LOCATION AND SIZE: The Ravenna City Health Department is located in Ravenna, Portage County, Ohio. It serves a population of 11,724 (2010 Census). Public Health Issue In 2011, our city began to explore a community health needs assessment and identified decreased physical activity and high childhood obesity as two areas for targeted intervention.
GOALS AND OBJECTIVES: The goals and objectives of the health department were to increase the health of the student population in one Ravenna City elementary school as a pilot program by providing moderate to vigorous physical activity sessions after school, provide healthy snacks, and provide education in the areas of exercise physiology, nutrition, exercise monitoring and safety, in home and community exercise and recreation opportunities and body composition.
HOW WAS THE PRACTICE IMPLEMENTED: The PIP program is a partnership program between the Ravenna Health Department, West Main Elementary School, Kent State University College of Education, and the Parks and Recreation Department of Ravenna, A leadership team was assembled meeting approximately 8 sessions to design the after-school program in the fall of 2012. This team was responsible for designing goals and content, infrastructure, and recruiting for supplies, volunteers and speakers. (See document 1 “PIP Schedule” for topics and classes) The voluntary program was open to all 3rd through 5th graders attending West Main Elementary School who were interested and had parental consent. Space was limited to 50 participants on a first come first serve basis. Students agreed to participate after school for one hour from 3:30 pm to 4:30 pm on Mondays and Wednesdays. During the school day, pre and post season attendance, BMI was attempted to be gathered on all students by the health commissioner. The assistant professor collected qualitative data targeting self esteem and body image through diary and video interviews. The Principal monitored student grades, behaviors and disciplinary actions. The school physical education teacher performed “Fitgrams” of students.Students, Instructors and volunteers came to the school gymnasium Mondays and Wednesdays where the students received a fresh fruit and/or vegetable snack and listened to a 15 education session. Students were then divided into three inter-mixed grade level groups. Groups then rotated through three 15 minute physical activity sessions designed in part to compliment the education topic. Sessions were held in the school gym and the library with some outdoor activities when weather allowed. Complimentary activities to enhance the program were a “Family Night” included in the schedule,a field trip to the local grocery, and an interactive snack preparation session provided by a local caterer and executive chef.
RESULTS AND OUTCOMESOf approximately 106 eligible students, we had an initial attendance of 32 students to participate. However, once the program kicked off, we had 49 students after two weeks, reaching almost 100% of our goal. We found positive changes relating to BMI,Fitgram scores and qualitative results concluded students reporting they feel better about themselves. Factors Leading to Success The complimentary composition of our Leadership team in regard to expertise anddiversity, as well as, the ability to work together and follow through with assigned roles was a significant factor in the program success. Our ability to integrate both public and private agencies in the community, and their willingness to participate, afforded a great community partnership. (See supporting document from local newspaper).
PUBLIC HEALTH IMPACT Results of the program evaluation and data support that the implementation of the "PIP" program has had a positive effect on addressing childhood obesity and the health issue of decreased physical activity. Due to the success of this program, we are evaluating ways of expanding this program into other elementary schools within Ravenna in efforts to meet our goals of decreasing childhood obesity and increasing physical activity throughout the community.
The Ravenna Health Department is located in Ravenna Ohio and serves approx. 11,724 city residents. The department has gone through significant financial and personnel changes over the past few years. At the time of this program it was staffed by a part-time interim Health Commissioner, a part-time Nurse/Health educator, and a full-time clerk/vital statistics staff. Funding for the department came from the City’s general fund, some grant work, and minimal state subsidy. Most environmental service inspections were handled through a contracted sanitarian. The Health Department’s Board of Directors has eight members appointed by the Mayor. The City of Ravenna is the County Seat of Portage County which impacts the demographics of the residents within the City. The population demographics show a median household income of $33,548. The median age of residents is 37.9 years. Race is about 88.4 % white, 6.9% black, 2.9 % two or more races and 1.5% Hispanic. Educational attainment indicates about 16% have less than a high school degree, 41% achieved a high school degree, 9% associate, 8% bachelors, and 5.6% a masters degree. 15.3% of all people are below the poverty level. 67.9% of those are made up of female households with no husband present and children under the age of 5. 12.4% of the population is between the ages of 5-14.Public Health Issue One of the problems the public health department was trying to address was high childhood obesity rates. Data from the 2008 Ohio Family Health Survey reports 49.93 percent of school-aged (11-17) males and 38.7 percent of females had an overweight or obese BMI in Portage County
Target Our target was 3-5th grade students at a local elementary school,that is located in an area of the City with the highest social economic indicator; 67% of the students at this school are on the Free or Reduced Lunch Program.
