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Objective: To evaluate Watch, Discover, Think and Act (WDTA), a theory-based application of CD-ROM educational technology for pediatric asthma self-management education. Design: A prospective pretest posttest randomized intervention trial was used to assess the motivational appeal of the computer-assisted instructional program and evaluate the impact of the program in eliciting change in knowledge, self-efficacy, and attributions of children with asthma. Subjects were recruited from large urban asthma clinics, community clinics, and schools. Seventy-six children 9 to 13 years old were recruited for the evaluation. Results: Repeated-measures analysis of covariance showed that knowledge scores increased significantly for both groups, but no between-group differences were found ( P = 0.55); children using the program scored significantly higher ( P < 0.01) on questions about steps of self-regulation, prevention strategies, and treatment strategies. These children also demonstrated greater selfefficacy ( P < 0.05) and more efficacy building attribution classification of asthma self-management behaviors ( P < 0.05) than those children who did not use the program. Conclusion: The WDTA is an intrinsically motivating educational program that has the ability to effect determinants of asthma self-management behavior in 9- to 13-year-old children with asthma. This, coupled with its reported effectiveness in enhancing patient outcomes in clinical settings, indicates that this program has application in pediatric asthma education.

article i nfo Keywords: Epilepsy Self-management e-Health Internet Technology e-Health tools Quality of life Meaningful access The Managing Epilepsy Well (MEW) Network was established in 2007 by the Centers for Disease Control and Prevention Epilepsy Program to expand epilepsy self-management research. The network has employed collab- orative research strategies to develop, test, and disseminate evidence-based, community-based, and e-Health interventions (e-Tools) for epilepsy self-management for people with epilepsy, caregivers, and health-care pro- viders. Since its inception, MEW Network collaborators have conducted formative studies (n = 7) investigating the potential of e-Health to support epilepsy self-management and intervention studies evaluating e-Tools (n = 5). The MEW e-Tools (the MEW website, WebEase, UPLIFT, MINDSET, and PEARLS online training) and af- filiated e-Tools (Texting 4 Control) are designed to complement self-management practices in each phase of the epilepsy care continuum. These tools exemplify a concerted research agenda, shared methodological principles and models for epilepsy self-management, and a communal knowledge base for implementing e-Health to im- prove quality of life for people with epilepsy.

BACKGROUND This study examined the acceptability and feasibility of using a biological outcome measure to evaluate a school-based sexuality education program. Confidential field-delivered sexually transmitted infection (STI) testing by nonmedical field staff and STI treatment by medically trained field staff was assessed in off-campus and off-clinic settings for adolescents enrolled in the trial. METHODS After parental and adolescent consent were obtained, a convenient time and location was identified to collect urine to test for chlamydia (Chlamydia trachomatis, CT), gonorrhea (Neisseria gonorrheae, NG), and trichomonas (Trichomonas vaginalis, TV) infection and to treat students with positive results. RESULTS A total of 391 of 1742 students had permission to participate (22%); 353 (90%) provided urine samples; 28 (8%) had positive test results: CT(18), NG(5), and TV(8). Testing and treatment occurred at home for 92% and 59% of students, respectively; on weekdays (for 69% and 96%, respectively) and between noon and 8 pm (for 76% and 88%, respectively). All students who tested positive were treated. Several lessons and strategies that may improve the likelihood that students will participate in field-delivered STI testing and treatment emerged. CONCLUSION STI testing and treatment are feasible for students enrolled in a school-based sexuality education program. However, obtaining parental consent may be challenging.

