La presencia de factores de riesgo cardiovascular en los niños aumenta el riesgo de enfermedades cardiovasculares en los adultos.

Blanco Rodríguez C, González Rodríguez MP. La presencia de factores de riesgo cardiovascular en los niños aumenta el riesgo de enfermedades cardiovasculares en los adultos. Evid Pediatr. 2023;19:8.

Valoración crítica del artículo: Jacobs DR, Woo JG, Sinaiko AR, Daniels SR, Ikonen J, Juonala M, et al. Childhood Cardiovascular Risk Factors and Adult Cardiovascular Events. N Engl J Med. 2022 May 19;386(20):1877-88.

Objetivo: establecer la relación causal entre la presencia de factores de riesgo cardiovascular (FRCV) en niños y el desarrollo de enfermedad cardiovascular (ECV) en el adulto.

Diseño: estudio de cohortes prospectivo con tiempo medio de seguimiento de 35 años.

Emplazamiento: participantes en i3C (consorcio de cohorte cardiovascular infantil) que incluye 7 cohortes registradas en Australia, Finlandia y Estados Unidos.

Población de estudio: se incluyeron 40 648 participantes del registro de i3C, realizado entre los años 1970-1990, con edades de 3 a 19 años.

Evaluación del factor de riesgo: se incluyeron el índice de masa corporal (IMC), la tensión arterial sistólica (TAS), los niveles de colesterol total, los niveles de triglicéridos y el hábito tabáquico. Se calcularon unas puntuaciones estandarizadas individuales, así como una puntuación combinada (calculada como la media no ponderada de la suma de las cinco individuales). Otras variables registradas fueron: edad, sexo, nivel educativo de las familias y de los participantes en edad adulta. Los calendarios de medición de estas variables fueron desiguales y no siempre completos en las siete cohortes. El consumo de tabaco se registró como sí o no.

Medición del resultado: las variables de resultado fueron ECV fatales (ECVF) y no fatales (ECVnF): infarto de miocardio, accidente cerebrovascular, angina, accidente isquémico transitorio, insuficiencia cardiaca isquémica, intervención carotidea, aneurisma de aorta abdominal o revascularización coronaria. La información se recogió entre 2015 y 2019 a través de encuestas a los participantes y, cuando no se localizaron, consultando los registros nacionales de mortalidad. Se codificaron según la Clasificación Internacional de Enfermedades 9 y 10. Los modelos se ajustaron por sexo, raza negra, cohorte, edad media de seguimiento, número de visitas en la infancia y educación parental. Los registros médicos fueron revisados por un comité médico que desconocía los datos de los participantes.

La imputación se basó en los 319 ECVF que ocurrieron en 38 589 participantes y 779 ECVF y ECVnF observados en 20 656 participantes. En un subgrupo de 13 401 participantes, de quienes se dispusieron los datos de factores de riesgo en la infancia y en la vida adulta (media de edad 31 años; desviación estándar [DE] 5,6 años), se incluyeron 115 ECVF y en 11 156 participantes 406 ECVF o ECVnF. Se estimaron los cocientes de riesgos instantáneos (hazard ratio [HR]) por cada unidad de aumento en las puntuaciones estandarizadas, excepto para el tabaco, que se estimó para fumar frente a no fumar.

Resultados principales: los ECV acontecieron a una edad media de 47 (DE 8) años, siendo más frecuentes en los pacientes de mayor edad, varones y con un nivel educativo inferior. Los resultados fueron similares en las siete cohortes estudiadas.

En el análisis de 38 589 participantes se produjo un ECVF en 319 (0,8%) (49,7% varones y 15% afroamericanos, edad media de visita en la infancia 11,8 años (DE 3,1). El HR para un ECVF fue 1,30 (intervalo de confianza del 95% [IC 95]: 1,14 a 1,47) por cada unidad de incremento en la puntuación del nivel de colesterol, 1,5 (IC 95: 1,33 a 1,7) para los triglicéridos, 1,44 (IC 95: 1,33 a 1,57) para el IMC, 1,34 (IC 95: 1,19 a 1,5) para la TAS y 1,61 (IC 95: 1,21 a 2,13) en consumo de tabaco. El HR para un ECVF en la puntuación combinada fue 2,71 (IC 95: 2,23 a 3,29).

