Family-based Social Support

Part 1: Needs Assessment

• Describe in detail the population and setting with which you will work. Identify the public health problem. Use surveillance data to support the needs of the community. As appropriate, discuss the health disparities of your target community. (20 points)

The goal of this project is to create an intervention to help Clayton County, Georgia youth ages 11-14, improve diet and nutrition, and increase physical activity using Family-based social support programming.  According to the United States Census Bureau, as determined in July of 2015, 28.1% of residents in Clayton County were under the age of 18.  This represented the largest age demographic in Clayton County.  Furthermore, 68.7% of Clayton County residents are African-American, representing the largest demographic.  Caucasian residents represented the second-largest demographic at 23% (U.S. Census Bureau, 2016).  In addition, 22.8% of Clayton County residents under age 65 lack health insurance and 22.9% of people in Clayton County are considered to be living in poverty (U.S. Census Bureau, 2016), demonstrating socioeconomic factors at play.

In determining a setting in which to engage Clayton County’s 11-14 aged demographic, it is important to consider school systems.   In the United States, children attend school for approximately six hours per day and 180 days per year (Demissie, et al., 2013).  This amount of school exposure makes the school environment a natural setting for working with the school-aged population and gaining access to the majority of youth in a particular U.S. community.  Since the 11-14 aged demographic are middle school students, the setting for this intervention will be Clayton County Public School system Middle Schools.  There are seventeen middle schools in the Clayton County Public Schools system (Clayton County Public Schools, 2016).  These seventeen middle schools will serve as the setting for this intervention.  Since the majority of Clayton County’s Population is African-American, the majority of people in the intervention group will be African-American.

Clayton County, Georgia ranks 61 out of 159 Georgia Counties in overall health outcomes (County Health Rankings, 2016). This is the lowest ranking of the Metro-Atlanta counties.  This low ranking is evidence that Clayton County is the most in-need county in the Metro-Atlanta area when it comes to improving health outcomes and decreasing health disparities.  36% of children in Clayton County live in poverty with 50% living in single-parent households (County Health Rankings, 2016).  Based on socioeconomic status health outcome indicators, we know that poverty is an indicator for poor health outcomes.  Clayton County ranks 105 out of 159 Georgia Counties in Quality of Life (County Health Rankings, 2016).  Clayton County’s Food Environment Index, considering factors that contribute to a healthy food environment, on a scale of 0 (worst) to 10 (best), is a 4.7 (County Health Rankings, 2016).  In addition, drinking water violations exist in the county (County Health Rankings, 2016).  On a positive note, 82% of the Clayton County Population reported having access to exercise opportunities (County Health Rankings, 2016).  The public health problem can best be described as health disparities that impact overall health outcomes.

The Centers for Disease Control and Prevention (CDC) Youth Risk Behavior Surveillance Survey (YRBSS) data is helpful to indicate the health behaviors of middle school youth in Georgia.  According to the 2013 YRBSS, 13.5% of Georgia’s middle school youth did not participate in at least 60 minutes of physical activity on at least one day in the seven days before taking the YRBSS.  Furthermore, 69.3% of Georgia’s middle school youth reported not doing any kind of physical activity that increased their heart rate and made them breathe hard for 60 minutes per day on each of the 7 days before taking the YRBSS.  When considering this same question for a 5 day period, the percentage dropped to 49.9%.  (CDC, 2016).  These figures show that Georgia’s middle school youth could be getting more exercise.  Since exercise and nutrition directly impact youth obesity outcomes, it is important to ensure that young people are getting physical activity.

Nationally, the obesity rate remains stable at approximately 17% for young people ages 2-19 years of age (CDC, 2015).  Childhood obesity has been found to be more common among certain racial and ethnic groups.  In 2011-2012, the obesity prevalence among African-Americans was 20.2%.  Childhood obesity has been found to be associated with the adult head of household’s education level.  Obesity prevalence among children’s who’s adult head of household completed college was approximately half the obesity prevalence among children who’s adult head of household did not complete high school (CDC, 2015).

References

1. Centers for Disease Control and Prevention (CDC), (2016). 1991-2015 Middle School Youth Risk Behavior Survey Data.
   Available at http://nccd.cdc.gov/youthonline/. Accessed on September 5, 2016.
2. Centers for Disease Control and Prevention (CDC), (2015). Childhood Obesity Facts. Retrieved from http://www.cdc.gov/obesity/data/childhood.html
3. Clayton County Public Schools, (2016). Middle Schools. Retrieved from http://www.clayton.k12.ga.us/about/middle_schools
4. County Health Rankings, (2016). Clayton (CT). Retrieved from http://www.countyhealthrankings.org/app/georgia/2016/rankings/clayton/county/outcomes/overall/snapshot
5. Demissie Z, Brener ND, McManus T, Shanklin SL, Hawkins J, Kann L. School Health Profiles 2012: Characteristics of Health Programs Among Secondary Schools. Atlanta: Centers for Disease Control and Prevention; 2013.
6. U.S. Census Bureau, (2016).  Quick Facts: Clayton, County, Georgia. Retrieved from http://www.census.gov/quickfacts/table/PST045215/13063

 

