RESEARCH ARTICLE
Using a Participatory Approach to the Development of a School-Based Physical Activity Policy in an Indigenous Community LINDSAY HOGAN, BPE, MAa ENRIQUE GARC´ıA BENGOECHEA, PhDb JON SALSBERG, MScc JUDI JACOBS,d MORRISON KING,e ANN C. MACAULAY, CM, MD, FCFPf
ABSTRACT BACKGROUND: This study is part of a larger community-based participatory research (CBPR) project to develop, implement, and evaluate the physical activity component of a school-based wellness policy. The policy intervention is being carried out by community stakeholders and academic researchers within the Kahnawake Schools Diabetes Prevention Project, a well-established health promotion organization in the Indigenous community of Kahnawake, Quebec. METHODS: We explored how a group of stakeholders develop a school physical activity policy in a participatory manner, and examined factors serving as facilitators and barriers to the development process. This case study was guided by an interpretive description approach and draws upon data from documentary analysis and participant observation. RESULTS: A CBPR approach allowed academic researchers and community stakeholders to codevelop a physical activity policy that is both evidence-based and contextually appropriate. The development process was influenced by a variety of barriers and facilitators including working within existing structures, securing appropriate stakeholders, and school contextual factors. CONCLUSIONS: This research offers a process framework that others developing school-based wellness policies may use with appropriate modifications based on local environments. Keywords: community-based participatory research; Indigenous health; physical activity; school wellness policy. Citation: Hogan L, Garc´ıa Bengoechea E, Salsberg J, Jacobs J, King M, Macaulay AC. Using a participatory approach to the development of a school-based physical activity policy in an Indigenous community. J Sch Health. 2014; 84: 786-792. Received on November 22, 2013 Accepted on April 29, 2014
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esearch has caused concern that levels of physical activity (PA) among children may be too low for optimal health.1-3 Owing to the health implications of declining PA levels and the benefits to be gained from being active, many health interventions have attempted to target this issue and schools increasingly have become sites for intervention. Reviews surrounding school-based interventions to increase PA have highlighted that many projects focus solely on education as the main intervention component, leading to mostly minor or short-term
outcomes, and that perhaps, more whole-school multicomponent approaches should be used.4-6 One whole-school multicomponent approach that has become widely adopted is that of the Health Promoting Schools, which is similar to the Coordinated or Comprehensive School Health in the United States and Canada respectively. A Health Promoting School is ‘‘one that constantly strengthens its capacity as a healthy setting for living, learning and working.’’7 Essentially, a Health Promoting School is one that adopts a holistic framework that seeks to use all
a
High School Physical and Health Education Teacher, ([email protected]), Department of Kinesiology and Physical Education, McGill University Montr´eal, Quebec H2W 1S4, Canada b Associate Professor, ([email protected]), Department of Kinesiology and Physical Education, McGill University Montreal, Quebec H2W 1S4, Canada. c Associate Director &ResearchManager, ([email protected]), CIET/Participatory Researchat McGill (PRAM), Department of Family Medicine, McGill University, Montreal, Quebec H2W 1S4, Canada. dIntervention Staff, ([email protected]), Kahnawake Schools Diabetes Prevention Project, Kahnawake, Quebec, Canada. e Intervention Staff, ([email protected]), Kahnawake Schools Diabetes Prevention Project, Kahnawake, Quebec, Canada. f Professor Family Medicine, ([email protected]), CIET/Participatory Research at McGill (PRAM), Department of Family Medicine, McGill University, Montreal, Quebec H2W1S4, Canada. Address correspondence to: Enrique Garc´ıa Bengoechea, Associate Professor, ([email protected]), Department of Kinesiology and Physical Education, McGill University Montreal, Quebec H2W 1S4, Canada. This research and author L. Hogan were supported by an operating grant from the Canadian Institutes of Health Research (KAL-114097).
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available resources and a variety of leaders to improve the health of the entire school community through a range of means, including health education, adapting environments, adopting health supporting policies and practices, and the provision of health services, programs, and opportunities.7 An important part of the puzzle, therefore, is to develop and implement a comprehensive local wellness policy that identifies a school or school district’s approach to the health of their students and staff members.8 A wellness policy is a formal document that outlines priorities, rules, guidelines, procedures, and/or parameters for action intended to promote health.9,10 A school wellness policy may consist of whatever a school or school district sees fit based on their particular context. Nevertheless, school wellness policies typically focus on components of nutrition and PA. An array of guides are available for the process of creating a wellness policy;11-13 however, many are produced for use at the national or regional level and only a few research examples of local policy development or implementation are found.14,15 Many of the resources available to guide local wellness policy formation come from the United States where federal legislation structures the components of policy.9 Furthermore, the available wellness policy literature, as well as existing wellness policy examples from the United States, tend to have more content surrounding the nutrition component of the policy.9,16,17 More research stemming from a variety of contexts surrounding local wellness policy development, implementation, and evaluation are needed to contribute to this field. This would provide policy groups at the local level with the opportunity to gain knowledge from other groups that share similar contexts by providing them with relatable and practical approaches. One community that has taken action on health promotion using a school-based policy intervention ´ approach is Kahnawake, a Kanien’keha:ka (Mohawk) community with a population of approximately 8000. In 1994, the Kahnawake Schools Diabetes Prevention Project (KSDPP) was launched in response to a high rate of type 2 diabetes in the community. KSDPP’s main goal is the prevention of type 2 diabetes by increasing PA levels, improving healthy eating habits, and promoting positive attitudes among community members with a focus on school-aged children. Since its inception, KSDPP has undertaken many research projects aimed at understanding the prevention of type 2 diabetes and evaluating KSDPP interventions. All research undertaken by KSDPP falls under the participatory research (PR) umbrella. PR is an approach to conducting research that involves researchers working collaboratively with those affected by the issue at hand and who will be the end-users or chief beneficiaries of the research project with the purposes of education, taking action, or effecting social Journal of School Health
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change.18,19 Key to PR approaches is the idea that those involved in the collaborative research effort are considered equals, with each having an area of expertise to contribute.20 In 2005, KSDPP began to work with community members to create the nutrition component of a wellness policy for 2 local elementary schools. The nutrition policy was implemented in the 20092010 school year. In summer 2011, responding to a community identified need, KSDPP researchers received a federal grant to develop and implement a PA component to add to the elementary school wellness policy. This PA policy intervention project began with a baseline evaluation, which involved the use of adult focus groups, photovoice with students, 2 student PA recall surveys, and the School Health Action Planning and Evaluation System (SHAPES) questionnaire.21 These tools produced data about current PA levels of children, children’s preferences, perceived barriers and facilitators to PA, current school practices and programs, and stakeholder opinions on potential policy content. Following the baseline evaluation, a policy committee of various community stakeholders was formed. In line with the KSDPP’s PR approach, these community stakeholders collaborated alongside academic researchers in an equitable partnership to develop the PA policy document. Using data produced during the policy development phase of the larger policy intervention project, this study aimed to explore the following 2 research questions: How do a group of stakeholders develop a local school-based physical activity policy in a participatory manner? and What are the facilitators and barriers to the policy development process?
