The Effect of Cardiovascular Health Promotion on

Health Behaviors in Elementary School Children:

An Integrative Review

Suzanne O. Nicholson, RN, BSN

This report provides on an integrative review of health promotion studies relevant to elementary school children published
between 1986 and 1998. The 22 research articles represented several disciplines including public health and nursing. The
studies varied in research design, sample characteristics, and approaches to health education. The most common interventions
targeted behavioral risk factors for cardiovascular disease, but it also was evident from the literature that family and community
involvement both played a significant role in health behaviors of children. Health promotion studies were under-represented in
the nursing literature, a gap that creates an impetus to study children and families to identify the ways they learn primary
preventive behaviors.
Copyright r 2000 by W.B. Saunders Company

U NHEALTHFUL lifestyle behaviors such as

physical inactivity, poor eating habits, to-
bacco use, and substance abuse including alcohol
and other drugs, are the leading causes of prema-
ture mortality in adults (Centers for Disease Con-
trol and Prevention [CDC], 1997). These health
behaviors cause many long-term problems such as
heart disease, hypertension, diabetes, cancer, and
accidental death (Felton et al., 1998). Heart disease
continues as the leading cause of death in the
United States according to the American Heart
Association (Shively & Pearce, 1998). Factors such
as age, education, gender, family history, socioeco-
nomic status, knowledge, attitudes, and values
potentially influence health behaviors (Petersen-
Martin & Cottrell, 1987).
People make lifestyle choices and partly deter-
mine their own risks for disease or injury; positive
health behaviors are reflected in health status and
longevity (Blomquist, 1986). It is essential, there-
fore, to recognize the link between health problems
in adults and health behaviors in childhood. Recog-
nition of this connection has provided the impetus
for creation of health promotion programs for
children (Quine, Stephenson, Macaskill, & Pierce,
1992).
One of our nation’s greatest priorities should be
the health and well being of children (Velsor-
Friedrich, 1991), and society should not let pro-
grams for the promotion of children’s health be
eliminated (Nelms, 1995). Because behaviors form
during childhood, promoting prevention strategies
is easier than intervention once unhealthful behav-
iors are established (US Department of Health and
Human Services, 1991). Current health behaviors
in American children showed the need for preven-
tion of heart disease in childhood (Howard, Bin-
dler, Synoground, & VanGemert, 1996). For ex-
ample, eating patterns show excess saturated and
total fat intake, experimentation with smoking
begins as early as third grade, and children are less
physically active (Howard et al., 1996).
Several researchers have found that health promo-
tion programs must be provided to children before
certain behavior patterns solidify (Howard et al.,
1996; Perry et al., 1990). For instance, it has been
shown that early drug use is associated with later
problem use of drugs (D’Elio, Mundt, Bush, &
Iannotti, 1993). Hansen, Johnson, Flay, Graham, &
Sobel (1988) stated that prevention of the initial
onset of substance abuse appears to decrease health
costs and social costs. With regard to heart disease,
many children possess one or more clinical risk
factors and also have shown clustering of risk
factors typically seen in adults (Downey et al.,
1988). Atherosclerosis may start early in life (Perry
et al., 1990) and school-age children are at an
From Northern Illinois University, IL.
Address reprint requests to Suzanne O. Nicholson, RN, BSN,
334 Taubert Ave, Batavia, IL 60510.
E-mail: ksanich@chicagonet.net
Copyright r 2000 by W.B. Saunders Company
0882-5963/00/1506-0001$10.00/0
doi:10.1053/jpdn.2000.16710

