Biomedical subjects

Joel Gittelsohn

Publications and source records attributed to Joel Gittelsohn.

At least 19 recordsLinked to original sources

PubMed2006

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

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

Caregivers↗

PubMed2006

Development and implementation of a food store-based intervention to improve diet in the Republic of the Marshall Islands.

Effective approaches for the prevention and reduction of obesity and obesity-related chronic diseases are urgently needed. Food store-centered programs represent one approach that may be both effective and sustainable. The authors developed a food store-based intervention in the Marshall Islands using qualitative and quantitative formative research methods, including a store usage survey (n = 184) and in-depth interviews with large-store managers (n = 13), small-store managers (n = 7), customers (n = 10), and community leaders (n = 4). This process was followed up by development and piloting of specific intervention components and workshops to finalize materials. The final intervention combined mass media (newspaper articles, video, radio announcements) and in-store components (shelf labels, cooking demonstrations, posters, recipe cards) and had high store-owner support and participation. High levels of exposure to the intervention were achieved during the 10-week period of implementation. This model for developing food store-based interventions is applicable to other settings.

Feeding Behavior↗

PubMed2006

Interventions to improve diet and weight gain among pregnant adolescents and recommendations for future research.

Pregnant adolescents are at particular risk for both inadequate and excessive gestational weight gain and for inadequate intake of micronutrients that support healthy fetal development. This article reviews the available literature on prenatal nutrition interventions intended to address such risks to identify effective strategies and needs for further research. A medical model providing enhanced prenatal care aimed at improved birth weight predominated. No studies rigorously evaluated the independent influence of nutrition education on prenatal dietary behaviors or outcomes; few applied a conceptual framework or targeted dietary attitudes, behaviors, skills, or self-efficacy. Positive effect on birth outcomes was evident, likely due to multidisciplinary teams supporting the special psychosocial needs of pregnant adolescents; individualized education and counseling encouraging optimal dietary choice and appropriate gestational weight gain; home visits providing prenatal education, support, and outreach to highest-risk teens; visual presentation and tracking of gestational weight gain; and support/discussion groups. Nevertheless, greater effects could likely be achieved by applying behavior-change strategies that have been implemented effectively with other, similar populations. Further research is needed to test such approaches with pregnant, high-risk teens.

Adolescent↗

PubMed2006

Prevalence of overweight among Baltimore City schoolchildren and its associations with nutrition and physical activity.

OBJECTIVE: To determine the prevalence of overweight and at-risk-for-overweight in schoolchildren from Baltimore City. RESEARCH METHODS AND PROCEDURES: Ten schools within city limits were randomly selected from each tertile of income, using eligibility for free school lunch as a proxy. A total of 209 third grade students from eight public schools in Baltimore City were surveyed in May 2000. Anthropometric data including height, weight, subscapular and triceps skinfold thickness, and percentage body weight from bioelectrical impedance were collected. Nutrition-related knowledge, attitudes, and behaviors were assessed using a validated questionnaire. Physical activity was assessed by questionnaire. RESULTS: Based on International Obesity Taskforce reference values for BMI-for-age, 20.7% of girls and 17.2% of boys were overweight (BMI > 95th percentile) and 15.3% of girls and 14.1% of boys were at-risk-for-overweight (BMI between the 85th and 95th percentiles). The prevalence of overweight and at-risk-for-overweight did not vary by self-reported physical activity levels or by nutrition-related knowledge and behaviors. DISCUSSION: The high prevalence of overweight and at-risk-for-overweight in this sample of inner-city children from Baltimore City highlights a need for targeted preventive and treatment interventions.

Baltimore↗

PubMed2006

Process evaluation determines the pathway of success for a health center-delivered, nutrition education intervention for infants in Trujillo, Peru.

Process evaluation was used to explain the success of a randomized, controlled trial of an educational intervention to improve the feeding behaviors of caregivers and the nutritional status of infants in Trujillo, Peru. Health personnel delivered a multicomponent intervention within the environment of usual care at government health centers. We created a model of the expected intervention pathway to successful outcomes. Process data were then collected on health center implementation of the intervention and caregiver reception to it. Using multivariate models, we found that variables of health center implementation, caregiver exposure, and caregiver message recall were all significant determinants in the pathway leading to improved feeding behaviors. These outcomes were consistent with our original intervention model. Further support for our model arose from the differences in caregiver reception between intervention and control centers. Process data allowed us to characterize the pathway through which an effective nutrition intervention operated. This study underscores the importance of including process evaluation, which will lead to the development and implementation of more effective nutrition interventions.

