Assess, Identify, Make it Happen (AIM) for Preschools: A Tool to Decrease Early Childhood Obesity.

Early childhood obesity is at epidemic proportions and is a major risk factor for the development of chronic diseases in adulthood. Since the majority of preschoolers are placed in center-based care, best practice policy, system, and environment (PSE) changes in early child care settings plays an important role in defining early development of obesogenic behaviors. However, implementation of best practice PSE changes is often a challenge in low resource settings due to staff turnover, time constraints, cultural beliefs, and lack of health-related knowledge. Assess, Identify, Make it Happen for Preschools (AIM-P) is a strategic planning process that was used with wellness teams in early child care centers to implement PSE changes that support adoption of health behaviors. AIM-P uses key change-making strategies based on intervention mapping including assets and needs assessments, prioritization of changes based on importance and feasibility, development of action steps and action plans, and identification of dissemination and sustainability plans. The AIM-P process resulted in implementation of 6.5 best practice PSE changes per site. Qualitative findings highlight lessons learned and the facilitators and barriers associated with using AIM-P to implement PSEs.

Little association between wellness policies and school-reported nutrition practices.

BACKGROUND: The Child Nutrition and WIC Reauthorization Act of 2004 mandated written school wellness policies. Little evidence exists to evaluate the impact of such policies. This study assessed the quality (comprehensiveness of topics addressed and strength of wording) of wellness policies and the agreement between written district-level policies and school-reported nutrition policies and practices in 48 low-income Michigan school districts participating in the School Nutrition Advances Kids study. METHOD: Written wellness policy quality was assessed using the School Wellness Policy Evaluation Tool. School nutrition policies and practices were assessed using the School Environment and Policy Survey. Analysis of variance determined differences in policy quality, and Fisher's exact test examined agreement between written policies and school-reported practices. RESULTS: Written wellness policies contained ambiguous language and addressed few practices, indicating low comprehensiveness and strength. Most districts adopted model wellness policy templates without modification, and the template used was the primary determinant of policy quality. Written wellness policies often did not reflect school-reported nutrition policies and practices. CONCLUSIONS: School health advocates should avoid assumptions that written wellness policies accurately reflect school practices. Encouraging policy template customization and stronger, more specific language may enhance wellness policy quality, ensure consistency between policy and practice, and enhance implementation of school nutrition initiatives.

Local Wellness Policy 5 years later: is it making a difference for students in low-income, rural Colorado elementary schools?

INTRODUCTION: The federally mandated Local Wellness Policy (LWP) was intended to promote student health in schools. This study assesses the 5-year effects of the LWP on the health practices of rural elementary schools in Colorado. METHODS: One year before and 5 years after the LWP mandate, a survey was administered to a random sample of principals, physical education (PE) teachers, and food-service managers in 45 rural, low-income elementary schools in Colorado. Response rates were 71% in 2005 and 89% in 2011. RESULTS: Minutes for PE and recess did not increase, nor did offerings of fresh fruits and vegetables. More schools adopted policies prohibiting teachers from taking recess away as punishment (9.7% in 2005 vs 38.5% in 2011, P = .02) or for making up missed instructional time, class work, or tests in other subjects (3.2% in 2005 vs 28.2% in 2011, P = .03). More schools scheduled recess before lunch (22.6% in 2005 vs 46.2% in 2011, P = .04) and developed policies for vending machines (42.9% in 2005 vs 85.7% in 2011, P = .01) and parties (21.4% in 2005 vs 57.9% in 2011, P = .004). CONCLUSION: Changes in school practices are modest, and arguably the important school practices such as increased PE and recess time and increased offerings of fruits and vegetables in the lunch line have not changed in the 5 years since the mandate went into effect. Further investigation is needed to identify the knowledge, skills, and attitudes as well as financial and physical resources required for school administrators to make changes in school practices.

Assessing the Readiness of Rural Public Health Agencies for Facilitating a School-based Intervention.