• What stakeholders may be needed along the way? Describe the role of each stakeholder, and the questions they may want answered about the intervention. Also briefly describe how a successful intervention would impact that stakeholder, and how an unsuccessful program might impact that stakeholder. Stakeholders may be individuals, groups, or organizations. (20 points)

Stakeholder	Role in Intervention	Questions from Stakeholder	Effect on Stakeholder of a Successful Program	Effect on Stakeholder of an Unsuccessful Program
Clayton County Public Schools (CCPS) School Board	Partner in intervention by allowing access to students and parents, access to schools, access to school facilities for program meetings, and access to school presentation areas (i.e. school bulletin boards) to showcase program components.	Will this intervention need any school resources? How will this intervention benefit the school system? Is this intervention evidence-based? Is there any liability for the school system?	A successful program will reflect positively on the CCPS school board as partners in the program.  In addition, a school system with healthier students will experience improved academic performance and student behavior. A successful program could also result in increased student and parent engagement in the school system.	The reason for lack of success would determine the effect on this stakeholder.  If the program was unsuccessful due to simply not being effective than anyone who supported the intervention may not be interested in the next program that is presented, kind of like participation fatigue.  In addition, the school system may see any resources given to the intervention, as wasted resources.
Clayton County Health Department	Partner in intervention by providing intervention support.	What health department resources will this intervention need? Are there any funds available to support the health department? Is this intervention evidence-based?	A successful intervention will reflect positively on the Health Department.  A successful intervention will improve health outcomes for youth in the County.  A successful intervention will be positive PR for the health department.	If the intervention does not go well, some members of the community could lose faith in the health department and be less likely to participate in the health department’s next program.
CCPS Parents/Families	Providers of Family based social support	What is the parent and family’s role in this intervention? How much time will it take for parents to participate?	A successful intervention would impact parents through healthier children.  Since the parents will play a large role in the intervention, the knowledge will likely rub off on parents and result in parent’s improved health as well, which again directly impacts the children as healthier parents will be better providers.	If the intervention does not go well, parents may feel that they wasted their time.  Parents may also feel decreased self-efficacy.  In addition, parents would also be placed in a position of helplessness, having an identified problem (child’s nutrition, diet, and weight), and potentially no foreseeable way to solve it.
CCPS Students	Intervention target population.	Why should students participate in this intervention? What will students get out of participation?	The students definitely have the most to gain through a successful intervention, including healthier lives and life-long health benefits, increased knowledge of healthy eating, nutrition, and physical fitness, and increased self-efficacy.	If the intervention is unsuccessful, students may face a sense of diminished self-efficacy.  Students may lose confidence in their family members to help them make positive life changes.  Students will miss out on positive life changes and improved health if the intervention is unsuccessful.

CCPS Teachers	Intervention Support through encouraging student participation in the intervention and processing intervention information with students.	How much time will it take for teachers to support the intervention? How will this intervention benefit teachers/students/the school?	If the intervention is successful, teachers will feel a morale boost from participation in a successful intervention. Students will be healthier, more alert, and therefore easier to teach.  Students’ increased morale may result in increased student motivation.	If the intervention is unsuccessful, teachers may feel that they wasted their time.  An unsuccessful intervention may be demoralizing for teachers who participated.
CCPS Middle School Principals	Allowance of school resources for the initiative. Teacher’s time, school facilities for meetings, school presentation areas (i.e. bulletin boards)	How much time will school participation take? What school resources will be needed? How will participation benefit the school?	A successful intervention will result in improved school climate.  Since health is tied to better life outcomes, a successful intervention will result in immediate improved school morale and  improved student performance. Parents will also be more likely to participate in the school’s future program’s after a track record of success.	If the intervention doesn’t go well, principals will have a harder time getting buy-in from students, teachers, and parents for future programs. Teachers may resent the principal if they feel like their time was wasted.

 

Part 2: Intervention Identification

• State and define the intervention strategy – what does it mean? What populations has this strategy been used with? What settings has it been used in? How are your community characteristics similar or different to those of the communities in which the strategy has been effective? (20 points)

The intervention strategy is Family-Based Social Support and this strategy is a behavioral and social approach to increase physical activity.  Family-Based Social Support interventions use approaches that boost family support to help the subject of the intervention achieve change.  These interventions might include individualized or family-focused educational health sessions, family behavioral contracts, goal-setting, problem-solving, or family behavioral management, while including physical fitness activities.  The intention of these programs is to bring about behavioral patterns, social interactions, and family norms that support increased physical activity.

These interventions have been used with all families, especially families with children and families from ethnic backgrounds that emphasize family connections and family-support.  Interventions focused on children and their families are often part of a larger school-based intervention in which the family-based social support becomes an adjunct to the larger school-based initiative.  For example, family record keeping, take-home information packets, family-focused special events and activities, etc., can all be used as part of a larger school-based program (Guide to Community Preventive Services, 2014).

Clayton County is predominantly African-American.  There is an emphasis on family in the African-American culture.  There are many other racial and ethnic groups that place an emphasis on family and many of these groups are represented in Clayton County.  In addition, the school-aged population in Clayton County could be impacted using family-based social support as part of a larger school-based intervention.

