Healthy Passages - American Journal of Preventive Medicine

Review and Special Articles

Healthy Passages A Multilevel, Multimethod Longitudinal Study of Adolescent Health Michael Windle, PhD, Jo Anne Grunbaum, EdD, Marc Elliott, PhD, Susan R. Tortolero, PhD, Sandy Berry, MA, Janice Gilliland, PhD, David E. Kanouse, PhD, Guy S. Parcel, PhD, Jan Wallander, PhD, Steve Kelder, PhD, Janet Collins, PhD, Lloyd Kolbe, PhD, Mark Schuster, MD, PhD Purpose:

To provide an overview of a multisite, long-term study that focuses on risk and protective factors, health behaviors (e.g., dietary practices, physical inactivity, tobacco use, and violent activity), and health outcomes (e.g., diabetes, obesity, and sexually transmitted diseases) for a fifth-grade cohort to be followed biennially from ages 10 to 20 years.

Methods:

A two-stage probability sampling procedure was used to select 5250 fifth-grade students from schools in Birmingham AL, Houston TX, and Los Angeles CA to ensure a sufficient sample size of African Americans, Hispanics, and non-Hispanic whites, to support precise statistical inferences. Computer-assisted technology was used to collect data from children and their primary caregivers. Teachers and other school personnel responded to questionnaires, and observational procedures were used to obtain information about schools and neighborhoods.

Results:

To exploit the multilevel, multimethod structure of the data, statistical models include latent-growth mixture modeling, multilevel modeling, time-series analysis, survival analysis, latent transition analysis, and structural equation modeling. Analyses focus both on the co-occurrence and predictors of growth trajectories for different health behaviors across time.

Conclusions: By using a prospective research design and studying the predictors and time course of multiple health behaviors with a multilevel, multimethod assessment protocol, this research project could provide an empirical basis for effective social and educational policies and intervention programs that foster positive health and well-being during both adolescence and adulthood. (Am J Prev Med 2004;27(2):164 –172) © 2004 American Journal of Preventive Medicine

Introduction

M

ost chronic diseases that occur across the life span have their origins in behaviors and associated lifestyle habits established during childhood and adolescence. For instance, cardiovascular disease and many forms of cancer are associated with tobacco use, physical inactivity, and poor dietary habits From the Center for the Advancement of Youth Health, University of Alabama at Birmingham (Windle, Gilliland, Wallander), Birmingham, Alabama; Division of Adolescent and School Health (Grunbaum), and National Center for Chronic Disease Prevention and Health Promotion (Collins), Centers for Disease Control and Prevention, Atlanta, Georgia; RAND Corporation (Elliott, Berry, Kanouse, Schuster), Santa Monica, California; Texas Prevention Research Center, School of Public Health, University of Texas Health Science Center (Tortolero, Parcel, Kelder), Houston, Texas; Sociometrics Corporation (Wallander), Los Altos, California; Department of Applied Health Science, Indiana University (Kolbe), Bloomington, Indiana; Departments of Pediatrics (Schuster), and Health Services (Schuster), University of California at Los Angeles, Los Angeles, California Address correspondence to: Michael Windle, PhD, University of Alabama at Birmingham, 912 Bldg., 1530 3rd Ave. South, Birmingham AL 35294. E-mail: [email protected].

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initiated in childhood.1,2 Similarly, early alcohol and other substance use and risky sexual behaviors may contribute to increased risks for adverse social outcomes (e.g., dropping out of school or encountering legal problems), debilitating psychiatric and substance use disorders, and acute and chronic medical conditions (e.g., human immunodeficiency virus, sexually transmitted diseases, and respiratory illnesses) that have both short- and long-term implications for health and well-being.3,4 Despite substantial increases in intervention activities in recent years, both national and local surveillance studies continue to report an alarming increase among youth in the rates of many health problems, such as obesity,5 as well as the consistent use of high levels of alcohol and other substances.6,7 It is widely recognized among healthcare professionals that health-related behaviors that unfold in adolescence are foreshadowed by experiences in early childhood that occur in the family, at school, and within the community. Nevertheless, relatively little research has been conducted to identify and trace these multiple influ-

Am J Prev Med 2004;27(2) © 2004 American Journal of Preventive Medicine • Published by Elsevier Inc.

