Tarrant County, with a population of 1.8 million, is an urban county located in the north central part of Texas. Tarrant County rates as one of the fastest growing urban counties in the United States today. With this growing trend also comes an increase in need of health services and education.
Kids Growing Healthy (KGH), implemented in October 2006, is a comprehensive program that addresses nutrition and physical activity behaviors among fifth graders (10-11 year olds) in Tarrant County schools. An average of 250-400 students were reached per year, bringing the total number reached overall to 1,973. Student demographics included 8% more females than males and a diverse range of races/ethnicities (including but not limited to African American, Hispanic-Latino, Caucasian and Asian). The socio-economic classes were also diverse, however the majority were in low-income communities.
At the time in which the program was developed, the United Way of Tarrant County reported that 1/3 of Texas school children were overweight. In addition, according to the Behavioral Risk Factor Surveillance Survey (BRFSS), only 25% of Tarrant County residents 18 and over consumed the recommended 5 or more fruits and vegetables per day. The BRFSS also revealed that only 45% of Tarrant County residents met the Center for Disease Control and Prevention’s physical activity recommendations.
The goal of KGH was to effectively develop, implement and evaluate a program that maximizes student participation, results in knowledge gained and nutrition/physical activity behavior changes. The program objective was to launch KGH into four different Independent School Districts (ISDs), within the targeted zip codes, during the 2006-2007 school year. The participant objective was to increase, by a minimum of 5%, students’ knowledge and increase by 30% the students’ consumption of fruits/vegetables and/or physical activity. The long-term impact of KGH is that the participants adopt healthy lifestyles that carry into adulthood.
Program implementation consisted of contacting, by mail, the school nurse at each elementary/intermediate school campus. Information provided included the purpose of the program, goals/objectives, lesson outlines and a request to implement. A follow up call was placed 2 weeks later. The start up costs associated with the program consisted of copies of the pre and post-tests; a nutrition/physical activity journal/workbook that each participant gets to keep at the conclusion of the program; and promotional items (ie. backpacks, jump ropes, measuring cups for fruits/vegetables, all with the KGH program logo). Funding was provided through Tarrant County Public Health (TCPH).
The program objective was met the first year as we were able to implement KGH in four targeted schools within four different ISDs reaching a total of 406 students. There was an 8% increase in student knowledge. However, the participant goal of increasing fruit/vegetable consumption and/or physical activity by 30% was not met. The information below outlines the pre and post test behavior results: Fruit/Vegetable consumption per day Pre-test = 5.4; Post-test = 6.0 Physical Activity recommendations met Pre-test = 52%; Post-test = 60% Modifications were made to the program before the 2007-2008 school year to address the issue of not meeting the goal of a 30% increase (ie. physical activity journaling). The keys to the program’s success included the interactive multiple lessons, each lesson building on the prior one as well as the food and physical activity journal that students maintained between lesson one and two.
Responsiveness The public health issue that this practice addressesThe major public health concern that KGH addresses is obesity prevention. In turn, as obesity rates increase, so do the rates of heart disease and type II diabetes. Therefore, if we are able to decrease the prevalence of obesity it can help in combating other chronic conditions. Since the two controllable risk factors associated with obesity are nutrition and physical activity we centered the program around these two components. From a public health perspective, immediate intervention is critical as research illustrates that most children who are overweight grow up to be overweight or obese adults (Centers for Disease Control and Prevention).
The process used to determine the relevancy of the public health issue to the communityThe program’s relevancy to the community was connected to the results of the 2004-2005 BRFSS. The rate of overweight or obese residents in Tarrant County (64%) was higher than the average for both Texas (63%) and the United States (60%) and an alarming 75% higher than the Health People 2010 objective. People living in Tarrant County who reported being overweight or obese were 2.3 times more likely to be diabetic, 2.3 times more likely to be hypertensive, 1.5 times more likely to be diagnosed with high cholesterol and 1.2 times more likely to live a sedentary lifestyle.
How the practice address the issueThe program addresses overweight/obesity by incorporating interactive lessons with a primary focus on becoming more aware of food selections and time spent doing physical activity. More specifically the following are addressed: • fruit/vegetable consumption • food portions • reading food labels correctly • frequency of fast food • food selection at fast food restaurants • keeping a food and physical activity journal • noting how much sedentary time is spent each day (ie. watching television, video game time, computer time, etc.)
It is important for students to be able to put the pieces of the puzzle together and see how health behaviors today can have a major impact on their health tomorrow. KGH addresses “Nutrition, Physical Activity and Obesity” which is one of CDC’s Winnable Battles.Innovation Evidence based strategies used in developing this practiceAn evidence based program, “Ways to Enhance Children’s Health and Nutrition” (We Can!) thru National Institutes of Health (NIH), http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/ provided a framework for KGH. Information and lesson ideas for KGH were also obtained from the American Heart Association’s Nutrition/Physical Activity Lesson Plans and the “yourSELF Nutrition Education Kit” thru the US Department of Agriculture.