Journal of Pediatric Nursing, Vol 15, No 6 (December), 2000 343

344
appropriate stage of development for cardiovascu-
lar risk prevention behaviors.
Nelms (1995) stated that everyone is aware of
the importance of education and guidance in preven-
tion of future health care problems. Evidence of
learning about healthful choices has been shown in
elementary school children and it has been sug-
gested that success depends on the design of the
program and delivery of health messages (Whit-
ener, Cox, & Maglich, 1998). If our society recog-
nizes the necessity of primary prevention in elemen-
tary school children, the question then becomes:
What is the most effective way to promote chil-
dren’s health? Traditionally, schools are considered
to be the most logical arena to provide health
education.
STATEMENT OF THE PROBLEM
Health promotion programs conducted in schools
and communities geared for children in grades
three through 10 have shown wide variation in
content and format (Howard et al., 1996). There
does not appear to be a basic model for health
promotion in children and many programs have
focused on imparting knowledge, but met with
little long-term success. Smoking prevention pro-
grams, for example, yielded poor results in the
1970s and 1980s, possibly caused by lack of
intensity for high-risk groups (Glynn, 1989). Brief
programs also have been viewed as inadequate.
Recent programs combining learning opportunities
that bolster self-esteem and decision-making skills
have met with greater success (Quine et al., 1992).
It is important to note that self-efficacy, as reported
in an integrative review, was the strongest determi-
nant of health promotion behavior in children and
adults (Gillis, 1993). Surprisingly, few studies have
attempted to counter the notion that health educa-
tion belongs exclusively to schools, although posi-
tive learning outcomes and retention of health
habits have been shown in programs that encour-
aged parental/family involvement (Howard et al.,
1996).
Family-focused research on primary prevention
has mainly targeted medical interventions such as
immunizations and physical examinations (Duffy,
1986). Also, because two-parent families are no
longer the norm and more than half of all children
who live in female-headed households are poor
(Velsor-Friedrich, 1991), national strategies now
consider the implications of variation in family
structure. Because the community can play a
critical role in national health reform (Poole, 1997)
and family health promotion is considered a vital
SUZANNE O. NICHOLSON
component of primary health care (Ford-Gilboe,
1997), it is reasonable to assume that the influences
of family and the community on children are
present in the literature. But, few studies have
focused on the family’s role in promoting health in
the impressionable school-age group.
The family’s role in promoting health includes
behaviors such as modeling. According to Blom-
quist (1986), modeling can have an effect on the
way children think, feel, and act. For example,
negative parental behaviors such as smoking have
been shown to influence children’s long-term risks
of having ‘‘lifestyle diseases’’ (Burke et al., 1998).
Each family also has its own patterns of problem-
solving and decision-making that impact health
behaviors (Perry et al., 1997), and family cohesion
has been found to be the most essential element for
successful ‘‘health work’’ (Ford-Gilboe, 1997). A
holistic approach to health education for children is
preferred as parents can reinforce health messages
delivered through school programs or mass media
(Perry et al., 1989). Parents help to establish and
maintain health behaviors in young children through
teaching and role modeling. Likewise, children can
influence the environment and the behavior of
adults. (Gans, Bain, Plotkin, Lasater, & Carleton,
1994).
The purpose of this integrative review is to
present, analyze, and synthesize the research con-
ducted over the past 15 years that represents the
outcomes of cardiovascular health promotion prac-
tices and programs for elementary school children
and determine if any have shown practical value.
Studies that produced positive results could be used
as models for delivery of future programs or
provide an impetus for change.
The significance of the problem in nursing
practice is clear. The study of cardiovascular health
promotion in adults has its place, but physically,
socially, and economically speaking, beginning the
process with children has greater potential for
long-term benefits. The outcomes of primary pre-
vention strategies and interventions will be re-
flected in the health status of future generations and
nurses need to play a key role in the delivery of
positive and accurate health messages.
DEFINITIONS
For the purpose of this review, the concept of
health promotion is limited to cardiovascular risk
factor reduction behaviors in children and is guided
by Pender’s (1996) health promotion model, which
is derived from social learning theory. Health
promotion focuses on increasing the well being of a
HEALTH PROMOTION
person or group, in this case, a child or a classroom
of children. Health promotion behaviors are af-
fected by both direct and indirect factors. Cognitive/
perceptual factors include perception of health
status, and perceived benefits and barriers to health
promoting behaviors. Modifying factors include
interpersonal influences, behavioral, and situ-
ational factors (Pender, 1996). The terms primary
prevention or disease prevention, often used inter-
changeably with the term health promotion, can be
viewed as components of the more comprehensive
concept of health promotion.
Health promotion practices and health promo-
tion programs are important concepts to define, as
they are broad and universally applicable to each
study in this integrative review. Health promotion
practices include behaviors such as regular exer-
cise, decreased consumption of fat, calories, and
sodium, maintenance of ideal body weight, absti-
nence from smoking and drug use, and use of
coping and relaxation skills. Behaviors are influ-
enced by environmental factors including family,
the community, health care professionals, the me-
dia, teachers, and peers. Personal variables includ-
ing health knowledge, attitudes, beliefs, percep-
tions, values, self-esteem and motivation, interact
with environmental influences to affect health be-
haviors.
Health promotion programs for children have
been conducted in schools and in the community
with the purpose of altering or maintaining certain
health practices. Programs provide health educa-
tion and interventions with emphasis on cardiovas-
cular risk reduction in general or they target a
single behavior such as smoking. Intervention
strategies focus on health behaviors, personal fac-
tors, and/or environmental factors.
SCOPE OF REVIEW
The literature source for this review included
studies that focused on process and structure of
care outcomes for health promotion in children that
were published between 1986 and 1998. Published
research cited in this review was obtained primarily
from on-line computer searches that included Cu-
mulative Index in Nursing and Allied Health Litera-
ture, MEDLINE, and Medscape. Because of nurs-
ing’s recent entrance into children’s health
promotion research, and a limited number of avail-
able studies, inclusion criteria were broad concern-
ing relevance to the topic. Criteria for exclusion of
studies included non-research program reviews,
unavailable journals, doctoral dissertations, and
duplicate studies.
345
OVERVIEW
Twenty-two published research papers were in-
cluded in this integrative review. The most fre-
quently utilized source was Health Education Quar-
terly (27%), followed by the Journal of School
Health (23%), Research in Health and Nursing
(14%), and Preventive Medicine (9%). The major-
ity of articles (72%) represented the medical,
public health, and health education fields with
emphasis on physical, behavioral, and learning
outcomes with some attention to social and per-
sonal factors that influence preventive health behav-
iors. Nursing research (23%) focused on identifica-
tion of cardiovascular risk factors, family roles in
health behavior, and identification of preventive
behaviors. Quantitative research designs (77%)
dominated the reviewed articles. Designs were
appropriate for the subject, provided a means to
examine questions and hypotheses, and threats to
validity were minimized with quasi-experimental
and longitudinal designs. (See Table 1 for a sum-
mary of studies.)
RESULTS
This section of the review includes a discussion
of theoretical frameworks used for the studies,
problems studied, sample characteristics, data col-
lection methods, conceptualization of problems
and findings of the studies, state of the art, and gaps
in the literature.
Theoretical Frameworks
Social learning theory has been used extensively
to guide research. The theory purports that indi-
vidual, behavioral, and environmental factors inter-
relate to affect behavior changes. Self-efficacy is
central to the theory and is joined with the pro-
cesses of experiential learning, goal-setting, self-
monitoring, modeling, behavior rehearsal, and rein-
forcement (Lytle & Achterberg, 1995). Eight studies
in this review used social learning theory (Arbeit et
al., 1992; Bush et al., 1989; Nader et al., 1989;
Parcel, Simons-Morton, O’Hara, Baranowski, &
Wilson, 1989; Perry et al., 1989; Perry et al., 1997;
Petchers, Hirsch, & Bloch, 1987; Walter, 1989).
Similar frameworks were used in three other stud-
ies, namely Bandura’s social cognitive theory (Fer-
guson, Yesalis, Pomrehn, & Kirkpatrick, 1989) and
social influences model, which is derived from the
social learning theory (Hansen et al., 1988; Kelder,
Perry, & Klepp, 1993). The PRECEDE health
education planning model was used in three studies
(Arbeit et al., 1992; Bush et al., 1989; Walter,
1989). It stresses the importance of targeting predis-
346 SUZANNE O. NICHOLSON

Table 1. Characteristics of Health Promotion Studies

Research Problem/ Data Collection
Study Design Variable Sample Methods Findings

Arbeit et al. (1992) Quasi-experimental Three predisposing Convenience, Physiologic measure- 4th-graders–higher
and longitudinal cardiovascular risk n ⫽ 530 4th- and ment, self-reports, knowledge gains;
factors targeted; 5th-graders (4 fitness levels, and 5th-graders–de-
outcomes of Heart schools) food analysis crease in BP and
Smart run/walk time
Bush et al. (1989) Quasi-experimental Increased hypertension Convenience, Physiologic measure- Positive changes in BP,
and longitudinal in blacks; program n ⫽ 1,041 4th- to ment including HDL, serum thiocy-
evaluation (Know 6th-graders; Afri- American Health nate, and fitness
Your Body) can-American Foundation health (long- and short-
screening, question- term)
naires, and dietary
recall
Cella et al. (1992) Quasi-experimental Culture-specific Convenience, Questionnaires, Rap contest method
medium; impact of n ⫽ 309, majority smoking attitudes, well-received; small
health messages on African-American and behavior scale assemblies more
minorities 6th- and 7th- derived from Botvin’s effective; no signifi-
graders life skills training cant changes in atti-
program (1985) tudes
D’Elio et al. (1993) Epidemiologic Positive health behav- Convenience, n ⫽ 303 Physiologic measure- Conflicting results; inte-
iors and substance African-American ment, Self-Report grated health pro-
abuse; studies lim- 5th-graders (with Health Behavior motion intervention
ited to adolescents family involvement) Scale, interviews, ineffective for urban
and adults surveys, fitness test African-Americans
Duffy (1986) Qualitative Primary preventive Convenience, Interviews, health Positive relationship
behaviors and bar- n ⫽ 228, 59 fami- diary, card sort between family’s
riers lies of children ability to change
⬍18 yr and grow and prac-
tice of primary pre-
ventive behaviors
Felton et al. (1998) Exploratory and longi- Health risk behaviors– Convenience, Physiologic measure- High prevalence of
tudinal single and concur- n ⫽ 352 5th- and ment, Previous Day obesity (greater in
rent; relationships 6th-graders (5 Physical Activity boys) linked to
between behaviors schools) Recall (Weston, physical inactivity
and social-psycho- Petosa, & Pate, and dietary prac-
logic risk factors 1997), School Youth tices; boys transition
Risk Behavior Survey into adult negative
(Kann, 1993) behaviors earlier
than girls
Ferguson et al. (1989) Exploratory Self-esteem, attitudes Convenience, n ⫽ 603 Survey, including Perceived benefits of
toward exercise and 6th- to 8th-graders modified (from exercise, attitudes,
relation to exercise Dielman et al., self-esteem, and
behavior 1984) Self-Esteem gender all significant
Index predictors of exer-
cise intent
Ford-Gilboe (1997) Exploratory Family characteristics Convenience, n ⫽ 138 Scales include FACES Family cohesion is an
and health practices families of 10- to III, FSS (Olson et al., important predictor
14-year olds 1985), FEM (Smith of health potential
et al., 1975), IHLCS and health work
(Watson et al.,
1978), GSE (Sherer
et al., 1972),
PRQ85-Part 2
(Brandt et al.,
1981), FSSI (Fink,
1993), HOS–devel-
oped as a measure
of Allen’s (1986)
health work
HEALTH PROMOTION 347