Percentage of Target Of the 106 eligible student participants (3-5th grade with parental consent) 49 students (46%) enrolled in the voluntary program. Due to space limitation we set a cut-off at 50 students, therefore our program reached almost 100% of our available participation rate.
Past Programs Addressing Childhood Obesity and Physical Activity The city health department had not been involved in any school physical activity/education programs like this in the past, nor had they worked in any collaboration with the school system other than with immunizations, flu shots and outbreaks. The Parks and Recreation department does offer summer camp programs for residents with some activities involving physical fitness throughout the year, however, this specific age was not targeted. The elementary school has initiated a program called “PEAK” for Physical activity and educational achievement, which offers students one activity session of 10 minutes throughout the school day do break sedentary time of over 1 hour, and occasional “Flash Mob” events.
Current Approach Advantages: The PIP program offers a substantial increase in the amount of actual physical activity in which the students participate. The education component is specifically targeted for the age group of participant. The snack affords another opportunity for a nutritious meal for students, some of which report it is their last meal of the day. An expanded time frame for education opportunity allows more specific education in areas of safety, physical activity, self esteem, nutrition, and personal and social responsibility.
Is the practice innovative? After-school physical activity and nutrition programs are not new. The State of New York in collaboration with the state health department has an example of a toolkit addressing some models and information, “Healthy Kids, Healthy New York After-School Initiative Toolkit” http://www.health.ny.gov/prevention/obesity/healthy_kids_healthy_ny/ healthy_kids_healthy_ny_afterschool_toolkit.pdf.
The Ravenna Health Departments PIP program shows an innovative practice at a local health department level. The health commissioner and board member were active participants not only in the leadership team, but also as instructors and activity leaders and participating in the activities with the students. The program itself also provides activity sessions tailored to reinforce the specific education topic. Also, the grand collaborative approach at grass roots might be new to health departments. Also, the grand collaborative approach at grass roots might be new to health departments. Not only were public agencies now working together towards similar goals, speakers and instructors were recruited from the local private and public community so that they also became stakeholders in the program. The Leadership team consisted of highly qualified educators, nurses, and exercise physiologist, and recreation specialists. Community sources brought in the expertise of social workers, mental health professionals, nutritionists, personal trainers, chefs, retailers, park rangers, and safety service providers. The Health Board member, University Professor and students, parent, and most all speakers participated as volunteers without financial compensation. Local grocery and product suppliers donated fruits and vegetables for the group. Finding this innovative approach to provide a ”close to zero cost” program was significant in our model.Creative use of existing tools When identifying the needs of the student population relating to obesity and physical activity we implemented some of the tools included in the Census Bureau’s “American Fact finder”, County Health Rankings ”Crosswalk of Measures” and Community Commons.Org - “Maps and data” and “ Vulnerable Population” maps. Vulnerable population maps helped us break down the city to find that many of the children at this school live in the lower income area, as well as, lower educated population of the city. CDC’s adolescent BMI calculators helped us chart and calculate students BMI’s. Overall we attempted to pinpoint more specific indicators relating to Childhood obesity, including review of food deserts, access to recreational facilities, obesity reports, and levels of activity.
