Promoting Physical Activity and a

Healthful Diet among Children:

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.
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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