Participatory action research to assess and enhance coordinated school health in one elementary school
Participatory Action Research to Assess and Enhance Coordinated School Health in One Elementary School Table of Contents Abstract i Acknowledgements iii List of Figures and Tables vii List of Appendices viii
Chapter 1 1 Rationale for the Study 1 Coordinated School Health Program 3 Participatory Research 6 Study Purpose and Research Questions 9 Delimitations, Limitations, Assumptions 11
Chapter 2: Review of the Literature 13 Introduction 13 Participatory Research 17 School Health 21 Coordinated School Health Program 24 School Health and Participatory Research 32 From CSHP to CSH, 2010 47 Conclusion 51
Chapter 3: Methods 53 Introduction 53 The School 60 Gaining Entrée 63 Recruitment Methods 68 The Participants 70 The Study Process—Meetings and Activities 71 The Study Process—Data Collection and Analysis 81 Summary 88
Chapter 4: Results 89 Introduction 89 The Process of Negotiating a PAR Study 93 The Formation of the Wellness Council Mores 103 School Health Index Scores 112 Assets, Student Health Needs, Impediments 113 Strategies Used to Improve the CSHP 119 Dissemination of Results to the School Community 122 End-of-Year Evaluation 123
Participatory Action Research to Assess and Enhance Coordinated School Health in One Elementary School Table of Contents (continued) Chapter 5: Discussion 127 Introduction 127 Summary of the Asset and Needs Assessment 131 Review of Programs and Policies Implemented 134 Discussion of the Evaluation 136 Implications for Practice and for Research 141 Final Reflection of the Researcher 149
Participatory Action Research to Assess and Enhance Coordinated School Health in One Elementary School List of Figures and Tables Figures Title Identifier Location
CSHP Model Figure 1 p. 25 CSHP in an Ecological Framework Figure 2 p. 48 "How I Learn about Health" Asset Poster Figure 3 p. 77 SHC Presenting to Peers Figure 4 p. 78 Wellness Council Asset Map Figure 5 pp. 85, 115
Tables Title Identifier Location
Alignment of Process with Research Questions Table 1 pp. 57-60 List of Assets Table 2 p. 114 Issues which Impede CSH Table 3 p. 118 Before and After Cougar Credit Snack Lists Table 4 p. 122
Participatory Action Research to Assess and Enhance Coordinated School Health in One Elementary School List of Appendices Israel et al. Principles of CBPR Appendix A 161 Green et al. Guidelines for PAR Appendix B 162 Sample Checklist from Mariner Model Appendix C 167 Sample Checklist from SHI Appendix D 168 Sample Checklist from Healthy School Report Card Appendix E 169 School Environment and Policy Survey Example Appendix F 170 KWL Lesson Questions and Table Appendix G 171 Recruitment Letter Appendix H 172 Research Study Information Sheet and Consent Form (Adult) Appendix I 173 Parent/Guardian Permission for Students to Participate Appendix J 176 Research Study Information Sheet and Assent Form (Child) Appendix K 179 Information Letter to Students for SHC Appendix L 180 Timeline for the Study, May 12, 2009 Appendix M 181 Invitation Letter for June 3, 2009 Planning Meeting Appendix N 182 Invitation Letter for June 23, 2009 Planning Meeting Appendix O 183 End-of-Meeting Reflection, template Appendix P 184 Invitation Letter from SHC for Spring Fling Appendix Q 185 Prioritized Concerns Appendix R 186 Snackwise® "Best Choice" List Appendix S 188 Wellness Council Evaluation Interview Prompts Appendix T 193 Wellness Council Evaluation Interview Transcription Appendix U 194 Student Health Council Evaluation Interview Prompts & Responses Appendix V 211 End-of-Meeting Reflection June 23, 2009 (compiled) Appendix W 218 End-of-Meeting Reflection August 11, 2009 (compiled) Appendix X 220 Module 1, SHI Appendix Y 221 End-of-Meeting Reflection September 16, 2009 (compiled) Appendix Z 222 End-of-Meeting Reflection October 5 or 6, 2009 (compiled) Appendix AA 223 End-of-Meeting Reflection October 27, 2009 (compiled) Appendix BB 224 SHI Modules 2-8, CCS Score Card Appendix CC 225 Student Health Needs Appendix DD 232 Prioritizations of Planned Actions Appendix EE 233 Strategies/Actions to Address Student Health Needs Appendix FF 234 CCS Wellness Policy Appendix GG 235 SHC Letter for New Cougar Credit Snacks Appendix HH 236 Acceptance for new Cougar Credit Snacks Appendix II 237
