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Supplemental Article

Development of Young Adults Eating and Active forHealth (YEAH) Internet-Based Intervention via

a Community-Based Participatory Research Model

Kendra K. Kattelmann, PhD, RDN; Adrienne A. White, PhD, RD;

Geoffrey W. Greene, PhD, RD; Carol Byrd-Bredbenner, PhD, RD;

Sharon L. Hoerr, RD, PhD, FACN; Tanya M. Horacek, PhD, RD;

Tandalayo Kidd, PhD, RD; Sarah Colby, PhD, RD;

Beatrice W. Phillips, EdD, RD; Mallory M. Koenings, PhD;

Onikia N. Brown, PhD, RD; Melissa Olfert, DrPH, MS, RD;

Karla P. Shelnutt, PhD, RD; Jesse Stabile Morrell, MS

This supplemental article was supported by a National Research Initiative

Grant from the US Department of Agriculture National Institute for

Food and Agriculture.

at www.jneb.org
Podcast available online
Supplemental Article

Development of Young Adults Eating and Active for Health(YEAH) Internet-Based Intervention via a Community-BasedParticipatory Research ModelKendra K. Kattelmann, PhD, RDN1; Adrienne A. White, PhD, RD2;Geoffrey W. Greene, PhD, RD3; Carol Byrd-Bredbenner, PhD, RD4;Sharon L. Hoerr, RD, PhD, FACN5; Tanya M. Horacek, PhD, RD6; Tandalayo Kidd, PhD, RD7;Sarah Colby, PhD, RD8,y; Beatrice W. Phillips, EdD, RD9; Mallory M. Koenings, PhD10,y;Onikia N. Brown, PhD, RD11,y; Melissa Olfert, DrPH, MS, RD10; Karla P. Shelnutt, PhD, RD12;Jesse Stabile Morrell, MS13

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ABSTRACT

Objective: To develop a tailored, theory-based, Web-delivered intervention to prevent excessive weightgain in young adults using a Community-Based Participatory Research model.Design: Investigators from 14 universities developed the intervention and supporting administrativeportal using the 4 phases of the PRECEDEmodel. Steering committees were composed of the target audi-ence (aged 19–24 years) and key health/wellness personnel were formed at each institution and providedinformation during each phase that was used to guide development of the intervention, Project YEAH(Young Adults Eating and Active for Health). Piloting results were used to refine the curriculum andidentify and avoid barriers to delivery.Results: Qualitative and quantitative data collected at each phase informed Project YEAH development.In Phase 1, factors of highest priority to young adults were identified. In Phase 2, environmental supportsfor healthful lifestyles were elucidated. In Phase 3, behavior and environmental changes consideredimportant and changeable were identified. In Phase 4, the 10-week, theory-based, stage-tailored,interactive-learning intervention with a 10-month reinforcement period was developed.Conclusions and Implications: Applying the PRECEDE model with fidelity during development ofProject YEAH resulted in an intervention that pilot participants found relevant and useful, gained atten-tion, instilled confidence in the ability to apply the information, and provided a sense of satisfaction.Key Words: weight management, Internet, young adult, Community-Based Participatory Research,PRECEDE-PROCEED (J Nutr Educ Behav. 2014;46:S10-S25.)

d Nutritional Sciences, South Dakota State University, Brookings, SDnce and Human Nutrition, University of Maine, Orono, MEnt of Nutrition and Food Sciences, University of Rhode Island, Kingston, RInt of Nutritional Sciences, Rutgers, The State University of New Jersey, New Brunswick, NJnt of Food Science & Human Nutrition, Michigan State University, East Lansing, MInt of Public Health, Food Studies and Nutrition, Syracuse University, Syracuse, NYnt of Human Nutrition, Kansas State University, Manhattan, KSnt of Nutrition, University of Tennessee, Knoxville, TNnt of Food and Nutritional Sciences, Tuskegee University, Tuskegee, ALent of Human Nutrition, West Virginia University, Morgantown, WVent of Nutrition, Dietetics, and Hospitality Management, Auburn University, Auburn, ALent of Family, Youth & Community Sciences, University of Florida, Gainesville, FLent of Molecular, Cellular, & Biomedical Sciences, University of New Hampshire, Durham, NHe this research was conducted, Dr Brown was at Purdue University, Dr Koenings was a doctoral candidate at the University ofMadison, and Dr Colby was at East Carolina University.r correspondence: Kendra K. Kattelmann, PhD, RDN, Health and Nutritional Sciences, South Dakota State University, Boxkings, SD 57007; Phone: (605) 688-4045; Fax: (605) 688-5603; E-mail: [email protected] FOR NUTRITION EDUCATION AND BEHAVIORoi.org/10.1016/j.jneb.2013.11.006

Nutrition Education and Behavior � Volume 46, Number 2, 2014 S11

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S12 Kattelmann et al Journal of Nutrition Education and Behavior � Volume 46, Number 2, 2014

INTRODUCTION

Young adults in transition fromadolescence to adulthood areemerging adults, characterized byself-focus, identity exploration, andunstable living situations.1,2 Formost, this time is marked by movingfrom childhood homes, starting andcompleting postsecondary education,starting full-time work, having non-family, live-in relationships, gettingmarried, and/or becoming parents.Such transitions are stressful andoften negatively affect health-relatedbehaviors by increasing use of tobaccoand alcohol, insufficient sleep andphysical activity, and unhealthfuleating.3,4 In fact, young adulthood isa critical time when adverse changesin body weight are likely to occur,with 18- to 25-year-olds at particularlyhigh risk for weight gain.5-7 Beingmildly or moderately overweightbetween ages 20 and 22 years islinked with substantial incidence ofobesity by age 35–37 years.8,9

This transitional time presents aunique challenge warranting explora-tion into thecontextof emergingadults'perceptions about health and quality oflife. Approaches targeted to this lifestage are needed to reach and help thisgroup prevent unhealthy weight gain,thereby reducing the need for futureweight loss. Such targeted interventionscan be important for preventing futurehealth problems.10

To date, few obesity prevention in-terventions have been personalized tothe sensibilities and interests of youngadults. The Community-Based Partici-patory Research (CBPR) process canhelp researchers and practitionerswork collaboratively with the targetaudience to assess needs as well asdevelop and implement programs.11,12

