Medicine and Health Sciences Commons^™

Impact Of Community-Driven Interventions On Dietary And Physical Activity Outcomes Among A Cohort Of Adults In A Rural Appalachian County In Eastern Kentucky, 2019–2022, Heather Norman-Burgdolf, Emily M. Dewitt, Rachel Gillespie, Kathryn Cardarelli, Stacey Slone, Alison Gustafson

Dietetics and Human Nutrition Faculty Publications

Several environmental level factors exacerbate poor health outcomes in rural populations in the United States, such as lack of access to healthy food and locations to be physically active, which support healthy choices at the individual level. Thus, utilizing innovative place-based approaches in rural locations is essential to improve health outcomes. Leveraging community assets, like Cooperative Extension, is a novel strategy for implementing community-driven interventions. This prospective cohort study (n = 152), recruited in 2019 and surveyed again in 2020 and 2021, examined individual level changes in diet and physical activity in one rural Appalachian county. During this time, multiple …

Exploring Extension Agent Capacity And Readiness To Adopt Policy, Systems And Environmental Change Approaches, Lisa T. Washburn, Heather Norman-Burgdolf, Natalie Jones, Lauren E. Kennedy, Soghra Jarvandi

Dietetics and Human Nutrition Faculty Publications

Introduction: Enhanced Extension outreach strategies combine traditional direct education programs with public health approaches like policy, systems, and environmental (PSE) change. However, the Cooperative Extension system and county-based Family and Consumer Sciences (FCS) Extension agents have historically prioritized direct education programming and diffusion of enhanced outreach strategies has varied. Extension personnel may lack capacity and readiness for successful PSE change implementation. This study explored perceived acceptability, capacity, and readiness for PSE change work among FCS Extension agents in two states.

Method: A survey was developed framed by selected domains from the Consolidated Framework for Implementation Research: Intervention Characteristics, Inner Setting, …

Examining The Perspectives And Experiences Of Nutrition Educators Working With Clients In Substance Use Recovery Settings, Cora Teets, Paula Plonski, Omolola Adedokun, Heather Norman-Burgdolf

Dietetics and Human Nutrition Faculty Publications

Substance use disorder (SUD) is one of the most detrimental health, social, and economic problems in the United States. Limited studies suggest providing tailored nutrition education during SUD treatment correlates with positive recovery outcomes. The University of Kentucky Nutrition Education Program conducted two focus group sessions to explore and determine educators’ instructional and programmatic needs who deliver nutrition education to clients in substance use recovery throughout Kentucky. The study team identified four emerging themes and several subthemes related to Nutrition Education Program educators working with clientele in recovery. The four emerging themes included: (1) current experiences working with the audience, …

Unifying Multi-State Efforts Through A Nationally Coordinated Extension Diabetes Program, Laura Balis, Shari Gallup, Heather Norman-Burgdolf, Julie Buck, Pam Daniels, Dan Remley, Lisa Graves, Margaret Jenkins, Gayle Price

Dietetics and Human Nutrition Faculty Publications

The Cooperative Extension System translates research to practice and “brings the University to the people” throughout the U.S. However, the system suffers from program duplication and is challenged to scale-out effective programs. One program, Dining with Diabetes (DWD), stands out for its dissemination to multiple states. DWD is a community-based program aimed at improving diabetes management, nutrition, and physical activity behaviors. DWD was coordinated through a national working group and implemented by state Extension systems. A pragmatic, quasi-experimental study was conducted to determine the effectiveness of the national coordination model and the overall impact of DWD. Four states reported data …

Online Pilot Grocery Intervention Among Rural And Urban Residents Aimed To Improve Purchasing Habits, Alison A. Gustafson, Rachel Gillespie, Emily M. Dewitt, Brittany Cox, Brynnan Dunaway, Lindsey Haynes-Maslow, Elizabeth Anderson Steeves, Angela C. B. Trude

Dietetics and Human Nutrition Faculty Publications

Online grocery shopping has the potential to improve access to food, particularly among low-income households located in urban food deserts and rural communities. The primary aim of this pilot intervention was to test whether a three-armed online grocery trial improved fruit and vegetable (F&V) purchases. Rural and urban adults across seven counties in Kentucky, Maryland, and North Carolina were recruited to participate in an 8-week intervention in fall 2021. A total of 184 adults were enrolled into the following groups: (1) brick-and-mortar “BM” (control participants only received reminders to submit weekly grocery shopping receipts); (2) online-only with no support “O” …