BACKGROUND: Partnerships are best positioned for success when the readiness of those engaged is assessed and discussed from the outset. Doing so requires an approach to readiness that is responsive to the particular context of the partnership. OBJECTIVES: This study contributes to the topic of partnership readiness through a readiness assessment used with rural local public health agencies (LPHAs) to partner with a university research team on implementing a Kindergarten to 12th-grade school-based health intervention called Assess, Identify, Make it happen. METHODS: Through case study methodology, we explored the readiness of LPHAs to partner with a university on this initiative as well as the role the readiness assessment played in facilitating this partnership. We conducted semistructured interviews with directors and agency staff in five rural LPHAs before (n = 8) and after (n = 5) they implemented Assess, Identify, Make it happen. We also documented their work with Kindergarten to 12th-grade schools and in partnership with us throughout the initiative. RESULTS: The findings of this study are presented in three phases. Phase 1 outlines the results from the initial readiness assessment interviews as aligned with select constructs of readiness. Phase 2 recounts how these constructs materialized through partnership between LPHAs and the university. Phase 3 includes findings from a postintervention interview focused on readiness for partnership. Collectively, these findings portray prospective, operational, and retrospective perspectives on LPHA readiness for partnership. CONCLUSIONS: This study contributes to the constructs of readiness for partnership, highlights the distinction between assessing and cultivating readiness, and demonstrates the benefits of a multiphase approach to readiness for partnership.

A Partnership Among Local Public Health Agencies, Elementary Schools, and a University to Address Childhood Obesity: A Scalable Model of the Assess, Identify, Make It Happen Process.

Background: One pathway to addressing childhood obesity is through implementing evidence-based practices (EBPs) shown to promote nutrition and physical activity in K-12 school settings. Assess, Identify, Make it happen (AIM) is a strategic planning process to engage stakeholders in implementing EBPs in their K-12 schools. Local Public Health Agencies (LPHAs) are a potential partner to facilitate this process to a broader audience of rural school communities. Methods: A process and outcome evaluation design was applied in this study to examine the extent to which LPHAs effectively implemented AIM with rural/frontier schools in comparison to university staff. Data collection included post-meeting surveys completed by facilitators, a post-intervention interview with facilitators, a survey of school task force members at the end of the AIM process, and systematic documentation of the intervention. Results: Reach -Among the 26 eligible elementary schools, 18 (69%) agreed to participate. Effect -In total, schools facilitated by LPHAs fully implemented an average of 4.0 changes per school, while schools facilitated by the university staff fully implemented an average of 3.7 changes. Adoption -Among the five LPHAs in the target region, all five agreed to partner on the initiative, but some agencies were unable to identify sufficient personnel to facilitate all schools in their catchment area. Implementation -(1) In total, 89 of 94 (95%) meetings scheduled by LPHA facilitators occurred. 47 of 48 (98%) meetings scheduled by the university staff occurred. (2) The university staff self-reported 93% of agenda items in the AIM process as "completely" followed while LPHA facilitators reported 41% of agenda items as "completely" followed. (3) Task force satisfaction with the AIM process and facilitator showed limited variance across LPHAs and university-facilitated schools. Maintenance -Of the 16 school districts that agreed to participate in the school-based version of AIM, 9 (56%) also participated in a district-wide version of AIM 2 years later. Conclusion: AIM is an effective process for implementing EBPs in elementary schools when facilitated by LPHAs. Effective partnerships, a nuanced approach to fidelity, scalability considerations, and the role of technical assistance and training all contributed to the successful implementation of this LPHA-Elementary school partnership.

The S.I.T.E. Framework: A Novel Approach for Sustainably Integrating Trauma-Informed Approaches in Schools.