En el análisis de 20 656 participantes, 779 tuvieron un ECVF o ECVnF (3,8%). El HR combinado para ECVF y ECVnF fue 2,75 (IC 95: 2,48 a 3,06).

En el grupo de 13 041 participantes con datos de factores de riesgo disponibles en la infancia y adultos, el HR combinado para ECVF fue 3,54 (IC 95: 2,57 a 4,87) y para ECVF y ECVnF 3,21 (IC 95: 2,69 a 3,85).

Los pacientes con puntuación estandarizada combinada ≥0 tuvieron un riesgo 2 a 9 veces más alto de ECV en la vida adulta que aquellos con puntuación <-0,5.

Conclusión: la presencia de factores de riesgo cardiovascular en la infancia y su progresión en la vida adulta se asocia a eventos cardiovasculares en el adulto de edad media.

Comentario Crítico (Evid Pediatr)

Justificación: la presencia de FRCV en la infancia se ha asociado con ECV en adultos. En general, los estudios realizados hasta ahora han encontrado una asociación con enfermedad subclínica1. Este estudio analiza la posible asociación con ECVF y ECVnF en la vida adulta. La prevención de la ECV es un problema de salud importante2, por lo que es prioritaria la identificación y el control de estos factores de riesgo desde la infancia.

Validez o rigor científico: se trata de un estudio de cohortes con una gran muestra poblacional y un amplio intervalo de edades durante la infancia, con largo seguimiento. Existe definición clara de la población, de la exposición y del efecto. La medición del resultado fue independiente. Existe una secuencia temporal entre la exposición y el efecto.

La mayoría de los participantes son de raza blanca (solo 15% raza negra), por lo que sus resultados no incluyen posibles diferencias raciales. A pesar de esta agrupación de datos de siete poblaciones distintas no existen diferencias entre las cohortes en la edad de inicio, de la patología cardiovascular (rara por debajo de la cuarta década de la vida) ni tampoco en los HR de los factores de riesgo cardiovasculares estudiados. Durante el seguimiento hay una pérdida del 46,5% de la población en la que no se pueden tener datos de posibles EVCnF, por lo que, aunque se realizan diferentes imputaciones estadísticas para evitar sesgos en los resultados, estos podrían existir y ser aún mayor la carga de enfermedad en pacientes con factores de riesgo presentes en la infancia y en la vida adulta.

Importancia clínica: los niveles elevados de triglicéridos o colesterol, un IMC elevado, cifras altas de TAS en la infancia o un hábito tabáquico desde edades tempranas se asocian con ECV en el adulto a partir de la cuarta década de la vida. Si el 0,8% de la población tiene una ECVF, la presencia de estos factores en la infancia eleva a más del doble la posibilidad de presentar un ECV en el adulto joven (2,7 más para ECVF y 2,75 más para ECVF o ECVnF).

Los niños con puntuaciones estandarizadas de riesgo altas (≥0) tienen entre un 2 y un 9% más de riesgo de sufrir ECV, siendo este riesgo directamente proporcional a dicha puntuación. Por tanto, el estudio de la presencia de FRCV y su prevención deben comenzar desde la infancia en todos los individuos1,2. La puesta en marcha de políticas poblacionales de educación para salud cardiovascular en la edad pediátrica es una medida prioritaria para cambiar el estilo de vida de niños y adolescentes y de esta forma reducir la morbimortalidad de esta patología y el impacto económico que la ECV supone para la sociedad. La OMS publica una guía de intervenciones para la prevención y control de ECV3. La eficiencia de estas políticas ya se ha puesto de manifiesto en algunos países como Finlandia, con campañas sobre dieta saludable, con un importante descenso en las tasas de mortalidad por ECV en este país5.

Aplicabilidad en la práctica clínica: los resultados son aplicables a nuestro entorno. Los FRCV en la infancia pueden producir ECV y muerte en adultos jóvenes. Se debería considerar una prioridad sanitaria potenciar programas de educación para la prevención primaria de estos factores en la infancia y adolescencia.

Conflicto de intereses de los autores del comentario: no existen.

Interactivity, Quality, and Content of Websites Promoting Health Behaviors During Infancy: 6-Year Update of the Systematic Assessment.