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Chapter 1 Rationale for the Study The promotion of positive health behaviors and the adoption of basic health knowledge and skills are fundamental public-education outcomes (Institutes of Medicine [IOM], 1997; U.S. Department of Health and Human Services [USDHHS], 2000). Fundamentally, the mission of schools and the mission of health promotion are interdependent; healthy children are ready to learn (Allensworth & Kolbe, 1987; American Association of School Administrators [AASA], 2006; American Cancer Society [ACS], 1992; Centers for Disease Control [CDC], 1997, 2003; CDC/Division of Adolescent School Health [CDC/DASH], 2009; Dewey, 1897; Horton & Friere, 1990; IOM, 1997; Kann, Brener, & Allensworth, 2001; Kann, Telljohann, & Wooley, 2007; Marx, Wooley, & Northrop, 1998; USDHHS, 2000; Vernez, Krop, & Rydell, 1999). Children learn about health by modeling their family members and other close caregivers; however, once they reach school age, children spend an average of six hours per day in school (CDC, 2000). The mission of schools is to teach, instill and reinforce healthy attitudes, behaviors and skills. The school setting is crucial because “schools have more influence on the lives of young people than any other social institution except the family and provide a setting in which friendship networks develop, socialization occurs, and norms that govern behavior are developed and reinforced” (USDHHS, 2000, p. 7-3). Risky behaviors associated with the leading causes of mortality and morbidity in adults, such as unhealthy nutrition habits and physical inactivity, begin when people are young. "Establishing healthy behaviors during childhood is easier and more effective than trying to change unhealthy behaviors during adulthood” (CDC/DASH, 2009, p. 2). Therefore, school health initiatives have the dual outcomes of reducing risky behaviors and
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positively affecting academic performance (Symons, Cinelli, James, & Groff, 1997). There is a strong, positive correlation between academic achievement and the health of students. Healthy students perform better academically (CDC, 2007; CDC/DASH, 2009; Marx et al., 1998; Symons et al., 1997). In 1987, the CDC established the Division of Adolescent and School Health to: monitor students and school health issues; research and evaluate programs and policies; and provide funding for schools to adopt or enhance school health programs (CDC, 2003). Also in 1987, Allensworth and Kolbe's landmark article was published, which delineated the necessity of a comprehensive school health program to ensure a healthy future through the complete education of children. A child who is healthy will be better prepared to learn (ACS, 1992; CDC/DASH, 2009; IOM, 1997; Kann et al., 2001; Kann et al., 2007; Marx et al., 1998; Symons et al., 1997). The publication of the CDC’s Guidelines for School and Community Programs to Promote Lifelong Physical Activity among Young People (1997) further established the crucial role of schools in the health of the nation by recommending that all students receive “planned and sequential health education from kindergarten through 12th grade” (CDC, 1997, p. 8). The importance of school health programs was elaborated and reinforced in the objectives of Healthy People 2010 (USDHHS, 2000). One of the focus areas was educational and community-based programs, with a specific goal to “increase the quality, availability, and effectiveness of educational and community-based programs designed to prevent disease and improve health and quality of life” (CDC & Health Resources and Services Administration [HRSA], 2000, p. 7-3). Four settings were identified for this goal: school (pre-Kindergarten through university); the
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workplace; healthcare settings; and the community. The proposed objectives of Healthy People 2020 retain the four settings and all of the school-based objectives (USDHHS, 2009). There were two objectives specific to elementary-school settings. One was to increase the proportion of schools that provide a curriculum of school health education to address the leading causes of morbidity and mortality: unintentional injury, violence and suicide; tobacco, alcohol and other drug use; unintended pregnancy, HIV/AIDS, and STD infection; unhealthy dietary patterns; inadequate physical activity; and environmental health (objective 7-2). The second objective was to increase the proportion of the nation’s elementary, middle, junior high, and senior high schools that have a nurse-to-student ratio of at least 1:750 to 50% of all schools (objective 7-4). Strategies to support the objectives of Healthy People 2010 in the school setting were published by the CDC (CDC & HRSA, 2000; CDC, 2003, 2005) and the Ohio Department of Education (ODE, 2006). In addition, by the beginning of the 2006-2007 academic year, all schools which received federal funding for school lunch were required to establish a "wellness policy” (Child Nutrition and WIC Reauthorization Act of 2004).