Efficacy Of An Enhanced Implementation Strategy To Increase Parent Engagement With A Health Promotion Program In Childcare, Courtney T. Luecking, Cody D. Neshteruk, Stephanie Mazzucca, Dianne S. Ward

Dietetics and Human Nutrition Faculty Publications

Previous efforts to involve parents in implementation of childcare-based health promotion interventions have yielded limited success, suggesting a need for different implementation strategies. This study evaluated the efficacy of an enhanced implementation strategy to increase parent engagement with Healthy Me, Healthy We. This quasi-experimental study included childcare centers from the second of two waves of a cluster-randomized trial. The standard approach (giving parents intervention materials, prompting participation at home, inviting participation with classroom events) was delivered in 2016–2017 (29 centers, 116 providers, and 199 parents). The enhanced approach (standard plus seeking feedback, identifying and addressing barriers to parent participation) …

Policy Implications Of The Covid-19 Pandemic On Food Security In Rural America: Evidence From Appalachia, Kathryn M. Cardarelli, Emily M. Dewitt, Rachel Gillespie, Rachel Hogg-Graham, Heather Norman-Burgdolf, Janet T. Mullins

Dietetics and Human Nutrition Faculty Publications

Rural communities are disproportionally affected by food insecurity, making them vulnerable to the consequences of supply disruptions caused by the COVID-19 pandemic. While access to food was initially diminished due to food supply disruptions, little is known about the mechanisms through which federal emergency assistance programs impacted food access in rural populations. Through a series of five focus groups in spring 2021, we examined the impact of the COVID-19 pandemic on food access in a rural Appalachian community in Kentucky. Data were analyzed using a Grounded Theory Approach. Findings revealed the following four primary themes: food scarcity in grocery stores; …

Sugar-Sweetened Beverage Consumption Among Adults In Rural Appalachia, Heather Norman-Burgdolf, Emily M. Dewitt, Kathryn M. Cardarelli, Rachel Gillespie, Stacey A. Slone, Alison A. Gustafson

Dietetics and Human Nutrition Faculty Publications

Sugar-sweetened beverage (SSB) consumption is decreasing nationally, yet intakes remain high in certain sub-populations as new varieties of SSBs are introduced. This study aims to expand on SSB intake patterns among adults living in Appalachia to develop policy, systems, and environmental (PSE) interventions to reduce consumption. Baseline cohort surveys were conducted to examine beverage consumption patterns of adults in one rural Appalachian county in Kentucky using a validated BEVQ-15 instrument. Ages were collapsed into three generational groups – Millennials (22–38 years), Generation X (39–54 years), and Boomers/Silents (≥55 years). Over half (n = 81; 54%) of the sample (n = …

Losses, Gains, And Changes To The Food Environment In A Rural Kentucky County During The Covid-19 Pandemic, Makenzie L. Barr, Courtney Martin, Courtney T. Luecking, Kathryn M. Cardarelli

Dietetics and Human Nutrition Faculty Publications

The COVID-19 pandemic has caused alterations to be made in the way many people access, prepare, and consume food. Rural communities are particularly impacted due to pre-existing structural vulnerabilities, i.e., poverty, lack of infrastructure, and limited fresh food options. This study aimed to characterize experiences of one rural Appalachian community’s changes to the food environment during the pandemic. In April 2021, six focus groups were conducted with residents of Laurel County, Kentucky. Using grounded theory, we identified losses, gains, and overall changes to the community food environment since the onset of COVID-19. Seventeen Laurel Countians (17 female; ages 30–74) participated …

Process Evaluation Of The Early Implementation Stages Of The National Diabetes Prevention Program Through Kentucky Cooperative Extension: Perceptions Of Adopters And Potential Adopters, Nicole Breazeale, Heather Norman-Burgdolf, Katherine Counts, Lovoria B. Williams

Dietetics and Human Nutrition Faculty Publications

With the growing demand for lifestyle change programs that prevent or delay Type 2 diabetes onset, community organizations with broad reach should be explored for national dissemination of the National Diabetes Prevention Program (NDPP). This study evaluates the early implementation of the NDPP through Cooperative Extension in four Kentucky counties and explores the feasibility of scaling up the program to additional counties. Using a qualitative approach, semi-structured telephone interviews were conducted with 12 Family and Consumer Sciences (FCS) Agents – four who were participating in the pilot (adopters) and eight who had no experience with the NDPP (potential adopters). Five …

