Suggested Citation: Gore TD, Caine-Bish N, Olds RS, et al. The 4:3:2:1 Healthy Kids Project: A Pilot Intervention to Reduce Childhood Obesity in Elementary School Students. Cases in Public Health Communication & Marketing. 2008; 2:87-104. Available from: www.casesjournal.org/volume2

Abstract

Four Midwestern school districts formed a community coalition to address increased rates of childhood obesity. Students in 3rd, 4th, and 5th grade participated in a study testing a two-part intervention to reduce childhood obesity. Students at one school received an after-school education program only, another school received a communication campaign only, and a third school received both the education program and communication campaign. A fourth school served as a control, receiving neither intervention. Children in all four conditions filled out assessments before and after the 10-week intervention. Based on the Stages of Change model, dependent variables included current habits and future likelihood to engage in four healthy target behaviors related to nutrition and exercise. Results showed no differences between the four schools with regard to their fruit and vegetable intake, dairy consumption, or increased physical activity. The two schools that received the communication intervention progressed in their intentions to reduce the number of hours they spent in front of "square screens" such as televisions and computers to fewer than 2 hours per day, whereas the other two schools did not progress positively in regard to this goal. The strengths and limitations of this school-based intervention are described in this case study, highlighting the importance of engaging a community coalition and the limitations of collecting cross-sectional pilot data in public elementary schools.

Introduction

Helping children maintain a healthy weight is an important public health goal proven to reduce illness and improve both the quality and quantity of life.^1,2 Over the last 15 years, however, the proportion of overweight youth 6 to 17 years of age in the United States has increased from 11% between 1988 to 1994 to 16% between 1999 through 2002.3 Given this information, a community coalition developed an intervention to reduce the rate of childhood overweight/ obesity through both education and communication campaign messages.

Background

Through leadership from the Portage County Child Health Services, in Ohio, this project began with the formation of a multidisciplinary community coalition of researchers, educators, and community members with expertise in the areas of health communication, health education, public health, physical education, nutrition, and exercise physiology, as well as school educators and administrators. First, the coalition conducted a needs assessment to determine the prevalence of child and adolescent overweight in the county. All eleven county school districts were invited to participate in the project during an orientation meeting with superintendents prior to the school year. Three of the eleven school districts agreed to participate. Researchers gathered height, weight, age, grade, and sex data for students in their physical education classes in the 3rd-8th grades for each participating district with the help of university student volunteers. Kent State University Institutional Review Board approval was obtained prior to data collection. Initial findings revealed that the prevalence of childhood overweight in the county exceeded national figures.⁴ Specifically, 37%, 36%, and 49% of students, respectively, in the three participating schools were at risk of being overweight based on a BMI percentile rank. Even more alarming, the prevalence of children classified as overweight in each school was 19%, 18% and 30%, respectively. These rates exceeded the national rate of 16%.³ This formative research revealed a serious public health problem facing the county regarding childhood overweight/obesity.

The purpose of this case study is to describe the process of the development, implementation, and evaluation of a comprehensive nutrition and physical activity campaign and intervention specifically designed for 3rd-5th grade children. The goal for this pilot intervention was to create a communication campaign and an after-school nutrition and exercise educational intervention for 3rd-5th graders focusing on age-appropriate education components that included nutrition and exercise behaviors. Researchers utilized the Stages of Change, a behavior change model allowing health practitioners to assess the stage of their target audience with regard to readiness to adopt certain behaviors.⁵

The Stages of Change Model is based on the theory that individuals can be classified into one of five stages of readiness for behavior change: precontemplation, contemplation, preparation, action, and maintenance. The theory states that the success of a behavior modification intervention depends, at least in part, on the category in which a person falls. Health practitioners can utilize the stages of change while designing and tailoring messages aimed at moving members of a specific target audience from one stage to another. For example, children who participate in an intervention may progress from early stages of precontemplation to contemplation, and then to more advanced stages like preparation and action. Each progression moves the participant closer to successful behavior change. Research has shown that the Stages of Change Model has been used successfully in previous interventions to increase children's fruit and vegetable consumption and promote healthy eating patterns.^6,7

Based on the formative research, the coali-short period of 10-weeks. However, they tion recognized that it was not feasible to felt they could effectively monitor changes record significant changes in BMI, nutri-in stage, and therefore behavior, using the tion, and physical activity habits in the Stages of Change Model.

