The evaluation of Arkansas Act 1220 of 2003 to reduce childhood obesity: conceptualization, design, and special challenges.

This article describes the evaluation of the Arkansas Act 1220 of 2003, a comprehensive legislative proposal to address the growing epidemic of childhood obesity through changes in the school environment. In addition, the article discusses specific components of the evaluation that may be applicable to other childhood obesity policy evaluation efforts. The conceptual framework for the evaluation, research questions, and evaluation design are described, along with data collection methods and analysis strategies. A mixed methods approach, including both quantitative (surveys, telephone interviews) and qualitative (key informant interviews, records reviews) approaches, was utilized to collect data from a range of informant groups including parents, adolescents, school principals, school district superintendents, and other stakeholders. Challenges encountered with the evaluation are discussed, as are strategies to overcome those challenges. Now in its 9th year, this evaluation has documented substantial changes to school policies and environments but fewer changes to student and family behaviors. The evaluation may inform the methods of other evaluations of childhood obesity prevention policies, as well as inform policymakers about how quickly they might expect implementation of such policies in their own states and localities and anticipate both positive and adverse outcomes.

Creating and using index scores in the analysis of school policy implementation and impact.

BACKGROUND: Epidemic increases in childhood obesity and associated health risks are resulting in efforts to implement school policies related to nutrition and physical activity (NPA). With multicomponent policy efforts, challenges exist in characterizing the extent of policy change across the breadth of NPA policies. METHODS: Aggregated policy indices were created to characterize NPA policy implementation in Arkansas public schools from 2004 through 2009. Index scores are presented by year, domain, and school level. RESULTS: Both mean and median index scores increased over time, with greater changes seen in nutrition than in physical activity policy scores. The composite index score was heavily dependent on the nutrition index score and, thus, is relatively less useful for the purposes of our evaluation. Policy index scores varied by school level, rurality, enrollment size, and percentage of students eligible for federal meal programs. CONCLUSIONS: The policy index approach facilitates the consideration of the effect of school policy change in a holistic, aggregated way. School characteristics influence policy adoption, and thus, should be taken into consideration in the promotion of policy change.

Public policy versus individual rights in childhood obesity interventions: perspectives from the Arkansas experience with Act 1220 of 2003.

Childhood obesity is a major public health problem. Experts recommend that prevention and control strategies include population-based policies. Arkansas Act 1220 of 2003 is one such initiative and provides examples of the tensions between individual rights and public policy. We discuss concerns raised during the implementation of Act 1220 related to the 2 primary areas in which they emerged: body mass index measurement and reporting to parents and issues related to vending machine access. We present data from the evaluation of Act 1220 that have been used to address concerns and other research findings and conclude with a short discussion of the tension between personal rights and public policy. States considering similar policy approaches should address these concerns during policy development, involve multiple stakeholder groups, establish the legal basis for public policies, and develop consensus on key elements.

Development and evaluation of the school cafeteria nutrition assessment measures.

BACKGROUND: Foods provided in schools represent a substantial portion of US children's dietary intake; however, the school food environment has proven difficult to describe due to the lack of comprehensive, standardized, and validated measures. METHODS: As part of the Arkansas Act 1220 evaluation project, we developed the School Cafeteria Nutrition Assessment (SCNA) measures to assess food availability in public school cafeterias (n = 113). The SCNA provides a measure to evaluate monthly school lunch menus and to observe foods offered in school cafeterias during the lunch period. These measures provide information on the availability of fruit, vegetables, grains (whole or white), chips (reduced fat or regular), side dishes, main dishes, beverages, à la carte selections, and desserts, as well as information on healthier preparation of these items. Using independent raters, the inter-rater reliability of the measure was determined among a subsample of these schools (n = 32). RESULTS: All food categories assessed, with the exception of the side dish and chip categories, had inter-rater reliability rates of 0.79 or greater, regardless of school type. The SCNA scores encompassed the majority of the possible scores, indicating the ability for the measures to differentiate between school cafeterias in the availability of healthier options. CONCLUSION: These measures allow comprehensive, rapid measurement of school cafeteria food availability with high inter-rater reliability for public health and school health professionals, communities, and school personnel. These measures have the potential to contribute to school health efforts to evaluate cafeteria offerings and/or the impact of policy changes regarding school foods.

