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Brittany KaczmarekPH1113

EXAM ONE: NEEDS ASSESMENT

Introduction

Obesity has become one of the greatest epidemics of this generation. Where once

infectious disease used to be the top public health concern, chronic disease has taken its place.

Obesity has played a major role in this shift, leading to greater risks for other chronic diseases

later in life. One of the most concerning aspects of the growth of obesity across the nation is the

increase in childhood obesity (CO). The World Health Organization (WHO) has classified CO as

one of the top global public health concerns of the 21st century (Langley-Evans & Moran, 2014).

Focusing on improving the health of children and adolescents who are obese should be a priority

for preventing future morbidity and premature mortality. In the following sections, determinants

putting school-age (SA) youth living in a low-income community of Houston, TX at greater risk

for CO will be identified and, from this information, methods will be developed to prevent and

reduce this health problem in this population.

Question 1A: Development of Planning Group

Establishing a planning group that will provide a variety of expertise in addressing the

health problem is essential to implementing an effective intervention. The planning group will

include developers, implementers and participants of the intervention. Involving the participants

in the planning group is important to gain the perspective of those who will actually be receiving

the intervention. SA youth involved will be classified as obese and non-obese, so youth from

both classifications can give personal insight to the intervention. Parents of obese and non-obese

SA youth will also be included in the planning group. Parent involvement promotes discussion

about differences in home life and lifestyle behaviors between the children.

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As implementers of the intervention, school representatives will be included in the

planning group. School administrators, principals, nurses, teachers, coaches and counselors of

the Houston Independent School District (HISD) are an important addition to the planning group.

Involving implementers will give sufficient insight to what is being done in the organization

currently and what can be improved to better the health problem. Representatives from local and

national organizations will also be involved in the planning group for the intervention.

Employees from The City of Houston Health and Human Services, commonly involved in the

fight against CO, will represent leaders in policy and health promotion programs in the Houston

area. Representatives from The Academy of Nutrition and Dietetics and The Academy of

Pediatrics will also contribute to the planning group, in which policy and common practices of

addressing CO will be the focus. As developers of the intervention, professionals from academia

and the health field will be essential in providing expertise in prevention and reduction of CO.

Such professionals include researchers from the University of Texas School of Public Health in

Houston as well as pediatricians, dietitians, nurses, and health educators from a local UTHealth

weight management clinic.

Each member of the planning group will have a specific role in the intervention. For

example, the health care workers will be involved in defining CO and the health risks associated

with the health problem. The participants, on the other hand, will be involved in identifying the

importance of quality of life factors due to CO. However, it is essential to have a cohesive

planning group rather than individual members with their own responsibilities. Every member

will be involved in each aspect of the intervention, in order for the planning group to work as an

interdisciplinary team.

Question 1B: Priority Population and Intervention Setting

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In the last 40 years, obesity rates among children and adolescents have tripled resulting in

approximately 13 million obese youth in the United States today (National Conference of State

Legislatures [NCSL], 2015). In Texas alone, the state prevalence of CO was approximately 19%

from 2003 to 2011 (NCSL, 2015). In 2011 to 2012, approximately 18% of 6 through 11-year

olds and 21% of 19-years olds were classified as obese (CDC, 2015a). These high percentages of

obesity in youth were found within the ages of 5 through 18. Therefore, this intervention will

focus on youth in this age group, referred to as SA youth.

Obesity not only affects more youth every year, but is an even greater threat to specific

populations within SA youth. Minority youth, especially African American and Hispanic

populations, have been found to have a greater occurrence of CO. The National Health and

Nutrition Examination Survey (NHANES) found the prevalence of obesity was higher in non-

Hispanic black and Mexican-American youth as compared to non-Hispanic white youth (Ogden,

Carroll, Curtin, McDowell, Tabak, & Flegal, 2006). These findings were reinforced by the

Centers for Disease Control and Prevention (CDC) (2015a), in which a study from 2011 to 2012

found the prevalence of obesity among children and adolescents was 22.4% for Hispanics, 20.2%

for non-Hispanic blacks and 14.1% for non-Hispanic whites. With such a difference in obesity

prevalence evident between ethnicities, the minority populations of Hispanics and non-Hispanic

blacks will be additional criteria for the priority population.

The final criteria for the priority population will be low-socioeconomic status. The CDC

(2015a) has reported greater CO prevalence among households with an income at or below the

poverty threshold. Research shows as income status decreases, CO rates increase (CDC, 2015a).

Therefore, the priority population will encompass SA youth who come from a low-income

family. This criterion for the priority population helped determine the setting for where the

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intervention will take place. An urban low-income community of Houston, TX, known as the

Greater Third Ward, is where the intervention will be implemented.

Within the community of the Greater Third Ward, the public schools run by HISD will be

the ultimate setting for the intervention implementation. SA youth spend a lot of time in the

school setting, approximately 1,260 hours in a school year (Desilver, 2014). This amount of time

spent in one setting creates an environment that can make a substantial impact on SA youth.

With this in mind, the three public HISD primary and secondary schools located in the Greater

Third Ward community will serve as the setting for the intervention.

Question 2:

Health Problem: Entry to PRECEDE Model

This intervention will be entering the PRECEDE Logic Model of Risk at the health

problem, which is identified as CO. CO is formally defined by using a youth’s Body Mass Index

(BMI) percentile based on age and gender. Unlike the measurement of obesity in adults,

assessing obesity in a child requires evaluating the measured BMI percentile on a growth chart

developed by the CDC. If a child is at or above the 95th percentile, then the child can be

classified as obese (CDC, 2015d). Many factors are involved in the growing prevalence rates of

CO. Some factors of CO are unchangeable by interventions, such as genetics and socioeconomic

status, while lifestyle and environmental factors can be modified to improve the health problem.

There are both short- and long-term effects of CO. In the short-term, obese youth are at

increased risk for health problems such as high blood pressure, high cholesterol, insulin

resistance and joint issues (Freedman, Mei, Srinivasan, Berenson, & Dietz, 2007; Whitlock,

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Williams, Gold, Smith , & Shipman, 2005; Han, Lawlor, Kimm, 2010). Breathing difficulties,

such as sleep apnea and asthma, have also been found to occur more often in obese youth (Han et

al., 2010; Sutherland, 2008). The health problems associated with obesity are not just physical

but mental and emotional as well. Obese youth are found to have higher rates of depression,

occurrence of behavioral difficulties and trouble in school (CDC, 2015b). The long-term effects

of CO further disrupt the quality of life of the youth in adulthood with increased risk for

morbidity and mortality. Obesity increases risk of chronic diseases including cardiovascular

disease (CVD), type 2 diabetes mellitus (T2DM), stroke, hypertension and types of cancers

(NCSL, 2015). If progressed further, obese youth are at greater risk for premature mortality. The

World Health Organization (WHO) (n.d.) reports approximately 2.6 million individuals die every

year due to being overweight or obese.

Quality of Life

CO puts SA youth at greater risk for a number of poor quality of life indicators. Youth

who are obese as youth have been found to have an 80% likelihood of being obese as an adult

(NCSL, 2015). Obesity is then a major risk factor for many other chronic illnesses which

decrease an individual’s quality of life. As a result of an increase in health conditions related to

obesity, health care costs increase as well. The average medical cost for an obese individual is

$1,429 greater than an individual of a normal weight (CDC, 2015c). In 2008, the annual medical

cost of obesity in the United States was $147 billion dollars (CDC, 2015c). These health care

costs can increase stress and play a significant role in decreasing an obese individual’s quality of

life.

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Low self-esteem is a quality of life issue proven to be common among youth who are

obese. Obese youth have been found to be at greater risk for poor self-regard and diminished

quality of life due to their perceived physical appearance, athletic capability and how they

function in social settings (Griffiths, Parsons, & Hill, 2010). A quality of life factor in reducing

self-esteem among obese youth is the stigmatization of this population. Social stigma commonly

suggests obese individuals are accountable for their condition (Griffiths et al., 2010; Puhl &

Latner, 2007). Due to stigmatization, obese youth commonly experience social rejection,

seclusion and judgement (Mustillo, Hendrix & Schafer, 2012). Feelings of negative self-image

and self-esteem tend to be internalized, thus affecting the emotional health of the individual

(Mustillo et al., 2012).

As a part of the needs assessment, evaluating the quality of life indicators among

participants is essential to understanding the importance of these factors within the population.

Surveys and focus groups will be the methods utilized to determine importance of quality of life

indicators among SA youth. This intervention will be working with a younger population,

therefore stigma and low self-esteem will be addressed using surveys. This method was selected

to collect anonymous feedback about this delicate issue. The SA youth might feel shy or fearful

to express their feelings about these sensitive topics to others but feel more obliged to be truthful

if they can answer the questions on a survey. The survey will have statements the participants

will rate on a five-point Likert scale. Such statements will include “I am happy with my physical

appearance”, “I have a high self-esteem”, and “My fellow peers speak negatively about obesity.”

The complexity of the statements will depend on the age of the participant completing the

survey. The second method utilized to determine importance of quality of life indicators within

the population will be focus groups. Focus groups will be conducted to measure how important

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physical health and prevention of chronic disease is to the priority population. There will be

open discussion about the importance of preventing obesity into adulthood. This method was

chosen to expose participants to their peer’s perceptions on the topic while being able to openly

express their own. This will create an open environment for the SA youth to discuss the impact

this health problem has on their lives as well as others.

Risk Factors for Childhood Obesity

Similar to adult obesity, CO has many factors contributing to the increased prevalence of

the health problem. There is no single factor that can be identified in causing CO (Langley-Evans

& Moran, 2014). Three behavioral risk factors playing a significant role in CO are poor food

choices resulting in high intake of energy-dense foods, lack of physical activity and high

consumption of sugar-sweetened beverages (SSBs). Environmental risk factors for CO can be

found at the interpersonal, organizational, community and society levels.

Behavioral Risk Factors

CO has been found to be associated with improper nutrition of youth, especially from

consumption of energy-dense foods. Energy from food is essential for life; however the excess

consumption of energy leads to excess weight. A balance of energy between what is consumed

from food and beverages and what is expended is essential to prevent excess weight. A healthy

diet rich in fruits and vegetables will be less energy-dense than a diet thriving on fast food and

sweets. The Dietary Guidelines for Americans 2010 recommends a healthy diet involving whole

grains, fruits, vegetables, lean protein and low-fat dairy products (United States Department of

Agriculture [USDA], 2010). Despite these recommendations, research has found children are

consuming large portions, excess calories and fewer vegetables (Colapinto, Fitzgerald, Taper, &

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Veugelers, 2007). A study by Scerri and Savona-Ventura (2011) found overweight and obese

children were less likely to eat fruit and vegetables and more likely to consume meats and chips.

Additionally, one-third of American SA youth consume fast food on a daily basis, increasing

their weight by six pounds every year (St-Onge, Keller, & Heymsfield, 2003).

A behavioral risk factor that is closely associated with poor food choices in increasing

CO is high consumption of SSBs. SSBs are drinks with little to no nutrients and include any

beverages that contain added sugar in the form of high fructose corn syrup or sucrose (CDC,

2010). Examples of SSBs include soda, fruit drinks, energy drinks and sweetened milk (CDC,

2010). SSBs, similarly to excess of energy-dense foods, provide empty calories to youth which

can be turned into excess weight when consumed in high amounts (Vartanian, Schwartz, &

Brownell, 2007). SSBs have been found to be the most common source of sugar and a significant

contributor of calories in the American youth’s diet (Reedy & Krebs-Smith, 2010). Between the

1970s and 1990s, there was a 123% increase in consumption of SSBs among children and

adolescents (French, Lin & Guthrie, 2003). By the mid-1990s, SSB consumption among youth

was double the amount of milk consumed (Harnack, Stang & Story, 1999; Yen & Lin, 2002).

Among youth in the United States, consumption of SSBs has reached an average of 224 calories

per day, contributing to 11% of daily caloric intake (CDC, 2010; Troiano, Briefel, Carroll, &

Bialostosky, 2000). Research has found 80% of youth consume SSBs on any given day (Wang,

Bleich, & Gortmaker, 2008). In particular, youth who consume the most SSBs are non-Hispanic

black, Hispanic, low-income and obese (CDC, 2010). There are several proposed mechanisms

linking SSB consumption and obesity, with the most common acknowledging that energy

obtained in the liquid form is less satisfying than energy obtained from solid foods (CDC, 2010;

Pereira, 2006). This can lead to overconsumption of calories and increased portion sizes, thus

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increasing risk for obesity (Pereira, 2006). A cross-sectional survey evaluated SSB intake and

body fat among 385 SA youth attending school in Santa Barbara, California (Giammattei, Blix,

Marshak, Wollitzer & Pettitt, 2003). The study found the odds of having a heavier weight was

46% greater among students who consume three SSBs per day than students who consume fewer

amounts (Giammattei et al., 2003). With this amount of evidence linking high consumption of

SSBs to CO, there is confidence in classifying this behavior as a risk factor.

