promoting healthy eating and physical activity in school

The Journal of Middle East and North Africa Sciences 2015; 1(6) http://s-o-i.org/1.18/Jomenas.2015.6

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Promoting Healthy Eating and Physical Activity in School Age Children and

Adolescents in Jordan: Public Health Project

Affaf Attar

Community Health Nursing, Faculty of Nursing, Al-Zaytoonah University, Jordan

[email protected]

Abstract: This document present a public health project concerned with promotion of health and wellness

among school age children and adolescents in Jordan, the focus of this project will be the eating behaviors and

physical activity among this group. Poor diet and physical inactivity among younger persons can lead to an

increased risk for certain chronic health conditions, including high blood pressure, type 2 diabetes, and obesity. By

the utilization of the Omaha system model as an assessment approach for this important group of the population, two

major health-related behavior domains were identified. These domains are the nutritional status and the physical

activity among school age children and adolescent. The school is a vital and conducive environment to enhance and

support this group of population to promote the optimal health conditions using a variety of resources. The Omaha

system identifies the problem signs and symptoms, and blueprints the intervention scheme for each health related

issue which may include; surveillance, teaching, guiding, and counseling. A detailed comprehensive plan guided by

a MAP-IT approach is used as an interventional approach to promote healthy eating and physical activity among

school age children and adolescents in Jordan. Finally, the MAP-IT approach describes the step-by-step approach

through the identification of the mission and vision of the people and organizations involved, establishing a

community coalition of stakeholders, identifying the resources and limitations, setting action plan based on priorities

and feasibility, and then implement and evaluate the progress of the plan, the action plans regarding the nutrition and

physical activity is blueprinted hereunder.

[Attar, A. (2015). Promoting Healthy Eating and Physical Activity in School Age Children and Adolescents in

Jordan. J. Middle East North Afr. sci, 1(6), 15-30]. (p-ISSN 2412- 9763) - (e-ISSN 2412-8937).

http://www.jomenas.org. 5

Keywords: Healthy Eating – Public Health Project- Physical Activity.

1. Introduction

Health promotion has been defined as “All of

the individual and community – wide strategies that

include communication, education, legal regulations,

changes in service organizations and public

development to increase individual’s control over

their own health to improve their health” (Selekman,

2006).

Health promotion or wellness promotion

aimed to the reduction of health problems and

disease, as well as lead to the enhancement of mental

and physical wellbeing (Mcloughlin & Kubick,

2004). It seems that health promotion look beyond

the physical body, it considered the physical,

psychological and mental health as integral parts;

changes in one consequently will lead to changes in

the other (Peterson, 2006).

Healthy or unhealthy lifestyles are developed

early in life and thereafter are very difficult to

change. Adults who do not have healthy and

balanced lifestyles are not good role models for

children. For this reason it is very important for

children to be taught how to live healthy lives during

their formal schooling (Selekman, 2006).

Healthy eating and regular physical activity

play a substantial role in preventing chronic diseases,

including heart disease, cancer, and stroke, the three

leading causes of death among adults aged >18

years. Poor diet and physical inactivity among

younger persons can lead to an increased risk for

certain chronic health conditions, including high

blood pressure, type 2 diabetes, and obesity (The

Surgeon general's call to action to prevent and

decrease Overweight and obesity, 2001).

2. Rationale for Choosing the Project Idea

As of 2009, the majority of children and

adolescents aged 5–17 years were enrolled in

schools. Schools have direct contact with students

for approximately 6 hours each day and for up to 13

critical years of their social, psychological, physical,

and intellectual development.

The health of students is strongly linked to

their academic success, and the academic success of

students is strongly linked with their health.

http://s-o-i.org/1.18/Jomenas.2015.6

mailto:[email protected]

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Therefore, helping students stay healthy is a

fundamental part of the mission of schools

(Shephard, 1996). School health programs and

policies might be one of the most efficient means to

prevent or reduce risk behaviors, prevent serious

health problems among students, and help close the

educational achievement gap (Allensworth,

Nicholson, &Wyche, 1997).

Schools offer an ideal setting for delivering

health promotion strategies that provide

opportunities for students to learn about and practice

healthy behaviors. Schools, across all regional,

demographic, and income categories, share the

responsibility with families and communities to

provide students with healthy environments that

foster regular opportunities for healthy eating and

physical activity. Healthy eating and physical

activity also play a significant role in students’

academic performance.

3. Project Purpose The purpose of our project is to promote

healthy eating and physical activity in school age

children and adolescents in Jordan by utilization of

the Omaha system model as an assessment approach

for the schools’ competencies related to healthy

eating and physical activity in school age children

and adolescent in Jordan and by creating an

integrated comprehensive plan guided by a MAP-IT

approach as an interventional approach to promote

healthy eating and physical activity in school age

children and adolescents in Jordan.