METHODS This research takes a case study design guided by an interpretive description approach. The interpretive description approach, originally developed for nursing research and now expanding into other disciplines,22,23 is a qualitative approach with the goal of searching for themes and patterns in health-related phenomena to produce new knowledge that has practice-based applications.24,25 In this case, the knowledge produced will surround how to create a school wellness policy and will identify supportive factors to the process. All data needed for this research had already been generated from work in the larger policy intervention study. This study drew upon data from documentary analysis and participant observation. The documentary sources were the materials produced during policy development meetings including transcriptions, policy drafts, agendas, committee member notes, research assistant field notes and reflections, and photographs of committee brainstorming notes. Also explored were the documents used within the meetings to inform
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the policy such as the baseline data, a school PA policy literature review, and policy examples from other jurisdictions. Data from participant observation also were drawn upon including field notes taken by the research assistant during the meetings and postmeeting summaries and reflections. Data Analysis Following the interpretive description approach, analysis began by looking at the big picture and asking questions like ‘‘what is happening here?’’ and ‘‘what am I learning about this?’’ in a series of data immersion periods prior to the start of any coding or creating links.24 To answer the ‘‘how’’ research question, a pragmatic descriptive approach was used. The various available documents and data from participant observation were drawn upon to provide a thorough description of how the committee was put together, which stakeholders were involved, how the meetings proceeded, and the different pieces of information used to inform the PA policy. To explore the barriers and facilitators to the policymaking process, a more interpretive approach was needed. A thematic content analysis focusing on the meeting transcripts was conducted. Using Nvivo9 (QSR International, Burlington, MA) software, ”chunks” of text from the transcripts that could be considered as factors that were either barriers or facilitators to the policy process were coded. Once this was complete, it was possible to identify emerging themes by grouping together similar factors. Member checking of this more interpretive section occurred with 3 of the committee members to ensure the findings were representative of their views and experiences.26
RESULTS Forming the Policy Committee Two members of the KSDPP intervention team took the lead in forming the policy committee. Their goal was to acquire various school stakeholders and to ensure equal representation from each of the schools. The policy committee consisted of 14 people: 2 principals, a classroom teacher, a health education teacher, a physical education teacher/parent, a teacher’s assistant, a hospital nutritionist, a parent, 3 members of the KSDPP intervention staff, 2 academic researchers in the area of kinesiology and physical education, and a graduate student research assistant. Policy Committee Meetings The policy committee had a series of 8 meetings to form the wellness policy’s PA component with dinner provided at each meeting. Consistent with a PR approach, the community stakeholders collaborated closely with the academic researchers to create a policy 788 •
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that was based on the best available information, but which was also contextually appropriate and viable. At every session, committee members engaged in a round-table dialogue that was a negotiation between what was ideal in terms of policy statements and what was feasible in terms of policy implementation. Initial meetings focused on discussing community health values and using a positive approach to health promotion as well as what would work and what would not work in their community. Later meetings focused on drafting a suitable policy considering everything viewed and discussed. The diverse group used their personal knowledge and experience, results from the policy’s baseline evaluation, evidence-based information from the literature, and any additional requested materials to develop the PA policy. Information Used by the Committee Research literature review and SHAPES results. A literature review by Lagarde and Leblanc27 investigated the evidence concerning school-based PA interventions and compiled what they found to help guide policy makers at the national and regional levels. Their review identified policy options (or statements) that were proven to be effective, were promising, or were based on untested expert opinion. Policy options tested and proven effective in increasing PA or producing health outcomes revolved around providing daily, quality, safe physical education, providing daily, quality, safe PA (in the classroom, recess, etc), providing extracurricular activities, training staff members to provide appropriate physical education and PA programs, ensuring funding for equipment and facilities, and teaming up with the community to optimize the use of PA resources. On the basis of the results of this review, the authors concluded that the best approach to achieving increased PA among children is to use multicomponent programs that target behavior change across multiple settings. As part of the policy intervention baseline evaluation, a tool from SHAPES was used. SHAPES is a collection of tools developed by the Propel Centre for Population Health Impact at the University of Waterloo (Canada). These tools can be used to gather data related to PA, tobacco use, healthy eating, and mental health at the student and school level for purposes such as needs assessment, intervention planning, program evaluation, and field research involving youth.21 For the policy intervention baseline evaluation, the principals and physical educators at each school worked together to complete the SHAPES administrator questionnaire, which acts as a scan of the school environment and explores school programs, policies and structures. Completion of the questionnaire generates a feedback report that shows the school how well or poorly they are doing in terms of a variety of indicators
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(healthy school environment, teaching and learning, supportive social environment, and community partnerships and services). Along with this feedback, a list of recommendations is provided regarding what schools can do to achieve top scores on each of the indicators to increase PA levels. To meet the needs and requests of the policy committee, a presentation was created by the research assistant that merged key information from the literature review27 with the locally relevant SHAPES results. The committee viewed and discussed the presentation in one meeting and revisited it in several later meetings to draft policy statements of their own. Wellness policy examples. To become familiar with what the format and content of a policy document might be, the committee members are requested to see examples of other wellness policies. A Web search generated a variety of school district policies. The group also reviewed the Kahnawake Education Centre’s existing nutrition policy, which the new PA policy will join to become a wellness policy. Photovoice results. Photovoice is a PR strategy developed and made popular by Caroline Wang that involves using photography to give a voice to people and their issues, and that has been shown to be appropriate and engaging when used with young populations.28 Photovoice is based on several key concepts. The 2 most basic concepts of photovoice are that images can teach and they can influence policy. Therefore, community members should be involved in creating and defining images that serve to shape health policies, and project planners should ensure an audience of influential people to view and hear the perspectives of participants. As seen in other PR approaches, an emphasis is placed on community and individual action.29 During the policy intervention baseline evaluation phase, a photovoice project was carried out to gather information on students’ views and practices of PA in and around school and how to promote it to meet their needs. Students were aware that a PA policy was being developed for their schools and that this project was a way for their experiences, opinions, and suggestions to be shared. The students took photographs about being active in their community, wrote captions for selected photographs, and engaged in photo-elicited focus groups. The focus groups and picture captions revealed a variety of ways the children enjoy being active as well as perceived barriers and facilitators to being active. On the basis of the identified barriers and facilitators, the children offered a number of wishes and suggestions that might lead to increased PA at school and around the community. These included increasing the number and types of extracurricular activities offered, making changes to the physical environment, such as more outdoor play structures or more greenery in the schoolyard, having access to Journal of School Health
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new equipment to play with at breaks, and increasing the time allotted for daily outdoor play. The policy committee was presented these results and stopped throughout the presentation to discuss any issues that the children raised or how to work the children’s suggestions into the PA policy. Adult focus groups. An adult focus group was carried out during the policy intervention baseline evaluation phase. The goal of this focus group was to explore the opinions of various stakeholders surrounding the topics of current child PA programs and opportunities, the school environment, and what they would like to see in a PA policy. The focus group consisted of 2 principals, 4 parents and 1 physical educator/parent. The main findings of this focus group included: •
