573923

research-article2015

HPPXXX10.1177/1524839915573923health promotion practicealaimo et al. / school nutrition policy and practice

Social Determinants of Food and Nutrition

The Michigan Healthy School Action Tools Process Generates Improvements in School Nutrition Policies and Practices, and Student Dietary Intake Katherine Alaimo, PhD1 Shannon Oleksyk, MS, RD2 Diane Golzynski, PhD, RD3 Nick Drzal, MS, RD3 Jennifer Lucarelli, PhD4 Melissa Reznar, PhD4 Yalu Wen, PhD5 Karen Krabill Yoder, MS6

The Michigan Healthy School Action Tools (HSAT) is an online self-assessment and action planning process for schools seeking to improve their health policies and practices. The School Nutrition Advances Kids study, a 2-year quasi-experimental intervention with low-income middle schools, evaluated whether completing the HSAT with a facilitator assistance and small grant funding resulted in (1) improvements in school nutrition practices and policies and (2) improvements in student dietary intake. A total of 65 low-income Michigan middle schools participated in the study. The Block Youth Food Frequency Questionnaire was completed by 1,176 seventh-grade students at baseline and in eighth grade (during intervention). Schools reported nutrition-related policies and practices/education using the School Environment and Policy Survey. Schools completing the HSAT were compared to schools that did not complete the HSAT with regard to number of policy and practice changes and student dietary intake. Schools that completed the HSAT made significantly more nutrition practice/ education changes than schools that did not complete the HSAT, and students in those schools made dietary improvements in fruit, fiber, and cholesterol intake. The Michigan HSAT process is an effective strategy to

Health Promotion Practice May 2015 Vol. 16, No. (3) 401­–410 DOI: 10.1177/1524839915573923 © 2015 Society for Public Health Education

initiate improvements in nutrition policies and practices within schools, and to improve student dietary intake. Keywords: school health; child/adolescent health; nutrition

1

Michigan State University, East Lansing, MI, USA Blue Cross Blue Shield of Michigan, Lansing, MI, USA 3 Michigan Department of Education, Lansing, MI, USA 4 Oakland University, Rochester, MI, USA 5 University of Auckland, Auckland, NZ 6 Michigan Department of Community Health, Lansing, MI, USA 2

Authors’ Note: The SNAK project was funded by the Robert Wood Johnson Foundation’s Healthy Eating Research Program, the Michigan Department of Community Health, and the USDA Supplemental Nutrition Assistance Program–Nutrition Education, supported by the Michigan Department of Human Services under contract numbers ADMIN-07-99010, ADMIN-08-99010, and ADMIN 09-99010. The authors are grateful to the students and staff of the schools that participated in the SNAK project. In addition, the authors thank the Richard Miles, Deb Bailey, Deanne Kelleher, Paul McConaughy, Ann Guyer, Paul Baumgartner, Donna Hensey, Larry Merx, Dru Szczerba, Elaine Belansky, and Julie Marshall. Additional thanks to Karen Petersmarck, PhD, MPH, and Caroline Crawford, MS, for assistance with manuscript preparation. Address correspondence to Katherine Alaimo, PhD, Michigan State University, 208C G. M. Trout FSHN Building, East Lansing, MI 48824-1224; e-mail: [email protected].

