PI ： Lee-Lan Yen ( 李 蘭 ) Szu-Hsien T. Lee ( 李思賢 ) Likwang Chen ( 陳麗光 )

1. CABLEChild and Adolescent Behaviors in Long-term Evolution:A School-Based Healthy Lifestyle Study PI：Lee-Lan Yen (李 蘭) Szu-Hsien T. Lee (李思賢) Likwang Chen (陳麗光) Chuhsing K. Hsiao (蕭朱杏) Ling-Yen Pan (潘怜燕) CABLE Research Team

2. Outline • Background & Study Design • Previous Work Accomplished • Proposal of Year 2004 • Significance of CABLE Project • Future Directions

3. Background & Study Design

4. Background • Childhood is an important developmental stage. • Early and successful interventions can improve children’s health behaviors and health status. • A lifestyle based study following the development of children and their health related behaviors has never previously been conducted in Taiwan.

5. Specific Aims of CABLE Project • To understand the status and types of health lifestyle among the selected metropolitan and rural students in Taiwan. • To investigate their developments and changes of health lifestyle over time. • To explore the factors on determinants of student’s healthy/unhealthy lifestyle. • To analyze the relationship between health lifestyle and health status among the selected students. • To conduct interventions to promote students’ health.

6. Cross-sectional Longitudinal Individual Family/Group Community/Society Changeability Study Design (1)

7. Study Design (2) Observational Follow-up -- Yearly Survey Interventions 2005 2006 2001 2010

8. StudyDesign (3) Observational Follow-up A1-A6: The 1st cohort of 2001-2005 in Taipei City B1-B6: The 1st cohort of 2001-2005 in Hsinchu County C1-C6: The 2nd cohort of 2001-2005 in Taipei City D1-D6: The 2nd cohort of 2001-2005 in Hsinchu County

9. Sampling Design Students and their parents are also our study participants

10. Intrapersonal Factors HealthLifestyle Health Status Interpersonal Factors Organizational Factors Study Framework~ Cross-sectional survey ~

11. Time i Time i Time i Time i Time i Time 1 Time 1 Time 1 Time 1 Time 1 Independent Variables 1.Children & Parental Factors (demographics, health history, personal characteristics, etc.) 2.Family Factors (family structure, SES, etc.) 3.School & Community Factors (size, resources, etc.) 4.Other Factors (survey time, study area, etc.) Intermediate Variables Dependent Variables Intrapersonal Factors Health Lifestyle Interpersonal Factors Health Status Organizational Factors Study Framework ~ Longitudinal Follow-up ~

12. Intrapersonal Factors HealthLifestyle Health Status Interpersonal Factors Organizational Factors Data Collection School Records Questionnaires Health Records School & Community Profiles

13. Instruments • Questionnaires for children • Questionnaires for parents • Children’s school records • Children’s health records • School resources profile

14. Contact schools Informed consents student name lists Field Survey -- Children -- Parents Interviewer training Procedures of Field Survey

15. Study Subjects in 2001

16. Study Subjects in 2002

17. Children Followed in 2002

18. Data Management • Coding, key in, and checking data • Creating different data files • Statistical analysis for specific purposes

19. Previous Work Accomplished • Data collection & management • Paper writing & publishing • Results dissemination • Professional training

20. Data collection & management • CABLE 2001 & 2002 surveys were conducted • Students’ academic & health records were collected • School profiles were collected • Various data files were created & analyzed • The third wave survey will be conducted at the end of 2003

21. Paper Writing & Publishing • Conference papers • International Conference on Adolescent Health; Annual Meeting of Taiwan Public Health Association; 130th APHA Annual Meeting, etc. • Journal articles • Published in IUHPE-Promotion and Education • Target journals: Journal of School Health, Preventive Medicine, Taiwan Journal of Public Health, Medical Education, etc. • General articles

22. Results Dissemination • Annual reports • CABLE 2001 has been published • CABLE 2002 is under preparation • CABLE conference • Held in August, 2002 • Target audiences: • Principles and teachers from study schools • Officers from health and education departments • Researchers and graduate students from academic institutes

23. Professional Training

24. Proposal of CABLE 2004

25. SPECIFIC AIMS ~ quantitative study~ • To keep abreast of the trends of children’s health behaviors and health status. • To explore factors associated with the trends of children’s health behaviors and health status. • To improve existing statistical models or develop new statistical models for trend analysis and multilevel analysis.

26. SPECIFIC AIMS ~ qualitative study ~ • To explore the formation and determinants of children’s concepts, values, and behaviors related to cigarette smoking. • To investigate the children’s cognition, perception, attribution, and resolution of parents’ marital conflicts, and their impact on child adjustment. • To explore how parents’ expectations toward achievements affect children’s psychological well-being and suicidal ideation.

27. METHODS - 1 A follow-up survey using same instruments (with some modification) will be implemented among four student cohorts with their parents. • Fourth graders: Following previous protocol to collect data. • Seventh graders: Mail or field survey will be used to collect data.