Exploring Perceived Importance Of A Novel Emergency Food Program During Covid-19 And Program Recipient Characteristics, Makenzie L. Barr, Kendra Oonorasak, Kristin Hughes, Lauren Batey, Kaela Jackson, Haley Marshall, Tammy Stephenson

Dietetics and Human Nutrition Faculty Publications

Following rising unemployment rates and consequent loss of income due to COVID-19, many people have been seeking meal assistance. This study examines the impact of a community-based free meal distribution program during the pandemic in Kentucky, reviewing characteristics of recipients of the program. Demographics, health behaviors, food insecure classification, and rating of importance of the meal program were collected. Qualitative feedback on the impact of the program was collected via open response. Of the 92 participants using the meal service, the cohort was female, Black, 43 years of age (43.5 ± 15.0 years), with a household income under 30,000 USD …

Assessment Of Cultural Sensitivity In Dietetics Education, Julie Plasencia, Heather Norman-Burgdolf, Lorraine Weatherspoon

Dietetics and Human Nutrition Faculty Publications

Cultural sensitivity and competency are skills needed for agricultural professionals including nutrition and dietetics practitioners. The objective of the current study was to examine the learning transference of cultural sensitivity topics taught in a cultural foods course into case study assessments of a capstone-level course. This study is a cross-sectional, content analysis of cultural sensitivity assessment rubric (CSAR) scores for two case study assessments. The study was conducted in a landgrant, research-intensive university and 55 students (60%) from a capstone-level dietetics course participated. T-tests were used to compare CSAR scores between students who had completed a cultural foods course and …

Screen Time Parenting Practices And Associations With Preschool Children’S Tv Viewing And Weight-Related Outcomes, Cody D. Neshteruk, Gina L. Tripicchio, Stephanie Lobaugh, Amber E. Vaughn, Courtney T. Luecking, Stephanie Mazzucca, Dianne S. Ward

Dietetics and Human Nutrition Faculty Publications

The purpose of this study was to examine associations between screen time (ST) parenting practices and 2–5-year-old children’s TV viewing and weight status. Data were collected from 252 parent–child dyads enrolled in a randomized parent-focused childhood obesity prevention trial from 2009–2012. ST parenting practices were assessed at baseline using a validated parent-reported survey. Parent-reported child TV viewing and objectively measured anthropometrics were assessed at baseline, post-intervention (35 weeks), and follow-up (59 weeks). Marginal effect models were developed to test the association between baseline ST parenting practices and children’s TV viewing, BMI z-score, and waist circumference across all time points. Limiting/monitoring …

Community-Based Efforts Aim To Improve The Food Environment Within A Highly Obese Rural Appalachian County, Rachel Gillespie, Emily M. Dewitt, Heather Norman-Burgdolf, Brynnan Dunaway, Alison A. Gustafson

Dietetics and Human Nutrition Faculty Publications

Rural communities in Appalachia are displaying increased obesity prevalence, yet traditional interventions have not provided a broad enough impact to improve dietary consumption patterns. Therefore, expanding efforts that address the food environment and incorporate behavioral nudges through community-developed marketing strategies may be a viable mechanism to improve food and beverage choices within this unique population. This study installed shelf-wobblers across n = 5 gas stations in one rural Appalachian county in Kentucky. Smart Snacks were identified from store inventory lists utilizing the CDC Food Service Guideline for Federal Facilities calculator and were categorized into high-protein snacks, low-fat carbohydrate snacks, meal …

Consumption Of Diet And Nutrition Information In Digital Magazines Marketing To Latinx Women, Julie Plasencia, Clara Barajas, Jordan Hinton

Dietetics and Human Nutrition Faculty Publications

Objective: To examine the types of nutrition and health-related articles published in digital magazines directed toward Latinx women; and to examine the extent to which advertisements about food, nutrition, and weight-loss are prevalent in these media.

Design: A descriptive content analysis was completed for five digital magazines marketing to Latinx women. A total of 1,234 articles and 3,001 advertisements were examined for nutrition and health-related content.