Adolescent↗

PubMed2006

The conceptualization of perceived insufficient milk among Mexican mothers.

This study sought to provide a comprehensive picture of maternal conceptualization of Perceived Insufficient Milk (PIM) using qualitative methods (semistructured interviews, free lists, and rankings) in Mexico. Two hundred and seven first-time mothers of infants younger than 6 months and mothers-to-be who were (or intended to be) breastfeeding were interviewed in waiting areas at a hospital and a health clinic in Mexico City, Mexico, from September 2000 to January 2001. Pattern searching and triangulation of the 3 qualitative methods indicated that women viewed crying as the chief symptom of PIM. Maternal diet and liquid intake were cited as both the most salient causes and treatments for PIM. The main coping strategy in the event of PIM was formula feeding. These findings highlight the need for addressing maternal concerns in relation to PIM, especially regarding the role of crying as the initiator of the PIM cycle.

Adult↗

PubMed2006

Formative research in school and community-based health programs and studies: "state of the art" and the TAAG approach.

Formative research uses qualitative and quantitative methods to provide information for researchers to plan intervention programs. Gaps in the formative research literature include how to define goals, implementation plans, and research questions; select methods; analyze data; and develop interventions. The National Heart, Lung, and Blood Institute funded the Trial of Activity for Adolescent Girls (TAAG), a randomized, multicenter field trial, to reduce the decline in physical activity in adolescent girls. The goals of the TAAG formative research are to (a) describe study communities and schools, (b) help design the trial's interventions, (c) develop effective recruitment and retention strategies, and (d) design evaluation instruments. To meet these goals, a variety of methods, including telephone interviews, surveys and checklists, semistructured interviews, and focus group discussions, are employed. The purpose, method of development, and analyses are explained for each method.

Adolescent↗

PubMed2006

Data to action: using formative research to develop intervention programs to increase physical activity in adolescent girls.

Formative research is used to inform intervention development, but the processes of transmitting results to intervention planners and incorporating information into intervention designs are not well documented. The authors describe how formative research results from the Trial of Activity for Adolescent Girls (TAAG) were transferred to planners to guide intervention development. Methods included providing oral and written reports, prioritizing recommendations, and cross-checking recommendations with intervention objectives and implementation strategies. Formative work influenced the intervention in many ways. For example, results indicated that middle schools offered only coeducational physical education and health education classes, so the TAAG intervention was designed to be appropriate for both sexes, and intervention strategies were developed to directly address girls' stated preferences (e.g., enjoyable activities, opportunity to socialize) and barriers (e.g., lack of skills, fear of injury) for physical activity. The challenges of using formative research for intervention development are discussed.

Adolescent↗

PubMed2005

Process evaluation of a store-based environmental obesity intervention on two American Indian Reservations.

Obesity and other diet-related chronic diseases are widespread in American Indian communities. Inadequate access to healthy food on many reservations has led to a high-fat, high-sugar diet. The purpose of this paper is to report on the results of the process evaluation of a food store-based program to improve diet on two American Indian reservations. Process data were collected from 11 intervention stores to document the implementation of the Apache Healthy Stores (AHS) program. Process evaluation instruments recorded the stocking of promoted foods, presence of in-store communication materials, implementation of and participation in the cooking demonstrations and taste tests, and the transmission of mass-media messages. At the store level, the program was implemented with a high level of dose and reach, and a moderate to high level of fidelity. At the community level, the AHS program was implemented with a moderate degree of fidelity and dose. At the individual level, the cooking demonstrations and taste tests reached a large number of community members with a high dose. Implementing the AHS program on multiple levels (store, community, individual) was challenging, and differed between levels. Overall, improvements were seen from start to finish as program staff monitored, documented and responded to barriers to implementation. Process data will be tied to outcomes and will be useful for the planning of future store-based programs.

