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research-article2014
HPPXXX10.1177/1524839914530399Health Promotion PracticeBergman et al. / Development, Implementation, and Assessment of Leadership Program for School Nutrition Directors
Stepping Up to the Challenge: The Development, Implementation, and Assessment of a Statewide, Regional, Leadership Program for School Nutrition Directors Jacqueline J. Bergman, BS1 Marilyn M. Briggs, PhD, RD, SNS1 Deborah L. Beall, MS, RD2 Sandy Curwood, MS, RD3 Pilar Gray, MA4 Scott Soiseth, BS5 Rodney K. Taylor, BS6 Sheri Zidenberg-Cherr, PhD1
A statewide professional development program was developed and implemented throughout California for school nutrition directors with the goal of creating healthy school environments and regional networks for collaboration and healthy school environment sustainability. Needs of school nutrition directors were identified through a needs assessment questionnaire. Results of the needs assessment questionnaire (n = 256) identified (a) planning cost-effective menus; (b) reducing calories, sodium, saturated fat, and trans fat in menus; and (c) using U.S. Department of Agriculture foods cost-effectively as the most useful topics. Highest rated topics informed the content of the professional development program. A post–professional development questionnaire identified key “insights, inspirations, and strategies” as (a) marketing of school foods program, (b) expansion of salad bars, and (c) collaboration with community partners. A 6-month follow-up questionnaire identified that 86% of participants made progress toward implementing at least one of their five insights, inspirations, and strategies in their school districts. Most common areas that were implemented were marketing and branding (32%), revamping salad
Health Promotion Practice January 2015 Vol. 16, No. (1) 122–131 DOI: 10.1177/1524839914530399 © 2014 Society for Public Health Education
bars (18%), and motivating staff (16%). School and Community Actions for Nutrition survey analysis showed a significant increase in the use of marketing methods in school nutrition programs from baseline to 6-month post–program implementation (p = .024). Keywords: behavior change; child/adolescent health; career development/professional preparation; health education; health promotion; nutrition; needs/assets assessment; program planning and evaluation; social marketing/health communication; coordinated school health programs; school health; obesity; chronic disease 1
Department of Nutrition, Center for Nutrition in Schools, University of California, Davis, Davis, CA, USA 2 California Department of Education, Sacramento, CA, USA 3 Ventura Unified School District, Ventura, CA, USA 4 Fort Bragg Unified School District, Fort Bragg, CA, USA 5 Turlock Unified School District, Turlock, CA, USA 6 Riverside Unified School District, Riverside, CA, USA Authors’ Note: Funded in part by U.S. Department of Agriculture 2010 Team Nutrition Training Grant. Address correspondence to Sheri Zidenberg-Cherr, University of California, Davis, One Shields Avenue, Meyer Hall, Davis, CA 95616, USA; e-mail: [email protected].
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Introduction >> In the United States, 32.6% of elementary school– age children are overweight or obese (Ogden, Carroll, Kit, & Flegal 2012). Although the cause of excess adiposity in children is multifactorial, childhood obesity is likely due to unhealthy behaviors such as overeating, lack of physical activity, or a combination of both (Baur, Hazelton, & Shrewsbury, 2011). Schools are uniquely positioned to play a critical role in the dietary and physical activity behaviors of children by establishing safe, supportive environments with policies and practices that foster healthy behaviors (Foster et al., 2008, Fox, Gordon, Nogales, & Wilson, 2009). In an effort to support healthy school environments, several federal initiatives and policies have emerged. For example, First Lady Michelle Obama’s Let’s Move! campaign was launched in 2010 with the following initiatives: create a healthy start for children; empower parents and caregivers; provide healthy food in schools; improve access to healthy, affordable foods; and increase physical activity (White House Task Force on Childhood Obesity, 2010). In addition, Nutrition Standards in the National School Breakfast and Lunch Programs (2012), new requirements for school meals, were published to align with the Dietary Guidelines for Americans, 2010 (U.S. Department of Agriculture [USDA] & U. S. Department of Health and Human Services, 2011). Although these federal initiatives and policies provide resources and guidance to improve the school environment, ultimately each school district is responsible for implementation, often with limited or no funding available. The purpose of this study was to develop, implement, and assess the impact of a statewide professional development program designed to equip school nutrition directors with the knowledge and skills needed to cost-effectively implement federal health and wellness initiatives and policies at the local level. The professional development program was titled “Stepping Up To the Challenge: Creating a Healthy School Environment Program” and was a unique partnership among state education agency staff, university researchers, and practitioners. A train-the-trainer (TTT) format was used to improve sustainability of the program, using four school nutrition directors who not only had experience as trainers but were also leading exemplary school nutrition programs.
Background >> The Centers for Disease Control and Prevention (2013) recommends a coordinated school health
approach as an effective method in creating a healthy school environment. The coordinated school health approach recognizes that an effective school health program consists of many components: health education; physical education; health services; nutrition services; counseling, psychological, and social services; healthy and safe school environment; health promotion for staff; and family/community involvement. In particular, the nutrition services component offers students a learning laboratory for classroom nutrition and health education, serves as a resource for linkages with nutrition-related community services, and is a key component of a healthy school environment. Although current federal initiatives and policies offer support to the nutrition services component of a healthy school environment, effectiveness is dependent on the implementation of changes at the school level. School nutrition directors have been identified as second (60.3%) only to superintendents (75.6%) as the individual generally held responsible for determining the level of implementation of health and wellness efforts in schools (Probart, McDonnell, Weirich, Schilling, & Fekete, 2008). In a study conducted by the California Department of Public Health in 2010, school nutrition directors identified the lack of professional development opportunities as a major barrier to implementing health and wellness activities that extend beyond the school lunch program (Agron, Berends, Ellis, & Gonzalez, 2010). The current study provides a best practices model that uses peer-trainers as a delivery method to facilitate a professional development program providing school nutrition directors with the knowledge and skills to enhance their contributions to health promotion efforts at their school districts by improving the healthy school environment. Train-the-Trainer Methods Research has shown that a major barrier to the sustainability of health promotion programs in elementary schools is the lack of continued professional support after the one initial intervention (Lytle, Ward, Nader, Pedersen, & Williston, 2003). The TTT format is an effective professional development method that expands the outreach to target audiences (Orfaly et al., 2005). For example, Dunn et al. (2006) demonstrated the effectiveness of the TTT format in implementing nutrition and physical activity standards. Brumby and Smith (2009) confirmed the success of the TTT format used in health trainings in extending the outreach of a community health program into rural areas.