Results: Early editions of digital magazines directed towards Latinx women included more advertisements than articles on the topics of food and health. Among the articles, very few (0-30%) included health and nutrition information that …

Fat And Carbohydrate Interact To Potentiate Food Reward In Healthy Weight But Not In Overweight Or Obesity, Emily E. Perszyk, Zach Hutelin, Jessica Trinh, Arsene Kanyamibwa, Sophie Fromm, Xue S. Davis, Kathryn M. Wall, Kyle D. Flack, Alexandra G. Difeliceantonio, Dana M. Small

Dietetics and Human Nutrition Faculty Publications

Prior work suggests that actual, but not estimated, energy density drives the reinforcing value of food and that energy from fat and carbohydrate can interact to potentiate reward. Here we sought to replicate these findings in an American sample and to determine if the effects are influenced by body mass index (BMI). Thirty participants with healthy weight (HW; BMI 21.92 ± 1.77; M ± SD) and 30 participants with overweight/obesity (OW/OB; BMI 29.42 ± 4.44) rated pictures of common American snacks in 120-kcal portions for liking, familiarity, frequency of consumption, expected satiety, healthiness, energy content, energy density, and price. Participants …

Alternative Community Nutrition Experiential Learning Opportunities For Dietetic Interns During Covid-19, Courtney T. Luecking, Elizabeth Combs, Heather Norman-Burgdolf

Dietetics and Human Nutrition Faculty Publications

In response to the COVID-19 pandemic, collaboration among faculty in the Department of Dietetics and Human Nutrition at the University of Kentucky yielded two, four-week virtual experiential learning opportunities with Cooperative Extension for 19 dietetic interns. Remote experiences focused on development of new programming regarding the role of nutrition in the prevention/management of the most prevalent chronic diseases affecting Kentuckians and translating an existing social marketing program that promotes quality family time through preparation of nutritious, affordable home-cooked meals. Weekly assignments took ~10 hours, included individual and groupwork, and came together to create program packages encompassing commonly used products (e.g., …

Leveraging Online Learning To Promote Systems Thinking For Sustainable Food Systems Training In Dietetics Education, Marie Spiker, Amanda Hege, Janice Giddens, Joanna Cummings, Jasia Steinmetz, Angie Tagtow, Erin Bergquist, Lauren Burns, Christina Campbell, Diane Stadler, Elizabeth Combs, Nancy Prange, Aaron Schwartz, Katie Brown, Kevin Sauer

Dietetics and Human Nutrition Faculty Publications

Educating and training a multisectoral food systems workforce is a critical part of developing sustainable, resilient, and healthy food and water systems. This paper shares perspectives from a working group of educators, learners, and food systems subject matter experts that collaborated over the course of a year to develop, pilot test, and evaluate two interactive webinar series with a multi-site cohort of dietetics interns and graduate students. The three-part webinar series format included a training webinar, a practice activity, and a synthesis webinar. In reflecting on the effectiveness of this format, we provide direct assessments of student learning from subject …

Healthy Trees – Healthy People: A Model For Engaging Citizen Scientists In Exotic Pest Detection In Urban Parks, Heather Norman-Burgdolf, Lynne K. Rieske

Dietetics and Human Nutrition Faculty Publications

Healthy Trees – Healthy People (HT-HP) is an outreach and education program created to enlist and train participants in exotic pest detection while providing them with structured opportunities to connect with urban nature and increase their physical and emotional health. HT- HP creates infrastructure to increase engagement by the urban populace in the urban tree canopy. The program solicits participants to engage in an 8-week intervention designed to expand capacity to detect non-native insect pests and pathogens, while increasing physical activity, raising awareness of healthy lifestyle choices, and improving the health of participants. Program participants were trained in tree and …

Integrating Policies, Systems, And Environments (Pse) Work Into Fcs Extension Programming: Lessons Learned From A Multi-State Training, Lisa T. Washburn, Heather Norman-Burgdolf, Karen L. Franck, Lauren E. Kennedy, Christopher T. Sneed