Lastly, inadequate physical activity has also been found to be a behavioral risk factor for

CO. The Physical Activity Guidelines for Americans 2008 recommends children engage in

physical activity for at least 60 minutes every day (United States Department of Health and

Human Services [DHHS], 2008). However, only 22% of American youth are meeting these

physical activity guidelines and 25% of youth are classified as living a completely sedentary

lifestyle (Troiano, 2002). These high rates of physical inactivity have been found be associated

with youth increasing their screen time rather than exercising (Gable, Chang, & Krull, 2007).

Youth spending more time watching television rather than being active has been found to be

directly linked to CO (Proctor, Moore, Gao, Cupples, Bradlee, Hood, & Ellison, 2003). Youth

who watch at least five hours of television per day is at 8.3 times greater risk for obesity than

youth who watch only up to two hours per day (Proctor et al., 2003). Studies have also found

overweight and obese youth are less active than non-obese youth. A recent study found

overweight and obese youth reported less average physical activity time as compared to their

leaner peers (Scerri & Savona-Ventura, 2011). Physical inactivity has become a major issue

among American youth; an issue continuing to increase the rates of CO if unaddressed.

Environmental Risk Factors

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Personal behaviors are not the only contribution to increase risk of CO. Environmental

risk factors play a role in influencing youth to act on risky behaviors leading to obesity. These

environmental risk factors influence the individual on many levels, ranging from relationships to

policies. No level is more important or significant than another. These levels of the environment

work cohesively to influence youth and produce CO as a result.

At the interpersonal level, family environment can play a key role in promotion of CO.

Eating dinner together has been found to have an impact on CO rates. Families who eat dinner

together three or more times per week have been found to be at decreased risk for obese children

(Veugelers & Fitzgerald, 2005). At the organizational level, the school environment has a strong

influence on CO. Many schools are now offering many SSB options in vending machines (Miller

& Silverstein, 2007). The majority of SSB availability in school is from non-soda beverages such

as juice (Terry-McElrath, O'Malley, & Johnston, 2012). However, the vending machines allow

for increased availability of sodas in schools (Terry-McElrath et al., 2012). Providing options for

sodas or other SSBs promotes these beverages to youth and encourages high consumption of

SSBs.

At the community level, accessibility of good nutrition sources and opportunities to be

physically active makes a significant impact on risk for CO. It is evident that a youth’s built

environment shapes their access to nutrient-dense foods and physical activity (Rahman, Cushing,

Jackson, 2011) Higher socioeconomic communities have been found to have access to three

times as many supermarkets than lower socioeconomic communities (NCSL, 2015). Availability

of supermarkets increases access to fresh fruits and vegetables as well as a greater selection of

healthy food options (NCSL, 2015). Individuals living in rural, minority and low-income

communities typically have less access to stores selling healthy foods they can afford (Larson,

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Story & Nelson, 2009). Additionally, these areas tend to have an overabundance of convenience

stores and fast food restaurants selling energy-dense foods and beverages to families (Larson et

al., 2009). Communities with access to high-caloric options and convenience stores increase the

risk for heavier youth, while supermarkets and farmer’s markets present in the community is

associated with decreased child BMI and risk for increased weight status (Rahman et al., 2011).

Low-socioeconomic communities also tend to have a built environment providing fewer

opportunities to be physically active (NCSL, 2015). In some communities, the environment may

be built where it is difficult for youth to be physically active (CDC, 2010). The Centers for

Disease Control and Prevention (CDC) (2010) report half of youth in the United States do not

have a park, community center or sidewalk in their neighborhood. A healthy lifestyle of good

nutrition and physical activity have been found to prevent obesity, but individuals won’t

participate in these healthy behaviors if the community environment doesn’t provide its

inhabitants with the ability to accomplish them (NCSL, 2015).

Lack of accessible potable drinking water has an effect on risk of obesity as well. In

2008, 8% of the United States population did not have access to clean drinking water (U.S.

Environmental Protection Agency [EPA], 2008). Those with a lack of access to potable drinking

water may consume more SSBs to replace water (CDC, 2010). A study in Alaska found a

community with little access to clean drinking water had 58% of 2 year-olds consuming two or

more SSBs per day as compared to 21-26% in communities with potable water access

(Fenaughty, Fink, Peck, Wells, Utermohle, & Peterson, 2009).

Society’s impact on CO is more prominent than expected. The food and beverage

industry, along with media, influences risky behaviors for CO on a daily basis. Portion sizes have

not only doubled in the past 20 years, but fast food restaurants now offer portions up to 20%

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larger (Colapinto, Fitzgerald, Taper, & Veugelers, 2007). Studies have found children eat these

larger portions without even realizing it, which in turn increases risk for CO (Fisher, Rolls, &

Birch, 2003; McConahy, Smiciklas-Wright, Mitchell, & Picciano, 2004). Media and the

entertainment industry contribute to CO through advertisements. Foods high in calories, fat,

sugar and sodium are advertised much more heavily towards youth than nutrient-dense foods

(CDC, 2015b; Institute of Medicine [IOM], 2005). Batada & Wootan (2007) found Nickelodeon,

a popular television channel for youth, aired commercials for foods of poor nutritional value for

94% of food advertising. Additionally, the study found food preferences of the youth can be

influenced by exposure to a 30 second television commercial (Batada & Wootan, 2007).

Advertisements for energy-dense snacks and beverages even reach youth within the school

environment. Approximately half of all middle and high schools in the United States allow

advertisements of unhealthy foods to the students (CDC, 2011). These advertisements influence

students to choose unhealthy food options rather than their more nutritious counterparts.

Federal and local policy is a societal level environmental risk factor that has the power to

make a true public health impact on CO (Kristensen et al., 2014). One of the most controversial

policies aimed at reducing obesity is taxation on SSBs. Taxation of SSBs has been the topic of

much debate, but has been passed in select states such as California (Robert Woods Johnson

Foundation [RWJF], 2014). A microsimulation was performed to estimate the effective ness of

an SSB excise tax on CO after 20 years of implementation (Kristensen et al., 2014). An SSB

excise tax was found to reduce CO, especially in the 13 to 19 year-old population (Kristensen et

al., 2014). The policy would decrease obesity the most in non-Hispanic blacks as well as

decrease obesity disparities overall (Kristensen et al., 2014). Therefore, taxation on SSBs can

reduce CO, especially among individuals belonging to the priority population. However, without

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a national requirement of implementing such a tax, the youth of the country are not reaping the

benefits.

Question 3: Prioritizing Behavioral and Environmental Risk Factors

Prioritization of the risk factors is essential to determine the focus of the present

intervention. Interventions focusing on nutrition education alone have been found to be

ineffective in significantly reducing CO (Summerbell, Waters, Edmunds, Kelly, Brown, &

Campbell, 2005). Interventions implementing programs focusing on physical activity made only

minor reductions in overall weight status of youth (Summerbell et al., 2005). Combining diet

education and physical activity components made positive impacts on BMI, but no significant

results (Summerbell et al., 2005). Focusing on overconsumption of SSBs in interventions has

been found to decrease consumption among youth (van de Gaar, Jansen, van Grieken,

Borsboom, Kremers, & Raat, 2014). Currently, there is a gap in the literature for effectiveness of

SSB interventions and their effect on CO. Due to great amounts of interventions already focusing

on nutrition and physical activity among obese youth, this intervention will aim to be more

innovative and focus on the behavioral risk behavior of high consumption of SSBs. An extensive

analysis found the relationship between SSB consumption and obesity has been found to have

temporality, strength, consistency, biological plausibility, experimental evidence and a dose-

response relationship (Hu, 2013). Therefore, an intervention focused on this behavioral risk

factor in reducing CO is promising.

The environmental risk factors must also be prioritized to narrow the scope of focus of

environment factors this intervention will address. Family influence and school environment are

two environmental risk factors that have been utilized in interventions often. Including parents in

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an intervention for CO has been found to have positive effects. Langley-Evans & Moran (2014)

encourages parental involvement in interventions because youth require the entire family to

make lifestyle changes. Many school interventions geared towards CO have been completed, all

exhibiting mixed results. However the MATCH program, which made SSBs less available in

schools, found the intervention to be effective in reducing mean zBMI and was sustainable after

a year of implementation (Lazorick, Fang, Hardison & Crawford, 2015). The environmental risk

factors of the built environment and accessibility have been used in interventions and have

showed promising effects on obesity. A study found change in built environment allowing better

transportation and accessibility was correlated with an average reduction in BMI and odds of

becoming obese (MacDonald, Stokes, Cohen, Kofner , Ridgeway, 2010). Policy has not been

implemented as often in interventions, but when used has exhibited little effect on BMI (Mayne,

Auchincloss, & Michael, 2015). Few interventions have been conducted addressing the food and

beverage industry’s effects on CO. When a 10% sales tax was added to fast food purchases in

Australia, there was a 10% decrease in sales (Stanton, 2008). However, the customers

disregarded the increased price soon after initial implementation and sales recovered (Stanton,

2008). Therefore, more evidence is needed to determine if methods such as price interventions

are effective. For media, social marketing campaigns have been utilized to promote healthy

behaviors and in turn decrease obesity. There is little evidence on the benefit of the use of social

marketing campaign interventions against CO; however they are most effective when

implemented on children because behavior is more easily changed (Walls, Peeters, Proietto, &

McNeil, 2011). After careful prioritization of this evidence, the intervention will focus on the

environmental risk factors involving availability of SSBs and potable drinking water as well as

use of media through a social marketing campaign in the school environment. Table 1, as seen

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below, prioritizes all behavioral and environmental risk factors for CO by relevance and

changeability. The factors to be utilized in the intervention are in italics.

Table 1. Priority Behavioral and Environmental Risk Factors for Intervention

Behavioral Risk Factors Relevance Changeability

High-consumption of SSBs +++ +++

Poor food choices resulting in an energy-dense diet

+++ ++

Inadequate physical activity +++ ++

Environmental Risk Factors Relevance Changeability

Availability of SSBs in school environment

+++ +++

Availability/accessibility of potable drinking water

+++ +++

Media +++ ++

Family environment +++ ++

Built environment (healthy options & physical activity opportunities)

+++ ++

Food & beverage industry +++ +

Government policy ++ +

Question 4. Program Objectives

There are few interventions with measurable objectives focusing on decreasing SSB

consumption among SA youth in the school environment available in the current literature.

However, an intervention encouraging consumption of water rather than SSBs found a

significant 23% decrease in mean daily intake of SSBs by the end of the school year (Sichieri,

Trotte, de Souza, & Veiga, 2008). Another study used education and environmental strategies by

providing greater access to water in the school environment (Muckelbauer, Libuda, Clausen,

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Toschke, Reinehr, & Kersting, 2009). This study found a decrease in the risk of being

overweight by 31% (Muckelbauer et al., 2009). These interventions were conducted over one full

school year, therefore determining the length of this intervention. Due to lack of available data in

the literature, the objectives for obesity reduction and availability of SSBs in schools were

determined using Healthy People 2020. Healthy People 2020 targets a 10% improvement in

obesity among children and adolescents ages 2 through 19 by the year 2020 (DHHS, 2010). The

objective for this intervention was carefully structured around this data. The Healthy People

2020 target for proportions of schools offering or selling SSBs was also utilized to create this

intervention’s environmental impact objective of availability of SSBs in schools. The measurable

objectives for this intervention are as follows:

Health Outcome:

1. Reduce the amount of participating children and adolescents ages 5 to 18 years old

attending school in the Greater Third Ward who are classified as obese by 5% within a

school year, as compared to a control group.

2. Reduce risk for being overweight by 30% among participating children and adolescents

ages 5 to 18 years old attending school in the Greater Third Ward within a school year, as

compared to a control group.

Behavioral Impact:

3. Reduce consumption of total daily caloric intake from sugar-sweetened beverages by

participating children and adolescents ages 5 to 18 attending school in the Greater Third

Ward by 25% within a school year, as compared to a control group.

Environmental Impact:

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4. Increase the amount of schools operating within the Greater Third Ward that do not offer

or sell sugar-sweetened beverages to students by 5% within a school year, as compared to

a control group.

5. Children and adolescents ages 5 to 18 years old participating in the intervention

implemented in schools within the Greater Third Ward will report a significant (p<0.05)

increase in potable water availability in school, as compared to a control group.

6. Children and adolescents ages 5 to 18 years old participating in the intervention

implemented in schools within the Greater Third Ward will report a significant (p<0.05)

increase in media focused on healthier beverage choices, as compared to a control group.

Question 5. Determinants

There are a variety of determinants associated with the risk factors leading to CO. These

determinants must be understood in order to identify what needs to be changed for the

intervention to be effective.

Determinants for Behavioral Risk Factors

From Social Cognitive Theory (SCT), self-efficacy plays a significant role in determining

behavioral risk factors for CO. Self-efficacy is defined as an individual’s confidence in their

ability to perform a behavior (Bandura, 1997). Low self-efficacy for drinking water as well as eating

fruits and vegetables was found in an African American community of 222 students using a validated

questionnaire (Elmore, Shakeyrah, Sharma, Manoj, 2013). Research has also found low self-

efficacy for physical activity is common among obese youth compared to their leaner

counterparts ( Deforche , De Bourdeaudhuij, Tanghe, Hills, De Bode, 2004). Additionally, obese

youth exhibit more perceived barriers, a construct from the Health Belief Model (HBM), to be

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physically active and are less confident to act on these barriers (Trost, Kerr, Ward, Pate, 2001).

