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Needs Assessment on Childhood Obesity among African American Girls aged 6-11years old April Chu University of Texas Health Science Center – Houston

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Introduction Childhood obesity is recognized as one of the most compelling worldwide public health problems that many children are experiencing today. Currently, about one in six American children are obese. Their sedentary lifestyles, poor eating habits, and environmental surroundings all have contributed to the rise of the obesity epidemic (CDC, 2011a). This paper concentrates on the determinants of the risk factors, and the associated behavioral and environmental risk factors that are linked to childhood obesity. The focus will be on African American females from ages 6-11 that reside in Harris County located in Houston, Texas. In addition, it focuses on the obese African American femalesâ€&#x; quality of life issues. Question 1a: Establish a Planning Group To develop an effective intervention to reduce the prevalence and risk of childhood obesity, public health planners must first start by putting together a diverse work group. A diverse work group should consist of stakeholders such as community agencies and government organizations which would give a wide perspective on the health problems. This diversity would help create a culturally appropriate intervention. According to Bartholomew et al. (2011), a work group should be considered as a linkage system between three crucial types of work group members: a resource system (program developers), an intermediate user system (implementers), and an end-user system (participants) (p. 178). For a school-based obesity prevention program, the program developers would be researchers from the University of Texas Health Science Center at Houston (UTHSC-H), chairperson and leaders from community and government organizations such as the American Dietetic Association (ADA), Houston Area Dietetic Association (HADA), City of Houston Health and Human Services, Texas Department of State Health Service, School Health Advisory

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Council (SHAC), Houston City Council, Coordinated Approach to Child Health (CATCH) program from the Harris County Public Health and Environmental Services, as well as local health care personnel such as physicians, nurses and registered dietitians. The implementers would be health educators, school teachers, coaches, nurses, and counselors. The participants would be all overweight and obese African American females ages 6-11. Individual who has BMI close to 85percentile will also be included. The work group membersâ€&#x; role is crucial when developing an appropriate intervention for the target population. Their individual strength is the determinant factors for the work load. The School Health Advisory Council (SHAC) can be the communication link within the community to contact other local health and education programsâ€&#x; representatives and parents to participate as the planning group members. They can also revise school policies to improve the health of the students. Local health care personnel such as counselors, psychiatrists, psychologists, and mentors can help participants with their quality of life issues, while research experts can collect information and investigate on the burden of disease, and its associated behavior and environmental factors. Finally, the community and government organizations can provide the suitable resources to participants. Question 1b: Priority Population and Intervention Setting In the United States, the obesity epidemic among children and adolescents has nearly tripled since 1980 (CDC, 2011b). This rising trend of obesity is not only limited to the United States, it is also recognized as a leading health catastrophe around the world. According to the Global Database on Body Mass Index from the World Health Organization [WHO] (WHO, 2011), 1.5 billion adults over the age of 20 and 43 million children under the age of 5 is overweight. WHO predicted nearly 2.3 billion adults will be overweight, and over 700 million

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will be obese by year 2015 (Nguyen & El-Serag, 2009, p. 754). According to the Institute of Medicine, the rise of childhood obesity is developing in all 50 states affecting all socioeconomic levels, racial groups, genders, and age. The southeastern states in particular have the highest obesity prevalence in U. S. (Kaplan et al., 2005, p. 131). Texas is ranked 32nd (50th as the worst) in the overall prevalence of childhood obesity, with 32.3% of children considered either overweight or obese (Children at risk, 2008). Before we decide on the target population, it is important to understand the available data on overweight and obese Texas children across different ethnicities and age groups. The tables below indicate the prevalence of overweight and obese children classified by: ethnicity and grade level for both genders. For the tables below, researchers defined children as overweight if their Body Mass Index (BMI) ≥ 85th percentile and < 95th percentile, and obese is defined as BMI ≥ 95th percentile based on age and gender. Table 1: Prevalence of Overweight and Obese children in 4th, 8th, and 11th Grade within Texas Between 2004 and 2005. Obese Overweight th 4 grade 23% 19% 8th grade 20% 19% th 11 grade 19% 17% Resource: DSHS, 2008b Table 2: Prevalence of Obese Children in 4th, 8th, and 11th Grade Across Different Races and genders within Texas in 2001. African American Hispanic White/Others* Girls 4th grade 30.8% 26.4% 13.7% 8th grade 23.1% 16.2% 15.3% th 11 grade 17.2% 19.4% 5.5% Boys 4th grade 21.6% 31.1% 17.7% th 8 grade 13.8% 15.0% 32.6% 11th grade 19.0% 29.5% 12.7% *indicates White and other ethnicities such as non-Hispanic White, Asian, Pacific Islander, Native American, and “other” 4


Resource: DSHS, 2008b Table 3: Prevalence of Overweight and Obese children in 4th, 8th, and 11th grade across different race and gender in Texas in 2001. African American Hispanic White/Others* Girls 4th grade 39.6% 32.9% 51.7% th 8 grade 39.2% 40.7% 34.5% 11th grade 44.3% 41.8% 14.0% Boys 4th grade 45.7% 50.0% 27.6% 8th grade 23.9% 49.2% 30.9% th 11 grade 45.6% 41.9% 21.4% *indicates White and other ethnicities such as non-Hispanic White, Asian, Pacific Islander, Native American, and “other” Resource: DSHS, 2008b Without any doubt, “White/other” children have the lowest prevalence rates of overweight and obese children in Texas compared to African American and Hispanic children. Although Hispanic boys in 8th grade have the highest obesity rates, African American girls in 4th grade have the highest combined prevalence of overweight and obese rates compared to others. In addition, the National Health and Nutrition Examination Survey (NHANES) shows obesity rates increased from 6.5% in 1976 to 19.6% in 2007among individuals aged 6-11 (Ogden & Carroll, 2010). This age group has the higher obesity rates compared to children aged 2-5 (10.4%) and adolescents aged 12-19 (18.1%). Thus, the target population for the intervention will focus on 6-11 year old African American girls. Currently, 23% of children live in or near poverty in Houston, Texas compared to the national level of 19% (Children at risk, 2008). It indicates that these children are more prone to poor health. Although there is no specific data on the prevalence rates of childhood obesity in Harris County, this county serves as one of the largest African American and Mexican American populations in the State of Texas (US Census Bureau). These children are more likely to live in low-income communities, which are more vulnerable to becoming overweight or obese. 5


Obesity is the second most preventable cause of death aside from tobacco use (Sharma, 2006, p. 261). According to Juster et al. (2004), children aged 6-11 spend an average of 34 hours a week at school. They spend more time in school than any other activities such as watching television, reading books, or time for play per week (Juster et al, 2004). To combat childhood obesity, an intervention targeting African American 6-11 years old girls at school is the most appropriate choice and due to its significance. The school setting is a good place to deliver obesity prevention programs because it can be cost-effective and safe for children to learn to adapt a healthier way of life since many lifestyle and behavioral choices are developed in early school-age children (Carter, 2002, p. 2180). In addition, school programs can influence the youthâ&#x20AC;&#x;s attitude and knowledge toward healthy eating habits which they can thus carry with them through to adulthood. Therefore, I am implementing a school-based intervention for African American females aged 6-11 tackle childhood obesity in the Houston Independent School Districtâ&#x20AC;&#x;s (HISD) elementary schools. Question 2: Needs Assessment Phase I am entering the needs assessment phase with the health problem, childhood obesity. Overweight and obesity in children is a major health condition that many youth and adolescents have been experiencing for the past 30 years (CDC, 2011b). Childhood obesity is influenced by overeating unhealthy items, inadequate physical activity, and behavioral and environmental components (U.S. Department of Health and Human Services, 2001). Today, the obesity rates for children ages 6-11 years old has quadrupled from 4.2% up to 17% (Pekruhn, 2009).WHO recognizes overweight and obesity as the fifth leading risk of death in the world (WHO, 2011). This is a great concern because overweight and obesity can impact other chronic health risks and poor quality of life. With the growing trend of obesity, an estimate of 20 million Texans will be

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overweight or obese in 2040. The annual cost of this health problem will be projected to reach 39 billion dollars in 2040 (DSHS, 2008a). Therefore, it is wise to reduce the rising epidemic of this worldwide health crisis now before it worsens. Behavioral Factors The youth‟s behaviors are a major contribution to the increased progression of childhood obesity. There are many behavioral factors that may impact obesity, and one of the factors is lack of physical activity. The recommended physical activity for youth aged 6-11 is a minimum of 60 minutes of moderate intensity exercise daily. They are also encouraged to do vigorous-intensity aerobics activity 3 times a week (U.S. Department of Health and Human Services, 2008). According to the YMC Longitudinal Survey [YMCLS] (Physical Activity Levels, 2003), it shows that “61.5% of children between the ages of 9-13 years old do not participate in any organized physical activity, and 22.6% do not engage in any free-time physical activity outside of school hours” (p. 785). The survey also indicates that non-Hispanic Black children and children from low-income families and with low parental education were extremely unlikely to engage in organized and free-time physical activity, compared to non-Hispanic white children (p. 786). Girls report more barriers to physical activity due to lack of transportation, neighborhood safety, and available play area compared to boys (Physical Activity Levels, 2003, p. 786-787). Finally, young children with inadequate physical activity intuitively are at greater risk to becoming overweight or obese. They are also at higher risk for developing conditions such as hypertension or diabetes. This is compounded by the fact that as age increases, exercise level usually decreases (CDC, 2011c). Another behavioral factor associated with childhood obesity is inadequate fruit and vegetable consumption. The daily recommended fruit intake for my target population is 1- 1 ½

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cups per day, and 1 ½ - 2 cups of vegetables per day (USDA, 2011). Studies have shown that increasing fruits and vegetables intake in diet can help overweight and obese children lose weight. However, it suggests that currently, significant amounts of overweight and obese children from low-income families are unable to meet the recommended fruits and vegetables intake compared to normal weight children due to limited access and money constraints (Miller et al., 2011, p. 396). Therefore, these children are more susceptible to becoming overweight or obese. The third behavioral factor linked to childhood obesity is consumption of sugarsweetened beverages. Based on a prospective observational study by Ludwig et al. (2001), data indicates 65% of girls and 74% of boys consume soft drinks daily in the U.S. (p. 505). An article points out that for each additional serving of soda intake every day, a child has an average of 60% increased chance to become obese (Sugar-sweetened Beverages, 2009). Sugar-sweetened drinks are unnecessary extra calories, which consequently lead to excess body weight. The last behavioral factor associated with childhood obesity is childrenâ&#x20AC;&#x;s exposure to excess screen time. Screen time represents the time spent on computer, television viewing, and playing video games. The American Academy of Pediatrics suggests children should be limited to 2 hours of screen time a day, especially individuals above 2 years of age. However, statistics has shown that 47% of children between the ages of 2-15 spend more than the recommended amount of screen time every day (Maniccia et al., 2011, p. 194). Increase viewing of television is positively correlated with many negative health outcomes, including increased weight. With such enticing commercials, children are more likely to eat junk food. Lastly, screen time is the perfect opportunity for children to sit back and enjoy their unhealthy snacks.

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Environmental Factors Environmental factors surrounding the youth can play a major role in childhood obesity. One of the many environmental factors linked to obesity in children is the lack of family support. Parents can serve as a role model to the children by practicing healthy eating habits. Since parents are in control of children‟s dietary intake, they can influence the children to consume healthy food items at home. With parental supervision over their children‟s nutritional intake, they can encourage their children to change their poor eating habits, which ultimately reduce weight gain (Wang et al., 2006, p. 98). A second environmental factor associated with childhood obesity is family meal time. According a study of low income areas by Andaya et al. (2011), eating family meals together has shown to improve children‟s dietary intake of fruits and vegetables, and reduced sugarsweetened beverages intake (p. 309). In addition, a study declared that there is a 45% increase in the recommended fruits and vegetables intake, and 30% decline in soft drinks and oily food when children eat more often with their family during meal time (Andaya et al., 2011, p. 309). Results from this study indicate frequent family meal time reinforces children to consume healthier food products in their diet, which would be beneficial to their weight. The third environmental factor connected to this health problem is the lack of nutritious foods being served in schools. The majority of students consume both breakfast and lunch during school hours. Implementing the National School Breakfast Program and National School Lunch Program in local schools can help these students to meet 1/3 or more of their Recommended Dietary Allowance that they may not receive from home. Studies show proper nutritional intake through the federal school meal programs can improve children‟s dietary behaviors, their academic performance, and decrease the risk of obesity in children (FRAC, 2010).

