- Email: [email protected]
Sesame Street: Changing Cardiovascular Risks for a Lifetime
NEWS AND VIEWS
Sesame Street: Changing Cardiovascular Risks for a Lifetime José L. Peñalvo, PhD,* Jaime Céspedes, MD,† and Valentín Fuster, MD, PhD*,‡ The prevalence of cardiovascular risk factors continues increasing, as its onset is drifting toward younger populations. The development of these factors is greatly influenced by lifestyle habits. It is known that early behaviors persist during childhood and are perpetuated in the adult. Research has proven that lifelong-acquired behavior is unlikely to change, and therefore acquisition of healthy behaviors should begin as early in life as possible. In this report we described the strategy and first stages of a school-based program aiming at promoting (cardiovascular) health through a multilevel intervention supported by Sesame Street materials and educational background. Semin Thoracic Surg 24:238-240 © 2012 Elsevier Inc. All rights reserved. Keywords: behavior change, education, cardiovascular health promotion The prevalence of unhealthy lifestyle habits, including substance abuse (tobacco, alcohol, etc) and inadequate dietary and physical activity patterns, is rising globally. These behavior-related habits contribute greatly to the development of cardiovascular disease and comorbidities such as diabetes and obesity.1 We believe there is a critical need for high-quality health education to introduce children (and their families and school environment) to a healthy lifestyle that can continue into a healthier life during adulthood. Sesame Street has a long tradition on high-impact educational programs, and based on their experience, we are targeting very young children, changing the conceptual approach of disease prevention to health promotion. For the acquisition of lifelong healthy behaviors, change can only be achieved through a comprehensive approach, working on the main factors that are modifiable by a behavior change, and by instilling the concept of a healthy lifestyle in very young children based on a sustainable innovative scheme using the school environment as the gateway. The school is a fundamen-
*Department of Epidemiology, Atherothrombosis and Imaging, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain. †Fundación Cardioinfantil, Instituto de Cardiología, Bogotá, Colombia. ‡Department of Cardiology, Mount Sinai School of Medicine, New York, New York. Address reprint requests to Valentín Fuster, MD, PhD, Department of Cardiology, Mount Sinai School of Medicine, 1 Gustave L. Levy Place, Box 1030, New York, NY 10029-6574. E-mail: [email protected]
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tal tool for the implementation of this type of intervention. In addition to the many levels of possible interventions, the schools offer an appropriate setting for the evaluation of the effectiveness of the intervention under controlled conditions. The most effective school-based interventions are those that involve the families and target early markers of behavior change such as improvement in the knowledge, attitude, and habits toward a healthy lifestyle as indicators of future cardiovascular health.2-4 In this vein, the Colombian Initiative for Healthy Heart Study was a 6-month intervention for the promotion of cardiovascular health conducted in 14 centers in Bogota (Colombia), including 1216 children (3-5 years of age), their parents, and teachers (Fig. 1). After evaluation through a cluster randomized controlled trial, the investigators found differences in the knowledge, attitude, and habit (KAH) scores between the intervention and control groups,5 which were stable even after 12 more months without intervention (Fig. 1). Building on the Colombian Initiative, the Program SI(!) (Salud Integral ⫽ Comprehensive Health) has been developed in Spain as an evolved intervention also with the collaboration of Sesame Street Workshop. The program targets children aged 3-16 years, aiming to establish healthful lifestyle behaviors in early life. Designed as a thorough, multilevel, school-based intervention study, the project is pursuing a global vision of promoting (cardiovascular) health, including the prevention of obesity. The project intervenes through 4 basic interrelated components: human body, physical activity, diet, and emotions’ management. This fourth component, emotions, was introduced here for the 1043-0679/$-see front matter © 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1053/j.semtcvs.2012.11.004
CHANGING CARDIOVASCULAR RISKS FOR A LIFETIME
Figure 1. Changes in the combined score for knowledge, attitudes, and habits in Colombian children aged ⬎18 months.5 (Color version of figure is available online at http://www.semthorcardiovascsurg.com.)
