1. CABLE Child and Adolescent Behaviors in Long-term Evolution: A School-Based Healthy Lifestyle Study PI Lee-Lan Yen ( ) Szu-Hsien T. Lee ( ) Likwang Chen ( ) Chuhsing K. Hsiao ( ) Ling-Yen Pan ( ) 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. Study Design (1) Cross-sectional Longitudinal Individual Family/Group Community/Society Changeability

7. Study Design (2) 2001 2010 Observational Follow-up -- Yearly Survey Interventions 20052006

8. Study Design (3) 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 Observational Follow-up

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

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

11. 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.) Dependent Variables Health Lifestyle Health Status Intermediate Variables Interpersonal Factors Intrapersonal Factors Organizational Factors Time 1 Time i Time 1 Time i Time 1 Time i Time 1 Time i Time 1 Time i Study Framework ~ Longitudinal Follow-up ~

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

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

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

15. Study Subjects in 2001 First gradeFourth grade TaipeiHsinChuSub-total TaipeiHsinChuSub-total Population (n)33652707240764 35242686442106 Sample selected (n)195016343584184217703612 Sample participated (n)13149412255110810102118 Participation rate (%)66.5%56.4%61.9%59.1%55.7%57.4% Sample completed (n) Children1297921221810899862075 Children s fathers99173617278678371704 Children s mothers1167796196310078811888 Completion rate (%) Children98.7%97.9%98.4%98.3%97.6%98.0% Children s fathers76.4%79.9%77.9%79.6%84.9%82.1% Children s mothers90.0%86.4%88.5% 92.5%89.4%91.0%

16. Study Subjects in 2002 Second gradeFifth grade TaipeiHsinChuSub-total TaipeiHsinChuSub-total Sample selected (n)194716333580186416513515 Sample participated (n)158211892771139611452541 Participation rate (%)81.3%72.8%77.4%74.9%69.4%72.3% Sample completed (n) Children155611742730136411352510 Children s fathers1300993229311029742076 Children s mothers144210502492123410222255 Completion rate (%) Children98.4%98.7%98.5%97.7%99.1%98.8% Children s fathers82.2%83.5%82.7%78.9%85.1%81.7% Children s mothers91.2%88.3%89.9% 88.4%89.3%88.7%

17. Children Followed in 2002 First grade in 2001Fourth grade in 2001 TaipeiHsinChuSub-total TaipeiHsinChuSub-total n 1215870208510038731876 % 93.794.594.0 92.188.590.4

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; 130 th 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 MasterDoctor 2001 2002 2003

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. 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 Wen-Chi Wu, Yi-Chen Chiang

45. Objectives To understand family interaction patterns in fourth graders families. To examine the relationship between 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 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

51. Conclusion (1) The existence of parental modeling effects on some child health behaviors, such as eating breakfast, drinking water, eating late at night, protective practice for traffic injuries, oral hygiene practice, dental care utilization and some pattern of watching television. No evidence for supporting the existence of parental modeling effects on fruit and vegetable consumption, physical activity, and violent behavior.

52. Conclusion (2) No substantial statistical evidence for supporting the point that maternal modeling effects are stronger than paternal modeling effects. No substantial statistical evidence for supporting the point that parental modeling effects are stronger in the fourth grade than in the first grade.

53. (4) The Association of Child Behavioral Problems and Maternal Psychiatric Disturbance Szu-Hsien Lee, Lee-Lan Yen, Li-Ting Chen

54. Objective Intended to examine the relationship between psychopathology in mothers, inter-parental conflict and children s internalizing and externalizing behavioral problems

55. Methods 2,218 first graders and 2,075 fourth graders Dependent variables Externalizing behavioral problems Conduct behavior and Substance use Internalizing behavioral problems Depression, Social anxiety, and Social loneliness Independent variables Demographics Inter-parental conflict Maternal psychiatric status

56. Conclusion Higher inter-parental conflict was associated with more internalizing and externalizing problems for both grades. Fourth-grade girls were more likely to have internalizing problems than boys, but boys were more likely than girls to have externalizing problems. Maternal psychiatric disturbance was not significantly predictive for internalizing and externalizing problem behaviors. The findings suggest that psychopathology in mothers may have no influence on behavioral development of a regular child.

57. (5) The Differences in Children s Health Behaviors between 2001 and 2002

58. The rates of performing positive behaviors among children in Taipei city, 2001 & 2002 a: high performance in 2001high performance in 2002 b: high performance in 2001low performance in 2002 c: low performance in 2001high performance in 2002 d: low performance in 2001low performance in 2002

59. The rates of performing positive behaviors among children in Hsinchu country, 2001 & 2002 a: high performance in 2001high performance in 2002 b: high performance in 2001low performance in 2002 c: low performance in 2001high performance in 2002 d: low performance in 2001low performance in 2002

60. The rates of performing negative behaviors among children in Taipei city, 2001 & 2002 a: high performance in 2001high performance in 2002 b: high performance in 2001low performance in 2002 c: low performance in 2001high performance in 2002 d: low performance in 2001low performance in 2002