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The fourth environmental factor associated with childhood obesity is poor access to the supermarket. The supermarket tends to offer a wide range of healthy food products at the lowest cost for consumers, whereas convenience stores sell mainly calorie dense foods with a limited selection of expensive fresh produce. Low income, minority residents living in rural communities have limited access to the supermarket, and studies indicate better access to the supermarkets is positively correlated to a lower risk of obesity due to the availability of healthier foods in the supermarket compared to the smaller convenience stores. (Larson et al., 2009, p. 75). The fifth environmental factor linked to childhood obesity is poor access to community physical activity areas. Low- income African American families reports a lack of available accessible recreational areas such as parks, public pools, bike path, and sidewalks within their community to stay physically active. Another major factor is that low-income families (31%) indicate the lack of neighborhood safety is preventing their children to play outside, compared to the medium-income family (15%) (Powell et al., 2004, p. 137). The combination of a lack of neighborhood safety and low availability of recreational areas for low socioeconomic children results in less overall physical activity. Therefore, it can contribute to the growing trend of obesity. The last environmental factor contributing to childhood obesity is the constant exposure to food marketing commercials on television. Statistic show children aged 2-11 years watched a little over 3 hours of television every day, and they are likely to be exposed to unhealthy food advertisements during those time of viewing (Powell et al., 2007, p. 553). According to Powell et al. (2007), most food advertisements on television promote food containing poor nutritional content, and significantly influence childrenâ&#x20AC;&#x;s dietary choices (p. 554). Consequently, television

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advertising has a strong correlation to excess adipose tissue in children‟s body which causes energy imbalance and weight gain. Quality of Life Quality of life measures are used to determine an individuals‟ well-being when associated with chronic conditions by researchers and physicians. Persistent obesity in children may result in sleep apnea, hypertension, cardiovascular disease, type 2 diabetes mellitus, and depression (Friedman & Fanning, 2004, p. S3-S4). However, it is the psychosocial consequences of being overweight or obese that helps better understand the burden of the disease. Significant quality of life issues that overweight and obese children experience over normal-weight peers include poor self-esteem, teasing, negative body images, and lower expectations of academic performance due to absenteeism (Daniel, 2008; Geier et al., 2007; O‟Dea, 2004; Taras & Potts-Datema, 2005; Strauss, 2000). In the Young-Human et al. study (2003), the authors suggest pediatric obesity is thought to be the preceding factor to the development of low self-esteem, especially in minority children. Although there are very few studies that examine the minority children‟s weight and self-esteem, it was shown that there is a strong association between low self esteem and higher weight in girls compared to boys(p<0.01) (p 463). Decreased levels of self-esteem in overweight and obese children is linked to elevated levels of depressive symptoms such as sadness and loneliness (Pinhas-Hamiel et al., 2005, p. 267), and potentially results in risky health behaviors including tobacco and alcohol use in adulthood (Stern et al., 2006, p. 217). Initiation of these risky behaviors can start in 4th-6th grade students (Strauss, 2000, p. 4). A literature review has found evidence that overweight and obese children with low self-esteem is linked to low academic performance, tardiness to school (mean of 6.31 days for the school year) and higher rates of

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school absence (mean of 8.6 days for the school year) (Shore et al., 2008, p. 1536). Studies have found that obese school-aged children attend school less frequently possibly due to difficulty in performing physical tasks in gym such as running, and jumping, lack of athletic ability which causes fear of embarrassment by peers (Geier et al., 2007, p. 2160; O‟Dea, 2005, p. 262). To examine the quality of life measures in overweight and obese children, the researchers frequently use qualitative methods such as questionnaires submitted by both children and their parents and focus group methodology to explore the quality of life outcomes (Pinhas-Hamiel et al., 2005; Stern et al., 2006; Young-Hyman et al., 2003). For my target population, 6-11 years old African American girls, I would ask them to answer the 36-item self-report questionnaire of the Harter Self-Perception Profile for Children. This instrument concentrates on child selfperception in areas for self-esteem including scholastic competence, social acceptance, athletic competence, physical appearance, behavioral conduct, and global self-worth. First, the child will simply decide which child in the statement selected is most like them. Then, the child will decide if the child in the statement was sort of like or really like them. The two step questionnaire has shown to provide acceptable reliability and validity for children 8 years and older, and easy enough for children as young as 5 years old to answer the questions (Young-Hyman et al., 2003, p. 465). Another method is to conduct a focus group by inviting both the target population and their mothers to address weight –related behaviors. The mother and child will be in separate rooms during the focus group sessions. The focus group will consist of open-ended questions to explore both mother and child‟s perceptions on the importance and meaning of healthy eating and exercise (Stern et al., 2006, p. 219). This interview or counseling style can help identify the mother and child‟s insight toward eating behaviors in children, weight-related quality of life concerns and also explore potential intervention activities. These qualitative method designs are

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chosen to reach both subjective and objective information from students and mothers. The information collected can provide a greater understanding on how obesity influences psychosocial behaviors in my target populationâ&#x20AC;&#x;s quality of life. Question 3: Prioritize Behavior and Environmental Factors To determine the most important behavior and environmental conditions related o the health problem, it is crucial to understand which factors are changeable and relevant. Changeability defines how easy it is to influence the change, and relevance refers to the strength of associations to certain health problem (Bartholomew et al., 2005). The most significant behavioral determinants associated with childhood obesity are unhealthy diets and physical inactivity (Baker et al., 2006, p. 1170; Gonzales-Suarez et al., 2009, p. 418; Nyberg et al., 2011, p.2; Sharma, 2006, p. 262; Siegrist et al., 2011, p.2). Children are consuming diets high in calories through unhealthy food choices, and not engaging in exercise. Without acknowledging poor diet and physical inactivity as the consequences of obesity, as a health professional, implementing nutritional and physical activity interventions is the best approach to prevent childhood obesity (Stevens, 2009, p.233). The programâ&#x20AC;&#x;s focus for the intervention includes students, their parents, as well as schools. The main behavioral factors to influence are: increasing childrenâ&#x20AC;&#x;s fruit and vegetables consumption and physical inactivity. Increased fruit and vegetables intake is necessary to maintain a healthy diet because diets high in fruit and vegetable intake contains good sources of fiber, vitamin A and C, potassium and folate, which can protect against chronic diseases such as obesity and maintain a healthy body (Fruit and Vegetable Benefits, 2011). Physical activity should replace sedentary behaviors such as television viewing, playing video games and using

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the computer. Inactive children should be encouraged to have 60 minutes of moderate intensity exercise daily (U.S. Department of Health and Human Services, 2008). Environmental factors that should be focused on are parents and schools. Parents, the home environment and school are vital influences on children‟s dietary and physical behaviors (Kipping et al., 2011, p. 1). Studies have shown that interventions with parental involvement helps promote long term behavioral changes in children, and parental support is associated with lower rates of obesity (Stevens, 2010, p. 235). Parents are the gatekeepers for their children‟s food choices. They can guide and direct children‟s food intake, increase accessibility and availability to fruits and vegetables, limit sugar-sweetened beverage consumption, and reduce television screen time (Klesges et al., 1991, p. 859; Sharma, 2006, p. 156; Story et al., 2008, p. 255). These behavioral factors are changeable because they can be addressed within the home environment through parental support (Kumanyika et al., 2008, p. 439; Story et al., 2008, p. 255). Children spend an average of 34 hours a week at school (Juster, 2004), and consume up to two meals and snacks at school every day (Story et al., 2008, p.257). Thus, the school environment plays a huge role on a child‟s diet. Health professionals or teachers can educate students to develop healthy dietary habits at an early age at school (Carter, 2002, p. 2180). Schools should participate in federal school meals programs, including the National School Breakfast program and the National School Lunch Program to help students meet their recommended dietary intakes (RDI) and incorporate nutrition education in the core curriculum (Pekruhn, 2009, p.17). In addition, schools should decrease and limit availability of junk foods in school and increase opportunities for students to participate in at least 30 minutes of physical activity every school day. These environmental factors are changeable because they can be addressed through school environment (Kumanyika, 2008; Pekruhn, 2009).

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On the other hand, there are several environmental factors that are not changeable. Factors include food marketing on television, neighborhood safety and socioeconomic status (Powell et al., 2004, p. 137; Powell et al, 2007, p. 554). Family income is not a factor that is changeable in an intervention. Neighborhood safety is out of our control since socioeconomic status is the determining factor of where families can afford to live. Exposure to advertisements for unhealthy food products strongly influences a child‟s food and beverage preferences. However battling food marketing advertisement online and in television commercials are not going to give us an immediate outcome for the length of the intervention. In this situation, limiting screen time and internet use would greatly limit their exposure to these advertisements and resultingly increase physical activity (Alvy & Calvert, 2008; Powell et al, 2007). Question 4: Program Objectives The program‟s objectives are to find positive measurable changes in health, behavior, and environment outcomes. The expected health outcome for this intervention is to reduce childhood obesity rates in HISD by 10-12% within 12 months of implementation. In Campbell‟s systematic review (2001), a school-based intervention successfully reduced obese individuals between the ages of 3-9 years old by 12.2% and overweight students by 12.1% (p. 151). The study showed a decrease in weight and BMI as a result of the program, which can be considered a successful and measureable outcome. In the „Be Smart‟ intervention, students between the ages of 5-7 years reported reductions of sweetened non-carbonated drinks from 20.6 ounces/day to 18.4 ounces/day, a reduction of 40%. They also reduced soda intake from 23 ounces/day to 17.7 ounces/day, a reduction of 23% in the EatWalk Survey (Contento et al, 2007, S181). Fruit and vegetable consumption and physical activity levels are feasible behavioral outcome measures. Just like the „Be Smart‟ intervention, we can use survey questionnaires to measure dietary and

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physical activity changes. The pretest and posttest will provide information on how effective the intervention was during the implementation process. (a)Health Outcome: 

Elementary school students will see a reduction of childhood obesity rates by 10-12%, within a year after intervention.

(b) Behavior outcomes: 

Elementary school students will reduce the percentage of sweetened noncarbonated beverages by 40%, after 12 months.

Elementary school students will reduce the percentage of soda intake by 23%, after 12 months.

Increase f/v consumption by 0.32 servings per day, after 1 years. (Gortmaker et al., 1999)

Increase moderate to vigorous physical activity to at least 60 minutes every day (U.S. Department of Health and Human Services, 2008).

Interventions addressing environmental factors such as family support, family meal time, and school have been shown to influence health practices (Stevens, 2009, p. 234). Providing a supportive family and healthy school environment can result in positive behavioral outcomes immediately and for the long term. (c) Environment outcomes: 

Frequency of family meal time per week will increase fruit (P<0.05) and vegetables (P<0.01) intake after intervention (Larson et al., 2007, p. 1505).

Parental support will increase children‟s f/v consumption by accessibility (P<0.001) (Pearson et al., 2009,p. 879)

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ď&#x201A;ˇ

School will provide students with at least 30 minute of moderate to vigorous physical activity a day and measure progress by using BMI screenings before and after one school year to determine changes (Pekruhn, 2009, p.11).

Question 5: Determinants of the Risk Behavior There are various personal determinants associated to the risk behaviors in this paper. Many literature reviews have demonstrated that the Social Cognitive Theory (SCT) is the most effective theory to improve changes in dietary behaviors and psychosocial constructs (Bandura, 2004; Contento et al., 2007; Foerster et al., 1998; Kreausukon et al., 2011). SCT posits that human behavior is the result of the interaction between personal, behavioral, and environmental influences (McAlister et al., 2008, p. 170). There are a number of interventions that have shown positive outcomes using The Transtheoretical Model (TTM) to provide useful strategies to develop activities to improve diet and physical activity or using the Health Belief Model (HBM) to explain factors associated to the risk behaviors (Sahay et al., 2006, p. 424). A combination of these theories will be used to specify the personal determinants related to the risk behaviors for childhood obesity. The target risk behavior for this paper will focus on inadequate fruit and vegetable consumption and physical inactivity in children. Self-efficacy is a construct from SCT, defined as beliefs about personal ability to achieve a desired outcome based on their performance (McAlister, 2008, p.171). This construct is found to be extremely important in changing dietary processes. Young children have limited abilities to make conscious choices for healthy diets, thus it is necessary to turn to the parents and school district administrators to provide and facilitate their healthy diet. The lack of abilities to make mindful choices is linked to excess sugar-sweetened beverage intake and inadequate fruit and vegetable consumption (Nyberg et al., 17


2011, p.2). In Story et al. study (2008), research suggests even when a child‟s taste preferences for fruits and vegetables were low, but fruits and vegetables were available and accessible at home, their fruit and vegetable intake still increased (p. 255). Parents and school district administrators‟ ability to make fruits and vegetables readily accessible at home and school (selfefficacy to help children to eat more fruits and vegetables), has shown to be a significant determinant for increased fruits and vegetables consumption among 4th to 5th grade students (Cullen et al., 2000, p. 346). Research indicates that individuals with high BMI are more likely to be less active than those with low BMI. Girls who report to have access to a safe place to play and engage in sports, feel confident in their ability to stay active without fear of safety (Adkins et al., 2004, p.39S). This shows self-efficacy to be physically active will have a positive effect to girls‟ physical activity level. Outcome expectation is another construct from SCT, defined as “beliefs about the likelihood and value of the consequences of behavioral choices” (McAlister et al., 2008, p.171). This applies to the Adkins et al.‟s study (2004), when girls have access to a safe place to play, they are more likely to increase their physical activity levels (p.39S). In Contento et al. study (2007), authors stated that personal behavior is motivated by an understanding of having personal control over their environment. Thus, when children are given choices and learn to take personal control or action, they will result in greater positive outcome expectations (p. S180). Perceived barrier is a construct from The Health Belief Model (HBM). Perceived barrier is defined as “belief about the tangible and psychological costs of the advised action” (Champion & Skinner, 2008, p. 48). Several studies have shown that low-income, minority residents that have greater access to convenience stores tend to be at higher risk for obesity. It suggests a lack of access to supermarkets or places that offer healthful food products impacts a youth‟s dietary

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intake (Larson et al., 2009, p. 75). In contrast, access to fast-food restaurants and convenience stores has been found to be easily accessible in lower income neighborhoods. Consequently, these two factors are the barriers that prevent increased fruits and vegetables consumption and greater energy-dense foods among a child‟s diet. Finally, the last construct is perceived norm. This construct is from Theory of Reasoned Action (TRA), and concentrates with the individual‟s attitude and perception of perceived social norm as the main component that strengthens behavior (Montaño & Kasprzyk, 2008). Research has shown that family support is a strong predictor for a youth‟s dietary behavior, however peer influence plays a bigger role in their lifestyle choices once they grow older (Finnerty et al., 2009, p.376). Peer influence was measured using a questionnaire called Social Support and Eating Habits/Exercise Survey in Finnety et al.‟s study. Some of the questions from the survey included: „During the past three months, my friend‟s (1) „encouraged me not to eat “unhealthy foods like cake, sweets, chocolate” when I was tempted to do so‟; (2) „participated in physical activity or exercise with me‟; (3) „criticized me or made fun of me for being physically active or exercising‟. Data indicated there is a significant positive correlation between peer influence and physical activity. However, there is no association between dietary intake and peer influence (Finnety et al, 2009, p.381). We can conclude that peers have greater influence in participating in exercise with children-like them, compared to dietary consumption. Thus, increasing physical activity among peers may influence other to increase exercise.