Students who present as dysregulated due to the impacts of trauma and toxic stress can challenge educators and find themselves improperly or insufficiently supported, punitively consequenced and unable to equitably access education. Trauma-informed approaches based on an understanding of brain development and function have been put forth as best practice for supporting students with trauma histories. The novel Sustainably Integrated Trauma-Informed Education Framework (S.I.T.E. Framework) facilitates systemic integration of trauma-informed approaches across a school and was developed through a community-informed process to address implementation challenges traditionally linked to trauma-informed initiatives. The S.I.T.E Framework promotes the science-based content of the Neurosequential Model in Education (NME) and was piloted during the 2017-18 school year at a metropolitan elementary school in Colorado. Mixed analytic methods identified four components, 1) establish and facilitate school-based Core Team, 2) deliver school-wide professional development training, 3) provide on-site staff support and consultation and 4) conduct a comprehensive evaluation as critical to the successful implementation of the framework. Pilot testing of the S.I.T.E. Framework's innovative, multicomponent structure illustrates the potential for sustainable, whole-school integration of brain-based, trauma-informed approaches that are supportive of both educators and students regardless of their trauma history.

An adapted version of Intervention Mapping (AIM) is a tool for conducting community-based participatory research.

The field of public health is increasingly using community-based participatory research (CBPR) to address complex health problems such as childhood obesity. Despite the growing momentum and funding base for doing CBPR, little is known about how to undertake intervention planning and implementation in a community-academic partnership. An adapted version of Intervention Mapping (AIM) was created as a tool for university and elementary school partners to create school-level environment and policy changes aimed at increasing student physical activity and healthy eating. After AIM was completed, interviews were conducted with school partners. Findings indicate AIM is closely aligned to 7 of 9 CBPR principles. Examples include equitable involvement of all partners, co-learning, and balancing knowledge generation and community improvement. Shortcomings, lessons learned, and suggestions for strengthening the AIM process are described.

Early impact of the federally mandated Local Wellness Policy on physical activity in rural, low-income elementary schools in Colorado.

The What's Working project described the initial impact of the United States' federally mandated Local Wellness Policy in rural, low-income elementary schools located in Colorado. Before and after the Local Wellness Policy mandate went into effect, a survey about school features related to nutrition and physical activity was sent to a random sample of 45 rural elementary schools (i.e., schools located outside of urban areas), in which at least 40% of students qualified for free or reduced-cost lunch. Overall, opportunities for physical activity did not change after the policy went into effect: although time in physical education increased by 14 min per week (P=0.10), time for recess decreased by roughly 19 min per week (P=0.10). Policies supporting student participation in physical education and recess (an unstructured time during school hours when students are allowed to play outside) did not change. The researchers coded Local Wellness Policies and found them to have weak wording that produced minimal impact. Content analysis of key informant interviews suggested several barriers to the impact of the Local Wellness Policies: (1) competing pressures facing school districts, (2) lack of resources devoted to the Local Wellness Policy, (3) principals' lack of knowledge about the policy, and (4) lack of accountability mechanisms to ensure policy implementation. Financial resources and more effective communication about Local Wellness Policies among school districts and principals are needed to elevate the importance of and increase opportunities for physical activity in rural, low-income Colorado elementary schools.

Coaching process outcomes of a family visit nutrition and physical activity intervention.

The purpose of this article is to report the process outcomes of a coaching methodology used in a study designed to increase fruit and vegetable consumption and physical activity in families. Eighty-eight families with second graders were recruited from a rural, biethnic community in Colorado and randomized to intervention and delayed intervention conditions. This article reports on the 27 families in the delayed intervention group. Families received up to 10 home visits over 10 months from a family advisor and completed activities to improve their dietary and physical activity behaviors. Coaching conversations took place during each home visit. Coaching process outcomes were evaluated by analysis of visit documentation, participant survey, and qualitative interviews. Results indicated that coaching, in conjunction with family activities, engaged families in the process of change and facilitated movement toward the achievement of their weekly nutrition or physical activity goals. Coaching methodology may be particularly useful for participatory research.

A Community-Engaged Approach to Collecting Rural Health Surveillance Data.

