A School-Based PSE Change-Making Strategy that Works: How to Implement and Evaluate It      *Funders Jini Puma, PhD Charlotte Farewell, PhD candidate Rocky Mountain Prevention Research Center University of Colorado Denver

Learning Objectives Increase awareness of an evidence-based strategic planning process to make best practice healthy eating and physical activity PSE changes in school-based settings Increase awareness about “menus of research-based PSE changes” that promote healthy eating and physical activity created for preschools and elementary schools that can be used by all SNAP-Ed implementing agencies doing school- based work

Early Childhood Obesity 1 in every 4 preschool children are overweight or obese Low-income and ethnic minority children are disproportionately affected by obesity Early development of gross motor skills and eating attitudes and behaviors are shaped in the first five years of life Childhood obesity is a major epidemic in the United States with one in four preschool children being overweight or obese1. Five-year-old children who are overweight are four times more likely to become obese by eighth grade than normal weight children 2. This trend continues into adulthood and is associated with chronic diseases such as heart disease and diabetes 3. Therefore, intervening in the first five years of life to address nutrition and physical activity-related behaviors that are carried long into adulthood is critical.

The Role of Early Childhood Education (ECE) Settings Over 11 million children under six spend an average of 30 hours a week in non-parental care Making healthy Policy, System, and Environment (PSE) changes in ECE settings has the potential to impact children’s physical activity and healthy eating behaviors (and reduce childhood overweight and obesity) The number of children under six who spend an average of 30 hours a week in non-parental care is over 11 million 4. This makes center-based care an important setting to focus early childhood obesity prevention efforts. Changing Policy, System, and Environmental (PSE) features focused on physical activity and healthy eating behaviors can play a key role in prevention strategies in early childhood education (ECE) settings because of their broad reach (all children in an ECE setting) and because they can be sustained over time, which allows for impact on children who enter the ECE setting year after year 5,6. In other words, making ongoing, foundational PSE changes can produce behavior changes that create long-term impacts 7.

Policy Change- Policy change includes policies at the center or organizational level. For example, institutionalizing new rules or procedures in ECE settings (Policy: Children go outside for 30 minutes/day) System Change-Systems change involves change made to the rules within an organization. Systems change and policy change often work hand‐in‐hand. Often systems change focuses on changing infrastructure within a school, park, worksite, or health setting or instituting processes or procedures at the system level that ensure a healthier workplace (e.g. garden to table programs in ECE settings) Environment Change-Environmental change is change made to the physical environment. Physical (Structural changes or programs or service), social (a positive change in attitudes or behavior about policies that promote health or an increase in supportive attitudes regarding a health practice), and economic factors (presence of financial disincentives or incentives to encourage a desired behavior) influence people’s practices and behaviors (e.g. improving fixed equipment on outdoor playspace)

Why PSE’s? Ongoing Foundational: Often produces behavior change over time Community-/population- Level Part of a Wellness Policy Sustainable

What is the COWP PSE Process? Changes Strategy 1: Assess healthy eating and physical activity in your center Strategy 2: Identify and decide on changes to make in your center Strategy 3: Make it happen **Intervention Mapping is intended to make the steps in planning interventions explicit enough to demystify the process to facilitate collaborative planning by individuals of varying backgrounds. *It also has a visual component including numerous diagrams and matrices used as landmarks for logical program development. *program development as requiring a linkage between a resource system (developers), an intermediate user system (implementers), and an end user system (program participants). *The linkages can span the range from inclusion of prospective program participants and intermediate users as planning team members, through a community empowerment model in which the community members are the planners. *The practice of health education involves three major program planning activities: conducting a needs and capacity assessment, developing and implementing a program, and evaluating the program's effectiveness. *In addition to models for conducting a needs assessment and program evaluation, the literature provides ecological models for conceptualizing the multiple levels of health education intervention, but it lacks specific models for program development. The Intervention Mapping (IM) protocol (Bartholomew et al., 2016) describes the iterative path from problem identification to problem solving or mitigation. Each of the six steps of IM comprises several tasks each of which integrates theory and evidence. The completion of the tasks in a step creates a product that is the guide for the subsequent step. The completion of all of the steps serves as a blueprint for designing, implementing and evaluating an intervention based on a foundation of theoretical, empirical and practical information.

COWP PSE Process Key Ingredients Center-based wellness Team Director participation COWP facilitator Interdisciplinary (4-8 participants) 4-6 monthly meetings 3 change-making strategies Goal: 4 health-promoting PSE changes implemented

Strategy 1: Strengths and Needs Assessment

Menu of Evidence-Based Best Practices: Sample of Healthy Eating-Related PSE’s

Menu of Evidence-Based Best Practices: Sample of Physical Activity-related PSE’s

Strengths and Needs Assessment Review Menu of Healthy Eating and Physical Activity PSE Best Practices Assess current level of implementation (Not, Partial, and Full) of all PSE practices

Strategy 2: Prioritizing PSE Changes IS IT FEASIBLE? IS IT IMPORTANT?

