Development of ACTION! Wellness Program for Elementary School ...

Development of ACTION! Wellness Program for Elementary School Personnel Larry S. Webber,* Carolyn C. Johnson,† Donald Rose,† and Janet C. Rice*

Abstract WEBBER, LARRY S., CAROLYN C. JOHNSON, DONALD ROSE, AND JANET C. RICE. Development of ACTION! Wellness Program for Elementary School Personnel. Obesity. 2007;15(Suppl 1):48S–56S. Objective: The prevalence of overweight and obesity has increased dramatically in the adult population over the past 2 decades. Almost two-thirds of the adult population works outside the home; thus, interventions implemented at the worksite are viable for obesity reduction. Elementary schools are worksites that have a number of resources that can encourage a healthy lifestyle. The purpose of this paper is to describe the formative research activities and how these were used to design the ACTION! Wellness Program for Elementary School Personnel. Research Methods and Procedures: Formative data were collected using focus groups, a school survey, and an environmental audit. Focus groups were conducted in three elementary schools, whereas the school survey and environmental audit were collected in 24 elementary schools. The intervention was then tested as a pilot study in one school to determine feasibility and receptivity and refine its components. Results: Participants in the focus groups indicated that most had experience with trying to lose weight, some had positive social support, and most had little free time at school; however, most were very receptive to having a weight control intervention program at their school. Eighteen (75%) of the schools had snack vending machines on the school site, and all had cold drink machines. All 24 schools had at least one indoor site that could be used for physical activity programs. All schools were in neighborhoods conducive for walking. Discussion: ACTION! will take advantage of the school

Departments of *Biostatistics and †Community Health Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana. Address correspondence to Larry S. Webber, Department of Biostatistics-SL18, Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, New Orleans, LA 70112. E-mail: [email protected] Copyright © 2007 NAASO

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resources in implementing an environmental intervention to reduce overweight and obesity. This paper describes the progression of events that led to the final trial. Key words: worksite wellness program, formative research, environmental interventions, schools, teachers

Introduction The dramatic increase in the prevalence of overweight and obesity during the past 2 decades among adults in the United States is well documented, with an age-adjusted prevalence of obesity (BMI ⱖ 30) of ⬃32% in 2003 to 2004 (1) and an increase of ⬎15% from 1976 to 1980 (2). The combined prevalence of overweight and obesity (BMI ⱖ25.0) has also increased over the same period, from 46% to 64.5% (1,2). Overweight and obesity are strongly associated with hypertension (3), depression (4), coronary heart disease (5), diabetes (5,6), and some cancers (3). The health consequences of these conditions place an enormous financial burden on health care systems (7). Interventions implemented at worksites hold promise for obesity reduction because they can reach large numbers of adults (8). A variety of physical, social, and adjoining community characteristics make worksite settings amenable to providing opportunities for healthful behavior. Many worksites have cafeterias, vending machines, indoor and outdoor hallways, and open spaces. Some worksites are close to community parks and playgrounds, fitness centers, and food outlets. Unfortunately, exercise and nutrition programs at the worksite are not common, likely due to the need for investment of resources (9). Matson-Koffman et al. (7) noted that worksite health promotion programs, in part, can have an impact on heart disease and stroke and may reduce employers’ health-related costs. Most interventions to promote healthful behaviors in schools have been directed toward students (10,11); however, schools are also worksites. In general, annual turnover is modest among employees at schools, making this setting a good location for a 2-year intervention to improve eating and physical activity behaviors to control or maintain

Worksite Wellness Program, Webber et al.

