Influence of Teachers' Personal Health Behaviors on Operationalizing Obesity Prevention Policy in Head Start Preschools: A Project of the Children&#x27;s Healthy Living Program (CHL)

doi:10.1016/j.jneb.2016.02.007

Journal of Nutrition Education and Behavior

Volume 48, Issue 5, May 2016, Pages 318-325.e1

https://doi.org/10.1016/j.jneb.2016.02.007 Get rights and content

Abstract

Objective

To quantify the Head Start (HS) teacher mediating and moderating influence on the effect of a wellness policy intervention.

Design

Intervention trial within a larger randomized community trial.

Setting

HS preschools in Hawaii.

Participants

Twenty-three HS classrooms located within 2 previously randomized communities.

Intervention

Seven-month multi-component intervention with policy changes to food served and service style, initiatives for employee wellness, classroom activities for preschoolers promoting physical activity (PA) and healthy eating, and training and technical assistance.

Main Outcome Measures

The Environment and Policy Assessment and Observation (EPAO) classroom scores and teacher questionnaires assessing on knowledge, beliefs, priorities, and misconceptions around child nutrition and changes in personal health behaviors and status were the main outcome measures.

Analysis

Paired t tests and linear regression analysis tested the intervention effects on the classroom and mediating and moderating effects of the teacher variables on the classroom environment.

Results

General linear model test showed greater intervention effect on the EPAO score where teachers reported higher than average improvements in their own health status and behaviors (estimate [SE] = −2.47 (0.78), P < .05).

Conclusions and Implications

Strategies to improve teacher health status and behaviors included in a multi-component policy intervention aimed at child obesity prevention may produce a greater effect on classroom environments.

Introduction

Children being overweight and obese is defined as having a body mass index for age above the 85th percentile. It is a serious public health concern in the US1, 2 and increases risk for cardiovascular disease, diabetes, and cancer and for being overweight and obese as adults.3, 4, 5, 6 Prevalence of childhood obesity is especially high in Native Hawaiian and Pacific Islander children.7, 8, 9 In Hawai‘i, about 39% of children entering kindergarten are overweight or obese.⁹

An obesogenic environment refers to the social and built environments (eg, policies, food availability, access to physical activity [PA], norms) that encourage people to eat more calories than they expend, leading to obesity.¹⁰ The already high prevalence of unhealthy weight combined with the dynamic interactions between personal and built environmental factors contributes to the risk for developing obesity and has created a need for multilevel interventions that address various environmental factors and influences of obesity.¹⁰

The early childhood years present a sensitive time when a child's lifelong eating habits and risk for future obesity are developed.11, 12 Child care centers are good venues for obesity prevention. About half of US children under age 5 years spend a significant amount of time in these centers, where they consume two-thirds of daily nutritional needs through meals and snacks.13, 14 Many US states have made progress toward implementing child care center licensing requirements that address preventing obesity, but such requirements are not currently in place in Hawai‘i.¹⁵

Head Start (HS) is a federally funded preschool program serving low-income children aged 3–5 years.¹⁶ Head Start teachers have an influential role in ensuring compliance with nutrition policies, and thus serve as a potential leverage point for obesity prevention efforts through policy change.17, 18 Successful HS interventions have used collaborative approaches and have provided training and technical assistance for new policy implementation and facilitated employee wellness activities to support childhood obesity prevention efforts.19, 20, 21, 22, 23, 24 For example, Lanigan's²³ wellness policy intervention was based on 3 principles that providers would be more likely to adopt childhood obesity prevention practices if: (1) they felt that failure to do so would be damaging to children, (2) they felt they could make a difference in children's eating habits, and (3) they were provided with training and tools to make changes. The intervention collaborated with teachers to create center goals for obesity prevention and provided education, training, and resources to implement the goals. The study found positive correlations between center staff's feeding knowledge, misconceptions, and self-efficacy and observed child care center meal time feeding practices, nutrition education, and family communication, which suggested that teachers are an influencing factor on classroom practices.²³ Another employee wellness intervention, targeting improving the health status and behaviors of preschool teachers, demonstrated a positive effect on teachers' self-efficacy for communicating nutrition information to parents and on the frequency of fruits and vegetables served at centers, which suggested that interventions promoting teacher wellness can have effects that affect child health, in this case increasing the availability of fruits and vegetables in classrooms.²² Other studies demonstrated that teachers' feeding styles influence children's food consumption²⁵ and that teachers' lack of concern about childhood obesity becomes a barrier to prevention efforts.¹⁸ These influences and findings regarding the effects of employee wellness on classroom availability of fruits and vegetables suggest that teacher-level characteristics could explain some level of intervention effectiveness or ineffectivness in these studies. It is plausible that teachers, who are making improvements to their own personal health habits, including physical activity and eating, may place a greater emphasis on PA and healthy eating in their classrooms.