Methodology

One control school and three intervention schools volunteered to be part of the intervention whereby one school acted as a control group and the other three schools received one of the following three intervention strategies: communication campaign only, after-school nutrition and exercise education program, or a combination of both the communication and after-school program (Figure 1). The schools were not randomly assigned due to logistical issues regarding gym space and researchers' accessibility in the schools. The intervention was funded by the Portage County Child Health Services and Kent State University.

Intervention Development

Based on results of the formative research, the community coalition selected 3rd through 5th graders as their target audience because the data demonstrated that the rates of overweight/obesity began climbing at the 5th grade and higher. The coalition's goal was to develop an intervention aimed at maintaining and/or decreasing the BMI in 3rd to 5th graders, thus reducing the incidence of overweight and obesity in higher grade levels.

The coalition completed interview sessions with school administrators and conducted focus groups with students and their parents in order to review current exercise and nutrition guidelines and to gain information about the audience's specific needs and concerns. Researchers asked school administrators (including principals and superintendents) what concerned them about student nutrition and physical activity and if they would be open to an intervention within the school. Focus groups with the children were held in school physical education classes. Researchers asked what areas of healthy eating and exercise were the most difficult for them to perform. In addition, children were questioned about nutrition and exercise concepts to measure their knowledge and the accuracy of their knowledge. Four focus groups with approximately 25 children each were completed. The classes chosen to participate in the focus groups were based on the children currently enrolled in physical education at the time of the data collection. In addition, one parent focus group was held. Parental involvement in the focus group was difficult to obtain due to timing and competing responsibilities even when a nominal incentive was offered ($10 gas card). Therefore, only one parent focus group was conducted. Researchers asked parents to identify their biggest concerns for their children's nutrition, what they would most like for their children to change about their nutrition and exercise habits, and what information they believed would help their children achieve better nutrition and exercise habits. After analyzing the focus group responses, the community coalition determined that the intervention should include a communication campaign and an after-school nutrition and physical activity education program.

The coalition subsequently developed a communication campaign involving both children and their parents. Formative data were used to develop persuasive messages on posters, log sheets, and newsletters. Logos and color schemes for all the media campaign materials were developed through a series of collaborative meetings with the university's graphic design department. Four messages were developed based on the most prevalent nutritional and exercise concerns addressed in the parent and child focus groups.

Researchers conducted message testing utilizing additional focus groups with children and parents who would not be participating in the intervention. One focus group of children and one focus group of parents were asked about the logo, color schemes, and messages, as well as other materials to be used for the communication campaign. Suggested changes and slight alterations to the campaign design were made based on their recommendations to better meet the needs of the target audience.

Based on the formative research findings, the coalition developed the 4:3:2:1 Healthy Kids campaign. This campaign encouraged kids and parents to set bi-weekly goals to eat more fruits and vegetables (more than 4 servings daily), consume more low-fat dairy products (at least 3 servings daily), engage in less "square screen time" (no more than 2 hours daily spent in front of the computer or television), and participate in more physical activities (at least 1 hour daily). The 2 hours of square screen time was selected from recommendations from Centers of Disease Control and American College of Sports Medicine Guidelines.⁸

Two participating schools (School 1 and School 2) received the communication campaign. Beginning with the "More than Four" message, posters were displayed in each of the 3rd-5th grade classrooms and in the halls and common areas of the school, including the entryway, cafeteria, and main hallways. Every two weeks, another one of the four posters was added next to the previous posters (i.e., messages; see Figure 2).

For each two-week period related to one of such as bracelets and glow-in-the-dark the nutrition or exercise messages, children pencils with the "4:3:2:1 Healthy Kids (HK)" were asked to record activities relevant to logo specifically developed for this project the campaign in exchange for incentives (see Figure 3, next page).

Researchers and university students went to the schools participating in the communication campaign to hand out bracelets and pencils to children who returned completed logs. This portion of the campaign was very popular and was in itself an incentive for the children to participate because the participants enjoyed interacting with university students and faculty. In an attempt to encourage participation in the 4:3:2:1 Healthy Kids Campaign, each week (approximately every other day), children were reminded over the public announcement system to record their activities. In hope of stimulating conversations and initiating interactive behaviors regarding the campaign topics, parents were asked to sign their children's weekly log sheets. Every two weeks, 93 a newsletter containing family-friendly tips about the current message was also sent home (see Appendix A). The resulting campaign ran for ten weeks with each message the focus of the campaign for two weeks as well as a week each for measuring BMI and completing a questionnaire with the participating grades.