Evidence Based Practice The health department members of the Leadership team utilized their personal expertise but can give some reference to support of evidence based practices through the CDC’s publications under Healthy Weight - it's not a diet, it's a lifestyle! http://www.cdc.gov/healthyweight/, State Indicator Report on Physical Activity 2010 http://www.cdc.gov/physicalactivity/downloads/PA_State_Indicator_Report_2010.pdf, and Let’s Move.Gov programs http://www.letsmove.gov/ Some evidence based practices were utilized designing Public Health Specific education and activity sessions including but not limited to: The Community Guide to Preventive Services, the Agency for Healthcare research and “Qualities Guide to Clinical preventative Services”, Campbell’s Fitness Lesson Plans Alignment to National Standards http://labelsforeducation.com/assets/pdf/national_standards_fitness.pdf and National Institute of Health’s “We Can! (Ways to Enhance Children's Activity and Nutrition)” http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/. The Health Department is unable to obtain any information relating to evidence based practices from the university assistant professor in regard to lesson plans for the activities they created or their lecturing at this time. The CDC’s Winnable Battles addressed is “Nutrition, Physical Activity, and Obesity”.
Nutrition, Physical Activity, and Obesity
The PIP Program goals identified by the Health Department Members of the Leadership team were as follows:
Improved physical health and fitness as measured by
Decreased BMI, Students Pre to Post PIP BMI’s will show a one or more level of improvement in score category or remain in Health Category
Increased physical activity opportunity
Students will add a minimum of 30 minutes of moderate to vigorous physical activity twice a week to their activity level.
When asked Students will be able to state the difference between Aerobic, flexibility, and strength training activities and state the benefits of each type of activity
Students will be able to identify at least 5 recreational areas within walking distance from their homes iv.Students will be able to report their training heart rate or Rate of Perceived Exertion or Speaking indicator of exertion and why it is important to monitor when exercising.
Increased “fitgram” scores and physical capacities, i.Student will show improved “Fitgram” scores from start to end of year evaluation by the PE teacher.
Students will make more healthy nutritional choices.
Students will be able to explain the “My Plate” food groups
Students will add at least two servings of fruit and /or vegetables to their diet twice a week
When given produce, staff manned blenders, and utensils, Students will be able to create at least three healthy snacks, including Fruit smoothies, Yogurt fruit parfaits, and Salsa.
After a field trip to the grocery store, student will be able to identify at least one previously unknown fruit and vegetable and identify the different food group areas of the grocery store.
Educational goals included:
Enhance Learning experiences of the students as measured by
Decreased disciplinary actions and Principal visits,
Improved self esteem.
In early fall of 2012 our department received a request from the principal of an Elementary School and members of our parks and recreation department (PRD) to consider involvement in implementing an after-school program. At team was assembled including members of the PRD, the principal and a teacher from the elementary school, the health department commissioner, a health board member, and an assistant professor of physical education from a local state university. The leadership team began meeting to discuss program goals, structure, needs, data collection and student needs. Educational goals included: Enhance Learning experiences of the students as measured by decreased disciplinary actions, improved grades, and improved self esteem. Public health goals included: Improved physical health as measured by decreased BMI, increased physical activity opportunity, physical capacity, and healthy nutritional choices.
Five Topic areas of impact were targeted by the team in design of the education sessions:
Personal and Social Responsibility
Each area was broken into specific units of education and activity topics that were to be executed at each Monday and Wednesday 1 hour after-school session. Team members were assigned units in order to procure speakers, either based on their personal expertise, or pooling community experts (see document attached for a “PIP Schedule” and breakdown of activity units). Based on the number of participants and available physical space, the team felt it would be best to split the group into 3 subgroups. Also based on learning and physical motor expectations, only 3-5th grades were included. Volunteers for physical activity leaders were recruited from PE students of the University. These PE student volunteers along with the assistant professor developed lesson plans for the 3, 15 minute activity sessions. Activities were to be designed to reinforce the topic the speaker was presenting. The program was presented to the students in order to gain interest and name the program. The students identified “Personal Improvement Program”, or PIP, as the name of the afterschool program. Releases were sent home and initially about 32 students signed up for the voluntary program and obtained a release for research data collection. The University assistant professor completed the IRB application process at the university as required for data collection. The IRB was pursued due to the data collection and the future ability to publish the results with the intent to make the PIP program evidence based. Pre-program measures were obtained for comparison. This included BMI calculations for all 3rd-5th graders at the school and a Qualitative questionnaire about personal feelings about self for participants. The session began on 1/28/2013 and continued through 5/29/2013. Each session included a fruit and/or vegetable snack and 15 min. education session with the full group, followed by three 15 minute sessions of physical activity. The students rotated through these sessions in three groups. The team worked to procure donations to assist in obtaining snacks, supplies, and Tee-shirts. The Health Department was able to provide the tee-shirts. That was the only cost we were not able to have donated. We also offered a “Family Night” where the PIP participants were able to invite all family members to attend an extended session of community education. The role and visibility of the Health Department was greatly expanded by involvement with this program. The use of private and public entities as instructors and supporters also help form collaboration as we move toward accreditation.