Mediation and moderation analysis offers a means to improve understanding of intervention and program outcomes.²⁶ A mediating variable is 1 that accounts for the significant relationship observed between an independent and dependent variable, providing a potential explanation for the results seen.²⁷ For example, an intervention successful at improving child behaviors, such as the level of PA, as the result of a policy intervention may be explained by an intervention effect on social or psychosocial variables, such as improved attitudes of intervention implementers regarding PA. On the other hand, a moderating variable affects the direction and/or strength of the relationship between an independent and dependent variable. This third variable represents an interaction effect between those variables and provides information about conditions in which an intervention can achieve the desired results.²⁷ A moderation analysis may determine that a PA intervention was successful at improving the PA levels of females but not males, thus identifying gender as a moderating variable. Childhood obesity prevention interventions have yielded varying levels of effect on child and environmental outcomes but often lack mediation and moderation analysis, resulting in imprecise implications for future practice.18, 19, 20, 21, 22, 23, 24, 25 Baranowski and Russell²⁶ provided a model for intervention evaluation that was specifically designed to enhance understanding of how interventions yield desired outcomes. Implementation of this analysis can provide more information about the mechanisms of intervention effects, thus improving the precision of recommendations for practice.

This study's primary objective was to build evidence about the influence of HS teachers on the effect of child care center wellness policies on the nutrition and PA environment of HS classrooms in Hawai‘i. Specifically, the focus was on HS teachers’ health status, eating and PA behaviors, and efficacy, misconceptions, and knowledge related to child nutrition and priority placed on childhood obesity prevention. Figure 1 depicts the framework for this study based on the social ecologic model,¹⁰ specifically the relationship among the wellness policy intervention, the teacher level mediating and moderating variables, the classroom environment, and child level outcomes related to obesity. The researchers hypothesized that the intervention effect on the HS PA and nutrition environment would be explained (mediated) in part by teachers' prioritization of child nutrition and beliefs that were consistent with evidenced-based practices for childhood obesity prevention, as measured by the Child Care Provider Healthy Eating and Activity survey (CCPHEA).²³ Improvements in teachers' scores, such as teacher priority, could explain why the intervention was effective in improving the classroom PA environment. Greater priority placed on childhood obesity, prevention, and healthy eating by teachers as a result of the intervention could explain why the policy intervention that included activities that promoted classroom PA were more effective in improving the classroom environment. The researchers also hypothesized that teachers' own personal health behaviors, PA and healthy eating, and health status would influence (moderate) the intervention effect on the classroom environment.

Section snippets

Setting

This research was embedded within the randomized community trial, the Children's Healthy Living Program for Remote Underserved Minority Populations in the Pacific Region.²⁸ A total of 23 HS classrooms located in 2 communities on O‘ahu joined the study, including 11 HS classrooms in the intervention group and 12 in the delayed-intervention group. After teachers completed informed consent, children from the 23 HS classrooms were recruited to participate at HS orientation meetings and in their

Results

The teacher sample included 46 teachers from 23 HS classrooms, 2 teachers per HS classroom. The EPAOs were completed at baseline and at 7-month follow-up for all 23 classrooms. The CCPHEA surveys were completed by 1 or both HS teachers in each classroom at baseline and follow-up. In cases where both teachers completed CCPHEA surveys, the mean score of the 2 teachers was used for analysis.

