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PREVENTIVE MEDICINE 25, 442–454 (1996)
ARTICLE NO. 0076

The Effects of the Child and Adolescent Trial for Cardiovascular Health
upon Psychosocial Determinants of Diet and Physical Activity Behavior
ELIZABETH EDMUNDSON, PH.D.,* GUY S. PARCEL, PH.D.,† HENRY A. FELDMAN, PH.D.,‡ JOHN ELDER, PH.D.,§
CHERYL L. PERRY, PH.D.,Ø CAROLYN C. JOHNSON, PH.D.,\ B. J. WILLISTON, M.ED.,§
ELAINE J. STONE, PH.D., M.P.H.,** MINHUA YANG, M.S.,‡
LESLIE LYTLE, R.D., PH.D.,Ø AND LARRY WEBBER, PH.D.\
*University of Texas at Austin, Austin, Texas 78712; †University of Texas Health Science Center, Houston, Texas 77225; ‡New England
Research Institutes, Inc., Watertown, Massachusetts 02172; §University of California at San Diego, La Jolla, California 92093;
Ø
University of Minnesota, Minneapolis, Minnesota 55454; \Tulane University School of Public Health and Tropical Medicine,
New Orleans, Louisiana 70118; and **National Heart, Lung, and Blood Institute, Bethesda, Maryland 20892

point to a need for greater understanding of adoles-

Background. The Child and Adolescent Trial for Car-
diovascular Health is a multisite study of a school-
based intervention to reduce or prevent the develop-
ment of risk factors for cardiovascular disease. The
purpose of this paper is to present the evaluation re-
sults of the 3-year intervention, focusing upon the psy-
chosocial variables conceptualized as determinants of
dietary and physical activity behaviors.
Methods. A total of 96 schools across four study sites
(California, Louisiana, Minnesota, and Texas) were
randomized to two treatment conditions: intervention
and control. Pre- and postmeasurements on the health
behavior questionnaire were collected from over 6,000
students. The data analyses utilized a nested design
approach in which schools served as the primary unit
of analysis. Repeated-measures multivariate analyses
were applied to investigate effect sizes for each deter-
minant and to explore theoretical relationships among
the determinants over time.
Results. The findings indicated sustained significant
effects in improved knowledge, intentions, self-effi-
cacy, usual behavior, and perceived social reinforce-
ment for healthy food choices (P õ 0.0001 for these
five variables) after 3 years. Intermittent effects were
observed for perceived support and self-efficacy for
physical activity. No gender by determinant interac-
tion effects were observed, and girls reported signifi-
cantly greater perceived reinforcement for healthy
eating than did boys.
Conclusion. The CATCH program was effective in
changing the psychosocial variables likely to influence
a reduction in behavior for cardiovascular disease.
The study is significant in that it demonstrates the via-
bility and effectiveness of a sustained multifaceted in-
tervention in a preadolescent population. The results
Address correspondence and reprint requests to Elizabeth Ed-
mundson, Ph.D., University of Texas at Austin, Department of Kine-
siology—BEL 222, Austin, TX 78712. Fax: (512) 471-8914.
cent developmental issues and the role of community
environment (particularly social support) in creating
effective curricula. q 1996 Academic Press, Inc.
Key Words: CVD; children; prevention; social cogni-
tive theory.
INTRODUCTION
The Child and Adolescent Trial for Cardiovascular
Health (CATCH) is a school-based, comprehensive, lon-
gitudinal cardiovascular disease risk factor interven-
tion that was implemented for 3 years among children
in 96 schools, from the beginning of third grade through
the fifth grade.1 – 4 The conceptual framework for the
CATCH intervention assumes a causal model in which
psychosocial risk factors influence behavioral risk fac-
tors (dietary, physical activity, and smoking) which in-
fluence physiological risk factors (blood lipids and blood
pressure), which finally determine morbidity and mor-
tality (heart attack and stroke).1 In this model, psy-
chosocial risk factors became the most proximal targets
for change by the CATCH intervention. The first step
of the process included identification of the behaviors
we wanted the children to adopt, specifically, to reduce
fat and sodium intake, to increase participation in mod-
erate to vigorous physical activity, and to resist the
initiation of smoking. Next, based upon Social Cogni-
tive Theory5 and limited empirical data, we selected
those psychosocial factors considered most likely to pre-
pare the children to perform the identified behaviors.
Finally, we designed the intervention components to
address the personal, environmental, and behavioral
factors identified as potential determinants of the risk-
reducing behaviors.
The theoretical underpinnings selected from Social
Cognitive Theory (SCT) and targeted in the CATCH