Criterion for selection of Participants Based on the recommendations of the Principal and teacher, it was suggested that k-2nd graders would not mix well with the 3-5th graders based on learning and physical capacity. The health commissioner/RN also reported that the 3rd through 5th graders were more likely to be displaying realistic measurable levels of obesity in their developmental stage.Time frame for the practice Since the leadership group formed in the fall, we did not feel prepared to begin the program until later in the school year. The sessions began the end of January 2013 and ended in May of 2013. Other Stakeholders The practice involved the collaboration of the Leadership team consisting of: the health commissioner, health board member, school principal and teacher representative, members of the parks and recreation department, and an assistant professor from a local state university. Once the structure was established, the team reached out to the community. Public organizations involved for approval and speakers included: the City school board and superintendent, state park rangers, city fire department, city police department, university IRP board, university PE and Nutrition departments, county mental health agency, dog warden. Private entities involved included: Local fitness center trainers, local catering and chef, local grocery, local produce distributor, local print shop. Costs The school did not incur any cost for the program implementation. Other than approx. $300.00 for T-Shirts for the students, provided by the health department at discount from local print shop, no costs were associated with the program. Printings and handouts for students were provided by the agencies or speakers themselves. Activity materials and equipment were either available at the school or borrowed from the university. Snacks were donated. Catering company and chef donated their own food and supplies. Transportation on field trips was provided through the recreation department’s bus.
Objectives of the Health Department: Goal: Implementation of an after-school program that increases the physical health of the students relating to childhood obesity and inactivity. 1. Improved physical health and fitness as measured by a. Decreased BMI, i. Students Pre to Post PIP BMI’s will show a one or more level of improvement in score category or remain in Health Category: Not Achieved but positive b. Increased physical activity opportunity, i. Students will add a minimum of 30 minutes of moderate to vigorous physical activity twice a week to their activity level. - Achieved ii. When asked Students will be able to state the difference between Aerobic, flexibility, and strength training activities and state the benefits of each type of activity- Achieved iii. Students will be able to identify at least 5 recreational areas within walking distance from their homes- Achieved iv. Students will be able to report their training heart rate or Rate of Perceived Exertion or Speaking indicator of exertion and why it is important to monitor when exercising. - Achieved c. Increased “fitgram” scores and physical capacities, i. Student will show improved “Fitgram” scores from start to end of year evaluation by the PE teacher.- Overall improvement in 4 of 5 measured categories. d. Students will make more healthy nutritional choices. i. Students will be able to explain the “My Plate” food groups- Achieved ii. Students will add at least two servings of fruit and /or vegetables to their diet twice a week- Achieved iii. When given produce, staff manned blenders, and utensils, Students will be able to create at least three healthy snacks, including Fruit smoothies, Yogurt fruit parfaits, and Salsa. - Achieved iv. After a field trip to the grocery store, student will be able to identify at least one previously unknown fruit and vegetable and identify the different food group areas of the grocery store. – Achieved
Primary Data Sources: All 3rd – 5th grade students were scheduled for a BMI assessment. The Health Commissioner, also an RN, collected this data at time intervals scheduled by the Principal, both pre- and post- PIP season. The health commissioner recorded the age, height, weight of the children following the CDC’s guidelines. Measurable goals relating to BMI show mixed results. Due to collection problems not all participants had a pre and post test BMI score. Of the 18 PIP students with pre and post test BMI’S, no participants in healthy category changed category. Although showing an increase in BMI, one underweight student remained underweight. Of 5 students in the overweight category, 2 students moved into the healthy category. Of 7 students in the obese category, 2 moved into the overweight and only one showed an increase in BMI. When comparing the total population of the school students grade 3-5 with pre and post BMI’s, we found that 48% of the students decreased their BMI. Of those students participating in the PIP program, 57% showed a decreased BMI. These outcomes suggest the program may have helped decrease BMI scores. The Principal of the elementary school reported: “Kids felt better about themselves, school discipline improved and counseling referrals decreased. Discipline referrals decreased from 55 in 2011-12 to 40 in 2012-13 for a 27% decrease. Counseling referrals decreased by 23%. The school physical education instructor collected “fitgram” data, following the FitnessGram® Procedures Manual. Here are the results of that data for students in the PIP program, summarized by the university professor.overall: Pacer 69%improvement Curl ups 56%improvement Push-ups 69% improvement Leg Flex- 31% improvement Trunk Lift 73% improvement
The university professor also recorded OAA’s, “The Ohio Achievement Assessments for grades 3-8 measure students on what they know and are able to do in various subjects” http://ohio3-8.success-ode-state-oh-us.info The students also reportedly reflected upon their experiences in PIP about how much they enjoyed the after school program, they felt better about themselves, some felt they had lost weight, were doing physical activity at home with their families, and their content knowledge about the 5 topics significantly increased even though we did not assess them on it. Secondary data was collected by the university professor relating to qualitative measures of: student reflections, behavior and counseling referrals.
