Start Strong: Move your feet and eat before school Program Evaluation

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Start Strong Move your feet and eat before
school! Program Evaluation

• Mollie Greves, MD

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Evaluation Design Using a Theory of Change Model

• What is a theory of change?
• An individuals or organizations beliefs about
  how to positively change conditions or behaviors
• Why is this process used?
• Develop a program systematically
• Communicate program to partners, funders
• Monitor implementation, inform decisions
• Develop evaluation to assess implementation and
  outcomes

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Components of Theory of Change

• Contextual analysis (Background/ setting)
• Knowledge and understanding of the problems
• Assumptions about what is needed to solve
  problems (may be based on theories of behavior
  change)
• Strategic Focus (What doing whyvery specific)
• Actions/Activities (How program will be
  implemented)
• Short-term Long-term outcomes (Identify changes
  expected)

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Pathway Map

• Visual depiction of how to link strategies,
  actions and outcomes
• May be similar to a logic model

Contextual analysis/ assumptions
Strategic Focus Program Goals
Actions/Activities (may list by goal)
Short-term outcomes
Long-term outcomes
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OMG Center for Collaborative Learning
To implement the Start Strong program by
providing nutritious breakfasts and
walking-to-school incentives while promoting
healthy lifestyles for family and community in
four Seattle public elementary schools.

• Over 1300 elementary students (ages 4-12) who
  are primarily low income and from racial/ethnic
  minorities at high risk of childhood obesity at
  Emerson, Graham Hill, Van Asselt, and Wing Luke
  elementary schools.

Seattle Start Strong Theory of Change
Strategic Focus
Target Population
Strategic Focus

• Assets
• Seattle public schools garnered national
  recognition in 2004 for progressive nutritional
  policies adopted by the district
• District policies establish guidelines on the
  nutrient quality of school meals and acknowledge
  the importance of a pleasant and relaxed
  environment in terms of food consumption.
• Despite budget cuts, the District has made
  progress in implementing policy goals, including
  an increase in its use of fresh, local,
  unprocessed foods and implementation of
  culturally diverse foods in its lunch menu.
• Individual schools are encouraged to supplement
  district-wide policies with local school-based
  initiatives.
• THE IFCK Seattle can draw from extensive
  resources through its unique partnership with
  Harborview Medical Center, Childrens Hospital
  Regional Medical Center, and Public health
  Seattle King County.
• The Start Strong program also has the resources
  available from the collaborative effort
  established between the Injury Free Coalition for
  Kids Seattle, Feet First, and Seattle Public
  Schools to combat childhood obesity.
• Two successful pilot programs at Bailey Gatzert
  Elementary School (The Walking School Bus
  Program) and T.T. Minor (Healthy Eating by
  Design) will serve as models for the Start Strong
  program at 4 other Seattle public elementary
  schools.
• Challenges
• Many children, especially low-income children
  from racial/ethnic minority groups, are
  overweight or at risk of being overweight
  because
• They are falling short of getting the ½ to 1 hour
  of recommended daily exercise
• They are not eating nutritionally sound meals
  that meet the recommended daily energy
  requirements.
• Student participation in school breakfast
  programs is low at Start Strongs partner
  schools Emerson (39), Graham Hill (14), Van
  Asselt (17), and Wing Luke (30)
• School arrival times, bus schedules, and
  unpalatable/culturally ill-suited food items, are
  possible factors prohibiting children and
  families from walking to school and participating
  in school breakfast programs.
• There are insufficient promotional activities to
  increase participation of parents and other
  family members in breakfast programs.
• Focus groups revealed that barriers to
  participation in free school breakfast programs
  might also be due to lack of time, concerns about
  nutritional value, and perceived stigma.

Contextual Problem Analysis
Program Goals

• Eating healthful and culturally appropriate
  breakfasts will contribute to reducing the
  incidence of obesity among children in
  participating schools.
• IFCK Seattle will be able to identify an array
  of culturally appropriate meals that are also
  nutritious and cost-effective.
• Culturally appropriate breakfasts prepared by
  food service staff will be palatable to students
  and families.
• Food service staff will be trained easily and
  efficiently on new menus and cooking methods.
• The increase in daily level of physical activity
  from Walk-to School program will contribute to
  improving physical fitness.
• Participating in school Healthy breakfast and
  Walk-to-School programs will change overall
  eating and exercise habits in children
• Parents and children will want to get involved as
  result of greater outreach efforts, education,
  and increased availability of information
  regarding Start Strong program.