Is the strategy recommended by the Task Force? Why or why not? (10 points)

This strategy is not currently recommended by the Task Force.  Due to inconsistent results, The Community Preventive Services Task Force has found insufficient evidence to determine the effectiveness of Family-Based Social Support interventions in improving fitness or increasing physical activity.  This means that the available studies do not provide sufficient evidence to deem Family-Based Social Support as effective or ineffective.  Therefore, additional research would be needed before this strategy could be determined effective or ineffective  (Guide to Community Preventive Services, 2014).  Eleven different studies were reviewed by The Community Preventive Services Task Force in coming to this conclusion.

Provide at least 3 examples from existing articles (peer-reviewed preferably, but could come from other places). These should be different than the research-tested intervention programs(RTIP) listed already. You can include or link to this information, but you should provide different examples. (45 points total)

• 1. Describe the intervention – what did the authors do? What was the procedure? How long was the intervention? Please describe individual components as well as the broader intervention plan.
  2. What were the outcomes measured?
  3. What amount of change did they find?

Example 1:  Social Support and Physical Activity Change in Latinas: Results From the Seamos Saludables Trial.  See Reference Below. 

• Goal of Study: Identify and Address which factors encourage and hinder physical activity amongst Latinas.
• Study Broader Context:  Social ties are associated with physical activity in the Latina culture.  Being married or having children at home increases the likelihood of physical activity.
• What was the intervention?:  This intervention evaluated the effectiveness of home and print-based materials to increase moderate to vigorous physical activity (MVPA), and how these interventions were affected by social support and family ties.  The intervention was home-based and used print materials delivered via mail to Spanish-speaking Latinas.  The intervention addressed barriers, and encouraged participants to adopt and sustain physical activity, using theoretical constructs from social cognitive theory and the transtheoretical model.
• Intervention Procedures: During a baseline visit the intervention group received physical activity education, were taught to set realistic activity goals, and problem-solved how to overcome barriers to physical activity.  Then the intervention group received regular mailings of motivation-matched manuals, including tip sheets and monthly newsletters, and individualized feedback.  Feedback reports were based on stage of change, self-efficacy for physical activity, and processes of change.  This was followed up with a goal-setting session at post-treatment.  The control group received tip sheets and pamphlets on heart-healthy behaviors other than physical activity.
• Length of Intervention: 6 months with a 12 month follow-up
• Outcomes Measured: Levels of social support were measures as assessed by the Social Support for Exercise Survey which gauged family participation, family rewards and punishments, and friend participation.  Self-reported minutes of MVPA were measured at baseline, post-treatment, and follow-up visits.
• Amount of Change: The intervention group increased and maintained MVPA compared to the control group as well as seeing improvements in support from friend and family groups.  These benefits were seen irrespective of family ties.

Example 2: The Early Childhood Obesity Prevention Program (ECHO): an ecologically-based intervention delivered by home visitors for newborns and their mothers. See Reference Below. 

• Goal of Study: This goal of this study was to evaluate the 12-month efficacy of a primary obesity prevention program targeting a child’s first year of life.  The program was administered by home visitors who engaged mothers as agents of change in their lives, the lives of their children, and the lives of the broader community through sharing new knowledge.
• Study Broader Context:  The broader context is whether or not Mothers can be used as a change agent to improve outcomes for their children in this culturally and ecologically-based intervention.
• What was the intervention?:  This study used education, skill-building around nutrition, physical activity, and wellness to turn mothers in change agents.  Fifty-seven mothers were recruited into the Nurturing Families Network home visitation program.  27 received the control and 30 received the intervention.  The intervention was focused on increasing maternal skills in goal-setting, stimulus control, and problem solving.  The intervention engaged family members as support systems and linked mothers to neighborhood resources.
• Intervention Procedures: Home visits were provided during which a curriculum, was administered by home visitors.
• Length of Intervention: 12 months.
• Outcomes Measured: Message specific maternal knowledge, intention and self-efficacy, breastfeeding extent and duration, feeding behaviors related to solids and juices, maternal diet and behavior, infant weight and length, perceived stress, family support, and intervention dose.
• Amount of Change:  Change is anticipated to be significant.  This article focused on the protocol for a study that is being carried out.  I chose this study because I thought it was a good example of family-based social support for mothers and infants, even though the study has yet to report results.

Example 3:  An Adaptation of Family-Based Behavioral Pediatric Obesity Treatment for a Primary Care Setting: Group Health Family Wellness Program Pilot. See Reference Below. 

• Goal of Study: To assess family-based group pediatric obesity treatment in a primary care setting.
• Study Broader Context: This study desired to examine on the broader level, experiences of social support for healthier lifestyles.
• What was the intervention?: An evidence based intervention was used in a group format using a single arm before and after trial.  The study was conducted in two clinics near Seattle, Washington.  The intervention was provided through a curriculum that was used to achieve the intended study goals (see more below).
• Intervention Procedures: Eligible families were identified via electronic medical records and had to have a child age 6 to 12 with BMI in 85th percentile or higher.  At least one parent had to have a BMI of 25 or higher.  Group class sessions were facilitated by educated and experienced instructors.  Parents and children met together to review health goals on a weekly basis followed by a one-hour long parent and child group.
• Length of Intervention: 16 weeks (twelve 16-week groups were completed over the course of 3 years)
• Outcomes Measured: program attendance and completion, changes in child and parent BMI, child quality of life, social support for putting into practice healthy lifestyle changes.
• Amount of Change: 63% of those enrolled in the program completed programming and an additional 16% attended at least 4 sessions.  Children who completed programming achieved mean change in BMI Z-scores of -0.1 (p<0.001).  There was significant improvement in parent-reported child quality of life.  Mean BMI of parents changed.  Parents reported that social support was important and reported that they received social support.