Community-Based Participatory Rese-arch includes the target audience indeveloping the intervention and usesthe community as anactive, equalpart-ner in the research process with theidea that the community is the experton the community. Use of PRECEDE-PROCEED13 process, a CBPR processmodel, enhances program effective-ness by ensuring that the multipleand complex factors associated withthe audience's health problems are ad-dressed.12,14,15 Figure 1 demonstratesthe phases of PRECEDE-PROCEEDand the tasks involved during each

phase.13PRECEDE-PROCEED isa struc-tured health program planning model,grounded in improving target popula-tions' health and quality of life usingorganizational and educational ap-proaches. Few people, particularlyyoung adults, are motivated to changetheir behavior solely for the purposesof their health; rather, they aremotivated by functional or improvedquality of life benefits. PRECEDE-PROCEED helps to close the gap be-tween research outcomes and practice(target audience motivations).14,15

PRECEDE-PROCEED has been usedeffectively to design interventions forhard-to-reach populations16-19 andthose with health problems,16,19-21

with encouraging outcomes.19,20,22

The first 4 phases of the process(PRECEDE) use mixed methods toassess the needs of the population.PRECEDE-PROCEED involves (1) socialor quality of life, (2) epidemiological,(3) educational (behavioral) andecological (environmental) with ante-cedents, and (4) administrative andpolicy assessments. Eachphase funnelsto the next for intervention design andalignment.

The PROCEED component, Phases5–8, involves implementation, andprocess, impact, and outcome evalua-tions. The PRECEDE phases are theformative evaluation, whereas PRO-CEED phases are the summative eval-uation.13 PRECEDE-PROCEED is aneffective and efficient process forguiding each step in the developmentof a relevant and sustainable healthintervention.13,19,20,22

The Internet is used by 94% ofyoung adults aged 18–29 years and81% of all adults over age 18 years.23

Typically, young adults use theInternet for schoolwork, onlinecourses, entertainment, and socialand professional communication.24

Despite the popularity of Internetuse among emerging adults and theplethora of applications designed forcontrolling calorie intake, there islimited evidence to support thismethod for effective use for obesityprevention programming in collegestudents.25 Development of a Web-based intervention program to pre-vent excessive weight gain couldgreatly benefit this population andextend program delivery to a broaderarray of 18- to 24-year-olds than thesmall, homogeneous samples that

typically participate in these pro-grams.26,27 In addition, Web-based in-terventions offer an opportunity toimprove effectiveness by tailoringma-terials individually to users andproviding feedback. According to asystematic review of Internet-basedinterventions, information-only Websites vs individually tailored Web siteswere less effective means of helpingparticipants with weight loss. Therewas greater effectiveness of Web-based programs with feedback andhigher contact frequency comparedwith those not including these com-ponents.28 Effective individuallytailored Web-based programs can beused alone or as a supplement to cur-rent health and wellness program-ming on university campuses.

The purpose of this article was todescribe the development and pilottesting of a tailored, theory-based,Web-delivered intervention for pre-vention of excessive weight gain incollege students and the associatedadministrative management portal formanaging the intervention. Investiga-tors developed both the interventionand the administrative portals usingPRECEDE, the first 4 phases of theCBPR process of the PRECEDE-PROCEED model. The goal was todevelop a Web-based program forstudy recruitment, participation, man-agement, and data collection. Pilottesting served to refine the interven-tion and identify and avoid potentialbarriers to Web-based delivery.

METHODSDesign of the Web-basedIntervention

Researchers from land-grant and pri-vate universities in the central, south-east, and northeast regions of the US(East Carolina University, KansasState University, Michigan State Uni-versity, Purdue University, RutgersUniversity, South Dakota State Uni-versity, Syracuse University, TuskegeeUniversity, University of Florida, Uni-versity of New Hampshire, Universityof Rhode Island, University ofWisconsin-Madison, and West Vir-ginia University) collaborated todevelop the Web-based interventionpromoting healthy weight behaviorsof college students, called ProjectYoung Adults Eating and Active for

Figure 1. PRECEDE-PROCEED health program model. (Used with permission from Green et al.13) Determinants of health specificto each phase of the PRECEDE-PROCEED model. Boxes represent determinants of health; arrows indicate the direction in whichthese determinants influence health.

Journal of Nutrition Education and Behavior � Volume 46, Number 2, 2014 Kattelmann et al S13

Health (YEAH). Approval from eachuniversity's institutional review boardwas received before to starting theproject. To work with campus com-munities using CBPR, steering com-mittees composed of the targetaudience (ie, college students) andkey health and wellness personnel(eg, health and nutrition faculty, din-ing services staff, health services staff,recreation services staff, facilities andservices administrators) were formedat each institution to assist in eachPRECEDE phase for interventiondevelopment and administration.These committees were frequentlyconsulted and helped guide the inter-vention development, implementa-tion, and evaluation. Target audienceparticipants for all phases were re-cruited from entry-level, non–healthmajors' classes, e-mail messages sentthrough the university communica-tion networks, flyers posted aroundcampus and in living units, andannouncement ads placed in schoolnewspapers.

Project YEAH was based on previ-ous findings from a theory-based,Web-delivered intervention knownas Project WebHealth,29,30 as well asother pertinent research with youngadults.31-33 Project WebHealth was anon-diet approach, Web-based,health promotion intervention devel-oped for college students using theModel of Instructional Design byDick et al.34 Although participantswho completed Project WebHealthincreased fruit and vegetable intakeand maintained physical activitylevels to a greater extent than controlparticipants, the intervention did notreduce the rate of weight gain over15 months.30 In follow-up interviews,Project WebHealth participants rec-ommended more learner-driven les-sons with greater personalization andinteraction. In addition, they recom-mended shorter lessons withenhanced use of technology.33 Toimprove the sustainability of ProjectYEAH and respond to recommenda-tions from previous intervention

research, Project WebHealth30 lessonswere redesigned and additional com-ponents such as brief e-mail messagesand videos (‘‘nudges’’) were developedusing the CBPR process of thePRECEDE-PROCEEDmodel. Interven-tion components were tailored to in-dividual stage of readiness for changefor fruit and vegetable intake, physicalactivity, and managing daily stress us-ing the Transtheoretical Model ofBehavior Change.35 A description ofProject YEAH development by phaseof the PRECEDE-PROCEED model isdescribed in the following results sec-tion, with an overview depicted inFigure 2.