0091-7435/96 $18.00 442

Copyright q 1996 by Academic Press, Inc.
All rights of reproduction in any form reserved.
 DETERMINANTS OF DIET AND PHYSICAL ACTIVITY
intervention include expectancies (the values placed on
a particular outcome); self-control and performance
(decisions made to achieve self-control, such as the set-
ting of a performance criterion); behavioral capability,
or the necessary knowledge to understand the behavior
and skills to perform the behavior; environment and
situation (the actual and perceived physical and social
environments); observational learning; and self-effi-
cacy.1,6
Self-efficacy is especially critical to the initiation of
skill acquisition; this finding has been reported for chil-
dren as well as adults.5,7 – 9 Beliefs of personal self-effi-
cacy operate in their own right upon behavior and they
act upon other SCT determinants.5,8 According to
Bandura,7 sustained high self-efficacy is contingent
upon several sources, the most authentic influence be-
ing successful mastery of increasingly challenging ex-
periences. As an individual begins to exercise control
over his/her environment, other forces act in concert
with self-efficacy to affect behavior. These efficacy-acti-
vated processes include cognitive (such as personal goal
setting and problem solving), motivational (anticipa-
tory beliefs about the likely outcomes and the value
placed on those outcomes), affective (e.g., perceptions
of potential threats and coping response processes,
such as perceived social reinforcement and support),
and selection (choices made regarding activities and
environments).5,8 The CATCH curricula were designed
to influence self-efficacy and selected efficacy-activated
processes during skill acquisition. Self-regulatory pro-
cesses such as self-monitoring and goal-setting activi-
ties were added during the fourth and fifth grades.1,2
Drawing from the concept of reciprocal determinism
from SCT,5,6 the intervention model addressed individ-
ual cognitive processes and behavioral processes and
influences, as well as the physical and social environ-
ment. The interventions included a series of skill-based
classroom curricula, modifications of the school envi-
ronment, and home-based activities—all designed to
help children exercise more control over their choices
for diet and physical activity behavior. The strategies
utilized in all three components of the reciprocal triad
included behavioral modeling, skills training, practice,
reinforcement, eliciting social support, goal setting, so-
cial norm setting, and improved access to the resources
needed for the performance of the behaviors (e.g., suf-
ficient physical education equipment and low-fat food
options in the school cafeteria).
The main effects of the CATCH trial on school-level
environmental determinants (such as the fat content
of foods provided by the school food service) and the
individual level outcomes (such as cholesterol values)
have been reported elsewhere.10 The effects of the inter-
vention upon psychosocial determinants related to
smoking are presented elsewhere in this issue of Pre-
ventive Medicine.11 Also in this issue, a detailed discus-
443
sion of the operational design and quality control proce-
dures implemented during the CATCH trial is pre-
sented by Stone and colleagues.12
In this paper, we present the effects of the interven-
tion on the personal determinants of behaviors related
to dietary behavior and physical activity. The effects
of the intervention presented and discussed in this pa-
per are the combined results of all the intervention
components. The only attempt to compare the effects
of individual components is an analysis of the additive
effect of the family component to the combined school-
based components of the intervention.
The primary evaluation questions are as follows.
First, was there an effect at any point during the longi-
tudinal intervention upon the personal determinants
of dietary and physical activity behavior? Second, were
any of the changes in the determinants sustained after
the 2.5-year period of intervention? The student out-
comes investigated here are self-reported behaviors,
knowledge, self-efficacy, perceived social reinforcement
and support, and intentions. The data are also ana-
lyzed for gender differences.
METHOD
Design
A total of 96 elementary schools participated in the
CATCH randomized intervention trial, which collected
data from an intervention group and a control group.
The intervention group was divided into two sub-
groups, each receiving different levels of CATCH inter-
vention. The first subgroup’s intervention consisted of
CATCH health education curricula, a physical educa-
tion program, a campus no-smoking policy, and a school
food service intervention program. The second sub-
group’s school-based intervention was enhanced by a
home-based intervention. The control group partici-
pated in the schools’ standard health education curricu-
lum, but did not receive any CATCH intervention.
The independent variable for this study was the
CATCH intervention program. The dependent vari-
ables are psychosocial determinants of behavior tai-
lored to measure specific antecedents of cardiovascular
disease (CVD) risk reduction behavior. These anteced-
ents were dietary intention, usual food choices, dietary
knowledge, perceived support for physical activity, per-
ceived social reinforcement for healthy food choices,
dietary self-efficacy, and physical activity self-efficacy.
Using a nested design, several variables were covaried
with the independent variable, such as school type and
baseline scores on each scale score. The study site was
also covaried as part of the SAS mixed-models proce-
dure. This strategy is discussed further in the paper.
Measurements of the psychosocial determinants
were made prior to intervention in the third grade and
444 EDMUNDSON ET AL.
throughout the intervention at the end of the school
year in grades 3, 4, and 5, between 1991 and 1994.
Outcome comparisons were made at the level of treat-
ment assigned, using school as the unit of analysis.
The CATCH team recruited 24 schools at each of its
four field sites (Austin, Minneapolis, New Orleans, and
San Diego), consisting of 10 control and 14 intervention
schools. The Coordinating Center, the New England
Research Institute, performed the randomization of
schools to the control or intervention condition. Seven
of the 14 intervention schools at each site were ran-
domly assigned to receive only the school based inter-
vention. The remaining 7 schools received the home-
based intervention in addition to the school-based pro-
grams.
Subjects
The focus of this paper is on school-wide averages,
in order to present the outcomes for all students ex-
posed, to the intervention not merely the CATCH co-
hort. The subjects began the study as third-grade stu-
dents (n Å 7,795) enrolled in the 96 CATCH schools
during the 1991–1992 academic year. The mean age
of the students at baseline was 8.75 years (SD Å 0.487).
There were no significant differences among study sites
or school type (i.e., control vs intervention) for age. The
numbers of male and female subjects were virtually
equal, with the exception of the Louisiana site which
had a slightly greater number of males (54% vs 46%).
During the fifth-grade administration, 7,944 students
completed the HBQ. A x2 analysis revealed no statisti-
cally significant gender or race differences in the sam-
ple distributions between the third-, fourth-, and fifth-
grade administrations.
The distribution of racial and ethnic representation
varied among the four sites. Minnesota had a predomi-
nately Caucasian sample (approximately 87%), with
African-Americans being the largest minority group
represented (3.5%). In California, Caucasians were also
the predominant racial/ethnic group (about 70%), with
Hispanic subjects being the largest minority group (ap-
proximately 16%). Louisiana had the largest represen-
tation of African-American subjects (about 30%), with
Caucasians making up 67% of the subject population.
The Texas site had the largest representation of His-
panic subjects (38%), with African-Americans consti-
tuting 16%, while approximately 44% of the study sam-
ple was Caucasian.
In the baseline administration (Fall 1991, grade 3),
7,795 of the 8,565 enrolled students (91%) completed
the health behavior questionnaire (HBQ). The partici-
pation rate remained at 91% in the subsequent two
spring administrations (grades 3 and 4) and at 89%
in the spring of grade 5. Participation did not differ
significantly between control and intervention schools
overall (x2 Å 0.10, P ú 0.70) or in any single semester,
gender, or ethnic subgroup. Participation was higher
by 2.4% in intervention schools than in control schools
at the Louisiana site, and lower by 1.7% in intervention
schools than in control schools at the California site;
with sample sizes of over 9,000, these differences were
statistically significant but too small to represent a
meaningful bias.
Among all students enrolled during any of the four
semesters when it was administered, 39% completed
the questionnaire on all four occasions. Sixteen percent
participated on three occasions, 20% twice, 20% once,
and 6% not at all. These rates did not differ signifi-
cantly between control and intervention schools (x2 Å
0.36, df Å 4, P ú 0.98)
Measurement
The HBQ was developed and piloted during Phase I
of CATCH (1988–1991), prior to the main field trials,