4. Background

Engaging children and adolescents in healthy

eating and regular physical activity can lower their

risk for obesity and related chronic diseases

(Daniels, et al., 2005).The dietary and physical

activity behaviors of children and adolescents are

influenced by many sectors of society, including

families, communities, schools, child care settings,

health-care providers, faith-based institutions,

government agencies, the media, and the food and

beverage industries and entertainment industry. Each

of these sectors has an important, independent role to

play in improving the dietary and physical activity

(Daniels, et al., 2005).

The school is an important area for health

promotion and enhancing positive health behavior.

Kolbe (2005) noted that ‘‘not all school health

programs are effective. Importantly, programs that

are not specifically designed and organized to

achieve a given goal should not be expected to attain

that goal”. The modern school health programs could

be one of the most efficient means for improving the

health and achievements of our children.

4.1. Impact of Healthy Eating and Physical

Activity

Healthy eating and physical activity have

been associated with increased life expectancy,

increased quality of life, and reduced risk for many

chronic diseases. Healthy living through healthy

eating and regular physical activity reduces the risk

for the top three leading causes of death in the

United States (heart disease, cancer, and stroke), as

well as for certain chronic conditions, such as high

blood pressure and type 2 diabetes (Kushi, et al.,

2012).

A healthy diet and regular physical activity

can prevent and reduce metabolic risk factors that

cause CVD, including hyperlipidemia (e.g., high

cholesterol and triglyceride levels), high blood

pressure, obesity, and insulin resistance and glucose

intolerance. For example, dietary fiber can decrease

the cholesterol concentration in the blood, and

physical activity can help maintain normal blood

glucose levels (Thompson, et al., 2003).

Some types of cancer can be prevented

through regular physical activity and a diet

consisting of various healthy foods with an emphasis

on plant sources (e.g., fruits, vegetables, and whole

grains) (Kushi, et al., 2012). Physical activity might

contribute to cancer prevention through its role in

regulating the production of hormones, boosting the

immune system, and reducing insulin resistance.

Healthy eating and physical activity also can

contribute to cancer prevention by preventing

obesity. Overweight and obesity are associated with

increased risk for numerous types of cancer,

including cancer of the breast, colon, endometrial,

esophagus, kidney, pancreas, gall bladder, thyroid,

ovary, cervix, and prostate, as well as multiple

myeloma and Hodgkin’s lymphoma (Kushi, et al.,

2006)

Poor diet and physical inactivity are risk

factors for numerous conditions that affect overall

health and quality of life, and many of these

conditions can lead to chronic diseases. Intermediate

outcomes such as obesity, metabolic syndrome, and

inadequate bone health, under nutrition, iron

deficiency, eating disorders, and dental caries can

begin in childhood, leading to earlier onset of disease

and subsequent premature death. Healthy eating and

physical activity control body weight through a

balance of energy expenditure and caloric consump-

tion. Weight gain occurs when persons expend less

energy through physical activity than they consume

through their diet. As this imbalance continues over

time, the risk for overweight and obesity increases

(Kopla, Liverman & Kraak, 2005).

Overweight is defined as having excess body

weight for a particular height from fat, muscle, bone,



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water, or a combination of these factors. Obesity is

the condition of excess body fat. Obesity in children

and adolescents is associated with numerous

immediate health risks, including high blood pres-

sure, high blood cholesterol levels, type 2 diabetes,

metabolic syndrome, sleep disturbances, orthopedic

problems, and social and psychological problems,

such as discrimination and poor self-esteem (Krebs,

et al., 2007).

These immediate health risks can have long-

term consequences for children and adolescents,

affecting them into adulthood. Insufficient public

health and education efforts to decrease or minimize

these health risks will affect both health-care and

education systems. Increasing rates of obesity among

children and adolescents are of particular concern

because those who are obese are more likely to

become overweight or obese adults and have related

chronic diseases. The probability of childhood

obesity persisting into adulthood increases as

children enter adolescence. Even obesity during

early childhood (ages 2–5 years) increases the risk

for adult obesity (Benjamin, 2010).

4.2. Factors Influencing the Eating Behaviors

among Children and Adolescent

Multiple factors including demographic,

personal, and environmental factors influence the

eating behaviors of children and adolescents. Male

adolescents report greater consumption of fruits and

vegetables and higher daily intakes of calcium, dairy

servings, and milk servings than females. Black

adolescents are more likely than white or Hispanic

adolescents to report eating fruits and vegetables five

or more times per day (Eaton, et al., 2010).

Children and adolescents from low-income

households are less likely to eat whole grain foods.