No baseline significant difference was observed between intervention HS classes and delayed intervention HS

Discussion

The findings of this study suggest positive effects of a policy intervention on the HS PA environment. More important, they demonstrate the significant impact that HS teachers' personal health behaviors have, as well as the priority they place on child nutrition, on the success of a classroom-based intervention. However, the policy intervention, which included changes to meal service style and types of foods and beverages served, did not have a significant impact on the HS nutrition environment.

Implications for Research and Practice

The findings from this study demonstrate the effects of a policy intervention for childhood obesity prevention on classroom-level outcomes, including the influence that teacher-level variables have on the intervention effect, the first of its kind in Hawai‘i. This study supports the hypothesis that HS teachers serve as a leverage point for creating environments that promote PA and possibly a gatekeeper for childhood obesity prevention in preschool settings. Future research and intervention

Acknowledgments

This project is supported by the Agriculture and Food Research Initiative, Grant No. 2011-68001-30335 from the US Department of Agriculture National Institute of Food and Agricultural Science Enhancement Coordinated Agricultural Program, the staff of the Children's Healthy Living Program, Honolulu Community Action Program Head Start Program.

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2023, Endocrinologia, Diabetes y Nutricion
This study aimed to assess the validity and reliability of a self-administered screening questionnaire to detect deficiencies in the health habits of the adult population of the Canary Islands (Spain).
The questionnaire initially included 30 items based on previous questionnaires and following the recommendations of the World Health Organization about healthy and unhealthy diet, screen time, physical activity, and sleep habits. It also included a section related to hygiene due to the importance that hygienic habits have in people's health.
The questionnaire was self-administered online.
Data was collected from 401 participants from the Canary Islands (age range: 18–73 years) who volunteered to fill in the questionnaire online.
The questionnaire revealed adequate overall reliability indexes (Cronbach's α > .70, Mcdonald's ω > .70), and construct validity. Hierarchical linear regression analysis revealed age, sex, and income to be significantly (p < .05) related to adults’ health lifestyle habits in our population, sex and age explaining the majority of the variance. However, education and incomes were found non-significant (p > .05) when education was introduced into the model. Those results pointed out that older people and women show healthier lifestyle habits.
The questionnaire proved to be a brief, reliable, and valid tool to assess health lifestyle habits in adults in the Canary Islands. Furthermore, results pointed out that in future intervention studies with children, variables such as adults’ sex, age, and, to a lesser extent, monthly income should be taken into consideration.
Este estudio tiene como objetivo evaluar la validez y fiabilidad de un cuestionario de cribado autoadministrado para detectar deficiencias en los hábitos de salud de la población adulta de Canarias (España).
El cuestionario incluía inicialmente 30 ítems basados en cuestionarios existentes y siguiendo las recomendaciones de la Organización Mundial de la Salud en relación con la alimentación, el tiempo dedicado a pantallas, la actividad física y los hábitos de sueño. También se incluyó un apartado relacionado con la higiene debido a la importancia que tienen los hábitos higiénicos en la salud de las personas.
Se recopilaron datos de 401 participantes de las Islas Canarias (rango de edad: 18-73 años), que se ofrecieron como voluntarios para completar el cuestionario en línea.
El cuestionario reveló índices de confiabilidad general adecuados (α de Cronbach >0,70, ω de Mcdonald >0,70) y validez de constructo. El análisis de regresión lineal jerárquica reveló que la edad, el sexo y los ingresos están significativamente (p < 0,05) relacionados con los hábitos de vida saludables de los adultos en nuestra población, con el sexo y la edad explicando la mayor parte de la varianza. Sin embargo, la educación y los ingresos no resultaron significativos (p > 0,05) cuando se introdujo la educación en el modelo. Los resultados señalaron que las personas mayores y las mujeres muestran hábitos de vida más saludables.
El cuestionario resultó ser una herramienta breve, fiable y válida para evaluar hábitos de vida saludables en adultos de Canarias. Además, los resultados señalaron que en futuros estudios de intervención con niños se deben tener en cuenta variables como el sexo de los adultos, la edad y, en menor medida, los ingresos mensuales.
Teachers’ Experiences Implementing a School Wellness Initiative in Anchorage, AK: A Qualitative Study
2022, Journal of the Academy of Nutrition and Dietetics
Teachers are uniquely poised to support students’ healthy eating habits and physical activity. However, research is needed to examine the successes and challenges teachers face when implementing a school wellness initiative. The purpose of this study was to examine teachers’ experiences implementing and managing a pilot school wellness initiative where students had longer lunch and recess, and more physical activity throughout the day.