Modifications to the practice. At this point we are attempting to increase the amount of moderate-vigorous activity to 40 or more minutes, 2 times a week. Our goal is to further affect decreasing BMI. We are also increasing the amount of flexibility education and programming. Our goal is to address weaker scores on the Fitnessgram.
Lessons Learned: Once the sessions began, we found that for some speaker sessions, the use of the library was better than the gym location. Also, some activity based lectures, were limited by time since food was being eaten. During the initial leadership sessions we found some conflict in our groups overall topic scheduling, but our team was able to produce an agreeable schedule outline. (See supporting document “PIP Schedule”) Our new schedule in the 2013-2014 year, with the increased program length, allows us to include more of the content some felt was missing in the original program. Some data collection became a problem due to conflicts with evaluators’ schedules and student’s attendance or field trip schedules. Unfortunately we were not able to gather all the data we hoped for all students. We are exploring new ways to collect BMI’s this year, pulling in more volunteers and student from a local medical college. We were able to get a local community college to underwrite the costs of our student t-shirts this year, further decreasing our costs. Also relating to cost, snacks are now being provided by a local not-for-profit organization dedicated to “promoting health lifestyles and healthy people”. On occasion, scheduled speakers cancelled their appearance. The leadership team was able to personally cover the topics and reschedule most speakers. Our end of the program review attempted to highlight strengths and weaknesses with suggestions for the next year implementation. The plan is to implement the PIP program in October of the new school year (and we have). As our school district was closing one elementary school, and increasing the number at our school, we opened enrolment to 60 students rather than 50. In turn, our session will be just 3 activities, each 20 minutes. One session includes a snack and education session with light physical activity, again reinforcing the topic. The other 2 are moderate to vigorous activity. The Speakers were evaluated and some of the same and new speakers are being recruited. It was decided a more formal attendance and discipline policy should be set up front in order to educate students on expectations. Also, it was suggested a team member speak with the student about the incident during any “time out”. We are implementing a waiting list to replace student who leave the program. Due to the success of our “family night” we are adding 2 others during the year and bringing in a nurse practitioner for a local hospital to perform some medical screening and adult community education.
Sustainability Due to the success of this program, we are evaluating ways of expanding this program into the Cities other 2 elementary schools in efforts to meet our goals of decreasing childhood obesity and increasing physical activity throughout the school-aged community. Our major limitations looking at expanding the program are obtaining enough activity leader volunteers and lack of specific activity lesson plans due to being unable to obtain them from the university. Supplementing the snacks could also be limiting based on donor’s willingness to provide for a larger group. Resources utilizing some grant money as stipends to this and other university students and volunteers might be an option. Involvement of the PTA might also expand our resources. Also, using other tools such as some identified in “A Resource Guide for Planning and Operating Afterschool Programs” www.sedl.org or "CATCH USA" Activity guides http://www.catchusa.org/ might be helpful and are being explored.
Colleague from another public health agency