0749-3797/04/$–see front matter doi:10.1016/j.amepre.2004.04.007

ences during the preadolescence period, or to examine the importance of racial and ethnic differences in the way these behaviors develop. This paper provides an overview of a multisite study entitled Healthy Passages: a Longitudinal Study of Adolescent Health. Healthy Passages uses a prospective research design that includes biennial assessments of multiple health behaviors and outcomes in a cohort of fifth-grade children followed from ages 10 to 20 years. The study employs a multilevel protocol to assess biological, family, peer, school, and neighborhood/community influences on youths’ health. The overarching objective of Healthy Passages is to provide an empirical basis for effective policies and intervention programs to promote the health and optimal development of adolescents and adults. The study has two major goals. The first goal is the characterization of development trajectories (i.e., patterns of intraindividual change across time) and the relative contribution of important multilevel risk and protective factors (e.g., family, peers, school, and community) on health behaviors (e.g., dietary practices, physical activity, and tobacco use). Social policy decisions based on such an approach may, for example, yield more cost-effective and encompassing interventions that target multiple health behaviors and their outcomes. The second goal is the elucidation of multilevel risk and protective factors that contribute to disparities in health, education, and social outcomes by race/ethnicity, gender, and socioeconomic status.8 –10

Background and Project History Many longitudinal studies, such as the National Longitudinal Study of Adolescent Health,11 National Survey of Family Growth,12 National Longitudinal Survey of Youth,13 and National Educational Longitudinal Study,14 have added greatly to an understanding of the association of risk behaviors and their determinants. These longitudinal studies, however, either do not extend beyond a 2- or 3-year follow-up period or limit their focus to a single risk area or subpopulation. Healthy Passages was designed to advance the research literature on adolescent health in several ways. Healthy Passages provides information on a broad range of outcomes and a comprehensive, multilevel set of predictors of the occurrence, maintenance, and change of health risk behaviors across time. In addition, Healthy Passages includes biennial in-depth assessment over multiple years to characterize the primary influences on adolescent health-risk behaviors and health and education outcomes. In 1999, after a competitive review process, the Centers for Disease Control and Prevention (CDC) funded three sites from the CDC Prevention Research Centers program. The three selected sites include the University of Alabama at Birmingham, University of

California at Los Angeles/RAND Corporation, and University of Texas Health Science Center at Houston. Each funded site signed a cooperative agreement with the CDC to develop a common protocol for use across the sites that would foster the goals of the Healthy Passages project. To accomplish the goals of Healthy Passages, three project phases were established. Phase I consisted of focus groups, cognitive testing, and one-on-one interviews to inform the development of the initial study measures. In addition, during spring 2003, a pilot study of 646 children provided feedback on all study protocols and measures. Phase II, which will begin in fall 2004, will involve the biennial collection of data on a cohort of fifth-grade children at baseline through age 20 years. Phase III, which will begin in fall 2016, will include long-term, periodic follow-up (e.g., every 3 years).

