal,
quasi-experimental
design
• 1 intervention
& 1 control
group
• 7 year FU
Theory: SLT &
Self-monitoring
Intervention:
• Curriculum
• Policy
• Varied by
year
Annual survey in
class - self-report
Not mentioned • Self-report
physical activity
• Clustering of
CV behaviors
• Tracking of
physical activity
• Females in the
intervention
reported more
hours of activity
per week
(compared to 6th
grade baseline) in
all years except
11th grade
• Males reported
increased
frequency of PA,
but it was only
significantly differ
ent from base line
in 7th and 11th
grades.
• Physical activity
declined overtime
(after grade 7),
but smaller
declines for all
grades for
intervention
CO
-J
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Table 2 (continued)
Study Subjects Research Design
Measurement
Design
Proposed
Mediators
Dependent
Variables Results
Child and
Adolescent
Trial for CV
Health
(CATCH)
(Edmundson
et a!., 1996)
• 5,106 Students
• 96 schools
• California, Louisiana,
Minnesota, Texas
• Multi-Ethnic
• Boys & girls
• Grades 3-5
• Followed-up in grades 6-8
Experimental,
Longitudinal
• 1 1ntervention
Group
• 1 Control Group
Theory: SCT &
Organizational
Change
Intervention:
• Curricula
• Changes in PE
Classes
• Changes in
school lunches
• 21/2 years
Health Behavior
Questionnaire
administered
twice, at the
beginning and the
end of third
grade, and then
each Spring for
the following 2
years
• Positive support
for PA
• Negative support
for PA
• PA self-efficacy
• PE(SOFIT)
• Self-report PA
• Fitness test
• Increasing
amount of PE
time students
spend in MVPA
• Increased MVPA
during PE
• Increased out of
school vigorous
PA (effect
maintained at 8th
grade FU)
• No fitness
change
Sports, Play,
and Active
Recreation
for Kids
(SPARK)
(Sallis,
McKenzie,
Alcaraz,
Kolody,
Fa8ucette, &
Hovell, 1997)
• 955 Students
• 7 elementary schools
• Poway, suburb of San Diego,
CA
• 82% white, 12% Asian-
Pacific Islander, 4% Latino,
2% African-American
• Upper & middle SES
• 53% male
• Grades 4,5
• 2 years long
Quasi-experimental,
cohort design
• 2 Intervention
Groups, 1
control group
• 1.5 year FU
Theory: SCT & Self-
Monitoring
Intervention:
• 1 -1 Specialist-led
PE
• I-2 teacher-led
PE
• Self-
[management
curriculum
Measures taken
at beginning and
end of each
school year
Not mentioned • PE (SOFIT)
• Self-report PA
• Fitnessgram
• Uniaxial
accelerometer
• Height, weight
• Both intervention
groups
increased MVPA
in PE
• Increased fitness
• No change in
out-of-school PA
• No change in
self
management
co
CD
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Table 2 (continued)
Study Subjects Research Design
Measurement
Design
Proposed
Mediators
Dependent
Variables Results
Eat Well and
Keep Moving
(Gortmaker et
al., 1999)
• 479 Students
• 14 Schools
• Baltimore, MD
• 91% African-American
• Boys & girls
• Grades 4,5
Quasi-experimental,
cohort design
• 1 1ntervention
Group (6
schools)
• 1 Control Group
(8 schools)
Theory: SCT & Social
Marketing &
Behavioral Choice
Intervention:
• Inter-disciplinary
curriculum
• 2 years long
FAS - food and
activity at baseline,
with both 24-hour
recalls and FAS for
follow-up
PA knowledge • PA by 24-
hour recall
• Self-report
PA and TV
viewing
frequencies
• No observable
increase of
physical activity
in intervention
group
• Marginal
reduction in
television
viewing
Planet Health
(Gortmaker et
al., 1999)
• 1,295 Students
• 10 Schools
• Boston, MA metropolitan
area
• Multi-Ethnic
• Boys & girls
• Grades 3-5
• Followed-up in Grade 6
Experimental
• 1 1ntervention
Group
• 1 Control Group
Theory: SCT &
Behavioral Choice
Intervention:
• Inter-disciplinary
curriculum
• 2 years long
Classroom
administration of
survey, teachers
trained to
administer-at
baseline and 2
years later
Television viewing only
mediator mentioned
• Reduction
in obesity (a
composite
indicator of
body mass
index and
triceps
skinfold)
• Self-report
PA
• Self-report
TV viewing
• Girls in
intervention
group showed
lower
prevalence of
obesity vs.
control
• Intervention
group had
reduced TV
viewing time vs.
control
L O
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Table 2 (continued)
United States: Rural
Study Subjects Research Design
Measurement
Design
Proposed
Mediators
Dependent
Variables Results
Southwest
CV Curr
iculum
Project
(Davis,
Lambert,
Gomez, &
Skipper, 1995)
• 2,018 Students
• 1 1 Schools
• Rural New Mexico
• Navajo and Pueblo Indians
• Boys & girls
• Grade 5
• 5-year program
Experimental
• 1 1ntervention
Group & 1
Control Group
Theory: Social
Influences & SLT
Intervention:
• Curriculum
• Incorporating
Native American
traditions &
values into
lessons and
activities
• 2 Semesters
Pre-test and post
test
Knowledge • Self-report
knowledge
• Self-report
PA
• Increased
knowledge in
intervention
group
• Increased PA -
70% of students
increased from
baseline
Nebraska
School Study
(Donnelly et
al., 1996)
• 200 Students
• 2 Schools
• Rural Nebraska
• 94% Caucasian
• Boys & girls
• Grades 3-5
• 2 years long
Quasi-experimental,
cohort
• 1 1ntervention
Group & 1
Control Group
Theory: SCT
Intervention:
• Curriculum
• Changes in PE
classes, school
lunch, policy
Measurement Pre-
and post
intervention
None mentioned • Level of PE
activity
(SOFIT)
• PA
checklist
• Fitness test
(1-mile run)
• Body
composition
(hydrostatic
weighing)
• Blood
chemistry &
blood
pressure
• 6% more PA
during PE
• 15% less PA
out of school
• No fitness
change
o
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Table 2 (continued)
Study Subjects Research Design
Measurement
Design
Proposed
Mediators
Dependent
Variables Results
CV Health in
Children
(CHIC)
(Harrell,
McMurray,
Bangdiwala,
Frauman,
Gansky, &K
Bradley, 1996)
• 1,274 Students
• 12 Schools
• Rural North Carolina
• Multi-Ethnic
• 48% boys
• Grades 3,4
Experimental
• 1 1ntervention
Group
• 1 Control Group
Theory: SCT
Intervention:
• AHA health
curriculum and
specially
designed PE
• 8-week program
• 2 years long
Pre-test post-test
control group
design
Knowledge (Healthy
Heart Knowledge test)
• PA as
measured by
a revised
Know your
body Health
Habits
Survey
• Test of
knowledge
• CV fitness
(Peak V02)
• Body
Composition
(% fat)
• Intervention
group increased
PA
• Intervention
group increased
knowledge
• No fitness
change
Pathways
(Davis et al.,
1999)
• 1,706 Students
• 41 Schools
• Rural Arizona, New Mexico,
South Dakota
• American Indians
• Boys & girls
• Grades 3-5
Experimental
• 1 1ntervention
Group
• 1 Control Group
Theory: SLT
Intervention:
• Changes in PE
Classes
• Changes in
school lunches
• Curriculum
• Family support
• 3 years long
Measurement at
baseline and after
intervention
• PA self-efficacy
• Social support for
PA
• Perceived barriers
to PA
• Physical self
perception
• % Body Fat
• Tritrac triaxial
acceleromete
r
• 2 day PA
recall
No published
baseline or results
except on a website:
• The program
had significant
effects on
several
components of
knowledge,
attitudes, and
behavior
• No reduction in
percent body
fat
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Table 2 (continued)
European: Rural and urban
Measurement Proposed Dependent
Study Subjects Research Design Design Mediators Variables Results
Oslo Youth • 828 Students Quasi-experimental, Pre-test. Post •
Knowledge
•
Self-report PA
•
Increased
Study • 6 elementary schools cohort design test, follow-up •
Beliefs •
Self-report knowledge
(Tell & Vellar,
• Rural Norway
• 1 1ntervention •
Attitudes knowledge &
•
Boys showed
• Boys & girls
Group attitudes increased
1988; Tell,
• Ages 11-15
• 1 Control Group •
Fitness frequency of
Vellar, &
• FU 12 years V02max vigorous PA
Monrad- Theory: Social •
Boys in the
Hansen, 1981)
Influences & Self-
Monitoring
• Curriculum based
on KYB
• 2 years long
•
intervention
group showed
increased CV
fitness
12 yr FU
increased PA
(Sahota et al, • 634 children Experimental Pre- and post •
Self-perception
•
BMI (weight &
•
Global self-
2001) • 7-11 years old (mean age 8.4 • 1 intervention test (global self-worth height) worth higher in
+ 0.63), grades 4 and 5 group measurement and competence in •
24-hour diet obese children
•
10 primary schools • 1 control group 5 domains) recall in intervention
•
Outside the inner-city area
•
Body image •
3 day food group
• Leeds, England
Theory: none stated satisfaction diaries
•
Increased
• 1 year
•
Knowledge •
PA and knowledge
Intervention:
• Curriculum -Active
Programme
Promoting
Lifestyle
Education in
Schools
(APPLES)
• School action
plans to promote
PA
•
Attitudes sedentary
activity by
questionnaire
•
No difference
in BMI or
psychological
variables
interventions. Seven used an experimental design and
six were quasi-experimental. Eleven studies sampled
U.S. populations, and two were European. Eight
studies were with urban or suburban students, and five
were completed in rural areas. The U.S. studies
sampled students between third and sixth grades, and
the European studies sampled students aged 7 to 15.
Project SPARK was a large-scale study that
randomly assigned seven elementary schools to receive
physical education either by mechanisms, trained
teachers, or specialized instructors. Controlled
intervention studies suggest that exercise
intervention in children may or may not have
beneficial effects, depending on the nature of the
intervention. Skinfold measurements and body mass
index were monitored for two years. The data showed a
non-significant trend for children exposed to
specialized physical education to have lower total
body fat after two years (Sallis, McKenzie, Alcaraz,
et al., 1993).
Results from other school-based studies that
included physical education are controversial with
43
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some showing no changes in adiposity (Bush, Zuckerman,
Taggart, et al., 1989), and others showing a decrease
(Killen, Telch, Robinson, Maccoby, Taylor, & Farquhar,
1988) . Studies that were less well-controlled and
short in duration (one month) do not report any
significant changes in body composition (Cohen,
McMillan, & Samuelson, 1991). Also, it is important
to bear in mind that promoting less sedentary physical
activity has been shown to be more effective in weight
loss in obese children compared to promotion of more
exercise (Epstein, Valoski, & Vara, 1995) .
Perhaps one of the most extensive prevention
studies for children was the school-based randomized
trial entitled Child and Adolescent Trial for
Cardiovascular Health (CATCH) (Luepker, Perry, &
McKinlay, 1996). It involved a total of 96 elementary
schools over a period of 3 years, which included
classroom curriculum regarding health, nutrition,
physical activity during physical education classes,
and food intake alterations in the school cafeteria.
The CATCH intervention was designed around an SCT
framework and promoted a healthy school environment,
44
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part of which included the "Eat Smart" program aimed
at improving the health quality of the food service
staff. After 3 years of intervention there were
significant improvements in knowledge and self-
efficacy for healthy food choices (Edmundson, Parcel,
Feldman, 1996), and a significant reduction in percent
of calories consumed as fat and saturated fat
(Osganian, Ebzery, & Montgomery, 1996).