A set of mediation analyses were carried out in this study using data from It’s Your Game. . .Keep It Real (IYG), a successful HIV/STI/pregnancy prevention program. The IYG study evaluated a skill and normbased. HIV/STI/pregnancy prevention program that was implemented from 2004 to 2007 among 907 urban low-income middle school youth in Houston, TX, USA. Analyses were carried out to investigate the degree to which a set of proposed psychosocial measures of behavioral knowledge, perceived self-efficacy, behavioral, and normative beliefs, and perceived risky situations, all targeted by the intervention, mediated the intervention’s effectiveness in reducing initiation of sex. The mediation process was assessed by examining the significance and size of the estimated effects from the mediating pathways. The findings from this study provide evidence that the majority of the psychosocial mediators targeted by the IYG intervention are indeed related to the desired behavior and provide evidence that the conceptual theory underlying the targeted psychosocial mediators in the intervention is appropriate. Two of the psychosocial mediators significantly mediated the intervention effect, knowledge of STI signs and symptoms and refusal self-efficacy. This study suggests that the underlying causal mechanisms of action of these interventions are complex and warrant further analyses.

H IGH INTAKE OF SUGAR-SWEETENED BEVERAGES and energy-dense foods, as well as low intake of healthy foods such as fruits, vegetables, and whole grains, has been linked to childhood obesity in the United States. School and after-school settings are promising locations to promote healthy nutrition to children, but barriers such as the need to expend resources for staff trainings and frequent staff turnover hamper successful implementation. Innovative approaches are needed to mitigate these barriers while providing educational fidelity, seamless implementation within the school day, and minimal teacher oversight. Educational video games may contribute to a solution. During the last decade, increasing research and application of serious games has demonstrated a positive impact on children’s cognitive development, dietary habits, andphysical activity behavior. However, few evidence-based educational games are currently available for elementary school children. The purpose of this article is to describe the theoretical foundation, function, andpreliminary feasibility results of a new three-dimensional (3D) computer-based video game for nutrition education in children (8 to 12 years of age): The Quest to Lava Mountain (QTLM).

Purpose To evaluate the efficacy of two, theory-based, multimedia, middle school sexual education programs in delaying sexual initiation. Methods Three-armed, randomized controlled trial comprising 15 urban middle schools; 1,258 predominantly African American and Hispanic seventh grade students followed into ninth grade. Both programs included group and individualized, computer-based activities addressing psychosocial variables. The risk avoidance (RA) program met federal abstinence education guidelines; the risk reduction (RR) program emphasized abstinence and included computer-based condom skills-training. The primary outcome assessed program impact on delayed sexual initiation; secondary outcomes assessed other sexual behaviors and psychosocial outcomes. Results Participants were 59.8% females (mean age: 12.6 years). Relative to controls, the RR program delayed any type of sexual initiation (oral, vaginal, or anal sex) in the overall sample (adjusted odds ratio [AOR]: .65, 95% CI: .54–.77), among females (AOR: .43, 95% CI: .31–.60), and among African Americans (AOR: .38, 95% CI: .18–.79). RR students also reduced unprotected sex at last intercourse (AOR: .67, 95% CI: .47–.96), frequency of anal sex in the past 3 months (AOR: .53, 95% CI: .33–.84), and unprotected vaginal sex (AOR: .59, 95% CI: .36–.95). The RA program delayed any sexual initiation among Hispanics (AOR: .40, 95% CI: .19–.86), reduced unprotected sex at last intercourse (AOR: .70, 95% CI: .52–.93), but increased the number of recent vaginal sex partners (AOR: 1.69, 95% CI: 1.01–2.82). Both programs positively affected psychosocial outcomes. Conclusions The RR program positively affected sexually inexperienced and experienced youth, whereas the RA program delayed initiation among Hispanics and had mixed effects among sexually experienced youth.

