Quality of Research
Review Date: January 2007
Documents Reviewed
The documents below were reviewed for Quality of Research. The research point of
contact can provide information regarding the studies reviewed and the availability
of additional materials, including those from more recent studies that may have been conducted.
Study 1Elliot, D. L., Goldberg, L., Moe, E. L., DeFrancesco, C. A., Durham, M. B., & Hix-Small, H. (2004). Preventing substance use and disordered eating: Initial outcomes of the ATHENA (Athletes Targeting Healthy Exercise and Nutrition Alternatives) program. Archives of Pediatrics and Adolescent Medicine, 158, 1043-1049. 
Elliot, D. L., Moe, E. L., Goldberg, L., DeFrancesco, C. A., Durham, M. B., & Hix-Small, H. (2006). Definition and outcome of a curriculum to prevent disordered eating and body-shaping drug use. Journal of School Health, 76, 67-73.
Elliot, D. L., Moe, E. L., Goldberg, L., DeFrancesco, C. A., Durham, M. B., & Lockwood, C. (2007). Long-term outcomes of the ATHENA (Athletes Targeting Healthy Exercise & Nutrition Alternatives) program for female high school athletes. Manuscript submitted for publication.
Supplementary Materials Elliot, D. L., & Goldberg, L. (2008). Athletes Targeting Healthy Exercise and Nutrition Alternatives: Harm reduction/health promotion program for female high school athletes. In C. W. LeCroy & J. E. Mann (Eds.), Handbook of prevention and intervention programs for adolescent girls (pp. 205-240). New York: John Wiley & Sons.
Goldberg, L., & Elliot, D. L. (2005). Preventing substance use among high school athletes: The ATLAS and ATHENA programs. Journal of Applied School Psychology, 21(2), 63-87.
Wilke, K. M., MacKinnon, D. P., Elliot, D. L., & Moe, E. L. (2006, May/June). Mediating mechanisms of an intervention with high school female athletes. Poster session presented at the annual meeting of the Society for Prevention Research, San Antonio, TX.
Outcomes
| Outcome 1: Diet pill use |
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Description of Measures
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Use of diet pills and other supplements was assessed using a self-report question format similar to the Monitoring the Future survey and the 2001 Youth Risk Behavior Survey.
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Key Findings
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When compared with students who did not receive the intervention, students who participated in ATHENA reported reduced diet pill use during the past 3 months (p < .05). Although initiation of any substance use during the sport season was rare among both groups, intervention athletes were less likely than members of the comparison group to report starting use of diet pills (p < .05).
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Studies Measuring Outcome
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Study 1
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Study Designs
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Experimental
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Quality of Research Rating
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2.9
(0.0-4.0 scale)
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| Outcome 2: Use of body-shaping substances |
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Description of Measures
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Use of body-shaping substances was assessed using a question format similar to the Monitoring the Future survey and the 2001 Youth Risk Behavior Survey.
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Key Findings
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Although initiating drug use during the sport season was infrequent, the ATHENA intervention group had fewer new users of body-shaping substances (i.e., amphetamines, anabolic steroids, muscle-building supplements) than did the comparison group (p < .05).
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Studies Measuring Outcome
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Study 1
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Study Designs
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Experimental
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Quality of Research Rating
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2.9
(0.0-4.0 scale)
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| Outcome 3: Behaviors and beliefs related to nutrition |
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Description of Measures
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Behaviors and beliefs related to nutrition were measured by asking participants to rate (1) their tracking of their protein intake, (2) the extent to which they had been eating more protein in the previous 2 months, (3) their belief that nutrition affects sport performance, and (4) daily calcium intake. These items were scored on a 7-point scale ranging from 1 (strongly disagree) to 7 (strongly agree).
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Key Findings
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When compared with students in schools without the intervention, students participating in ATHENA indicated more tracking of their protein intake (p < .005), increased total daily protein consumption (p < .001), and greater belief that what they ate affected their athletic performance (p < .05). At follow-up 1 year after the intervention (1-3 years following high school graduation), graduates from ATHENA schools had greater calcium intake than did graduates from comparison schools (p < .001).
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Studies Measuring Outcome
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Study 1
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Study Designs
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Experimental
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Quality of Research Rating
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2.5
(0.0-4.0 scale)
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| Outcome 4: Risk and protective factors |
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Description of Measures
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Potential influences on drug use and disordered eating (e.g., peers, coaches, media, society) were assessed. In addition, individuals' knowledge and characteristics concerning disordered eating, depression, self-image, and self-esteem were indexed. For self-esteem, body image, and perceptions about peers and teammates, 3 to 7 items were grouped into constructs, and the mean was used as the score.
