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Can School Health Education Programs Make a Difference?1

ELAINE J. STONE, Ph.D., M.P.H.

Division of Epidemiology and Clinical Applications, National Heart, Lung, and Blood Institute, 2 Rockledge Center, Room 8134, 6701Rockledge Drive, Bethesda, Maryland 20892-7936

The impact of behavior on health, with a special em-phasis on children and adolescents, is a central focusfor current health policy and for the prevention agendain Healthy People 2000 (1). Since our nation’s schoolsprovide an infrastructure for reaching our youth, thereis renewed attention to research providing evidence ofthe effectiveness of school-based programs as a publichealth prevention strategy. During the 1980s and1990s school-based research has undergone consider-able advances. Earlier studies focused on measuringknowledge and attitudes since health education wasbeing taught as an information approach. The thrust inthe late 1970s to identify school programs that preventthe onset of cigarette smoking showed that the infor-mation programs had little or no effect. This led to amovement toward behavioral models from social psy-chology as the theoretical underpinnings for affectingbehaviors in smoking as well as other health areassuch as eating and physical activity. Coupled with thismovement was a shift in school-based research to morerobust designs, improved measurement approachesand instruments, and more appropriate analysis strat-egies paralleling the behavioral theoretical models (2).The National Heart, Lung, and Blood Institute

played a major role in providing support for researchover the past several decades to help advance the fieldto where it is today in the cardiopulmonary arena. Thefirst pioneering multiple cardiovascular health behav-ior study the NHLBI supported was the Know YourBody Study with the American Health Foundation inthe late 1970s (3, 4). The cumulative findings from thisand numerous other NHLBI-supported studies pro-vided the foundation for the Child and Adolescent Trialfor Cardiovascular Health.The Child and Adolescent Trial for Cardiovascular

Health (CATCH) was an 8-year multicenter random-ized trial (1987–1994) investigating the questionwhether behaviorally oriented cardiovascular school-and family-based health programs can produce posi-tive changes in the health habits that favorably affect

the cardiovascular risk profile of elementary schoolpreadolescents. The multiyear interventions includedclassroom curricular and school environmental modifi-cations related to food consumption, physical activity,and tobacco use, as well as family- and home-basedprograms to complement the school-based activities.The trial involved 96 schools, 24 at each of four siteslocated in California, Louisiana, Minnesota, andTexas, that were randomized across experimentalarms: (a) a combined school-based and family-basedintervention arm involving 56 schools and (b) a controlarm involving 40 schools in which the usual curricular,food service, and physical education programs andsmoking policy occurred. The public schools repre-sented a diversity of socioeconomic, ethnic, and cul-tural groups (5–12).CATCH 1 was a 3½-year feasibility study success-

fully completed in March 1991. The full-scale trialCATCH 2 began in April 1991. Twenty-four elemen-tary schools were recruited at each of the four studycenters by August 1991, and baseline measurementswere completed by early February 1992. All field centerstaff and participating schools remained blinded torandomization assignment until the baseline measure-ment was completed in all 24 schools at that field cen-ter. The third-grade cohort was defined as children en-rolled in a CATCH 2 school on the date of final riskfactor assessment in that school for which a total cho-lesterol result was available (n 4 5,106). Over 7,000students received the classroom interventions and par-ticipated in the psychosocial measurements. At base-line overall mean age was 8.76 years and 52% weremale for the study cohort. The racial distribution wasas follows: 69% Caucasian, 13% African-American,14% Latino/Hispanic, and 4% other. This distributionvaried across the four study centers.Following completion of baseline measurements, the

24 schools at each field center were randomized intothe two experimental groups. The grade 3 classroomand family curricula and school environmental modifi-cations were implemented during the spring of 1992.The fourth-grade curriculum was implemented duringthe fall of 1992 and continued to be implemented untilthe end of the 1992–1993 school year. The fifth-grade

1 Presented at the symposium The American Health Foundation:A 25th Anniversary Program, Tarrytown, New York, November 16–17, 1994.

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0091-7435/96 $18.00Copyright © 1996 by Academic Press, Inc.All rights of reproduction in any form reserved.