to measure psychosocial constructs related to diet,
physical activity, and intentions to smoke (fifth grade)
among elementary schoolchildren. The constructs mea-
sured are behaviors and considered determinants of
behaviors underlying CVD risk factors. The scales were
based on SCT: some had been utilized in previous work,
including Hearty Heart and Friends,13 the Minnesota
Heart Health Program,14 and GO for Health,15 while
others were developed specifically for CATCH. Several
SCT constructs were considered for the assessment.
Ultimately, the constructs selected for measurement
were those that guided the intervention.
The constructs measured by the HBQ include dietary
intention, usual food consumption, dietary knowledge,
positive support for physical activity, negative support
for physical activity, perceived social reinforcement for
healthy food choices, dietary self-efficacy, physical ac-
tivity self-efficacy, and smoking acquisition. The smok-
ing acquisition scale is the focus of another paper, thus
those findings are not reported here.
The procedures undertaken to establish the reliabil-
ity and validity of the scales that measured dietary
intention, usual food choices, and dietary knowledge
have been reported elsewhere.13,14 The scales that mea-
sured self-efficacy, for dietary choices and for physical
activity, were first described by Parcel et al.15 Addi-
tional psychometric evidence for the dietary self-effi-
cacy scale and usual food choices scale was obtained
during the CATCH pilot study.16 Scales which mea-
sured perceived social reinforcement for healthful food
choices and perceived support for physical activity were
developed and evaluated during the CATCH pilot.
Those scales were evaluated for internal consistency
(coefficient a), content validity, and factorial validity.
Perceived support for physical activity was conceptual-
ized as two constructs: positive social support and neg-
 DETERMINANTS OF DIET AND PHYSICAL ACTIVITY
ative social support (e.g., criticism). The coefficient a
and factor analyses supported maintaining the concep-
tual distinction; the result was two scales, one for each
type of support. The perceived social reinforcement for
healthful food choices scale also demonstrated evidence
of reliability and validity. Additionally, in order to max-
imize the validity of the children’s responses, the proto-
col for the administration of the HBQ was pilot-tested
for strategies to ensure student confidentiality.
Overall, the reliability values were reasonable for
third-grade children,4 and therefore were retained for
the subsequent measurement periods. Cronbach’s a co-
efficients were calculated for every scale for each of the
four measurement periods, for the total sample, and for
the control and experimental groups separately. The
results for the two groups were essentially the same.
The largest difference in a coefficients between control
and intervention, for a same measurement period com-
parison, was 0.07 (which appeared for one scale only);
the mode difference for all the scales was 0.02. Given
the stability of these coefficients, a brief description of
each scale with the standardized reliability coefficient
values for all students, during third grade and 2 years
later when they completed the questionnaire in fifth
grade, is provided below.
Dietary intention. This scale was designed to mea-
sure students’ intentions to choose foods considered
heart healthful, i.e., those foods with lower fat and
lower sodium. The scale consisted of 13 dichotomous
forced-choice items in which students were asked
which food they would choose, e.g., ‘‘Which food would
you ask for, frozen yogurt or ice cream?’’ The food prod-
ucts presented in each item were realistic options for
each comparison, wherein one of the choices was either
lower in sodium, lower in fat, or lower in both than the
other. The standardized coefficient a for this scale was
acceptable (third grade a Å 0.78; fifth grade a Å 0.76).
Usual food choices. This 14-item scale specifically
asked about usual food choices (behavior) in a forced-
choice format, again focusing on lower fat or lower so-
dium food options (third grade a Å 0.76; fifth grade a
Å 0.76). In each item students were asked which of the
two foods presented they eat more often, e.g., ‘‘What
foods do you eat most of the time, cookies or apples?’’
Comparable foods were presented across a variety of
binary choices, with one of the two foods being more
heart healthy than the other. This scale was designed
to measure usual food selections, rather than serve as
a daily record of consumption. Therefore, this scale
measures what a child eats most of the time.
Dietary knowledge. The third scale was knowledge-
based and targeted foods considered heart healthful,
i.e., those foods with lower fat and lower sodium. Stu-
dents were asked to identify which food was ‘‘better for
445
your health,’’ for example, whole wheat bread or white
bread. A total of 14 items were used in the scale, where
one choice was more heart healthful (lower fat, lower
sodium) than the other option (third grade a Å 0.76;
fifth grade a Å 0.78).
Perceived support for physical activity. This section
of the HBQ was divided into two subscales: a positive
support for physical activity subscale (11 items, third
grade a Å 0.68; fifth grade a Å 0.67) and a negative
support subscale (7 items, third grade a Å 0.60; fifth
grade a Å 0.56). The dichotomously scored items at-
tempted to measure perceived support (positive or neg-
ative) for physical activity among family members,
teachers, and friends (e.g., ‘‘One or both of my parents
or guardians do exercises with me like running, jog-
ging, dancing, or skating’’). This scale was developed
specifically for CATCH.
Social reinforcement for healthy food choices. This
21-item scale, developed specifically for CATCH, mea-
sured perceived social reinforcement from family,
teachers, and friends for heart-healthy foods (third
grade a Å 0.86; fifth grade a Å 0.89). Utilizing the
dichotomous forced-choice format, students were asked
whether or not their family members wanted them to
eat the lower fat or lower sodium food presented in the
question (e.g., apples instead of cookies). The scale also
measured students’ perception of social reinforcement
from teachers and friends for eating the same heart-
healthy foods used in the family items. A sample item
is ‘‘Who wants you to eat lots of fruits and vegetables?
Your parents (yes/no)? Your teachers (yes, no)? Your
friends (yes, no)?’’ The potential changes in perceived
reinforcement from the different social groups (par-
ents, teachers, friends) were salient to investigate: we
expected to see an increase in the influence of peers as
the students grew from childhood to preadolescence.
Therefore, coefficient a’s (third and fifth grade, respec-
tively) for each source of social reinforcement are as
follows: social reinforcement from family (a Å 0.58;
0.73) teachers (a Å 0.74; 0.87), and friends (a Å
0.67; 0.83).
Dietary self-efficacy. The 16 items that constituted
this scale measured the children’s self-efficacy to
choose foods lower in fat and sodium. The scale used a
3-point ordinal response set (i.e., not sure, a little sure,
very sure) for each item. As with the other dietary
scales, the children were asked to choose between two
foods or preparation techniques wherein one of the
foods was more heart healthful, e.g., ‘‘How sure are you
that you can eat cereal instead of a donut?’’ (third grade
a Å 0.83; fifth grade a Å 0.87)
Physical activity self-efficacy. The last scale com-
prised five items (third grade a Å 0.67; fifth grade a
446 EDMUNDSON ET AL.
Å 0.69) and followed the 3-point ordinal response set
applied to the dietary self-efficacy scale. These items
measured children’s confidence in their ability to par-
ticipate in various age appropriate aerobic activities.
A sample item from this scale is ‘‘How sure are you
that you can be physically active 3–5 times a week?’’
Several strategies were undertaken to investigate
the validity of these scales. Factorial validity was esti-
mated for the physical activity measures. The food
choices presented in the dietary measures were compa-
rable across all four of the scales, in order to ensure
that any findings observed could be attributed to real
differences between the constructs rather than scaling
artifacts. Additionally, a multiple regression analysis
was employed to explore the concurrent form of crite-
rion-related validity17 for the dietary measures, in
which the usual food choices scale was the dependent
variable. Usual food choice is a measure of behavior
and therefore the logical choice for examining the valid-
ity of the other dietary scales. We conducted this pre-
liminary analysis to examine whether the dietary psy-
chosocial determinants were performing according to
theory. This type of analysis is commonly used to inves-
tigate latent constructs for evidence of validity (as fac-
tor analysis is used to provide evidence of one type of
construct validity).
The outcome of the multiple regression analysis pro-
vided additional evidence of validity for the dietary
scales. Dietary intention was highly correlated with
the dependent variable; to avoid potential suppressor
variable effects, it was not included in the analysis.
CATCH field site, school type, baseline values for the
psychosocial determinants, and determinants by gen-
der interaction terms were included in the model as
