Developing a coordinated school health approach to child obesity prevention in rural Appalachia : results of focus groups with teachers , parents , and students

Introduction: High prevalence rates of obesity, particularly among those residing in US rural areas, and associated physical and psychosocial health consequences, direct attention to the need for effective prevention programs. The current study describes an initial step in developing a school-based obesity prevention program in rural Appalachia, USA. The program, modeled on the Centers for Disease Control and Prevention Coordinated School Health (CSH) Program, includes a community-based participatory research approach to addressing the health needs specific to this region. Methods: Focus groups with teachers, parents, and 4 grade students were used to understand perceptions and school policy related to nutrition, physical activity, and the role of the school in obesity prevention. Results: Results revealed that these community stakeholders were concerned about the problem of child obesity and supported the idea of their school doing more to improve the diet and physical activity of its students. Specifically, all groups thought that foods and drinks consumed by students at school should be healthier and that they should have more opportunities for physical activity. However, they cited limitations of the school environment, academic pressures, and lack of parental support as potential barriers to making such changes. Parents were most concerned that their children were not getting enough to eat and they and the teachers


Introduction
Approximately 19% of US children aged 6 to 11 years are classified as obese (ie sex-specific Body Mass Index [BMI] for age ≥95 th percentile) and an additional 18% overweight (85 th to <95 th percentile) 1 . Children who are obese are at increased risk of numerous physical and psychosocial health consequences, including type 2 diabetes, risk factors for cardiovascular disease, social difficulties, and lower selfesteem, as well as additional health complications in adulthood 2 . Additionally, research shows associated economic burdens, with overweight accounting for approximately 9% of total annual medical expenditures in the US in 1998 3 .
Similar to trends observed in ethnic minority groups 1 , the problem of overweight is more common in children residing in rural areas 4 . Both higher prevalence rates and greater health risk behaviors, including unhealthy diet and less physical activity, have been documented among individuals in rural areas 5,6 . The Appalachian Region Commission has described Appalachia as a particularly high-risk population with an excess of premature deaths due to overweight/obesity related causes (eg cardiovascular disease, diabetes, cancer) 7 . The Institute of Medicine recently concluded that more evidence from varied types of evaluations in diverse settings is needed to identify promising approaches to preventing childhood obesity 8 . This article describes results from focus groups conducted with teachers, parents, and students in one school community during the development of a school-based obesity prevention initiative in rural Appalachia, called Winning with Wellness.

Setting
The setting for this 2005 study was an elementary school with students in kindergarten through fourth grade, located in a rural northeast Tennessee (TN) county (timeline shown in Table 1). At the time of the study the county was one of 10 pilot sites for the Tennessee Coordinated School Health (CSH) Project. The state of TN Department of Education was appropriated funding for a pilot study of CSH after the legislature passed TCA 49-1-1002-the CSH Improvement Act of 2000. The CSH model, developed by Allensworth and Kolbe 9 , includes 8 components: (i) nutrition services; (ii) physical education; (iii) health services; (iv) health education; (v) counseling/psychological/social services; (vi) family/community involvement; (vii) health promotion for staff; and (viii) healthy school environment.

The US Centers for Disease Control and Prevention (CDC)
has advocated use of the CSH Program model as a comprehensive approach to promoting child health via involvement of schools, families, healthcare organizations, media, and community groups 10 . In 2004, amid concern about the problem of child obesity in northeast TN, a partnership between TN CSH, a local department of education, a regional hospital system, and the Department of Pediatrics at East Tennessee State University facilitated the formation of a multidisciplinary coalition including health care providers, educators, researchers, parents, media, and business personnel who began discussing how to curb the epidemic of child obesity through a school-based initiative based on the CSH model. Employing a community based participatory research approach to program development and evaluation, the coalition sought input from school community stakeholders 11 . The elementary school has a total of 491 students, 41 teachers, and 105 total staff. Approximately 52% of students are classified as economically disadvantaged 13 . Purposeful sampling ensured participation by members of 3 stakeholder groups in the school community: teachers, parents, and fourth-grade students 14 . All teachers and academic staff at the school were invited to participate; school administrators identified parents who had volunteered at the school to invite to participate in the study. One fourthgrade class was chosen to participate by the principal.

Procedure
Human subject approval and study oversight was provided by the East Tennessee State University Institutional Review Board.
Focus groups were conducted according to established methodology [14][15][16][17][18][19] . Data were collected during the summer- Written informed consent was obtained from both teachers and parents. A letter that described the study was sent home with students asking parents to indicate if they did not want their child to participate. Verbal informed assent was obtained from child participants prior to their participation.
At the beginning of each focus group, the trained moderators (ie Caucasian medical doctor and Caucasian medical student) discussed the estimated length (ie 60-90 min for adults and 30-40 min for students) and the purpose of the discussion, as well as rules to assist the discussion to proceed smoothly. All focus groups were audio-recorded. As an incentive, teachers received refreshments and US$10 for their participation. The school received $10 for each parent and student who participated in the study.

