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Citation:

Baranowski T, Baranowski J, Cullen KW, Marsh T, Islam N, Zakeri I, Honess-Morreale L, deMoor C. Squire’s Quest! Dietary outcome evaluation of a multimedia game. Am J Prev Med. 2003;24(1):52-61.


PubMed ID: 12554024
Study Design:
Group Randomized Controlled Trial
Class:
A - Click here for explanation of classification scheme.
POSITIVE: See Research Design and Implementation Criteria Checklist below.
Research Purpose:

The objective of this project was to demonstrate dietary change immediately after implementation of the Squire's Quest! multi-media nutrition education program.

Inclusion Criteria:

Elementary schools in the Houston Independent School District were solicited.   In participating schools, children and their parents who agreed, completed an informed assent form.

Exclusion Criteria:

None specifically mentioned.

Description of Study Protocol:

Recruitment Elementary school was the unit of recruitment with principals and teachers making the decisions of whether to participate.   All fourth grade students in participating elementary schools were invited to participate. 

Design Group randomized controlled trial.  A two group design (treatment and control) with pre- and post-assessment was employed.

Blinding used (if applicable)  not applicable

Intervention (if applicable) Squire's Quest! was a ten-session interactive multimedia game, each session taking about 25 minutes, including nutrition education, virtual recipes, etc., with the goal of increasing fruit, fruit juice, and vegetable (FJV) consumption.

Statistical Analysis Differences between pre- and post-assessments and between treatment and control groups were tested by chi-square statistics.  Differences between these groups in mean servings of FJV were tested by independent t test.  ANOVA was used to calculate intraclass correlations for the clustering effect of school and for reliability of recalls across 4 days. 

 

Data Collection Summary:

Timing of Measurements Diet recall was done for 4 days at baseline over a two week period, the intervention was conducted over 5 weeks, and post-assessment took about 2 weeks per school, so the cycle was completed in one school semester.  These data were collected in 1999 and 2000. 

Dependent Variable 

  • Fruit, fruit juice and vegetable servings consumed.  Intake was measured with a computer-assisted recall system (FIRSSt) for four days at baseline and 4 days after the education. 

Independent Variables

  • Squire's Quest! multi-media nutrition education

Control Variables

 

Description of Actual Data Sample:

Initial N: 26 schools participated; 73.2% of students in treatment schools provided informed consent, while 67.6% of students provided informed consent in the control schools. A total of 1578 students were recruited. 

Attrition (final N): 1539 students, 736 boys and 803 girls.  5.3% of students did not complete both pre- and post-tests.

Age: 8-12 years

Ethnicity: African American (268), Euro-American (690), Hispanic (476) and other (105).

Other relevant demographics:

Anthropometrics

Schools were pair-matched on size and percentage of free or reduced-price lunch.

Location:  Houston TX

 

Summary of Results:

Key Findings

  • At baseline, the means of quartiles for total FJV ranged from 0.61 to 8.36 servings. 
  • The treatment group post-assessment quartile means for total FJV servings ranged from 2.48 to 6.59, while the control post-assessment quartile means ranged from 1.76 to 5.24 servings. 
  • The difference in means between treatment and control groups at post-assessment, after controlling for pre-assessment values, was 0.91 servings of FJV or 1.0 servings of total FHV+HFV (high fat vegetables) per day. Contributions were made from each food group, but the statistically significant differences were for F (0.52 servings) and regular vegetables (0.24 servings).
  • There was no evidence of moderation of effect by age, gender, or ethnicity.
  • Girls ate more fruit and vegetables, but not juice.
Author Conclusion:

The Squire's Quest! game resulted in a 1.0 serving difference of FJV between treatment and control groups at the end of the 5-week, ten-session program, after controlling for baseline FJV consumption. 

Reviewer Comments:

Authors note the following strengths:

  • Large sample of schools and students
  • Mixed ethnic and SES composition of the sample
  • Using the school as the unit of assignment and analysis
  • Random assignment of school to condition
  • Minimal differences in consumption by groups at baseline
  • Ability of the computer to deliver the intervention as designed
  • Similar results for all approaches to outcome analysis

How long this increased FJV intake would be maintained was not studied.  While the increase of 1 serving of consumption was substantial, it was not enough to achieve the goal of 5 servings per day. 


Research Design and Implementation Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies)
Yes
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about?
Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to nutrition or dietetics practice?
Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies)
Yes
 
Validity Questions
1. Was the research question clearly stated?
Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified?
Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated?
Yes
  1.3. Were the target population and setting specified?
Yes
2. Was the selection of study subjects/patients free from bias?
Yes
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study?
Yes
  2.2. Were criteria applied equally to all study groups?
Yes
  2.3. Were health, demographics, and other characteristics of subjects described?
Yes
  2.4. Were the subjects/patients a representative sample of the relevant population?
???
3. Were study groups comparable?
Yes
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT)
Yes
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline?
Yes
  3.3. Were concurrent controls used? (Concurrent preferred over historical controls.)
Yes
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis?
N/A
  3.5. If case control or cross-sectional study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable. Criterion may not be applicable in some cross-sectional studies.)
N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")?
N/A
4. Was method of handling withdrawals described?
Yes
  4.1. Were follow-up methods described and the same for all groups?
Yes
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.)
Yes
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for?
Yes
  4.4. Were reasons for withdrawals similar across groups?
N/A
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study?
N/A
5. Was blinding used to prevent introduction of bias?
Yes
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate?
N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.)
Yes
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded?
N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status?
N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results?
N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described?
Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied?
Yes
  6.2. In observational study, were interventions, study settings, and clinicians/provider described?
N/A
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect?
Yes
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured?
Yes
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described?
N/A
  6.6. Were extra or unplanned treatments described?
N/A
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups?
Yes
  6.8. In diagnostic study, were details of test administration and replication sufficient?
N/A
7. Were outcomes clearly defined and the measurements valid and reliable?
Yes
  7.1. Were primary and secondary endpoints described and relevant to the question?
Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern?
Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur?
Yes
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures?
Yes
  7.5. Was the measurement of effect at an appropriate level of precision?
Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes?
Yes
  7.7. Were the measurements conducted consistently across groups?
Yes
8. Was the statistical analysis appropriate for the study design and type of outcome indicators?
Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately?
Yes
  8.2. Were correct statistical tests used and assumptions of test not violated?
Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals?
Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)?
N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)?
Yes
  8.6. Was clinical significance as well as statistical significance reported?
Yes
  8.7. If negative findings, was a power calculation reported to address type 2 error?
N/A
9. Are conclusions supported by results with biases and limitations taken into consideration?
Yes
  9.1. Is there a discussion of findings?
Yes
  9.2. Are biases and study limitations identified and discussed?
Yes
10. Is bias due to study’s funding or sponsorship unlikely?
Yes
  10.1. Were sources of funding and investigators’ affiliations described?
Yes
  10.2. Was the study free from apparent conflict of interest?
Yes
 
 

Copyright American Dietetic Association (ADA).