Results of a School-Based Intervention Study A B S T R A C T Bruee G. Simons-Morton, EdD, MPH, Guy S. Parcel, PhD, Tom Baranowski, PhD, Ronald Forthofer, PhD, Nancy M. O'Hara, PhD Background: National heaith objectfves call for improved diet and more regular physical activity amoi^ children. We tested the effects of a school-based program to improve students' diet and physical activity behavior at school. Methods: Two of the four ele- mentary schools in one Te?as school district were afffiigned to intervention Mid two to control conditions. The three intervention components were classraom health education, vigorous physical education, and tower fat, lower sodium school lunches- Nutri- ents from school lunches and the total day and the amount of physical activ- i ^ students obtained during physicaJ education were assessed as outcome. Results: Analysis of school lunches showed declines from base line to posttest in the two intervention schools of 15.5% and 10.4% for total fat, 31.7% and 18.8% fw saturated fat, and 40.2% and 53.6% for sodium; posttest values were lower in the in- tervention schools. Observation of ph>ical activity during physical edu- cation clas.ses indicated an increase in the intervention schools from baseline to posttest in the percent of time chil- dren engaged in moderate-to-vigorous physical activity from less than 10% of class time at baseline to about 40% of class time at posttest; posttest values were higher in the intervention schools than in the control schtwls. Conclusions: TTiis efficacy study demonstrates the feasibility of sub- stantially modifying schooJ lunches and school phj^iai! education to im- prove children's diet and physical ac- tivity behavior at school. (A'" J Pub- lic Health. 199i;81;986-991) Introduction Childhtxxi diet and physical activity may lead to increased risk for cardiovas- cular disease {CVD) in adulthood.' Pro- moting a healthful diet and regular vigor- ous physical activity among children is a national public health objective.^ School is an ideal setting in which to promote healthful diet and physical activity be- cause these topics usually are part of the health education curriculum, and feder- ally supported food services and state- mandated physical education {PE) are widespread.^ School food services pro- vide nutritious meals for 73.4^( of all US public school students,"^'^^ but the high fat and sodium content is a concern.^ An es- timated 97% of first- through fourth-grade children in US public schools are enrolled in school PE programs for an average of 100 minutes per week.^ However, the fre- quency and duration of PE classes and the amount of moderate to vigorous physical activity {MVPA) children obtain during PE may be less than recommended."'' This study was designed to influence the school environment in terms of affect on student diet and physical activity at sch(X5l. The Go For Health {GFH) pro- gram included a be haviorally-based health education curriculum, fitness-oriented PE, and lower fat and sodium school lunches. We report the effects of the pro- gram on children's dietary intake and physical activity during school. Methods Design and Study Population The Texas City Independent School District (TCISD) was selected for the study because it is conveniently close to the university, it has an ethnic mix of stu- dents, and it has curriculum, school lunch, and PE components. The district partici- pated in the US Department of Agricul- ture school lunch program, and each school had its own on-premises kitchen, cafeteria, and focxl preparation staff. Third and fourth graders had PE daily, taught by PB specialists. Facilities at each school include a modem gymnasium and large outdoor playground area. The population of students was 62.3% Anglo-American, 20.9% Mexican-American, and 14.8% Afro-American. The ethnic distributions were comparable for both treatment and control conditions. Two of the four elementary schools {kindergarten through fourth grade) were assigned to intervention and two to con- trol additions. Third and fourth graders were assessed annually during three spring data collection periods. Intervention The three GFH intervention compo- nents, based on social cognitive theory,'" were the Go For Health