Taste preferences of children and adolescents are a

strong predictor of their food intake. Taste

preference for milk, among both males and females,

is associated with calcium intake (Zabinski, et al.,

2006).

Taste preferences for fruits and vegetables

are one of the strongest reported correlates of fruit

and vegetable intake among males and females.

Male and female adolescents who reported frequent

fast-food restaurant visits (three or more visits in the

past week) were more likely to report that healthy

foods tasted bad, that they did not have time to eat

healthy foods, and that they cared little about healthy

eating (Zabinski, et al., 2006).

The home environment and parental

influence are strongly correlated with youth eating

behaviors. Home availability of healthy foods is one

of the strongest correlates of fruit, vegetable, and

calcium and dairy intakes. Family meal patterns,

healthy household eating rules, and healthy lifestyles

of parents influence fruit, vegetable, calcium and

dairy, and dietary fat intake of adolescents

(Neumark-Sztainer, Wall, Perry, & Story, 2003).

4.3. Factors Influencing the Physical Activity

among Children and Adolescent

Physical activity is defined as “any bodily

movement produced by the contraction of skeletal

muscle that increases energy expenditure above a

basal level”. Examples of physical activity include

walking, running, bicycling, swimming, jumping

rope, active games, resistance exercises, and

household chores.

Regular participation in physical activity

among children and adolescents is related to

demographic, personal, social, and environmental

factors. Gender is correlated with physical activity

levels, with males participating in more overall

physical activity than females. This trend continues

through adulthood, with females remaining less

physically active than males.

Adolescent males also report a greater

intention to be physically active in the future than

females. Children and adolescents who intend to be

active in the future and who believe physical activity

is important for a healthy lifestyle engage in more

activity. Overall, personal fulfillment influences the

motivation both of boys and girls to be physically

active (Trends in leisure-time physical inactivity by

age, sex, and race/ethnicity--United States, 1994-

2004, 2005).

Dowda, Dishman, Pfeiffer & Pate (2007),

defined the parent and family support for physical

activity can as a child’s perception of support (e.g.,

perceiving parents will do physical activity with

them and sign them up for sports or other physical

activities) to a parent’s reported support (e.g., regular

encouragement of physical activity or regularly

placing value on being active).

Youth perceptions and parent reports of

support for physical activity are strongly associated

with participation in both structured and non-

structured physical activity among children and

adolescents (Dowda, Dishman, Pfeiffer & Pate,

2007).

The physical environment can be both a

benefit and a barrier to being physically active.

Environmental factors that might pose a barrier to

physical activity include low availability of safe

locations to be active, perceived lack of access to

physical activity equipment, cost of physical

activities, and time constraints. The school

environment can also influence the participation of

children and adolescents in physical activity (Motl,

Dishman, Saunders, Dowda, & Pate, 2007).



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4.4. Impact of Television Viewing on the Eating

and Physical Behaviors among Children and

Adolescents

Television viewing, non-active computer use,

and non-active video are all considered sedentary

behaviors. Television viewing among children and

adolescents, in particular, has been shown to be

associated with childhood and adult obesity

(Hancox, Milne & Poulton, 2004). Potential

mechanisms through which television viewing might

lead to childhood obesity include: Lower resting

energy expenditure, displacement of physical

activity, food advertising that influences greater

energy intake, and excess eating while viewing

(Epstein, Roemmich & Robinson, 2008).

The American Academy of Pediatrics (2001)

recommends no more than 2 hours of television and

video viewing per day for children aged ≥2 years.

Overall, persons aged 8–18 years spend an average

of 7 hours and 11 minutes per day watching

television, using a computer, and playing video

games. In 2009, 33% of 9th- through 12th-grade

students reported watching ≥3 hours of television on

an average school day, and 25% reported using a

computer ≥3 hours on an average school day (Center

for Disease Control, 2010).

4.5. School Health in Jordan

In Jordan the Global School-based Student

Health Survey (GSHS), (2007) has been used to

periodically monitor the prevalence of important

health-risk behaviors and protective factors related to

the leading causes of mortality and morbidity among

students aged 13-15 years; dietary behaviors,

hygiene, mental health, physical activity, protective

factors, sexual behaviors that contribute to HIV

infection, tobacco use, and violence and

unintentional injuries.

A representative sample of students in 8th

through 10th grades was selected from 25 schools;

seventy classrooms were randomly selected intact

from each school to participate. The sample of

students eligible to participate was 2243 students.

The results regarding physical activity was 14.3% of

students were physically active for a total of at least

60 minutes daily for 7 days, while 83.5% of students

participated in insufficient physical activity, on the

other hand 39.3% of students spent three or more

hours per day doing sitting activities, and 76.6% of

students usually took less than 30 minutes to get to

and from school each day.