We compared the scores on self-management and associated psychosocial scales of patients with epilepsy at two clinics in Houston, TX, USA, to determine if there were systematic differences associated with socioeconomic status (SES). Patients of low SES reported higher scores on overall, information, and safety management (P

Improvements in the medical management of HIV have reduced the rate of perinatal transmission from mothers to their children, and 91% of U.S. children with perinatally acquired HIV survive into adolescence and young adulthood.1 Nevertheless, youth continue to acquire HIV through risky behaviors such as unprotected sex and injection-drug use. The Centers for Disease Control and Prevention (CDC) estimates that at least half of all new HIV infections in the United States are among people younger than 25 and are largely due to these two risk behaviors.1 The extended survival of perinatally infected youth, combined with rising numbers of behaviorally infected youth, presents health care providers with the critical challenge of providing HIV-positive youth with information and methods to prevent secondary HIV transmission. Successes in HIV medical management have not been matched by successes in behavioral interventions to curtail risky behaviors among HIV-positive youth. Despite researchers’ advanced understanding of the pathophysiology and transmission of HIV, as well as the use of clinic-based education relating to risk reduction, the translation of relevant health messages into behavioral practice remains flawed, as HIV-positive youth continue to engage in risky behaviors.2–6 In one study, 43% of HIV-positive youth reported not using a condom at last intercourse.2 A small number of behavioral interventions for HIV-positive youth have been rigorously evaluated, but the assessment of their effectiveness has been hampered by poor attendance.5,7,8 To fully understand the challenges of preventing secondary HIV transmission among youth, the experiences of both HIV-positive youth and health care providers need to be explored. Although quantitative studies9–11 have examined the attitudes and perceptions of such youth toward sexual risk reduction and disclosure of their HIV status, qualitative data to inform the development of interventions have been limited.12,13 Furthermore, little is known about providers’ attitudes toward risk reduction and disclosure among HIV-positive youth.14 The present study explores the views of health care providers and HIV-positive youth about disclosure and sexual risk reduction, and suggests how prevention efforts and clinical behavioral interventions might be strengthened.

Serious games are gaining profile as a novel strategy to impact health behavior change in the service of national health objectives. Research has indicated that many evidence-based programs are effective because they are grounded in behavioral and motivational theories and models such as the PRECEDE model, the Health Belief Model, Social Cognitive Theory, the Theory of Reasoned Action, the Transtheoretical Model, Attribution Theory, and the ARCS model. Such theories assist in understanding health behavior problems, developing salient interventions, and evaluating their effectiveness. It follows, therefore, that serious games can be made optimally effective in changing health behavior if they are also informed by these theories. A successful intervention development framework (Intervention Mapping) provides a means to enable game developers to use theory to inform the design of effective games for health. This chapter describes useful theories and models for health game design, introduces the intervention mapping process, and describes a case study of a theory- and empirically-based serious health game intervention that has used these approaches and has been rigorously evaluated.

E-learning applications are becoming ubiquitous in the classroom. However, they are more commonly implemented within the context of flat, 2D content presentation and testing. In some cases an immersive, 3D learning environment may be more compelling, yet implementation of these systems is often costly and resource-intensive, requiring high-cost development tools and hard to find skill sets. This paper describes a low-cost innovative development and implementation of a successful LAN-based HIV, STD, pregnancy prevention middle school curriculum that featured a 3D gaming interface, 2D tailored activities, and video components. The resulting 3D virtual world containing embedded, pre-existing, 2D activities and video at activity stations met criteria for functionality and usability while meeting educational objectives and cost constraints.

Asthma has emerged as a significant chronic disease affecting an estimated 300 million people worldwide (Masoli et al. 2004), including over 20 million people in the United States. Poor asthma control results in significant morbidity including lost work days for adults and school days for children (11.8 million and 14.7 million, respectively, in 2002), preventable mortality (estimated at 4,261 deaths per year), and also contributes substantially to the burden of health-care expenditures (estimated at a total cost of $16.1 billion in 2004) (Schiller and Bernadel 2004; NHLBI 2004). Prevalence of childhood asthma, as estimated in the 2007 National Health Information Survey, remains at historically high levels with 9.1% of children (6.7 million) estimated to have asthma (Akinbami et al. 2009). Controlling asthma is a public health challenge. Complicating this are reported discrepancies in how asthma is managed by health-care providers and patients. These discrepancies include under-estimation of disease severity by patients (Worstell 2000), under-treatment of symptoms by health-care providers (Wolfenden et al. 2003), low rates of outpatient follow-up after emergency room visits and hospitalizations (Smith et al. 2004; Cabana et al. 2003), and under-utilization of preventive measures such as influenza vaccination (Figaro and Belue 2005).