Dietetics and Human Nutrition Faculty Publications

Public health efforts have emphasized changes to policies, systems and environments (PSEs) to improve health behaviors for individuals and communities. Extension has increasingly emphasized these approaches, particularly for work of Family and Consumer Sciences (FCS) agents. In part, this emphasis on PSEs in Extension has been driven by SNAP-Ed and other federally funded initiatives, such as the Centers for Disease Control and Prevention (CDC) High Obesity Programs (HOP). However, broader adoption and implementation of PSEs at the local level has lagged in some states for various reasons. These include limited understanding about PSE interventions and how this work fits with …

“We’Re, Like, The Most Unhealthy People In The Country”: Employing An Equity Lens To Reduce Barriers To Healthy Food Access In Rural Appalachia, Kathryn Cardarelli, Emily M. Dewitt, Rachel Gillespie, Heather Norman-Burgdolf, Natalie Jones, Janet Tietyen Mullins

Dietetics and Human Nutrition Faculty Publications

Introduction

Obesity disproportionately affects rural communities, and Appalachia has some of the highest obesity rates in the nation. Successful policy, systems, and environmental (PSE) interventions to reduce obesity must reflect the circumstances of the population. We used a health equity lens to identify barriers and facilitators for healthy food access in Martin County, Kentucky, to design interventions responsive to social, cultural, and historical contexts.

Methods

We conducted 5 focus groups in Martin County, Kentucky, in fall 2019 to obtain perspectives on the local food system and gauge acceptability of PSE interventions. We used grounded theory to identify perceived barriers and …

Exercise For Weight Loss: Further Evaluating Energy Compensation With Exercise, Kyle D. Flack, Harry M. Hays, Jack Moreland, Douglas E. Long

Dietetics and Human Nutrition Faculty Publications

PURPOSE: This study assessed how individuals compensate for energy expended during a 12-wk aerobic exercise intervention, elucidating potential mechanisms and the role exercise dose plays in the compensatory response.

PARTICIPANTS AND DESIGN: Three-arm, randomized controlled trial among sedentary adults age 18 to 40 yr, body mass index of 25 to 35. Groups included six exercise sessions per week, two sessions per week, and sedentary control.

METHODS: Rate of exercise energy expenditure was calculated from a graded exercise test averaged across five heart rate zones. Energy compensation was calculated as the difference between expected weight loss (based on exercise energy expenditure) …

Barriers And Facilitators Of Parent Engagement With Health Promotion In Child Care: A Mixed-Methods Evaluation, Courtney T. Luecking, Phillip Dobson, Dianne S. Ward

Dietetics and Human Nutrition Faculty Publications

BACKGROUND: Early care and education providers cite lack of parent engagement as a central barrier to promoting healthy behaviors among young children. However, little research exists about factors influencing parent engagement with promoting healthy eating and activity behaviors in the this setting.

AIMS: This study aimed to address this gap by examining low and high parent engagement with the Healthy Me, Healthy We campaign to identify barriers and facilitators of parent engagement with the intervention.

METHOD: This comparative case study used an explanatory sequential mixed-methods approach. We created center-level parent engagement scores using process evaluation data from the effectiveness trial …

Rural Snap Participants And Food Insecurity: How Can Communities Leverage Resources To Meet The Growing Food Insecurity Status Of Rural And Low-Income Residents?, Emily M. Dewitt, Rachel Gillespie, Heather Norman-Burgdolf, Kathryn Cardarelli, Stacey A. Slone, Alison A. Gustafson

Dietetics and Human Nutrition Faculty Publications

The burden of obesity disproportionately influences poor health outcomes in rural communities in the United States. Various social and environmental factors contribute to inadequate food access and availability in rural areas, influencing dietary intakes and food insecurity rates. This study aims to identify patterns related to food insecurity and fruit and vegetable consumption within a SNAP-eligible and low-income, highly obese rural Appalachian community. A prospective cohort was implemented to identify gaps in resources addressing obesity and food insecurity challenges. SAS 9.4 software was used to examine differences in dietary intakes and shopping practices among SNAP participants. Among participants (n …

Policy, Systems, And Environmental Change: A Planning Tool For Community Health Implementation, Lauren E. Kennedy, Christopher T. Sneed, Karen L. Franck, Heather Norman, Lisa Washburn, Soghra Jarvandi, Janet Mullins

Dietetics and Human Nutrition Faculty Publications

Extension educators across the United States are being asked to expand their direct education efforts to include policy, systems, and environmental (PSE) changes. However, professional development opportunities and tools are needed to familiarize Extension professionals with PSE change approaches, build their capacity to implement PSE change, and make the process relevant to their work. We describe a planning tool developed for a unique multistate PSE change intervention training and designed to facilitate the process of PSE change implementation at the local level. An example of the tool and recommendations for others wishing to use it are included.