The practice is new to the field of public health
The process used to determine that the practice is new to the field of public healthTarrant County Public Health and Texas AgriLife Extension staff conducted research to see what existing nutrition and physical activity programs were in place for school aged children. We Can!, launched in 2005, focused on three primary components: healthy eating, increased physical activity, and reduced time sitting in front of the screen. The specific topics that were adopted for KGH included: portions, reading nutrition labels, eating out/fast food, physical activity plans, tips to be more physically active and strategies to reducing sedentary activities (ie. screen time).
How this practice differs from other approaches used to address the public health issueMany programs researched looked at empowering school administrators and/or other key decision makers regarding nutrition policy changes, although also of importance, KGH takes a different approach in that it empowers the child to make behavior changes by working in collaboration with parents and families. Many programs that were reviewed also looked specifically at nutrition or solely at physical activity, however KGH incorporates both as being equal counterparts in the fight against childhood obesity. KGH is a new, dynamic program in the field of public health, as it merges nutrition and physical activity into one program, designed to reach the target population.
Nutrition, Physical Activity, and Obesity
Primary stakeholdersThe primary stakeholders in the development and implementation of KGH consisted of Tarrant County Public Health, Texas AgriLife Extension Service, formerly Texas Cooperative Extension Services, and local ISDs.
LHD's role TCPH’s role in the process was to serve as the lead agency, providing staff (ie. health educators) to deliver the program in the schools as well as perform data entry of pre-test/post-test scores, results of the behavioral surveys and follow-up evaluation results. In addition, TCPH provided primary funding for the program costs, which included printing expenses, journals/workbooks for students and program incentives for participants.
Stakeholders/partners The role of Texas AgriLife Extension staff was to assist with program development and the initial pilot phase of implementation. The primary role of the school’s Curriculum Development Coordinators/Directors of PE/Health, were to assist in the implementation phase, having their support when approaching the individual campus contact is critical to program success.
Tarrant County Public Health fosters collaboration with community stakeholders on a variety of issues and views it as a vital part to any program or policy success. One example of this process is the Mobilizing for Action through Planning and Partnerships (MAPP). This system of strategic planning includes a diverse group of agencies and individuals; elected officials, hospitals, local ISDs, businesses and community members. These community leaders, from the public and private sector, have joined forces to choose and begin implementation of an evidence based policy regarding access to healthy foods/physical activity countywide. MAPP also serves as a foundation to the ongoing KGH message within the community.
Lessons learned The benefits of having community collaborations outweigh any negatives, however there were a few lessons learned during the process. First, the sustainability of the collaboration was difficult due to uncontrollable factors of staff turnover within partner agencies/organizations. Second, is the “buy-in” by Administration at a few local ISDs within the targeted zip codes. In addition, after the initial round of approval from the Curriculum/Instruction Office comes the approval at each individual campus and often times, if approved, can take several weeks. Therefore, if implementation is planned at a new ISD/campus for the Spring semester promotion of the program would need to begin the semester before, in the Fall.
ImplementationThe pre/post test was developed based on the framework of each individual lesson. Two to three main points were taken from each session and applied to the test. In regards to the increase in fruit/vegetable consumption an entire lesson (Lesson #2) was devoted to the importance and benefits of consuming a variety of colors of fruits and vegetables. Students were able, thru an activity in the journal/workbook, to make a connection between specific fruits/vegetables and vitamins/minerals within that food that help specific body functions and/or processes. This session answers the question of “why” these vital nutrients are needed in our diet. During the physical activity lesson (Lesson #4) students are able to see a visual of 5 pounds of muscle vs. 5 pounds of fat. We compare the role of each in the body but also discuss the negative health consequences to having too much body fat.
Time frame The timeframe of program development was approximately 4 months, which included meetings with partners several times per month, research on existing programs and what materials and/or resources were available. The initial implementation of four schools took 1 school year (2 per semester). The evaluation and data entry phase took approximately 2 months. Overall, from start to finish, the process took about a year and a half to complete.
Outline of some basic steps taken in implementing the practice.• Initial contact was made in the spring (prior to implementation in the fall). • A letter was mailed in April to the nurse and/or PE teacher at the elementary/intermediate schools for each targeted zip code. • A follow-up phone call was placed if the contact did not respond to the letter. • Program dates were set for early to mid fall. • When the fall semester began, an e-mail reminder was sent confirming the upcoming program dates.
Lessons learned Lessons learned included: • Timing of implementation - due to the program being taught once a week for four weeks, implementation must be done the first half of the semester. This provides adequate time (2 months) for the follow up evaluation.
• Avoid implementation near state testing dates - students often get pulled out for tutoring and can miss valuable program information - This also can negatively impact or skew outcome measures.
