Assessing School Wellness Policies and Identifying Priorities for Action in Greater Kansas City Area Schools

Assessing School Wellness Policies and Identifying Priorities for Action in Greater Kansas City Area Schools Children s Mercy Hospitals and Clinics in collaboration with the University of Kansas Medical Center Funded by the Health Care Foundation of Greater Kansas City

Childhood obesity has tripled in the past 30 years Age 6 to 11: 6.5% (1980) to 19.6% (2008) Age 12 to 19: 5.0% (1980) to 18.1% (2008) Local school wellness policy Mandated by Congress in 2004 to address escalating rates of childhood obesity Healthy Hunger-Free Act of 2010 Greater emphasis on implementation, evaluation and public reporting on progress of local policies Will be issuing new proposed regulations this fall

Project Overview 3 Main Components 1. Assess local school wellness policies in the bi-state, Greater KC area 2. Conduct discussion groups with school personnel 3. Administer School Wellness Policy Survey

Project Overview 1. Assess local school wellness policies in the bi-state, greater KC area 7-county bi-state area 5 Missouri counties Jackson, Lafayette, Cass, Clay, Platte 2 Kansas counties Johnson, Wyandotte 48 school districts Only public schools included in sampling frame Multi-stage probability sampling procedure 222 schools selected 144 elementary, 42 middle, 36 high schools

Project Overview 2. Conduct discussion groups with school personnel Identify supports needed Priorities Benefits/challenges related to writing and implementing school wellness policies

Project Overview 3. Administer School Wellness Policy Survey Identify current practices and policies at their individual schools Asked how beneficial those practices or policies were in supporting a healthy school environment

Assess local school wellness policies in the bi-state, Greater KC area Contacted each selected school to gain school wellness policy Wellness School Assessment Tool (WellSAT) Standard method for quantitative assessment Offers a consistent and reliable means of assessing Comprehensiveness of school wellness policies Extent to which recommended content areas are covered in the policy Strength of school wellness policies within or among states Describes how strongly the content is stated Not intended for use in assessing the degree to which school districts have implemented their wellness policies

50 policy items, categorized in 5 sections 1. Nutrition education and wellness promotion 2. Standards for USDA Child Nutrition Programs and school meals 3. Nutrition standards for competitive and other beverages 4. Physical education and physical activity 5. Evaluation

WellSAT gives school wellness policies two scores: comprehensiveness score (measuring the extent to which content areas are covered) strength score (measuring how strong the content is stated). Overall score is the combination of those two scores (range from 0 to 100) The tool measures the policy language only Does not measure a policy s implementation efforts.

0 = Not Mentioned Item is not included in the text of the policy 1 = Weak Assign a rating of 1 when the item is mentioned, but: The policy will be hard to enforce because the statement is vague, unclear or confusing. Statements are listed as goals, aspirations, suggestions or recommendations There are loopholes in the policy that weaken the enforcement of the item. The policy mentions a future plan to act without specifying when the plan will be established. Words often used include may, can, would, should, might, encourage, suggest, urge, some, partial, make an effort and try. 2 = Meets/Exceeds Expectations Assign a rating of 2 when the item is mentioned, and it is clear that the policymakers are committed to making the item happen because: The item is described using specific language (e.g., a concept followed by concrete plans or strategies for implementation). Strong language is used to indicate that action or regulation is required, including: shall, will, must, have to, insist, require, all, total, comply and enforce. A district is unable to enforce an item (e.g., teachers role modeling healthy behaviors), but the goal is clearly stated (e.g., shall encourage teachers to role model healthy behaviors ).