Finally, obese youth exhibit low intentions to eat healthy foods as compared to underweight or

normal weight youth (Mohd, 2011). Intention to perform a behavior originates from the Theory

of Reasoned Action (TRA) and Theory of Planed Behavior (TPB) and is linked to attitude,

subjective norm and perceived control about a behavior (Motaño & Kasprzyk, 2008). All of

these determinants contribute to SA youth participating in risky behaviors that can lead to CO.

Determinants for Environmental Risk Factors

Many of the determinants for the environmental risk factors of CO originate with the

youth’s parents. For example, the weight status of a parent alone affects whether or not their

child will be obese. If both parents are obese, the risk for obesity in the child is 11 times greater

than a child with non-obese parents (Kleiser, Schaffrath Rosario, Mensink, Prinz-Langenohl, &

Kurth, 2009). Even youth with only one obese parent are at greater risk for CO (Kleiser et al.,

2009). Parental stress and feelings of safety has been found to negatively affect the ability of

families to eat dinner together. As parental stress and feelings of being unsafe in either their

home or neighborhood, family dinners per week decreased (Hearst, Martin, Rafdal, Robinson &

McConnell, 2013). Parents feelings of lack of street safety also influenced whether they’d let

youth go outside to be physically active (Rodríguez-Oliveros, Haines, Ortega-Altamirano,

Power, Taveras, González-Unzaga, & Reyes-Morales, 2011). Parents of youth who are obese

have also been found have a lack of nutrition knowledge leading to preparation of unhealthy

meals (Rodríguez-Oliveros et al., 2011; Hearst et al., 2013). Cultural beliefs influence the way a

parent feeds their children as well as how children are taught to select food for themselves

(Kumanyika, 2008). These cultural beliefs of food will vary among ethnicities and communities,

leading to the greater burden of CO in low-income, minority populations (Kumanyika, 2008).

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Social norms play a large role in a youth’s environment, especially outside the home. To

meet the current social norm, youth have greater difficulty decreasing rather than increasing their

BMI (Wang, Bleich, & Gortmaker, 2008). For example, vending machines at schools have

become a social norm by providing products such as SSBs and sweets in approximately 90% and

80% of schools, respectively (W van den Berg, Mikolajczak, & Bemelmans, 2013). Nutrition

standards for what is provided in vending machines helps shape social norms as well as influence

government agencies and food industries (National Alliance for Nutrition and Activity, n.d.).

Lastly, funding for schools allows food and beverage companies to market unhealthy food

products to students on school grounds. Schools receive funding for placing vending machines in

schools selling SSBs, desserts, and high-fat snacks (Miller & Silverstein, 2007). Pouring-rights

contracts give permission to companies to exclusively sell products in vending machines and at

school events in exchange for funding for the school district (Nestle, 2012). Schools then are

promoting specific brands by advertising and selling competitive foods such as SSBs (Nestle,

2012). If SA youth are purchasing these competitive foods, they are less likely to be consuming

more nutritious foods offered by the school. This phenomenon favors profit over nutrition,

leading to health problems such as CO (Nestle, 2012).

19


20

Question 6: PRECEDE Logic Model of Risk


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EXAM TWO: OUTCOMES, OBJECTIVES, MATRICES, METHODS AND PRACTICAL APPLICATIONS

Question 7: Behavioral and Environmental Outcomes

To develop an intervention properly, it is essential to assess not only the behavioral and

environmental risk factors of a health problem but also the factors leading to health promoting

behavior. For this intervention, the health promoting behavior will reduce the risk of childhood

obesity in school-age (SA) youth. After prioritizing risk factors from the needs assessment,

health promoting behavioral and environmental outcomes which reduce risk of childhood obesity

were established. To reduce the risk of childhood obesity, SA youth will reduce consumption of

sugar-sweetened beverages (SSBs). Decreasing daily consumption of SSBs and replacing these

beverages with water is correlated with lower total caloric consumption and decreased

prevalence of obesity (Popkin, 2010; de Ruyter, Olthof, Seidell, & Katan, 2012). Therefore,

students in the intervention will: Select water, rather than SSBs, as their beverage of choice

[BO1].

Water is calorie-free and individuals who replace SSBs with water are able to maintain a

healthy weight (Muchelbauer, Libuda, Clausen, Toschke, Reinehr, & Kersting, 2009). Two

studies indicate drinking water rather than SSBs assists in prevention of obesity among SA youth

(Ebbeling, Feldman, Osganian, Chomitz, Ellenbogen, & Ludwig, 2006; Wang Ludwig,

Sonneville, & Gortmaker, 2009). One study found replacing SSBs with water was related to

significant decreases in total energy intake of approximately 200 calories per day (Stookey,

Constant, Gardner, & Popkin, 2007). Tate and colleagues (2012) observed the effect of replacing

caloric beverages with water for 6 months in overweight and obese individuals. Participants who 27


did not consume calories from beverages experienced a significant weight reduction over a six

month period and were twice as likely to accomplish a 5% weight loss. While adults who replace

SSBs with water have increased weight loss, youth who replace SSBs with water have reduced

energy intake and risk of obesity (Tate et al., 2012; Popkin, D'Anci, Rosenberg, 2010; Briefel,

Wilson, Cabili, Hedley Dodd, 2013). One study used a healthy lifestyle education program

which aimed to reduce SSB intake among SA youth by encouraging selection of water as a

beverage (Sichieri, Trotte, de Souza & Veiga, 2008). The program found students in the

intervention who focused on drinking water instead of SSBs exhibited a greater reduction in both

SSBs and BMI than the control group (Sichieri et al., 2008).

Environmental conditions play a role in reducing risk of obesity in SA youth as well. The

needs assessment established how the school environment plays a key role in influencing health

behaviors of SA youth. The school environmental factors that influence SSB consumption

include the availability of SSBs and clean drinking water as well as exposure of students to

media. Therefore, the school environment is the focus of this intervention and the school will:

Not offer or sell SSBs [EO1]; Make clean drinking water readily available [EO2]; Not

advertise for any SSBs [EO3]; and Promote beverages that do not fall into the SSB

category, specifically water [EO4].

There is a correlation between foods offered by schools and foods purchased by students

(Mazur et al., 2008). Beverage products offered or sold by schools also influence dietary choices

among students. The HEALTHY school-based intervention evaluated the effects of eliminating

all SSBs from vending machines, a la carte lines, school stores, and the cafeteria (Siega-Riz,

28


2011). Students at the intervention schools reported an increase in water consumption by two

fluid ounces higher than students in the control schools (Siega-Riz, 2011).

SA youth spend a majority of their day at school so it is essential to ensure that water

provided at the school is safe and clean (Patel & Hampton, 2011). Additionally, studies have

shown providing access to clean water at school can reduce SSB consumption among SA youth

(Patel, Bogart, Uyeda, Rabin, & Schuster, 2010; Wang, Ludwig, Sonneville, & Gortmaker, 2009;

Ebbeling, Feldman, Osganian, Chomitz, Ellenbogen, & Ludwig, 2006). Enhancing the

availability of healthful beverages, such as water, in schools is related to improved dietary intake

among students (Cullen, Hartstein, Reynolds, Vu, Resnicow, Greene, White, 2007; Terry-

McElrath, O'Malley, Delva, Johnston, 2009). A study by Elbel and colleagues (2015) evaluated

the influence of drinking water dispensers on water consumption in New York City schools.

Three months after installing the water dispensers, water taking was tripled as compared to

schools without access to clean drinking water (Elbel et al., 2015). After one year of

implementation, 80% of students in intervention schools reported noticing the water dispensers

and 50% of students who noticed the jets reported drinking more water due to the availability of

the dispensers (Elbel et al., 2015). Therefore, this study found providing clean drinking water to

students through use of water dispensers was related to an increase in the amount of students

who drink water (Elbel et al., 2015). A similar study assessed how offering clean, filtered tap

water using dispensers in a middle school influenced student’s water consumption (Patel, Bogart,

Klein, Schuster, Elliott, Hawes-Dawson, Lamb, & Uyeda, 2011). The dispensers had a

significant positive influence on water consumption among students (Patel et al., 2011). Students

29


from schools with increased availability of clean drinking water through dispensers had higher

adjusted odds of drinking water at school as compared to students who do not (Patel et al., 2011).

Research concludes enhancing drinking water infrastructure, modernizing water fixtures, and

improving clean water accessibility can increase water intake among students in school (Kenney,

Gortmaker, Carter, Howe, Reiner, & Cradock, 2015).

SA youth are influenced by a variety of media on a daily basis which makes a significant

impact on their behavior. School environments are sources of advertising when allowed by

policymakers, administrators, and other stakeholders involved in the school (Larson, Davey,

Coombes, Caspi, Kubik, & Nanney, 2014). Food and beverage marketing in schools are

presented in various forms such as products, promotional materials, messaging, logos,

sponsorship of school events and incentive programs (Story & French, 2004). Banning

advertising of SSBs in the school environment shows promise of reducing SSB consumption

among students. Current research evaluating effectiveness of banning SSB advertising in schools

is scarce, however findings of a particular study found a change over time in the amount of

schools banning advertising for unhealthy products in an attempt to improve student dietary

choices (Larson et al., 2014). The results of this study suggest schools recognize the need to ban

advertising for products, such as SSBs, to reduce obesity risk among SA youth (Larson et al.,

2014).

Replacing advertisements endorsing SSBs with messages promoting water consumption

will further improve SA youth beverage selection behavior. There are various studies within

empirical literature supporting the strategy of promoting water through media to improve water

30


intake among SA youth. Loughridge and Barratt (2005) compared the effect of promoting water

consumption along with improved water access to only improving water access within the school

environment. The study concluded adding the promotion of water consumption in schools

increased water intake among students more than just enhancing water access (Loughridge &

Barratt, 2005). Springer and colleagues (2013) developed the CATCH social marketing get ur

H2O campaign to increase water intake and reduce consumption of SSBs among students. Get ur

H2O involved messaging within the school environment to increase student water consumption

(Springer, Kelder, Byrd-William, Pasch, Ranjit, Delk, & Hoelscher, 2013). Water promotion

messaging strategies included posters and messages on water bottles given to students (Springer

et al., 2013). The greatest increase in water intake among students was found in schools with the

social marketing condition (Springer et al., 2013).

Different forms of promotion for water consumption have been utilized and been

successful in previous studies. One study used reusable water bottles as the strategy to promote

water consumption in a German elementary school (Muckelbauer, Libuda, Clausen, Toschke,

Reinehr, & Kersting, 2009). There were planned daily schedules to fill-up water bottles and

teachers assisted students in filling up their water bottles every morning (Muckelbauer et al.,

2009). The study found an overall improved water intake and reduction in risk of overweight

among students from the intervention school as compared to those in the control group

(Muckelbauer et al., 2009). Kenney and colleagues (2015) utilized signage suggesting water as a

primary beverage choice and provided disposable cups near water sources as promotion methods

(Kenney, Gortmaker, Carter, Howe, Reiner, & Cradock, 2015). The amount of students who

31


drank water during lunch doubled from baseline as compared to control students (Kenney et al.,

2015). Additionally, the amount of students seen with SSBs was reduced after implementation of

the intervention (Kenney et al., 2015).

Question 8: Priority Population Differentiation

When developing an intervention using the intervention mapping approach, it is essential

to determine whether or not the priority population determined in the needs assessment should be

differentiated before proceeding further. In determining whether or not to differentiate the

intervention population, it is important to understand the population is made up of individuals

with varying attributes and needs which will not be able to be addressed by a single intervention

if the variation is too great (Bartholomew, Parcel, Kok, Gottlieb, & Fernandez, 2011). Major

differences in age, gender, ethnicity, education, geographic location, and socioeconomic status

are important aspects to consider when determining whether or not to differentiate the

intervention population (Bartholomew et al., 2011). The priority population for this intervention

was sufficiently narrowed concerning ethnicity, geographic location and socioeconomic status

with the target population being low-income African-American and Hispanic SA youth attending

school in the Third Ward of Houston, TX. However the age gap set for this intervention, SA

youth ages five through eighteen, is too broad and leaves variations in knowledge level. The age

and education level of the target population needs to be narrowed to an age group based on

school level. Despite the wide age gap, there is no evidence suggesting there is a difference in

determinants of behavior between the age groups. Therefore, rather than differentiating the

priority population, the targets will only be narrowed to middle school students ages 11 through

32


13. This age group would benefit from the intervention the most because the prevalence of SSBs

has tripled among adolescents 11 through 19 years old and behaviors of middle school students

are more likely to be changeable than high school students (Han & Powell, 2013).

Some studies have also found a difference in genders in response to water promoting

interventions. For example, a nutrition education program aimed at improving water

consumption behaviors in SA youth found a significant difference in increased water

consumption and resulting BMI reduction in girls (Sichieri, Trotte, de Souza, & Veiga, 2008).