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Key Findings
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Compared with students in schools without the intervention, students who participated in ATHENA (1) were more likely to believe that their mood was affected by what they did (p < .01) and that they had increased skill in controlling their mood (p < .005); (2) typically indicated increased ability to turn down an offer to engage in drug use and disordered eating behaviors (p = .05); (3) were less likely to believe in the truth of advertisements (p < .005) and disagreed more often with a statement that men find thin women most attractive (p < .05); (4) agreed less often that their closest friends used body-shaping drugs (p < .001) and agreed more often that their closest friends would be against their drug use (p < .001); and (5) reported a significant decrease in perceived pressure from other females to lower their body weight (p < .05).
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Studies Measuring Outcome
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Study 1
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Study Designs
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Experimental
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Quality of Research Rating
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2.6
(0.0-4.0 scale)
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| Outcome 5: Alcohol and other drug use |
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Description of Measures
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The study assessed 3-month, 1-year, and lifetime alcohol and illicit drug use. Alcohol and drug use measures were recoded into dichotomous variables (e.g., < 5 days of marijuana use in the past 3 months, < 10 days of marijuana use in the past year, < 10 days of marijuana use in lifetime).
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Key Findings
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At follow-up 1 year after the intervention (1-3 years following high school graduation), compared with students in schools without the intervention, graduates who participated in ATHENA reported significant reductions in lifetime (p < .05), 1-year (p < .05), and 3-month (p < .001) marijuana use; and significantly less lifetime (p < .05), 1-year (p < .005), and 3-month (p < .001) alcohol use.
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Studies Measuring Outcome
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Study 1
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Study Designs
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Experimental
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Quality of Research Rating
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2.5
(0.0-4.0 scale)
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| Outcome 6: Tobacco use |
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Description of Measures
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The study assessed 3-month, 1-year, and lifetime tobacco use. Tobacco use measures were recoded into dichotomous variables (e.g., < 20 days of cigarette use in the past 3 months, < 20 days of cigarette use in the past year, < 20 days of cigarette use in lifetime).
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Key Findings
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At follow-up 1 year after the intervention (1-3 years following high school graduation), compared with students in schools without the intervention, graduates who participated in ATHENA reported significantly less lifetime cigarette use (p < .05).
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Studies Measuring Outcome
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Study 1
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Study Designs
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Experimental
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Quality of Research Rating
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2.5
(0.0-4.0 scale)
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| Outcome 7: Knowledge of curriculum content |
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Description of Measures
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Knowledge of specific topics was measured. For each topic, 3 to 7 survey items were grouped into constructs, and the mean was used as the score.
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Key Findings
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Following their sport season, compared with students in schools without the intervention, students who participated in ATHENA increased their understanding and retention of the curriculum's knowledge domains, including the detrimental effects of using anabolic steroids (p < .001) and alcohol (p < .001). They also had better knowledge of their calcium needs (p < .01) and the basics of sport nutrition (p < .001).
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Studies Measuring Outcome
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Study 1
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Study Designs
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Experimental
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Quality of Research Rating
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2.6
(0.0-4.0 scale)
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Study Populations
The following populations were identified in the studies reviewed for Quality of
Research.
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Study
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Age
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Gender
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Race/Ethnicity
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Study 1
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13-17 (Adolescent)
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100% Female
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92.5% White
7.5% Race/ethnicity unspecified
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Quality of Research Ratings by Criteria (0.0-4.0 scale)
External reviewers independently evaluate the Quality of Research for an intervention's
reported results using six criteria:
For more information about these criteria and the meaning of the ratings, see Quality of Research.