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Question 6: Personal Determinants Lack of knowledge to make mindful choices Low self-efficacy -to play sports -to eat more f/v Perceived barrier to physical activity and eat healthy food Outcome expectation Perceived social norm

PRECEDE Model Behavioral Factors Lack of physical activity (recommended >60mins/day) Inadequate fruit & vegetables consumption (recommended >2cups/day) High sugar-sweetened beverages Excessive screen time (recommended <2hrs/day)

Environmental Factors

Personal Determinants Low Social economic status Living in a poor neighborhood / food desert Lack of support system Lack of parental communication Low education level Lack of parental knowledge about nutrition

Interpersonal: Lack of family support/involvement Family meal time Organizational: Federal school meals programs Community: Poor access to supermarket Poor access to community physical activity setting Neighborhood safety / crime Society: Food Marketing on Television 20

Enter here Health Problem Childhood Obesity among African American girls aged 6-11

Quality of Life Emotional impact: Low self-esteem Experience bullying Teasing Body dissatisfaction/image Health impact: Sleep apnea Hypertension Cardiovascular Disease Type 2 Diabetes Mellitus Depression Physical impact: Difficulties participating in sports Difficulties to participate in daily activity / functional status Other impact: Absenteeism Poor academic achievement

Note: Priority factors are highlighted in RED


References for Exam 1 Adkins, S., Sherwood, N.E., Story, M., & Davis, M. (2004, September). Physical Activity among African American Girls: the Role of Parents and the Home Environment. Obes Res, 12(Suppl), 38S-45S. Alvy, L.M., & Calvert, S.L. (2008). Food Marketing on Popular Children‟s Web Sites: A Content Analysis. J Am Diet Assoc., 108, 710-713. Andaya, A. A., Arredondo, E. M., Alcaraz, John E., Lindsay, S. P, & Elder, J. P. (2011). The Association between Family Meals, TV Viewing during Meals, and Fruit, Vegetables, Soda, and Chips Intake among Latino Children. Journal of Nutrition Education and Behavior, 43(5), 308-315. Baker, E. A., Kelly, C., Barnidge, E., Strayhorn, J., Schootman, M., Struthers, J., & Griffith, D. (2006, July). The Garden of Eden: Acknowledging the Impact of Race and Class in Efforts to Decrease Obesity Rates. American Journal of Public Health, 96(7), 1170-1174. Bandura, A. (2004). Health Promotion by Social Cognitive Means. Health Education and Behavior, 31(2), 143-164. Bartholomew, L.K., Parcel G.S., Kok, G., Gottlieb, N.H., & Fernández, M. E. (2011). Planning Health Promotion Programs: An Intervention Mapping Approach (4th ed., pp. 171-238). San Francisco, CA: Jossey-Bass. Bartholomew, L.K., Parcel, G. S., Kok, G., & Gottlieb, N. H. (2005). Using Core Processes [Power Point slides]. Retrieved from UTHSC Blackboard. Carter R.C. (2002). The Impact of Public Schools on Childhood Obesity. JAMA, 288, 2180. CDC: The Obesity Epidemic. (2011a, July 22). Retrieved September 20, 2011, from http://www.cdc.gov/CDCTV/ObesityEpidemic/Transcripts/ObesityEpidemic.pdf CDC: Obesity Rates among All Children in the United States. (2011b, April 21). Retrieved September 20, 2011, from http://www.cdc.gov/obesity/childhood/data.html CDC: Physical Activity Facts. (2011c, September 15). Retrieved September 26, 2011, from http://www.cdc.gov/healthyyouth/physicalactivity/facts.htm Champion, V. L. & Skinner, C. S. (2008). The Health Belief Model. In Glanz, K., Rimer, B. K., & Viswanath, K. (4th ed). Health Behavior and Health Education: Theory, Research, and Practice (p. 45-65). San Francisco: Jossey-Bass. Children at Risk: Growing up in Houston. (2008). Retrieved September 20, 2011, from http://childrenatrisk.org/research/book/

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Contento, I. r., Koch, P. A., Lee, h., Sauberli, w., & Calabrese-Barton, A. (2007). Enhancing personal agency and competence in eating and moving: Formative evaluation of a middle school curriculum – Choice, control, and change. Journal of Nutrition Education and Behavior, 39(5), S179-S186. Cullen, K.W., Baranowski, T., Rittenberry, L., Cosart, C., Owens, E., Hebert, D., & Moor, C. (2000). Socioenvironmental influences on Children‟s Fruit, Juice and Vegetable Consumption as reported by Parents: Reliability and Validity of Measures. Public Health Nutr, 3(3), 345-356. Daniel, D. Y. (2008, Dec). Examining Attendance, Academic Performance, and Behavior in Obese Adolescents. Journal of School Nursing, 24(6), 379-387. DSHS: The Burden of Overweight and Obesity in Texas: The Costs in Dollars and Lives. (2008a, June 30). Retrieved September 20, 2011, from www.dshs.state.tx.us/obesity/pdf/Cost_Obesity_Report.pdf DSHS: Texas Overweight and Obesity Statistics. (2008b, November). Retrieved September 20, 2011, from http://www.dshs.state.tx.us/obesity/NPAOPdata.shtm Finnerty, T., Reeves, S., Dabinett, J., Jeanes, Y.M., & Vögele, C. (2009. September). Effects of Peer Influence on Dietary Intake and Physical Activity in Schoolchildren. Public Health Nutrition, 13(3), 376-383. Foerster, S. B., Gregson, J., Beall, D. L., Hudes, M., Magnuson, H., Livingston, S. et al. (1998). The California children's 5-a-day-power play! campaign: Evaluation of a large-scale social marketing initiative. Family and Community Health, 21, 46-64. FRAC: National School Lunch Program. (2010). Retrieved September 26, 2011, from http://frac.org/newsite/wp-content/uploads/2009/09/cnnslp.pdf Friedman, N. & Fanning, E. L. (2004). Overweight and Obesity: An Overview of Prevalence, Clinical Impact, and Economic Impact. Disease Management, 7(1), S1-S5. Fruit and Vegetable Benefits. (2011). Retrieved September 27, from http://www.fruitsandveggiesmatter.gov/benefits/nutrient_guide.html Geier, A. B., Foster, G. D., Womble, L. G., McLaughlin, J., Borradaile, K. E., Nachmani, J., Sherman, S., Kumanyika, S., & Shults, J. (2007, August). The Relationship between Relative Weight and School Attendance among Elementary Schoolchildren. Obesity, 15(8), 2157-2161. Gonzales-Suarez, C., Worley, A., Grimmer-Somers, K., & Dones, V. (2009). School-Based Interventions on Childhood Obesity – a Meta-Analysis. Am J Prev Med, 37(5), 418-427.

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Gortmaker, S.L., Peterson, K., Wiecha, J., Sobol, A.M., Dixit, S., Fox, M.K., & Laird, N. (1999). Reducing Obesity via a School-Based Interdisciplinary Intervention among Youth. Arch Pediatr Adolesc Med., 153, 409-418. Juster, F. T., Ono, H., & Stafford, F. P. (2004, November). Changing Times of American Youth: 1981-2003. Retrieved September 20, 2011, from http://ns.umich.edu/Releases/2004/Nov04/teen_time_report.pdf Klesges, R.C., Stein, R.J., Eck, L.D., Isbell, T.R., & Klesges, L.M. (1991). Parental Influence on Food Selection in Young Children and its Relationships to Childhood Obesity. Am J Clin Nutr, 53, 859-864. Koplan, J. P., Liverman, C. T., & Kraak, V. I. (2005). Preventing Childhood Obesity: Health in the Balance: Executive Summary. Journal of American Dietetic Association, 105 (1), 131-138. Kreausukon, P., Gellert, P., Lippke, S., & Schwarzer, R. (2011, August 7). Planning and Selfefficacy can Increase Fruit and Vegetable Consumption: a Randomized Controlled Trial. J Behav Med., 1-9. doi:10.1007/s10865-011-9373-1 Kumanyika, S.K., Obarzanek, E., Stettler, N., Field, A.E., Fortmann, S.P., Franklin, B.A., Gillman, M.W., Lewis, C.E., Poston II, W.C., Stevens, J., & Hong, Y. (2008, July 22). Population-Based Prevention of Obesity – the Need of Comprehensive Promotion of Healthful Eating, Physical Activity, and Energy Balance. AHA Scientific Statement, 428464. Larson, N.I., Neumark-Sztainer, D., Hannan, P.J., & Story, M. (2007). Family Meals during Adolescence are Associated with Higher Diet Quality and Healthful Meal Patterns during Young Adulthood. J Am Diet Assoc., 107, 1502-1510. Larson, N. I., Story, M. T., Nelson, M. C. (2009). Neighborhood Environments: Disparities In Access to Healthy Foods in the U.S. Am J Prev Med, 36(1), 74-81. Ludwig, D. S., Peterson, K. E., & Gortmaker, S. L. (2001, February 17). Relation between Consumption of Sugar-sweetened Drinks and Childhood Obesity: a prospective, observational analysis. The Lancet, 357, 505-508. Maniccia, D.M., Davison, K. K., Marshall, S. J., Manganello, J. A., & Dennison, B. A. (2011, June 27). A Meta-analysis of Interventions that Target Children‟s Screen Time for Reduction. Pediatrics, 128(1), 193-210. McAlister, A.L., Perry, C.L., & Parcel, G.S. (2008). How Individuals, Environments, and Health Behaviors Interact – Social Cognitive Theory. In Health Behavior and Health Education: Theory, Research, and Practice (4th ed., pp. 169-188). San Francisco, CA: Jossey-Bass.

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Miller, P., Moore, R. H., & Kral, T. V. E. (2011). Children‟s Daily Fruit and Vegetable Intake: Associations with Maternal Intake and Child Weight Status. Journal of Nutrition Education and Behavior, 43(5), 396-400. Montaño D.E. & Kasprzyk, D. (2008). Theory of Reasoned Action, Theory of Planned Behavior, and the Intergrated Behavioral Model. In Health Behavior and Health Education: Theory, Research, and Practice (4th ed., pp. 68-96). San Francisco, CA: Jossey-Bass. Nguyen, D. M. & El-Serag, H. B. (2009). The Big Burden of Obesity. Gastrointestinal Endoscopy, 70(4), 752-757. Nyberg, G., Sundblom, E., Norma, A, & Elinder, L. S. (2011). A Healthy School Start-Parental Support to Promote Healthy Dietary Habits and Physical Activity in Children: Design and Evaluation of a Cluster-randomised Intervention. BMC Public Health, 11(185), 1-7. O‟Dea, J. A. (2004, August 24). Prevention of Child Obesity: „First, do no harm‟. Health Education Research, 20(2), 259-265. Ogden, C. & Carroll, M. (2010, June 18). Prevalence of Obesity among Children and Adolescents: United States, Trends 1963-1965 Through 2007-2008. Retrieved September 20, 2011, from http://www.cdc.gov/nchs/fastats/overwt.htm Pearson, N., Atkin, A.J., Biddle, S., & Gorely, T. (2009, August 20). A Family-based Intervention to Increase Fruit and Vegetable Consumption in adolescents: a pilot-study. Public Health Nutrition, 13(6), 876-885. Pekruhn, C. (2009). Preventing Childhood Obesity – a School Health Policy Guide. Retrieved September 21, 2011, from http://www.rwjf.org/files/research/20090506nasbeguide.pdf Physical Activity Levels among Children aged 9-13 years -- United States, 2002. (2003, August 22). MMWR: Morbidity & Mortality Weekly Report, 52(33), 785-788. Pinhas-Hamiel, O., Singer, S., Pilpel, N., Fradkin, A., Modan, d., & Reichman, B. (2005, October 4). Health-related quality of life among children and adolescents: associations with obesity. International Journal of Obesity, 30, 267-272. Powell, L. M., Slater, S., & Chaloupka, F. J. (2004). The relationship between community physical activity settings and race, ethnicity and socioeconomic status. Evidence-Based Preventive Medicine, 1(2), 135-144. Powell, L. M., Szczypka, G., & Chaloupka, F. J. (2007, June). Exposure to Food Advertising on Television among US Children. Arch PediatrAdolesc Med, 161, 553-560. Taras, H. & Potts-Datema, W. (2005, October). Obesity and Student Performance at School. Journal of School Health, 75(8), 291-295.