fixed effects. Statistically significant (P õ 0.0001) vari-
ables in the model were knowledge, self-efficacy, and
perceived social reinforcement for healthful food
choices from parents and friends. Self-efficacy and per-
ceived social reinforcement from parents for healthy
food choices accounted for approximately 41% of the
variance in usual food choices (partial r Å 0.26 and
0.15, respectively). Perceived social reinforcement from
friends had a partial r Å 0.10. Results indicated the
interactions by gender were not significant for any of
the variables in the model. Overall, the result of this
analysis supported the validity of the dietary psychoso-
cial constructs.
Procedures
During the 1991–1992 academic year, the HBQ was
administered twice, at the beginning and at the end of
the third-grade year, to 6,956 students enrolled in 96
schools at four sites across the United States. The anal-
ysis in this paper employs a cohort of 96 schools, in
which a cross-sectional ‘‘snapshot’’ of psychosocial de-
terminants was taken at each time point. With respect
to children, the analysis is cross-sectional, and the fol-
low-up rate for individual children is not of concern.
With respect to schools, the randomized units, all 96
schools participated at every time point.
Questionnaires were also distributed during the next
2 years to each student in attendance during a regular
class period, in Spring 1993 and Spring 1994 (after the
classroom curriculum had been completed). The ques-
tionnaire was administered as an approved school dis-
trict activity so all students present on that class day
were encouraged and expected to participate.
Survey administrators for all 3 years were members
of the CATCH evaluation staff at each site, who were
trained to implement the standardized protocols devel-
oped by the Coordinating Center. For the purpose of
this study, a standardized protocol refers to strict ad-
herence to one specific protocol, applicable to all four
field sites, which was implemented during every ad-
ministration of the survey. This protocol included in-
structions for survey administration to ensure the in-
tegrity of the data collection process and protect
against a positive response bias. Many strategies were
employed to maximize the integrity of the data; several
will be discussed here.
First, the sequence of the scales within the survey
was such that intention and behavior were measured
prior to knowledge, social reinforcement, and self-effi-
cacy. This arrangement minimized the potential for
students to base their behavioral responses on what
they thought was healthy for them, or what they
thought their parents (or teachers or friends) wanted
them to eat.
Second, evaluation staff, not intervention staff or
teachers, administered the surveys. None of the inter-
vention staff were allowed to participate in the data
collection for these assessments.
The third strategy pertained to the protocol for the
survey administration. The Coordinating Center pro-
vided an annual training which included at least one
representative from each site. These CATCH evalua-
tion staff, in turn, coordinated and supervised the
training of additional evaluation staff back at their site.
To ensure staff compliance with the survey protocol,
each administrator was randomly observed by a data
collection supervisor during the assessment period. Ad-
ditionally, site visits were conducted by the Coordinat-
ing Center during the data collection periods.
The HBQ was read aloud; therefore, survey adminis-
trators were trained to avoid voice inflections which
could be construed to prefer one choice over another.
Each potential administrator was required to master
this skill before being allowed to read the survey to the
children. Additionally, at least two CATCH staff were
present in the room for each administration. One per-
son read the questions aloud, while the students fol-
 DETERMINANTS OF DIET AND PHYSICAL ACTIVITY
lowed and recorded responses onto their copies of the
questionnaire. The second staff person proctored the
survey by walking around answering questions from
the children. Children were not allowed to ask ques-
tions out loud—they were instructed to raise their
hand if they had a question, and the proctor would
come to their desk to answer it. Children were also
instructed to use a cover sheet while they completed
the survey so that their answers would be private.
At the beginning of every section of the survey, chil-
dren were informed that there were no right or wrong
answers and that this was not a test. Teachers stayed
in the classroom during the administration to maintain
class discipline, but were requested not to walk around
and were prohibited from viewing children’s responses.
The questionnaire required approximately 30–40 min
to complete. When the administration was complete,
the questionnaires were collected and immediately re-
moved from the school.
Students whose primary language was Spanish re-
ceived a Spanish version of the questionnaire, while a
bilingual CATCH staff person read the questionnaire
aloud in Spanish. The initial Spanish translation of the
HBQ was supervised by one site and cross-translated
for accuracy by another. The Texas and California sites
alternated these two responsibilities during the 3-year
period. Professional Spanish translators, with experi-
ence in translating elementary school educational ma-
terials, were hired at both sites to ensure the accuracy
and readability level. Less than 2% of the total third-
grade sample, and less than 1% of the fifth-grade sam-
ple, took the Spanish version of the HBQ.
Analysis
Because schools were the randomized units in
CATCH (rather than individual children), the present
analysis was conducted on school-level average mea-
sures of determinants of health behavior. All respon-
dents to the HBQ were included in the school average,
whether or not they were members of the CATCH co-
hort as defined by venipuncture data. The items within
each scale of the HBQ were summed to produce an
individual scale score. The individual scores were ag-
gregated to produce school average scale scores at each
of the four measurement periods (semesters 1, 2, 4, and
6). The number of data points available for each scale
was thus 384 (96 schools 1 4 periods).
Repeated-measures multivariate analysis of vari-
ance (MANOVA) was conducted to determine whether
the CATCH intervention schools diverged from the con-
trol schools over time. The analysis was performed sep-
arately for each HBQ scale as dependent variable. In-
dependent variables in the MANOVA included a main
effect for CATCH field site (3 df), to adjust for any
demographic, geographic, or other site-related varia-
447
tion, in addition to the main effects of time (3 df),
CATCH intervention group (2 df), and time 1 interven-
tion interaction (6 df).
The interaction term was divided into three orthogo-
nal contrasts for the following principal research ques-
tions or tests: (a) Would the separation between inter-
vention and control HBQ scores be different at the end
of CATCH (semester 6), i.e., would CATCH produce a
lasting effect on the HBQ score? (b) Did the separation
between intervention and control HBQ scores change
between baseline (semester 1) and the interim time
points (semesters 2 and 4)? That is, did CATCH pro-
duce at least a transient effect on the HBQ score? (c)
Did the separation, if any, between schools receiving
school-based intervention only and schools receiving
additional home-and-family intervention change over
the four measurement periods, i.e., did the family com-
ponent of CATCH have some effect on the HBQ score?
Numerator degrees of freedom for these three tests
were 1, 2, and 3, respectively. Denominator degrees of
freedom were 279 in each case. To supplement each
significance test, an effect size was calculated as fol-
lows: h Å [F/(F / dfn/dfd,)]1/2, where F indicates the
Fisher F statistic from MANOVA and dfn and dfd indi-
cate numerator and denominator degrees of freedom,
respectively.18
The SAS/STAT MIXED procedure was used for re-
peated-measures analysis.19,20 Additional SAS/STAT
procedures were used for Cronbach a and correla-
tions.21 Pearson product moment correlations were cal-
culated among all of the psychosocial determinants to
investigate several theoretical relationships. First,
SCT5 emphasizes the interactive nature of the relation-
ships among these determinants; thus a sense of the
general strength of each relationship would be ob-
served among reliable and valid measures of the deter-
minants. Second, Bandura and others have reported
that, as the skill acquisition process unfolds, constructs
other than self-efficacy within SCT tend to exert more
influence on behavior, particularly after individuals
have practiced and reached a moderate level of mas-
tery. Therefore, these correlations were calculated for
the intervention and control groups separately, for each
of the four measurement periods, in order to test the
relative strength of these relationships over time.
The effect of gender upon the psychosocial variables
was examined with the multivariate procedure, MAN-
COVA. MANCOVA was used to examine the intermit-
tent and the final effects of each psychosocial determi-
nant by gender, and an h coefficient was calculated for
each variable.
RESULTS
Figures 1, 2, and 3 represent mean differences and
standard errors of the two intervention conditions from
448 EDMUNDSON ET AL.