Using a grounded theory approach, transcripts were analyzed qualitatively using principles of content analysis to identify themes and domains. Application of the codes and interrater reliability were conducted with a trained research assistant.
Focus groups were conducted to understand the challenging and successful experiences of teachers as they implemented and managed a school wellness initiative. The participants were teachers (N = 39) from six purposively selected elementary schools participating in a school wellness initiative. Focus groups were conducted in-person at participating schools.
Teachers observed calmer students who ate more lunch with longer lunch periods. In addition, teachers observed improved focus in the classroom and fewer behavior issues with more physical activity opportunities. Successful strategies included reversing lunch and recess and implementing physical activity into daily lessons. However, some teachers had difficulty managing the extra time in the cafeteria and scheduling physical activity throughout the day, particularly in schools where administrators were not as supportive of the initiative. In the schools with greater administrative buy-in and support, teachers had easier, more positive experiences implementing the wellness initiative.
School wellness initiatives in which teachers play a large role have the potential to support teachers and students. This study found that teachers value student health and understand students need to be nourished to learn, but teachers’ experiences suggest they need support and buy-in from their administrators to be successful.
Food-Based Science, Technology, Engineering, Arts, and Mathematics (STEAM) Learning Activities May Reduce Decline in Preschoolers’ Skin Carotenoid Status
2021, Journal of Nutrition Education and Behavior
To assess the effectiveness of food-based science, technology, engineering, arts, and mathematics (STEAM) learning activities on preschoolers’ liking of 9 target vegetables and objectively-assessed fruit and vegetable (FV) intake.
Seven hands-on, food-based STEAM learning activities were implemented to expose children to 9 target vegetables in 3 Head Start preschools (11 classrooms) across North Carolina. Child-reported vegetable liking scores and skin carotenoid status (SCS) were dependent variables collected at baseline, midpoint, and posttest. Adjusted repeated-measures ANOVA was used to examine intervention impact.
A total of 113 children (intervention = 49; comparison = 64) participated. Children were an average age of 3.7 ± 0.57 years at baseline. Mean target vegetable liking scores for the intervention and comparison groups, respectively, were 3.2 ± 0.19 and 3.2 ± 0.17 at baseline, 2.9 ± 0.17 and 3.1 ± 0.15 at midpoint, and 2.8 ± 0.15 and 3.1 ± 0.13 at posttest. A time × group interaction was not significant for target vegetable liking scores. Mean SCS were 268.6 ± 13.24 and 270.9 ± 12.13 at baseline, 271.3 ± 12.50 and 275.6 ± 11.46 at midpoint, and 267.8 ± 11.26 and 229.6 ± 10.32 at posttest for the intervention and comparison groups, respectively. A time × group interaction was significant for SCS (F_1,77 = 3.98; P = 0.02; r = 0.10). Both groups declined from baseline to posttest (intervention = 0.06%; comparison = 15.09%), which occurred after winter break, with a smaller decline observed in the intervention group (P = 0.02).
Food-based STEAM learning activities may present a unique opportunity to affect FV intake while meeting academic standards. More research is needed to understand how liking for familiar FV changes over time and its relationship with consumption. In addition, more implementation research featuring larger sample sizes, teachers as the interventionist, and a longer study duration is needed to confirm the outcomes of food-based STEAM learning observed in the current study and the long-term impact this approach may have on children's’ dietary quality.
CHAMP: A cluster randomized-control trial to prevent obesity in child care centers
2019, Contemporary Clinical Trials
Citation Excerpt :
Items are scored on a four point Likert scale from “strongly disagree” to “strongly agree” and “low priority” to “high priority.” The subscales of Efficacy, Misconceptions, Feeding Knowledge, and Priority have shown good internal consistency (α = 0.75, 0.70, 0.71, and 0.64 respectively) [100] and demonstrated initial validity [4,101]. The Child Care Food and Activity Practices Questionnaire (CFAPQ) is comprised of items from the CFPQ (described above) and select items from the Preschooler Physical Activity Parting Practices (PPAPP) questionnaire.
Foundational elements of lifelong health are formed during the preschool years. Child care attendance has nearly doubled in the past 5 years making child care centers an ideal setting to establish healthy habits that prevent pediatric obesity. Despite the promising evidence of efficacy of child care-based obesity prevention interventions, limited attention has been directed to criteria needed for implementation at scale. There is potential to improve children's dietary and physical activity behaviors in diverse communities through theory-based, culturally appropriate, manualized interventions, delivered by child care staff. CHAMP (Creating Healthy Habits Among Maryland Preschoolers) is a 3-arm cluster randomized controlled childhood obesity prevention trial, aiming to improve motor skills, physical activity and willingness to try new foods among 864 preschoolers (age 3–5 years) enrolled in 54 child care centers in 10 Maryland counties. CHAMP is informed by social-cognitive and bioecological theories and based on an evidence-based program, The Food Friends®. The two intervention arms include: 1) child care-center based lessons (18-week gross motor and 12-week nutrition) administered by trained child care staff, and 2) a web-based intervention for caregivers in addition to center-based lessons. Evaluations are conducted among children, caregivers, and child care staff at fall enrollment, midline, and spring, following intervention completion. Analyses include linear mixed-models, accounting for clustering and repeated measures, incorporating center-arms as moderators. CHAMP will provide evidence-based information to inform wellness guidelines and policies that can be disseminated broadly, to ensure that child care centers provide opportunities for children to develop healthy eating, and physical activity habits.