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Sahay, T.B., Ashbury, F.D., Roberts, M., & Rootman, I. (2006, October). Effective Components for Nutrition Interventions: a Review and Application of the Literature. Health Promotion Practice, 7(4), 418-427. Siegrist, M., Hanssen, H., Lammel, C., Haller, B., & Halle, M. (2011). A Cluster Randomised School-based Lifestyle Intervention Programme for the Prevention of Childhood Obesity and Related Early Cardiovascular Disease (JuvenTUM 3). BMC Public Health, 11(258), 1-7. Sharma, M. (2006). School-based Interventions for Childhood and Adolescent Obesity. Obesity Review, 7, 261-269. Shore, S., Sachs, M., Lidicker, J., Brett, S., Wright, A., & Libonati, J. (2008). Decreased scholastic achievement in overweight middle school students. Obesity, 16(7), 1535-1538. Strauss, R. S. (2000, January). Childhood Obesity and Self-Esteem. Pediatric, 105(1), 1-5. Stern, M., Mazzeo, S. E., Porter, J., Gerke, C., Bryan, D., & Laver, J. (2006, September). SelfEsteem, Teasing and Quality of Life: African American Adolescent Girls Participating in a Family-Based Pediatric Overweight Intervention. Journal of Clinical Psychology in Medical Settings, 13(3), 217-228. Stevens, C.J. (2010, July). Obesity Prevention Interventions for Middle School-Age Children of Ethnic Minority: A Review of the Literature. Journal of Specialists in Pediatric Nursing, 15(3), 233-243. Story, M., Kaphingst, K.M., Robinson-Oâ&#x20AC;&#x;Brien, R. & Glanz, K. (2008). Creating Healthy Food and Eating Environments: Policy and Environmental Approaches. Annu. Rev. Public Health, 29, 253-272. Sugar-sweetened Beverages: Extra Sugar, Extra Calories, and Extra Weight. (2009, November). Retrieved September 26, 2011, from http://www.cdph.ca.gov/programs/wicworks/Documents/RethinkYourDrink/WICRethinkYourDrink-SugarSweetenedBeveragesCACPHA.pdf U.S. Census Bureau. Harris County quick facts. Retrieved September 20, 2011, from http://quickfacts.census.gov/qfd/states/48/48201.html USDA: Food Groups. (2011, June 21). Retrieved September 26, 2011, from http://www.choosemyplate.gov/foodgroups/index.html U.S. Department of Health and Human Services: Childhood Obesity. (2001). Retrieved September 21, 2011, from http://aspe.hhs.gov/health/reports/child_obesity/

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U.S. Department of Health and Human Services: Physical Activity Guidelines for Americans. (2008, October 17). Retrieved September 26, 2011, from http://www.health.gov/paguidelines/factsheetprof.aspx Wang, Y., Tussing, L., Odoms-Young, A., Braunschweig, C., Flay, B., Hedeker, D., & Hellison, D. (2006). Obesity Prevention in Low Socioeconomic Status Urban African-American Adolescents: Study Design and Preliminary findings of the HEALTH-KIDS study. European Journal of Clinical Nutrition, 60(1), 92-103. WHO: Overweight and Obesity. (2011, March). Retrieved September 20, 2011, from http://www.who.int/mediacentre/factsheets/fs311/en/ Young-Hyman, D., Schlundt, D. G., Herman-Wenderoth, L., & Bozylinski, K. (2003). Obesity, Appearance, and Psychosocial Adaptation in Young African American Children. Journal of Pediatric Psychology, 28(7), 463-472.

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Exam 2 - Matrices, Methods, and Applications on Childhood Obesity April Chu University of Texas Health Science Center â&#x20AC;&#x201C; Houston

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Question 7: Behavioral outcomes and environmental conditions Poor dietary intake and physical inactivity are the two most important behaviors associated with obesity. (Baker et al., 2006, p. 1170; Gonzales-Suarez et al., 2009, p. 418; Nyberg et al., 2011, p.2; Sharma, 2006, p. 262; Siegrist et al., 2011, p.2; Stevens, 2009, p. 233). Therefore, it is crucial to focus on changing dietary behaviors and increasing physical activity in this intervention for my targeted population. Behavioral outcomes that must be addressed include increasing physical inactivity, increasing fruit and vegetables consumption, reducing sugarsweetened beverages, and limiting television screen time. Although there are many possible behavioral changes that may work, I will only concentrate on the changes for lack of physical activity and inadequate fruit and vegetables consumption for this intervention. Parents are the gatekeeper for a child‟s food choices at home, while the school acts like a gatekeeper while at school. Home and school are two settings where children spend a significant amount of their time in. Thus it is important to incorporate parents and schools into the objectives of the intervention. The first behavioral change is to increase at least 1 – 1 ½ cups of fruit and 1 ½ - 2 cups of vegetables consumption every day. Studies have shown that increasing fruits and vegetables intake is essential to maintain a healthy diet, which also helps overweight and obese children to lose weight (Fruits and Vegetables Benefits, 2011; Miller et al., 2011; Sahay et al., 2006). The second behavioral change is to increase moderate to vigorous physical activity to at least 60 minutes every day. Regular physical activity can prevent weight gain and promote a healthier body image among school age children (Evans et al., 2008; Nyberg et al., 2011). Physical activity should replace sedentary behaviors such as television viewing, playing video games and using the computer. Children should aim to engage in at least 60 minutes of physical activity

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every day (CDC, 2011; U.S. Department of Health and Human Services, 2008). These behavioral factors are all changeable and can be addressed within the home and school environment with the help of parents and school teachers (Kumanyika, 2008; Pekruhn, 2009). Environmental factors that must be address are parents and schools. Parental involvement has shown to correlate with improvement on childrenâ&#x20AC;&#x;s fruit and vegetable intake and physical activity level, which lower the rate of obesity (Andaya et al., 2011; Stevens, 2010; Wang et al., 2006). Parents are great role model to guide children to eat healthier food choices during family meal time, and encourage them to participate in physical activity. In addition, parents need to increase accessibility and availability to fruit and vegetables, and increase social support for adherence to a healthy diet. These behavioral factors are all changeable and can be addressed within the home environment through parental support (Klesges et al., 1991, p. 859; Kumanyika, 2008, p. 439; Sharma, 2006, p. 156; Story et al., 2008, p. 255). Children spend a significant amount of time in school and consume up to 2 meals each day in school (Story et al., 2008, p.257). Health professional or teachers can help to address and reinforce healthy dietary habits and active lifestyles at an early age (Carter, 2002, p. 2180). Therefore, school is a crucial component for the environmental factor. Schools can also provide social support to eliminate bullying and teasing, thus children can learn to focus on the positive behavioral changes in a safe environment and avoid negative quality of life. Schools should participate in federal school meals program to help students meet their recommended dietary intake (RDI) and incorporate nutrition education in the core curriculum (Pekruhn, 2009, p.17). Finally, schools should limit availability of competitive foods and aim to provide opportunities for students to participate in at least 30 minutes of physical activity every school day. These

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environmental factors are changeable because they can be addressed through school and home environment (Kumanyika, 2008; Pekruhn, 2009). Question 8: Priority population differentiation As described in Exam 1, the priority population for the childhood obesity intervention program is addressed to target African American girls from ages 6-11, living in Houston, Texas. According to the DSHS Obesity Data Sheet, prevalence of obesity and obese combined for children in Texas was highest among African American girls in the 4th grade, with 51.7%. The rates for Hispanic boys in the 4th and 8th grade were 50%, and 49.2%, respectively (2008). The prevalence rates for both genders and ethnicity were very close, therefore it is impractical to focus on girls, or just African American population only in the intervention. The intervention is going to target all school age children in Houston Independent School District (HISD) and across all ethnicities. All the participants in the intervention will receive the same program with no differences among the priority population. Intervention will have separate objectives designed for both parents and schools, and there will not be any subgroups between the three specific groups. In addition, the determinants and objectives will remain the same between the groups even though the intervention consists of diverse ethnic group. Question 9: Performance objectives In order to develop an effective intervention program, we must create measurable and realistic objectives for achievable behavioral outcomes. Performance outcome (PO) is the steps needed to follow to achieve the desired behavior objective (BO) and environmental objective (EO). The appropriate performance objectives for the health promotion objectives are listed below:

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Behavioral Objectives and Performance Outcomes: BO1: All children will increase consumption to at least 1 – 1 ½ cups of fruit and 1 ½ - 2 cups of vegetables every day at home. PO 1.1 Make the decision to eat more f/v at home. PO1.2 Ask their parents to purchase more f/v at the grocery store. PO 1.3 Help parents identify other food that has f/v content. PO 1.4 Try new f/v. PO 1.5 Eat f/v snacks that are readily available and easily prepared by parents at home. BO2: All children will increase moderate to vigorous physical activity to at least 60 minutes every day. PO 2.1 Make the decision to participate in physical activity. PO 2.2 Find places to engage in physical activity. PO 2.3 Ask peers to join them in physical activity. PO 2.4 Do physical activity by themselves or with peers. Environmental Objectives and Performance Outcomes: EO1: School district will increase children‟s fruit and vegetables consumption at school. PO 1.1 Make the decision to provide more f/v options for school. PO 1.2 Provide a variety of f/v options to school children. PO 1.3 Limit offerings of competitive foods. PO 1.4 Enforce federal nutrition standards for all f/v items sold during school. PO 1.5 Identify possible resources to increase f/v purchases. EO2: Parents will increase children‟s fruit and vegetables consumption at home. PO 2.1 Find stores that carry fresh and/or frozen f/v options. PO 2.2 Purchase f/v at grocery stores. PO 2.3 Prepare family meals with f/v by using healthy cooking methods. PO 2.4 Encourage children to eat more f/v during meal time. PO 2.5 Monitor their child‟s f/v consumption. PO 2.6 Increase frequency of family meal time. PO 2.7 Communicate with their child about the importance of healthy eating behavior during family meal time. PO 2.8 Make f/v snack options accessible for children at home. EO3: Parents will increase physical activity. PO 3.1 Encourage child to participate in physical activity. PO 3.2 Make time to participate in physical activity with child. PO 3.3 Plan physical activity to participate with child. EO4: Schools will provide opportunity for students to participate in at least 30 minutes of physical activity every school day. PO 4.1 Encourage students to participate in physical activity. PO 4.2 Offer time for students to participate in physical activity during school hours. PO 4.3 Plan physical activity for students. PO 4.4 Participate in planned physical activity with students. 11


EO5: Schools will incorporate nutrition education in the core curriculum. PO 5.1 Choose a successful coordinated health program like SPARK or CATCH. PO 5.2 Adopt the coordinated health program. PO 5.3 Implement the coordinated health program.