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Kern’s Curriculum Development Process Curriculum development in health education should be a methodical and scholarly, yet practical, process that addresses the needs of both students and society at large. Kern’s approach to curriculum development is a theoretical approach that achieves these goals in six steps: problem identification and general needs assessment, needs assessment of targeted learners, development of educational program goals, delineation of educational strategies, implementation, and assessment (Kern, Thomas, Howard, & Bass, 1998). The current study uses an adapted version of this approach. Use of the Social Ecological Approach in the K–12 School Setting A recent position statement from the Academy of Nutrition and Dietetics, School Nutrition Association, and Society for Nutrition Education and Behavior emphasizes that to increase healthy behaviors in school-age children, health promotion efforts should focus not only on the individual’s choices but also on factors that influence those choices (Briggs, Fleischhacker, & Mueller, 2010). This social ecological approach recognizes that an individual’s behavior is shaped by multiple levels of influence, including individual, interpersonal, organizational, community, and political/public policy levels (McLeroy, Bibeau, Steckler, & Glanz, 1988). A description of each level of the social ecological model can be found in Supplemental Figure 1 (available at http://hpp.sagepub.com/supplemental). Social ecological strategies are commonplace in the development of successful, large-scale health interventions, such as the Women, Infant, and Children Supplemental Feeding Program training programs (Newes-Adeyi, Helitzer, Caulfield, & Bronner, 2000). In the school setting, Johnston, Denniston, Morgan and Bordeau (2009) showed positive results in parent and student’s perceptions toward their school’s nutrition program after social ecological strategies were implemented. Joshi and Azuma (2010) demonstrated how farm-to-school programs can target the various levels of the social ecological model in the context of school nutrition. First, the student (individual) may be targeted in the classroom by providing food-literacy education. Next, parents (interpersonal) may be targeted through newsletters that include seasonal recipes and other farm-to-school messages. The school (organizational) may also get involved by implementing “farm-fresh salad bars” with produce procured from local farms. Also, farmer’s markets may be encouraged (community). Finally, policy changes,
such as local procurement policies, may help support farm-to-school programs and ultimately contribute to a healthy school environment. The “Stepping Up to the Challenge: Creating a Healthy School Environment” program integrated a social ecological approach both in the delivery of the instructional program and as a theme in the content of the curriculum for school nutrition directors. Peer trainers provided reinforcement by including practical examples of successful use of this approach in the school setting, with the goal of improving children’s nutrition and health. As an example, the program delivery incorporated the interpersonal level through the use of key opinion leaders and peers, and the public policy level through the translation of national policies to nutrition and wellness policy changes at the local level.
Method >>
Professional Development Session Four 2-day, professional development sessions were held regionally within California as the first phase of the professional development program (Figure 1). An adapted version of Kern et al.’s (1998) curriculum development process was used to inform curriculum development. Step 1: Problem Identification and General Needs Assessment. The current project was designed to assist school nutrition directors in the local implementation of nutrition federal initiatives and policies. The general needs and interests of school nutrition directors were identified through a series of expert interviews with nutrition education consultants, researchers, and school nutrition directors selected to act as trainers in the professional development program, referred to as “ambassadors.” This information informed the content of the needs assessment questionnaire. Step 2: Needs Assessment of Targeted Learners. The needs assessment questionnaire was divided into five “content areas” and four to six “components” within each content area, pertinent to current federal initiatives and policies supporting a healthy school environment. The Dillman’s (2000) tailored design method was used to survey 1,478 school nutrition directors through e-mail. The school nutrition directors were asked to indicate the degree of usefulness of the content areas and respective components based on their training needs and interests. Ratings were based on a five-point Likert-type scale
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Needs Assessment Questionnaire (Participants: School Nutrition Directors = 256; Ambassadors = 5) + School and Community Action for Nutrition (SCAN) Survey (School Nutrition Directors = 61)
Content Development (Development Team: Project Director, UC Davis Graduate Student, 4* Ambassadors)
Northern California Professional Development Session (Attendees = 28)
Central California Professional Development Session (Attendees = 39)
Central Coast Professional Development Session (Attendees = 42)
Los Angeles Area Professional Development Session (Attendees = 40)
Professional Development Session Feedback Questionnaire (School Nutrition Directors = 129)
4 Northern California TA Sessions (Attendees ≈ 7/session)
4 Central California TA Sessions (Attendees ≈ 9/session)
3 Central Coast TA Sessions (Attendees ≈ 16/session)
4 Los Angeles Area TA Sessions (Attendees ≈ 16/session)
Project Feedback Questionnaire (School Nutrition Directors = 103) + 6-month follow-up SCAN (School Nutrition Directors = 61)
Figure 1 Stepping Up To the Challenge: Creating a Healthy School Environment Professional Development and Technical Assistance Program Summary
(1 = least useful to 5 = most useful). A description of content areas and content area components listed on the questionnaire is provided in Supplemental Table 1. Step 3: Goals. The overarching goal of each lesson was to address the school nutrition directors’ top professional development needs and interests through the use of social ecological techniques. Step 4: Strategies. The ambassadors used a variety of pedagogical methods that address multiple learning styles such as interactive engagement (Crouch, Watkins, Fagen, & Mazur, 2007), media-enhanced teaching (Champoux, 2001), and cooperative learning (University of Washington, 2011). After 10 weeks of independent development professional development presentations, supplemental resources, agenda, and other logistics were finalized. Step 5: Implementation. Four professional development sessions were held at four regional locations. Ambassadors presented their portion of the professional development session at all four sessions. Step 6: Assessment. The knowledge acquired by the school nutrition directors was assessed by a professional
development session feedback questionnaire. Attendees reported their top five insights, inspirations, and/or strategies that would be useful at their school districts/ sites. Further technical assistance needs were also assessed. Technical Assistance Sessions Fifteen half-day professional development sessions were held as the second phase of the professional development program as diagramed in Figure 1. An adapted version of Kern et al.’s (1998) curriculum development process was also used to develop, implement, and assess the technical assistance sessions. Steps. 1 and 2: Problem Identification, General Needs Assessment, Needs Assessment of Targeted Learners. Results from the professional development session feedback questionnaire informed the content of the subsequent technical assistance sessions. Step 3: Goals. The goals of each session varied according to the specific needs and interests of the technical assistance attendees. For example, one technical assistance session expanded on best practices in implementing a
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Table 1 Needs Assessment Questionnaire: School Nutrition Director’s Content Area Rankings (n = 256) Rank 1
2 3 4 5
Content Area
Rating (M)
SD
Menu Planning to Meet the New Meal Pattern Proposed Rule Healthy School Environment Fresh Fruits and Vegetable Use and Promotion Let’s Move! Campaign Farm to School programs (Know Your Farmer, Know Your Food Initiatives)
4.52
0.7
4.36 4.31
0.7 0.8
4.12 3.91
0.8 0.9
NOTE: The degree of usefulness of each content area was rated based on the training needs and interests of the ambassadors and school nutrition directors, 1 (least useful) to 5 (most useful). Content areas were ranked based on the highest mean scores, 1 (highest mean rating) and 5 (lowest mean rating)
farm-fresh salad bar, whereas another focused on recipe development. Step 4: Strategies. The technical assistance sessions were centered on the peer-led team learning pedagogy. Fifteen school nutrition directors who attended the professional development session were recruited as peer leaders. The technical assistance sessions provided supportive environments that helped each school nutrition director participate actively in the process of learning (Arendale, 2004). Step 5: Implementation. The ambassadors planned 3 or 4 sessions within their regions for a total of 15 technical assistance sessions. Each session included groups of 5 to 18 school nutrition directors, one peer leader, one ambassador, and the state agency project director. Step 6: Assessment. At the end of each technical assistance session, the school nutrition directors completed a program feedback questionnaire. Responses served as part of the impact assessment of the entire program. Participants reported their implemented “insights, inspirations, and/or strategies.” The impact of the entire program was also assessed by the School and Community Actions for Nutrition (SCAN) Survey. The SCAN Survey, developed by University of
California, Davis, researchers, is an assessment tool used to evaluate school environments (Briggs, 2007, 2012). Categories include Wellness Policy, School Environment, Student Education Programs, Professional Development Programs, and Parent Involvement. A random sample of the school nutrition directors completed an electronic version of the SCAN Survey before and after they attended the professional development series. The evaluation of the professional development program focused on the assessment of immediate outputs (school nutrition director’s acquired knowledge as reported by “insights and inspirations”) and intermediate outcomes of changes in school environments as reported by school nutrition directors. The University of California, Davis, Institutional Review Board approved all components of the current study with exempt status.