PURPOSE: In order for communities to make health-related, data-driven decisions concerning resource allocation, needed services, and intervention priorities, they need an accurate picture of the health status of residents. While state and national health surveillance systems exist to help local communities make data-driven health decisions, rural communities face unique challenges including: (1) limited county-level data; (2) underrepresented segments of the population; and (3) a lack of survey items to address local health concerns. The purpose of this study was to take a community-engaged approach to collecting population-based health status data in a rural area in an effort to address some of these unique challenges. METHODS: Using a community-based participatory research (CBPR) approach, over 1,500 residents from 6 rural and frontier counties were randomly selected with a stratified, multistage cluster study design. Surveys were primarily completed over the phone. FINDINGS: Response rates by county ranged from 59% to 80% (overall = 66%). Males and younger adults (18-24 year olds) were underrepresented in the sample, but Hispanics, low-income residents, and cell phone-only users were adequately represented. Prevalence rates for chronic disease and health behavior varied by county. CONCLUSIONS: The implications of this project are that engaging stakeholders in community surveillance efforts increases the quality, relevance and utility of the information collected and can help reach otherwise difficult-to-reach populations. This can result in a more accurate picture of the health status of residents, which can lead to making health-related, data-driven decisions concerning resource allocation, needed services, and intervention priorities.

The Prevention Research Centers Healthy Aging Research Network.

BACKGROUND: The Prevention Research Centers Healthy Aging Research Network (PRC-HAN), funded by the Centers for Disease Control and Prevention's (CDC's) Healthy Aging program, was created in 2001 to help develop partnerships and create a research agenda that promotes healthy aging. The nine universities that participate in the network use their expertise in aging research to collaborate with their communities and other partners to develop and implement health promotion interventions for older adults at the individual, organizational, environmental, and policy levels. CONTEXT: The population of older adults in the United States is growing rapidly; approximately 20% of Americans will be aged 65 years or older by 2030. The health and economic impact of an aging society compel the CDC and the public health community to place increased emphasis on preventing unnecessary disease, disability, and injury among older Americans. METHODS: The PRC-HAN has a broad research agenda that addresses health-promoting skills and behaviors, disease and syndrome topics, and knowledge domains. The network chose physical activity for older adults as its initial focus for research and has initiated two networkwide projects: a comprehensive, multisite survey that collected information on the capacity, content, and accessibility of physical activity programs for older adults and a peer-reviewed publication that describes the role of public health in promoting physical activity among older adults. In addition to participating in the core research area, each network member works independently with its community committee on PRC-HAN activities. CONSEQUENCES: As a result, the network is 1) expanding prevention research for older adults and their communities; 2) promoting the translation and dissemination of findings to key stakeholders; 3) strengthening PRC-HAN capacity through partnerships and expanded funding; and 4) stimulating the adoption of policies and programs by engaging policymakers, planners, and practitioners. In 2003, the PRC-HAN initiated an internal evaluation to better define the network's contributions to healthy aging, formalize internal processes, and better equip itself to serve as a model for other PRC thematic networks. The PRC-HAN is conducting a pilot evaluation for eventual inclusion in the PRC national evaluation. INTERPRETATION: The PRC-HAN has established itself as an effective research network to promote healthy aging. It has developed trust and mutual respect among participants, forged strong ties to local communities, and shown the ability to combine its expertise in healthy aging with that of partners in national, state, and local organizations.

Adapting and implementing a long-term nutrition and physical activity curriculum to a rural, low-income, biethnic community.

This study adapted an urban-based school nutrition program for delivery in a rural community. Specific aims were to adapt the curriculum; expand it to include physical activity; determine effectiveness on students' attitudes, knowledge, and self-efficacy; and assess teachers' impressions. Three cohorts were established: 173 students taught by a resource teacher, 170 students taught by classroom teachers, and 187 students who did not receive the curriculum. Pre- and posttest surveys measured outcomes, and classroom teachers were observed and interviewed. The curriculum was shown to be effective in enhancing student outcomes for both the resource teacher and classroom teacher cohorts. Teachers reported that lessons needed to be simplified and that children enjoyed them. Findings support the transferability of an urban-based nutrition curriculum to a rural community and the need for students to receive health education annually.

Disseminating Evidence-Based Physical Education Practices in Rural Schools: The San Luis Valley Physical Education Academy.