Coordinated School Health Program Health education, school nurses and written wellness policies are important, but are only part of a school’s health program. The school should also provide a safe and healthy learning
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environment; address nutrition and psycho-social needs of the students; promote the health of teachers and staff; and the school’s policies should explicitly support these broader holistic missives (Allensworth & Kolbe, 1987; Austin, Fung, Cohen-Bearak, Wardle, & Cheung, 2006; Belansky, Cutforth, Chavez, Waters, & Horch, in press; CDC, 2003, 2005, 2007; Cornwell, Hawley, & St. Romain, 2007; Gosin, Dustman, Drapeau, & Harthun, 2003; Hoyle, Samek, & Valois, 2008; IOM, 1997; Kann et al., 2001; Kann et al., 2007; Kolbe, 2005; Marx et al., 1998; ODE, 2006; Patton, Bond, Butler, & Glover, 2003; Staten et al., 2005; Symons et al., 1997; Valois & Hoyle, 2000; Weiler, Pigg Jr., & McDermott, 2003). To support the child’s health and academic potential, a Coordinated School Health Program (CSHP) is recommended, comprising eight interconnected components: 1. School Health and Safety Policies and Environment 2. Health Education; 3. Physical Education and Other Physical Activity Programs; 4. Nutrition Services; 5. Health Services; 6. Counseling, Psychological, and Social Services; 7. Health Promotion for Staff; 8. Family and Community Involvement (Allensworth & Kolbe, 1987; CDC, 2007, 2008; IOM, 1997; Kann et al., 2001; Kann et al., 2007; Marx et al., 1998). This holistic approach to school health has been adopted by the CDC as the model for all schools in the United States. The incorporation of a CSHP is recommended in order for schools to provide the structure, systems and environment that support children’s health, and thus, learning. School
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health needs are contextual and specific to the environment and culture of the school; therefore, establishing the eight-component CSHP should begin with an assessment of the school’s current health programs and services (American School Health Association [ASHA], 2008; Austin et al., 2006; Belansky et al., in press; CDC, 2005; Cornwell et al., 2007; Kann et al., 2001; Kann et al., 2007; Hoyle, Bartee, & Allensworth, 2010; Marx et al., 1998; ODE, 2006; Patton et al., 2003; Sherwood-Puzzello, Miller, Lohrmann, & Gregory, 2007; Staten et al., 2005; Valois & Hoyle, 2000; Weiler et al., 2003). Beginning with a broad-stroke assessment affirms the health-learning connection, and provides an awareness of the framework of coordination (Rosas, Case, & Tholstrup, 2009; Sherwood-Puzzello et al., 2007). Schools can conduct the assessment of their health programs on their own, by simply reviewing each of the eight components and determining whether they have met the recommendation. However, it is not merely a matter of “yes” or “no” for each component. There are multiple programs or services for each component which could be delivered in a variety of ways, making a self-directed assessment challenging. To help schools, the CDC developed the School Health Index (SHI), a tool to guide school personnel through their assessment (CDC/DASH, 2005). The SHI has both an elementary-school and middle/high-school version to address the different social and academic needs. The evaluation of a CSHP should occur with input from all stakeholders: administrators, teachers, staff, students, parents and the community (ASHA, 2008; Austin et al., 2006; Belansky et al., in press; CDC, 2005; Cornwell et al., 2007; Kann et al., 2001; Kann et al., 2007; Hoyle et al., 2010; Marx et al., 1998; ODE, 2006; Patton et al., 2003; Sherwood-Puzzello et al., 2007; Staten et al., 2005; Valois & Hoyle, 2000; Weiler et al., 2003). When all the stakeholders participate in the process of assessing the school’s current status in each of the eight components,
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the outcome is a solid foundation for sustainability of a comprehensive CSHP (Austin et al., 2006; Belansky et al., in press; Cornwell et al., 2007; Hoyle et al., 2008; Staten et al., 2005). The inclusion of all stakeholders and building capacity for sustaining a program or change through the process of equal and open participation are two key elements of a participatory research approach/philosophy (Cargo & Mercer, 2008; Faridi, Grunbaum, Gray, Franks, & Simoes, 2007; George, Green, & Daniel, 1996; Israel, Schulz, Parker, & Becker, 1998; Minkler & Wallerstein, 2008; Reason & Bradbury, 2006; Viswanathan et al., 2004; Whitehead, Taket, & Smith, 2003), making participatory research a natural fit for studying school health.