Results >> This section covers results from: the needs assessment questionnaire, professional development session content that was developed based on the needs assessment questionnaire results, professional development session feedback questionnaire, program feedback questionnaire, and SCAN survey. Needs Assessment Questionnaire Results Response Rates. Of the 1,478 school nutrition directors that were surveyed, 256 (17%) completed the needs assessment questionnaire. Content Area and Components. Results of the needs assessment questionnaire content area rankings are presented in Table 1. The school nutrition directors rated each of the five content areas based on their professional development needs and interests. Content areas were then rated based on highest to lowest mean scores (1 = highest rating, 5 = lowest rating). The content area titled “Planning Menus to Meet Proposed Rule” received the highest mean rating and the highest ranking out of the five content areas (M = 4.52, SD = 0.7), followed by the Healthy School Environment content area (M = 4.36, SD = 0.7). Table 2 provides the top 15 content area components as rated by the school nutrition directors. Although all 32 content area components were highly rated, the top 5 rated content area components were those related to the implementation of the new federal menu planning mandate, with “ Planning Cost-Effective Menus” (M = 4.53, SD = 0.8) receiving the highest rating.
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Table 2 Needs Assessment Questionnaire: School Nutrition Director’s Top 15 Content Area Components (n = 256) Content Area V V V V V II III V III V III
I III III III
Content Area Component
Rating
SD
Planning cost-effective menus Reducing calories, sodium, saturated fat, and trans fat in school menus Using U.S. Department of Agriculture foods (commodities) to costeffectively enhance school menus Increasing dark green and orange vegetables in school menus Increasing whole grains in school menus Meeting the HealthierUS School Challenge criteria Incorporating the 2010 Dietary Guidelines into the school environment Increasing dry beans and peas in school menus Marketing your healthy school meals and snacks Implementing food-based, whole-food approach in menu planning Using resources from other partners such as the California Department of Education, the U.S. Department of Agriculture, and the California Department of Public Health Promoting nutrition education related to fresh fruits and vegetables for meals and snacks Implementing wellness policies that direct change Promoting healthy foods with nutritional promotions and education Increasing fresh fruits and vegetables in school menus, including salad bars (techniques and promotions)
4.53 4.48 4.44
0.8 0.8 0.9
4.40 4.38 4.33 4.29 4.26 4.25 4.21 4.20
0.8 0.8 0.8 0.8 0.7 0.7 0.8 0.8
4.19
0.8
4.19 4.18 4.13
0.8 0.9 0.8
NOTE: The degree of usefulness of each content area was rated based on the training needs and interests of the ambassadors, 1 (least useful) to 5 (most useful). Content areas are as follows: I. Fresh Fruits and Vegetable Use and Promotion, II. Let’s Move! campaign, III. Healthy School Environment, IV. Farm to School programs (Know Your Farmer, Know Your Food initiatives), V. Menu Planning to Meet the New Meal Pattern Proposed Rule.
Other components receiving high mean ratings were “Meeting the HealthierUS School Challenge criteria” (M = 4.33, SD = 0.8); “Using resources from other partners such as the California Department of Education, the USDA, and the California Department of Public Health” (M = 4.20, SD = 0.8); and “Implementing Wellness Policies that direct change” (M = 4.19, SD = 0.8). Professional development lesson topics and content addressed top needs and interests through social ecological approaches. For example, the highly rated content area components regarding the federal menu planning mandate were addressed through social ecological approaches in the lessons titled “A Taste of California: From Apples & Beans to Grains & Zucchini” and “Promoting Creative School Food Cost-Effectively.” “Promoting nutrition education . . .” and “Implementing wellness policies . . .,” also highly rated content area components, were addressed using social ecological techniques in the lesson titled “Wellness for Our Kids: Connecting the Classroom, Cafeteria, & Community. Table 3 provides a summary of curriculum lesson titles
and content, in addition to examples of teaching methodologies used. Professional Development Session Feedback Questionnaire Results Of the 140 school nutrition directors who attended the professional development sessions, 129 completed the professional development session feedback questionnaire. Strategies, Insights, and Inspirations. The most frequent insights, inspirations, and/or strategies reported were marketing for school foods program (16.9%), expansion of salad bars (11.8%), and collaboration with community partners (8.7%). Technical Assistance Needs Assessment. School nutrition directors expressed the need for further technical assistance in culinary arts/recipes/menus (28%), locating local farmers (23%), forming community
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Table 3 Professional Development Topics, Objectives, and Content Summaries Lesson Title
Content Summary
Lesson Methodology
An interactive lecture was used to engage school nutrition directors in a discussion about the application of the social ecological model and the use of a social marketing approach. A multimedia lecture was used to share videos 1. Demonstrate the importance of establishing Wellness For Our and photos of successful community community connections to achieve health and Kids: Connecting relationships such as a local timber company. wellness goals. 2. Evaluate school wellness the Classroom, Cooperative learning was used to assess a policy as a guide for creating a healthy school Cafeteria, & sample wellness policy. Methods for environment. 3. Showcase nutrition education Community marketing your program through nutrition as an effective component of a healthy school education and applications to the social environment ecological model were provided. Cooperative learning was used to complete 1. Review basic marketing guidelines and Marketing Your social marketing activities and apply to the activities that will help school nutrition Healthy School social ecological model. Teams were services: (a) increase participation, (b) Foods Program challenged to complete a “SWOT” (Strengths, increase customer satisfaction, (c) increase With a Focus on Weaknesses, Opportunities and Threats) recognition for providing healthy food Change analysis of their school nutrition services choices, (d) improve public relation, (e) program. empower staff An interactive, multimedia lecture was used to Promoting Creative 1. Marketing a school nutrition program share marketing ideas (e.g., community School Food Costthrough community outreach and how this barbeques employing a chef to market the Effectively applies to the social ecological model, (2) culinary arts). Marketing through the use of culinary arts Cooperative learning was used to complete the 1. Revamp menu using HeathierUS Challenge; A Taste of HeathierUS Challenge, with application to 2. Create seasonal, regional, cost-effective California: From menus with fruits and vegetables (institutional the social ecological model. Sample recipes Apples & Beans to with taste-testings were also included. A level of the social ecological model); 3. Grains & Zucchini multimedia lecture showcased food safety Incorporate safe fruits and vegetables from and composting ideas. procurement to composting An interactive, multimedia lecture was used to The Farmers’ Market 1. How a farmer’s market salad bar program cover ideas on how to market a salad bar and Salad Bar Program works, 2. Provide examples of resources apply this to the social ecological approach. needed to successfully implement the program
Stepping Up To Create a Healthy School Environment
1. Demonstrate the purpose of the professional development program, 2. provide an overview of the framework and the social ecological model, 3. Introduce ambassadors
collaborations (22%), obtaining more information on USDA initiatives (22%), and other (5%). Program Feedback Questionnaire Results Strategies, Insights, and Inspiration Implementation. Results from the program feedback questionnaire indicated that 86% of school nutrition directors were making progress in implementing at least one of their five insights, inspirations, and strategies within their school district, with 20% of school nutrition directors implementing one out of five, 18% implementing two
out of five, 25% implementing three out of five, 11% implementing four out of five, 14% implementing five out of five, and 21% implementing zero out of five. Areas that were most frequently implemented included marketing and branding their school lunch program (32%), expanding salad bars (18%), motivating staff (16%), and trying new recipes (12%). SCAN Survey Results A random sample of the participating school nutrition directors (n = 61) completed the SCAN before the
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professional development program and after they attended the subsequent technical assistance session professional development sessions. The SCAN analysis comparing school environments at baseline with 6 months postprogram showed only one statistically significant improvement, with “Marketing and media messages on the school premises reinforce food and nutrition education” increasing from a mean score of 1.3 to 2.6 (p = .024).