Jawad D, Cheng H, Wen L, Rissel C, Baur L, Mihrshahi S, Taki S

J Med Internet Res 2022;24(10):e38641   URL: https://www.jmir.org/2022/10/e38641

DOI: 10.2196/38641

Background:

As of 2021, 89% of the Australian population are active internet users. Although the internet is widely used, there are concerns about the quality, accuracy, and credibility of health-related websites. A 2015 systematic assessment of infant feeding websites and apps available in Australia found that 61% of websites were of poor quality and readability, with minimal coverage of infant feeding topics and lack of author credibility.

Objective:

We aimed to systematically assess the quality, interactivity, readability, and comprehensibility of information targeting infant health behaviors on websites globally and provide an update of the 2015 systematic assessment.

Methods:

Keywords related to infant milk feeding behaviors, solid feeding behaviors, active play, screen time, and sleep were used to identify websites targeting infant health behaviors on the Google search engine on Safari. The websites were assessed by a subset of the authors using predetermined criteria between July 2021 and February 2022 and assessed for information content based on the Australian Infant Feeding Guidelines and National Physical Activity Recommendations. The Suitability Assessment of Materials, Quality Component Scoring System, the Health-Related Website Evaluation Form, and the adherence to the Health on the Net code were used to evaluate the suitability and quality of information. Readability was assessed using 3 web-based readability tools.

Results:

Of the 450 websites screened, 66 were included based on the selection criteria and evaluated. Overall, the quality of websites was mostly adequate. Media-related sources, nongovernmental organizations, hospitals, and privately owned websites had the highest median quality scores, whereas university websites received the lowest median score (35%). The information covered within the websites was predominantly poor: 91% (60/66) of the websites received an overall score of ≤74% (mean 53%, SD 18%). The suitability of health information was mostly rated adequate for literacy demand, layout, and learning and motivation of readers. The median readability score for the websites was grade 8.5, which is higher than the government recommendations (<grade 8). Overall, 74% (49/66) of the websites obtained a poor rating for interactivity, measuring active control, 2-way communication, and synchronicity. The most common features found on websites were social media links (61/66, 92%), frequently asked questions (48/66, 73%), and videos (44/66, 67%). Only 14% (9/66) of websites presented culturally responsive information.

Conclusions:

Quality, content, readability, and interactivity of websites promoting health behaviors during infancy ranged between poor and adequate. Since the 2015 systematic assessment, there was a slight improvement in the quality of websites but no difference in the Suitability Assessment of Materials rating and readability of information. There is a need for researchers and health care providers to leverage innovative web-based platforms to provide culturally competent evidence-based information based on government guidelines that are accessible to those with limited English proficiency.

Screening for Eating Disorders in Adolescents and Adults: US Preventive Services Task Force Recommendation Statement.

Davidson KW, Barry MJ, Mangione CM, et al.

JAMA. 2022 Mar 15;327(11):1061-1067. doi: 10.1001/jama.2022.1806.

Importance: Eating disorders (eg, binge eating disorder, bulimia nervosa, and anorexia nervosa) are a group of psychiatric conditions defined as a disturbance in eating or eating-related behaviors that impair physical or psychosocial functioning. According to large US cohort studies, estimated lifetime prevalences for anorexia nervosa, bulimia nervosa, and binge eating disorder in adult women are 1.42%, 0.46%, and 1.25%, respectively, and are lower in adult men (anorexia nervosa, 0.12%; bulimia nervosa, 0.08%; binge eating disorder, 0.42%). Eating disorder prevalence ranges from 0.3% to 2.3% in adolescent females and 0.3% to 1.3% in adolescent males. Eating disorders are associated with short-term and long-term adverse health outcomes, including physical, psychological, and social problems.

Objective: The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening for eating disorders in adolescents and adults with a normal or high body mass index. Evidence limited to populations who are underweight or have other physical signs or symptoms of eating disorders was not considered. The USPSTF has not previously made a recommendation on this topic.

Population: Adolescents and adults (10 years or older) who have no signs or symptoms of eating disorders (eg, rapid weight loss, weight gain, or pronounced deviation from growth trajectory; pubertal delay; bradycardia; oligomenorrhea; and amenorrhea).

Evidence Assessment: The USPSTF concludes that the evidence is insufficient to assess the balance of benefits and harms of screening for eating disorders in adolescents and adults. The evidence is limited and the balance of benefits and harms cannot be determined.

