INVESTMENTS TO PROMOTE CHILDREN ‘S HEALTH :
A systematic literature review and economic analysis
of interventions in the preschool period
Bernard Guyer
Sai Ma
Holly Grason
Kevin Frick
Deborah Perry
Alyssa Wigton
Jennifer McIntosh
Women‘s and Children‘s Health Policy Center
John Hopkins Bloomberg School of Public Health
Baltimore, MD
ACKNOWLEDGEMENTS:
This study is funded by both the Partnership for America‘s Economic Success and the Zanvyl and
Isabelle Krieger Fund. The authors appreciate the thoughtful review from Susan Bale and Beth Hare,
and the great support from Sara Watson, Elaine Weiss, and Lauren Zerbe.
Release date: January 22, 2008
ABSTRACT
In this study, we argue that poor health of children is not merely a product of individual choices, but rather, it is
shaped by a broad set of environmental, genetic, and socioeconomic determinants that affect children both
directly and through the conditions that confront their families. Furthermore, poor child health outcomes can
disadvantage everyone in the society, as both workforce productivity and community stability are greatly
affected by the way that health gets built into the early brain architecture of the developing child. The present
study examines both the short- and long-term economic and health impact of health promotion and disease
preventive interventions on four selected health problems of particular concern to young children (prenatal to
age five) – exposure to tobacco use, obesity, unintentional injury, and mental health problems. The results
show compelling evidence of the long-term health impact and societal economic burdens of these four
problems when manifested in the preschool years. While the evidence on the effectiveness of preventive
interventions is uneven, it does show that, from society‘s perspective, the benefits outweigh the costs of such
interventions. We conclude this review by making the case that adopting an ―investment‖ approach to
children‘s health policy offers new opportunities to enhance the health and economic well-being of the entire
U.S. population.
BACKGROUND
The National Research Council/Institute of Medicine report From Neurons to Neighborhoods (2000)1
reviewed the biological, behavioral, social, and environmental forces that shape the growth of an
infant‘s brain and the development of the young child. That report and related research make the
argument that interventions in the early period of children‘s lives have positive benefits in strengthening
school readiness. From Neurons to Neighborhoods was a catalyst for a large body of work and social
policy thinking about early investments in education. While many of these investments are, technically,
health-related interventions, the report did not focus specifically on ―health‖ as an outcome or as an
important mediator for lifetime human development.
AN ARGUMENT FOR SOCIETAL INVESTMENTS IN
CHILDREN’S HEALTH
The idea of societal investment in education has
been widely accepted and embraced. Building a
parallel argument for societal investment in
children‘s health may be more difficult,
however, for several reasons. First, there is a
long history of academic interest and efforts to
link early education and later economic returns,
including higher productivity and a lower crime
rate.2 In contrast, the research linking early child
health to economic outcomes is more recent and
less extensive. Second, the pathways that link
early educational investments to economic
productivity are apparent, including high school
graduation and college degree attainment. It
may be more difficult to identify the
mechanisms through which better children‘s
health results in economic benefits for all of
society. Also, education has been traditionally
perceived as a societal responsibility, with
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accountability resting in the public or
governmental sectors. Health, on the other hand
is generally perceived to be a matter of
individual choices- for one‘s own life style or
for accessing good preventive and medical care
for one‘s children. In this study, however, we
argue that the health of children is a societal
responsibility, because it is shaped by a broad
set of determinants that include socioeconomic
status, physical and socio-emotional
environments, genetic endowment and
biological influences, access to preventive and
curative medical technologies and others. In the
case of young children, these forces act upon
them both directly and through the
circumstances faced and choices made by their
families.
The rationale for societal investments in the
health of young children must be grounded in
evidence that subsequent poor health outcomes
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disadvantage everyone. For example, failure to
make investments in early child immunizations
results in the spread of infectious diseases even
to those who choose to take care of themselves.
This argument has been widely used to justify
mandatory vaccinations for school enrollments.
The failure to address the precursors in early life
of serious chronic illness- diabetes and coronary
heart disease- might drive up direct medical
costs required to treat these conditions in later
life; and these costs may be redistributed across
all of society. Societal investments in child
health are linked to economic productivity by
affecting learning ability and enabling children
to be maximally productive in their adult
workforce participation. Taking care of sick
children can also limit parents‘ full participation
in work, and thus affect their personal
productivity. This can reduce their income and
employment-based benefits, and even their
ability to manage their household in the way
that they would find optimal. Finally, poor
children‘s health- particularly poor mental
health- may have additional direct links to the
costs borne by society related to criminal
behavior and criminal justice costs and other
aspects of dependency.
are linked to brain development at many stages
of the growth and development process, so that
separating them is difficult. The trajectories of
health and development are thus closely linked.5
Forces that shape fetal and child health and
development also have implications for adult
health five and six decades later. While these
observations from Barker6 and others are now
well supported, their mechanisms are just
beginning to receive needed research attention.
The intrauterine environment- including
nutrition, inflammation and infection- appears to
interact with the genetic make-up of the fetus,
influencing organ development and creating
vulnerability to later environment-gene
interactions. These early influences and
subsequent environmental exposures across the
lifespan increase the risk of heart disease,
stroke, and cancer. In addition, we now
acknowledge that prenatal exposure and
exposure of young children to environmental
toxins- heavy metals, pesticides, and other
chemicals- has enormous implications for
health, development and learning.7,8
GOAL OF THIS PAPER
The goal of this paper is to systematically
review selected areas of the available research
on the short- and long-term impacts of health
promotion and disease preventive interventions
for children from before birth to age five,
including their prenatal period. The reviews
include the patterns and monetary burden of
poor child health, the cost-implications of
preventing and treating child health problems,
and cost-benefit analyses related to the
interventions. Since the age range of interest
includes the period before birth, this paper
summarizes studies of interventions during
pregnancy that report child health and economic
outcomes (e.g., prevention of cigarette smoking
during pregnancy). In keeping with the broad
definition of health proposed in Children’s
Health, the Nation’s Wealth9, we include studies
that address mental health as well as physical
well-being.
The case for investing in children‘s health pulls
together the various threads from the arguments
above. Because children are the most
vulnerable and dependent members of society,3
their health is considered to be a measure of the
overall health of a society. As such, rates of
infant and child mortality are accepted measures
of societal health. Disparities in health are often
shaped early in life and sustained across the
lifespan. The social class gradient in birth
weight is an example of such a disparity that
begins with maternal health and has
implications for future health consequences as
well as for high school graduation.4 On the other
hand, health is also a mediator of economic
productivity across the lifespan. The ability of
adults to be productive workers is limited by
their health. Similarly, the ―work‖ of early
childhood is development and learning; the state
of a child‘s health affects his/her ability to do
this ―work.‖ Child health and disease patterns
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METHODOLOGY
experimental studies as well. The second
inclusion criterion was met if the study
measured a change in outcomes (such as
overweight rate) or associated behaviors (such
as installation of smoke detectors).
Selection of topics
We selected health topics that would be
meaningful to a policy audience, reflect the
priorities set in The Year 2010 Objectives for the
Nation,10 and provide examples demonstrating
the wide range of societal interventions that are
needed to address them effectively. The four
areas of review include: tobacco exposure,
obesity, unintentional injury, and mental health.
Presentation of findings
SYNOPSES OF THE FINDINGS: This
part of the paper
contains synopses of the findings from each of
the four literature reviews and figures showing
the interventions in the lifespan conceptual
framework. In general, only the most recent
citations to the statement are provided in the
present paper, due to space limitations. For a
complete bibliography on a specific health
topic, please refer to the full summary in each of
the four appendices.
Systematic reviews of the literature
Systematic reviews comprehensively identify
relevant literature, hence minimizing selection
bias and making explicit the methods used to
conduct the review.11, 12 In the present study, we
intend to answer the following questions: What
are the health and cost consequences of the four
problem areas in early childhood and across the
lifespan? What are the effectiveness, cost, and
cost-benefit/effectiveness of early childhood
interventions, based on recent and rigorous
scientific evidence?
We present the effectiveness of the included
interventions according to the level of the
intervention (individual-, family-, community-,
and national/state-level). We then review the
cost implications of implementing such
interventions based on available costeffectiveness/ cost-benefit studies, cost-burden
studies, and the aggregated effectiveness of
included interventions. We use the Consumer
Price Index (CPI) to translate dollar amount
presented in previous research into the relative
value of the U.S. dollar in 2006.
Search strategies and inclusion criteria
Primarily, we searched four databases for early
childhood interventions: PubMed, National
Health Service Economic Evaluation Database,
National Bureau of Economic Research‘s
working paper database, and EconLit. A set of
key words, such as intervention, program,
prevention, or evaluation were selected to
combine with specific keywords for each topic.
Our search was restricted to studies focusing on
children, published in English between 1996
and June 2007. Finally, we also manually
checked publications of key authors in each
field and bibliographies of key review articles
for completeness.
A LIFESPAN CONCEPTUAL FRAMEWORK:
Preventive
interventions are often interdisciplinary and
multifaceted in nature, and the effects of such
interventions can be short-term as well as lifelong. In order to conceptualize and visualize the
interactions between the nature and the effect of
interventions, we developed a lifespan impact
framework (as shown in Figures 1 to 4).
The figure rows represent the strata for the level
of interventions: individual, family, community,
and national. These levels are defined by the
identity of the intervention‘s primary target,
rather than by the setting in which it takes place.
For example, we classify an intervention that is
initiated by community leaders but delivered via
home visits as a community-level intervention,
even though the intervention takes place in each
household, because such an intervention
Two other key criteria were used in deciding
whether to include studies in the systematic
review. First, we selected interventions that used
an experimental or quasi-experimental design.
The evaluation of an intervention is more
objective when the intervention adopted a
randomized controlled trial (RCT) approach.
However, for social science research, a RCT is
often infeasible; therefore we included quasiJHU  WCHPC
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RESULTS: SYNOPSES OF THE LITERATURE
REVIEWS
involves people and resources above the family
level. This distinction is often hard to make. Our
rule of thumb is to use a top-down approach
examining the far periphery of a specific
intervention first; if an intervention involves
national-level campaigns or law enforcement,
then we classify it as national-level, even though
it might also incorporate family-level
components. The columns represent four
lifespan stages: preconception/ pregnancy,
infant/childhood, adolescence, and adulthood.
Tobacco exposure
Prevention and cessation of smoking at home and
in public can improve the health of children at
multiple stages throughout the lifespan. Smoking
impacts young children through prenatal
exposure, environmental tobacco smoke (ETS),
and teen smoking, as smoking habits seen during
pregnancy most often form during adolescence.13
Almost one-half million U.S. babies are born each
year to mothers who smoked during pregnancy14
and an estimated 25-50% of children are exposed
by household members to ETS.15,16 Prenatal
exposure to cigarette smoking is associated with
many risks, including preterm delivery, low birth
weight, Sudden Infant Death Syndrome,17,18 and
Attention Deficit Hyperactivity Disorder.19 In
turn, low birth weight, for example, has been
associated with developmental setbacks, later poor
school attainment, and adverse labor market
outcomes.20, 21, 22, 23,24 In the same vein, ETS
exposure among young children can lead to health
consequences that include respiratory symptoms
and infections,25, 26 more frequent and severe
asthma attacks, allergies, and ear infections.27, 28
For each intervention, we use dark grey shading
to indicate when an intervention takes place, and
light grey shading to designate the evidence of
its extended impact. For example, a car safetyseat adoption campaign targets parents with
very young children (age 0-3), but a long-term
evaluation may find positive spillover effects in
the use of booster seats and seat belts when
those children grow up. In this case, we would
depict this intervention in dark grey in the
infant/childhood column (when it takes place)
and in light grey in adolescence and adulthood
columns (extended impact). Since the present
study focuses on interventions targeting young
children, we didn‘t search for or include
interventions that exclusively target other age
groups. Therefore, a blank cell in the adolescent
or adult period should not be interpreted as the
lack of an intervention, but rather, as being
beyond the search scope in the present study.
The monetary burdens associated with smoking
during pregnancy are substantial as well: annual
smoking-attributable costs of neonatal care were
estimated to be $2.3 billion 29 and the annual
costs of smoking-attributable complicated births
were $1.85 billion in 2006 dollars.30 In addition,
the cost to treat childhood illnesses caused by
parental smoking has been estimated at $7.9
billion per year in 2006 dollars.31 Based on
these figures, just a 15% reduction in parental
smoking could save $1 billion in direct medical
costs at the prenatal and neonatal levels and into
childhood.
SUMMARY PAPERS AND EVIDENCE TABLES: Appended
to this overview paper are summary papers for
each health topic- tobacco exposure, obesity,
unintentional injury, and mental health. Each
summary paper is supported by an evidence
table that includes extensive details of the
reviewed interventions, including principal
author‘s name and publication year, study
question, study design (e.g. randomized
controlled trial, quasi-experimental design),
nature of the intervention (e.g. components,
length, intensity), target population, setting in
which the intervention was delivered, sample
size and attrition rate, measure of outcomes,
results, and our comments. A full bibliography
follows each evidence table.
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Even simple interventions targeting pregnant
women can be effective both in increasing
smoking cessation and in reducing negative
birth outcomes.32 However, a review of 18
interventions aiming to reduce children‘s
exposure to household ETS reported wide
variation in both intervention components and
impact.33 Three of these studies that can be
generalized to the U.S. population showed a
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interventions targeting youth39 and with policylevel interventions, such as increasing the price
of tobacco products.40 Enforcement of age bans
is effective as well.41 In summary, there is
considerable evidence that many anti-tobacco
interventions, particularly those employing a
multifaceted approach, are effective, can
improve child health, and save healthcare
dollars in the long term.42
statistically significant impact on parentreported smoking or household nicotine
levels.34,35,36 Youth smoking prevention and
cessation also has been effective when programs
emphasize cognitive-behavioral therapy and
address the social environment.37, 38 The
evidence supports mass media campaigns as
effective, particularly when they are
implemented in conjunction with other
Figure 1. Lifespan Impact of Tobacco Treatment and Prevention Efforts
LIFESPAN STAGE INTERVENTION AND IMPACT
LEVEL OF
INTERVENTION
Preconception/
Pregnancy
Smoking cessation
i
therapy
Individual
Infant/Childhood
Adolescence
Adulthood
Smoking cessation
ii
therapy
Smoking cessation
therapy with partner
iii
support
Smoking cessation
therapy targeting
relapse
Smoking cessation for
iv
adults living with children
Family
Local/ Community/
Workplace/ School
Media campaigns
v
Bans/restrictions in
workplaces and
vi
public
Community
vii
mobilization
National/State
Price increases
viii
Enforcement of age
ix
ban on sales
Age period when interventions take place
Age period with continuing positive impacts of intervention
i
Albrecht et al 2006; Lumley et al 2004; Johnson et al 2006; DiClemente et al 2000; Fiore et al 2000; USDHHS 2001; NIH 1994; Melvin et al
2000; Walsh et al 1997; Windsor et al 1985; Windsor et al 1993; Ershoff et al 1989; Samet et al 1994
ii
Lantz et al 2000; Thomas & Perera 2006; Levy et al 2004; Ranney et al 2006; McDonald et al 2003; Albrecht et al 2006; Colby et al 2005;
Sussman 2002
iii
Donatelle et al 2000; Stanton et al 2004
iv
Emmons et al 2001; Hovell et al 2000; Hovell et al 1994; Hovell et al 2002; Wahlgren et al 1997; Zhang & Qiu 1993; Abdullah et al 2005
v
Lantz et al 2000; Sowden & Arblaster 1998; Task Force on Prev Services 2003; Hersey et al 2005, Hyland et al 2005
vi
Hopkins et al 2001; Levy et al 2004; USDHHS 2001
vii
CDC 1999; Lantz et al 2000; Slater et al 2006
viii
CDC 2000; Levy et al 2004; Task Force on Prev Services 2000; Ranney et al 2006
ix
Pbert et al 2003; Task Force on Prev Services 2000; DiFranza et al 2001
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Obesity
In addition, obesity is associated with increased
morbidity and mortality among pregnant
women,52 who are also, regardless of their
health prior to pregnancy, at increased risk for
pregnancy complications, labor and delivery
problems, and cesarean delivery.53 In addition,
maternal overweight is associated with infant
birth defects54 and macrosomia.55
Childhood obesityi is a significant and growing
problem in our society. Over the past thirty
years, the obesity rate has nearly tripled among
preschool children, from five to 14%.43 The
prevalence of overweight among children and
youth from certain ethnic minority groups is
estimated to be even higher. This surge in
weight increase among young children cannot
be simply attributed to uninformed parenting
behaviors or bad genes, but rather, is a result of
a collection of societal phenomena that
contributes to increasing calorie intake and
decreasing physical activity: the rise of fast
food, aggressive food marketing to children,44
suburbanization and sprawl, and increases in
computer games and TV programs.
Researchers studying the economic costs of
obesity in the United States estimate that direct
costs reach $109 billion per year and indirect
costs total $75 billion (in 2006 dollars).56
Among pregnant women, the costs of prenatal
care for those who are overweight are estimated
to be five to 16 times higher than for women of
healthy weights, increasing with level of
obesity.57 Among children, the economic costs
also are significant. Obesity-related hospital
costs for children ages six-to-17 increased
almost four-fold between 1979 and 1999 from
$44 million to $160 million in 2006 dollars, as
the discharges for diabetes nearly doubled. 58
In the absence of effective interventions, for
many children, overweight persists throughout
the lifespan. Preschool children ever overweight
have been found to be five times more likely
than preschool children with normal weights to
be overweight at age 12.45 In addition, obesity
persists into adulthood for an estimated 50-80%
of overweight children and adolescents.46
However, the overall effectiveness of
interventions to prevent or treat overweight in
childhood is unclear, and few studies target
young children in particular. To date, evidence
of some programmatic success among
preschoolers is limited to the ‗Hip-Hop to
Health Jr‘ program, and only when it was
implemented among a group of AfricanAmerican children.59 A 2005 Cochrane Review
concluded that studies to prevent childhood
overweight were ―heterogeneous in terms of
study design, quality, target population,
theoretical underpinning, and outcome
measures, making it impossible to combine
study findings using statistical methods.‖60
Because of the limited evidence to date,
researchers question the approach of single or
multiple behavioral interventions targeting
childhood overweight and instead suggest that,
like many other public health problems, a
successful approach to reducing childhood
obesity will require multifaceted educational,
environmental, and structural factors.61,62
The physical health consequences of childhood
overweight include orthopedic complications,
metabolic disturbances, type 2 diabetes,
disrupted sleep patterns, poor immune function,
endocrine problems, impaired mobility,
increased blood pressure and hypertension, and
increased risk of coronary heart disease in
adulthood.47,48 The psycho-social consequences
include low self-esteem, social alienation,
discrimination, lower self-reported quality of
life, and depression.49 It is projected that
pediatric obesity might shorten life expectancy
by two to five years by midcentury in the United
States.50,51
i
Although measures and cutoff points of defining
childhood obesity have changed over time, the US
Centers for Disease Control and Prevention (2000), which
uses the term ‗overweight‘ rather than ‗obesity‘, uses a
cutoff of body mass index (weight [kg] / height [m2]) at or
above the 95th percentile for age and sex based on the
reference population of the CDC 2000 growth charts. The
CDC designates children ―at risk for overweight‖ if they
have a BMI between the 85th and 95th percentiles.
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Figure 2. Lifespan Impact of Obesity Interventions
LIFESPAN STAGE INTERVENTION AND IMPACT
LEVEL OF
INTERVENTION
Individual
Preconception/
Pregnancy
Infant/Childhood
Observational studies
Adolescence
Adulthood
i
Observational studies
ii
Family
Preschool education
Parent education
Local/
Community/
Workplace/
School
iii
iv
Teacher curriculum
v
National/State
Age period when interventions take place
Age period with continuing positive impacts of intervention
i
Eriksson et al. 2001; Nader et al. 2006
Field et al 2005
iii
Fitzgibbon et al. 2005
iv
Golan et al. 2006
v
Summerbell et al. 2003
ii
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Unintentional Injury Prevention
estimate both immediate medical costs and
longer-term costs due to productivity loss,
including costs to victims, families, government,
insurers, and taxpayers. One recent study66 that
estimated cost burdens of all injuries found that
both fatal and nonfatal injuries among children
ages zero to four had resulted in $4.7 billion in
life-long medical costs and $14 billion for both
present and future productivity losses. In 1996,
about three in every 1ten children suffered an
unintentional injury serious enough to require
medical treatment or cause at least half a day of
restricted activity, at an estimated average cost
per victim of $4,626 in 2006 dollars. 67
Injuries are the leading cause of disability,
death, and health care utilization for children
and teenagers between the ages of one and 19 in
the United States. It was estimated that, in
1996, unintentional injuries left approximately
150,000 children and adolescents permanently
disabled. 63 Injuries are associated with
environmental hazards and poor quality of
housing,64 poverty, poor parenting, single
parenting, alcohol and substance abuse, and
neglect.65
Studies assessing the monetary burdens of child
injuries generally take a societal perspective to
Figure 3. Lifespan Impact of Injury Prevention Efforts
LIFESPAN STAGE INTERVENTION AND IMPACT
LEVEL OF
INTERVENTION
Preconception/
Pregnancy
Infant/Childhood
Individual
Gun safety education
Family
Home visits
Prenatal home visitation
Adolescence
Adulthood
i
ii
iii
Education against the use of
iv
baby walkers
Local/
Community/
Workplace/
School
Community education
combined with incentives
distribution for road
v
safety
Smoke detector
distribution
National/State
Changes in baby walker
vi
safety standards
Child passenger safety
vii
laws
Age period when interventions take place
Age period with continuing positive impacts of intervention
i
Hardy 2002
Johnston 2006, Posner 2004, Mallonee 2000, Sznajder 2003
iii
Kitzman 1997
iv
Kendrick et al 2005
v
Greenberg-Seth et al. 2004
vi
Roders & Leland 2005
vii
Segui-Gomez et al. 2001
ii
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Historical trends show that the occurrence of
injuries can be reduced. Between 1985 and
2000, for example, the incidence rate of injuries
decreased from 2,259 to 1,740 per 10,000 for
children between 0-4. 68 Many studies show that
preventive interventions can effectively reduce
the incidence of injuries in such areas as gun,
road, home, and community safety. A majority
of interventions aimed at improving road and
home safety found significant changes in
desired behaviors. For example, one incentive
program that provided bilingual education
materials and rewards for positive behavior to a
low-income Hispanic community significantly
increased child rear seating from 33 to 49% in
the intervention city.69 Another program that
targeted elementary school children in Quebec
and included persuasive communication and
activities to facilitate bicycle helmet acquisition
was found to significantly increase the use of
helmets for the group exposed to the program
from 1.3 to 33%.70 In addition, a multifaceted
community campaign including education, car
seat training, and discount coupons for booster
seats in Washington State considerably
increased booster seat use.71 Finally, among
seven home safety intervention studies, six
72,73,74,75,76,77
found significant improvement in
the intervention group for at least one safety
measure, such as lowering tap water
temperature, compared to the control group.
Fewer studies investigated changes in the injury
rate per se as outcomes, but some of those
studies did find positive changes as well.
infants, toddlers and preschoolers manifest some
form of problematic behavior with cost
implications that are significant. For children
between the ages of one and six, 3.4-6.6%
exhibit externalizing behaviors—or acting out—
and 3.0-6.6% manifest internalizing behaviors—
withdrawal, depression or anxiety.79,80 The
annual cost of treating children ages one to five
nationwide was estimated at $864 million in
2006 dollars. 81 One U.K. study found that the
average total societal cost (such as health
service, public sector services) for individual
with unsolved conduct disorder at age ten was
£70,019 by age 28 ($141,161 in 2006 dollars),
ten times higher than for those without such
problems.82
The etiology of early childhood mental health
problems is multi-factorial, with important
contributions made by genetic, dispositional,
and environmental factors. The incidence of
early childhood behavior problems has been
shown to be associated with poverty, maternal
depression, and insecure attachment to
caregivers, as well as harsh, inconsistent
discipline. Early disruptive and aggressive
behavior tends to persist and develop into
chronic and severe forms of anti-social
behavior.83 As such, behavior problems are
found to have a large negative effect on other
outcomes, such as educational attainment,84
unemployment,85 and violent crimes
committed.86
A variety of early intervention strategies having
different targets and theoretical underpinnings
have been tested in the past decade. The
majority (34 of 59) of the studies examined here
used parent-focused training, in which parents
learn from a psychologist or educator [or video
tape] about effective behavior management
skills. In general, more intensive versions
yielded better results than less intensive
ones.87,88 Other programs focus on improving
the quality of the relationship between parents
and children and providing parents with skills to
manage disruptive behavior; 13 of the 14 studies
89,90,91,92,93,94,95,96,97,98,99,100,101
reported that such
interventions improved either infant/toddlerparent interaction, children‘s security or
In sum, unintentional injury prevention is a
good example of a multifaceted public health
approach that has succeeded through the use of
a variety of preventive strategies, including:
changing engineering or environments,
improving parents‘ and children‘s knowledge
and safety behaviors, and adopting the use of
safety devices.
Mental Health
In 1999, the Surgeon General estimated that
20% percent of children had mental disorders
causing at least mild functional impairments.78
Younger children are not immune to mental
health concerns; a significant minority of
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behaviors, or/and maternal depressive
symptoms. In addition, nine
studies102,103,104,105,106,107,108,109,110 targeted
various risk factors and provided family-level
training programs, both parent- and childfocused, in group settings. It appears that childand parent-training each made a unique
contribution to the improvement of children‘s
outcomes. At the system-level, New Hope, an
employment-based antipoverty program for
adults living in poverty, with strong work
support through extensive child-care assistance
and health care subsidies, had a positive effect
on teacher-reported child behavior problems.111
There is limited data on the sustained impact of
these interventions, with the longest follow-up
data from the Carolina Abecedarian Project, a
comprehensive early education program for
preschoolers at-risk. Researchers using these
data found that, at age 21, individuals who had
child-care treatment reported fewer depressive
symptoms than those in the control group (26
vs. 37 percent).112
Figure 4. Lifespan Impact of Interventions for Mental Health Disorders
LIFESPAN STAGE INTERVENTION AND IMPACT
LEVEL OF
INTERVENTION
Preconception/
Pregnancy
Individual
Infant/Childhood
Child-focused training
Parent-focused programs
Adolescence
Adulthood
i
ii
iii
Child-focused training ;
Parent-focused training
iv
programs
Parent- and childv
focused programs ;
Collaborative problem
vi
solving
Family
Local/ Community/
Workplace/ School
National/State
School-based: Fast Track
vii
viii
New Hope
Age period when interventions take place
Age period with continuing positive impacts of intervention
i
Abecedarian project
Healthy Steps, Early Head Start
iii
Incredible Years‘ Dinosaur Curriculum
iv
Triple P
v
Infant Health and Development Program (IHDP); Webster-Stratton, C., & Hammond, M. (1997).
vi
Greene R, et al. 2004
vii
Conduct Problems Prevention Research Group 2004
viii
Huston AC et al. 2005
ii
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DISCUSSION, INFERENCES AND CONCLUSIONS
Overall magnitude of children’s health burden
We selected four children‘s health topics to review: tobacco exposure, obesity, unintentional
injury and mental health. These topics are not specific disease conditions, but represent a broad
array of health problems and exposures. They were selected, in part, because they constitute a
significant burden of the health problems faced by children and because solutions to these major
health concerns go well beyond the simple medical model of a doctor treating a sick child.
Addressing the underlying health needs of American children will require policy makers to
understand the complexity and multiple determinants of health conditions.
We attempted to estimate the magnitude of the burden of these four topics on the overall health
of America‘s children by summarizing findings from a variety of prevalence studies. First, an
estimated 25-50% of children are exposed to environmental tobacco smoke by household
members; 10.2% of women giving birth in 2004 in the United States smoked during pregnancy.
Second, over the past thirty years, the prevalence of obesity has nearly tripled for preschool
children (from five to 14%). Third, annually, about three in ten children suffer an unintentional
injury serious enough to require medical treatment or cause at least a half-day of restricted
activity. Finally, for children between the ages of one and six, 3.4-6.6% are estimated to have
externalizing behaviors, or acting out, and 3-6.6% manifest withdrawal, depression or anxiety—
often referred to as internalizing behaviors. The rate of co-morbid (both externalizing and
internalizing) mental health conditions is estimated to be around 3.3%.
There is no simple way to aggregate the impact of these conditions on preschool children in the
United States We cannot simply add the prevalence estimates, because there are high
correlations among the four health problems; for example, obese girls are often also depressed.
Furthermore, all four health problems are highly correlated with disadvantaged socioeconomic
status, so children from poor families are more likely to experience more than one problem.
Regardless of the exact number, it is clear that the prevalence and impact of these four problems
impose a universal risk on American children and society‘s overall health and well-being. This
assessed burden is consistent with Markel and Golden‘s recommendation for improving
children‘s health: ―[A]ttack the biggest health problems. Not the most scientifically interesting
ones.‖113 As emerging health problems, such as autism, attract increasing attention and resources,
it is critical that researchers, policy-makers and investors remember that ―less interesting‖ health
problems, like smoking exposure and unintentional injury, still affect a sizable proportion of U.S.
children and lead to tremendous health and economic consequences. Considerable preventive
intervention efforts still remain to be made in those ―aging‖ fields to benefit the majority of the
child population.
Inferences from the literature
Some general themes emerge from the literature reviews and economic analyses. First, the
evidence of the health impact and economic costs and long-term consequences of these four
health problems among preschool children is compelling. Since the economic data come from a
wide variety of sources and types of studies, it is not possible to create an exact estimate of their
total economic cost. However, it is likely that the lifetime societal burden of these problems
attributable to the preschool period, if untreated, is well into the hundreds of billions of dollars
for each birth cohort; assuming that the four health problems combined may affect
approximately 50% of each birth cohort — about two million children each year — an average
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of total lifetime societal costs (including health care, special education, productivity loss, civil
justice, etc.) of $50,000 per child will translate to $100 billion for the whole birth cohort.
Second, there is enough evidence from the intervention studies to indicate that, particularly in the
case of tobacco control and injury prevention, effective interventions are available, and the cost
savings from their implementation would be considerable. Unfortunately, the evidence from
intervention studies across all four areas is uneven; the strategies for intervention are different,
and the effectiveness of programs is mixed. For example, to date, few interventions have
targeted obesity among preschoolers.
Third, the evidence for cost-effectiveness of interventions is also limited. Economic evaluations
in the areas of obesity prevention and mental health treatment are particularly underdeveloped;
these are areas of more recent concern and have less completed research. This is not because we
are unaware of the substantial potential savings from preventing the public health problems, but,
rather, because we have little data on the cost of effective interventions that have long-term
consequences. Data are absent at all points along the continuum—we lack any cost data,
effectiveness data, and links to long-term consequences.
Fourth, our ability to draw global inferences is limited by the variability of the preventive
strategies according to problem area. For example, most interventions to address emotional and
behavioral problems adopted tertiary strategies that provide intensive interventions to a small
percentage of children and families who have serious and persistent challenging behaviors; few
examples currently exist of primary prevention of mental health problems. For tobacco
exposure, obesity, and injury, however, universal or primary interventions were implemented to
target most children.
Fifth, across all four health problem areas, few intervention studies demonstrate long-term
effects. This limitation of the literature reflects the well-known problem that research funders
have been generally unwilling to support longitudinal research. Thus, the scientific evidence
linking early childhood health policy to adult health outcomes remains theoretical and
observational. While complex epidemiological, mathematical models can be constructed to link
early childhood interventions with later outcomes, only well-designed longitudinal studies will
demonstrate causality.
Lastly, we were struck repeatedly by the paucity of research data on these important health
problems and on their prevention. Unlike areas of adult health policy, where enormous bodies of
preventive intervention research have formed the basis of policy, the children‘s health area is
much neglected. Thus, in the very age group in which we believe there may be the biggest
opportunity for long-term health gains, there is the least evidence on both effectiveness and the
cost of achieving effective changes.
CONCLUSION
This review shows that our society has failed to take advantage of opportunities to approach the
health of young children as an investment; the high costs experienced by unhealthy adolescents
and adults could be mitigated by helping young children be healthier. There is evidence that the
costs of interventions for young children are relatively low in comparison with the later costs,
when the problems are more prevalent and costly. Further, the costs of unhealthy children can be
large even in childhood, and there are interventions that can effectively bring change.
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We conclude that adopting an ―investment‖ approach to children‘s health policy offers new
opportunities to enhance the health of the U.S. population. Investors generally expect returns on
their investments. While, in theory, preventive interventions promise such gains, the hard
evidence is not yet strong enough to support the theory. We have identified only a handful of
rigorous intervention studies during this review of four major child health topics. Those studies
begin to support the case for investing in effective interventions to promote early child health,
but they need to be reinforced by a larger body of evidence and a policy process that is willing to
wait for returns on investments to support a major policy agenda.