However, difference in determinants of the health promoting behavior between genders was not

found in the literature. There was no other contributing evidence within the literature to suggest

differentiation was necessary for this intervention. Therefore, there will not be a differentiation

of the priority population.

Question 9: Performance Objectives

Understanding the specific steps in which the SA youth and schools will have to take to

achieve the outcomes determined is essential in constructing an effective intervention. The

creation of performance objectives for both the individual and the environment describes the

process of how to accomplish the desired result. Table 1 presents the performance objectives for

the individual, the student, selecting water as their beverage of choice rather than SSBs. These

performance objectives, with the exception of cleaning the water bottle when empty, were

previously utilized in various interventions effective at reducing SSB consumption and

increasing water intake in SA youth. Muckelbauer and colleagues (2009) structured an

intervention with objectives for students to obtain a reusable water bottle, obtain water from 33


fountains, drink water, and refill the water bottle with water when it is empty. With these

objectives, the intervention was effective in reducing the risk of overweight in students by

increasing water consumption (Muckelbauer, Libuda, Clausen, Toschke, Reinehr, & Kersting,

2009). Another intervention using the objectives for students to make the decision to drink water

and refuse SSBs was also successful in increasing student water consumption (Kenney,

Gortmaker, Carter, Howe, Reiner, & Cradock, 2015). The objective of cleaning the water bottle

when empty was added as a behavioral performance objective because bacteria will accumulate

in reusable water bottles if they are not disinfected properly between uses.

Table 1. Behavioral Performance Objectives

Performance objectives for the environment are also necessary to consider the steps the

schools will take to decrease the availability of SSBs while increasing the availability of clean

drinking water and changing media messages about beverages in the school environment. The

performance objectives for the school environment in this intervention are shown in Table 2.

34

Behavioral Outcome 1: Students will select water, rather than SSBs, as their beverage of choice

Students will:

PO1.1 Make the decision to drink water

PO1.2 Obtain a reusable water bottle

PO 1.3 Obtain water from a water station or purchase water if reusable bottle is unavailable

PO1.4 Drink water

PO1.5 Clean reusable water bottle when empty

PO1.6 Refill reusable water bottle with water when empty

PO1.7 Refuse alternative beverages including SSBs


These objectives were also previously utilized in studies aiming for similar environmental

outcomes as the present intervention. The study by Muckelbauer and colleagues (2009)

implemented environmental objectives such as installing water stations, supplying reusable water

bottles, and allowing water in class. The objective of discontinuing advertising of SSBs in the

school environment was supported in a study by Larson and colleagues (2014), while the

objective of promoting water consumption was used in an effective intervention by Kenney and

colleagues (2015). Finally, replacing SSBs from places of purchase in the school environment

with water was an objective used in an intervention known as The Zuni High School Diabetes

Prevention Program (Ritenbaugh et al., 2003). The intervention found availability of SSBs was

significantly related to consumption among students (Ritenbaugh et al., 2003). After three years

of implementation, the students consumed nearly no SSBs at school. SSBs were substituted by

approximately 24 ounces of water per week by each student (Ritenbaugh et al., 2003).

Table 2. Environmental Performance Objectives

35

Environmental Outcomes 1-4: Schools will not offer or sell SSBs; make clean drinking water readily available; not advertise for any SSBs; and promote beverages that do not fall into the SSB category, specifically water

PO 2.1 Food and nutrition staff will replace all SSBs from places of purchase (cafeteria, vending machines etc.) with bottled water

PO 3.1 Principals will order installation of water stations to supply potable drinking water

PO 3.2 Principals will order reusable water bottles to supply to students

PO 3.3 Teachers will allow water in class

PO 4.1 Principals will discontinue advertising for SSBs including logos, posters and videos

PO 5.1 Principals and teachers will promote drinking water using various forms of media


Multiple strategies will be used to validate both the behavioral and environmental

performance objectives. For the behavioral performance objectives, observation of students

completing objectives would be useful in visualizing the steps being taken to accomplish the

behavioral outcome. Additionally, key informant interviews with students discussing how they

accomplish the desired behavioral outcome would assist in validation of the behavioral

performance objectives. For the environmental performance objectives, similar strategies will be

utilized for validation. Observation of school staff completing tasks on site and key informant

interviews with the staff will be conducted. The interviews with school staff will include

principals, teachers, and food and nutrition staff. Additional interviews can be conducted with

others involved in the objectives such as vendors who supply beverages to the school as well as

the water station installation company. These validation strategies for the environmental

performance objectives will assist in confirming the proper steps are being taken to accomplish

the desired environmental outcomes of the intervention.

Question 10: Determinants

Assessing the determinants of both the individual and the environment are essential in

understanding why SA youth engage in the health promoting behavior of drinking water instead

of SSBs. Within existing literature, there are specific determinants for the individual and

environment recognized as important in influencing the health promoting behavior among SA

youth.

Individual Determinants

36


Knowledge: Knowledge is derived from communication theory and is defined as the

information leading to understanding and engaging in informed action (Finnegan Jr. &

Viswanath, 2008). Knowledge, particularly nutrition knowledge, impacts dietary choices of SA

youth (Taylor, Evers, & McKenna, 2005). Wardle and colleagues (2000) found existing nutrition

knowledge was related to better dietary quality. Another study examining the association

between knowledge of daily calorie recommendations and SSB consumption found similar

results (Gase, Robles, Barragan, & Kuo, 2014). Results indicated participants who could

correctly identify the recommended daily calorie needs drank an average of nine fewer SSBs per

month than participants who did not know the recommended daily calorie needs (Gase et al.,

2014).

Skills and Self-Efficacy: Self-efficacy is a construct of the Social Cognitive Theory

(SCT) and is defined as an individual’s confidence in their ability to accomplish a desired

behavior (Bandura, 1997). A study by Shannon and colleagues (1990) examined self-efficacy as

a primary factor in dietary behavior. Data was collected from 170 women who participated in a

10 week course at pre-intervention, post-intervention, and two months afterward (Shannon,

Bagby, Wang, & Trenkner, 1990). Self-efficacy significantly determined dietary behavior at pre-

and post-intervention (Shannon et al., 1990). Another study evaluating 350 children ages 11 or

12 years old as a cohort for 6-month time intervals found self-efficacy to be positively associated

with healthy dietary behaviors among youth (Masui, Sallis, Berry, Broyles, Elder, & Nader,

2002).

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Skills are a part of self-efficacy and involve an individual’s expertise influencing their

ability to perform a behavior. A study conducted within high schools looked at the relationships

between cognitive beliefs, healthy lifestyle choices, and healthy lifestyle behaviors among

adolescents (Kelly, Melynk, Jacobson, & O’Haver, 2011). The study found a significant

correlation between behavioral skills and healthy lifestyle choices (Kelly et al., 2011). Therefore,

both self-efficacy and skills are important determinants in SA youth choosing water rather than a

SSB.

Attitudes: Attitudes are from the Theory of Planned Behavior (TPB) and are a direct

determinant of an individual’s behavioral intention determining behavior (Montano & Kasprzyk,

2008; Fishbein & Ajzen, 1975). Attitudes and intentions were found to be a correlate of dietary

behavior among multiple samples of SA youth (McClain, Chappuis, Nguyen-Rodriguez, Yaroch,

& Spruijt-Metz, 2009). Patel and colleagues (2014) also discuss the influence of attitude on

drinking water at school among middle school students. The study found attitudes toward school

drinking fountains were associated with intentions to drink water at school and intentions to

drink water at school were related to total water intake (Patel, Bogart, Klein, Cowgill, Uyeda,

Hawes-Dawson, Schuster, 2014). Therefore, positive attitudes about drinking water among SA

youth are essential determinants in whether or not this population will drink water instead of

SSBs.

Outcome Expectations: Outcome expectations are another construct from SCT and are

defined as the beliefs about the probability and significance of what will occur due to performing

a specific behavior (McAlister, Perry, & Parcel, 2008). Outcome expectations have been found

38


to be linked with health behaviors such as increased water consumption. A study by Sharma and

colleagues (2006) evaluated specific SCT constructs in predicting four health behaviors,

including increased water consumption, among 159 elementary school students. The study found

amount of water consumed per day was determined by expectations for drinking water (Sharma,

Wagner, & Wilkerson, 2006). Positive outcome expectations for drinking water were found to be

a significant determinant of students obtaining the recommended amount of eight glasses of

water per day (Sharma et al., 2006).

Environmental Determinants

There are also determinants of the school environment influencing SA youth to

participate in the health promoting behavior. Determinants for these environmental conditions

include knowledge, attitudes, and self-efficacy and skills. Hughes (2010) found the principal’s

knowledge plays a key role in the success of students. Therefore, behavior of students can be

determined by the knowledge of leaders in the school environment and how these leaders apply

such knowledge within the environment to influence the students (Hughes, 2010). A study

conducted by Chen and colleagues (2010) looked at whether teachers are resources and role

models for students with respect to healthy dietary behavior. The study evaluated knowledge of

the teachers and how this knowledge influences the behavior of the students they teach (Chen,

Yeh, Lai, Shyu, Huang, & Chiou, 2010). Better dietary behaviors were found to be correlated

with classrooms whose teachers had more nutrition knowledge (Chen et al., 2010).

Attitudes of school staff toward drinking water rather than SSBs can also play a role in

influencing student’s behavior. A cross-sectional study evaluating the Healthy School Canteen 39


Program, a program aimed at improving student dietary behaviors in schools, assessed

determinants for schools choosing to participate in the program (Milder, Mikolajczak, van den

Berg, van de Veen-van Hofwegen, & Bemelmans, 2015). Attitudes of school staff were

classified as a determinant for why a school chose to promote healthier dietary behaviors such as

drinking water (Milder et al., 2015). School staff at intervention schools encouraged healthier

dietary behaviors, believed overweight among students is a health problem and had a sense of

responsibility in preventing overweight among their students (Milderet al., 2015). Therefore, the

staff at intervention schools had attitudes leading to the promotion of healthier dietary behavior

among students.

Finally, self-efficacy and skills are considered environmental determinants of the health

promoting behavior among SA youth as well. Domsch (2009) studied the relationship between

effective behaviors and efficacy by evaluating practices of principals and teachers. This

relationship was measured using surveys in which the participants self-reported self-efficacy

scales and student achievement (Domsch, 2009). Instructional skills were also included in the

analysis for teachers (Domsch, 2009). Higher skill level among teachers was related to principal

efficacy (Domsch, 2009). Additionally, the study indicated principal efficacy scores were

positively correlated with student achievement (Domsch, 2009). These finding suggest school

staff are key in influencing changes in the environment to encourage health promoting behaviors

among students.

New Research

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The behavioral and environmental determinants for the health promoting behavior found

in the literature need to be confirmed in order to indicate whether these determinants are

sufficient for the target population. Therefore, new research will be done to conclude if

determinants properly represent why SA youth are drinking water rather than SSBs or if other

theoretical determinants are more influential. This research would be conducted using focus

groups and key informant interviews with SA youth who are actually participating in the health

promoting behavior as well as interviews with school staff.

Question 11: Change Objectives

Refer to Matrix 1 for the changes objectives of the behavioral outcome and Matrix 2 for

the changes objectives of the environmental outcomes.

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Matrix 1. Behavioral Outcome: [BO1]

Determinants

PerformanceObjectives

Knowledge Skills and Self-efficacy Attitudes Outcome Expectations

PO1.1 Students will make the decision to drink water rather than a SSB

K.1.1 Explain how the health benefits of drinking water is a deciding factor in selecting water as a beverage

SSE.1.1. Have confidence in the ability to choose water as a beverage over other options

A.1.1 Express positive belief about the importance of deciding to drink water

OE.1.1 Expect that making the decision to drink water will reduce consumption of sugar-sweetened beverages

PO1.2 Students will obtain a reusable water bottle

K.1.2 Describe how to receive a reusable water bottle

SSE.1.2a Have confidence in the ability to obtain a reusable water bottle for useSSE.1.2b Demonstrate the ability to obtain a resuable water bottle

OE.1.2 Expect that obtaining a reusable water bottle will increase water consumption

PO 1.3 Students will obtain water from a water station or purchase water if reusable bottle is unavailable

K.1.3 Explain how to locate water station or vending machines to obtain water

SSE.1.3a Have the confidence in the ability to find a water station or vending machine to obtain water SSE.1.3b Demonstrate the ability to find a water station or vending machine to obtain water

OE.1.3 Expect obtaining or purchasing water will decrease sugar-sweetened beverage consumption

PO1.4 Students will drink water SSE.1.4 Have confidence in the ability to drink water

A.1.4 Express positive attitudes about drinking water rather than sugar-sweetened beverages

OE.1.4 Expect drinking water will decrease sugar-sweetened beverage consumption and improve overall health

PO1.5 Students will clean water bottle when empty

K.1.5a Explain the importance of cleaning reusable water bottles in preventing water-borne illnessesK.1.5b Explain proper procedures of how to clean reusable water bottle

SSE.1.5a Have confidence in the ability to properly clean resuable water bottleSSE.1.5b Demonstrate the ability to properly clean reusable water bottle