weight. In an August 2005 report, the Alliance for Excellent Education indicated that nationwide, 5.8% of teachers left the profession, and another 7.4% transferred to other schools annually. The percentages are slightly larger in Louisiana (6.1% and 9.1%, respectively) (12). Newer teachers are more likely to leave than established teachers; however, for Jefferson Parish Public Schools, the site for this research, 85.3% of the teachers have 4 or more years of teaching experience, with 61.1% having 11 or more years of teaching experience, indicating a rather stable teaching population (13). School employees include the principal, teachers, classroom aides, administrators, food service workers, and clerical and maintenance staff. These individuals have diverse educational backgrounds and wide-ranging socioeconomic status. Because they have worked together, generally for a number of years, they can provide mutual support for program participation. Schools also have a number of resources available for an intervention. They have cafeterias, vending machines, a teacher’s lounge, and other areas where didactic information and media messages can be provided, physical activity equipment, and both indoor and outdoor activity areas. Many schools also have access to big screen television sets and either a videocassette recorder or compact disc player that can be used for playing physical activity videos. These resources address some of the strategies for weight control that have been recommended for schools and worksites (14). Elementary schools nationwide are of a generally uniform structure with an administrative head (principal), other administrative staff, academic staff (teachers, teacher aides), and support staff (food service personnel, custodians). Because of this generally uniform structure with diverse personnel, the potential for dissemination, if the program is successful, is high. Uses/Purpose of Formative Analyses Formative research is essential before the development of any intervention. Formative research gathers data that provide information to intervention designers about the targeted audience and the community and settings in which the research is implemented (15). Formative research also generates the first links and methods of interaction between the researchers and the targets of the intervention and establishes a rapport that assists in recruiting and retaining participants. Through the conduct of formative research, the data needed to develop an intervention that will be appropriate for and applicable to all of the diverse members of a particular target group can be obtained. The goal is for the intervention to be appropriate for the setting in which it is implemented and appealing to the intended recipients. Both qualitative and quantitative methods are appropriate for use in obtaining formative data, allowing for several avenues of

input to assure both breadth and depth of the data to be used in developing the intervention. Description of ACTION! ACTION! is a group-randomized trial in which the school is the unit of randomization and the unit of analysis. The primary aim of the trial is to show a difference of 3.0 kg in body weight between participants in intervention schools compared with those from control schools after a 2-year intervention and after adjusting for baseline values. This translates into a difference in BMI of 1.0 kg/m2. We obtained measurements at both the level of the school and the level of the individual. All schools that are participating in ACTION! are from a single large school district in suburban New Orleans, LA. Although we identified eligible schools in 2004 and planned to begin collection of baseline measurements in fall 2005, we postponed baseline data collection until fall 2006 due to the effects of Hurricane Katrina. A total of 22 schools were selected to participate in the main trial, and all opened in October 2005; however, conditions such as physical aspects of the school, stable enrollment of students, and motivation toward participation were not conducive to a research study until fall 2006. This unexpected extension of the program timeline provided the opportunity to continue formative research and pilot studies during the spring semester 2006. ACTION! addresses the two major determinants of overweight and obesity: diet and physical activity. The program uses a social-ecological framework (16,17). The framework goes beyond addressing separate behavior and environmental changes by contributing to a more complete understanding of the dynamic interplay among persons and groups and their physical and social milieu. The ecological perspective views health behaviors as dynamic actions between individuals, the groups to which they belong, and the sociophysical milieu in which the groups exist. It follows then that behavior change cannot be expected without addressing the resources and/or restrictions within the work environment. Specifically, ACTION! targets environmental changes to influence eating behaviors at school such as lunch and snacks while providing media message and informational sessions about meal planning. In addition, ACTION! targets environmental changes to target physical activity behavior at school by providing opportunities for walking and other activities. The behavioral goals are to decrease caloric intake by ⬃250 kcal/d and increase energy expenditure by 250 kcal/d.