Curriculum, Chil- dren' s Active Physical Education {CAPE), and the New School Lunch {NSL)." Following the model of Charter Bruce G. Simons-Morton, Guy S. Parcel, Ron- ald Forthofer, and Nancy M. O'Hara are with the School of Public Health of the University of Texas Health Science Center, Houston, TX. Tom Baranowski is with the Georgia Preven- tion Institute, Medical College of Georgia, Au- gusta, Ga. Requests for reprints should be sent to Bruce G. Simons-Morton, EdD, MPH, Center for Health Promotion Research and Develop- ment, School of Public Health, University of Texas Health Science Center, PO Box 20f86, Houston, TX 77225. This paper was submitted to the journal September \X 1990, and accepted with revi- sions April 23, 1991. 986 American Joumal of Public Health Augustl991, Vol. 81,No. 8 CtiUdren's Diet and Physicai Activity TABLE 1 Average Nutrients per Luncii (N = 12 Meais per School} at Baseline, Mkttest, and Posttest, with 95% Confidence Intervais: Go for l^ealth Recipe Analysis Treatment condition Baseline" Mean Lower 95% Ci Upper 95% Ci Midtest Mean Lower 95% CI Upper 95% CI Posttest Mean Lower 95% CI Upper 95% CI Baseline^ Mean Lower 95% CI Upper 95% Ci Midtest Mean Lower 95% CI Upper 95% CI Posttest Mean Lower 95% CI Upper 95% CI Baseline Mean Lower 95% Ct Upper 95% Ct Midtest Mean Lower 95% CI Upper 95% CI Posttest Mean Lower 95% CI Upper 95% CI Baseline Mean Lower 95% CI Upper 95% CI Micftest Mean Lower 95% CI Upper 95% CI Posttest Mean Lower 95% CI Upper 95% CI Energy (kcal) 1049.2 1014.3 1084.1 997.5 949.3 1045.8 B98.2 870.4 926.0 1049,2 1014.3 1084.1 1038.3 996.4 1080.3 943.5 918.6 968.4 1077,5 1037,8 1117.1 890.4 856.3 924.5 849.3 816.8 881,8 1021.0 856.6 985.4 887.3 856.6 918.0 840.9 800,7 881,1 Protein (g) 38.3 37.4 39.2 36.2 35.2 37.3 35.3 34,4 36,2 38.3 37.4 39.2 37.1 35.7 38.4 37.1 36.1 38.0 37.3 36.3 38.3 37.7 36.4 38.9 35.0 34.4 35.7 39.3 37.9 40.6 33.8 32.7 34.8 35.7 35.0 36,4 CartMjhydrate (g) Controi school 1 115.1 112.7 117.3 107.7 104.5 111.0 100.4 98.2 102.4 Controi school Z 115,1 112.7 117.1 114.9 112,4 117.8 103.6 102,2 105,3 Intervention school 3 117,8 114,9 120.6 105.3 102.5 108.1 100.8 97.8 104.0 intervention school 4 112.2 110.4 114.4 108.2 106.1 110,3 96,9 93.0 100.6 ^Baseiine tor cwitrof schools imputed from the average of the intervention sdiods. Fat (g) 48,4 46.0 50,9 46.9 43,4 50.3 39.5 37.8 41.3 48.4 46.0 50,9 47,8 44,9 50,6 42.3 40.6 43.9 50.8 48.1 53.5 35.4 33.4 37.4 34,0 32.0 35.9 46.1 43.6 48.5 35.5 33.5 37.5 34.5 32.1 37.0 Cholesterol (mg) 123.8 116.5 131.1 113.2 104.5 121.6 94,6 90,4 98.7 123.8 116.5 131.1 112.2 104.2 120.2 111.7 103.4 119.9 137,7 129,8 145,6 98.1 91.6 104.7 79.0 76.8 81.1 110,0 101.8 118.1 83,5 78,2 88,7 79.3 77,1 81,4 Vitamin A (lU) 2722.7 2291,0 3154.4 2985,3 2301,4 3669.2 2071.5 1738.3 2404.7 2722.7 2291.0 3154.4 2418.6 2019.6 2817,7 2106,0 1756,4 2455.5 2809.4 2365.6 3253.1 3559.6 3020.8 4098.4 3393.0 2916.7 3869.3 2636,0 2210,9 3061,0 3430,8 2903,0 3958,6 3907,6 3305.2 4509,9 Calcium (mg) 535.5 516.4 554.6 537.2 510.5 564.0 480,3 461,4 499.3 535,5 516,4 554,6 539.9 507.9 572.0 511.7 488.7 534.7 544.0 522.3 565.6 514.5 496,2 532,7 474.7 462,1 487.2 527-0 508.3 545.7 501.5 481.3 521.7 469.5 452,4 486.6 and Joncs,'^ we employed a four-step ap- proach to program implementation and in- stitutionalizatioti.'^ To foster quality im- plementation, the GFH staff provided ample training, consultation, and techni- cal support to both teachers and food ser- vice staff. The purposes of the classroom health education, which consisted of six, bchav- iorally based modules, were to teach knowledge and skills essential to lifelong performance of the target diet and physi- cal activity behaviors and foster the trans- fer of learning about these behaviors from school to out-of-school environments.'" The NSLwas designed to provide low- er-fat, lower-sodium lunches within the am- text of the existing school lunch program. Food purchasing, menus, recipes,, and food preparation practices were modified. CAPE, which consisted of five, 6- to 8-week units, was designed to encourage enjoyable MVPA among children during PE classes. Each unit included two or three main cardiovascular fitness activi- ties, such as dancing, running, aerobic games, jump