Health Education & Behavior

The Practice Notes section is intended to keep readers informed about health education practice around the country. It is an attempt to spread the word about exemplary strategies, initiatives, and programs and share successes in overcoming obstacles or challenges. Periodically, articles presenting perspectives on practice-related issues are also included in Practice Notes.

Research is lacking on how to make effective programs available on a large scale and how to maintain levels of implementation. CATCH: A Study of Institutionalization (CATCH-ON) was designed to help us understand the conditions under which such programs are institutionalized after the trial has ended. The Child and Adolescent Trial for Cardiovascular Health (CATCH) was the largest field trial of school-based health promotion in the United States conducted in 96 schools in four geographic areas of the United States: California, Louisiana, Minnesota, and Texas. The intervention was multicomponent, targeting school policy and practices in nutrition, physical activity, health education, and smoking. This report provides background on the CATCH study design, the conceptual framework for research on institutionalization of the CATCH program, and an overview of the seven original reports that present results from the CATCH-ON study in this theme issue.

The Child and Adolescent Trial for Cardiovascular Health (CATCH) Eat Smart Program targeted the food service of the 56 CATCH intervention elementary schools to effect positive changes in the total fat and saturated fat content of school lunch. Maintenance of the food service intervention in former intervention (n = 56) and control (n = 20) schools was evaluated 5 years postintervention. After 5 years of follow-up and no further intervention, the former CATCH intervention schools not only maintained prior levels but also had further decreases in the mean percentage of calories from total and saturated fat to 31% and 10.4%, respectively. Significant decreases in these nutrients were also observed in the former CATCH control schools; however, the former intervention schools more closely approached the Eat Smart goal for total fat. Overall, sodium levels rose in both school conditions and did not differ significantly at follow-up.

This article describes the implementation of the U.S. Department of Agriculture's National School Lunch Program (NSLP) standards in school lunch menus in 56 intervention and 20 control schools from the Child and Adolescent Trial for Cardiovascular Health (CATCH) 5 years after the main trial, compared with 12 schools previously unexposed to CATCH. School food service personnel completed questionnaires to assess CATCH guideline implementation, demographic data, behavioral constructs, training, program material use, and par ticipation in competing programs. Five days of menus and recipes were collected from school cafeteria staff, averaged, and compared to USDA School Meal Initiative (SMI) standards. Significant differences between intervention and unexposed schools were found for training and knowledge of CATCH and in mean percentage energy from fat and carbohydrates. Intervention schools most closely met USDA SMI recommendations for fat. Thus, the CATCH Eat Smart Program assisted school cafeterias in meeting USDA guidelines 5 years postimplementation.

Long-term maintenance effects of physical education (PE) curriculum and staff development programs have not been studied. The authors assessed the sustainability of the Child and Adolescent Trial for Cardiovascular Health (CATCH) PE intervention using direct observations of 1,904 PE lessons in former intervention and control schools in four U.S. states 5-years postintervention. Student physical activity levels, lesson contexts, and level of CATCH PE training of teachers were analyzed. Student energy expenditure levels and proportion of PE time in moderate-to-vigorous physical activity in intervention schools were maintained 5 years later, but vigorous activity declined sharply. Meanwhile, postintervention gains in former control schools, influenced by delayed program implementation and secular trends, resulted in a convergence of activity levels in intervention and control schools. Use of CATCH PE curricula was associated with increased levels of teacher training and school support for PE in both former intervention and control schools.

To test the effectiveness of the Child and Adolescent Trial for Cardiovascular Health (CATCH) program, a randomized trial was conducted in 96 elementary schools in four regions of the United States. Results from the original trial indicated a significant positive effect on the delivery of physical education (PE). All 56 former intervention schools (FI), 20 randomly selected former control schools (FC), and 12 newly selected unexposed control schools (UC) were assessed 5 years postintervention. Results indicate a strong secular trend of increasing moderate to vigorous physical activity (MVPA) in PE classes among both FC and UC schools. The FI schools surpassed the Healthy People 2010 goal for MVPA during PE lesson time (i.e., 50%), whereas the FC and UC schools came close to it. Barriers to implementing CATCH PE included insufficient training and lower importance of PE compared to other academic areas and indicate the need for in-service training.

Maintenance of the interactive Child and Adolescent Trial for Cardiovascular Health (CATCH) third- to fifth-grade curricula was studied in the 56 original intervention schools and 20 of the original control schools 5 years postintervention in four regions of the United States. Target grade teachers completed a self-administered survey that included questions regarding use of the CATCH materials, training in CATCH or other health education, barriers and perceived support for health education, and amount of health education currently taught. Percentage of teachers who continued to teach CATCH in the classroom was low; however, percentages were significantly higher in former intervention compared with control schools, even though control schools received training and materials following the main field trial. The results of this study can provide useful information for future development of classroom health promotion materials with a higher level of sustainability.

School climate refers to various physical and psychosocial structures that shape schools' social and physical environments. The Child and Adolescent Trial for Cardiovascular Health (CATCH) study provided an opportunity to study how aspects of school climate are associatedwith continuedimplementation of the CATCH pro gram. Nutrient analysis of menus, observations of physical education (PE) classes, and teacher and staff self-reports were used to measure CATCH program components. Results of this study indicate that aspects of school climate were associated with continued implementation of the CATCH classroom component but not the CATCH foodservice or PE components. These findings have implications for how we plan for the progression of innovative school health promotion programs from the initial trial stage to institutionalization. Measures of school climate may be useful in determining a school's readiness to adopt and implement an innovative health promotion curriculum.

To better understand the institutionalization process in Child and Adolescent Trial for Cardiovascular Health (CATCH) intervention and control schools, 199 key informant interviews were conducted with school food service staff, physical education teachers, classroom teachers, and administrators at the four CATCH-ON field centers. School personnel were asked to talk about the degree of CATCH program implementation, who at the school or school district was instrumental in promoting CATCH, and the conditions that facilitated or impeded the institutionalization of CATCH activities and philosophies. The CATCH Physical Education (PE) component appeared to have the highest level of institutionalization, and the CATCH classroom curriculum and family components appeared to have the lowest levels of institutionalization. The primary barriers expressed included the low priority for health promotion activities and time constraints of schools; lack of mechanisms for training of school staff; and lack of sufficient funds for materials, equipment, and lower fat vendor products.