Part 2 References:

1. Cloutier, M. M., Wiley, J., Zhu, W., Grant, A., & Gorin, A. A. (2015). The Early Childhood Obesity Prevention Program (ECHO): an ecologically-based intervention delivered by home visitors for newborns and their mothers. BMC Public Health, 15(1), 1-13. doi:10.1186/s12889-015-1897-9
2. Guide to Community Preventive Services. Behavioral and social approaches to increase physical activity: family-based social support. www.thecommunityguide.org/pa/behavioral-social/familysupport.html. Last updated: 01/23/2014.
3. Marquez, B., Dunsiger, S. I., Pekmezi, D., Larsen, B. A., & Marcus, B. H. (2016). Social Support and Physical Activity Change in Latinas: Results From the Seamos Saludables Trial. Health Psychology, doi:10.1037/hea0000421
4. Riggs, K. R., Lozano, P., Mohelnitzky, A., Rudnick, S., & Richards, J. (2014). An Adaptation of Family-Based Behavioral Pediatric Obesity Treatment for a Primary Care Setting: Group Health Family Wellness Program Pilot. Permanente Journal, 18(3), 4. doi:10.7812/TPP/13-144

Part 3: Intervention Fit

• Provide a logic model and SMART Objectives for your intervention. You should have a SMART objective for each behavior you anticipate changing. (35 points; 10 points for SMART objectives, 25 points for the logic model)

SMART Objectives:

1.  By May 22, 2018 (last day of Clayton County Public Schools 2017-2018 school year) increase percentage of adolescents at target middle schools who are physically active at least 60 minutes per day on 5 or more days per week, from baseline (approximately 50.1%-Georgia, Middle School Youth Risk Behavior Survey (YRBS), 2013) to 70% as based on each student’s Fit Bit fitness tracker data.   Desired Behavior Change: Increase physical activity amongst target population.
2.  By May 22, 2018 decrease obesity rate of adolescents at target middle schools from baseline (approximately 16.5%-2011 National Survey of Children’s Health, obesity rates for Georgia’s children ages 10 to 17) to 10% (approximate best state data for obesity in children ages 10 to 17-2011 National Survey of Children’s Health)  as based on student BMI measures.  Desired Behavior Change:  Decrease Obesity Rate through increased physical fitness and healthy eating amongst target population.
3.  By May 22, 2018 increase family-based social support for Physical Activity by 20% from base-line for adolescents at target middle schools as based on student-reported pre-test (baseline) and post-test (outcome) survey findings.  Desired Behavior Change: Increase Family support for Physical Activity amongst target population.
4. By May 22, 2018 increase family-based social support for Nutritious Eating by 20% from base-line at target middle schools (as based on foods eaten and entered into Fit Bit food Consumption tracker) as measured by student-reported nutritious eating family support on pre-test (baseline) and post-test (outcome).  Desired Behavior Change:  Increase Family-Based Social Support for nutritious eating amongst target population.
5. By May 22, 2018 improve nutrition of adolescents at target middle schools from baseline to at least 70% of students recording a diet within calorie goal ranges (as based on foods eaten and entered into Fit Bit food Consumption tracker) on at least 80% of days recorded on food consumption tracker.  Desired Behavior Change:  Decrease over consumption of calories.
6. By May 22, 2018 improve nutrition of adolescents at target middle schools from baseline to at least 70% of students recording a diet that includes at least 2.5 cups of vegetables per day and 2 cups of fruit per day on at least 80% of days recorded on food consumption tracker. Desired Behavior Change: Increase intake of vegetables and fruits.