Table 1. Characteristics of Health Promotion Studies (Cont’d)

Research Problem/ Data Collection
Study Design Variable Sample Methods Findings

Hansen et al. (1988) Quasi-experimental Lack of emphasis on Convenience, Questionnaires, physi- Resistance training
and longitudinal behavioral out- n ⫽ 2,863 7th- ologic measurement, effective; decrease
comes, social influ- graders (44 schools) Minnesota Smoking onset of tobacco,
ences, and coping Index alcohol, and mari-
skills juana
Howard et al. (1996) Quasi-experimental Problem with program Convenience, n ⫽ 98 Questionnaires include Short-term knowledge
and longitudinal variation; outcomes 4th- to 6th-graders Self-Reported Health gains; long-term
of cardiovascular Habits, Diet Habit exercise; positive
risk reduction pro- Survey (Connor & change in BP and
gram Connor, 1986), HDL
CAFT fitness test,
physiologic mea-
sures, knowledge
tests
Kelder et al. (1993) Epidemiologic and Physical activity out- Convenience, Questionnaires, Increased physical
longitudinal comes; school and n ⫽ 2,376 6th- annual surveys activity for females
community involve- grade and up (13 in the intervention
ment schools and 3 com- group throughout
munities) follow up
McIntyre et al. (1996) Quasi-experimental Problem: limited time Convenience, n ⬃ 900 Questionnaires, inter- Failure to implement
and longitudinal; and resources for 4th- to 6th-graders views, physiologic intervention; pro-
qualitative arm health education; (19 schools) measurement gram well-received
outcomes of Coordi-
nated Approach
Murphy et al. (1994) Descriptive Evaluation of nutrition Random selection, Survey, interviews Results varied across
knowledge, atti- n ⫽ 270 5th-, 8th-, grade level; children
tudes, and practices and 11th-graders were motivated to
learn and preferred
active involvement
Nader et al. (1989) Quasi-experimental CVD risk factors; Convenience, Questionnaire, self- Increased knowledge
and longitudinal family as a vehicle n ⫽ 623; 206 fami- report logs, physi- and positive
for change lies of 4th- and 5th- ologic measurement, behavior change;
graders direct observation parent involvement
effective
Parcel et al. (1989) Quasi-experimental Need to foster healthful Convenience, Interviews, question- Statistically significant
and longitudinal diet and exercise; n ⫽ 300-400 3rd- naires include changes for diet,
outcomes of Go For and 4th-graders (4 Dietary Behavior self-efficacy, and
Health schools) Capability (adapted knowledge
from Perry, 1985),
Food Behavior Con-
sumption (based on
Baranowski, 1986)
Perry et al. (1989) Epidemiologic and Outcomes of school- Convenience, Physiologic measure- Home-based program-
longitudinal based vs. home- n ⫽ 2,250 3rd- ment, dietary recall, –more behavior
based health educa- graders (31 schools) food shelf inventory, changes (e.g.,
tion program interviews reduced fat con-
sumption)
Perry et al. (1997) Epidemiologic and Outcomes of combined Convenience, n ⫽ 96 Interviews, score Positive changes in
longitudinal school and home- schools in 4 states cards, physiologic cardiovascular
based interventions measurement health behaviors,
school food service,
and physical educa-
tion
Petchers et al. (1987) Quasi-experimental CVD risk factors; out- Convenience, n ⫽ 647 Questionnaire, Health No parental effects on
comes of Heart 6th-graders and Knowledge Scale, student’s knowledge
Health Curriculum n ⫽ 322 parents attitude scale, health or behavior; positive
(26 schools) activity log attitudes for diet only
348 SUZANNE O. NICHOLSON

Table 1. Characteristics of Health Promotion Studies (Cont’d)

Research Problem/ Data Collection
Study Design Variable Sample Methods Findings

Purath et al. (1995) Exploratory Cardiovascular risk Convenience, Physiologic measure- Significant relation-
factors; relation to n ⫽ 357 1st- to ment, questionnaire, ships between exer-
family history and 5th-graders fitness tests cise patterns of
risk behaviors mother and child
and between choles-
terol and exercise
Quine et al. (1992) Descriptive Effectiveness of LEC on Convenience, Questionnaire and Attendance at LEC was
drug awareness; n ⫽ 2,336 5th- and state-wide survey a predictor of drug
enjoyment of LEC, 6th-graders knowledge, but not
sociodemographic of intent to use
differences
Tudor-Smith et al. Descriptive Effect of LEC on stu- Convenience, Questionnaire No improvement in
(1995) dents’ knowledge, n ⫽ 339 10- and students’ ability to
beliefs, and behav- 11-year-olds choose a healthy
iors (e.g., substance course of action;
abuse) program well liked
Walter (1989) Quasi-experimental CVD risk factors; pro- Convenience, Physiologic measure- Decreased total choles-
and longitudinal gram evaluation n ⫽ 3,388 4th- ment, dietary recall, terol and smoking
(Know Your Body) grade students (22 interviews, question-
schools) naires

Abbreviations: BP, blood pressure; HDL, high-density lipoprotein; FACES, Family Adaptibility and Cohesion Evaluation Scale; FSS, Family Strengths
Scale; IHLCS, Internal Health Locus of Control Scale; GSE, General Self-Efficacy; FSSI, Family Social Support Index; CAFT, Canadian Aerobic Fitness
Test; CVD, Cardiovascular disease; LEC, Life Education Centres.