The prevalence of obesity is highest among people with fewer years of education, especially in the minority population. Research indicates that nutrition education could provide students the tools they need to make healthy choices regarding healthy eating and physical activity (Carter, 2002). By implementing nutrition education in the core curriculum, research has found that it can potentially influence studentsâ&#x20AC;&#x; beliefs and attitudes toward eating a healthy diet and maintaining a healthy weight (Story, 1999). According to the Youth Behavior Surveillance System, the percentage of students attending physical education classes has dropped 10% from 1991-2001 (Blumenthal, Hendi & Marsillo, 2002). Schools have the necessary equipments such as gymnasium, outdoor play area, and a physical education program to benefit students and help them meet their recommended daily amount of physical activity. Lastly, by implementing a coordinated health program, it can expose students to learn healthy eating patterns, and physical activity skills to adopt at home. These performance objectives were chosen based on research from other obesity intervention programs. However, it is important to observe the progress from students, parents, and any faculty and staff from school involved in the intervention to evaluate for validity. Question 10: Specific determinants Many literature reviews have demonstrated that the Social Cognitive Theory (SCT) is the most effective theory to improve changes in dietary behaviors, physical inactivity and psychosocial constructs, particularly for school-based interventions (Bandura, 2004; Contento et al., 2007; Foerster et al., 1998; Gortmaker et al., 1999; Kreausukon et al., 2011) There are a 12


number of interventions that have shown positive outcomes using The Transtheoretical Model (TTM) to provide useful strategies to develop activities to improve diet and physical activity (Patrick et al., 2011) or using the Health Belief Model (HBM) to explain factors associated to the risk behaviors (Sahay et al., 2006, p. 424). A combination of these theories will be used to specify the personal determinants related to the risk behaviors for childhood obesity. To validate the performance objectives, I will observe and interview the participants, parents, teachers and program facilitators by conducting a focus group to determine if the determinants are appropriate for the program. Through observation and feedback from participants, parents, teachers and program facilitators can provide a better insight on how to improve the performance objectives (Bartholomew et al., 2011, p. 267). Obesity prevention programs that emphasis on increasing knowledge and skills are the most successful at helping youth adopt healthy eating behavior and maintain a physically active lifestyle (Rowe et al., 1997; Story, 1999; Warren et al., 2003). If people lack of knowledge and skills on how to improve their health, they will have no intention to change their lifestyle (Bandura, 2004, p. 144). Study has shown that increasing knowledge and skills in both parents and children are linked to improve dietary quality and physical activity (Gibson, Wardle, & Watts, 1998; Gortmaker et al., 1999; Sahay et al., 2006). Thus, these determinants must be incorporate in parents and childrenâ&#x20AC;&#x;s curriculum for the intervention to ensure that they are exposed to the tools needed to succeed at making healthy lifestyle changes. Self-efficacy is a construct from SCT, defined as beliefs about personal ability to achieve a desired outcome based on their performance (McAlister, 2008, p.171). This construct is found to be extremely important in changing dietary processes. Young children have limited abilities to make conscious choices for healthy diets, thus it is necessary to turn to the parents

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and school district administrators to provide and facilitate their healthy diet. The lack of abilities to make mindful choices is linked to excess sugar-sweetened beverage intake and inadequate fruit and vegetable consumption (Nyberg et al., 2011, p.2). In Story et al. study (2008), research suggests even when a child‟s taste preferences for fruits and vegetables were low, but fruits and vegetables were available and accessible at home, their fruit and vegetable intake still increased (p. 255). Parents and school district administrators‟ ability to make fruits and vegetables readily accessible at home and school (self-efficacy to help children to eat more fruits and vegetables), has shown to be a significant determinant for increased fruits and vegetables consumption among 4th to 5th grade students (Cullen et al., 2000, p. 346; Hoelscher et al., 2003). Research indicates that individuals with high BMI are more likely to be less active than those with low BMI. Girls who report to have access to a safe place to play and engage in sports, feel confident in their ability to stay active without fear of safety (Adkins et al., 2004, p.39S). This shows self-efficacy to be physically active will have a positive effect to girls‟ physical activity level. Outcome expectation is another construct from SCT, defined as “beliefs about the likelihood and value of the consequences of behavioral choices” (McAlister et al., 2008, p.171). This applies to the Adkins et al.‟s study (2004), when girls have access to a safe place to play, they are more likely to increase their physical activity levels (p.39S). In Contento et al. study (2007), authors stated that personal behavior is motivated by an understanding of having personal control over their environment. Thus, when children are given choices and learn to take personal control or action, they will result in greater positive outcome expectations (p. S180). Perceived barrier is a construct from The Health Belief Model (HBM). Perceived barrier is defined as “belief about the tangible and psychological costs of the advised action” (Champion & Skinner, 2008, p. 48). Several studies have shown that low-income, minority residents that

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have greater access to convenience stores tend to be at higher risk for obesity. It suggests a lack of access to supermarkets or places that offer healthful food products impacts a youthâ&#x20AC;&#x;s dietary intake (Larson et al., 2009, p. 75). In contrast, access to fast-food restaurants and convenience stores has been found to be easily accessible in lower income neighborhoods. Consequently, these two factors are the barriers that prevent increased fruits and vegetables consumption and greater energy-dense foods among a childâ&#x20AC;&#x;s diet. The last selected determinant is social norms, targeted to focus in home and school environment. Many studies have found that overweight and obese children experience over normalweight peers include poor self-esteem, teasing, and negative body images (Oâ&#x20AC;&#x2122;Dea, 2004; Taras & PottsDatema, 2005; Strauss, 2000). Social norms have been shown to be an effective determinant for behavior change and improving self-esteem (Strauss et al., 2001). It is crucial that parents and teachers serve as positive role model to reinforce and encourage students to make healthy food choices and participate in physical activity.

Question 11: Change objectives Although there are many performance objectives mentioned above for this intervention, I only create matrices for few of them. Keep in mind that I will implement all the performance objectives with its appropriate change objectives for the intervention.

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BO1: All children will increase consumption to at least 1 – 1 ½ cups of fruit and 1 ½ - 2 cups of vegetables every day at home. Personal Determinants Performance Objective (PO)

Knowledge (K)

Skills (S)

Self-Efficacy (SE)

PO. 1.1 Make the decision to eat more fruit and vegetable (f/v) at home

K.1.a Identify what f/v are.

S.1.a N/A

SE.1.a Express confidence in ability to increase and/or maintain daily f/v intake at home.

K.1.b List health benefits when meeting the daily recommendation of f/v intake.

K.1.c List health problems associated with childhood obesity. PO. 1.2 Ask their parents to purchase more f/v at the grocery store

K.1.d State the best way to approach parents to buy more f/v at the grocery store.

S.1.b Demonstrate ability to talk to their parents to buy more f/v at the grocery store.

SE.1.b Express confidence in ability to ask their parents to make the purchase.

PO. 1.3 Help parents identify other food that has f/v content

K.1.e List other food that has f/v content.

S.1.c Demonstrate ability to negotiate with parents to change snack options that contain acceptable f/v content.

SE.1.c Express confidence in ability to distinguish other f/v options for parents.

K.1.f Define snack and beverage alternative that has acceptable f/v content. PO. 1.4 Try new f/v

K.1.g Identify f/v that is S.1.d Demonstrate the not normally included in ability to try new f/v children’s diet. options.

SE.1.d Express confidence the willingness to try new f/v options.

PO. 1.5 Eat fruit and vegetable snacks that

K.1.h Identify the positive outcome when

SE.1.e Express confidence to eat

S.1.e Demonstrate the ability to eat and/or 10


are readily available and consuming f/v easily accessible prepared by parents at home. K.1.i Identify the positive outcome when eat readily available and easily accessible fruit and vegetable snacks instead of the highcalories snack items.

maintain the daily recommended f/v intake.

available fruit and vegetable snacks instead of the highcalories snack items.

S.1.g Demonstrate ability to not consume high-calories snack items and choose to eat healthy options when they are available and easily accessible.

K.1.j Locate where parents store the prepared f/v snacks at home.

EO1: School district will increase childrenâ&#x20AC;&#x;s fruit and vegetable consumption at school. Personal Determinants Performance Knowledge Skills (S) Self-Efficacy Outcome Social Norms Objective (K) (SE) Expectations (SN) (PO) (OE) PO 2.1 Make K.2.a List the S.2.a SE.2.a OE.2.a Expect SN.2.a N/A the decision benefits for Demonstrate Express that more f/v to provide providing the ability to confidence in options more f/v more f/v budget for ability to available at options for options for f/v provide more school will school school purchases. fruit and increase children. vegetable school options. childrenâ&#x20AC;&#x;s f/v K.2.b Define daily recommended SE.2.b recommended daily value for Express level. f/v confidence in ability to K.2.c Find locate places place to buy to purchase f/v within f/v in budget. affordable price. PO 2.2 K.2.d List S.2.b SE.2.c OE.2.b SN.2.b Provide a what f/v that Demonstrate Express Expect that Recognize 11


variety of f/v options to school children

school children are familiar and un-familiar with. K.2.e List ways to introduce familiar and un-familiar f/v to school children.

PO 2.3 Limit offerings of competitive foods

PO 2.4 Enforce federal nutrition standards for all f/v items sold during school

PO 2.5

K.2.f List the competitive foods available at school. K.2.g Demonstrate the negative consequence of offerings competitive foods to children. K.2.h Recognize the needs to meet proper nutrition standards for all f/v item.

K.2.i List

the ability to survey what f/v school children are familiar and not familiar with.

confidence in ability to offer a variety of f/v to school children after receiving survey results.

introducing un-familiar f/v to school children will not feel strange toward them anymore. OE.2.c. Expect that introducing f/v to school children will increase their f/v consumption. OE.2.d Expect that limiting competitive foods will improve childrenâ&#x20AC;&#x;s choices to more healthy food items.

S.2.c Demonstrate the ability to reduce the availability of competitive foods at school.

SE.2.d Express confidence in ability to reduce offerings of competitive foods.

S.2.d N/A

SE.2.e Express confidence in ability to meet the recommended nutrition standards for all f/v items sold at school.

OE.2.e Expect that meeting the proper school nutrition standards for all f/v items sold during school will improve childâ&#x20AC;&#x;s recommended daily intake.

S.2.e

SE.2.f

OE.2.f Expect

12

others like them are also providing a variety of f/v options to other school districts.

SN.2.c Recognize others like them are restricting competitive foods availability.

SN.2.d Recognize that others like them are meeting school nutrition standard protocol to help meet children recommended f/v daily intake. SN.2.e N/A


Identify possible resources to increase f/v purchases

resources for f/v options

Demonstrate ability to find potential f/v providers

Express confidence to partner with f/v providers

S.2.f Demonstrate ability to establish a relationship with f/v providers

that working with f/v providers will increase a variety of fresh produces available for school cafeteria.

EO2: Parents will increase childrenâ&#x20AC;&#x;s fruit and vegetable consumption at home. Personal Determinants Performance Knowledge Skills (S) Self-Efficacy Social Objectives (K) (SE) Norms (SN) (PO) PO 3.1 Find K.3.a Define S.3.a SE.3.a Express SN.3.a stores that what fresh Demonstrate confidence to Recognize carry fresh and frozen the ability to find these other parents and/or frozen f/v options locate these stores that like them are f/v options are. stores that carry fresh finding stores carry fresh and/or frozen that carry K.3.b. List and/or f/v. fresh and/or stores that frozen f/v. frozen f/v carry fresh options. and frozen f/v items. PO 3.2 K.3.c. S.3.b SE.3.b Express SN.3.b Purchase f/v Identify Demonstrate confidence to Recognize at grocery where f/v are the ability to purchase f/v at other parents stores located at the find f/v at grocery stores. like them grocery the store, purchase stores. and buying fruits and them. vegetables. K.3.d. Make a list of f/v to purchase at grocery stores. PO 3.3 K.3.e List S.3.c SE.3.c Express SN.3.c Prepare different Demonstrate confidence to Recognize family meals healthy the ability to incorporate other parents 13

Barriers (B)

B.3.a Access to stores that carry fresh and/or frozen f/v options

B.3.b Assign money to purchase f/v at grocery store.

B.3.c Allow enough time to prepare family


with f/v by using healthy cooking methods

cooking techniques to prepare meals with f/v. K.3.f Acknowledge the advantage and disadvantage of different cooking techniques.

PO 3.4 Encourage children to eat more f/v during meal time

PO 3.5 Monitor their child‟s f/v consumption

PO 3.6 Increase

K.3.g Recognize the benefit of including f/v in family meals. K.3.h Identify different strategies to encourage children to eat more f/v during meal time. K.3.i Identify ways to increase monitoring child‟s f/v intake. K.3.j. Recognize and describe how much and what f/v children are consuming. K.3.k List the advantage of

prepare family meals by using healthy cooking techniques.

daily recommended levels of f/v for family meals.

like them prepare fruits and vegetables by using healthy cooking techniques.

meals using healthy cooking methods

S.3.d Demonstrate using different strategies to encourage children to eat more f/v during meal time. S.3.e Keep a food log to help monitor the amount of f/v children are consuming.

SE.3.e Express confidence to use different strategies to encourage children to eat more f/v during meal time.

SN.3.d

B.3.e Provide accessible to healthy choices during meal time.

SE.3.f Express confidence to continue monitoring their child‟s f/v consumption.

SN.3.e Recognize other parents like them monitor their child‟s f/v intake.

B.3.e N/A

S.3.f N/A

SE.3.g Express confidence to

SN.3.f Recognize

B.3.f Plan to increase

SE.3.d. Express confidence to cook f/v by using healthy cooking techniques.

14

Recognize other parents like them encourage children to consume more f/v during meal time.

B.3.d Recognize other healthy cooking methods.


frequency of family meal time

having more family meal time.

PO 3.7 Communicate with their child about the importance of healthy eating behavior during family meal time

K.3.l Recognize facts about healthy eating behavior.

PO 3.8 Make f/v snack options accessible for children at home

K.3.n List the f/v snack options that their child prefer to eat.

eat with their child more during meal time.

S.3.g N/A

K.3.m List the advantages of adapting healthy eating behavior.

S.3.h Prepare f/v snack options accessible for children K.3.o Locate to eat at where parents home. store the prepared f/v snacks at home.

other parents like them eat with their child more during meal time. SE.3.h SN.3.g Demonstrate Acknowledge open other parents communication like them with child communicate with their SE.3.i Express child about confidence in the talking with importance of child. healthy eating SE.3.j. Express behavior. confidence in ability to present accurate information about healthy eating behavior. SE.3.k Express SN.3.h confidence in Recognize ability to make other parents f/v snack like them accessible for prepare f/v children at snack options home. accessible for their children at home.

15

frequency of family meal time.

B.3.g Allow open communication with child about the importance of healthy eating behavior during family meal time.

B.3.h Plan to make f/v snack options accessible for children at home.


