JOURNAL OF COMMUNITY HEALTH NURSING, 2006, 23(2), 6980 Copyright 2006, Lawrence Erlbaum Associates, Inc.

Development of an Obesity Prevention and Management Program for Children and Adolescents in a Rural Setting
Suzanne R. Hawley, PhD, MPH, Heidi Beckman, PhD, and Thomas Bishop, PsyD
Prairie View, Inc., Newton, Kansas

This study1 applied theory-based health behavior change constructs to childhood obesity prevention. Constructs such as goal setting, self-efficacy, and readiness for change were used within a rural community-based program designed to be developmentally appropriate for 6th graders. The project included 2 studies across 12 months. The 1st assessed the scope of the obesity problem within a 3-county area with key stakeholders in health and education. The 2nd implemented a pilot community intervention program within a rural middle school. Participants in the intervention included 65 middle-school students and the families of 25 of these students. Qualitative and quantitative analyses were conducted to assess the effectiveness of the intervention. Changes from pre- to postintervention on relevant measures were statistically significant for families but not for students. Issues related to family versus individual behavior change are discussed, along with implications for managing behaviorally based activity and nutrition interventions within a rural community.

The increasing incidence of obesity at all ages has been well documented and is one of todays most important public health issues (U.S. Department of Health and Human Services, 2000). At present, at least 15% of young people age 6 to 19 are obese, according to the guidelines of the American Obesity Association (2002). Obesity in youth places a person at greater risk of adulthood obesity (Must & Strauss, 1999), high blood pressure, high cholesterol, and Type 2 diabetes (Dietz, 1998). Overweight young people may also experience higher rates of depression and social withdrawal and may have lower self-esteem than their peers of healthy weight (Erermis et al., 2004). Childhood obesity is thought by some to result from a toxic environment that supports sedentary behavior and an unhealthful diet rather than health-conscious lifestyle choices
Correspondence should be addressed to Suzanne R. Hawley, Department of Preventive Medicine and Public Health, University of Kansas School of MedicineWichita, 1010 N. Kansas, Wichita, KS 672143199. E-mail: shawley@kumc.edu 1This project was funded in part by Grant RFP 02-101 from the Sunflower Foundation of Kansas.

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(Wadden, Foster, & Brownell, 2002). Many obesity prevention and management programs are designed to help participants work toward the goals of increasing physical activity, reducing sedentary behavior, and following the guidelines of good nutrition. There is often a strong educational component to such programs. However, acquiring knowledge about fitness and nutrition does not necessarily translate into meaningful efforts to improve health. Therefore, it is important to look at both the environmental and individual factors that facilitate change to strengthen the possibility that participants take action toward their goals. Recent studies have identified the successful application of several psychological concepts of behavior modification to health objectives such as weight loss and obesity prevention. Goal-setting strategies, for example, structure a persons progress toward attainable goals and are believed to be an effective enhancement to weight management programs (Cullen, Baranowski, & Smith, 2001). The strengthening of self-efficacy, or the belief in ones capacity to take steps toward a desired goal (Bandura, 1986), has proven helpful in managing chronic health conditions (Shortridge-Baggett, 2001). Finally, the transtheoretical model of change has been useful in explaining individual readiness for behavior change in terms of five stages: precontemplation (unaware of or uninterested in a need for change), contemplation (ambivalent about changing), preparation (planning to change), action (making behavioral changes), and maintenance (continuing and reinforcing new behavior; Prochaska & DiClemente, 1986; Prochaska, DiClemente, & Norcross, 1992). These constructs allow active participation in behavioral change, as well as the creation of a unique change plan for each individual participant in a weight management program (Rollnick, 1996). The involvement of outside entities in the weight management process has also proven helpful in bringing about change. According to a recent review, family-based interventions are both the most studied and most effective short- and long-term weight loss initiatives (Faith, Saelens, Wilfley, & Allison, 2001). Wadden et al. (2002) noted that school-based interventions have demonstrated positive effects on diet and physical activity in students, although Levine and Smolak (2001) pointed out that no long-term benefits have yet been observed. Other researchers have speculated that obesity prevention and treatment programs could benefit from community involvement. For instance, Epstein, Myers, Raynor, and Saelens (1998) suggested that clinical activity be linked to community programs to reinforce treatment efforts. Sallis and Patrick (1994) proposed that a multifaceted community effort would help to promote physical activity in adolescents, as they would receive consistent messages from multiple external sources. Despite these promising ideas, rural areas attempting to implement a health intervention may face unique difficulties, such as limited health resources or limited access to existing resources due to geographical distance, lack of transportation, or economic hardship. In Kansas, rural health issues are particularly relevant, as 96 of the states 105 counties were classified as rural or frontier in 2003, according to federal guidelines for