401

Introduction And Background >> Trends in dietary intake indicate that U.S. youth are not receiving optimal nutrition with intake levels below recommendations for key food groups and nutrients such as fruits, vegetables, calcium, magnesium, potassium, vitamin A, vitamin E, vitamin C, and fiber (Ervin, Wright, Wang, & Kennedy-Stephenson, 2004; Institute of Medicine, 2006; Kant, 2003; Moshfegh, Goldman, & Cheveland, 2005; Reedy & Krebs-Smith, 2010; Subar, Krebs-Smith, Cook, & Kahle, 1998; U.S. Dietary Guidelines Advisory Committee, 2010; Wright, Wang, Kennedy-Stephenson, & Ervin, 2003). Schools are ideal settings for advancing nutrition among youth. Improvements in nutrition education such as marketing healthy foods in the cafeteria, nutrition environments such as improving the healthfulness of competitive foods, and nutrition policies such as restricting access to sugar-sweetened beverages have been associated with improved student dietary intake (Briefel, Crepinsek, Cabili, Wilson, & Gleason, 2009; Briefel, Wilson, Cabili, & Hedley Dodd, 2013; Crawford & Gosliner, 2012; Cullen & Watson, 2009; Cullen, Watson, & Zakeri, 2008; Gordon, Crepinsek, Briefel, Clark, & Fox, 2009; Gortmaker & Story, 2012; Hubbard et al., 2014; Larson & Story, 2010; Wansink, Just, Payne, & Klinger, 2012; Waters et al., 2011). However, the pathway to achieve comprehensive and sustained nutrition education, policy, and practice improvements can be complex and involves many stakeholders (Belansky, Cutforth, Gilbert, et al., 2013; Belansky et al., 2010; Moag-Stahlberg, Howley, & Luscri, 2008). Many organizations from both the public and private sectors promote a participatory model for effectively implementing improvements in school nutrition environments and policies. In this model, grounded in empowerment (Zimmerman, 2000) and socioecological (Green & Kreuter, 1999; Sallis & Owen, 2002; Story, Nanney, & Schwartz, 2009) frameworks, a team of school and community stakeholders and leaders is convened. They self-assess current nutrition practices, including nutrition education, and nutrition policies using evidencebased criteria; identify and prioritize possibilities for improvement; create improvement plans; and continue working together to implement the plans. Monitoring and evaluation of progress through regular reassessment and revision of the improvement plan are integral to the model. The advantage of this type of grassroots effort is that action steps arising from the process are individually tailored to the values and resources of the stakeholders and schools. Tools to facilitate this type of self-assessment and action planning became nationally available in 2000,

402  HEALTH PROMOTION PRACTICE / May 2015

when the Centers for Disease Control and Prevention launched the School Health Index (SHI; Centers for Disease Control and Prevention, 2000) and the U.S. Department of Agriculture’s Food and Nutrition Service launched Changing the Scene: Improving the School Nutrition Environment (CTS; U.S. Department of Agriculture, 2000). The nutrition items in both tools are drawn from research-based policies and practices most likely to promote lifelong healthy eating (Centers for Disease Control and Prevention, 1996). In 2006, two additional national tools became available online, with nutrition content and planning processes similar to that used in the SHI. The Healthy Schools Inventory, a component of the Alliance for a Healthier Generation’s obesity prevention initiative, has been used by over 15,000 schools (Alliance for a Healthier Generation, 2006; Nicole Walker, personal communication, April, 12, 2012). The Association for Supervision and Curriculum Development’s Healthy School Report Card—more broadly aimed at school improvement—has been used by an estimated 1,200 schools (Adriane Tasco, personal communication, April 12, 2012; Lohrmann, 2010). In 2004, Michigan introduced the online Healthy School Action Tools (HSAT; Michigan Team Nutrition et al., 2004). The original HSAT Assessment (focused on nutrition and physical activity) came out of a collaborative effort of the Michigan Department of Community Health, the Michigan Department of Education, Michigan State University Extension, Michigan Team Nutrition, and United Dairy Industry of Michigan. Adapted from the SHI and CTS, the HSAT is a Michigan-specific online assessment and action planning process whereby schools choose a topic area to address, that is, healthy eating and nutrition; complete a number of questions about their school environment, education, practices, and policies; are given ideas for improvement; and develop an action plan based on their own assessment and desires. Because the tool is online, school personnel can access online resources aggregated on the website and easily share findings and action plans among themselves. In addition, the statelevel online tool permitted staff from the Michigan Departments of Community Health and Education to identify and support schools ready to move ahead on health improvement efforts. Topic areas have been added over time, and the action planning tool has been expanded. From 2007 to 2012, a total of 758 Michigan schools registered on the HSAT website and worked on the assessment and 500 schools completed the HSAT assessment one or more times (Krabill Yoder, personal communication, February 16, 2012). The HSAT offers technical assistance in the form of online training; guidance for objectively assessing