Recommendation: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for eating disorders in adolescents and adults. (I statement).

Estimated effect of secondary screening for hip dislocation.

Wenger D, Tiderius CJ, Düppe H.

Archives of Disease in Childhood Published Online First: 03 July 2020. doi: 10.1136/archdischild-2020-319250

Abstract

Objectives 

To quantify the effect of secondary screening for hip dislocations.

Design

Retrospective analysis of hospital files from participants in a prospectively collected nationwide registry.

Setting

Child healthcare centres and orthopaedic departments in Sweden.

Participants

Of 126 children with hip dislocation diagnosed later than 14 days age in the 2000–2009 birth cohort, 101 had complete data and were included in the study.

Interventions

The entire birth cohort was subject to clinical screening for hip instability at 6–8 weeks, 6 months and 10–12 months age. Children diagnosed through this screening were compared with children presenting due to symptoms, which was used as a surrogate variable representing a situation without secondary screening.

Main outcome measures

Age at diagnosis and disease severity of late presenting hip dislocations.

Results

Children diagnosed through secondary screening were 11 months younger (median: 47 weeks) compared with those presenting with symptoms (p<0.001). Children diagnosed through secondary screening had 11% risk of having a high (severe) dislocation, compared with 38% for those diagnosed due to symptoms; absolute risk reduction 27% (95% CI: 9.7% to 45%), relative risk 0.28 (95% CI: 0.11 to 0.70). Children presenting due to symptoms had OR 5.1 (95% CI: 1.7 to 15) of having a high dislocation, and OR 11 (95% CI: 4.1 to 31) of presenting at age 1 year or older, compared with the secondary screening group. The secondary screening was able to identify half of the children (55%, 95% CI: 45% to 66%) not diagnosed through primary screening.

Conclusions

Secondary screening at child healthcare centres may have substantially lowered the age at diagnosis in half of all children with late presenting hip dislocation not diagnosed through primary screening, with the risk of having a high dislocation decreased almost to one-quarter in such cases.

View Full Text

http://dx.doi.org/10.1136/archdischild-2020-319250

Treatment of Depression in Children and Adolescents: A Systematic Review.

Viswanathan M, Kennedy SM, McKeeman J, Christian R, Coker-Schwimmer M, Cook Middleton J, Bann C, Lux L, Randolph C, Forman-Hoffman V. 

Comparative Effectiveness Review No. 224. (Prepared by the RTI International–University of North Carolina at Chapel Hill Evidence-based Practice Center under Contract No. 290-2015-00011-I.) AHRQ Publication No. 20-EHC005-EF. Rockville, MD: Agency for Healthcare Research and Quality; April 2020. 

Background. Depressive disorders can affect long-term mental and physical health functioning among children and adolescents, including increased risk of suicide. Despite access to several nonpharmacological, pharmacological, and combined treatment options for childhood depression, clinicians contend with sparse evidence and are concerned about harms associated with treatment.

Methods. We conducted a systematic review to evaluate the efficacy, comparative effectiveness, and moderators of benefits and harms of available nonpharmacological and pharmacological treatments for children and adolescents with a confirmed diagnosis of a depressive disorder (DD)—major depressive disorder (MDD), persistent depressive disorder (previously termed dysthymia) or DD not otherwise specified. We searched five databases and other sources for evidence available from inception to May 29, 2019, dually screened the results, and analyzed eligible studies.