Participatory Research Participatory research is grounded in fundamental tenets no matter how it is named; e.g., “Community-Based Participatory Research,” “Participatory Action Research,” or some other name (“Feminist Action Research,” “Critical Action Research,” “Community-Applied Research,” etc.). It involves the people whom the research is intended to help, moving the “objects of the research” to “active partners in its formation, execution and application” (Green, O’Neill, Westphal, & Morisky, 1996, p.3). Participatory research: requires democratic processes that support and enhance autonomy of all, with emphasis on capacity building, empowerment, and ownership; is context/environment specific: problems, priorities, needs and solutions are derived from and with the participants; the participants own the answers and the action; involves participants in the selection, development and/or adaptation of instruments;
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is collaborative and constructivist in the way knowledge is created and meaning is understood: the research process includes education, research and social action; requires shared reflection, consolidation and (re-)examination of socio-ecological conditions; creates, shares and implements findings, lessons learned and implications with the participants (Brydon-Miller, 2001; Brydon-Miller, Greenwood, & Maguire, 2003; Cargo & Mercer, 2008; George et al., 1996; Reason & Bradbury, 2006; Israel et al., 1998; Minkler & Wallerstein, 2008; Park, Brydon-Miller, Hall, & Jackson, 1993; Viswanathan et al., 2004). Conducting PAR requires the researcher to take a different “epistemological attitude” (Green et al., 1996, p. 3): to question knowledge ownership, generation and application; indeed, even why to conduct research. The researcher-researched relationship must be significantly different than the typical positivist model of scientific inquiry dictates. The PAR researcher must give over the control of the process of the research to the participants, at least to some degree, and embrace other, different ways of knowing (Brydon-Miller, 2001; Brydon-Miller et al., 2003; Cargo & Mercer, 2008; George et al., 1996; Reason & Bradbury, 2006; Israel et al., 1998; Minkler & Wallerstein, 2008; Park et al., 1993). Israel et al. (1998) describe the adherence to the constructivist philosophy—of knowledge being co-created and owned by others than the academy—as a fundamental aspect of the position of the PAR researcher. PAR is a natural fit with the fundamental aim of health promotion to enable and empower people with knowledge, skills and practice which support healthy behaviors (Cargo & Mercer, 2008; George et al., 1996; Green et al., 1996; Israel et al., 1998; Minkler & Wallerstein, 2008; Reason & Bradbury, 2006; Whitehead et al., 2003). Because of the inclusionary principles underscoring PAR, it is also a
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natural fit for research in schools with the many stakeholders required for assessment, enhancement and evaluation of school health. This study was called Participatory Action Research instead of Community-Based Participatory Research because the setting was limited to one school. The school has attributes of a community: a shared physical location (the building) in which people belong; and teachers, students, staff and administration identify with each other as sharing common interests. This sense of belonging was intended to be the catalyst for full participation and long-term sustainability. “Participatory Action Research” makes two distinctions explicit. First, it recognizes that the school and its participants belong to other communities which influence the school; e.g., the surrounding city, the geographic communities of the teachers and staff and the socio-cultural identities of each. Second, it places emphasis on creating ownership, building community and taking action. The literature demonstrates the academic and health benefits of health promotion and education in schools in the United States. Schools are the place for children to learn about, practice and adopt healthy behaviors for life. Schools must also work in concert with families and other community members. Coordinated School Health offers the foundation upon which educators, families and policy makers can integrate schools’ academic and health missions. Empirically, participation by many stakeholders is occurring in schools; however, publication seems to be focused mainly on describing the results or outcomes of research, such that there were not many research studies which describe and critically examine the participatory process for Coordinated School Health. Because the literature does not typically describe the process, questions remain about how to invite or increase participation. In addition, the underlying principles of health educators are process-oriented, and if the intended outcome is an integration
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of school health into the fabric of the school, describing how the process occurs will explicitly link school-health process to school-improvement processes (Hoyle et al., 2010; Symons et al., 1997). The need for this research study is supported by the small number of published participatory research studies conducted in elementary and middle schools.