aspects of the environment and for generating a summary report, topic-specific resources, and templates for follow-up publicity and communications; as well as access to state-level content experts and to technical support. External grant funding has permitted many schools to receive valuable onsite training, facilitation, and ongoing encouragement for using these tools. There have been few quantitative research studies undertaken to evaluate the effectiveness of school selfassessment and action planning tools such as the HSAT. Qualitative research has shown that the SHI has been effective in helping schools develop collaborations to benefit children and in creating plans for improving the nutrition environment particularly when an outside facilitator guides the planning process and when school principals support the process (Austin, Fung, Cohen-Bearak, Wardle, & Cheung, 2006; Butler, Reed, & Thomas, 2011; Foster et al., 2008; Lohrmann, 2010; Pearlman, Dowling, Bayuk, Cullinen, & Thacher, 2005; Sherwood-Puzzello, Miller, Lohrmann, & Gregory, 2007; Staten et al., 2005; Teufel-Shone, Siyuja, Watahomigie, & Irwin, 2006). In addition, in case studies, the SHI process has been shown to result in improvements in school nutrition environments, such as moving all candy sales out of the cafeteria, converting school bake sales to healthy snack or fruit and vegetable sales, and establishing a policy prohibiting the use of food as a reward (Austin et al., 2006; Staten et al., 2005). Using pre- and postintervention scores on the Healthy Schools Inventory completed by 1,295 schools, Beam, Ehrlich, Black, Block, and Leviton (2012) showed that the assessment-/planning-based intervention resulted in improvements in the nutrition environment (56% of schools improved one or more school meal items, and 48% of schools improved one or more items on competitive foods and beverage items), and that the training and technical assistance aspects of the intervention helped schools improve the school environment more quickly and undertake more improvements (Beam et al., 2012). Only one study has been conducted to assess whether undertaking the SHI process has resulted in improvements in dietary intake or nutrition knowledge. Benjamins and Whitman (2010) evaluated the result of the SHI process and a subsequent 2-year tailored environmental intervention in two Jewish schools. Student surveys pre- and postintervention revealed some improvements in nutrition knowledge but none in nutrition behaviors. No improvements in the nutrition environment were noted by the students (Benjamins & Whitman, 2010). The current study evaluated whether undertaking the Michigan HSAT process (assessment, planning, and

prioritizing) and receiving assistance from a facilitator and a small amount of grant funding resulted in (1) improvements in school nutrition practices (including nutrition education) and policies among low-income middle schools and (2) improvements in student dietary intake.

Method >> The School Nutrition Advances Kid (SNAK) project was a 2-year study conducted in low-income middle schools in Michigan from 2007 to 2010. The project design included both a modified experimental intervention and a natural experiment whereby schools were encouraged to make self-selected nutrition policy and practice changes and followed over time. Schools were recruited through an application for small grant funding with award values ranging from $2,000 to $4,600. Eligibility criteria included having 50% or more of students eligible for free or reduced-price meals, and having seventh and eighth grades within the same building (for follow-up purposes). Recruitment methods included direct mailings, e-mails, and phone calls to eligible schools, as well as a posting on the Michigan Team Nutrition website. There were two overlapping cohorts with schools recruited in 2007 and 2008 and follow-up assessments measured in the next school year. Sixtyfive schools were randomized into four intervention groups: three intervention groups that participated in the HSAT process and a control group that was offered the HSAT intervention after the study was completed. All study procedures and instruments were approved by the Michigan State University Institutional Review Board. Details of recruitment, design, and study groups have been published elsewhere (Alaimo et al., 2013). Intervention schools were asked to convene a Coordinated School Health Team (CSHT) with representatives from various sectors of the school, including administration, faculty, food service, health care, and students, and were provided with a trained facilitator to meet with their CSHT one time to complete the HSAT healthy eating and nutrition topic area. For this study, the HSAT included questions on the following topics: school nutrition policies, school nutrition environment, school health education programs including nutrition education, and school food service programs. At the end of each module, schools were to brainstorm several “bright ideas” they could implement. Once the assessment was complete, CSHTs were taken to a summary section where the identified bright ideas for each section were shown together to facilitate the development of an action plan with SMART goals (Specific, Measurable, Attainable, Realistic, and Timely). Schools