first time as a fundamental behavior-related component, aiming to prevent substance (tobacco, alcohol, and drugs) abuse. These complementary components are again studied in 3 domains: knowledge, attitudes, and habits (KAH). These domains correspond to an evolving concept for each component, from understanding (K) the component, through setting the knowledge into practice (A), to the acquisition of the behavioral pattern (H). Before its countrywide implementation, the effectiveness of Program SI! was first evaluated through a school-based randomized controlled intervention trial involving ⬎2000 children, their parents, and teachers, which demonstrated that intervened children (3-5 years old) had significantly higher KAH scores after 1-year
follow-up (J.L. Peñalvo, unpublished data December 2012). Based on our experience, 6 basic concepts are needed for a successful school-based health promotion program: (1) preschoolers (3-5 years old) as initial target population, and outreach to other end users (parents, teachers, and schools), (2) focus on 4 learning components: human body, diet, physical activity, and emotions, (3) use of new technologies and interactive activities to engage families, (4) school-based program, integrated into the school curriculum, (5) evaluation of effectiveness, including replication in several countries through cluster randomized controlled trials, and (6) cost-effectiveness evaluation to support adoption by the local gov-
Figure 2. Dr. Ruster, a new Sesame Street character, introduces children to health promotion messages and activities. (Color version of figure is available online at http://www.semthorcardiovascsurg.com.) Seminars in Thoracic and Cardiovascular Surgery ● Volume 24, Number 4
239
CHANGING CARDIOVASCULAR RISKS FOR A LIFETIME ernments. The project is based on successful materials and strategies including Sesame Street characters that are being used in the Colombian and Spanish projects, under a continuous evaluation scheme. Information from qualitative research will constitute the basis for improvement of all the strategies being applied, and a thorough evaluation of the findings will allow the improvement of the comprehensive health promotion curriculum developed and validated by medical, child development, and communication experts. Already identified as strength, improved materials and strategies will feature Sesame Street characters, including a new tailor-made Muppet, Dr. Valentin Ruster (Fig. 2), that will center and convey most messages and activities. Other Sesame Street materials include video segments with a “view and do” approach for use in classrooms, printed materials made to fit the distribution strategy in school settings, including a colorful storybook and interactive board game on healthy behaviors, flash cards on
1. Alwan AE: Global status report on noncommunicable diseases 2010, 2010. Available at: http:// www.who.int/nmh/publications/ncd_report_full_ en.pdf 2. Caballero B, Clay T, Davis SM, et al: Pathways: A school-based, randomized controlled trial for the prevention of obesity in American Indian
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emotions and self-regulation, and a teacher’s guide. The development of a smartphone application is planned to improve engagement between parents and their children. The success of a long-term intervention should also be demonstrable. Because it is a long-term process, success is assessed through impact evaluation of the different phases of the intervention by measuring changes in determinants of health, which can comprise a range of intermediate indicators from basic behavioral changes (KAH) to clinical markers of health (body mass index) to early indicators of disease (eg, hypercholesterolemia). The final goal of a health promotion intervention is to reduce mortality, morbidity, and disability of the population. By acting on the behavior of the very young children, we expect to avoid the onset of lifestyle-related cardiovascular disease risk factors, and therefore even small effects of the intervention will have a great impact on the future adults, given the increasing prevalence of the problem.