Distinctive Features of Healthy Passages The Healthy Passages cohort consists of 5250 children who were in fifth grade at baseline and are assessed biennially. This study design has several unique and important features. First, because the prevalence of many risk behaviors is low among fifth graders, data collection begins before most risky behaviors are initiated, thereby allowing for the assessment of both the initiation and escalation of those behaviors. Second, data are collected frequently enough to identify the initiation of and changes in risk behaviors (e.g., from nonuse to initiation, and from initiation to high levels of use); critical transitions (e.g., from elementary school to middle school, from prepubescence to puberty); and the multilevel predictors of these transitions. Such detailed information is essential for guiding health, social, and education policies and interventions regarding when to intervene and which behaviors to target. Third, the selection of risk and protective factors for assessment in Healthy Passages is comprehensive, and includes such factors as mental health, parental communication, peer relations, quality of life, physical activity, substance use, sexual behaviors, and violence and injury. Fourth, multiple methods of assessment are used (e.g., ratings from children, primary caregivers, and teachers; official school record data; and observations of school and neighborhood environments), thereby permitting an in-depth examination of school and community influences in conjunction with more traditional individual, family, and peer factors. Finally, the sampling plan provides sufficient statistical power to examine racial/ethnic and socioeconomic factors that may contribute to health disparities among African-American, Hispanic, and white youth.

Conceptual Framework The conceptual framework provided in Figure 1 represents the domains of outcomes and etiologic factors Am J Prev Med 2004;27(2)

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Figure 1. Conceptual framework for Healthy Passages.

investigated in Healthy Passages, and shows the interrelationships among these domains. The examples within each of the domains in Figure 1 are not exhaustive. As the framework demonstrates, genetic, personal, and environmental factors contribute to the occurrence and level of health behaviors, which, in turn, influence health and education outcomes either indirectly, through biological mediators or indicators, or directly, without mediation. For instance, a family history of obesity and poor family and peer role models for eating and physical activity may influence dietary behaviors and physical inactivity, which, in turn, contribute to obesity. Obesity in adolescence and adulthood increases the risks for diabetes, cardiovascular disease, and other medical conditions. Other features of significance in the conceptual framework are that the flow of influences is assumed to be bidirectional, rather than unidirectional, and the processes are dynamic (i.e., changing across time). For example, consistent with the notion of bidirectional influences, not only do family factors and health behaviors contribute to depressive disorders, but also a depressive disorder may contribute to an increase in unhealthy behaviors (e.g., cigarette use and self-medicating substance use) and disturbed family and peer relationships. Likewise, the model posits that genetic and environmental factors may interact or correlate with one another to influence expression of health behaviors and health outcomes. With regard to dynamic relations, interrelationships among domains outlined in Figure 1 are embedded within changing sociohistorical conditions. Hence, the prevalence of health behaviors and outcomes and the interrelationships with 166

other factors may be influenced by major historical events (e.g., wars and economic depression) and secular trends (e.g., increasing availability of drugs or lethal weapons and shifts in family structure).

Goals of Healthy Passages The conceptual framework in Figure 1 illustrates some of the complexities involved in the investigation of adolescent health as it unfolds across the life span. Six specific research goals were prioritized for Healthy Passages. First, biological, behavioral, and environmental factors will be identified that predict the onset, escalation, maintenance, and termination of health behaviors, positive health, resilience, and quality of life. It is important to study factors influencing the developmental course of health behaviors and outcomes, and to study both positive and problematic components of these behaviors.11 Second, the multivariate constellation of intrapersonal, social, and environmental factors that optimally predict health behaviors and outcomes across time will be studied. The multilevel assessment, with the inclusion of biological influences (e.g., pubertal development) and family, peer, school, and neighborhood factors, will provide a rich resource for explaining variation in outcomes. Third, patterns of change (e.g., linear and quadratic) will be identified that best characterize the growth in health behaviors across time. It cannot be assumed that all health behaviors (e.g., dietary practices, substance use, or violence) manifest the same pattern of change from ages 10 to 20 years; intraindividual trajectories will be charted across multiple health behaviors. Fourth, co-

American Journal of Preventive Medicine, Volume 27, Number 2

variation, or co-occurrence, of these distinct trajectories (e.g., for alcohol use, physical inactivity, and dietary practices) will be analyzed across time. Fifth, the biological, behavioral, and environmental factors that predict intra-individual health behavior trajectories across time will be described, and common and unique predictors of these trajectories will be identified (e.g., whether family influences have common or unique effects on increases in alcohol use and sexual activity). Finally, mediating and moderating risk and protective factors related to positive and negative health behaviors and health and educational outcomes across time will be studied.11 The existing literature will be used as a guide to test specified moderator/mediator statistical models. In summary, the specific goals of Healthy Passages are focused on exploiting the enriched data set to address cutting-edge issues for guiding social policy and interventions to improve health.