Alaimo et al. / SCHOOL NUTRITION POLICY AND PRACTICE  403

were asked to prioritize their goals and received $1,000 to implement nutrition education or nutrition marketing activities in their action plans. An updated version of the HSAT was launched in October 2014 (see http:// www.mihealthtools.org/hsat). Data Collection School Characteristics. The percentage of students eligible for free or reduced-price school meals at each school was obtained through the Michigan Department of Education. School setting (urban, rural, or suburban) was determined using 2000 U.S. Census data for each community. Type of food service program was determined through interactions with each school. A variable was created distinguishing kitchen types: traditional (a full-service or satellite kitchen in the district with food prepared on site), satellite kitchen district (large district with a central kitchen with limited preparation done onsite), vendor operated (a vendor brings in prepared foods to the school), operations run by a local food service management company, smaller districts with heat and serve kitchens (without full cooking capacity), or a large district with a heat and serve operation. School Nutrition Environment. The middle school School Environment and Policy Survey (SEPS) was used to assess building-level nutrition policies, nutrition education, and nutrition practices at baseline and follow-up (Belansky, Chriqui, & Schwartz, 2009). Two forms of the survey were used: one for administrators/ principals and one for food service directors/kitchen managers. Each survey took approximately 30 minutes to complete, either online or by paper. A $25 gift card was provided for each completed survey. Response rates ranged from 86% to 94%. The follow-up SEPS ended with an item asking respondents to report on whether improvements had been made in 15 nutrition practices or whether they had adopted any of six nutrition policies since the beginning of the study. A new practice or policy was considered to have been adopted if either the administrator or the food service professional reported it. The most popular nutrition practices/education adopted were marketing healthy foods in the cafeteria, adding posters for healthy foods in cafeteria, adding nutrition information to newsletters or materials sent home with students, offering taste tests to students, and removing advertisements for unhealthy foods and beverages. Other practices they could select were adding nutrition information to service lines/menus, changing placement of foods and beverages to highlight healthy choices, requiring that more than 50% of foods and beverages offered at classroom parties/celebrations

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be healthy, increasing the amount of nutrition education classes, coordinating nutrition education with classroom teachers in other subject areas, coordinating nutrition education with the food service department, providing after-school nutrition-related activities for students, hosting nutrition-related events for parents, hosting a health fair to promote nutrition, and/or eliminating use of food as a reward. The six policies that could have been selected were to enhance healthy foods and beverages by (1) offering them in vending machines, (2) including them in à la carte menus in the cafeteria, (3) offering them at concession rates at school events, (4) having them during classroom parties/celebrations, (5) eliminating use of food as a reward, and (6) eliminating sale of unhealthy foods and beverages as fund-raisers. Two scale scores were created: the total new nutrition practices/ education implemented (0-14; Cronbach’s α = .74) and total new policies adopted (0-6; Cronbach’s α = .76). Schools were then categorized by the number of new practices/education changes (0-2, 3-6, or 7-14 changes) and the number of new policies (0, 1-2, or 3-6). Process Data: Completion of the HSAT Intervention. To determine whether and when schools had completed the HSAT, exit interviews, school observation notes, HSAT process notes, e-mail and phone logs, the HSAT website, information from the Michigan Department of Community Health, and the SEPS were used. Schools were categorized into five groups in order to reflect their actual participation in the HSAT assessment process prior to and/or during the intervention period: (1) never completed the HSAT or similar program, (2) never completed HSAT but completed a similar nutrition program/ grant prior to or during SNAK, (3) completed the HSAT prior to SNAK and not during SNAK, (4) completed the HSAT during SNAK but not prior, and (5) completed the HSAT prior to and during SNAK (see Table 1). Student-Level Dietary Intake.  Written parental consent and student assent were obtained. The Block Kids Food Frequency Questionnaire 2004 (ages 8-17 years) assessed usual student dietary intake over the previous week at baseline and follow-up (Cullen et al., 2008; Smith & Fila, 2006). A total of 1,176 students from 55 schools had complete data for analysis. Detailed description of data collection procedures have been published elsewhere (Alaimo et al., 2013). Variables included in these analyses include kilocalories, percentage of calories from fat, percentage of calories from saturated fat, cholesterol (mg), fiber (g), sodium (mg), calcium (mg), vitamin A (mg), vitamin C (mg), fruit (cups), fruit and fruit juice (cups), total vegetables (cups), added sugars (g), and whole grains (oz equivalents).