RESULTSPRECEDE Phase 1:Social Assessment

The purpose of PRECEDE Phase 1, aswell as Phases 2 and 3, was to gatherand evaluate information needed toguide the intervention development.

Figure 2. Overview of Project Young Adults Eating and Active for Health (YEAH) devel-opment by phase of the PRECEDE-PROCEED health program model. Eight phases ofthe PRECEDE-PROCEED model and the specific tasks performed during each phase.


To design the most appealing andtailored weight management inter-vention, PRECEDE social assessmentdetermines the students' motivations,barriers, and desires beyond healthand weight to assess what is reallyimportant to them. The situationalanalysis and social assessment ofPhase 1 included a literature reviewfor weight control and wellness pro-gramming for young adults, with afocus on the behavioral and environ-mental factors that influence healthand quality of life for young adults.

Other activities in this phase wereto conduct key informant interviewswith the steering committees andconduct online focus groups withthe target audience. The purpose ofthe key informant interviews andfocus groups was to determine factorsthat affect students' quality of life,salient health issues and concerns,how current lifestyle choices can

affect future health, how current envi-ronment impacts personal health,and perceptions of weight-related is-sues among young adults. Focusgroup questions were cognitivelytested with the target audience toverify clarity and comprehensionbefore conducting the focus groups.

Sixteen online focus groups36,37

(7–8 participants/group) were con-ducted with students, ages 18–24years, approximately 50% femalewith race and ethnicity emulatingthe 12 participating institutions, toidentify quality-of-life factors thatwere important to them and subse-quently use the factors to create aframework to plan the intervention.Focus group data, analyzed usinggrounded theory methodology proce-dures,38 revealed that factors thatdefined students' quality of life wereconcerns about academic achieve-ment, congruence of faith teachings

with lifestyle choices, limited freetime to ‘‘hang out’’ and enjoyhobbies, general health, high stressfrom daily activities and schoolwork,obstacles to achieving personal goals,and difficulties managing personal fi-nances. Other factors identified asaffecting quality of life were eatinghabits, stress and time managementskills, and lack of time and construc-tive methods for relaxation. Salienthealth issues and concerns identifiedwere how physical activity improvesmood and energy level; how illnesscreates unhappiness; and concernsabout eating habits, being in shapeand toned, and feeling healthy. Stu-dents' concerns about how currentlifestyles will affect their future weresubstance abuse, poor weight man-agement, and poor sleep habits. Cur-rent environmental factors identifiedby students that will affect futurehealth included access to unhealthyfoods; limited facilities for preparingfood; how others affected the fre-quency, amount, and time they ate;peer pressure; air quality; and pollu-tion. Weight-related issues identifiedwere media pressure to achieve idealweight and body shape, disorderedeating and restrictive eating practices,weight discrimination and stigma(including name calling), weight-based judgments made by others,poor eating habits, poor self-image,and low self-confidence.39-41

PRECEDE Phase 2:Epidemiological, Behavioraland Environmental Assessment

This phase included an assessment ofthe environment to allow the behav-ioral focusof the intervention to incor-porate environmental aspects for amore ecological view. For this phase,the steering committee on eachcampus described the factors in thecampus environment (includingadjacent non-campus areas comm-only frequented by students) thataffected weight-related behaviors.Each campus conducted a walkabilityand bikeability audit,42 eating envi-ronment assessment (ie, on-campuseating venues, such as dining halls,restaurants, and vending machines;and near-campus restaurants),43,44

and food availability appraisal of on-and near-campus grocery and


convenience stores.45 In addition,supports in the built environment forphysical activity, recreation servicesand programs, and relevant healthpolicies were evaluated on eachcampus.46,47 Each of theseenvironmental evaluations allowedthe team to gain an understanding ofhow campus physical environmentscould support or thwart students'health-related behaviors and providedevidence for making environmentaland policy changes.

Detailed methods and results ofPhase 2 environmental assessmentsare reported in detail elsewhere.42-46

In brief, the environmental assess-ments indicated that improvementsto support walking and biking couldbenefit most postsecondary educa-tional institution campuses, becauseonly one fifth of the path segmentsevaluated were rated as providingexcellent support for walking andbiking.42 Campus dining halls werefound to provide limited support forhealthy eating and obesity preventionand could be improved by providingadditional healthy options, nutritioninformation, and other point-of-selection supports for healthy eatingand weight gain prevention.43 Vend-ing machines provided high-calorie,low–nutrient-dense options and couldbe improved upon by offering a greaternumber of higher-fiber, lower-fat,reduced-sugar, and reduced-caloriesnack and beverage options.44 Campusgrocery and convenience stores hadlimited healthful options and couldimprove by providing more fresh andfrozen fruits and vegetables, healthyconvenience meals, and wholegrains.45 Evaluation of the health pol-icies, recreation services and programs,and built environment found thatcampuses had wide differences in thenumber and types of recreational facil-ities, but most had extensive healthpromotion programs. Campuses couldbe improved with specific health-related policies and additional builtenvironment supports (such as bikeracks and signage promoting stairwelluse) to prevent obesity. Although orga-nizationandpolicychangeswere advo-cated for on respective campuses, thosechanges are time-intensive and long-term solutions require longitudinalmeasures beyond the length of the pro-posed intervention. For the interven-tion, curriculum suggestions were

made for dealing with environmentaldifficulties such as coping withweather, facilities, food availability,and transportation.46,47

PRECEDE Phase 3:Educational and EcologicalAssessment

During Phase 3 of PRECEDE, theresearch team evaluated how thetarget population viewed the impor-tance and changeability of thebehavior (eg, eat healthy foods, eatmore vegetables and fruits, preparehealthy meals, get 7-9 hours of sleep,exercise at least 30–60 minutes mostdays) and environmental factors (eg,availability of healthy foods in stores,restaurants, and dining halls; avail-ability of exercise programs and placesto exercise; health education pro-grams) that were determined inPhases 1 and 2. Students (n ¼ 1,283)on all campuses completed the Behav-ioral, Environmental, and Change-ability Survey48 to rank importanceand their willingness to change thebehavioral and environmental factorsfor the intervention. A description ofthe students, analysis, and findingsof this survey for Phase 3 were previ-ously published.48 Briefly, nutritionfactors students ranked as willing tochange to maintain a healthy weightwere to eat healthful foods, improvesleep habits, get regular exercise, andmanage stress and time. The environ-mental changes desired were reducedcost and improved options of health-ful foods on campus or at work, easierand safer walking paths, and greateravailability of places to exercise. Stu-dents' prioritization for importanceand changeability of the behavioraland environmental factors directlyinfluenced the length, detail, and pri-ority of topics in the curriculum.48