Methods Study Population The study population includes all fifth-grade students enrolled in public schools with an enrollment of ⱖ25 fifth graders in each of three geographic areas (this represents over 99% of all students enrolled in public schools in each of the three sites). These geographic areas are the catchment areas of (1) 25 contiguous public school districts in Los Angeles County, CA (2) approximately 20 contiguous public school districts in and around Birmingham AL and (3) the largest public school district in Houston TX. Population inferences will be made for each of the three sites and will be compared for consistency. If inferences are consistent across sites, inferences will be made for the combined population of the three sites. Inferences also will be made by gender, socioeconomic status, and race/ethnicity (African American, Hispanic, white), as well as for two-way combinations of subgroups.

Overview of Sampling In each of the three sites, a two-stage probability sampling procedure was employed. In the first stage, schools were randomly selected with probabilities proportionate to a weighted measure of the scarcity (or very low representation) of its students relative to racial/ethnic targets. In the second stage, all fifth-grade students in sampled schools were invited to participate. The small number of students who were not identified as African American, Hispanic, or white were categorized into the category “Other.” During data collection, primary caregivers were asked to describe their child in terms of the ethnic/racial categories in the 2000 U.S. Census. However, for purposes of data analysis, sample sizes for many subgroups were quite small, and racial/ethnic group categories corresponding to the Youth Risk Behavior Surveillance System were used. Participants with more than one primary racial/ethnic group identity were classified as “Other.” These weighted measures helped to ensure sufficient sample size in three racial/ethnic groups (African American, Hispanic, and white) to support precise inferences within these subgroups.

Table 1. Healthy Passages Phase II study participant targets by site and racing/ethnicity Race/ethnicity

Birmingham Houston Los Angeles Total

African American 805 Hispanic 12 White 898 Other 35 Total 1750

497 825 377 51 1750

372 836 399 143 1750

1674 1673 1674 229 5250

Sample Size Table 1 displays the sample targets for each of four racial/ ethnic groups within each of the three sites. Targets were selected to (1) maximize power to compare racial/ethnic groups across sites, (2) maximize power to compare sites for consistency of effects, (3) maximize power to compare patterns across sites within race/ethnicity, and (4) minimize the design effect within sites (loss of statistical power associated with sampling). We anticipated achieving these targets with about 30 to 40 participating schools per site. Assuming 5% annual attrition during the first 2 years and 4% each subsequent year would result in 4987 children retained in 7th grade, 4788 retained in 9th grade, 4596 retained in the 11th grade, and 4412 retained 1 year after twelfth grade.

Accounting for Sample Design in Analyses Simulation-based design weights will be constructed to account for differential probabilities of selection of students according to their school (oversampling of schools with more members of the race/ethnicity strata that are being oversampled at a given site). It is estimated that these weights will have an average design effect (DEFF) of 1.15. Logistic regression models that include school characteristics, gender, and race/ethnicity will be used to test for differential rates of initial participation; if these exist, models will be used to construct nonresponse weights that are estimated to have a DEFF of 1.10. For the longitudinal data, statistical information from earlier waves of the study will be used to construct statistically enriched logistic regression models to test for differential rates of dropout and to construct appropriate attrition weights. It is projected that these weights will inflate the DEFF by 1% annually. Finally, assuming an intraclass correlation coefficient (ICC) of 0.01, a DEFF of 1.74 is anticipated from the clustering of students within schools. All analyses will employ the weights previously discussed and will correct for design effects from weighting (using the linearization method) and from clustering (using the Huber–White method).15