As a nation, we have, for a long time, invested relatively small amounts in children‘s health. A
recent study114 estimated that the Federal
government‘s total investment spending for children in 2006 was 1.6% of GDP, and the share of
the federal budget is projected to decline by 14-29% between 2006 and 2017. Now may be the
time to reverse this trend of disinvestment, if we are to improve the health of children and avert
future health and cost consequences. There is an urgent need for more rigorous research to
examine the longitudinal causal relationships and provide solid economic data to convince
policy-makers to invest more heavily and more urgently in improving the health of children and
their families. The recently launched Children‘s Health Study (www.nationalchildrensstudy.gov)
may represent a good start to building such a body of research, but other efforts will be needed to
address the broad range of policy-relevant questions. The failure to strengthen prevention
research and practice in this young age group brings with it the risk that future researchers a
decade from now will still find the literature inadequate to make a strong policy case, and that
the magnitude of the burden of poor health attributable to missed opportunities for early
prevention will be even greater.
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APPENDIX A: TOBACCO USE PREVENTION AND INTERVENTION
MAGNITUDE: Cigarette smoking is the leading cause of preventable death in the United States,115
resulting in more than 440,000 deaths each year.116 Approximately 21% of adults,117 23% of
high-school students,118 and 8% of middle school students smoke.119 Additionally, an estimated
25-50% of children are exposed to environmental tobacco smoke (ETS)120,121 by household
members and the median exposure level of children ages four to eleven years is twice as high as
that of adults.122 Further, almost one-half million US babies are born each year to mothers who
smoked during pregnancy.123
DETERMINANTS: Several factors are associated with tobacco use and exposure within the maternal
and child health population. Among pregnant women, identified factors include partners‘ and
friends‘ smoking habits, socioeconomic status, age at first pregnancy, educational attainment,
and parity.124 Among adolescents, factors include parental education, family socioeconomic
status, parental smoking, and personal/ psychological traits.125 Poor educational attainment and
single parenthood is associated with children‘s exposure to ETS at home.126
HEALTH CONSEQUENCES: Smoking impacts young children through prenatal exposure, ETS, and
teen smoking, where smoking habits seen during pregnancy most often form during
adolescence.127 Prenatal exposure to cigarette smoke is associated with increased risks of preterm
delivery, premature rupture of membranes, placenta previa, low birth weight, spontaneous
abortion, ectopic pregnancy, and Sudden Infant Death Syndrome.128,129 Smoking during
pregnancy is also associated with a reduced likelihood of breastfeeding, 130 and, for the child,
increased risks for Attention Deficit Hyperactivity Disorder131 and wheezing during the first few
years of life.132
Studies have shown that exposure to ETS among young children can lead to health consequences
that include respiratory symptoms (including cough, wheezing, and breathlessness), acute lower
respiratory infections, asthma, more frequent and severe asthma attacks, allergies, ear infections,
and recurrent otitis media133, 134, 135, 136
ECONOMIC CONSEQUENCES: Tobacco use also has significant economic consequences. The total
cost of smoking among US adults was estimated at more than $167 billion per year between
1997-2001 due to direct medical expenses and lost productivity.137 In addition, adult smokers
cost their employers an extra $960 each year [$1,636 in 2006 dollars] and have 30% more
absenteeism than their non-smoking colleagues.138 The monetary burden associated with
smoking during pregnancy is substantial as well: Nationally, costs of neonatal care attributed to
smoking were estimated to be $1.8 billion in 1996 [$2.3 billion in 2006 dollars] 139 and the added
costs of complicated births were $1.4 billion [$1.85 billion dollars].140 Another study, conducted
in 1999, estimated that if smoking prevalence among pregnant women were to drop by just 1%,
$21 million [$25 million in 2006 dollars] in direct medical costs would be saved in the first year
alone.141 If the prevalence continued dropping by 1% annually, $572 million in direct medical
costs would be saved over 7 years.142 Smoking during pregnancy has a well-documented
association with low birth weight, which is linked to developmental setbacks, future poor school
attainment, and, finally, adverse labor market outcomes. 143, 144, 145, 146,147 An economic study
based on data of female twins estimated that a mother who smoked one pack of cigarettes per
day would reduce the lifetime earnings of her child by over 10%. 148
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In addition, the cost to treat childhood illnesses caused by parental smoking has been estimated
at $7.9 billion, with costs due to loss of life as high as $13.76 billion [in 2006 dollars].149 A 15%
reduction in parental smoking could save $1 billion in direct medical costs.
EVIDENCE FOR SUCCESSFUL PREVENTION AND TREATMENT: There is considerable evidence that
many anti-tobacco interventions are effective and can improve child health and save healthcare
dollars.150 For example, the literature examining the impact of interventions targeting pregnant
women demonstrates that even simple interventions can be effective both in increasing smoking
cessation and in reducing negative birth outcomes, such as low birth weight and preterm birth,
while increasing birth weight.151,152,153,154,155,156,157,158,159 Successful examples include:
Incorporating augmented or extended psychosocial interventions that exceed minimal
physician advice tripled cessation rates among pregnant women.160
A brief 5-15 minute counseling session with pregnancy-specific educational materials
delivered by a trained provider increased cessation rates among pregnant women (risk
ratio 1.7 [95% CI =1.3-2.2]).161
The involvement of a member of the pregnant woman‘s social network to provide
support tripled cessation rates (p<.0001).162
While there is good evidence for effective prevention of smoking during pregnancy, relapse
during the postpartum period poses as a challenge.163,164,165 Suggestions to improve programs‘
effectiveness include addressing postpartum stresses, incorporating the programs into routine
health care, and involving the woman‘s social support network, including her partner.166
Addressing postpartum smoking is particularly important because of its direct link to childhood
exposure to ETS.
Evidence of the effectiveness of interventions that target child household ETS exposure is mixed.
A review of 18 interventions aimed at reducing children‘s exposure to household ETS reported
wide variation in both intervention components and impact.167 Three of the studies reviewed that
can be generalized to the U.S. population, all of which provided intensive counseling to smoking
parents, showed a statistically significant impact on parent-reported smoking or household
nicotine levels.168,169,170
Preventing smoking and increasing smoking cessation among youth has also been a major focus
of interventions. Among those based in schools, sufficient evidence exists that many
interventions, particularly those that emphasize cognitive-behavioral therapy and the social
environment (including peers, family and culture), can have at least a short-term
impact.171,172,173,174,175 Evidence suggests that mass media campaigns are effective, particularly
when they are implemented in conjunction with other interventions targeting youth.176,177,178
There is also strong evidence for the effectiveness of adolescent anti-smoking interventions
implemented at the policy level, such as increasing the price of tobacco products179,180,181,182 and
enforcing age bans.183,184,185
COST IMPLICATIONS OF INTERVENTIONS: Several studies have shown the results of cost-benefit
studies of anti-tobacco interventions.186 For example, one meta-analysis of programs that
disseminate smoking cessation materials among pregnant women estimates that, if this simple
intervention were implemented among all US expectant women who smoked and resulted in an
additional four percent cessation rate, it would yield $77 million of savings for direct medical
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costs in the first year (adjusted to 2006 dollars).187 The authors suggest that this program has an
estimated cost-to-benefit ratio of 1:12.188 An earlier analysis concluded that even a single 5 to 15
minute counseling session by a trained provider can save $3 in neonatal intensive care costs for
every $1 spent.189 Similarly, the CDC estimates that giving Medicaid participants one counseling
session that costs $30 and can be expected to result in an 18% quit rate can save almost $3.50 in
averted neonatal care expenditures for every $1 spent.190
Anti-tobacco policies targeting adolescents can be cost-effective as well. For example, one 2001
study estimated that a program to enforce age bans (including licensing of tobacco vendors,
quarterly inspections of all vendors for underage shopping, and civil penalties for vendors who
made illegal sales to underage shoppers) costed between $44 and $3,100 per year of life saved,
depending on assumptions on cost and efficacy. These estimates show this program to be more
cost-effective than mammographies, and the cost could be funded by a one cent per-pack tax.191
Another study concluded that a 10% increase in the price of tobacco products would reduce teen
smoking by four percent.192 The smoking rates of adolescent males and minorities especially
may be sensitive to changes in price.193
Neither the cost nor the cost-effectiveness of interventions to reduce childhood ETS exposure
has been examined to date.194
CONCLUSION: Prevention and cessation of smoking can improve the health of children and their
families at multiple stages throughout the lifespan. Effective interventions exist, although the
evidence base for those implemented among maternal and child health populations is mixed and,
in some cases, still limited, particularly regarding long-term effects and the cost-effectiveness of
programs to reduce childhood ETS exposure.
A review of the literature suggests that comprehensive strategies attempting to build on synergies
across settings may have the greatest impact.195,196,197,198,199 Further, interventions that prevent or
stop early exposure to tobacco can have significant effects throughout the lifespan (Figure).
Given the significant health and economic costs associated with tobacco use, future interventions
should build upon the current evidence base to guide the development of the most effective
strategies to protect young children and their families from its consequences.
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Figure 1: Lifespan Impact of Tobacco Treatment and Prevention Efforts
LIFESPAN STAGE INTERVENTION AND IMPACT
LEVEL OF INTERVENTION
Preconception/ Pregnancy
Individual
Smoking cessation
xxxi
therapy
Infant/Childhood
Adolescence
Adulthood
Smoking cessation
xxxii
therapy
Smoking cessation
therapy with partner
xxxiii
support
Smoking cessation
therapy targeting relapse
Smoking cessation for
adults living with children
Family
xxxiv
Local/ Community/
Workplace/ School
Media campaigns
xxxv
Bans/restrictions in
xxxvi
workplaces and public
Community mobilization
xxxvii
National/State
Price increases
xxxviii
Enforcement of age ban
xxxix
on sales
Age period when interventions take place
Age period with continuing positive impacts of intervention
xxxi
Albrecht et al 2006; Lumley et al 2004; Johnson et al 2006; DiClemente et al 2000; Fiore et al 2000; USDHHS 2001; NIH 1994; Melvin et al 2000; Walsh et al 1997; Windsor
et al 1985; Windsor et al 1993; Ershoff et al 1989; Samet et al 1994
xxxii
Lantz et al 2000; Thomas & Perera 2006; Levy et al 2004; Ranney et al 2006; McDonald et al 2003; Albrecht et al 2006; Colby et al 2005; Sussman 2002
xxxiii
Donatelle et al 2000; Stanton et al 2004
xxxiv
Emmons et al 2001; Hovell et al 2000; Hovell et al 1994; Hovell et al 2002; Wahlgren et al 1997; Zhang & Qiu 1993; Abdullah et al 2005
xxxv
Lantz et al 2000; Sowden & Arblaster 1998; Task Force on Prev Services 2003; Hersey et al 2005, Hyland et al 2005
xxxvi
Hopkins et al 2001; Levy et al 2004; USDHHS 2001
xxxvii
CDC 1999; Lantz et al 2000; Slater et al 2006
xxxviii
CDC 2000; Levy et al 2004; Task Force on Prev Services 2000; Ranney et al 2006
xxxix
Pbert et al 2003; Task Force on Prev Services 2000; DiFranza et al 2001
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Table 1. Studies on Tobacco Use
TOBACCO USE PREVENTION AND CESSATION —ECONOMIC STUDIES
Authors
Study Question
Perspective
Adams et al
To derive
estimates of the
smokingattributable costs
for direct medical
expenditures
(i.e., inpatient,
physician,
hospital
outpatient, and
emergency
department
costs) related to
pregnancy
outcomes
Societal
To determine the
economic
influence of
pediatric disease
attributable to
parental smoking
Payer
Pub: 1997
Cost: 1987 and
1995
Aligne &
Stoddard
Pub: 1997
Cost: 1993
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Study type and design
Cost estimate
Analysis of 1987 National
Medical Expenditures
Survey data
Cost estimates based on
amounts paid by all
insurers and by persons
paying out-of-pocket for
health care
The probability of
pregnancy complications
and expected
expenditures were
estimated based on sociodemographic factors,
receipt and timing of
prenatal care, and
smoking status
Cost estimate
Population
and Setting
Civilian, noninstitutionalized US
population
Results/Comments
Medical-care expenditures attributable to smokers with complicated
births (e.g., hemorrhage from placenta previa, maternal infection, fetal
distress, or mal-position of the fetus) were an estimated $791 million,
representing 11% of the total medical expenditures for all complicated
births ($7 billion). When a smoking prevalence during pregnancy of
27% was used in the calculation, the estimated smoking-attributable
costs were $1.1 billion (15% of total expenditures).
Smoking-attributable costs of complicated births were updated to 1995
by accounting for medical-care cost inflation and the number of liveborn infants in 1995 (3.9 million). The estimated smoking-attributable
costs were $1.4 billion (11% of costs for all complicated births) in 1995
dollars, based on a smoking prevalence during pregnancy of 19%, and
an estimated $2.0 billion (15%) based on a smoking prevalence of
27%.
Setting:
US
population
Inclusion:
Neonate to
18 years old
18
Total Costs:
Direct Medical: $4.6 billion; Loss of Life: $8 billion
Cost attributable to LBW:
Direct Medical: $1.2 billion; Loss of Life: $3.7 billion
Cost attributable to SIDS:
Loss of Life: $2.7 billion
Cost attributable to RSV:
Direct Medical: $130 million; Loss of Life: $1.5 billion
Cost attributable to Otitis Media:
Direct Medical: $150 million
Cost attributable to Otitis Media with Effusion:
Direct Medical: $290 million
Cost attributable to Asthma:
Direct Medical: $180 million; Loss of Life: $19 million
Cost attributable to Burns:
Direct Medical: $24 billion; Loss of Life: $330 million
January 2008
TOBACCO USE PREVENTION AND CESSATION —ECONOMIC STUDIES
Authors
Study Question
Perspective
Study type and design
Armour et al
To develop
estimates of
smoking
attributable
mortality, years
of potential life
lost (YPLL) for
adults and
infants and
productivity
losses for adults
To estimate the
impact of
behavioral risk
factors on
absenteeism and
health-care costs
Societal
Used the CDC‘s Adult and
Maternal and Child Health
Smoking-Attributable
Mortality, Morbidity and
Economic Cost (SAMMEC)
software to estimate costs
To provide
national
estimates of
annual smokingattributable
mortality,
years of potential
life lost (YPLL),
smokingattributable
medical
expenditures for
adults and
infants, and
productivity costs
for adults.
Societal
Pub: 2005
Cost: 2001
Bertera
Pub: 1991
Cost: 1988
Centers for
Disease Control
and Prevention
Pub: 2002
Cost: 1996
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employer
A cross-sectional design
was used to evaluate
health risk appraisal and
physical-examination data
collected from 1984
through 1988.
Used the CDC‘s Adult and
Maternal and Child Health
Smoking-Attributable
Mortality, Morbidity and
Economic Cost (SAMMEC)
software to estimate costs
Population
and Setting
Adult men and
women and
infants in the
US
45,976
employees of
Dupont (a
large,
diversified
industrial
workforce in
the US)
Adult men and
women and
infants in the
US
19
Results/Comments
During 1997–2001, cigarette smoking and exposure to tobacco smoke
resulted in approximately 438,000 premature deaths in the United
States, 5.5 million YPLL, and $92 billion in productivity losses annually
(approximately $61.9 billion for men and $30.5 billion for women).
Employees with any of six behavioral risks had significantly higher
absenteeism (range = 10% to 32%) compared with those without
risks (in particular, smokers had 30% more absenteeism than nonsmokers).
These differences led to significantly higher illness costs (defined as
compensation, health care, and non-health care benefits) for those
with risks compared with those without risks. Annual excess illness
costs per person at risk were smoking, $960; overweight, $401;
excess alcohol, $389; elevated cholesterol, $370; high blood
pressure, $343; inadequate seatbelt use, $272; and lack of exercise,
$130. Only one factor, lack of exercise, was not significant after
adjusting for age, education, pay category, and the six other
behavioral risks. The total cost to the company of excess illness was
conservatively estimated at $70.8 million annually.
During 1995–1999, the average annual mortality-related productivity
losses attributable to smoking for adults were $81.9 billion (Table 2). In
1998, smoking-attributable personal health-care medical expenditures
were $75.5 billion. For each of the approximately 46.5 million adult
smokers in 1999, these costs represent $1,760 in lost productivity and
$1,623 in excess medical expenditures. Smoking-attributable neonatal
expenditures were $366 million in 1996, or $704 per maternal smoker
($8 per adult smoker). Maternal smoking accounted for 2.3% of total
neonatal medical expenditures in 1996. The economic costs of
smoking totaled $3,391 per smoker per year.
January 2008
TOBACCO USE PREVENTION AND CESSATION —ECONOMIC STUDIES
Authors
Study Question
Perspective
Study type and design
DiFranza et al
To estimate the
costeffectiveness of
active
enforcement of
tobacco sales to
minors on a
national level.
Societal
To identify
effective,
experimentally
validated
tobacco
dependence
treatments and
practices
Societal
The intervention included
employing minors to attempt
tobacco purchases,
licensing tobacco vendors,
and civil penalties for
vendors who illegally sold
tobacco products to minors.
Analyses were based on
enforcement costs of $50,
$150, $250, and $350,
where marginal expense is
lowest at the community
level and highest at the
federal level.
Review of evidence on costeffectiveness of smoking
cessation interventions
To estimate
excess direct
medical costs of
low birth weight
from maternal
smoking and
short-term cost
savings from
smoking
cessation
programs before
or during the first
trimester of
pregnancy.
To estimate the
projected cost
benefit of
maternal
smoking
cessation
Societal
Pub: 2001
Cost: check this
with original
article
Fiore et al
Pub: 2000
Cost: various
Lightwood et al
Pub: 1999
Cost: 1995
Windsor
Pub: 2003
Cost: 2002
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Societal
Simulations using data on
neonatal costs per live birth.
Outcome measures were
mean US excess direct
medical cost per live birth,
total excess direct medical
cost, reductions in low birth
weight, and savings in
medical costs from an
annual 1 percentage point
drop in smoking prevalence
among pregnant women.
Meta analysis
Cost Benefit Analysis
Population
and Setting
Setting: USA
Results/Comments
Primary outcome measures consisted of four levels of reduction
in youth tobacco use ranging from 5% to 50%, with subsequent costeffectiveness ratios ranging from $44 to $3100 per year of life saved.
Inspecting an estimated 543,000 tobacco outlets would cost up to $190
million annually. An enforcement program could save 10 times as
many lives as the same amount spent on mammography or screening
for colorectal carcinoma. A one-cent per pack cigarette tax could fully
fund enforcement.
Various
Setting:
US
Setting:
US, Norway,
Canada, and
Sweden
20
Cost-effectiveness analyses have shown that smoking cessation
treatments compare quite favorably with routine medical interventions
such as the treatment of hypertension and hypercholesterolemia, and
with other preventive interventions such as periodic mammography. In
fact, smoking cessation treatment has been referred to as the ―gold
standard‖ of preventive interventions. Smoking cessation treatment
remains highly cost-effective, even though a single application of any
effective treatment for tobacco dependence may produce sustained
abstinence in only a minority of smokers.
Mean average excess direct medical cost per live birth for each
pregnant smoker was $511; total cost was $263 million. An annual
drop of 1 percentage point in smoking prevalence would prevent 1300
low birth weight live births and save $21 million in direct medical costs
in the first year of the program; it would prevent 57,200 low birth weight
infants and save $572 million in direct medical costs in 7 years.
Quitting methods most heavily influence lighter smokers
Exposing 800,000 smokers could result in 4% cessation rate
Estimated potential savings based on healthier mother and baby:
$64 million
Cost to benefit ratio is $1:$12
Costs only include medical costs during first year of life
January 2008
TOBACCO INTERVENTIONS—PRECONCEPTION AND PRENATAL PERIODS
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Albrecht et al
2006
To evaluate the
short and longterm effects of
smoking cessation
strategies tailored
to the pregnant
adolescent to
attain and
maintain
abstinence.
Pregnant adolescents ages
14 to 19 years
142
31 did not
complete
1 year
follow up
Aveyard et al
2005
To examine effect
of smoking
cessation
programs on
pregnant women‘s
partners
Design:
Randomized
Controlled Trial
(RCT)
Intervention:
3 arms: Teen
FreshStart (TFS, a
program modeled
after the American
Cancer Society's
educational and
motivational
FreshStart for
adults), Teen
FreshStart Plus
Buddy (TFS-B, which
added the support of
a female nonsmoking peer), and a
control group
receiving usual care
and education (UC)
measured at
baseline, 8 weeks
post-randomization,
and 1-year following
study entry.
Design:
RCT
Intervention:
Three arms: (a)
standard smoking
cessation, (b)
midwife trained in
smoking cessation,
or (c)midwife plus
questionnaire giving
feedback on stage of
change
Setting:
West Midlands, UK
71
18.6%
Inclusion:
Pregnant women aged 16
or older
Outcomes/Comments
There were no significant differences among
the three treatment groups at baseline in
terms of the racial distribution, age,
gestational age, age of menses initiation,
number in family household, number of family
members who smoked, or tobacco use. A
significant difference between the UC group
and the TFS-B group (p = .010) was seen in
smoking behaviors measured 8 weeks
following treatment initiation. At 1 year
following study entry, however, there were no
differences between the groups in smoking
behaviors.
The TFS-B intervention was more effective in
attaining short-term smoking cessation in the
pregnant adolescent than TFS or UC.
Findings suggest that the peer-enhanced
programming had a limited effect but could
not sustain the participant beyond postpartum
(1 year following study entry). Future studies
should include relapse prevention to sustain
smoking abstinence into the postpartum
period.
Partners quitting at 30 wks gestation:
a) 3.3%
b) 4.1%
c) 5.2%
Partners quitting at 30 wks gestation:
a) 3.3%
b) 4.1%
c) 5.2%
Probability of quitting did not differ by trial arm
More studies looking at mobilization of social
support of smoking partners should be considered
Follow up at 30
weeks gestation
JHU  WCHPC
21
January 2008
TOBACCO INTERVENTIONS—PRECONCEPTION AND PRENATAL PERIODS
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Campbell et al
2006
To assess
effectiveness of
two methods of
delivering smoking
cessation
materials
Design:
Group randomized
trial
Setting:
New South Wales, Australia
Wave 1
SD: 2,900
ID: 4,211
Wave 1
SD: 6%
ID: 4%
Wave 2
SD: 1,813
ID: 2,001
Wave 2
SD: 7%
ID: 8%
1050
N/A
Coleman et al
2007
DiClemente et
al 2000
JHU  WCHPC
To determine
whether or not
nicotine
replacement
therapy (NRT) is
effective, costeffective and safe
when used for
smoking cessation
by pregnant
women
To review the
literature
regarding the
process of
smoking
cessation in the
context of
pregnancy and the
postpartum
periods
Intervention
―Simple
dissemination‖
clinics received
written information
and staff training
materials
―Intensive
dissemination‖
received written
information, offer of
staff training visit,
sample clinic
policy, and support
from study
facilitators
Design:
RCT
Intervention:
Women will receive
either nicotine or
placebo transdermal
patches with
behavioral support.
Review of
epidemiological data,
extant
reviews of the
literature, and current
original research
reports
Inclusion:
Clinics: All antenatal clinics
in New South Wales,
Australia
Women: all women
attending clinic over age 16,
speaking English and in
good health
Setting:
UK
Inclusion:
pregnant women attending
antenatal care between 12-24
weeks pregnant
Not specified
Not specified
22
N/A
Outcomes/Comments
Patient smoking status assessed using cross
sectional before and after surveys
No difference was found between groups
Within groups no difference was found before and
after dissemination of materials
The primary outcome measure is biochemicallyvalidated, self-reported, prolonged and total
abstinence from smoking between a quit date
(defined before randomization and set within two
weeks of this) and delivery. At six months after
childbirth self-reported maternal smoking status will
be ascertained and two years after childbirth, selfreported maternal smoking status and the behavior,
cognitive development and respiratory symptoms of
children born in the trial will be compared in both
groups.
Results not yet available as recruitment will begin in
2007
Understanding obstacles and pathways for
pregnancy and postpartum smoking cessation can
guide implementation of effective existing programs
and development of new ones. Recommendations
include promoting cessation before and at the
beginning of pregnancy, increasing delivery of
treatment early in pregnancy, helping spontaneous
and intervention assisted quitters to remain tobacco
free postpartum, aiding late pregnancy smokers, and
involving the partner of the woman smoker.
January 2008
TOBACCO INTERVENTIONS—PRECONCEPTION AND PRENATAL PERIODS
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Outcomes/Comments
Donatelle et al
2000
To determine
whether the
combination of
bolstered social
support and
financial
incentives had an
effect in
significantly
reducing smoking
behavior among
low income, high
risk, pregnant and
postpartum
women
Design:
RCT
Intervention:
A theory based
―three pronged‖
approach: positive
incentives,
―bolstered‖ social
supports, and
community
participation.
Women enrolled in Oregon‘s
Women, Infants, and Children
(WIC) program, age 15 years
or older; self reported smoker
(―even a puff in the last seven
days‖); English speaker/
reader; and 28 weeks
gestation or less
220
T: 32% at
eight
months
gestation
and 36%
at two
months
postpartum.
Significant differences existed between treatment
and control groups in percentages of smokers who
were biochemically confirmed as quit at eight months
gestation ÷2 = 18.4 (p < 0.0001), and also at two
months postpartum ÷2 = 11.0 (p < 0.0009).
To test the
effectiveness of a
prenatal self-help
smoking cessation
program that
consisted
predominately of
printed materials
received through
the mail.
Design:
RCT
Intervention:
Brief health educator
discussion of risks
(3-5 minutes);
advised of a free
smoking cessation
class; and
pregnancy-specific
self-help materials
mailed weekly for 7
weeks
Ershoff et al
1989
JHU  WCHPC
Recruitment occurred
between June 1996 and June
1997.
Participants were
followed through two
months postpartum
(for a maximum of 10
intervention months).
Socioeconomically and
ethnically diverse group of
pregnant women enrolled in a
large health maintenance
organization (HMO) who
reported they were smoking
at the time of their first
prenatal visit
242
C: 51.5%
at eight
months
gestation
and 52%
at two
months
postpartum.
6% of
treatment
group and
8% of
control
group
Biochemical confirmation of continuous abstinence
achieved prior to the 20th completed week of
pregnancy and lasting through delivery revealed
22.2% of the women in the eight-week serialized
program quit versus 8.6 per cent of controls with
usual care. The adjusted odds ratio was 2.80 (95 per
cent CI=1.17, 6.69).
A low-cost prenatal self-help intervention can
significantly affect the public health problem of
smoking during pregnancy and its associated risks
for maternal and child health.
23
January 2008
TOBACCO INTERVENTIONS—PRECONCEPTION AND PRENATAL PERIODS
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Outcomes/Comments
Fang 2004
To review existing
research, current
strategies, and
directions for
future research on
smoking cessation
relapse and
relapse prevention
in pregnancy and
postpartum
A MEDLINE/
PubMed search in
2002 and 2003 for
articles containing
the key words
―smoking,‖
―pregnancy,‖
―cessation,‖ and
―cessation relapse
prevention‖ and
references of
retrieved papers
yielded a review of
more than 500
articles.
To be included in this review,
articles had to address preor postnatal relapse
prevention or treatment.
Articles were also included if
they allowed comparisons of
women who relapsed versus
those who remained smoke
free. Of the 146 articles that
contained references to
postpartum relapse, only 14
specifically described
strategies to increase
cessation among pregnant
women through relapse
prevention programs (2 of
these 14 articles discussed
the same program).
Abstinence data were
included only if they were
Bio-chemically confirmed,
due to reports of high levels
of deception regarding
smoking status found in
pregnant women. Studies
that had follow-up time points
of less than 5 months were
included because of the
desire for pre-parturition data.
For the meta-analysis, either
minimal interventions (<3
minutes) or interventions
labeled as ―usual care‖
constituted the reference
condition.
14 studies
N/A
Although there is much information on the rationale
and strategies for smoking cessation for pregnant
women, fewer studies exist on how to prevent
relapse. Maintaining and accelerating progress in
cessation during pregnancy and postpartum requires
more research that focuses on relapse prevention
and cessation. Programs should incorporate
stresses particular to postpartum women, should be
part of routine health care, and should involve the
woman‘s social support network, including her
partner, to maximize effectiveness.
Fiore et al
2000
JHU  WCHPC
To identify
effective,
experimentally
validated tobacco
dependence
treatments and
practices
Review
24
7 studies
N/A
Research is needed that examines how the following
optimally influence relapse prevention: stages of
change, confidence level, perception of level of ease
of quitting, and support systems. Interventions that
involve the woman‘s partner need further
exploration.
A ―usual care‖ intervention with pregnant smokers
typically consists of a recommendation to stop
smoking, often supplemented by provision of selfhelp material or referral to a stop-smoking program.
Extended or augmented psychosocial interventions
typically involve these treatment components as well
as more intensive counseling than minimal advice.
An augmented smoking cessation intervention is 2.8
times as likely (95% CI: (2.2- 3.7%) to result in a
pregnant women quitting than usual care.
January 2008
TOBACCO INTERVENTIONS—PRECONCEPTION AND PRENATAL PERIODS
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Lawrence et al
2005
To evaluate the
effect on quitting
smoking at 18
months
postpartum of
smoking cessation
interventions
based on the
Transtheoretical
Model (TTM)
delivered in
pregnancy
compared to
current standard
care.
Population:
Pregnant women
Setting:
Antenatal clinics in general
practices in the West
Midlands, UK.
N=918
393 lost
Lumley et al
2004
To evaluate the
impact of smoking
cessation
programs
implemented
during pregnancy
Design:
Cluster randomized
trial
Intervention:
One hundred general
practices were
randomized into the
three trial arms.
Midwives in these
practices delivered
three interventions: A
(standard care), B
(TTM-based self-help
manuals) and C
(TTM-based self-help
manuals plus
sessions with an
interactive computer
program giving
individualized
smoking cessation
advice).
Searched Cochrane
Pregnancy and
Childbirth register,
Cochrane Tobacco
register, EMDLINE,
EMBASE, PsychLIT,
NICAHL, and
AUSTHEALTH plus
hand searching
specific journals
Setting:
No setting specified
N=64 studies
N/A
Design:
Review of
literature reviews and
meta-analyses
Not specified
16 studies
N/A
Melvin et al
2000
JHU  WCHPC
To review the
evidence base
underlying
recommended
cessation
counseling
for pregnant
women who
smoke
Inclusion:
Randomized and quasirandomized of smoking
cessation programs
implemented during
pregnancy
25
Outcomes/Comments
Outcomes were self-reported continuous and point
prevalence abstinence since pregnancy
When combined together, there was a slight and
not significant benefit for both TTM arms compared
to the control, with an odds ratio of 1.20 (95% CI:
0.29–4.88) for continuous abstinence. For point
prevalence abstinence, the OR was 1.15 (CI: 0.66–
2.03). Seven of the 54 (13%) women who had quit
at the end of pregnancy were still quit 18 months
later, and there was no evidence that the TTMbased interventions were superior in preventing
relapse.
The TTM-based interventions may have shown
some evidence of a short-term benefit for quitting
in pregnancy but no benefit relative to standard
care when followed-up in the longer-term.
Significant reduction in smoking in intervention
groups (RR 0.94; 95% CI 0.93-0.95)
Interventions reduced LBW (RR 0.81; 95% CI 0.70.94)
Interventions reduced preterm birth (RR 0.84; 95%
CI 0.72-0.98)
Interventions increased birth weight by 33g (95%
CI 11-15 g)
No differences found for VLBW, stillbirths, perinatal
or neonatal mortality
A brief cessation counseling session of 5–15
minutes, when delivered by a trained provider with
the provision of pregnancy specific, self help
materials, significantly increases rates of cessation
among pregnant smokers. This low intensity
intervention achieves a modest but clinically
significant effect on cessation rates, with an average
risk ratio of 1.7 (95% confidence interval 1.3 to 2.2).
There are five components of the recommended
method—―ask, advise, assess, assist, and arrange.‖
January 2008
TOBACCO INTERVENTIONS—PRECONCEPTION AND PRENATAL PERIODS
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Outcomes/Comments
Mullen 2004
To review
accumulated
knowledge about
factors that
influence
restarting smoking
and the
effectiveness of
interventions to
decrease it.
Review of the
literature
Studies were international,
with diverse candidate
predictors, intensity and
timing of interventions,
theory, designs, and
measures of quitting and of
maintenance postpartum.
Six trials, six
multivariate
predictor
studies,
supplemented
by qualitative
and more
focused
quantitative
studies
N/A
Park et al
2004
To evaluate the
impact of partner
support on
smoking cessation
programs
Searched Cochrane
Tobacco register,
CDC and preventionTobacco Information
and Prevention
Database, Caner Lit,
EMBASE, CINAHL,
PsychInfo, ERIC,
PsycLit, Dissertation
Abstracts, and
Healthstar
Setting:
No setting specified
Inclusion:
Randomized trials
comparing interventions
with partner support to
identical intervention with
no partner support
Follow up of 6 months or
more
8 studies
NA
Recommendations: (a) Partner smoking must be
addressed in interventions with cessation messages.
(b) Intervention studies should include women of
lower socioeconomic status and Black women. (c)
Program developers and researchers should adopt a
consistent standard for cessation. (d)Communication
laboratory methods should test ways to increase
intrinsic reasons for abstinence and success
attributions to stable, internal causes. (e) Staging for
postpartum smoking should supplant relapse
prevention alone. (f) Among those whose intention it
is to maintain nonsmoking postpartum, standard
relapse prevention treatment is insufficient to combat
environmental cues that also have been suspended
for the pregnancy and typical problems of
sleeplessness, stress, depression, and weight
concern. (g) Interventions ideally should begin in late
pregnancy, when postpartum smoking goals can be
revised and plans made to manage postpartum
issues. (h) Innovative methods for reducing
postpartum problems should be tested. (i) Study of
incentives for pregnancy cessation should include
varying patterns, carryover to early postpartum
months, and focus on their impact on long-term
change.