posing, enabling, and reinforcing factors to succeed Sample Characteristics

with school-based health education programs. It
also recognizes the effects of modeling by parents,
teachers, and the community. The health belief
model (Walter, 1989), the Kolbe model (McIntyre
et al., 1996), the development of health model
(Ford-Gilboe, 1997), and the American Heart Asso-
ciation model of health promotion (Howard et al.,
1996) were also used.
Problems/Variables Studied
All of the researchers in these studies stated a
purpose or problem and provided a literature re-
view, but only half stated a hypothesis or research
question. The most frequently addressed problems
included inadequate diet and exercise in school-
aged children and lack of knowledge regarding
cardiovascular risk factors (Arbeit et al., 1992;
Bush et al., 1989; Felton et al., 1998; Howard et al.,
1996; Nader et al., 1989; Parcel et al., 1989;
Petchers et al., 1987; Purath, Lansinger, & Ragheb,
1995; Walter, 1989). (Refer to Table 1 for a
complete listing.) A common purpose for most of
these studies was to test the effectiveness of
interventions aimed at modifying health behaviors
or to examine variables or relationships among
them that affect health choices. Variables included
cardiovascular risk factors, physiologic measures,
health behaviors and attitudes, self-concept and
self-esteem, coping skills, and outcomes of interven-
tions.
The subjects were elementary-aged children rang-
ing in grade level from one to eight, with fifth-
graders being evaluated most often (14 studies).
Three of these studies (Duffy, 1986; Kelder et al.,
1993; Murphy, Youatt, Hoerr, Sawyer, & Andrews,
1994) also used adolescent or parent subjects either
as part of their study or for follow-up. Among the
22 studies, sample size was defined three different
ways: number of subjects, number of families, and
number of schools. The number of actual subjects
ranged from 98 (Howard et al., 1996) to 3,388
(Walter, 1989). Power analysis was not discussed in
any of the studies. It is not known if all the samples
were sufficient to avoid Type II errors, but the
majority of samples were large.
Thirteen studies provided information on ethnic-
ity of subjects. African-Americans and Caucasians
were studied almost equally overall. One study
compared Caucasians to African-Americans using
two separate homogenous samples (Walter, 1989),
while others showed less diversity. Asian-Ameri-
cans and American Indians were under-represented
at less than 10% of the samples (see Table 2).
Socioeconomic class varied with predominantly
middle-class subjects represented. The majority of
studies addressed gender of participants and the
distribution of males and females was equal over-
all. Study locations varied from major regions of
the United States to Canada and Australia.
HEALTH PROMOTION
Table 2. Ethnicity of Subjects (Reported in 13 Studies)
Study African-American
Arbeit et al. (1992) 32%
Bush et al. (1989) 100%
Cella et al. (1992) 57%
D’Elio et al. (1993) 100%
Felton et al. (1998) 72%
Ferguson et al. (1989)
Hansen et al. (1988) 30.5%
Nader et al. (1989)
Parcel et al. (1989) 66%
Perry et al. (1989)
Petchers et al. (1987) 5.8%
Purath et al. (1995) 4.3%
Walter (1989) 48.9%
Samples in this review were entirely samples of
convenience, with the exception of one descriptive
study that obtained subjects through random sam-
pling (Murphy et al., 1994). In half of the studies
subjects/classrooms were randomly assigned to an
experimental or control group (Arbeit et al., 1992;
Bush et al., 1989; Cella, Tulsky, Sarafian, Thomas,
& Thomas, 1992; Hansen et al., 1988; Howard et
al., 1996; McIntyre et al., 1996; Nader et al., 1989;
Perry et al., 1989; Perry et al., 1997; Petchers et al.,
1987; Walter, 1989). Regarding the rights of human
subjects, parental consent for children to participate
in these studies was only reported in 45% of the
studies and all but five (Felton et al., 1998; Hansen
et al., 1988; Nader et al., 1989; Perry et al., 1989;
Perry et al., 1997) of the 11 researchers who
collected physiologic data from laboratory tests
were among those that reported consent proce-
dures.
Data Collection Methods
The most commonly used instrument in the
collection of data was a questionnaire which was
used in all but three studies (Arbeit et al., 1992;
Duffy, 1986; Perry et al., 1989). Only nine research-
ers referred to by name or named the questionnaire
that was created for the study (Cella et al., 1992;
D’Elio et al., 1993; Felton et al., 1998; Ferguson et
al., 1989; Ford-Gilboe et al., 1997; Hansen et al.,
1988; Howard et al., 1996; Parcel et al., 1989;
Petchers et al., 1987). (See Table 1 for a detailed
listing.) The most frequently evaluated variables on
the questionnaires were health behaviors and health
knowledge, including human physiology and pre-
vention of coronary artery disease.
The next most common method of data collec-
tion, physiologic measurement, was used in 54% of
the studies (Arbeit et al., 1992; Bush et al., 1989;
D’Elio et al., 1993; Felton et al., 1998; Hansen et
al., 1988; Howard et al., 1996; McIntyre et al.,
349
Caucasian Hispanic Asian Other/Unknown
58% 2% ⬃10%
19% 24%
28%
majority
21.7% 38.4% 5.8% 3.6%
26% 46% 28%
34%
predominant
92.1% 2.1%
90.1% 3.4% 2.2%
24.6% 23.2% 3.3%
1996; Nader et al., 1989; Perry et al., 1989; Perry et
al., 1997; Purath et al., 1995; Walter, 1989). All but
five (Felton et al., 1998; Hansen et al., 1988;
McIntyre et al., 1996; Perry et al., 1989; Perry et
al., 1997) of these studies examined serum choles-
terol levels. Other tests included saliva analysis
(Hansen et al., 1988; Walter, 1989), serum thiocy-
nate (Bush et al., 1989; Walter, 1989), VOmax
(McIntyre et al., 1996), and urine for sodium and/or
potassium (Nader et al., 1989; Perry et al., 1989).
Interviews were used solely or in combination
with other methods in six studies (Duffy, 1986;
D’Elio et al., 1993; McIntyre et al., 1996; Murphy
et al., 1994; Perry et al., 1989; Walter, 1989). Data
collection methods less frequently used included
fitness tests, logs, card sort, food analysis, and food
shelf inventory.
Conceptualization of Problems and
Findings of Studies
Several terms and concepts occurred consis-
tently in all studies and definitions. In general,
health, health promotion, heart health, and cardio-
vascular disease were defined most frequently.
Other terms included healthful lifestyle (D’Elio et
al., 1993), health habits (Howard et al., 1996),
health risk behaviors (Felton et al., 1998), health
work (Ford-Gilboe, 1997), primary preventive be-
haviors (Duffy, 1986), and predisposing factors
(Perry et al., 1990). The terms predisposing factors
or cardiovascular risk factors can be categorized by
types: physiologic, genetic, behavioral, and psycho-
social. Psychosocial risk factors are further defined
by environmental factors, individual factors, and
behavioral factors. Environmental and individual
or personal risk factors were previously defined.
Behavioral factors include coping skills, goal-
setting, and behavior rehearsal (Perry et al., 1990).
Results of these studies were further categorized in
350
terms of interventions or influences that alter
certain structures, processes, or behaviors.
In this review, findings of the studies are divided
into three categories that reflect the type of interven-
tion or influence studied and risk factor type that