OE.1.5 Expect water to be free of impurities or contaminants

PO1.6 Students will refill bottle with water when empty

SSE.1.6a Have confidence in the ability to refill water bottle when emptySSE.1.6b Demonstrate the ability to refill water bottle when empty

OE.1.6 Expect refilling water bottle when empty will increase water consumption

PO1.7 Students will refuse alternative beverages including

K.1.7a Explain refusal of alternative beverages is due to health benefits of

SSE.1.7 Have the confidence in the ability to refuse alternative beverages

A.1.7 Express positive feelings about refusing any beverages other than

OE.1.7 Expect refusing alternative beverages will decrease sugar-

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SSBs waterK.1.7b Explain characteristics of an effective refusal

water sweetened beverage consumption

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Matrix 2. Environmental Outcomes: [EO1-4]

DeterminantsProgram Objective Knowledge Skills and Self-Efficacy AttitudesPO 2.1 Food and nutrition staff will remove all SSBs from places of purchase (cafeteria, vending machines etc.) and replace with bottled water

K.2.1 Explain all locations students could access SSBs

SSE.2.1a Express confidence in promoting water through removing sugar-sweetened beverages from places of purchaseSSE.2.1b Demonstrate ability to work with vendors on replacing SSBs with water

A.2.1 Express positive attitudes about eliminating all sugar-sweetened beverages from the school environment and replacing them with water to benefit the student’s health

PO 3.1 Principals will order installation of water stations to supply potable drinking water

K.3.1a Describe benefits in providing clean drinking water to students through water station installationK.3.1b Describe steps required to install water stations

A.3.1 Express positive attitudes towards increasing water access in the school environment by installing water stations

PO 3.2 Principals will order reusable water bottles to supply to students

K.3.2 Describe how reusable water bottles will be supplied with budget, sources and storage information

A.3.2 Express positive beliefs in supplying students with reusable water bottles to increase water consumption

PO 3.3 Teachers will allow water in class K.3.3 Describe importance of allowing water in class for students to increase water consumption and stay hydrated

SSE.3.3 Have confidence in the ability to permit students to drink water in the classroom

A.3.3 Express positive feelings towards students being allowed to drink water in the classroom

PO 4.1 Principals will discontinue advertising for SSBs including logos, posters and videos

K.4.1 Describe risk of SSB advertising towards students and the health benefits of discontinuing advertising

SSE.4.1a Have confidence in the ability to cease SSB advertising within the school environmentSSE.4.1b Demonstrate the ability to remove advertising for SSBs in the school environment

A.4.1 State belief that advertising for SSBs in the school have negative health outcome for students

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PO 5.1 Principals and teachers will promote drinking water using various forms of media

K.5.1a Describe health benefits of drinking water instead of SSBs used in promotionsK.5.1b Describe different ways to promote drinking water

SSE.5.1a Have confidence in the ability to promote drinking water through mediaSSE.5.1b Demonstrate the ability to promote drinking water by using media as a source

A.5.1 Express positive attitudes towards media promoting water consumption geared toward students to change behavior

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Question 12: Methods and Practical Applications

Theoretical methods are utilized to influence changes in determinants of behavior within

the target population or environmental condition (Bartholomew, Parcel, Kok, Gottlieb, &

Fernandez, 2011). The methods are matched to a change objective from the matrices and are

linked by the determinant (Bartholomew et al., 2011). The practical applications are the

strategies used by the intervention to implement a particular method. Methods and practical

applications are used for both the behavioral outcomes as well as environmental conditions of the

intervention.

Methods chosen for the behavioral outcome of this intervention include belief selection,

persuasive communication, facilitation, imagery, modeling, counter-conditioning, repeated

exposure, and cultural similarity (Bartholomew, Parcel, Kok, Gottlieb, & Fernandez, 2011).

Belief selection utilizes messages aimed at supporting positive beliefs, weakening negative

beliefs, and introducing new beliefs (Bartholomew et al., 2011; Fishbein & Ajzen, 2010). This

method was found to be effective in a healthy lifestyle education program utilizing messages to

encourage positive beliefs about water consumption in place of SSBs (Sichieri, Trotte, de Souza

& Veiga, 2008). The primary approach of the intervention was to teach students the message that

drinking water is positive (Sichieri et al., 2008). On average, the consumption of sodas per class

decreased by four times the amount in the intervention group as compared to the control group

(Sichieri et al., 2008). Additionally, the intervention group exhibited a greater reduction in BMI

status than the control group (Sichieri et al., 2008). The intervention also successfully utilized

imagery, persuasive communication, repeated exposure, and cultural similarity as methods.

Imagery utilizes objects with a resemblance to a particular subject (Bartholomew et al., 2011).

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For imagery, Sichieri and colleagues (2008) used a ‘pyramid of drinking’ showing water at the

base of the pyramid and SSBs at the top of the pyramid to encourage water consumption.

Persuasive communication, which directs individuals to adopt a desired behavior by utilizing

arguments, was used in the intervention by creating the center of the campaign around the health

benefits of choosing water over SSBs (Bartholomew et al., 2011; Sichieri et al., 2008). Repeated

exposure is a method aimed at ensuring a stimulus is continuously available to the individual’s

senses (Bartholomew et al., 2011; Zajonc, 2001). The intervention utilized this method by

exposing the students continuously to the message and lessons promoting water consumption.

Finally, within this intervention, cultural similarity was used to create an intervention relatable to

the target population. Cultural similarity is defined as the utilization of features of the targets in

source, message and channel (Bartholomew et al., 2011; Kreuter & McClure, 2004). Cultural

similarity was used in the intervention by previously analyzing the messages for understanding

in two groups of students who were the same age and socio-economic status as the participants

of the study (Sichieri et al., 2008). With the significant success of this particular study, these

methods were determined to be suitable for this intervention.

Facilitation is defined by Bandura (1986) as the creation of an environment conducive to

performing an action (Bartholomew, Parcel, Kok, Gottlieb, & Fernandez, 2011). Facilitation is

used as a method in many effective water promotion programs because an actual alteration of the

intervention environment occurs. For example, a study that installed water fountains and had

school teachers present classroom lessons to promote water consumption resulted in a reduced

risk for overweight among students (Muckelbauer, Libuda, Clausen, Toschke, Reinehr, &

Kersting, 2009). Counter-conditioning, defined as learning healthy behaviors used to substitute

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risky behaviors, have also been found to be an effective method in similar interventions

(Bartholomew et al., 2011; Prochaska, Redding, & Evers, 2008). A recent study had participants

replace two or more servings of SSBs per day with noncaloric beverages (Tate et al., 2012).

Participants had significantly greater reductions in calories per day when they

Change Objectives Methods Practical Applications Parameters K.1.1, K.1.7a, SSE.1.1,SSE.1.4, SSE.1.7, A.1.1, A.1.4, A.1.7, OE.1.1, OE.1.3, OE.1.4

Belief Selection (TPB/TRA) Posters hung in school hallways and near water stations with messages of positive beliefs toward drinking water rather than SSBs

Research student’s existing attitudinal, normative and efficacy beliefs before intervening

K.1.1, K.1.7a, SSE.1.1, SSE.1.7, A.1.1, A.1.4, A.1.7, OE.1.1, OE.1.3, OE.1.4

Persuasive Communication (SCT)

Video advertisements shown during morning announcements emphasize the health benefits of drinking water rather than SSBs

Water messages should be applicable to student’s beliefs; includes surprise, replication and arguments

K.1.2, K.1.3, SSE.1.1, SSE.1.2a, SSE.1.2b, SSE.1.3a, SSE.1.4, SSE.1.6a, SSE.1.6b, OE1.2, OE.1.3

Facilitation (SCT) Installation of water fountains dispensing potable drinking water for students along with distribution of free reusable water bottles

Requires changes be made in the school environment; recognizes barriers and implementers; intervention should be at a higher (organizational) level

SSE.1.1, SSE.1.4, SSE.1.6a, SSE.1.7, OE.1.1, OE.1.3, OE.1.4

Imagery (Theories of Information Processing)

Recognition of logos printed on posters, water stations, reusable water bottles and featured in advertisements helps students to remember to drink water

Accustomed images used in media act as a parallel to a less accustomed practice

K.1.2, K.1.3, K.1.5a, K.1.5b, K.1.7a , K.1.7b , SSE.1.1, SSE.1.2a, SSE.1.2b, SSE.1.3a, SSE.1.3b, SSE.1.4, SSE.1.5a, SSE1.5b, SSE.1.6a, SSE.1.6b, SSE.1.7, OE.1.2, OE.1.5, OE1.6, OE.1.7

Modeling (SCT) Role models in video advertisements provides strategies for deciding to drink water, locating water, how to obtain/use/properly clean reusable water bottle, and how to refuse SSBs

Use of attention, remembrance, self-efficacy and skills; students must be able to identify with role models; model must be reinforced; use of coping rather than mastery model

SSE.1.1, SSE.1.4, A.1.7 Counter-Conditioning (TTM) Replace all SSBs in places of purchase with water so students will substitute risky behavior with a healthier behavior

Accessibility of clean drinking water, the substitute for SSBs

K.1.1, K.1.7a, SSE.1.1, SSE.1.4, SSE.1.7, A.1.1, A.1.4, A.1.7, OE.1.1, OE.1.2, OE.1.4, OE.1.7

Repeated Exposure (Theories of Learning)

Various forms of mass media (posters on walls, advertisements in classrooms) constantly expose students to messages encouraging drinking water rather than SSBs

Impartiality of original attitude toward drinking water

K.1.1, SEE.1.1, SSE.1.2a, SSE.1.3a, SSE.1.4, SSE.1.7, A.1.1, A.1.4, A.1.7, OE.1.1, OE.1.3, OE1.4, OE.1.7

Cultural Similarity (Persuasion-Communication Matrix)

Media delivering messages promoting water consumption will be culturally relevant to African-American and Hispanic middle school students residing in a low socioeconomic urban community

Uses basic characteristics of SA youth to improve receptiveness of water message; uses social-cultural characteristics to further increase receptiveness of water

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messagesubstituted SSBs with a healthier beverage (Tate et al., 2012).

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Table 3. Methods and Practical Applications for Behavioral Outcome

TPB/TRA: Theory of Planned Behavior/Theory of Reasoned Action, SCT: Social Cognitive Theory, TTM: Trans-theoretical Model; Parameters adapted from Bartholomew, Parcel, Kok, Gottlieb, & Fernandez (2011).


Methods for the environment include advocacy, modeling, mass media role-modeling and

mobilizing social networks (Bartholomew, Parcel, Kok, Gottlieb, & Fernandez, 2011). Advocacy

is a method used to give active support to a desired cause (Bartholomew et al., 2011). This

method has been found to be effective in previous studies similar to the present intervention. A

specific study advocated with schools to improve the infrastructure of the environment in an

attempt to increase water consumption for obesity prevention among students (Laurence,

Peterken, & Burns, 2007). By one year, the amount of students with filled water bottles increased

by 25%. Modeling is another effective method to be used in addressing the environment in this

intervention. Modeling was utilized in a water campaign with the statements ‘Water is the best

thing I can give to my child!’ from caretakers of students (van de Gaar, Jansen, van Grieken,

Borsboom, Kremers, & Raat, 2014). This social marketing campaign emphasized the importance

of the adult influencing the child’s healthier behaviors and reflected this message onto caregivers

viewing the media (van de Gaar et al., 2014). After implementation of the intervention, average

SSB consumption as well as average SSB servings decreased in the intervention students (van de

Gaar et al., 2014). Caregivers in the social marketing campaign were also shown being

reinforced for encouraging water consumption among SA youth, which is a method known as

mass media role-modeling (van de Gaar et al., 2014). Mass media role-modeling is a method

using models shown being reinforced for a desired action using mass media (Bartholomew et al.,

2011; Bandura, 1997; Rogers, 2003). The final method being used within the environment is

known as mobilizing social networks. Mobilizing social networks is a method involved in

encouraging the social networks of the target population in providing various forms of support to

make acting on a desired action easier for the targets (Bartholomew et al., 2011; Heaney &

Israel, 2008). This method has been effective in many interventions with a SA youth’s social

50


network including parents telling stories about the importance of drinking water, teachers

repeating the health message of drinking water during lessons, and teachers assisting children

with retrieving water from accessible sources (van de Gaar et al., 2014; Sichieri, Trotte, de Souza

& Veiga, 2008; Muckelbauer, Libuda, Clausen, Toschke, Reinehr, & Kersting, 2009).

Table 4. Methods and Practical Applications for Environmental OutcomesChange Objectives Methods Practical Applications Parameters

K.3.1a, K.3.1b, K.3.2, K.3.3, K.4.1, SSE.2.1a, SSE.4.1a, SSE.4.1b, A.2.1, A.3.1, A.3.2, A.4.1, A.5.1

Advocacy (Stage Theory of Organizational Change)

Students issue letters to school administrators urging the removal of both SSBs and media for SSBS in the school environment, installing water stations to provide clean drinking water to students, and implementing a water campaign to improve health of students.