Definition of partner varied between studies
OR for self reported abstinence at 6-9 months:
1.08; 95% CI 0.81-1.44
12 month OR: 1.0; 95% CI 0.75-1.34
Only two studies found increased partner support
at follow up
JHU  WCHPC
26
January 2008
TOBACCO INTERVENTIONS—PRECONCEPTION AND PRENATAL PERIODS
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Outcomes/Comments
Rigotti et al
2006
To evaluate the
effectiveness of
telephone
counseling to help
pregnant women
quit smoking
Design:
RCT
Intervention:
All women received
smoking cessation
booklet and phone
counseling
Intervention group
received follow up
calls and additional
materials
Participants were
followed up
immediately post
partum and 3
months post
partum
Design: RCT
Intervention:
Video on effects of
smoke on infants,
info packet with
nicotine patches,
audio tape, and
stickers, phone
intervention with GP
Controls sent
brochure with contact
info for available
smoking cessation
options
Design: RCT
Intervention:
All received standard
health promotion to
stop smoking
Setting:
Prenatal care clinics in MA
I: 220
C: 222
I: 31%
C: 36%
No significant differences were found among
participants receiving additional phone support and
standard care
N=561
I: 23%
C: 16%
Intervention group had significantly higher quit rate
than control at 6 months follow up (16.5% vs.
9.3%; OR 0.52; 95% CI 0.31-0.86)
The number of smoking men who had to be treated
to achieve one stopping smoking (NNT) during
their partner‘s pregnancy was 13 to 14.
Women consented to partners being participants
which may have biased population
I: 351
C: 411
I: 4%
C: 3%
Similar percentage of people in each group quit
smoking (4.8% intervention, 4.6% control)
Overall motivational interviews did not have a
significant effect on quit rates
Stanton et al
2004
Tappin et al
2005
To evaluate the
impact of smoking
cessation targeted
at men during
wife‘s pregnancy
To determine if
motivational
interviewing helps
pregnant smokers
quit
Eligibility:
Gestation < 26
Aged 18 or older
Smoking in last week
Commitment or intention to
quit not required
Setting:
Men with partners attending
public antenatal clinics in
metropolitan Australian city
Inclusion:
Not stated
Setting:
Antenatal clinic in Glasgow
Inclusion:
All smokers attending clinic <
24 weeks gestation
Intervention received
standard care plus
motivational home
interviews
JHU  WCHPC
27
January 2008
TOBACCO INTERVENTIONS—PRECONCEPTION AND PRENATAL PERIODS
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Outcomes/Comments
USDHHS
2001
To review the
evidence for
effectiveness of
smoking
prevention and
cessation
programs among
pregnant and
postpartum
women (Ch. 5)
Review of the
literature
Various
Various
NA
Van‘t Hof et al
2000
To examine the
effectiveness of a
provider delivered
smoking relapse
prevention
strategy
Design:
RCT
Intervention:
smoking history
obtained at delivery,
and transmission of
the history to the
infant‘s pediatric
provider
287
(I=141,
C=146)
I=133
C=144
Wahlgren et al
1997
To examine the
long-term
maintenance of a
previously
reported
behavioral
counseling
intervention to
reduce asthmatic
children‘s
exposure to
environmental
tobacco smoke
(ETS).
Participants were
randomized to one of
three groups:
behavioral
counseling to reduce
ETS exposure, selfmonitoring control,
and usual medical
care control.
Counseling
concluded at
month 6, and the
original trial ended at
month 12. Two
follow-up interviews
occurred at months
20 and 30.
All women delivering babies
at six participating Portland,
Oregon, metropolitan area
hospitals who received an inhospital screening, reported
smoking during the 30 days
before the pregnancy and
quitting during pregnancy,
and were willing to speak with
a nurse about having quit
smoking.
Families of asthmatic children
(6 to 17 years), including at
least one parent who smoked
in the home, recruited from
four pediatric allergy clinics.
91 families
N=67
families
Among women, biopsychosocial factors such as
pregnancy, fear of weight gain, depression, and the
need for social support appear to be associated with
smoking maintenance, cessation, or relapse.
A higher percentage of women stop smoking during
pregnancy, both spontaneously and with assistance,
than at other times in their lives.
Using pregnancy-specific programs can increase
smoking cessation rates, which benefits infant health
and is cost-effective. Only about one-third of women
who stop smoking during pregnancy are still
abstinent one year after the delivery.
Communicating a new mother‘s smoking status from
the delivery service to the infant‘s pediatric provider
can be done quickly and effectively, and leads to
increased rates of provider delivered smoking
relapse prevention advice.
However, there was no difference in the relapse rate
between women in the intervention (41%) and
control (37%) groups. Even when all those lost to
follow up were considered to have relapsed,
differences between intervention (42%) and control
(38%) groups did not vary significantly.
The originally reported analysis of baseline to 12
months was reanalyzed with a more robust restricted
maximum likelihood procedure. The 2-year follow-up
period was analyzed similarly. Significantly greater
change occurred in the counseling group than the
control groups and was sustained throughout the 2
years of follow-up. Further exploratory analyses
suggested that printed counseling materials given to
all participants at month 12 (conclusion of the
original study) were associated with decreased
exposure in the control groups.
Such long-term maintenance of behavior change is
highly unusual in the general behavioral science
literature, let alone for addictive behaviors. We
conclude that ETS exposure can be reduced and
that a clinician-delivered treatment may provide
substantial benefit.
JHU  WCHPC
28
January 2008
TOBACCO INTERVENTIONS—PRECONCEPTION AND PRENATAL PERIODS
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Outcomes/Comments
Walsh et al
1997
To evaluate the
impact of a
smoking cessation
program
implemented at a
public antenatal
clinic
Design:
RCT
Intervention:
Physician advice
regarding risks (2-3
minutes); videotape
with information on
risks, barriers, and
tips for quitting;
midwife counseling in
one 10-minute
session; self-help
manual; and followup letters
Women attending the
antenatal clinic of an urban
teaching hospital in Australia.
252
(I=127 and
C=125)
At
midpoint,
10%, end
of pregnancy,
10%,
postpartum,
25%
Except for the postpartum self-report, self-report and
biochemically validated quit rates in the experimental
group were significantly higher than in the control
group at all three points, whether point prevalence or
consecutive cessation measures were used.
Design:
RCT
Intervention:
Pregnancy-specific
self-help materials
(Pregnant Woman’s
Self-Help Guide To
Quit Smoking) and
one 10-minute
counseling session
with a health
educator
Design:
RCT
Intervention:
Cessation skills and
risk counseling in a
15-minute session by
a counselor;
education on how to
use pregnancyspecific self-help
materials; a
follow up letter; and
social support with a
buddy letter, a buddy
contract, and a
buddy tip sheet
Women (less than 7 months
pregnant) attending three of
five high-volume Public
Health Maternity Clinics of the
Jefferson County Health
Department in the
metropolitan area of
Birmingham, Alabama
309
Population:
Pregnant smokers who
entered prenatal care before
7 months
Setting: the four highest
census maternity
clinics of the Jefferson
County Health
Department in Birmingham,
Alabama.
814
(I=400
C=414)
Windsor et al.
1985
Windsor et al
1993
JHU  WCHPC
To evaluate the
effectiveness of
low-cost, self-help
smoking cessation
methods
for public health
clinic populations
initiated at the first
prenatal visit
To evaluate the
behavioral impact
of smoking
cessation health
education among
pregnant smokers
29
15%
The experimental program cost more per patient
than the control intervention (US$13.95 vs US$1.83).
The cost per end-of-pregnancy validated abstainer
was
US$121.41 in the experimental group, compared
with US$37.88 in the control group.
This study demonstrates that a smoking cessation
program conducted by usual care providers in a
public antenatal clinic can produce significant
increases in sustained quit rates.
The evidence from this trial indicates that the
smoking behavior, (cessation and/or significant
reduction) of approximately one of five smokers was
changed due to exposure to the methods used
Beyond the observed behavior change, the
cessation methods applied in this study
demonstrated a high degree of feasibility and
acceptability among pregnant women and public
health maternity clinic staff.
15%
The treatment group (E) exhibited a 14.3% quit rate
and the control group had an 8.5% quit rate. An
historical comparison (HC) group exhibited a 3.0%
quit rate. Black E and HC group patients had higher
quit rates than white E and HC group patients.
A cost-benefit analysis found cost-to-benefit ratios of
$1:$6.72 (low estimate) and $1:$17.18 (high
estimate) and an estimated savings of $247,296 (low
estimate) and $699,240 (high estimate).
January 2008
TOBACCO INTERVENTIONS—SMOKING AMONG PARENTS AND OTHER CAREGIVERS
Authors
Study Question
Intervention
Abdullah et al
2005
To examine
whether telephone
counseling based
on the stages of
change
component of
Transtheoretical
model of behavior
change together
with educational
materials could
help nonmotivated
smoking parents
of young children
to cease.
Participants were
randomly allocated
into two groups: the
intervention
group received
printed self-help
materials and threesession telephonebased smoking
cessation counseling
delivered by trained
counselors; the
control group
received printed selfhelp materials only. A
structured
questionnaire was
used for data
collection at baseline
and at 1, 3 and 6
month follow up.
Hong Kong Special
Administrative Region, PR
China
Smoking fathers and
mothers of Chinese
children aged 5 years
Design: RCT
Intervention:
Motivational
intervention (MI)
group received a 30to 45-minute MI
session with a trained
health educator, 4
follow-up calls,
feedback from
household air nicotine assessments and
the participant‘s CO2
level.
Self-help (SH) group
received a smoking
cessation manual,
passive smoke
reduction tip sheet,
and resource guide in
the mail.
Low-income smoking
parents/caregivers (N 5 291)
who had children who were
younger than 3 years and
who were recruited through
primary care settings
Emmons et al
2001
JHU  WCHPC
To determine
whether a
motivational
intervention for
smoking parents
of young children
will lead to
reduced
household passive
smoke exposure
Population & Setting
N
Attrition
Outcomes/Comments
952
(I=467 and
C=485)
49 lost by
end of
study
Outcomes:
7 day point prevalence quit rate at 6 months
determined by self reports, self-reported 24 hour
point prevalence quit rate and self-reported
continuous quit rate and bio-chemically validated quit
rate at 6 months
Results:
The 7 day point prevalence quit rate at 6 month
follow up was significantly greater in the intervention
group (15.3%; 68/444) than the control group (7.4%;
34/459) (P<0.001). The absolute risk reduction was
7.9% (95% confidence interval: 3.78% to 12.01%).
The number needed to treat to get one additional
smoker to quit was 13 (95% CI: 8–26). The adjusted
odds ratio was 2.1 (95% CI: 1.4–3.4) (adjusted for
age, number of years smoked, and alcohol
dependency).
5291
MI: 26
nonresponders at 6
months
follow up
SH: 18
nonresponders at 6
months
follow up
30
Proactive telephone counseling is an effective aid to
promote smoking cessation among parents of young
children.
The 6-month nicotine levels were significantly lower
in MI households. Repeated measures analysis
of variance across baseline, 3-month, and 6-month
time points showed a significant time-by-treatment
interaction, whereby nicotine levels for the MI group
decreased significantly and nicotine levels for the SH
group increased but were not significantly different
from baseline.
January 2008
TOBACCO INTERVENTIONS—SMOKING AMONG PARENTS AND OTHER CAREGIVERS
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Outcomes/Comments
Hovell et al
2002
To test the
efficacy
of coaching to
reduce
environmental
tobacco smoke
(ETS) exposure
among asthmatic
Latino children
Design: RCT
Intervention:
After asthma
management
education, families
assigned to no
additional service or
to coaching for ETS
exposure reduction
(approximately 1.5
hours of asthma
management
education and 7
coaching sessions
(45 mins each) to
reduce ETS
exposure)
Latino children
(ages 3–17 years) with
asthma in San Diego, CA
204
16 lost
Parents in the coached condition reported their
children exposed to significantly fewer cigarettes
than parents of control children by 4 months
(postcoaching). Reported prevalence of exposed
children decreased to 52% for the coached families,
but only to 69% for controls. By month 4, mean
cotinine levels decreased among coached and
increased among control children. Cotinine
prevalence decreased from 54% to 40% among
coached families, while it increased from 43% to
49% among controls. However, cotinine levels
decreased among controls to the same level
achieved by coached families by the 13-month
follow-up.
Design: RCT
Intervention:
Mothers given seven
counseling sessions
over three months
Ethnically diverse mothers
living in low income homes in
San Diego County, CA who
exposed their children (aged
< 4 years) to tobacco smoke
in the home.
Hovell et al
2000
JHU  WCHPC
To test the
efficacy of
behavioral
counseling for
smoking mothers
in reducing young
children's
exposure to
environmental
tobacco smoke
31
108
14 lost
Asthma management education plus coaching can
reduce ETS exposure more than expected from
education alone, and decreases in the coached
condition may be sustained for about a year. The
delayed decrease in cotinine among controls is
discussed.
Mothers' reports of children's exposure to their
smoke in the home declined in the counseled group
from 27.30 cigarettes/ week at baseline, to 4.47 at
three months, to 3.66 at 12 months and in the
controls from 24.56, to 12.08, to 8.38. The
differences between the groups by time were
significant (P = 0.002). Reported exposure to smoke
from all sources showed similar declines, with
significant differences between groups by time (P =
0.008). At 12 months, the reported exposure in the
counseled group was 41.2% that of controls for
mothers' smoke (95% confidence interval 34.2% to
48.3%) and was 45.7% (38.4% to 53.0%) that of
controls for all sources of smoke. Children's mean
urine cotinine concentrations decreased slightly in
the counseled group from 10.93 ng/ml at baseline to
10.47 ng/ml at 12 months but increased in the
controls from 9.43 ng/ml to 17.47 ng/ml (differences
between groups by time P = 0.008). At 12 months
the cotinine concentration in the counseled group
was 55.6% (48.2% to 63.0%) that of controls.
January 2008
TOBACCO INTERVENTIONS—SMOKING AMONG PARENTS AND OTHER CAREGIVERS
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Outcomes/Comments
Hovell et al
1994
To test a
behavioral
medicine program
designed to
reduce asthmatic
children‘s
exposure to
environmental
tobacco smoke
(ETS) in the home
Design: RCT
Intervention:
Experimental group: a
6-month series of
counseling sessions
designed to decrease
ETS exposure,
monitored smoking,
exposure, and
children‘s asthma
symptoms. Monitoring
group: did not receive
counseling
Usual treatment
control group
received outcome
measures only.
Families with at least one
parent who smoked
cigarettes and a child (6 to
17 years) with asthma were
recruited from four allergy
clinics in San Diego
91 families
Not
specified
Roseby et al
2003
To evaluate
interventions
aimed at reducing
exposure of
children to second
hand smoke
Searched Tobacco
Addiction Group
studies, MEDLINE,
EMBASE,
bibliographies, plus
other data bases and
specialists
Setting
Community, school, or
family setting
Inclusion
Studies addressing parent,
family member, child care
workers or teachers
All studies including
smoking cessation, effect
of legislation, smoke free
policies, and other health
promotion included
18 studies
N/A
Wahlgren et al
1997
To examine longterm maintenance
of a previously
reported
behavioral
counseling
intervention to
reduce asthmatic
children‘s
exposure to ETS
Design: RCT
Intervention:
Participants
randomized to three
groups: behavioral
counseling to reduce
ETS exposure, selfmonitoring control,
and usual medical
care control.
Families of asthmatic
children (6 to 17 years),
including at least one parent
who smoked in the home,
recruited from four pediatric
allergy clinics in San Diego.
84 families
20
families
lost by
end of
study
Parents reported the daily number of cigarettes
children were exposed to during the week preceding
interviews. A nicotine air monitor and construct
validity analysis confirmed the validity of exposure
reports. Exposure to the parent‘s cigarettes in the
home decreased for all groups. The experimental
group attained a 79 percent decrease in children‘s
ETS exposure, compared with 42 percent for the
monitoring control and 34 percent for the usual
treatment control group. Repeated-measures
analysis of variance resulted in a significant
F([1O,350]1.92, p<O.O5) group by time effect. After
12 months, only the experimental/counseling group
sustained a decrease in children‘s exposure to
cigarettes in the home from all smokers (44 percent),
while the monitoring control increased 14 percent
and the usual treatment group increased exposure
22 percent from pre-intervention.
3 interventions aimed at population level, 7 studies
conducted in well child visits, 8 studies in ill child
visit
4 studies found statistically significant reduction in
parent reported cigarette smoking or household
nicotine levels, 3 of these used intensive patient
counseling
The fourth study involved children in China writing
letters to their fathers, not clear how generalizable
this is
5 studies trended towards significance
No clear difference in effect of setting (well child,
peripartum, school)
Insufficient evidence exists regarding effect on
child health indicators
The original analysis (baseline-12 months) was
reanalyzed with a more robust restricted maximum
likelihood procedure. The 2-year follow-up period
was analyzed similarly. Significantly greater change
occurred in the counseling group than the control
groups and was sustained throughout the 2 years of
follow-up. Further analyses suggest that printed
counseling materials given to all participants at the
conclusion of the original study were associated with
decreased exposure in the control groups.
JHU  WCHPC
32
January 2008
TOBACCO INTERVENTIONS—SMOKING AMONG PARENTS AND OTHER CAREGIVERS
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Winickoff et al
2005
To review impact
of parental
smoking on child
health and
pediatrician
initiated
interventions
aimed at parents
To evaluate
feasibility and
impact of parental
smoking cessation
intervention at
child‘s
hospitalization
NA
No inclusion criteria stated
Not stated
NA
3 clinic based studies showed improved quit rates
3 showed no improvement
Pediatrician offices are promising place for parent
smoking interventions, but more research needed
Design:
Prospective cohort
Intervention:
20 minute
counseling session
1 wk of free NRT
2 follow up phone
calls
Referral to MA
Smoker‘s Quitline
Follow up with PCP
Participants
followed up at 2
months
In treatment schools:
a tobacco-use
prevention
curriculum,
encouragement to
implement smokingcontrol policies to
severely limit or
restrict smoking, and
encouragement of
teachers to be nonsmoking role models.
Students whose
fathers smoked
monitored, recorded
and reported their
fathers‘ smoking
status.
Setting:
Children‘s Hospital in
Boston
Inclusion:
All parents of children
admitted with respiratory
illness
Parents must smoke, have
phone, speak English
N=71
20%
5 parents (7%) called free quitline
35 parents (49%) made quit attempt within last 24
hrs
15 (21%)parents reported 7-day abstinence at 2
months
No control group so difficult to interpret results
Demonstrates feasibility of implementing
intervention at hospitalization
Setting:
Schools in the Jiangan
district of Hangzhou from
May 1989
through January 1990
10,395
students in
grades 1–7
from 23
primary
schools and
their fathers.
The reference
group
comprised
9987 students
in grades 1–7
from 21
primary
schools and
their fathers
Not
provided
Winickoff et al
2003
Zhang & Qiu
1993
JHU  WCHPC
To increase knowledge of the health
consequences of
cigarette smoking,
promote healthier
attitudes among
elementary school
students, and
motivate fathers
who smoke to
quit.
33
Outcomes/Comments
Scores of students in the intervention group were
significantly higher than both the reference group
follow-up scores and the intervention group baseline
scores. Based on the daily recordings maintained by
students in the intervention group, 1037 (15.2%)
fathers had not smoked cigarettes for 180 or more
days. In comparison, based on the interviews of
health educators, 800 (11.7%) fathers reported that
they maintained cessation. For a later period, the
reported smoking rate for fathers in the intervention
group decreased from 68.8% to 60.7% (p<0.05)
while the reported rate remained approximately the
same among fathers in the reference group.
Approximately 90% of the fathers in the intervention
group who were smokers in May 1989 were reported
to have quit smoking for at least 10 days. The 6month cessation rate for fathers in the intervention
group was 11.7% compared with 0.2% in the
reference group.
January 2008
TOBACCO INTERVENTIONS—SMOKING AMONG YOUTH
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Outcomes/Comments
Colby et al
2005
To evaluate the
efficacy of
motivational
interviewing (MI)
encouraging teens
to quit smoking
Design
RCT
Setting:
Emergency department
and adolescent health
clinic in the Northeast US
I: 43
C: 42
I: 20%
C: 20%
Results:
3 month quit rates: no different between groups
Dalton et al
2003
JHU  WCHPC
To ascertain
whether
exposure to
smoking in movies
predicts smoking
initiation
Intervention
Control: Standard
care of brief advice
(BA)
Intervention: MI
with 1 wk booster
contact
Follow up
appointments: 1, 3,
and 6 months
Design: Prospective
Intervention:
Exposure to smoking
in movies was
estimated for
individual respondents on the basis of
the number of
smoking occur-ences
viewed in unique
samples of 50
movies, which were
randomly selected
from a larger sample
pool of popular
contemp-orary
movies. Students
were re-contacted
13–26 months later to
determine whether
they had initiated
smoking.
6 month quit rates: MI=23%, n=8; BA=3%, n=1
Results support that MI may be effective in medical
setting
High attrition rates made results difficult to interpret
Inclusion
Aged 12-19 and reported
smoking in previous 30
days
Setting:
14 schools in Vermont and
New Hampshire
Inclusion:
Adolescents (aged 10–14
years) who reported in a
baseline survey that they
had never tried smoking
34
3547
2603
(73% of
original
sample)
Overall, 10% (n=259) of students initiated smoking
during the follow-up period. In the highest quartile of
exposure to movie smoking, 17% (107) of students
had initiated smoking, compared with only 3% (22) in
the lowest quartile. After controlling for baseline
characteristics, adolescents in the highest quartile of
exposure to movie smoking were 2·71 (95% CI
1·73–4·25) times more likely to initiate smoking
compared with those in the lowest quartile. The
effect of exposure to movie smoking was stronger in
adolescents with non-smoking parents than in those
whose parent smoked. In this cohort, 52·2% (30·0–
67·3) of smoking initiation can be attributed to
exposure to smoking in movies.
January 2008
TOBACCO INTERVENTIONS—SMOKING AMONG YOUTH
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Grimshaw &
Stanton
2006
To evaluate the
effectiveness of
strategies that
help young people
stop smoking
Searched CENTRAL,
Cochrane Tobacco
Addiction Group,
MEDLINE, EMBSE,
PsychINFO, ERIC,
CINAHL, and
bibliographies
Setting:
All levels including
individual, organizational,
or community
Inclusion:
Randomized controlled
trials, cluster-randomized
trials, and controlled trials
Primary outcome measure
was smoking status at 6
months
15 Studies
NA
Hersey et al
2005
To evaluate the
impact of state
anti smoking ads
on youth smoking
Design:
Cross sectional
observational
Setting:
United States
States broken down into
three categories of
campaigns: established,
new, no campaign
States with established
campaigns: CA, FL, MA
States with ―new‖
campaigns: IN, MS, MN,
NJ
Wave 1: 3,424
Wave 2:
12,967
Wave 3:
10,855
NA
Intervention:
Compared rates of
smoking between
1999-2002 in states
with smoking
prevention
campaigns
Three separate
surveys fielded: one
before and two after
implementation of
campaign
Hyland et al
2005
JHU  WCHPC
To assess the
relationship
between exposure
to state-sponsored
anti- smoking ads
and smoking
cessation
Design:
Cross sectional/
observational
Intervention:
Compared smoking
behavior among
those living in states
with state sponsored
media campaigns and
those without.
Inclusion:
Lived in same community
in 1998 and 2001
Resided in one of top 75
media markets
Smokers in 1999
35
Pooled results of trials bases on transtheoretical
(TTM) model achieved moderate long term
success
TTM pooled OR at 1 yr: 1.7, 95% CI 1.25-2.33
TTM pooled OR at 2 yrs: 1.38, 95% CI 0.99-1.92
Pharmacological interventions did not result in
statistically significant results
Cognitive behavior interventions did not achieve
statistical success
Motivational interviewing achieved statistical
success (OR = 2.05, 95% CI 1.10-3.80) but difficult
to isolate effects of interview from other study
elements
Greater declines seen in states with established
and new anti smoking campaigns vs. other states
(p<0.05)
Decline in Smoking 1999-2002 based on program
Established: 55% (12.3 to 5.5%)
New: 47% (15.0 to 7.9%)
No Campaign: 25% (12.5 to 9.4%)
Exposure to campaign only assessed by residency
in state, not individual level exposure
Campaigns usually included school based
programming,--factors in addition to media most
likely responsible for decline
Inclusion:
Youth aged 12-17
Data collected using
national sample, over
sampling African
Americans, Hispanics, and
Asians
Setting:
Setting: CA, IA, MA, NM, NJ
NY, NC, OR, WA, Ontario
Outcomes/Comments
2,061
NA
Those reporting that anti-tobacco information had
increased ‗a lot‘ showed significant increase in quit
rate (RR1.19, 95% CI 1.03-1.38)
States above median exposure to ads had
significantly higher quit rates (12.9% vs. 11.0%;
P=0.047)
Higher exposure leads to increases in quit rates
Not able to assess individual exposure
Controlled for other anti-tobacco policies (tax
increases) but not able to control for other potential
confounders
January 2008
TOBACCO INTERVENTIONS—SMOKING AMONG YOUTH
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Outcomes/Comments
Lantz et al
2000
To provide a
comprehensive
review of
interventions and
policies aimed at
reducing youth
cigarette smoking
in the US,
including
strategies that
have undergone
evaluation and
emerging
innovations that
have not yet been
assessed for
efficacy
Medline literature
searches, books,
reports, electronic list
servers, and
interviews with
tobacco control
advocates
Various
Number of
studies
reviewed is
not specified
N/A
Interventions and policy approaches were
categorized using a typology with seven categories
(school based, community interventions, mass
media/public education, advertising restrictions,
youth access restrictions, tobacco excise taxes, and
direct restrictions on smoking). Novel and largely
untested interventions were described using nine
categories. Youth smoking prevention and control
efforts have had mixed results. However, this review
suggests a number of prevention strategies that are
promising, especially if conducted in a coordinated
way to take advantage of potential synergies across
interventions. Several types of strategies warrant
additional attention and evaluation, including
aggressive media campaigns, teen smoking
cessation programs, social environment changes,
community interventions, and increasing cigarette
prices. A significant proportion of the resources
obtained from the recent settlement between 46 US
states and the tobacco industry should be devoted to
expanding, improving and evaluating ‗youthcentered‘ tobacco prevention and control activities.
JHU  WCHPC
36
January 2008
TOBACCO INTERVENTIONS—SMOKING AMONG YOUTH
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Outcomes/Comments
Levy et al
2004
Review of tobacco
control policies‘
contribution to
smoking cessation
and initiation
Examined studies
evaluating (1) taxes,
(2) clean air laws, (3)
restrictions on
advertising, (4) antismoking media
campaigns, (5) health
warning labels, (6)
enforcement of youth
access laws, (7)
school education
programs, and (8,
9)policies to increase
utilization of cessation
treatments
Inclusion:
Not stated
NA
NA
Taxes
A 10% increase in cigarette price would result in a
3-5% decrease in demand for cigarettes per adult
Youth are more susceptible to the price of
cigarettes; higher prices influence progression to
established smoker
Among adolescents, a 10% increase in cigarette
price would reduce the number of young smokers
by 7%
Clean Indoor Air Laws
States with clean air laws have 10% lower smoker
prevalence vs. other states
Worksites with smoking bans can see significant
increases in quit rates, ranging from 0-20%
Comprehensive bans on smoking could result in an
11% quit rate
Advertising Restrictions
Results are mixed—for bans to be effective they
must be comprehensive
A comprehensive ban could result in a decrease in
smoke prevalence by 4%; a partial ban would
result in a 2% decrease
Media Campaigns
Results are mixed, but when combined with other
programs media campaigns can potentially reduce
smoking prevalence by 7%
School Education Programs
Evidence from school programs is mixed; many
result positively affect attitudes and lead to only
short term change in use
Access to Treatment
Broad coverage and requirements for physician
involvement could lead to a 3.5% reduction in
prevalence over 10 years
Telephone Quit Lines
Absolute difference in quit rates between quit line
users and non-users ranges from 3.4-23%
JHU  WCHPC
37
January 2008
TOBACCO INTERVENTIONS—SMOKING AMONG YOUTH
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Outcomes/Comments
McDonald et al
2003
To offer program
managers,
policymakers, and
researchers a
scientific basis for
developing and
selecting smoking
cessation
treatments
for adolescents
Various
20 studies
N/A
The 9 studies that reported treatments that
increased cessation were based on social cognitive
theory.
Cognitive-behavioral interventions are a promising
approach for helping young smokers quit smoking.
Evidence is insufficient to draw other conclusions at
this time.
Muñoz et al
2006
To evaluate
internet based
smoking cessation
programs in both
English and
Spanish speaking
populations
An evidence review
panel systematically
rated published and
unpublished
reports of cessation
treatments
for youth to make
recommendations
on theoretical
foundations,
delivery settings,
types of intervention,
and provider type.
Design: RCT
Intervention:
1)Guia smoking
cessation guide +
individually timed
educational
messages (ITEMs)
2)Guia + ITEMs +
mood management
Setting:
Participants recruited via
press releases, search
engine links, email
messages, announcements
on health information sites
English
intervention:
280
English:
65%
Participants followed
up at 1, 3, 6, and 12
months
JHU  WCHPC
Inclusion
18 years of age
Planning to quit smoking
in next 3 months
Using Internet weekly
38
Spanish
intervention:
288
Spanish:
39%
Among English speakers, Guia + ITEM alone had
higher quit rates at 12 months (17.0 vs. 8.6%,
p=0.036)
There was no significant difference in quit rates
among Spanish speaking participants
Study provides evidence that internet interventions
are possible
Limited support for efficacy of studied intervention
No base line measurements reported
Very high attrition rates
January 2008
TOBACCO INTERVENTIONS—SMOKING AMONG YOUTH
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Outcomes/Comments
Murphy-Hoefer
et al 2005
To review
interventions
designed to
reduce the
prevalence of
smoking among
college/university
students.
Seven databases
were searched for
relevant articles
published in English
between 1980 and
2005, and reference
lists were examined
for additional
published studies.
The studies were
categorized as (1)
individual
approaches, such as
on-campus cessation
programs, and (2)
institutional
approaches, such as
smoke-free policies.
The studies were
categorized by type of
institution and
geographic location,
study design, sample
demographics, and
outcomes.
Various
14 studies
N/A
Ranney et al
2006
To examine
effective
interventions at
the community
and population
level to prevent
tobacco use and
increase demand
for effective
cessation
interventions
Design:
Searched MEDLINE,
CINAHL, Cochrane
libraries and Clinical
Trial Register,
Psychological
Abstracts, and Social
Abstracts
Setting:
None stated
N=102
NA
Only 5 of the 14 studies identified received a
―satisfactory‖ rating based on evaluation criteria.
Most studies were based on convenience samples,
and were conducted in 4-year institutions. Seven
studies used comparison groups, and three were
multi-institutional. Individual approaches included
educational group sessions and/or individual
counseling that were conducted on campus mostly
by healthcare personnel. None used nicotine
replacement or other medications for cessation. The
quit rates for both smokeless tobacco and cigarette
users varied, depending on definitions and duration
of follow-up contact. Institutional interventions
focused mainly on campus smoking restrictions,
smoke-free policies, antitobacco messages, and
cigarette pricing. Results indicated that interventions
can have a positive influence on student behavior,
specifically by reducing tobacco use (i.e., prevalence
of cigarette smoking and use of smokeless products,
amount smoked) among college students, and
increasing acceptability of smoking policies and
campus restrictions among both tobacco users and
nonusers.
While some promising results have been noted,
rigorous evaluations of a wider range of programs
are needed, along with studies that address cultural
and ethnic diversity on campuses.
Strong evidence exists for increasing price of
tobacco products and mass media campaigns
concurrent with other interventions
Sufficient evidence exists for short term effects of
school based programs
Insufficient evidence for long term effects of school
based programs
Strong evidence supporting telephone support
increases cessation in adults; insufficient evidence
in adolescents
Community based pharmacist interventions
successful in reducing adult quit rates
JHU  WCHPC
Inclusion:
Randomized trials,
observational studies, and
systematic reviews all
included
39
January 2008
TOBACCO INTERVENTIONS—SMOKING AMONG YOUTH
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Outcomes/Comments
Roddy et al
2006
To evaluate the
impact of nicotine
replacement
therapy on quit
rates of low
income youth
smokers
Design: RCT
Setting:
Youth community center in
inner city Nottingham, UK
Inclusion
Aged 12-20
Current smoker, nonpregnant
I: 49
C: 49
70% of
total
remained
at end of
study
Median number of weeks of patch therapy: 1 wk
High attrition rates make study result difficult to
interpret.