was targeted. The first group of studies includes
school-based behavioral intervention studies.
Schools used various methods to convey health
messages to students and evaluated outcomes using
pretest/posttest methods. The second category in-
cluded the same target structure, but with the
inclusion of family and/or community involve-
ment. Families were included in classroom curricu-
lum and/or participated in health activities with
students. The last category summarizes findings
from studies that examined various influences on
health independent of the educational system such
as community education and correlational studies
regarding health attitudes and behaviors. The follow-
ing content compares and contrasts most of the
studies reviewed as they apply to each category.
Elementary school-based behavioral interven-
tion programs. Three of the 13 school-based
behavioral intervention programs targeted specific
behavior change and used a school-based interven-
tion as the independent variable (Cella et al., 1992;
Hansen et al., 1988; Howard et al., 1996). Cella’s
study used a nontraditional approach, a rap contest,
as a smoking prevention intervention. Children
were asked to create antismoking messages, and
convey them through a rap music performance to
the rest of the school. No significant findings
resulted, but the method was found to be practical
and well-received. In comparison, one nursing
study found negative long-term (1 year) retention
of smoking prevention messages (Howard et al.,
1988) that were presented through classroom cur-
riculum. In contrast, the social influences resistance
training used in Project SMART reduced the onset
of drug abuse, but goal-setting strategies, behavior
alteration, and self-image enhancement had no
effect (Hansen et al., 1988).
Behavior change school-based programs incor-
porating family/community involvement. Seven
(Bush et al., 1989; Kelder et al., 1993; Nader et al.,
1989; Perry et al., 1989; Perry et al., 1997; Petchers
et al., 1987; Walter, 1989) of the 13 intervention
studies incorporated family or community involve-
ment to augment the school-based cardiovascular
curriculum. Classroom curricula included cardiovas-
cular physiology and primary prevention messages
related to smoking, exercise, and diet. In addition,
many programs provided health screening for par-
ents as well as students and/or supplied parents
SUZANNE O. NICHOLSON
with the same curriculum as students via newslet-
ters, seminars, and activities. The Know Your Body
programs yielded favorable physiologic changes in
the experimental group including decreased blood
pressure, increased HDL (Bush et al., 1989), and
decreased total blood cholesterol (Walter, 1989).
These studies varied in location and sample charac-
teristics, but produced similar results, improving
the validity of the program. It also was reported that
subjects decreased their intake of calories from fat
in two studies (Bush et al., 1989; Perry et al., 1989).
The PRECEDE model (also used by Arbeit et al.,
1992) supported the use of goal setting, rehearsal,
feedback, and reinforcement in the Bush et al.
(1989) study. Positive change for eating behaviors
was also reported by Nader et al. (1989) and
positive change in exercise behaviors by Bush et al.
(1989) and Kelder et al. (1993). Improved knowl-
edge of skills required to change behavior was
reported by Nader et al. (1989) for one intervention
group after 1 year, with greater change among
Caucasians. In that same study, some negative
correlations were found for Mexican students whose
fathers created barriers to behavior change (Nader
et al., 1989).
In a study comparing home-based to school-
based programs, the home-based programs pro-
duced greater behavior changes at posttest. Parents
of subjects participating in the Minnesota Home
Team intervention groups were given instruction on
how to function as positive role models and gate-
keepers for their children through a 5-week corre-
spondence course (Perry et al., 1989). Parent
participation influenced positive effects in three
other studies as well (Bush et al., 1989; Nader et al.,
1989; Walter, 1989). The San Diego Family Health
Project sponsored an impressive program that inte-
grated physical activity, physiologic measurement/
feedback, and group meetings featuring games and
discussion. Topics included family health behav-
iors, problem solving and goal setting for families,
and dietary education (Nader et al., 1989). In
contrast, Petchers et al. (1987) reported that the
parent component of the Heart Health intervention,
which featured parent newsletters only, had no
effect on student’s cardiovascular knowledge or
behavior. Both experimental and control groups
achieved the equivalent knowledge gains and atti-
tude changes, although attitudes on smoking were
unchanged.
As part of its intervention strategy, the Minne-
sota Heart Health Program/Class of 1989 con-
ducted a community-wide program that provided
cardiovascular education, physical activity goals,
HEALTH PROMOTION
and risk factor screening with support from local
churches, restaurants, mass media, and health pro-
fessionals (Kelder et al., 1993). The study showed
significant gender differences for exercise behav-
iors, with females exercising more than males as a
result of school and community-wide interventions
(Kelder et al., 1993). While this study had success
with community involvement, the Canadian study
utilizing the Coordinated Approach that focused on
heart health and mental health outcomes, did not.
Positive feelings about the program emerged and
students’ awareness of health issues improved, but
the interventions had no effect (McIntyre et al.,
1996).
Behavioral, environmental, and individual influ-
ences independent of the school. Of the nine
remaining studies, two evaluated learning out-
comes in a non-school-based program called Life
Education Centres (LECs), which are mobile health
education resources with a drug prevention focus
(Quine et al., 1992; Tudor-Smith, Frankland, Playle,
& Moore, 1995). Sample characteristics and loca-
tions varied, but results were similar between the
studies. The major outcome was increased gains in
drug knowledge, but program attendance was not a
predictor of intent to use tobacco or alcohol.
Long-term benefits were unclear, but the children’s
response to the program was favorable (Quine et
al., 1992; Tudor-Smith et al., 1995).
Five studies were noninterventional and sur-
veyed participants regarding health attitudes and
behaviors, including three studies that involved
families (Duffy, 1986; Ford-Gilboe, 1997; Purath et
al., 1995). Relationships were found to exist be-
tween a family’s ability to change and grow and
their practice of primary preventive behaviors in
the qualitative nursing study (Duffy, 1986). Addi-
tionally, family cohesion was found to be an
attribute that influences health work, and participa-
tion in health work is not culture or status specific
(Ford-Gilboe, 1997). Purath et al. (1995) found
mothers to be important role models for their
school-aged children for exercise behaviors.
In addition to environmental influences, personal
factors related to exercise have been addressed as
well. Ferguson et al. (1989) reported that many
factors contributed independently and significantly
to exercise intent and exercise behavior, including
attitudes, self-esteem, perceived benefits, and gen-
