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.

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.

Population seroprevalence of human papillomavirus types 6, 11, 16, and 18 in men, women, and children in Australia.

BACKGROUND: Representative population-based data on human papillomavirus (HPV) epidemiology are important for public health decision making but are difficult to obtain. Seroepidemiology is a valuable tool, although the relationship between HPV infection and seropositivity is incomplete. METHODS: We obtained a large representative sample using residual diagnostic test serum samples obtained from individuals aged 0-69 years (1247 samples from male patients and 1523 samples from female patients) in Australia. Serum antibody levels to HPV types 6, 11, 16, and 18 were measured using an immunoassay. RESULTS: Overall, seroprevalence of HPV types 6 and 16 was higher than seroprevalence of HPV types 11 and 18. Among female patients, peak HPV seropositivity occurred among those who were 30-39 years of age for types 6, 16, and 18 (22%, 22%, and 10.5%, respectively) and among those who were 40-49 years of age for HPV 11 (11.8%). Among male subjects, peak HPV seropositivity occurred among those who were 40-49 years of age for types 6 and 11 (15.4% and 9.1%, respectively) and among those who were 50-59 years of age for types 16 and 18 (14.3% and 8.2%, respectively). No cases of HPV seropositivity were detected in individuals <10 years of age. CONCLUSIONS: Australian seroepidemiological data, showing differing age-specific patterns of HPV seropositivity in male and female patients, are likely to be generalizable to other developed countries and add to other data supporting completion of HPV vaccination before adolescence.

Where in the world am I? Where should I be? Experiences and exhortations of an itinerant pediatric nurse practitioner.

This article describes the development of a lifelong interest in and commitment to the well-being of the world's children. Following a trip to Africa as a teenager, the author chose nursing as a vehicle for involvement with the delight, diversity, and disparities among children. The "accidents" of birth and the impact of geography and poverty on child health are demonstrated in global statistics but are better grasped by experiences in resource-poor countries such as Haiti, as presented here. Interest, involvement, and advocacy by pediatric nurse practitioners are encouraged and needed.

Tobacco Use Among Arab Immigrants Living in Colorado: Prevalence and Cultural Predictors.

PURPOSE: The authors determined the prevalence of smoking among Arab immigrants living in Colorado. The authors also evaluated the relationship between acculturation and tobacco use, including both cigarettes and hookah among Arab immigrants. METHOD: A cross-sectional survey of 100 adult Arab immigrants living in Colorado was carried out. RESULTS: The results revealed that 19% of the study participants were current cigarette smokers and 21% were current hookah smokers. Participants who were more integrated into Arab culture were more likely to use tobacco products ( p = .03) and to have family members ( p = .02) and friends who use tobacco products ( p = .007). CONCLUSIONS: Acculturation plays a major role in affecting the health habits of Arab immigrants living in Colorado, especially in the area of hookah smoking. IMPLICATIONS FOR PRACTICE: Understanding some culturally relevant predictors of tobacco use might assist health care providers in designing successful smoking cessation programs.

Identifying patterns of obesity risk behavior to improve pediatric primary care.

PURPOSE: To develop profiles of obesity risk behaviors for children and adolescents. DESIGN AND METHODS: Risk assessments were obtained from patients (n = 971) at a school-based health center. Latent class analysis was used to create subgroups based on seven indicators measuring diet, activity, and screen time. RESULTS: Four classes emerged, with 44% classified as the "Healthiest," 8% as the "Least Healthy," 37% as "Mixed Diet/Low Activity/Low Screen Time," and 11% as "Mixed Diet/High Activity/High Screen Time." Several demographic predictors distinguished the classes. PRACTICE IMPLICATIONS: Obesity risk factor profiles may help providers identify strengths and risks, tailor counseling, and plan interventions with families.

Clinician adherence to childhood overweight and obesity recommendations by race/ethnicity of the child.

PURPOSE: This study describes school-based health center (SBHC) providers' adherence to obesity guidelines. DESIGN AND METHODS: Providers (n = 28) were from SBHCs in six states serving children 5-12 years of age. A random sample of well-child charts (n = 850) were audited for body mass index percentage, blood pressure percentage, overweight/obesity diagnosis, and laboratory assessment. RESULTS: Body mass index percentage was documented on 73% of charts and blood pressure percentage on 30.5%. Providers accurately diagnosed 40% overweight and 49.3% obese children. Laboratory guidelines were followed in 80.4% of cases. Assessments differed by child's race/ethnicity (p < .05), with most criteria having higher adherence in minority youth. PRACTICE IMPLICATIONS: There is a need for increased accuracy in how SBHC providers screen overweight/obese children.

Comparing the Effectiveness of CDSS on Provider's Behaviors to Implement Obesity Prevention Guidelines.

Obesity is a global epidemic demanding the use of clinical decision support tools to help clinicians in the identification, assessment and management of healthy weight gain in children. Over the last decade, numerous systematic reviews have shown that clinical decision support systems (CDSS) have positively impacted clinician's performance for drug ordering/dosing and preventive care reminders. CDSS that are built into the clinician's workflow at the point of care also have a positive impact on provider's performance. There are limited studies that examine CDSS in nursing practice. This paper describes a comparative effectiveness study being conducted in school-based clinics to examine the impact of web-based training with and without a CDSS that contains tailored recommendations. The study involves the use of a CDSS tool focused on cardiovascular risks, HeartSmartKids™. This research is an important example of an interdisciplinary team using information technology to address the global issue of obesity prevention.