5. Application of the Omaha System Theory

5.1. Rationale for Using Omaha System Theory

Omaha system theory is a research-based,

comprehensive, standardized taxonomy that exists in

the public domain. It is designed to enhance practice,

documentation, and information management. It is

intended for use across the continuum of care for

individuals, families, and communities who

represent all ages, geographic locations, medical

diagnoses, socio-economic ranges, spiritual beliefs,

ethnicity, and cultural values. We decided to use this

theory because it has terms that are arranged in a

hierarchy (i.e. from general to specific), and are

intended to be easily understood by health care

professionals and the general public. It provides a

structure to document children and adolescents needs

and strengths, describe multidisciplinary practitioner

interventions, and measure children and adolescent

outcomes in a simple and user-friendly, yet

comprehensive, manner. Furthermore, it enables

collection, aggregation, and analysis of clinical data.

It supports quality improvement, critical thinking,

and communication. It fosters research involving

best practices/evidence-based practice. It links

clinical data to demographic, financial,

administrative, and staffing data.

5.2. First Domain: Health Related Behavior

Problem: Nutrition:

Problem signs and symptoms:

1) Overweight: BMI 25.0 or more.

2) Underweight: BMI 18.5 or less.

3) Lacks established standards for daily caloric/fluid

intake.

4) Exceeds established standards for daily

caloric/fluid intake.

5) Unbalanced diet.

6) Improper feeding schedule for age.

7) Does not follow recommended nutrition plan.

8) Unexplained/progressive weight loss.

9) Unable to obtain/prepare food.

10) Hypoglycemia/hyperglycemia.

Intervention Scheme

The following table will illustrate the general

guide line that will be established in Promoting

healthy Eating in School Age Children and

Adolescents in Jordan according to Omaha system

theory (see Appendix A).

Based on the Omaha system care plan above,

we will screen the school age children and

adolescent for healthy eating and obesity using the

following surveillance technique: measuring body

mass index, measuring waist circumference,

assessing risk factors in children and adolescent,

assessing life style (dietary recall& eating habit), and

assess the readiness to change. Body mass index can

be calculated by dividing the weight on the square

tall in meter and compare it to the normal range

which lies between18.5 – 24.9. Assessing the waist



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circumference is a good way in assessing abdominal

fat among children and adolescent and this will help

us to know the level of risk for disease onset.

Assessing life style risk factors may include

assessing tobacco use, cholesterol level, physical

inactivity, and impaired fasting glucose (110-

125mg/dl). The desire of the children and adolescent

to change will be assessed by asking them the

following question: does he\she want to lose weight?

What are the reasons and motivation for weight loss?

and did he\she has any previous attempt to lose

weight?

As we know the Omaha system theory has

teaching, guiding, and counseling category beside

the surveillance category. During our assessment

process, we can provide teaching and counseling

about the weight loss benefits versus obesity risks

for children and adolescents. In addition, we can

provide them a recommendation for a healthy weight

loss and recommendation for physical activity level.

Because we established the Omaha system as an

assessment tool, we will illustrate more about the

teaching and guiding interventions using the MAP-

IT theory as an interventional tool in the intervention

part.

5.3. Second Domain: Health Related Behavior

Problem: Physical activity Problem signs and symptoms:

1) Sedentary life style

2) Inadequate/inconsistent exercise routine

3) Inappropriate type /amount of exercise for age/

physical condition.

4) No scheduled physical activities.

Intervention Scheme The following table will illustrate the general

guide line that will be established in promoting

physical activity in school age children and

adolescents in Jordan according to Omaha system

theory (See Appendix B).

Based on the Omaha system care plan above,

we will screen the school age children and

adolescent for adequacy and appropriateness of

physical activity using the following surveillance

technique: assessing life risk factors, assessing the

daily life routine exercise, and assessing attitudes

toward physical activity.

Many technological advances and

conveniences that have made our lives easier and

less active, many personal variables, including

physiological, behavioral, and psychological factors,

may affect our plans to become more physically

active. In fact, there are many reasons for not

adopting more physically active lifestyles as Don’t

have enough time to exercise, lack of self-

motivation, finding exercise boring, low self-

efficacy, fear of being injured, and lack of

encouragement and support from family and friends.

Understanding common barriers to physical activity

and creating strategies to overcome them may help

in making physical activity part of children and

adolescent daily life. These recommendations will be

addressed in the interventional guideline by utilizing

the MAP-IT model.

6. Mobilize, Assess, Plan, Implement, Track

(MAP-IT)

MAP-IT is a framework that can be used to

plan and evaluate public health interventions in a

community. Both seasoned and new public health

professionals can utilize the steps in MAP-IT to

create a healthy community. This process involves

time, effort, and a series of steps to ‘map out’ the

path toward the desired change in a community.