Cost of implementationBelow is an itemized budget for the KGH program (for year 1): • Printing (ie promotion letters, pre/post tests, follow up evaluations) – $200 • Postage - $50 • Student journals/workbooks - $350 • Fast Food Calorie and Fat Counter Book (for instructor) - $10 • Occluded Artery Model - $150 • 5 pounds of muscle and fat - $220 • Visual aids for serving sizes (dice, tennis ball, ping pong ball, cards) - $4 • Pens, whiz rings, measuring cups, hi-lighter, back packs - $1500 • In-kind (ie, staff time, travel, etc.) - $2,000 Total - $5,020
Objective 1:Increase student awareness and knowledge regarding nutrition and physical activity behaviors.
The program outcome performance measures revealed both an increase in knowledge and awareness regarding food choices and/or physical activity habits. As mentioned in the overview section, pre/post tests revealed an 8% increase in participant knowledge, from an average of 77.4% to 83.3%. In addition, 64% of students reported they were more aware, after the program, of how often they consume fast food and 61% were more aware of food choices they made at fast food restaurants. Also, just over half (52%) said they started reading food labels as a result of the program. And an estimated 77% were more aware of chronic diseases related to poor nutrition choices and lack of regular physical activity (ie. heart disease and diabetes) since completing the program.
The primary data source used were pre/post tests which were both knowledge and behavior based. The knowledge section consisted of multiple choice questions, 2 to 3 from each lesson. TCPH Health Educators administered the tests/surveys, collected them and entered the data into a spreadsheet designated for each school.
The evaluation results revealed the outcome of the program was overall a success. There was an 8% increase in knowledge gained and an increase reported in awareness among nutrition choices, physical activity time vs. sedentary time and related chronic diseases. In addition, many of the students reported sharing information they learned during the program with their parents/family. This is a very important step in the right direction in that parents are the decision makers when it comes to the types of foods purchased and prepared.
The evaluation results were provided to Texas AgriLife Extension Services, each contact within the individual school (ie. school nurse, PE teacher, etc.) and the TCPH Extended Leadership Team.
Objective 2:Increase consumption of fruits/vegetables and amount of time spent engaging in physical activity.
The program outcome performance measures revealed that 85% of participants increased physical activity (ie. duration, frequency, etc.) in some capacity during the program.
The behavioral component of the primary data source (pre/post tests) looked at amount of fruits consumed per day, amount of vegetables consumed per day, number of days per week fast food was consumed, minutes a day spent in sedentary activities (ie. television, video games, computer) and minutes a day being physically active. It also looked at barriers that kept them from eating fruits/vegetables as well as barriers to being more physically active. As noted above, TCPH Health Educators administered the tests/surveys, collected them and entered the data into a spreadsheet designated for each school. In addition, the follow up evaluation, administered 2 months post program completion, consisted of 6 yes/no questions with an explanation/open ended question box for each question. Students self reported, since the program, fruit/vegetable consumption changes, physical activity changes, reading of food labels, fast food consumption and increased awareness of health effects from eating unhealthy and not being active.
In regards to results, we learned, through self reporting, that participants were consuming more fruits/vegetables (even at the pre-test level) than we first determined and this remained consistent throughout the duration of the program. However, we did find for those that were not getting at least 5 fruits/vegetables a day, the most reported barrier was that there were not fruits/vegetables available for them at home. Therefore, as a result we included a “Parent Section” to the student journal/workbook so students could share valuable information with parents. (ie. media habits, being a healthy role model, recipes, etc.)
As with the awareness and knowledge based results the behavior results were also shared with Texas AgriLife Extension Services, each contact within the individual school (ie. school nurse, PE teacher, etc.) and the TCPH Extended Leadership Team.
Stakeholder Commitment Tarrant County Public Health’s mission is to “Safeguard Our Community’s Health” and the efforts of KGH fall in line with that statement. TCPH supports KGH and continues to provide in-kind and the financial resources needed to sustain the program. In addition, the ISDs and individual schools/campuses also play a vital role in sustaining the program, through allowing us to reach their students during valuable instruction time. Many of the nurses, teachers and/or counselors believe in the program and have seen positive results in their students that they attempt to request the program a year in advance.
SustainabilityAs mentioned prior, KGH is going into its seventh year and thus far sustainability has not been jeopardized. Due to the program’s success, multiple staff have been trained. The only ongoing cost is printing and any promotional items provided to participants. (ie. pens, jump ropes, measuring cups, etc.) However, the student journal/workbook has recently been converted to an electronic format, which allows it to be used on an ipad or computer if printing ever becomes an issue. Year one we were able to provide a “goodie item” at every lesson, now students receive one to two items during the course of the four lessons. This is a way to cut costs but still be able to reach students. Many of the items purchased in year one (ie. occluded arteries, muscle/fat, etc.) were a one time cost and can be used year after year.