Discussion >>
which supports positive changes at the institutional level. This category included comments ranging from starting a salad bar to expanding an existing salad bar to target more levels of the social ecological model, such as sourcing produce from local farmers and/or supplementing with nutrition education material. Professional development topics regarding the use of social marketing strategies to target all levels of the social ecological model were also widely implemented as reported by the program feedback questionnaire. Using Social Marketing Strategies to Implement the Social Ecological Model
Limitations
The primary long-term goal of the current professional development program was the improvement of student health outcomes. Unfortunately, due to limiting funding, data on student outcomes were not collected in this study. Instead, the impact evaluation of the current professional development program focused on the assessment of immediate outputs, such as school nutrition directors’ acquired knowledge as reported by “insights and inspirations” and intermediate outcomes of self-reported changes in school environments. A second limitation to the study was the brevity between pre- and postresults as measured by the SCAN questionnaire and program feedback questionnaire. Assessments were conducted only 6 months after the professional development program. This limitation may have contributed to the fact that 21% of school nutrition directors had not yet implemented their reported “insights and inspirations.” Another limitation was the low response rate of the needs assessment questionnaire (17%). Although the questionnaire was distributed to all school nutrition directors in California, only the school nutrition directors willing and able to attend the professional development program completed the needs assessment questionnaire. For future studies, the needs of the entire school nutrition director population should be assessed before program development, followed by an invitation to attend the program. Using the Social Ecological Model for Positive, Sustainable Change Postprogram assessments showed that school nutrition directors were motivated by the ambassadors’ messages regarding the benefits of the social ecological approach. For example, using the community level of the model, school nutrition directors identified topics such as collaboration with community partners as a top “insight/inspiration/strategy.” Another top “insight/ inspiration/strategy” was the expansion of salad bars,
Social marketing strategies applied in health promotion programs have shown a profound impact on the target individual’s behavior (Griffiths, Blair-Stevens, & Parish, 2009). The major advantages of social marketing are a direct immediate benefit and an effect on behavior at multiple levels of social organization (Maibach, Rothschild, & Novelli, 2002). Based on these findings, it is no wonder the program’s participants responded well to social marketing strategies presented. The connections among social marketing and social ecological strategies were discussed as part of the program curriculum. For example, one ambassador used school nutrition “marketing” funds to promote physical activity by purchasing a score board for the school’s baseball team. In return, he was able to display his school nutrition program’s logo on the scoreboard. He also used these “marketing” funds to host community harvest parties during which he raffled off sports equipment and gardening supplies. It was through his social marketing efforts that he was able to promote a healthy lifestyle to the entire community while changing the perception of his school nutrition program. Results of the postprogram assessments highlight the impact that the ambassador’s instruction regarding social marketing had on school nutrition directors’ behaviors. For example, SCAN results demonstrated a significant increase in the implementation of “marketing and media messages on the school premises reinforce food and nutrition education” in the school nutrition directors’ school districts/sites. Also, the most implemented “insight/inspiration/strategy” was the marketing and branding of the school nutrition program. The Ambassador Model: A Sustainable Professional Development Approach An unexpected outcome of this project was the success of the “ambassador” model. Although it was predicted that the ambassadors would provide insight during the development and implementation of the
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program, their impact on the sustainability of the program was not anticipated. The original ambassadors continue to offer regular technical assistance sessions to those that are interested, and many school nutrition directors were also inspired to become “healthy school environment ambassadors.” Years after the initial program was hosted, the new ambassadors continue to offer technical assistance sessions that offer networking opportunities with colleagues.
Conclusions >> In response to the nation’s focus on addressing rising childhood obesity rates, many innovative federal initiatives and policies have resulted. The current study describes a method to assist school nutrition directors in the implementation of sustainable strategies to promote a healthy school environment at the local level. With the positive results at the level of intermediate outcomes, assessment of student outcomes is recommended for future studies implementing similar methods. Plans for Further Implementation A third component of the professional development program will include a web-based resource tool titled “The Fresh, Regional, Education-Supportive, Healthy (FRESH) Meals at Schools Electronic Toolkit.” This resource is currently in development and will include the program curriculum as well as supplementary resources generated based on the results of needs assessments conducted in this study.
SUPPLEMENTAL MATERIAL The supplemental material is available at http://hpp.sagepub .com/supplemental.
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Lytle, L. A., Ward, J., Nader, P. R., Pedersen, S., & Williston, B. J. (2003). Maintenance of a health promotion program in elementary schools: Results from the CATCH-ON study key informant interviews. Health Education & Behavior, 30, 503-518. Maibach, E. W., Rothschild, M. L., & Novelli, W. D. (2002). Social marketing. In K. Glanz, B. Rimer, & F. M. Lewis (Eds.), Health behavior and health education (pp. 437-461). San Francisco, CA: Jossey-Bass.