analysis of each of the subscales of the social reinforce-

ment scale (i.e., reinforcement from friends, parents,
and teachers) revealed a significant effect for gender
during the fifth grade: girls perceived greater reinforce-
ment for healthful eating than boys. Self-efficacy for
dietary choices and physical activity increased moder-
ately during the third grade, but subsequently declined
during the last 2 years of the intervention.
No statistically detectable effect for the perceived
negative or positive support for physical activity was
found at the end of the intervention. Perceived positive
support for physical activity did improve immediately
following the third-grade program, but this effect was
not sustained in the subsequent years. The CATCH
program did not affect a reduction in perceived nega-
tive support for physical activity. (See Fig. 3.) Signifi-
cant improvements were observed in self-efficacy for
physical activity after the third-and fourth-grade inter-
ventions, but dropped to the same levels as controls
during fifth grade. This overall decline in the effects
provides additional support that these findings were
not due to a positive response bias.
The results presented in these figures display base-
line values as well as the outcomes at the completion
of each year of the intervention. The values for the
effect sizes, in this case the h coefficients, provided evi-

FIG. 1. Effects of CATCH intervention on diet-related behavior

and knowledge, according to self-report in elementary-school chil-
dren. All three scales rose significantly in intervention schools com-
pared with control schools in the interim period (spring semester,
grades 3 and 4) and remained significantly elevated at follow-up
(grade 5). Range of each scale is indicated in parentheses. Symbols
indicate estimated mean { standard error, from repeated-measures
analysis of variance. For statistical details see Table 1.

the control condition (which is represented by the bro-

ken line in each figure) at each of the four measurement
periods. Scores for the control condition served as the
contrast values for the repeated measures analysis,
which adjusts for lack of independence among the re-
peated measures.
Dietary intention, usual food choice, and knowledge
improved significantly within the intervention schools,
and that effect was sustained across the 3 years. (See
Fig. 1.) The largest improvement occurred at the begin-
ning of the program. Declines in the effects were ob-
served as the children were exposed to 3 years of the
FIG. 2. Effects of CATCH intervention on diet-related social rein-
intervention; this pattern of a plateau effect or of a forcement and self-efficacy, according to self-report in elementary-
decrease in the size of the effect was not unexpected school children. Both scales rose significantly in intervention schools
for a longitudinal program. compared with control schools at the first interim observation (spring
Figure 2 presents the results for dietary self-efficacy semester, grade 3). Social reinforcement scale remained significantly
and perceived social reinforcement for healthy food elevated at subsequent follow-up periods (grades 4 and 5), while
self-efficacy scale returned to control levels. Range of each scale is
choices. The intervention effect was strongest for the indicated in parentheses. Symbols indicate estimated mean { stan-
reinforcement determinant, and these effects were sus- dard error, from repeated-measures analysis of variance. For statisti-
tained at relatively high levels during all 3 years. An cal details see Table 1.
 DETERMINANTS OF DIET AND PHYSICAL ACTIVITY 449