Setting:
New Zealand
I: 852
C: 853
I: 30%
C: 21%
Six week risk of quitting:
RR 2.2 (95% CI 1.70-2.70; P < 0.001)
12 week risk of quitting:
RR 1.3 (95% CI 1.3-1.84; P < 0.001)
26 week risk of quitting
RR 1.07 (95% CI 0.91-1.26; P = 0.04)
At 12 and 26 weeks % of quitting in control group
increased (18.8% and 23.7% respectively)
20.8% of those reporting not smoking at 6 weeks
failed oral cotinine test
Approximately 1/3 of each group aged 16-19—may
be an effective strategy for youth
Of 4,216
students
recruited, 66%
consented
68.6%
provided
data at all
four
collection
points
Rodgers et al
2005
Slater et al
2006
JHU  WCHPC
To determine the
effectiveness of a
mobile phone text
messaging
smoking cessation
program
To test the impact
of an in-school
mediated
communication
campaign, in
combination
with a
participatory,
community-based
media
effort, on
marijuana, alcohol
and tobacco
uptake among
middle-school
students
Intervention:
All participants
offered counseling
Randomized to
placebo or active
NRT patches
Design: RCT
Intervention:
Received text
messages with
smoking cessation
advice and one
month free text
messaging after
quit day—
encouraged to
contact family
Matched with quit
buddy to provide
support
Followed up at 6,
12, and 26 weeks
Design: RCT
Intervention:
Schools in media
communities
randomized to
media plus
curriculum or media
alone
Schools in non
media communities
randomized to
curriculum or no
intervention
Inclusion:
Aged > 16 years (one third
of sample 16-19 years)
Currently smoking but
interested in quitting
Able to send and receive
text messages
Setting:
Middle and junior high
schools
Inclusion:
Communities recruited
using National Center for
Educational Statistics
40
Authors suggest NRT not effective in this population
based on poor compliance.
OR = 0.49 for tobacco use in the media +
curriculum communities vs. control (p=0.039)
OR = 0.72 for tobacco use in curriculum
communities (p < 0.0050
Notes
Schools assignment not completely random—
based on staffing capabilities
Results may also be biased by active consent
procedures
January 2008
TOBACCO INTERVENTIONS—SMOKING AMONG YOUTH
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Outcomes/Comments
Sowden &
Arblaster
2000
To review
effectiveness of
mass media
campaigns in
preventing uptake
of smoking by
youth
Searched MEDLINE,
28 other electronic
databases, plus hand
searched key journals
and contacted
experts
Setting:
Not specified
Inclusion:
Randomized trials,
controlled trials, and time
series studies
Assessed smoking
behavior of people under
age 25
N=6
NA
Sussman 2002
To review
research in
adolescent and
young-adult
tobacco use
cessation
Literature review
Studies focusing on
adolescents and youth
66 tobacco
cessation
intervention
studies as well
as 17
prospective
studies of
adolescent
self-initiated
tobacco
use cessation
Average
reach and
retention
across
the
intervention
studies
was 61%
and 78%,
respectively
Some evidence exists that mass media campaigns
can be effective, but evidence is not strong
Two studies concluded that mass media were
effective in influencing smoking behavior of young
people
One successful study found students in
communities where TV and radio messages were
combined with a school based program had a
lower risk of weekly smoking than those in
communities receiving only the schools-based
component (OR 0.62, 95% CI: 0.49 to 0.78)
A Norwegian campaign found the odds ratio for
being a smoker in the intervention county
compared with being a smoker in the control
county was 0.74 (95% CI: 0.64 to 0.86) after
adjustment for smoking at baseline and gender
Effective campaigns had solid theoretical bases,
and used formative research
A comparison of intervention theories revealed that
motivation enhancement (19%) and contingencybased reinforcement (16%) programs showed higher
quit-rates than the overall intervention cessation
mean. Classroom-based programs showed the
highest quit rates (17%). Computer-based (expert
system) programs also showed promise (13% quitrate), as did school-based clinics (12%).
These data suggest that use of adolescent tobacco
use cessation interventions double quit rates on the
average. In the 17 self-initiated quitting survey
studies, key predictors of quitting were living in a
social milieu that is composed of fewer smokers,
less pharmacological or psychological dependence
on smoking, anti-tobacco beliefs (e.g., that society
should step in to place controls on smoking) and
feeling relatively hopeful about life. Key variables
relevant to the quitting process may include
structuring the context of programming for youth,
motivating quit attempts and reducing ambivalence
about quitting, and making programming enjoyable
as possible. There also is a need to help youth to
sustain a quit-attempt. In this regard,
one could provide ongoing support during the acute
withdrawal period and teach youth social/life skills.
JHU  WCHPC
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TOBACCO INTERVENTIONS—SMOKING AMONG YOUTH
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Swartz et al
2006
To test the short
term efficacy of an
internet smoking
cessation program
Design: RCT
Intervention:
Randomized to
program or wait list
Intervention
consisted of
personalized
computer based
modules mimicking
smoking cessation
counselor
Participants
followed up at 90
days
After 90 day wait
period controls also
had access to
program
Multidisciplinary
teams developed an
approach to
organizing, grouping,
and selecting the
interventions for
review, assessed the
quality of the body of
evidence of
effectiveness for
interventions and
summarizing the
strength of this body
of evidence,
summarized
information regarding
other evidence, and
identified and
summarized research
gaps.
Setting:
Subjects recruited from
internet and worksite
promotions
I: 171
C: 180
I: 49%
C: 39%
Task Force on
Community
Preventive
Services 2000
JHU  WCHPC
To conduct
systematic
reviews on 14
selected
interventions and
make subsequent
recommendations
42
treatment cessation rate: 24.1% (n=21)
control cessation rate: 8.2% (n=9), p=0.002
Intention-to-treat Analysis:
treatment cessation rate: 12.3% (n=21)
control cessation rate: 5.0% (n=9) p=0.015
Study had high attrition rate
Tobacco use self reported, no biochemical
validation
Inclusion:
At least 18 years old
currently smoking
considering quitting, willing
to make quit attempt
Interventions were either
single-component or multicomponent. To be included
in the reviews of
effectiveness, studies had to
meet these criteria: a) they
were limited to primary
investigations of
interventions selected for
evaluation; b) they were
published in English from
January 1980 through May
2000; c) they were
conducted in industrialized
countries; and d) they
compared outcomes in
groups of persons exposed
to the intervention with
outcomes in groups of
persons not exposed or less
exposed to the intervention
(whether the comparison
was concurrent or beforeafter).
Outcomes/Comments
166 studies
N/A
On the basis of the evidence of effectiveness, the
Task Force either strongly recommended or
recommended nine of the 14 strategies evaluated
including one intervention to reduce exposure to
ETS (smoking bans and restrictions), two
interventions to reduce tobacco-use initiation
(increasing the unit price for tobacco products and
multicomponent mass media campaigns), and six
interventions to increase cessation (increasing the
unit price for tobacco products; multicomponent
mass media campaigns; provider reminder systems;
a combined provider reminder plus provider
education with or without patient education program;
multicomponent interventions including telephone
support for persons who want to stop using tobacco;
and reducing patient out-of-pocket costs for effective
cessation therapies).
January 2008
TOBACCO INTERVENTIONS—SMOKING AMONG YOUTH
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Outcomes/Comments
Thomas &
Perera
2006
To review
behavioral
interventions in
school to prevent
smoking initiation
Searched Cochrane
Central Register of
Controlled Trials,
Cochrane Tobacco
Register, MEDLINE,
EMBASE, PsycINFO,
ERIC, CINAHL,
Health Star, individual
authors, and
dissertation abstracts
N=94
NA
Werch et al
1996
To examine the
extent to which
program
comprehensiveness, programmatic outcomes,
program
integration, and
environmental
factors are being
addressed by
college and
university drug
use prevention
programs
Need to fill this in
when we get the
hardcopy of the
article
Setting
Schools
Inclusion
Students, classes,
schools, or school districts
randomized
Children aged 5-12 or 1318
Measured non-smoking,
no biochemical validation
required
urban and rural US colleges
and universities
Some evidence supporting social influence
models, although largest most rigorous study
(HSPP) showed no effect
Many researchers question methods and
generalizability of HSPP results
Pooled results from social influence studies also
showed no effect
Pooled results from ―life skills‖ interventions were
positive but non-significant
3 of 4 Programs using multi-modal approach had
positive results, but evaluation less rigorous
College-based prevention programs employed a
range of programmatic goals, prevention
communication channels, and prevention strategies
within a centralized department for drug use
prevention. Most program coordinators reported no
perceived change in alcohol, tobacco and other drug
use, alcohol/drug-related problems, faculty/staff drug
use, and alcohol and drug-related crime resulting
from prevention efforts on campus. The level of
prevention activity differed across institutional type.
JHU  WCHPC
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23 identified
as high quality
336 schools
N/A
January 2008
APPENDIX B: ADDRESSING OBESITY ACROSS THE LIFESPAN
MAGNITUDE: Childhood overweightxl is a significant and growing problem in our society, up
sharply in recent decades.200 Over the last thirty years, the obesity rate has nearly tripled for
preschool children, increasing from five to 14%.201 In 2006, an estimated 18% of children ages
six to 11 years and 17% of adolescents ages 12-19 years were overweight.202 Moreover, the
prevalence of overweight among children and youth from certain ethnic minority groups is
estimated to be even higher.203
DETERMINANTS: There are multiple identifiable risk factors within children‘s physical and social
environments that can encourage weight gain among them.204 Research points to overeating, lack
of physical activity, lack of sleep, time spent watching television or playing video games,
consumption of high-calorie liquids (e.g., sodas) and eating away from home as important
contributory factors.205,206,207,208,209,210,211 The term ―obesogenic‖ is frequently used to describe
the current environment within which childhood overweight has soared.212
The factors that influence weight status early in life can continue over the long term. As a result,
in the absence of effective interventions, overweight persists for many children throughout the
lifespan. Preschool children ever overweight have been found to be five times more likely to be
overweight at age 12 than preschool children with normal weights,213 and obesity persists into
adulthood for an estimated 50-80% of overweight children and adolescents.214,215,216
HEALTH CONSEQUENCES: The physical health consequences of childhood overweight include
orthopedic complications, metabolic disturbances, type 2 diabetes, disrupted sleep patterns, poor
immune function, endocrine problems, impaired mobility, and increased blood pressure and
hypertension.217,218 The psycho-social consequences associated with childhood overweight
include low self-esteem,219,220 social alienation,221,222 discrimination,223,224 lower self-reported
quality of life,225 and depression.226,227 Other studies show that overweight adolescents are as
much as 20 times more likely to become overweight as adults,228,229 and approximately 70 to
77% of overweight adolescents will remain obese as adults. 230,231 Furthermore, obesity is
associated with increased morbidity and mortality among pregnant women.232 Obese women
have an increased risk of pregnancy complications (e.g., gestational diabetes and hypertensive
disorders) regardless of their health prior to pregnancy,233,234,235,236,237,238,239,240 and high maternal
body mass index (BMI) is correlated with labor and delivery problems and an increased risk of
cesarean delivery.241,242,243,244,245 Maternal overweight is also associated with infant birth
defects246 and macrosomia.247
ECONOMIC CONSEQUENCES: Researchers studying the economic costs of obesity in the United
States estimate that direct costs reach $109 billion per year and indirect costs total $75 billion (in
2006 dollars).248 A significant portion of these costs is borne by government and businesses;
Medicare and Medicaid are estimated to fund approximately 50% of all U.S. obesity-related
costs,249 and U.S. businesses spent $12.7 billion on obesity in 1994 [$17.3 billion in 2006
dollars] through health insurance, life insurance, disability time, and paid sick leave.250
xl
The US Centers for Disease Control and Prevention (2000) uses the term ‗overweight‘ to describe children and
youth with a body mass index (weight [kg] / height [m2]) at or above the 95th percentile for age and sex based on the
reference population of the CDC 2000 growth charts. The CDC designates children ―at risk for overweight‖ if they
have a BMI between the 85th and 95th percentiles.
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Among overweight pregnant women, the costs of prenatal care are estimated to be five to 16
times higher than for women of healthy weights, increasing with level of obesity.251 In addition,
the duration of prenatal and postpartum hospitalization is approximately 4.4 days longer for
obese women (whose BMI was >29) than for women with healthy weights.252
Among children, the economic costs of overweight also are significant. Obesity-related hospital
costs for children ages six to17 increased four-fold between 1979 and 1999, rising from $44
million to $160 million (in 2006 dollars) as the discharges of diabetes nearly doubled. 253 One
study of children ages five to18 who presented at an urban primary care clinic showed that the
yearly expenditures for children with diagnosed obesity were significantly higher than the
expenditures for their healthy-weight counterparts (adjusted mean difference=$172; 95% CI).254
Even children with overweight and undiagnosed obesity had higher expenditures, which, when
extrapolated, suggest that unhealthy weight results in $25,688 of excess spending each year for
every 1,000 children ages five to18 years.255
EVIDENCE FOR SUCCESSFUL PREVENTION AND TREATMENT: The overall effectiveness of
interventions to prevent or treat overweight in childhood is unclear256,257,258 and few studies
target young children in particular.259 To date, evidence of programmatic success among
preschoolers is limited to the ‗Hip-Hop to Health Jr‘ program, and that was effective only when
implemented among a group of African-American children.260,261 The evidence for program
effectiveness among elementary school-aged children is mixed and weak as well.
Other reviews of interventions that target childhood overweight concur that the evidence is
varied and not well established. For example, a 2005 Cochrane Review concluded that studies to
prevent childhood overweight were ―heterogeneous in terms of study design, quality, target
population, theoretical underpinning, and outcome measures, making it impossible to combine
study findings using statistical methods.‖262 The Prevention Group of the International Obesity
Task Force determined that the evidence base for the effectiveness of prevention efforts targeting
children is even harder to determine than for treatment efforts.263 Further, many of the programs
that demonstrate an impact can only claim small and short-term improvements in outcomes,264,265
the majority of which are limited to activity and nutrition outcomes rather than to improvements
in body fat.266,267,268 Moreover, a 2003 study by Caballero et al269 demonstrates that even longerterm, intensive school-based interventions with multiple components have questionable
effectiveness.270 A RCT of intensive home visiting intervention in preventing the early onset of
childhood overweight among children between two and five has been undertaken in
disadvantaged areas of Sydney, Australia.271
Because of the limited evidence of program effectiveness to date, researchers question the
scientific testing of single or multiple behavioral interventions targeting childhood overweight
and suggest that indirect approaches that address economic, educational and/or social problems
within society may be more effective.272,273 Similarly, others conclude that the ―epidemic of
childhood obesity [is] unlikely to be resolved without concerted political action to detoxify the
obesogenic environment in which we live.‖274 Such an approach will require the active
involvement of the medical community, health administrators, teachers, parents, food producers
and processors, retailers and caterers, advertisers and the media, recreation and sport planners,
urban architects, city planners, politicians and legislators.275
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COST IMPLICATIONS OF INTERVENTIONS: Given the current dearth of literature demonstrating
intervention effectiveness, it is not surprising that evidence on the cost implications of
interventions that aim to prevent or treat overweight among young children is lacking. One
reason for this is that researchers face important challenges in completing cost-effectiveness
studies on obesity. These include the need to determine the most relevant measurement outcomes
and to develop consensus models of lifetime effects in terms of QALYsxli for each outcome (with
consideration paid to differences that may exist by age, sex and race),. Also, as noted above, the
evidence for any long-term impacts of interventions is still weak in part because this research
area has only recently emerged.276
Two relevant studies in the literature demonstrate potential methods for determining obesityrelated intervention cost benefits. Wang et al277 conducted a cost-effectiveness study that focused
on ‗Planet Health,‘ a school-based intervention to improve nutrition and increase physical
activity among middle-school aged children. This study concluded that the program helped girls,
at a cost of $4305 per QALY, but that there was no effect for boys. Elixhauser et al.278 modeled a
comprehensive hospital program of preconception diabetes care and concluded that it would
reduce maternal and infant hospitalizations (particularly those due to major congenital
malformations), resulting in net benefits of $1,720 per enrollee [$2,796 in 2006 dollars].
CONCLUSION: The myriad causes of childhood overweight and its numerous consequences have
been well documented. Less well-understood are the most appropriate ways to prevent or treat
the problem. Future interventions should carefully document program activities and ensure that
evaluations are comprehensive and long-term, with attention paid to the cost implications of
interventions. They should target the immediate/direct causes of childhood overweight, taking
into account the context within which it occurs. Such research will contribute to our collective
understanding of the most appropriate and cost-effective methods to curb the current epidemic of
childhood overweight. Without such interventions, the already considerable physical, psychosocial and economic costs to America‘s children are likely to continue unabated. One challenge
to economic motivations for interventions that address the societal contributors is the inherent
difficulty of tracing and measuring the many effects of context interventions that may be useful
for changing much more than only childhood obesity.
xli
A QALY is a quality-adjusted life year and represents a measurement of improved physical or mental health or
both, as well as additional years of life. For more information about QALYs see: Gold MR, Siegel JE, Russell LB,
Weinstein MC. (1996). Cost-Effectiveness in Health and Medicine. New York, NY: Oxford University Press.
JHU  WCHPC
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January 2008
Figure 1. Lifespan Impact of Obesity Interventions
LIFESPAN STAGE INTERVENTION AND IMPACT
LEVEL OF INTERVENTION
Preconception/ Pregnancy
Individual
Observational studies
Infant/Childhood
Adolescence
Adulthood
i
Observational studies
Family
Preschool education
Parent education
Local/ Community/
Workplace/ School
ii
iii
iv
Teacher curriculum
v
National/State
Age period when interventions take place
Age period with continuing positive impacts of intervention
i
Eriksson et al. 2001; Nader et al. 2006
Field et al 2005
iii
Fitzgibbon et al. 2005
iv
Golan et al. 2006
v
Summerbell et al. 2003
JHU  WCHPC
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47
January 2008
Table 1. Studies on Obesity
OBESITY PREVENTION—ECONOMIC STUDIES
Authors
Study Question
Perspective
Colditz G
Pub: 1999
Cost: 1995
To assess the
economic cost of
inactivity and
obesity
Societal
Hampl et al
Pub: 2007
Cost: 2003
To compare health
care utilization and
expenditures for
healthy-weight
patients, overweight
patients, and
patients with
diagnosed and
undiagnosed obesity
and to examine
factors associated
with a diagnosis of
obesity.
Primary care
clinic within
an urban
hospital
setting
Finkelstein et al
Pub: 2005
To review causes
and consequences
of obesity
Thompson et al
Pub: 1998
Cost: 1994
Wang et al
Pub: 2003
Cost: 1996
JHU  WCHPC
Population
& Setting
Study type & design
Results/Comments
US
Sedentary behavior and lack of physical exercise costs the US 24.3
billion dollars/year in direct healthcare costs (2.4% of US healthcare
expenditures)
Direct medical costs related to obesity total $70 billion (7% of US
healthcare costs)
Indirect costs associated with obesity total $48 billion
Retrospective study using
claims data from a large
pediatric integrated delivery
system in an urban
academic children‘s
hospital.
US
Of 8404 patients, 17.8% were overweight and 21.9% were obese. Of
the obese children, 42.9% had a diagnosis of obesity.
Increased laboratory use was found in both children with diagnosed
obesity (odds ratio [OR], 5.49; 95% confidence interval [CI], 4.656.48) and children with undiagnosed obesity (OR, 2.32; 95% CI, 1.972.74), relative to the healthy-weight group.
Health care expenditures were significantly higher for children with
diagnosed obesity (adjusted mean difference, $172; 95% CI, $138$206) vs the healthy-weight group.
Factors associated with the diagnosis of obesity were age 10 years
and older (OR, 2.7; 95% CI, 2.0-3.4), female sex (OR, 1.5;95%CI,
1.2-1.8), and having Medicaid (OR, 1.6; 95% CI, 1.1-2.3).
NA
Review of published
literature (search terms
include BMI, obesity, and
other economic indicators)
US
To estimate the cost
of obesity to US
employers
Payer
Standard methods for risk
attribution and for
ascertaining cost of illness
were used to estimate
obesity-attributable
expenditures on selected
employee benefits
Total US
population
aged 25-65
years
To assess the cost
effectiveness and
cost-benefit of a
school based
obesity prevention
program
Societal
Initial study: RCT
CEA/CB
Examined cases of adult
overweight prevented
(medical and lost
productivity), QALYs, and
cost of program
10 middle
schools in
the Boston
area over 2
years
(310 girls,
331 boys)
Review of Medline for
studies reporting cost of
obesity, inactivity, or cost
of illness
Calculated population
attributable risk for
diseases related to obesity
48
Children 518 years
Obesity accounts for 5% of health expenditures among business and
employer sponsored health plans
Medicare pays for ~50% of all obesity attributable costs
Obese individuals more likely to experience absenteeism, costing
employers $2.4 billion
Total (direct and indirect) costs of obesity as high as $139 billion/year
US businesses spent $12.7 billion on obesity in 1994
$7.7 billion spent on health insurance, $1.8b on life insurance, $0.8b
on disability insurance, and $2.4b on paid sick leave
Comments:
Obesity data from 1993, most likely underestimating the current costs
Many obesity expenditures occur after age 65
Does not account for expenditures of uninsured
For girls, odds ratio of obesity in intervention schools vs. control =
0.47 (p=0.03)
No differences found among boys
Medical costs averted: $15,887
Cost of lost productivity averted: $25,104
CER: $4,305/QALY
Results sensitive to discount rate, robust to other parameters
January 2008
OBESITY PREVENTION—ECONOMIC STUDIES
Population
& Setting
Authors
Study Question
Perspective
Study type & design
Wang & Dietz
Pub: 2002
Cost: 2001
To examine the
trend of obesityassociated diseases
in youths and
related economic
costs
Hospitals
Used the National Hospital
Discharge Survey (1979–
1999) to analyze changes in
costs among youths (based
on discharges with obesity
listed as a principal or
secondary diagnosis)
US youth
ages 6-17
years
Results/Comments
The percent of all discharges that were obesity-associated diseases
increased dramatically over a 20 year time period: discharges of
diabetes nearly doubled (from 1.43% to 2.36%), obesity and
gallbladder diseases tripled (0.36% to 1.07% and 0.18% to 0.59%,
respectively), and sleep apnea increased fivefold (0.14% to 0.75%)
96 percent of discharges with a diagnosis of obesity listed obesity as
a secondary diagnosis.
Obesity-associated annual hospital costs increased more than
threefold; from $35 million to $127 million
OBESITY PREVENTION—REVIEW ARTICLES
Authors
Study Question
Methods
Population & Setting
N
Budd and
Volpe 2006
To provide an
overview of schoolbased RCTs
intended to
prevent increases
in BMI
Searched Medline,
Cinahl, PsychINFO,
and Cochrane using
obesity, prevention,
child, weight
management
Setting:
School-based
Inclusion:
RCTs with BMI for
age and gender as an
outcome
Published between
1985-2004
US elementary,
middle and high
schools
Published in peerreviewed journal
12 studies
JHU  WCHPC
49
Outcomes/Comments
Successful interventions more likely to target older children
Use of a multi-component, comprehensive, and detailed nutrition
and physical activity curricula for students in higher grades can
contribute to program success
The positive effects of small and brief RCTs might change if longer
follow-up periods occurred
4 successful RCTs used behavior change curriculum (including selfmonitoring, goal setting, and cognitive restructuring)
2 programs had significant effects only on girls
For older students, classroom instruction and physical education
can promote moderate to vigorous physical activity both in and out
of school, especially for girls
Younger students can benefit from behavior change programs that
reduce sedentary behavior
January 2008
OBESITY PREVENTION—REVIEW ARTICLES
Authors
Study Question
Methods
Population & Setting
N
Outcomes/Comments
Doak et al
2006
To identify aspects
of successful
childhood
overweight
prevention
programs
Medline, personal
contacts with
researchers, Internet
web searches,
references from
published reviews,
and additional
Medline searches of
authors with ongoing
intervention studies
Setting:
School-based
Inclusion:
Up to August 2005
Children ages 6–19
years
anthropometric
measurements at
baseline and f/u
intervention on diet,
physical activity or
both
documentation of
monitoring/
evaluation
25 studies
17 of the 25 studies were ‗effective‘ based on a statistically significant
reduction in BMI or skin-folds for the intervention group. Four
interventions were effective by BMI as well as skin-fold measures. Of
these, two targeted reductions in television viewing. The remaining
two studies targeted direct physical activity intervention through the
physical education program combined with nutrition education. Of all
the interventions reported, one was effective in reducing childhood
overweight but was also associated with an increase in underweight
prevalence.
Flodmark et al
2006
To review medical
interventions
aimed at
preventing obesity
during childhood
and adolescence
Searched PubMed,
Cochrane Library,
NHSEED, PubMed
databases, reference
lists of relevant
articles, other review
articles
Setting:
Various
Inclusion:
2001 to May 2004
prevention studies with
controls, follow-up at
least 12 months,
description of %
overweight subjects,
BMI or skinfold
thickness as outcomes,
general population
39 studies
Fifteen studies reported that prevention had a statistically significant
positive effect on obesity, 24 reported neutral results and none
reported a negative result (sign test; P=0.0078). Adding the studies
included in five other systematic reviews yielded, in total, 15 studies
with positive, 24 with neutral and none with negative results. Thus,
41% of the studies, including 40% of the children studied, showed a
positive effect from prevention.
Flynn et al
2006
To develop best
practice
recommendations
based on finding,
selecting and
critically appraising
programs
addressing
prevention and
treatment of
childhood obesity
and related risk of
chronic diseases
Comprehensive
search of 18 library
databases (covering
medical/academic
and grey literature)
and the Internet.
Setting:
Various
Inclusion:
1982-October 2003
Indices of overweight
as outcomes
Risk factors for
obesity
Chronic disease risk
factors/markers
associated with
obesity
Description of attrition
Description of
participants
Process evaluation
information
158 articles
(representing
147 programs)
JHU  WCHPC
50
Current programs lead to short-term improvements in outcomes
relating to obesity and chronic disease prevention with no adverse
effects noted.
Schools are a critical setting for programming where body
composition, chronic disease risk factors and fitness can all be
positively impacted.
Efforts could be directed towards better integration of chronic
disease prevention programs to minimize duplication and optimize
resources.
Programs require comprehensive evaluation that will ascertain if
long-term impact such as sustained normal weight is maintained.
Lack of evidence on programs for immigrants, children ages 0–
6 years, and males, and programs implemented in community and
home settings.
January 2008
OBESITY PREVENTION—REVIEW ARTICLES
Authors
Study Question
Methods
Population & Setting
N
Harvey et al
2006
To review studies
of provider
management of
overweight and
obese people
Searched Cochrane
MEDLINE, EMBASE,
Sigle, Sociofile,
dissertation
abstracts,
Conference Papers
Index, Resource
Database in
Continuing Medical
Education, plus hand
searching
Setting:
Health care settings
Inclusion:
RCTs, controlled
clinical trials,
controlled before and
after studies and
interrupted time series
designs
Interventions targeting
providers or
organization of care
6 studies
Overall studies were small and of questionable quality
Further research needed to determine optimal management of
obesity
Two reminder systems reported changes in provider behavior, but
only one recorded patient outcomes
Reminder system reporting patient outcomes resulted in an
additional 4.3 lbs and 12.9 lbs lost among women and men in
intervention group at 22-24 months
Other promising interventions include brief training interventions,
shared care, in-patient care, and dietitian led training
Kumanyika et
al
2003
To summarize
Girls Health
Enrichment Multisite Studies
(GEMS)
Review of pilot
studies aimed at
preventing obesity in
African American
girls
Setting:
After school
programs, summer
camps in Memphis,
Houston, Palo
Alto/Oakland,
Minneapolis
Inclusion:
Adolescent African
American girls
4 pilot studies
No significant changes in BMI or waist circumference seen with any
program
No significant changes seen in physical activity
Girls in Memphis had a significant decrease in consumption of
sweetened beverages, but other dietary outcomes were not
significant
Katz et al
2005
To review school
or work based
programs to
control overweight
and obesity
Setting:
School- or workbased programs
Inclusion:
Interventions related
to diet, physical
activity, or both
1966-2001
Common weight
measure used
Followed for at least 6
months
10 school
based
programs
JHU  WCHPC
Searched
electronic data
bases
Hand search of
reference lists,
Cochrane reviews,
and reports
51
20 work based
programs, 7
used for
comparison
Outcomes/Comments
School Based
Evidence was insufficient to determine if school based programs
are successful
Interventions that produced modest but positive changes include 1)
including nutrition and physical activity components in combination;
2) allotting additional time to physical activity during the school day;
3) including noncompetitive sports (e.g., dance); and 4) reducing
sedentary activities, especially television viewing
Work Based
Programs using both diet and exercise were effective in the work
place—each component alone was no effective
Cost to engage 1% of at risk population <$1
January 2008
OBESITY PREVENTION—REVIEW ARTICLES
Authors
Study Question
Methods
Population & Setting
N
Sharma 2006
To review
population-based
interventions for
preventing
childhood obesity
carried out in
school settings
Searched CINAHL,
ERIC, MEDLINE
Setting:
School-based
US and UK
Inclusion:
1999-2004
Kindergarten through
high school
Focus on general
(not just overweight)
children and
adolescents
11 programs
Snethen 2006
To conduct a meta
analysis of
intervention
studies designed
to reduce
overweight/obesity,
improve activity,
and nutrition
Searched multiple
data bases using
obesity, children,
intervention, weight
loss, exercise,
nutrition, and dietary
Setting:
Various
Inclusion:
Studies between
1980-2002 focusing
specifically on
overweight children
(not general
population)
N>7
Mean age no older
than 12
Intervention focused
on weight loss
7 studies
Stice et al
2006
1) To provide a
summary of
prevention
programs for
children and
adolescents and
their effects. 2) To
examine
participant,
intervention,
delivery, and
design features
that are associated
with larger
intervention
effects.
PsycINFO, MEDLINE, Dissertation
Abstracts
International,
CINAHL, tables of
content of various
journals, reference
sections of identified
articles, established
obesity prevention
researchers were
contacted and asked
for copies of unpublished articles
(under review or in
press)
Setting:
Various
Inclusion:
1980-Oct 2005;
outcome: proxy
measure of body fat;
RCTs; active
interventions not
focused on weight gain
prevention; trials with
relevant comparison
group; trials targeting
children and
adolescents
64 programs
JHU  WCHPC
52
Outcomes/Comments
Most interventions focused on short-term changes right after the
intervention
Interventions resulted in modest changes in behaviors and mixed
results with indicators of obesity
TV watching seems to be the most modifiable behavior, followed by
physical activity and nutrition behaviors
Most programs had multiple components so it was not possible to
say which components worked and to what extent
Outcome measures such as BMI, triceps skin-fold thickness and
waist circumference not measured by all studies included in this
review
Results (reported by outcomes):
4 outcomes had small effect sizes
4 outcomes were medium
7 outcomes from 4 studies had large effect sizes (p = 0.00)
Longer interventions tended to have better results
Effective programs exist, not clear which programs are most
effective
No maintenance studies found
Most interventions do not produce the hypothesized weight gain
prevention effects and the overall average intervention effect was
small.
For most programs that produced significant weight gain prevention
effects, the effect sizes are clinically meaningful but are usually
confined to pre–post effects.
Several prevention programs targeting a variety of health
behaviors, such as eating pathology and smoking, produced weight
gain prevention effects.
Larger weight gain prevention effects were observed for programs
targeting children and adolescents (vs. preadolescents), females,
and self-presenting samples; programs that were relatively brief;
programs solely targeting weight control versus other health
behaviors (e.g., hypertension); and programs evaluated in pilot
trials.
January 2008
OBESITY PREVENTION—REVIEW ARTICLES
Authors
Study Question
Methods
Population & Setting
N
Summerbell et
al 2005
Cochrane review
to assess
effectiveness of
programs to
prevent obesity in
children
Searched Medline,
PsychINFO,
Embase, Cinahl, and
Central databases;
non-English
language papers
were included and
experts contacted.
Setting:
Various
Inclusion:
1990-2005
RCTs with a minimum
duration of 12 weeks
Outcomes: weight and
height, percent fat
content, BMI,
ponderal index, skinfold thickness
22 studies
Nearly all studies resulted in positive changes in diet and physical
activity, although results regarding BMI were mixed
Five of six studies combining dietary education and physical activity
showed no effect—one had an effect on girls but not boys
Nutrition education alone was not effective
Multimedia approach to increasing physical activity effective
The studies were heterogeneous in terms of study design, quality,
target population, theoretical underpinning, and outcome measures,
making it impossible to combine study findings using statistical
methods. There was an absence of cost-effectiveness data.
Summerbell
2003
Cochrane review
to assess effects of
lifestyle
interventions to
treat childhood
obesity
Searched CCTR,
Setting:
Not specified
Inclusion:
1985-July 2001
Included studies with
lifestyle interventions
RCTs with 6 months
observation
Age < 18 yrs
Primary outcome
height and weight or
weight measurement
18 studies
May be some support for programs involving parents, overall not
enough evidence to make generalized recommendations
Many studies reviewed were small and had high drop out rates
Future research should focus on role of families, culturally specific
messages
MEDLINE,
EMBASE, CINAHL,
PsychLIT, Science
Citation Index, and
Social Science
Citation Index;
contacted experts in
child obesity
JHU  WCHPC
53
Outcomes/Comments
January 2008
OBESITY PREVENTION—REVIEW ARTICLES
Authors
Study Question
Methods
Population & Setting
N
Whitlock et al
2005
To examine the
evidence for the
benefits and harms
of screening and
early treatment of
overweight among
children and
adolescents in
clinical settings
Cochrane, Medline,
PsycINFO, DARE,
and CINAHL
Setting:
Primary care
Inclusion:
1966-April 2004;
studies
demonstrating a)
direct evidence that
screening for
overweight leads to
improvements, b) the
benefits and harms of
overweight
screening and
interventions, c) the
validity of screening
tests for predicting
health outcomes in
adulthood, d) the
efficacy of behavioral
counseling,
pharmacotherapeutic,
and surgical
interventions, and e)
studies showing
interventionassociated harms.