Two States, One Mission: Building Policy, Systems, And Environmental Change Capacity Of County Extension Educators, Christopher T. Sneed, Karen L. Franck, Heather Norman, Lisa Washburn, Lauren E. Kennedy, Soghra Jarvandi, Janet Mullins

Dietetics and Human Nutrition Faculty Publications

Policy, systems, and environmental (PSE) change interventions are a key part of comprehensive nutrition and health education. Although Extension educators find value in PSE approaches and report being involved in PSE work, many still indicate a lack of understanding regarding PSE approaches. We describe a unique multistate training designed to increase Extension educators' understanding, skills, and capacity related to implementing PSE change interventions. Data demonstrating success of the training are presented. Additionally, best practices for others wishing to create similar multistate programs conclude the article.

The Consequences Of Exercise-Induced Weight Loss On Food Reinforcement. A Randomized Controlled Trial, Kyle D. Flack, Harry M. Hays, Jack Moreland

Dietetics and Human Nutrition Faculty Publications

BACKGROUND: Obesity remains a primary threat to the health of most Americans, with over 66% considered overweight or obese with a body mass index (BMI) of 25 kg/m2 or greater. A common treatment option many believe to be effective, and therefore turn to, is exercise. However, the amount of weight loss from exercise training is often disappointingly less than expected with greater amounts of exercise not always promoting greater weight loss. Increases in energy intake have been prescribed as the primary reason for this lack of weight loss success with exercise. Research has mostly focused on alterations in hormonal mediators …

Incentive Sensitization For Exercise Reinforcement To Increase Exercise Behaviors, Kyle D. Flack, Harry M. Hays, Jack Moreland

Dietetics and Human Nutrition Faculty Publications

Individuals can be sensitized to the reinforcing effects of exercise, although it is unknown if this process increases habitual exercise behavior. Sedentary men and women (body mass index: 25–35 kg/m², N = 52) participated in a 12-week aerobic exercise intervention. Exercise reinforcement was determined by how much work was performed for exercise relative to a sedentary alternative in a progressive ratio schedule task. Habitual physical activity was assessed via accelerometry. Post-intervention increases in exercise reinforcement predicted increases in physical activity bouts among those who expended over 2000 kcal per week in exercise and who compensated for less than …

A Brief Report On A Facilitated Approach To Connect Cooperative Extension Southern Region State-Level Health Specialists, Samantha M. Harden, Lisa Washburn, Alison Berg, Ninfa Pena-Purcell, Heather Norman-Burgdolf, Nancy Franz

Dietetics and Human Nutrition Faculty Publications

Improving the nation’s health will require collaboration among many stakeholders and systems, including representatives from Cooperative Extension Services (CES). This paper describes the process of establishing a multistate collaboration and discusses initial outcomes of a third-party facilitated participatory planning meeting. State-level specialists with expertise and responsibilities in “health” promotion participated. Satisfaction with meeting format; feasibility, acceptability, and appropriateness of the proposed approach to public health impact; and general meeting feedback were collected through a survey and cultural artifacts (e.g., notes, worksheets). Preparation and attendance costs were captured. Seventeen of the 20 attendees (85%) responded to the survey and reported the …

Contributions Of Early Care And Education Programs To Diet Quality In Children Aged 3 To 4 Years In Central North Carolina, Courtney T. Luecking, Stephanie Mazzucca, Amber E. Vaughn, Dianne S. Ward

Dietetics and Human Nutrition Faculty Publications

BACKGROUND: Parents and early care and education (ECE) are the key influencers of young children's diets, but there is limited information about how each contribute to children's overall diet quality.

OBJECTIVE: This study aimed to determine what proportion of children's dietary intake occurs within the ECE setting and whether diet quality is higher at ECE centers and, consequently, on weekdays than weekends.

DESIGN: This cross-sectional analysis of a larger cluster randomized controlled trial used multiple 24-hour dietary intakes measured through a combination of the Dietary Observation in Child Care protocol and parent-reported food diaries.

PARTICIPANTS/SETTING: Participants (N=840) included children aged …