Arizona↗

PubMed2005

A pilot school-based healthy eating and physical activity intervention improves diet, food knowledge, and self-efficacy for native Canadian children.

The Sandy Lake school-based diabetes prevention program is a culturally appropriate intervention for Ojibway-Cree students in the 3rd, 4th, and 5th grades. This paper reports the results of the program in changing dietary intake behaviors and related psychosocial factors. Physical activity results are not included. The study was a pretest/post-test, single-sample design conducted during the 1998-1999 school year. A total of 122 students completed all 4 measurements (anthropometry, 24-h dietary recall, and 2 questionnaires), at baseline and follow-up. There were significant increases (P < 0.0001) in dietary intention, dietary preference, knowledge, and dietary self-efficacy, and in the curriculum knowledge scale between baseline and follow-up. Intervention exposure was significantly associated with being in the highest category for knowledge about foods that were low in dietary fat [Medium Exposure odds ratio (OR): 3.4; P < 0.05; High Exposure OR: 6.4; P < 0.05], being in the highest category for dietary self-efficacy (Medium Exposure OR: 3.7; P < 0.05; High Exposure OR: 3.9; P < 0.1), being in the highest category for knowledge about curriculum concepts (Medium Exposure OR: 3.4; P < 0.05; High Exposure OR: 9.4: P < 0.01), and for having met the age + 5 g dietary fiber intake/d (Medium Exposure OR: 2.9; P < 0.1; High Exposure OR: 11.0; P < 0.01). Exposure to the intervention was not associated with dietary intent or the percentage of energy from dietary fat. This program was associated with improved knowledge and the psychosocial factors related to healthy eating and dietary fiber intake of students in a remote First Nations community.

Adolescent↗

PubMed2004

Intervention-related bias in reporting of food intake by fifth-grade children participating in an obesity prevention study.

Data collected as part of Pathways, a school-based trial for the primary prevention of obesity in American Indian children conducted between 1997 and 2000, were analyzed to examine possible intervention-related bias in food reporting. The authors hypothesized that children in the intervention schools may have systematically underreported their dietary intake relative to children in the control schools. Nutrient intake estimates for lunch derived from record-assisted 24-hour dietary recalls were compared with intake estimates from observed lunch intakes. Reported nutrient intakes were included in regression analyses as the dependent variables; observed intake, intervention condition, and age were included as independent variables. Results indicated that, among females, intervention condition was a significant predictor of reported energy, fat, and saturated fatty acid intakes. Independently of observed intake, reported lunch energy intake among females in the intervention schools was 66.8 calories lower than reported intake among females in the control schools (p = 0.03). These findings suggest that investigators should consider bias in reporting of dietary intake by intervention condition when conducting diet-focused intervention studies. Specifically, enhancing measures that rely on self-reports with objective measures of dietary intake would help investigators to evaluate whether differential reporting by treatment group has occurred.

Bias↗

PubMed2004

Validity of self-reported dietary intake at school meals by American Indian children: the Pathways Study.

OBJECTIVE: To examine the validity of a modified diet record-assisted 24-hour recall in third-grade (8 to 10 years old) American Indian children. DESIGN: The children were trained to record their food intake using diet records, and then they recalled their 24-hour food intakes, using the diet records as memory prompts, during interviews by trained staff using the Minnesota Nutrition Data System (NDS; version 2.6, 1993, Food database version 8A, Nutrient database version 23; Nutrition Coordinating Center, University of Minnesota, Minneapolis). The modified method added training in portion size estimation. Direct observation of the children's intakes during school meals was used to validate the accuracy of their self-reported recalls. SUBJECTS: Eighty third-grade children recruited from schools from four of the American Indian Nations participating in the Pathways Study. Statistical analyses performed Pearson correlations were used for nutrient level data. A mixed regression model (PROC MIXED), with no other fixed effects and site as a random effect, was used to test the null hypothesis that the difference between recalled and observed intakes was zero (H(o): beta(o)=0). Food intake data were obtained from the Nutrition Data System Record Reports. RESULTS: There were no significant differences between recalled and observed energy intakes for the school meals combined or for either meal individually. Percentages of energy intake from fat, protein, and carbohydrate from recalls were not significantly different from those observed for the combined school meals. Pearson correlations for energy and energy-providing nutrients ranged from 0.52 to 0.86 for both meals, from 0.55 to 0.86 for school lunch, and from 0.61 to 0.86 for school breakfast. Agreement between recalled and observed food items was 75%. Children recalled 57% of food quantities within +/-10% of observed quantities. CONCLUSIONS: At the group level, American Indian children were able to accurately report the macronutrient proportions of their total energy intake, and their reporting of total energy intake (+13% of criterion) compares favorably with that of other ethnic groups of children of similar age. They were able to accurately recall the majority of foods that they were independently observed consuming during school meals.