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Outcome
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Reliability
of Measures
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Validity
of Measures
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Fidelity
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Missing
Data/Attrition
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Confounding
Variables
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Data
Analysis
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Overall
Rating
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1: Diet pill use
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3.5
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3.5
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3.5
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1.5
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2.5
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3.0
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2.9
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2: Use of body-shaping substances
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3.5
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3.5
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3.5
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1.5
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2.5
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3.0
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2.9
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3: Behaviors and beliefs related to nutrition
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2.5
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2.5
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3.5
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1.5
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2.3
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2.5
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2.5
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4: Risk and protective factors
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2.5
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2.5
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3.5
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1.5
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2.5
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3.0
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2.6
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5: Alcohol and other drug use
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3.5
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2.5
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3.5
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1.5
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1.5
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2.5
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2.5
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6: Tobacco use
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3.5
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2.5
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3.5
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1.5
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1.5
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2.5
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2.5
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7: Knowledge of curriculum content
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2.5
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2.5
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3.5
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1.5
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2.5
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3.0
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2.6
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Study Strengths The Monitoring the Future survey question format used by ATHENA researchers has been shown to have acceptable levels of reliability and validity. In the cross-sectional study, factor analysis was used to determine 3- to 7-item scales to reflect various constructs; these had good internal consistency. Most individual items had face validity, and the fact that several measures were impacted similarly by the intervention lends support for their validity. Because this intervention targets girls involved in sports and cheerleading, whereby increased muscle strength benefits performance, measuring changes in the girls' protein intake and tracking of protein intake is logical. Intervention fidelity was ensured through the use of training manuals with standardized scripts, lesson plans, workbooks, leader training, and checklists. In addition, all 20 teams completed the 8 sessions; based on observations and ratings from a research assistant, 80% of the content was delivered. Attrition at the postseason measurement point (26%-30%) was reasonably low and equal across the two groups. The strategy of matching schools and type of team was a strength of the design, and no preexisting differences between the groups emerged at baseline. The researchers used analysis of covariance generalized estimating equations (GEE), a state-of-the-art analytic approach that can factor in team- and school-level clustering.
Study Weaknesses Evaluation of the intervention's effect on eating behaviors relied on self-reported agreement with relatively global statements rather than on measures with greater validity. Data measuring alcohol and other drug use were dichotomized based on frequency cutoffs that appeared arbitrary; it is not clear whether they were set a priori. The dose of intervention received by the follow-up students varied from one to three seasons of participation; individual attendance and homework completion were not recorded. Attrition at follow-up (1-3 years following high school graduation) was 45%-49% and was similar across the two groups, but no analyses were done to test for potential attrition bias (i.e., to determine whether retained participants were similar to those lost to attrition). In addition, as the authors pointed out, alcohol and other drug use in this age group can be influenced by any number of factors that were not assessed in the study. Covariates were said to be used "when appropriate," but it was unclear in some analyses whether they were used for any particular variable; in the case of drug use measures, baseline rates of alcohol and other drug use were not covaried. Clustering by schools and teams was no longer taken into account in the follow-up analyses, even though these effects may have been significant.
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Readiness for Dissemination
Review Date: January 2007
Materials Reviewed
The materials below were reviewed for Readiness for Dissemination. The implementation
point of contact can provide information regarding implementation of the intervention
and the availability of additional, updated, or new materials.
ATHENA Coach CD [CD-ROM]
ATHENA informational DVD
ATHENA Program Dissemination Materials for NREPP Review [Binder]
ATHENA T-shirt
ATHENA Web site, http://www.athenaprogram.com
Elliot, D., Goldberg, L., & Center for Health Promotion Research. (n.d.). The ATHENA program coach manual. Portland, OR: Authors.
Elliot, D., Goldberg, L., & Center for Health Promotion Research. (n.d.). The ATHENA program squad leader manual. Portland, OR: Authors.
Elliot, D., Goldberg, L., & Center for Health Promotion Research. (n.d.). The ATHENA program team workbook. Portland, OR: Authors.
Goldberg, L., Elliot, D., & Center for Health Promotion Research. (n.d.). The ATHENA program athlete's guide. Portland, OR: Authors.
Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)
External reviewers independently evaluate the intervention's Readiness for Dissemination
using three criteria:
- Availability of implementation materials
- Availability of training and support resources
- Availability of quality assurance procedures
For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.
Implementation
Materials
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Training and Support
Resources
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Quality Assurance
Procedures
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Overall
Rating
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3.5
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3.5
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3.3
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3.4
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Dissemination Strengths Program manuals and the team workbook are easy to follow and appropriate for their intended audience. The athlete's guide is comprehensive but still small enough to tuck into a gym bag. The T-shirt is a nice detail emphasizing the team approach. Customized training is available both on-site and over the phone for coaches, coaches and students, or school liaisons. Developers use periodic newsletters, routine phone calls, and e-mails to maintain contact with and provide ongoing support for implementation sites. Quality assurance is supported by participant surveys that are administered pre- and postintervention and are anonymous. Developers also offer additional fidelity and assessment tools for schools that request them.
Dissemination Weaknesses Little information or support is available for adaptation of this program for other populations (e.g., deaf athletes, more diverse cultural groups). No guidance is provided for conducting a local evaluation of outcomes. In addition, the researchers do not make it clear if or how participating schools can be a part of the broader evaluation of program effectiveness discussed on the program Web site.
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