Overview of Analytic Approach These data have a multilevel longitudinal structure, and statistical analyses will include recent advances in quantitative modeling.16,17 Future analysis with these data will include specific hypothesized relations that are informed by the existing literature. However, this level of description is beyond the scope of this paper and discussion is limited to the types of quantitative models to be used. Latent variable mixture modeling and time-series analysis will be used for autocorrelated continuous outcomes (e.g.,

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Table 2. Detectable effect size (standard deviation units) for continuous outcomes Population (pooled across sites) All subjects Either gender One of three largest racial/ ethnic subgroups Either gender of one of the three largest racial/ ethnic subgroups

Less powerdemanding hypotheses

Powerdemanding hypotheses

0.09a 0.13a 0.16b

0.27b 0.39c 0.48d

0.23b

0.67e

a

Very small effects. Small effects. c Small to medium effects. d Medium effects. e Medium to large effects. b

level of physical activity and body weight) and will allow for the specification of both time-lagged effects and subgroups with different growth and correlational structures. Survival analysis will be used to model initiation of states; time of first occurrences; repeat occurrences; and termination of states, such as age at first vaginal intercourse and mortality. Latent transition analysis will be used for staged sequential models, such as staging of pubertal development and gateway models of substance use. Structural equation modeling will be used to test the plausibility of predictive model structures and specific hypotheses that incorporate mediators and moderators.

Statistical Power To provide an overview of the statistical power afforded by Healthy Passages, the minimum detectable effect size attributable to a dichotomous predictor of a continuous outcome (in standard deviation [SD] units) was summarized. Cohen18 characterizes effect sizes of 0.2 SDs as “small,” those of 0.5 SDs as “medium,” and those of 0.8 SDs as “large.” To be conservative, we considered a longitudinal analysis of change in an outcome from age 10 to age 20, using only the sample that is retained until age 20 and considering all design effects previously discussed. Some hypotheses may require more statistical power than others due to less variance in independent variables or (for longitudinal analyses) lower withinsubjects correlation. To capture a range of hypotheses, “power-demanding hypotheses” (25%:75% prevalence split on key independent variable, 0.49 within-subject correlation of outcome from ages 10 to 20, 90% power desired) and “less power-demanding hypotheses” (50%:50% prevalence split on key independent variable, 0.90 within-subject correlation of outcome from ages 10 to 20, 80% power desired) are illustrated. Table 2 illustrates the minimum detectable effect sizes for each type of hypothesis, both overall and for subgroups, for a longitudinal analysis of change from ages 10 to 20 with a continuous outcome, using a two-sided test and a 5% level of significance. As can be seen, small effects can be detected even in gender by racial/ethnic subgroups for less powerdemanding hypotheses. For more power-demanding hypotheses, small effects can be detected overall, and medium effects can be detected within subgroups.