Purpose This study tested the effects of a theory-based, middle-school human immunodeficiency virus, STI, and pregnancy prevention program, It's Your Game: Keep it Real ( IYG ), in delaying sexual behavior. We hypothesized that the IYG intervention would decrease the number of adolescents who initiated sexual activity by the ninth grade compared with those in the comparison schools. Methods The target population consisted of English-speaking middle school students from a large, urban, predominantly African-American and Hispanic school district in Southeast Texas. Ten middle schools were randomly assigned either to receive the intervention or to the comparison condition. Seventh-grade students were recruited and followed through ninth grade. The IYG intervention comprises 12 seventh-grade and 12 eighth-grade lessons that integrate group-based classroom activities with computer-based instruction and personal journaling. Ninth-grade follow-up surveys were completed by 907 students (92% of the defined cohort). The primary hypothesis tested was that the intervention would decrease the number of adolescents who initiated sexual activity by the ninth grade compared with those in the comparison schools. Results Almost one-third (29.9%, n=509) of the students in the comparison condition initiated sex by ninth grade compared with almost one-quarter (23.4%, n=308) of those in the intervention condition. After adjusting for covariates, students in the comparison condition were 1.29 times more likely to initiate sex by the ninth grade than those in the intervention condition. Conclusions A theory-driven, multi-component, curriculum-based intervention can delay sexual initiation up to 24 months; can have impact on specific types of sexual behavior such as initiation of oral and anal sex; and may be especially effective with females. Future research must explore the generalizabilty of these results.

Translating behavioral theories, models, and strategies to guide the development and structure of computer-based health applications is well recognized, although a continued challenge for program developers. A stepped approach to translate behavioral theory in the design of simulations to teach chronic disease management to children is described. This includes the translation steps to: 1) define target behaviors and their determinants, 2) identify theoretical methods to optimize behavioral change, and 3) choose educational strategies to effectively apply these methods and combine these into a cohesive computer-based simulation for health education. Asthma is used to exemplify a chronic health management problem and a computer-based asthma management simulation (Watch, Discover, Think and Act) that has been evaluated and shown to effect asthma self-management in children is used to exemplify the application of theory to practice. Impact and outcome evaluation studies have indicated the effectiveness of these steps in providing increased rigor and accountability, suggesting their utility for educators and developers seeking to apply simulations to enhance self-management behaviors in patients.

Background: Methamphetamine use is associated with numerous adverse physical and mental health outcomes. This study investigated the prevalence and distribution of lifetime methamphetamine use (MU) as well as the association between methamphetamine use and engagement in sexual risk behaviors among a nationally representative sample of U.S. high school students. Methods: A secondary analysis of the 2003 Youth Risk Behavior Survey (n = 15,240) was carried out. Weighted descriptive and logistic regression analyses were conducted to determine the prevalence of MU by socio-demographic characteristics and the association between drug use and sexual risk behaviors. Results: Prevalence of having used methamphetamine ≥1 times (lifetime methamphetamine use) (7.6%; 95%CI ± 1.0) was comparable to lifetime cocaine use but over double the rate of lifetime heroin use. Males reported slightly higher MU than females (8.3%±1.4 vs. 6.8%±1.0). MU was more than twice as high for white (8.1%±1.1) and Hispanic (8.2%±2.2) students compared to black students (3.1%±1.0). MU was associated with ∼2 to 11 times the likelihood of engaging in one of the six sexual risk behaviors examined. Heavy methamphetamine users were >4 times more likely to report having had sexual intercourse before age 13, sex with multiple partners, and having been/gotten someone pregnant compared to those who used methamphetamine 1–2 times. Conclusion: Findings indicate that a substantial number of U.S. youth have used methamphetamine, that white and Hispanic high school students may be at higher risk for methamphetamine use, and that methamphetamine users may be at higher risk for engaging in sexual risk behaviors.

