School-based health education programs can be maintained over time: results from the CATCH Institutionalization study

Abstract

Background. Developing and evaluating interventions to influence students' opportunities for healthful choices has been a focus of school-based health promotion research; however, few studies have examined the sustainability of these programs and viability of continued organizational implementation.

Methods. The purpose of this study was to determine the maintenance of Child and Adolescent Trial for Cardiovascular Health (CATCH) school-level changes in former intervention (n = 56) and former comparison (n = 20) schools 5 years post-intervention. Twelve schools unexposed to CATCH were measured as controls. Macronutrient content of 5 days of school lunch menus, amount and type of physical education (PE) classes, and health instruction practices in the classroom were assessed. An institutionalization score for schools was developed, using program maintenance variables: % kcal from fat and saturated fat in school lunches, % PE class spent in vigorous and moderate-to-vigorous physical activity, and class time devoted to CATCH topics.

Results. Menus from 50% of former intervention cafeterias met the Eat Smart guidelines for fat, compared to 10% of former control cafeterias and 17% of unexposed school cafeterias (P < 0.005). There were no significant differences in implementation of CATCH PE goals between conditions. Although the total time spent teaching CATCH was low in former CATCH schools, the former intervention schools spent significantly more time teaching CATCH and taught more lessons as compared to former comparison schools. Former intervention schools had a higher mean institutionalization score than former comparison schools (P < 0.001). Training had the greatest impact on maintenance of CATCH.

Conclusions. Results from this study suggest that changes in the school environment to support healthful behaviors can be maintained over time. Staff training is an important factor in achieving institutionalization of these programs.

Introduction

School-based health promotion research has given considerable attention to developing and evaluating multi-component programs that target the school environment and curriculum to impact students' opportunities for healthful food and physical activity choices. To date, the most common program components that have been evaluated include: changes in the school curriculum [1], [2], [3], altering the foods available in schools [4], [5], [6], [7], or modifying physical education classes [8], [9], [10]. In most instances, individual-level change has remained the primary outcome for evaluation with environmental-level changes examined as secondary outcomes [11], [12], [13].

When primary prevention programs for children are implemented within the school setting, an inherent question is one of sustainability of effects and programs. If health promotion programs ultimately intend to affect morbidity and mortality, then programmatic efforts must have positive impact on health behaviors both during implementation of the intervention, and these changes must be maintained over the long term. This is especially true as the child moves into a new environment. Several studies [14], [15], [16] have examined the maintenance of children's health behaviors after exposure to a health promotion program and have found effects to persist. However, an equally important issue pertains to the viability and sustainability of effective health promotion programs within the organizational context and studies that examine these effects are rare.

Researchers have applied diffusion theory [17] to describe the stages leading to the institutionalization of innovative public health programs [18], [19], [20], [21], [22]. Most studies focus on evaluation of the effectiveness of a particular program during the research phase, leaving questions of organizational institutionalization and further dissemination largely ignored. For an effective public health program to achieve broad impact, factors that inhibit or promote organizations to institutionalize the program must be evaluated.

The Child and Adolescent Trial for Cardiovascular Health (CATCH) was the largest school-based health education study ever funded in the United States [3], [23], [24], [25]. CATCH was designed as a coordinated school health program to decrease cardiovascular risk factors in children, and included a classroom curriculum accompanied by a complementary family component, a physical education (PE) curriculum, a school foodservice component (Eat Smart), and a program to promote smoke-free school policies. Results from the main trial showed that children from the CATCH intervention schools had lower consumption of fat and saturated fat, and higher levels of self-reported physical activity when compared to those from comparison schools [3]. Furthermore, CATCH children maintained their individual-level results for 3 years (until 8th grade) without further intervention [26]. School-level measures were also significantly changed during the main trial. Physical education classes in intervention schools showed a significantly greater proportion of time spent in moderate to vigorous physical activity than classes in comparison schools [27], and intervention cafeterias offered school meals that were significantly lower in fat and saturated fat compared to comparison schools [3], [28].

The CATCH Institutionalization Study was conducted to determine the level of institutionalization of the CATCH program in former intervention and comparison schools by measuring the extent to which the CATCH school-level goals for levels of moderate to vigorous activity in PE classes and the amount of total and saturated fat in school lunches were achieved, as well as the extent to which CATCH classroom lessons were implemented in the former CATCH intervention and comparison schools. This report describes the institutionalization of the CATCH program 5 years after the end of the main research trial.