Only one significant effect was noted between the

school-only condition and the school-plus-family condi-
tion. Students enrolled in the school-plus-family inter-
vention scored significantly higher on the construct di-
etary knowledge (P õ 0.02). None of the other psychoso-
cial determinants were meaningfully different between
the two intervention conditions.
Recall that a MANCOVA was conducted to deter-
mine the effects of gender upon the variable outcomes.
A gender effect was detected only for perceived social
reinforcement from friends for healthful eating, which
was significant for girls. The influence of the family
intervention for girls was observed in the effect size for
dietary knowledge (P õ 0.006). No other significant
gender differences were observed from this analysis.
Pearson correlations between the psychosocial deter-
minants were calculated for all four measurement peri-
ods (i.e., preintervention third-grade baseline and ev-
ery spring after completion of the curriculum for grades
3, 4, and 5). The patterns over time are illustrated here
by the data collected at the end of the third grade and
the end of the fifth grade curriculum: these correlations
are presented in Tables 2a, 2b, 3a, and 3b. Table 2a
illustrates the interrelationships among the variables
when the subjects were in the third grade, while the
second part of the table, 2b, presents the correlations
calculated during the fifth grade for the intervention
FIG. 3. Effects of CATCH intervention on social support and
self-efficacy related to physical activity, according to self-report in
elementary-school children. Positive support and self-efficacy scales
diverged modestly from control at the first interim period (spring TABLE 1
semester, grade 3) but returned to control levels by follow-up (grade
5). Range of each scale is indicated in parentheses. Symbols indicate Effects of CATCH Intervention on Psychosocial
estimated mean { standard error, from repeated-measures analysis Determinants of Cardiovascular Risk Behavior
of variance. For statistical details see Table 1.
Interima Finalb

Effect Effect
dence to determine whether there were longitudinal size Significance size Significance
sustained effects at the end of the 3 years: these results Psychosocial scale (h) (P) (h ) (P)
are presented in Table 1. Intermittent effects that may
Dietary intention 0.581 õ0.001 0.265 õ0.001
have occurred during the third and/or fourth grade, but Usual food choice 0.553 õ0.001 0.236 õ0.001
perhaps did not prevail into the fifth grade, are also Dietary knowledge 0.661 õ0.001 0.406 õ0.001
presented. Scores from the intervention schools were Physical activity
significantly higher for each dietary related scale, with Positive support 0.202 0.003 0.021 0.70
Negative support 0.048 0.72 0.047 0.43
the most substantial differences observed for the di- Food choice
etary social reinforcement, intention to eat healthy, Social
and knowledge scales. Table 1 illustrates the effect reinforcement,
sizes and P values for the mean HBQ scale scores, com- total 0.591 õ0.001 0.452 õ0.001
paring the control group with the combined interven- From friends 0.395 õ0.001 0.123 0.040
From parents 0.501 õ0.001 0.342 õ0.001
tion groups, adjusted for preintervention values as well From teachers 0.645 õ0.001 0.600 õ0.001
as site and school variation. There was no significant Self-efficacy
interaction between intervention effect and gender. Dietary 0.235 õ0.001 0.102 0.088
Ethnic composition of the school at each time point, Physical activity 0.171 0.016 0.107 0.074
when added to the MANOVA as a school-level covariate a
From F test of H0 : (intervention 0 control)semesters2,4 Å (interven-
(in the form of the percentages of Caucasian, African- tion 0 control)semester1; df Å 2, 279.
American, and Hispanic respondents), had negligible b
From F test of H0 : (intervention 0 control) semester 6 Å (intervention
impact on the statistical inferences and effect sizes. 0 control) semester1 ; df Å 1, 279.
450 EDMUNDSON ET AL.

TABLE 2a
Descriptive Statistics and Pearson Correlations among Psychosocial Determinants for Third-Grade Students
after 1 Year of CATCH Intervention—Intervention Condition (n Å Approx 4,400)

Measure 1 2 3 4 5 6 7 Mean SD

1. Dietary intention — 6.29 6.39

2. Usual food choices 0.72* — 4.27 7.28
3. Dietary knowledge 0.45* 0.38* — 9.46 4.76
4. Diet. soc. reinforcement 0.45* 0.44* 0.37* — 6.92 9.78
5. Dietary self-efficacy 0.51* 0.51* 0.36* 0.40* — 7.69 6.57
6. Positive support for PA 0.26* 0.29* 0.20* 0.38* 0.31* — 6.40 4.43
7. Negative support for PA 0.14* 0.12* 0.28* 0.20* 0.19* 0.24* — 4.34 2.89
8. Phys. act. self-efficacy 0.29* 0.31* 0.26* 0.30* 0.53* 0.38* 0.18* 2.97 2.24

* All correlations are significant at P õ 0.0001.

group. Tables 3a and 3b present the correlations for
the control group.
The correlation matrices revealed weak to moderate
interrelationships among most of the determinants,
with one exception. The relationship between intention
and usual food choices remained high (r Å 0.73 to 0.76)
across all 3 years. According to Bandura,7,8 intention
is a proximal goal; thus the students were setting short-
term goals which were compatible with their reported
usual behavior. Although the correlation between in-
tention and usual food choice behavior suggested simi-
larity between the constructs, the relationship demon-
strated a theoretically consistent amount of unshared
variance, in this case about 66% (the coefficient of
alienation value, or k).21 Therefore, the empirical evi-
dence reflected very well the hypothesized theoretical
relationship for both the intervention and the control
group.
Excluding the correlation between intention and
usual food choices, the correlations among the dietary
constructs (knowledge, usual behavior, self-efficacy,
and intention) were moderate, which provided empiri-
cal evidence for the unique variance expressed by those
constructs. This evidence demonstrates that the con-
structs are not the same, and the scales used to mea-
sure the constructs were valid and adequately sensitive
to detect the dissimilarity as well as the similarity
among the constructs.
Correlations among the physical activity determi-
nants remained about the same across the 3 years of
measures for control and intervention groups. Physical
activity self-efficacy was moderately correlated with
perceived positive support for physical activity, while
the relationship between self-efficacy and perceived
negative support was weak.
DISCUSSION
The combined effects of the classroom curriculum
strategies, environmental changes in the school food
service, and the physical education program did lead
to changes in what children themselves expect to do,
their confidence in being able to perform the behavior,
and their perceived support for their behavior to con-
sume lower fat, lower sodium food, and to engage in
additional moderate-to-vigorous physical activity. Sig-
nificant effects were found early in the intervention for