61. The rates of performing negative behaviors among children in Hsinchu country, 2001 & 2002 a: high performance in 2001high performance in 2002 b: high performance in 2001low performance in 2002 c: low performance in 2001high performance in 2002 d: low performance in 2001low performance in 2002

62. Incidence rates of children (the 1st graders in 2001) who performed positive behaviors in 2002

63. Incidence rates of children (the 1st graders in 2001) who performed negative behaviors in 2002

64. Research Topics Going On~ Lee-Lan Yen: A comparison of health behavioral performance between 2001 and 2002. Likwang Chen: Parents and children s health behaviors – Exploration of parental influences over elementary school children s developmental stages. Tony Szu-Hsien Lee: Locus of control, social anxiety and social loneliness in forth grade children. Ling-Yen Pan: Family interaction and children s deviant behaviors. Wen-Chi Wu: Comparison of characteristics between follow-up and new participants in a longitudinal study – Are they different?

65. Master Theses Ju-Yu Chen The Relationship between Childrens Unhealthy Behaviors and Parents Unhealthy Behaviors. Yi-Chen Chiang Factors related to suicide ideation among elementary school students. Chi-Chen Wu The Association of Family Conflict, Interpersonal Coping, and Psychosocial Distress among Children. Fang-Mei Lin The Relationship between Children's Eating Behaviors and Parental Eating Paterns. Ching-Ju Chiu A Typology of the 4th Graders Health Behaviors. Li-Ting Chen The Relationship between Parental Conflict, Parenting Behaviors, and Children Internalizing Behaviors.

66. (M1) The Relationship of Unhealthy Behaviors in Grade Four Children and their Parents Master: Ju-Yu Chen Advisor: Lee-Lan Yen

67. Major Findings The most prevalent health-risk behaviors of children are staying up late, eating in the late night, and eating fast food. The prevalence rates are 82.8%, 69.2% and 64.6%, respectively. Health-risk behaviors can be categorized into four factors: unhealthy lifestyle, antisocial behaviors, substance use, and intake of high calorie food.

68. (M2) Factors Related to Suicide Ideation among Elementary School Students Master: Yi-Chen Chiang Advisor: Shiao-Chi Wu Lee-Lan Yen Lee-Lan Yen

69. Major Findings The prevalence rates of having suicide ideation in the past andhaving had suicide ideation over the past month among fourth graders were 19.77% and 8.39%, respectively. Findings from the structure equation model showed that the factors which increase the likelihood of having suicide ideation in the past through the function of depression or social loneliness were girls, using substance, often punished by parents, having older mother, and having less family support. Factors that were indirectly related to the emergence of suicide ideation over the past month through the function of depression or social loneliness were residence in Taipei City, using substance, violence-oriented, and having less family support.

70. (M3) The Association of Family Conflict, Interpersonal Coping and Psychosocial Distress among Children Master: Chi-Chen Wu Advisor: Tony Szu-Hsien Lee Lee-Lan Yen Lee-Lan Yen

71. Major Findings Family conflict, gender, parental support, discipline, number of friends, and peer relationship were significant predictors of social anxiety and social loneliness. With respect to social loneliness, there were direct and indirect influences of family conflict and coping. Only direct effects of family conflict were found in terms of children s social anxiety.

72. The Relationship between Children's Eating Behaviors and Parental Eating Patterns (M4) The Relationship between Children's Eating Behaviors and Parental Eating Patterns Master: Fang-Mei Lin Advisor: Lee-Lan Yen

73. Major Findings The most frequent matching type of eating behaviors in eating breakfast and eating fruit and vegetables is father high vs. mother high. The most frequent matching type in eating in late night and eating fast food is father low vs. mother low. The relationship between school children s eating behaviors and matching types of their parental eating behaviors is significant in eating breakfast, eating in late night, and eating fast food.

74. (M5) A Typology of the 4th Graders Health Behaviors Master: Ching-Ju Chiu Advisor: Lee-Lan Yen

75. Major Findings The children s health behaviors can be categorized into five factors, which were named positive health behavior, deviant health behavior, substance use behavior, violent inclination behavior, and health indulgent behavior. Based on the factor scores, the subjects were clustered into four groups, and they were named as healthy type (48%), indulgent type (32.9%), violent type (17.8%), and deviant type (1.3%).

76. (M6) The Relationship between Parental Conflict, Parenting Behaviors and Children Internalizing Behaviors Master: Li-Ting Chen Advisor: Ruey-Ling Chu Tony Szu-Hsien Lee Tony Szu-Hsien Lee

77. Major Findings In general parental conflict group: Parental conflict has indirect effect on child internalizing behaviors through severe punishment. Parental conflict has no influence on supportive parenting behavior, but supportive parenting behaviors and severe punishment have protective effect on parental conflict and child internalizing behaviors. In severe parental conflict group: Parental conflict affect child internalizing behaviors directly and strongly. Parental conflict affect supportive parenting behaviors, but supportive parenting behaviors have no protecting effect on parental conflict and severe punishment.