Based on 7
key questions:
353 articles
for questions
1 and 2, 198
articles for
questions 4
and 5, 36
articles for
questions 3
and 6, 41
articles for
question 2, 22
articles for
questions 4
and 5, and 4
articles for
question 6.
JHU  WCHPC
54
Outcomes/Comments
Interventions to treat overweight adolescents in clinical settings
have not been shown to have clinically significant benefits, and they
are not widely available.
The overall evidence is poor for the direct effects of screening (and
intervention) programs and screening harms. The overall evidence
is fair/poor for behavioral counseling interventions, because of
small, non-comparable, short-term studies with limited
generalizability that reported health or intermediate outcomes, such
as cardiovascular risk factors, rarely.
Trials are particularly inadequate for nonwhite subjects and children
2 to 5 years of age. Fair/poor evidence is available for behavioral
counseling intervention harms because of very limited reporting.
Fair evidence supports childhood BMI as a risk factor for adult
overweight, although data are limited for nonwhite subjects, and
data addressing BMI as a risk factor for adult morbidities generally
do not control for confounding by adult BMI. Good evidence is
available for overweight prevalence based on BMI measures in all
groups, except Native American and Asian groups.
January 2008
OBESITY INTERVENTIONS—SCHOOL BASED
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Outcomes/Comments
Caballero et al
2003
To evaluate the
effectiveness of a
school-based
intervention
Design:
RCT,
randomization at
school level
Intervention:
Classroom
curriculum, skill
building for food
services employees,
increased physical
education, family
support
Setting:
41 elementary schools in
Native American
communities of Arizona,
New Mexico, and South
Dakota
Inclusion:
Schools with > 15 children
rd
rd
in 3 grade, > 90% of 3
grade students American
Indian ethnicity, > 70%
rd
th
retention from 3 to 5
grades
I: 879
C: 825
I: 17%
C: 17%
No changes in BMI, calories consumed through
school lunch, or self efficacy attitudes
Significant decrease in energy consumption
Physical activity improved but motion sensor
activity did not
Community support was strong
Significant differences in changing the food service
environment to reduce the fat content of school
lunches, improving self-reported out-of-school
physical activity, and reducing self-reported dietary
fat intake among intervention children.
Comment:
The homogenous American Indian sample might
have required a more intense or longer intervention,
considering that this population has a high rate of
obesity and diabetes.
Carrel et al
2005
To determine
whether a schoolbased fitness
program can
improve body
composition,
cardiovascular
fitness level, and
insulin sensitivity
in overweight
children
Design:
RCT
Intervention:
lifestyle-focused,
fitness-oriented gym
classes (treatment
group) or standard
gym classes (control
group) for 9 months
Setting:
Rural middle school and an
academic children's hospital
Inclusion:
Overweight children with a
BMI above 95th percentile
for age
50
None
Baseline test results for cardiovascular fitness,
body composition, and fasting insulin and glucose
levels
Treatment group demonstrated a significantly
greater loss of body fat, greater increase in
cardiovascular fitness, and greater improvement in
fasting insulin level.
Coleman et al
2005
To assess the
impact of Child
and Adolescent
Trial for
Cardiovascular
Health (CATCH)
Design:
Quasi-experimental
matched controlled
design with
pretest/post test
Intervention:
CATCH training for
PE teachers, food
services staff, and
home room teachers,
gym equipment
purchased
Setting:
Schools located in the El
Paso school district, Texas
Inclusion:
Third grade children with
permission from parents
I: 723
C: 473
Overall:
th
By 4 grade:
9%
Girls and boys in control schools had a significant
increase in risk of overweight or overweight (both
CATCH and control groups increased, but rate of
increase was larger in control group)
Percentage of overweight in girls did not vary
between intervention and control throughout
intervention
Percentage of overweight increased among boys in
both CATCH and control arms
Results of physical fitness inconclusive, and no
results from cafeteria changes
JHU  WCHPC
55
th
By 5 grade:
27%
January 2008
OBESITY INTERVENTIONS—SCHOOL BASED
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Outcomes/Comments
Donnelly et al
1996
To attenuate
obesity and
improve physical
and metabolic
fitness in
elementary school
children
Design:
2 year cohort
Intervention:
Enhanced physical
activity, grade
specific nutrition
education, and a
lower fat and sodium
school lunch
program. Controls
continued with a
regular school lunch
and team sports
activity program.
Setting:
Two school districts in rural
Nebraska
108
Not indicated
in abstract
available on
the web
Intervention school lunches had significantly less
energy (9%), fat (25%), sodium (21%), and more
fiber (17%). However, measures of 24-hour energy
intake for intervention and control groups showed
significant differences for sodium only. Physical
activity in the classroom was 6% greater for Int
compared to Con (p < 0.05) but physical activity
outside of school was approximately 16% less for Int
compared to Con (p < 0.05). Body weight and body
fat were not different between schools for normal
weight or obese children. No differences were found
for cholesterol, insulin, and glucose. It appears that
compensation in both energy intake and physical
activity outside of school may be responsible for the
lack of differences between Int and Con.
To assess the
impact of dietary
and physical
activity on BMI
Design:
RCT
Intervention:
20 minutes
instruction on healthy
eating and 20
minutes of exercise
3x/week, parents
received weekly
newsletters and
homework, controls
received general
health information
Setting:
Head Start programs in the
Archdiocese of Chicago
Inclusion:
All children and families
eligible to participate—
program did not target
overweight youth
I: 197
C: 212
Post
intervention:
I: 9%, C: 14%
Post intervention BMI did not differ between
groups
At 1 year, the mean increase in BMI between
2
groups was significantly different (0.02 k/m vs.
2
0.64 k/m , p=0.002)
At 2 year, the mean increase in BMI between
2
groups was significantly different (0.48 k/m vs.
2
1.14 k/m , p=0.008)
Effects were similar for boys and girls
No effect seen on intake of fat, dietary fiber, or
exercise
Culturally specific program using specially trained
early childhood educators, so generalizablity
questionable
Design:
RCT
Intervention:
Culturally proficient
14-week (three times
weekly) diet/physical
activity intervention.
Parents completing
weekly homework
assignments.
Controls received
general health
information.
Setting:
Twelve predominantly Latino
Head Start centers
Inclusion:
All children and families at
centers
401
Fitzgibbon et
al
2005
Fitzgibbon et
al 2006
JHU  WCHPC
To assess the
impact of dietary
and physical
activity on BMI
among Latino
preschoolers
Inclusion:
Cohorts from grades 3 to 5
56
Year 1:
I: 27%, C: 31%
Year 2:
I: 26%, C: 28%
Year 1: 16%
Year 2: 17%
No significant differences between intervention and
control schools in either primary or secondary
outcomes at post-intervention, Year 1, or Year 2
follow-ups.
When Hip-Hop to Health Jr. was conducted in
predominantly black Head Start centers, it was
effective in reducing subsequent increases in BMI
in preschool children. In contrast, it was not
effective in Latino centers (although it was very well
received). Future interventions with this population
may require further cultural tailoring and a more
robust parent intervention
January 2008
OBESITY INTERVENTIONS—SCHOOL BASED
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Gortmaker et
al 1999
To evaluate the
impact of a
school-based
health behavior
intervention
(Planet Health) on
obesity among
boys and girls in
grades 6 to 8.
Design:
RCT with 5
intervention and 5
control schools.
Outcomes were
assessed using preintervention (fall
1995) and follow-up
measures (spring
1997), including
prevalence,
incidence, and
remission of obesity.
Setting:
10 ethnically diverse public
schools in 4 Massachusetts
communities
1560
83%
Inclusion:
grade 6 and 7 students
Intervention:
Sessions within
existing curricula
using classroom
teachers focused on
decreasing television
viewing, decreasing
consumption of highfat foods, increasing
fruit and vegetable
intake, and
increasing moderate
and vigorous
physical activity.
JHU  WCHPC
57
Outcomes/Comments
The prevalence of obesity among girls in
intervention schools was reduced compared with
controls, controlling for baseline obesity (odds ratio,
0.47; P = .03), with no differences found among
boys. There was greater remission of obesity
among intervention girls vs control girls (odds ratio,
2.16; P = .04).
The intervention reduced television hours among
both girls and boys, and increased fruit and
vegetable consumption and resulted in a smaller
increment in total energy intake among girls.
Reductions in television viewing predicted obesity
change and mediated the intervention effect.
Among girls, each hour of reduction in television
viewing predicted reduced obesity prevalence
(odds ratio, 0.85; P = .02).
January 2008
OBESITY INTERVENTIONS—SCHOOL BASED
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Jamner et al
2004
To evaluate the
effect of an
intervention
designed to
increase physical
activity among
sedentary
adolescent
females.
Design:
Specific individuals
targeted pre-test,
post-test
Setting:
Two public high schools in
Orange County, California
I: 36
C: 25
I: 25
C: 22
To examine the
effects of a
school-based
intervention called
PLAY (Promoting
Lifestyle Activity
for Youth) on
physical activity
levels and BMI
Design:
Tx schools
randomized into
PLAY, PE, PLAY and
PE, and no-treatment
No baseline data
606
Not indicated
in abstract
available on
the web
Pangrazi et al
2003
JHU  WCHPC
Intervention:
Special PE class
(five days/week for
60 minutes each day
with 40 minutes of
aerobic activity), and
a lecture/ discussion
(one day/week)
focusing on health
benefits of physical
activity and
strategies for
becoming physically
active.
Inclusion:
Sedentary (i.e. fewer than
three 20-minute vigorous
bouts of exercise per week
or fewer than five 30minute bouts of moderate
exercise per week) females
enrolled in the 10th or 11th
grade
Females at or below the
75th percentile of predicted
cardiovascular fitness
(based on age and gender)
Females physically able to
exercise without restrictions
Setting:
35 schools in Arizona and
new Mexico
Outcomes/Comments
Significant effect on cardiovascular fitness (p
=.017), lifestyle activity (p =.005), and light (p
=.023), moderate (p =.007), and hard (p =.006)
activity. All changes were in a direction that favored
the intervention. There was no effect of the
intervention on psychosocial factors related to
exercise.
Lean body mass and BMI percentile did not change
over time.
Intervention effective at increasing the physical
activity level of children (steps/day), especially girls.
No significant differences between groups were
found for BMI.
Inclusion:
Fourth-grade students
Intervention:
12 week intervention
promoting play
behavior, teacher
directed activities,
and encouraging
self-directed play
58
January 2008
OBESITY INTERVENTIONS—SCHOOL BASED
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Robinson
1999
To assess the
effects of
reducing
television,
videotape, and
video game use
on changes in
adiposity, physical
activity, and
dietary intake
Design:
RCT conducted from
September 1996 to
April 1997
Intervention:
18-lesson, 6-month
classroom curriculum
to reduce television,
videotape, and video
game use.
Setting:
Two socio-demographically
and scholastically matched
public elementary schools in
San Jose, Calif.
198
192
Children in intervention group had statistically
significant relative decreases in BMI (P=.002),
triceps skinfold thickness (P=.002), waist
circumference (P<.001), and waist-to-hip ratio
(P<.001).
Relative to controls, intervention group changes
were accompanied by statistically significant
decreases in children's reported television viewing
and meals eaten in front of the television.
No statistically significant differences between
groups for changes in high-fat food intake,
moderate-to-vigorous physical activity, and cardiorespiratory fitness.
Sallis et al
1997
To increase
physical activity
during physical
education classes
and outside of
school
Design:
Schools randomized
into treatment or
control
Intervention:
Health-related
physical education
taught by PE
specialists or trained
classroom teachers
Setting
Seven schools outside San
Diego, CA
Inclusion:
Grades 4-5
955
Number not
provided;
however, no
differences
seen in attrition
between
groups.
Students spent more minutes per week being
physically active in specialist-led (40 min) and
teacher-led (33 min) PE classes than in control
classes.
After 2 years, girls in the specialist-led group were
superior to girls in the control group on abdominal
strength and endurance (P < .001) and cardiorespiratory endurance (P < .001).
No effects on physical activity outside of school.
Spiegel 2006
To evaluate the
effectiveness of a
multidisciplinary
school based
intervention
Design:
RCT
Intervention:
Based on Theory of
Reasoned Action
All activities
incorporated into
core curriculum
Year long program
consisting of 7
modules
Both regular and
PE teachers
involved
Setting:
Delaware, Florida, Kansas,
North Carolina
Inclusion:
Grades 4-6
Sampling done at district
level, controls selected
from same school
69
classes
in 16
schools
particip
ated
I: 13.7%
1.5% reduction in intervention children classified as
>85% to <95% BMI (P = 0.01)
No significant shift noticed in control group
Both groups reported consuming more
fruits/vegetables but still consumed less than
recommended
Physical activity increased from 59min/wk to
102.5min/wk in intervention group.
JHU  WCHPC
Inclusion:
rd
th
3 and 4 grade students
I: 534
C: 479
C: 16.2%
Outcomes/Comments
Comment:
Method of reporting food intake not very rigorous
Teachers applied to participate in program
59
January 2008
OBESITY INTERVENTIONS—CLINIC BASED
Authors
Study Question
Intervention
Population & Setting
N
Patrick et al
2006
To improve
adolescent
physical activity,
to limit their
sedentary
behaviors and to
improve their
dietary intake of
fruits and
vegetables, fiber,
or total dietary fat.
Design:
RCT
Intervention:
Primary care, office-based,
computer-assisted diet and
physical activity assessment
and stage-based goal setting
followed by brief provider
counseling and 12 months of
monthly mail and telephone
counseling ; A comparison
group received information
addressing sun exposure
protection
Setting:
Primary care with
follow-up at home
Inclusion:
adolescent girls and
boys aged 11 to 15
years
878
Attrition
Outcomes/Comments
Intervention girls and boys significantly reduced
sedentary behaviors (P = .001);
Intervention boys reported more active days per
week (P = .01)
The number of servings of fruits and vegetables for
intervention girls approached significance (P = .07).
No intervention effects were seen for percentage of
calories from fat or minutes of physical
activity/week.
Percentage of adolescents meeting recommended
health guidelines was significantly improved for
girls for consumption of saturated fat [relative risk,
1.33] and for boys' participation in days/week of
physical activity [relative risk, 1.47].
No between-group differences were seen in BMI.
OBESITY INTERVENTIONS—FAMILY BASED INTERVENTIONS
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Ebbeling et al
2006
To examine the
effect of
decreasing sugarsweetened
beverage (SSB)
consumption on
body weight
Design:
RCT
Intervention:
Home deliveries of
noncaloric beverages
to displace SSBs
Setting:
Recruited from pediatric
population at Children‘s
Hospital Boston
103
None
JHU  WCHPC
Inclusion:
Adolescents 13-18
years who regularly
consumed SSBs
60
Outcomes/Comments
Consumption of SSBs decreased by 82% in the
intervention group and did not change in the control
group. Change in BMI between tx and cx was not
significant overall. However, baseline BMI was a
significant effect modifier. Among the subjects in
the upper baseline-BMI tertile, BMI change differed
significantly between the intervention and control
groups. The interaction between weight change
and baseline BMI was not attributable to baseline
consumption of SSBs.
This simple environmental intervention almost
completely eliminated SSB consumption in a
diverse group of adolescents. The beneficial effect
on body weight of reducing SSB consumption
increased with increasing baseline body weight.
January 2008
OBESITY INTERVENTIONS—FAMILY BASED INTERVENTIONS
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Epstein et al
2005
To test whether
alternatives to
eating can
influence weight
control
Design:
RCT
Intervention:
Families received
information about
Traffic Light Diet,
Food Guide Pyramid,
and healthy eating.
Also received
information about
physical activity and
praise/ reinforcement
systems; intervention
group received
points for engaging
in non-food related
activities
Setting:
Recruited from
newspaper flyers,
physicians, and other
healthcare providers
I: 19
C: 22
I: 1 (5%)
C: 5 (22%)
No significant differences found between groups
Both groups had significant declines in which was
maintained at 12 and 24 months (p<0.001)
Differences consistent with both intention to treat
and measured BMI
Episodes of eating also significantly decreased
over time (p<0.001)
Possible that no difference seen between groups
due to implementation problems
Design:
RCT
Intervention:
1 hr support and
education session
weekly for 10 wks,
biweekly for 4 wks,
monthly for 2
months
Monthly 40-50
minute
interventions per
family
Emphasized health
eating, exercise,
and parenting skills
Setting:
Israel
Inclusion:
Children 6-11 yrs
th
Children >85
percentile BMI
No other wt loss
program participation
32 families
4: parent only
Follow up occurred 12 months after end of program
(total of 18 months)
80% of parent only group had full attendance vs.
55% in parent child group
Parent only group overweight change was -9.5%
vs. -2.4% in parent/child group
Difference between groups sig. for change in BMI
(P=0.024) and change in % overweight (P=0.02)
Both groups reported a reduction in obesogenic
habits (22% in parent vs. 15% in parent/child), but
difference between groups significant (P<0.05)
More permissive parents found fewer changes in
child‘s BMI
Golan et al
2006
JHU  WCHPC
To compare the
effects of
targeting parents
alone vs. parents
and children in
obesity treatment
Inclusion:
Families with child
aged 8-12 with BMI >
th
85 percentile
One parent reporting
willingness to attend
to treatment needs
1: parent child
Outcomes/Comments
Large difference in attendance at sessions may
signify baseline difference in groups, and may
explain variation in program effectiveness
61
January 2008
EXCLUDED STUDIES
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Datar et al
2004
Examine effect of
physical
education time on
BMI change
Design:
Observational
longitudinal cohort
Intervention:
No intervention
made—
observational
study
Setting:
National sample of
kindergarten students
Inclusion:
Data from Early
Childhood Longitudinal
Study
N 19,028
5,177 missing
from waves 2
and 4
Observational study
PE instruction had strong negative effect on BMI in
girls, but no significant impact on boys
10,211 had all
measurements
at all waves
Danielzik et al
2005
To evaluate the
effects of
preventive school
measures on long
term obesity
Design:
Cross sectional
population based
surveys
Intervention:
Six hour school
based intervention
Three to five home
visits for families
with obese children
Setting:
Kiel, Germany
Inclusion:
All first graders
entering school
between 1996 and
2001 (T0), and all
fourth graders
entering school
between 2000 and
2005 (T1)
T0: 257
T1: 257
NA
Edwards et al
2006
Assess
acceptability and
impact of family
based behavioral
treatment (FBBT)
for childhood
obesity
Design:
Pre-post test
evaluation of four
consecutive groups
Intervention:
Advice for whole
family on lifestyle
changes, weight
control plan for
child, and
strategies
Setting:
Clinic in the UK
Inclusion:
Referred from general
practitioners, school
nurses, or
pediatricians
At least one parents
willing to participate
Children excluded if
existing organic
cause of obesity
N=33
12 wks: 19%
3 mo: 40%
Goldfield
2006
Assess impact of
open loop
feedback plus
reinforcement vs.
open loop
feedback on
physical activity,
body composition
JHU  WCHPC
Outcomes/Comments
Interim study—data not available on all school
children
4 year incidence of overweight reduced in
intervention group (36.5 vs. 41.7%)
Children participating in family program had slower
increase in fat mass compared to both intervention
and non-intervention group (10% vs. 27% and 32%
respectively)
Primary follow up only 12 wks
No control group—just pre/post test design
Significant reduction seen for %BMI and total BMI
(p<0.001)
Self concept score (Piers-Harris) and depression
(CDI) went up (p<0.001), although this was not
related to change in BMI
Children and families chose to participate—were
referred by nurses and clinicians
Large scale feasibility questionable due to cost
Only 8 wks in duration
62
January 2008
EXCLUDED STUDIES
Authors
Study Question
Intervention
Population & Setting
N
Jurg et al
2006
To assess a
school-based
intervention that
focuses on the
use of theory,
environmental
changes and
parental
influences
Design:
quasi-experimental
pre-test/post-test
Setting:
Grades 4, 5 and 6 of
four intervention
schools and two control
schools in Amsterdam
510 children
Saelens et al
2002
To evaluate the
effect of
behavioral weight
control initiated in
a primary care
setting
Design:
RCT
Intervention:
Behavioral skills
development using
computer
assessment,
physician consult,
and telephone
reinforcement
Parents of
intervention group
also sent
information
Controls received
physician nontailored counseling
on healthy eating
and activity and no
follow up
Setting:
Pediatric primary
clinics in Southern
California
Inclusion:
Ages between 12-16
20%-100% above
median BMI for sex
and age
I: 23
C: 21
Taylor 2005
Assess education
and exercisebased in family
centered
environment
8 wk group
intervention
Recruited from
pediatricians, school
nurses, newspapers,
PSAs
Age: 8-15
th
BMI: > 85 percentile
Other: stable vitals,
adequate coordination
JHU  WCHPC
Attrition
Outcomes/Comments
Full text not on web
Measures not appropriate
I: 12%
C: 9%
Treatment program only 4 months
Significantly more control subjects increased their
BMI z scores compared to intervention (p<0.03)
More intervention adolescents decreased BMI z
score at post treatment (40.0% vs. 10.5%, p<0.04)
Overall BMI did not produce an overall average
loss of weight among participants
Study not long enough in duration
63
January 2008
EXCLUDED STUDIES
Authors
Zahner et al
2006
JHU  WCHPC
Study Question
To increase
overall PA and to
improve fitness
and health in 6- to
13-year-old
children
Intervention
Design:
RCT
Intervention:
two additional
physical education
classes per week
given by trained
physical education
teachers adding up
to a total of five
physical activity
classes per week
short physical
activity breaks (2-5
min each) during
academic lessons
physical activity
home work
adaptation of
recreational areas
around the school
Population & Setting
Setting:
Two provinces in
Switzerland
Inclusion:
N
I: 298
C: 204
64
Attrition
Outcomes/Comments
Excluded because results are not yet available
January 2008
APPENDIX C: UNINTENTIONAL INJURY PREVENTION AND INTERVENTION
MAGNITUDE OF THE PROBLEM: Injuries are the leading cause of death, disabilities, and health care
utilization for children and teenagers between the ages of one and nineteen in the United States.
In 2004, nearly 16,000 children died of unintentional injuries and an estimated 240,000 children
under 15 years old were hospitalized due to injuries.279 Each year between 1995 and 2004,
among children under eighteen, there were an estimated nine million emergency department
visits made as a result of unintentional injury.280
Historical trends show that the occurrence of injuries can be reduced. Between 1985 and 2000,
the incidence rate of injuries decreased from 2,259 to 1,740 per 10,000 for children between the
ages of zero and four, and from 2,699 to 1,925 per 10,000 for those ages five tofourteen.281 This
reduced occurrence rate coincides with a decreased death rate due to injuries: from 1979 to 1998,
unintentional injury deaths declined by 52%, 51% and 45% among children ages one to four,
five to nine, and ten to fourteen, respectively.282
DETERMINANTS AND RISK FACTORS: Research has shown that environmental hazards and poor
quality of housing are associated with injuries. Other risk factors include poverty, poor parenting,
being a single parent, alcohol and substance abuse, and neglect.283,284
HEALTH CONSEQUENCES: In 1996, unintentional injuries (primarily brain, spinal cord, burn, and
limb injuries) left an estimated 150,000 children and adolescents permanently disabled.285
Unintentional injuries account for two thirds of all injury-related deaths of children in the United
States. 286,287
ECONOMIC CONSEQUENCES: Studies assessing the cost burdens of child injuries generally take a
societal perspective to estimate both immediate and longer-term costs, including costs for
victims, families, government, insurers, and taxpayers. Those costs are comprised of direct or
resource costs (such as medical costs) and indirect or productivity costs (such as future wage loss
due to disability).
Miller estimates that approximately 15% of total medical spending went to injury-related care,
and as much as $14 billion [$18 billion in 2006 dollars] in lifetime medical spending and $66
billion [$85 billion in 2006 dollars] in present and future work losses resulted from unintentional
childhood injuries occurring in 1996. 288 Two studies 289,290 estimated the monetary burdens
resulting from a range of injuries and concluded that the combination of fatal and nonfatal
injuries among children aged zero to four had resulted in $4 billion [$4.7 billion in 2006 dollars]
in medical costs and $12 billion [$14 billion in 2006 dollars] in productivity losses. In 1996, 22.2
million children, about three in every ten, suffered unintentional injuries serious enough to
require medical treatment or cause at least half a day of restricted activity. Resource and
productivity cost due to these injuries was estimated to average $3,600 per victim [$4,626 in
2006 dollars].291
The leading causes of both resource and productivity costs of unintentional injuries to children
aged zero to four resulted from falls, $7 billion [$9 billion in 2006 dollars]; struck by/against
objects, $2.5 billion [$3.2 billion in 2006 dollars]; motor vehicle traffic, $1.5 billion [$1.9 billion
in 2006 dollars]; burn/anoxia $1 billion [$1.3 billion in 2006 dollars]; and cut/pierce $0.7 billion
[$0.9 billion in 2006 dollars].292 As for specific injuries among children, the total lifetime cost of
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injuries to pedestrians and pedal-cyclists caused by collisions with motor vehicles was estimated
to be $1.1 billion [$1.4 billion in 2006 dollars] and $45 million [$58 million in 2006 dollars],
respectively, for children aged zero to four.293 National costs associated with bicycle handlebarrelated abdominal and pelvic organ injuries among children nineteen or younger were $9.6
million [$12 million in 1996 dollars) in total hospital charges, $10 million [$13 million in 2006
dollars] in lifetime medical costs, $11.5 million [15 million in 2006 dollars] in lifetime
productivity losses, and $504 million [$648 million in 2006 dollars] in lifetime monetized
quality-adjusted life-years. 294
INTERVENTIONS TO REDUCE OCCURRENCE: Many studies have found evidence of preventive
interventions that can effectively reduce the incidence of injuries.
Gun safety:
Several studies found no significant difference between intervention and control groups for
interventions targeting children‘s manner of playing with guns295 or parents‘ gun
ownership.296,297 However, studies reported mixed evidence of effects on storage behaviors: two
studies298,299 found that, among those parents who owned guns, there was a significant
intervention effect on safety behaviors such as purchasing trigger locks and using locked storage,
while Sidman et al.300 found that a community education campaign had no effect on purchasing a
lock-box.
Road safety:
Pedestrians/road safety: Burke 301 found that a stencil in the shape of a school bus applied to the
pavement at a bus stop reduced children‘s risky behaviors. An Australian study302 found
increased road safety activities, as well as a significant reduction in the volume of traffic on local
access roads over the trial period of a community intervention, when both road safety
interventions and development of traffic calming features were implemented.
Passenger safety: Interventions aimed at improving passenger safety for children include
promoting rear seating and the use of child car seats, booster seats, and lap and shoulder belts. A
six-month program that provided bilingual education materials for a low-income Hispanic
community and distributed rewards to those families whose children were rear seated in cars
significantly increased child rear seating from 33% to 49% in the intervention city.303 A
multifaceted community campaign including education, car seat training, and discount coupons
for booster seats increased booster-seat use to 26% in the intervention communities, significantly
higher than the control communities.304 A child safety-seat loaner program targeting Hispanic
preschoolers found that the use of restraints among those who attended health centers increased
significantly, compared to other groups.305
Bicycle helmets: Wu 306 reported that distributing free helmets significantly increased reported
helmet use in the experimental group compared to both the control group (nearly 16 times
higher) and the second intervention group, who received only vouchers. A multifaceted bicycle
helmet promotion program 307 targeting low income children, which comprised classroom
instruction, educating parents, obtaining and fitting helmet for each child to use, and conducting
bicycle rodeos for children to practice safe riding skills, found that helmet use in the intervention
group more than doubled, from 43% to 89%, significantly higher than the increase in the control
group. A four-year program targeting elementary school children in Quebec,308 including
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January 2008
persuasive communication and activities to facilitate helmet acquisition, was found to
significantly increase the use of helmets for groups exposed to the program from 1.3% to 33%.
Home safety:
General home injury: Two interventions309,310 delivered at the community level included injury
prevention campaigns and home visits by trained local collaborators. Together, these studies
found significant improvement in behavioral change, such as adoption of safety devices or
practices, than they did in incidence of injuries. Among seven studies that only measured
behavioral changes, six311,312,313,314,315,316 found significant improvement in the intervention group
for at least one safety measure, compared to the control group. Five out of six studies that
reported significant improvement assessed programs that provided discounted or free safety
devices as part of the home visiting intervention. On the other hand, only two317,318 out of four
studies reported significant reduction in injury or injury-related doctor visits, and the remaining
two studies 319,320 did not find significant differences in injury incidence between intervention
and control groups.
Smoke alarms: Three studies reviewed interventions that distributed smoke alarms or detectors to
assigned households. Two studies321,322 reported a significant reduction in the rate of injuries or
hospitalizations associated with residential fires in the intervention communities.
Baby walkers: Kendrick323 found that postpartum home visits not only significantly reduced the
ownership of baby walkers, a seat in a frame on wheels for infants between three and 12 months
that has been found unsafe to infants, but also successfully discouraged parents who owned baby
walkers from using them.
Lawnmowers: An intervention324 aimed at reducing child injuries from lawnmowers reported that
an intervention in which parents watched a 20-minute education video produced significant
increases in four out of six safety practices.
Community safety:
Playground: A New Zealand study325 reported that a health promotion program consisting of
providing information about hazards, an engineer‘s report, regular contact between the school
and program facilitators, and assistance in obtaining funding, was associated with a 52%
reduction in height/surface hazards.
Shopping carts: Harrell326 found no intervention effects of using two warning signs on improving
adult supervision or reducing risky child activities in grocery carts.
Safe Communities Model: The WHO Safe Community model is a community-based, all-age, allinjury prevention program, relying on input from local politicians, civil servants, representatives
of non-governmental organizations, and public health workers to identify problems and
implement actions.327,328 In New Zealand, this program was found to significantly reduce injuryrelated hospitalizations (p<0.05) for children aged zero to fourteen in the intervention
communities; in Sweden, the risk of child (aged zero to six) injury in the intervention community
decreased significantly more than it did in the control.329
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January 2008
ECONOMIC STUDIES: Eight studies concluded that the interventions reviewed were cost-effective,
including three smoke alarm distribution programs,330,331,332 three car seat use programs,333,334,335
one on bicycle helmet use,336 and one based on home visits.337 One additional review study338
found that more than half of the 84 preventive interventions included in the study yielded net
societal cost savings. However, a U.K. study339 concluded a RCT of a smoke alarm give-away
program was unlikely to represent a cost-effective use of resources, in part because too few
alarms were installed and maintained.
CONCLUSION: In sum, a majority of studies found that preventive interventions effectively
improved parents‘ and children‘s knowledge and safety behaviors and increased the use of safety
devices. Fewer studies investigated changes in the injury rate per se as outcomes, but some of the
studies that did so found positive changes.340,341,342,343
Most economic studies found that the reviewed interventions were cost-effective. It is worthy to
note that some extremely high positive returns might be an overestimation, in part because those
cost-outcome studies only considered the cost of safety devices, but not the cost to facilitate the
adoption of such devices, which would include the costs of promotion as well as the cost of fees
for administration, operation, personnel, and so forth. Nevertheless, including these additional
costs is unlikely to change the conclusion that most interventions studied were found costeffective.