rope, and obstacle courses. Each class session consisted of warmup, fitness development, cool down, and skill development or game activities. August 1991, Vol. 81, No. 8 American Journal of Public Health 987 Simons-Mortun et al. School 3 Schoiil INTERVENTION FIGURE 1Means and 95% Confi- dence Intervals for Total Fat and Saturated Fat as a Percent of Calories in Schooi Lunches {N = 12 meals per school ) in Control and Intervention School s at Basei i ne (Pre), after 1 Year (Mid), and after 2 Years (Post). Measures and Procedures Program effects were assessed by an- alyzing the nutrient contents of lunches, conducting 24-hour dietary recalls, and observing students' physical activity dur- ing FE. Nutrient Analysis of School Lunches. The identical menu was repeated in March and April each year of the study. At base- line, 12 meals were selected randomly from the March and April menus and analyzed for nutrient content. Recipe analyses, based on detailed interviews with each cook in the intervention schools at baseline and in all four schools at midtest and posttest, were ctinducted by trained staff nutritionists and analyzed by the Nutrition Coding Center Diet Recall. The 24-hour dietary re- call interview was administered at posttest to random, cross-sectional subsamples of children, stratified by study school. Inter- viewers were trained according to NCC procedures and followed the NCC proto- col for diet interviews. Each child was in- terviewed at home in the company of one parent, who was asked about ingredients, food preparation, and other items as needed. Physical Activity. The time {in min- utes) of MVPA performed by children during physical education was assessed by trained observers using the Children's Physical Activity Observation Form {CPAOF). '^ Study schools were observed on randomly selected days over a 2-monf h period each spring; all third- and fourth- grade classes were observed. Observers recorded on a minutc-by-minute basis the type {e.g., basketball, jump rope) and in- tensity of physical activity. The CPAOF intensity categories have been validated against heart rate,'^ and the average heart rate for MVPA was 172.2 (SD = 21.2) beats per minute. Interobserver agree- ment was 97.0% {n = 57 paired observa- tions). Analysis For energy and selected nutrients of potential concem in this age group, we calculated the means and 95% confidence intervals {CIs) of the repeated samples of schcxjl lunches in each school. For each separate treatment condition, we calcu- lated the mean nutrient intakes from the 24-hour dietary interviews for selected nu- trients and examined the contribution of school and bag lunches to total daily nu- trient intakes. For each school at each reporting pe- riod, we calculated the MVPA means, standard deviations, medians, and 95% CIs for the medians."' The median is the most appropriate statistic for purposes of comparing treatment effects because in- creases in the amount of MVPA on the part of only a few students could affect the mean value, obscuring true program ef- fects. Percent of class time is preferable to minutes as an outcome because the sched- uled length of PE classes varied somewhat from year to year, and the effective class time available for PE teachers and stu- dents, although similar in each school for a given year, varied somewhat from school to school due to local scheduling. The annual surveys are presented sepa- rately for each grade because most of one year' s third graders became the next year's fourth graders; hence the data for each grade are not independent across years. Results Diet Recipe Analysis. Table 1 includes the means and the 95% CIs for total en- ergy {in kilocalories[l kcal =4. 2kJ] ) and six nutrients in the 12 meals served in each study school each year. Baseline values for the control schools, which were not collected directly, were esti- mated by averaging the values of the two intervention schools. Declines from baseline to posttest in each school for protein, carbohydrates, total fat, choles- terol, and calcium are the product of de- clines in energy. The decline in calories served in the intervention schools ap- pears to have been due mainly to a re- duction in the amount of fat and carbo- hydrates. Despite the declines in energy, vitamin A and calcium did not decline, and posttest values for all schools ex- ceeded the USDA school lunch require- ments for each nutrient. For example, at every reporting the average intake of en- ergy in each school exceeded 33% of the total daily requirement for energy, which is 6(K) to 7(X) kcal per mcal.'