In addition, the CATCH intervention included a
standardized program to strengthen the physical
education curriculum of participating schools.
Children in treatment schools were observed to have
greater levels of moderate to vigorous physical
activity during physical education classes, and also
reported significantly greater physical activity in
general, amounting to almost 1.5 hours per week. The
CATCH study was a success in implementing results in
immediate physical activity levels, curricular and
environmental changes, but long-term effects to
obesity were not found (McKenzie, Nader, & Strikmille
1996).
4
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Another study was the "5-a-day for Better Health
Initiative." This initiative included nine community
intervention trials to develop and test innovative
dietary intervention strategies to increase fruit and
vegetable consumption in selected populations.
Working with elementary school children, the specific
aims of this initiative were to: (a) develop a school-
based intervention to increase the fruit and vegetable
consumption of fourth graders, and (b) test this
intervention in a controlled 2-year longitudinal study.
It targeted the fruit and vegetable consumption of
fourth grade children and their parents through three
intervention modalities: classroom, parent, and
school cafeteria activities. The project was
evaluated using a randomized experimental design in
which school served as the unit of assignment and
analysis. Schools were randomized to the special
intervention or to the delayed intervention control
condition. Habitual dietary intake was assessed in
children and one of their parents, as well as
psychosocial measures related to dietary consumption,
such as perceived self-efficacy. In addition,
46
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cafeteria observations were completed that measured
fruit and vegetable consumption in a random sub-sample
of children in the cafeteria. This family
intervention component was modeled on the traditional
intervention approach that has been used successfully
in previous school-based studies having a family
component (Luepker, Perry, McKinlay, 1996) . Changes
in consumption of fruits and vegetables were closely
related to the number of sessions attended, baseline
stage of change, race, and education. The results of
this study showed significant changes in knowledge,
attitudes, self-efficacy, and social support (Snyder,
Anliker, Cunningham-Sabo, 1999) .
Most of the goals relating to physical activity
in children from the Healthy People 2000 objectives
have not been met and physical activity participation
decreases with age and with progression through the
high-school years (TJ.S. Department of Health and Human
Services, 1996). Moreover, there is evidence that the
level of physical activity decreases in girls,
immediately prior to puberty (Goran, Gower, Nagy, &
Johnson, 1998) .
47
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Schools are an extremely important and useful
site for instituting obesity prevention programs since
the majority of children attend school and a great
deal of a child's eating and exercise is carried out
in this setting. School-based programs that encourage
physical activity are important for increasing
children's energy expenditure because children are
less likely to participate in physical activity in the
absence of adult supervision (Sallis, McKenzie,
Alcaraz, Kolody, Hovell, & Nader, 1993). These
programs may also create expectations for regular
physical activity that may continue into adulthood.
In order to increase physical activity among children
regardless of their athletic abilities, the Center for
Disease Control (1994) recommends daily physical
education classes that emphasize health-related
fitness activities over activities requiring specific
athletic abilities. However, in 2001 only half of
high-school students participated in physical
education classes and less than one-third of students
had physical education daily. In addition to
requiring physical education, other opportunities for
48
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schools to increase energy expenditure include
encouraging physical activity during recess and
providing after-school sports and health-related
fitness programs (Center for Disease Control and
Prevention, 1994).
School-based education programs designed and
tested in elementary schools are attractive due to the
large amount of contact time with children, the
existing organizational, social, and communication
structures, and the potential to reach a large
percentage of children at a low cost. Schools could
potentially have a large impact on determinants of
obesity but the results of school-based studies in
prevention of obesity have been variable. The
variability of results in school-based interventions
studies amplifies the fact that many influences
outside schools are important determinants of
children's body weight. While childhood obesity may
not be overcome by the efforts of the education system
alone, schools provide an important opportunity for
prevention. Also, findings show that strategies aimed
at younger children have better long-term results than
49
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those focused on adolescents suggests that eating and
physical activity behaviors are more difficult to
change as children get older (Story, 1999).
Furthermore, results from various school-based obesity
interventions which have targeted high-risk children
and adolescents show more success when implemented and
can reach substantial numbers of children in need of
obesity prevention (Forster, Hunter, Hester, Dunaway,
& Shuleva, 1994; Resnicow, 1993; Seltzer & Mayer,
1970). Obese children in treatment groups have
consistently shown greater reductions in percent
overweight than untreated obese controls. Results
over periods of 3-6 months are modestly encouraging
and justify school-based interventions in obesity.
Schools also have the potential to influence
students' beliefs and attitudes regarding nutrition
and weight control. A 2001 national survey documented
poor eating behaviors among American youth. Only
21.4% of high-school students had eaten more than five
servings per day of fruits and vegetables, 13.5%
reported fasting for more than 24 hours to lose weight,
9.2% reported using diet pills that were not
50
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prescribed by a physician, and 5.4% reported using
vomiting or laxatives as a weight control measure
(Center for Disease Control and Prevention, 2001) . In
another national survey, fat comprised an average of
35% of total caloric intake in youth aged 2 to 19
years, and almost two-thirds of these youth did not
eat recommended amounts of fruits and vegetables.
Nutrition education could give students the tools they
need to make healthy choices regarding eating and
physical activity. More research is needed to examine
the effects of such education programs on behaviors
and body weight.
Increasing physical activity through integrating
regular exercise programs into the school curriculum
is a strategy that has often been proposed as an
effective means of improving weight and health
awareness of children (Sleap & Warburton, 1990). The
evaluation of a 2-year project in South Australia
where 50 minutes of daily physical activity was
introduced into a number of primary schools
demonstrated that children who took part in the
intervention were fitter, slimmer, and had lower
51
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diastolic blood pressure in boys, than their non
participating counterparts (Dwyer, Coonan, Leitch, et
al., 1983)1 A subsequent study which built on this
project by including classroom lessons on nutrition
and physical health was also able to demonstrate
improvements in fitness and body fat levels. Similar
interventions have also been run in U.S. (Nader, 1993)
and Singapore schools where short term results are
promising. Despite demonstrating positive benefits,
the maintenance of these prevention programs within
the school curriculum in the long-term has proven more
difficult due to competition for school time, the need
for teacher/adult supervision and financial
limitations.
In addition to the school-based aspects of
intervention aimed at improving lifestyle related
behaviors, evidence strongly suggests that it is also
important to include family and community-based
components (Perry, Luepker, Murray, 1988) . For
example, a previous 2-year intervention aimed at
improving school-food service and physical education
classes was successful in improving school meals, such
52
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as less fat and sodium, and physical activity in the
classroom, but had no beneficial effects on 24-hour
dietary fat intake, and reported habitual physical
activity (Donnelly, Jacobsen, Whatley, 1996). This
study suggests that the positive changes in intake and
physical activity in school may be negated by opposing
changes outside of the school setting. Clinical
interventions for obesity treatment in children have
been shown to be most effective when a family-based
component is included (Epstein Baloski, Wing, &
McCurley, 1990). In addition, positive outcomes with
respect to knowledge and attitude regarding healthy
behavior changes are significantly influenced by the
degree of family involvement in the intervention
(Nader, 1993).
The growing problem of childhood obesity is a
disease of epidemic proportions that needs emergent
intervention and preventive care. Obesity is an
important public health concern associated with a
variety of physiological, psychological, and social
consequences in children. Programs to manage obesity
are unlikely to achieve the same spectacular rates of
53
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success as those in the past associated with the
control of infectious disease because it is not
feasible to target and remove a single cause of
obesity. Isolation and management of a major
contributing factor to obesity can not be identified
as is with other non-communicable diseases. However,
school-based programs have great potential for
instituting obesity prevention programs. Results from
various school-based obesity intervention programs
suggest that when successfully implemented substantial
numbers of children in need of obesity prevention can
be reached.
Theoretical Basis of
Behavioral Intervention
Intervention must be grounded in good theory in
order to be successful. A variety of theories have
been used in physical activity intervention and in CD-
ROM health education interventions. These theories
include Social Learning Theory and Social Cognitive
Theory. The Theory of Reasoned Action and Theory of
Planned Behavior, Behavioral Choice, Organizational
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Change, Social Influences, and Health Locus of Control
have also been utilized and are variants of Bandura's
Social Cognitive Theory. Social Learning Theory,
Social Cognitive Theory, Theory of Reasoned Action and
Theory of Planned Behavior are most commonly used to