PRECEDE Phase 4:Administrative and PolicyAssessment and InterventionAlignment

In Phase 4 of PRECEDE, teams of con-tent experts used findings from Phases1, 2, and 3 in concert with the Modelof Instructional Design by Dick et al,34

Keller's49 Motivational Design of In-struction, and the Transtheoretical

Model35 to develop Project YEAH, atheory-driven, Web-based interven-tion to prevent excessive weight gainin young adults. The intervention (a10-week intense intervention fol-lowed by a 10-month reinforcementperiod) was focused on quality-of-lifeissues, specifically healthful eating be-haviors, physical activity, and copingwith stress. Participants were stagedfor their readiness to consume 5 cupsof fruit and vegetable per day, engagein 150 minutes of moderate physicalactivity per week, and manage stressmost days of the week at baselineand postintervention, and e-mailedstage-tailored nudges for the respec-tive behavior. All intervention com-ponents were available through apassword-protected Web site. Adescription of the components fol-lows. Figure 3 is a screen shot of thewelcome page that provided expecta-tions and directions to the interven-tion participants.

Student volunteers at each univer-sity assisted in developing, refining,and evaluating the Web-based inter-vention components. All interventioncomponents were cognitively testedindividually with student volunteersto ensure understanding and interestfor this age group. Cognitive testinginvolved an online evaluation by10–12 students from each partici-pating institution to determine lessonappeal, wording comprehension,their interest in seeing the other les-sons, and the perceived take-homemessage. Based on feedback fromcognitive tests, changes were madein language and visual presentation(eg, adding pictures of students fromparticipating institutions and makingcolor changes to theWeb site banner).

Development of Project YEAHparticipant portal. The interventioncomponents were available at apassword-protected Web site createdfor the program's 21 mini-educational lessons, e-mail messages(nudges) tailored for stage of readinessto change, and goal-setting features.Participants accessed interventioncomponents via the Project YEAHParticipant Portal welcome page.

During the 10-week intervention,intervention participants weree-mailed 4 nudges/wk (1 stage-tailored for each of the 3 targeted

Figure 3. Intervention participant welcome page. Screenshot of what Project YoungAdults Eating and Active for Health (YEAH) participants saw when they logged in tothe intervention Web site. Here, Project YEAH participants found an overview of theWeb site and directions regarding its use.


behavior and a fourth nudge toremind participants to access theWeb site to view lessons and setbehavior change goals). Nudge con-tent emulated the content of the les-sons and was personalized by statingthe participant's name at the begin-ning of the message, and was tailoredto eachparticipant's Stage ofChange35

for consuming 5 cups of fruits and veg-etables per day, engaging in 150 mi-nutes of moderate physical activityper week, and managing stress mostdays of the week. To capture the tar-geted audience's interest and atten-tion, short, entertaining videos weredeveloped and linked to each of thebehavior-focused nudges. Participantsself-identified their stages of changefor the targeted behavior via comple-tion of a required survey administeredthrough the participant Web siteportal. Consequently, participantsreceived staged-tailored nudges withvideos focusing on tips to encouragehealthful behavior that supportphysical activity, fruit and vegetableintake, and stress managementthrough e-mail. For example, to rein-force the idea that everyone canbenefit from exercise, a participantin precontemplation would receive amessage such as ‘‘You don't have tobe an athlete to be fit! ANY exerciseis better than none. If you're not

ready to go to the gym, start with ano-brainer like taking the stairsinstead of the elevator.’’ A participantin contemplation/preparation wouldreceive ‘‘No matter your currentshape, exercise improves your health(physically and mentally). Benefitsoccur with as little as 3 10-minutebouts of physical activity per day’’Someone in action/maintenancewould receive ‘‘Remember to keepmoving, even on the busiest days!It's your body's way of preventing dis-eases and helps fight stress.’’ Nudgesand video were created for those inthe precontemplation, contempla-tion/preparation, or action/mainte-nance stages. Based on previousresearch that the change processesused to move through the stagesoverlap,50-52 nudges were combinedfor the contemplation and prepar-ation stages and for the action andmaintenance stages.

After the 10-week intervention wascomplete, intervention participantswere reassessed for staging of each ofthe 3 behaviors and received the 4nudges (3 behavior plus 1 reminderto set goals) each month for 10months. The nudges and videos,once delivered by e-mail, were avail-able to participants via the Nudgetab on the welcome page of the partic-ipant portal.

The Activities tab on the welcomepage took participants to the Activ-ities landing page and gave them ac-cess to the lessons. Lessons werecalled Activities rather than lessonsto make them seem less formal anddecrease the academic feel. (Note: inthis article, the term lesson will beused to differentiate lessons from themyriad of other intervention activ-ities.) Lessons were designed to beshort and interactive with attention-getting material, lesson goals, educa-tional content, and encouragementsuggestions for trying new activitiesor behavior and goal setting.

Project YEAH's lessons (Table 1)were designed to address 4 topic cate-gories: Eating, Physical Activity, StressManagement, and My HealthyWeight, and included an introduc-tion, Getting Started, and a summary,Moving Forward. Material from previ-ously developed Project WebHealthlessons29,30 was subdivided toproduce shorter, more conciselessons for Project YEAH. The Stressconstruct was added to addressexpressed concerns about lifesatisfaction identified by studentsduring PRECEDE Phase 1 that wererelated to self-confidence in manag-ing time; having the ability to balancetime with friends and academic re-quirements, recognize hunger andsleeping cues, and get sufficient sleep;and concerns about smoking cessa-tion and alcohol consumption. Linksfor additional informationwere addedto all lessons to satisfy those whowanted more information, and inter-active self-assessment quizzes wereincreased to enhance interest.