Social services utilization and need among a community sample of persons living with HIV in the rural south.

HIV prevalence has increased faster in the southern USA than in other areas, and persons living with HIV (PLWHIV) in the south are often rural, impoverished, or otherwise under-resourced. Studies of urban PLWHIV and those receiving medical care suggest that use of social services can enhance quality of life and some medical outcomes, but little is known about patterns of social service utilization and need among rural southern PLWHIV. The AIDS Alabama needs assessment survey, conducted in 2007, sampled a diverse community cohort of 476 adult PLWHIV representative of the HIV-positive population in Alabama (66% male, 76% Black, and 26% less than high school education). We developed service utilization/need (SUN) scores for each of 14 social services, and used regression models to determine demographic predictors of those most likely to need each service. We then conducted an exploratory factor analysis to determine whether certain services clustered together for the sample. Case management, assistance obtaining medical care, and financial assistance were most commonly used or needed by respondents. Black respondents were more likely to have higher SUN scores for alcohol treatment and for assistance with employment, housing, food, financial, and pharmacy needs; respondents without spousal or partner relationships had higher SUN scores for substance use treatment. Female respondents were more likely to have higher SUN scores for childcare assistance. Black respondents and unemployed respondents were more likely to have SUN scores in the highest quartile of the overall score distribution. Factor analysis yielded three main factors: basic needs, substance use treatment, and legal/medical needs. These data provide important information about rural southern PLWHIV and their needs for ancillary services. They also suggest clusters of service needs that often occur among PLWHIV, which may help case managers and other service providers work proactively to identify important gaps in care.

Public health professionals as policy entrepreneurs: Arkansas's childhood obesity policy experience.

In response to a nationwide rise in obesity, several states have passed legislation to improve school health environments. Among these was Arkansas's Act 1220 of 2003, the most comprehensive school-based childhood obesity legislation at that time. We used the Multiple Streams Framework to analyze factors that brought childhood obesity to the forefront of the Arkansas legislative agenda and resulted in the passage of Act 1220. When 3 streams (problem, policy, and political) are combined, a policy window is opened and policy entrepreneurs may advance their goals. We documented factors that produced a policy window and allowed entrepreneurs to enact comprehensive legislation. This historical analysis and the Multiple Streams Framework may serve as a roadmap for leaders seeking to influence health policy.

Changes in school environments with implementation of Arkansas Act 1220 of 2003.

Changes in school nutrition and physical activity policies and environments are important to combat childhood obesity. Arkansas Act 1220 of 2003 was among the first and most comprehensive statewide legislative initiatives to combat childhood obesity through school-based change. Annual surveys of principals and superintendents have been analyzed to document substantial and important changes in school environments, policies, and practices. For example, results indicate that schools are more likely to require that healthy options be provided for student parties (4.5% in 2004, 36.9% in 2008; P

Promoting dietary change among state health employees in Arkansas through a worksite wellness program: the Healthy Employee Lifestyle Program (HELP).

INTRODUCTION: Maintaining a healthy and productive workforce is essential for employers in public and private sectors. Poor nutrition and obesity contribute to chronic diseases and influence health care costs and productivity. Research indicates that eating a healthy diet is associated with lower body mass index and reduced risk for developing chronic disease. METHODS: The Arkansas Department of Health implemented the Healthy Employee Lifestyle Program to encourage wellness among state health employees. During the pilot year, participants completed a health risk assessment at baseline and again after 1 year that assessed diet and physical activity, other health risk factors, and readiness to make behavioral changes. Participants were encouraged to eat healthfully, participate in regular exercise, report health behaviors using a Web-based reporting system, accumulate points for healthy behaviors, and redeem points for incentives. Differences in participants' (n = 214) reported dietary behaviors between baseline and follow-up were assessed using chi2 analyses and tests of symmetry. RESULTS: Consumption of sweets/desserts, fats, protein, grains, processed meats, and dairy did not differ significantly from baseline to follow-up. However, at follow-up more participants reported eating 3 or more fruits and vegetables per day than at baseline and being in the action and maintenance stages of readiness to change for eating 5 or more fruits and vegetables per day and for eating a diet low in fat. CONCLUSION: Further study is needed to examine physical activity and other health risk factors to determine whether the program merits a broader dissemination.