28. Mail survey • The students’ permanent addresses will be collect and verify in June, 2004, before they graduate from the elementary schools. • A set of questionnaires and a stamped addressed return envelope will be mailed to the subjects in October, 2004. • After two weeks, a reminding postcard will be sent to those who have not returned the questionnaires. • Following another two weeks, the whole set of questionnaires will be sent out again to the non-respondents.

29. METHODS - 2 A series of focus group discussions will be conducted to collect qualitative data among the fourth graders and their parents.

30. Topics will be discussed in focus groups • A. The formation and determinants of cigarette smoking among the students • B. Marital conflict, attribution and conflict resolution among the students • C. The relationship between Parental expectation and children’s performance and happiness.

31. Participants of Focus Groups~ students ~ Each school from Taipei City and Hsin-Chu County, separate from CABLE schools, will be purposively selected to avoid contaminating the natural observation of existing CABLE cohorts. • Three classes of fourth graders will be randomly selected. • In each class, students will be randomly assigned into three groups. • Each group will be randomly assigned to a research topic.

32. Participants of Focus Groups~ Parents and Teachers ~ • Parents: • Invitation letters will be sent out. • The volunteers will be randomly assigned to 6 groups. (3 groups for topic a and 3 groups for topic c) • Teachers: • 10 teachers in each schools, who are in charge of teaching fourth graders, will be invited to attend the focus group interviews for topic a.

33. Significance Of CABLE Project

34. Significance (1) • To establish a model for long-term study in the field of health behavioral sciences. • To help the development of theories related to health behaviors. • To systematically describe the patterns of behavioral developments and changes in childhood and adolescence. • To identify the factors influencing children’s and adolescents’ lifestyles.

35. Significance (2) • To Build up longitudinal datasets and open to public use. • To provide our government the research results as references for making health policies for children and adolescents. • To strengthen the research abilities and experiences of research teams. • To establish a cooperative relationship between the universities and the NHRI.

36. Future Directions

37. Future Directions • To continue following the development and changes of children’s health and behaviors. • To intensively investigate the impact of behavioral, psychological and social factors on health using qualitative methodology. • To conduct a series of interventional experiments in order to develop school health promotion models. • To empower the faculty and staff of study schools.

38. CABLE Research Team Division of Health Policy Research, National Health Research Institutes Institute of Health Policy and Management, College of Public Health, National Taiwan University Department of Humanities and Social Sciences, National Defense Medical Center, National Defense University ~Thank You~

39. Thank You!

40. (1) Distribution of Health Behaviors in 2001 Lee-Lan Yen, Likwang Chen, Szu-Hsien Lee, Chuhsing Hsiao, Ling-Yen Pan

41. Behaviors Positive to Health • 65-90% of both first and fourth graders. • walking, seatbelt, helmet, washing hands, brushing teeth, breakfast, fruit and vegetables and drinking water. • Exercise (apart from school physical education classes) was relatively lower, at about 55 to 65%.

42. Behaviors Negative to Health • Unhealthy behaviors reported by more than 50% of subjects • First graders: staying up late, eating fast food, watching TV, and eating late at night. • Fourth graders: staying up late, eating food late at night, watching TV, eating fast food, using vulgar language, getting into fights, and suppressing urination.

43. Conclusion • The proportion of students with positive behaviors was less than ideal. • The proportion of children displaying negative behaviors was by no means low. • Despite variations in health behaviors according to sex, area and grade, the results demonstrate that all students need to establish healthier lifestyles.

44. (2) Family Interaction and Children’s Mental Health Ling-Yen Pan, Lee-Lan Yen, Wen-Chi Wu, Yi-Chen Chiang

45. Objectives • To understand family interaction patterns in fourth graders’ families. • To examine the relationshipbetween family interaction and the mental health status of these children (including depression, social loneliness, and social anxiety).

46. Methods • 1959 fourth graders from 18 primary schools participating in the 2001 survey. • 1008 male；951 female • 1037 from Taipei City；922 from HsinChu County

47. Conclusion • In regards to family support, functional support is more common. • Majority of parents still use traditional methods such as scolding to punish their child. • Family activities and family support were negatively related to negative mental health status. • The causal relationship between family interaction and children’s mental health needs to be clarified.

48. (3) The Relationship between Parents’ and Children’s Health Behaviors Likwang Chen, Lee-Lan Yen, Ya-Ling Chiu, Chen-Lin Yeh, Wei-Chih Yang

49. Objectives • The links between parents and children in some behaviors that play a significant role in obesity, injury, and oral and visual health. • Differences between paternal and maternal modeling effects. • Differences in parental modeling effects between the first and fourth grades.

50. Methods • Types of health behaviors investigated • Dietary habits(4) • Physical activity(1) • Behaviors related to injuries(2) • Behaviors related to oral health(2) • Behaviors related to visual health(1) • Statistical model:the logit model