Child↗

PubMed2003

Who infects whom? HIV-1 concordance and discordance among migrant and non-migrant couples in South Africa.

OBJECTIVES: To measure HIV-1 discordance among migrant and non-migrant men and their rural partners, and to estimate the relative risk of infection from inside versus outside primary relationships. DESIGN: A cross-sectional behavioural and HIV-1 seroprevalence survey among 168 couples in which the male partner either a migrant, or not. METHODS: A detailed questionnaire was administered and blood was collected for laboratory analysis. A mathematical model was developed to estimate the relative risk of infection from inside versus from outside regular relationships. RESULTS: A total of 70% (117 of 168) of couples were negatively concordant for HIV, 9% (16 of 168) were positively concordant and 21% (35 of 168) were discordant. Migrant couples were more likely than non-migrant couples to have one or both partners infected [35 versus 19%; P = 0.026; odds ratio (OR) = 2.28] and to be HIV-1 discordant (27 versus 15%; P = 0.066; OR = 2.06). In 71.4% of discordant couples, the male was the infected partner; this did not differ by migration status. In the mathematical model, migrant men were 26 times more likely to be infected from outside their regular relationships than from inside [relative risk (RR) = 26.3; P = 0.000]; non-migrant men were 10 times more likely to be infected from outside their regular relationships than inside (RR = 10.5; P = 0.00003). CONCLUSIONS: Migration continues to play an important role in the spread of HIV-1 in South Africa. The direction of spread of the epidemic is not only from returning migrant men to their rural partners, but also from women to their migrant partners. Prevention efforts will need to target both migrant men and women who remain at home.

Adult↗

PubMed2003

Pathways: lessons learned and future directions for school-based interventions among American Indians.

BACKGROUND: Pathways, a multicenter study to test the effect of a school-based program to prevent obesity in American Indian children, yielded many benefits and encountered many challenges. This paper explores what we have learned from this study and examines possible future directions. METHODS: Information presented in this paper is based on formative research, study results, and discussions with staff and investigators. RESULTS: Some of the lessons learned relate to having a strong relationship with the tribes, how best to engage the communities, the importance of formative research and achieving standardization in culturally diverse settings, how to incorporate cultural information into curricula, and the importance of family involvement. One of the strengths of the study was the collaborative process that teamed American Indian and non-American Indian investigators and staff. Researchers recognized that they must work in cooperation with research participants including their schools and communities to address challenges, to ensure accurate findings and analyses, and to share benefits. CONCLUSIONS: The lessons learned from Pathways offer valuable insights for researchers into successful approaches to the challenges inherent in research in American Indian communities, particularly in schools, and how to maximize the benefits of such a study.

Child↗

PubMed2003

Pathways process evaluation results: a school-based prevention trial to promote healthful diet and physical activity in American Indian third, fourth, and fifth grade students.

BACKGROUND: Pathways was a large-scale, multisite, 3-year, study testing a school-based intervention designed to lower percent body fat in American Indian children. METHODS: At the 21 intervention schools process evaluation data were collected for training of school personnel; implementation of the classroom and physical activity curricula; implementation of the project's food service guidelines in the school cafeterias; adult participation in the family events; and, students' perceived exposure to the Pathways interventions. RESULTS: Students received about 93% of the classroom curriculum lessons. The minimum requirement of physical education being taught three times per week for at least 30 minutes duration was achieved by the fifth grade. The implementation of the food service behavioral guidelines increased from 51% in the third grade to 87% in the fifth grade. The family events had lower than anticipated adult participation. The participation rates were 45% during the third grade, and 41 and 63% during the fourth and fifth grades, respectively. There was a significant difference between intervention and control students' perceived exposure to Pathways type interventions. CONCLUSION: The Pathways interventions were successfully implemented with good reach, high extent, and fidelity.