0 = Not Mentioned Item is not included in the text of the policy 1 = Weak Assign a rating of 1 when the item is mentioned, but: The policy will be hard to enforce because the statement is vague, unclear or confusing. Statements are listed as goals, aspirations, suggestions or recommendations There are loopholes in the policy that weaken the enforcement of the item. The policy mentions a future plan to act without specifying when the plan will be established. Words often used include may, can, would, should, might, encourage, suggest, urge, some, partial, make an effort and try. 2 = Meets/Exceeds Expectations Assign a rating of 2 when the item is mentioned, and it is clear that the policymakers are committed to making the item happen because: The item is described using specific language (e.g., a concept followed by concrete plans or strategies for implementation). Strong language is used to indicate that action or regulation is required, including: shall, will, must, have to, insist, require, all, total, comply and enforce. A district is unable to enforce an item (e.g., teachers role modeling healthy behaviors), but the goal is clearly stated (e.g., shall encourage teachers to role model healthy behaviors ).

0 = Not Mentioned Item is not included in the text of the policy 1 = Weak Assign a rating of 1 when the item is mentioned, but: The policy will be hard to enforce because the statement is vague, unclear or confusing. Statements are listed as goals, aspirations, suggestions or recommendations There are loopholes in the policy that weaken the enforcement of the item. The policy mentions a future plan to act without specifying when the plan will be established. Words often used include may, can, would, should, might, encourage, suggest, urge, some, partial, make an effort and try. 2 = Meets/Exceeds Expectations Assign a rating of 2 when the item is mentioned, and it is clear that the policymakers are committed to making the item happen because: The item is described using specific language (e.g., a concept followed by concrete plans or strategies for implementation). Strong language is used to indicate that action or regulation is required, including: shall, will, must, have to, insist, require, all, total, comply and enforce. A district is unable to enforce an item (e.g., teachers role modeling healthy behaviors), but the goal is clearly stated (e.g., shall encourage teachers to role model healthy behaviors ).

Conduct discussion groups with school personnel School personnel invited to participate Tried to hold discussions in conjunction with preestablished meeting times All discussions recorded and transcribed, and analyzed for common themes Administered two-page survey following discussions that was identical to the online survey

Administer School Wellness Policy Survey Invited school personnel to complete one-page on-line survey Survey Monkey https://www.surveymonkey.com/s/school_wellness Paper copies were available, too, for those who did not have internet access

School Wellness Policy Assessment Contacted all 222 schools Verified schools followed district policies Requested written copies of policies Received policies for: 38 targeted school districts in Missouri 174,384 enrolled students 8 out of 10 targeted school districts in Kansas 118,696 enrolled students Scored policies using the WellSAT

Discussion groups with school personnel 7 focus group discussions held School administrators School nutrition services personnel School nurses Teachers and PE instructors Average of 10 individuals per session Transcribed and analyzed for common themes across groups

School Wellness Policy Survey Who completed? 156 individuals completed the survey 56% elementary school 28% middle school 23% high school 15% district level

School Wellness Policy Survey Respondents by professions 1% 8% 6% 10% principals nutrition services physical education teacher 66% school nurse 10% other

School Wellness Policy Survey From what state are respondents? 22% Kansas 78% Missouri

5 Cross-Cutting Issues 1. Regulation of Foods Sold for Funding 2. Foods Used as Rewards 3. Access to Free Drinking Water 4. Community Use of School Facilities for Physical Activity Outside of the School Day 5. Restriction of Physical Activity as Punishment

Cross-Cutting Issues Regulation of Foods Sold Survey results indicate: > 50% of schools use chocolate, candy and high-fat baked goods in current funding practices When asked about how beneficial these practices are, about 2/3 of survey respondents reported it does not support a healthy school environment---makes it worse

Cross-Cutting Issues Regulation of Foods Sold for Funding WELLSAT results indicated: 7 out of 46 school districts did not mention how food sold was to be regulated If mentioned, the majority of school districts provided weak statements in their school wellness policies Discussion groups indicated significant challenges and barriers to implementing and enforcing policies Rely on revenue generated from vending machines Need revenue to support athletic programs

Foods Used As Rewards > 2/3 of survey respondents indicated food is used as rewards/incentives 60% of respondents indicated this practice does not support a healthy school environment makes it worse > 60% of school district policies did not address foods used as rewards or rated as weak Only one school district out of 46 districts met/exceeded expectation for this nutrition standard School personnel believe this wellness standard (not to use food as a reward) is a priority for change