Importance and Feasibility Consider the following when thinking about IMPORTANCE of a best practice in your ECE center Evidence-based? How often will it impact children? Will this affect all preschool-aged children or just some groups? Consider the following when thinking about FEASIBILITY of a best practice at your ECE center Will this cost money? Will this cost time? Do staff and administrators support this?

Importance and Feasibility HEALTHY EATING BEST PRACTICES Low, Med, High for IMPORTANCE Low, Med, High for FEASIBILITY

Strategy 3: Action Planning

Action Planning STEPS Who is responsible for completing this step? What resources do they need? When does this need to be accomplished? Notes

Remember: Consider the following: Action Planning Remember: Consider the following: Getting approval for the change Getting buy in from key stakeholders Putting the change in place Communicating the change to school and community Planning for sustainability Walk team through the action planning process and make sure there are action steps related to each of these key points *plan for dissemination and sustainability is key*

COWP Wellness Policy Poster Highlights policies that the center had prior to COWP and new changes that occurred through the COWP PSE Process Site Specific

Follow-up and On-going Support with Implementation PSE toolkits Technical assistance follow-up Ongoing quarterly meetings with wellness team and wellness champions Toolkits: Purchases to support specific PSE changes- portable play equipment toolkit, meal time environment toolkit (child-friendly dishes, aprons, etc) Teams provide ongoing TA support to ensure changes are implemented and sustained over time (e.g. LLP coaching sessions, resources, ongoing wellness team meetings to troubleshoot barriers, etc)

Evaluation and SNAP-Ed Indicators Medium-Term Outcomes: Changes adopted by the end of the COWP PSE Process MT5: Nutrition Supports MT6: Physical Activity Supports Long-Term Outcomes: PSE Changes sustained over time LT5: Nutrition Supports LT6: Physical Activity Supports MT5-Sites and organizations that newly adopt PSE (policy, systems, and environmental) changes and complementary promotion such as favorable procurement, meal preparation activities, or other interventions that expand access to and promote healthy eating; associated potential audience reached MT6-This indicator reports sites and organizations that newly adopt PSE changes that expand access and promote physical activity and reduced time spent being sedentary; associated potential audience reached. LT5: Nutrition Supports Implementation-This indicator measures the number, type and reach in different settings sustained implementation and effectiveness of PSE changes. Implementation is defined as the aggregate number of sites or organizations in each type of setting within the eat, learn, live, play, shop, and work domains that report a multi-component and multi-level intervention effectiveness is defined as the aggregate number of sites or organizations with improved food environment assessment scores. LT6: Physical Activity Supports Implementation -This indicator measures the sustained implementation and effectiveness of PSE changes. Implementation is defined as the aggregate number of sites or organizations in each type of setting within the eat, live, work, learn, shop, and play domains that report a multi-component and multi-level intervention effectiveness is defined as the aggregate number of sites or organizations with improved physical activity environment assessment scores.

Evaluation of PSE changes Instrument: Outcome Evaluation Form, measures implementation and sustainability of PSE changes after completion of the PSE Process Completed by Director/Wellness Champion Completed: 1-month, 6-months, 1-year, 2-years Not Implemented: The PSE Change is Not Currently being implemented at your center Partially Implemented: The PSE Change is sometimes being implemented at your center (some classrooms, some days, etc.) Fully Implemented: The PSE change is always being implemented at your center (all classrooms, all days)

Outcomes to Date (through 2018) Medium-Term (MT5 & 6) 657 adopted changes across 125 ECE settings (average of 5.3 changes/setting) 47% focused on healthy eating changes 53% were focused on physical activity changes

Outcomes to Date Long-Term (LT5 & 6) After 6 months, 48% of the changes adopted are fully implemented After 1 year, 66% of the changes adopted are fully implemented After 2 years, 70% of changes adopted are fully implemented

Sustainability of PSE Changes

What Providers have said about the COWP PSE Process “I would tell them to do it, definitely. It’s a way of getting the blinders off and getting some new ideas and good things to happen in your school.” “It was a very good experience. I never once went, “Oh I wish I didn’t have to go!” “I enjoyed the brainstorming and hearing people’s ideas… because even though you may have a good idea, someone might add a little twist to it and that makes it that much better… it’s like two brains are better than one.”

COWP PSE PROCESS - Looking Ahead… Currently piloting various adaptations of the COWP PSE process: Professional Development and Technical Assistance Format Remote Facilitation Format Home-Based ECE settings Total Worker Health Adaptation Analyzing factors related to successful dissemination and implementation of PSE changes in ECE settings

Resources Culture of Wellness in Preschools website - http://cowpprogram.com Integrated Nutrition Education Program – PSE tool for elementary schools Contact Julie Atwood at julie.atwood@ucdenver.edu

Charlotte Farewell, PhD Candidate Thank You! Jini Puma, PhD jini.puma@ucdenver.edu Charlotte Farewell, PhD Candidate charlotte.farewell@ucdenver.edu