^ Shown in Figure I for each school is the average total fat and saturated fat as a percent of kcal served in the sample of 12 lunches. For both intervention schools the upper CIs of the posttest means were less than the pretest means, and in schcx)l 3 the upper and lower CI values did not overlap. The mean percent fat declined in school 3 by 15.5%, from 41.3% to 35.6% of calo- ries, and in school 4 by 10.3%, from 39.7% to 35.6% of calorics. Average percent sat- urated fat declined in school 3 by 31.7%, from 16.1% to 11.0% of calorics, and in school 4 by 18.8%, from 13.8%' to 11.0% of calories. The means for percent total faf and saturated fat at posttest in the control school were within the imputed pretest 95% CIs. Figure 2 shows that the sodium con- tent in the school f(X)d declined from base- line to posttest in schooi 3 by 53.6% from 2141.1 mg to 993.0 mg, and in schtwl 4 by 40.2%, from 1730.0 mg to 1034.5 mg. These differences remained after control- ling for kcals served. Sodium in the con- trol schixils did not decline from the im- puted baseline value. Dietary Recall. Table 2 shows the analysis of the posttest 24-hour recalls for the nutrients of interest. Students in the intervention group, compared with stu- dents in the control group, reported fewer calories {2094 vs 2135 [1 calorie = 4.2 J]) and less total fat (77 g vs 90 g), saturated fat {29 g vs 34 g), and sodium (2873 mg vs 3378 mg) for the total day. In comparison with control group students, intervention group students reported consuming less total fat, saturated fat, and sodium in both tray and bag lunches. 988 American Joumal of Public Health August 1991, Vol. 81, No. 8 ChUdren*s Diet and Physical Activity Physical Activity Table 3 shows medians, means, and standard deviations for minutes of MVPA for observed students in grades three and four at each study school at baseline, midtest, and posttest. At baseline, mean MVPA for third and fourth graders was less than 3 minutes at each school; medi- ans were 2.0 minutes or lower. At post- test, mean minutes had increased in school 3 to 11.7 (third grade) and 15.0 (fourth grade) and in school 4 to 16.2 (third grade) and 16.1 (fourth grade) per class. Median minutes as a percent of class time and 95% CIs around the medians are shown for third and fourth grade in Figure 3. For both grades, the median percent of class time in MVPA at baseline was zero in three schools and less than 10% in school 3. At posttest, the control school medians were still no greater than 5% of class time. In the intervention schools, however, the posttest medians were sub- stantially higher, 28% of class time for third graders in school 3, and 39% of class time or greater for the other Intervention groups. Except for fourth grade in school 3, the upper and lower 95% CI values do not overlap with the baseiine means. Discussion The results show strong positive pro- gram etfects on children's diet and phys- ical activity at school. At posttest, school lunches in the intervention schools pro- vided less energy, fat, and sodium com- pared with baseline and with the control schools, white adequate levels of other es- sential nutrients were maintained. Simi- larly, children's physical activity in the in- tervention schools was much higher at posttest than at baseline and in compari- son with the control schools. Several studies have demonstrated that sodium reductions can be accom- plished by intervention directed at school meals.'"'