Phase I/II trial of single-fraction high-dose-rate brachytherapy-boosted hypofractionated intensity-modulated radiation therapy for localized adenocarcinoma of the prostate.

PURPOSE: A Phase I/II protocol was conducted to examine the toxicity and efficacy of the combination of intensity-modulated radiation therapy (IMRT) with a single-fraction high-dose-rate (HDR) brachytherapy implant. METHODS AND MATERIALS: From 2001 through 2006, 26 consecutive patients were treated on the trial. The primary objective was to demonstrate a high rate of completion without experiencing a treatment-limiting toxicity. Eligibility was limited to patients with T stage ≤2b, prostate-specific antigen (PSA) ≤20, and Gleason score ≤7. Treatment began with a single HDR fraction of 6Gy to the entire prostate and 9Gy to the peripheral zone, followed by IMRT optimized to deliver in 28 fractions with a normalized total dose of 70Gy. Patients received 50.4Gy to the pelvic lymph node. The prostate dose (IMRT and HDR) resulted in an average biologic equivalent dose >128Gy (α/ß=3). Patients whose pretreatment PSA was ≥10ng/mL, Gleason score 7, or stage ≥T2b received short-term androgen ablation. RESULTS: Median followup was 53 months (9-68 months). There were no biochemical failures by either the American Society of Therapeutic Radiology and Oncology or the Phoenix definitions. The median nadir PSA was 0.32ng/mL. All the 26 patients completed the treatment as prescribed. The rate of Grade 3 late genitourinary toxicity was 3.8% consisting of a urethral stricture. There was no other Grade 3 or 4 genitourinary or gastrointestinal toxicities. CONCLUSIONS: Single-fraction HDR-boosted IMRT is a safe effective method of dose escalation for localized prostate cancer.

Evaluation of technology to identify and assess overweight children and adolescents.

PURPOSE: The current obesity epidemic has produced a generation of children that may be the first to have a life expectancy shorter than their parents. To address the obesity epidemic, experts have published recommendations for providers. Research suggests the publication of guidelines may not change provider behavior. DESIGN AND METHODS: This study evaluates computer assistance for implementing obesity guidelines in school-based health centers. RESULTS: Significant improvements in identification and assessment of obesity in children with technology support were noted. PRACTICE IMPLICATIONS: Computer decision support shows promise for promoting the implementation of current recommendations by supporting providers in identifying, assessing, and providing tailored recommendations for children at risk of obesity.

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.

Cardiovascular risk in Hispanic and non-Hispanic preschoolers.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death in the United States for both men and women among all racial and ethnic groups. Identifying risk factors early in life can facilitate use of preventive strategies to reduce risk and improve health status across the life span. OBJECTIVE: The aim of this study was to identify modifiable (tobacco smoke exposure, physical inactivity, dietary fat intake, overweight, and high blood pressure [BP]) and nonmodifiable (family history, gender, and age) cardiovascular risk factors in low-income preschool children. METHODS: Low-income preschool children (N = 205) 3-5 years old were recruited to participate. Parents completed a multigenerational cardiovascular health history form and a 24-hour dietary recall for themselves and their child. The children's height, weight, and BP were obtained. RESULTS: Of the 205 children, 61% reported ethnicity as Latino or Hispanic, 31.7% non-Hispanic White, 1% non-Hispanic Black, 3.9% Asian, and 2.4% mixed race. The number of males (50.7%) and females (49.3%) was similar. Only 22 (10.7%) children had no identified cardiovascular risk factors. At least one modifiable risk factor was present in 179 (87.3%) children. Fifty-two (25.5%) children had a body mass index (BMI) > or = 85th percentile for gender and age; 44 (22.3%) had a systolic or diastolic BP over the 90th percentile for gender, age, and height; 128 (66.3%) had a dietary fat intake of > 30%; 77 (37.6%) watched TV or played video games more than 2 hr/day; and 48 (23.4%) were exposed to passive tobacco smoke. DISCUSSION: The identification of cardiovascular risk factors in almost 90% of presumably healthy preschoolers provides evidence to support testing of interventions that can improve health behaviors and reduce risks.

A guide to assist nurse practitioners with standardized nursing language.

The purpose of this project was to develop a guide to support use of the Omaha System in primary care. The Omaha System is a community practice-based standardized nursing language developed by the Visiting Nurses Association (VNA) of Omaha, NE. Nurse practitioners at a primary care faculty practice clinic began using the Omaha System to describe more completely the advanced nursing care provided to clients, beyond ICD-9 and CPT codes. After 9 months of data collection, key faculty members convened to analyze the data and discuss issues in coding and interpretation. To simplify use of the system and facilitate orientation of new faculty, this group devised a Primary Care Guide for the Omaha System. High-frequency problems and interventions were identified. Definitions of the intervention categories were reviewed, and targets appropriate for the primary care environment were recorded. The result was a concise, user-friendly guide to assist the primary care nurse practitioner in the use of standardized nursing language.