Inputs/Resources	Activities	Outputs	Short-term Outcomes	Intermediate Outcomes	Long-term Outcomes
Personnel: -PE Teachers at each Middle School – Non-PE Teachers at each Middle School -School Cafeteria Staff – County Intervention Director Equipment/Materials: – Fit Bit Fitness Trackers for all students in program – Parent/Family-Support System Website for to Intervention – Scales for determining student weight and height – Pre-Surveys and Post-Surveys for Students and Parents Relationships: -Partnership with the Clayton County Public School System and each middle school, including a Memorandum-of-Agreement Other: -Use of School Facilities Funding: – State and Federal Grant Funds	– The Daily Wind-Down: 60 minutes of student choice-based physical activity at the end of every school day, 5 days per week for all students. -Student Incentives for positive participation in Daily Wind down. -Morning Announcements and school cafeteria bulletin board about healthy eating. – Lesson plan creation for Physical Activities that meet Physical Activity Guidelines for Adolescents. -School cafeteria staff offers breakfast and Lunch meals that are within standard calorie guidelines -School cafeteria staff presents more options for vegetable and fruit consumption at breakfast and lunch meals -School cafeteria staff decreasing high-sugar and nutrient poor breakfast and lunch options. -Training for PE Teachers who will head up The Daily Wind-Down at each middle school. -Training for Non-PE Teachers who will implement the initiative with their home room class at the end of the day. -Weekly Parent and Support System Website Updates, including nutrition information and weekly healthy but affordable recipes. -Parent Incentives for interacting with the intervention website – Quarterly Weigh-Ins and BMI checks. -Completion of Pre-Survey and Post-Survey. -Student’s Support System (Family) Quarterly Field Day. -Tracking of Daily Physical Fitness on Fit Bit fitness tracker. -Tracking of Daily Food Consumption on Fit Bit Fitness tracker.	-Daily Wind-down, every in-session school day (except for standardized Testing days and mock test days) = 165 daily wind-downs. -4 Trained PE Teachers per middle school. -48 Non-PE Teachers trained in the initiative. -School Cafeteria staff trained to decrease calories and sugar offered at meal times while increasing vegetable and fruit offerings. -More nutritious breakfast and lunch options for students on every school day. -Fewer calorie dense and nutrient poor food options offered at school meals times. -2 unique and new PE lesson plans every week and 3 “back by popular demand” repeats = 68 Unique Physical Fitness Activities/Games. -4 Unique Family-Support System Field Days. -4 Quarterly Weigh-Ins (BMI checks)  per student. -Fit Bit, BMI, and pre-test/post-test survey Data for school year -42 weekly website updates	– Immediate Benefits of increased exercise – Improved student self-esteem -Increased Family knowledge of physical fitness importance -Increased Student knowledge of physical fitness importance -Increased Family knowledge of Nutrition -Increased student knowledge of nutrition. -Improved health that results from more nutritious foods. -Improved school morale	-Increased Family Social Support for Physical Activity (was MOVED) -Increased Family Social Support for Nutritious Eating (was MOVED) -Increase in adolescents who are physically active at least 60 minutes per day on 5 or more days per week -Increase in adolescents whose food consumption is within standard calorie limits/goals. -Increase in adolescent consumption of fruits and vegetables. -Decreased Obesity rates at target schools	-Improved Health Status of adolescents at intervention schools. -Cardiorespiratory Fitness -Stronger Muscles -Potential Reduced Symptoms of anxiety and depression -Increased chances of healthy adulthood. -Lower risk factors for long-term chronic diseases later in life.

• Explain the logic of why this intervention may work. For example, why would teaching children about healthy eating change their actual eating behaviors? Or why would adding sidewalks increase physical activity for transportation or recreation? (15 points)
  1. Think about the “Field of Dreams” problem – if you offer the intervention, will it actually change behavior?

This intervention increases physical activity through a school-wide Daily Wind-down Campaign in which 60 minutes at the end of every school day are set aside for physical activity.  Teachers use lesson plans to implement fun physical fitness activities that provide adolescents with an opportunity to engage in aerobic, muscle-strengthening, and bone-strengthening Moderate to Vigorous Physical activity.  This school wide campaign emphasizes fun and school-wide morale boosting involvement, producing  a level of excitement that makes students want to participate!  Using positive peer pressure, students will engage in daily physical activity because “everyone is doing it”.  Because students will have the ability to choose between at least two activities during every daily wind-down, this will decrease the likelihood that students will not feel forced to participate in certain activities.  By placing the daily wind-down at the end of every school day, the physical activity is also therapeutic, allowing students to work out/off the events of the school day, positive or negative, through physical activity.  Not only does this benefit students through physical activity but it will also teach students to utilize exercise to deal with stressors.   By placing the daily wind-down at the end of the school day, students will be less concerned about exercising early in the morning or mid-day and being sweaty or un-kept for the remainder of the day as a result of morning exercise (as experienced when students have PE classes throughout the school day).

Incentives will be used to encourage students to participate in the daily wind down physical activities.  For example, positive participation will earn a student “Wind-Down Dollars” that can be used to “purchase” healthy or helpful incentives.  For example, Six Flags/White Water Season Passes, Subway Meals, Yogurt or smoothies at local shops, school supplies, and Weekend and School Break Field Trips to places like Stone Mountain, The Georgia Aquarium, or The Fox Theatre.  Most of the incentives will be donated by local sponsors who understand that healthy students = a future healthy work force = a healthy community.  This community involvement will also open doors for sustainability from community partners.

Family-Based Social support will be utilized through the intervention’s website where parents and family members will be able to find information on the week’s daily wind-down activities, the daily nutrition announcements, and healthy recipies.  Each student will be allowed two intervention website accounts for parents or family members.  These accounts will function like a “members only” area of the site where parents will be able to receive additional information about how they can support their student’s physical activity and healthy eating.  Parent log-ins and interactions with the “members only” area of the website will be tracked and parents will be eligible for free grocery give-aways based on the frequency of their interactions with the website.  These free grocery give-aways will be donated by local grocery stores and will feature all of the ingredients for a parent and student to make a healthy recipe together.  The Family Field Days will also encourage family physical activity and increased involvement from parents and family members.