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McLeroy, K. R., Bibeau, D., Steckler, A., & Glanz, K. (1988). An ecological perspective on health promotion programs. Health Education, 15, 351-377. Retrieved from http://www.ncbi.nlm.nih. gov/pubmed/3068205 National Institute of Mental Health. (2009). Anxiety disorders (NIH Publication No. 09-3879). Retrieved from http://www.nimh. nih.gov/health/publications/anxiety-disorders/nimhanxiety.pdf Newes-Adeyi, G., Helitzer, D. L., Caulfield, L. E., & Bronner, Y. (2000). Theory and practice: Applying the ecological model to formative research for a WIC training program in New York State. Health Education Research, 15, 283-291. Nutrition Standards in the National School Lunch and School Breakfast Programs, 7 C.F.R. § 210 and 220 (2012). Ogden, C. L., Carroll, M. D., Kit, B. K., & Flegal, K. M. (2012). Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010. Journal of the American Medical Association, 307, 483-490. doi:10.1001/jama.2012.40 Orfaly, R. A., Frances, J. C., Campbell, P., Whittemore, B., Joly, B., & Koh, H. (2005). Train-the-trainer as an educational model in
public health preparedness. Journal of Public Health Management Practices, November(Suppl.), S123-S127. Retrieved from http:// www.ncbi.nlm.nih.gov/pubmed/16205531 Probart, C., McDonnell, E., Weirich, J. E., Schilling, L., & Fekete, V. (2008). Statewide assessment of local wellness policies in Pennsylvania public school districts. Journal of the American Dietetic Association, 108, 1497-1502. doi:10.1016/ j.jada.2008.06.429 University of Washington. (2011). Changing a course from lecture format to cooperative learning. Retrieved from http://depts .washington.edu/cidrweb/OLD/resources/CooperativeLearning .html U.S. Department of Agriculture & U.S. Department of Health and Human Services. (2011), Dietary guidelines for Americans, 2010 (7th ed.). Washington, DC. U.S. Government Printing Office. White House Task Force on Childhood Obesity. (2010). Solving the problem of childhood obesity within a generation. Retrieved from http://www.letsmove.gov/sites/letsmove.gov/files/TaskForce_on_ Childhood_Obesity_May2010_FullReport.pdf
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research-article2014
HPPXXX10.1177/1524839914530399Health Promotion PracticeBergman et al. / Development, Implementation, and Assessment of Leadership Program for School Nutrition Directors
Stepping Up to the Challenge: The Development, Implementation, and Assessment of a Statewide, Regional, Leadership Program for School Nutrition Directors Jacqueline J. Bergman, BS1 Marilyn M. Briggs, PhD, RD, SNS1 Deborah L. Beall, MS, RD2 Sandy Curwood, MS, RD3 Pilar Gray, MA4 Scott Soiseth, BS5 Rodney K. Taylor, BS6 Sheri Zidenberg-Cherr, PhD1
A statewide professional development program was developed and implemented throughout California for school nutrition directors with the goal of creating healthy school environments and regional networks for collaboration and healthy school environment sustainability. Needs of school nutrition directors were identified through a needs assessment questionnaire. Results of the needs assessment questionnaire (n = 256) identified (a) planning cost-effective menus; (b) reducing calories, sodium, saturated fat, and trans fat in menus; and (c) using U.S. Department of Agriculture foods cost-effectively as the most useful topics. Highest rated topics informed the content of the professional development program. A post–professional development questionnaire identified key “insights, inspirations, and strategies” as (a) marketing of school foods program, (b) expansion of salad bars, and (c) collaboration with community partners. A 6-month follow-up questionnaire identified that 86% of participants made progress toward implementing at least one of their five insights, inspirations, and strategies in their school districts. Most common areas that were implemented were marketing and branding (32%), revamping salad
Health Promotion Practice January 2015 Vol. 16, No. (1) 122–131 DOI: 10.1177/1524839914530399 © 2014 Society for Public Health Education
bars (18%), and motivating staff (16%). School and Community Actions for Nutrition survey analysis showed a significant increase in the use of marketing methods in school nutrition programs from baseline to 6-month post–program implementation (p = .024). Keywords: behavior change; child/adolescent health; career development/professional preparation; health education; health promotion; nutrition; needs/assets assessment; program planning and evaluation; social marketing/health communication; coordinated school health programs; school health; obesity; chronic disease 1
Department of Nutrition, Center for Nutrition in Schools, University of California, Davis, Davis, CA, USA 2 California Department of Education, Sacramento, CA, USA 3 Ventura Unified School District, Ventura, CA, USA 4 Fort Bragg Unified School District, Fort Bragg, CA, USA 5 Turlock Unified School District, Turlock, CA, USA 6 Riverside Unified School District, Riverside, CA, USA Authors’ Note: Funded in part by U.S. Department of Agriculture 2010 Team Nutrition Training Grant. Address correspondence to Sheri Zidenberg-Cherr, University of California, Davis, One Shields Avenue, Meyer Hall, Davis, CA 95616, USA; e-mail: [email protected].
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Introduction >> In the United States, 32.6% of elementary school– age children are overweight or obese (Ogden, Carroll, Kit, & Flegal 2012). Although the cause of excess adiposity in children is multifactorial, childhood obesity is likely due to unhealthy behaviors such as overeating, lack of physical activity, or a combination of both (Baur, Hazelton, & Shrewsbury, 2011). Schools are uniquely positioned to play a critical role in the dietary and physical activity behaviors of children by establishing safe, supportive environments with policies and practices that foster healthy behaviors (Foster et al., 2008, Fox, Gordon, Nogales, & Wilson, 2009). In an effort to support healthy school environments, several federal initiatives and policies have emerged. For example, First Lady Michelle Obama’s Let’s Move! campaign was launched in 2010 with the following initiatives: create a healthy start for children; empower parents and caregivers; provide healthy food in schools; improve access to healthy, affordable foods; and increase physical activity (White House Task Force on Childhood Obesity, 2010). In addition, Nutrition Standards in the National School Breakfast and Lunch Programs (2012), new requirements for school meals, were published to align with the Dietary Guidelines for Americans, 2010 (U.S. Department of Agriculture [USDA] & U. S. Department of Health and Human Services, 2011). Although these federal initiatives and policies provide resources and guidance to improve the school environment, ultimately each school district is responsible for implementation, often with limited or no funding available. The purpose of this study was to develop, implement, and assess the impact of a statewide professional development program designed to equip school nutrition directors with the knowledge and skills needed to cost-effectively implement federal health and wellness initiatives and policies at the local level. The professional development program was titled “Stepping Up To the Challenge: Creating a Healthy School Environment Program” and was a unique partnership among state education agency staff, university researchers, and practitioners. A train-the-trainer (TTT) format was used to improve sustainability of the program, using four school nutrition directors who not only had experience as trainers but were also leading exemplary school nutrition programs.
Background >> The Centers for Disease Control and Prevention (2013) recommends a coordinated school health
approach as an effective method in creating a healthy school environment. The coordinated school health approach recognizes that an effective school health program consists of many components: health education; physical education; health services; nutrition services; counseling, psychological, and social services; healthy and safe school environment; health promotion for staff; and family/community involvement. In particular, the nutrition services component offers students a learning laboratory for classroom nutrition and health education, serves as a resource for linkages with nutrition-related community services, and is a key component of a healthy school environment. Although current federal initiatives and policies offer support to the nutrition services component of a healthy school environment, effectiveness is dependent on the implementation of changes at the school level. School nutrition directors have been identified as second (60.3%) only to superintendents (75.6%) as the individual generally held responsible for determining the level of implementation of health and wellness efforts in schools (Probart, McDonnell, Weirich, Schilling, & Fekete, 2008). In a study conducted by the California Department of Public Health in 2010, school nutrition directors identified the lack of professional development opportunities as a major barrier to implementing health and wellness activities that extend beyond the school lunch program (Agron, Berends, Ellis, & Gonzalez, 2010). The current study provides a best practices model that uses peer-trainers as a delivery method to facilitate a professional development program providing school nutrition directors with the knowledge and skills to enhance their contributions to health promotion efforts at their school districts by improving the healthy school environment. Train-the-Trainer Methods Research has shown that a major barrier to the sustainability of health promotion programs in elementary schools is the lack of continued professional support after the one initial intervention (Lytle, Ward, Nader, Pedersen, & Williston, 2003). The TTT format is an effective professional development method that expands the outreach to target audiences (Orfaly et al., 2005). For example, Dunn et al. (2006) demonstrated the effectiveness of the TTT format in implementing nutrition and physical activity standards. Brumby and Smith (2009) confirmed the success of the TTT format used in health trainings in extending the outreach of a community health program into rural areas.