locally relevant data are needed to form the policy; current child PA opportunities are limited and need to be diversified; • the policy needs to be flexible and formed by those who will apply it; • there is a need for more human resources for PA programming; and • other school policies may not be supporting the extracurricular work of the physical education teacher. •
These results were presented to and discussed with the policy committee. Resulting PA Policy After careful consideration of the available information and local circumstances, the group crafted a PA policy document. The resulting policy, introduced by a philosophy statement outlining guiding principles, targets 9 policy areas to increase or enhance PA opportunities for students and school staff: (1) physical education; (2) lunch and recess; (3) extracurricular physical activities; (4) classroom; (5) family; (6) community; (7) staff; (8) active transportation; and (9) safety. Recommendations for implementation and evaluation of the policy are also included in the document. Barriers and Facilitators The policy development process was influenced by a variety of factors, some of which helped move the process along more smoothly and others that made decision-making and progress more difficult. These factors included the existing structures of KSDPP, appropriate stakeholders, and school contextual factors. Kahnawake Schools Diabetes Prevention Project is well established in the community, and following a PR approach, the members of KSDPP have successfully
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collaborated with many community stakeholders on both research and intervention projects since its launch in 1994. The schools within Kahnawake have shown that they are committed to working with KSDPP over the years. Having this positive community reputation made recruiting and retaining policy committee members for this project much easier. Furthermore, the acquisition of the PA policy intervention research grant by KSDPP researchers allowed funds for catered meetings, a research assistant, and the collection of baseline data. Securing the appropriate stakeholders to be on the policy committee was key in the policy development process. Having many end users of the product (teachers, administrators, and parents) helped to maximize its appropriateness and its likelihood of implementation. However, several questions were raised during the policy’s development that were difficult to address without the appropriate people at the table. This refers either to stakeholders who were absent for the particular meeting or to stakeholders we did not secure to be on the committee. For example, the school principals involved in this project understandably had a busy schedule and were not able to attend all meetings. When this was the case, the group felt it was inappropriate to address schoollevel policies such as allowing skateboards at school to promote more active commuting to and from school. Furthermore, as we acquired fewer parents for the committee than had been desired, the group had a hard time deciding what could be done in terms of family involvement and responsibility. Existing school programs and practices served both to help and constrain the work of the policy group. On the one hand, the schools already do a lot to promote PA like running a number of afterschool or lunchtime sports, providing daily recess, and teaming up with community recreation organizations. The policy committee simply had to find ways to build on these promising programs and practices. On the other hand, some school programming and practices restricted the ideas of the committee. Several committee members suggested the possibility of increasing physical education minutes, time devoted to being active in the classroom and/or time spent outside for lunch and recess in order for the children to have more time to move during the day. The complexity of changing the school schedule raised a lot of concerns. If the schools were able to redistribute or extend school time, extra PA would not necessarily be the first priority. Instead, certain academic subjects might get more attention. One principal noted in reference to the school day: ‘‘I know if ours got extended, we’re sticking in more math.’’ Further, if they were to extend outdoor recess or lunch, they would need to find room in the budget to pay the schoolyard monitors for their added time. As one committee member put it: ‘‘Everything 790 •
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has a domino effect on something else.’’ So, because of the complexity of school programs and practices, the schedules were considered to be inflexible and the committee instead had to find ways to fit PA opportunities into current ways of doing things.
DISCUSSION The adoption of school wellness policies has been identified as a promising strategy to promote health. This study demonstrated how healthy school policy can be developed at the local level. Policies developed locally have been shown to be stronger and more comprehensive than template-based policies,30 and thus, it is important to be aware of how best to support local policy-making processes. Our study contributes to this understanding by identifying factors that may act as barriers or facilitators to the school wellness policy development process. Also, to the best of our knowledge, it is one of only a few research examples of PA policy development and the first in an Indigenous school district. The use of a participatory approach to developing school policy shows promise. Cargo and Mercer18(p327) suggest: ‘‘A key strength of [PR] is the integration of researchers’ theoretical and methodological expertise with nonacademic participants’ real-world knowledge and experiences into a mutually reinforcing partnership.’’ In this case, the collaboration between academic researchers and local stakeholders led to the creation of a sound PA policy that is evidence-based as well as contextually appropriate. The academic researchers contributed by securing funding for the project that allowed for human and physical resources, and a baseline and future follow-up evaluation, and by delivering evidence-based information at the request of the committee. The stakeholders contributed their local knowledge and were able to decide what would work best in their schools and their community. In addition, one of the key elements of PR is mutual education.20,31 By developing the PA policy in a participatory manner, the community stakeholders were able to learn about important PA and health-related information as well as ways of collecting and interpreting data and the academic researchers were able to learn more about community decision-making processes and what is important to the school community. This enhances the capacity of both parties for similar future projects. Limitations As this research took the form of a case study, only the one case was explored. The findings are then only applicable to the particular context in which the school PA policy development took place. However, as this is an underresearched area, this case study sought to provide insight and understanding of the process
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of developing comprehensive school wellness policies. Detailed information was provided to allow readers to determine how applicable or transferable the findings are to other settings. Conclusions Written school wellness policies are now considered a promising strategy for school-based health promotion and an integral component of school health approaches such as Health Promoting Schools, Comprehensive School Health and Coordinated School Health.32 As few studies exist that explore the processes of policy development, implementation, monitoring, and evaluation, this study offers a process framework for developing a school PA policy in a participatory manner that others may utilize with appropriate modifications based on their own environments.
IMPLICATIONS FOR SCHOOL HEALTH Branching out as far as is possible and sensible to other community stakeholders is recommended to other groups looking to develop healthy school policy. While this policy effort included principals, teachers, parents, academic researchers, a nutritionist, and intervention staff from a local health promotion group, other stakeholders can be a range of people including students, health professionals, members of nongovernmental organizations, community members, or private sector professionals. Each stakeholder is considered to be a representative of others who share their roles in society and each has unique information and opinions to contribute to the policy process.33 Although we were able to secure the core stakeholders needed to develop a sound PA policy, additional stakeholders could have served to enhance the scope of the project further. For example, if the policy group had been able to include representatives from the public works office or the local police, the committee may have been able to address the active transportation target area better. The committee members felt more could have been added to this section of the policy, but that they were not the right people to be creating or ensuring further policy statements in this section. While this project was done in a participatory manner, which stresses equality amongst stakeholders, having KSDPP members as the lead organizers may have been essential to keeping the effort afloat. The committee members were all busy people with agendas competing against this project. PR and school wellness policy literature acknowledge that projects like this may need a champion at the forefront to maintain a strong focus on the final goal and to keep people on board in the face of competing priorities.33,34 Having the funds to provide dinner each session was a big Journal of School Health
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draw for the members as well. With this said, it will be important during the implementation phase to shift this responsibility toward the school stakeholders to make this a sustainable project. Other wellness policy case studies have suggested that it is important to identify clear lines of accountability within the schools for the policy to succeed.14,15 Human Subjects Approval Statement This research was approved by the McGill University Research Ethics Board and by the KSDPP Community Advisory Board.