The PE Teachers and the County Intervention Director will be key staff members in delivering a successful intervention.  Since all students will receive PE daily through the Daily wind-down at the end of every day, PE teachers will be able to use the school day to plan intervention activities.

Through website access to the intervention website, parents will be presented with tools that will aid their ability to support their child in physical activity and healthy eating.  Parents will be able to post on message boards on the website where they can receive input from other parents as well as intervention staff.  Parents will be encouraged to interact with the website and gain this information through the use of the mentioned incentives.

• Discuss limitations of the selected strategy, and things to look out for/be mindful of along the way. Examples may be limitations of resources, community capacity, or anticipated effect of the intervention. (15 points)

Technology Limitations:  Most Fit Bit devices require a smart phone or a computer to input food intake.  Students without smart phones will be able to enter their food intake using a computer.  If students do not have computers at home, they will have to recall more food information when they have the opportunity to enter their food intake information in the computer at school.  Some students without phones may not enter their information in the computer at all.  Students with Smart Phones may not be willing to enter their food intake information in their cell phone’s Fit Bit app.  There will likely be limitations on when students can use phones during the school day since most schools do not allow students to use cell phones at-will.  Some parents may not have internet access to interact with the Intervention website.  Most middle schools offer a parent resource room where parents can come and use the computer but it is unlikely that all parents will be able to come to the school.

Student Unwillingness to Participate in the Intervention:  There will likely be some students who do not want to participate in the Daily Wind-down.  The students who do not want to participate may negatively impact the participation desires of other students.  It will be important to make the program seem “exciting” and “cool” to students so that they will want to participate.  Most students today love to dance so dance contests are one way that physical activity can be made fun for students.  Even with all efforts, there may still be some students who do not want to participate and the school and the program must have a policy on how they will handle students who do not want to participate in the activities.  Since the program is collecting data, informed consent may be necessary and if so, no students can be made to participate.  At the same time, the Daily Wind-down is still a school PE activity and students who do not participate in school activities often face school consequences.  The realms of what is allowable and what is not allowable in the environment of the intervention must be discussed to ensure that the rights of each student as a research participant (for those whose parents consent to their research participation) are respected.  All teachers and school staff will need to be trained on how the intervention works to ensure that they are respecting the rights of the students to participate in the program.

Students Not recording their Food intake in the Fit Bit:  Students may forget or just choose not to record their food information in the Fit Bit.  This will result in missing data and the intervention will need to decide how to handle the missing data.

Lack of Community Support:  Some members of the community may grow tired of providing free student incentive donations to the program.  Since incentives are an important part of the program, this could become problematic, especially if students are used to receiving incentives and the incentives resources begin to run low.

Teacher Unwillingness to Participate in the Intervention:  Teachers in the public school system have a lot of responsibilities.  Some teachers may not be excited about participating in this initiative and they may see it as an additional responsibility that they do not have time for.  This could directly affect the success of the intervention as enthusiasm from teachers will be be an important part of a successful intervention.  It may be worth considering if there is enough funding available to bring in intervention staff members to run the Daily wind-down.

Parent Unwillingness to Participate in the Intervention:  Some parents may not be interested in participating in the intervention, may feel that the intervention is unnecessary, or may want to participate but may not have the time or resources.  As students enter middle school, some parents begin to take a less-involved role, believing that their students are old enough to do many things for themselves.

Schools and the School-System may be concerned about time and resource requirements of this intervention:  It is very important to maintain good will with the school system, since the school system directly impacts the ability of the program to operate.

• What data would you collect to know if you are implementing the strategy the way it was intended (process evaluation/implementation monitoring)? Refer back to your logic model and the Logic Model module as needed. Be sure to cover dose, reach, fidelity, and implementation. (40 points)

To determine if the strategy is being implemented as intended, it would be important to collect information reflecting the implemented program components and then check those components against what should have been implemented to determine any gaps.   I would begin by considering if all the intended resources had been available in the intervention.  I would determine if any resources were not present.  For example, if the intervention was unable to obtain the Fit Bit Fitness Trackers or unable to launch the website, these would be major changes to the intervention.

Next I would look at the activities.  Were all of the intended activities implemented as planned?  For example, did the students at the target schools receive the intended dose of 60 minutes of physical activity per day?  Was time allotted for students to transition to the physical activity area and also to dress out so that they still had a full 60 minutes for physical activity or did students spend 15 minutes transitioning and dressing out so that they actually only received 45 minutes of physical activity?  It would also be important to track incentives and makes sure they were used properly and determine if the incentives were helpful for encouraging participation.  I would track the morning announcements to determine if they were completed on every intended morning and if the intervention bulletin board was updated as planned.  It would be important to consider the lesson plans and make sure that they met the standards set for aerobic, muscle-strengthening, and bone-strengthening physical activities.

Staff training goals and objectives and possibly staff feedback (via training evaluation surveys) about the trainings would be important to collect to determine if the trainings taught and imparted the intended information.  It would be important to see how many times the intervention website was updated.  Was it updated every week as intended.  Did family members log-in to the members only area of the website?  Since this is a big component of the family-based social support, did parents and family members engage with this component?  In addition, did the Family Field Days take place as intended and did family members participate in the Field Days?