TABLE 2b
Descriptive Statistics and Pearson Correlations among Psychosocial Determinants for Fifth-Grade Students
after 3 Years of CATCH Intervention—Intervention Condition (n Å Approx 4,250)

Measure 1 2 3 4 5 6 7 Mean SD

1. Dietary intention — 1.19 6.58

2. Usual food choices 0.76* — 0.33 6.87
3. Dietary knowledge 0.32* 0.32* — 10.09 4.88
4. Diet. soc. reinforcement 0.45* 0.44* 0.30* — 3.54 10.20
5. Dietary self-efficacy 0.54* 0.54* 0.32* 0.37* — 5.77 7.15
6. Positive support for PA 0.25* 0.26* 0.23* 0.31* 0.28* — 5.76 4.38
7. Negative support for PA 0.16* 0.17* 0.34* 0.18* 0.23* 0.32* — 4.93 2.61
8. Phys. act. self-efficacy 0.24* 0.27* 0.24* 0.22* 0.46* 0.39* 0.22* 2.79 2.24

* All correlations are significant at P õ 0.0001.

 DETERMINANTS OF DIET AND PHYSICAL ACTIVITY 451

TABLE 3a
Descriptive Statistics and Pearson Correlations among Psychosocial Determinants
for Third-Grade Students—Control Condition (n Å Approx 3,100)

Measure 1 2 3 4 5 6 7 Mean SD

1. Dietary intention — 1.95 6.22

2. Usual food choices 0.70* — 0.54 6.41
3. Dietary knowledge 0.46* 0.39* — 5.43 5.54
4. Diet. soc. reinforcement 0.42* 0.38* 0.32* — 0.43 9.72
5. Dietary self-efficacy 0.44* 0.41* 0.35* 0.30* — 6.08 6.62
6. Positive support for PA 0.23* 0.23* 0.22* 0.30* 0.22* — 5.56 4.60
7. Negative support for PA 0.18* 0.12* 0.32* 0.13* 0.21* 0.17* — 3.86 3.11
8. Phys. act. self-efficacy 0.25* 0.25* 0.27* 0.23* 0.46* 0.33* 0.18* 2.52 2.34

* All correlations are significant at P õ 0.0001.

some of the physical activity determinants; however,
those effects were not significant by fifth grade.
The effects of CATCH could have been diluted by
the loss of exposed students and the in-migration of
unexposed students. This could lead to Type II error,
i.e., failing to obtain significant findings where effects
actually existed. With respect to these results, how-
ever, we did not lack for significant findings. Therefore,
Type II error was not a great concern.
Alternately, the effects observed from the CATCH
intervention could have been positively biased by the
children, who may have responded to please the inves-
tigators, rather than reporting their true beliefs and
behaviors. This potential threat to obtaining valid re-
sults from survey research is called social desirability
bias. To minimize this potential influence upon the
data, a rigorous survey administration protocol was
implemented. The protocol was grounded in state of
the art recommendations for survey research and psy-
chometric data collection. Strict adherence to this pro-
tocol was discussed earlier in this paper. While these
procedures may not have completely prevented the in-
fluence of social desirability bias, the results indicate
that students did not aim to please the investigators
for several of the variables. Therefore, we do not believe
this potential source of bias greatly affected the effects
reported in this study.
Implications for School-Based Health Promotion
Programs for Youth
Although significant effects were noted for most of
the psychosocial determinants, the decline in all of the
fifth-grade measures implies a need for programming
modifications for older preadolescents. At a time when
youth are preparing for the transition from childhood
to adolescence and from elementary school to middle
school, the influence of the developmental stage and
the perceived cultural demands rapidly increases.
Thus, the preadolescents are in flux, which lays the
groundwork for the competitive influences of other psy-
chosocial factors with the CATCH program. Develop-
mentally, children begin to experience a need for auton-
omy as well as peer approval. These seemingly conflict-
ing needs tend to result in a shift from parental/adult
influence to peer influence upon behavior. The out-
comes observed in the fifth graders with regard to the
decreased support from friends for nutritional eating

TABLE 3b
Descriptive Statistics and Pearson Correlations among Psychosocial Determinants
for Fifth-Grade Students—Control Condition (n Å Approx 2,900)

Measure 1 2 3 4 5 6 7 Mean SD

1. Dietary intention — 00.83 5.93

2. Usual food choices 0.75* — 01.16 6.30
3. Dietary knowledge 0.34* 0.34* — 7.73 5.44
4. Diet. soc. reinforcement 0.38* 0.37* 0.29* — 02.31 10.97
5. Dietary self-efficacy 0.46* 0.45* 0.33* 0.21* — 5.99 7.16
6. Positive support for PA 0.17* 0.17* 0.18* 0.24* 0.18* — 5.62 4.33
7. Negative support for PA 0.14* 0.15* 0.30* 0.14* 0.17* 0.28* — 4.66 2.68
8. Phys. act. self-efficacy 0.18* 0.19* 0.22* 0.15* 0.40* 0.32* 0.20* 2.86 2.20

* All correlations are significant at P õ 0.0001.