REFERENCES 1. Colley R, Garriguet D, Janssen I, Craig C, Clarke J, Tremblay M. Physical activity of Canadian adults: accelerometer results from the 2007 to 2009 Canadian Health Measures Survey. Health Rep. 2011;22(1):7-14. 2. Colley R, Garriguet D, Janssen I, Craig C, Clarke J, Tremblay M. Physical activity of Canadian children and youth: accelerometer results from the 2007 to 2009 Canadian Health Measures Survey. Health Rep. 2011;22(1):15-24. 3. Tremblay M, Shields M, Laviolette M, Craig CL, Janssen I, Gorber SC. Fitness of Canadian children and youth: results from the 2007-2009 Canadian Health Measures Survey. Health Rep. 2009;21(1):1-14. 4. Salmon J, Booth ML, Phongsavan P, Murphy N, Timperio A. Promoting physical activity participation among children and adolescents. Epidemiol Rev. 2007;29(1):144-159. 5. Timperio A, Salmon J, Ball K. Evidence-based strategies to promote physical activity among children, adolescents and young adults: review and update. J Sci Med Sport. 2004;7(S1):20-29. 6. van Sluijs EM, McMinn AM, Griffin SJ. Effectiveness of interventions to promote physical activity in children and adolescents: systematic review of controlled trials. BMJ. 2007;335:703-707. 7. World Health Organization. School and Youth Health: What is a Health Promoting School? xxxx. Available at: http:// www.who.int/school_youth_health/gshi/hps/en/index.html. Accessed April 17, 2012. 8. Schwartz MB, Henderson KE, Falbe J, et al. Strength and comprehensiveness of district school wellness policies predict policy implementation at the school level. J Sch Health. 2012;82(6):262-267. 9. Chriqui J, Schneider L, Chaloupka F, Ide K, Pugach O. Local Wellness Policies: Assessing School District Strategies for Improving Children’s Health. School Years 2006-07 and 200708. Bridging the Gap, Health Policy Center, Institute for Health Research and Policy, University of Illinois at Chicago, Chicago; 2009. 10. Nutbeam D. Health Promotion Glossary. Geneva, Switzerland: World Health Organization; 1998. 11. Connecticut State Department of Education. Action Guide for School Nutrition and Physical Activity Policies. Hartford: Connecticut State Department of Education; 2009. 12. Simovska V, Dadaczynski K, Grieg K, et al. HEPS Tool for Schools: A Guide for School Policy Development on Healthy Eating and Physical Activity. Woerden, the Netherlands: NIGZ; 2010. 13. World Health Organization (WHO). Global Strategy on Diet, Physical Activity and Health: A Framework to Monitor and Evaluate Implementation. Geneva, Switzerland: WHO; 2008. 14. Gleddie DL. The devil is in the details: development of policy and procedure in the Battle River Project. Health Educ J. 2010;71(30):30-38.
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´ 15. Sanchez V, Hale R, Andrews M, et al. School wellness policy implementation: insights and recommendations from two rural school districts. Health Promot Pract. 2012;15:340-348. 16. California School Board Association, California Project Lean. Student Wellness: A Health Food and Physical Activity Resource Guide. West Sacramento: California School Board Association; 2005. 17. National Alliance for Nutrition and Activity. Model Local School Wellness Policies on Physical Activity and Nutrition. Available at: http://www.schoolwellnesspolicies.org/ resources/NANAWellnessPolicies.pdf. Accessed June 13, 2012. 18. Cargo M, Mercer S. The value and challenges of participatory research: strengthening its practice. Annu Rev Public Health. 2008;29:325-350. 19. Green LW, George MA, Daniel M, et al. Study of Participatory Research in Health Promotion: Review and Recommendations for the Development of Participatory Research in Health Promotion in Canada. Ottawa, ON: Royal Society of Canada; 1995. 20. Macaulay A, Commanda L, Freeman W, et al. Participatory research maximizes community and lay involvement. BMJ. 1999;319:774-778. 21. Leatherdale S, Manske S, Wong S, Cameron R. Integrating research, policy, and practice in school-based physical activity prevention programming: the School Health Action, Planning, and Evaluation System (SHAPES) Physical Activity Module. Health Promot Pract. 2009;10(2):254-261. 22. Clark M, Spence J, Holt N. In the shoes of young adolescent girls: understanding physical activity experiences through interpretive description. Qual Res Sport Exerc Health. 2011;3(2):193-210. 23. Hunt M. Strengths and challenges in the use of interpretive description: reflections arising from a study of the moral experience of health professionals in humanitarian work. Qual Health Res. 2009;19(9):1284-1292.
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24. Thorne S, Reimer Kirkham S, MacDonald-Emes J. Interpretive description: a noncategorical qualitative alternative for developing nursing knowledge. Res Nurs Health. 1997;20:169-177. 25. Thorne S, Reimer Kirkham S, O’Flynn-Magee K. The analytic challenge in interpretive description. Int J Qual Methods. 2004;3(1):1-11. 26. Green J, Thorogood N. Qualitative Methods for Health Research. 2nd ed. London, UK: Sage; 2009. 27. Lagarde F, Leblanc M. Policy options to support physical activity in schools. Can J Public Health. 2010;101(S2):S10-S13. 28. Wang C. Youth participation in photovoice as a strategy for community change. J Community Pract. 2006;14(1-2):147-161. 29. Wang C. Photovoice: a participatory action research strategy applied to women’s health. J Womens Health. 1999;8(2):185-192. 30. Smith E, Capogrossi K, Estabrooks P. School wellness policies: effects of using standard templates. Am J Prev Med. 2012;43(3):304-308. 31. Jagosh J, Macaulay A, Pluye P, et al. Uncovering the benefits of participatory research: implications of a realist review for health research and practice. Milbank Q. 2012;90(2):211-346. 32. Harriger D, Lu W, McKyer ELJ, Pruitt BE, Goodson P. Assessment of school wellness policies implementation by benchmarking against diffusion of innovation framework. J Sch Health. 2014;84(4):275-283. 33. Pan Canadian Joint Consortium for School Health. Stakeholder engagement for improved school policy: development and implementation. Can J Public Health. 2010;101(S2):S20-23. 34. Minkler M, Wallerstein N, eds. Community-Based Participatory Research for Health. 2nd ed. San Francisco, CA: Jossey-Bass Publishers; 2010.