design physical activity interventions and CD-ROM
health education interventions.
Social Learning Theory and Social
Cognitive Theory
Modern Social Learning Theory was introduced by
Bandura in 1977 and was renamed Social Cognitive
Theory in 1986. Key elements of this theory include
modeling, reinforcements, behavioral capability,
expectations, expectancies, incentives, self-control,
self-efficacy and reciprocal determinism (between the
person, behavior, and environment). Perceived self-
efficacy denotes an individual's ability to perform
the behavior and changes pertaining to the performance
(Bandura, 1986). Born out of behavioral theory,
cognition acts as a mediator between stimulus and
response, placing individual control over behavioral
55
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responses to stimuli. One limitation of this theory
is that the comprehensiveness and complexity of
behavioral responses make it difficult to
operationalize. Many applications of Social Learning
Theory and Social Cognitive Theory focus on only one
or two constructs and do not fully operationalize the
theory (Baranowski, Perry & Parcel, 1990). These
theories were originally designed to describe adult
behavior, and were inappropriate for younger children,
especially Social Cognitive Theory, which relies upon
independent thought.
Most of the successful prevention programs
relating to diet and physical activity in children
have been based on the Social Cognitive Theory (SCT)
approach to behavior change (Bandura, 1986). The SCT
proposes that behavior is influenced through the
combined interaction of events at the environmental,
behavioral, and individual levels. In addition,
school-based nutrition and lifestyle education is
thought to be particularly effective due to the
availability of the school to access children, to
provide an opportunity to practice healthy eating
56
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(especially in conjunction with the USDA Team
Nutrition Program), and the availability of skilled
educators. Also schools provide ready access to a
heterogeneous group of children and their families.
Nutrition education programs have been shown to
positively benefit child nutrition behavior,
especially when incorporated with a behavior change
strategy (King, Saylor, Foster, 1988; White & Skinner
1988) .
Potential Use of Interactive
Multimedia on Obesity
Regarding intervention studies, there were no
studies found that used a CD-ROM to promote physical
activity. However there were studies that assessed
the success of a variety of health education CD-ROM
programs. Table 3 describes multi-media intervention
studies, including the CD-ROM intervention studies.
Of the seven studies reviewed, three covered sun
safety, two asthma, one leukemia, and one
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Table 3
Multimedia Intervention Studies: CD-ROM Interventions for Children
Study Subjects Research Design
Measurement
Design
Proposed
Mediators
Dependent
Variables Results
Sunny Days,
Healthy Ways
(Buller et al.,
1999)
• 162 students
• 4th and 5th grade
• 8 classrooms
•
• Story: Users to clean up the
sun safety attic while
Grandma is away - provides
tailored messages based on
risk assessment
Experimental
Intervention vs. control
Theory: SCT
(modeling) &
TRA/TPB (attitudes)
Pre-test and post
test
• Knowledge
• Attitudes
• Sun safety
knowledge
• Attitudes
• Behavior
(tanning)
• Improvemen
tsin
knowledge
• Did not
directly
improve sun
protection or
attitudes
Playing it
safe in the
sun
(Hornung et
al., 2000)
• 209 students
• Grades 3 and 4
• 1 school
• Rural North Carolina
• 56% female
Experimental
• Computer
intervention
group
• Standard
teacher-led
classroom
intervention
• Control
Theory: none explicitly
stated
SLT (modeling)
1 session - 3 cartoon
characters modeling
different behaviors
Surveyed 1 day
Pre- and 1 day
post- intervention,
and 7 months post
intervention
• Knowledge
about sun and
UV radiation
• Attitudes
regarding
tanning
• Knowledge
• Behavioral
practices of UV
radiation
protection
• Increase in
knowledge
of computer
group
• Significant
differences
in attitudes
between 3
groups at
time 2, no
difference in
attitudes at
time 3
• No
significant
changes in
behavior
( j i
oo
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Table 3 (continued)
Study Subjects Research Design
Measurement
Design
Proposed
Mediators
Dependent
Variables Results
Air Academy:
The Quest for
Airtopia
(Bartholomew
et al., 2000;
Yawnetal.,
2000)
• 87 students
• 4h-grade classes
• 1 elementary school
• Metropolitan Minnesota
• 75% Caucasian
• Space adventure game
• Could play game in lab 20
minutes, 3 times a week for 6
weeks
Experimental
• Control
• CD-ROM only
• CD-ROM + %
hour talk on
asthma in class
Theory: None stated
Topics include:
• Asthma
knowledge
• Management
skills
Pre-test and 2
post-test
assessments of
asthma knowledge
(immediately
following
intervention and 4
weeks later)
None mentioned Asthma knowledge • Asthma
knowledge
increased
• The addition of
3 4 hour
classroom
session did not
significantly
increase
knowledge
Watch,
Discover,
Think, and
Act
(Bartholomew
et al., 2000)
• 171 inner city children
• Ages 6-17 (mean age 10.9)
• 65% mate
• 42.1 % Hispanic, 52.9%
African-American, 5% other
• Primarily Medicaid recipients
• Recruited from and
participated in project in
physician offices
CD tailored to individual -
• Can choose gender &
ethnicity of main character
• Specific asthma triggers,
symptoms and medications
Experimental
• Computer vs.
usual care
Theory: SCT
(modeling, self
monitoring, skill
building)
• Asthma-specific
skills training
• Adventure game
- older child in
game serves as
coach and model
Prospective Pre
test post- test
design
• Self-efficacy for
performing asthma
self-management
• Knowledge of
asthma
management
• Knowledge of self-
regulatory steps
• Self
management
• Symptoms
• Functional
status
• Hospitalizatio
n & ER visits
• Fewer
hospitalizations
• Better symptom
scores
• Increased
functional status
• Greater
knowledge of
asthma
management
• Better child self
management of
behavior
u i
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Table 3 (continued)
Study Subjects Research Design
Measurement
Design
Proposed
Mediators
Dependent
Variables Results
Refuse to
Use
(Duncan et al.,
2000)
• 74 students from 6 classes in
3 high schools
• 39% female
• Grades 9-12, mean age 15.2
±1.3
• Race/ethnicity not mentioned
Experimental
CD vs. control
Theory: Social
influences (not stated
but implied) & SCT
(skills-building) &
TRA/TPB (social
norms)
Pre- test and post
test (11-item
survey)
• Self-efficacy for
refusal
• Social norms
• Recall of
refusal
strategies
• Efficacy to
refuse offer
of
marijuana
• Intention to
refuse
marijuana
• Social
norms
• Increased efficacy
to refuse an offer of
marijuana
• Lowered intentions
to use marijuana if
offered
• Changes in social
norms associated
with substance use
and importance of
respecting
another’s decision
to refuse a drug
offer
Note: CD-ROM done as
group in classroom - so
cannot assess
effectiveness of CD
alone without classroom
Sun-safe
(Hewitt,
Denman, L.,
Pearson, &
Wallbanks,
2001)
• 376 children aged 10-11
(Year 5 and 6)
• 16 schools
• Nottingham, England
Interactive CD-ROM follows
central character (armadillo) on his
way to the “Sun City” theme park
Experimental, cluster,
controlled evaluation
design
• 12 schools
assigned to
workbook or
computer
• 4 schools self
selected to
control
Theory: no theory
stated, but TRA/TBB
(intentions & attitudes)
Self-completed
questionnaire, Pre
test and again in 6
weeks,
administered in
classroom
• Knowledge
• Attitudes
• Knowledge
• Attitudes
• Behavioral
intentions
• Increase in
knowledge in all 3
groups, but only
workbook arouD
significantly
increased
• Both intervention
groups’ sun safety
intentions improved
significantly
o
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Table 3 (continued)
Study Subjects Research Design Measurement
Design
Proposed
Mediators
Dependent
Variables
Results
Kidz with • 41 children aged 4-11 (14 Experimental Pre- and post-test No proposed • Health locus • Children in CD-
Leukemia: A were 4-6 and 17 were 7-11) • CD-ROM vs. assessments mediators of control ROM group
Space
• All were diagnosed with book (You and • Under showed increased
Adventure
leukemia Leukemia - standing of feelings of control
(Dragone et
• Majority Caucasian usual care) leukemia over their health
• Mean 2.6 years from • Satisfaction • All CD-ROM users
al., 2002)
diagnosis
Theory: Health Locus
of reported
• Majority Caucasian
of Control & SLT
participants satisfaction, and it
• All had to have a computer at
with was highest
home
• Users can pick
age 4-6,7 or
older, or adult
• A “Space-Buddy"
is user’s guide
through games
assigned
intervention
among young
children and their
families
Reproduced w ith permission o f th e copyright owner. Further reproduction prohibited without permission.
Table 3 (continued)
Study Subjects Research Design
Measurement
Design
Proposed
Mediators
Dependent
Variables Results
Refuse to
Use
(Duncan et al.,
2000)
• 74 students from 6 classes in
3 high schools
• 39% female
• Grades 9-12, mean age 15.2
±1.3
• Race/ethnicity not mentioned
Experimental
CD vs. control
Theory: Social
influences (not stated
but implied) & SCT
(skills-building) &
TRA/TPB (social
norms)
Pre- test and post
test (11-item
survey)
• Self-efficacy for
refusal
• Social norms
• Recall of
refusal
strategies
• Efficacy to
refuse
offer of
marijuana
• Intention
to refuse
marijuana
• Social
norms
• Increased
efficacy to refuse
an offer of
marijuana
• Lowered
intentions to use
marijuana if
offered
• Changes in social
norms associated
with substance
use and
importance of
respecting
another’s
decision to refuse
a drug offer
Note: CD-ROM done
as group in classroom
- so cannot assess
effectiveness of CD
alone without
classroom
O'!
N3
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Table 3 (continued)
Measurement Proposed Dependent
Study Subjects Research Design Design Mediators Variables Results
Sun-safe • 376 children aged 10-11 Experimental, cluster, Self-completed • Knowledge • Knowledge • increase in
(Year 5 and 6) controlled evaluation questionnaire, Pre
• Attitudes
•
Attitudes knowledge in all 3
(Hewitt,
• 16 schools
design test and again in 6 •
Behavioral
groups, but only
Denman, L.,
• Nottingham, England • 12 schools weeks,
intentions
workbook arouD
Pearson, & assigned to administered in significantly
Wallbanks,
Interactive CD-ROM follows
workbook or classroom increased
2001)
central character (armadillo) on his
way to the “Sun City" theme park
computer
• 4 schools self
selected to
control
Theory: no theory
stated, but TRA/TBB
(intentions & attitudes)
• Both intervention
groups’ sun safety
intentions
improved
significantly
Kidz with • 41 children aged 4-11 (14 Experimental Pre- and post-test No proposed mediators • Health • Children in CD-
Leukemia: A were 4-6 and 17 were 7-11) • CD-ROM vs. assessments locus of ROM group
Space
• All were diagnosed with book (You and control showed increased
Adventure
leukemia Leukemia - • Under feelings of control
(Dragone et
• Majority Caucasian usual care) standing of over their health
