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Participatory research looking at the school food environment and by obr18219


									School Environment and Students Achieving Wellness (SEASAW)
Improving the school health environment through community based participatory research

Daniel Berg, MD
Advisor: Maureen Cadorette (note: she has not advised me on this project)

1. Introduction/Importance; Goals
This pilot program will analyze the diet and exercise environments among St. Louis area schools through
participatory research techniques involving 5th and 6th grade students, teachers and administrators. It will
be coupled with education and student involvement in improving the health environments at their schools.
Long term outcomes will focus on whether this project leads to improved health environments and health
outcomes at participating schools. In developing this project I have been working with a pediatric
endocrinologist at St. Louis Children’s Hospital and the head of the Barnes-Jewish Hospital Foundation’s
(BJH) health education outreach program.

Childhood obesity is a major health problem in America with 16% of children overweight 1 and nine
million children over age six obese 2. While this epidemic affects all demographic groups, research
conducted at Johns Hopkins Bloomberg School of Public Health found large differences in obesity rates
related to socioeconomic status and race. These growing differences will likely exacerbate existing healthy
inequities found in the local community. In St. Louis, African-Americans die from the complications of
diabetes at a rate 1.7 times higher than whites 3. If trends in obesity rates continue, this inequality and
others will worsen.

Numerous groups including the Institute of Medicine2 have made specific recommendations for school
districts to implement changes which could lead to improved health among students. Several researchers
have used ideas taken from these recommendations to create “report cards” for school districts 4, 5. We are
currently in the process of developing a set of criteria based upon the Alliance for a Healthier Generation
(AHG) school wellness checklist since the district is going to use this program next year.

Although there are clearly serious deficiencies in the current system, there is reason to believe that
interventions on the school food environment can significantly impact the food consumption patterns of
students. The relative availability of different types of foods strongly affects consumption patterns 6. This
conclusion taken from a study taking a city-wide geographic approach can also be applied to the high
school food environment as shown by a study looking at disadvantaged Scottish teens 7. More direct
evidence for the efficacy of interventions comes from looking at a statewide effort to change nutrition
policy in Texas schools. Outcomes analysis showed improvements in healthy food consumption behavior
among schoolchildren after statewide policy implementation8.

The process for achieving change may come through various mechanisms. As opposed to a traditional
approach, community based participatory research (CBPR) has the capacity to integrate community
members into the process of formulating research design and implementation. CBPR has become an
increasingly popular model to conduct public health research, and has been successfully used in the past to
look at inequalities in the food environment 9.

CBPR is particularly well suited to studying the food and exercise environment since the potential solutions
can only succeed if they reflect the tastes and values of the community. This particular project aims to
increase student awareness, understanding and interest in the health environment and inequalities within
our community. The students will then assist in creating evaluation methods and proceed to evaluate their
own school environment and dialogue with their school administration and local decision-makers about
changes which would improve the school environment. The students’ suggestions will form the basis for
the School Wellness Committee which is likely to be mandated by the district at every school by next fall.

2. Methods
Participating schools will be recruited from St. Louis City. For the first year’s pilot project we plan to
involve 4 schools which already have a relationship with the BJH Foundation. In order to participate, a
school administrator and 5th or 6th grade teacher must meet with the research team, and sign a form which
explains the project, permits the research and creates a commitment to participate for at least 1 year.
SEASAW plans to contract with the BJH Foundation to provide teacher/research assistants at $75/hour of
classroom time. They have agreed to help us develop the physical curriculum free of charge. Once this is
completed by early June, we plan to present it to the Washington University IRB.

At least two weeks prior to the curriculum, the school nurse will weigh and measure each child in a private,
confidential setting. This is already being done at all city schools by school nurses, but we will need to
make sure that the measurements are done in a timely manner. The data collected will be the property of
the school and will only be shared with the researchers in de-identified form. The teacher will also provide
the researchers with de-identified demographic information on the class including gender, age and race. A
letter about the project will be sent to all parents, and will solicit involvement.

The curriculum entails 6 sessions. These classes will occur either during after school enrichment classes or
regular classroom time, but will not take away from scheduled PE. A research assistant will conduct the
curriculum along with the regular teacher.

                            Session 1                    Session 2                    Session 3

Week 1                      General introduction to      Learning about the           Students evaluate the
                            healthy foods and            Institute of Medicine        school in small groups
                            exercise. (1 hour)           Criteria for healthy         through field research. (2
                                                         schools. (1 hour)            hours or after school)
Week 2                      Review the evaluation of     Develop and polish ideas     Feedback from students
                            the school and begin to      for improvement. (1          and parents to
                            develop ideas for            hour)                        administrators, PE
                            improvement. (1 hour)                                     teachers and cafeteria
                            Homework.                                                 workers. (1 hour)

The Healthy Youth Project (HYP) in St. Louis is currently formulating policy for the St. Louis School
District, and is recommending that every school create a Wellness Committee along the guidelines of the
Alliance for a Healthier Generation. After we presented this project at the HYP meeting in early March,
we are now reassured that the students’ recommendations will be very useful to spark action from these
committees. The researchers will visit the school at 6 months in order to personally re-evaluate the school
using the same criteria. Our program will create an incentive for positive change by recognizing successful
schools with a plaque and a $150 donation toward equipment for physical education given 6 months after
the initial program.

Primary outcomes analysis of the pilot project will include each school’s initial score on the criteria scale
and the BMI of the students. We plan to track the school’s score over several years and analyze whether
this program leads to positive changes and whether these changes relate to the average BMI of the children.
We also plan to scale up based upon our initial findings, feedback and successes.
4. Allocation of expenses
Papers, stamps, copies                       $242
School incentives                            $600
Contracted teacher/ researcher time          $2250
PI time (my time away from hospital work) $1908
Total costs for first year                   $5000
Other income sources                         $4000
My department chair in the Division of Hospital Medicine at Washington University has promised me
$4000 of departmental money towards this project. $1000 from the Delta Omega Scholarship would help
me to achieve our budgetary needs.
Literature cited

1. Wang MC, Kim S, Gonzalez AA, MacLeod KE, Winkleby MA. Socioeconomic and food-related
physical characteristics of the neighbourhood environment are associated with body mass index. J
Epidemiol Community Health 2007;61:491-8.

2. Progress in Preventing Childhood Obesity: Focus on Schools. Institute of Medicine,

3. Quesada L. Understanding Our Needs. St. Louis Health Department, 2004.

4. Greves HM, Rivara FP. Report card on school snack food policies among the United States' largest
school districts in 2004-2005: room for improvement. Int J Behav Nutr Phys Act 2006;3:1.

5. 2007 School Lunch Report Card. Physician's Committee for Responsible

6. Morland K, Wing S, Diez Roux A. The contextual effect of the local food environment on residents'
diets: the atherosclerosis risk in communities study. Am J Public Health 2002;92:1761-7.

7. Wills W, Backett-Milburn K, Gregory S, Lawton J. The influence of the secondary school setting on the
food practices of young teenagers from disadvantaged backgrounds in Scotland. Health Educ Res

8. Cullen KW, Watson K, Zakeri I. Improvements in Middle School Student Dietary Intake After
Implementation of the Texas Public School Nutrition Policy. Am J Public Health 2007;.

9. Sloane DC, Diamant AL, Lewis LB, et al. Improving the nutritional resource environment for healthy
living through community-based participatory research. J Gen Intern Med 2003;18:568-75.

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