Advocacy for water must equate style of the students and schools represented; comprises policy advocacymessage tailored toward water consumption

K.5.1b, SSE.2.1b, SSe.5.1a, SSE.5.1b

Modeling (SCT) Video advertisements presented during morning announcements show how school staff can assist students in choosing water as their beverage instead of SSBs

Models specific to school environment and staff (principals, teachers, food and nutrition staff)

K.3.1a, K.3.3, K.4.1, SSE.2.1a, SSE.4.1a, SSE.5.1a, A.2.1, A.3.1, A.3.2, A.3.3, A.5.1

Mass Media Role-Modeling (Diffusion of Innovations Theory, SCT)

A story printed in the school newspaper about how the school’s involvement benefited the decrease in SSB intake by students through improving water consumption

Intervention circumstances include modeling and persuasive communication

K.2.1, K.3.3, K.5.1a, K.5.1b, SSE.3.3, SSE.5.1a, SSE.5.1b, A.3.3, A.5.1

Mobilizing Social Networks (Theories of Social Networks and Social Support)

School staff are trained in assisting students with utilizing water stations and how to use provided media for promotion of water consumption among students

Accessibility of social network and potential supporters (principals, teachers, food and nutrition staff)

SCT: Social Cognitive Theory; Parameters adapted from Bartholomew, Parcel, Kok, Gottlieb, & Fernandez (2011).

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EXAM 3: PROGRAM DEVELOPMENT, ADOPTION, IMPLEMENTATION, & EVALUATION

Question 13: Program

The proposed intervention, titled H2O My Health: Here to Own My Health, is aimed at

reducing risk of childhood obesity among middle school students by decreasing sugar-sweetened

beverage (SSB) consumption by increasing intake of water. The program aims to accomplish

these outcomes by reducing access to SSBs, eliminating all media promoting SSBs, initiating a

media campaign for drinking water, and increasing accessibility to clean drinking in the school

environment. H2O My Health will be based in Jackson Middle School located in the Third Ward

district of Houston, Texas. Participants will include middle school students attending Jackson

Middle School. School staff assisting the facilitation of the intervention will include the

principal, teachers, and Food and Nutrition Services (FNS) employees. Delivery channels to be

utilized by the intervention to convey messages include print media, videos containing peer

models, and interpersonal discussion about the importance of drinking water with homeroom

teachers. The main theme of H2O My Health emphasizes the importance of drinking water rather

than SSBs to promote optimal health. H2O My Health aims to reduce central challenges of

selecting water over SSBs, such as lack of access to clean drinking water and the negative

influence of media promoting SSBs in a youth’s environment. H2O My Health creates a

supportive environment for middle school students to make the healthier choices concerning

beverage selection. The title of the program, meaning “here to own my health”, aims to empower

students in taking control of their own health by choosing water over SSBs.

The program will begin a month before the start of the school year, between the months

of July and August. During this time, preparation for the intervention to be implemented during

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the school year will begin. The principal will participate in “train the trainer” sessions, in which

they will learn how to train employees for the program. These sessions will be two hours a day

for one work week. The principal will learn about the purpose of the program, the tasks that must

be completed for the program to be properly implemented, and who among the school staff must

complete specific tasks. Following the principal training week, the teachers and FNS employees

will be trained by the school principal about the H2O My Health program. Both teachers and FNS

staff will attend an overall training session educating the employees on the purpose of the

program and why it is important for the health of the students. The employees will then be split

up into training sessions for the teachers and FNS staff on following days. The teachers will be

trained on how to assist students with obtaining water from the water stations, the importance of

replacing SSB advertisements with program posters in classrooms and nearby hallways, how to

utilize program videos, and how to actively promote drinking water to the students. The FNS

staff will be trained on how to remove SSB products and advertisements from places of purchase

as well as the importance of promoting the consumption of water to students. Training sessions

for both the teachers and the FNS staff will be over the course of one day for three hours. After

the completion of training, the principal will order the water stations and reusable water bottles

as well as observe the proper installation of the water stations in the schools. The principal will

also personally approve all program media before use. The FNS staff will then remove all SSBs

from places of purchase and replace the SSBs with water products. The FNS staff will also

replace all advertisements of SSBs from places of purchase with posters promoting water

consumption among students. The teachers will also assist in replacing advertisements for SSBs

in school hallways and classrooms with program posters. Before the school year begins, students

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of Jackson Middle School will receive schools newsletters at home including information about

H2O My Health and the health benefits of drinking water instead of SSBs.

The second phase of the implementation of the H2O My Health program comprises the

entire nine month school year, from the end of August to the following May. At this time the

water stations, which will be called “hydration stations”, will be installed and no SSB products

will be offered or sold anywhere in the school environment. Advertisements for SSBs will not be

displayed and an active pro-water media campaign will be established in the school environment.

This media campaign will include educational videos promoting water consumption shown

during the first homeroom class of every month as well as promotional posters located in all

classrooms and school hallways. The focus of the educational component of the program will be

based in homeroom class, in which the teachers conduct group discussions once a month about

the importance of drinking water after the program video is shown. There is not a formal

education curriculum for the homeroom teachers, but active participation from the students on

the topic addressed in the video should be encouraged. Homeroom teachers will distribute

reusable water bottles as well as present locations of hydration stations to students during the

first homeroom class of the year. Outside of homeroom class, all teachers should assist students

with obtaining water from the hydration stations when needed and encourage student water

consumption in class. The principal will be responsible for ensuring employees are implementing

the program with fidelity. This follow-up by the principal will be accomplished through monthly

meetings with all teachers and FNS staff of the middle school. In the meetings, the principal will

go over employee responsibilities, check in with each employee, and allow the opportunity for

the staff to ask questions concerning the program. Refer to Table 1 for the overall scope and

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sequence of the H2O My Health program and Table 2 for further description of the nine program

videos shown in homeroom class.

Table 1. Overall Scope and Sequence of the “H2O My Health” Intervention

Months: 1 2 3 4 5 6 7 8 9 10Principal -Train the trainer

sessions-Order and oversee installation of hydration stations-Order reusable water bottles-Approve educational videos and promotional posters promoting water consumption

-Ensure all tasks are being completed by employees in monthly meetings

Teachers -Trained about program-Replace any advertisements for SSBs with promotional posters in classroom and hallways

-First day of homeroom class: Provides free reusable water bottles and demonstrates location of all hydration stations to students

-First homeroom class of every month: shows monthly educational video promoting water consumption among students-Active involvement in the promotion of drinking water during homeroom including group discussions about monthly video-Assists students in locating and utilizing hydration stations-Supports drinking water in class

FNS Staff -Trained about program-Removes all SSBs from places of purchase and replace with water products-Removes all advertisements of SSBs from cafeteria and vending machines to replace with promotional posters

-Ensures proper products are available for purchase (no SSBs are available)

Students -Receive school newsletter about program

- First day of homeroom class: Given free reusable water bottles and sown location of hydration stations

-Open group discussion in homeroom class about monthly videos and the importance of drinking water rather than SSBs

-Access to hydration stations located in various areas of the school

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Table 2. Scope and Sequence of Monthly 10-Minute Homeroom Promotional Videos

Video Number Video Title Description & Topics Covered

Channel/Vehicle Participant

1 “H2O and Your Body” Discusses the anatomy and physiology of the body and how water hydrates and nourishes the body

Videotape Students

2 “Nutrition of H2O” Discusses how water purely hydrates the body, without adding empty calories like alternative beverages

Videotape Students

3 “The Many Sources of H2O”

Discusses the many sources of clean drinking water one can acquire and how water can be free versus alternative beverages

Videotape Students

4 “H2O and Performance” Discusses the importance of water in the role of performing physically in sports and mentally in school

Videotape Students

5 “Staying Hydrated with H2O”

Discusses why drinking water throughout the day is important and how it’s the only beverage to keep the body properly hydrated

Videotape Students

6 “H2O On the Go” Discusses how to prepare to stay hydrated by drinking water when not at home or school

Videotape Students

7 “Saying No When Not H2O”

Discusses how to properly refuse alternative beverages that are not water

Videotape Students

8 “H2O at Home” Discusses how to ask parents to buy water, rather than alternative beverages, for the home environment

Videotape Students

9 “H2O Your Health” Gives an overview of what was previously discussed and also goes into further detail about how drinking water, rather than alternative beverages, maintains an overall healthy lifestyle

Videotape Students

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Question 14: Design Document

Design documents are essential in the creation of important materials for the H2O My

Health program such as the educational videos and promotional posters. Table 3 represents how

the design documents for the H2O My Health program will be formulated. The following

example is a sample design document for promotional posters displayed in classrooms and

school hallways.

Table 3. Sample Design Document

Product: Promotional posterTheme: “H2O My Health: Here to Own My Health”- encouraging students to take ownership of their health by making healthier beverage selectionsChannel/vehicle: Display printAudience: Middle school students ages 11-13Theoretical Methods: Belief selection, imagery, repeated exposure, cultural similarityChange Objective: Students will have confidence in the ability to choose water as a beverage over other options. Posters should increase self-efficacy about drinking water.

Sample Description: Poster will be 18 x 24 dimensions with an ocean blue, white and grey color scheme. A picture of a water droplet as the back drop of the poster is preferred. The chosen font for the poster is Comic Sans MS. Poster should have the name of the program, H2O My Health: Here to Own My Health, in the center and have surrounding pro-water slogans. Please refer to the following section for examples of slogans promoting water consumption among students. The overall message of the poster is to encourage students to drink water rather than other, calorie-laden beverages. Have poster emphasize that students are in charge of their own health. Instill the feeling of empowerment for the students to make the healthier beverage choice.Sample Slogans:

“Be in the know and drink H2O” “Water: A body’s best friend” “When offered drinks with fizz and caffeine, say no. Just drink H2O” “Water: the healthiest drink you’ll never have to pay for”

Question 15: Pretesting

Pretesting is defined as the method of analyzing messages conveyed by program products

among the target population before the final production of the program (Bartholomew, Parcel,

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Kok, Gottlieb, & Fernandez, 2011). Pretesting is essential in the determining whether or not the

planning of the program to this point has resulted in clear, engaging messages as well as if the

program can actually be implemented (Bartholomew et al., 2011). The pretesting will evaluate if

the program materials and implementers meet the cultural needs of the target population

(Bartholomew et al., 2011). It is important for the program to be comprehensible and inoffensive

to the culture it is addressing as well as utilize concepts of the culture when making program

changes to increase community capacity once the program is complete (Bartholomew et al.,

2011). The pretesting phase is also a period for checking parameters of theoretical methods

(Bartholomew et al., 2011). This review is important in assessing if methods were

operationalized appropriately (Bartholomew et al., 2011). For the H2O My Health program, it is

imperative for the middle school students of Jackson Middle School to accept the messages of

the program in order to see a response to the program. Therefore, the slogans and media utilized

to covey the program messages will first be pretested in focus groups with middle school

students. The focus groups will present the various promotional posters and videos to the group

of middle school students and receive feedback on the vernacular and attractiveness of the

program material. Questions addressed in the focus group are as follows: “Do you like the

poster?” “Can you understand the message of the poster?” “How do you feel about the design of

the poster?” “Do the posters appeal to you? How or how not?” “Do these posters encourage you

to drink water rather than other beverages?” “If you could change the poster, what would you

change?” “How do you feel about the videos?” “Did you understand the message of the video?

Were you interested in the message?” “Are the peer models in the video like you and others your

age? If not, what would you change about them?” “If you could change the video, what would

you change?”

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The qualitative data collected in these focus groups will assist in deciding whether or not

to alter program materials. If the majority of the responses are positive, then the program

materials can remain the same for actual program implementation. However, if there are many

negative responses to the program materials in the focus groups then changes to the materials

will be made to better suit the target population. If any changes are made to the program posters

or videos, proper operationalization of theoretical methods will need to be assessed again. A pilot

test of the H2O My Health program within Jackson Middle School will occur after the pretesting

phase is complete. Pilot testing is a method in which the program is conducted with the

implementers and participants preceding actual implementation (Bartholomew, Parcel, Kok,

Gottlieb, & Fernandez, 2011). The pilot test will assist in confirming whether or not the H2O My

Health program is ready for complete implementation (U.S. Department of Health and Human

Services (HHS), n.d.).

Question 16: Cultural Relevance

As previously mentioned, the H2O My Health program is based in Jackson Middle School

located in the Third Ward district, an area of Houston, Texas with a high minority population.

The Third Ward was specifically chosen for implementation of the program because the needs

assessment found the prevalence of childhood obesity to be higher in non-Hispanic black and

Mexican-American youth as compared to non-Hispanic white youth (Ogden, Carroll, Curtin,

McDowell, Tabak, & Flegal, 2006). Although the focus of this intervention is on minority

middle school youth, non-Hispanic white students are still likely to attend Jackson Middle

School. Therefore, the H2O My Health program needs to be culturally relevant to various ethnic

backgrounds. It is essential for the program to also be applicable to all genders, religions, and

ages present within the target population. Relevance to the middle school students is important

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for overall acceptance of the program; therefore taking all major cultural differences into

consideration is critical for H2O My Health. Cultural variation will be primarily addressed within

the planning group. Those within the planning group are familiar with the community and the

variety of cultures making up the target population. Therefore, members of the planning group

are essential in creating materials appropriate for the cultural background of the target

population. Ensuring cultural relevance will also be addressed in the focus groups conducted

during the pretesting phase.