Keep in mind that there is no “right” way to follow

this approach, and some of the steps will need to be

taken multiple times. Using MAP-IT, a step-by-step,

structured plan can be developed by a coalition that

is tailored to a specific community’s needs

(Community Tool Box, 2013)

In this project we will utilize the MAP-IT

model to make tomorrow's generations healthier and

active and so for the whole community. The project

will address two major health risk-related behaviors;

the physical inactivity and poor nutrition. The

following steps will be followed as an interventional

approach to implement the MAP-IT model.

6.1. Step I: Mobilize Individuals and

Organizations That Care about the Health of

your Community into A coalition.

6.1.1. Building Community Coalition

The first step in the MAP-IT process is to

mobilize key individuals and organizations into a

coalition. Look for partners who have a stake in

creating healthy communities, and who will

contribute to the process. Aim for broad

representation. A coalition will often work with the

health department and other health organizations in

the community. However, it can also help mobilize a

wider range of resources to address health issues

(Community Tool Box, 2013).

It is typically easier to engage potential

coalition members around issues that are already of

special concern to the community, who are involved

and have direct or indirect impact in providing

varied sources of support to bring up the

governmental concern on the issue of healthy eating

and physical activity among school age children

(Community Tool Box, 2013).



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Coalition members can help facilitate

community input through meetings, events, or

advisory groups. They can also develop and present

education and training programs, lead fundraising

and policy initiatives, and provide technical

assistance in planning or evaluation.

The members of our project include:

1) Education representatives: Teachers,

administrators

2) Medical representatives: Medical pediatrics

associations, Child health physicians and nurses.

3) National organization: National Council of Family

Affairs.

4) Children and parents representatives

5) Social activist representatives

6) Media representatives

7) University academics

8) Business representatives

9) Governmental sectors

10) International organization: WHO, UNICEF,

USAID

At this stage, plan to identify the vision and

mission of the coalition, reason for bringing people

together, individuals who should be represented are

potential partners in the community, such as

organizations and businesses. One of the biggest

challenges in creating a healthy community coalition

is to sustain members’ involvement in the process.

This challenge can be overcome in part by agreeing

as early as possible on a vision for the community.

6.1.2. School Health Programs to Promote Healthy

Eating and Physical Activity (CDC, 2011)

Schools have direct contact with students for

approximately 6 hours each day and for up to 12

years of their social, psychological, physical, and

intellectual development. The health of students is

strongly linked to their academic success, and the

academic success of students is strongly linked with

their health. Therefore, helping students stay healthy

is a fundamental part of the mission of schools.

School health programs and policies might be

one of the most efficient means to prevent or reduce

risk behaviors, prevent serious health problems

among students, share the responsibility with

families and communities to provide students with

healthy environments that foster regular oppor-

tunities for healthy eating and physical activity.

Healthy eating and physical activity also play a

significant role in students’ academic performance.

6.1.3. Coalition Vision

Promoting healthy eating and physical activity

among school-age children and adolescents should

be considered a part of routine preventive public

health care, therefore school health programs would

be a good start for this initiatives. Assessment and

counseling for health eating and physical activity

also should be included in a comprehensive

preventive services package for school-age children

and adolescents. We are looking forward to establish

a health community through the emphasizing on

health eating and physical activity among our

tomorrow's leaders.

6.1.4. Coalition Mission

Our mission is to help prevent obesity and

promote physical activity and healthy eating through

school health programs' policies, practices, and

supportive environments. This mission of promoting

healthy eating and physical activity, including

coordination of school policies and practices,

supportive environments, school nutrition services;

physical education and physical activity programs,

health education, and social services ,and family and

community involvement.

6.1.5. Agenda Setting

The public issue of concern to the coalition is

the health of children and adolescent, the importance

of this issue is affecting the whole health care system

in general and the school health in specific. This

issue should gain the attention of policymakers for

addressing it as policy problem, the coalition

members will meet together to identify their

prioritization, goals and values, refine the issue.

The issue definition and mobilization of

support from community members and media

involvement, and full participation of coalition

members and concerned organizations facilitate the

move of the child and adolescent health issue to the

governmental policy agenda.

6.2. Step II: Assess the Areas of Greatest Need in

the Community, as well as the Resources and

Other Strengths.

The coalition should set priorities by

identifying what community members and key

stakeholders see as the most important issues.

Consider feasibility, effectiveness, and measurability

in determining priorities (Community Tool Box,

2013).

6.2.1. Setting Priorities

Setting priorities is a matter of consensus; all

coalition members should agree on which issues

need to be addressed immediately and which can be

postponed to until a later date.