• Implement Seattle Walks program in four public
  elementary schools

Assumptions

• Increase student participation in Seattle
  Breakfast program at four public elementary
  schools

• Increase family and community involvement in
  Walk-to-School and Healthy Breakfast programs

• Strengthen and Coordinate Partnerships (Feet
  First, SPS, STEPS, COAT, etc.)

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Short Term Outcomes 18 months
OMG Center for Collaborative Learning
Seattle Start Strong Theory of Change
Intermediate Outcomes 2-5 years
Program Activities

• Goal 1 Implementation of Seattle Walks programs
• Coordinate efforts with Feet First and Seattle
  Public Schools to Identify safe walking routes
  to school Identify a point person interested in
  exercise promotion (PTA parents, school nurse, PE
  teacher and/or other staff member
• Outreach to family and community members (the
  elderly especially) to accompany students in
  Walk-to-School programs.

• Goal 1 Implementation of Seattle Walks
• Four partner schools will offer Seattle Walks
  program.
• Students acquire positive attitudes about
  physical fitness
• Goal 2 Increase Participation in Seattle
  Breakfasts
• 10 increase in student participation at each
  partner school.
• Policy changes are in place that allow students
  to arrive 20 minutes before school begins to eat
  breakfast at four partner schools.
• Breakfast choices will contain more fiber, have a
  higher whole grain content and will offer more
  whole fruit at all four partner schools.
• Four partner schools will have increased access
  to healthy breakfast foods.
• Increased knowledge of healthy eating habits.
• Goal 3 Increase Family and Community Involvement
• 10 increase in parent participation in school
  breakfast and Walk-to-School (?) program at four
  partner schools.
• Elderly community members are trained in
  neighborhood safety issues and their
  participation increases in special breakfast
  school events and Walk-to-School programs.
• Established network of volunteers to educate and
  promote Seattle WalksGoal 4 Strengthen and
  Coordinate Partnerships
• Partners are clear on their roles and work
  collaboratively to meet desired outcomes.

• Increased physical activity and healthy food
  consumption for children in the target
  population.
• Increased parent and community involvementand
  leadership in programs.
• Plan is developed for replicating best policies
  and strategies of Start Strong program for future
  expansion to other schools and districts.

• Goal 2 Increase student participation in Seattle
  breakfast programs
• Research culturally appropriate breakfast
  options, test recipes, and offer taste tests in
  September and October.
• Research current breakfast choices being offered,
  conduct nutrition analysis, and identify barriers
  to current practices regarding whole grains and
  whole fruit
• Identify low-cost options to improve healthy food
  choices
• Work with district and food service workers to
  provide nutritious and palatable breakfasts with
  increased availability of whole grains and fresh
  fruit.
• Establish school and school transport policies
  supportive of breakfast participation
• Implement promotional activities and present to
  schools at weekly morning assembly to kick-start
  the program.

Long-term Outcomes 5 years

• Goal 3 Increase Family and Community Involvement
  in the Seattle Walks and Seattle Breakfasts
  Programs
• Recruit volunteers to do outreach with area
  senior centers to recruit elders willing to serve
  as walking champions and to promote
  intergenerational partnerships for pedestrian
  activity.
• Prepare and display promotional materials to
  engage parents in special breakfast events and in
  walking and neighborhood safety issues
• Update the nutrition bulletin regularly with
  nutrition information on breakfast consumption,
  healthy eating tips, etc.
• Send communications home regarding new options to
  school breakfast
• Set up coffee carts for parents as incentive to
  sit with children while they eat breakfast.
• Present at family night periodically to gain
  parent support and offer a taste test
• Organize special breakfast events with students,
  family, and community members

• Students improve physical fitness habits
• Students improve eating habits.
• District and state-wide policies are adopted for
  ensuring culturally appropriate and nutritious
  choices in school food.
• High level of participation and leadership from
  parents and community
• Improved capacity of IFCK-Seattle and Seattle
  elementary public schools to work in partnership
  with likeminded organizations to implement
  policies and programs that promote healthy school
  communities.
• Partnership is institutionalized as a vehicle
  towards systemic change in childhood obesity, as
  indicated by acknowledgement by the community
  that the partnership is an integral part of the
  effort to reduce childhood obesity and enhance
  childrens health
• Changes are sustained and there is
  institutionalization of successful policies and
  practices related to healthy eating and
  exercising habits in all participating schools