Trial Registration: NCT03111264; https://clinicaltrials.gov/ct2/show/NCT03111264
Schoolteachers’ Nutrition Knowledge, Beliefs, and Attitudes Before and After an E-Learning Program
2019, Journal of Nutrition Education and Behavior
Citation Excerpt :
All of these teachers’ beliefs and attitudes were improved after the e-learning program. Nevertheless, most existing intervention studies focused on teachers’ food-related beliefs and attitudes in relation to childhood obesity14,48,49 whereas none evaluated their associations with teachers’ nutrition knowledge before or after implementing a training program. Multivariate analysis showed that teachers’ beliefs regarding the importance of nutrition along with their attitudes toward acting as role models could determine their good level of nutrition knowledge before the intervention, whereas their beliefs regarding being effective role models were not associated with teachers’ nutrition knowledge.
Το explore teachers’ nutrition knowledge, beliefs, and attitudes and to examine the effectiveness of an electronic learning (e-learning) program in teachers’ nutrition knowledge.
Cross-sectional and experimental design.
The study took place in Greece, while schoolteachers were invited by e-mail.
Teachers of primary and secondary education, with no exclusion criteria, were enrolled in the study between March, 2015 and 2016.
Schoolteachers' nutrition knowledge, beliefs, and attitudes.
Teachers completed a 36-item nutrition questionnaire and then a subgroup participated in an e-learning program. After the intervention, teachers completed the same questionnaire.
Principal component analysis and multivariate logistic regression were used for data analysis.
A total of 1,094 teachers completed the questionnaire; 619 participated in the e-learning program. Teachers showed moderate nutrition knowledge scores (ie, 65% correct answers) before the intervention, whereas their attitudes regarding acting as role models and their belief in the importance of the role of nutrition were associated with 74% (odds ratio, 1.28; 95% confidence interval, 1.13–1.45) and 79% (odds ratio, 1.21; 95% confidence interval, 1.07–1.37) increased possibility of having good nutrition knowledge, respectively. The e-learning program was effective in strengthening teachers’ nutrition knowledge (P < .001) and improving their beliefs and attitudes (P < .05).
Future research is needed to validate the current results, which can be used to design and implement similar educational programs to teachers as a means of creating health-promoting schools.
A Mixed-Methods Exploration of Barriers and Facilitators to Evidence-Based Practices for Obesity Prevention in Head Start
2019, Journal of Nutrition Education and Behavior
Citation Excerpt :
Consistent with previous work on general determinants of mealtime practices,58,59 the context for feeding (eg, scheduling and mealtime setting) held influence over an educator's ability to be a role model and use positive feeding practices with WISE. To date, most studies designed to understand mealtime practices have focused on individual-level characteristics (eg, knowledge and personal health habits).60–65 Current findings on the influence of context highlight the need to measure and attend to contextual factors66 in interventions in the early care and education setting.
To identify positive and negative deviant cases using quantitative fidelity data from a previous implementation of a nutrition intervention, Together, We Inspire Smart Eating (WISE), and to determine barriers and facilitators to fidelity by conducting qualitative interviews with deviant cases.
Explanatory sequential mixed methods.
Head Start Program agencies in 2 southern US states.
Quantitative fidelity data were collected in 42 Head Start classrooms. Recruitment for qualitative interviews prioritized those who were positive or negative deviants across fidelity components (African American, n = 21; white, n = 19; and Hispanic, n = 3).
WISE introduces children to fruits and vegetables using evidence-based practices of role modeling, positive feeding, mascot use, and hands-on exposure.
A directed content analysis approach informed by the integrated Promoting Action on Research Implementation in Health Service framework.
Barriers and facilitators to WISE evidence-based practices implementation.
Qualitative analyses identified themes of culture, leadership support, and mechanisms for embedding change as key contextual factors. Key findings related to recipient characteristics were beliefs about what works, personalized strategies to use WISE, and classroom management. Primary themes for the innovation construct were time and preparation, degree of fit, and WISE advantage. Finally, findings relative to the construct of facilitation included trainer support and desire for additional training.
The study of cases at the extreme ends of the fidelity spectrum can provide unique perspectives on barriers and facilitators to implementation of interventions.