• Mean 2.6 years from leukemia • All CD-ROM users
al., 2002)
diagnosis
• Majority Caucasian
Theory: Health Locus
of Control & SLT
•
Satisfaction
of
reported
satisfaction, and it
• All had to have a computer at
• Users can pick
age 4-6,7 or
older, or adult
• A “Space-Buddy”
is user’s guide
through game
participants was highest
home
with
assigned
intervention
among young
children and their
families
< T >
U)
drug prevention. All studies used an experimental
design. CD-ROM programs were based in Social Learning
Theory and/or Social Cognitive Theory, the Theory of
Reasoned Action and/or Theory of Planned Behavior,
Social Influences, and Health Locus of Control.
All studies utilized questionnaires to measure a
variety of variables, the most common being knowledge.
CD-ROM health education interventions varied in
their success. The physician-based asthma program
("Watch, Discover, Think, and Act") had several
significant findings, including fewer hospitalizations,
fewer symptoms, increased functional status, and
improved self-management of behavior. The "Air
Academy: The Quest for Airtopia" CD-ROM program
increased knowledge in the workbook condition, but not
the CD-ROM condition. Two studies reported no
behavior change, and in the leukemia study, children
reported increased feelings of control following the
intervention.
One previous study has shown that computer-
assisted behavioral counseling was more effective than
64
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educational handouts in encouraging high-school
students to consume a more healthful diet (Burnett,
Magel, Harrington, 1989). Similarly, an interactive
computer program related to diet and cancer prevention
was compared to traditional types of educational tools
in a group of 92 undergraduate students (Kumar, Bostow,
Schapira, & Kritch, 1993). Students receiving the
interactive computer education showed a significantly
greater increase in knowledge as well as a
significantly higher reduction in reported dietary fat
intake (Kumar et al., 1993).
One example of a multi-media tool is "Dr
Health'nstein's Body Fun," an interactive game
produced by the Cancer Research Foundation of America.
This game is designed around the concept of creating a
character who is healthy enough (through selecting
good nutrition and physical activities) to beat
challengers in various sporting competitions. This
game was found to be reasonably strong from a
conceptual and graphic standpoint. However, it was
not designed using any type of behavioral change model
and was not truly interactive, did not teach concepts
65
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well, did not involve other family members, and was
not cohesive or captivating.
Another example of a CD-ROM for. nutrition
education in children is the 5 A Day Adventures
produced by The Dole Food Company in partnership with
the Society for Nutrition Education. This product is
available free to schools and focuses on educating 5-
10 year old children to consume at least five servings
per day of fruit and vegetables. Its impact is
measured by the fact that it is currently used by
29,000 schools nationwide. Some of the scenarios are:
Animated vegetables (e.g., skateboarding Bobby Banana)
are used to guide children through an adventure
theater of 42 animated fruit and vegetable characters
(e.g., explains how fruits are grown), The Body Shop
(explains how fruits and vegetables are important for
body function), Cook's Kitchen (simple recipes for
children), and the Salad Factory (preparation of
salads and nutrition analysis). Its specific focus is
to promote increased consumption of fruits and
vegetables among children, but no outcome evaluation
data is available. Limitations of the 5 A Day
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Adventures CD-ROM are that it was not designed using a
theory based behavioral model, it is specifically
focused on fruit and vegetable consumption, and that
it has not been rigorously examined for its impact and
effect on outcome.
Interactive multi-media provides tremendous
potential as a medium to develop school-based, health
promotion and education tools that can also
incorporate family involvement and can be designed
around effective models of behavior change such as
Social Cognitive Theory. It is likely that the
increased use of creative and interactive multi-media
tools will lead to a stronger impact and play a key
role in long-term preventive efforts. In fact, the
use of novel multi-media teaching approaches has been
recognized as one of the most important ways to
improve the status of nutrition education in children
(Burnell, Magel & Harrington, 1989).
Only a few interactive multi-media tools have
been developed for nutrition and health related
education in children, but none that are based on a
theoretical approach to behavior change, and none have
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been tested for their outcome effects. Furthermore,
there have been no interactive multi-media tools
developed to promote physical activity in children.
Summary
This chapter reviewed a number of studies
demonstrating the major findings of obesity and gaps
that still exist in the prevention of obesity. A
number of studies were cited demonstrating the health
significance of the problem of obesity, childhood
obesity in particular. Various the needs for
effective health education in schools were described.
Information was provided on previous studies relating
to the prevention of obesity. A theoretical basis for
behavioral interventions was given. The potential
used of interactive multi-media in the prevention of
obesity was demonstrated.
This chapter has reviewed existing knowledge that
suggests an urgent need to develop new and effective
strategies for the primary prevention of obesity
through the promotion of physical activity in children.
The many conditions relating to obesity are difficult
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to treat and it is likely that a significant portion
of these health risks can be averted by a long-term
commitment to primary prevention. These conditions,
most commonly type 2 diabetes, also have one other
feature in common, in that they have been recognized
as having a major involvement of lifestyle, and in
particular to physical activity. Thus, there is a
very strong link between lifestyle, disease prevention,
health costs, and mortality. Clearly, the best way to
treat the increasing prevalence of obesity and
lifestyle-related chronic-health conditions is by
prevention through public-health promotion. Thus,
there is a critical emerging need to develop health
promotion tools to improve the physical activity
profile across the diversity of the population.
Interactive multi-media provides tremendous
potential as a medium to develop school-based, health
promotion and education tools that can also
incorporate family involvement and can be designed
around effective models of behavior change such as
Social Cognitive Theory. However, interactive multi-
media has not yet been widely explored as a tool for
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delivery of effective health-behavior interventions in
children. Only a few interactive multi-media tools
have been developed for nutrition and health-related
education in children, but none that are based on a
theoretical approach to behavior change, and none have
been tested for their outcome effects. This study was
designed to address this gap.
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CHAPTER 3
METHODS AND PROCEDURES
The purpose of this chapter is to set forth a
description of: (a) the design of the study,
including details of the pilot study, (b) the
characteristics of the sample, (c) procedures in the
test administration, (d) methods employed in the data
analyses, and (e) a citation of the methodological
assumptions.
Design
An experimental design to test the effect of
exposure to interactive multi-media on physical
activity, knowledge, attitudes and feelings was
employed. Four elementary schools were selected and
assigned. Two schools were assigned to the
intervention group and two schools to the unrelated
treatment control group based the on percent of free
and reduced fee meals served (Title I schools).
Control schools received an attention control
intervention in which they were provided with a series
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of commercially available educational CD-ROMS with
similar contact time hours, but the topics were
unrelated to physical activity. Other curricular
areas, such as reading and math, were covered rather
than physical activity.
The theory-based intervention includes a total
exposure of at least 10 hours of structured material
in the initial pilot phase. This contact time is
composed of the following: (a) eight CD-ROM
interactive computer sessions at 30 minutes each (4
hours), (b) four classroom sessions at 45 minutes each
(3 hours) to provide opportunities to enact behavior
and receive reinforcement, and, (c) four home-based
activity sessions at 45 minutes each (3 hours) to be
completed with at least one parent in the family
environment.
A pilot study was done in the spring of 2002 with
approximately 65 students. The Appendix presents the
Demographic Survey (Form A) and the Impact Study (Form
B). Selected components of the main IMPACT
intervention were pilot-tested in two fourth-grade
classrooms. After the feasibility study, focus groups
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were utilized to make necessary changes to the
program to assess the overall level of difficulty and
to receive suggestions on improvements of specific
games (Appendix, Forms C and D). Two classrooms that
were most closely matched with each other in terms of
ethnicity and SES, and most well equipped and willing
to participate in the proposed intervention were
selected. Females and minorities were adequately
represented. In addition, a large percentage of
children were receiving meal assistance, suggesting a
substantial proportion of low-income families. Minor
changes in the difficulty of games and added
instructions throughout the CD-ROM were implemented as
a result of the pilot study.
Sample
The main intervention recruited 168 students from
four schools and eight classrooms. Two hundred and
forty students were recruited from local elementary
schools with a 70% consent rate. Subjects of this
study were fourth grade students from a large public
elementary school district. The district had over
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10,000 students, 66% of whom were Hispanic, 7%
African-American, 10% Asian, 4% Filipino, and 13%
White (Table 4). The district was considered to be at
average achievement in reading and math on
standardized tests and was also considered a low-
income population according to the free-lunch
percentage, which was 49% of the student population.
This study focused on 8-9 year old boys and girls
(fourth grade). There were many reasons that justify
this choice. This age is old enough to allow good
communication between children and the investigators.
At this age, children do make some decisions about