6.2.2. Community and Need Assessment

Successful obesity prevention programs

address the needs and wants of the community. The



21

best way to find out what a community needs and

what it wants is to conduct a community assessment

by following the community assessment process

which include; defining the target community

(School-age children and Adolescent), gathering

information and summarizing and reporting (Move

to the Future, 2013).

Data collection and evaluation about the

health issues of healthy eating and physical activity

in the community is important to identify and

analyze the nature of the problem, and this will form

a baseline of the problem and help in making

decisions on the needed interventions.

When no data are available, the coalition may

need to begin collecting data to form a realistic

picture of community needs. The information about

health eating and physical activity can be gathered

using a worksheet that contains the most common

indicators related to this issue, for example; fruit and

vegetables intake, fat intake, fiber intake, calcium

intake, physical activity (minutes per day), TV

viewing, dental caries, low hemoglobin.

Many resources are available in Jordan about

the children and adolescent health indicators;

international organization (WHO, UNICEF), Jordan

department of statistics, ministry of health, ministry

of education, Jordan food and drug administration

and universities and research centers.

6.2.3. Community Resources and Strengths

Once community assessment is completed,

develop a list of strengths and resources within that

community. Resources go beyond financial

resources, every community has a wealth of non-

monetary resources that can be used to address areas

of concern, the resources available in Jordan to

support the program of healthy eating and physical

activity includes the availability of infrastructure,

such as schools, playing yards, parks, sport clubs,

health system, professional expertise, data,

community-based organizations as the National

Council of Family Affairs, and community leaders

(Appendix 1) (Move to the future, 2013).

International organization such as WHO,

UNICEF, and USAID provide adequate support to

the children health programs in many different ways,

experts’ opinions, surveys, policymaking and

organizing implementation.

6.3. Step III: Plan Your Approach

During the planning phase, start with a vision

of where you want to be as a community, then add

strategies and action steps to help you achieve that

vision. Objectives should be specific to each issue or

community, and should address the goal of the

program, what is needed in order to reach the goal,

and a way of measuring progress in order to know

when the goal has been reached. A plan of action

should include: Action steps, assignment of

responsibility, information collection, and a feasible

timeline.

Our action plan to work on the promotion of

health eating and physical activity contains the

following goals, objectives and action steps, for that

a specific template will be used to address this action

plan (CDC, 2011; Community Tool Box, 3013).

6.4. Step IV: Implement Your Plan Using

Concrete Action Steps

Once the action plan is established, coalition

members can begin to implement the action steps

identified in the plan. Coalition members should

work on completing the tasks that have been

assigned to them according to the set timeframe.

Monitoring of events is key to implementation. The

phase of implementation requires attention to

develop a budget, carry out the interventions/actions

and managing the plan timelines.

6.4.1. Develop a budget

To do anything with your plan you need

money. And to get money you need a budget. Grants

require a budget, sponsoring organizations require a

budget, and donors like to know how much the

project will cost before they make a contribution,

which you know from doing a budget. A budget is an

estimate of the money you will receive and the costs

you will incur to implement your program. It is your

best guess at the time you develop the budget but

should be as accurate as possible. A budget should

cover a specific time period such as 9 months, 12

months, or 18 months.

6.5. Step V: Track Your Progress over Time.

Evaluation is the process of collecting data to

determine how well your program is succeeding and

whether changes need to be made. Evaluation data

might be collected during implementation, in which

case the collection process is often called

monitoring. Monitoring is useful to identify

problems so that a program can be improved in mid-

course (Move to the Future, 2013).

Conversely, comprehensive evaluations are

typically done at the conclusion of a program, or at

the conclusion of distinct phases of a program. In

addition to your own desire to create the most

effective program possible, another strong incentive

for evaluating is that many funders require well-

conducted evaluations. Although it is true that much

of your evaluation may be carried out after your

program is completed, do not wait until the

program's completion to plan your evaluation.



22

Successful evaluation is best planned at the same

time you are planning your programs interventions

therefore, evaluation planning should be an integral

part of your program planning (Community Tool

Box, 2013).

Conduct regular evaluations to measure and

track your progress over time. Tracking is a two-part

step that involves analyzing the data and reporting

on progress. Make sure to note to what extent the

plan was followed, any changes that were made, and

whether the goal was reached. The following points

should be considered at time of evaluation:

1) Evaluation and tracking are vital to the long-term

success of the coalition’s efforts.

2) Consider partnering with a local university or

State center for health statistics to help with data

tracking.

3) Data validity and reliability: Watch out for

revisions of survey questions and/or the development

of new data collection systems. This could affect the

validity of your responses over time.

4) Data Availability: Data collection efforts are not

always performed on a regular basis.

5) Documenting the progress and success

6) Remember to share your progress and successes

with your community. If you see a positive trend in

data, issue a press release or announcement.