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Measures The measures selected for Healthy Passages provide a comprehensive assessment of adolescent health and behavior across multiple levels of influence, and with data from multiple sources (e.g., survey reports from children, primary caregivers, and teachers; interviewer observations of school and neighborhood environments). Using this approach across time, the resulting multilevel information data will provide a comprehensive portrait of influences on adolescents’ health that can be used as an empirical foundation for the generation of effective social policies and interventions. Table 3 lists selected domains and associated constructs measured in Healthy Passages. The domains correspond to the conceptual framework (Figure 1), and a nonexhaustive listing of constructs or indicators is provided. Across the course of the study, age-appropriate indicators of these domains will be assessed, such as sexual identity in middle adolescence and education attainment and occupation functioning in young adulthood. The CDC has identified six behaviors that place adolescents at higher risk for acute and chronic health conditions that are a major focus for this study: (1) low levels of physical activity, (2) sexual activity, (3) substance use, (4) tobacco use, (5) unhealthy dietary behaviors, and (6) violence and unintentional injuries.7 Undoubtedly, knowledge about the predictors and time course of these behaviors will facilitate the development of more effective intervention strategies and policies to reduce the disease burden. Healthy Passages also focuses on the leading causes of death among 5- to 24-year-olds, which include unintentional injuries, homicides, and suicides.19 Behaviors that contribute to these leading causes of death among youth and young adults include not using seat belts while riding in or driving motor vehicles, not wearing helmets while bicycling, drinking and driving, carrying weapons, physical fighting, and suicide attempts. Healthy Passages will investigate sexual risk behaviors that contribute to substantial morbidity and social problems and that result in early and unwanted pregnancies and sexually transmitted diseases. Education outcomes, including academic achievement, education attainment, and school dropout, will also be studied. Education attainment is a powerful determinant of both adult life experience20 and adult mortality.21 Although some researchers suggest that adolescent health and education status are closely linked through biological and behavioral factors,22 few prospective studies have investigated this hypothesis; Healthy Passages will be valuable for studying these interrelationships. A description of some of the specific measures for the fifth-grade (baseline) assessment is provided in Table 4, along with the data source. Sociodemographic factors


Table 3. Overview of measurement domains assessed in Healthy Passages Domains Genetic factors Family history Personal factors Health history Temperament Self-competence Ethnic identity Multilevel environmental factors Family Peer School Neighborhood Media Health behaviors Tobacco, alcohol and other substance use Injuries and violence Sexual behavior Dietary behavior Physical activity Educational attainment Biological indicators Height and weight Outcomes Quality of life Mental health Diseases and disorders

Sample constructs or indicators Psychiatric and substance abuse disorders, medical conditions Low birth weight, prenatal exposure to toxins, childhood disease Activity level, distractibility, behavioral flexibility Perceptions of cognitive and social competence Perceived strength of identity, language, and cultural activities Family cohesion, parental monitoring, nurturance, and communication Quality of peer relationships, involvement with deviant peers School connectedness, school program availability, school involvement Availability of services for children, community ties and connectedness Time spent on music, video, Internet, and video games, TV content, TV co-viewing Age of onset, frequency, intensity, acquisition Bullying, overt and relational aggression, victimization, injuries Predating behaviors, sexual activity, condom use Dietary intake, marker foods, supplement use Types, frequency, duration, inactivity Highest grade levels, grade point average, achievement awards Body mass index, obesity Physical, emotional, social, and school functioning Positive and negative affect, behavioral and emotional problems Obesity, diabetes, homicide, suicide, sexually transmitted diseases, psychiatric disorders

(e.g., parental education, income, housing density, immigration status, healthcare access and utilization) were also collected to facilitate comparisons with other studies and to evaluate the generalizability of the findings. Standardized measures were used when feasible, and efforts were made to select survey items and measures that could be compared with national data. Because of age-related constraints on the cognitive abilities and knowledge base of fifth graders, primary caregivers provided more extensive information on sociodemographic characteristics (e.g., family structure, sources of income, migration and residential mobility, and insurance coverage), child health history (e.g., diseases, learning disabilities, and current prescription use or therapy), and health service utilization (e.g., school, outpatient, and inpatient health services), in addition to rating a child’s mental health and social competence. Observation procedures measure features of the school environment (e.g., food options in vending machines) and the neighborhood social and environmental climate.35 School climate and availability of school health services are measured using survey items from the School Health Policies and Programs Study.32 The administration schedule for these measures is initially to collect anthropometric data followed by personal interview data both for primary caregivers and children. More sensitive information (e.g., income)

collected via personal interview was asked toward the latter part of the interview to facilitate the establishment of interviewer rapport and subject trust. The most sensitive data (e.g., child substance use and delinquency) were measured via the audio computer-assisted personal interview (CAPI) method after the personal interview.