An after-school educational intervention called "Healthy Kids" was developed with the goal of engaging children who voluntarily enrolled to participate and learn about healthy eating approaches and physical activity practices. This component of the complete intervention was used to determine if the communication campaign alone was enough to create behavior change, or if more intensive education would result in greater impact. It was the coalition's goal to create an approach that would reach a large number of students in the school for a moderate time and cost, as these were both concerns of the school administration. The nutrition and exercise education program was an after-school program that met once a week for 10-weeks for 90 minutes each week. The nutrition education consisted of a snack as well as nutrition games and activities. The physical activity portion was 45 minutes of physical activity that included cardiovascular as well as muscle strength and endurance activities. More information about the educational program is available from the second author, upon request.

Evaluation

Students in each of the four groups (education program only, communication campaign only, both education program and communication campaign, and control with no intervention) were tested at baseline (Time 1) and then again after intervention (Time 2) to measure change using the Stages of Change. Students were surveyed about their habits relative to the four components of the campaign: 1. fruit and vegetable consumption, 2. dairy consumption, 3. physical activity, and 4. square screen usage.

Based on the research by DiClemente and Prochaska,⁹ a questionnaire was developed using one-item indicators to assess students' progress toward each of the four goals of the 4:3:2:1 Healthy Kids project: 1) consuming more than four servings of fruits and vegetables, 2) consuming at least three servings of dairy products, 3) spending no more than two hours spent in front of "square screens", and 4) participating in at least one hour of daily physical activity. For example, with regard to fruit and vegetable consumption, children were asked to circle the statement that best describes their current habits. An example of one of the questions can be found in Appendix B. The respondents were asked to circle the statement that best described their current situation for each of these four goals.

Results

The communication intervention reached approximately 475 students in the 3rd, 4th, and 5th grade in two different elementary schools. The parents of the children were also exposed to the messages through the newsletters and logs that were sent home, which meant that more than 1,000 individuals were exposed to the communication campaign. Furthermore, the posters were placed in common areas of the school; therefore, all the students were exposed to the messages depicted on the posters, not just 3rd-5th graders. At the conclusion of the communication campaign, over 65% of the participating children correctly identified the four main objectives of the campaign. In addition, a second evaluation conducted four months after the campaign's end revealed that 50% of the children could still identify the four objectives of the communication campaign. After the conclusion of the intervention, the two schools that engaged in the communication campaign kept and continued to use (to this day) both the posters and reproducible handouts. In addition, both schools have taken further steps to create an environment that encourages healthy nutrition and exercise in their respective schools.

With regard to eating at least four servings of fruits and vegetables daily, no significant differences were recorded amongst the four intervention groups (p = 0.42). Similarly, there were no significant differences between schools related to consuming at least three servings of dairy per day (p = 0.57) or engaging in at least one hour of daily physical activity (p = 0.15). However, schools did differ significantly regarding the goal of spending no more than two hours daily in front of "square screens" (p =0.03). Specifically, the means for the Schools 3 and 4 went down (reflecting less readiness to engage in the behavior), while the means for Schools 1 and 2 went up (reflecting movement toward the goal). Schools 1 and 2 both received the communication campaign intervention, whereas the other two schools did not. The schools that moved toward the means for the square screen time goal were between the preparation and action phases of the Stages of Change Model (see Table 1, next page, for mean scores for all four schools).

At the conclusion of the program, the only to adopting the goal (in the action phase) school with significant movement toward of being physically active for at least one program goals was School 1 (the school that hour per day (p = 0.02), consuming at least received both the communication and educa-three servings of dairy daily (p = 0.05), and tional interventions). At the posttest mea-spending no more than two hours daily in surement, students in School 1 were closer front of "square screens" (p = 0.02).

Discussion and Limitations

Researchers utilized the Stages of Change Model in designing the intervention,⁹ hoping to see students move toward adoption of four healthy behaviors. Since the means of most pretest and posttest measures settled around the 3 and 4 out of a possible 5 at baseline (i.e., between preparation and action in the Stages of Change model), most children in all four conditions reported that they already engaged in some of these healthy behaviors, especially exercise and dairy consumption.