452 EDMUNDSON ET AL.
among males and declining self-efficacy may be a re-
flection of this shift.
In particular, the decline in self-efficacy may relate
to a failure in the curriculum to effectively identify
salient barriers encountered by the fifth graders to se-
lecting healthy food items. Bandura8 has emphasized
the successful mastery of activities which are contin-
gent upon experiences that are very similar to situa-
tions regularly faced in the environment. Mastery and
self-efficacy can be undermined by verbal persuasion
(such as high-tech, sophisticated mass media messages
portrayed in advertisements) and social influences of
the environment8 (e.g., the cultural popularity of high
fat, fast food meals and convenience snacks and seden-
tary social activities).
Given the increasing pressure of social conformity,
shifts in social support networks, and increasing inde-
pendence experienced during early adolescence,23,24 it
is possible that the environmental and psychosocial
barriers experienced by the fifth graders in their daily
lives were not adequately addressed by the curriculum
skill-building activities or mechanisms of social sup-
port. The predictive strength of self-efficacy has been
demonstrated in some studies to decline over time.9,25,26
This is due in part to an increase in the salience of
other influences as a task becomes less new, and the
dynamic changing nature of behavior and its context,
rendering previous efficacy judgments less predictive.
Therefore, perhaps the fifth-grade curriculum was of
insufficient intensity and duration to achieve mastery
or at least balance the environmental and social
changes encountered in the rapidly changing world of
the preadolescent. On the other hand, there may be a
limit to the power of a school-based curriculum in the
face of the dominant culture.
As image and social needs become more important
in decision making, cultural messages become more
valued. The act of eating may shift in meaning from a
nutritional event to a social event; food choices may
become signs of camaraderie or symbols of indepen-
dence. As a result, programs for students in fifth grade
and higher may need to account for the differences in
meanings of dietary behaviors, as well as the high prev-
alence of convenience stores and fast food restaurants
where students often socialize.
Implications for Physical Activity and Measurement
of Determinants
The initial effects upon the physical activity determi-
nants observed during the 1st year of the intervention
were not sustained. Possible explanations may relate
to the curriculum, environmental support, or actual
activity trends.27 – 29. For example, the CATCH PE cur-
riculum was not designed to directly influence external
sources of support or reinforcement for physical activ-
ity. The dominant goal of the PE curriculum was to
increase the amount of moderate to vigorous physical
activity during PE class with activities that were fun
and cooperative. Although the CATCH classroom cur-
riculum included lessons designed to influence the psy-
chosocial determinants of physical activity, fewer les-
sons were devoted to physical activity compared with
dietary change. Because the students were receiving a
curriculum devoted to physical activity via CATCH PE,
and because of the practical limitations of how many
classroom health education lessons could be taught,
the classroom curricula included proportionately more
dietary lessons. Assumptions regarding the indirect ef-
fects of such physical activity programs on psychosocial
determinants of behavior should be examined.
The CATCH findings on perceived social support may
also help explain the decline of physical activity with
age that has been observed in school-age children and
adolescents. Physical activity options span a broad
range of involvement. This includes individual activi-
ties, team play, and even sedentary activities, all of
which the child chooses to initiate, or to join a some-
what organized group, in order to participate. Per-
ceived support for these efforts could prove crucial for
the child’s participation. Even when physical activity
is a positively valued experience, participation often
requires planning and resources to ensure access to
equipment and a relatively safe place to play; many
activities also require the availability of teammates.
Physical activity choices have been previously demon-
strated to change over time, particularly for girls, who
become less active and engage in more sedentary social
activities as they become older.29,30
The lower reliability coefficients for the physical ac-
tivity scales and the trends over time suggest a need
for modifications in the measurement approach of the
psychosocial determinants of physical activity used in
CATCH, the measurement of additional determinants,
and possibly a better match between the goals and ob-
jectives of the PE curriculum with SCT.5 These recom-
mendations are timely: sedentary behavior tracks
over adolescence and adulthood and is resistant to
change.30 – 32 Additional research with psychometrically
sound measures that span several SCT determinants,
which in turn can be used to ground the physical activ-
ity intervention, could help break the pattern for seden-
tary behavior among youth.
Implications for Future Research
Our findings support the results of other studies
which demonstrated that SCT and social influences
theory methods can be effectively applied to school
health promotion programs.30 – 36 Additional studies
which evaluated school-based smoking or substance
abuse prevention programs have reached similar con-
 DETERMINANTS OF DIET AND PHYSICAL ACTIVITY
clusions regarding the relative effectiveness of health
promotion programs based on social cognitive or social
influences theories for youth.37,38,39 – 42 Evidence sup-
porting the need to move beyond knowledge-only ap-
proaches into theory-based programming was de-
scribed in the recent Surgeon General’s report on pre-
venting tobacco use among young people.43
The body of evidence on this new generation of school
health promotion implicates several salient features
which appear to account for the effectiveness of school-
based programs. These features include interventions
of longer duration, community and environmental sup-
port, comprehensive programming, and changing social
norms and influences.42,44 – 47 Analyses of smoking pre-
vention program effectiveness, including meta-analy-
ses, emphasize the importance of modifying social in-
fluences for creating sustained effects.40 – 42,48,49 Results
from smoking interventions that have been primarily
school-based, without the support or training of the
family or community (via mass media or family-based
programs), have also been limited.46,50
The comparison between the school-based interven-
tion condition and the school- plus-family intervention
condition revealed a greater improvement in dietary
knowledge of lower fat and lower sodium foods for those
students who had the additional family intervention.
However, there were no additive effects as a result of
the family intervention upon the other dietary determi-
nants nor for the determinants of physical activity be-
havior. The family program implemented in CATCH
may not have sufficient power to influence additional
effects in the psychosocial variables. These findings de-
part from previous health promotion research which
targets a single behavior (eating) among young chil-
dren: the multiple behaviors addressed by CATCH may
require family programs of longer duration and greater
involvement.10 Alternatively, the family program may
not have been sufficiently implemented by parents.
This question cannot be answered by the CATCH proj-
ect: parental involvement data were not collected. We
recommend that future research studies investigate
these questions on family involvement more thor-
oughly.
CONCLUSION
The results presented in this paper provide evidence
for the effectiveness of the CATCH program to influ-
ence changes in the psychosocial determinants of diet
and physical activity behavior. These results are en-
couraging because the CATCH program represents an
effort to translate theoretical methods of behavior
change into practical strategies that can work in a
school setting. These findings can help improve our
understanding of the application of theory to practical
problems and improve the development and design of
453
instruments used to evaluate the psychosocial determi-
nants of school-based health promotion programs.
Since CVD risk factors have their origins early in life,
early interventions through school-based programs
represent the most promising means of reaching an
entire population of children in a community to modify
risk factors that lead to CVD during adulthood.
Applying the causal model assumed in the CATCH
project, the starting place to reduce risk is to address
the psychosocial determinants that lead to lifestyle be-
haviors that contribute to increased risk for CVD. The
evaluation of CATCH suggests that we can be success-
ful in this first step.
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