The "Partners in School Asthma Management" program for inner-city elementary school children comprises (1) case finding; (2) linkage of school nurses, parents, and clinicians; (3) a computer-based tailored educational program; and (4) school environmental assessment and intervention. Case finding identified 1730 children in 60 elementary schools with probable asthma; 835 (96% Hispanic or African American) joined the study. Baseline, posttest, and follow-up measures of asthma knowledge, self-efficacy, and self-management behavior were obtained from the children, and data on symptoms, emergency department visits, and hospitalizations were obtained from their parents. The schools provided data on grades and absences. Each school had a baseline and follow-up environmental assessment. The children in the intervention group showed greater increases in knowledge, self-efficacy, and some aspects of self-management. No differences between groups were found in health status variables, school performance, attendance, or levels of environmental allergens in schools. In 15 schools, an enhanced intervention allowed children and their parents to meet with a project physician, develop an asthma action plan, and receive a 1-month supply of medication; the project physician then followed up with the child's community physician. Children participating in this enhanced intervention had better school performance and fewer absences than the comparison group. Overall, the program was effective in improving children's asthma self-management but not in improving their health status. While the case-finding, computer-based self-management training program and linkage system were successfully implemented, the program failed in creating needed changes in the medical (action plans by community physicians) and physical environments (reduced school allergen levels) of the children.

Existing guidelines for the clinical management of asthma provide a good framework for such tasks as diagnosing asthma, determining severity, and prescribing pharmacological treatment. Guidance is less explicit, however, about establishing a patient-provider partnership and overcoming barriers to asthma management by patients in a way that can be easily adopted in clinical practice. We report herein the first developmental phase of the "Stop Asthma" expert system. We describe the establishment of a knowledge base related to both the clinical management of asthma and the enhancement of patient and family self-management (including environmental management). The resultant knowledge base comprises 142 multilayered decision rules that describe clinical and behavioral management in three domains: 1) determination of asthma severity and control; 2) pharmacotherapy, including prescription of medicine for chronic maintenance, acute exacerbation, exercise pretreatment, and rhinitis relief; and 3) patient self-management, including the process of intervening to facilitate the patient's asthma medication management, environmental control, and well-visit scheduling. The knowledge base provides a systematic and accessible approach for intervening with family asthma-related behaviors.

An interactive multimedia computer game to enhance self-management skills and thereby improve asthma outcomes in inner city children with asthma was evaluated. Subjects aged 6-17 were recruited from four pediatric practices and randomly assigned to the computer intervention condition or to the usual-care comparison. The main character in the game could match the subject on gender and ethnicity. Characteristics of the protagonist's asthma were tailored to be like those of the subject. Subjects played the computer game as part of regular asthma visits. Time between pre- and post-test varied from 4 to 15.6 months (mean, 7.6 months). Analysis of covariance, with pre-test scores, age, and asthma severity as covariates, found that the intervention was associated with fewer hospitalizations, better symptom scores, increased functional status, greater knowledge of asthma management, and better child self-management behavior for those in the intervention condition. Interactions with covariates were found and discussed in terms of variable efficacy of the intervention.

In this report we describe the development of the Watch, Discover, Think and Act asthma self-management computer program for inner-city children with asthma. The intervention focused on teaching two categories of behaviors – asthma specific behaviors such as taking preventive medication and self-regulatory processes such as monitoring symptoms and solving asthma problems. These asthma self-management behaviors were then linked with empirical and theoretical determinants such as skills and self-efficacy. We then further used behavioral science theory to develop methods such as role modeling and skill training linked to the determinants. We matched these theoretical methods to practical strategies within the computer simulation and created a culturally competent program for inner-city minority youth. Finally, we planned a program evaluation that linked program impact and outcomes to the theoretical assumptions on which the intervention was based.