Table 1 HSAT Status by Intention to Treat Group Study Group Study Groups Experimental study groups School HSAT status groups   1. Never completed the HSAT or similar program   2. N  ever completed HSAT but completed a similar nutrition program/grant prior to or during SNAK   3. C  ompleted the HSAT prior to SNAK and not during SNAK   4. Completed the HSAT during SNAK but not prior   5. Completed the HSAT prior to and during SNAK

Total

Control

HSAT Intervention

59

19

40

5 8

5 4

0 4

6 29 11

6 3 1

0 26 10

NOTE: HSAT = Healthy School Action Tools.

Statistical Analysis. Statistical analyses were completed using SAS statistical software. In all analyses, a p > Baseline school characteristics are shown in Table 2. Table 3 shows that there were no significant differences in nutrition policy or practice score between the experimental study groups and control schools. Analyzing the data based on actual HSAT completion (prior to and/or during the intervention period) revealed statistically significant differences. Schools that completed the HSAT prior to but not during the SNAK project reported adopting more nutrition policies than schools that never completed the HSAT or a similar program (2.2 vs. 0.4 nutrition policies). Schools that completed the HSAT at any time (prior to but not during the SNAK, during but not prior to, and both prior and during the SNAK project) reported adopting significantly more nutrition practices than schools that never completed the HSAT or a similar program (6.8, 5.8, 7.0, vs. 1.6 nutrition practices, respectively). Schools that completed a similar assessment or grant program before or after the SNAK project also reported adopting significantly more nutrition practices than schools that never completed the HSAT (4.3 vs. 1.6 nutrition practices). Students in schools that were randomized to complete the HSAT reported consuming significantly more fruit (17.5%) and fiber (4.9%) and less cholesterol (4.2%) than students in the control schools (data not shown). Nutrient and food group changes by actual

Alaimo et al. / SCHOOL NUTRITION POLICY AND PRACTICE  405

Table 2 Baseline School Characteristics Study Group

  School Characteristics Percentage of children eligible for free/reduced price school lunch, M (SD) Seventh-grade enrollment, M (SD) Setting, %  Urban  Rural   Urban cluster/suburban Kitchen type, %  Traditional   Satellite kitchen  Vendor-operated   Local food service company   Small district with heat and serve kitchen   Large district with heat and serve kitchen

Total (n = 59 Schools)

Control Group (n = 19 Schools)

HSAT Intervention Groups (n = 40 Schools)

No. of schools % or M (SD) No. of schools % or M (SD) No. of schools % or M (SD) 59

70.2 (15.0)

19

67.6 (15.7)

40

71.5 (14.7)

59

132.1 (83.7)

19

140.6 (104.1)

40

128.0.1 (73.3)

38 12 9

64.4 20.3 15.3

12 5 2

63.2 26.3 10.5

26 7 7

65.0 17.5 17.5

23 6 4 12 4

39.0 10.2 6.8 20.3 6.8

9 1 0 5 1

47.4 5.3 0.0 26.3 5.3

14 5 4 7 3

35.0 12.5 10.0 17.5 7.5

10

17.0

3

15.8

7

17.5

NOTE: HSAT = Healthy School Action Tools.

HSAT completion are shown in Table 4. For this analysis, schools were divided into three categories: (1) schools that completed the HSAT during the intervention period and (2) schools that completed it only before the study were compared to (3) schools that had never completed the HSAT. Similar to the findings for analysis by randomized intervention group, students in schools that completed the HSAT during the intervention reported consuming significantly more fruit (20.1%) and fiber (5.1%) and less cholesterol (8.4%) than students in schools that had never completed the HSAT.

Discussion >> The analysis comparing the schools randomized to conduct the HSAT to the control schools did not show statistically significant differences in nutrition practice or policy changes. However, when we compared schools in relation to their actual completion of the HSAT or similar assessments, we found strong support 406  HEALTH PROMOTION PRACTICE / May 2015

for the value of the HSAT process for schools adopting nutrition practices. As a group, the schools that underwent the HSAT process—convening stakeholders, selfassessing the current nutrition environment, and identifying possibilities and priorities for improvement—before and/or during the intervention period— made significantly more improvements in school nutrition practices than schools that had never completed the HSAT. These findings are supported by qualitative case studies of schools also conducted as part of the SNAK project that found that although the HSAT process could be challenging in terms of completion time and scheduling, the HSAT process educated and motivated school personnel to implement health initiatives (Lucarelli et al., 2015). Support from administrators, teamwork among staff, the presence of school health champions, and acknowledging student preferences facilitated positive changes (Lucarelli et al., 2014). Interestingly, only the schools that had completed the HSAT prior to the SNAK project, but not during, made more nutrition policy changes than