Question 12: Methods and practical applications Methods for achieving desire behavior change are general technique or process designed to influence changes in the determinants of behavioral and environmental conditions (Bartholomew et al., 2011). Practical applications are techniques chosen to apply the methods in ways that fit the intervention (Bartholomew et al., 2011). Methods and applications for this intervention were mostly based on the Social Cognitive Theory. However, Goal-setting Theory, Theories of Social Networks and Social Support, Theories of Automatic, Impulsive, and Habitual Behavior, Theories of Self-Regulation, Theories of Learning, Trans Theoretical Model, Health belief Model and Theories of Information Processing were also used for the intervention as well. Methods and application that were selected for this intervention were broken into three tables based on the behavioral and environmental changes. Table 1: Methods and Applications for Behavioral Objective 1 BO1: All children will increase consumption to at least 1 â&#x20AC;&#x201C; 1 ½ cups of fruit and 1 ½ - 2 cups of vegetables every day at home. Determinants Change Methods Applications Objectives Knowledge K.1.a, K.1.b, Active learning Facilitators will teach students about K.1.c, K.1.e, K.1.f, different f/v, the health benefit when K.1.g, K.1.h, K.1.i Role-play/ meeting the daily recommended f/v modeling intake, the health problems linked with childhood obesity, other food Cues to action that has f/v content, f/v snack and beverage alternative, try new f/v, and positive outcome when consuming f/v and f/v snacks through practice skills, workbook, etc. Facilitators will provide information on the health benefit, health problems associated with childhood obesity, positive outcome when consuming f/v to students. Then, students will pair up, and one student will pretend to be the dietitian giving out info, and another student will 21


pretend to not know anything relate to f/v.

Skills

K.1.d

Discussion

K.1.j

Direct experience

S.1.b-S.1.g

Guided practice Self-monitoring of behavior Role-play/ modeling

Facilitators hang up posters of healthy eating info around the classroom. Students will have a discussion on how to approach their parents to buy more f/v. Parents will direct students at home to locate where the prepared f/v snacks are at. Facilitators will model the appropriate behavior on how to approach their parents to purchase more f/v and change snack options, and turn down high-calories snack items. Then ask the students to perform the behavior back. Afterward, facilitators will provide feedback for both correction and emphasis on aspects done well. Students will keep a food diary to keep track on the amount of f/v consumed.

Self-efficacy

SE.1.a-SE.1.e

Goal setting

Facilitators will create a script and ask students to act out how to talk to their parents to buy more f/v. Facilitators will discuss the recommended amount of f/v for students to consume, and then students will set their own goals of how much f/v they will consume each day.

Table 2: Methods and Applications for Environmental Objective 1 EO1: School district will increase childrenâ&#x20AC;&#x2122;s fruit and vegetable consumption at school. Determinants Change Methods Applications Objectives

22


Knowledge

K.2.a, K.2.b, K.2.f, Active learning K.2.h

K.2.c, K.2.i

Direct experience

K.2.d, K.2.e

Counterconditioning

K.2.g

Consciousness raising

S.2.a, S.2.c, S.2.e, S.2.f

Self-monitoring of behavior

S.2.b

Participation

Self-efficacy

SE.2.a-SE.2.f

Public commitment

Outcome Expectation

OE.2.a-OE.2.f

Consciousness raising

Social Norms

SN.2.b-SN.2.d

Developing new social network linkages

Skills

Reinforcement 23

School dietitian will educate school board director about the benefit for providing more f/v options for students, recommended daily value for f/v, competitive foods available at school, the needs to meet proper nutrition standards for all f/v items. School board director will locate places and resources to purchase more f/v. Facilitators and school dietitian will brainstorm to demonstrate unfamiliar f/v to students. School dietitian reminds school board director the negative consequence of offerings competitive foods to students. School board director will keep a log of budget for f/v purchases, keep track of potential f/v providers, and build relationship with f/v providers. School board director and program coordinator include students to develop a list of unfamiliar f/v. School board director sign contracts to provide more f/v, purchase more f/v, limit offerings of competitive foods, partnering with f/v providers, and meet the recommended nutrition standards for all f/v items sold at school, which are then placed on the schoolâ&#x20AC;&#x;s office for all to see. School board director will provide more f/v option, limit competitive food, enforce federal nutrition standards, and working with f/v providers to increase variety of fresh produces available at school, which all will improve studentsâ&#x20AC;&#x; f/v intake. School board director will meet with superintendents from different school districts to provide support and feedback to improve f/v consumption in students.


Provision of federal nutrition standards for National breakfast and lunch meals. Table 3: Methods and Applications for Environmental Objective 2 EO2: Parents will increase childrenâ&#x20AC;&#x2122;s fruit and vegetable consumption at home. Determinants Change Methods Applications Objectives Knowledge K.3.a, K.3.b, Active learning Facilitators will teach parents about K.3.c, K.3.e, different fresh and frozen f/v K.3.g, K.3.h, K.3.n options, stores that carry f/v items, different healthy cooking techniques, strategies to encourage children to eat more f/v, and f/v snack options. K.3.d, K.3.f, Consciousness Facilitators remind parents the K.3.g, K.3.k, raising benefit of using healthy cooking K.3.m techniques, including f/v in family meals, having more family meal time, and adapting healthy eating behavior. Parents remember to make a list of f/v to purchase when grocery shopping. K.3.i, K.3.j Self-monitoring of Facilitators teach parents to keep a behavior log to keep track of how much and what f/v children are consuming. K.3.o Direct experience Parents will direct students at home to locate where the prepared f/v snacks are at. Skills S.3.a-S.3.e, S.3.h Guided practice Facilitators will model on healthy cooking techniques, and different Modeling easily accessible snack options for children to consume. Self-monitoring of behavior Facilitators will role-play with parents to determine how to encourage children to eat more f/v.

Self-efficacy

SN.3.a-SN.3.k

Goal setting Modeling 24

Parents will keep a log to keep track of how much and what f/v children are consuming. Parents demonstrate ability to find stores that carry f/v and making purchases. Parents will create goals that are acceptable to improve childrenâ&#x20AC;&#x;s f/v intake by purchasing (more) f/v,


Facilitation

Social norms

SN.3.a-SN.3.h

Mobilizing social networks

Barriers

B.3.a-B.3.e, B.3.f, B.3.h

Goal-setting Feedback

B.3.g

Discussion

using healthy cooking methods, have open communication with children on the benefit of healthy eating behavior. Facilitators provide a guide practice for planning f/v snacks. Parents are paired with other parents to provide support such as learning from each otherâ&#x20AC;&#x;s healthy cooking techniques, sharing snack recipes, technique to encourage their child to consume more f/v, tips on communicating with their child, and eat together with their child during meal time. Parents plan to find stores that carry fresh and/or frozen f/v options, assign funding to purchase f/v, allowing time to prepare meals using healthy cooking methods, provide healthy choices during meal time and increase frequency of family meal time, then try to reach these goals to increase childâ&#x20AC;&#x;s f/v consumption. Discuss barriers with facilitators. Parents will have open communication with child on the importance of healthy eating behavior.

This intervention will use active learning, and modeling as methods for knowledge from the Social Cognitive Theory (Bartholomew et al., 2011). These methods can be accomplished by practicing hands-on skill, working out examples in workbooks, role-playing, and group activitybased experience. The parameters for using these methods are to stimulate learning, increase knowledge, increase attention and higher remembrance factor among students (Bartholomew et al., 2011). Research has shown that providing information is an effective way to modify positive behavioral changes (Evans et al., 2008). Providing information and hand-on activities to students 25


allow students to absorb information better and become less distracted. Other methods such as discussion, cues to action, consciousness raising, self-monitoring of behavior, counterconditioning and direct experience are also used in the knowledge section. The parameters for using these methods are to listen to the students and encourage open communication, raise awareness by providing feedback to increase problem-solving competency and action, selfmonitoring by keep a diary to determine whether students are meeting the recommended fruit and vegetables intake (Strauss et al., 2001), and recognizing positive outcomes from locating prepared fruit and vegetable snacks at home to eat (Bartholomew et al., 2011). This can allow students to monitor their progress and recognize other ways to change their behavior through self-awareness and cues to action for influencing knowledge. Modeling as a method has been applied to many successful intervention through applications such as role-play, and group activities (Bartholomew et al., 2011). As mentioned above, the parameters for using modeling increases studentsâ&#x20AC;&#x; remembrance factor and easily capture studentsâ&#x20AC;&#x; attention. Students typically are more alert during hands-on and group activities and able to remember the skills learned from participating. Students can also replicate positive behaviors after seeing behaviors performed through modeling. This method will be used along with guided practice, and self-monitoring. Guided practice and self-monitoring demonstrate skills training by facilitators (Bartholomew et al., 2011). When students practice desired behavior changes through enactment at school, they are likely to receive positive feedback and reinforcement from peers and facilitators, and be more aware of their actions. In addition, facilitators can also use guided practice to ensure parents are providing positive environment at home to promote healthy behaviors (Evans et al., 2008). Lastly, self-monitoring can allow students and parents to track their progress to achieve desired goals (Strauss et al., 2001).

26


The methods selected to build self-efficacy include goal setting, public commitment, modeling, and facilitation. Goal setting should be directed from facilitators to be sure the goals are measurable and reachable (Bandura, 2004; Hoelscher et al., 2004). Students and parents should be educated on writing realistic goals for their family. Facilitators will then provide feedback and facilitate on making positive behavior changes. Providing constructive criticism after modeling activities will provide guidance to enhance skills. The parameters for using goal setting, public commitment, modeling and facilitation as methods for self-efficacy can reduce barriers to action, commitment to the goals and express confidence to facilitate a positive environment to promote healthy lifestyle change (Bartholomew et al., 2011). Consciousness raising is the method chosen for outcome expectation. Facilitators can use this opportunity to remind the parents the benefit of using healthy cooking techniques, increase fruit and vegetables in family meals, having frequent family meal time, and adapting healthy eating behavior to increase studentsâ&#x20AC;&#x; fruit and vegetable consumption, which prevent weight gain. The goal for this intervention is to promote positive lifestyle changes by reinforcing the importance of healthy diet and physical activity as a social norm (Strauss et al., 2001). Reinforcement is importance due to the fact that it provides encourage to adopt the new behavior (Bartholomew et al., 2011). In addition, this intervention will also use mobilization of social networks and social network linkages as methods to achieve social norms. When the parents and school board director are paired up with others like them, they may begin to feel more positive about addressing the new changes at home and at school because they are receiving support by their peers. The parents can share ideas with one another on how to improve their childrenâ&#x20AC;&#x;s eating and exercise habit based on experiences, while school board director can provide support and feedback from other superintendents to implement the national breakfast and lunch meal

27


program at school. This intervention will focus on eliminating negative feelings and fostering healthy lifestyle.

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References for Exam 2

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Klesges, R.C., Stein, R.J., Eck, L.D., Isbell, T.R., & Klesges, L.M. (1991). Parental Influence on Food Selection in Young Children and its Relationships to Childhood Obesity. Am J Clin Nutr, 53, 859-864. Kumanyika, S.K., Obarzanek, E., Stettler, N., Field, A.E., Fortmann, S.P., Franklin, B.A., Gillman, M.W., Lewis, C.E., Poston II, W.C., Stevens, J., & Hong, Y. (2008, July 22). Population-Based Prevention of Obesity – the Need of Comprehensive Promotion of Healthful Eating, Physical Activity, and Energy Balance. AHA Scientific Statement, 428464. Larson, N. I., Story, M. T., Nelson, M. C. (2009). Neighborhood Environments: Disparities In Access to Healthy Foods in the U.S. Am J Prev Med, 36(1), 74-81. McAlister, A.L., Perry, C.L., & Parcel, G.S. (2008). How Individuals, Environments, and Health Behaviors Interact – Social Cognitive Theory. In Health Behavior and Health Education: Theory, Research, and Practice (4th ed., pp. 169-188). San Francisco, CA: Jossey-Bass. Nyberg, G., Sundblom, E., Norma, A, & Elinder, L. S. (2011). A Healthy School Start-Parental Support to Promote Healthy Dietary Habits and Physical Activity in Children: Design and Evaluation of a Cluster-randomised Intervention. BMC Public Health, 11(185), 1-7.

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O‟Dea, J. A. (2004, August 24). Prevention of Child Obesity: „First, do no harm‟. Health Education Research, 20(2), 259-265. Pekruhn, C. (2009). Preventing Childhood Obesity – a School Health Policy Guide. Retrieved September 21, 2011, from http://www.rwjf.org/files/research/20090506nasbeguide.pdf Rowe, L., Hunt, P., Bradshaw, H., & Rayner, M (1997). Health Promotion Effectiveness Reviews to Promote Healthy Eating. Health Education Authority, London. Sahay, T.B., Ashbury, F.D., Roberts, M., & Rootman, I. (2006, October). Effective Components for Nutrition Interventions: a Review and Application of the Literature. Health Promotion Practice, 7(4), 418-427. Sharma, M. (2006). School-based Interventions for Childhood and Adolescent Obesity. Obesity Review, 7, 261-269. Siegrist, M., Hanssen, H., Lammel, C., Haller, B., & Halle, M. (2011). A Cluster Randomised School-based Lifestyle Intervention Programme for the Prevention of Childhood Obesity and Related Early Cardiovascular Disease (JuvenTUM 3). BMC Public Health, 11(258), 1-7. Stevens, C.J. (2010, July). Obesity Prevention Interventions for Middle School-Age Children of Ethnic Minority: A Review of the Literature. Journal of Specialists in Pediatric Nursing, 15(3), 233-243. Story, M. (1999, March 2). School-based Approaches for Preventing and Treating Obesity. Int J Obes., 23(2), S43-S51. Story, M., Kaphingst, K.M., Robinson-O‟Brien, R. & Glanz, K. (2008). Creating Healthy Food and Eating Environments: Policy and Environmental Approaches. Annu. Rev. Public Health, 29, 253-272. Strauss, R. S. (2000, January). Childhood Obesity and Self-Esteem. Pediatric, 105(1), 1-5. Strauss, R. S., Rodzilsky, D., Burack, G., & Colin, M. (2001). Psychosocial correlates of physical activity in healthy children. Archives of Pediatrics & Adolescent Medicine, 155(8), 897-902.