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Using a Participatory Approach to the Development of a School-Based Physical Activity Policy in an Indigenous Community LINDSAY HOGAN, BPE, MAa ENRIQUE GARC´ıA BENGOECHEA, PhDb JON SALSBERG, MScc JUDI JACOBS,d MORRISON KING,e ANN C. MACAULAY, CM, MD, FCFPf
ABSTRACT BACKGROUND: This study is part of a larger community-based participatory research (CBPR) project to develop, implement, and evaluate the physical activity component of a school-based wellness policy. The policy intervention is being carried out by community stakeholders and academic researchers within the Kahnawake Schools Diabetes Prevention Project, a well-established health promotion organization in the Indigenous community of Kahnawake, Quebec. METHODS: We explored how a group of stakeholders develop a school physical activity policy in a participatory manner, and examined factors serving as facilitators and barriers to the development process. This case study was guided by an interpretive description approach and draws upon data from documentary analysis and participant observation. RESULTS: A CBPR approach allowed academic researchers and community stakeholders to codevelop a physical activity policy that is both evidence-based and contextually appropriate. The development process was influenced by a variety of barriers and facilitators including working within existing structures, securing appropriate stakeholders, and school contextual factors. CONCLUSIONS: This research offers a process framework that others developing school-based wellness policies may use with appropriate modifications based on local environments. Keywords: community-based participatory research; Indigenous health; physical activity; school wellness policy. Citation: Hogan L, Garc´ıa Bengoechea E, Salsberg J, Jacobs J, King M, Macaulay AC. Using a participatory approach to the development of a school-based physical activity policy in an Indigenous community. J Sch Health. 2014; 84: 786-792. Received on November 22, 2013 Accepted on April 29, 2014
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esearch has caused concern that levels of physical activity (PA) among children may be too low for optimal health.1-3 Owing to the health implications of declining PA levels and the benefits to be gained from being active, many health interventions have attempted to target this issue and schools increasingly have become sites for intervention. Reviews surrounding school-based interventions to increase PA have highlighted that many projects focus solely on education as the main intervention component, leading to mostly minor or short-term
outcomes, and that perhaps, more whole-school multicomponent approaches should be used.4-6 One whole-school multicomponent approach that has become widely adopted is that of the Health Promoting Schools, which is similar to the Coordinated or Comprehensive School Health in the United States and Canada respectively. A Health Promoting School is ‘‘one that constantly strengthens its capacity as a healthy setting for living, learning and working.’’7 Essentially, a Health Promoting School is one that adopts a holistic framework that seeks to use all
a
High School Physical and Health Education Teacher, ([email protected]), Department of Kinesiology and Physical Education, McGill University Montr´eal, Quebec H2W 1S4, Canada b Associate Professor, ([email protected]), Department of Kinesiology and Physical Education, McGill University Montreal, Quebec H2W 1S4, Canada. c Associate Director &ResearchManager, ([email protected]), CIET/Participatory Researchat McGill (PRAM), Department of Family Medicine, McGill University, Montreal, Quebec H2W 1S4, Canada. dIntervention Staff, ([email protected]), Kahnawake Schools Diabetes Prevention Project, Kahnawake, Quebec, Canada. e Intervention Staff, ([email protected]), Kahnawake Schools Diabetes Prevention Project, Kahnawake, Quebec, Canada. f Professor Family Medicine, ([email protected]), CIET/Participatory Research at McGill (PRAM), Department of Family Medicine, McGill University, Montreal, Quebec H2W1S4, Canada. Address correspondence to: Enrique Garc´ıa Bengoechea, Associate Professor, ([email protected]), Department of Kinesiology and Physical Education, McGill University Montreal, Quebec H2W 1S4, Canada. This research and author L. Hogan were supported by an operating grant from the Canadian Institutes of Health Research (KAL-114097).
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available resources and a variety of leaders to improve the health of the entire school community through a range of means, including health education, adapting environments, adopting health supporting policies and practices, and the provision of health services, programs, and opportunities.7 An important part of the puzzle, therefore, is to develop and implement a comprehensive local wellness policy that identifies a school or school district’s approach to the health of their students and staff members.8 A wellness policy is a formal document that outlines priorities, rules, guidelines, procedures, and/or parameters for action intended to promote health.9,10 A school wellness policy may consist of whatever a school or school district sees fit based on their particular context. Nevertheless, school wellness policies typically focus on components of nutrition and PA. An array of guides are available for the process of creating a wellness policy;11-13 however, many are produced for use at the national or regional level and only a few research examples of local policy development or implementation are found.14,15 Many of the resources available to guide local wellness policy formation come from the United States where federal legislation structures the components of policy.9 Furthermore, the available wellness policy literature, as well as existing wellness policy examples from the United States, tend to have more content surrounding the nutrition component of the policy.9,16,17 More research stemming from a variety of contexts surrounding local wellness policy development, implementation, and evaluation are needed to contribute to this field. This would provide policy groups at the local level with the opportunity to gain knowledge from other groups that share similar contexts by providing them with relatable and practical approaches. One community that has taken action on health promotion using a school-based policy intervention ´ approach is Kahnawake, a Kanien’keha:ka (Mohawk) community with a population of approximately 8000. In 1994, the Kahnawake Schools Diabetes Prevention Project (KSDPP) was launched in response to a high rate of type 2 diabetes in the community. KSDPP’s main goal is the prevention of type 2 diabetes by increasing PA levels, improving healthy eating habits, and promoting positive attitudes among community members with a focus on school-aged children. Since its inception, KSDPP has undertaken many research projects aimed at understanding the prevention of type 2 diabetes and evaluating KSDPP interventions. All research undertaken by KSDPP falls under the participatory research (PR) umbrella. PR is an approach to conducting research that involves researchers working collaboratively with those affected by the issue at hand and who will be the end-users or chief beneficiaries of the research project with the purposes of education, taking action, or effecting social Journal of School Health
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change.18,19 Key to PR approaches is the idea that those involved in the collaborative research effort are considered equals, with each having an area of expertise to contribute.20 In 2005, KSDPP began to work with community members to create the nutrition component of a wellness policy for 2 local elementary schools. The nutrition policy was implemented in the 20092010 school year. In summer 2011, responding to a community identified need, KSDPP researchers received a federal grant to develop and implement a PA component to add to the elementary school wellness policy. This PA policy intervention project began with a baseline evaluation, which involved the use of adult focus groups, photovoice with students, 2 student PA recall surveys, and the School Health Action Planning and Evaluation System (SHAPES) questionnaire.21 These tools produced data about current PA levels of children, children’s preferences, perceived barriers and facilitators to PA, current school practices and programs, and stakeholder opinions on potential policy content. Following the baseline evaluation, a policy committee of various community stakeholders was formed. In line with the KSDPP’s PR approach, these community stakeholders collaborated alongside academic researchers in an equitable partnership to develop the PA policy document. Using data produced during the policy development phase of the larger policy intervention project, this study aimed to explore the following 2 research questions: How do a group of stakeholders develop a local school-based physical activity policy in a participatory manner? and What are the facilitators and barriers to the policy development process?