BACKGROUND: To address childhood obesity, strategies are needed to maximize physical activity during the school day. The San Luis Valley Physical Education Academy was a public health intervention designed to increase the quality of physical education and quantity of moderate to vigorous physical activity (MVPA) during physical education class. METHODS: Elementary school physical education teachers from 17 schools participated in the intervention. They received SPARK curriculum and equipment, workshops, and site coordinator support for 2 years. A pre/post/post within physical education teacher design was used to measure intervention effectiveness. System for Observing Fitness Instruction Time (SOFIT) and a physical education teacher survey were collected 3 times. RESULTS: MVPA increased from 51.1% to 67.3% over the 2-year intervention resulting in approximately 14.6 additional hours of physical activity over a school year and 4662 kcal or 1.33 lbs. of weight gain prevention. More time was spent on skill drills and less time on classroom management and free play. CONCLUSIONS: The San Luis Valley Physical Education Academy succeeded in increasing rural, low-income students' physical activity. The multicomponent intervention contributed to the program's success. However, cost-effective approaches are needed to disseminate and implement evidencebased practices aimed at increasing students' physical activity during the school day.

A Community-Engaged Approach to Translating Research into Practice: A Physical Education Story.

BACKGROUND: The National Institutes of Health's Clinical and Translational Sciences Award program emphasizes the need to speed up the process of putting evidence-based practices into place. One strategy they promote is community engagement; however, few studies describe a process for meaningfully engaging communities in the translation process. OBJECTIVE: This article describes steps taken by a university- community partnership to create a plan for implementing evidence-based physical education (PE) practices in rural schools. This partnership's efforts resulted in the acquisition of a $1.86 million grant to implement the plan. METHODS: Qualitative data collected during the planning process were analyzed using content analysis. RESULTS: Key steps included undertaking a baseline assessment of community needs, reviewing and selecting evidence-based practices, developing a multilevel, community-driven action plan and establishing its feasibility with community stakeholders. LESSONS LEARNED: These steps could be applied to other health topics across a variety of settings. Several strategies that made the process successful are described. Recommendations are made for expanding the roles of Clinical and Translational Science Awards (CTSAs) and local health foundations in supporting community-engaged translational research. CONCLUSIONS: University-community partnerships have the potential to create plans and obtain large-scale funding for translating evidence-based research into practice.

Adapted intervention mapping: a strategic planning process for increasing physical activity and healthy eating opportunities in schools via environment and policy change.

BACKGROUND: School environment and policy changes have increased healthy eating and physical activity; however, there has been modest success in translating research findings to practice. The School Environment Project tested whether an adapted version of Intervention Mapping (AIM) resulted in school change. METHODS: Using a pair randomized design, 10 rural elementary schools were assigned to AIM or the School Health Index (SHI). Baseline measures were collected fall 2005, AIM was conducted 2005-2006, and follow-up measures were collected fall 2006 and 2007. Outcome measures included number and type of effective environment and policy changes implemented; process measures included the extent to which 11 implementation steps were used. RESULTS: AIM schools made an average of 4.4 effective changes per school with 90% still in place a year later. SHI schools made an average of 0.6 effective changes with 66% in place a year later. Implementation steps distinguishing AIM from SHI included use of external, trained facilitators; principal involvement; explicitly stating the student behavior goals; identifying effective environment and policy changes; prioritizing potential changes based on importance and feasibility; and developing an action plan. CONCLUSION: The AIM process led to environment and policy changes known to increase healthy eating and physical activity.

Long-term student outcomes of the Integrated Nutrition and Physical Activity Program.