Child↗

PubMed2003

Impact of the Pathways intervention on dietary intakes of American Indian schoolchildren.

BACKGROUND: The Pathways study was a randomized, 3-year trial of obesity prevention in American Indian Children. An important goal of the Pathways intervention was to significantly decrease the percentage of calories eaten as fat by the intervention children, relative to controls. This paper reports the effects of the Pathways intervention on dietary intake. METHODS: Two types of dietary data were analyzed from random samples of children in 41 schools: direct observation of school lunch intake at baseline (2nd grade) and follow-up (5th grade) (n=470), and 24-hour dietary recalls at follow-up only (n=620). Nutrient contents of school meals and recalls were calculated by NDS and NDS-R software (University of Minnesota), using vendor products and recipes from each school. RESULTS: Based on lunch observations, the intervention was associated with significant decreases in mean percentage of calories from total fat (3.6%) and saturated fat (2.1%) relative to controls, and a significant increase in the percentage of calories from total carbohydrate (3.7%). Compared with the control children, intervention children reported significantly smaller 24-hour intakes of energy (263 kcal), protein (9.5 g), total fat (15.1 g), saturated fat (6.0 g), and polyunsaturated fat (2.3 g); and as a percent of calories, total fat (2.5%) and saturated fat (1.1%). Mean intake of carbohydrates as a percentage of calories was significantly greater in intervention children by 2.5%, compared with controls. CONCLUSIONS: The Pathways intervention successfully reduced the intake of percent calories from fat and saturated fat, at school lunch and over the whole day.

Child↗

PubMed2003

School climate and implementation of the Pathways study.

BACKGROUND: Pathways was a multisite school-based study to prevent obesity in American Indian school children by encouraging healthy eating and physical activity. METHODS: Over the 3-year study, a total of 290 in-depth interviews were conducted with school administrators, food service managers, classroom teachers, and physical education instructors in all 21 intervention schools to examine support and barriers for Pathways. Analysis included qualitative assessment of key themes using NUD*IST and quantitative modeling of the impact of a school climate score on implementation of intervention components. RESULTS: Overall, teachers, food service managers, and physical education instructors were supportive of the Pathways interventions. School administration and lack of family participation were perceived barriers at some schools. Attitudes toward the program ranged from neutral to positive during the first year, with about two-thirds giving positive ratings, with greater variation in successive years. Overall, the mean score was 3.5 on a 5-point scale (1=very negative, 5=very positive). School climate score was positively associated with classroom curriculum and student exposure indices, but not with family attendance, food service, or physical activity implementation indices. The latter two indices were associated with site. CONCLUSIONS: An assessment of school climate through interviews is useful in understanding successes and failures in a school-based health intervention and can predict implementation success for some programs.

Child↗

PubMed2003

Pathways curriculum and family interventions to promote healthful eating and physical activity in American Indian schoolchildren.

BACKGROUND: Pathways, a multisite school-based study aimed at promoting healthful eating and increasing physical activity, was a randomized field trial including 1704 American Indian third to fifth grade students from 41 schools (21 intervention, 20 controls) in seven American Indian communities. METHODS: The intervention schools received four integrated components: a classroom curriculum, food service, physical activity, and family modules. The curriculum and family components were based on Social Learning Theory, American Indian concepts, and results from formative research. Process evaluation data were collected from teachers (n=235), students (n=585), and families. Knowledge, Attitudes, and Behavior Questionnaire data were collected from 1150 students including both intervention and controls. RESULTS: There were significant increases in knowledge and cultural identity in children in intervention compared to control schools with a significant retention of knowledge over the 3 years, based on the results of repeating the third and fourth grade test items in the fifth grade. Family members participated in Family Events and take-home activities, with fewer participating each year. CONCLUSION: A culturally appropriate school intervention can promote positive changes in knowledge, cultural identity, and self-reported healthful eating and physical activity in American Indian children and environmental change in school food service.

Child↗