METHODS This research takes a case study design guided by an interpretive description approach. The interpretive description approach, originally developed for nursing research and now expanding into other disciplines,22,23 is a qualitative approach with the goal of searching for themes and patterns in health-related phenomena to produce new knowledge that has practice-based applications.24,25 In this case, the knowledge produced will surround how to create a school wellness policy and will identify supportive factors to the process. All data needed for this research had already been generated from work in the larger policy intervention study. This study drew upon data from documentary analysis and participant observation. The documentary sources were the materials produced during policy development meetings including transcriptions, policy drafts, agendas, committee member notes, research assistant field notes and reflections, and photographs of committee brainstorming notes. Also explored were the documents used within the meetings to inform
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the policy such as the baseline data, a school PA policy literature review, and policy examples from other jurisdictions. Data from participant observation also were drawn upon including field notes taken by the research assistant during the meetings and postmeeting summaries and reflections. Data Analysis Following the interpretive description approach, analysis began by looking at the big picture and asking questions like ‘‘what is happening here?’’ and ‘‘what am I learning about this?’’ in a series of data immersion periods prior to the start of any coding or creating links.24 To answer the ‘‘how’’ research question, a pragmatic descriptive approach was used. The various available documents and data from participant observation were drawn upon to provide a thorough description of how the committee was put together, which stakeholders were involved, how the meetings proceeded, and the different pieces of information used to inform the PA policy. To explore the barriers and facilitators to the policymaking process, a more interpretive approach was needed. A thematic content analysis focusing on the meeting transcripts was conducted. Using Nvivo9 (QSR International, Burlington, MA) software, ”chunks” of text from the transcripts that could be considered as factors that were either barriers or facilitators to the policy process were coded. Once this was complete, it was possible to identify emerging themes by grouping together similar factors. Member checking of this more interpretive section occurred with 3 of the committee members to ensure the findings were representative of their views and experiences.26
RESULTS Forming the Policy Committee Two members of the KSDPP intervention team took the lead in forming the policy committee. Their goal was to acquire various school stakeholders and to ensure equal representation from each of the schools. The policy committee consisted of 14 people: 2 principals, a classroom teacher, a health education teacher, a physical education teacher/parent, a teacher’s assistant, a hospital nutritionist, a parent, 3 members of the KSDPP intervention staff, 2 academic researchers in the area of kinesiology and physical education, and a graduate student research assistant. Policy Committee Meetings The policy committee had a series of 8 meetings to form the wellness policy’s PA component with dinner provided at each meeting. Consistent with a PR approach, the community stakeholders collaborated closely with the academic researchers to create a policy 788 •
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that was based on the best available information, but which was also contextually appropriate and viable. At every session, committee members engaged in a round-table dialogue that was a negotiation between what was ideal in terms of policy statements and what was feasible in terms of policy implementation. Initial meetings focused on discussing community health values and using a positive approach to health promotion as well as what would work and what would not work in their community. Later meetings focused on drafting a suitable policy considering everything viewed and discussed. The diverse group used their personal knowledge and experience, results from the policy’s baseline evaluation, evidence-based information from the literature, and any additional requested materials to develop the PA policy. Information Used by the Committee Research literature review and SHAPES results. A literature review by Lagarde and Leblanc27 investigated the evidence concerning school-based PA interventions and compiled what they found to help guide policy makers at the national and regional levels. Their review identified policy options (or statements) that were proven to be effective, were promising, or were based on untested expert opinion. Policy options tested and proven effective in increasing PA or producing health outcomes revolved around providing daily, quality, safe physical education, providing daily, quality, safe PA (in the classroom, recess, etc), providing extracurricular activities, training staff members to provide appropriate physical education and PA programs, ensuring funding for equipment and facilities, and teaming up with the community to optimize the use of PA resources. On the basis of the results of this review, the authors concluded that the best approach to achieving increased PA among children is to use multicomponent programs that target behavior change across multiple settings. As part of the policy intervention baseline evaluation, a tool from SHAPES was used. SHAPES is a collection of tools developed by the Propel Centre for Population Health Impact at the University of Waterloo (Canada). These tools can be used to gather data related to PA, tobacco use, healthy eating, and mental health at the student and school level for purposes such as needs assessment, intervention planning, program evaluation, and field research involving youth.21 For the policy intervention baseline evaluation, the principals and physical educators at each school worked together to complete the SHAPES administrator questionnaire, which acts as a scan of the school environment and explores school programs, policies and structures. Completion of the questionnaire generates a feedback report that shows the school how well or poorly they are doing in terms of a variety of indicators
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(healthy school environment, teaching and learning, supportive social environment, and community partnerships and services). Along with this feedback, a list of recommendations is provided regarding what schools can do to achieve top scores on each of the indicators to increase PA levels. To meet the needs and requests of the policy committee, a presentation was created by the research assistant that merged key information from the literature review27 with the locally relevant SHAPES results. The committee viewed and discussed the presentation in one meeting and revisited it in several later meetings to draft policy statements of their own. Wellness policy examples. To become familiar with what the format and content of a policy document might be, the committee members are requested to see examples of other wellness policies. A Web search generated a variety of school district policies. The group also reviewed the Kahnawake Education Centre’s existing nutrition policy, which the new PA policy will join to become a wellness policy. Photovoice results. Photovoice is a PR strategy developed and made popular by Caroline Wang that involves using photography to give a voice to people and their issues, and that has been shown to be appropriate and engaging when used with young populations.28 Photovoice is based on several key concepts. The 2 most basic concepts of photovoice are that images can teach and they can influence policy. Therefore, community members should be involved in creating and defining images that serve to shape health policies, and project planners should ensure an audience of influential people to view and hear the perspectives of participants. As seen in other PR approaches, an emphasis is placed on community and individual action.29 During the policy intervention baseline evaluation phase, a photovoice project was carried out to gather information on students’ views and practices of PA in and around school and how to promote it to meet their needs. Students were aware that a PA policy was being developed for their schools and that this project was a way for their experiences, opinions, and suggestions to be shared. The students took photographs about being active in their community, wrote captions for selected photographs, and engaged in photo-elicited focus groups. The focus groups and picture captions revealed a variety of ways the children enjoy being active as well as perceived barriers and facilitators to being active. On the basis of the identified barriers and facilitators, the children offered a number of wishes and suggestions that might lead to increased PA at school and around the community. These included increasing the number and types of extracurricular activities offered, making changes to the physical environment, such as more outdoor play structures or more greenery in the schoolyard, having access to Journal of School Health
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new equipment to play with at breaks, and increasing the time allotted for daily outdoor play. The policy committee was presented these results and stopped throughout the presentation to discuss any issues that the children raised or how to work the children’s suggestions into the PA policy. Adult focus groups. An adult focus group was carried out during the policy intervention baseline evaluation phase. The goal of this focus group was to explore the opinions of various stakeholders surrounding the topics of current child PA programs and opportunities, the school environment, and what they would like to see in a PA policy. The focus group consisted of 2 principals, 4 parents and 1 physical educator/parent. The main findings of this focus group included: •