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Kern’s Curriculum Development Process Curriculum development in health education should be a methodical and scholarly, yet practical, process that addresses the needs of both students and society at large. Kern’s approach to curriculum development is a theoretical approach that achieves these goals in six steps: problem identification and general needs assessment, needs assessment of targeted learners, development of educational program goals, delineation of educational strategies, implementation, and assessment (Kern, Thomas, Howard, & Bass, 1998). The current study uses an adapted version of this approach. Use of the Social Ecological Approach in the K–12 School Setting A recent position statement from the Academy of Nutrition and Dietetics, School Nutrition Association, and Society for Nutrition Education and Behavior emphasizes that to increase healthy behaviors in school-age children, health promotion efforts should focus not only on the individual’s choices but also on factors that influence those choices (Briggs, Fleischhacker, & Mueller, 2010). This social ecological approach recognizes that an individual’s behavior is shaped by multiple levels of influence, including individual, interpersonal, organizational, community, and political/public policy levels (McLeroy, Bibeau, Steckler, & Glanz, 1988). A description of each level of the social ecological model can be found in Supplemental Figure 1 (available at http://hpp.sagepub.com/supplemental). Social ecological strategies are commonplace in the development of successful, large-scale health interventions, such as the Women, Infant, and Children Supplemental Feeding Program training programs (Newes-Adeyi, Helitzer, Caulfield, & Bronner, 2000). In the school setting, Johnston, Denniston, Morgan and Bordeau (2009) showed positive results in parent and student’s perceptions toward their school’s nutrition program after social ecological strategies were implemented. Joshi and Azuma (2010) demonstrated how farm-to-school programs can target the various levels of the social ecological model in the context of school nutrition. First, the student (individual) may be targeted in the classroom by providing food-literacy education. Next, parents (interpersonal) may be targeted through newsletters that include seasonal recipes and other farm-to-school messages. The school (organizational) may also get involved by implementing “farm-fresh salad bars” with produce procured from local farms. Also, farmer’s markets may be encouraged (community). Finally, policy changes,
such as local procurement policies, may help support farm-to-school programs and ultimately contribute to a healthy school environment. The “Stepping Up to the Challenge: Creating a Healthy School Environment” program integrated a social ecological approach both in the delivery of the instructional program and as a theme in the content of the curriculum for school nutrition directors. Peer trainers provided reinforcement by including practical examples of successful use of this approach in the school setting, with the goal of improving children’s nutrition and health. As an example, the program delivery incorporated the interpersonal level through the use of key opinion leaders and peers, and the public policy level through the translation of national policies to nutrition and wellness policy changes at the local level.
Method >>
Professional Development Session Four 2-day, professional development sessions were held regionally within California as the first phase of the professional development program (Figure 1). An adapted version of Kern et al.’s (1998) curriculum development process was used to inform curriculum development. Step 1: Problem Identification and General Needs Assessment. The current project was designed to assist school nutrition directors in the local implementation of nutrition federal initiatives and policies. The general needs and interests of school nutrition directors were identified through a series of expert interviews with nutrition education consultants, researchers, and school nutrition directors selected to act as trainers in the professional development program, referred to as “ambassadors.” This information informed the content of the needs assessment questionnaire. Step 2: Needs Assessment of Targeted Learners. The needs assessment questionnaire was divided into five “content areas” and four to six “components” within each content area, pertinent to current federal initiatives and policies supporting a healthy school environment. The Dillman’s (2000) tailored design method was used to survey 1,478 school nutrition directors through e-mail. The school nutrition directors were asked to indicate the degree of usefulness of the content areas and respective components based on their training needs and interests. Ratings were based on a five-point Likert-type scale
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Needs Assessment Questionnaire (Participants: School Nutrition Directors = 256; Ambassadors = 5) + School and Community Action for Nutrition (SCAN) Survey (School Nutrition Directors = 61)
Content Development (Development Team: Project Director, UC Davis Graduate Student, 4* Ambassadors)
Northern California Professional Development Session (Attendees = 28)
Central California Professional Development Session (Attendees = 39)
Central Coast Professional Development Session (Attendees = 42)
Los Angeles Area Professional Development Session (Attendees = 40)
Professional Development Session Feedback Questionnaire (School Nutrition Directors = 129)
4 Northern California TA Sessions (Attendees ≈ 7/session)
4 Central California TA Sessions (Attendees ≈ 9/session)
3 Central Coast TA Sessions (Attendees ≈ 16/session)
4 Los Angeles Area TA Sessions (Attendees ≈ 16/session)
Project Feedback Questionnaire (School Nutrition Directors = 103) + 6-month follow-up SCAN (School Nutrition Directors = 61)
Figure 1 Stepping Up To the Challenge: Creating a Healthy School Environment Professional Development and Technical Assistance Program Summary
(1 = least useful to 5 = most useful). A description of content areas and content area components listed on the questionnaire is provided in Supplemental Table 1. Step 3: Goals. The overarching goal of each lesson was to address the school nutrition directors’ top professional development needs and interests through the use of social ecological techniques. Step 4: Strategies. The ambassadors used a variety of pedagogical methods that address multiple learning styles such as interactive engagement (Crouch, Watkins, Fagen, & Mazur, 2007), media-enhanced teaching (Champoux, 2001), and cooperative learning (University of Washington, 2011). After 10 weeks of independent development professional development presentations, supplemental resources, agenda, and other logistics were finalized. Step 5: Implementation. Four professional development sessions were held at four regional locations. Ambassadors presented their portion of the professional development session at all four sessions. Step 6: Assessment. The knowledge acquired by the school nutrition directors was assessed by a professional