Question 17: Linkage for Adoption and Implementation

In the needs assessment for the H2O My Health program, a planning group involving a

variety of professionals was established as a step in implementing an effective program. The

planning group established in the needs assessment includes school-age (SA) youth, parents of

obese and non-obese SA youth, Houston Independent School District (HISD) Board of

Education, principals, nurses, teachers, coaches, counselors, employees from The City of

Houston Health and Human Services, representatives from The Academy of Nutrition and

Dietetics and The Academy of Pediatrics, researchers from the University of Texas School of

Public Health in Houston, pediatricians, dietitians, nurses, and health educators from a local

UTHealth weight management clinic.

Before adoption and implementation of the H2O My Health program, any potential

additions to the planning group need to be considered. A useful addition to the planning group

who would be helpful in the adoption and implementation of the H2O My Health program are

beverage sales representatives for HISD. Negative pushback on breaking vendor contracts and

funding by removing SSBs and related advertisements from the school environment is likely.

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However, if beverage sales representatives are members of the planning group, discussions about

using the company’s water products will settle any uncertainty. Removal of the beverage

company’s advertisements within the school environment will also be discussed.

Another group to be added to the planning group includes the Texas branch of Clean

Water Action. Clean Water Action is an organization dedicated to protecting not only the

environment but also the health of individuals through ensuring clean and affordable drinking

water to communities (Clean Water Action, n.d.). Involving members of this organization in the

planning group could be vital in the selection of the best water station devices responsible for

supplying the students with clean drinking water as a part of the program.

Question 18: Adoption, Implementation, Maintenance Performance Objectives

As the intervention transitions from the development phase to actual implementation,

specific steps need to be taken to ensure proper adoption, implementation and maintenance of the

program. For H2O My Health, the program must be adopted by the HISD Board of Education,

implemented in Jackson Middle School by school personnel, and maintained within the middle

school to determine institutionalization of the program. Program objectives are essential in

guiding the adoption, implementation, and maintenance process of the H2O My Health program.

The following performance objectives describe the steps taken to accomplish desired outcomes

for the adoption, implementation, and maintenance of the H2O My Health program.

Adoption Outcome: The Board of Education of the Houston Independent School

District decides to adopt the H2O My Health obesity prevention program as indicated by the

superintendent signing the form for program adoption.

Performance Objectives for Adopters

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The HISD Board of Education will:PO1.1 Assess the target population’s need for a program such as H2O My HealthPO2.1 Review the H2O My Health program materialsPO3.1 Consider the H2O My Health program objectives, methods, and overall advantagesPO4.1 Acquire reactions to the program from the participating principal, teachers, FNS staff, and student parentsPO5.1 Collect current evidence on the effectiveness of other school districts using a similar programPO6.1 Note any potential obstacles of utilizing the H2O My Health programPO7.1 Approach the linkage system for ideas and solutions on how to undertake program obstaclesPO8.1 Acquire support for program adoption from the principal, teachers and FNS staffPO9.1 Formulate an announcement including an endorsement for the adoption of the programPO10.1 Finalize the form for adoption of the H2O My Health programPO11.1 Have the completed adoption form signed by the HISD superintendent and returned

Implementation Outcome: Jackson Middle School will implement the H2O My Health

obesity prevention program including clean water accessibility, use of a pro-water media

campaign as well as removal of all SSB products and advertisements from the school

environment.

Performance Objectives for Implementers

PO1.2 The Jackson Middle School principal will order hydration stations and reusable water bottles needed for the implementation of the H2O My Health programPO2.2 The Jackson Middle School principal, teachers and FNS Staff will undergo training in preparation for the implementation of the H2O My Health programPO3.2 The Jackson Middle School FNS will remove all SSBs from places of purchase within the school environment and replace the SSBs with water productsPO3.2 The Jackson Middle School teachers and FNS Staff will remove any advertisements for SSBs within the school environment and replace with H2O My Health promotional postersPO4.2 The Jackson Middle School teachers will show students all locations of hydration stations and distribute free reusable water bottles to students during the first homeroom class of the school yearPO5.2 The Jackson Middle School teachers will integrate the nine H2O My Health program videos, and a discussion about topics from the videos, into the first homeroom class of every month throughout the school yearPO6.2 The Jackson Middle School principal, teachers, and FNS Staff will implement the H2O My Health program as trained and will be follow-up during monthly meetings

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Maintenance (Sustainability) Outcome: Jackson Middle School will institutionalize the

H2O My Health obesity prevention program into the organization’s practices.

Performance Objectives for Maintenance (Sustainability)

PO1.3 The Jackson Middle School principal will train future teachers and FNS staff on how to properly implement the H2O My Health program every yearPO2.3 The Jackson Middle School principal will order any needed material for the implementation of the H2O My Health program (e.g. hydration stations, reusable water bottles, promotional posters and videos)PO3.3 The Jackson Middle School principal will include implementation of the H2O My Health program in teacher and FNS staff job responsibilitiesPO4.3 The Jackson Middle School principal will announce yearly program outcomes to the HISD Board of Education to maintain adequate fundingPO5.3 The Jackson Middle School principal will include the H2O My Health program in the yearly budgetPO6.3 The Jackson Middle School principal will sustain an open communication channel with all members of the linkage system concerning any inquiries

Question 19: Adoption and Implementation Matrix

Refer to Matrix 1 for the change objectives for the adopters of the program and Matrix 2

for the change objectives for the implementers of the program.

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Matrix 1. Change Objectives for Program Adopters

Determinants: Knowledge and Awareness(K)

Attitudes (A) Self-Efficacy (SE) Outcome Expectations (OE)

PO1.1 Assess the target population’s need for a program such as H2O My Health

K1.1 Explain needs of the target population and why H2O My Health is essential in

improving the students’ health

A1.1 Express that meeting the needs of the students is important for the students’ health

SE1.1 Have confidence in the ability to assess the target population’s need for the H2O My

Health program

OE1.1 Expect that assessing the needs of the target population will be beneficial to the students’ health

PO2.1 Review the H2O My Health

program materials

K2.1 Describe the H2O My Health program

materials and their purpose in the H2O My

Health program

A2.1 Express that the H2O My Health program

materials should be easily utilized in the middle school environment

SE2.1 Have confidence in the ability to review the H2O My Health program materials

OE2.1 Expect that materials are appropriate for the target population

PO3.1 Consider the H2O My Health

program objectives, methods, and overall advantages

K3.1 Describe the objectives, methods and advantages of the H2O My Health program

A3.1 Express that the objectives, methods and advantages of the H2O My Health program will

benefit the target population

SE3.1 Have confidence in the ability to study all objectives, methods, and advantages of the H2O My Health program

OE3.1 Expect that the H2O My Health program

objectives, methods, and advantages are appropriate for the target population

PO4.1 Acquire reactions to the program from the participating principal, teachers, FNS staff, and student parents

K4.1 Describe the different reactions as well as the overall consensus of the H2O My

Health program

A4.1 Express that obtaining reactions about the H2O My Health program is important in

deciding whether or not to adopt the H2O My

Health program

SE4.1 Have confidence in the ability to obtain reactions about the H2O My Health program

OE4.1 Expect that obtaining reactions about the program will result in a positive consensus

PO5.1 Collect current evidence on the effectiveness of other school districts using a similar program

K5.1 Describe other school districts who used a similar program and the effectiveness of these programs

A5.1 Express that reviewing effectiveness of similar programs in other districts is essential in deciding whether or not to adopt the H2O My

Health program

SE5.1 Have confidence in the ability to determine whether or not similar programs were effective in other school districts

OE5.1 Expect that reviewing effectiveness of similar programs in other school districts will assist in the decision to adopt the H2O My

Health program

PO6.1 Note any potential obstacles of utilizing the H2O My Health program

K6.1 Describe any potential obstacles of the H2O My Health program

A6.1 Express that identifying potential obstacles of the program is important in the preparation for adoption of the H2O My Health

program

SE6.1 Have confidence in the ability to identify any potential obstacles of the H2O My Health

program

OE6.1 Expect that identifying potential obstacles will assist in preparing for such obstacles in the future

PO7.1 Approach the linkage system for ideas and solutions on how to undertake program obstacles

K7.1 Describe solutions for addressing the program obstacles

A7.1 Express that solutions will prevent obstacles from hindering utilization of the H2O

My Health program

SE7.1 Express confidence in the ability to come up with ideas and solutions for program obstacles

OE7.1 Expect that the linkage system will be able to assist in overcoming program obstacles

PO8.1 Acquire support for program adoption from the principal, teachers and FNS staff

K8.1 Explain who supports program adoption

A8.1 Express that support from school personnel is important for program adoption

SE8.1 Express confidence in the ability to acquire support for program adoption from school personnel

OE8.1 Expect that support for program adoption from school personnel will assist in the decision of adopting the H2O My Health

program

PO9.1 Formulate an announcement including an endorsement for the adoption of the program

K9.1 Explain reasons why the adoption of the H2O My Health program is being

endorsed

A9.1 Express that endorsing the program is important for the organization to support the adoption of the H2O My Health program

SE9.1 Express confidence in the ability to endorse the adoption of the H2O My Health

program

OE9.1 Expect that endorsing the program will gain overall support for the adoption of the H2O My Health program

PO10.1 Finalize the form for adoption of the H2O My Health program

K10.1 Describe components on the adoption form that were completed for the H2O My

Health program

A10.1 Express that completing the form is important for the adoption of the H2O My

Health program

SE10.1 Express confidence in the ability to complete the adoption form for the H2O My

Health program

OE10.1 Expect that completing the form will lead to the final steps for adopting the H2O My

Health program

PO11.1 Have the completed adoption form signed by the HISD superintendent and returned

K11.1 Explain the reasons why the HISD superintendent must sign and return the form in order to adopt the H2O My Health

A11.1 Express that having the adoption form signed and returned by the HISD superintendent is essential for the adoption of

SE11.1 Express confidence in the ability to have the HISD superintendent sign and return the program adoption form

OE11.1 Expect that having the HISD superintendent sign and return the form will result in adoption of the H2O My Health

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program the H2O My Health program program

Matrix 2. Change Objectives for Program Implementers

Determinants: Knowledge and Awareness(K)

Attitudes (A) Skills & Self-Efficacy (SSE) Outcome Expectations (OE)

PO1.2 The Jackson Middle School principal will order hydration stations and reusable water bottles needed for the implementation of the H2O My Health program

K1.2 Identify what needs to be ordered and how much of the budget will contribute to the purchases

A1.2 Express that the purchased materials are essential to the implementation of the H2O My

Health program

SSE1.2a Express confidence in the ability to order needed materials for the implementation of the H2O My Health

programSSE1.2b Demonstrate the ability to order needed materials for the implementation of the H2O My Health program

OE1.2 Expect that ordering the needed materials will assist in the proper implementation of the H2O My Health

program

PO2.2 The Jackson Middle School principal, teachers and FNS Staff will undergo training in preparation for the implementation of the H2O My Health program

K2.2 Describe what the training for the H2O My Health program will cover

A2.2 Express that training is important in order to properly implement the H2O My

Health program

SSE2.2a Express confidence in the ability to attend the program trainingSSE2.2b Demonstrate the ability to perform specific skills learned from program training sessions

OE2.2 Expect that attending program training sessions will increase likelihood of proper implementation of the H2O My

Health program

PO3.2 The Jackson Middle School FNS will remove all SSBs from places of purchase within the school environment and replace the SSBs with water products

K3.2 Describe all locations in which SSBs are sold and will be replaced with water products

A3.2 Express that replacing SSBs with water will assist the students in making healthier beverage choices

SSE3.2a Express confidence in the ability to replace all SSBs sold with water productsSSE3.2b Demonstrate the ability to replace all SSBs sold in the school environment with water products

OE3.2 Expect that replacing all SSBs sold in the school environment with water products will increase water consumption among students

PO4.2 The Jackson Middle School teachers will show students all locations of hydration stations and distribute free reusable water bottles to students during the first homeroom class of the school year

K4.2a Describe all locations of hydration stationsK.42b Describe when to retrieve reusable water bottles from principal and how to properly distribute the bottles to the class

A4.2 Express that presenting all locations of hydration stations and distributing free reusable water bottles to students during the first homeroom class of the school year will encourage students to actively utilize hydration stations

SSE4.2a Express confidence in the ability to assist students in locating hydration stations and obtaining their reusable water bottleSSE4.2b Demonstrate the ability to show hydration stations and distribute reusable water bottes

OE4.2 Expect that presenting hydration stations and distributing reusable water bottles will increase use of hydration stations among students

PO5.2 The Jackson Middle School teachers will integrate the nine H2O My Health program videos, and a discussion about topics from the videos, into the first homeroom class of every month throughout the school year

K5.2 Describe the nine H2O My

Health program videos and the main topics for discussion each month

A5.2 Express that showing and discussing H2O My Health program videos each month

will encourage students to make healthier beverage selections

SSE4.2a Express confidence in the ability to show and discuss all nine program videosSSE4.2b Demonstrate the ability to present and discuss topics of each program video with the first homeroom class of every month

OE5.2 Expect that presenting and discussing program videos will result in increased water consumption among students

PO6.2 The Jackson Middle School principal, teachers, and FNS Staff will implement the H2O My Health program as trained and will be follow-up during monthly meetings

K5.2 Describe tasks and responsibilities for proper implementation of the H2O My Health

program

A6.2 Express that following up on employee responsibilities of the H2O My Health

program will ensure fidelity of implementation

SSE6.2a Express confidence in the ability to discuss proper implementation of the H2O

My Health program

OE6.2 Expect that having monthly meeting will ensure fidelity of the H2O My Health

program

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Question 20: Promotion of Adoption and Implementation Methods and Applications

Utilization of health promotion programs within an organization entails respect of various

factors such as the organization’s goals, structure of authority, roles within the organization,

regulations, and relationships (Beyer & Trice, 1978; Goodman, Steckler, & Kegler, 1997; Riley,

Taylor, & Elliott, 2003; Rogers, 1983). Therefore, the H2O My Health program needs to

encourage the adoption decision as well as implementers to take ownership towards tasks of

program operation (Batholomew, Parcel, Kok, Gottlieb, & Fernandez, 2011). Within this

process, the planning team of the H2O My Health program will utilize theoretical methods and

practical applications to encourage program adoption and implementation (Bartholomew et al.,

2011). Methods utilized by the H2O My Health planning team to design practical applications to

accomplish adoption and implementation of the program originate from theories including Social

Cognitive Theory, Theories of Information Processing, Health Belief Model, and Theories of

Goal Directed Behavior (Bartholomew et al., 2011).