Methodology The distinctive features and broad scope of Healthy Passages present both challenges and opportunities for data collection. To address the challenges, qualitative studies were conducted during Phase I to evaluate the appropriateness of language (e.g., readability and comprehension across subgroups) and the general acceptability of field procedures (e.g., anthropometric measurement and sensitive topics) and the introductory materials (e.g., brochures, incentive materials, and informed-consent materials). Three types of qualitative studies were used to collect this information: (1) focus groups with fifth graders and their primary caregivers; (2) open-ended, semistructured interviews with primary caregivers in order to understand parental concerns about proposed questions on child self-reported sexual activity; and (3) cognitive interviews. All Phase I studies were approved by both the CDC and each study site’s institutional review board (IRB). Based on the design requirements and results of the qualitative and quantitative studies, the following materials


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Table 4. Overview of selected baseline measures and data sources, by construct Constructs

Measure (reference)

Data source

Items adapted from NHIS23 and YRBS7 Dimensions of Temperament Scale24,25 Social Skills Rating System, Child and Parent subscales26

Caregiver Caregiver Child and caregiver

Family Adaptability and Cohesion Evaluation Scales (FACES III), Cohesion Scale27 Items adapted from several sources28–30 Items adapted from several sources11,31

Caregiver

Items adapted from School Health Policies and Programs Study32 Newly developed Newly developed

School administrators

Items adapted from YRBS7 and NYTS33 Items adapted from YRBS7, NYTS33, and MTF6 Items adapted from YRBS7

Child Child

Items adapted from MTF6 and NHSDA34

Child

Items adapted from YRBS7

Child

Items from Los Angeles Family and Neighborhood Survey (LAFANS)35 Items from LAFANS and Chicago Neighborhood Survey36

Interviewer observation

Child

Mental health

Pediatric Quality of Life Inventory (PedsQL)37 Positive and Negative Affect Schedule-Child (PANAS-C)38, and Strengths and Difficulties Questionnaire39,40

School achievement

GPA; Stanford 9 test scores

Personal factors Child health history Temperament Self-emotional competence Multilevel environmental factors Family cohesion Friendships and quality of friendships School context: characteristics, environment, child connectedness School climate and availability of school health services Teacher evaluation of student behavior School and vending machine observation Health behaviors Tobacco use and history Tobacco use: intentions, expectancies, motives, offers, and availability Alcohol and other substance use: history Alcohol and other substance use: intentions, expectancies, motives, offers, and availability Violence exposure, aggression and delinquent behaviors Neighborhood observation Community connectedness Outcomes Quality of life

Child Child

Teacher Interviewer observation

Child

Caregiver

Child Caregiver School records

GPA, grade point average; MTF, Monitoring the Future Surveys; NHIS, National Household Interview Survey; NYTS, National Youth Tobacco Survey; NHSDA, National Household Survey on Drug Abuse; YRBS, Youth Risk Behavior Survey.

were developed: standardized data collection protocols, interviewer training protocol and materials, and quality control procedures. Participant self-report data were collected by means of CAPI and audio computer-assisted self-interview (A-CASI) systems for both the child and his or her primary caregiver. Based on prior research,41 questions focusing on sensitive topics, such as drug use, familial conflict, and sexual behaviors, were included in the A-CASI to increase the validity of reporting. To standardize the data collection processes across the three sites, detailed job qualifications and job descriptions for field staff were developed. A training of trainers (TOT) model was adopted as the most effective and cost-efficient method for implementing standardized training of all field interviewers. Standardized training protocols, training manuals, field manuals, and validation procedures for the study were developed and used across all three sites. Field interviewer training consisted of 60 hours of instruction, plus additional hours of practice in interviewing, neighborhood