In regards to the outputs, were the output goals met?  It is important to consider each output goal and determine if the goal was met.  If any goals were not met, this may affect the intervention dose.  For example, the intervention calls for the offering of two unique PE lesson plans every week as well as 3 “back by popular demand” repeats to make 68 Unique Physical Fitness Activities/Games over the course of the school year.  If unique lesson plans were not offered and the Daily Wind-down became basket ball in the gym every day or walking around the track, then students may not have been as excited about the Daily wind-down time and may not have achieved moderate to vigorous physical activity.  Another example demonstrates dose.  The program was expected to provide 165 doses of daily wind-down.  The first thing to consider would be how many doses were actually provided.  165 doses out of 180 days of school allows for 15 days in which students did not receive a dose, possibly because of testing or an end of the day school assembly.  Did the students receive the intended dose?  In addition, what was school attendance like.  Were there some students who missed a lot of school and didn’t receive the intended dose due to missing school days?  It is not anticipated that students will have 100% attendance at school.  Therefore, it is important to consider what dosage most students received.  If the process of the intervention was conducted properly and as planned, then the program should achieve the desired outcomes.

It is also important to consider reach.  Did the program reach the students?  Did most of the students participate in daily wind-down?  The Fit Bit data as well as the school attendance data should demonstrate this.  Fidelity is also important to consider.  Did the teachers teach the lessons as intended?  Were there some teachers that made unauthorized changed to the lesson plans?  Were fidelity logs kept to demonstrate if teachers made changes to any lessons?  Fidelity is a very important issue since it demonstrates if the program was taught as it was intended to be.  All of these items determine if the program was implemented as intended which is a very important question to answer in a process evaluation.

Part 3 References:

1. 2008 Physical Activity Guidelines for Americans. Physical Activity Guidelines Advisory Committee.  Washington, DC: U.S. Department of Health and Human Services, October, 2008.
2. Centers for Disease Control and Prevention (CDC). 1991-2015 Middle School Youth Risk Behavior Survey Data.
   Available at http://nccd.cdc.gov/youthonline/. Accessed on October 31, 2016.

3. National Survey of Children’s Health, 2007. Overweight and Physical Activity Among Children: A Portrait of States and the Nation 2009, Health Resources and Services Administration, Maternal and Child Health Bureau. (accessed October 31, 2016 from http://stateofobesity.org/children1017/)

4. Physical Activity Guidelines for Americans Midcourse Report Subcommittee of the President’s Council on Fitness, Sports & Nutrition. Physical Activity Guidelines for Americans Midcourse Report: Strategies to Increase Physical Activity Among Youth. Washington, DC: U.S. Department of Health and Human Services, 2012.

Part 4: Reflection

• Oftentimes when working with communities, the initial plan is not what ultimately happens. What would your second choice strategy be for your identified behavior and community? Why would you choose this strategy? In other words, in what ways would this strategy also address the needs of the community based on your assessment for Part 1? (25 points)

My second choice strategy would be “Obesity: School-Based Programs”, a strategy presented by The Community Guide.   The intervention definition for school-based strategies, according to The Community Preventive Services Task Force, is interventions that “are conducted in the classroom and may seek to increase physical activity and/or improve nutrition, both in school and at home.  Classroom and physical education teachers may receive special training to carry out the programs” (The Community Guide, 2013).  In October 2003, the Task Force found “insufficient evidence” available “to determine the effectiveness of school-based programs to prevent or reduce overweight and obesity among children and adolescents because interventions varied and reported outcomes (that) were not comparable” (The Community Guide, 2013).  However, I would still choose this strategy because of its fit with my identified behavior and community.  In addition, after further review of the CDC MMWR report detailing the Task Force findings, the task force reviewed 10 qualifying studies and ran into the issue that “no studies or only a limited number of studies with comparable outcomes were identified” (CDC, 2005).  I take this to mean that the school-based programs are so diverse that outcomes cannot easily be compared.  Of course, this wouldn’t mean that school-based programs don’t work, but rather that there is insufficient evidence, which is the exact finding of the task force.  I am convinced that a well-designed school-based program could be very effective in impacting youth health.

The goal of this project was to improve diet, nutrition, and increase physical activity among Clayton County youth ages 11-14.  The school setting was chosen as the venue for this intervention due to the data and research shared in Part 1, showing the number of hours that young people are in the school setting.  In particular, in Part 1, it was shared that in the United States, children attend school for approximately six hours per day (25% of the day) and 180 days per year (Demissie, et al., 2013).   For this reason the public school setting presents an opportunity to reach the youth of a community as a captive audience.  Furthermore, according to The National Center for Education Statistics, in the Fall of 2016, 50.4 million students attended public elementary and secondary schools (NCES, 2016).  Considering that this large number of students is in school for 25% of every day, the school setting proves to be a resource for programs looking to impact the lives of students.  My current project plan could fit very well into the “school-based programs” strategy through the creation of a partnership with the school system to “house” the intervention under the umbrella of the school.  Because school-based programs highlight the use of classroom and physical education teachers, an element of my proposed intervention, school-based programs would be a good fit for my intervention.