locally relevant data are needed to form the policy; current child PA opportunities are limited and need to be diversified; • the policy needs to be flexible and formed by those who will apply it; • there is a need for more human resources for PA programming; and • other school policies may not be supporting the extracurricular work of the physical education teacher. •
These results were presented to and discussed with the policy committee. Resulting PA Policy After careful consideration of the available information and local circumstances, the group crafted a PA policy document. The resulting policy, introduced by a philosophy statement outlining guiding principles, targets 9 policy areas to increase or enhance PA opportunities for students and school staff: (1) physical education; (2) lunch and recess; (3) extracurricular physical activities; (4) classroom; (5) family; (6) community; (7) staff; (8) active transportation; and (9) safety. Recommendations for implementation and evaluation of the policy are also included in the document. Barriers and Facilitators The policy development process was influenced by a variety of factors, some of which helped move the process along more smoothly and others that made decision-making and progress more difficult. These factors included the existing structures of KSDPP, appropriate stakeholders, and school contextual factors. Kahnawake Schools Diabetes Prevention Project is well established in the community, and following a PR approach, the members of KSDPP have successfully
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collaborated with many community stakeholders on both research and intervention projects since its launch in 1994. The schools within Kahnawake have shown that they are committed to working with KSDPP over the years. Having this positive community reputation made recruiting and retaining policy committee members for this project much easier. Furthermore, the acquisition of the PA policy intervention research grant by KSDPP researchers allowed funds for catered meetings, a research assistant, and the collection of baseline data. Securing the appropriate stakeholders to be on the policy committee was key in the policy development process. Having many end users of the product (teachers, administrators, and parents) helped to maximize its appropriateness and its likelihood of implementation. However, several questions were raised during the policy’s development that were difficult to address without the appropriate people at the table. This refers either to stakeholders who were absent for the particular meeting or to stakeholders we did not secure to be on the committee. For example, the school principals involved in this project understandably had a busy schedule and were not able to attend all meetings. When this was the case, the group felt it was inappropriate to address schoollevel policies such as allowing skateboards at school to promote more active commuting to and from school. Furthermore, as we acquired fewer parents for the committee than had been desired, the group had a hard time deciding what could be done in terms of family involvement and responsibility. Existing school programs and practices served both to help and constrain the work of the policy group. On the one hand, the schools already do a lot to promote PA like running a number of afterschool or lunchtime sports, providing daily recess, and teaming up with community recreation organizations. The policy committee simply had to find ways to build on these promising programs and practices. On the other hand, some school programming and practices restricted the ideas of the committee. Several committee members suggested the possibility of increasing physical education minutes, time devoted to being active in the classroom and/or time spent outside for lunch and recess in order for the children to have more time to move during the day. The complexity of changing the school schedule raised a lot of concerns. If the schools were able to redistribute or extend school time, extra PA would not necessarily be the first priority. Instead, certain academic subjects might get more attention. One principal noted in reference to the school day: ‘‘I know if ours got extended, we’re sticking in more math.’’ Further, if they were to extend outdoor recess or lunch, they would need to find room in the budget to pay the schoolyard monitors for their added time. As one committee member put it: ‘‘Everything 790 •
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has a domino effect on something else.’’ So, because of the complexity of school programs and practices, the schedules were considered to be inflexible and the committee instead had to find ways to fit PA opportunities into current ways of doing things.
DISCUSSION The adoption of school wellness policies has been identified as a promising strategy to promote health. This study demonstrated how healthy school policy can be developed at the local level. Policies developed locally have been shown to be stronger and more comprehensive than template-based policies,30 and thus, it is important to be aware of how best to support local policy-making processes. Our study contributes to this understanding by identifying factors that may act as barriers or facilitators to the school wellness policy development process. Also, to the best of our knowledge, it is one of only a few research examples of PA policy development and the first in an Indigenous school district. The use of a participatory approach to developing school policy shows promise. Cargo and Mercer18(p327) suggest: ‘‘A key strength of [PR] is the integration of researchers’ theoretical and methodological expertise with nonacademic participants’ real-world knowledge and experiences into a mutually reinforcing partnership.’’ In this case, the collaboration between academic researchers and local stakeholders led to the creation of a sound PA policy that is evidence-based as well as contextually appropriate. The academic researchers contributed by securing funding for the project that allowed for human and physical resources, and a baseline and future follow-up evaluation, and by delivering evidence-based information at the request of the committee. The stakeholders contributed their local knowledge and were able to decide what would work best in their schools and their community. In addition, one of the key elements of PR is mutual education.20,31 By developing the PA policy in a participatory manner, the community stakeholders were able to learn about important PA and health-related information as well as ways of collecting and interpreting data and the academic researchers were able to learn more about community decision-making processes and what is important to the school community. This enhances the capacity of both parties for similar future projects. Limitations As this research took the form of a case study, only the one case was explored. The findings are then only applicable to the particular context in which the school PA policy development took place. However, as this is an underresearched area, this case study sought to provide insight and understanding of the process
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of developing comprehensive school wellness policies. Detailed information was provided to allow readers to determine how applicable or transferable the findings are to other settings. Conclusions Written school wellness policies are now considered a promising strategy for school-based health promotion and an integral component of school health approaches such as Health Promoting Schools, Comprehensive School Health and Coordinated School Health.32 As few studies exist that explore the processes of policy development, implementation, monitoring, and evaluation, this study offers a process framework for developing a school PA policy in a participatory manner that others may utilize with appropriate modifications based on their own environments.
IMPLICATIONS FOR SCHOOL HEALTH Branching out as far as is possible and sensible to other community stakeholders is recommended to other groups looking to develop healthy school policy. While this policy effort included principals, teachers, parents, academic researchers, a nutritionist, and intervention staff from a local health promotion group, other stakeholders can be a range of people including students, health professionals, members of nongovernmental organizations, community members, or private sector professionals. Each stakeholder is considered to be a representative of others who share their roles in society and each has unique information and opinions to contribute to the policy process.33 Although we were able to secure the core stakeholders needed to develop a sound PA policy, additional stakeholders could have served to enhance the scope of the project further. For example, if the policy group had been able to include representatives from the public works office or the local police, the committee may have been able to address the active transportation target area better. The committee members felt more could have been added to this section of the policy, but that they were not the right people to be creating or ensuring further policy statements in this section. While this project was done in a participatory manner, which stresses equality amongst stakeholders, having KSDPP members as the lead organizers may have been essential to keeping the effort afloat. The committee members were all busy people with agendas competing against this project. PR and school wellness policy literature acknowledge that projects like this may need a champion at the forefront to maintain a strong focus on the final goal and to keep people on board in the face of competing priorities.33,34 Having the funds to provide dinner each session was a big Journal of School Health
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draw for the members as well. With this said, it will be important during the implementation phase to shift this responsibility toward the school stakeholders to make this a sustainable project. Other wellness policy case studies have suggested that it is important to identify clear lines of accountability within the schools for the policy to succeed.14,15 Human Subjects Approval Statement This research was approved by the McGill University Research Ethics Board and by the KSDPP Community Advisory Board.
