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Citation:

Cullen KW, Watson K, Baranowski T, Baranowski JH, Zakeri I. Squire's Quest: Intervention changes occurred at lunch and snack meals. Appetite. 2005; 45: 148-151.


PubMed ID: 15927302
Study Design:
Randomized Controlled Trial
Class:
A - Click here for explanation of classification scheme.
POSITIVE: See Research Design and Implementation Criteria Checklist below.
Research Purpose:

This research reports on new analyses to identify specific meal-environment changes that occurred from participation in Squire's Quest!, an innovative curriculum-only psychoeducational multimedia game. The intervention included specific goals for the students to eat fruits and vegetables (or 100% juice) at specific meals and snacks.

Inclusion Criteria:
  • All 4th grade students in 26 Houston-area elementary schools were invited to participate
  • All children completed an informed assent form
  • All parents completed an informed consent form for their child and themselves
  • This study was approved by the Baylor College of Medicine Institutional Review Board.

 

Exclusion Criteria:
  • Students in grades other than 4th
  • Students attending non-participating elementary schools
  • Students whose parents did not provide informed consent (number not reported).
Description of Study Protocol:

Recruitment

The Houston Independent School District (the third largest school district in the United States) agreed to participate. A comprehensive recruitment program was implemented, starting with contact with administrators and presentations to principals, and followed by presentations to teachers at schools with principals agreeing for their schools to participate. Decisions to participate were often made by the principal in consultation with the teachers.

Design

Randomized Control Trial.

Dietary Intake/Dietary Assessment Methodology

Fruit, 100% juice, vegetable (FJV) servings consumed by meal was assessed by the Food Intake Recording Software System (FIRSSt). FIRSSt was administered for four days at baseline and at post-assessment. FIRSSt is an interactive multimedia dietary assessment program which simulates a multiple pass 24-hour dietary recall self-completed by the child.

Intervention

  • Squire’s Quest! was designed as a 10-session, interactive multimedia game, with each session taking about 25 minutes to complete.
  • The story line for the game was as follows:
    • The kingdom of 5A Lot was being invaded by the Slimes (snakes) and the Mogs (moles), who were attempting to destroy the kingdom by destroying the fruit and vegetable crops. King Cornwell and Queen Nutritia were leading their knights (e.g., Sir Sarah See-a-Solution and Sir Alex Try-to-be-Right) to defeat the invaders. In the first session, the fourth-grade child committed to becoming a squire in the pursuit of becoming a knight to help the king and queen. The squire had to face challenges in his/her quest. The challenges involved skills and goals related to eating more fruit, 100% fruit juice, and vegetables. The squire prepared FJV recipes (in a virtual kitchen) to provide energy for the king and court to fight the invaders. A wizard mentored the child through the challenges, and the castle robot (Mad Maxie) facilitated many of the educational sessions. The invaders kidnapped the good chef (Chef Karat) and replaced him with Chef Mog, a bumbling fool, who always usurped the squire’s accomplishments to make himself look good to the king.
  • Before the end of each session, the child set goals to make the recipe (prepared in the virtual kitchen) during that session, eat another FJV serving at a meal or as a snack, or to ask for his/her favorite FJV to be more available at home. The children participated in a decision-making activity between their favorite fruit, juice or vegetable and a more common snack. The FJV was selected based on the child’s food preferences reported at baseline. The decision criteria were the three most important outcome expectancies reported by the child at baseline.
  • Sessions two to 10 began with an assessment of whether the goal from the previous session was completed, for which dragon-scale points were assigned. A problem-solving routine was employed to help the child assess how he/she might change practices to increase the likelihood of goal attainment.
  • All children attained knighthood (10 possible levels) at the end of the 10 sessions, with the level determined by the number of dragon-scale points earned. Points were earned primarily by attainment of goals, with smaller amounts of points earned from the educational games. Examples of these games included identifying what counted as fruit, what counted as vegetables, and whether a demonstration of asking would likely result in making FJV more available.
  • Focus group discussions with fourth-grade children were employed in the design of Squire’s Quest! to assess interest in the story line and to identify child-desired characteristics of characters. Squire’s Quest! focused on fourth-grade children alone, based on advice from developers of children’s games. The primary creative writer attended two national conferences of developers of interactive multimedia games to benefit from their insights.