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: Conflict of Interest Disclosures: The authors’ conflict of interest disclosures can be found online with this article on www.jneb.org.

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Research ArticleInfluence of Teachers' Personal Health Behaviors on Operationalizing Obesity Prevention Policy in Head Start Preschools: A Project of the Children's Healthy Living Program (CHL)

Abstract

Objective

Design

Setting

Participants

Intervention

Main Outcome Measures

Analysis

Results

Conclusions and Implications

Introduction

Section snippets

Setting

Results

Discussion

Implications for Research and Practice

Acknowledgments

Prevalence of overweight and obesity among US children, adolescents, and adults, 1999-2002

JAMA

Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010

JAMA

Changes in terminology for childhood overweight and obesity

Natl Health Stat Report

Cardiovascular risk factors and excess adiposity among overweight children and adolescents: the Bogalusa Heart Study

J Pediatr

Relationship of childhood obesity to coronary heart disease risk factors in adulthood: the Bogalusa Heart Study

Pediatrics

The relation of childhood BMI to adult adiposity: the Bogalusa Heart Study

Pediatrics

Systematic review of prevalance of young child overweight and obesity in the United States–Affiliated Pacific region compared with the 48 contiguous states: the Children’s Healthy Living Study

Am J Public Health

Ethnic differences in the prevalence of overweight among young children in Hawai‘i

J Am Diet Assoc

Overweight and obesity among Hawai‘i children aged 4 to 5 years enrolled in public schools in 2007-2008 and comparison with a similar 2002-2003 cohort

Hawai‘i J Med Public Health

A systems-oriented multilevel framework for addressing obesity in the 21st century

Prev Chronic Dis

Development of food variety in children

Appetite

Do obese children become obese adults? A review of the literature

Prev Med

America’s Children: Key National Indicators of Well-being

Obesity prevention in child care: a review of U.S. state regulations

BMC Public Health

Research Article
Influence of Teachers' Personal Health Behaviors on Operationalizing Obesity Prevention Policy in Head Start Preschools: A Project of the Children's Healthy Living Program (CHL)