Research Methods and Procedures During the formative research phase, we collected data using focus groups, a school survey, an environmental audit, and then a pilot study. School personnel participated in the focus groups in 2003 and 2005. The principal or his/her OBESITY Vol. 15 Supplement November 2007

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designee completed the school survey in 2005, and ACTION! staff completed the environmental audit in 2005 to 2006 with assistance from school personnel. The pilot study began in 2005 at one school not participating in the main trial. Focus Groups We implemented three focus groups to obtain qualitative data to complement and enhance the formative survey data (n ⫽ 23 participants); one at the pilot school in 2003, and two at schools randomly selected from the pool of potential study schools in spring 2005. Twenty participants were white, and three were African American; 13 were single, and 10 were married; and one was pregnant, 21 (91%) were currently trying to lose weight, and one was trying to maintain current weight. The only male participant was a maintenance worker at the pilot school who was of normal weight and did not have the weight control experiences of the other participants. Although he offered suggestions, we did not include his responses in the focus group results. Fourteen participants were teachers. Other participants, in addition to the maintenance worker, were one principal, one food service worker, and five paraprofessionals who had various school-based roles and responsibilities. The format of the focus groups included 34 open-ended questions (with probes) distributed across five domains: personal experiences, social environment, physical environment-home, physical environment-school, and program receptivity. Examples of questions in each of the domains included: personal experiences, “What are the kinds of things you do when you want to lose weight?”; social environment, “What has been your experience with working with a group to lose or maintain weight?”; home physical environment, “What kinds of changes could you make at home that would be helpful to you to be more physically active?”; school physical environment, “If you wanted to be more physically active at school, what would be your suggestions for changing the school environment so that you could be more physically active?”; and program receptivity, “In general, if there were a program at your school that would help you to lose weight, what would you think about that?” School Survey Each school’s principal or his/her designee completed a detailed self-report School Survey during spring 2005. The survey included various sections related to the number and composition of school personnel, the day structure at the school, school facilities, after-school programs, recreational and other facilities near the school, modes of transportation to the school, means of communication among school personnel, school policies, and questions about the school food environment. The survey included questions concerning the duration and frequency of classes, lunch periods, and planning peri50S


ods, and the daily work day starting and ending times for each different category of personnel, including faculty, clerical staff, food service staff, and other staff to provide us information on the day structure at the school. The school facilities section of the questionnaire included yes/no questions on the existence of a gym, playing field, walking path, basketball court, paved area, an indoor multipurpose space for activities, an outdoor recreational space separate from the sports area, and other school facilities. There were also questions on the availability of various sorts of audio-visual equipment (e.g., television, digital video disc player, liquid crystal display projector) that might be used for future exercise classes. The school survey included additional questions on the existence of facilities for personnel to shower and/or change clothes. Detailed questions about the school food environment requested information about the school cafeteria, vending machines, and other sites in the school where food and beverages could be purchased. Some questions asked whether school personnel were allowed to purchase food from the school cafeteria. Other information obtained included the number and location of drink and food vending machines, school vending machine policies, and the person responsible for selecting vending machine items and setting their prices. Lastly, there were questions about the type of facilities (e.g., microwave, refrigerator, and seating near food preparation area) available to school personnel and their location. Environmental Audit ACTION! staff developed an environmental audit to assess physical characteristics of the school and the surrounding neighborhood. One or two ACTION! staff members together completed the audit by walking through the school and its grounds. We completed some of the audits in spring 2005 and some in spring 2006 when the schools reopened after Hurricane Katrina. A school employee usually escorted the staff person for at least part of the tour. The audit included information on the physical properties of the school such as number of buildings and floors, presence or absence of facilities such as a gymnasium, playground or stage, and the number and type of vending machines. The audit also included information about the neighborhood surrounding the school including types of stores and restaurants within walking distance, condition of the streets, and safety of the neighborhood. The data collected by the school survey and the environmental audit intentionally overlapped. School personnel completed the survey, whereas ACTION! staff completed the environmental audit. ACTION! staff assessed the condition of the facilities, in addition to noting their presence or absence.