The Getting Started introductionlesson was delivered as a video andprovided an explanation of the Website, the expectations of the interven-tion, and the steps to get started.Each participant completed the Get-ting Started video before moving onto other lessons. One to 3 new lessonswere released each week during theintervention. The Eating categorycontained 7 lessons that helped par-ticipants learn to eat healthful foods,eat regularly, plan and prepare meals,enhance food variety, enjoy eating,and identify hunger and fullness sig-nals. The Physical Activity categorycontained 4 lessons on the impor-tance of exercise, how to find exer-cises that fit one's lifestyle and


preferences, how to have fun and stayfit, and fitness finesse. The Stress Man-agement category contained 6 lessonson mindful eating, connecting mindand body, time management, sleep,smoking and alcohol, and balancingfriends and classes. The My HealthyWeight category had a lesson on sizeacceptance and 1 on tips for manag-ing weight. In Moving Forward, alllesson content was summarized withencouragement to continue healthfulhabits. This lesson also provided di-rections for the 12-month follow-upportion of the intervention.

Based on post-evaluation resultsfrom the Project WebHealth,29,30,33

and to help participants personalizetheir own intervention, participantswere in control of their access to thelessons. Participants could decide,based on their desires and needs,which lessons they wanted to viewand for how long. Participants werenot required to complete anyparticular lesson or to completethem in a specific order (other thanthe first lesson, Getting Started, andfinal lesson, Moving Forward).Participants were required to setgoals and were allowed to set a goalin each category no more frequentlythan every 4 days.

The My Comparison tab on thewelcome page provided access to thegoal setting and respective feedbackfor the 3 targeted behaviors. Interven-tion participants were encouraged toset goals for 1–3 behaviors: eating 5cups of fruits and vegetables eachday, getting 150 minutes of moderatephysical activity each week, andcoping constructively with stressmost days of the week. Participantswere able to set a goal for the weekand later check their progress towardthe goal. The participants were pro-vided with a graph of the goal theyset, what they reported doing, andthe current recommendations foreach goal behavior. Intervention par-ticipants were considered active ifthey either looked at a lesson or set agoal every 6 days. Intervention partic-ipants who had not viewed an activityor set a goal in 7 days were sent auto-matic e-mail reminders to access theWeb site.

Development of administrative man-agement portal. The administrativemanagement portal was simulta-

neously developed and evaluatedwith the Web-based intervention dur-ing Phase 4. The lead researcher (K.K.)worked with the project softwarevendor to create a functional Website for intervention delivery andadministrative management. TheWeb site was developed using Micro-soft's Asp.net technology and all Website data were stored in a MicrosoftSQL Server database (Redmond, WA).

The primary goal during develop-ment of the administrative manage-ment portal was to provide a fullyinteractive tool for adding and updat-ing lesson content and study datacollection survey instruments, moni-toring participant activity, andretrieving study data. The administra-tive management portal was designedto allow members of the researchteam with varying technical back-grounds to easily access administra-tion functions, and permitted 2levels (full and limited) of access andcontrol. The super coordinator,housed in the lead researcher's institu-tion, had full control access to all as-pects of the Web site, whereas thecampus coordinator, housed in eachinstitution except the lead re-searcher's institution, had limitedcontrol access and could access onlyareas of the Web site that pertainedto the specific institution. Each insti-tution had a designated campus coor-dinator.

Pilot test. The pilot test involved allaspects of the intervention and had atwofold purpose: (1) to evaluate thecontent of the lessons for relevanceto the target audience, and (2) toensure that the Project YEAH partici-pant portal and administrative man-agement portal were functioningcorrectly. Twenty participants from13 universities (n ¼ 260), primarilywhite, ages 18–24 years, and approxi-mately 60% female, were recruitedand enrolled in the 10-week pilotintervention. After piloting, a subsetof 87 participants were also queriedusing Keller's49 36-item, 5-point(‘‘not true’’ to ‘‘very true’’) Likert-typeInstructional Materials MotivationSurvey (Table 2) and 4 open-endedquestions from Attention, Relevance,Confidence, and Satisfaction Theory(Table 3). The 36-item InstructionalMaterials Motivation Survey queried

for attention with question-statements such as ‘‘There was some-thing interesting at the beginning ofthis lesson that got my attention,’’for relevance with questions such as‘‘It is clear to me how the content ofthis material is related to things Ialready know,’’ for confidence withquestions such as ‘‘When I first lookedat this lesson, I had the impressionthat it would be easy for me,’’ andfor satisfaction with questions suchas ‘‘Completing the exercises in thislesson gave me a satisfying feeling ofaccomplishment.’’ Higher scores(range, 1–5) indicated greater atten-tion, relevance, confidence, and satis-faction. Using the combination ofnumerical scores (mean responsesranging from 2.5 � 0.5 to 4.1 � 1.6)and open ended responses (describedbelow), investigators were able toascertain whether the lessons gainedparticipants' attention, were per-ceived as useful, instilled confidencein the ability to apply the informationgained, and provided a sense of satis-faction. Table 3 summarizes responsesto the Attention, Relevance, Confi-dence, and Satisfaction Theoryopen-ended questions by category oflessons. When asked to describe waysin which lessons captured their atten-tion, students indicated interactivecomponents and the ability to applyand relate the information to theirown lives. The parts of lessons stu-dents identified as useful were supple-mental Web links and useful tipsfor exercise (eg, exercises to do ininclement weather), eating (eg, eatingon a college meal plan), avoidingstress (eg, information for stressmanagement available at respectivecampuses), and time management be-haviors (eg, writing daily lists). Whenasked what was less useful, studentsnoted that Web site images neededimprovement and the amount ofreading needed to be shortened.When asked whether they understoodthe material presented, students re-ported being more aware and willingto improve nutrition, learning newways to be active, becoming aware ofmindless eating, learning constructivemethods for relieving stress, settingsmall goals to get things done, and ac-cepting body image. Students indi-cated that the following gave them asense of satisfaction after completingthe lessons: realizing weight

Table 1. Project YEAH Educational Lesson Activity Titles, Availability, and Descriptions

Topic Category Lesson Name Week Availablea Lesson Focus

Getting Started Getting Started 1 Provided overview of expectation and requirements forlessons and introduction to Web site.

Eating 1. Eating Healthy 1 Why eat healthy, how much time will it take, simple stepsto move toward healthier eating.

2. Eating Regularly 2 Benefits of regular eating, how to control snacking, andbetter snack options.

3. Meal Planning 3 Making a shopping list, controlling food cost, and mealideas.

4. Eating a Variety 4 Importance of variety in diet and how to add variety todiet.

5. Eating Enjoyment 5 How to enjoy food while gaining nutritional value as wellas psychological and social value and assessing yourown food enjoyment.