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low population density (Kansas Rural Health Policy Agenda, 2003). Thirty-five percent of Kansass population was nonmetropolitan in 2003, nearly double the national average of 18% (Kaiser Family Foundation, 2003). The state experiences health disparities common to rural populations (Patterson, Moore, Probst, & Shinogle, 2004), such as higher rates of overweight and obesity (Centers for Disease Control and Prevention [CDC], 2002) and lower rates of physical activity (CDC, 2003) than the national average. Research indicates that, in general, rural populations are aware of the importance of good nutrition and the dangers of sedentary behavior and excess weight for young people (Omar, Coleman, & Hoerr, 2001; Puskar, Tusaie-Mumford, Sereika, & Lamb, 1999). Individuals do not always translate this knowledge into changed behaviors, as evidenced by the persistence of weight disparities between urban and rural populations (CDC, 2002). Community-level weight-control and nutrition programs have, however, been implemented with some success in schools (Carrel et al., 2005) as well as with older populations (Mayer-Davis et al., 2004), as ways to support rural individuals efforts at improving physical health. All of these findings motivated the development of a pilot community-, school-, and family-based obesity prevention program for rural sixth-graders in Kansas. The Pilot Community Prevention Program was intended to address the usual rural health challenges of accessibility and distance while also ensuring community buy-in by building on the existing community base of health leaders and resources. The program took place in three east-central Kansas counties: Marion County, McPherson County, and Harvey County.

PURPOSE The pilot programs goals were to deliver messages about the importance of eating healthfully and becoming more active and to raise students motivation for these goals by using cutting-edge behavior-change techniques. The program provided education and practice in the skills identified as important to the health behavior change process: goal setting, building self-efficacy, and enhancing readiness for change. It also addressed environmental factors by including school, family, and community components to reinforce the treatment efforts. The project included two studies over 12 months to build on knowledge gained and to expand the scope of the intervention as the project progressed. Study 1 was designed to raise community awareness of obesity in youth, assess the scope of the problem within a three-county catchment area, evaluate risk factors and how they may pertain to rural community interventions, and establish a multiagency network of concerned professionals. Study 2 implemented a community-based obesity prevention program for sixth graders in Hesston, a town of 3,500 people in Harvey County.

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Hawley, Beckman, Bishop STUDY 1: PREINTERVENTION PHASE: COMMUNITY ASSESSMENT AND NETWORKING

Method

Participants. One hundred thirteen community members were selected to participate in a survey about obesity-related issues. Participants were professionals representing key community agencies and systems selected from the three-county catchment area. Professionals included health department representatives, cooperative extension representatives, physical and health education instructors, mental health practitioners, directors of recreational centers and programs, physicians, dietitians, and school counselors. Agencies that participated in the formation of a community-based obesity referral network included the Health Advisory Council of the Head Start Programs, a school nurses group, an existing multiagency community group, the Cooperative Extension Office, representatives of the Partnership/Communities in Schools, the Hesston Recreation Commission and Hesston Ministerial Alliance, and an advisory council for the middle school in which the obesity prevention program took place. Other contacts included the state health departments bureau of health promotion and its statistical center, as well as a state-level philanthropic health foundation.

Instrument and procedure. Information regarding salient risk factors for childhood and adolescent obesity was identified through literature reviews and through consultation with dietitians and pediatricians. These findings were then utilized in formulating a Health and Wellness Questionnaire to raise awareness of youth obesity, obtain feedback regarding professionals assessment of the problem, and elicit interest in further development of community interventions. The Health and Wellness Questionnaire consisted of two parts. The first half consisted of open-ended questions designed to gather demographic information and assess qualitative perceptions of community efforts in addressing youth nutrition and exercise (e.g., community resources, community activities, potential barriers to healthy nutrition and exercise, strengths of the community, groups that may be at risk, and ideas regarding prevention and treatment). The second half of the questionnaire consisted of 43 quantitative questions about obesity risk factors, grouped into six categories: psychological, cognitive, and emotional; physical activity; nutritional; behavioral attributes and skills; social and cultural; and physical environment. For each of the 43 questions, respondents indicated their perception of a risk factors centrality to the problem of child and adolescent obesity in their community by choosing a number on a 5-point Likert-type scale from 1 (minimal importance) to 5 (critical importance). Following the distribution of the survey, key community partners were solicited for participation in an obesity referral network. Community meetings were conducted in