Table 4. Methods and Practical Applications for Adoption and Implementation

Determinants Methods Practical Applications Parameters

Attitudes, Outcome Expectations

Persuasive Communication (SCT) A: Video encouraging adoption of program through use of arguments about how drinking SSBs increases a student’s risk for childhood obesity and therefore the H2O My Health program will reduce such risk among students. Video will include school principals, teachers, FNS staff, and students discussing the benefits of such a program in the school environment.I: Video shown during staff training discussing the importance of the H2O My Health program implementation in reducing risk for childhood obesity among students. Video uses arguments from school principals, teachers, and FNS staff for why the implementation in the school is important for the health of the students.

Messages need to be applicable to individual’s beliefs; includes surprise, replication and arguments

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Self-Efficacy, Skills Modeling (SCT) A: Newsletter featuring real stories from school principals, teachers, FNS staff, and students about the positive impact a program like H2O My Health has on beverage selection and overall student health (McAlister, 1995; McAlister & Fernandez, 2002).

Use of attention, remembrance, self-efficacy and skills; individuals must be able to identify with role models; model must be reinforced; use of coping rather than mastery model

Self-Efficacy, Skills Facilitation (SCT) I: Installation of hydration stations and removal of SSB products and advertisements will aid in the implementation process of the program

Requires changes be made in the environment; recognizes barriers and implementers; intervention should be at a higher level

Knowledge Imagery (Theories of Information Processing)

A: Newsletters and examples of promotional posters for the program will be delivered to the HISD Board of EducationI: Promotional posters utilized in training sessions

Accustomed images act as a parallel to a less accustomed practice

Attitudes, Knowledge Discussion (Theories of Information Processing)

A: Scheduled meetings with HISD Board of Education in which the program planning team will give an oral presentation about H2O My Health and follow the presentation with questions and comments from the audience

Listening to those learning to confirm right schemas are initiated

Knowledge Advance organizers (Theories of Information Processing)

A: The planning team of H2O My Health will present an overview of the program material in scheduled meetings with the HISD Board of Education to encourage adoption of such a programI: Educational videos utilized in training sessions will give an overview of the H2O My Health program, why it is important, and how to properly implement the program within the school environment

Representation of content and what is to be learned

Knowledge, Awareness, Self-Efficacy

Consciousness Raising (HBM) A: Adoption video provides information about the causes, consequences for high consumption of SSBs leading to childhood obesity among students

Can utilize feedback and confrontation but awareness raising must be followed by enhancement of problem-solving capability and self-efficacy

Self-Efficacy, Skills, Outcome Expectations

Implementation Intentions (Theories of Goal Directed Behavior)

I: During training sessions, Jackson Middle School staff will undergo role-playing opportunities in which they will connect circumstances with responses to obtain desired outcomes for implementation

Current positive intention

Self-Efficacy, Skills Enactive Mastery Experiences (SCT)

I: Training sessions will teach Jackson Middle School principal, teachers, and FNS staff how to properly implement the program through use of educational videos, role-playing opportunities, and practice with all program materials

Reliable source

SCT: Social Cognitive Theory, HBM: Health Belief Model, A; adopters, I: implementers

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Question 21: Evaluation

Evaluating H2O My Health is essential for determining if the program has been

implemented with fidelity, is effective in producing desired outcomes and informing

stakeholders about methods for improving childhood obesity (Rossi, Lipsey, & Freeman, 2004).

Two types of evaluation are utilized in the evaluation of a program: process evaluation and effect

evaluation. Process evaluation determines whether a program is delivered to the target

population as planned (Rossi et al., 2004). Process evaluation will assess both the delivery and

the coverage of the program. Outcome evaluation measures the changes in outcomes in relation

to the program (Rossi et al., 2004). Therefore changes in outcomes such as health, environment,

behavior, and risk determinants will be determined in the outcome evaluation for the H2O My

Health program. The quality of life outcomes do not have their own evaluation questions

because it is not feasible to measure these outcomes within the time frame of the program

evaluation. The design proposed for the evaluation of the H2O My Health program is a

nonrandomized two-group quasi-experimental design with pre- and post-tests given to both

intervention and comparison groups. The evaluation design notation for the H2O My Health

program is as follows:

O1 X O2

NR ------------------- O1 O2

Material from all five steps of intervention mapping is utilized in the development of an

evaluation plan for a program. Steps 4 and 5 are used in process evaluation in which adoption,

implementation and sustainability are assessed. These steps guide process questions concerning

program coverage. Fidelity will be evaluated from step 3, in which theory-based methods and

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practical applications selected for the program will be evaluated. Effect evaluation will assess

program impact on outcomes of health, behavior, and environment as well as behavioral and

environmental determinants. These factors originate from steps 1 and 2, the needs assessment

and matrices of change objectives.

Table 5. Evaluation Plan Summary for the H2O My Health program

Type of Evaluation Evaluation Question Variable/Indicator Measure Source Data Collection Timing

Effect (Health Outcome) Did H2O My Health make an impact on the prevalence of childhood obesity among Jackson Middle School students as compared to the control group?

% obese students The Children's BMI Tool for Schools (Centers for Disease Control and Prevention, 2015)

Middle school students Baseline (August), follow-up (May), and second follow-up two years post-intervention

Effect (Behavioral Outcome)

Did H2O My Health reduce SSB consumption among Jackson Middle School students as compared to the control group?

% SSB consumption Self-report questionnaire Middle school students Baseline (August) and follow-up (May) , and second follow-up two years post-intervention

Effect (Environmental Outcome)

Did H2O My Health reduce availability of SSBs to Jackson Middle School students as compared to the control group?

% SSBs offered Direct observation Data collectors Baseline (August) and follow-up (May) , and second follow-up two years post-intervention


Did H2O My Health increase accessibility of potable drinking water to Jackson Middle School students as compared to the control group?

% clean water sources a. Self-report questionnaire

b. Direct observation

a. Middle school students

b. Data collectors

Baseline (August) and follow-up (May) , and second follow-up two years post-intervention


Did H2O My Health decrease media promoting unhealthy beverage options to Jackson Middle School students as compared to the control group?

% media promoting SSBs a. Self-report questionnaire

b. Direct observation

a. Middle school students

b. Data collectors


Effect (Behavioral Determinant)

Did H2O My Health increase knowledge about the importance of drinking water among Jackson Middle School students as compared to the control group?

Knowledge (Likert Scale) Self-report questionnaire (Gase, Robles, Barragan, & Kuo, 2014)

Middle school students Baseline (August) and follow-up (May) , and second follow-up two years post-intervention


Did H2O My Health increase skills and self-efficacy of selecting water rather than SSBs among Jackson Middle School students as compared to the control group?

a. Self-Efficacy (Likert Scale)

b. Skills

a. Self-Efficacy: Self-report questionnaire (Masui et al., 2002)

b. Skills: Direct observation

a. Self-Efficacy: Middle school students

b. Skills: Data collectors



Did H2O My Health increase positive attitudes about drinking water among

Attitudes (Likert Scale) Self-report questionnaire (Patel et al., 2014)

Middle school students Baseline (August) and follow-up (May) , and second follow-up two

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Jackson Middle School students as compared to the control group?

years post-intervention


Did H2O My Health increase positive outcome expectations about drinking water among Jackson Middle School students as compared to the control group?

Outcome Expectations (Likert Scale)

Self-report questionnaire (Sharma, Wagner, & Wilkerson, 2006)

Middle school students Baseline (August) and follow-up (May) , and second follow-up two years post-intervention

Effect (Environmental Determinant)

Did H2O My Health increase knowledge about the importance of promoting water consumption among Jackson Middle School personnel as compared to the control group?

Knowledge (Likert Scale) Self-report questionnaire (Chen et al., 2009)

Principal, teachers, and FNS staff



Did H2O My Health increase skills and self-efficacy to promote selection of water rather than SSBs among Jackson Middle School personnel as compared to the control group?

a. Self-efficacy (Likert Scale)

b. Skills

a. Self-Efficacy: Self-report questionnaire (Domsch, 2009)

b. Skills: Direct observation

a. Self-Efficacy: Principal, teachers, and FNS staff

b. Skills: Data collectors



Did H2O My Health increase positive attitudes about promoting water consumption among Jackson Middle School personnel as compared to the control group?

Attitudes (Likert Scale) Self-report questionnaire (Midler et al., 2014)

Principal, teachers, and FNS staff


Process (Program Coverage)

How many students participate in the H2O My Health program activities?

% students reached Self-report questionnaire Principal, teachers, and FNS staff

Throughout implementation (Collected first of the month, August-May)


How many homeroom sessions containing modeling videos and group discussion are delivered in each classroom?

Dose delivered a. Direct observation

b. Self-report implementation logs

Data collectors

b. Principal, teachers, and FNS staff

Throughout implementation (Collected first of the month, August-May


How many homeroom sessions containing modeling videos and group discussion do each student receive?

Dose received In-depth interview Middle school students Throughout implementation (Collected first of the month, August-May

Process (Program Delivery)

Do Jackson Middle School personnel deliver the H2O My Health program components/activities as intended?

Fidelity a. Direct observation

b. Self-report implementation logs

a. Data collectors

b. Principal, teachers, and FNS staff

Throughout implementation (Collected first of the month, August-May)

Process (Program Delivery)

How satisfied are students with the H2O My Health program as a whole?

Student satisfaction In-depth interview Middle school students Throughout implementation (Collected first of the month, August-May)

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Resources:

-Personnel: Jackson Middle School

Employees (Principal, Teachers, FNS

Staff)

-Funding allotted from HISD Board

of Education

-Program Materials: hydration

stations, reusable water bottles,

videos, posters

-Time for implementation

Implementation of Program

Activities and Materials:

-Training for school principal,

teachers, and FNS staff

-Newsletter sent to students

-Removal of SSBs

-Provision of clean drinking water

(hydration stations & water products)

-Removal of SSB media

-Program posters

-Distribution of reusable water

bottles

-Modeling videos

-Group discussions

Program Inputs

Behavioral

Theoretical

Methods:

-Belief selection

-Persuasive

communication

-Facilitation

-Imagery

-Modeling

-Counter-

conditioning

-Repeated exposure

-Cultural similarity

Environmental

Theoretical

Methods:

-Advocacy

-Modeling

-Mass media role-

modeling

-Mobilizing social

networks

Program Outputs

Behavioral

Determinants:

-Knowledge

-Skills & Self-Efficacy

-Attitudes

-Outcome Expectations

Environmental

Determinants:

-Knowledge

-Skills & Self-Efficacy

-Attitudes

Students will:

-Make the decision to drink water

-Obtain a reusable water bottle

-Obtain water from a water station or purchase water if reusable bottle is unavailable

-Drink water

-Refill reusable water bottle with water when empty

-Refuse alternative beverages including SSBs

-FNS staff will replace all SSBs with bottled water

-Principals will install water stations

-Principals will provide reusable water bottles to supply to students

-Teachers will allow water in closed containers in class

-Principals will discontinue advertising for SSBs including logos, posters and videos

Students will select water, rather than SSBs, as their beverage of choice

School staff will support students in selecting water, rather than SSBs, as their beverage of choice

Health Outcome: Reduced risk for childhood obesity and sequela (CVD, T2DM, stroke, HTN, types of cancer, mortality)

Quality of Life:

-Reduced risk for being obese as an adult

-Reduced health care cost

-Improved self-esteem

-Less likely to be stigmatized

Logic of Change Outcomes

Process Evaluation Effect Evaluation

Figure 1. Evaluation Logic Model


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