OBJECTIVE: To examine the long-term effects of the Integrated Nutrition and Physical Activity Program (INPAP), a school-based nutrition education program. DESIGN: Quasi-experimental design comparing intervention and comparison cohorts at 3-6 years after delivery of the INPAP intervention on nutrition- and physical activity-related outcomes. SETTING: This study was conducted in 1 school district in a low-income rural county of ∼15,000 residents in south-central Colorado. PARTICIPANTS: In second grade, intervention and comparison cohorts included 173 (fall 2000) and 190 (fall 1999) students, respectively. Approximately 60% of these students completed assessments in eighth grade. INTERVENTIONS: INPAP is an experiential school-based nutrition education program, grounded in social cognitive theory and Piaget's cognitive development theory and adapted for use in a rural setting. OUTCOMES: Nutrition and physical activity knowledge, self-efficacy, attitudes and behaviors, body mass index. ANALYSIS: Wilcoxon signed rank test, chi-square test for proportions, and t test for means. RESULTS: Long-term effects were observed in nutrition-related knowledge and attitudes but not self-efficacy or behavior change. The effects that did occur were attenuated over time. CONCLUSION AND IMPLICATIONS: This study found that INPAP implemented in elementary school had limited lasting effects by the end of middle school, a time when students have increased autonomy to make food choices.

Fear of injury with physical activity is greater in adults with diabetes than in adults without diabetes.

OBJECTIVE: Physical activity is a cornerstone of treatment for diabetes, yet people with diabetes perform less moderate and vigorous physical activity (MVPA) than people without diabetes. In contrast, whether differences in walking activity exist has been understudied. Diabetes-specific barriers to physical activity are one possible explanation for lower MVPA in diabetes. We hypothesized that people with diabetes would perform less walking and combined MVPA and would be less likely to anticipate increasing physical activity if barriers were theoretically absent, compared with people without diabetes. RESEARCH DESIGN AND METHODS: We surveyed 1,848 randomly selected rural Colorado adult residents by telephone from 2002 to 2004. Respondents reported weekly walking and MVPA duration and their likelihood of increasing physical activity if each of seven barriers was theoretically absent. RESULTS: People with diabetes (n = 129) had lower odds of walking and MVPA than people without diabetes (walking: adjusted odds ratio 0.62 [95% CI 0.40-0.95]; MVPA: adjusted odds ratio 0.60 [0.36-0.99]; ≥10 vs. <10 min/week, adjusted for age, sex, BMI, and ethnicity). Respondents with diabetes reported fear of injury as a barrier to physical activity more often than respondents without diabetes (56 vs. 39%; P = 0.0002), although this relationship was attenuated after adjusting for age and BMI (adjusted odds ratio 1.36 [0.93-1.99]). CONCLUSIONS: Although walking is a preferred form of activity in diabetes, people with diabetes walk less than people without diabetes. Reducing fear of injury may potentially increase physical activity for people with diabetes, particularly in older and more overweight individuals.

Early effects of the federally mandated Local Wellness Policy on school nutrition environments appear modest in Colorado's rural, low-income elementary schools.

To increase opportunities for healthy eating and physical activity, US school districts participating in the National School Lunch Program were required to create a Local Wellness Policy (LWP) by June 2006. The What's Working project described the initial influence of this mandate on nutrition environments and policies. In 2005 and 2007 (before and after the mandate went into effect), a survey about school features related to nutrition and physical activity was sent to a random sample of 45 low-income, rural elementary foodservice managers and principals. Schools averaged 204 students, 27% Hispanic. Districts' LWPs were coded for strength and comprehensiveness. In addition, key informant interviews were conducted with foodservice managers almost 2 years after the LWP went into effect. Three improvements were observed: increases in the percent of schools with policies stipulating predominantly healthy items be offered in classroom parties (21.4% in 2005 vs 48.7% in 2007), daily fresh fruit offerings in the lunchroom (0.80 choices in 2005 vs 1.15 choices in 2007), and the percent of schools using skinless poultry (27% in 2005 vs 59% in 2007). LWPs were weakly worded and rarely addressed energy content. Nutrition guideline elements most commonly addressed included vending machines, school stores, and à la carte food offerings. Seveny-three percent of foodservice managers were familiar with their district's LWP but did not perceive it changed lunchroom practices. Although LWPs offer a framework to support opportunities for healthy eating, few evidence-based practices were implemented as a direct result of the mandate. Schools need more information about evidence-based practices, as well as technical and financial assistance for implementation.