Table 3 Associations Between Completing the HSAT and Adopting Nutrition Policies, Education, and Practices

Study Groups Experimental study groups   Control group   HSAT group School HSAT status groups   Never completed HSAT or similar program  Completed HSAT prior to and not during SNAK  Completed HSAT during SNAK but not prior  Completed HSAT prior to and during SNAK   Never completed HSAT but completed a similar assessment, or another nutrition program/grant prior to and/or during SNAK

N

Mean Nutrition Policy Change Score (Range: 0-6); M (SD)

Mean Nutrition Education and/or Practice Change Score (Range: 0-14); M (SD)

19 40

1.2 (1.6) 1.4 (1.6)

4.8 (3.7) 5.9 (3.2)

5 6 29 11 8

0.4 2.2 1.2 1.9 1.0

1.6 6.8 5.8 7.0 4.3

(0.55) (2.4)** (1.5) (1.8)† (1.4)

(1.9) (3.5)** (2.9)** (2.6)** (5.0)*

NOTE: HSAT = Healthy School Action Tools; SNAK = School Nutrition Advances Kid. † p < .10. *p < .05. **p < .01. Significantly different from “never completed HSAT or similar program” schools after adjusting for school setting, school kitchen type, and percentage of students eligible for free and reduced-price school meals.

schools that never completed the HSAT. Through discussion with school and facilitators, we have learned that oftentimes when schools first undertake the HSAT, they work on practice changes, but over time, they increasingly tackle policies, which can be more challenging to adopt. This study is the first large sample study we are aware of that evaluated the effects of a school self-assessment and action planning process on student dietary intake. In addition to practice changes, students in schools that completed the HSAT showed marked improvements in diet compared to students in schools that did not complete the HSAT with regard to fruit, fiber, and cholesterol. The success of the HSAT at improving student dietary behavior is important to note; not only are nutrition practice improvements achieved but also these improvements influence students’ dietary behaviors. Additional data analysis from this project showed significant improvements in student dietary intake in schools that had implemented nutrition policy and practice changes and in schools starting lunchtime à la carte lines with primarily or entirely healthy items (Alaimo et al., 2013). One other study evaluated student-level diet changes due to a school wellness policy planning and implementation process in two schools, and found improvements in student nutrition knowledge and physical activity but not in student nutrition attitudes, other health behaviors, or the school nutrition environment (Benjamins & Whitman, 2010).

Our findings for improvements in nutrition practices are consistent with other published studies evaluating schools using the SHI, the Healthy School Inventory, and similar nutrition environment selfassessment and planning tools (Austin et al., 2006; Butler et al., 2011; Foster et al., 2008; Lohrmann, 2010; Pearlman et al., 2005; Sherwood-Puzzello et al., 2007; Staten et al., 2005; Teufel-Shone et al., 2006). Processes such as the HSAT likely work because they are able to harness schools readiness and desire for improvements with evidence-based procedures that can assist schools in overcoming the challenges and complications that arise. Research to date has shown that several factors are associated with effective implementation of processes such as the HSAT: presence of a school health champion, support of administration, stakeholder support, awareness of the importance of student health and prioritization of health initiatives, provision of training and technical assistance, ongoing engagement and support of external facilitators, tailoring of the interventions to local priorities and values, and ability to make systemic (i.e., policy) rather than just programmatic changes (Austin et al., 2006; Belansky, Cutforth, Chavez, et al., 2013; Belansky, Cutforth, Chavez, Waters, & Bartlett-Horch, 2011; Belansky, Cutforth, Gilbert, et al., 2013; Fung et al., 2012; Kaplan, Liversman, & Kraak, 2005; Lohrmann, 2010; Lucarelli et al., 2014; Pearlman et al., 2005; Sherwood-Puzzello et al., 2007; Staten et al., 2005).