7) make sure to involve the media so that you’ll be

able to put the word out when you need to.

8) Data Quality: make sure to check for

standardization of data collection, analysis, and

structure of questions.

7. Potential Limitations

The financial support is considered as one of

the most potential problem for the implementation

process since it is required in every step of our plan.

In addition, the weak infrastructure of some schools

could delay or limit the process of implementation.

Furthermore, the absence of school nurse specialty in

our educational system could create a gap in the

professional team that should guide the process of

change in school children and adolescents.

Overcoming the resistance from the students,

families, and teacher is a key factor to succeed in the

implementation of the project.

8. Conclusion Studies showed during the last decades, the

prevalence of obesity has tripled among persons

aged 5-18 years. Multiple chronic disease risk

factors, such as high blood pressure, high cholesterol

levels, and high blood glucose levels are related to

obesity. Schools have a responsibility to help prevent

obesity and promote physical activity and healthy

eating through policies, practices, and supportive

environments.

The promotion of health in the community is

starting from the individuals, families, groups and

society, the school age children and adolescents are a

vital population for the community, maintaining and

promoting them healthy will result in a healthy

community even if later.

The implementation of public health nursing

concepts into the actual community by utilizing the

models as Omaha model and MAP-IT approach to

assess, plan, intervene and evaluate will enable the

public health professional with the necessary tools.

To get a success, the implementation of these

approaches requires the correct identification of

health-related problems, intervention schemes,

mobilize the coalition, set agenda, move the issue to

the governmental table, involve the media, and

parliament members to gain support.

Finally, the studies in Jordan is limited in this

public health issue; the healthy eating and physical

activity, initial research reported the physical

inactivity among school age children, the health

professionals are invited to investigate more in this

issues and establish a national guidelines to promote

the health and wellness for this population.

Corresponding Author: Affaf Attar

Community Health Nursing, Faculty of Nursing, Al-

Zaytoonah University, Jordan

E-mail: [email protected]

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24

Appendix A. Intervention Scheme

Intervention Scheme

Category Target Care description

Surveillance Physical Sign/Symptom Assess BMI

Surveillance Physical Sign/Symptom Waist Circumference

Surveillance Physical Sign/Symptom Assess for risk factors: co-

morbidities

Surveillance Dietary Management Lifestyle – dietary recall

Surveillance Wellness Assess lifestyle risk

factors

Surveillance Behavior Modification Assess Motivation for change

Teaching, Guiding, &

Counseling

Behavior Modification

Weight loss benefits Versus risks


Counseling

Dietary management

Recommendations for

Healthy Weight Loss


Counseling

Behavior Modification

Attitudes toward physical activity

Appendix B. Intervention Scheme

Intervention Scheme

Category Target Care description

Surveillance Physical Signs / symptoms Assess life risk factors

Surveillance

Physical Signs / symptoms Assess the daily life routine exercise

Surveillance

Physical Signs / symptoms Assessing attitudes toward physical

activity

Teaching, Guiding, and Counseling Exercise Recommendation for exercise

Teaching, Guiding, and Counseling Wellness Life style activities

Teaching, Guiding, and Counseling Behavioral modification Behavior Therapy Combined with

Dietary Adjustments And Routine

Physical Activity

Teaching, Guiding, and Counseling Support system Adequate Support Systems Help

Improve Weight Loss Outcomes



25

Appendix C. Action Plan of Promoting Healthy Eating and Physical Activity among

Children and Adolescents

Goal 1: Establish a coordinated approach to develop, implement, and evaluate healthy eating and physical activity

policies and practices.

Objective 1.1: Establish a school health council at each city in Jordan

Action steps Due date Responsibility

Resources

needed

Communicate with representatives from different segments of the

school and community, including health and physical education

teachers, nutrition service staff members, students, families, school

nurses, social service professionals, and religious and civic leaders to

form School health councils

Jan.2015 Program

director

Define the functions and responsibilities of School health council Jan. 2015 Program

director

Objective 1.2: Establish a school health team and designate a school health coordinator at the school level


Resources

needed

Each school should establish a school health team, representative of

school and community groups, to work with the greater school

community to identify and address the health needs of students.

Jan. 2015 School

director

Identify the responsibility of school health team Jan. 2015 School

director

Objective 1.3: Develop and implement healthy eating and physical activity policies


Resources

needed

Identify and involve key stakeholders from the beginning of the policy

process.

Jan. 2015 Program

director



26

Draft the policy language Jan. 2015 Program

director

Adopt, implement, and monitor healthy eating and physical activity

policies.

Jan. 2015 Program

director

Conduct outcome evaluation of healthy eating and physical activity

policies, programs, and practices.