REFERENCES 1. Colley R, Garriguet D, Janssen I, Craig C, Clarke J, Tremblay M. Physical activity of Canadian adults: accelerometer results from the 2007 to 2009 Canadian Health Measures Survey. Health Rep. 2011;22(1):7-14. 2. Colley R, Garriguet D, Janssen I, Craig C, Clarke J, Tremblay M. Physical activity of Canadian children and youth: accelerometer results from the 2007 to 2009 Canadian Health Measures Survey. Health Rep. 2011;22(1):15-24. 3. Tremblay M, Shields M, Laviolette M, Craig CL, Janssen I, Gorber SC. Fitness of Canadian children and youth: results from the 2007-2009 Canadian Health Measures Survey. Health Rep. 2009;21(1):1-14. 4. Salmon J, Booth ML, Phongsavan P, Murphy N, Timperio A. Promoting physical activity participation among children and adolescents. Epidemiol Rev. 2007;29(1):144-159. 5. Timperio A, Salmon J, Ball K. Evidence-based strategies to promote physical activity among children, adolescents and young adults: review and update. J Sci Med Sport. 2004;7(S1):20-29. 6. van Sluijs EM, McMinn AM, Griffin SJ. Effectiveness of interventions to promote physical activity in children and adolescents: systematic review of controlled trials. BMJ. 2007;335:703-707. 7. World Health Organization. School and Youth Health: What is a Health Promoting School? xxxx. Available at: http:// www.who.int/school_youth_health/gshi/hps/en/index.html. Accessed April 17, 2012. 8. Schwartz MB, Henderson KE, Falbe J, et al. Strength and comprehensiveness of district school wellness policies predict policy implementation at the school level. J Sch Health. 2012;82(6):262-267. 9. Chriqui J, Schneider L, Chaloupka F, Ide K, Pugach O. Local Wellness Policies: Assessing School District Strategies for Improving Children’s Health. School Years 2006-07 and 200708. Bridging the Gap, Health Policy Center, Institute for Health Research and Policy, University of Illinois at Chicago, Chicago; 2009. 10. Nutbeam D. Health Promotion Glossary. Geneva, Switzerland: World Health Organization; 1998. 11. Connecticut State Department of Education. Action Guide for School Nutrition and Physical Activity Policies. Hartford: Connecticut State Department of Education; 2009. 12. Simovska V, Dadaczynski K, Grieg K, et al. HEPS Tool for Schools: A Guide for School Policy Development on Healthy Eating and Physical Activity. Woerden, the Netherlands: NIGZ; 2010. 13. World Health Organization (WHO). Global Strategy on Diet, Physical Activity and Health: A Framework to Monitor and Evaluate Implementation. Geneva, Switzerland: WHO; 2008. 14. Gleddie DL. The devil is in the details: development of policy and procedure in the Battle River Project. Health Educ J. 2010;71(30):30-38.
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´ 15. Sanchez V, Hale R, Andrews M, et al. School wellness policy implementation: insights and recommendations from two rural school districts. Health Promot Pract. 2012;15:340-348. 16. California School Board Association, California Project Lean. Student Wellness: A Health Food and Physical Activity Resource Guide. West Sacramento: California School Board Association; 2005. 17. National Alliance for Nutrition and Activity. Model Local School Wellness Policies on Physical Activity and Nutrition. Available at: http://www.schoolwellnesspolicies.org/ resources/NANAWellnessPolicies.pdf. Accessed June 13, 2012. 18. Cargo M, Mercer S. The value and challenges of participatory research: strengthening its practice. Annu Rev Public Health. 2008;29:325-350. 19. Green LW, George MA, Daniel M, et al. Study of Participatory Research in Health Promotion: Review and Recommendations for the Development of Participatory Research in Health Promotion in Canada. Ottawa, ON: Royal Society of Canada; 1995. 20. Macaulay A, Commanda L, Freeman W, et al. Participatory research maximizes community and lay involvement. BMJ. 1999;319:774-778. 21. Leatherdale S, Manske S, Wong S, Cameron R. Integrating research, policy, and practice in school-based physical activity prevention programming: the School Health Action, Planning, and Evaluation System (SHAPES) Physical Activity Module. Health Promot Pract. 2009;10(2):254-261. 22. Clark M, Spence J, Holt N. In the shoes of young adolescent girls: understanding physical activity experiences through interpretive description. Qual Res Sport Exerc Health. 2011;3(2):193-210. 23. Hunt M. Strengths and challenges in the use of interpretive description: reflections arising from a study of the moral experience of health professionals in humanitarian work. Qual Health Res. 2009;19(9):1284-1292.
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24. Thorne S, Reimer Kirkham S, MacDonald-Emes J. Interpretive description: a noncategorical qualitative alternative for developing nursing knowledge. Res Nurs Health. 1997;20:169-177. 25. Thorne S, Reimer Kirkham S, O’Flynn-Magee K. The analytic challenge in interpretive description. Int J Qual Methods. 2004;3(1):1-11. 26. Green J, Thorogood N. Qualitative Methods for Health Research. 2nd ed. London, UK: Sage; 2009. 27. Lagarde F, Leblanc M. Policy options to support physical activity in schools. Can J Public Health. 2010;101(S2):S10-S13. 28. Wang C. Youth participation in photovoice as a strategy for community change. J Community Pract. 2006;14(1-2):147-161. 29. Wang C. Photovoice: a participatory action research strategy applied to women’s health. J Womens Health. 1999;8(2):185-192. 30. Smith E, Capogrossi K, Estabrooks P. School wellness policies: effects of using standard templates. Am J Prev Med. 2012;43(3):304-308. 31. Jagosh J, Macaulay A, Pluye P, et al. Uncovering the benefits of participatory research: implications of a realist review for health research and practice. Milbank Q. 2012;90(2):211-346. 32. Harriger D, Lu W, McKyer ELJ, Pruitt BE, Goodson P. Assessment of school wellness policies implementation by benchmarking against diffusion of innovation framework. J Sch Health. 2014;84(4):275-283. 33. Pan Canadian Joint Consortium for School Health. Stakeholder engagement for improved school policy: development and implementation. Can J Public Health. 2010;101(S2):S20-23. 34. Minkler M, Wallerstein N, eds. Community-Based Participatory Research for Health. 2nd ed. San Francisco, CA: Jossey-Bass Publishers; 2010.
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