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January 2008
Figure 1. Lifespan Impact of Injury Prevention Efforts
LIFESPAN STAGE INTERVENTION AND IMPACT
LEVEL OF INTERVENTION
Preconception/ Pregnancy
Infant/Childhood
Individual
Gun safety education
Family
Home visits
Prenatal home visitation
Adolescence
Adulthood
i
ii
iii
Education against the use of baby walkers
Local/ Community/
Workplace/ School
iv
Community education
combined with incentives
distribution for road safety
v
Smoke detector
distribution
National/State
Changes in baby walker
vi
safety standards
Child passenger safety
vii
laws
Age period when interventions take place
Age period with continuing positive impacts of intervention
i
Hardy 2002
Johnston 2006, Posner 2004, Mallonee 2000, Sznajder 2003
iii
Kitzman 1997
iv
Kendrick et al 2005
v
Greenberg-Seth et al. 2004
vi
Roders & Leland 2005
vii
Segui-Gomez et al. 2001
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ii
69
January 2008
Table 1. Studies on Injury Prevention
INDIVIDUAL-LEVEL INTERVENTIONS: GUN SAFETY
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Hardy 2002
Assess
effectiveness of
skills-based
firearm safety
program
Design: Randomized
controlled trial
Intervention:
Intervention group
received four lessons
delivered by trained
undergraduate students
on gun safety aimed at
changing behavior when
guns are encountered
Follow up period not
clearly stated—appears to
be directly after
intervention
Control group received
intervention 1 wk after
evaluation
Setting: Three day care
centers in urban
southeastern US
Inclusion:
Children attending day
care whose parent‘s
consented
I: 34
C: 36
none
Outcomes/Comments
The intervention had no effect on likelihood
children would play with guns or alert adults
when guns found during play
Among children who played with guns, there
was no difference in gun related behavior
such as play shooting or displays of
aggressive behavior
Children reporting that their parents owned a
gun were more likely to play with guns
(P=0.001) and significantly more gun-related
(shooting) behavior (P=0.017)
FAMILY-LEVEL INTERVENTIONS: GUN SAFETY
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Carbone et
al 2005
Evaluate the
effectiveness of
gun safety
counseling by
pediatricians
Design:
Controlled pre-test, posttest
Intervention:
Physicians trained in
Steps to Prevent Firearm
Injury (STOP 2) program
Families receiving
intervention counseled by
physician, given brochures
and gun lock
Families followed up with
one month after the
intervention
Setting:
Pediatric clinic within a
community Health Center
in Tucson, AZ
Inclusion
All families with children
younger than 18,
attending clinic who
reported owning guns
I= 73 families
C= 78
16%
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70
Outcomes/Comments
The intervention had no effect on gun
ownership
Among families reporting no locks at baseline,
no significant effect seen on increasing lock
use
Overall gun safety (defined as any change in
locked storage of gun, improved type of gun
storage, or storing gun unloaded) practice
increased among intervention group (RR
2.29; 95% CI 1.52-3.44; P<0.001)
Frequency of locked storage increased in
intervention group (RR 5.2; 95% CI 1.5917.32; P<0.003)
Control group more likely to have proper gun
storage at baseline
January 2008
FAMILY-LEVEL INTERVENTIONS: GUN SAFETY
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Grossman
et al
2000
Determine
effectiveness of
gun safety
counseling in
well child visits
Design:
Randomized controlled
trial, unit of randomization
was provider
Intervention:
Physicians trained by
academic detailers, given
reading materials,
bibliography, and audio
tape to assist in
counseling
Parents received only one
counseling session
Follow up with parents
occurred 3 months after
office visit
Setting:
Primary care clinics at
Group Health
Cooperative in
Washington State
Inclusion:
Providers—those seeing
at least 5 patients <18
years of age per month
Families—had a
scheduled well child visit
for child aged 2 months 18 years
Providers:
I: 28
C: 28
Providers:
None
Families:
I: 618
C: 677
Families:
23%
Attrition
Outcomes/Comments
No statistical difference between control and
intervention groups in acquisition of firearms,
removal of guns, or acquisition of safe
storage boxes
FAMILY-LEVEL INTERVENTIONS: ROAD SAFETY
Bicycle helmet use
Authors
Study Question
Intervention
Population & Setting
N
Wu et al.
2005
To evaluate the
effectiveness of
3 competing
pediatric
emergency
department (ED)
interventions
aiming to
increase sport
helmet use in a
state without
helmet
legislation.
Design:
RCT
Intervention:
I1: received free helmet
I2: received a voucher for
helmet
C: received counseling
Setting:
pediatric
emergency department
(ED)
Inclusion:
English-speaking children
aged 5-16
I1: 78
I2: 65
C: 57
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71
At follow-up
I1: 77
I2: 62
C: 53
Outcomes/Comments
Directly receiving a free helmet in the ED
significantly increased reported helmet use
relative to the control group; the odds that a
parent reported helmet use were nearly 16
times higher (P < 0.01), and the odds that a
child reported helmet use were nearly 10
times higher (P < 0.01).
January 2008
FAMILY-LEVEL INTERVENTIONS: GENERAL HOME SAFETY
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Clamp 1998
To assess
effectiveness of
general practitioner
advice about child
safety, and provision
of low cost safety
equipment to low
income families, on
use of safety
equipment and safe
practices at home.
Design:
Randomized,
unblinded, controlled
trial
Intervention:
General practitioner
safety advice
Access to safety
equipment at low
cost.
Control families
received usual care.
Setting:
A general practice in
Nottingham.
Inclusion:
169 families with
children aged up to 5
registered with the
practice
I: 83
C: 82
None
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72
Outcomes/Comments
After intervention,
intervention group
used more safety
equipments:
fireguards (relative
risk 1.89, 95% CI
1.18 to 2.94), smoke
alarms (1.14, 1.04 to
1.25), socket covers
(1.27, 1.10 to 1.48),
locks on cupboards for
storing cleaning
materials
(1.38, 1.02 to 1.88),
and door slam
devices (3.60, 2.17 to
5.97).
Also, significantly
more families in
intervention group
showed very safe
practice in storage of
sharp objects
(1.98, 1.38 to 2.83),
storage of medicines
(1.15, 1.03 to 1.28),
window safety
(1.30, 1.06 to 1.58),
fireplace safety
(1.84, 1.34 to 2.54),
socket safety
(1.77, 1.37 to 2.28),
smoke alarm safety
(1.11, 1.01 to 1.22),
and door slam safety
(7.00, 3.15 to 15.6).
January 2008
FAMILY-LEVEL INTERVENTIONS: GENERAL HOME SAFETY
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Gielen et al. 2002
To present the results
of an intervention trial
to enhance parents'
home-safety practices
through pediatric
safety counseling,
home visits, and an
on-site children's
safety center
Design:
RCT
Intervention:
I1: Parents in the
enhancedintervention group
received the
standard services
plus a home-safety
visit by a community
health worker.
I2: Parents in the
standard-intervention
group received
safety counseling
and referral to the
children's safety
center from their
pediatrician.
Setting:
A hospital-based
pediatric resident
continuity clinic in
inner city
Inclusion:
First- and second-year
pediatric residents and
their patient-parent
with children no older
than 6 months
I1: 94
I2: 93
12-month follow up:
Evaluate pilot program
adding family injury
prevention to low
income pre-school in
Washington state
Design:
Quasi experimental
Programs partitioned
into two groups based
on size, geographic
location, and staff
Intervention:
Group 1: standard
care plus written
materials
Group 2: in addition
to standard care,
case workers added
safety counsel,
tested safety
devices, and given
safety supplies
Setting:
Two counties in
Washington state
Inclusion:
Families of children
aged 4 or 5 years
enrolled in Head
Start or Washington
State preschool
program
I: N = 258
I: 18%
C: N = 160
C: 7%
Johnston et al 2000
JHU  WCHPC
73
I1: 62
I2: 60
Outcomes/Comments
The prevalence of
safety practices
ranged from 11% of
parents who stored
poisons safely to 82%
who had a working
smoke alarm.
No significant
differences in safety
practices were found
between study
groups.
Families who visited
the children's safety
center compared with
those who did not had
a significantly greater
number of safety
practices (34% vs
17% had > or 3).
Intervention families
were more likely to
have obtained first
working smoke
detector (RR 3.3; 95%
CI 1.3-8.6) or to have
added a smoke
detector (RR 2.0; 95%
CI 1.2-3.1)
Because families
were given smoke
detectors by case
workers, does not
show evidence of
change in parent
behavior
January 2008
FAMILY-LEVEL INTERVENTIONS: GENERAL HOME SAFETY
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Johnston et al 2006
Evaluate healthy steps
(HS) program on child
development,
parenting practices,
and parental wellbeing
Design: Concurrent
comparison at clinic
level with nested
randomized trial in
intervention arm
Intervention:
Usual care (UC)
Standard HS (HS):
Post natal home
counseling on child
development,
telephone support,
and developmental
assessment
HS plus 3 prenatal
visits (HSP)
Setting:
Large integrated
delivery system in the
Pacific Northwest
Inclusion:
Less than 22 wks
gestation
Younger than 45 yrs
UC = 136
HS = 152
HSP + prenatal = 151
UC: 23%
HS: 23%
HSP: 19%
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74
Outcomes/Comments
Families followed up
at 3 months
Intervention families
more likely to use stair
gates (RR 1.19; 95%
CI 1.15 1.23) and
have access to poison
control centers (RR
1.08; 95% CI 1.031.12) but less likely to
have safety latches
(RR 0.88; 95% CI
0.83-0.93)
Other safety
measures included
non-home outcomes
Non-participants
significantly different
than participants (less
maternal education,
lower family income)
January 2008
FAMILY-LEVEL INTERVENTIONS: GENERAL HOME SAFETY
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Kendrick et al. 1999
To assess the
effectiveness of safety
advice, provision of
low cost safety
equipment, and first
aid training on
frequency and severity
of unintentional
injuries in children at
home.
Design:
Cluster randomized
controlled trial.
Intervention:
A package of safety
advice at child health
surveillance
consultations at 6-9,
12-15, and 18-24
months
provision of low cost
safety equipment to
families on means
tested state benefits;
home safety checks
first aid training by
health visitors.
Setting:
36 general practices in
Nottingham.
Inclusion:
All children aged 3-12
months registered with
participating practices.
I: 1,124
C: 1,028
25-month:
I: 1,020 (7%)
C: 960 (6%)
No significant
difference was found
in frequency of at
least one medically
attended injury (odds
ratio 0.97, 95% CI:
0.72 to 1.30), at least
one attendance at an
accident and
emergency
department for injury
(1.02, 0.76 to 1.37), at
least one primary care
attendance for injury
(0.75, 0.48 to 1.17), or
at least one hospital
admission for injury
(0.69, 0.42 to 1.12).
No significant
difference in the
secondary outcome
measures was found
between the
intervention and
control groups.
King et al 2001
Examine effectiveness
of home visit program
to improve home
safety and decrease
frequency of injury to
children
Design: Randomized
controlled trial
Intervention:
All groups received
home inspection
Non-intervention arm
receive general
safety pamphlet
Intervention arm
received information
package, coupons,
and specific
instructions
Participants
contacted by phone
4-8 months after
I: 601
C: 571
1-year
I: 482 (20%)
C: 469
(18%)
Overall intervention
did not significantly
impact injury
prevention behaviors
Intervention group
more likely to have
hot water <54ºC (OR
1.31; 95% CI 1.141.50; P<0.001)
Rate ratio of injury
requiring doctor visit:
0.75; 95% CI 0.580.96
All injury data self
reported
JHU  WCHPC
Setting: Multicenter
trial in 5 hospitals in 4
Canadian urban
centers
Eligibility:
1,172 Children aged
<8 initially enrolled in
an injury case-control
study
75
Outcomes/Comments
January 2008
FAMILY-LEVEL INTERVENTIONS: GENERAL HOME SAFETY
Authors
Study Question
King et al. 2005
To review the longterm (36-month)
effects of the previous
study
Kitzman et al. 1997
Review the
effectiveness of homevisitation services as a
way of improving
maternal and child
outcomes
JHU  WCHPC
Intervention
Population & Setting
home visit
Design:
RCT
Intervention:
Free transportation
for scheduled
prenatal care
Free screening o
Intensive nurse
home-visiting
(average=7)
Control group
received free
transportation and
screening
Setting:
Public system of
obstetric care in
Memphis
Inclusion:
Women at less than
29 weeks‘ gestation
No previous live
births
>=2 following SES
risks: unmarried, <12
years of education,
unemployed
76
N
Attrition
36-month
I: 403
C: 371
I: 33%
C: 35%
I: 228
C: 615
I: 5%
C: 22%
24-month
I: 216
C: 481
Outcomes/Comments
Participants in the
intervention group
(63%) reported that
home visits changed
their knowledge,
beliefs, or practices
around the prevention
of home injuries
compared with those
in the non-intervention
group (43%; p<
0.001).
the rate of injury visits
to the doctor was 0.74
(95% CI 0.63 to 0.87)
However, the
effectiveness of the
intervention appears
to be diminishing with
time (rate ratio for the
12–36 month study
interval = 0.80; 95%
CI 0.64 to 1.00).
In the first 2 years of
children‘s lives,
intervention group
encountered fewer
injuries or ingestions
(0.43 vs. 0.55;
p=0.05); fewer
hospitalization due to
injury or ingestion
(0.03 vs. 0.16,
p<0.01)
January 2008
FAMILY-LEVEL INTERVENTIONS: GENERAL HOME SAFETY
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Outcomes/Comments
Mayer et al. 1998
To evaluate a 20minute video
intervention to
increase parents‘
safety awareness and
preventive actions to
avoid child injuries
from lawnmower
Design:
RCT
Intervention:
Parents in the
intervention group
viewed a 20-minute
video.
I: 30
C: 35
I: 25%
C: 12.5%
Differences favoring
the intervention group
were found for four of
six behavior
outcomes. For
example, the
proportion reporting
never allowing
children near
operating mowers
increased from half to
two-thirds with no
change among
comparison group
parents.
Posner et al
2004
Assess effectiveness
of emergency
department (ED)
based home safety
intervention
Design:
Randomized
controlled trial
Intervention:
All participants
received verbal
counseling and
home safety hand
out
Intervention group
received additional
counseling plus
home safety kit
Participants were
contacted 6-8 weeks
after initial ED visit
Setting:
An outpatient
orthopedic clinic at
Cardinal Glennon
Children‘s Hospital in
St. Louis, Missouri.
Inclusion:
Parents who
have access to a
lawnmower and
have operated it
within the past year
have pre-teen
children living at
home
agree to participate
Setting:
Urban pediatric ED
Inclusion:
All caregivers of
children up to 5
years of age
I: N= 49
C: N=47
I: 29%
C: 30%
Intervention group
had higher overall
safety score (73% vs.
66.8%, P<0.002)
Intervention group
had higher scores for
cut/piercing safety
(P<0.001) and burn
safety (P<0.03) but no
difference found for
falls, water safety,
aspiration prevention,
or fire prevention
Most of safety
improvement from kit
distribution
All safety
improvements are self
reported
JHU  WCHPC
77
January 2008
FAMILY-LEVEL INTERVENTIONS: GENERAL HOME SAFETY
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Sznajder et al
2003
Test effectiveness of
free preventive
devices and
counseling for injury
prevention
Design:
RCT
Intervention:
Standard
intervention of
counseling, two
pamphlets on
domestic injury,
emergency call
numbers
Standard
intervention plus a
safety kit containing
home safety items
Both groups followed
up at 6-8 weeks after
first visit
Setting:
Hauts-de-Seine near
Paris
Inclusion:
Usual criteria for
social services
I: N=50
C: N=50
I: 2%
C: 0%
JHU  WCHPC
78
Outcomes/Comments
Participants not
random—families
selected by Mother
and Child Protection
Services
Only assesses
behavior, not injury
outcome
Groups receiving kits
had significantly more
safety improvements
related to falls, fire,
poisoning, and
suffocation (P<0.02)
but specific activities
not reported
Where specific unsafe
behaviors were
observed, group
receiving kits had
overall higher
increase in reduction
of these behaviors
(64.4% vs. 41.2%,
P<0.02)
Behaviors not related
to the kits also
improved
January 2008
FAMILY-LEVEL INTERVENTIONS: BABY WALKERS
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Kendrick et al
2005
Evaluate the
effectiveness of
educating pregnant
women to reduce baby
walker possession and
use
Design:
Cluster randomized
controlled trial
Intervention:
Control group
received standard
advice on baby
walkers
Intervention group
received advice at
recruitment and
home visits at 10
days and 3-4 months
post partum
Setting:
Practices in
Nottingham and
Newark and Sherwood
primary care trust, UK
Pregnant women at
least 28 wks gestation
I: N=525
C: N=631
I: 11%
C: 14%
Outcomes/Comments
Participants followed
up when infant aged
3-4 months
OR owning baby
walker: 0.63 (95% CI
0.43-0.93, P=0.02)
OR using baby
walker: 0.26 (95% CI
0.08-0.84, P=0.03)
Participants not
blinded to study group
Walker use is self
reported
COMMUNITY-BASED INTERVENTIONS: GUN SAFETY
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Sidman et al
2005
Evaluation of a
broad public
education
campaign to
promote safe
hand gun
storage
Design:
Quasi-experimental
Intervention:
Campaign included media
campaign, PSA‘s, fact
sheets, discount coupons
for lock boxes, and a hotline
Baseline data collected in
1996, program
implemented in 19972001, follow up data
collected in 2001
Setting: King County,
Washington
Inclusion:
Families with at least 1
child < 18 and owned a
gun
9 control counties
identified west of the
Mississippi—selected
based on population
Intervention:
Baseline:
N = 151 Follow
up:
N = 217
NA
JHU  WCHPC
79
Outcomes/Comments
No significant difference found between
intervention and control group
Both control and intervention groups had
increases in guns stored in lock boxes (12.5%
for intervention, 11.4% for control)
Control:
Baseline:
N=151
Follow up:
N =128
January 2008
COMMUNITY-BASED INTERVENTIONS: ROAD SAFETY
Pedestrian/Road Safety
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Burke et al.
1996
To evaluate the
effectiveness of
a stencil in the
shape of a
school bus
applied to the
pavement at a
bus stop in
improving safe
behaviors
To assess the
effectiveness of
community/envir
onmental
interventions
undertaken as
part of the Child
Pedestrian Injury
Prevention
Project (CPIPP).
Design:
Randomly controlled trial
Intervention:
Children were instructed to
remain within a safe area
during boarding that was
demarcated by a pavement
stencil
Setting:
9 bus stops in Farmington,
CT
Inclusion:
I: 5 stops; 145
observations
C: 4 stops;
174
observations
N/A
Children in the control group were twice as
likely to show unsafe behavior while waiting
(OR=2.1).
Design:
A quasi-experimental
community intervention trial
over 3 years
Intervention:
Three communities were
assigned to either:
A community
/environmental road safety
intervention and a school
based road /pedestrian
safety education program
(intervention group 1)
a school based
road/pedestrian safety
education program only
(intervention group 2)
Or to no road safety
intervention (comparison
group).
Setting:
Three communities (local
government areas) in the
Perth metropolitan area,
Western Australia.
Inclusion:
I1: 1
community
I2: 1
community
C: 1
community
N/A
Greater road safety activity was observed in
intervention group 1 compared with the other
groups.
A significant reduction in the volume of traffic
on local access roads was also observed over
the period of the trial in intervention group 1,
but not in the remaining groups.
Stevenson
et al. 1999
JHU  WCHPC
80
Outcomes/Comments
January 2008
COMMUNITY-BASED INTERVENTIONS: ROAD SAFETY
Bicycle Helmet
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Britt et al.
1998
To evaluate the
effectiveness of
a multifaceted
bicycle helmet
promotion
program for low
income children
Setting:
Preschool Head Start
programs in Washington
State
Inclusion:
Eligible families in either
program must have
incomes at or below the
federal poverty level
Children must be 3 or 4
years old and their
siblings up to 14
I: 14 sites; 543
children
C: 4 sites; 200
children
I: 30%
C: 10%
Helmet use in the intervention group more
than doubled, from 43% to 89%, while use in
the control group increased from 42% to 60%
(p<0.05 for intervention group changes v
control group changes).
Intervention own helmet: RR=1.53 (1.34 to
1.79)
Intervention always wear helmet: RR= 1.58
(1.25 to 1.99)
Farley et al.
1996
To assess the
effectiveness of
a 4-year program
of bicycle helmet
promotion that
targeted
elementary
school children in
one region of
Quebec
Design:
Treatment and control sites
are not randomly selected
Intervention:
Provide classroom
instruction to children
Educate parents
Obtain and fit helmets for
each child
Conduct bicycle rodeos
that allowed the children to
practice safe riding skills
and to see other children
wearing helmets
require children wear
helmets while riding on
school grounds
Design:
Quasi-experimental
Intervention:
Persuasive
communication and
community organization
Combining standard
educational activities and
activities to facilitate
helmet acquisition and use
(e.g. offering coupons).
Setting:
25 municipalities in
Monteregie region
Inclusion:
Children 5-12 residing in
those municipalities
I: 6,087
C: 2,025
N/A
Helmet use increased from 1.3% to 33% in
1993 in the intervention communities.
OR of use of helmet for group exposure to
program vs. not was 1.78 (99% CI 1.10 2.89)
JHU  WCHPC
81
Outcomes/Comments
January 2008
COMMUNITY-BASED INTERVENTIONS: ROAD SAFETY
Car Seat
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Ebel et al.
2003
To evaluate the
effectiveness of
a multifaceted
community
booster seat
campaign in
increasing
observed booster
seat use among
child
Design:
Prospective,
nonrandomized, controlled
community intervention trial.
Intervention:
The campaign targeted
both parents and children.
Broad-based community
education program
Discount booster seat
coupons
Car seat training programs
I: 4
communities
C: 8
communities
N/A
Before the campaign began, 13.3% of eligible
children in the intervention communities and
17.3% in the control communities were using
booster seats, adjusting for child age, driver
seat belt use, and sex of driver.
15 months after the start of the campaign,
adjusted booster seat use had increased to
26.1% in the intervention communities and
20.2% in the control communities (P=.008 for
the difference in time trends between
intervention and control communities).
GreenbergSeth et al.
2004
To evaluate
short-term effect
of a communitybased effort to
promote child
rear seating in a
low-income
Hispanic
community
I: 1 community
C: 2 cities
N/A
Post-intervention, the percentage of motor
vehicles with all children rear-seated
significantly increased from 33% to 49%
(p<.0001), which was significantly different
from the increase in the control cities
(p<0.0001).
Istre et al.
2002
To evaluate a
program to
increase
child restraint
use among
Hispanics
Design:
Quasi-experiment
Intervention:
―Kids in the Back‖
Community education
Incentive programs over 6
months: gave gifts to
reward those who put kids
in the back; and gave
information on risks to
those who didn‘t
Design:
NRCT
Intervention:
establishing a child safety
seat loaner program
educating parents in small
classes
identifying mothers as
authority figures to help
communicate the
message
addressing the issue of
fatalism or destiny
Using videos that
graphically showed what
happens to a child held on
an adult‘s lap in a car
Setting:
The campaign was initiated
in 4 communities (250,000)
in the greater Seattle,
Wash, area between
January 2000 and March
2001. Eight communities
in Portland, Ore, and
Spokane, Wash, served as
control sites.
Inclusion:
Children aged 4-8 years
and weighing 18-36 kg [4080 lb]
Setting:
Holyoke, MA, a low-income
community with a
substantial proportion of
Hispanics
Inclusion:
Child passengers younger
than 12 years
Setting:
Three adjacent zip codes
(75208, 75211, and 75212)
in the west sector of Dallas;
other parts of Dallas served
as comparison
Inclusion:
Children <5
I: 3 zip code
areas (7,413
observations)
C: the rest of
Dallas (4,137
observations)
N/A
Child restraint use among preschool-aged
Hispanic children increased significantly in all
3 settings between 1997 and 2000 (P<.0001)
Observed driver seat belt use also increased
significantly in each of the 3 settings
(P<.001), whereas little change in driver seat
belt use for other parts of Dallas (not
significant).
JHU  WCHPC
82
Outcomes/Comments
January 2008
crash.
COMMUNITY-BASED INTERVENTIONS: GENERAL HOME SAFETY
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Petridou et
al 1997
To assess
effectiveness
(follow-up 255
days) of a health
education injury
prevention
programme
focusing on
home injuries
among the young
(<=18 years old)
and elderly
(>=65 years old)
Setting:
on the Greek islands of
Naxos (intervention) and
Spetses (control)
Inclusion:
Residents on both islands
I: 172
households
C: 177
households
N/A
Naxos (intervention) had statistically
significant improvements with respect to 11 of
the 28 examined variables, whereas on the
island of Spetses (control), such improvement
was only noted for one variable.
Home accident incident rate per 105 persondays among 0-18 was 87 in the intervention
and 110 in the compare group, which are not
significantly different, one-side p-value=.09.
For total home accidents happened to
targeted 0-18 years old in intervention group,
RR=0.79, 90% CI (0.60, 1.06)
Ytterstad et
al. 1998
To describe the
long term
effectiveness of
a community
based program
targeting
prevention of
burns in young
children
Design:
Community controlled trial
Intervention:
There was an injury
prevention campaign at
Naxos involving virtually
all opinion leaders and
implemented through
lectures, workshops and
publicity in the local
media.
The main intervention
focused on 172
households on the island
of Naxos and was done by
trained local collaborators
who visited each
household weekly
Design:
Quasiexperimental
Intervention:
the purchase and
installation of cooker
safeguards (guard rail
around the edge of the
stove)
Lowering tap water
thermostat settings to
55°C in homes,
kindergartens, and public
buildings.
Setting:
The Norwegian city of
Harstad (main
intervention), six
surrounding municipalities
(intervention diffusion), and
Trondheim (reference).
Inclusion:
Children 0-5
I1: population
23,000
I2: population
14,000
C: population
134,000
N/A
The mean burn injury rate decreased by
51.5% after the implementation of the
intervention in Harstad (p < 0.05) and by
40.1% in the six municipalities (not
significant).
Rates in the reference city, Trondheim,
increased 18.1% (not significant).
JHU  WCHPC
83
Outcomes/Comments
January 2008
COMMUNITY-BASED INTERVENTIONS: GENERAL HOME SAFETY
Smoke alarm/detector
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Mallonee
2000
Assess impact of
smoke detector
distribution
program
Design:
Quasi experimental
Intervention:
Distribution of smoke
detectors to targeted
neighborhoods
Distribution of written
materials to selected
populations
Setting: Oklahoma City
Eligibility:
Residents of targeted
neighborhood
Neighborhood chosen
based on high rate
residential fires
NA
NA
Ginnelly et
al. 2005
To determine
whether a smoke
alarm give-away
program is
effective and
cost-effective in
reducing the risk
of fire-related
deaths & injuries
Design:
cluster RCT
Intervention:
―Let‘s Get Alarmed‖:
Smoke alarms, batteries
and fire safety brochures
were distributed to
intervention groups
Setting:
40 wards in inner London
Boroughs of Camden and
Islington
Inclusion:
Households above average
material deprivation
I: 73,399
households
C: comparable
size
N/A
Peleg et al.
2005
To map Israeli
child burn
prevention
programs and to
measure their
success from the
rate of burnrelated
hospitalizations.
Design:
Community comparison;
historical comparison
Intervention:
13 interventions were
identified in the intervention
communities
Setting:
Israeli communities
Inclusion:
Only Jewish communities
were compared in the
evaluation
I: 13
communities
C: 35
communities
N/A
JHU  WCHPC
84
Outcomes/Comments
10,100 smoke alarms distributed
80% of houses in need and 25% of total
homes received alarm
At 48 months 46% of alarms installed and
functioning
Injury rate associated with residential fires
decreased by 81% in targeted area and 7% in
non-targeted area
Injury rate per 100 fires decreased 76% in
targeted group and 12% in non-targeted
areas
Estimated that 60 injuries and deaths
prevented during six year follow up
The mean cost for a household in a giveaway ward, including the cost of the program,
was £12.76, compared to £10.74 for the
control ward.
The total mean number of deaths and injuries
was greater in the intervention wards than the
control wards, 6.45 and 5.17.
When an injury/death avoided is valued at
£1000, a smoke alarm give-away has a
probability of being cost effective of 0.15.
From 1998 to 2000, a 25% reduction in the
burn-related hospitalization rate of children 04, from 1.39/1000 to 1.05/1000 infants and
toddlers (p = 0.03) was realized in
intervention communities.
No change was observed in the nonintervention group, where the rate at the two
measurements remained stable at 1.26/1000
infants and toddlers
January 2008
COMMUNITY-BASED INTERVENTIONS: GENERAL COMMUNITY SAFETY
School Safety
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Roseveare
et al. 1999
to evaluate the
relative
effectiveness of
two methods of
reducing
playground
hazards in
schools.
Design:
Randomly controlled trial
Intervention:
The intervention group
received a health
promotion programme
consisting of information
about the hazards, an
engineer‘s report, regular
contact and
encouragement to act on
the report, and assistance
in obtaining funding.
The control group only
received information about
hazards in their
playground.
Setting:
Twenty four schools in
Wellington,
New Zealand
Inclusion:
The 12 schools that made
up the intervention goup
were randomly sampled
from the 60 primary shools
in Wellington City
I: 12 schools
C: 12 schools
none
JHU  WCHPC
85
Outcomes/Comments
A key result was the 52% reduction in
height/surface hazards achieved in the
intervention schools, compared with an 8%
reduction in the controls
By the second follow up, nine of the 12
intervention schools had eliminated at least
one height/surface hazard compared with
only three control schools.
January 2008
COMMUNITY-BASED INTERVENTIONS: GENERAL COMMUNITY SAFETY
Community injuries
Authors
Study Question
Intervention
Population & Setting
N
Attrition
Coggan et
al. 2000
To evaluate the
outcome of the
World Health
Organization
(WHO) Safe
Community
model with
respect to child
injuries.
To evaluate the
effectiveness of
two warning
signs on adult
supervision and
child risky
activities in
grocery carts
Design:
population based quasiexperimental
Interventions:
(WHO Safe Community
model: 1995-97)
Implementation of WHO
safe community model
Setting:
Waitakere, New Zealand
population 155,000;
Control community:
147,000
I: 1 community
C: 1
Community
N/A
For children 0-14, community showed a
decrease in injury hospitalization rates in the
intervention/post-intervention period
Design:
Quasi-experimental
Interventions:
One supermarket had
signs to prompt adults not
to allow children to stand
in the cart seat or basket
The other supermarket
had signs to inform
parents of the risk of injury
to a child in carts
Design:
population based quasiexperimental
Interventions: (WHO Safe
Community model: 1985-89)
Local mass media provide
regular information about
injury prevention.
Trained nurses provide
information to parents
indoor environments at
schools and sports
facilities were evaluated
Setting:
Two supermarkets in
similar size in Canada
Inclusion:
Children 1-6
I1: 100
I2: 100
N/A
No effect was found
Setting:
Intervention (Motala
municipality) and control
(Mjolby municipality) areas,
both in Ostergotland
county, Sweden.
Inclusion:
I: 1 community
C: 1
Community
N/A
The total relative risk of child injury in the
intervention community decreased more
(odds ratio 0.74; 95% confidence interval (CI)
0.68 to 0.81) than in a control community
exposed only to national level injury
prevention programs (0.93; 95% CI 0.82 to
1.05).
The risk of severe or fatal (AIS 3-6) injuries
remained constant.
Harrell 2003
Lindqvist et
al. 2002
To evaluate the
outcome of the
World Health
Organization
(WHO) Safe
Community
model with
respect to child
injuries.
JHU  WCHPC
86
Outcomes/Comments
January 2008
INJURY ECONOMIC STUDIES
Authors
Study Question
Perspective
Study type and design
Cook et al.
1999
To develop
reliable US
estimates of the
medical costs of
treating gunshot
injuries
Medical cost
Cost burden
Corso et al.
2006
To measure
national
incidence,
medical costs,
and productivity
losses of
medically treated
injuries
To reduce fires
and fire related
injuries by
increasing the
prevalence
of functioning
smoke alarms in
high risk
households.
Societal
Cost burden of all injuries
Design:
cluster RCT
Intervention:
―Let‘s Get Alarmed‖:
Smoke alarms, batteries
and fire safety brochures
were distributed to
intervention groups
Cost of the program
Ginnelly et
al. 2005
Evaluate cost
effectiveness of
mass smoke
alarm distribution
Societal
Cost effectiveness
Haddix et al
2001
Evaluate cost
effectiveness of
target smoke
alarm distribution
Societal
Cost effectiveness
DiGuiseppi
et al. 1999
JHU  WCHPC
Population
and Setting
National
acute-care and
follow-up
treatment
costs and
payment
sources for
gunshot
injuries
All injuries in
2000
Setting:
40 wards in
inner London
Boroughs of
Camden and
Islington
Inclusion:
Households
above average
material
deprivation
Residents of
under
privileged
wards of inner
London
Boroughs
Oklahoma City
residents living
in targeted
high risk
neighborhood
87
Outcomes/Comments
Mean medical cost per injury was about 17,000
The 134,445 gunshot injuries in 1994 produced $2.3 billion
(95% CI, $2.1-2.5 billion) in lifetime medical costs (1994
dollars)
Injury in 2000 resulted in lifetime costs of $406 billion; $80
billion for medical treatment and $326 billion for lost
productivity.
Males had a 20% higher rate of injury than females.
Injuries resulting from falls or being struck by/against an
object accounted for more than 44% of injuries.
In total distributed 20 050 free smoke alarms.
The giveaway programme cost £145 087, of which more
than 60% was for personnel costs (table 2). The one year
reminder postcards cost £12 736, most of which paid for
data entry.
Actual installation remains unknown.: ―Given our target
population, we speculate that a substantial proportion of the
alarms may not
20,050 alarms distributed among 73,399 intervention
households
Injuries and deaths more common from fires in intervention
households (6.45 vs. 5.17 over 24 months)
Costs for the give away program were also higher than
control wards
No lost productivity costs accounted for
Program was cost saving from both societal and health care
system perspective
Total discounted cost of intervention was $531,000 over 5
years
Estimated medical costs prevented over 5 years: $1.5 million
Estimated productivity costs averted: $14 million
Medical costs do not include emergency room, rehabilitation,
or out of pocket expenses
January 2008
INJURY ECONOMIC STUDIES
Population
and Setting
188 families
who attended
the sychoprophylactic
delivery
classes at
the University
Maternity
Hospital
‗‗Alexandra‘‘ in
Athens
Authors
Study Question
Perspective
Study type and design
Kedikoglou
et al. 2005
To present an
infant carrestraint loan
scheme and
evaluate its costeffectiveness
Intervention:
Car-restraints were lent for a
six-month period to eligible
prospective parents for a
modest fee.