Results Focus Groups Results are presented for each of the five domains described above. Personal Experiences. Almost all of the participants have had experience with trying to lose weight; some were successful, but many were not. Attempts to lose weight seemed to be a recurrent process in their lives because even those who were successful at losing weight were not particularly successful at maintaining the weight loss. The attitudes expressed were frustration, “I lose it, gain it; it’s a constant yo-yo,” and defeat, “I think the weight is part of me that will be there . . . ” Self-efficacy regarding losing weight was low, but even lower for maintaining weight loss. Self-efficacy is one’s perceived confidence that one can accomplish a specific task (18). It was clear from the majority of the focus group comments that individuals knew they could lose weight but were much less confident about maintaining the weight loss. This lowered self-efficacy about maintaining weight loss decreased their motivation to try again. Almost all said that they had the knowledge and knew what to do to lose weight; however, the participants identified many barriers. The most cited barriers to healthy eating and being physically active were identified, in no particular order, as: fruits/vegetables sometimes did not taste good, but chips and candy were always good, also fruits/vegetables spoiled quickly; lack of time, especially during the school year; the convenience of fast foods and unhealthy snacks; stress and exhaustion; family preferences; and health problems. Almost all participants said that they knew that being physically active was important, and they knew how to be active; however, motivation was another barrier. Experiencing embarrassment, for example, because “I’m a klutz. . . and have no rhythm . . . ” was also a concern. Some indicated that they were just not having any fun while exercising. Although participants reported that weight, physical activity, and healthy eating were always on their minds and were of high priority, they did not always take action because of various obligations that were of higher priority. Social Environment. Participants had mixed thoughts regarding social support for weight loss. One group was overwhelmingly positive about social support with just a few exceptions. The other two groups, however, were not as enthusiastic. For example, they said that some family members (e.g., daughters) could be supportive and helpful, but other family members (e.g., husbands) wanted the meals they were used to eating. Weight loss programs, such as Weight Watchers, were helpful to some, but others did not find the group setting for losing weight helpful. Some thought that friends and coworkers would be supportive if they were informed of one’s intention to lose weight; however, in the past, this concern had not prevented them from

bringing a lot of food to school. The participants recognized, though, that this would be detrimental to a weight control program. “We’ve got to stop the doughnuts; we got to tell the principal she’s got to stop the doughnuts on Thursday mornings in groups.” “You walk by the lounge and the snack machine [is] in there—it’s awful.” Physical Environment at Home and Other Places. “The biggest thing is that I am exhausted when I get home.” “I had my little treadmill . . . My husband uses it to hang clothes on.” “. . . the weight set we got in January, the weights are still in the box.” These comments indicate a general feeling among participants that despite opportunities in their home environment for physical activity, there remain barriers to making healthy choices. Participants reported that such barriers and distractions included “neighborhood safety, caring for children, family food preferences, and not having the time to prepare foods properly.” One participant said, “planning meals at home is important; otherwise you eat whatever’s convenient. My home is junk food city.” Others made suggestions for healthier eating at home including: “make a grocery list, don’t go to the store hungry, eat healthy foods before they spoil, and portion control.” Many participants thought that it would be helpful to use pedometers, have a scale that monitors body fat, and make one change at a time using realistic ageappropriate weight goals. Most of the participants reported that they ate more food at home than they did at school. Physical Environment at School. Most thought that the school environment was stressful because their day was regulated by the clock and their students and that their free time was extremely limited. Some thought pedometers at school would be helpful as a way to monitor activity because most thought they did a lot of moving at school, but not in organized activities. Stress, exhaustion, and lack of time headed the list of barriers at school. The vending machines usually had junk food and sugar sodas, but removing these vending machines was not an option, commenting. “When I need chocolate, I need it.” The teachers usually did not like the cafeteria food and did not eat in the cafeteria. Most brought food from home or got lunch from a nearby fast food restaurant. Healthful food options at school suggested by participants were fruit smoothies, salads, and healthy sandwiches. Receptivity to a Weight Loss Program. Most of the participants were very positive about having a weight loss program on site at their school. Some indicated that they would attend activities before school in the morning; however, others thought that activities after school would be more convenient. Most indicated that other jobs or family responsibilities would preclude attendance after school. Most participants also indicated that they were not interested in attending lectures or workshops; they wanted activities that allowed them to interact. They thought that they had the knowledge, just not the motivation. Some offered OBESITY Vol. 15 Supplement November 2007