physical activity. A useful degree of computer
literacy is likely to have been established, and if
not can be taught.
Measures
Demographic variables were collected via
questionnaire that was filled out at the same time as
the consent form. Variables included: relationship
of person completing questionnaire to child, marital
status, race of mother and father, level of education
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Table 4
Demographics
Student Ethnicity Percent
African American 7%
Asian 10%
Filipino 4%
Hispanic 66%
Native American 0%
Pacific Islander 0%
White 13%
Mixed race or no response 0%
Student Gender
Males 48%
Females 52%
Student Age
8 10.3%
9 78.4%
10 10.8%
11 0.5%
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of mother and father, and combined household annual
income.
Psychosocial measures of self-efficacy, beliefs
about physical activity, and social influences for
physical activity were assessed through a self-report
questionnaire. Scales developed by Saunders, Felton,
Dowda, Weinrich, Ward, Parsons, & Baranowski (1997)
were utilized to assess these measures. The Social
Cognitive Theory scale provided the theoretical
foundations for the instruments used in this study.
The internal consistency reliabilities for the
psychosocial measures were above 0.70 in a study
performed on 422 fifth grade students (Saunders et al
1997). A cross-validation design was employed for
psychometric development of the scales, including
factor analysis, reliability, and validation by
correlating scale scores with intention to be
physically active. (Saunders, 1997).
The Self-Efficacy scale, taken from Social
Cognitive Theory, contained 12 items. This scale
includes confidence in overcoming barriers to physical
activity (Bandura, 1986).
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The Beliefs Scale contained 16 items, which was
taken from the "beliefs about consequences of
participating in" physical activity from the "attitude
toward the behavior" component of the theory of
reasoned action (Ajzen, 1980). This component also
corresponds to the "outcome expectations" component of
Social Cognitive Theory (Bandura, 1986).
The Social Influence scale contained eight items,
which included items addressing perceived expectations
of others from the theory of reasoned action (Ajzen,
1980), as well as social modeling from Social
Cognitive Theory (Bandura, 1986). The sources of the
original instruments, primary concepts being measured,
and sample items of final instruments are presented in
Table 4.
The internal consistency reliabilities for the
Social Influences, Self-Efficacy, and Beliefs physical
outcomes scale were above 0.7 0 in the development
sample. For the Social Influences and Self-Efficacy,
the test-retest correlation coefficients were also
0.7 0 in the development sample. These levels are
considered adequate (Nunnally, 1978). The internal
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consistency reliability and test-retest correlation
coefficients were somewhat lower for the Self-Efficacy
positive alternatives and the Beliefs social outcomes
scales (Saunders, 1997).
Self-report may be the most commonly used type of
measure simply because of its low cost and convenience.
Four types of self-report measures have been
identified: interviewer administered, self
administered, diary, and proxy report (Sallis, 1991).
There are concerns about the reliability and validity
of all these, and any behavioral self-report by
children involves substantial cognitive demands
(Baranowski, 1988). However, there is growing
evidence that children as young as 8 years old can
provide self-reports of at least modest reliability
and validity (Sallis, 1993).
Procedures
In order to make the intervention as non-invasive
to the school as possible, the proposed outcome
measures were collected in 45 minutes for physical
activity and psychosocial measures, which is completed
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by questionnaire during a class period. Thus, there
was minimal disruption to the students during the data
collection period. Two members of the project staff
conducted the assessment with one reading the
questionnaire aloud to the children while they
completed the questionnaire, and the second team
member circulating to answer questions from the
students. The questionnaires were edited immediately
after completion by the project staff members
conducting the questionnaires. The questionnaires
were items with a 3- to 5-point response format which
is readily understood by students of this age.
After the pilot test, minor adjustments were made
to the questionnaire in response to student feedback.
The questionnaire administrator read the instructions
and questionnaire items to the class using a
standardized script. The script included an
introduction in which physical activity was defined as
"any active games, active play, sports, or exercise
that gets you moving, breathing faster, and your heart
beating faster." This introduction was accompanied by
poster pictures illustrating the range of possible
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physical activities, such as dancing, swimming,
playing on the playground, biking, cheerleading, and
walking. An assistant monitored the room during the
questionnaire to answer questions and check for
students having problems.
Prior to participation in the treatments,
students in both intervention and control groups took
the questionnaire (Appendix Form B) to serve as a pre
test for this study. Scores on this test were
examined to determine the baseline data to compare
with the post-test results. Toward this end,
descriptive measures (means and standard deviations)
for each group were calculated, and an analysis of
variance was performed to compare the pre-test versus
post-test scores among the groups.
Students in the four schools then participated in
the study as described in Chapter 3. Over an eight-
week period, all students in the treatment groups
received the interactive multimedia to promote
physical activity while the control groups received
their regular computer-based instruction on reading or
math during their computer lab time. The theory-based
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intervention included a total exposure of at least 10
hours of structured material. This contact time was
composed of the following: (a) eight CD-ROM
interactive computer sessions at 30 minutes each (4
hours), (b) four classroom sessions at 45 minutes each
(3 hours) to provide opportunities to enact behavior
and receive reinforcement, and (c) four home-based
activity sessions at 45 minutes each (3 hours) to be
completed with at least one parent in the family
environment.
At the conclusion of the treatment period, the
questionnaire was administered to all eight classes
again. The resulting post-test data were then
analyzed to test the original hypotheses.
Data Analysis
The data were coded and prepared for computerized
analysis using SPSS. A two-sided p-value of 0.05 or
less was selected to determine the statistical
significance of the test statistics. Descriptive
statistics and other appropriate statistical tests
were included: (a) mean (SD) for continuous/ordinal
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variables and N (%) for categorical variables, (b) a
Wilcoxon Signed-Ranks test to compare the distribution
of ordinal variables before and after intervention, (c)
a McNemar test was utilized to compare the
distribution of responses to categorical variables
before and after intervention, (d) a Wilcoxon Signed-
Ranks test to compare the distribution of ordinal
variables before and after intervention, (e) a
Kruskal-Wallis or Mann-Whitney U test was utilized as
appropriate to compare the change in ordinal variables
from pre to post intervention between categorical
demographic variables, and (f) Spearman's rho was used
to evaluate the association between the change in
ordinal variables from pre to post with
continuous/ordinal demographic variables.
Methodological Assumptions
The following methodological assumptions were
implicit in this investigation:
1. The fourth grade students making up the
sample in this study are representative of all fourth
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grade students which allows the results to be
generalized to these specified populations.
2. The respondents provided honest responses
for pre- and post-test questionnaires.
3. The reliability and validity of the
instruments used were sufficient to permit accurate
information related to physical activity.
4. The intervention was consistent throughout
to eliminate bias.
5. The research design and data analysis
procedures used in this study are appropriate.
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CHAPTER 4
RESULTS
In this chapter, the statistical outcomes
corresponding of the three research questions stated
in the first chapter are reported. Subsequently,
these statistical results are interpreted and
discussed as well as related to other relevant
research. To facilitate communication of the findings
of this investigation, the acronyms or codes of the
test variables are listed adjacent to the names of the
relevant measures in my subsequent tables.
Analysis of Findings
For the results of this study, a McNemar's test
was utilized to compare pre versus post intervention.
The idea with a McNemar test is analogous to a
Wilcoxon Signed-Ranks test because there is paired
data, before and after. The only difference is there
is ordinal data instead of categorical data. The
McNemar test compares the percentage of discordant
response, PI versus P2 where PI is the percentage of
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patients that answered Yes at baseline and No at
follow up, and P2 is the percentage of patients that
answered No at Baseline and Yes at follow up. The
null hypothesis is that these two percentages are
equal. If the p-value is less than 0.05, we reject
the null hypothesis and conclude that there is a
difference. It can be shown algebraically that
comparing the percentage discordant is the same as
comparing the percentage "Yes" at baseline with the
percentage "Yes" at follow up, which is usually the
more useful information to consider.
For example in question 1, to test self-efficacy
in the questionnaire, "I think I can be physically
active most days after school," 15% of students
answered "No" at baseline and "Yes" at follow-up while
18% answered "Yes" at baseline and "No" at follow-up.
The P-value for the comparison of these two
percentages is 0.512. Thus, the null hypothesis is
not rejected and concludes that a student is no more
likely to change their mind to this question if they
started out a "No" than if they started out a "Yes"
(Table 5).
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Table 5
Self-efficacy Measures: Pre-test Versus Post-test Using a McNemar’s Test
Measure Code
“No” at
baseline
“Yes” at
baseline Percent
“No” at
follow-up
“Yes” at
follow-up Percent
Total
Number
P-value
1 think 1 can be physically active most days after
school.
SE1 31 147 82.6% 37 141 79.2% 178 .512