6. Hunger and Fullness Signals 8 Hunger and fullness signals, what affects these signals,and assessing how well you respond to these signals.

7. ‘‘In-tune Eating’’ 9 Factors that influence ‘‘in-tune’’ eating, tips to avoidbeing hungry, and overview of tips to improve eatinghabits.

Exercise 1. Moving Matters 1 Benefits of physical activity.2. Moving Your Way 2 Recommendations for physical activity amounts and

typical activity patterns.3. Staying Active 3 Importance of having fun while staying active, added

benefits of exercise, tips to keeping physical activityfrom becoming boring, and examples of exercises todo while home on break or during inclement weather.

4. Fitness Finesse 6 Examples of and benefits from different types of physicalactivity and facts about sedentary vs physically activelifestyles.

Stress 1. Mindless Eating 1 What mindless eating is, consequences of mindlesseating, triggers and how to redirect them, and how tobecome a mindful eater.

2. Mind and Body 2 Find ways to relieve stress, appreciate your body andmind–body connection when managing stress, andlive healthfully and prevent unwanted weight gain.

3. Time Management 3 Find out how well you manage your time, reduce stressusing time management tips, and manage your timeand weight with quick, healthy meals.

4. Sleep 4 Assess your sleep quality; see how sleep, weight gain,and stress interact; and get tips for better sleep.

5. Balancing Act 7 Balancing social and academic aspects of college life tomanage stress, reducing stress by avoiding stress-filled environments and people, and thinking aboutreasons why college students use alcohol and theeffect alcohol use can have on both weight gain andquality of life.

6. Smoking 1 Reasons for quitting, your triggers for smoking, dealingwith stress without smoking, effect of smoking andquitting on weight, and how healthful eating andexercise can help when quitting.

Managing Weight 1. Size Acceptance 5 Your attitudes toward your own body, how you acttoward a variety of body sizes and shapes, societalvalues about body images both today and in history,identifying a great body beyond just considering sizeand shape, and being able to accept the size ofyourself and others.

(continued)


Table 1. Continued

Topic Category Lesson Name Week Availablea Lesson Focus

2. Managing Your Weight 6 Discovering your estimated energy needs, discoveringhow calories affect your weight gain or loss over time,and discovering resources for expert advice on weightmanagement information.

Moving Forward Moving Forward 10 Reinforce skills needed for achieving and maintaininghealthy weight by briefly reviewing information inactivities, exploring your goals for the next year, andassessing your motivation to work on goals after theprogram is over.

aLessons became available over the course of 10 weeks.


management does not have to be diffi-cult, being more motivated to partici-pate in physical activity, gaininginformation regarding triggers foreating, being on the right track fortime management, learning that

Table 2. Results from Pilot Instructional MTheorya

Lesson Titleb (n)At

(Me

Eating1. Eating Healthy (7) 2.2. Eating Regularly (4) 2.4. Eating a Variety (5) 3.5. Eating Enjoyment (6) 2.6. Hunger and Fullness Signals (4) 2.7. ‘‘In-Tune Eating’’ (4) 3.

Exercise1. Moving Matters (4) 2.2. Moving your way (4) 3.3. Staying Active (5) 2.4. Fitness Finesse (3) 4.

Stress1. Mindless Eating (4) 2.2. Mind and Body (5) 2.3. Time management (4) 2.4. Sleep (4) 3.5. Balancing Act (5) 2.6. Smoking (5) 2.

Managing Weight1. Size Acceptance (4) 3.2. Managing Your Weight (6) 3.

Moving Forward1. Moving Forward (4) 2.

Total (87) 2.

aMean � SD, average scores of 5 anchotrue’’ (midpoint ¼ 3), to ‘‘very true’’ (highbecause it was developed from this evaluConfidence, and Satisfaction Theory was

eating habits can be controlled bysleeping more, and doing well on thequizzes.

Student comments about the inter-vention components overall wereoverwhelmingly positive and were

aterials Motivation Survey Using Attention, Re

tentionan ± SD)

Relevance(Mean ± SD)

Confidenc(Mean ± SD

9 � 0.6 3.6 � 0.2 3.2 � 0.64 � 0.7 3.0 � 1.1 2.8 � 0.30 � 0.2 3.2 � 0.3 3.0 � 0.37 � 0.5 2.6 � 0.7 2.9 � 0.42 � 0.4 3.0 � 0.8 2.7 � 0.24 � 1.8 4.2 � 1.5 3.6 � 1.7

6 � 0.8 3.5 � 0.8 3.0 � 0.24 � 1.6 4.3 � 1.3 3.4 � 1.36 � 0.3 3.4 � 0.3 2.8 � 0.30 � 1.8 4.2 � 1.5 3.9 � 1.8

7 � 0.5 3.8 � 0.9 2.9 � 0.36 � 0.3 3.3 � 0.6 2.8 � 0.36 � 0.7 3.4 � 0.3 2.9 � 0.41 � 0.7 3.3 � 0.5 3.1 � 0.66 � 0.3 3.2 � 0.5 2.8 � 0.25 � 0.5 3.2 � 0.7 2.8 � 0.6

0 � 0.2 3.5 � 0.3 3.1 � 0.30 � 0.7 4.2 � 0.5 3.3 � 0.4

8 � 0.3 3.6 � 0.6 2.9 � 0.4

8 � 0.8 3.5 � 0.8 3.0 � 0.7

red response categories ranging from ‘‘not¼ 5) (n ¼ 87); bLesson titles for intervention.ation. The Getting Started introduction wasqueried using Keller’s49 Instructional Materi

also helpful in making productivechanges to the participant portal.Changes included refinements to theWeb site to improve its flow and func-tion and help participants identifywhat to do and better understand

levance, Confidence, and Satisfaction

e)

Satisfaction(Mean ± SD)

Total(Mean ± SD)

3.9 � 0.3 3.3 � 0.33.8 � 1.8 2.9 � 0.82.9 � 0.5 3.0 � 0.32.5 � 0.9 2.7 � 0.52.3 � 1.4 2.5 � 0.54.1 � 1.5 3.8 � 1.6

3.3 � 0.9 3.0 � 0.44.4 � 1.6 3.8 � 1.43.4 � 0.6 3.0 � 0.34.4 � 1.4 4.1 � 1.6

3.3 � 1.1 3.1 � 0.62.7 � 0.6 2.8 � 0.43.0 � 0.0 2.9 � 0.33.3 � 0.5 3.2 � 0.63.0 � 0.4 2.9 � 0.33.5 � 1.2 2.9 � 0.6

3.3 � 0.3 3.2 � 0.24.2 � 1.0 3.6 � 0.4

3.1 � 1.2 3.1 � 0.5

3.4 � 1.1 3.1 � 0.7

true’’ (low ¼ 1) through ‘‘moderatelyEating 3: Meal Planning not includednot evaluated; Attention, Relevance,als Motivation Survey.