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the idea of competitions as a motivating factor. Summer activities and programs were welcomed by some because they had more time and were not in school. Suggestions for incentives for participation were mostly personal, such as pedicures, massages, gift certificates to local malls or stores, or American Express gift cards. School Survey Information from the School Survey and Environmental Audit provided quantitative data that, combined with the focus groups, were particularly useful in guiding choices of environmental interventions. Although only 17.4% of the sampled schools had indoor gymnasiums, all of the schools had either an outdoor playing field or recreational space. Efforts to change the eating environment at elementary schools often focused on the food served in cafeterias. Although the School Survey showed that all of the schools allowed their personnel to purchase food from cafeterias, the focus groups revealed that few of the teachers actually ate there. Moreover, our preliminary investigation showed that food service is centralized at the district level, making it difficult to develop school-level interventions for healthy cafeteria food service. Such school-level variability is necessary because all of our schools are in one district. The school surveys did, however, reveal that all of the schools had vending machines located in staff lounges and that there was significant school-level variability in the choice and pricing of items in the machines. Some schools had a few products in the vending machines that would be considered healthful; however, most items were not. The School Survey also provided logistical information, necessary to coordinate daily activities of the study such as the structure of the school day, including the length and frequency of classes, teacher planning periods, and lunch periods. Results from the School Survey indicated that all schools communicated with their staffs through staff mailboxes, 91% of schools communicated to their staffs through meetings, and 74% used bulletin boards to communicate information. All schools had e-mail and Internet capability, and 14% of the principals indicated that they communicate with personnel by e-mail. The vast majority of school personnel in the ACTION! schools lived more than 1 mile from their school, and almost all used a car to get to work. Two schools (8.3%) were within walking distance of a shopping center, five (20.8%) were within walking distance of a convenience store, and four (16.7%) were within walking distance of a food shop. Environmental Audit ACTION! staff completed environmental audits of 24 schools. These included 23 schools eligible for the main trial and one pilot school. Within the building, 11 schools 52S


Table 1. Visible facilities in school neighborhoods: ACTION! Environmental Audit, Spring 2005 to Spring 2006 Facility

Number of schools

Percentage

Fitness facility Park Tennis courts Shopping center Convenience store Food shop Any of the above

1 4 1 2 5 4 10

4.2 16.7 4.2 8.3 20.8 16.7 41.7

(45.8%) had more than one floor. All schools had at least one site on the grounds that can be used for physical activity, and 23 of the 24 schools had multiple sites. Three schools (12.5%) already had walking trails on the grounds. The school neighborhoods had a number of characteristics that encouraged physical activity. People were more likely to walk if they had a destination. Table 1 shows the facilities visible from the school. Ten (41.7%) of the schools had at least one facility that was visible from the school. Five (20.8%) of the schools were near a convenience store, whereas four (16.7%) schools were near a food shop. In addition, four (16.7%) schools were near a park. People were also more likely to walk in the neighborhood if it is pleasant and safe. Some of the features for a walkable neighborhood are given in Table 2. Almost all of the schools had at least one built sidewalk. All of the neighborhoods had well-maintained housing, pleasant landscape, and few signs of disorder, indicating that all of the schools were in residential rather than in commercial or industrial areas. Vending machines were very common in these elementary schools. At the time of the survey, each school had at least one cold drink machine, whereas only one school had a hot drink machine. Eighteen (75.0%) of the schools had

Table 2. Neighborhood features to induce walking: ACTION! Environmental Audit, Spring 2005 to Spring 2006 Feature

Number of schools

Percentage

At least one sidewalk Well maintained housing Pleasant landscape Few signs of disorder

21 20 20 20

87.5 83.3 83.3 83.3


Figure 1: Conceptual model for the ACTION! Study. The primary outcome is defined as a reduction in BMI. Intervention activities are those strategies that are expected to have an effect on changes at the environmental and individual level. Process is the process of implementation that explains the study outcomes. Mediators are variables that may or may not be targeted by the intervention and that are expected to influence behavior change leading to the primary outcome. Moderators are variables that are not targeted by the intervention and are not expected to change during the course of the study but could influence the primary outcome. Environmental level changes are modifications to the school environment that are expected to have a positive impact on individual behavior change. Individual level changes are modifications in the behavior of participants that will have a direct influence on the primary outcome. Contextual factors are those within the environment that could influence intervention activities but are often beyond the ability of the program to change. Examples of these are socioeconomic influences, school district policies, weather, and neighborhood crime.

snack machines, but only one had a machine that could hold refrigerated snacks. All schools had at least one refrigerator and one microwave accessible to school staff.