1 think 1 can ask my parents or other adult to do
physically active things with me.
SE2 65 112 63.3% 35 142 80.2% 177 .001
1 think 1 can be physically active after school even
if 1 could watch TV or playvideo games instead.
SE3 56 118 67.8% 35 139 79.9% 174 .011
1 think 1 can be physically active after school even
if my friends want me to do something else.
SE4 59 119 66.9% 38 140 78.7% 178 .017
1 think 1 can ask my parent or other adult to sign
me up for sport, dance, or other physical activity.
SE5 39 136 77.7% 38 137 78.3% 175 1.00
1 think 1 can be physically active even if it is hot or
cold outside.
SE6 50 128 71.9% 38 140 78.7% 178 .188
1 think 1 can ask my best friend to be physically
active with me.
SE7 34 145 81.0% 37 142 79.3% 179 .798
1 think 1 can ask my parent or other adult to get
me the equipment 1 need to be physically active.
SE8 56 122 68.9% 35 142 80.2% 177 .017
1 think 1 can ask my parent or other adult to take
me to a physical activity or sport practice.
SE9 51 129 71.7% 38 142 78.9% 180 .193
1 think 1 can be physically active, even if 1 have a
lot of homework.
SE10 74 105 58.7% 37 142 79.3% 179 .000
1 think 1 can be physically active even if 1 have to
stay at home.
SE11 30 150 83.3% 38 142 78.9% 180 .332
1 think 1 have the skills 1 need to be physically
active.
SE12 30 150 83.3% 38 142 78.9% 180 .366
CO
Looking at this another way, 147/178 (83%) said
"Yes" at baseline while 141/178 (79%) said "Yes" at
follow-up. These are not very different and, again,
that explains why the comparison is not statistically
significant.
With respect to question 2 on the self-efficacy
questionnaire, "I think I can ask my parents or other
adult to do physically active things with me," there
is a statistically significant difference. We see
that 32% of students said "No" at baseline and "Yes"
at follow-up while only 15% of patients said "Yes" at
baseline and "No" at follow-up (P=0.001). Stated
another way, 112/177 (63%) said yes at baseline while
142/177 (80%) said yes at follow-up (P=0.001)
(Table 5).
Initially, the data were analyzed to confirm
independence of scores. An intra-class correlation
was calculated and was significant with r<.01. Then,
a paired t-test was utilized to compare the means of
all subjects who had worked with the prevention
program with the means of all subjects who did not.
Results of the test are shown in Table 5 for
8
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Self-Efficacy, Table 6 for Beliefs About Physical
Activity, and Table 7 for Social Influence.
These results confirmed the hypothesis: those
students participating in an interactive multimedia
obesity prevention program will show significantly
greater self-efficacy, beliefs about physical activity,
and social influence.
The Effect in Relation to Self-efficacy Measures
Regarding Physical Activity
As evident in Table 5, the results of the data
analysis yielded the following findings in relation to
the research questions and hypothesis in regards to
the self-efficacy measures assessed.
Comparing pre versus post intervention using a
McNemar's test indicated that there is a significant
difference among the treatment and unrelated treatment
control group in regards to self-efficacy in physical
activity. The measures that were significant in
relation to self-efficacy were questions 2, 3, 4, 8,
and 10 with P values ranging from .000 to .017.
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Table 6
Beliefs About Physical Activity Measures: Pre-test Versus Post-test Using a McNear’s Test
Measure Code
“No” at
baseline
“Yes” at
baseline Percent
“No” at
follow-up
“Yes” at
follow-up Percent
Total
Number P-value
If 1 were to be physically active most
days it would help me spend more
time with my friends.
BEL1 59 120 67.0% 38 141 78.8% 179 .022
If 1 were to be physically active most
days it would make me get hurt.
BEL2 125 54 30.2% 37 142 79.3% 179 .000
If 1 were to be physically active most
days it would help me be healthy.
BEL3 9 170 95.0% 37 142 79.3% 179 .000
If 1 were to be physically active most
days it would cause pain and muscle
soreness.
BEL4 101 76 42.9% 38 139 78.5% 177 .000
If 1 were to be physically active most
days it would help me control my
weight.
BEL5 24 153 86.4% 38 139 78.5% 177 .070
If 1 were to be physically active most
days it would help me look good to
others.
BEL6 47 122 72.2% 31 138 81.7% 169 .040
If 1 were to be physically active most
days it would help me work out my
anger.
BEL7 59 117 66.5% 37 139 79.0% 176 .008
If 1 were to be physically active most
days it would make me tired.
BEL8 63 114 64.4% 38 139 78.5% 177 .004
If 1 were to be physically active most
days it would give me energy.
BEL9 37 139 79.0% 37 139 79.0% 176 .000
If 1 were to be physically active most
days it would make me embarrassed
in front of others.
BEL10 139 40 22.3% 38 141 78.8% 179 .000
If 1 were to be physically active most
days it would help me spend more
time with my friends.
BEL11 14 166 92.2% 38 142 78.9% 180 .001
co
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Table 6 (continued)
Measure Code
“No” at
baseline
“Yes” at
baseline Percent
“No” at
follow-up
“Yes” at
follow-up Percent
Total
Number P-value
If 1 were to be physically active most
days it would make me get hurt.
BEL12 90 88 49.4% 38 140 78.7% 178 .000
If 1 were to be physically active most
days it would help me be healthy.
BEL13 1 1 163 93.7% 38 136 78.2% 174 .000
If 1 were to be physically active most
days it would cause pain and muscle
soreness.
BEL14 100 56 35.9% 28 128 82.1% 156 .000
If 1 were to be physically active most
days it would help me control my
weight.
BEL15 149 31 17.2% 38 142 78.9% 180 .000
If 1 were to be physically active most
days it would help me look good to
others.
BEL16 12 167 93.3% 38 141 78.8% 179 .000
o
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Table 7
Social Influence Measures: Pre-Test Versus Post-Test Using a McNemar’s Test
Measure Code
“ No” at
baseline
“Yes” at
baseline Percent
“ No” at
follow-up
“Yes” at
follow-up Percent
Total
Number P-value
My family thinks 1 should be
physically active.
SI1 25 147 85.5% 37 135 78.5% 172 .111
Someone in my family has offered to
be physically active with me in the
past 2 weeks.
SI2 105 71 40.3% 38 138 78.4% 176 .000
Someone in my family has
encouraged me to be physically
active in the past 2 weeks.
SI3 69 106 60.6% 37 138 78.9% 175 .000
Someone in my family has been
physically active with me in the past
2 weeks.
SI4 86 90 51.1% 37 139 79.0% 176 .000
My friends think 1 should be
physically active.
SI5 77 92 54.4% 33 136 80.5% 169 .000
A friend has offered to be physically
active with me in the past 2 weeks.
SI6 89 85 48.9% 38 136 78.2% 174 .000
A friend has encouraged me to be
physically active in the past two
weeks.
SI7 93 82 46.9% 35 140 80.0% 175 .000
A friend has been physically active
with me in the past 2 weeks.
SI8 67 109 61.9% 38 138 78.4% 176 .002
To clarify the results of this study, statistics
are narrated for the self-efficacy measures that were
significant. With respect to question 2 on the self-
efficacy questionnaire, "I think I can ask my parents
or other adult to do physically active things with
me," there is a statistically significant difference.
Sixty-three percent (112/177) said "Yes" at baseline
while 80% (142/177) said "Yes" at follow-up (P=0.001).
With respect to question 3 on the self-efficacy
questionnaire, "I think I can be physically active
after school even if I could watch TV or play video
games instead," there is a statistically significant
difference. 118/174 (68%) said "Yes" at baseline
while 139/174 (80%) said Yes at follow-up (P=0.011).
Question 4 on the self-efficacy questionnaire, "I
think I can be physically active after school even if
my friends want me to do something else," there is a
statistically significant difference. Sixty-seven
percent (119/178) said "Yes" at baseline while 79%
(140/178) said yes at follow-up (P=0.017).
On question 8 on the self-efficacy questionnaire,
"I think I can ask my parent or other adult to get me
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the equipment I need to be physically active," there
is a statistically significant difference. Sixty-nine
percent (122/177) said "Yes" at baseline while 80%
(142/177) said Yes at follow-up (P=0.017).
With respect to question 10 on the self-efficacy
questionnaire, "I think I can be physically active
even if I have a lot of homework," there is a
statistically significant difference. Fifty-nine
percent (105/179) said "Yes" at baseline while 79%
(142/179) said Yes at follow-up (P=0.000).
The Effect in Relation to Beliefs about
Physical Activity Measures
Regarding Physical Activity
As evident in Table 5, the results of the data
analysis yielded the following findings in relation to
the research questions and hypothesis in regards to
the beliefs about physical activity measures assessed.
Comparing pre versus post intervention using a
McNemar's test indicated that there is a significant
difference among the treatment and unrelated treatment
control group in regards to beliefs about physical
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activity. Beliefs about physical activity showed the
most significant changes. All of the measure (BE1-
BE16) showed statistically significant differences
ranging from .000 to .022. But, all of these were not
positive differences, BE3, BE5, and BE 11 were
negative changes (Table 6).
The Effect in Relation to
Social Influence Measures
Regarding Physical Activity
As evident in Table 7, the results of the data
analysis yielded the following findings in relation to
the research questions and hypothesis in regards to
the social influence measures assessed.
Comparing pre versus post intervention using a
McNemar's test indicated that there is a significant
difference among the treatment and unrelated treatment
control group in regards to social influence of peers
in physical activity. As for the Social Influence,
all but one of the measures was positively
statistically significant with the P values ranging
from .000-.002 (Table 7).
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Of the 36 questions on the questionnaire, 28
showed a statistically significant change in the
students' in relation to self-efficacy, beliefs about
physical activity, and social influence.
These results confirm the hypothesis: those
students involved in an interactive multimedia obesity
prevention program will show statistically significant
differences in relation to self-efficacy, beliefs
about physical activity, and social influence.
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CHAPTER 5
SUMMARY, DISCUSSION, AND RECOMMENDATIONS
Summary
Only a few interactive multi-media tools have
been developed for nutrition and health-related
education in children, but none are based on a
theoretical approach and have been tested for their
outcome effects for behavior change. Also, there is
no information on interactive multi-media tools
relating to the promotion of physical activity in
children.
Interactive Multimedia for the Promotion of
Physical Activity, an obesity prevention program for
fourth grade children, includes CD-ROM, classroom, and
family/homework sessions that promote physical