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observation, and anthropometrics. Field interviewers were required to meet pre-established standards and undergo a final 2-hour pass–fail certification process to demonstrate that they had acquired the necessary skills to conduct the interviews. Included in the standardized training were components related to subject informed consent, confidentiality of data, and risk management. IRB approval for Phase II of the study was obtained from the CDC and from IRBs at each of the participating sites. A federal certificate of confidentiality was also obtained to further protect the confidentiality of the data. Within the informed consent form, subject rights were provided (e.g., confidentiality of data, rights to refuse to answer questions and to withdraw from the study), as were statements indicating that interviewers are required by law to report to the state if they learn that the child is being abused or that he/she plans to hurt himself/herself or someone else. Field supervisors and interviewers were trained in risk management procedures including calling 911 for immediate


emergencies and the completion and appropriate distribution of incident reports for critical events. In addition, the informed consent forms indicated that data collected on individual children would not be available to parents, but that aggregate findings across children would be provided in newsletters and research reports. Monetary incentives were provided for all participants in this study (e.g., $50 for primary caregivers and a $20 gift card for children). Informed consent will be obtained at each subsequent wave to cover new measures that will be added to the protocol. The pilot study provided the opportunity to evaluate the multiple components of the research protocol, including process evaluation of the field procedures. Process evaluation data included weekly reports on recruitment and enrollment to determine response rates and nonresponse patterns in schools and households, interview completion rates, field staff concerns, and implementation of other data collection activities. These results were used to modify the research procedures prior to implementation of Phase II. For Phase II, maintenance of the sample across time will include efforts to track participants by maintaining current addresses (e.g., by having periodic mail contact, by identifying significant others who know of address changes) and by engaging in activities to foster commitment to the project, such as newsletters and small gifts (e.g., pens/pencils with Healthy Passages inscribed).

Discussion Healthy Passages builds on previous cross-sectional and longitudinal research to address significant issues in social development and health promotion among youth in an effort to assist in the development of health policies and programs. This study will advance the science in several ways by simultaneously focusing on multiple health behaviors (e.g., dietary practices, injurious behaviors, physical activity, and substance use), measuring multilevel determinants of health behaviors and outcomes, employing multiple methods of assessment, using multiple waves of data, and selecting a diverse sample with regard to race/ethnicity, gender, and socioeconomic status in order to facilitate the testing of important hypotheses. Healthy Passages will inform social and education policies and intervention programs in numerous ways. For example, tracking the onset, escalation, and trajectories of various health behaviors (e.g., aggression, physical activity, and tobacco use) across gender and racial/ethnic groups will facilitate the identification of when optimal intervention should be made and with whom. By repeatedly assessing the multiple levels of influence (i.e., family, peer, school, and neighborhood) and multiple determinants of health outcomes, guidelines may be provided as to where (physical location) efforts should be focused and what specific behaviors might be targeted for interventions. In addition, by investigating the co-occurrence of changes in health behaviors and health outcomes across time, more cost-effective interventions may be developed that are targeted on multiple, rather than single, outcomes.

Collectively, these efforts will contribute to the identification of key targets for multilevel, multicomponent interventions that will likely be more effective in producing more comprehensive and sustained behavioral change among youth than many existing single-level, single-component interventions. Data from Healthy Passages will be analyzed and findings disseminated at baseline and after each subsequent wave of data collection. Thus, policy and intervention implications can be assessed during key shortterm transitions (e.g., from elementary school to middle/junior high school, from high school to college or full-time employment), as well as across the long term (e.g., the effect of parental communication at baseline on positive health and education outcomes). The three sites selected for this study are from urban settings; thus, there are some constraints in generalizing the findings and policy implications to rural settings. Nevertheless, using this rich corpus of data to study specific hypotheses about key predictors of changes in health behaviors and outcomes across time, Healthy Passages is well positioned to achieve its overarching objective to provide an empirical basis for effective policies and intervention programs that foster positive health and well-being in adolescence and adulthood. This research was supported by the Centers for Disease Control and Prevention (Cooperative Agreements CCU409679, CCU609653, and CCU915773).

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