The coalition was pleased to see the positive progression from pretest to posttest with regard to the goal of restricting time spent in front of square screens to less than two hours daily. One possible explanation for this finding is that the "square screen" message could have been a novel message to the children compared to the "eat more vegetables" and "be more physically active" messages, and that this was communicated most in the communication and education condition.

Overall, post-intervention focus groups demonstrated that students remembered the communication campaign messages but had difficulty remembering to fill out their activity and nutrition logs. Participants also discussed the importance of incentives in motivating them to complete tasks. Given this information, the coalition aims to find more attractive incentives to help children meet the learning and behavioral objectives of the program.

There were limitations involved in this study that should be addressed in future programs. First, the schools in this intervention were self-selected; volunteer or self-selection bias may have impacted the study's findings. The largest limitation was a lack of parental involvement. Researchers believe this made it difficult for children to make a behavior change since parents act as "gatekeepers" to many nutrition decisions and exercise opportunities. The program attempted to elicit parental involvement by asking parents to sign their children's nutrition/exercise log sheets. In addition, bi-weekly newsletters including information on that week's specific topic were sent home. These included tips and recipes to aid parents in creating a home environment conducive to behavior change. However, in spite of the researchers' efforts, it appeared as if the parents were not as engaged as the coalition hoped. Less than 10% of the log sheets were returned to researchers in the communication-only school. Several explanations for this low return rate are possible. For example, the children may have been unreliable in delivering log sheets to parents or returning completed logs to school or the parents and children could have failed to complete the log sheets at home. In either case, identifying other ways to directly include parents in the campaign may have elicited different outcomes. This linkage is crucial because parents provide such an important foundation for children's eating habits and exercise behaviors.¹⁰ It is the coalition's goal to develop new ways to engage parents in the nutrition and physical activity education initiatives. It should also be noted that parents may not have been engaged because the children may not have brought the materials home to the parents;therefore, the parents may not have been given the opportunity to be engaged.

The length of the intervention was identified as another major limitation. Regrettably, it is common for nutrition and exercise interventions to have abbreviated measurement periods due to the time constraints of participants and intervention site and lack of sufficient funding. Furthermore, according to Stevens et al.,interventions are typically difficult to modify midstream, as changes in educational strategies during the intervention period do not occur even if problems are identified.¹¹ It was a goal of the multi-disciplinary team throughout this pilot intervention period to identify concerns to create a successful and sustainable intervention.

In spite of the aforementioned limitations, this pilot intervention is credited as having an overall positive impact on one school that voluntarily continued the communication campaign with the 3rd-5th grade students. Several months post-intervention, the teachers at this school reported that the children in grades 1 through 5 understood and could repeat the objectives of the communication campaign. In addition, teachers reported that an overall healthier culture had developed within the school, All of the schools involved in this project have continued to use the posters and have created other nutrition and exercise activities such as a nutrition week, walking club, and the continuation of a nutrition education after-school program.

Lessons Learned

The purpose of the 4:3:2:1 Healthy Kids communication campaign was to increase awareness and change the nutrition and exercise behaviors of 3rd-5th grade students. The results of this pilot intervention set the stage for planning a more comprehensive, longitudinal plan to impact childhood overweight in this population. The following are important lessons learned from this project:

• Because the parents are important gatekeepers to a child's eating and exercise behaviors, the parents need to be more involved in future communication campaigns in order to achieve significant results.
• Novelty in campaign messages can increase message retention, as was demonstrated with the significant positive behavior change regarding the two hours square screen time message.^12,13
• Layering nutrition and exercise messages and utilizing multiple communication channels such as posters, logs, and newsletters can dramatically increase message effects.¹⁴
• It is important when developing community nutrition and exercise education campaigns that community constituents such as school administrators and teachers are directly involved in development, implementation, and evaluation with external agencies and resources. These community constituents should work with public health researchers to form multi-disciplinary teams for conducting and evaluating interventions.

Conclusions

The creation of the 4:3:2:1 Healthy Kids communication campaign demonstrated success in creating a multi-disciplinary coalition that included both researchers and important community members. The intervention contributed to the development of a campaign to meet the needs of the community based on previous community assessments (i.e., BMI data and focus groups). The campaign itself was able to create significant behavior change regarding square screen time. Furthermore, post-intervention focus groups and evaluation of the campaign and after-school program initiatives gave the coalition the necessary guidance to refine the current campaign to meet the better address the needs of the community, increasing its chances for success. The greatest lesson learned from this effort is the importance of including community constituents when developing community nutrition and exercise education campaigns. Community involvement will continue to be a focal point with the continuation of a more comprehensive research project targeting child obesity. The next step of the program is to determine if an intervention longer than 10 weeks would result in more behavior change. It is also the hope of the researchers to expand the program to include more school districts and other intervention strategies.