Access to Drinking Water Schools are required to make water available during mealtimes at no cost to students (Child Nutrition Act 2010) About 90% of survey respondents reported their schools allow students to have water in the classroom About 97% indicated this is a beneficial practice that supports a healthy school environment WELLSAT scores indicated only 1 out of 46 school districts mentioned this policy Discussion group participants did not mention access to drinking water as a priority

Community Use of School Facilities for Physical Activity Outside of School Day 31 out of 46 schools districts did not address this standard Of those districts that had policies, 13 districts met/exceeded the expectations for this standard 27% of survey respondents indicated their schools allow use of indoor facilities for recreation outside school hours More than half (~53%) of respondents indicated it was not allowed About 70% of respondents believed allowing this practice does not support a healthy school environment makes it worse Who will replace broken or lost equipment when the community uses the facilities?

Community Use of School Facilities for Physical Activity Outside of School Day Discussion group participants did not mention community access as a priority for change Stressed the need to enhance community partnerships with schools Infrastructure to support physical activity outside of the school day Community events to support physical activity Partner with experts in nutrition and physical activity Ask them to speak at family nights Provide families and staff with information on community resources for healthy eating and active lifestyles

Restriction of Physical Activity as Punishment 18% of school personnel indicated use of PA as a form of punishment is a current practice (e.g., pushups or run laps for misbehavior) ~40% of respondents indicated withholding recess or PE class as punishment is a current practice ~80% of respondents indicated these practices do not support a healthy school environment; makes it worse Discussion group participants indicated restriction of PA as an important policy to be addressed Participants want to prohibit PA from being taken away or used as punishment for student misbehavior

Restriction of Physical Activity as Punishment 30 out 46 (65%) school districts failed to address not restricting PA as punishment When addressed, only 8 districts met/exceeded expectations for regulating this PEPA standard Remaining district policies were rated as weak for this standard

More Content and Use of Specific and Directive Language NUTRITION EDUCATION AND WELLNESS PROMOTION Establishes an advisory committee to address health and wellness that is ongoing beyond policy development School districts with 2 Rating N=46 34 (73.9%) PHYSICAL EDUCATION AND PHYSICAL ACTIVITY Address written PE curriculum/program for each grade level 31 (67.4%)

Less content and Weaker Language NUTRITION EDUCATION AND WELLNESS PROMOTION School districts with 2 Rating N=46 Encourages staff to be role models for healthy behaviors 1 Nutrition information for school meals is available 1 PHYSICAL EDUCATION AND PHYSICAL ACTIVITY Addresses time/week of PE for elementary school students 0 Addresses teacher-student ratio for PE 0

Less content and weaker language School districts with 2 Rating N=46 NUTRITION STANDARDS FOR COMPETITIVE AND OTHER FOODS & BEVERAGES Regulates food served at class parties and other school celebrations Addresses food sold for fundraising 0 Addresses free access to water 1 Addresses access to and/or promotion of School Breakfast Program 0 0

34 out of 46 districts had policies that established advisory committees to address health and wellness 37 out of 46 districts had policies that specified restriction of marketing of unhealthful choices 31 out of 46 districts had policies that addressed written PE curriculum/programs for each grade level

WellSAT provides scores for comprehensiveness and strength of written policies; not implementation Policies related to nutrition and physical activity could have been addressed by school districts in other ways (i.e., under a different rubric instead of school wellness) Majority of online surveys completed by school nurses (64%) while classroom teachers comprised 16% (and primarily elementary school level)

Schools can provide opportunities for children to engage in healthy behaviors Students spend their formative years attending school Students spend the majority of their day at school (at least 6 hours per day 5 days per week) School wellness policies have the potential to promote healthy nutrition and physical activity Significant improvements can be made in the strength and comprehensiveness of written wellness policies Bridging the gap between current practices and the desired beneficial practices to support a healthy school environment is needed