schoolchildren. Am J Clin Nutr 78:1030-1038, 2003 3. Gorely T, Nevill ME, Morris JG, et al: Effect of a school-based intervention to promote healthy lifestyles in 7-11 year old children. Int J Behav Nutr Phys Act 6:5, 2009 4. Katz DL: School-based interventions for health
promotion and weight control: Not just waiting on the world to change. Annu Rev Public Health 30:253-272, 2009 5. Cespedes JA, Briceno G, Farkouh ME, et al: Targeting preschool children to promote cardiovascular health: Cluster randomized trial. Am J Med 2012 Oct 9 (Epub ahead of print)
Seminars in Thoracic and Cardiovascular Surgery ● Volume 24, Number 4
Sesame Street: Changing Cardiovascular Risks for a Lifetime José L. Peñalvo, PhD,* Jaime Céspedes, MD,† and Valentín Fuster, MD, PhD*,‡ The prevalence of cardiovascular risk factors continues increasing, as its onset is drifting toward younger populations. The development of these factors is greatly influenced by lifestyle habits. It is known that early behaviors persist during childhood and are perpetuated in the adult. Research has proven that lifelong-acquired behavior is unlikely to change, and therefore acquisition of healthy behaviors should begin as early in life as possible. In this report we described the strategy and first stages of a school-based program aiming at promoting (cardiovascular) health through a multilevel intervention supported by Sesame Street materials and educational background. Semin Thoracic Surg 24:238-240 © 2012 Elsevier Inc. All rights reserved. Keywords: behavior change, education, cardiovascular health promotion The prevalence of unhealthy lifestyle habits, including substance abuse (tobacco, alcohol, etc) and inadequate dietary and physical activity patterns, is rising globally. These behavior-related habits contribute greatly to the development of cardiovascular disease and comorbidities such as diabetes and obesity.1 We believe there is a critical need for high-quality health education to introduce children (and their families and school environment) to a healthy lifestyle that can continue into a healthier life during adulthood. Sesame Street has a long tradition on high-impact educational programs, and based on their experience, we are targeting very young children, changing the conceptual approach of disease prevention to health promotion. For the acquisition of lifelong healthy behaviors, change can only be achieved through a comprehensive approach, working on the main factors that are modifiable by a behavior change, and by instilling the concept of a healthy lifestyle in very young children based on a sustainable innovative scheme using the school environment as the gateway. The school is a fundamen-
*Department of Epidemiology, Atherothrombosis and Imaging, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain. †Fundación Cardioinfantil, Instituto de Cardiología, Bogotá, Colombia. ‡Department of Cardiology, Mount Sinai School of Medicine, New York, New York. Address reprint requests to Valentín Fuster, MD, PhD, Department of Cardiology, Mount Sinai School of Medicine, 1 Gustave L. Levy Place, Box 1030, New York, NY 10029-6574. E-mail: [email protected]
238
tal tool for the implementation of this type of intervention. In addition to the many levels of possible interventions, the schools offer an appropriate setting for the evaluation of the effectiveness of the intervention under controlled conditions. The most effective school-based interventions are those that involve the families and target early markers of behavior change such as improvement in the knowledge, attitude, and habits toward a healthy lifestyle as indicators of future cardiovascular health.2-4 In this vein, the Colombian Initiative for Healthy Heart Study was a 6-month intervention for the promotion of cardiovascular health conducted in 14 centers in Bogota (Colombia), including 1216 children (3-5 years of age), their parents, and teachers (Fig. 1). After evaluation through a cluster randomized controlled trial, the investigators found differences in the knowledge, attitude, and habit (KAH) scores between the intervention and control groups,5 which were stable even after 12 more months without intervention (Fig. 1). Building on the Colombian Initiative, the Program SI(!) (Salud Integral ⫽ Comprehensive Health) has been developed in Spain as an evolved intervention also with the collaboration of Sesame Street Workshop. The program targets children aged 3-16 years, aiming to establish healthful lifestyle behaviors in early life. Designed as a thorough, multilevel, school-based intervention study, the project is pursuing a global vision of promoting (cardiovascular) health, including the prevention of obesity. The project intervenes through 4 basic interrelated components: human body, physical activity, diet, and emotions’ management. This fourth component, emotions, was introduced here for the 1043-0679/$-see front matter © 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1053/j.semtcvs.2012.11.004
CHANGING CARDIOVASCULAR RISKS FOR A LIFETIME
Figure 1. Changes in the combined score for knowledge, attitudes, and habits in Colombian children aged ⬎18 months.5 (Color version of figure is available online at http://www.semthorcardiovascsurg.com.)