Taras, H. & Potts-Datema, W. (2005, October). Obesity and Student Performance at School. Journal of School Health, 75(8), 291-295. U.S. Department of Health and Human Services: Physical Activity Guidelines for Americans. (2008, October 17). Retrieved September 26, 2011, from http://www.health.gov/paguidelines/factsheetprof.aspx

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Wang, Y., Tussing, L., Odoms-Young, A., Braunschweig, C., Flay, B., Hedeker, D., & Hellison, D. (2006). Obesity Prevention in Low Socioeconomic Status Urban African-American Adolescents: Study Design and Preliminary findings of the HEALTH-KIDS study. European Journal of Clinical Nutrition, 60(1), 92-103. Warren, J.M., Henry, C.J., Lightowler, H.J., Bradshaw, S.M., & Perwaiz, S. (2003). Evaluation of a Pilot School Programme Aimed at the Prevention of Obesity in Children. Health Promotion International, 18(4), 287-296.

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Exam 3 – Program, Adoption and Implementation April Chu University of Texas Health Science Center – Houston December 8, 2011

33


Eat Healthy, Be Active Question 13: Program proposal This intervention is titled Eat Healthy, Be Active, and is designed to prevent childhood obesity in Houston Independent School District (HISD), Houston, Texas. This program will adopt the curriculum from Coordinated Approach To Child Health (CATCH). CATCH has been successful at encouraging dietary and physical activity behavior changes among school-aged children (Campbell et al., 2001; Hoelscher et al., 2003; Sahay et al., 2006; Story, 1999). Similar interventions have been implemented in the past to change dietary and physical activity behaviors, however they lacked the family component. Family involvement in obesity prevention program has shown to be the most successful intervention for school-aged children (Eriksson et al., 2008; Pearson et al., 2010; Sahay et al., 2006). Thus, my intervention will incorporate family component in addition to the curriculum from CATCH. The scope and sequence of the intervention outline the program materials and the order in which the materials are delivered over a specific period of time (Bartholomew et al., 2011). The scope of Eat Healthy, Be Active will include 12 lessons over 11 weeks. Facilitators will review students and parentsâ&#x20AC;&#x; progress and goals over the duration of the intervention at week 12, and discuss the lessons learned over the past 11 weeks. The sequence was designed so each lesson will build upon the previous lessons. CATCH materials can be used for all lessons, and students will be given a handout from each lesson to take home. Examples of these handouts can be reviewed in Appendix A and B. The program sequence will be carefully reviewed by trained professionals for effectiveness. Descriptive details about the scope and sequence for this intervention can be reviewed in Table 1. Both parents and students will receive the same lesson, but some of the lesson activities are designed differently for parents and students.

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The intervention will be delivered at school once a week by trained program facilitators. Each class will last for an hour. At the beginning of each lesson, facilitators will discuss with students whether they have made any changes in their diet and physical activity level since week 1. Parents will have the option of attending once-a-week after school classes or classes on Saturday. Whichever class the parents choose to attend, they can bring their children with them. There will be an open gym for children to play with their peers while the parents are in class. Option for parents to choose the classes will provide flexibility with familiesâ&#x20AC;&#x; schedule and opportunity for family involvement. Family involvement can provide support for students on improving dietary and physical activity recommendations. Design document Design document is designed as a tool for creative team members to understand the project and planning team membersâ&#x20AC;&#x; intent to develop effective and appropriate materials needed for the intervention (Bartholomew et al., 2011). The design document should include specific methods for delivery, messages and themes. This will ensure the program materials are conveying the desired message to targeted participants. The intervention materials will not be tailored specifically for each participant due to the diverse population at HISD. Instead, the materials presented in this intervention will consist of basic nutritional and fitness guidelines for all participants. In addition, the materials will be pilot tested for accuracy. Once the materials are finalized, the Eat Healthy, Be Active program materials will be pre-tested and implemented through schools in HISD. The CATCH program uses a space theme with a group of space characters, Heart Heart and friends to teach children about nutrition and physical activity (Bartholomew et al., 2011). The Eat Healthy, Be Active program will adopt this space theme and the message for the

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program is “Houston, Let‟s Get Healthy”. This message is developed to help Houstonian to adopt healthy lifestyle by being more active and learn to eat right. The planning group members will use display print such as handouts to promote healthy lifestyle change among school-aged children in Houston, Texas for the intervention. Program strategies Methods for achieving desire outcome are general technique or process designed to influence changes according to the determinants (Bartholomew et al., 2011). To have an effective prevention program, methods must match the determinants. Strategies are techniques chosen to apply the methods in ways that fit the intervention (Bartholomew et al., 2011). Strategies must be thought-out carefully for each method and include them in the curriculum. Methods and strategies for this intervention were mostly based on the Social Cognitive Theory. The Eat Healthy, Be Active program is targeted to improve dietary and fitness recommendation in school-aged children and parents. Program facilitators will use active learning as method for knowledge from the Social Cognitive Theory (Bartholomew et al., 2011). This method can be accomplished by practicing hands-on skill, working out examples in workbooks, and group activity-based experience. Program facilitators will also provide an opendiscussion environment for students and parents to speak freely while learning. Modeling as a method has been applied to many successful intervention through strategies such as role-play, and group activities (Bartholomew et al., 2011). Modeling increases students‟ remembrance factor and easily capture students‟ attention. Students typically are more alert during hands-on and group activities and able to remember the skills learned from participating. Students can also replicate positive behaviors after seeing behaviors performed through modeling. This method will be used along with guided practice, and self-monitoring.

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Guided practice and self-monitoring demonstrate skills training by facilitators (Bartholomew et al., 2011). These strategies will be used in the students and parentsâ&#x20AC;&#x; curriculum. When students practice desired behavior changes through enactment at school, they are likely to receive positive feedback and reinforcement from peers and facilitators, and become more aware of their actions. In addition, facilitators can also use guided practice to ensure parents are providing positive environment at home to promote healthy behaviors (Evans et al., 2008). Lastly, self-monitoring can allow students and parents to track their progress to achieve desired goals (Strauss et al., 2001). Consciousness raising is the method chosen for outcome expectation. Facilitators can use this opportunity to remind parents the benefit of using healthy cooking techniques, increase fruit and vegetables in family meals, having frequent family meal time, and adapting healthy eating behavior to increase studentsâ&#x20AC;&#x; fruit and vegetable consumption, which prevent weight gain. The goal for this intervention is to promote positive lifestyle changes by reinforcing the importance of healthy diet and physical activity as a social norm (Strauss et al., 2001). Reinforcement is importance due to the fact that it provides encouragement to adopt the new behavior (Bartholomew et al., 2011). In addition, this intervention will also use mobilization of social networks and social network linkages as methods to achieve social norms. When the parents and school board director are paired up with others like them, they may begin to feel more positive about addressing the new changes at home and at school because they are receiving support from their peers. The parents can share ideas with one another on how to improve their childrenâ&#x20AC;&#x;s eating and exercise habit based on experiences, while school board director can provide support and feedback from other superintendents to implement the national breakfast and lunch meal

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program at school. This intervention will focus on eliminating negative feelings and fostering healthy lifestyle. Scope and Sequence Table 1: Scope and Sequence for Eat Healthy, Be Active Timing Lesson Activities Week 1 (1) MyPlate Students are introduced to the MyPlate by a registered dietitian and learn to (2) Physical Activity â&#x20AC;&#x201C; Letâ&#x20AC;&#x;s classify foods into the appropriate food get Moving group through demonstration and discussion. Students are introduced to the importance of staying physically active. Students will brainstorm ways to become more active every day. Students will share the selected activities and demonstrate ability to perform them with peers in class. Students are introduced to diet and physical activity log books to record their daily food intake and physical activity level.

Week 2

(3) Reach for your goals

Week 3

(4) Reading Food Label

Anthropometric measures are recorded on all participants for baseline data. This lesson focuses on setting realistic and measurable goals for physical activity and food consumption. Students will brainstorm barriers to perform exercise and eating healthy foods in groups. Then, they will roleplay to overcome the barriers. Students will set appropriate and measurable dietary and wellness goal. Students learn to read nutrition facts labels and demonstrate ability to identify the content of food labels through workbook activity. Facilitator will split up the class in a group of 4, and give each group few food labels. Students will work in groups to promote confidence toward label 38


Week 4

(5) Portion Size

Week 5

(6) Fruits and Vegetables

Week 6

(7) Healthy Families, Healthy Lifestyle

reading. Students will be asked to bring in a food label next class to share with their peers. Students will participate in a portion distortion interactive quiz. Students will work in groups to play an interactive game to guess the portion sizes for different foods, monitored by trained facilitators. For example, hand student a box of raisin and ask them to measure what a cup of raisin is in a bowl without any measuring instrument. Then, students will measure out a cup of raisin using the measuring cups to compare the difference. Facilitator will be trained on provide positive feedback and reinforcement. See Appendix A for handout of portion size. This lesson focuses on the importance of eating a variety of fruits and vegetables. Students will list fruits and vegetables and learn how to select the good fruits and vegetables. Trained facilitator will introduce new fruits and vegetables by allowing students to touch, smell, and taste the produce. Students will set a goal to increase f/v consumptions or try new f/v outside the class. For parents: This lesson focuses on the importance of practicing healthy behaviors with the entire family. Families will set goals to create and plan activities and healthy family meals. Parents will provide support to make changes to childâ&#x20AC;&#x;s physical activity and dietary behaviors. Trained facilitator will provide strategies for parents to promote positive encouragement. For students: This lesson focuses on the importance of practicing healthy behaviors with the entire family. Trained facilitator will help students to brainstorm ideas for parents to create

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Week 7

(8) Let‟s Eat Dinner!

Week 8

(9) What‟s for Breakfast?

Week 9

(10) Snack Time

healthy family meals and plan activities. Students will be provided with strategies to encourage their family members to get healthy and be active with them. For parents: This lesson focuses on planning healthy dinner and modifying favorite family recipes. Registered dietitian will teach parents on meal planning and substitute unhealthy ingredients for better alternatives. This lesson is targeted to improve the quality of family meals and increase frequency of family meal time. For students: this lesson focuses on reading recipes. Registered dietitian will introduce „Go, Slow, and Whoa‟ list to students. Registered dietitian will pass out recipes to class and teach students to identify the unhealthy and healthy ingredients. Students will set goals to avoid „Slow and Whoa‟ food. See Appendix B for handout of ‘Go, Slow, Whoa’ List. This lesson focuses on the benefit of eating breakfast every day. Students will be asked to list out their favorite breakfast items, and brainstorm ways to eat breakfast on the go in group discussion. Then, students will present their ideas in front of the class. Facilitator will put together all the ideas and give each student a copy of the list. Students will set goals to try the suggested breakfast ideas. This lesson focuses on providing cooking demonstration to make healthy snacks, introduce food safety and sanitation techniques. Registered dietitian will get involved with students to make and prepare healthy snacks, and allow them to try the healthy snacks. Students will brainstorm to create new snacks and share with the peers. Students will be provided with recipes of the snacks made during 40


Week 10

school to take home. Students will set a goal to choose to eat healthy snacks outside the class. For parents: this lesson focuses on teaching families to allow children in selecting their preferred healthy foods at the grocery store. Parents will set a goal to allow children to make their decision on selecting and trying one new healthy food from the grocery store each week.

(11) Select and Purchase

Week 11

(12) Let‟s Get Cooking – Kids in the Kitchen

Week 12

Review

For students: this lesson focuses on teach students in selecting „Go‟ food at the grocery store. Facilitator will review the „Go, Slow, and Whoa‟ food with students. Students will set a goal to select and try one new healthy food from the grocery store each week. This lesson focuses on encouraging children to get involved in preparing healthy meals at home. Students will help setting up table and serving their family. This lesson focuses on families and students‟ progress and goals over the duration of the intervention with facilitators. Students will have open discussion with the facilitators to discuss the lessons learned over the past 11 weeks. Final anthropometric measures are recorded on all participants for evaluation data.