Although the strategy that I chose for this project, “Family-Based Social Support” is often part of a larger school based intervention, using a broader strategy like “School-Based Programs” would provide me with more flexibility in the scope of the intervention.  I still appreciate the value in family-based social support, but I think that using this strategy under the umbrella of a school-based program, which I would create first, may be a better direction to take than implementing school-based programs under the umbrella of “family-based social support”.  In addition, at times in the creation of this project, I felt that I was trying to address obesity, physical activity, and nutrition under the specific category of family-based social support when a broader category, like school-based programs would have provided me the flexibility to truly create a dynamic intervention to impact the lives of young people.  It is important to note that there are tensions to be aware of when trying to deliver a program in a school setting.  Since teachers and school administrators are so busy, and already have academics and other school initiatives to focus on, school-based programs should be careful to walk the fine line between doing enough to have an impact and not doing so much that the intervention becomes a hassle for school administrators and staff or begins to take time away from academics.  A solution for this could be to offer academic lessons that include obesity prevention, physical activity, and nutrition elements so that students receive the intervention information as part of their academic content.

• Reflect on how you may use the Community Guide, Nutrition Education Library, and other resources in the future. What did you like about these resources? What didn’t you like? Provide suggestions on how you would make the sites easier for practitioners to use. (20 points)

I found the Community Guide to be a very helpful tool for locating evidence-based findings for obesity, physical activity, and nutrition interventions.  In my future public health practice work settings, the Community Guide could be a useful tool in determining potential interventions to impact community health issues.  In particular, I am considering starting an obesity and chronic disease prevention non-profit in the future.  The broad goal of the non-profit would be to decrease the prevalence of obesity and chronic diseases in various communities.  Starting out, I would likely focus on the metro-Atlanta area.  The Community Guide could assist me in researching strategies for effective interventions.  I can see myself in the future, referencing information from the Community Guide in a grant proposal application or when pitching school principals, superintendents, and school boards on why they should allow my non-profit to work with their youth!  This resource allows practitioners in the field to benefit from the experiences of others which is invaluable for making strides in community prevention.  Being able to use the website to gather review information presented on the Community Guides’s three questions, focused on what has worked for others, intervention cost and return-on-investment, and evidence gaps, puts anyone who uses The Community Guide, three steps ahead in the process of researching interventions that can positively impact communities.

In regards to specifics that I like about The Community Guide, The “My Guide” tool is amazing and really allows users to gain the specialized and specific information that they are looking to gain from the website.  I like how the “My Guide” tool asks a website user to classify who they are and what they want to do to provide that user with a list of specialized tools and resources that might be helpful to them.  These types of classification systems can save website users the time that they might have spent looking through resources and tools to determine which ones might apply to them.  In addition, the “What Works Fact sheets” provide a helpful summary of directions that community members can take to impact an issue.

When we first began using The Community Guide in August of 2016, the updated website had not been launched so we are in an interesting position to be able to compare the older version of the website to the one that is available currently.  Although the change was needed to improve and enhance the website, I didn’t particularly like having to adjust to using the new version of the website.  Since I didn’t visit the Community Guide website every day, it is possible that transitioning for users was done and that I just didn’t visit the website during the transition period.  If transitioning wasn’t done, then I would definitely recommend more transition for regular users in future recreations of the website, if applicable.  Furthermore, even though I like the “My Guide” tool, it seems that a lot of the interactive services that the website offers are embedded within this tool so that the preferences chosen determine which tools are presented.  This could make it challenging for practitioners to get to certain tools on the site that they might like to access.  I would suggest having an area on the website where all the tools offered by the website are listed so that a practitioner who wants to see everything that the site offers can do so easily by reviewing the list of tools.  I don’t believe that I saw this option on the site at present, although it is possible that I overlooked it.

I didn’t use Nutrition Evidence Library in completing this project but I see how this could also be a helpful tool in gathering information about nutrition-related systematic reviews.  This website seems to offer evidence-based resources that are similar to The Community Guide but more focused on nutrition.  I am glad that I am aware of this website as an option for locating evidence-based information on nutrition interventions and could also see myself using this website in the future in connection with the creation of non-profit nutrition interventions.  As nutrition is not my educational back ground as much as public health is, another use for a site like this is to give expert advice and assistance to people who may not be experts in the field.  Through a website like this, people can benefit from the knowledge that is available on topics like nutrition.

References

1. Centers for Disease Control and Prevention (CDC).  MMWR Report.  Public Health Strategies for Preventing and Controlling Overweight and Obesity in School and Worksite Settings: A Report on Recommendations of the Task Force on Community Preventive Services. October 7, 2005.
2. Demissie Z, Brener ND, McManus T, Shanklin SL, Hawkins J, Kann L. School Health Profiles 2012: Characteristics of Health Programs Among Secondary Schools. Atlanta: Centers for Disease Control and Prevention; 2013.
3. The Community Guide. Obesity Prevention and Control: School-Based Programs. https://www.thecommunityguide.org/sites/default/files/assets/Obesity-School-based-Programs.pdf. Updated October 17, 2013.
4. National Center for Education Statistics (NCES). Fast Facts. Back to School Statistics. http://nces.ed.gov/fastfacts/display.asp?id=372 . Retrieved December 7, 2016.
5. Nutrition Evidence Library.  http://www.nel.gov/ . Retrieved December 7, 2016.