Cost effectiveness
Kopjar et al.
2000
Estimate costeffectiveness
of helmet use
based on an
estimated risk
reduction
Societal
Cost effectiveness
Included all
cases of head
injuries
reported
through the
registration
system from
1990 through
1996 in U.S.
The risk of head injury was highest among children aged 5
to 16. the greatest reduction in absolute risk of head injury,
1.0 to 1.4% over 5 years estimated helmet lifetime, occurred
among children who started using a helmet between 3 and
13
Estimates indicate it would cost U.S. $2,200 in bicycle
helmet expenses to prevent any one upper head injure
between 3-13
In contrast, it would cost $10,000-25,000 to avoid an adult
injury
Kim et al.
1997
To determine
whether asking
for a $5.00
donation for
bicycle helmets,
compared with
distribution free
of charge, would
affect helmet use
among children
Six clinic sites were
randomly assigned to either
free helmet distribution or to
a $5.00 suggested donation
for the helmets
Willingness-to-pay
Six public
health clinic
sites (506
eligible
children) in
King County,
Washington
82% of children whose parents were asked for a copayment
and 77% of children who received free helmets were
reported to wear their helmets every time they rode their
bicycles (p=0.20).
The adjusted odds ratio for the association between
copayment compared with free helmets and helmet use was
1.66 (95% confidence interval 0.94 to 2.92).
King et al
2001
Canadian
1999
Examine
effectiveness of
home visit
program to
improve home
safety and
decrease
frequency of
injury to children
Design: Randomized
controlled trial
Intervention:
All groups received home
inspection
Non-intervention arm
receive general safety
pamphlet
Intervention arm received
information package,
coupons, and specific
instructions
Setting: Multicenter trial in
5 hospitals in 4 Canadian
urban centers
Eligibility:
Children aged <8 initially
enrolled in an injury casecontrol study
I: N=601
C: N=571
See above for clinical outcomes
Incremental cost per participant: $48.11
Cost per injury prevented: $372
JHU  WCHPC
88
Outcomes/Comments
92% of the participants reported proper use of the device
and 82% had already purchased the second-stage car
restraint.
The cost-effectiveness ratio varies between J 418.00 and J
3,225.00 per life-year saved, depending on whether the
modest administrative fee is considered.
January 2008
INJURY ECONOMIC STUDIES
Authors
Study Question
Perspective
Study type and design
Levitt &
Doyle 2006
test the relative
effectiveness of
child safety
seats, lap-andshoulder seat
belts, and lap
belts in
preventing
injuries among
motor vehicle
passengers
aged 2-6.
Societal
Miller et al.
2006
To analyze the
societal return on
investment in
booster seats
and in laws
requiring their
use in the United
States.
Societal
Cost effectiveness;
3 data sets:
the General Estimates
Survey (GES), a
nationally representative
sample of approximately
50,000 crashes each
year for sixteen years;
New Jersey Department
of Transportation
(NJDOT) data covering
all crashes in that state
between 2001 and 2004
A Wisconsin data set
that includes the
universe of crashes with
police reports in that
state from 1994 to 2002,
and links these crashes
to hospital discharge
records.
Cost-Outcome Analysis
Miller et al.
2003
To estimate the
costs of
pedestrian and
bicycle crash
injuries in the US
Societal
Cost-Outcome Analysis
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Population
and Setting
US children
aged 2-6.
Booster Seats
for Auto
Occupants
Aged 4 to 7
Years
Outcomes/Comments
No apparent difference in the two most serious injury
categories for children in child safety seats versus lap-andshoulder belts.
Child safety seats provide a statistically significant 25%
reduction in the least serious injury category.
Lap belts are somewhat less effective than the two other
types of restraints, but far superior to riding unrestrained.
A booster seat costs $30 plus $167 for maintenance and
time spent on installation and use.
This investment saves $1854 per seat, a return on
investment of 9.4 to 1.
Even lower bound estimates in sensitivity analysis indicated
that society would benefit from the use of booster seats.
Seat laws offer a return of 8.6 to 1.
Costs of pedestrian and bicyclists injuries in 2000 are total
$40 billion over the lifetimes
Youth aged 5-14 face greater annual risks
January 2008
INJURY ECONOMIC STUDIES
Authors
Study Question
Perspective
Study type and design
Miller et al
2000
(future of
children)
Quantify cost of
unintentional
injuries to
children in the
US
Societal
Cost burdens
Miller &
Levy 2000
To review costoutcome
analyses in injury
prevention and
control and
estimate
associated
benefit-cost
ratios and cost
per qualityadjusted lifeyear.
Societal
Cost-outcome analysis
Miller et al
1997
Discuss
methodology of
cost outcomes
related to injury,
cost effective
analysis of
smoke detectors
To estimate the
costs of US
gunshot and
cut/stab wounds
by intent
Societal
Benefit cost analysis
Societal
Cost estimation
Miller &
Cohen 1997
JHU  WCHPC
Population
and Setting
Unintentional
injuries of US
children aged
0-19
Medline and
Internet
search,
bibliographic
review, and
federal agency
contacts
identified
published and
unpublished
studies from
1987 to 1998
for the U.S.
All US homes
Gunshot and
cut/stab
wounds
90
Outcomes/Comments
Cost of unintentional injury in millions of 1996 dollars
Total: $81,400
Productivity: $66,500
Medical Costs: $13,800
Other Resources: $1,100
Per victim costs by injury
Burn/Anoxia: $4,500
Caught between objects: $1,900
Drowning/Submersion: $21,000
Fall: $4,200
Firearm: $17,000
Suffocating/Choking: $11,000
Cost estimates are incidence-based and based on multiple
national data sources
Productivity costs undervalue lives of women and minorities
as they are paid less than white males
Some data (cost of coroners) date back 10-20 years
More than half of the 84 injury prevention measures
reviewed yielded net societal cost savings.
12 measures had costs that exceeded benefits.
Of 33 road safety measures analyzed, 19 yielded net cost
savings.
Of 34 violence prevention approaches studied, 19 yielded
net cost savings, whereas 8 had costs that exceeded
benefits.
Estimated cost savings for each detector are $210-$636
Benefit/cost ratio: 5.5-15.5 per detector
Costs include medical, other tangible costs, quality of life
gains, but not property damage savings
Parental time caring for children not included
In 1992, gunshot wounds cost an estimated US $126 billion,
cut/stab wounds cost another $51 billion dollars.
January 2008
INJURY ECONOMIC STUDIES
Authors
Study Question
Perspective
Study type and design
Roberts et
al. 1998
Estimate costs of
injuries based on
prevalence of
incidence
Societal
Cost estimation
Population
and Setting
U.S. 0-15
Winston et
al. 2001
Provide national
estimates of
incidence and
costs of handlebar related child
injuries
Societal
Cost estimation
U.S. <20
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Outcomes/Comments
Road accident cost
Home accident cost
Hidden cost of injury
An estimated 1,147 subjects in the US had serous nonmotor-involved bicycle-related abdominal or pelvic organ
injury leading to hospitalization in 1997
An estimated $9.6 million in total hospital charges
10 million in lifetime medical costs
$11.5 million in life productivity losses
$503.9 million in lifetime monetized quality-adjusted lifeyears
January 2008
APPENDIX D: MENTAL HEALTH DISORDER INTERVENTIONS
MAGNITUDE: While the majority of young children are emotionally and psychologically healthy,
a substantial minority of these infants, toddlers and preschoolers manifest some form of
problematic behavior. A 1999 Surgeon General‘s report 344estimates that about 20% of children
have mental disorders that cause at least mild functional impairments. For children between the
ages of one and six years, these often take the form of externalizing behaviors, or acting out
(ranging 3.4%-6.6%). In other cases, even very young children can manifest withdrawal,
depression or anxiety—often referred to as internalizing behaviors (ranging 3.0%-6.6%).345,346,347
Within this age group, oppositional defiant disorder (ODD)/conduct disorder (CD) and attentiondeficit hyperactivity disorder (ADHD) are the most frequently-reported specific emotional and
behavioral problems. 348,349
DETERMINANTS AND RISK FACTORS: The etiology of early childhood mental health problems is
multi-factorial, with important contributions made by dispositional, environmental, and genetic
factors. A systematic review reveals that the incidence of early childhood behavior problems is
higher for young children living in poverty than for the general population.350 It is also well
established that maternal depression increases the risk for child behavioral and emotional
problems. 351,352,353,354 Insecure attachment to caregivers and harsh, inconsistent discipline have
also been implicated. 355,356
HEALTH CONSEQUENCES: Despite the prevalent misperception that emotional and behavioral
problems among preschoolers are ―normal‖ and will be eventually ―outgrown,‖357,358 extensive
research shows that early disruptive and aggressive behavior tends to persist and develop into
chronic and more severe forms of anti-social behavior.359,360,361,362,363 Additionally, behavior
problems in one domain may spill over into others, and serious externalizing problems in early
childhood may lead to internalizing problems in young adulthood by lowering academic
competence. 364
ECONOMIC CONSEQUENCES: Behavior problems have negative effects on other outcomes, such as
educational attainment,365 unemployment,366,367 and violent crimes committed.368 Moreover, the
high prevalence and enduring consequences of mental health problems in children have
considerable financial implications for society, families, and individuals, both immediately and
in the longer term. Sturm et al.369 estimate that the cost of treating children ages one to five
nationwide approached $698 million dollars [$864 million in 2006 dollar value]. From a family
perspective, Busch and Barry,370 using a U.S. national data set, demonstrated that caring for a
child with mental health care needs affects family financial well-being, far more than caring for a
child with other special health care needs. From a societal perspective, a U.K. study assessed the
cost consequences across six domains (foster and residential care in childhood, provision of
special educational, state benefits received in adulthood, breakdown of relationships, health, and
crime) and estimated that children ten years of age with persistent antisocial behavior would cost
society £70,019 [$134,406 in 2006 U.S. dollars] by the time they were 28 years old––ten times
as much as those without such behavior problems.371, 372
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EVIDENCE FOR PREVENTION AND TREATMENT: A wide range of early intervention strategies with
different targets and a variety of theoretical underpinnings have been developed and tested over
the past decade. We included only randomized controlled trials (RCT) in this review.
Parent-focused:
The majority (34 of 59) of the studies summarized in this review used a parent-focused training
approach, in which parents learn from a psychologist or educator about effective behavior
management skills. A number of forms of behavioral parent training programs, based on social
learning models (e.g., Patterson, 1982373), have been developed. They typically focus on teaching
parents how to increase positive interactions with their children while reducing coercive and
inconsistent parenting practices. Six studies374,375,376,377,378,379 evaluated the application of
different forms of Triple P (the Positive Parenting Program), a multi-level system of intervention
for parents of young children. Together, they found that this program had significant short-term
effects on reducing child behavior problems, as well as improving parenting style. In general,
more intensive interventions were superior to less intensive ones.
Another popular parent-training model involves videotape vignettes developed by WebsterStratton and colleagues.380 ―The Incredible Years‖ provides training on a sequence of topics
including parent–child play, praise, incentives, limit-setting, problem-solving and discipline.
Five of six RCTs found that behavior problems among children receiving the intervention were
significantly reduced compared to those in the control groups.381,382,383,384,385 A study of a
videotape training program found that, at the 3-month follow-up, children in the intervention
group had a significantly greater reduction in problem behavior than those in the control
group.386
Studies also found that parent-training programs yielded no effect on child behavior when
delivered by non-specialist nurses rather than therapists.387 Neither parent counseling nor
advising programs work effectively this way.388,389 Another set of programs focus on improving
the quality of the relationship between parents and their children. One, Parent-Child-Interaction
Therapy (PCIT), a 14-week therapy developed by Eyberg and colleagues,390,391 focuses on
improving child–parent relationships and providing parents with skills to manage disruptive
behavior. Two studies reported that both immediate and continued improvement in disruptive
behaviors resulted from PCIT.392,393 Relationship-focused interventions also include
Infant/toddler-parent psychotherapies. Based on attachment theory, these programs are designed
to improve the quality of early relationships between parents and young children, and often are
used to help improve attachment security among offspring of depressed mothers.
Eleven394,395,396,397,398,399,400,401,402,403,404of the twelve studies, reported that such interventions
improved infant/toddler-parent interaction and/or the children‘s security or behaviors, as well as
maternal depressive symptoms. Muntz et al.405 has suggested that video-recording parent-child
interactions may be more cost-effective than the standard parent-training programs. Dozier et
al.‘s study 406 targeted foster children, and parents in the intervention group reported positive but
not significant improvement in their children‘s behavior problems.
Parent support programs do not necessarily provide direct training sessions to parents of at-risk
children, but provide parents with supportive consultation about their children‘s well-being.
Despite the positive effect of the Healthy Steps consultant on parenting practices and care
utilization, there was a significant increase in parents‘ reports of their children‘s aggressive
behavior and sleeping issues compared to control mothers, due to the program increasing the
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mothers‘ awareness of such problems.407, 408 One of the barriers to implementing interventions
with young children is parental motivation. Two studies found that enhancing parents‘ awareness
of children‘s competencies and parenting practices can be useful in improving both parental
involvement and child behavior problems. 409,410
Child-focused:
McLaughlin et al. 411 examined the long-term influences of the Carolina Abecedarian project, a
comprehensive early education program for at risk preschoolers, in which they received fulltime, high-quality educational intervention in a childcare setting from infancy through age five.
Individuals who received child-care treatments reported fewer depressive symptoms, on average,
at age 21, than those in the control group (26% vs. 37%).
Family-focused:
Berlin et al.412 and Blair et al. 413 found significant effectiveness in the Infant Health and
Development Program (IHDP) on behavior problems of low-birth weight premature infants.
Nine studies 414,415,416,417,418,419,420,421,422 (reporting on seven interventions) targeted various risk
factors, and provided both parent- and child-focused family-level training programs in group
settings. In particular, Webster-Stratton and Hammond 423 found that those in the parent and
child-training group demonstrated significant improvements in problem-solving and conflict
management skills, compared to those in the parent-training-only group. They also showed more
positive parent and child interactions than those who received child-training alone. All of these
improvements were sustained at the one-year follow-up. It appears that child- and parent-training
each made a unique contribution to the improvement of children‘s outcomes.
Teacher-focused:
Five programs424,425,426,427,428 involving school teachers that primarily focused on preschool
children were identified, and another seven studies (six interventions) targeted school-age
children. Across these studies, intervention group children improved significantly more than
comparison group children in their teacher-rated (but not always in parent-rated) social skills, as
well as in internalizing and externalizing problems. Webster-Stratton and colleagues 429
compared different strategies and argued that it was difficult to demonstrate statistically
significant additive effects of teacher training. Programs that targeted school-aged children all
reported some significant improvement in at least one study outcome, such as social competence
and conduct problems. 430,431,432,433,434,435,436
System-level:
A RCT was implemented to assess the impact of welfare reform as an example of the effects of
national-level policy change on children‘s behavior. New Hope, an employment-based program
for adults living in poverty, which provided strong work support through extensive child-care
assistance and health care subsidies, had a positive affect on teacher-reported, but not parentreported, child behavior problems.437
COST IMPLICATIONS OF INTERVENTIONS: Although the number of economic evaluations has grown
in many fields, they are still scarce in the area of child mental health prevention and intervention.
Scott and colleagues438, 439 examined the outcome of a 13-to-16 week long Webster-Stratton
basic videotape program administered to parents of children three-to-eight years old, who were
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referred with antisocial behavior. They found that the program cost of groups was £571 [$1,096
in 2006 U.S. dollars] per child and the effect size on the primary outcome measure was 1.06,
giving a cost of £540 [$1,037 in 2006 U.S. dollars] per standard deviation improvement in
antisocial behavior. They concluded that this parenting group intervention was more costeffective than routine clinic treatment, but this number is difficult to interpret in the absence of
studies of other interventions reporting results in similar units. Muntz et al. 440 suggested that
treatments using videotaped recording of parent-child interactions may be more cost-effective
than standard parent-training programs. Jensen et al. 441 conducted the only study to date on
cost-effectiveness of major ADHD treatments; they reported that, for 14 months of treatment,
medical management costed $1,180 [$1,381 in 2006 dollars] per group, intensive behavior
treatment costed $6,988 [$8,181], combined medical management and behavior treatment costed
$7,827 [$9,163], and routine community care costed $1,071 [$1,254]. Combining the
effectiveness of each treatment, they concluded that medical management treatment, although
not as effective as combined medical management and behavior treatment, was likely to be more
cost effective in routine treatment for children with ADHD, especially for those without
comorbid disorders. Finally, McAuley et al. 442 examined outcomes of a U.K. program called
Home-Start, which offers volunteer support to families under stress where there is at least one
child under five years old. On average, families supported by Home-Start costed £3,058 [$5,954
in 2006 U.S. dollars] more than comparison group families. When considering volunteer time,
the average cost of intervention was £8,831 [$17,194 in 2006 U.S, dollars] higher than for the
comparison group. After considering the effectiveness, they concluded that Home-Start did not
appear to be a cost-effective alternative to standard health visitor-based services.
CONCLUSION: This review finds that the literature on parent training are extensive, and most
programs aimed at directly improving parenting skills yield positive results; however, these
improvements in children‘s behavior do not necessarily generalize to settings outside the home.
In general, interventions that focus on multiple risk factors are more effective. Most studies
explicitly target young children‘s externalizing behavior problems, especially ODD/CD or
ADHD, with fewer studies intentionally targeting internalizing behavior problems.
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Figure 1. Lifespan Impact of Interventions for Mental Health Disorders
LIFESPAN STAGE INTERVENTION AND IMPACT
LEVEL OF INTERVENTION
Preconception/
Pregnancy
Infant/Childhood
Individual
Child-focused training
Parent-focused programs
Adolescence
Adulthood
i
ii
iii
Child-focused training ; Parentiv
focused training programs
Parent- and child-focused
v
programs ; Collaborative
vi
problem solving
Family
Local/ Community/
Workplace/ School
National/State
School-based: Fast Track
vii
viii
New Hope
Age period when interventions take place
Age period with continuing positive impacts of intervention
i
Abecedarian project
Healthy Steps, Early Head Start
iii
Incredible Years‘ Dinosaur Curriculum
iv
Triple P
v
Infant Health and Development Program (IHDP); Webster-Stratton, C., & Hammond, M. (1997).
vi
Greene R, et al. 2004
vii
Conduct Problems Prevention Research Group 2004
viii
Huston AC et al. 2005
ii
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Table 1. Studies on Prevention and Intervention for Mental Health Disorders
INDIVIDUAL-LEVEL INTERVENTIONS: PARENT-FOCUSED
Authors
Study Question
Intervention
Population & Setting
N/Attrition
Bor et al.
2002
To review the
Effects of the
Triple P-Positive
Parenting
Program
on Preschool
Children with
Co-Occurring
Disruptive
Behavior or
ADHD
Design:
RCT
Intervention: Tripe P
enhanced BFI (EBFI)
standard BFI (SBFI)
waitlist (WL)
Setting:
I1: 26
I2: 29
C:32
To review a foursession psychoeducational
group for parents
of preschoolers
with behavior
problems,
delivered in
community
agencies.
To review a
program
promoting
secure
attachment in the
offspring of
depressed moms
To contrast the
effectiveness of
an infant-led with
an alternate form
of parent–infant
psychotherapy
Design:
RCT
Intervention: Brief
Psychoeducational
Parenting Program:
3 weekly group sessions
and a 1-month booster,
focusing on being to support
effective discipline
Setting:
community agencies in
metropolitan Toronto
Inclusion:
Parents of 3-4 children
I: 89
C: 109
Design:
RCT
Intervention:
Mothers and toddlers
participated joint therapy
sessions
Setting:
I: 27
C1: 36
C: 45
BDI
DIS-III-R
AQS
Design:
RCT
Intervention:
Watch, Wait, and Wonder
(WWW)
Or, mother–infant
psychotherapy (PPT).
Design:
RCT
Intervention:
Parents were required to
read a workbook each
week for 10 weeks
Weekly telephone contact
Setting:
Hincks-Dellcrest Centre for
Children‘s Mental Health
Inclusion:
10- to 30-month-old infants
and their mothers who
were referred to the center
Setting:
home
Inclusion:
Families reside in rural
area in Australia, children
aged 2-6 without
development delays
I1: 34
I2: 33
CBCL
YSR
I: 12
C: 11
ECBI
PSOC
PS
DASS
PDRC
Bradley et al.
2003
Cicchettie et
al.
Cohen et al.
1999
Connell et al.
1997
To evaluate the
effectiveness of
a self-directed
family program
on oppositional
behaviors in rural
and remote
areas
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Inclusion:
87 preschoolers with cooccurring disruptive
behavior and
attentional/hyperactive
difficulties.
Inclusion:
Toddlers with mothers with
or without depression
history
97
Measures
ECBI
PDR
28%
1 year follow
up: 25%
PS
PBQ
PCQ
BSI
Outcomes/Comments
At postintervention both BFI programs were
associated with significantly lower levels of
parent-reported child behavior problems
(p<0.05), lower levels of dysfunctional
parenting, and greater parental competence
than the WL condition
The gains achieved at postintervention were
maintained at 1-year follow-up.
The enhanced program was not shown to be
superior to the standard program using any of
the outcome measures at either
postintervention or follow-up.
At 3 months, the parents who received the
intervention reported significantly greater
improvement in parenting practices and a
significantly greater reduction in child
problem behavior than the control group.
At 1-year follow up, changes in parenting
behavior appeared to be sustained over a 1year follow-up, although these follow-up
results may not be representative of the
sample as a whole.
To promote secure attachment
Infants in the WWW group were significantly
more likely than infants in the PPT group to
move towards either a secure or organized
attachment relationship ( p < .03)
Before treatment began mothers and infants
in both groups exhibited greater reciprocity in
play and less conflict
There was a significantly lower level of
disruptive child behavior in the treatment
group than the control group at posttreatment, p=.0005
A significant reduction in ECBI intensity
scores for the treatment, but not significant
for the control, p=.0005
January 2008
INDIVIDUAL-LEVEL INTERVENTIONS: PARENT-FOCUSED
Dozier et al.
2006
Funderburk
et al. 1998
Gardner et
al. 2006
Gardner et
al. 2003
Design:
RCT
Intervention:
Attachment and
Biobehavioral Catch-up:
The foster parents
received in-home training
for 10 weekly sessions.
Control intervention group
received an educational
program: Developmental
Education for Families
Comparison group: nonfoster children
Design:
Setting:
Foster care
Inclusion:
Infants and toddlers in
foster care
I1: 30
I2: 30
C: 104
Setting:
I: 12
C¨72
Intervention:
14-session parent-child
interaction programs
Inclusion:
Children 2-7; had behavior
problem;
To test
effectiveness of
a parenting
intervention, for
reducing conduct
problems in
clinically-referred
children.
Design:
RCT
Intervention:
Webster-Stratton Incredible
Years video-based 14-week
group program
Setting:
9 sites across one county
in UK
Inclusion:
children referred for
conduct problems, aged 2–
9, primarily low-income
families
I: 44
C: 32
To determine
whether early
psychosocial
intervention with
LBW-Term
infants improved
cognition and
behavior
Design:
RCT
Intervention:
weekly home visits by
paraprofessionals for the
first 8 weeks of life
Setting:
Kingston, Jamaica
Inclusion:
LBW-Term infants (weight
<2500 g).
I: 66
C: 69
To present
preliminary data
testing the
effectiveness of
an intervention
delivered to
foster children
To review the
maintenance of
treatment effects
of parent-child
interaction
therapy
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PDR
A main effect for Intervention Group
emerged, p < .002.
Post hoc analyses revealed differences
between the control intervention group and
the other two groups (p < .001), but not
between the experimental intervention group
and the typically developing group (p > .20)
The Intervention group main effect on
behavior was not significant, nor were
differences significant when considering only
the toddler group, p > .10
SESBI
Conners
index
WalkerMcConnell
Scale of
Social
Competence and
school
adjustment
ECBI
Parenting
Scale
BDI
(parents)
At the 12-month follow up, treatment children
maintained post-treatment improvements in
conduct problems
At the 18-month follow up, children were
found declined on most measures into the
range of pre-treatment levels
Four 9-point
rating scales
(developed in
Brazil)
LBW-T intervened infants had higher scores
than LBW-T control infants on the cover test
(P < .05) and were more cooperative (P <
.01) and happy (P < .05).
N/A
th
7% at 6
month; 10%
th
at 12 month
Post-treatment improvements were found in
child problem behavior, by parent-report
(effect size (ES) .48, p= .05) and direct
observation (ES .78, p = .02)
child independent play (ES .77, p = .003)
observed negative (ES .74, p = .003) and
positive (ES .38, p = .04)
parenting; parent-reported confidence (ES
.40, p = .03) and skill (ES .65, p = .01),
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INDIVIDUAL-LEVEL INTERVENTIONS: PARENT-FOCUSED
Gianni et al.
2006
Hart et al.
1998
Horowitz et
al. 2001
Hutchings et
al. 2002
To evaluate the
effects of an
early postdischarge
developmental
mother—child
intervention
program on
neurodevelopme
nt outcome at
36months in
VLBW infants.
To assess the
effectiveness of
a short-term
intervention for
improving
interaction
behaviors of
newborns with
their depressed
mothers
To test the
efficacy of an
interactive
coaching
intervention to
promote
responsiveness
between
depressed
mothers and
their infants
To compare a
standard
program to an
intensive
program
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Design:
RCT
Intervention:
Mother-child pairs attend
group meetings with
psychologist and a
psychometrician
Setting:
Outpatients‘ department
Inclusion:
Infants with bwt < 1250g,
being singleton, infant fed
preterm formula, without
abnormal MRI
I: 18
C 18
Griffiths
Mental
Development
Scale
compared to controls, children in intervention
group exhibited higher scores in personal—
social subscales ([mean (S.D.)]=101.4 (9.3)
vs. 92.9 (12.1), P =0.02)
Design:
RCT
Intervention:
Mothers were trained to use
Assessment of the Behavior
of her Infant (MABI)
independently and
periodically at home.
Setting:
home
Inclusion:
Depressed mothers
I: 14
C: 13
CES-D
(mothers)
At 1 month, infants in the experimental group
were performing more optimally than infants
in the control group on Social Interaction, F(l,
25) = 5.76, p < . 05
Design:
RCT
Intervention:
Interaction coaching for atrisk parents and their infants
(ICAP)
Setting:
Hospital in Boston
Inclusion:
postpartum women
I: 60
C: 57
Mother:
EPDS
BDI
Interaction
DMC
A significant difference in responsiveness
was found between the treatment and control
groups (p=.006).
The treatment group had a significantly
higher DMC mean score than did the control
group at Time 2 (t=-3.15, df=116, p=.002)
and at Time 3 (t=-2.22, df=115, p=.029).
Design:
CT
Intervention:
Intensive program had
home visit of average 25
hours
Standard program had
home visit of average 7
hours
Setting:
home
Inclusion:
New referrals to mental
health service, children
aged 2-10, with ECBI in the
top half of the clinical range
I1: 22
I2: 19
CBCL
BDI
Parenting
scale
Child behavior improved significantly in both
groups
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INDIVIDUAL-LEVEL INTERVENTIONS: PARENT-FOCUSED
Johnson et
al. 2005
Johnson et
al. 2006
Leung et al.
2003
Lieberman et
al. 2005
Lieberman et
al. 2006
To test the
effectiveness of
a home based
developmental
education
intervention in
improving
outcome at 5
years for very
preterm infants.
To test Healthy
Steps impacts on
child‘s behavior
Design:
RCT
Intervention:
developmental education
program (Portage)
or, a social support
intervention
or standard care.
Setting:
home
Inclusion:
babies born <33 weeks
gestational age
I1: 97
I2: 90
C: 97
Design:
RCT
Intervention:
Healthy Steps (HS)
Or PrePare (PP) + HS
Setting:
At providers‘ and home
Inclusion:
Pregnant women < 22
weeks‘ gestation at study
enrollment, < 45 years,
English speaking, and
planning to use a study
clinic for pediatric care.
Setting:
I1: 117
I2: 122
C: 104
To evaluate the
effectiveness of
Triple P in Hong
Kong
Design:
RCT
Intervention:
Triple P
4 weekly group sessions
of 2 hours duration
4 weekly phone
consultations of 15-30
minutes
To compare the
efficacy of childparent
psychotherapy
(CPP) and case
management
plus treatment
Design:
RCT
Intervention:
Child-parent
psychotherapy (CPP):
weekly parent-child
sessions for 1 year
Or, community referral for
individual treatment
CBCL
intervention group reported higher scores
than those in the control group on the
aggressive behavior subscale (7.74 vs. 6.80;
adjusted β, 0.83 [95% CI, 0.37-1.30]),
although neither group reached a subscale
score of clinical significance
No group differences in reported sleep
problems or problems with depression or
anxiety.
Post-treatment, a significant difference on
mean PDR scores was found between the
two groups: F(1,64)=7.19, p<.01
The intervention group also had significant
lower ECBI problem and ECBI intensity:
F(2,62)=13.94, p<.001
Significant group difference was also found in
SDQ conduct problem, hyperactivity, peer
problem, and emotional symptom, but not
prosocial behavior.
CPP group had a significant intake posttest
reduction in the number of traumatic stress
disorder symptoms (t (32) = 5.46, p < .001),
whereas the comparison group did not.
only the CPP group showed significant
reductions in behavior problems (CPP: intake
mean = 60.32, SD = 9.00; post-test mean =
54.16, SD = 8.71, t (18) = 3.10, p < .01;
comparison: intake mean = 58.86,SD = 8.82;
posttest mean = 59.64, SD = 13.11
Follow-up analyses revealed that only the
CPP group evidenced significant reductions
(TC: t26 = 3.92, p G .001 and ITT: t41 = 4.07,
p G .001).
22%
I: 33
C: 36
ECBI
PDR
SDQ
PS
PSOC
PPC
RQI
I1: 36
I2: 29
CBCL
I1: 14%
I2: 12%
To assess the
effect of the CPP
6-month after
termination of
the program
JHU  WCHPC
Although the two intervention groups had
significantly higher scores than the term
reference group (p< 0.05), there were no
differences between the three preterm
groups.
The small advantage shown at 2 years of age
is no longer detectable at 5 years.
5-year
I1: 63
I2: 61
C: 63
Inclusion:
Children aged 3-7, with
behavioral problems but no
disability
Setting:
Community?
Inclusion:
Children aged 3-5 of
divorced mothers
CBCL
6-month:
I1: 6% (27)
I2: 14% (23)
100
CBCL
SCL-90
Symptoms
Checklist,
Revised.
January 2008
INDIVIDUAL-LEVEL INTERVENTIONS: PARENT-FOCUSED
Linares et al.
2006
Minkovitz et
al. 2003
Morawska &
Sanders
2006
Muntz et al.
2004
To compare the
effectiveness of
a pairs
intervention with
usual care on
foster child‘s
externalizing
behavior
problems
To evaluate
effects of a
classroom-based
social skills
program for prekindergarten
children
Design:
RCT
Intervention:
I1: Pairs intervention: 12week parenting course
(Incredible Years); coparenting component
I2: Usual care
Setting:
At agency
Inclusion:
Foster children aged 3-10
without disabilities, from
NYC
I1: 80
I2: 48
PPI
ECBI
CBCL
Intervention families reported children as
having lower CBCL externalizing T score,
F(1, 97) = 2.71, p < .10, and ECBI total T
score, F(1, 94) = 2.30, p < .13, at follow-up,
although the differences were not significant.
Design:
RCT
Intervention:
Healthy Steps: incorporating
developmental specialists
and enhanced
developmental services into
pediatric care
I: 832
C: 761
CBCL
Levels of behavioral problems for the Healthy
Steps children were similar to those generally
healthy children
Mothers in the intervention group had
increased reporting of aggressive behaviors
compared to control group
To examine the
efficacy of a selfadministered
behavioral family
intervention
Design:
RCT
Intervention: Triple P
I1: self-administered BFI
alone, 10 weeks
I2: or, self-administered BFI
plus brief therapist
telephone assistance
Setting:
Pediatric care
Inclusion:
Newborns up to 3 were
enrolled at birth or first
office visit, who were not
adopted or in foster care,
or too ill to visit doctor‘s
office
Setting:
Home
Inclusion:
toddler between the ages
of 18 and 36 months and
that the family lived within
the Brisbane metropolitan
area, Australia
I1: 42
I2: 43
C: 41
ECBI
PS
To estimate the
longer term costeffectiveness of
an intensive
practice
Design:
RCT
Intervention:
I1: intensive parent
behavioral training
I2: standard parent
behavioral training
Setting:
Home
Inclusion:
Children aged 2-10, who
were referred to mental
health service because of
severe behavior problems
I1: 22
I2: 19
JHU  WCHPC
101
Post:
I1: 34
I2: 41
C:37
ECBL
CBCL
Short term:
A significant intervention effect was found for
child behavior problems for mothers‘ report,
F(4, 212) =5.46, p < .001
The TASD-BFI group improved more
compared with the WLC group on both the
ECBI Intensity and Problem scales, p < .01,
p < .05, respectively, whereas the SD-BFI
group did not differ from the WLC group on
either scale
Long term (6-month):
Effect maintained.