Measures
Moderators used a written guide (available from the authors) developed specifically for the study and participant group, bearing in mind the CSH model, with input from the coalition to facilitate the discussion and provide consistency across the groups. Open-ended questions and queries were used to facilitate discussion. All groups were asked similar questions regarding perceptions of school nutrition (eg 'What do you think about the food served in the school cafeteria?') and physical education (eg 'How much physical activity and physical education do students get at school?'). Questions also assessed family and community involvement with children's eating and physical activity as well as views regarding the relationships among eating and physical activity, school behavior and academic performance. In addition, teachers and parents were asked about perceptions of child overweight and perceived barriers/reactions to a school-based obesity prevention program based on the CSH model. Students were asked about school rules and changes the school should make regarding nutrition and activity. Nothing was asked about 'weight' or discussed during the student focus groups.

Analysis
Data analysis included a systematic approach aimed at preserving the reliability and validity of the data 20,21 .
Transcripts were made from focus group audio-recordings.
Using an induction method and following a multistage interpretive thematic process, these transcripts were first

Results
The participants were 23 teachers (96% female), 12 parents (92% female), and 19 fourth grade students (58% female) out of a total of 97 students. A repetition of themes was heard within and across participant groups 16 . Common themes are presented according to CSH model component in statements provided by teachers, parents, and students (Table 2).

Nutrition services
Teachers, parents and students all agreed that there were not enough healthy food choices offered in the school cafeteria.
Teachers reported that students were only expected to have three items on their cafeteria tray, and the school policies about selection of these items (ie students are not required to choose a fruit or vegetable) and purchase of a la carte items did not promote healthy eating. Parents perceived their children as unable to make healthy choices without guidance and suggested parent volunteers were needed to assist children in making healthy food choices. Students were aware of healthy options in the cafeteria, but many admitted to choosing less healthy foods. Lunches brought from home also included unhealthy options.
Teachers and parents agreed that students performed better academically if they made healthy food choices and participated in physical activity. Students also perceived diet to negatively impact behavior. "They get teased." "You don't have a good opinion of yourself." "They don't wanna go to the gym." "They still get teased" - "Most like those video games or movies, not riding a bike." "I'm concerned that too many of the children aren't getting outside enough when they're not involved in a lot of activities." "There's not even a park around but in [the next town], that's 15 to 20 minutes away." "I'm concerned that that too many of the children aren't getting outside enough when they're not involved in a lot of activities." "There's just a handful whose parents are willing to take them to be a part of the ball teams and all, the rest of them don't "Some kids come home and go straight to those [video] games." "They come home and sit and don't do anything." "Now you can't let your kids go in the road or the woods, something would happen to them." now "Sometimes I play my PS2 and X-Box." "Mostly I'm lazy." "My mom and dad don't do nothing with me." Health promotion for staff • Teacher/staff overweight "We're all overweight"

Health services/health education
Teachers believed that child overweight was not prevalent in their school, citing only 'one or two big kids'. Teachers seemed hesitant to label children as overweight/obese. One teacher said, 'He's a little chunky, but not obese', and that 'they can't help it, we're all overweight'. Parents were aware of child overweight with several admitting their child was overweight; however, some parents stated that they do not feel able to change their child's weight. BMI screening at school was not perceived favorably by several teachers or parents.

Counseling/psychological/services
Teachers perceived that overweight children have low selfesteem, get picked on, and do not participate in gym activities. Parents were also concerned that overweight children are teased, although one parent thought this was less of a problem since overweight has become more common.

Family and community involvement
Parents indicated concern that children would not eat enough if forced to eat healthy foods. They often reported that knowing their child was eating something at lunch everyday was important, whether what they ate was healthy or not.
Financial constraints to parental provision of healthy foods and guidance on healthy eating were also noted by both teachers and parents.
Although some of the students stated that they were active, many reported playing video games or watching TV after school. Related to concerns about physical activity away from school, one teacher stated that the community does not have a safe place for children to play; others cited lack of parent involvement in promoting physical activity through sports participation.

Health promotion for staff
While teacher/staff health was not among the planned discussion topics for these focus groups, the high prevalence of overweight among teachers and staff was mentioned by a teacher who seemed to sympathize with overweight students: 'They can't help it we're all overweight'. In fact, 85% of teachers surveyed as part of the Winning with Wellness pilot project evaluation described themselves as overweight 22 .