Table 3. Summarized Participant Responses for Evidence of Attention, Relevance, Confidence, and Satisfaction With SelectedLessonsa

TopicAttention, Relevance, Confidence, and Satisfaction Items

Activity/lessons

In what ways did thislesson capture your

attention?

To help you enjoy(topic of lesson),

differentiate betweenwhat parts of thelesson you found

useful.

In what ways do youfeel you will be better

able to (topic oflesson) as a result ofreviewing the content

in this lesson?

What has given you asense of satisfactionor enjoyment fromcompleting this

lesson?

Eating 1: Eating Healthy � Allowed me to viewthe eating patterns

� Allowed me to viewthe lack of vegetablesand fruits consumed

� What should be eating� Vitamins and minerals

associated with thecolors of fruits andvegetables

� Make smarter, health-ier decisions

� To cook and eathealthier in ownapartment than cafefood

� Breaking it down andmaking it easier for usto be successful ateating healthy whilestill living a demandingcollege life

Eating 2: EatingRegularly

� Related to somethingI am concerned about

� Tips� Research findings� Supplemental links

� Tip about trying a fewimprovements out atfirst, rather than tryingto do an immediatechange in eatinghabits

� Fact that I know thatthe tips will probablywork

� Reassuring to knowthat I already followsome of the tips

Eating 4: Eating a Variety � Pictures. nice to lookat

� Very informative

� Useful information � More conscious aboutdiet variety

� Increasing your foodvariety increases vari-ety of nutrients

� That I know variety is agood thing

Eating 5: EatingEnjoyment

� Interactive quizzes � Made me feel likeshould be more caringabout what eat

� Won’t connect enjoy-ing food with obesity

� It is okay to eat to en-joy rather than survive

� International eatinghabits

Eating 6: Hunger andFullness Signals

� Visuals and the setup� Hunger and fullness

quiz

� Do not need to eat justbecause others areeating

� It takes about 20 minfor the body to recog-nize that it’s full

� Will eat more slowlyand smaller portions

� To know that what Iam doing is okay

Eating 7: ‘‘In-TuneEating’’

� The interactive graphand photos

� Addressed other hun-ger/fullness issuesrather than justfocusing solely oneating healthy

� Eating out as a treat� Having green salad

before meal� Carrying snacks

throughout the day� Value meals are bad

for the waistband

� Tips and tricks tomanage better eatingand finances

� Buying food in bulkand split with a friend

� It was a nice realitycheck

� Assured that eatinghealthy and managingweight do not have tobe difficult

Exercise 1: MovingMatters

� Not an overwhelmingamount of text perpage

� Allowed me to see myown thoughts aboutphysical activitycompared with statis-tics

� Realization of howmuch time is wasted ina college student’s life

� Something as simpleas staying active for 30min/d is helpful

� Learning more aboutproper exercise habits

� More motivated nowto participate in phys-ical activity

Exercise 2: Moving YourWay

� Really made me thinkabout what type ofperson I was

� Visual examples of atypical day

� Descriptions aboutdifferent personalitieshelpful

� Graphs and daily ex-amples were useful

� To see how active I amon a daily basis

� To take small steps tolive better

� To realize that workoutis enough

� To realize that I am nota couch potato

(continued)


Table 3. Continued


Activity/lessons


attention?



useful.



in this lesson?


lesson?

Exercise 3: StayingActive

� Related to me per-taining to stress andnot having time, aswell as not enjoyingtypical exercise rou-tines like jogging, andexcuses to not workout

� Activities to do in poorweather or duringvacations were useful

� To find something Ireally enjoy doing anddo in a short amountof time

� Will stop thinking ofexercising as a chore

� Exercise can be easy� I am a healthy personbecause I do a lot ofthe things this lessondiscussed

Exercise 4: FitnessFinesse

� Learned more aboutexercise

� True/false questionswere useful. kept myattention better thanjust facts

� Doing the exercise atthe right levels

� Learned quite a bit ofinformation that Ididn’t know before

� Motivated me to exer-cise more

Stress 1: MindlessEating

� Didn’t realize therewere so many thingsthat could causemindless eating

� Information onemotional triggers

� Self-analysis ques-tions were good

� Information on whattriggers mindlesseating

� Ways to help stopmindless eating wererealistic

� Ask myself if mind-lessly eating andconsider how hungry Iam

� Slowing down andenjoying food

� Learned something Ican use everyday thatwill better my quality oflife

� Information regardingtrigger identificationwas good

� Slowing down andenjoying food

Stress 2: Mind and Body � Aesthetics, colors� Real-life examples� Each fact was to thepoint with no mean-ingless informationpresented

� Exercise and progres-sive muscle relaxationmore helpful thanbreathing exercises

� Links to stress-relieving techniques

� Interested in alterna-tive mind–body exer-cises

� Enjoyed learningabout different exer-cises to relieve stress

� Now have tools andmethods for dealingwith stress

Stress 3: TimeManagement

� Time management issomething I strugglewith and need to dobetter on

� Tips about writing apaper a little bit eachday

� Write daily lists

� Make small goals firstinstead of looking atthe whole list andtrying to finish every-thing

� Writing a dailyschedule to map outmy productiveness forthe day

� Time managementisn’t as bad as Ithought it was

� Keep good health tohelp decrease stress

Stress 4: Sleep � Did not know that oneshould have 7–9 h ofsleep

� Did not know gainedweight with the loss ofsleep

� Ways to adjustsleeping habits

� Will not study in mybed

� Tips about sleeping� Control my eatinghabits by sleepingmore

(continued)


Table 3. Continued


Activity/lessons


attention?



useful.



in this lesson?


lesson?