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each of the counties in the catchment area. The intent of these meetings was to elicit support and participation, assess specific community needs and barriers to addressing youth obesity, identify potential community risk factors, and heighten the awareness of health concerns regarding youth obesity. Additional information was presented through a health fair and an educational workshop at one of the county recreation centers. To gain a still more complete representation of the communitys health, the director of the local recreation commission was interviewed regarding perceptions of youth obesity, barriers to prevention and intervention, community resources in impacting the health of youth, and programming suggestions. The director was also asked to complete a second questionnaire entitled Our Views on Childrens Health. This questionnaire provided qualitative information about the agencys sense of self-efficacy and readiness for change in helping children and adolescents reach their fitness and nutrition goals. A community church was contacted and a representative also completed the same questionnaire.

Results and Discussion Forty-four of the 113 Health and Wellness Questionnaires distributed were returned (39% response rate). All but 5 of these were from women, most of whom were school personnel who possessed experience dealing with students from kindergarten to high school age. From the quantitative portion of the questionnaire, means and standard deviations were calculated for each of the six obesity risk factor categories to provide a picture of rural community perceptions about youth obesity (see Table 1). On the 5-point Likert-type scale, respondents indicated means of at least 3.00 (moderate importance) for all risk factor categories. Means for each category ranged between 3.00 (for environmental factors) and 4.04 (for psychological factors). In the qualitative portion of the questionnaire, respondents identified a number of resources within their rural communities for recreation and physical activity, but they also

TABLE 1 Means for Health and Wellness Questionnaire: Obesity Risk Factor Category Risk Factor Category Psychological, cognitive, emotional Physical activity Nutritional Behavioral attributes and skills Social and cultural Physical environment M Perception of Importancea 4.0435 3.8824 3.9545 3.7059 3.5652 3.0000 SD .20851 .33211 .57547 .68599 .50687 .45883

Note. N = 44. aItems were rated on a Likert-type scale ranging from 1 (minimal importance) to 5 (critical importance).

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cited a number of problems that may limit childrens participation in healthy lifestyles. Some consistent recommendations included the following: 1. Pay special attention to youth from families of lower socioeconomic status and from families where parents are less involved. 2. Improve access to recreational activities when specific activities and resources are not distributed evenly throughout the townships in a given county. 3. Address the transportation difficulties that are common in rural areas. 4. Improve financial assistance to parents of children who may want to participate in organized sports but cannot afford it. 5. Provide physical activity options that extend beyond organized sports. 6. Improve efforts at reaching youth and families who do not enjoy seeking physical activity, with more community activities aimed at nonathletes. 7. Increase access to nutritious foods and decrease access to unhealthful and fast foods. 8. Offer programs that involve the family, mentoring methods, or coaching methods to increase childrens sense of accountability for their participation in fitness activities. The obesity referral networks qualitative responses to the Our Views on Childrens Health survey indicated that agencies had both a sense of self-efficacy and readiness for change in helping children and adolescents reach their fitness and nutrition goals. They indicated both support for and willingness to assist in community change regarding youth obesity, and their relationship and involvement with this project continued throughout the two-study intervention until the posttest data were collected. Continued involvement with the referral network was encouraged but was not monitored by the study investigators.

STUDY 2: INTERVENTION PHASE: IMPLEMENTATION OF A PILOT COMMUNITY PREVENTION PROGRAM Method The Pilot Community Prevention Program was conducted in the rural town of Hesston, Kansas. This program consisted of two components: delivery of a five-session middle school classroom program over a 6-week period and implementation of a community event (a Family Fun Night) to promote physical activity and nutrition. This program integrated the recommendations gleaned from the community survey in Study 1 to increase cultural appropriateness, community support, and the overall fit of the program to the place in which it was implemented.