der. African-American boys, and to a lesser extent
girls, in a study identifying health risk behaviors,
were found to have a high prevalence of obesity
because of physical inactivity and dietary prefer-
ences. Girls inactivity was influenced by telephone
351
and television use (social environment) and person-
ality. Many perceived themselves to be in poor
shape. Boys often had friends that were uninvolved
with sports or who drank alcohol. Gender differ-
ences were found to exist and may be related to an
earlier transition to adult negative behaviors in
boys (Felton et al., 1998).
State of the Art
Results of health education programming varied
based on the diversity of curricula and inclusion or
exclusion of environmental factors. Longitudinal
studies provided important information regarding
retention of programming and allowed for greater
applicability. A multidisciplinary approach to health
education yielded consistently successful out-
comes. Children learned healthy behaviors and
improved on physical measurements. Comprehen-
sive studies that combined personal, behavioral,
and/or environmental interventions met with suc-
cess as well, because of the role of reinforcement of
messages through activities and modeling at home,
at school, and in the community. Results, in gen-
eral, were highly supportive of the positive effect
parents can have on young children. Also, several
personal and behavioral factors affecting health
behaviors were identified in the descriptive, explor-
atory, and qualitative studies. Researchers investi-
gating health promotion in children were mainly
from the public health and education arenas, but
nursing research was found to be equally valuable.
Gaps in the Literature
Educational systems alone cannot produce posi-
tive health outcomes in children, and it should not
be expected of them (Petchers et al., 1987). Many
gaps exist in the literature including family health
promotion studies, examination of the role of the
nurse in promoting health for children, and studies
that address the barriers to application of programs.
Barriers include lack of awareness of the need for
school health education, provider concerns over
paperwork, and fragmentation of services. There
are few qualitative studies that examine personal
factors related to health behaviors in children and
the number of nursing studies is limited. Lastly,
efficiency and cost-effectiveness of programming is
poorly researched, as are the effects of mass media
on children’s health behaviors. In general, research
has not delivered answers to problems such as:
what are the best ways to modify unhealthy behav-
iors in children, how should we prevent the onset of
unhealthy behaviors, and what are the best ways to
deliver preventive health information to children?
352
LIMITATIONS OF THE STUDIES
While many strengths were apparent in these
studies such as quasi-experimental and longitudinal
designs, controls, and large samples, there were
also limitations noted. In all the studies reviewed,
samples of convenience were used, but in the
quasi-experimental studies (Arbeit et al., 1992;
Bush et al., 1989; Cella et al., 1992; Hansen et al.,
1988; Howard et al., 1996; McIntyre et al., 1996;
Nader et al., 1989; Parcel et al., 1989; Petchers et
al., 1987; Walter, 1989), all subjects were random-
ized to groups. Nonetheless, sampling bias exists
and limits generalizability. The majority of studies
under-represented minority populations. Seven re-
searchers attempted to improve rigor by obtaining
subjects from diverse populations (Arbeit et al.,
1992; Ford-Gilboe, 1997; Hansen et al., 1988;
Nader et al., 1989; Parcel et al., 1989; Petchers et
al., 1987) and/or matching groups (McIntyre et al.,
1996), while others gained strength from enlisting
groups from a large accessible population (Kelder
et al., 1993; Murphy et al., 1994; Perry et al., 1989;
Perry et al., 1997; Walter, 1989). Two samples were
comprised of volunteers who placed a higher value
on health education before the study (Ford-Gilboe,
1997; Quine et al., 1992). Similarly, families who
volunteered may have been ‘‘early adopters’’ of
change in health behaviors (Nader et al., 1989) and
thus not representative of the population.
When dealing with large samples and longitudi-
nal designs, there are economic and resource issues
that might impact results. Insufficient funding to
train support staff and teachers, involve families,
provide booster sessions and follow-up activities
was identified as problematic (Kelder et al., 1993;
Murphy et al., 1994). Attrition was also an issue
(Bush et al., 1989; Hansen et al., 1988; Kelder et
al., 1993; Perry et al., 1989; Perry et al., 1997;
Quine et al., 1992; Walter, 1989). Finally, the
applicability of the two Canadian studies (Ford-
Gilboe, 1997; McIntyre et al., 1996) may pose
limitations for replication in the United States
because of a different health care delivery system
and the progressive approach to school health.
Self-report measures were the most commonly
used methods of data collection. The most frequent
concerns for response bias included accuracy, hon-
esty, literacy, cultural, and comfort barriers. Reliabil-
ity measures for instruments were only discussed in
six of the studies (D’Elio et al., 1993; Felton et al.,
1998; Ferguson et al., 1989; Ford-Gilboe, 1997;
Murphy et al., 1994; Nader et al., 1989), thus the
risk of type I error for the remaining studies. Also,
most of the instruments were developed for and
SUZANNE O. NICHOLSON
tested on adult populations and may not be as
reliable for children.
Problems existed in studies that used classrooms
and schools as units of analysis. Lack of consistent
program effects were noted in several studies
because of uneven implementation across groups
(Bush et al., 1989; Howard et al., 1996; Parcel et
al., 1989; Quine et al., 1992; Tudor-Smith et al.,
1995). It was reportedly impossible to provide
consistency in the school health curriculum based
on varying levels of creativity among instructors
(McIntyre et al., 1996). By nature, people and
institutions are constantly changing, affecting data
collection. In addition, in studies where schools
were treated as units of analysis, statistical power
was set low because of differential history and
attrition (Kelder et al., 1993; Tudor-Smith et al.,
1995), which also lessened generalizability.
Other limitations stated by researchers included
instructional sessions too brief to develop practical
skills, insufficient evaluation time, session not
intense enough, contamination between groups, use
of media to enhance community-wide activities
prevented by design, and significant nonattendance
of parents in high-risk populations.
Type I and type II errors were possible in these
studies caused by issues with sampling, design,
data collection, data analysis, and intervention
errors. Also, one study stated a potential type III
error because of failure to implement the interven-
tion, especially in the school environment (McIn-
tyre et al., 1996). Overall, the findings of these
studies are only generalizable to populations with
similar characteristics.
NURSING PRACTICE IMPLICATIONS
The delivery of health education to children or
lack thereof, impacts children, families, and the
health care system. Children can be screened for
risk factors and tracked over time. To screen only