Jan. 2015 Program

director

Goal 2: Establish school environments that support healthy eating and physical activity

Objective 2.1: Provide access to healthy foods and physical activity opportunities and to safe

spaces, facilities, and equipment for healthy eating and physical activity.


Resources

needed

Provide adequate and safe spaces and facilities for healthy eating,

establish a place with chairs and tables

2015 School

director

Ensuring sufficient time to receive and consume a meal for eating

breakfast and lunch.

2015 School

director

Providing opportunities for students to wash or sanitize their hands in

a convenient place before eating;

2015 School

director

Schools also should ensure that students have access to safe, free, and

well-maintained drinking water fountains or dispensers during school

meals

2015 School

director

Ensure that spaces and facilities for physical activity meet or exceed

recommended safety standards

2015 School

director

Develop, teach, implement, and enforce safety rules 2015 School

director

Maintain high levels of supervision during structured and unstructured 2015 School



27

physical activity programs. director

Increase community access to school physical activity facilities. 2015 School

director

Objective 2.2: Ensure that all foods and beverages sold or served at school are nutritious


Resources

needed

Implement nutrition standards can be an effective strategy to improve

the nutritional quality of foods offered and purchased in the school

setting

2015 School

director

Market healthier foods and beverages. 2015 School

director

Offer a free fruit and vegetable program 2015 School

director

Train students grow vegetables in a school garden 2015 School

director

Collect suggestions from students and families for meals and snack

items that might be offered

2015 School

director

Goal 3: Implement a comprehensive physical activity program with quality physical education as the cornerstone

Objective 3.1: Provide ample opportunities for all students to engage in physical activity outside

of physical education class


Resources

needed

The school setting can offer multiple opportunities for students to

enjoy physical activity outside of physical education class and increase

daily amounts of physical activity

2015 School

director

Offer students opportunities to participate in intramural physical

activity programs during after-school hours.

2015 School

director



28

Implement and promote walk- and bicycle-to-school programs. 2015 School

director

Objective 3.2: Ensure that physical education and other physical activity programs meet the

needs and interests of all students


Resources

needed

Promote and ensure inclusion of all students 2015 School health

Nurse (S.H.N)

All students, regardless of sex, race/ethnicity, health status, or physical

or cognitive ability or disability, should have access to physical

education and other physical programs.

2015 S.H.N

Goal 4: Implement health education that provides students with the knowledge, attitudes, skills, and experiences

needed for healthy eating and physical activity

Objective 4.1: Establish health education from kindergarten through grade 12


Resources

needed

Nutrition and physical activity topics also can be integrated into other

academic disciplines to complement comprehensive health education

and physical education programs

2015 School Health

Nurse (S.H.N)

Integration of health topics throughout the school curriculum should

not replace health education as a course in school; a comprehensive

health education curriculum is necessary

2015 S.H.N

Objective 4.2: Use classroom instructional methods and strategies that are interactive, engage all

students, and are relevant to their daily lives and experiences


Resources

needed



29

Use interactive learning strategies. 2015 School

Teachers &

S.H.N

Use methods and strategies that are developmentally appropriate. 2015 School

Teachers &

SHN

Integrate computer-based instruction into health education. 2015 School

Teachers &

SHN

Goal 5: Provide students with health, mental health, and social services to address healthy eating,

physical activity, and related chronic disease prevention

Objective 5.1: Assess student needs related to physical activity, nutrition, and obesity, and provide counseling and

other services to meet those needs.


Resources

needed

Assess eating and physical activity behaviors of students. 2015 School

Teachers &

SHN

Schools initiating BMI measurement programs should implement

safeguards.

2015 School

Teachers &

S.H.N

Counsel students on how to achieve healthy eating and physical

activity recommendations.

2015 School

Teachers &

S.H.N

Goal 6: Partner with families and community members in the development and implementation of healthy eating

and physical activity policies, practices, and programs.

Objective 6.1: Encourage communication among schools, families, and community members to



30

promote adoption of healthy eating and physical activity behaviors among students.


Resources

needed

Communicate frequently and use various dissemination methods. 2015 School Health

Nurse

Objective 6.2: Involve families and community members on the school health council

The school health council (SHC) should identify strategies for

establishing partnerships with families and community members.

2015 S.H.C

Objective 6.3: Develop and implement strategies for motivating families to participate in school-

based programs and activities that promote healthy eating and physical activity.

Provide various formats for involving families and offer frequent

opportunities for participation.

2015 S.H.C, S.H.N

Recruit parent, family, and community volunteers to assist with

healthy eating and physical activity initiatives.

2015 SHC, SHN

Appendix D. Community Assessment Sheet

Received November 23, 2015; revised November 30, 2015; accepted December 5, 2015; published online December

16, 2015.


promoting healthy eating and physical activity in school

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