Arkansas Act 1220 of 2003 to reduce childhood obesity: its implementation and impact on child and adolescent body mass index.

Arkansas was among the first states to pass comprehensive legislation to combat childhood obesity, with Arkansas Act 1220 of 2003. Two distinct but complementary evaluations of the process, impact, and outcomes of Act 1220 are being conducted: first, surveillance of the weight status of Arkansas children and adolescents, using the statewide data amassed from the required measurements of students' body mass indexes (BMIs); and second, an independent evaluation of the process, impact, and outcomes associated with Act 1220. Various stakeholder groups initially expressed concerns about the Act, specifically concerns related to negative social and emotional consequences for students and an excessive demand on health care. Evaluation data, however, suggest that few adverse effects have occurred either in these areas of concern or in other concerns which have emerged over time. Schools are changing environments and implementing policies and programs to promote healthy behaviors and BMI levels have not increased since the implementation of Act 1220 in 2004. The Arkansas experience to date may serve to inform the efforts of other states to adopt policies to address the epidemic of childhood obesity.

No change in weight-based teasing when school-based obesity policies are implemented.

OBJECTIVES: To examine rates of weight-based teasing before initiation of school-based childhood obesity prevention policies (Arkansas Act 1220 of 2003) and during the 2 years following policy implementation, as well as demographic factors related to weight-based teasing. DESIGN: Analysis of consecutive random cross-sectional statewide telephone surveys conducted annually across 3 years. SETTING: Sample representative of Arkansas public school students with stratification by geographic region, school level (elementary, middle, and high school), and school size (small, medium, and large). PARTICIPANTS: Parents of children enrolled in Arkansas public schools and index adolescents 14 years or older. Intervention Statewide school-based obesity policies, including body mass index screening. MAIN OUTCOME MEASURES: Survey items about weight-based teasing, other teasing, body weight and height, and sociodemographic factors, as well as school characteristics obtained from the Common Core of Data of the National Center for Education Statistics. RESULTS: At baseline, 14% of children experienced weight-based teasing by parental report. The prevalence of weight-based teasing did not change significantly from baseline in the 2 years following school-based policy changes. Children and adolescents most likely to be teased because of weight were those who were overweight, obese, white, female, and 14 years or older, as well as those teased for other reasons. Adolescent report of weight-based teasing yielded similar patterns. CONCLUSION: Although the effectiveness of school-based obesity prevention policies remains unclear, policy changes did not lead to increased weight-based teasing among children and adolescents.

Policy and environmental indicators for heart disease and stroke prevention: data sources in two states.

INTRODUCTION: Investigators in South Carolina and Alabama assessed the availability of data for measuring 31 policy and environmental indicators for heart disease and stroke prevention. The indicators were intended to determine policy and environmental support for adopting heart disease and stroke prevention guidelines and selected risk factors in 4 settings: community, school, work site, and health care. METHODS: Research teams used literature searches and key informant interviews to explore the availability of data sources for each indicator. Investigators documented the following 5 qualities for each data source identified: 1) the degree to which the data fit the indicator; 2) the frequency and regularity with which data were collected; 3) the consistency of data collected across time; 4) the costs (time, money, personnel) associated with data collection or access; and 5) the accessibility of data. RESULTS: Among the 31 indicators, 11 (35%) have readily available data sources and 4 (13%) have sources that could provide partial measurement. Data sources are available for most indicators in the school setting and for tobacco control policies in all settings. CONCLUSION: Data sources for measuring policy and environmental indicators for heart disease and stroke prevention are limited in availability. Effort and resources are required to develop and implement mechanisms for collecting state and local data on policy and environmental indicators in different settings. The level of work needed to expand data sources is comparable to the extensive work already completed in the school setting and for tobacco control.