6-month follow-up: the mean score for the
intensive group decreased significantly to
below the clinical cut-off score
4-year follow-up: the intensive group‘s mean
further decreased, but the standard group‘s
mean increased, so the improvement since
baseline score was no longer significant in
the standard group
Significant difference between the group
mean at 4 year follow up (t=2.54, p=.027)
Switching to the intensive treatment will not
only provide greater clinical effect but is £224
less costly per unit of decrease on the CBCK
scale than the standard treatment
January 2008
INDIVIDUAL-LEVEL INTERVENTIONS: PARENT-FOCUSED
Nixon et al.
2003
Patterson et
al. 2002
Sanders et
al. 2000
To compare
standard and
abbreviated
treatments for
oppositional
defiant
preschoolers
Design:
RCT
Intervention:
I1: standard parent– child
interaction therapy (PCIT;
STD)
I2: modified PCIT that
used didactic videotapes,
telephone consultations,
and face-to-face sessions
to abbreviate treatment
Setting:
To assess the
effectiveness of
a parenting
program,
delivered by
health visitors in
primary
care, in
improving the
mental health of
children and their
parents
To compare
three variants of
Triple P with
comparison
group
Design:
RCT
Intervention:
Webster-Stratton 10 week
parenting program
Parents group sessions
lasting about two hours
each, once a week for 10
weeks.
Design:
RCT
Intervention:
Behavioral family
intervention (BFI): Triple P
I1: enhanced BFI: 60- to
90-mintue weekly
sessions (14 hr in total)
with a practitioner on
individual base in local
community center
I2: standard BFI: parents
received 10 hr of
intervention on average
I3: self-directed BFI:
parents received a 10session self-directed
program
C: waiting list
JHU  WCHPC
I1: 17
I2: 20
C: 18
DSM–IV
Structured
Interview
ECBL
HSQ-M
Setting:
Health centers and
community center
Inclusion:
Parents of children aged
2–8 years who scored in
the upper 50% on a
behaviour inventory
I: 60
C:56
ECBI
SDQ
GHQ
Setting:
I1: 76
I2: 77
I3: 75
C: 77
ECBI
BDI
Inclusion:
Children aged 3-5
exhibiting behavioral
difficulties
Inclusion:
Families with 3-year old
who are at risk of behavior
problems
102
Immediate effect:
- Mothers in both the STD and ABB
conditions reported less oppositional and
conduct problem behavior (ECBI, ODD
symptoms) than mothers in the WL condition.
Mothers in the STD condition also reported
less severe behavior problems around the
home (HSQ-M) compared with WL mothers,
but ABB mothers did not.
6-month follow-up
- all pre–posttreatment improvements were
maintained at follow-up
the 21 intervention group children whose
initial scores fell in the clinical range
decreased by 26.1 points from
preintervention to six month follow up (p <
0.001); those of the 39 children initially
scoring in the normal range decreased by 9.2
points (p = 0.002) over this period.
The 25 control group children with initial
scores in the clinical range decreased by only
9.3 points (p = 0.001); those in the normal
range (n = 31) decreased by 5.9 points (not
significant).
Overall children in EBFI showed greater
reliable improvement than children in other
groups
By 1-year follow-up, children in all 3
treatment groups achieved clinically reliable
change in observed disruptive behavior.
January 2008
INDIVIDUAL-LEVEL INTERVENTIONS: PARENT-FOCUSED
Scott et al.
2001
Shaw et al.
2006
SonugaBarke et al.
2001
SonugaBarke et al.
2004
To evaluate a
behaviorally
based group
parenting
program for
antisocial
behaviors in
children
To test the
effectiveness
of the Family
Check-Up in
sustaining
maternal
involvement and
preventing the
exacerbation of
child conduct
problems
To evaluate two
different parentbased therapies
for preschool
attentiondeficit/hyperactivi
ty disorder
(ADHD)
To assess the
effectiveness of
the same PT
program when
delivered as part
of routine
primary care by
non-specialist
nurses.
JHU  WCHPC
Design:
Controlled trial
Intervention:
Webster-Stratton basic
videotape program
administered to parents of
six to eight children over
13-16 weeks.
Design:
RCT
Intervention: Family-Based
Interventions
Family Check-Up (FCU) is
a brief three-session
intervention
―get-to-know-you‖ (GTKY)
feedback sessions,
average number of
sessions=3.26
Design:
RCT
Intervention: a structured 8week program involving
8 1-hour weekly visits by
one of two specially trained
health visitor therapists.
I1: Parent training:
received coaching in child
management techniques.
I2: parent counseling and
support group: received
nondirective support and
counseling
or, waiting-list control
group
Design:
RCT
Intervention:
PT consisted of a structured
eight-week program
involving eight, one-hour
weekly visits. All sessions
were carried out on a oneto-one basis with mothers
and their AD/HD children in
their homes.
Setting:
4 local child and
adolescent mental health
services
Inclusion:
141 children aged 3-8
years referred with
antisocial behavior
Setting:
Inclusion:
Mothers with at-risk
toddler-age boys were
recruited from the WIC
program
Setting:
Inclusion:
Three-year-old children
displaying a preschool
equivalent of ADHD
Setting:
home
Inclusion:
3-year-old children with
AD/HD
103
I: 90
C: 51
SDQ
CBCL
Children in the intervention group showed a
large reduction in antisocial behavior; those
in the waiting list group did not change (effect
size between groups 1.06 SD (95%
confidence interval 0.71 to 1.41), P < 0.001).
BDI
CBCL
HOME
At the 2-year follow up, intervention group
(change in mean= 2.44, SD= 3.11) showed a
significant decrease in CBCL Destructive
scores, compared with those in the control
group (change in mean= 0.75, SD = 3.20),
F(1, 108) =7.81, p < .01.
I1: 30
I2: 28
C: 20
PACS
GHQ
PSOC
ADHD symptoms were reduced (F2, 74 =
11.64; p < .0001) and mothers‘ sense of wellbeing was increased by PT relative to both
other groups (F2,74 = 10.32;p < .005).
53% of children in the PT group displayed
clinically significant improvement (2 = 4.08;
p = .048).
I: 59
C: 30
PACS
WWP
CBCL
GHQ
PSOC
There was no significant improvement in
AD/HD symptoms in both groups
While PT is an effective intervention for
preschool AD/HD when delivered in
specialized settings, these benefits do not
appear to generalize when program are
delivered as part of routine primary care by
non-specialist nurses.
Follow-up
I: 73
C:37
I: 60
C: 60
2-year follow
up
I: 46
C: 46
January 2008
INDIVIDUAL-LEVEL INTERVENTIONS: PARENT-FOCUSED
StewartBrown et al.
2004
To test the
effectiveness at
one year of the
Webster Stratton
Parents and
Children Series
group parenting
program in a
population
sample of
parents.
Design:
RCT
Intervention: The Incredible
Years
Webster-Stratton‘s 10
week parenting program
led by trained and
supervised health visitors.
Parents groups
Setting:
Local center
Inclusion:
parents of children aged 2–
8 years in who scored in
the upper 50% on a
validated behavior
inventory,
I: 60
C: 56
ECBI
SDQ
PSI
GHQ
RSE
Van Zeijl et
al. 2006
To evaluate a
home-based
video-feedback
intervention to
promote positive
parenting and
sensitive
discipline (VIPPSD)
Design:
RCT
Intervention:
Discussing actual parent–
child interactions in six 1.5hr sessions with individual
families at home.
Setting:
home
Inclusion:
1- to 3-year-old children‘s
relatively high scores on
externalizing behavior.
I: 120
C: 117
CBCL
Velderman et
al. 2006
To evaluate an
intervention
aimed at
breaking
potential
intergenerational
cycle of insecure
attachment
Design:
RCT
Intervention:
Four home visits when the
infants were between 7 and
10 months old.
I1: VIPP video-feedback
and brochures
I2: VIPP-R additional
discussions of mothers‘
childhood attachment
experience
Setting:
Home
Inclusion:
Insecure mothers with firstborn 4-month-old children,
and with 8-14 years
education
I1: 28
I2: 26
C: 27
AAI
IBQ
SSP
JHU  WCHPC
104
At 12 months significant change (p , 0.05) in
a positive direction was observed for
intervention group children on the intensity
scale of the ECBI, and the total, conduct, and
hyperactivity scales of the SDQ.
Significant change in a positive direction was
also observed for intervention group parents
on all scales of the GHQ, with the exception
of the anxiety subscale; on all scales of the
PSI, with the exception of parent-child
interaction subscale; and on the RSE scale.
At 12 months there were no significant
differences between the control and
intervention group as regards any of the
scales measuring children‘s emotional and
behavioral adjustment.
after receiving the intervention, mothers in
the intervention group had more favorable
attitudes toward sensitivity, F(1, 235) _ 18.88,
p _ .01 (partial _2 _ .07), and toward
sensitive discipline, F(1, 235) _ 4.49, p _ .05
(partial _2 _ .02), than control group mothers
at the posttest
In families with more marital discord and in
families with more daily hassles, the
intervention resulted in a decrease of
overactive problem behaviors in the children.
Outcome is mother-infant interaction
January 2008
INDIVIDUAL-LEVEL INTERVENTIONS: PARENT-FOCUSED
Verduyn et
al. 2003
Zubrick et al.
2005
To evaluate the
effect of group
cognitive
behavioral
therapy (CBT) on
child behavior
problems and
maternal
depression in a
group of women
with young
children.
To evaluate the
effectiveness of
a universally
delivered group
behavioral family
intervention (BFI)
in preventing
behavior
problems
in children
JHU  WCHPC
Design:
RCT
Intervention:
I1: CBT for depression
and parenting skills
enhancement, received 16
group sessions.
I2: mothers‘ support group
attended mother and
toddler groups run by a
health visitor together with
an experienced clinical
psychologist.
Design:
Quasi-experimental
longitudinal
Intervention: Triple-P
Parenting groups: 2hr/week, 4 weeks
Telephone support
sessions
Reading materials & video
Setting:
Inclusion:
mothers with children aged
between 2 years 6 months
and 4 years, and both
mothers showed
depression and children
showed problems
Setting:
Community health services
Inclusion:
Preschool aged children
and their parents recruited
from the Eastern
Metropolitan Health Region
of
Western Australia
105
I1: 47
I2: 44
C: 28
CBCL
ECBL
There were significant differences in the
primary outcome of child behavior pretest to
post-test (P<0.001), pre-test to 6-month
follow-up (P=0.006) and to 12- month followup (P=0.006) on CBCL total scores for the
CBT group but not for the two control groups.
The CBT group also displayed an
improvement in ECBI problem scores from
pre-test to 6-month follow-up (P<0.01) and to
12-month follow-up (P=0.007), whereas the
two control groups did not.
ECBI
PS
PPC
ADAS
DASS
The immediate effect: parent- reported child
behavior decreased in adjusted mean ECBI
by an estimated 22.4 points (95% CI=20.38,
24.48). this improvement was .83 of a
standard deviation, which corresponds to a
large effect size
At 12- and 24-month, post-intervention, this
improvement attenuated but was still
statistically significant with decreases in the
adjusted mean ECBI score of 11.3 (95%
CI=9.1, 13.5) and 12.9 (95% CI=10.4, 15.4),
respectively, corresponding to a medium
effects.
70%
I: 804
C: 806
January 2008
INDIVIDUAL-LEVEL INTERVENTIONS: CHILD-FOCUSED
Authors
Study Question
Intervention
Population & Setting
N/Attrition
McLaughlin
et al. 2007
To evaluate
effects of early
childhood
interventions on
young adult
depressive
symptoms
Design:
RCT
Intervention:
Abecedarian study
Full-day, year-round,
center-based, free,
educational child care
from infancy through 5.
Setting:
Center-based
Inclusion:
Infants at high risk for poor
cognitive/academic
outcomes due to
environmental factors such
as poverty.
I: 57
C: 54
N/Attrition
Measures
BSI
HOME
age-21
follow-up:
104 out of
111
participated
Outcomes/Comments
37% of the individuals in the control group
rated themselves as having depressive
symptoms, in contrast to 26% of those who
were in the treatment group
FAMILY-LEVEL INTERVENTIONS
Authors
Study Question
Intervention
Population & Setting
Barkley et al.
2000
To examine the
effectiveness of
a multi-method
psychoeducational
intervention for
preschool
children with
disruptive
behavior
Design:
RCT
Intervention:
Four groups:
no treatment (42)
parent training only (39)
full-day treatment
classroom only (37)
combination of parent
training with the
classroom treatment (40)
Setting:
Worcester Public Schools
Inclusion:
158 children at
kindergarten having high
levels of aggressive,
hyperactive, impulsive, and
inattentive behavior.
Berlin et al.
1998
To examine the
effectiveness of
early intervention
Design:
longitudinal randomized trial
Intervention:
Infant Health and
Development Program
(IHDP):
Home visiting
Extrafamilial education
from 12 months for 20h
per week
Parent groups
Setting:
8 medical institutions,
between January 7, 1985
and October 9, 1985
Inclusion:
Low-birth-weight premature
infants
JHU  WCHPC
106
C=42
I1=39
I2=37
I3=40
I: 377
C: 608
Measures
CBCL
HSQ
Normative
Adaptive
Behavior
Checklist
PSI
SSQ
SSRS
Woodcock
Johnson
Psycho
educational
Test
Battery
CPT
BCL
CBCL
HOME
ICQ
Outcomes/Comments
No significant effects were found on any of
the clinic lab tests.
Two subscales focusing on attention
problems and aggression were statistically
significant.
The children receiving the special classroom
intervention had significantly higher levels of
social skills and significantly fewer behavioral
problems than did those children not
receiving this intervention.
Parent training produced no significant
treatment effects, probably owing largely to
poor attendance.
At 24 and 36 months, intervention children‘s
mothers reported fewer behavior problems
than mothers of follow-up children, measured
by BCL and CBCL.
January 2008
FAMILY-LEVEL INTERVENTIONS
Authors
Study Question
Blair et al.
2003
To examine
maternal control
strategy and
child compliance
as a function of
early intervention
To review a pilot
study testing a
prevention
program
promoting
families at risk
Brotman et
al. 2003
Brotman et
al. 2005
Brotman et
al. 2005
To examine the
potential
beneficial effects
of a family-based
preventive
intervention
on the older
siblings of
targeted
preschoolers at
risk for
conduct
problems
To investigate
the immediate
impact of an 8month centerand home-based
prevention
program for
preschoolers at
high risk for
conduct
problems
JHU  WCHPC
Intervention
Population & Setting
N/Attrition
Measures
Outcomes/Comments
Among children in the intervention group,
consistent maternal guidance was related to
lower externalizing and to lower internalizing
Design:
RCT
Intervention:
Combined Incredible Years
with additional components,
including
home visit
Parenting groups
Child groups
Parent and child group
activities
Design:
RCT
Intervention:
22 weekly 90-min
concurrent groups for
parents and preschoolers
an additional 30 min of
guided parent–
preschooler interactions at
the end of each group
10 biweekly home visits,
and 5 booster sessions
Program elements for
siblings
Design:
RCT
Intervention:
Incredible Years Series
Parenting groups
Child groups
Home visits
Setting:
Home and clinic
Inclusion:
Children age 2.5-5 with
older relatives with criminal
record or with CD or ODD
I: 16
C: 14
Setting:
DSM-III-R
DPICS
Children in intervention group showed
decreases in externalizing behaviors over
time, whereas control group showed
2
increases; the effect (eta =1.41) is
considered large.
I: 26
C: 21
NYPRS
NYTRS
CPRS–R
CTRS–R
In all domains with significant interactions,
there were intervention effects for adolescent
siblings but not for school-age siblings.
I: 50
C: 49
PPI
Observation (
OPPUS)
The intervention yielded significant effects on
negative parenting, parental stimulation for
learning, and child social competence with
peers
0%
Inclusion :
all families in the trial with
at least one older sibling
(5–17 years old) living in
the family
Setting:
Center- and home-based
Inclusion:
Families were identified
over a 5-year period from
family court records of
youths in Manhattan and
the Bronx, NY, who had
siblings under 5.
107
25%
January 2008
FAMILY-LEVEL INTERVENTIONS
Authors
Study Question
Intervention
Population & Setting
N/Attrition
Feinfield &
Baker 2004
To evaluate the
efficacy of a
manualized
multimodal
treatment
program for
young
externalizing
children
To examine the
effectiveness of
a cognitivebehavioral model
of intervention of
collaborative
problem solving
(CPS)
Design:
RCT
Intervention:
Parent and child together
groups
Parent groups
Individual meetings
Child groups
Setting:
I: 24
C: 23
CBCL
ECBI
HSQ
SSQ
TRF
Treatment parents reported significant
reductions in child behavior problems,
improved parenting practice
Five months following the treatment, teachers
reported significant improvements in child
behaviors
Design:
RCT
Intervention:
I1: Collaborative problem
solving (CPS): 7-16
sessions where therapists
identified cognitive–
behavioral therapy as their
primary therapeutic
orientation
I2: parent training (PT):
10-week behavior
management program
Design:
RCT
Intervention:
parent-training,
child-training,
Parent- and child-training,
a waiting-list control
group.
Setting:
I1: 28
I2: 19
GAF score
PCRI
PSI
ODD
Rating
Scale
Clinical
Global
Impression
On the PCRI, the CPS condition produced
significant improvement on both the Limit
Setting subscale (Z= 3.52, p < .01) and the
Communication subscale (Z= 2.27, p <.05)
At 4-month follow-up, 80% of children in the
CPS condition evidenced an excellent
response to treatment, vs. 44% of those in
the PT condition
CT: 27
PT: 26
CT+PT: 22
Comp: 22
ECBI
DSM-III
All treatment children showed significant
improvements in problem solving as well as
conflict management skills
Favored the CT condition over the PT
condition.
At home, PT and CT + PT parents and
children had significantly more positive
interactions, compared with CT parents and
children.
One-year follow-up: all the significant
changes noted immediately post treatment
had been maintained over time
CT + PT condition produced the most
significant improvements in child behavior at
1-year follow-up.
Greene et al.
2004
WebsterStratton &
Hammond
1997
To examine
different
strategies
JHU  WCHPC
Inclusion:
Families of children with
externalizing behavior
problems, between 4 and
8, not developmentally
delayed
Inclusion:
Affectively dysregulated
children with Oppositionaldefiant disorder (ODD)
between 4 and 12, IQ > 80
Setting
Inclusion:
children aged 4 to 8 with
early-onset conduct
problem
108
Measures
Outcomes/Comments
January 2008
COMMUNITY-BASED INTERVENTIONS
Authors
Study Question
Intervention
Conduct Problems
Prevention Research
Group 2004
To examine the
effects of the Fast
Track program on
children with earlyonset conduct
problems, from 1st
grade through high
school.
Design
RCT
Intervention:
Fast Track (1-grade):
Parent groups with
home visiting
Academic tutoring
Social-skill training.
A universal
intervention was
delivered to
everyone in the
school
To evaluate effects of
a classroom-based
social skills program
for pre-kindergarten
children
Design:
RCT
Intervention:
RECAP (Reaching
Educators, Children,
& Parents program:
class program
site-based teacher
training
group parents
training
Han et al. 2005
JHU  WCHPC
Population &
Setting
Setting:
Classrooms in
primary schools
Inclusion:
high-risk children
screened from
kindergarten
Setting:
School
Inclusion:
aged 4–5 years) in
the
12 participating prekindergarten
classrooms
109
N
I: 445
C: 446
Measures
CPPRG
PDR
I: 10%
C: N/A
I: 83
C: 66
10%
CBCL
SSRS
C-TRF
Outcomes/Comments
Interventions have
significant effects:
OR=0.66, 0.61, 0.70
for three outcomes
respectively (social
cognition and social
competence
problems, peer
deviance, and home
and community
problems)
Probability of having
problems in the
intervention group are
6 to 7 percentage
points less than the
control group for the
three domains with
significant effects (.16
vs .23; .12 vs .18; .22
vs .29).
Significant treatment
effects were found for
teacher but not parent
reports
Treatment group
children improved
significantly more than
comparison group
children in their
teacher-rated social
skills and internalizing
and externalizing
problems.
January 2008
COMMUNITY-BASED INTERVENTIONS
Authors
Study Question
Intervention
Harrington et al. 2007
To test the hypothesis
that a community
based intervention by
secondary child and
adolescent
mental health
services would be
significantly more
effective and less
costly than a hospital
based
intervention
To compare a
standard program to
an intensive program
Design:
RCT
Intervention:
Parental education
groups.
Each service used
their routine
interventions for
behavioral disorder
for the age group
being studied.
Hutchings et al. 2002
King et al. 1998
JHU  WCHPC
To evaluate the
efficacy of a 4-week
cognitive behavior
treatment program for
children who refuse to
go to school program
for children who
refuse to go to school
program for children
who refuse to go to
school program for
children who refuse to
go to school
Design:
CT
Intervention:
Intensive program
had home visit of
average 25 hours
Standard program
had home visit of
average 7 hours
Design:
RCT
Intervention:
A 4-week program
including
Individual child
cognitive-behavior
therapy
Parent/teacher
training
Population &
Setting
Setting:
Community vs.
hospital
Inclusion:
Parents of 3 to 10
year old children with
behavioral disorder
who had been
referred to mental
health services
Setting:
home
Inclusion:
New referrals to
mental health service,
children aged 2-10,
with ECBI in the top
half of the clinical
range
Setting:
Inclusion: :
Children aged 5-15,
who met criteria for
school refusal
110
N
I1: 72
I2: 69
Measures
Outcomes/Comments
ECBI
BDI
No significant
differences between
the community and
hospital based groups
on any of the outcome
measures, or on
costs.
I1: 22
I2: 19
CBCL
BDI
Parenting scale
Child behavior
improved significantly
in both groups
I: 17
C: 17
Fear thermometer
R-CMAS
CDI
CBCL
GAF
Significant differences
in self-reported were
found post-treatment
between the two
groups:
- Fear thermometer:
p<.01
- Fear survey
schedule for
children II: p<.05
- R-CMAS: p<.01
- CDI: p<.05
- SEQSS: p<.01
No significant
between-group
differences in
externalizing problems
reported by parents
One-year 18%
January 2008
COMMUNITY-BASED INTERVENTIONS
Authors
Study Question
Intervention
McGoey et al. 2005
To investigate a
comprehensive multicomponent
intervention on
children at-risk for
ADHD
Nafpaktitis &
Perlmutter 1998
To investigate schoolbased early mental
health intervention on
at risk children
Design:
RCT
Intervention:
Early intervention:
- School-based
consultation
- Parent training
(12 weeks); 9
monthly booster
sessions
- If necessary,
pharmacological
treatment
Or, community
treatment control
Design:
RCT
Intervention:
4 to 12 30-minute
individual play
sessions
Owens et al. 2005
To assess the
effectiveness of
YESS program on
children with ADHD
JHU  WCHPC
Design:
RCT
Intervention:
Youth Experiencing
Success in School
(YESS)
Behavioral
parenting sessions
Teacher
consultation
Coordination of care
Individual child
sessions with
clinicians
Population &
Setting
Setting:
Home and school
Inclusion:
Children aged 3-5, atrisk for ADHD
Setting:
School
Inclusion:
At risk children aged
5-10, enrolled in two
rural elementary
schools in central CA
Setting:
Elementary schools in
rural Ohio
Inclusion:
Children (1-6 grade)
showing ADHD
symptoms
111
N
Measures
Outcomes/Comments
I1: 30
I2: 27
PKBS
Observa-tion
Teacher reports on
the PKBS showed
great improvements in
both groups
Both parent and
teachers‘ reports
found greater
improvement in the
community treatment
control group
I: 20
C: 20
T-CRS
The group difference
was significant
F(7,28)=2.95, p<.05
I: 30
C: 12
DBD
IRS
CBCL
Based on parentsrated symptoms,
treatment group,
compared to the
waitlist, had significant
improvement in
oppositional and
defiant behaviors,
peers relations, and
aggression
Based on teacherrated symptoms,
treatment group has
significant
improvement in
inattention, teacher
relations, academics,
self-esteem, overall
IRS score, attention,
and DSM ADD.
January 2008
COMMUNITY-BASED INTERVENTIONS
Authors
Study Question
Waschbusch et al.
2005
To evaluate 3 distinct
but overlapping
approaches to
delivering a
behavioral schoolbased intervention on
children disruptive
behaviors
Webster-Stratton
1998
Two types of
parenting programs
with Head Start
mothers were
compared
JHU  WCHPC
Intervention
Design:
RCT
Intervention:
SW: focused on
factors in the child‘s
school, consisting of
both universal and
targeted service
TS: used a targeted
service focused on
factors in school
TH: used a targeted
service focused on
both school and
home factors
Design:
RCT
Intervention:
I1: Experiment group
(Incredible Years)
Weekly parent
group meetings (816 parents for 2 hr,
once a week).
Groups viewed
videotapes of
modeled parenting
skills
the group leaders
led a focused group
discussion of the
parent-child
interactions
teacher training
workshops
I2: regular Head Start
curriculum
Population &
Setting
Setting:
School & home
Inclusion:
Students from
elementary schools
aged from 5 to 12
Setting:
Head Start centers
Inclusion:
Children in the Head
Start program who
are at risk for
developing problems
112
N
Measures
Outcomes/Comments
SW: 26
TS: 27
TH: 24
C: 29
DSM-IV
CIRS
STR
Results showed that
the behavior of
disruptive children in
all schools improved
during the course of
the year, with some
evidence that
interventions provided
complementary
effects
I1: 296
I2: 130
CES-D
CBCL
ECBI
DPICS-R
CII
Short-term: The
intervention children
significantly (p < .01)
increased in positive
behaviors at both
home and schools
from pre- to postassessment, whereas
the control children
remained unchanged.
Long-term (12-18
months), pattern of
change across the
three time points in
the mothers'
perceptions of child
adjustment was not
significantly different
for the intervention
and control groups.
January 2008
COMMUNITY-BASED INTERVENTIONS
Authors
Study Question
Intervention
Webster-Stratton et
al. 2001
Two types of
parenting programs
with Head Start
mothers were
compared
Webster-Stratton et
al. 2004
To compare four
different intervention
strategies
Design:
RCT
Intervention:
I1: Experiment group
(Incredible Years)
12-Week parent
group meetings (816 parents for 2 hr,
once a week).
Groups viewed
videotapes of
modeled parenting
skills
the group leaders
led a focused group
discussion of the
parent-child
interactions
6 monthly 1-day
teacher training
workshops
I2: regular Head Start
curriculum
Design:
RCT
Intervention:
PT (parent training)
PT+TT (PT+ Teacher
training)
CT (child training)
CT+TT
PT+CT+TT
Design
RCT
Intervention:
Medication
Behavioral
treatment
Combined
medication and
MTA Cooperative
Group 1999
JHU  WCHPC
To compare longterm effects of 4
treatment strategies
on ADHD of schoolaged children
Population &
Setting
Setting:
Head Start centers
Inclusion:
Children in the Head
Start program who
are at risk for
developing problems
Setting:
Inclusion:
Families with 4-8 old
children with ODD
Setting:
Community/schoolbased
Inclusion:
Children aged 7 to
9.9 years with ADHD
combined type
113
N
Measures
Outcomes/Comments
I1: 191
I2: 81
CES-D
CBCL
ECBI
DPICS-R
CII
Short-term: Analyses
of the children of
intervention attenders
compared with the
control children
revealed significant
intervention effects at
home, F(1, 171) =
4.47, p < .05, and at
school F(1, 32) =4.63,
p < .04
Long-term (1 year),
80% of the
experimental children
were below our ―atrisk‖ cutoff (fewer than
nine problems per 30
min) for conduct
problems at home
PT: 31
PT+TT: 24
CT: 30
CT+TT: 23
PT+CT+TT: 25
C: 26
ECBI
DPICS-R
CII
Following the 6-month
intervention, all
treatments resulted in
significantly fewer
conduct problems with
mothers, teachers,
and peers compared
to controls.
M: 144
B: 144
CT: 145
CC: 146
DSM-IV
DISC
Children in the
combined treatment
and medication
management showed
significantly greater
improvement than
those given intensive
behavior treatment
and community care.
January 2008
COMMUNITY-BASED INTERVENTIONS
Authors
Study Question
Jensen et al. 2005
To compare costeffectiveness of the
four ADHD
treatments
Intervention
Population &
Setting
N
Measures
behavioral
treatment
Community care
Outcomes/Comments
Medical management
treatment, although
not as effective as
combined medical
management and
behavioral treatment,
is likely to be more
cost-effective in
routine treatment for
children with ADHD,
particularly those
without comorbid
disorders.
SYSTEM-LEVEL
Authors
Study Question
Intervention
Huston et al. 2005
To review the longterm impacts of New
Hope on children‘s
outcomes
Design:
RCT
Intervention:
New Hope: provided
three financial
benefits
earnings
supplement
health insurance
child-care subsidies
JHU  WCHPC
Population &
Setting
Setting:
Community
Inclusion:
Families had one or
more children
between the ages of
13 months and 10
years 11 months
114
N/Attrition
I:
C:
5-year
I: 23%
C: 27%
Measures
Positive Behavior
Scale
Problem Behavior
Scale from the
SSRS
Lone-liness and
Social Dissatisfaction Questionnaire
Outcomes/Comments
Parents of children in
New Hope families
rated them higher on
positive social
behavior than did
parents of control
children, but there
were no program
effects on parent
ratings of problem
behaviors
Teachers rated New
Hope boys
significantly higher on
positive social
behavior than they did
control boys. They
rated New Hope girls
significantly higher
than controls on
internalizing problems
January 2008
ECONOMIC STUDIES
Population
and Setting
Children with
ADHD in US
and Canada
Authors
Study Question
Perspective
Study type and design
Currie &
Stabile,
2004
To estimate
effects of ADHD
Societal
Using data from
Canadian National
Longitudinal Survey of
Children and Youth
American National
Longitudinal Survey of
Youth.
Dretzke et
al., 2005
Effectiveness
and costeffectiveness of
parent training/
education
program for the
treatment of
child conduct
disorder
The only study
on costeffectiveness of
major ADHD
treatments
Cost-effectiveness
Cost-effectiveness
Using NIMH‘s Multimodal
Treatment Study of
Children with ADHD (MTA
study)
Children with
ADHD
McAuley et
al., 2004
To evaluate the
effectiveness of
Home-Start
support:
Cost-effectiveness
U.K. program called
Home-Start
Children from
disadvantage
d background
Muntz et al.,
2001
To compare a
standard and an
intensive parentchild interaction
training program
Cost-effectiveness
Six-month RCT
Child with
severe
behavior
problems
Jensen et
al., 2005
JHU  WCHPC
child with
conduct
disorder
115
Outcomes/Comments
ADHD symptoms increase the probability of future grade
repetition and special education and reduce future reading
and mathematics test scores.
th
A score at the 90 percentile of the distribution of a
hyperactivity score based on symptoms increases the
probability of grade repetition by 6 percent in Canada, and
by 7 percent in the U.S.
Income has little effect on the probability of treatment
No significant difference in either effectiveness or costs
between the community and hospital based group
parental education programs.
They reported during 14 months of treatment, medical
management cost $1,180 (in 2000 dollars) per group,
intensive behavior treatment cost 6,988, combined
medical management and behavior treatment cost $7,827,
and routine community care cost $1,071.
Combining with effectiveness of each treatment, they
concluded medical management treatment, although not
as effective as combined medical management and
behavior treatment, was likely to be more cost effective in
routine treatment for children with ADHD, especially those
without comorbid disorders.
On average, families supported by Home-Start cost
£3,058 more than comparison group families.
When considering volunteers time, the average cost of
intervention was £8,831 higher than comparison group.
After considering the effectiveness, they concluded HomeStart did not appear to be a cost-effective alternative to
standard health visitor-based services.
The study suggested that the treatment using videotaped
recording of parent-child interactions may be more costeffective than the standard parent-training programs.
January 2008
ECONOMIC STUDIES
Authors
Study Question
Perspective
Study type and design
Romeo et al.
2006
To identify the
costs incurred
by children with
antisocial
behaviors in UK
Estimate effects
of treating
antisocial
behaviors
Cost of care
Using the Client Service
Receipt Inventory for
Childhood
Societal
investigated the
costs and
outcomes of a
reduced version
of the Common
Sense Parenting
program, with
approximately
30 hours of staff
time to serve 10
families
Cost-effectiveness
Costs applied to data of
10 year old children from
the inner London
longitudinal study
selectively followed up to
adulthood.
Three-month follow-up
control-trial comparison
Scott et al.,
2001
Thompson
et al. 1996
JHU  WCHPC
116
Population
and Setting
Child (3-8)
referred to
mental health
services
Outcomes/Comments
Mean annual total cost was £5,960, ranging 48-19,940
The greatest cost burden of £4,637 was borne by the
family
Child with
conduct
disorders
Cost was £571 per child
Cost-effectiveness: £540 per standard deviation
improvement in antisocial behaviors
Cost-benefit: children with conduct disorder would cost
public services around £75,000.
90 families
who were
referred to
Common
Sense
Parenting
Cost about $70 (in 1996 prices) per family.
They found parents who completed this program reported
more improvement in externalizing, but not in internalizing,
child problems than untreated controls, and the treatment
effects were maintained at 3-month follow-up.
January 2008
JHU  WCHPC
117
January 2008
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