^^ However, no studies have re- ported systematic reductions in fat and so- dium in school lunches. In the GFH inter- vention schools, sodium content was reduced to target levels, saturated fat re- ductions of 31.7% and 18.8% occurred, and posttest values approached the target goal of 10% of kcals served. Total fat re- ductions were modest, 15.5% and 10.3%, and the target goal of 30% of kcals was not reached, indicating that it is easier, even in institutional settings, to substitute fat type than to reduce the amount of fat. The 24-hour dietaiy recall data indi- cate that the changes in nutrients served in 2600 2400 2200 2000 1800 1600 1400 1200 1000 800 600 0 Sodium (mg) pre mid post pre mid post School 1 School 2 CONTROL pre mid post pre mid post School 3 School 4 INTERVENTION FIGURE 2Means and 95% Confidence Intervals for Sodium in School Lunches (N = 12 Meals per School) in Control and Intervention Schools at Baseline (Pre), after 1 Year (Mid), and after 2 Years (Post). T^ UE 2~-Means and %% Confldice Intervals of Selected Nutrients from Bag or Tray Lunch Based on 24-4Hour Diet Recalls in the Intervention and Controi Schools Variables Energy (kcal) Total fat (g) Saturated fat (g) Sodium (mg) Control Total day (n = 68) Mean Lower 95% CI Upper 95% 01 Tray lunch (n = 49) Mean Lower 95% C! Upper 95% CI Total day avwage (%) SE Bag!undi(n = 19) Mean Lower 95% CI Upper 95% CI Total day average (%) SE Total day (n = 67) Mean Lower ^ % CI Upper 95% CI Tray lundi (n = 48) Mean Lower 95% CI Upper 95% 01 Ttrtal day average (%) SE Bag lunch (n = 19) Mean Lower 95% Ct Upper 95% CI Tcrtai day average (%) SE 2135.3 1978.3 2292.3 806.9 730.7 883.0 37.8 1.8 681.4 568.8 794.1 35.7 2.e 2094.5 1922.6 2266.5 790.2 676.9 903.4 36.5 1.9 657.7 516.8 798.6 36.1 2.7 90.0 80.8 99.1 34.8 30.8 38.8 40.1 2.4 27.3 21,5 33,0 34.4 2,7 Intnventlon 78.6 70,0 87.2 29.7 25.6 33.8 38.0 2.2 25.1 18.8 31.3 37.2 2.8 33.9 30.3 37.6 13.8 11.9 15.8 40.7 2.4 9.0 6.9 11,0 32.5 3.4 28.5 25.0 32.0 10.0 8,3 11.6 35.4 2.3 7.8 5.6 10.0 32.6 3,2 3377,6 3044.1 3711.0 1283.4 1137.2 1429.6 39.7 2.3 966.0 794,8 1137.3 33.4 2.7 2872.6 2554,2 3190,7 909.1 756.6 1052.7 32,5 2.0 789.5 645.5 933.5 31.3 2.4 Augustl991, Vol. 81,No. 8 American Joumal of Public Health 989 Simons-Morton ct al. TABL 3Average Tinie (in Minutes) of MVPA Obsved during Physical Education Tre^ment Condition Bas^ine Midpant Posttest School 2 B^eline Midpoint Posttest Schoot3 Bas^ne Midpoint Posttest School 4 Bas^ine Midpoint Posttest N 32 27 37 34 24 36 31 34 38 32 38 58 Third Grade Median 0.0 1.0 2.0 0.0 1,0 2.0 2.0 1.5 10.5 0.0 4.5 16.0 Mean 0.4 2.8 2.9 0.5 2.0 3.5 2.0 2.6 11.7 2.8 4.9 16.2 SD Control 0.9 5.0 3.5 1.1 2.2 3.9 Intervention 1.4 2.6 7.5 5.0 4.3 7.8 N 41 36 35 26 10 51 45 24 26 36 24 49 in Control and intervention Schoois Fourtii Grade Median 0.0 0.5 1.0 0.0 0.0 1.0 2.0 2.5 20.0 0.0 7.0 16.0 Mean 0.3 1.1 1.5 0.4 2.2 4.5 2.4 6.8 15.0 1.9 8.0 16.1 SD 0.7 1.5 1.9 0.9 3.4 5.9 1.9 7.4 10.6 3.6 4.4 7.4 THIRD GRADE Median % Class Time in MVPA during PE 11 1 I t FOURTH GRADE \ I 1 1, School 1 Scliool 2 CONTROL RGURE 3Medians and 95% Confi- dence intervais for Per- centage of Physical Ed- ucation Class Time in Moderate to Vigorous Physicai Activity (MVPA) in Control and Interven- tion Schools at Baseline (Pre), after 1 Year (Mid), and after 2 Years (Post); Third and Fourth Grade. school lunch contributed to improve- ments in total daily dietary intake of cal- ories, total fat, saturated fat, and sodium. Children did not make up in other meals for reductions of fat and sodium in school lunches. Energy, calcium, and vitamin A remained adequate at posttest in all schools, suggesting that reductions in fat can be accomplished without undue re- ductions in other essential nutrients. Several studies have demonstrated that it is possible to modify PE to improve cardiorespiratory fitness.^"^^ Our results indicate that it is possible to increase time devoted to MVPA from less than 10% to more than 40% of available class time. At posttest, the typical student in the inter- vention schools obtained about 16 min- utes of MVPA per daily PE period, or 80 minutes of MVPA per week. It must be noted that these modest results were ob- tained after 2 years of intervention that involved one staff person virtually full time in the provision of intensive training of PE teachers. Because PE accounts for nearly half of children's total daily physi- cai activity,^ the extremely low level of MVPA observed in all schools at baseline is a cause for concem, particularly if fu- ture research determines that low levels of activity during PE are prevalent in Amer- ican schools. This is the first US study to demon- strate the potential of altering the school environment to promote a more healthful diet and more vigorous physical activity among children, although at least one suc- cessful European study has been report- ed.'