Stress 5: Balancing Act � Subheads, boldedwords, and bulletshelped keep myattention so that thepresentation wasn’t 1long piece of textthrown at me

� Tone of the lessonvery relatable

� Really liked the tips oncontrolling alcoholconsumption

� Areas to study veryuseful

� How to avoid stressfulsituations

� How to study better

� Surprised that �15%of people in the UnitedStates haven’t drunkin a year. encour-aging statistic forsomeone who doesn’twant to feel pressuredinto drinking

Stress 6: Smoking � Calculator on thecosts of smoking

� Information to helpfriends quit

� Coping techniqueswere useful

� Addressed smokingand relationship toweight

� How to quit smoking� How to avoid situa-

tions that encouragesmoking

� Knowing that I can quit

Managing Weight 1: SizeAcceptance

� That it’s an issue thatother deal with also

� Interesting facts aboutbody image

� Ability to self-evaluateor report my own sizeacceptance behaviorand what is a ‘‘goodbody’’

� More conscious ofwhat I think when Ilook at someone’sbody or my own

� Accept that somethings cannot beforced to look a certainway

� Seeing what othershave said about bodyimage and knowingthat it matches up withwhat thought

Managing Weight 2:Managing YourWeight

� Not a typical go outand do some worklesson

� Cool to see all facts� Realized that I am do-

ing the amount ofrecommended exer-cise

� Running or walkingthe mile burns sameamount of calories

� Eating healthier andmore filling foods

� Feel great aboutmyself and my exer-cise level, as well asmy healthy lifestyle

an ¼ 87, summarized responses to 4 open-ended questions from the Attention, Relevance, Confidence, and Satisfaction(ARCS) Theory summarized by lesson. The introductory lesson, Getting Started, and the summary lesson, Moving Forward,were not reported. Eating 3: Meal Planning was created in response to ARCS evaluation, and therefore, participant responsesfor that lesson are not included.


the material presented. For example,the overall Web site color schemewas changed per student preferences,landing pages or title pages wereadded for each section of the Website to improve navigation, and morepictures depicting actual students onparticipating campuses were addedto each lesson and landing page.Lesson content was shortened inresponse to participant requests todecrease the amount of reading oneach page. The Eating Regularly lessoncontent was divided to develop a new

Meal Planning lesson. Pilot-test par-ticipants requested more interactivequizzes in the lessons. Links for addi-tional information also were addedto the lessons to satisfy those whodesired more specific information.

As a result of the pilot test, the re-searchers also made changes to theadministrative management portal toimprove management and trackingof participants by the super coordi-nator and campus coordinators. AfterWeb site refinements were complete,a second mini-pilot test was conduct-

ed to review participant portal appear-ance and ensure full functionality ofall aspects of the Web site. Theindividual at each university desig-nated as the campus coordinator thor-oughly reviewed the lesson content,pictures, quizzes, overall Web sitefunctionality, and ease of use of theWeb site. Additional refinementswere made to the administrative man-agement portal to further enhance theability of the campus coordinators tomonitor and track participant activityat the Web site.


Conclusions

Other researchers have used the PRE-CEDE-PROCEED13 process of CBPRto develop health education interven-tions16,19-21; however, to the authors'knowledge, this is the firstapplication of the model to a staged-tailored, Web-based, multisite inter-vention for college students focusingon lifestyle modifications for preven-tion of excessive weight gain. Thetheoretical basis for the interventionis CBPR, with additional theory usedto develop the components. Interven-tion nudges were tailored to the indi-vidual stage of readiness for changefor fruit and vegetable intake, physicalactivity, and managing daily stress us-ing the Transtheoretical Model ofBehavior Change.35 Lessons were de-signed using the Model of Instruc-tional Design by Dick et al.34

Application of the CBPR process tocollege communities and inclusionof 14 different institutions fromgeographically dispersed regions inthe US present unique challenges ad-dressed in article, but also strengthensgeneralizability to other college cam-puses. Including college students inthe research process helped maintainthe focus on issues important to stu-dents' perceived quality of life, suchas stress management, as well as thefocus on a healthful diet and physicalactivity. This differs from previous in-terventions such as WebHealth30 andMy Student Body53 in that extensiveinput was gathered from the targetaudience in 14 regionally disperseduniversities. One of the strengths ofPRECEDE-PROCEED model is itsextensive formative evaluation pro-cess. This report describes the exten-sive formative evaluation and howresults were used to modify the inter-vention: for example, the inclusionof solutions for stressful situationsthat interfere with life satisfactionand decrease quality of life for the col-lege student. Just as important to stu-dents was material that waspresented with a minimum of textand more pictures, especially picturesof students like themselves.

To fully understand the value ofProject YEAH regarding young adultcollege students' changeable behaviorsfor weight management (ie, healthfuleating behaviors, physical activity,and coping with stress), completion of

the 4 phases of the PROCEED portionof the PRECEDE-PROCEED model isrequisite. Many published studies us-ing PRECEDE-PROCEED only focuson educational and ecological assess-ment defining predisposing, reinforc-ing, and enabling antecedents to thebehavior.13,54,55 The researchersinvolved with development of projectYEAH used the full PRECEDE-PROCEED model to maintain fidelity,with goal of developing an effectiveand useable product for the targetaudience.

IMPLICATIONS FORRESEARCH ANDPRACTICE

Applying the CBPR process of thePRECEDE portion of the PRECEDE-PROCEED model with fidelity duringdevelopment of Project YEAH resultedin an intervention that pilot-test col-lege student participants found rele-vant and useful, gained participants'attention, instilled confidence in par-ticipants' ability to apply the informa-tion gained, and provided a sense ofsatisfaction. However, a limitation ofincluding only the target populationin the formative work is that thegeneralizability of the interventionmay be limited to the target popula-tion of college students. The proce-dures used in this study to addressthe 4 PRECEDE phases as well as theonline participant and administrativemanagement portals can serve asmodels to other online, multisitehealth intervention developers.Indeed, as Lachausse56 posited, thechallenges of managing multisitestudies can be lessened by digital tool-kits such as those developed for Proj-ect YEAH.

ACKNOWLEDGMENT

This project was supported by Na-tional Research Initiative Grant 2009-55215-05460 from theUSDepartmentof Agriculture, National Institute forFood and Agriculture.

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