• Goal 4 Strengthen and Coordinate Partnerships
  (Feet First, School Board President SPS,
  Nutrition Services Director SPS, Nutrition
  Education Coordinator STEPS, COAT, Washington
  State Childrens Alliance, etc.)
• Work with Feet First to develop monthly
  activities to promote the relationship between
  the walking program and the breakfast program
• Organize monthly Start Strong meetings with key
  partners
• Organize quarterly partner meetings
• Contact Operation Frontline to determine
  potential of offering a 6-week cooking class and
  nutrition education for parents.
• Collaborate with Seattle Nutrition Action
  Consortium (SNAC) and MissionDelicious to offer
  nutrition education and cooking demonstrations in
  classrooms at partner schools.
• Partner with SPS Nutrition Services in developing
  collaborative relationship with Seattle Public
  Schools Nutrition Services Department.
• Develop relationships within each school (food
  service workers, family services coordinators,
  teachers and staff, PTA president and principal)

• Goal 4 Strengthen and Coordinate Partnerships
• Work with Feet First to develop monthly
  activities to promote the relationship between
  the walking program and the breakfast program
• Organize monthly Start Strong meetings with key
  partners (scheduled the last Thursday of every
  month)
• Organize quarterly partner meetings
• Develop relationships within each school (food
  service workers, family services coordinators,
  teachers and staff, PTA president and principal)

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Start Strongs Project Goals

• Primary dual focus on physical activity and
  nutrition for children in low-income,
  ethnically-diverse schools
• Increase walking to school
• Increase school breakfast participation
• Secondary
• Promote parent participation, improve social
  connectedness of school-family community
• Improve nutrition and palatability of school
  breakfast offerings
• Improve partnership between organizations

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Intervention components

• School-wide walking and breakfast tasting
  kick-off days
• Helping parents/staff establish walking school
  buses
• Monthly breakfast taste-testing, breakfast
  promotion and nutrition activities
• Additional school activities
• Classroom lesson plans (e.g. classroom cookbook,
  climb Mt. Rainier challenge)
• Assemblies
• Family nights
• Translated school newsletters

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Measurement/Evaluation

• Pre-intervention focus groups to gather parent
  perceptions of beliefs, barriers
• Quantitativeobjectively measure behaviors
• Hands-Up classroom surveystime series
  measurement during school year
• Breakfast participation from school reportstime
  series measurement throughout school year
• Qualitativeassess attitudes/knowledge
• Pre-post surveys of parents, 5th graders
• Mid-year key-informant interviews

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Focus GroupsMethods

• 6 non-English (2 each in Somali, Vietnamese,
  Spanish), 1 English
• 1 trained facilitator, 1 interpreter per language
• Script, questions developed by project oversight
  team
• 9-12 parents/grandparents of school-aged children
  per group
• Recruited from community centers, schools,
  pediatric clinic

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Focus groups resultsWalking

• Supported walking in general
• Exercise
• Quality time with children
• Being in nature
• Concern about child adult obesity since moving
  to U.S. due to lifestyle changes that include
  less walking
• More concern about others than about their own
  children

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Barriers to walking to school

• Lack of time to walk with children
• Fearful for children walking alone
• Language barriers, not knowing/trusting others
• Lack of safe routes, crossing guards
• Abductions, bullying
• Distance too farmany children not going to local
  neighborhood schools
• Weather

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How to overcome barriers to walking to school

• Help parents meet, develop trust with other
  parents
• Help establish adult-child walking groups led by
  parents or teachers/staff
• Identify safe routes
• Improve safety
• Crossing guards, safety training, walking paths,
  pedestrian-friendly street crossings
• Promote walking activities during school

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Focus group results School breakfast concerns

• Lack of quality, variety, and hot foods
• Lack of culturally-diverse foods (although
  children eating all types of food at home)
• Lack of adult supervision to ensure children eat
  breakfast at school
• Children play instead of eating
• School buses late

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School breakfast recommendations from parents

• More fresh fruits/vegetables and hot entrees,
  less juice and less processed foods
• Offer taste tests
• Offer more culturally-relevant foods tortillas,
  chicken, ham and cheese (Spanish), noodle soup,
  rice, Vietnamese sandwiches (Vietnamese), halal
  meat, injera (Somali)
• Remind children to go to breakfast
• Ensure breakfast available when buses are late

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Hands-up survey

• Methodology used in pilot study on walking to
  school
• Challenge to ensure 5 schools do on the same day
• Depend on teachers, principals for accurate
  completion

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Hands Up Student Breakfast and Transportation
Survey
Please enter the number of students who raise
their hand for each of the following
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Hands-up Survey Results
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Key Informant Interviews

• Qualitative, in-depth assessment of staff and
  parent perspectives on
• Walking to school and school breakfast overall
• Start Strong program activities
• Solicit feedback and ideas
• Inform our program to modify, improve activities
  and implementation