development session feedback questionnaire. Attendees reported their top five insights, inspirations, and/or strategies that would be useful at their school districts/ sites. Further technical assistance needs were also assessed. Technical Assistance Sessions Fifteen half-day professional development sessions were held as the second phase of the professional development program as diagramed in Figure 1. An adapted version of Kern et al.’s (1998) curriculum development process was also used to develop, implement, and assess the technical assistance sessions. Steps. 1 and 2: Problem Identification, General Needs Assessment, Needs Assessment of Targeted Learners. Results from the professional development session feedback questionnaire informed the content of the subsequent technical assistance sessions. Step 3: Goals. The goals of each session varied according to the specific needs and interests of the technical assistance attendees. For example, one technical assistance session expanded on best practices in implementing a
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Table 1 Needs Assessment Questionnaire: School Nutrition Director’s Content Area Rankings (n = 256) Rank 1
2 3 4 5
Content Area
Rating (M)
SD
Menu Planning to Meet the New Meal Pattern Proposed Rule Healthy School Environment Fresh Fruits and Vegetable Use and Promotion Let’s Move! Campaign Farm to School programs (Know Your Farmer, Know Your Food Initiatives)
4.52
0.7
4.36 4.31
0.7 0.8
4.12 3.91
0.8 0.9
NOTE: The degree of usefulness of each content area was rated based on the training needs and interests of the ambassadors and school nutrition directors, 1 (least useful) to 5 (most useful). Content areas were ranked based on the highest mean scores, 1 (highest mean rating) and 5 (lowest mean rating)
farm-fresh salad bar, whereas another focused on recipe development. Step 4: Strategies. The technical assistance sessions were centered on the peer-led team learning pedagogy. Fifteen school nutrition directors who attended the professional development session were recruited as peer leaders. The technical assistance sessions provided supportive environments that helped each school nutrition director participate actively in the process of learning (Arendale, 2004). Step 5: Implementation. The ambassadors planned 3 or 4 sessions within their regions for a total of 15 technical assistance sessions. Each session included groups of 5 to 18 school nutrition directors, one peer leader, one ambassador, and the state agency project director. Step 6: Assessment. At the end of each technical assistance session, the school nutrition directors completed a program feedback questionnaire. Responses served as part of the impact assessment of the entire program. Participants reported their implemented “insights, inspirations, and/or strategies.” The impact of the entire program was also assessed by the School and Community Actions for Nutrition (SCAN) Survey. The SCAN Survey, developed by University of
California, Davis, researchers, is an assessment tool used to evaluate school environments (Briggs, 2007, 2012). Categories include Wellness Policy, School Environment, Student Education Programs, Professional Development Programs, and Parent Involvement. A random sample of the school nutrition directors completed an electronic version of the SCAN Survey before and after they attended the professional development series. The evaluation of the professional development program focused on the assessment of immediate outputs (school nutrition director’s acquired knowledge as reported by “insights and inspirations”) and intermediate outcomes of changes in school environments as reported by school nutrition directors. The University of California, Davis, Institutional Review Board approved all components of the current study with exempt status.
Results >> This section covers results from: the needs assessment questionnaire, professional development session content that was developed based on the needs assessment questionnaire results, professional development session feedback questionnaire, program feedback questionnaire, and SCAN survey. Needs Assessment Questionnaire Results Response Rates. Of the 1,478 school nutrition directors that were surveyed, 256 (17%) completed the needs assessment questionnaire. Content Area and Components. Results of the needs assessment questionnaire content area rankings are presented in Table 1. The school nutrition directors rated each of the five content areas based on their professional development needs and interests. Content areas were then rated based on highest to lowest mean scores (1 = highest rating, 5 = lowest rating). The content area titled “Planning Menus to Meet Proposed Rule” received the highest mean rating and the highest ranking out of the five content areas (M = 4.52, SD = 0.7), followed by the Healthy School Environment content area (M = 4.36, SD = 0.7). Table 2 provides the top 15 content area components as rated by the school nutrition directors. Although all 32 content area components were highly rated, the top 5 rated content area components were those related to the implementation of the new federal menu planning mandate, with “ Planning Cost-Effective Menus” (M = 4.53, SD = 0.8) receiving the highest rating.
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Table 2 Needs Assessment Questionnaire: School Nutrition Director’s Top 15 Content Area Components (n = 256) Content Area V V V V V II III V III V III
I III III III
Content Area Component
Rating
SD
Planning cost-effective menus Reducing calories, sodium, saturated fat, and trans fat in school menus Using U.S. Department of Agriculture foods (commodities) to costeffectively enhance school menus Increasing dark green and orange vegetables in school menus Increasing whole grains in school menus Meeting the HealthierUS School Challenge criteria Incorporating the 2010 Dietary Guidelines into the school environment Increasing dry beans and peas in school menus Marketing your healthy school meals and snacks Implementing food-based, whole-food approach in menu planning Using resources from other partners such as the California Department of Education, the U.S. Department of Agriculture, and the California Department of Public Health Promoting nutrition education related to fresh fruits and vegetables for meals and snacks Implementing wellness policies that direct change Promoting healthy foods with nutritional promotions and education Increasing fresh fruits and vegetables in school menus, including salad bars (techniques and promotions)
4.53 4.48 4.44
0.8 0.8 0.9
4.40 4.38 4.33 4.29 4.26 4.25 4.21 4.20
0.8 0.8 0.8 0.8 0.7 0.7 0.8 0.8
4.19
0.8
4.19 4.18 4.13
0.8 0.9 0.8
NOTE: The degree of usefulness of each content area was rated based on the training needs and interests of the ambassadors, 1 (least useful) to 5 (most useful). Content areas are as follows: I. Fresh Fruits and Vegetable Use and Promotion, II. Let’s Move! campaign, III. Healthy School Environment, IV. Farm to School programs (Know Your Farmer, Know Your Food initiatives), V. Menu Planning to Meet the New Meal Pattern Proposed Rule.