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Participants. All 65 sixth graders at Hesston Middle School and their families were solicited for participation in the project, and all 65 participated in the classroom curriculum. The families of 25 of these students (16 boys and 9 girls) also consented to have data collected on their physical activity levels and eating behavior. All 25 students were White and they ranged in age from 11 years old (4, 16%) to 12 years old (20, 80%), with 1 student missing data for age. Of the study participants, 84% of the students came from two-parent families, whereas 8% came from single-parent families and 8% reported no answer. Eleven of these students and families completed the posttest questionnaires.

Procedure. The intent of this pilot school program was to educate students and families about the importance of good nutrition and exercise and to motivate them to reach these goals by using principles of behavior change described in recent health psychology literature. The program included instruction in nutrition, fitness, goal setting, self-efficacy, and stages of change. This project used a cohort, repeated measures design. The program consisted of five 40-min sessions during physical education classes for all sixth-grade students. The sessions took place over the course of 6 weeks during the spring semester (a 2-week interval elapsed between two of the sessions to accommodate scheduling needs of the school). Sessions consisted of adventure-based/experiential games and tasks. During the solicitation period of the project, all students were given a Family Field Guide that included guidelines for getting started (i.e., goal setting and self-efficacy), changing behaviors, charting and monitoring goals, and having fun working toward health goals, as well as information about health basics (i.e., eating from the five food groups, lowering fat, and decreasing sedentary activity), nutrition, and fitness. Students and families were also provided with a description of the project; a consent form for participation in the study; and a pretest of nutrition and exercise knowledge, attitudes, and behaviors that covered goal setting, self-efficacy, and stages of change. At the end of the program, posttest questionnaires were provided to participating students and their families. Students who participated in the study were given incentives such as water bottles, passes to the community swimming pool, and other health-related recreational materials. To measure self-reported physical activity, respondents identified which of 20 activities they had engaged in for a minimum of 15 min over the previous day outside of school. They assigned metabolic equivalent scores (METs) to each activity in a method developed by Sallis et al. (1993). Self-reported eating behavior was measured by calculating total calories and fat grams for the foods consumed by students and family members over the past 24 hr as described by Lytle et al. (1996). Body mass index was estimated for students by dividing their weight in kilograms by their height in meters squared. A Family Fun Night for the entire community was conducted at the local wellness center toward the end of the school intervention period. This event was designed to address

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the specific health needs communicated by participants in Study 1. All activities were free of charge; thus participation was not limited by an individuals socioeconomic status. The event also provided a fitness option beyond organized sports and offered encouragement to families working toward health-related goals. Activities included educational stations that addressed nutrition and exercise, as well as games that highlighted goal setting, readiness for change, and self-efficacy. Families were also able to use the wellness centers pool or take part in a self-guided community walk. Prizes and nutritious snacks were provided for participants. Families who attended the Family Fun Night provided positive feedback about the event.

Results and Discussion Although there were no significant changes in students individual health attitudes and behaviors from intervention pretest to posttest, significant changes did occur among families across the 6-week intervention period (see Table 2). Using a 7-point Likert-type scale to gauge self-efficacy, from 1 (not important at all) to 7 (extremely important), families saw the goal of eating healthfully as significantly more important after the intervention than they did before, from a mean of 5.73 at pretest to a mean of 6.10 at posttest (z = 2.00, p < .05). In the area of self-reported behavior, families as a whole significantly increased their level of physical activity over the course of the intervention, from a mean of 1.44 METs at pretest to a mean of 7.56 METs at posttest, t(8) = 4.22, p < .01. Families also showed a significant improvement on the four fitness knowledge questions, answering a mean of 0 correctly at pretest and improving to 2.45 at posttest, t(10) = 11.84, p < .001. However, they did not show significant improvement in their knowledge of nutrition and goal setting or in their view of the importance of being physically active. Several significant results were also revealed regarding the stages of change variable for families. Over the course of the intervention, there was a shift in the families readiness for change in the areas of exercise and nutrition (see Tables 3 and 4). On average,
TABLE 2 Changes in Mean Family Ratings: Pretest and Posttest Interventions Response Area Importance of goal-setting for eatinga Reported level of physical activity (in METs) Fitness knowledgeb Pretest M 5.73 1.44 0.00 Posttest M 6.10 7.56 2.45 p < .050 < .010 < .001

Note. N = 11. MET = metabolic equivalent score. aOn Likert-type scale ranging from 1 (not important at all) and 7 (extremely important). bMean number of questions answered correctly, out of 4.