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curricula were implemented during the 1993–1994school year. The school food service and physical edu-cation interventions began in spring of 1992 and wereongoing in the 1992–1993 and 1993–1994 school years.The fifth-grade final cohort measurement was con-ducted from January through June 1994. Data analy-sis is in progress for reporting study results.The special design feature of the study was the unit

of the randomization. In CATCH the unit of random-ization was the school rather than the individual stu-dent. At the individual student level, the primarystudy comparison was school- and family-based (S + F)and school-based (S) interventions combined versuscontrol with respect to change in serum cholesterolfrom baseline to the end of the intervention period. Itwas hypothesized that the intervention would lead to amean serum cholesterol that was lower than the con-trol group level at the end of fifth grade. At the schoollevel, there were two primary endpoints by which theeffectiveness of the CATCH food service and physicaleducation interventions was assessed. Specifically, theschool lunches in intervention schools, compared withcontrol schools, would maintain recommended levels ofessential nutrients and student participation while re-ducing the levels of total fat and saturated fat served inschools. In addition, the CATCH physical educationclass would engage students in moderate to vigorousactivity for an increased portion of the class period. Theeffect of the intervention compared with control alsowas evaluated in terms of various secondary outcomemeasures, including dietary, physical activity, and psy-chosocial measures, as well as physiologic measuressuch as blood pressure, nine-minute run, and skinfoldthickness. In addition, the combination of the school-based programs was compared with the administrationof the school- and family-based programs.The study interventions also included an anti-

smoking component that was delivered to students inthe fifth grade. Because there were low prevalencerates of regular smoking among fifth-grade students,the study design did not have sufficient power for theestimation of differences in actual smoking rates as anoutcome variable. Therefore, follow-up at the end of thefifth grade included the measurement of students’ in-tentions regarding smoking in the future. At the schoollevel, the effectiveness of implementing a policy relatedto smoke-free buildings and grounds was assessed.

CATCH 3 began funding in December 1994 and willtrack the CATCH cohort through grades 6, 7, and 8.

REFERENCES

1. U.S. Department of Health and Human Services. Healthy people2000: national health promotion and disease prevention objec-tives related to mothers, infants, children, adolescents, andyouth. Washington: Public Health Service, 1991.

2. McKinlay S, Stone EJ, and Zucker DM. Research design andanalysis issues. Health Educ Q 1989; 16:307–14.

3. Walter HJ, Hofman A, Vaughan RD, and Wynder EL. Modifica-tion of risk factors for coronary heart disease: five year results ofa school-based intervention trial. N Engl J Med 1988; 318:1093–100.

4. Resnicow K, Cohn L, Reinhardt J, Cross D, Futterman R, andKirschner E, et al. A three-year evaluation of the Know YourBody Program in inner-city schoolchildren. Health Educ Q 1992;19:463–80.

5. Perry CL, Parcel GS, Stone EJ, Nader PR, McKinley SM, Luep-ker RV, and Webber LS. The Child and Adolescent Trial forCardiovascular Health: overview of the intervention programand evaluation methods. J Cardiovasc Risk Factors 1992; 2:36–44.

6. Zucker DM, Lakatos E, Webber LS, Murray DM, McKinlay SM,Feldman HA, Kelder SH, and Nader PR, for the CATCH StudyGroup. Statistical design of the Child and Adolescent Trial forCardiovascular Health (CATCH): implications of cluster ran-domization. Controlled Clin Trials 1995; 16:96–118.

7. Stone EJ, McGraw SA, Osganian SK, and Elder JP, editors.Process evaluation in the Child and Adolescent Trial for Cardio-vascular Health (CATCH) multicenter trial. Health Educ Q1994; 2:S1–S145.

8. Lytle LA, Johnson CC, Bachman K, Nader PR, Stone EJ, andKelder SH. Recruitment strategies and issues for school-basedhealth promotion: experiences from CATCH. J School Health1994; 64:405–9.

9. Webber LS, Osganian SK, Luepker V, Feldman HA, Stone EJ,Elder J, Perry CL, Nader PR, Parcel GS, Broyles SL, and Mc-Kinlay SM, for the CATCH Study Group. Cardiovascular riskfactors among third grade children in four regions of the UnitedStates: the CATCH study. Am J Epidemiol 1995; 141:428–39.

10. McKenzie TL, Feldman H, Woods SE, Romero KA, Dahlstrom V,Stone EJ, Strikmiller PK, Williston JM, and Harsha DW. Chil-dren’s activity levels and lesson context during third-gradephysical education. Res Q Exerc Sport 1995; 66:184–93.

11. Nicklas TA, Stone E, Montgomery D, Snyder P, Zive M, EbzeryMK, Clesi A, Hann B, and Dwyer J. An overview of the CATCHEat Smart school nutrition program: a model for the future. JHealth Educ 1994; 25:299–307.

12. Osganian SK, Nicklas T, Stone EJ, Nichaman M, Ebzery MK,Lytle L, and Nader P. Perspectives on the School Nutrition Di-etary Assessment Study and CATCH. Am J Clin Nutr 1995;61:241S–4S.

Received April 18, 1995Revision requested August 2, 1995Accepted August 2, 1995

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