Other components receiving high mean ratings were “Meeting the HealthierUS School Challenge criteria” (M = 4.33, SD = 0.8); “Using resources from other partners such as the California Department of Education, the USDA, and the California Department of Public Health” (M = 4.20, SD = 0.8); and “Implementing Wellness Policies that direct change” (M = 4.19, SD = 0.8). Professional development lesson topics and content addressed top needs and interests through social ecological approaches. For example, the highly rated content area components regarding the federal menu planning mandate were addressed through social ecological approaches in the lessons titled “A Taste of California: From Apples & Beans to Grains & Zucchini” and “Promoting Creative School Food Cost-Effectively.” “Promoting nutrition education . . .” and “Implementing wellness policies . . .,” also highly rated content area components, were addressed using social ecological techniques in the lesson titled “Wellness for Our Kids: Connecting the Classroom, Cafeteria, & Community. Table 3 provides a summary of curriculum lesson titles
and content, in addition to examples of teaching methodologies used. Professional Development Session Feedback Questionnaire Results Of the 140 school nutrition directors who attended the professional development sessions, 129 completed the professional development session feedback questionnaire. Strategies, Insights, and Inspirations. The most frequent insights, inspirations, and/or strategies reported were marketing for school foods program (16.9%), expansion of salad bars (11.8%), and collaboration with community partners (8.7%). Technical Assistance Needs Assessment. School nutrition directors expressed the need for further technical assistance in culinary arts/recipes/menus (28%), locating local farmers (23%), forming community
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Table 3 Professional Development Topics, Objectives, and Content Summaries Lesson Title
Content Summary
Lesson Methodology
An interactive lecture was used to engage school nutrition directors in a discussion about the application of the social ecological model and the use of a social marketing approach. A multimedia lecture was used to share videos 1. Demonstrate the importance of establishing Wellness For Our and photos of successful community community connections to achieve health and Kids: Connecting relationships such as a local timber company. wellness goals. 2. Evaluate school wellness the Classroom, Cooperative learning was used to assess a policy as a guide for creating a healthy school Cafeteria, & sample wellness policy. Methods for environment. 3. Showcase nutrition education Community marketing your program through nutrition as an effective component of a healthy school education and applications to the social environment ecological model were provided. Cooperative learning was used to complete 1. Review basic marketing guidelines and Marketing Your social marketing activities and apply to the activities that will help school nutrition Healthy School social ecological model. Teams were services: (a) increase participation, (b) Foods Program challenged to complete a “SWOT” (Strengths, increase customer satisfaction, (c) increase With a Focus on Weaknesses, Opportunities and Threats) recognition for providing healthy food Change analysis of their school nutrition services choices, (d) improve public relation, (e) program. empower staff An interactive, multimedia lecture was used to Promoting Creative 1. Marketing a school nutrition program share marketing ideas (e.g., community School Food Costthrough community outreach and how this barbeques employing a chef to market the Effectively applies to the social ecological model, (2) culinary arts). Marketing through the use of culinary arts Cooperative learning was used to complete the 1. Revamp menu using HeathierUS Challenge; A Taste of HeathierUS Challenge, with application to 2. Create seasonal, regional, cost-effective California: From menus with fruits and vegetables (institutional the social ecological model. Sample recipes Apples & Beans to with taste-testings were also included. A level of the social ecological model); 3. Grains & Zucchini multimedia lecture showcased food safety Incorporate safe fruits and vegetables from and composting ideas. procurement to composting An interactive, multimedia lecture was used to The Farmers’ Market 1. How a farmer’s market salad bar program cover ideas on how to market a salad bar and Salad Bar Program works, 2. Provide examples of resources apply this to the social ecological approach. needed to successfully implement the program
Stepping Up To Create a Healthy School Environment
1. Demonstrate the purpose of the professional development program, 2. provide an overview of the framework and the social ecological model, 3. Introduce ambassadors
collaborations (22%), obtaining more information on USDA initiatives (22%), and other (5%). Program Feedback Questionnaire Results Strategies, Insights, and Inspiration Implementation. Results from the program feedback questionnaire indicated that 86% of school nutrition directors were making progress in implementing at least one of their five insights, inspirations, and strategies within their school district, with 20% of school nutrition directors implementing one out of five, 18% implementing two
out of five, 25% implementing three out of five, 11% implementing four out of five, 14% implementing five out of five, and 21% implementing zero out of five. Areas that were most frequently implemented included marketing and branding their school lunch program (32%), expanding salad bars (18%), motivating staff (16%), and trying new recipes (12%). SCAN Survey Results A random sample of the participating school nutrition directors (n = 61) completed the SCAN before the
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professional development program and after they attended the subsequent technical assistance session professional development sessions. The SCAN analysis comparing school environments at baseline with 6 months postprogram showed only one statistically significant improvement, with “Marketing and media messages on the school premises reinforce food and nutrition education” increasing from a mean score of 1.3 to 2.6 (p = .024).
Discussion >>
which supports positive changes at the institutional level. This category included comments ranging from starting a salad bar to expanding an existing salad bar to target more levels of the social ecological model, such as sourcing produce from local farmers and/or supplementing with nutrition education material. Professional development topics regarding the use of social marketing strategies to target all levels of the social ecological model were also widely implemented as reported by the program feedback questionnaire. Using Social Marketing Strategies to Implement the Social Ecological Model
Limitations
The primary long-term goal of the current professional development program was the improvement of student health outcomes. Unfortunately, due to limiting funding, data on student outcomes were not collected in this study. Instead, the impact evaluation of the current professional development program focused on the assessment of immediate outputs, such as school nutrition directors’ acquired knowledge as reported by “insights and inspirations” and intermediate outcomes of self-reported changes in school environments. A second limitation to the study was the brevity between pre- and postresults as measured by the SCAN questionnaire and program feedback questionnaire. Assessments were conducted only 6 months after the professional development program. This limitation may have contributed to the fact that 21% of school nutrition directors had not yet implemented their reported “insights and inspirations.” Another limitation was the low response rate of the needs assessment questionnaire (17%). Although the questionnaire was distributed to all school nutrition directors in California, only the school nutrition directors willing and able to attend the professional development program completed the needs assessment questionnaire. For future studies, the needs of the entire school nutrition director population should be assessed before program development, followed by an invitation to attend the program. Using the Social Ecological Model for Positive, Sustainable Change Postprogram assessments showed that school nutrition directors were motivated by the ambassadors’ messages regarding the benefits of the social ecological approach. For example, using the community level of the model, school nutrition directors identified topics such as collaboration with community partners as a top “insight/inspiration/strategy.” Another top “insight/ inspiration/strategy” was the expansion of salad bars,
Social marketing strategies applied in health promotion programs have shown a profound impact on the target individual’s behavior (Griffiths, Blair-Stevens, & Parish, 2009). The major advantages of social marketing are a direct immediate benefit and an effect on behavior at multiple levels of social organization (Maibach, Rothschild, & Novelli, 2002). Based on these findings, it is no wonder the program’s participants responded well to social marketing strategies presented. The connections among social marketing and social ecological strategies were discussed as part of the program curriculum. For example, one ambassador used school nutrition “marketing” funds to promote physical activity by purchasing a score board for the school’s baseball team. In return, he was able to display his school nutrition program’s logo on the scoreboard. He also used these “marketing” funds to host community harvest parties during which he raffled off sports equipment and gardening supplies. It was through his social marketing efforts that he was able to promote a healthy lifestyle to the entire community while changing the perception of his school nutrition program. Results of the postprogram assessments highlight the impact that the ambassador’s instruction regarding social marketing had on school nutrition directors’ behaviors. For example, SCAN results demonstrated a significant increase in the implementation of “marketing and media messages on the school premises reinforce food and nutrition education” in the school nutrition directors’ school districts/sites. Also, the most implemented “insight/inspiration/strategy” was the marketing and branding of the school nutrition program. The Ambassador Model: A Sustainable Professional Development Approach An unexpected outcome of this project was the success of the “ambassador” model. Although it was predicted that the ambassadors would provide insight during the development and implementation of the
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program, their impact on the sustainability of the program was not anticipated. The original ambassadors continue to offer regular technical assistance sessions to those that are interested, and many school nutrition directors were also inspired to become “healthy school environment ambassadors.” Years after the initial program was hosted, the new ambassadors continue to offer technical assistance sessions that offer networking opportunities with colleagues.
Conclusions >> In response to the nation’s focus on addressing rising childhood obesity rates, many innovative federal initiatives and policies have resulted. The current study describes a method to assist school nutrition directors in the implementation of sustainable strategies to promote a healthy school environment at the local level. With the positive results at the level of intermediate outcomes, assessment of student outcomes is recommended for future studies implementing similar methods. Plans for Further Implementation A third component of the professional development program will include a web-based resource tool titled “The Fresh, Regional, Education-Supportive, Healthy (FRESH) Meals at Schools Electronic Toolkit.” This resource is currently in development and will include the program curriculum as well as supplementary resources generated based on the results of needs assessments conducted in this study.
SUPPLEMENTAL MATERIAL The supplemental material is available at http://hpp.sagepub .com/supplemental.
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