Study Purpose and Research Questions The original purpose of this study was to: conduct an asset and needs assessment of health programs and services; implement or improve programs, services or policies which would enhance a CSHP; evaluate the effects of these programs, services or policies, in one elementary school. The research questions were: 1) What are the health needs of the students at this school? 2) What are the assets of this school which support the development and delivery of a CSHP? 3) What are the issues in this school which impede the school in developing, implementing and sustaining a CSHP? 4) What strategies should be used to develop and/or improve a CSHP in this school? 5) What issues will a process evaluation reveal once these strategies are implemented? 6) What will the results of these strategies be on the children’s knowledge, attitudes, behaviors and health status? Using the Coordinated School Health Program as the “gold standard,” Participatory Action Research provided a holistic approach to examine the school’s health programs and services while building relationships and collaboration among the school’s stakeholders for sustainable
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change. Given the United States’ current obesity epidemic, physical health —specifically physical education, physical activity, recess and nutrition—was at the forefront of initial discussions. Through the process of PAR and the needs and assets assessments, the participants considered the school’s health programs and services within the context of the students’ overall growth and development, not merely as obesity-prevention measures. This study was just the beginning of an ongoing, multi-year process of assessment, implementation and evaluation moving the school toward a complete and comprehensive CSHP. Over the course of one school year, the study moved through three phases—assessment, implementation, evaluation—that are distinct, yet overlapping and cyclical. Adhering to the nature of PAR, the purpose of the study and the research questions evolved over the course of the school year. The participants made the decision to shift the focus of evaluation and evaluate the process and document outcomes as a result of their work—to reflect upon and articulate the changes they noticed and experienced. Thus, the purpose of the study became: conduct an asset and needs assessment of health programs and services; implement or improve programs, services or policies which would enhance a CSHP; evaluate the process of this assessment and implementation, in one elementary school. Because of this change, the participants also changed the research questions, dropping the last research question from consideration. The process of conducting the assessment brought the school’s health programs and services into closer alignment with the CSHP recommendations, and the implementation addressed some of the student and school needs identified. The evaluation and dissemination of the outcomes from the study to the school community established the start point for the 2010-2011 school year, during which the participants in the
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study planned to evaluate the impact of changes in programs, policies or services on students’ knowledge, attitudes, behaviors and health status.
Delimitations, Limitations, Assumptions The delimitations of this study include its setting, the participants, and the time frame. Specifically, the study was confined by the following: The study setting was one elementary school (pre-K through grade eight), which was hand-selected by the researcher for convenience. The participants who engaged in the research were volunteers. The principal and teachers consented to the study in concept, and then were invited to participate in the research along with the staff, parents and students when the Institutional Review Board (IRB) approved the study. All participation was autonomous and voluntary. Participants were able to drop out of the study at any time, for any reason. This study was limited to one school year. It began on April 20, 2009, and ended May 5, 2010. Some issues about the setting and the participants were out of the researcher’s control, and are important limitations of the study: The school is an inner-city Catholic school; grades pre-K through eight, with only one class of students per grade (11 teachers and 174 students). Most of the students (79.3%) are in the Free/Reduced Price Lunch program. The participants were volunteers. Attendance at meetings was inconsistent for some. Contributions may have been guarded (i.e., participants may not have shared their experience fully).
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Participants’ contributions were from their perspective, and may have been misinterpreted by the researcher or other members, such that the conclusions may be biased. The findings of this study may not apply to other school settings with different participants. The assumptions of this study were related to the limitations. A key assumption was that the Participatory Action Research approach would make participation complete and democratic for all stakeholders. The participants would engage fully in all meetings and feel safe to fully disclose their opinions and perspectives. This study relied on the willing participation by these stakeholders. Other assumptions included: The administration supported the research, so that financial resources could be made available as indicated by the asset and needs assessment. The teachers, staff, parents and students were concerned and valued the health of the students and each other.