Results. We included in our analyses data from 60 studies (94 articles) that met our review eligibility criteria. For adolescents (study participants’ ages range from 12 to 18 years) with MDD, cognitive behavioral therapy (CBT), fluoxetine, escitalopram, and combined fluoxetine and CBT may improve depressive symptoms (1 randomized controlled trial [RCT] each, n ranges from 212 to 311); whether the magnitude of improvement is clinically significant is unclear. Among adolescents or children with MDD, CBT plus medications (8–17 years) may be associated with lower rates of relapse (1 RCT [n = 121]). In the same population (6–17 years), selective serotonin reuptake inhibitors (SSRIs) may be associated with improved response (7 RCTs [n = 1,525]; risk difference [RD], 72/1,000 [95% confidence interval (CI), 2 to 24], I2 = 9%) and functional status (5 RCTs [n = 941]; standardized mean difference, 0.16 [95% CI, 0.03 to 0.29]; I2 = 0%). For adolescents or children with any DD (7–18 years), CBT or family therapy may be associated with improvements in symptoms, response, or functional status (1 RCT each, n ranges from 64 to 99). Among children with any DD (7–12 years), family-based interpersonal therapy may be associated with improved symptoms (1 RCT, n = 38). Psychotherapy trials did not report harms. SSRIs may be associated with a higher risk of serious adverse events among adolescents or children with MDD (7–18 years; 9 RCTs [n = 2,206]; RD, 20/1,000 [95% CI, 1 to 440]; I2, 4%) and with a higher risk of withdrawal due to adverse events among adolescents with MDD (12–18 years; 4 RCTs [n = 1,296], RD, 26/1,000 [95% CI, 6 to 45]; I2, 0%). Paroxetine (1 RCT [n = 180]) may be associated with a higher risk of suicidal ideation or behaviors among adolescents with MDD (12–18 years). Evidence was insufficient to judge the risk of suicidal ideation or behavior for other SSRIs for adolescents and children with MDD or other DD (7–18 years) (10 RCTs [n = 2,368]; relative risk, 1.14 [95% CI, 0.89 to 1.45]; I2, 8%). However, this report excluded data on inpatients and those without depressive disorders, whom the Food and Drug Administration included in finding an increased risk of suicidality for all antidepressants across all indications.

Conclusion. Efficacious treatments exist for adolescents with MDD. SSRIs may be associated with increased withdrawal and serious adverse events. No evidence on harms of psychotherapy were identified.

Global Prevalence of Hypertension in ChildrenA Systematic Review and Meta-analysis

Song P, Zhang Y, Yu J, Zha M, Zhu Y, Rahimi K, Rudan I.
JAMA Pediatr. 2019;173(12):1154-1163. doi:10.1001/jamapediatrics.2019.3310

Key Points
Question: What is the prevalence of hypertension in the general pediatric population
Findings:  In this systematic review and meta-analysis of 47 articles, the prevalence of childhood hypertension increased from 1994 to 2018 and the increase was associated with higher body mass index, with the pooled estimate being 4.00% among individuals 19 years and younger. In 2015, the prevalence of childhood hypertension ranged from 4.32% among children aged 6 years to 3.28% among those aged 19 years and peaked at 7.89% among those aged 14 years.
Meaning: The findings suggest that childhood hypertension is becoming more common in the general pediatric population, representing a considerable public health challenge worldwide.

Abstract
Importance: Reliable estimates of the prevalence of childhood hypertension serve as the basis for adequate prevention and treatment. However, the prevalence of childhood hypertension has rarely been synthesized at the global level.
Objective: To conduct a systematic review and meta-analysis to assess the prevalence of hypertension in the general pediatric population.
Data Sources: PubMed, MEDLINE, Embase, Global Health, and Global Health Library were searched from inception until June 2018, using search terms related to hypertension (hypertension OR high blood pressure OR elevated blood pressure), children (children OR adolescents), and prevalence (prevalence OR epidemiology).
Study Selection: Studies that were conducted in the general pediatric population and quantified the prevalence of childhood hypertension were eligible. Included studies had blood pressure measurements from at least 3 separate occasions.
Data Extraction and Synthesis: Two authors independently extracted data. Random-effects meta-analysis was used to derive the pooled prevalence. Variations in the prevalence estimates in different subgroups, including age group, sex, setting, device, investigation period, BMI group, World Health Organization region and World Bank region, were examined by subgroup meta-analysis. Meta-regression was used to establish the age-specific prevalence of childhood hypertension and to assess its secular trend.
Main Outcomes and Measures: Prevalence of childhood hypertension overall and by subgroup.
Results: A total of 47 articles were included in the meta-analysis. The pooled prevalence was 4.00% (95% CI, 3.29%-4.78%) for hypertension, 9.67% (95% CI, 7.26%-12.38%) for prehypertension, 4.00% (95% CI, 2.10%-6.48%) for stage 1 hypertension, and 0.95% (95% CI, 0.48%-1.57%) for stage 2 hypertension in children 19 years and younger. In subgroup meta-analyses, the prevalence of childhood hypertension was higher when measured by aneroid sphygmomanometer (7.23% vs 4.59% by mercury sphygmomanometer vs 2.94% by oscillometric sphygmomanometer) and among overweight and obese children (15.27% and 4.99% vs 1.90% among normal-weight children). A trend of increasing prevalence of childhood hypertension was observed during the past 2 decades, with a relative increasing rate of 75% to 79% from 2000 to 2015. In 2015, the prevalence of hypertension ranged from 4.32% (95% CI, 2.79%-6.63%) among children aged 6 years to 3.28% (95% CI, 2.25%-4.77%) among those aged 19 years and peaked at 7.89% (95% CI, 5.75%-10.75%) among those aged 14 years.
Conclusions and Relevance: This study provides a global estimation of childhood hypertension prevalence based on blood pressure measurements in at least 3 separate visits. More high-quality epidemiologic investigations on childhood hypertension are still needed.