first time as a fundamental behavior-related component, aiming to prevent substance (tobacco, alcohol, and drugs) abuse. These complementary components are again studied in 3 domains: knowledge, attitudes, and habits (KAH). These domains correspond to an evolving concept for each component, from understanding (K) the component, through setting the knowledge into practice (A), to the acquisition of the behavioral pattern (H). Before its countrywide implementation, the effectiveness of Program SI! was first evaluated through a school-based randomized controlled intervention trial involving ⬎2000 children, their parents, and teachers, which demonstrated that intervened children (3-5 years old) had significantly higher KAH scores after 1-year
follow-up (J.L. Peñalvo, unpublished data December 2012). Based on our experience, 6 basic concepts are needed for a successful school-based health promotion program: (1) preschoolers (3-5 years old) as initial target population, and outreach to other end users (parents, teachers, and schools), (2) focus on 4 learning components: human body, diet, physical activity, and emotions, (3) use of new technologies and interactive activities to engage families, (4) school-based program, integrated into the school curriculum, (5) evaluation of effectiveness, including replication in several countries through cluster randomized controlled trials, and (6) cost-effectiveness evaluation to support adoption by the local gov-
Figure 2. Dr. Ruster, a new Sesame Street character, introduces children to health promotion messages and activities. (Color version of figure is available online at http://www.semthorcardiovascsurg.com.) Seminars in Thoracic and Cardiovascular Surgery ● Volume 24, Number 4
239
CHANGING CARDIOVASCULAR RISKS FOR A LIFETIME ernments. The project is based on successful materials and strategies including Sesame Street characters that are being used in the Colombian and Spanish projects, under a continuous evaluation scheme. Information from qualitative research will constitute the basis for improvement of all the strategies being applied, and a thorough evaluation of the findings will allow the improvement of the comprehensive health promotion curriculum developed and validated by medical, child development, and communication experts. Already identified as strength, improved materials and strategies will feature Sesame Street characters, including a new tailor-made Muppet, Dr. Valentin Ruster (Fig. 2), that will center and convey most messages and activities. Other Sesame Street materials include video segments with a “view and do” approach for use in classrooms, printed materials made to fit the distribution strategy in school settings, including a colorful storybook and interactive board game on healthy behaviors, flash cards on
1. Alwan AE: Global status report on noncommunicable diseases 2010, 2010. Available at: http:// www.who.int/nmh/publications/ncd_report_full_ en.pdf 2. Caballero B, Clay T, Davis SM, et al: Pathways: A school-based, randomized controlled trial for the prevention of obesity in American Indian
240
emotions and self-regulation, and a teacher’s guide. The development of a smartphone application is planned to improve engagement between parents and their children. The success of a long-term intervention should also be demonstrable. Because it is a long-term process, success is assessed through impact evaluation of the different phases of the intervention by measuring changes in determinants of health, which can comprise a range of intermediate indicators from basic behavioral changes (KAH) to clinical markers of health (body mass index) to early indicators of disease (eg, hypercholesterolemia). The final goal of a health promotion intervention is to reduce mortality, morbidity, and disability of the population. By acting on the behavior of the very young children, we expect to avoid the onset of lifestyle-related cardiovascular disease risk factors, and therefore even small effects of the intervention will have a great impact on the future adults, given the increasing prevalence of the problem.
schoolchildren. Am J Clin Nutr 78:1030-1038, 2003 3. Gorely T, Nevill ME, Morris JG, et al: Effect of a school-based intervention to promote healthy lifestyles in 7-11 year old children. Int J Behav Nutr Phys Act 6:5, 2009 4. Katz DL: School-based interventions for health
promotion and weight control: Not just waiting on the world to change. Annu Rev Public Health 30:253-272, 2009 5. Cespedes JA, Briceno G, Farkouh ME, et al: Targeting preschool children to promote cardiovascular health: Cluster randomized trial. Am J Med 2012 Oct 9 (Epub ahead of print)
Seminars in Thoracic and Cardiovascular Surgery ● Volume 24, Number 4