Question 14: Pre-testing program The Eat Healthy, Be Active planning group will be responsible for organizing focus groups prior to implementing the intervention by pre-testing the materials and delivery of the program. The planning group members will test and retest the materials to determine whether the program activities and materials are acceptable and resulted in understandable messages prior to 41


implementation. This process allows the planning group to make any additional changes most appropriate for the target population. However, if there are a great deal of adjustments after the second pre-test, then planning team should consider developing new materials or modify the current materials for pre-testing again. To ensure the materials will achieve the goals of the intervention, the following questions will be presented to the focus group: 1. Was the information provided in the lessons useful to you and your family? 2. Were materials easy to read and understand? 3. Did the program facilitators explain the information in a clear manner? 4. Were the activities used in lessons relevant to the topic? 5. Was the class environment enjoyable? 6. Were the activities enjoyable? 7. Is the class time flexible for you and your family? 8. Did you find the handouts helpful for you and your family? 9. What are some activities that you and your family enjoy doing together? Question 15: Cultural considerations Cultural competency must be addressed for the program development. This includes consideration on different racial and ethnicity background as well as sensitive cultural relevance among the target audience. Since my program consists of diverse population, it is critical to hire staff from various cultural groups to work with the planning team. They can provide insight on proper communication styles, family relationships, rules for emotional expression, and level of acculturation of the target audience (Bartholomew et al., 2011). Understanding the cultural competency, planning team and creative professionals can design materials that not only attract the interest of the school-aged children, but also include community values and cultural

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insensitive matters to allow the intended audience become more comfortable when learning the program activities. Question 16: Planning group To develop an effective intervention, it is important to put together a strong diverse planning group to achieve desired outcomes. The planning group members should be actively involved with the process of adoption and implementation for the program. Planning group members should have the opportunity to provide input, voice concerns, and possibly solutions for the program (Bartholomew et al., 2011). The planning group members for the intervention include chairperson and leaders from community and government organizations, physicians, nurses and registered dietitians. New members for the program include students, parents, teachers, counselors, program facilitators, school food service staff and program coordinator. Students and parents can provide feedback on the design document to determine whether the materials are age-appropriate for participants to understand the lessons and the activities effectively. Teachers and counselors can assist program facilitators to ensure the lesson and activities are running smoothly, while the program facilitators are delivering the lesson and activities. School food service staff can work with school dietitian to develop kids-friendly lunch menu that will attract the students to consume more fruit and vegetables at school. The program coordinator is needed to oversee the program, report the progress to the program adopters and ensures the program is going according to plan. The program adopters include school administrators, teachers, counselors, policy funders, and school food service staff. Program adopters will need to consult the HISD school board director and approve the program before adoption. The program implementers include trained program facilitators, program coordinator, and school board director. The targets audience includes students and parents.

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Question 17: Performance objectives The Eat Healthy, Be Active program should be adopted independently in all schools in HISD. The short term goal is to invite all school to participate in Eat Healthy, Be Active. Schools that are willing to participate will be randomized in control and intervention groups for evaluation purposes. The long term goal is to adopt this program in all the schools in HISD. Program adopter is the school administrators, teachers, counselors, policy funders, and school food service staff. The objectives for adoption are as follow: OA1: Review program materials OA2: Identify program objectives and program advantage OA3: Identify barriers to adopt the program OA4: Seek solution to barriers OA5: Recommend program to the school board for program adoption OA6: Choose to adopt the program OA7: Complete forms for program adoption To implement the program, it is important to introduce the program to school staff to increase support and acceptability for the intervention during implementation process. The implementers include school board director, program coordinator, and program facilitators. The objectives for each implementer are different, and they are listed below: School board director: PO1: Approves funds to hire a program coordinator PO2: Approves funds to allow program coordinator to hire facilitators PO3: Hire program coordinator and facilitators Program coordinator:

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PO1: Schedule curriculum classes during school PO2: Tailor curriculum lessons for students and parents Program Facilitators: PO1: Participate in training for implementing the program PO2: Teach lessons to students and parents PO3: Distribute handout for students and parents to take home The HISD will maintain the Eat Healthy, Be Active program into school organizational routines. Below are the performance objectives for sustaining the Eat Healthy, Be Active program within the Houston Independent School District. OS1: School board director will determine more funding for the program OS2: Superintendents will approve implementation of the program to other HISD schools OS3: School board director and program coordinator will monitor the program results and participants satisfactory throughout the duration of the program OS4: Program coordinator will organize a training session yearly to refresh facilitators on the curriculum

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Question 18: Matrices for adoption and implementation Table 2: Matrix for adoption - School administrators, teachers, counselors, policy funders, and school food service staff Performance Determinants Objectives Knowledge (K) Skills (S) and Attitude (A) Outcome Self-efficacy Expectation (SE) (OE) OA1: Review K.1.a. Describe S.1. Demonstrate A.1.a Believe OE.1.a Expect program where to find ability to review that program is that the program materials materials program important to be materials is materials reviewed beneficial for K.1.b. Identify adoption program topics to SE.1. Express be reviewed prior confidence in to adoption ability to review program materials OA2: Identify K.2. List S.2. Demonstrate A.2. Believe that OE.2. Expect program program ability to list program that program objectives and objectives and program objectives and advantage program program advantage program outweighs the advantage advantage advantage are disadvantage SE.2. Express important for confidence in adoption ability to identify program objective OA3: Identify K.3. List barriers S.3. List A.3. Believe that OE.3. Expect barriers to adopt to adopt the potential barriers identifying that by the program program to adopt the barriers can be identifying program addressed and potential barriers overcome can allow SE.3. Express program confidence in developer to ability to identify address the potential barrier barriers and to adopt the overcome them program before program adoption OA4: Seek K.4. List S.4. List A.4. Believe that OE.4. Expect solution to solutions to potential barriers there is solutions that solutions to barriers overcome and possible to overcome barriers will help barriers solutions barriers make the program become 46


OA5: Recommend program to the school board for program adoption OA6: Choose to adopt the program

OA7: Complete forms for program adoption

K.5. N/A

K.6. N/A

K.7. Learn to complete forms for program adoption

SE.4. Express confidence in seeking appropriate solution to barriers SE.5. Express confidence in gaining support for adopting the program S.6. Adopt the program SE.6. Express confidence in successfully adopting the program S.7. Demonstrate ability to complete forms for program adoption SE.7. Express confidence in complete forms for program adoption

more successful

A.5. N/A

A.6. Believe that adopting the program will make a difference in obesity prevalence in HISD students A.7. Believe that completing forms is acknowledging program adoption

OE.5. Expect that gaining support will influence program adoption OE.6. Expect that adopting the program will make a difference in obesity prevalence in HISD students OE.7. Expect that completing forms for program adoption will better serve the needs for at-risk overweight and obese students in HISD

Table 3: Matrix for implementation - School board director, program coordinator, program facilitators Performance Determinants Objectives Knowledge (K) Skills (S) and Attitude (A) Outcome Self-efficacy Expectation (SE) (OE) School Board Director PO1: Approves K.1.a List the SE.1 Express A.1. Believe that OE.1. Expect funds to hire a available funding confidence in funds are that by approving program to hire program ability to available for funds to hire a coordinator coordinator for determine hiring a program program program appropriate coordinator coordinator, then funds for the program will 47


PO2: Approves funds to hire facilitators

PO3: Hire program coordinator and facilitators

K.1.b. Recognize the need to hire a program coordinator to oversee the program K.2. List the available funding to hire facilitators for program

program coordinator position

SE.2. Express confidence in ability to determine appropriate funds for facilitator positions K.3. Identify SE.3.a Express good personality confidence in and characteristic ability to needed to be interview the program potential coordinator and candidates for facilitators program coordinator and facilitator positions

get implemented

A.2. Believe that funds are available for hiring facilitators

A.3. Believe that hiring program coordinator and facilitators can help run the program smoothly and successfully

OE.2. Expect that by approving funds to hire facilitators, then they will be trained to teach the curriculum in HISD schools OE.3. Expect that hiring program coordinator and facilitators, then the program will run smoothly and successfully

A.1. Believe that school can find an available time slot to implement the program into the schedule

OE.1.a Expect that the program will be completed in the available time slot

SE.3.bExpress confidence in ability to hire the best candidate for program coordinator and facilitator positions Program Coordinator PO1: Schedule K.1.a Review curriculum schoolâ&#x20AC;&#x;s classes during schedule and school hours determine best times to implement the program during school hours

SE.1. Express confidence in ability to work with principals and teachers to determine appropriate schedule for program

K.1.b. List who to contact to make schedule 48

OE.1.b Expect that curriculum will integrate with school hours and not


PO2: Tailor curriculum lessons for students and parents

K.2. Describe appropriate lessons for behavioral changes

Program Facilitators PO1: Participate K.1.a Describe in training for the program implementing the component program K.1.b. Describe their role in the program

PO2: Teach lessons to students and parents

K.2. Identify each lesson materials

PO3: Distribute handout for students and parents to take home

K.3. Identify crucial component with the handout

conflict with the academic schedule OE.2. Expect that the tailored curriculum will be enjoyable and easy for students and parents to follow, which can help them to get healthier

SE.2. Express confidence in ability to tailor curriculum for students and parents

A.2. N/A

SE.1.a Express confidence in ability to teach the curriculum

A.1. Believe that taking time to be trained will prepare them to facilitate the lessons successfully

OE.1. Expect to be successful in teaching the curriculum

A.2. Believe that each lesson is crucial to improve behavioral changes

OE.2. Expect that students and parents will learn skills to be physically active and increase f/v consumption OE.3. Expect that distributing handout for students and parents will apply and incorporate lessons in their daily lives

SE.1.b. Express confidence in ability to demonstrate various method designed for the curriculum SE. 2. Express confidence in ability to teach each lesson

SE.3. Express confidence in ability to remember distribute handout for students and parents to take home

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A.3. N/A


Question 19: Methods and strategies for adoption and implementation Methods for achieving desire outcome are general technique or process designed to influence changes according to the determinants (Bartholomew et al., 2011). The methods for this intervention include active learning, discussion, modeling, goal setting, feedback, guided practice and consciousness raising. These methods will be applied with the strategies during the training sessions for adopters and implementers. The table below provides strategies specifically for the intervention program. Table 4: Methods and Strategies for Adoption and Implementation Determinants Methods Strategies Knowledge Provide program materials, and practice  Active Learning skills through training session. Have open  Discussion discussion with others. Skills & Self-efficacy Role-play during training session.  Modeling Provide feedback from group training  Goal setting skills. Set measurable and realistic goals  Feedback to adopt and implement the program.  Guided Practice Attitude Role-play during training session.  Modeling Provide feedback from group training  Feedback skills. Outcome Expectation Aware of the negative consequence and  Consciousness create positive environment. raising

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References for Exam 3 Bartholomew, L.K., Parcel G.S., Kok, G., Gottlieb, N.H., & Fernรกndez, M. E. (2011). Planning Health Promotion Programs: An Intervention Mapping Approach (4th ed., pp. 379-507). San Francisco, CA: Jossey-Bass. Campbell, K., Waters, E., O'Meara, S., & Summerbell, C. (2001). Interventions for preventing obesity in childhood. A systematic review. Obesity Reviews, 2(3), 149-157. Eriksson, M., Nordqvist, T., & Rasmussen, F. (2008). Associations between parents' and 12year-old children's sport and vigorous activity: The role of self-esteem and athletic competence. Journal of Physical Activity & Health, 5(3), 359-373. Evans, R.R., Roy, J., Geiger, B.F., Werner, K.A., & Burnett, D. (2008, July). Ecological Strategies to Promote Healthy Body Image among Children. Journal of School Health, 78(7), 359-367. Hoelscher, D.M., Mitchell, P., Dwyer, J., Elder, J., Clesi, A, & Snyder, P. (2003, August). How the CATCH Eat Smart Program Helps Implement the USDA Regulations in School Cafeterias. Health Education & Behavior, 30(4), 434-446. Pearson, N., Atkin, A.J., Biddle, S.J.H., & Gorely, T. (2010). A Family-based Intervention to Increase Fruit and Vegetable Consumption in Adolescents: a Pilot Study. Public Health Nutrition, 13(6), 876-885. Sahay, T.B., Ashbury, F.D., Roberts, M., & Rootman, I. (2006, October). Effective Components for Nutrition Interventions: a Review and Application of the Literature. Health Promotion Practice, 7(4), 418-427. Story, M. (1999, March 2). School-based Approaches for Preventing and Treating Obesity. Int J Obes., 23(2), S43-S51. Strauss, R. S., Rodzilsky, D., Burack, G., & Colin, M. (2001). Psychosocial correlates of physical activity in healthy children. Archives of Pediatrics & Adolescent Medicine, 155(8), 897-902.

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Appendix A: handout for portion size lesson

Portion Distortion Muffin 20 years ago

Now

210 calories

500 calories

Popcorn 20 years ago

Now

270 calories

630 calories

Tips in making smarter choices!!

1 cup of greens =

(a Baseball)

1 cup of cereal =

3 oz of meat, fish, poultry =

1 pancake =

(Deck of cards)

(compact disc) 52

(fist)

2 Tbsp of peanut butter =

(golf ball)


Appendix B: Handout for “Go, Slow, Whoa” List

GO, SLOW, WHOA. Guide to Make Healthful Food Choices GO SLOW WHOA

Healthiest foods. Low in sodium (salt). Low in added sugar. Lowest in fat. Good to eat anytime. Sometimes foods. Should not be eating them every day. Least healthy foods. Highest in salt, added sugar, and fat. Eat only once in a while.

Examples of

GO Food:

Examples of

SLOW Food:

Examples of

WHOA Food:

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Childhood Obesity aged 6-11 years old