^" Strengths of the present stucty in- clude planned implementation of theory- based individual and organizational interventions, two intervention and two control schools within the same district, and objective measures of diet and phys- ical activity. Limitations of the study in- clude the lack of baseline recipe data for the control schools, nonrandom assign- ment of schiK)ls to treatment conditions, and the small number of study schools. The results of this efficacy study sug- gest that school is a potentially important site for improving children's diet and physical activity and that such changes are possible. In our experience, however, schools do not change readily, and sub- stantial staff training should accompany policy changes regarding healthful school lunch and vigorous physical education. Before widespread implementation of these changes txxurs, effectiveness stud- ies with larger numbers of schtwis are needed to determine the ability to gener- alize these approaches and to assess cost effectiveness. D Acknowledgments This research was funded by NHLBI Grant 33376. We gralefuily acknowledge the admin- istrators, teachers, and staff of the Texas City Independent Schtx)! District for their support and ctxjperation. Aiso, we thank Renee Fleish- man for data preparation and Ids Huang for statistical analyses. This research was presented at the annual meeting of the Amedcan Public Heaith Asso- ciation held in New York City September 30 to October 4, 1990. References 1. Hetzei BS, Berenson GS. Cardiovascular Risk Factors in Childhood: Epidemiology and Pre\'ention. New York: Elsevier Sci- ence Pubiishers; 1987. 2. Public Health Service. Promoting Health/ Preventing Disease: Year 2000 Objective.s for the Nation. Washington, DC: US Dept of Health and Human Services; 1991. DHHS Pubiieation II (PHS) 91-50213. 3. Pigg RM Jr. The contdbution of school 990 American Joumal of Public Health August 1991, Voi. 81, No. 8 Children's Diet and Physical Activity health programs to the broader goals of public health: the American experience. 7 Sch Heatth. 1989;59:25-30. 4. Radzikowski J, Gale SK. Requirements for the national evaluation of school nutrition pr ogr ams. Am J Clin Nutr. 1984; 40{suppl):365-367. 5. Hanes S, Vermeersch J, Gale S. 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Holtz H. Atherosclerosis precursors in school childrenresults of a two-year interven- tion stucty. Cor Vasa 1987;29:421-427. National Primary Care Nurse Practitioner Symposium Issuing Call for Abstracts The 17th National Primary Care Nurse Practitioner Sym- posium is accepting abstracts of research, innovative clinical practice/models and roles, and other professional papers re- lating to primaiy eare nursing. Abstracts are being accepted for presentation (plenary) or poster sessions. This symposium, sponsored by the University of Colorado Health Sciences Center School of Nursitig, will be held July/early August, 1992, in a Colorado mountain resort. Please send three ^ e d copies (300 words or fewer), lim- ited to one page, single spaced, with l-i/4 inch margins. Ab- stracts must be photocopy-ready and include title. A separate page with author contact information may be used. Format includes title, brief statement of purpose, methods, conclu- sions, and clinical application(s) or, if not a re.search abstract, brief summary of project/paper. Include author vita and indi- cate interest in presentation (plenary) and/or poster session. Preference will be given to abstracts with strong clinical applicability, innovative role development models and papers with future-oriented perspective. Presentera are provided tuition waiver for registration the day of their presentation, but are responsible for their own travel and expenses. Deadline is October 14. 1991. Contact Ellen Lemberg, RN,C, MS, Nurse Practitioner Symposium Offits, School of Nursing, University of Colorado Health Sciences Center, 4200 East 9th Avenue, Box C287, Denver, Colorado 80262. Tel: 303/270-7436. August 1991, Voi. 81, No. 8 American Joumai of Public Health 991