children from high-risk families leave many with
problems that are not identified (Purath et al.,
1995). Extensive physiologic evaluation is not
practical for school-administered health programs
(Arbeit et al., 1992), so nurses and physicians must
expand their roles in the community. If children are
instructed on personal and behavioral factors influ-
encing their choices for health during routine
examinations and screenings, they may be more
likely to avoid premature and chronic illness.
School nurses are in an excellent position to
monitor cardiovascular screening and to assist in
the design and implementation of wellness pro-
grams as well as altering school lunch programs,
HEALTH PROMOTION
Table 3. Nursing Practice Implications
Ways nurses can affect change and/or encourage maintenance of
healthful behaviors in children.
Assess for gaps in systems of care.
Analyze risk factors for illness in primary settings and schools.
Become involved in screening and implementation of programs.
Become involved in policy development.
Encourage community involvement through role modeling.
Enlist parent involvement in screening and health education
programs.
Develop culture-specific materials for educating children
and parents.
Develop holistic approaches to health education/primary
prevention.
Support school health programs.
Apply the roles of educator, promoter, and researcher.
Advocate children’s rights to be safe, informed, and healthy by
being a good source of positive and consistent health messages.
physical education requirements, and working with
families. School-based programs impact health
behavior to varying degrees.
Early intervention, before age 11 has the poten-
tial for stronger impact as children and parents
show greater enthusiasm at the elementary-school
level (Bush et al., 1989; Perry et al., 1989) and
parents have greater influence during these years
(Purath et al., 1995). Enlisting parent involvement
requires creativity and less traditional approaches
(Perry et al., 1989) and can be implemented with
minimal financial resources (Howard et al., 1996).
Teachers are impacted by incentives as are students
and families (Bush et al., 1989; McIntyre et al.,
1996; Parcel et al., 1989). If teachers cut health
education because of lack of curriculum time, the
outcomes for children are clear. Nursing’s priority
should be to contribute to the health of the commu-
nity by assessing for gaps in systems of care and
support systems, analyzing risk factors, and setting
goals for change. Playing a part in policy develop-
ment in addition to community involvement is
paramount. Institutionalization of programs re-
quires a commitment from administration and the
community if achievement of national health goals
is to be met.
Students may be impacted more by behavioral
approaches (Perry et al., 1989), but converting
cognitive gains into behavioral and attitude change
will require support from the healthcare system.
Also, racial and socioeconomic factors may ac-
count for differences in learning outcomes (Cella et
al., 1992; Nader et al., 1989) and culture specific
materials need to be developed. Psychologic fac-
tors may have an equally important impact on
learning and behavior. A holistic approach would
require self-esteem and confidence building activi-
ties.
353
Community health nurses, primary care nurses,
and advanced practice nurses frequently encounter
traditional and nontraditional families. Assessment
of primary preventive behaviors that the family
perceives they are practicing plays a role in identi-
fying motivators and barriers to health promotion
(Duffy, 1986). Values placed on health by the
healthcare system is an important factor when
modifying health behaviors. Nurses must be educa-
tors and promoters, creating situations where cli-
ents re-evaluate the importance of health in their
lives (Petersen-Martin & Cottrell, 1987). When the
community places a high value on health, the
attitudes of individuals are positively affected.
Community-based health education may also serve
children at risk more effectively (Arbeit et al.,
1992). Overall, there is a greater chance for posi-
tive outcomes if the child is supported by family,
peers, and resource opportunities (Walter, 1989).
Changes in health behavior, however small, over
time and across populations, have significant public
Table 4. Recommendations for Future Research
Patient-focused outcomes
Examine personal risk factors that influence learning and health
behaviors, e.g. attitudes, self-esteem.
Evaluate the effects of programs on children younger than eleven
years old.
Isolate socio-demographic variables and examine their impact on
primary preventive behaviors.
Process of care outcomes
Determine optimal intensity, frequency, and duration of health
education programming.
Determine the best ways to deliver health messages to children in
primary care settings.
Determine best method of dissemination of existing educational
materials and programs.
Examine ways to help families set health priorities and use
resources.
Evaluate culturally appropriate interventions/educational mate-
rials.
Evaluate ways to deliver resources to underprivileged.
Identify creative approaches for the delivery of health information
to parents.
Identify ways to elicit positive family involvement in health educa-
tion and modeling.
Evaluate the effectiveness of nurse’s health teaching in primary
care settings, school, and in the community.
Conduct longitudinal follow-up and replication studies.
Structure of care outcomes
Replication and evaluation of community-wide health education
programs including before and after school programs, camp,
and church-based instruction.
Evaluate the family unit as a change agent.
Examine the role of the advanced practice nurse in primary pre-
vention.
Determine the effects of mass media on health promotion behav-
iors in children.
Compare efficiency of programs to cost-effectiveness.
354
health implications. (See Table 3 for a summary of
nursing practice implications.)
FUTURE RESEARCH
Based on the gaps that exist in children’s health
promotion research, future studies need to evaluate
child-focused process of care and structure of care
outcomes. Patient-focused outcomes research might
examine individual or personal factors that may
impact health care decisions, including demo-
graphic variables, knowledge, and attitudes. Pro-
cess of care outcomes research could address ways
to best deliver health messages to families and
REFERENCES
Arbeit, M.L., Johnson, C.C., Mott, D.S., Harsha, D.W.,
Nicklas, T.A., Webber, L.S., & Berenson, G.S. (1992). The
Heart Smart cardiovascular school health promotion: Behavior
correlates of risk factor change. Preventive Medicine, 21, 18-32.
Blomquist, K.B. (1986). Modeling and health behavior:
Strategies for prevention in the schools. Health Education,
17(3), 8-10.
Burke, V., Gracey, M.P., Milligan, R.A., Thompson, C.,
Taggert, A.C., & Beilin, L.J. (1998). Parental smoking and risk
factors for cardiovascular disease in 10- to 12-year-old children.
Journal of Pediatrics, 133(2), 206-213.
Bush, P.J., Zuckerman, A.E., Taggart, V.S., Theiss, P.K.,
Peleg, E.O., & Smith, S.A. (1989). Cardiovascular risk factor
prevention in black school children: The ‘‘Know Your Body’’
evaluation project. Health Education Quarterly, 16(2), 215-227.
Cella, D.F., Tulsky, D.S., Sarafian, B., Thomas Jr., C.R., &