Healthy school environments
Proposed changes and potential barriers to promoting healthy eating and physical activity were discussed. Teachers were worried that time, teacher enthusiasm, and administrative and parental support could be barriers to implementing an overweight prevention program. One teacher said, 'There's going to be parents who complain about [the program], they complain about anything'.
Teachers recommended opening the gym after school, establishing a walking trail on school grounds and a daily fitness program with incentives for students. One teacher suggested that students 'exercise to music'. Many teachers were also in favor of students having pedometers to help them become more aware of their activity level. Parents suggested discontinuing the use of food as a reward and no longer withholding physical activity as a punishment. A student recommended putting 'healthy ice cream' in the cafeteria. Teachers also agreed that encouraging healthy snacks could be beneficial to students. Parents and students suggested students should have physical education daily.

Discussion
The school setting continues to be recognized as important for promoting the development of healthy behaviors in children 23 . While demonstrating improvements in diet and increases in physical activity 24 , school-based obesity prevention programs have produced small changes in weight, indicating a need for more effective programs 25 . A recent review of existing programs recommended tailoring future programs to the needs of specific populations 26 . Research documenting effective school-based prevention programs, particularly among rural populations, is limited.
The three largest and most successful school-based programs emphasized the importance of involving stakeholders in planning, implementing, evaluating, and disseminating programs. These programs also included easy to use curricula, training, sound research methodology, and use of the CDC School Health Index for development and evaluation, as well as implementation 27 . Additional researchers have suggested more comprehensive approaches incorporating the involvement of stakeholders, programmatic and policy change, and sustainability 24,26 .
In the current study, teachers, parents, and students described cafeteria menus and practices as not promoting healthy eating and identified a need for additional physical activity during school hours. These reports are not uncommon. The recent Expert Committee Recommendations on the prevention of childhood obesity suggest improvements are needed in both diet and physical activity across school settings 23 . A recent review of school-based programs 26 provides support for programs targeting these issues.
In the current study, students admitted to making less healthy food choices at school.  28 . Teachers suggested having children exercise to music, wear pedometers, and receive incentives for physical activity.
Parents recommended that withholding physical activity not be used as a punishment for misbehavior. In a prior study of perceptions of overweight factors, parents and students favored encouragement and reward for sustaining child involvement in nutrition and physical activity 29 .
Teachers also reported concerns that children were sedentary at home (eg television, video games) and attributed lack of parental involvement and areas to play safely as problems.
Parents provide an important influence on the development of eating and activity behaviors in children 30 . Parents in rural areas may face additional barriers to providing healthy food options and opportunities for activity because of higher rates of poverty 4 as well as fewer facilities and resources promoting healthy activity 31 . Teachers in the current study suggested developing a walking trail at the school.
The lack of involvement by some parents with the school was recognized by teachers as a significant barrier with speculation that increased working demands among parents contributed to this issue. On the other hand, some parents reported feeling that the school did not want them to be involved and suggested that parent involvement should be encouraged to promote healthier eating in the school cafeteria. Although research is limited, reviews of interventions for children who are overweight and/or obese clearly support parental involvement 32,33  The current study was qualitative and exploratory in nature.
Limitations included the small sample size and collecting data in only one rural school setting. There was also potential for bias in those who were willing to participate. However, the current study provided important information that contributed to the development of a pilot intervention, Winning with Wellness, that was based on the CSH model, and aimed at improving nutrition and physical activity in the same rural elementary school 22 . This study, to our knowledge, represents the first attempt to understand multiple stakeholders' perceptions of school nutrition, physical activity, child overweight and the schools' role in obesity prevention in a rural school setting. This is important given the higher rates of overweight, poorer health outcomes, and limited health resources in rural populations.
Further, individualized assessment regarding needs, barriers, and proposed changes are needed for prevention programs to be successful.
A pilot study in Florida demonstrated both feasibility and sustainability along with improved school performance using the CDC CSH approach 36 . Additionally, coordinated school health programs for healthy eating in Nova Scotia were associated with healthier diets, greater physical activity, and lower percentages of overweight among children, compared with schools only reporting policies and practices for offering healthy food alternatives 43 . Similar approaches may be especially important for rural areas where prevalence rates of obesity are higher 4 and resources more limited 44 .

Conclusion
The existence of the TN CSH Project in the county school system provided both a model for developing interventions and an infrastructure for implementation and evaluation.
This on-going study is utilizing a community based participatory research approach to ensure that the needs and perspectives of this population are considered in the design and implementation of school-based obesity prevention efforts, and that information-sharing and dissemination of evaluation findings are a priority. Additional information is also being gathered via multiple methods (self-report, anthropometric measures, cafeteria record review) and multiinformants (students, teachers, school staff) to further direct the development and sustainability of Winning with Wellness.