Alaimo et al. / SCHOOL NUTRITION POLICY AND PRACTICE  407

Table 4 Student Dietary Intake Changes by School HSAT Completion Groups (Compared With Schools That Did Not Conduct the HSAT; n = 1,176 Students) HSAT Before Only (n = 6 schools) FFQ Outcome  Calories, kcal % kcal from fat % kcal from saturated fat Cholesterol (mg) Fiber (g) Sodium (mgb) Calcium (mg) Vitamin A (mg) Vitamin C (mg) Fruit (cups) Fruit and fruit juice (cups) Total vegetables (cups) Added sugars (g) Whole grains (oz equivalents)

Estimation −0.04 0.18 −0.07 −0.05 0.01 −51.43 −0.01 −0.04 −0.08 0.03 0.05 −0.04 0.07 −0.07

CI [−0.16, [−1.42, [−0.65, [−0.14, [−0.08, [−124.88, [−0.09, [−0.15, [−0.27, [−0.27, [−0.18, [−0.19, [−0.07, [−0.25,

0.08] 1.77] 0.51] 0.03] 0.09] 22.03] 0.08] 0.08] 0.1] 0.33] 0.28] 0.12] 0.21] 0.12]

p

HSAT During (n = 39 schools) ya

.53 −3.7% .82 0.2% .81 −0.1% .24 −4.9% .89 0.6% .17 −51.4% .87 −0.7% .53 −3.5% .37 −7.9% .84 3.0% .67 5.1% .63 −3.7% .30 7.5% .47 −6.5%

Estimation −0.08 −0.64 −0.28 −0.09 0.05 −29.32 0.02 0.00 0.07 0.18 0.14 0.03 0.02 0.00

CI [−0.18, [−1.82, [−0.61, [−0.14, [0.01, [−74.2, [−0.03, [−0.1, [−0.05, [0.02, [−0.02, [−0.11, [−0.06, [−0.11,

0.02] 0.54] 0.06] −0.03] 0.09] 15.57] 0.07] 0.1] 0.19] 0.35] 0.31] 0.16] 0.11] 0.11]

p

ya

.13 −7.5% .28 −0.6% .10 −0.3% .00 −8.4% .02 5.1% .19 −29.3% .46 1.9% .99 −0.1% .25 7.1% .03 20.1% .09 15.4% .68 2.8% .58 2.5% 1.00 0.0%

NOTE: HSAT = Healthy School Action Tools; FFQ = Food Frequency Questionnaire; CI = confidence interval. All analyses adjusted for baseline value, interaction of race-ethnicity * gender, kitchen type, urbanization, and percentage of children eligible for free/reduced price meals. a y = (1 − exp(Coeff)) and is interpreted as percentage change for the treatment group compared to the group that never completed the HSAT (n = 10) controlling for the baseline value. bCoefficient = additional change for the treatment group compared to the control group controlling for the baseline value in milligram.

There are some limitations to this study. Because they responded to a call for small grant funding to improve the nutrition environment in their school, the schools that participated in the SNAK project may have been more motivated to improve the health of their students than schools that did not respond. The process evaluation in this study revealed some important information, including challenges we encountered maintaining our randomization process. While almost all of the schools randomized to the HSAT intervention group completed the HSAT during the intervention, four of the control schools who agreed to wait until after the intervention period before implementing the HSAT went ahead and convened a team and undertook the process on their own, one of them for a second time. Six schools randomized to the control group had completed the HSAT prior to the SNAK study period. We believe that it would have been unethical to actively discourage schools from making improvements that they believed would improve kids’ health during the intervention period. These types of challenges have

408  HEALTH PROMOTION PRACTICE / May 2015

been described in other studies (French, Story, Fulkerson, & Hannan, 2004; Fulkerson, French, Story, Nelson, & Hannan, 2004; Woodward-Lopez et al., 2010). Another limitation was that the response rates for the student dietary intake surveys were very low; at most schools, this was due to the difficulty in receiving signed consent forms back from parents.

Conclusions >> In conclusion, providing a facilitator and a small amount of grant funding for schools to undertake the Michigan HSAT’s self-assessment, planning, and action process was an effective strategy to initiate improvements in nutrition policies and practices within schools and to improve student dietary intake. Schools and school districts bring unique needs, challenges, and resources to their efforts to improve the nutrition environment of schools. School health assessments capture that information and help schools make data-driven decisions when working to implement

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