Thomas Sr., C.R. (1992). Culturally relevant smoking preven-
tion for minority youth. Journal of School Health, 62(8),
377-381.
Centers for Disease Control and Prevention (CDC). U.S.
Department of Health and Human Services (1999). Summaries
of 1997 Youth Risk Behavior Surveillance System National
Data. [On-line]. Available: www.cdc.gov
D’Elio, M.A., Mundt, D.J., Bush, P.J., & Iannotti, R.J. (1993).
Healthful behaviors: Do they protect African-American, urban
preadolescents from abusable substance abuse? American Jour-
nal of Health Promotion, 7(5), 354-363.
Downey, A.M., Virgilio, S.J., Serpas, D.C., Nicklas, T.A.,
Arbeit, M.L., & Berenson, G.S. (1988). ‘‘Heart Smart’’—A staff
development model for school-based cardiovascular health
intervention. Health Education, 19(2), 64-71.
Duffy, M.E. (1986). Primary prevention behaviors: The
female-headed, one-parent family. Research in Nursing and
Health, 9(2), 115-122.
Felton, G.M., Pate, R.R., Parsons, M.A., Ward, D.S., Saun-
ders, R.P., Trost, S., & Dowda, M. (1998). Health risk behaviors
of rural six-graders. Research in Nursing and Health, 21(6),
475-485.
Ferguson, K.J., Yesalis, C.E., Pomrehn, P.R., & Kirkpatrick,
M.B. (1989). Attitudes, knowledge, and beliefs as predictors of
exercise intent and behavior in schoolchildren. Journal of
School Health, 59(3), 112-116.
Ford-Gilboe, M. (1997). Family strengths, motivation, and
resources as predictors of health promotion behavior in single-
parent and two-parent families. Research in Nursing and Health,
20(3), 205-217.
Gans, K.M., Bain, S.L., Plotkin, B., Lasater, T.M., & Carle-
ton, R.A. (1994). Implementation and institutionalization of
heart health programming in schools: The Pawtucket Heart
Health Program experience. Journal of Health Education, 25(2),
89-96.
SUZANNE O. NICHOLSON
children in primary care settings, schools, and in
the community, as well as identifying ways that
primary prevention behaviors are learned. Studies
that assess cultural variations in health beliefs and
variations in setting family health priorities would
provide useful in the delivery of health messages.
Structure of care outcomes research might examine
the role of the advanced practice nurse in primary
prevention or replicate intervention programs in
varied settings. Research on the effects of mass
media on health behaviors in children might also
prove enlightening. (Refer to Table 4 for a sum-
mary of recommendations for future research.)
Gillis, A.J. (1993). Determinants of a health-promoting
lifestyle: An integrative review. Journal of Advanced Nursing,
18(3), 345-353.
Glynn, T.J. (1989). Essential elements of school-based smok-
ing prevention programs. Journal of School Health, 59(5),
181-188.
Hansen, W.B., Johnson, A., Flay, B.R., Graham, J.W., &
Sobel, J. (1988). Affective and social influences approaches to
prevention of multiple substance abuse among seventh grade
students: Results from Project SMART. Preventive Medicine,
17, 135-154.
Howard, J.K.H., Bindler, R.M., Synoground, G., & VanGe-
mert, F.C. (1996). A cardiovascular risk reduction program for
the classroom. Journal of School Nursing, 12(4), 4-11.
Kelder, S.H., Perry, C.L., & Klepp, K. (1993). Community-
wide youth exercise promotion: Long-term outcomes of the
Minnesota Heart Health Program and the Class of 1989 Study.
Journal of School Health, 63(5), 218-223.
Lytle, L. & Achterberg, C. (1995). Changing the diet of
America’s children: What works and why? Journal of Nutrition
Education, 27(5), 250-256.
McIntyre, L., Belzer Jr., E.G., Manchester, L., Blanchard, W.,
Officer, S., & Simpson, A.C. (1996). The Dartmouth Health
Promotion Study: A failed quest for synergy in school health
promotion. Journal of School Health, 66(4), 132-137.
Murphy, A.S., Youatt, J.P., Hoerr, S.L., Sawyer, C.A., &
Andrews, S.L. (1994). Nutrition education needs and learning
preferences of Michigan students in grades 5, 8, and 11. Journal
of School Health, 64(7), 273-278.
Nader, P.R., Sallis, J.F., Patterson, T.L., Abramson, I.S., Rupp,
J.W., Senn, K.L., Atkins, C.L., Roppe, B.E., Morris, J.A.,
Wallace, J.P., & Vega, W.A. (1989). A family approach to
cardiovascular risk reduction: Results from the San Diego
Family Health Project. Health Education Quarterly, 16(2),
229-244.
Nelms, B.C. (1995). Children first: Is it ever going to happen?
Journal of Pediatric Health, 9(197), 198.
Parcel, G.S., Simons-Morton, B., O’Hara, N.M., Baranowski,
T., & Wilson, B. (1989). School promotion of healthful diet and
physical activity: Impact of learning outcomes and self-reported
behavior. Health Education Quarterly, 16(2), 181-199.
Pender, N.J. (1996). Health promotion in nursing practice
(3rd ed.). Stamford, CA: Appleton & Lange.
Perry, C.L., Sellers, D.E., Johnson, C., Pedersen, S., Bach-
man, K.J., Parcel, G.S., Stone, E.J., Luepker, R.V., Wu, M.,
Nader, P.R., & Cook, K. (1997). The child and adolescent trial
for cardiovascular health (CATCH): Intervention, implementa-
tion, and feasibility for elementary schools in the United States.
Health Education and Behavior, 24(6), 716-735.
HEALTH PROMOTION
Perry, C.L., Stone, E.J., Parcel, G.S., Ellison, R.C., Nader,
P.R., Webber, L.S., & Luepker, R.V. (1990). School-based
cardiovascular health promotion: The child and adolescent trial
for cardiovascular health (CATCH). Journal of School Health,
60(8), 406-413.
Perry, C.L., Luepker, R.V., Murray, D.M., Hearn, M.D.,
Halper, A., Dudovitz, B., Maile, M.C., & Smyth, M. (1989).
Parent involvement with children’s health promotion: A one-
year follow-up of the Minnesota Home Team. Health Education
Quarterly, 16(2), 171-180.
Petchers, M.K., Hirsch, E.Z., & Bloch, B.A. (1987). The
impact of parent participation on the effectiveness of a heart
health curriculum. Health Education Quarterly, 14(4), 449-460.
Petersen-Martin, J. & Cottrell, R.R. (1987). Self-concept,
values, and health behavior. Health Education, 18(5), 6-9.
Poole, D. (1997). Achieving national health goals in preven-
tion with community organization: The ‘‘bottom up’’ approach.
Journal of Community Practice, 4(2), 77-91.
Purath, J., Lansinger, T., & Ragheb, C. (1995). Cardiac risk
evaluation for elementary school children. Public Health Nurs-
ing, 12(3), 189-195.
Quine, S., Stephenson, J.A., Macaskill, P., & Pierce, J. (1992).
355
A role for drug awareness and prevention programs external to
school? Health Education Research, 7(2), 259-267.
Shively, V.P. & Pearce, W.H. (1998). American Heart Associa-
tion 70th Scientific Sessions. Cardiovascular Surgery, 6(3),
215-219.
Tudor-Smith, C., Frankland, J., Playle, R., & Moore, L.
(1995). Life education centres: An evaluation of a mobile health
education resource in Wales for children. Health Education
Journal, 54(393), 404.
U.S. Department of Health and Human Services. (1991).
Healthy People 2000: National health promotion and disease
prevention objectives. (DHHS Publication PHS 91-50212).
Washington, D.C.: U.S. Government Printing Office.
Velsor-Friedrich, B. (1991). Health goals for children and
families. Journal of Pediatric Nursing, 6(1), 62-63.
Walter, H.J. (1989). Primary prevention of chronic disease
among children: The school-based ‘‘Know Your Body’’ interven-
tion trials. Health Education Quarterly, 16(2), 201-214.
Whitener, L.M., Cox, K.R., & Maglich, S.A. (1998). Use of
theory to guide nurses in the design of health messages for
children. Advances in Nursing Science, 20(3), 21-35.