activity. The interactive multimedia intervention,
developed through collaboration of researchers,
teachers, script writers, and production team members,
focuses on individual, behavioral, and environmental
factors and merges constructs from Social Cognitive
Theory (SCT). The focus of this study was to examine
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IMPACT to evaluate the psychosocial correlates of
physical activity specifically focusing on self-
efficacy, beliefs about physical activity, and social
influences.
This study was undertaken to determine the
efficacy combining interactive multimedia with health
education. It examined computer-based learning in the
area of obesity prevention in fourth-grade students.
The hypothesis investigated in this study was
that fourth grade students who were involved in a
theory-based interactive obesity prevention program
will demonstrate a significantly greater improvement
in self-efficacy, beliefs about physical activity, and
social influence than students given tradition
interactive multimedia programs during their computer
lab time.
At the conclusion of the study, all students took
a post-test to determine whether there had been
changes in students' self-efficacy, beliefs about
physical activity, and social influence.
The data were coded and prepared for computerized
analysis using SPSS. A two-sided p-value of 0.05 or
97
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less was selected to determine the statistical
significance of the test statistics. Descriptive
statistics and other appropriate statistical tests
were utilized.
Of the 36 questions on the questionnaire, 28
showed a statistically significant change in the
students in relation to self-efficacy, beliefs about
physical activity, and social influence. These
results confirm the hypothesis: those students
involved in an interactive multimedia obesity
prevention program will show statistically significant
differences in relation to self-efficacy, beliefs
about physical activity, and social influence.
On the basis of the statistical findings for the
fourth grade sample students studied, the following
conclusions became evident:
1. Comparing pre versus post intervention using a
McNemar's test indicated that there is a significant
difference among the treatment and unrelated treatment
control group in regards to self-efficacy in physical
activity.
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2. Comparing pre versus post intervention using a
McNemar's test indicated that there is a significant
difference among the treatment and unrelated treatment
control group in regards to beliefs about physical
activity.
3. Comparing pre versus post intervention using a
McNemar's test indicated that there is a significant
difference among the treatment and unrelated treatment
control group in regards to social influence of peers
in physical activity.
Discussion
This interactive multimedia intervention to
promote physical activity in fourth grade students
resulted in statistically significant changes in the
students in relation to self-efficacy, beliefs about
physical activity and social influence. The strengths
of this research include the large sample of schools
and students, the mixed ethnic and SES composition of
the sample, using the school as the unit of assignment
and analysis, minimal differences in consumption by
groups at baseline, the ability of the computer to
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deliver the intervention as designed, and similar
results for all approaches to outcome analysis. It is
not clear, however, how long this increased change
would be maintained beyond the end of the program.
This study was unique from all previous studies
because it combined a theory-based interactive
multimedia prevention program to promote physical
activity. Other interactive multimedia programs have
been developed but none that were theory based.
There are still many gaps in the research. There
is no "gold standard" measure of physical activity in
youth. Self-report is often biased, observation
tedious, labor intensive and time-consuming, and there
are problems with objective measures as well (Montoye,
Kemper, Saris, & Washburn, 1996). One unanswered
question, then, is what is the best measure of
physical activity in this age group? Is there a
viable alternative to self-report? Many scientists
use more objective measures of physical activity
including pedometers (measure steps), heart rate
monitors, and motion sensors or accelerometers
(measure movement in either one or three planes).
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There are many problems with these measurement tools,
including cost, whether they really pick up all
activity that youth engage in, and interpretation of
data (Freedson & Miller, 2000; Trost, 2001). What is
also unclear is what health behavior theory, or
theories, best explains and predicts elementary
school-age youth physical activity.
There are also gaps in the research related to
the use of CD-ROM in health education. No
interventions using CD-ROM have been published that
promote physical activity. In the few CD-ROM health
education programs designed for youth, many have
failed to change behavior. Also, some studies failed
to compare CD-ROM interventions with more traditional
classroom-delivered interventions. Which, if either,
is more effective? What combination of components is
most effective at initiating behavior change? And why
is it that CD-ROM programs directed towards self
management of disease seemed to be more successful
than those promoting behavior changes in healthy
children? What is also important to uncover is
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whether or not a CD-ROM intervention can be successful
in promoting physical activity in youth.
Recommendations
There are some areas yet to be explored in the
promotion of physical activity in elementary school-
aged youth. Programs ought to target girls, since
their levels of activity lower with age. This decline
in activity is more evident for black girls than for
white girls (Kimm et al., 2001). African-Americans,
Hispanics and low-income youth, have a higher
prevalence of overweight (Kimm et al., 2001; Strauss &
Pollack, 2001), and subsequently are at increased risk
for health problems. The relationship between
race/ethnicity and decline in physical activity is not
as strong for boys, indicating the need for different
theoretical models for boys and girls and perhaps for
different ethnic groups.
Interventions should be designed to involve
parents and families of children. Parental
involvement plays an important role in the success of
behavior change programs for children (Donnelly et al. ,
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1996; Epstein, Valoski, Wing, & McCurley, 1990; Nader,
1993; Perry et al., 1988). After an intervention is
finished, periodic follow-up contact, such as a
newsletter, may reinforce new behavior and aid in
maintenance. The area of maintenance of physical
activity behavior change in children is another area
that needs further investigation. The role of policy
should be studied and tested as well. For example,
enforcing the California Education Code mandate for
200 minutes of PE every 10 days might boost activity.
Environmental approaches to activity should be
investigated as well. And lastly, perhaps other
settings--after-school sports and/or learning programs,
churches— may be appropriate settings for physical
activity interventions, lessening the burden on
elementary schools, their administrators, and their
teachers.
Future studies should be done to expand the scope
of the intervention, and examine whether interactive
multimedia can have beneficial and sustained effects
on health behaviors (i.e., nutrient consumption,
physical activity participation), body composition,
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fat distribution, and disease risk factors (blood
lipid levels, glucose intolerance, and blood pressure)
Expanding the scope of the intervention may require
the development of additional complementary elements
such as mass media and inclusion of an internet site
to link classrooms and teachers. This type of
approach has worked well in other health campaigns in
children relating to smoking cessation and drug abuse,
and is currently being used in studies relating to
skin cancer for example. A randomized and controlled,
school-based intervention studies to examine the
longer-term effects of the intervention would be the
intent.
In addition, future work will be needed to ensure
that interactive multimedia tools are culturally
appropriate for the diversity of the population. Also
there is great potential to develop an extended series
of other CD-ROMs dealing with related issues. For
example, another potential area for future development
relates to addressing school policy issues relating to
improving nutrition and physical activity
participation in the school environment. For the
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proposed intervention to be most effective, behavioral
changes should be accompanied by policy and
environmental changes. For example, changes in school
policy and environment may work in synergy with the
effects of increased nutrition and physical activity
education to have maximal beneficial effects on
changing children's behavior.
105
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APPENDIX
DATA COLLECTION MATERIALS
Macromedia Authorware and Director was used for
the creation of a variety of multimedia productions,
including business presentations, web content,
interactive advertising pieces, kiosk productions, and
CD-ROM. Director can be used to import 2D and 3D
graphics, text, animations, sounds, and digital video
(or create 2D graphics and text using Director's
built-in graphics and text editors). These media
elements were integrated, synchronized, and animated
over time using Director's powerful animation and
integration tools. Interactive elements were added
using simple pull-down menus and options. The
completed production was distributed to users via
self-running executables (projectors) or over the Web
using Shockwave.
The minimum playback requirements were expected
to be as follows for Macintosh: 68020 processor or
faster, including Power Macintosh, Macintosh 7.5.1 or
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later, and 8 MB RAM (12 MB recommended). Additional
requirements for Macintosh include: QuickTime
extension, 640 x 480 resolution and 8-bit color (256
colors) monitor or higher. The minimum playback
requirements were expected to be as follows for
Windows: 386/25, 486 or Pentium® processor, Windows
3.1x or Windows 95, and 8 MB RAM (12 MB recommended).
Additional requirements for windows included an 8 or
16-bit sound card, 640 x 480 resolution, and 8-bit
color (256 colors) monitor or higher.
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Form A
Demographic Survey
Demographic survey (to be completed by parents)
1. What is the name of the
student who brought home
this survey? ________
2. What is your
relationship to the student