Discussion We used the data collected from the focus groups, school survey, and environment audit to design a pilot study at one school in the same school district as the main trial study schools. We then used the results of the pilot study to further inform the intervention before implementation in the main trial. The pilot, therefore, was intermediate between formative evaluation and implementation of the study. The physical characteristics of the school and the demographic characteristics of the school staff for the pilot study were similar to those in the main trial schools. The goals of the pilot study were to explore the feasibility of implementing various intervention activities within the school and to test various measurement procedures that would be used for baseline and follow-up examinations. The intervention components that were tested in the pilot school were in large part based on information obtained

through the results of the three formative research methods used in this study. Figure 1 shows a schematic of a conceptual model for ACTION! and defines how the overall study will function. The intervention activities included all of the strategies that were expected to have an effect on the process of change at the environmental and individual levels. These strategies trigger a process of environmental and individual level changes that is expected to result in the primary outcome, weight maintenance or weight reduction. Formative evaluation has been most useful in developing intervention activities. Process of implementation and its effect on outcomes will be reflected in a planned and systematic process evaluation. Included in process evaluation will be contextual factors that occur within the environment during the course of the study over which ACTION! has no control but which could influence the outcome. Formative research also helped in identifying mediators and moderators that could influence the process of behavior change and the primary outcome. Examples of these, measured at baseline and again at follow-up, are demographic OBESITY Vol. 15 Supplement November 2007

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variables, stress levels, environmental supports and/or barriers for eating and physical activity, self-efficacy, and social support. Particularly informative was the information from both the focus groups and school survey that almost none of the adult school personnel ate in the school cafeteria. We have extensive experience guiding cafeteria modifications for healthier school lunches, and we considered this as an intervention component; however, with these formative data, we realized that this would not be a viable intervention. Another important environmental modification relative to food consumption was information about vending machines. We learned that every teacher’s lounge had vending machines that are not accessible to students. These vending machines were important conveniences for adult personnel, but they admitted that the vending machines were tempting with the unhealthy foods they contained. Removing the machines was not an option, and it was clear from the focus groups that replacing all of the food choices with healthier items was not a popular idea. Consequently, the vending machine intervention will focus on providing ACTION!approved choices along with a reduced number of regular snack items. We also developed snacking activities to introduce and taste test healthier snacks. Information from the focus groups indicated that walking was a good choice for a physical activity, and the school surveys and environmental audits informed us that there was external space available on campus and sometimes in the surrounding neighborhoods for well-defined walking trails. This, along with after-school physical activity classes, became the focus of environmental change to promote increased physical activity. Climbing stairs will be promoted at those schools that have a second or third level. A walkto-school program would not be effective because almost all school staff lived more than 1 mile from their worksite. The focus groups indicated a high level of receptivity to and enthusiasm for a weight control program based at school, especially if the personnel could have some input into what the program would be. This information led to the idea of a wellness committee that could help plan activities and announce and support events. The purposes of the committee are to facilitate buy-in from the intended target audience, to assure that the interventions are tailored to each school, and to promote sustainability after the completion of the program. The committees consist of representatives from school administration, faculty, food service personnel, and other support staff. The development of the wellness committee and after-school physical activity events were tested in the pilot school and were then refined in concept based on results of this pilot-testing. The pilot testing also contributed to the recognition that teachers do not have the time for, nor are they willing to disrupt their regular routine, for a lot of extraneous activities. As a result, the intervention includes policy changes relative to the kinds of foods that 54S