Editorial
Understanding the Global Prevalence of Hypertension in Children and Adolescents

POSITION STATEMENT
Early detection for autism spectrum disorders in young children

Zwaigenbaum L, Brian JA, Ip A; Canadian Paediatric Society, Autism Spectrum Disorder Guidelines Task Force
Paediatr Child Health 2019 24(7):424–432.
Posted: Oct 24 2019

Abstract
Autism spectrum disorder (ASD) is a life-long neurodevelopmental disorder, characterized by impairments in social communication, repetitive, restricted patterns of behaviour, and unusual sensory sensitivities or interests. ASD significantly impacts the lives of children and their families. Currently, the estimated prevalence of ASD is 1 in 66 Canadians aged 5 to 17 years. General paediatricians, family physicians, and other health care professionals are, therefore, seeing more children with ASD in their practices. The timely diagnosis of ASD, and referral for intensive behavioural and educational interventions at the earliest age possible, may lead to better long-term outcomes by capitalizing on the brain’s neuroplasticity at younger ages. This statement provides clear, comprehensive, evidence-informed recommendations and tools to help community paediatricians and other primary care providers monitor for the earliest signs of ASD—an important step toward an accurate diagnosis and comprehensive needs assessment for intervention planning.

Adolescent Mental Health Program Components and Behavior Risk Reduction: A Meta-analysis.

Skeen S, Laurenzi CA, Gordon SL, du Toit S, Tomlinson M, Dua T, Fleischmann A, Kohl K, Ross D, Servili C, Brand AS, Dowdall N, Lund C, van der Westhuizen C, Carvajal-Aguirre L, Eriksson de

Carvalho C, Melendez-Torres GJ.

Pediatrics. 2019 Aug;144(2). pii: e20183488. doi: 10.1542/peds.2018-3488. Epub 2019 Jul 1.

CONTEXT: Although adolescent mental health interventions are widely implemented, little consensus exists about elements comprising successful models.

OBJECTIVE: We aimed to identify effective program components of interventions to promote mental health and prevent mental disorders and risk behaviors during adolescence and to match these components across these key health outcomes to inform future multicomponent intervention development.

DATA SOURCES: A total of 14 600 records were identified, and 158 studies were

included.

STUDY SELECTION: Studies included universally delivered psychosocial interventions administered to adolescents ages 10 to 19. We included studies published between 2000 and 2018, using PubMed, Medline, PsycINFO, Scopus, Embase, and Applied Social Sciences Index Abstracts databases. We included randomized controlled, cluster randomized controlled, factorial, and crossover trials.

Outcomes included positive mental health, depressive and anxious symptomatology,  violence perpetration and bullying, and alcohol and other substance use.

DATA EXTRACTION: Data were extracted by 3 researchers who identified core components and relevant outcomes. Interventions were separated by modality; data  were analyzed by using a robust variance estimation meta-analysis model, and we estimated a series of single-predictor meta-regression models using random effects.

RESULTS: Universally delivered interventions can improve adolescent mental health and reduce risk behavior. Of 7 components with consistent signals of effectiveness, 3 had significant effects over multiple outcomes (interpersonal skills, emotional regulation, and alcohol and drug education).

LIMITATIONS: Most included studies were from high-income settings, limiting the applicability of these findings to low- and middle-income countries. Our sample included only trials.

CONCLUSIONS: Three program components emerged as consistently effective across different outcomes, providing a basis for developing future multioutcome intervention programs.