Acknowledgments

The authors wish to recognize several individuals and groups without whom the completion of this project would not have been possible including Ruth Carnes, Director of Child Health Services in Portage County, Ohio; Valora Renicker, Glyphix Department at Kent State University; the participating school districts including school nurses, teacher and building administrators who partnered with us to plan, implement and evaluate this project; and the multiple graduate and undergraduate students in Nutrition, Physical Education and Health Education who helped in the data collection and entry.

References

1. Obesity Recommendations, 2005. Centers of Disease Control Web Site.. http://cdc.gov/nccdphp/ dphp/dnpa/obesity/recommendations.htm. Accessed June 12, 2005.
2. Healthy People 2010, 2000. U.S. Department of Health and Human Services Web Site. http:// www.healthpeople.com/Document/HTML/Vol1. Accessed November 1, 2006.
3. Centers for Disease Control and Prevention. National Center for Health Statistics. National Health and Nutrition Examination Survey Data. Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2003. http://www.cdc.gov/ nchs/nhanes.htm. Accessed June 26, 2005.
4. National Summit on Obesity: Building a plan to reduce obesity in America. American Medical Association, 2004. http://www.ama-assn.org/ama1/pub/upload/mm/433/exec_sum.pdf. Accessed December 14, 2005.
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8. Pate RR, Pratt M, Blair SN, et al. Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA. 1995;273:402–407
9. DiClemente CC, Prochaska JO. Processes and stages of change: Coping and competence in smoking behavior change. In Shiffman S, Wills TA, eds. Coping and Substance Abuse. New York: Academic Press; 1985.
10. Signorielli N, Staples J. Television and children's conceptions of nutrition. Health Communication. 1997;9:289-301.
11. Stevens J, Taber DR, Murray I, Ward DS. Advances and controversies in the design of obesity prevention trials. Obesity. 2007;25(9):2163-2170. 100
12. Murray-Johnson L, Witte K. Looking towards the future: Health Message Design Strategies. In Thompson T, Dorsey A, Miller K, Parrott R, eds. Handbook of health communication. Mahwah, NJ: Erlbaum; 2003:473-495.
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Appendix

1. Please circle the ONE answer that is closest to how you feel about exercise.
Read all 5 answers before picking one.

• When I am not in school I do not exercise.
• Sometimes I think that I should exercise more.
• I have decided to start exercising more and I am going to start trying.
• I already exercise sometimes when I am not in school.
• I exercise at least 3 times a week when I am not in school.

2. Please circle the ONE answer that is closest to how you feel about eating fruits and vegetables.
Read all 5 answers before picking one.

• I hardly ever eat a lot of fruits and vegetables
• Sometimes I think that I should eat more fruits and vegetables.
• I have decided that I should eat more fruits and vegetables and I am going to start trying.
• (have asked my parents to buy more??)
• I already eat a few fruits and vegetables each day.
• I eat fruits and vegetables more than 4 times a day.

3. Please circle the ONE answer that is closest to how you feel about eating dairy products like milk, cheese, and yogurt.
Read all 5 answers before picking one.

• I do not drink a lot of milk or eat other dairy products.
• Sometimes I think I should drink more milk and eat more dairy products.
• I have decided to drink more milk and I am going to start trying. (have asked my parents to buy more??)
• I drink milk and eat dairy products sometimes.
• I drink milk and/or eat dairy products at least 3 times a day.

4. Please circle the ONE answer that is closest to how you feel about watching TV, playing video games, and playing on the computer.
Read all 5 answers before picking one.

• When I am not in school I spend a lot of time watching TV, playing video games, or playing on the computer.
• Sometimes I think that I should not watch as much TV (play video games, or play on the computer).
• I have decided to spend less time watching TV, playing video games, and/or playing on the computer and I am going to start trying.
• I already pay attention to how much time I spend watching TV, playing video games and/ or playing on the computer.
• I don't spend more than 2 hours a day watching TV, playing video games, or playing on the computer.