are served at meetings and socials, so that positive change can occur within the normal workday rather than in addition to routine activities. Obtaining logistical information helped with the coordination of baseline measurement in such a way that there was minimal disruption to participants’ work schedules. The most viable methods of communicating with personnel were valuable for getting information to them relative to announcements of upcoming events, encouragement to participation, and social recognition of participant achievements. Our formative data told us that the school personnel were not interested in too many didactic sessions; they wanted to actively participate, to interact. In the pilot school, we did try multiple ACTION! Chats relative to both diet and physical activity. These met with limited success; therefore, these sessions have been reduced, and much of the information will now be delivered through eye-appealing visual aids. The ACTION! intervention, therefore, went through several iterations because of data from the three formative research methods and the pilot study. We implemented activities in various formats in the pilot school and then modified, as needed, to be made ready for the main trial. This was an on-going process during the baseline measurement phase for the main trial and during the early stages of implementation of the main trial intervention. Activities that have been planned for the 2nd year of ACTION! are being implemented in the pilot school, whereas the 1st year activities are ongoing in the main trial. Based on the formative research and the pilot, we created a cohesive implementation plan. The physical activity component of ACTION! is directed at changing the environment to attract and promote increased activity engagement with such items as safe walking paths on or around the school grounds, enhancement of existing school fitness facilities, on-site physical activities, and a fitness area with equipment and videotapes that can be used on site or checked out for use away from the school. Policy changes include increased accessibility and availability of physical activity facilities, establishment of goals for employees, formal recognition of employees who achieve their goals, and having fitness breaks at meetings and workshops. The plan also encourages partnerships with nearby community recreation centers and health clubs. Although Craig et al. (18) noted a positive effect of a walk to work program, this is not likely to be effective with school employees because most live too far from the school where they work. The dietary component of ACTION! is directed to improving the nutritional content of vending machine items, providing healthy snacks at meetings, eating healthier lunch items, and increasing consumption of fruits, vegetables, and whole grains. An important component of ACTION! is a media campaign to promote increased physical activity and improved diet. Nutrition and physical activity information and reminders of upcoming activities are reinforced through


a monthly newsletter. Frequent promotional challenge events occur to motivate employees to participate, provide employees with goals that are achievable, and provide recognition for those who meet or exceed their goals. There are properties of schools as worksites that are associated with high participation in healthful activities. Generally, schools are small worksites, and participation rates in worksite programs tend to be higher in smaller worksites, although smaller sites are less likely to offer the appropriate facilities, and their interventions are often not sustained for long periods of time (19). Crump et al. (20) showed that employees are more likely to participate if there are numerous efforts made to inform, market, and provide incentives to encourage participation and if organizations make efforts to reduce barriers to employee participation. In a review of the literature, Sorensen et al. (21) showed that successful worksite health promotion programs should focus on reducing barriers to organizational and environmental change, should include worker participation in program planning, and address contextual factors that effect behavior. ACTION! developed a number of media campaigns and challenges to inform school personnel. Most of the challenges included small incentives such as water bottles and key-holders to encourage participation. We also included policy change programs to provide time, for example, at faculty and staff meetings for a few minutes of physical activity. Endorsement from employees and support from management are important for employee participation (9). The school principal, thus, becomes a key person in implementing ACTION!. Programs with the flexibility to allow options and modifications are more likely to attract participants and be adopted (22). The Wellness Committee helps identify which programs and activities are likely to succeed at the schools. The committee is also in place to help sustain the program after the research is completed. Although there have been very few worksite health promotion programs that are environmental in nature in schools, these programs have been successfully implemented in other sites. In a systematic review, Engbers et al. (23) identified 13 such trials. Effects on dietary intake were noted with strategies such as food labeling, using media materials, and increasing the availability of healthy products. The results on physical activity were inconclusive, perhaps due to the small of number of studies that incorporated this. In one study, using signs to encourage stair use was effective (24). In summary, the formative research was an essential step in developing this ecological intervention aimed at a specific target audience, elementary school personnel. If successful, this 2-year intervention will be disseminated to other school districts. Much of what we learned during this formative research phase will be directly applicable to school districts in other parts of the United States.

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