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TABLE 3 Percentage of Families at Each Stage of Change for Exercise Goals at Pre- and Postintervention Stage of Change Precontemplation Contemplation Preparation Action Maintenance Total Note. N = 11. Pretest 0 21 25 37 17 100 Posttest 0 0 46 27 27 100

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TABLE 4 Percentage of Families at Each Stage of Change for Nutrition Goals at Pre- and Postintervention Stage of Change Precontemplation Contemplation Preparation Action Maintenance Total Note. N = 11. Pretest 0 13 4 54 29 100 Posttest 0 0 27 18 55 100

families moved forward approximately one fourth of a stage in the area of exercise and almost one half of a stage in the area of nutrition (M change score for exercise = 0.27, M change score for nutrition = 0.45). One explanation for this change is that families had more room to move forward on this dimension than did students. Many students began the intervention in the action and maintenance stages of change, whereas families tended to be in the preparation and action stages. Families also indicated they were significantly more ready to change their eating behavior when they perceived the goal of eating healthfully to be more important. These findings suggest that enhancing participants sense of self-efficacy may be a key to effective intervention in the area of nutrition. Additional explanations for the pilot studys lack of impact with students were also identified. In general, students indicated relatively high fitness knowledge (M = 2.4, SD = 0.8, range = 1 to 4) and activity levels (M = 16.3 METs per day) at pretest. Therefore, it seems that the students were much more active on their own than with other family members. This was consistent with comments made by respondents to the Health and Wellness Questionnaire and with their ratings of social and cultural risk factors for youth obesity, which described poor parental modeling of fitness and nutrition and limited levels of parental involvement in youth fitness activities.

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Hawley, Beckman, Bishop CONCLUSIONS FOR STUDIES 1 AND 2

The two-step Pilot Community Prevention Program represents an important beginning in addressing youth obesity in Kansas. In compiling a study-specific list of risk factors and recommendations, much was revealed about the unique challenges of designing a weight management program for a rural community. This information provided a strong foundation on which to build an intervention that addressed the communitys particular nutrition and activity challenges. The pilot school program addressed these unique needs; its incorporation into the school day avoided problems of participant access and transportation, and it provided fitness options beyond organized sports. As a result, the program was able to reach all students in the target school population. By involving interested families in the intervention as well, students received an additional level of support and were able to pass on the information learned through their school program. This connection also provided a link with the community-oriented Family Fun Night, giving yet another level of reinforcement to the nutrition and activity information imparted in the school program. Beneficial project approaches and outcomes included the development of a network of interested community professionals and a greater awareness of obesity risk factors for youth, as well as a significant improvement in participant families knowledge, readiness for change, and reported level of physical activity. The involvement of the community and its resources was a vital contributor to the success of the program. The pilot intervention not only drew attention to the issue of youth obesity, but also modeled a community-based approach by having key stakeholders impact aspects of an empirically validated pilot program. Study 1 participants described a need for the improved identification, assessment, treatment, and prevention of obesity in young people. Such improvement can occur only when agencies assist families with behavioral change. This intervention highlighted the ways in which agencies could focus their impact on the family and deal with youth obesity as a developmental and sociocultural issue. Study limitations include the small number of participants and the short intervention period in Study 2. The results of Study 2 indicated that the student sample might have been more advanced than expected in their understanding of the importance of good nutrition and fitness; still, a longer intervention period might have allowed improved family modeling of fitness and nutrition to positively impact individual student attitudes and behaviors. However, the intervention did appear to impact families movement toward change, and they were able to show significant improvements in a relatively short period of time. Further study is necessary to clarify what other variables may play a role in youth fitness and eating behaviors. Nonetheless, the project provides a starting point for additional efforts to address obesity in rural youths. Future interventions could look at issues such as accessing community-specific resources and needs, fostering a greater focus on family interventions, developing programs that extend beyond school districts and recreational centers, and

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creating prevention programs aimed at reaching nonathletes. Future research might also consider either including youth in the development of school and community projects or investing greater effort in reducing access to unhealthy foods and drinks while improving access to healthy foods and drinks. With more attention from future researchers, the often-ignored rural sector of the population can achieve real and lasting improvement in the physical health of its youth.

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