Statistical Analysis

  • Mixed model analysis of covariance was used to test for differences between treatment and control groups (fixed effect) in FJV consumption at each meal or snack at post, controlling for corresponding pre-values and for the school clustering effect
  • To test for possible moderating effects by age, gender or ethnicity, the demographic term and a groupX demographic interaction term were added to the above in separate models
  • Data were analyzed using the Statistical Package for Social Sciences (SPSS version 10.1 for Windows, 2000, SPSS, Inc., Chicago)
  • Power calculations revealed that 26 elementary schools were necessary to detect a 0.5 standard-deviation (SD) change in servings of FJV with 80% power and 5% type-one error assuming a school-associated intra-class correlation of 0.02.
Data Collection Summary:

Timing of Measurements

  • Baseline (four days pre-intervention)
  • Daily (four days post-intervention).

Dependent Variables

  • Fruit servings
  • 100% juice servings
  • Vegetable servings.

Calculated based on serving size listed in Food Guide Pyramid

Independent Variables

Squire's Quest! a 10-session interactive multi-media formatted games based on Social Cognitive Theory.


 

Description of Actual Data Sample:
  • Initial N: 1,578 children were invited to participate (736 males and 803 females; no explanation as to why these do not add up to 1,578)
  • Attrition (final N): 1,489 completed pre-/post-assessments (689 males and 763 females)
  • Age: 4th grade students (eight to 12 years old)
  • Ethnicity:
    • African-American (261)
    • Euro-American (643)
    • Hispanic (452)
    • Other (102)
  • Other relevant demographics: Not applicable
  • Anthropometrics: Not reported
  • Location: Houston, TX (Houston Independent School System).

 

Summary of Results:
  • The difference in means between treatment and control groups at post was significantly higher for fruit and 100% fruit juice at snacks (both a school and home meal-environment), but not for other FJV groups or other meals
  • The difference in means between treatment and control groups at post was significantly higher for regular, non-fried vegetables at lunch (a school meal-environment), but not for other FJV groups or other meals
  • Analyses including mother's education, age, gender, and ethnicity were performed and results indicated these demographic characteristics did not significantly (NS) moderate consumption.

Table. Means, Standard Errors, and Differences in Food Group Intakes Between Treatment and Control Groups by Meal at Post from Squire's Quest! Using Mixed Models ANCOVA with Pre-Consumption as Covariate

Variable

Treatment

Control

Difference

 

M

SE

M

SE

M

SE

Breakfast

 Fruit

0.22

0.03

0.17

0.03

0.04

0.04

 Regular vegetables

0.03

0.01

0.02

0.01

0.01

0.01

 Juice

0.26

0.02

0.24

0.02

0.02

0.03

 High fat vegetables

0.05

0.01

0.03

0.01

0.02

0.01

Snacks

 Fruit***

0.62

0.03

0.36

0.03

0.26

0.05

 Regular vegetables

0.08

0.01

0.08

0.01

0.00

0.02

 Juice*

0.22

0.02

0.15

0.02

0.06

0.03

 High fat vegetables

0.05

0.01

0.03

0.01

0.02

0.01

Lunch

 Fruit

0.45

0.04

0.37

0.04

0.08

0.05

 Regular vegetables**

0.44

0.03

0.28

0.03

0.16

0.05

 Juice

0.12

0.02

0.12

0.02

0.00

0.03

 High fat vegetables

0.08

0.01

0.11

0.01

0.03

0.02

Dinner

 Fruit

0.25

0.04

0.18

0.04

0.07

0.06

 Regular vegetables

0.62

0.05

0.53

0.05

0.09

0.07

 Juice

0.16

0.02

0.13

0.02

0.03

0.03

 High fat vegetables

0.15

0.02

0.13

0.02

0.02

0.02

Full-size table

*P<0.05, **P<0.01, ***P<0.001.

 

Author Conclusion:
  • Squire's Quest! demonstrates that multimedia games with meal and environment targeted goal setting and intervention messages can induce meal and food specific dietary behavior change among elementary school children in those environments
  • Further research to identify strategies to increase change in other meals is warranted.
Reviewer Comments:

Some content of this worksheet from: Baranowski T, Baranowski J, Cullen KW, et al. Squire's: Quest! Dietary outcome evaluation of a multimedia game. Am J Prev Med. 2003 Jan; 24 (1): 52-61.


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?
Yes
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?
No
  4.4. Were reasons for withdrawals similar across groups?
???
  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?
Yes
  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)?
No
  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?
Yes
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