who brought home this
survey?
□ Birth parent
□ Step parent
□ Adoptive parent
□ Romantic partner
(boyfriend or girlfriend)
of child's parent
□ Grandparent
□ Other relative (aunt,
uncle, sister, brother
cousin, etc.)
□ Other guardian:
3. What is your marital
status?
□ Married
□ Divorced
□ Widowed
□ Separated
□ Never married
□ Living together as
married
□ Other:
Questions 4-6 are about the
student's mother:
4. Is the student's mother
Spanish/Hispanic/Latino?
□ No, not
Spanish/Hispanic/Latino
□ Yes, Mexican, Mexican
American, Chicano
□ Yes, Cuban
□ Yes, other
Spanish/Hispanic/Latino:
5. What is the race of the
child's mother? Mark all
that apply.
□ White
□ Black, African American
□ American Indian or Alaska
Native
□ Asian Indian
□ Chinese
□ Filipino
□ Japanese
□ Korean
□ Vietnamese
□ Other Asian: ____________
□ Native Hawaiian
□ Guamanian or Chamorro
□ Samoan
□ Other Pacific Islander:
□ Other race:
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6. What is highest level
of education of the child's
mother?
□ Didn't go to elementary
school or didn't graduate
from elementary school
□ Elementary school
graduate
□ Junior high school
graduate
□ Senior high school
graduate or GED
□ Training/vocational
school graduate
□ Some college
□ College graduate
□ Postgraduate degree
Questions 7-9 are about the
student's father:
7. Is the student's father
Spanish/Hispanic/Latino?
□ No, not
Spanish/Hispanic/Latino
□ Yes, Mexican, Mexican
American, Chicano
□ Yes, Cuban
□ Yes, other
Spanish/Hispanic/Latino:
8. What is the race of the
child's father? Mark all
that apply.
□ White
□ Black, African American
□ American Indian or Alaska
Native
□ Asian Indian
□ Chinese
□ Filipino
□Japanese
□ Korean
□ Vietnamese
□ Other Asian: ____
□ Native Hawaiian
□ Guamanian or Chamorro
□ Samoan
□ Other Pacific Islander:
□ Other race: _____
9. What is the highest
level of education of the
student's father?
□ Didn't go to elementary
school or didn't graduate
from elementary school
□ Elementary school
graduate
□ Junior high school
graduate
□ Senior high school
graduate or GED.
□ Training/vocational
school graduate
□ Some college
□ College graduate
□ Postgraduate degree
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Question 10 is about the
entire household:
10. What is your combined
household yearly income
(before taxes)?
□ Under $20,000
□ $20,000 - $39,999
□ $40,000 - $59,999
□ $60,000 - $79,999
□ $80,000 - $99,999
□ $100,000 - $119,99
□ $120,000 - $139,999
□ $140,000 or over
End of questionnaire.
Thank you for your time.
Participant number:
For office use only.
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Form B: Impact Study Questionnaire
Student Survey
Your name
Circle one: Boy Girl
School
Grade: 4th
Birth date
Teacher
Today's Date
Participant number: For office use only.
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We are gathering information on physical activity
and fourth graders. Physical activity is any play,
game, sport or exercise that gets you moving and
breathing harder. We would like you to answer some
questions about your ideas and the things that you do.
There are no right or wrong answers. Please fill out
the questionnaire after we read the question to you.
That is, mark your answer to each question after we
read it to you.
There will be instructions for each part of the
questionnaire. We will read them aloud. For most
questions, you will read each item, then check (X) the
box that best describes your answer. Please be sure
to mark only one box--the one that best fits your
answer. Please do not go ahead of the person reading
the survey. Complete each question as it is read. If
there is a question you are not comfortable with you
can skip it.
This is not a test. There are no right answers
and everyone will have different answers. Be sure
that your answers show how you feel about yourself.
PLEASE DO NOT TALK ABOUT YOUR ANSWERS WITH ANYONE
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ELSE. We will keep your answers private and not show
them to anyone.
When you get to the end of a section and it says
STOP HERE, please stop and wait for instructions.
When we begin, please read each sentence and
decide your answer (you may read quietly to yourself
as we read aloud).
STOP HERE - WAIT FOR INSTRUCTIONS
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WHAT DO YOU THINK YOU CAN DO?
Now we are going to ask you some questions about
what you believe. Please put a check by "YES" or "NO"
for each of the following sentences. "YES" means that
you agree with the sentence. "NO" means that you do
not agree with the sentence. There are no wrong
answers. Put a check by what you think. Remember
that physical activity is any play, game, sport or
exercise that gets you moving and breathing harder.
I think I can be physically active most
days after school.
o YES o NO
I think I can ask my parents or other
adult to do physically active things
with me.
o YES O NO
I think I can be physically active
after school even if I could watch TV
or play video games instead.
o YES 0 NO
I think I can be physically active
after school even if my friends want me
to do something else.
o YES o NO
I think I can ask my parent or other
adult to sign me up for sport, dance,
or other physical activity.
o YES 0 NO
I think I can be physically active even
if it is hot or cold outside.
o YES o NO
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I think I can ask my best friend to be
physically active with me.
o YES o NO
I think I can ask my parent or other
adult to get me the equipment I need to
be physically active.
o YES o NO
I think I can ask my parent or other
adult to take me to a physical activity
or sport practice.
o YES o NO
I think I can be physically active,
even if I have a lot of homework.
o YES O NO
I think I can be physically active even
if I have to stay at home.
o YES 0 NO
I think I have the skills I need to be
physically active.
o YES O NO
STOP HERE
132
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WHAT CAN PHYSICAL ACTIVITY DO FOR YOU?
Once again, please put a check by "YES" or "NO"
for each of the following sentences.
If I were to be physically active most
days it would help me spend more time
with my friends.
o YES o NO
If I were to be physically active most
days it would make me get hurt.
o YES 0 NO
If I were to be physically active most
days it would help me be healthy.
o YES o NO
If I were to be physically active most
days it would cause pain and muscle
soreness.
o YES o NO
If I were to be physically active most
days it would help me control my
weight.
o YES O NO
If I were to be physically active most
days it would help me look good to
others.
o YES O NO
If I were to be physically active most
days it would help me work out my
anger.
o YES o NO
If I were to be physically active most
days it would make me tired.
o YES 0 NO
If I were to be physically active most
days it would give me energy.
o YES o NO
If I were to be physically active most
days it would make me embarrassed in
front of others.
o YES o NO
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If I were to be physically active most
days it would be fun.
o YES O NO
If I were to be physically active most
days it would help me make new friends.
o YES 0 NO
If I were to be physically active most
days it would get or keep me in shape.
0 YES O NO
If I were to be physically active most
days it would make me more attractive
to the opposite sex.
o YES O NO
If I were to be physically active most
days it would be boring.
o YES o NO
If I were to be physically active most
days it would make me better in sports.
0 YES O NO
STOP HERE
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WHAT DO OTHER PEOPLE DO?
Again, please put a check by "YES" or "NO" for
each of the following sentences.
My family thinks I should be physically
active.
o YES O NO
Someone in my family has offered to be
physically active with me in the past 2
weeks.
o YES O NO
Someone in my family has encouraged me
to be physically active in the past 2
weeks.
o YES 0 NO
Someone in my family has been
physically active with me in the past 2
weeks.
0 YES 0 NO
My friends think I should be physically
active.
o YES 0 NO
A friend has offered to be physically
active with me in the past 2 weeks.
O YES O NO
A friend has encouraged me to be
physically active in the past two
weeks.
0 YES 0 NO
A friend has been physically active
with me in the past 2 weeks.
0 YES O NO
STOP HERE - END OF SURVEY
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Form C:
Focus Group Protocol
CD-ROM 1 Goal Setting
Date ___________
Classroom # ________
Teacher's Name
Interviewer
1. What was the most important thing you learned in
this CD-ROM session?
2. Overall, was the CD-ROM game too easy, just
right, or too difficult?
• What sticks out in your mind as having been
too difficult?
• What sticks out in your mind as having been
too easy?
3. What was your favorite game in the CD-ROM
session?
4. What was your least favorite game in the CD-ROM
session?
5. Was the GRID GAME too easy, just right, or too
difficult?
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6. What could be done to make the GRID GAME better
7. Was the MAZE too easy, just right, or too
difficult?
8. What would you do to make the MAZE better?
9. What could be done to improve the CD-ROM game?
10. Would you play this game again?
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Form D:
Focus Group Protocol
CD-ROM 2 Self-Monitoring
Date ___________
Classroom # _______
Teacher's Name ______________________________
Interviewer ________________________________
1. What was the most important thing you learned in
this CD-ROM session?
2. What is self-monitoring?
3. Overall, was the CD-ROM game too easy, just
right, or too difficult?
4. What sticks out in your mind as having been too
difficult?
5. What sticks out in your mind as having been too
easy?
6. What was your favorite game in the CD-ROM
session?
7. What was your least favorite game in the CD-ROM
session?
8. Were any of the games too hard? To easy?
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9. Who is your favorite character? What do you like
about him/her?
10. What could be done to improve the CD-ROM game?
11. Would you play this game again?
139
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Asset Metadata

Creator Chung, Susan K. (author)

Core Title Effects of interactive multimedia for the prevention of obesity on self-efficacy, beliefs about physical activity, and social influence

School Rossier School of Education

Degree Doctor of Education

Degree Program Education

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag education, curriculum and instruction,education, health,education, technology of,OAI-PMH Harvest

Language English

Contributor Digitized by ProQuest (provenance)

Advisor Rueda, Robert (committee chair), Hitchcock, Maurice (committee member), Kazlauskas, Edward (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c16-662092

Unique identifier UC11340277

Identifier 3145183.pdf (filename),usctheses-c16-662092 (legacy record id)

Legacy Identifier 3145183.pdf

Dmrecord 662092

Document Type Dissertation

Rights Chung, Susan K.

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA