Healthy Schools Colorado Initiative SY2009-10 to SY2011-12

Evaluation Findings

October 2012

Report prepared by:

RMC Health

& Center for Research Strategies

 

 

   

   

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Background The Healthy Schools Colorado (HSC) Initiative, funded by The Colorado Health Foundation, has been designed to create healthy school environments that encourage students to adopt healthy living choices. Using the Coordinated School Health Model (CSH), the HSC Initiative funds school district and regional coordinators to recruit and train school teams. School teams in turn use the School Health Index to assess their school’s health and safety policies and programs in each of the eight components of the Coordinated School Health Model. The teams then develop School Health Improvement Plans (SHIPs) that define goals for improving policies and programs in the areas of physical education, physical activity, or nutrition. The SHIPs may target additional components of the Coordinated School Health Model as well. In addition to creating an infrastructure within the schools that supports and sustains the Coordinated School Health Model, the HSC Initiative has also funded a cadre of Physical Education and School Nurse Trainers who provide professional development training to physical education instructors and school nurses. These professional development opportunities are designed to increase the capacity of school personnel to utilize best practices in physical education instruction and chronic disease management. While the ultimate program goal of the HSC Initiative is for all Colorado children to be healthy and ready to learn, the long-term outcomes of the grant promote changes in school policy and their implementation to support youth in adopting healthy living choices. These long-term outcomes include:

Increase the number of children who receive healthy meals at school and have access to healthy food and drinks in vending machines;

Increase the number of children and adults who eat adequate amounts of fruits and vegetables daily; Increase the number of children and adults who engage in moderate or vigorous physical activity; Increase the quality of physical education in schools; and Increase the number of patients who receive evidence-based care for chronic disease.

This report reflects the final results from the three-year grant initiative, summarizing data from school years 2009-10 through 2011-12. Data collected by participating schools have been analyzed to assess change in performance measures over a three-year period. In addition to summarizing the activities and results for the performance measures, this report details process learnings and recommendations for the future. Demographics The HSC Initiative consisted of five grantees that include a total of 10 Colorado school districts. Three grantees represent large metropolitan school districts, while two grantees are regions with two to five smaller school districts, as listed below:

Douglas County School District Jefferson County School District Poudre School District Adams County Region:

o Adams D14 o Adams D50

Pikes Peak Region: o Academy D20 o Colorado Springs D11 o Falcon D49 o Harrison D2 o Manitou Springs D14

   

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During the course of the three-year initiative, grantees were asked to recruit 10 or more schools annually. The ultimate recruitment goal for the HSC Initiative was 180 schools, with 30 schools for each region and 40 schools within each large district. As depicted in Figure 1, the grantees exceeded this recruitment goal by ultimately reaching a total of 190 schools including two outdoor education laboratories. By the final year of the initiative, 98.4% of these schools (187) remained active participants.1 Schools in this initiative educate 117,385 students. Figure 2 displays the incremental increase in the number of students each year. Figure 1. Number of Schools by School Year Figure 2. Number of Students by School Year

Table 1 depicts the number of schools recruited by each grantee. Table 1. District Characteristics: School & Student Figures (2009-2012)2

Grantees/School Districts (S.D.) No. of Schools

Percent of

Schools

No. of Students

Percent of Students

Grantee Districts Douglas County S.D. 37 19.5% 26,544 22.6% Jefferson County S.D. 45 23.7% 29,030 24.7% Poudre S.D. 41 21.6% 22,806 19.4%

Grantee Regions Adams County Region: 29 15.3% 16,925 14.4%

Adams D14 11 5.8% 7,149 6.1% Adams D50 18 9.5% 9,776 8.3%

Pikes Peak Region: 38 20.0% 22,080 18.8% Academy D20 8 4.2% 6,139 5.2%

Colorado Springs D11 11 5.8% 5,309 4.5% Falcon D49 5 2.6% 4,090 3.5%

Harrison D2 10 5.3% 5,032 4.3% Manitou Springs D14 4 2.1% 1,510 1.3%

Total 190 100.0% 117,385 100.0%

                                                                                                                         1 Two schools were lost due to closures; only one school withdrew from the HSC Initiative. 2 These figures include all schools recruited by the initiative (including inactive schools) and two outdoor education laboratories.  

78  

151  190  

0  

50  

100  

150  

200  

Num

ber  o

f  Schoo

ls  

2009-­‐10SY   2010-­‐11SY   2011-­‐12SY  

48,984  

94,257  117,385  

0  

50,000  

100,000  

150,000  

Num

ber  o

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nts  

2009-­‐10SY   2010-­‐11SY   2011-­‐12SY  

   

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As illustrated in Figure 3 and Table 2, the majority of participating schools were elementary schools. These schools educate approximately 58,000 students, nearly half of the student population served by the HSC Initiative. In addition, two outdoor education laboratories offered programming to 4,826 sixth grade students in Jefferson County School District during the 2011-12 school year. Other categories of participating schools include high schools (27,755 students), middle schools (23,881) and K-8 and K-12 schools (4,401 students). Figure 3. Number of Schools by Type and School Year

Table 2. Student Figures by School Type3 (SY2009-10 to SY2011-12) No. of

Students Percent of Students

K-8 1,448 1.2% K-12 2,953 2.5% Elementary 58,250 49.6% Middle 23,881 20.3% High 27,755 23.6% Outdoor Laboratories4 3,098 2.6% Total 117,385 100.0%

                                                                                                                         3 These figures include all schools recruited by the initiative (including inactive schools). 4 This figure represents an unduplicated count of sixth grade students served by one of the two outdoor education laboratories from schools not participating in the HSC Initiative.    

2   1  

43  

20  12  

0  2   1  

99  

27   22  

0  3   3  

126  

33  23  

2  0  

20  

40  

60  

80  

100  

120  

140  

Num

ber  o

f  Schoo

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2009-­‐10SY   2010-­‐11SY   2011-­‐12SY  

   

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Performance Measurement Results To assess progress towards its intended goals, The Colorado Health Foundation has established a measurable results process to document the progress of its grantees and to determine what works and which areas may require more targeted resources. In the following section, we report on the progress made by the Healthy Schools Colorado (HSC) Initiative towards these intended milestones. (Details regarding the ways in which the following data results were captured are provided in Appendix A: Methods.) Increase the number of children who receive healthy meals at school and have access to healthy food and drinks in vending machines.

As detailed below, the participating HSC schools have had a broad impact on their students in terms of promoting access to healthy meals within the cafeteria, through vending machines and school stores, and as a result of policies related to healthy snacks and lunches brought from home. Results show the reach of these policies and practices during the 2011-12 school year as well as improvements in the proportion of schools achieving these results over the three-year grant period.5 Measurable Result - Number of Students Impacted During 2011-12 (Appendix B, Table A1)

111,144 students have access to healthful food choices in appropriate portion sizes.

76,164 students benefit from schools encouraging parents to provide a variety of nutritious foods for students bringing lunch or snacks from home.

103,200 students are in schools that put restrictions in place for student access to vending

machines, school stores, and other venues that contain foods of minimal nutritional value.

Measurable Results - Change Observed for the First Cohort of Schools (2009-10 to 2011-12)

A 22.8% increase in schools (31.1% to 38.2%) requiring that healthy food choices be available to students at every school function.

15.3% increase in schools (73.0% to 84.2%) that encourage parents to provide a variety of

nutritious foods for students bringing lunch or snacks from home.

An 6.7% increase in schools (85.1% to 90.8%) restricting student access to vending machines, school stores, and other venues that contain foods of minimal nutritional value.

                                                                                                                         5  Change from 2009-10 to 2011-12 is reported as percent increase change: ((y2 - y1) / y1)*100 = your percentage change.

   

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Success Story Results In addition to healthy food policies, school teams implemented building-level changes in the following areas:

Food policy guidelines for activities during and after school; Policies regarding classroom/birthday celebrations; Hand-washing policies; Policies regarding foods as a reward; and Nutrition policies promoting healthy snacks and “brain breaks”.

More broadly, a quarter of the school teams report explicitly aligning their work with district-level wellness policies while instituting school policies that promote healthy food choices in the classroom and within the larger school community.

Northfield Elementary, Douglas County Birthday Bag 2011-12

To address the norm for sugary treats to celebrate birthdays, Northfield Elementary adopted a new policy instituting no edible treats for birthday celebrations. A letter was sent home by the principal and discussed with students, with parents at Back to School Nights, and in newsletters. As an alternative, the school provided students non-edible items in a birthday bag. Students’ names would also be displayed on the main lobby’s television wishing them a happy birthday. Parents were asked to make donations and over $400 was received to purchase birthday bag gifts including pencils, erasers, markers, stickers, water bottles, and more. Teachers reported that students enjoyed the birthday bags and were excited to see their name posted on the television. “I like the eraser cube and the no homework pass!” Parent feedback has been very positive.

Increase the number of children and adults who eat adequate amounts of fruits and vegetables daily.

Complementing efforts to enhance access to healthy food choices, school teams instituted practices that increased the consumption of fruits and vegetables during the school day. These improvements benefitted nearly all (96%) of students within the participating schools. Within schools that had participated in all three years of the Initiative, the reach of these changes impacted 99% of all students. Measurable Result - Number of Students Impacted During 2011-12 (Appendix B, Table A1)

112,758 students have access to fresh fruits and vegetables during the school day.

   

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Measurable Results - Change Observed for the First Cohort of Schools (2009-10 to 2011-12)

A 5.9% increase in schools (93.2% to 98.7%) providing students with access to fresh fruits and vegetables during the school day.

Success Story Results While working on policy changes related to healthy foods, the school teams reported targeted improvements to increase access to school breakfast programs, to improve healthy food options during lunch, and to promote healthy snack choices. One school team, as an example, successfully implemented a NO PROCESSED SUGAR SERVED TO STUDENTS statement within their school’s student/parent handbook. Other school teams set up salad bars and instituted fruit and vegetable challenges. SUCCESS STORIES WITH NUTRITION AS A TOPIC (2011-12 SCHOOL YEAR) School Health Improvement Plan Goals Number of

Schools Increased Access to Breakfast 19 Instituted Healthy Lunch Programs 56 Promoted Healthy Snacks 46

Wayne Carle Middle School, Jefferson County The School Breakfast Program 2011-12

When a survey indicated that only 45% of students were eating breakfast, Wayne Carle Middle School developed a SHIP to provide a breakfast program and promote consistent breakfast consumption. A student health team was formed and met three times. Communications were sent to parents, staff, and students about the program. School announcements were made, posters were strategically placed around the school, and breakfast giveaways were awarded. Overall, the breakfast promotion increased the number of participants from 20 to 40 students. In addition, the cafeteria has become a gathering place in the morning where students can hang out and feel part of the school community.

Increase the quality of physical education in schools. The National Association for Sport and Physical Education (NASPE) recommends 150 minutes of physical education (PE) per school week for elementary school children and 225 minutes for middle and high school students. Assuming a 36-week school year, this translates into 90 hours of PE for elementary age students and 135 hours for middle and high school students per school year. As shown in Table A5 in Appendix B, most schools participating in the HSC Initiative fall short of this recommendation. The mean number of

   

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hours of physical education per school year ranges from 38 to 47 hours for primary school students and 67 to 78 hours for secondary school students. At the same time, participating HSC schools reported that most of their PE teachers received professional development to assist them with their PE programs. The trainings were offered through the Colorado Department of Education Physical Education Cadre and promoted best practices and skill-building to enhance PE programs. A particular emphasis of the training focused on teaching PE teachers how to define goals, objectives, and expected outcomes for PE programming. The results reported below show the extensive reach of the PE training in terms of numbers of students impacted. Measurable Result - Number of Students Impacted During 2011-12 (Appendix B, Table A4)

103,616 students have the opportunity to benefit from PE teachers or specialists who received professional development on PE during the current school year.

96,513 students have the opportunity to benefit from PE instructors who have been certified, licensed, or endorsed by the state in PE.

The PE teachers of 97,173 students have been provided with goals, objectives, and expected

outcomes.

Measurable Results - Change Observed for the First Cohort of Schools (2009-10 to 2011-12)

Schools with PE teachers or specialists who received professional development on PE during the current school year increased from 88.7% to 91.9%; this represents an increase of 3.6%.

Schools  providing  PE  teachers  with  assessment  plans  increased  from  66.1%  to  68.9%  

which  represents  an  increase  of  4.1%.      

Similarly,  schools  providing  PE  teachers  with  written  curriculum  increased  from  66.1%  to  68.9%  to  achieve  a  4.1%  increase.  

Professional Development Results The Colorado Department of Education’s (CDE) cadre of physical education trainers provides professional development on best practice guidelines for quality physical education to physical educators across the state. This cadre has developed and implemented training on Colorado’s new physical education content standards and on best practices in assessment strategies for physical education and in assessing student fitness levels. In addition to reaching physical education instructors, the cadre of physical education trainers also offered school personnel training on how to increase movement in the classroom and to incorporate brain-based learning techniques. Trainings include topic intensive half-day workshops as well as full-day conference-style institutes. In all, these trainings have reached 2,709 teachers and other school personnel.67

                                                                                                                         6 This is the attendance figure for trainings through August 2012; the PE cadre will contain to offer trainings through September and October.

7 As participants may attend multiple trainings, these figures do not provide a count of unique participants.

   

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Evaluation results of these trainings indicate that the trainings have had a positive impact on the

participating schools and districts. The majority of participants (89% to 95%) express their intent to apply their acquired knowledge and skills to improve physical education classes through the use of best practices in instructional techniques and fitness assessment and by incorporating the new statewide physical education standards.8

Follow-up survey data for the physical education standards training confirm that 92% of participants have indeed taken steps to implement a standards-based physical education program in their school/district and 80% of participants have incorporated the activities used in the training into their programs. Furthermore, 85% of participants agree that their physical education programs have improved as a result of attending the related trainings.9

Similar to the training on best practice guidelines for physical education, the evaluation results for the brain-based learning training indicate that the trainings have had a positive impact on the participating schools and districts. Participants found the training useful.10 Over 86% of the participants report their intention to develop and implement plans to incorporate physical activity into their classrooms so that students may benefit from physical activity breaks throughout the school day. 11

Success Story Results School teams worked to promote evidence-based physical education and physical activity programming through curricula such as SPARK, the Great Body Shop, CrossFit Kid, and JAMmin Minute. They encouraged classroom teachers to institute “brain breaks” and provided resource materials such as the Monster Health Book and activity decks to encourage students to become more active. Other classroom changes include fitness equipment purchases, teacher training, and classroom team incentives. SUCCESS STORIES WITH PHYSICAL EDUCATION/ACTIVITY AS A TOPIC (2011-12 SCHOOL YEAR)

School Health Improvement Plan Goals Number of Schools Instituted Curricula Changes 21 Promoted Physical Activity in Classrooms 81 Offered Teacher Training 23

                                                                                                                         8 Respondents were asked the extent to which they agreed with each statement based on a five-point scale where 4 = “Agree” and 5 = “Strongly Agree.” Results display respondents who either agreed or strongly agreed with each statement across the trainings for the last school year. N=197. 9 Respondents were asked the extent to which they agreed with each statement based on a five-point scale where 4 = “Agree” and 5 = “Strongly Agree.” Results display respondents who either agreed or strongly agreed with each statement. N=60. 10 Respondents were asked the extent to which they agreed with each statement based on a five-point scale where 4 = “Agree” and 5 = “Strongly Agree.” Mean scores ranged from 4.90 to 5.0. N=195. 11 Respondents were asked the extent to which they agreed with each statement based on a five-point scale where 4 = “Agree” and 5 = “Strongly Agree.” Results display respondents who either agreed or strongly agreed with each statement across the trainings for the last school year. N=73.  

   

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Coyote Creek Elementary, Douglas County The Great Body Shop 2011-12

Coyote Creek Elementary school began the HSC Initiative with no health curriculum in place. Feeling that this was a gap, the school health team focused their SHIP on implementing the Great Body Shop curriculum. Four classroom teachers were trained on the curriculum and then they trained the entire staff. Throughout the year, grade-level teams discussed what was working and what was not working in order to implement the curriculum more effectively. Students were given a pre/post test on the curriculum, which consisted of four monthly lessons. Coyote Creek increased the amount of health instruction by 35 minutes each week. The teacher survey indicated that 100% of the teachers taught the weekly curriculum. Teachers said students were engaged and student test scores increased from 35% of students answering 80% correct on the pre-test to 56% of students answering 80% correct on the post-test. There was a 22% increase in the number of students who scored at a proficient level on the health standards.

   

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Promoting Physical Activity and Providing High Quality Physical Education

Colorado is only one of two states in the nation that does not require physical education at any grade level. According to NASPE, quality physical education helps all students develop health-related fitness, physical competence, cognitive understanding, and positive attitudes about physical activity so that they can adopt healthy and physically active lifestyles. To build capacity among physical education instructors to deliver quality physical education, the Physical Education Coordinator at the Colorado Department of Education developed a cadre of physical education trainers to provide professional development on best practice guidelines for quality physical education to physical educators across the state. Evaluation results indicate that the trainings have had a positive impact as participants intend to use their newfound knowledge and skills to improve physical education classes and to incorporate movement throughout the school day. Additionally, participants reported that their physical education programs have improved as a result of the training on the physical education content standards. Furthermore, as a result of the training on brain-based learning and of H.B. 11-106912, one Colorado school district has made a policy change to increase physical activity among its entire student population. The Englewood School District,13 which serves approximately 3,000 students, has added the “Stretch Breaks and Energizers” policy to their District’s Wellness Policy. The policy states "Classroom staff for grades K-12 will incorporate physical movement into their classes with a minimum duration of one minute at least two times per hour." Colorado’s school children are benefiting by receiving the quality physical education that helps all students develop health-related fitness, physical competence, cognitive understanding, and positive attitudes about physical activity so that they can adopt healthy and physically active lifestyles. Additionally, as more schools and districts incorporate policies and practices to increase physical movement in the classrooms, students will benefit from improved cognition, memory, and mood are that are linked to physical activity.

                                                                                                                         12 House Bill 11-1069, Physical Activity Expectations in Schools, requires elementary schools to provide their students with 600 minutes of physical activity per month or 30 minutes of physical activity a day. 13 While this school district is not a HSC grantee, it shows the importance of the inclusive reach of the physical education cadre to physical educators and other school personnel across Colorado.  

   

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Increase the number of children and adults who engage in moderate or vigorous physical activity.

To complement the physical education standards previously described, NASPE recommends that school age children also accumulate at least 60 minutes of physical activity per day or 300 minutes per week. Physical activity may include recess or a structured physical activity that increases the heart rate of students. As shown in Table A6 in Appendix B, most HSC schools are not meeting this recommendation. The mean number of minutes of physical activity per school week ranges from 145 to 171 minutes for primary school students and 96 to 143 minutes for secondary school students. HSC schools do offer their students substantial opportunities for physical activity through intramural activities and physical activity clubs. Recess and physical activity breaks are widely available with HSC schools participating over a three-year period showing marked improvements in the number of minutes allotted for physical activity, particularly within the middle school grades. In addition to the physical activity breaks offered in schools, some districts offer opportunities for older primary school students to participate in outdoor education laboratories. Two outdoor education laboratories in the Jefferson County School District participated in the HSC Initiative and served nearly 5,000 sixth grade students during the 2011-12 school year.14 These students engaged in 900 minutes of physical activity during their week-long excursion, which is the equivalent to three hours of daily physical activity for five days. Measurable Result - Number of Students Impacted During 2011-12

79,662 students have opportunities at school to participate in intramural activities or physical

activity clubs. (Appendix B, Table A4)

An estimated 76,985 students have recess or physical activity breaks that increase their heart rates. (Appendix B, Table A6)

4,826 sixth grade students in Jefferson County School District participated in 900 minutes of

physical activity over one week while attending an outdoor education laboratory.

Measurable Results - Change Observed for the First Cohort of Schools (2009-10 to 2011-12)

Schools increased the estimated number of minutes for physical activity breaks for students in

kindergarten through eighth grade. The percent change in the mean number of weekly physical activity minutes ranged from 5% for first grade students to nearly 48% for eighth grade students.

                                                                                                                         14 The total number of students attending the Outdoor Education Laboratories during the 2011-12 school year was 4,993. This figure includes sixth grade students attending HSC schools and an additional 3,098 students in schools not participating in the HSC Initiative.

   

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Table 3 and Figure 4 detail the change in the mean number of minutes per grade for each school year.

Table 3. First Cohort of Schools - Percent Change in Mean Number of Estimated Weekly Physical Activity Minutes (2009-10SY to 2011-12SY)

Grade No. of Schools Mean Number of Weekly Physical Activity Minutes Percent

Change 2009-10SY 2011-12SY

K 32 145 155 6.9% 1 33 161 169 5.0% 2 33 159 169 6.3% 3 33 140 155 10.7% 4 33 130 145 11.5% 5 33 126 145 15.1% 6 22 121 133 9.9% 7 15 71 99 39.4% 8 15 67 99 47.8% 9 3 8 8 0

10 3 8 8 0 11 3 8 8 0 12 3 8 8 0

Figure 4. First Cohort of Schools - Change in Mean Number of Estimated Weekly Physical Activity Minutes (2009-10SY to 2011-12SY)

Success Story Results In their efforts to promote physical activity, school teams addressed changes within the classroom, during recess and outside of school hours through structured recess programs, sports clinics, and intramural games. Fitness challenges included the Flat 14ers, recess mileage clubs, and running programs for

145  161   159  

140  130   126   121  

71   67  

155  169   169  

155  145   145  

133  

99   99  

0  20  40  60  80  100  120  140  160  180  

K   Gr.  1   Gr.  2   Gr.  3   Gr.  4   Gr.  5   Gr.  6   Gr.  7   Gr.  8  

Mean  No.  of  M

inutes  

School  Grade  2009-­‐10SY   2011-­‐12SY  

   

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students, teachers, and parents. Other school teams sponsored “fitness days” to engage the entire school community in physical activity events. School teams also focused on staff wellness, promoting physical activity among teachers and staff through workshops, wellness programs, workout centers, and incentive programs. Several school teams coupled their staff wellness programs with stress-reduction initiatives. SUCCESS STORIES WITH PHYSICAL ACTIVITY AS A TOPIC (2011-12 SCHOOL YEAR) School Health Improvement Plan Goals Number of Schools Instituted Walking Clubs 29 Promoted Physical Activity Breaks 109 Encouraged Movement 37 Developed Fitness Programs 42 Offered Structured Recess Programming 45

Westminster Elementary, Adams 50 Walk the Block Success Story 2011-12

Westminster Elementary has a population of students in which 84% qualify for free and reduced lunch and 42% are considered English Language Learners. The community consists primarily of working class immigrant households, so the goal of the school health team was to target the entire school community through an affordable, simple, and sustainable program. After completing the School Health Index, the team decided to create a walking program. The walking program used small rewards, plastic feet in different colors, to reward participants. Each color of feet represented a specific distance walked. As each student reached a walking milestone and turned in their walking chart, they received a plastic foot. A class competition was also created. Participants included 30% of the school community. The Walk the Block program generated 8,260 miles walked by 110 participants including 85 students, 6 staff, and 19 family members. The school has plans to continue the program and increase participation as well as to add challenges such as who can walk the most in the school year, a month, a week, or a day.

Increase the number of patients who receive evidence-based care for chronic disease.

Nurses within HSC schools tracked the numbers of students with chronic diseases and the proportion able to self-manage their conditions. To promote and advance the use of evidence-based practices, the CDE Nurse Training Cadre developed a series of trainings related to chronic disease conditions such as asthma, obesity, and behavioral health. The results reported below demonstrate the important reach of these efforts.

   

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Measurable Result - Number of Students Impacted During 2011-12

7,292 students have asthma, 360 students have diabetes (types 1 and 2), and 1,375 students have behavioral/mental conditions. (Appendix B, Table A7)

2,097 students with asthma and 254 students with diabetes have medicine at school. Among these students, 1,782 students with asthma and 149 students with diabetes are able to self-manage their disease. (Appendix B, Table A9)

School nurses have screened over 67,000 students for vision and hearing and nearly 2,600 students for oral health. Among these students, 7.9%, 1.8% and 20.2% of them were referred to specialists for vision, hearing, and oral health respectively. (Appendix B, Table A8)

School nurses identified 3,304 students who were without health insurance coverage; 73.3% of

these students were referred to child health plan specialists. (Appendix B, Table A8) Professional Development Results

The Colorado Department of Education cadre of nurse trainers has developed and implemented a series of training programs and conferences over the last three years to promote best practices in school health services targeting the 520 school nurses serving Colorado students. The cadre offered two types of professional development opportunities: conferences and topic intensive workshops. Topic intensive workshops offered online training in addition to in-person training Conferences tended to cover multiple topics and range from one to four days in length. Four conferences were designed to target one of the following: 1) new school nurses; 2) school nurse leaders; 3) practicing school nurses; and 4) all Colorado school nurses. The intensive training workshops were usually four hours in length. Four workshops were created to target one of the following topics: 1) asthma care and management; 2) healthy living and obesity-related issues; 3) the nurse’s role in behavioral and mental health; and 4) diabetes care and management. All trainings educate nurses on the latest best practices for those topics.

Over the past three years, 2,883 participants attended the professional development opportunities offered by the cadre; this figure includes participants who attended multiple trainings. Schools nurses from each HSC district have attended trainings.

Evaluation results consistently demonstrate that the learning objectives for the intensive training

workshops have been met. Three of the four workshops utilized pre and post test survey instruments that demonstrated statistically significant gains in confidence levels and in knowledge and skills. Additionally, participants found the trainings to be useful.15 (See insert on “Promoting Best Practices in School Health Services” for more details.)

                                                                                                                         15 Two workshops asked participants whether they agreed that the workshops “were useful” using a five-point scale where 1 = “Strongly Disagree” and 5 = “Strongly Agree.” Mean scores ranged from 4.3 to 4.4. N=676.

   

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Students within HSC districts as well as those in schools not participating in the initiative benefit from nurses using the evidence-based care promoted during these statewide trainings for school nurses.

In addition to promoting best practices in Colorado, members of the cadre shared their training

programs with nurses nationwide by presenting at the National Conference for School Nurses and the American School Health Association in 2011.

WE MOVE Mesa County 2011-12 Health Services Success Story

The impact of the “Healthy Living = Healthy Learners: Saving a Generation” training has reached beyond the boundaries of the schools and into the community. A large pediatric medical group practice that serves nearly 300 children a day recently received a grant to offer weight and nutrition-related counseling to children and youth ages six through 18. As a result of local nurses attending the healthy living training offered by the CDE nurse cadre, this practice will incorporate the 5-2-1-0 messaging and motivational intervening techniques to promote physical activity and healthy eating. The 5-2-1-0 messaging promotes “5 servings of fruits and vegetables, 2 hours or less of screen time, 1 hour or more of physical activity, and 0 sweetened beverages per day”. Additionally, participants will complete a survey documenting their efforts towards meeting the 5-2-1-0 goals.

   

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Promoting Best Practices in School Health Services

According to the National Association of School Nurses (NASN), school nurses help children learn by assessing student health status and making referrals, identifying vision and hearing problems that impact learning, delivering emergency care, administering medication and vaccines, performing health care procedures, disaster preparedness, and providing health counseling and wellness programs. NASN outlines the benefits of hiring school nurses as follows:

Helps students manage chronic illness, increasing attendance; Improves attendance which translates into academic success; Addresses health concerns and keeps students at school and parents at work; Allows teachers to teach instead of providing health care for children; Reduces number of 911 calls; and Promotes health professional input on wellness programs for the school community. 16

The Colorado Department of Education developed a cadre of school nurse trainers to provide training to school nurses across Colorado. Additionally, the cadre also developed and disseminated educational tools and newsletters on chronic disease management to and for school nurses, students, and families. School nurses in schools participating in the HSC Initiative were required to attend the professional development training provided by this cadre. Nurses from each HSC school district attended these cadre trainings. ASTHMA CARE AND MANAGEMENT (2009-10) Evaluation results demonstrated a statistically significant increase in self-reported confidence by nurse participants in all components of asthma control and in nursing expertise within a coordinated school health program.17 Additional statistically significant gains were made in the nurses’ perceived level of knowledge and skills related to asthma care . Mean scores in the post test ranged from 4.4 to 4.7 for items that asked nurses to indicate the impact of the training on their knowledge and skills.18 Nearly 390 nurses participated in these statewide trainings. HEALTHY LIVING = HEALTHY LEARNERS: SAVING A GENERATION (2010-11) The school nurse cadre provided 26 trainings (both online and in person) on obesity-related issues and healthy living strategies and reached 382 participants statewide. Results showed a statistically significant increase in self-reported confidence by nurse participants in all skills related to addressing obesity issues and promoting healthy living for students and family. Mean scores in the post test for these items ranged from 2.7 to 3.6.19 Nurses reported gaining the most confidence in skills related to 5-2-1-0 messaging and in their ability to describe the state’s guidelines for addressing obesity issues. The majority of participants (86%) reported finding the training useful. 20

                                                                                                                         16 Healthy Children Learn Better! School Nurses Make a Difference. National Association of School Nurses. February 2010. 17 A four-point scale was used where 1 = “Not at all Confident” and 4 = “Completely Confident”; range of mean scores post test scores: 2.9 to 3.1. N = 275. 18 A five-point scale was used where 1 = “Don’t Agree” and 5 = “Very Much Agree.” N=288. 19 A four-point scale was used where 1 = “Not at all Confident” and 4 = “Completely Confident.” N=315. 20 Respondents were asked the extent to which they agreed with each statement based on a five-point scale where 4 = “Agree” and 5 = “Strongly Agree.” Results display respondents who either agreed or strongly agreed with the statement. N=315.  

   

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ALL HANDS ON DECK: THE NURSE’S ROLE IN BEHAVIORAL AND MENTAL HEALTH (2011-12) The cadre of school nurse trainers developed and delivered 27 face-to-face trainings and two web-based trainings to 408 participants. The goal of the trainings was to increase participants’ confidence in addressing a variety of behavioral and mental health issues of preschool and school-aged students. Findings reveal a statistically significant increase in self-reported confidence by nurse participants for each of the learning objectives. Mean scores in the post test for these items ranged from 2.6 to 3.321. The areas of greatest gain include the ability to describe student assistance options and to give an example of how the PBIS program establishes a school environment that is predictable, positive, safe, and consistent. Ninety-one percent of participants anticipated that the information they received in the training would be useful in their work and many found the training to be empowering.22 The findings confirm that the nurses indeed benefited from the training and increased their skills and knowledge in behavioral and mental health issues for preschool and school-aged students. Furthermore, the results indicate that little variation existed between training delivery modes (face-to-face vs. web-based), suggesting that both delivery modes are worthwhile. HELPING ADMINISTER TO THE NEEDS OF STUDENTS WITH DIABETES IN THE SCHOOLS (2011-12) To address diabetes care and management, the cadre of school nurse trainers created and provided training on this chronic disease issue to 158 nurses in six sessions across the state. The training offered nurses “hands-on” experience on diabetes devices including insulin pumps and continuous glucose monitoring systems. Ninety-eight percent of participants agreed that the training contributed to their professional growth and 100% agreed that the materials presented in the session enhanced their ability to apply the content to practice.23

                                                                                                                         21 A four-point scale was used where 1 = “Not at all Confident” and 4 = “Completely Confident.” N=338. 22 Respondents were asked the extent to which they agreed with each statement based on a five-point scale where 4 = “Agree” and 5 = “Strongly Agree.” Results display respondents who either agreed or strongly agreed with the statement. 23 Respondents were asked the extent to which they agreed with each statement based on a four-point scale where 3 = “Agree” and 4 = “Strongly Agree.” Results display respondents who either agreed or strongly agreed with the statement. N=109 respondents for professional growth question and N=79 for second item.  

   

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Process Learning The goals of the Healthy Schools Colorado (HSC) Initiative were to help support healthy living choices and prevent childhood obesity. The previous sections highlighted the successes of schools on specific school health indicators aligned with the goals of The Colorado Health Foundation. These achievements to improve school health policies, increase physical activity, increase access to healthy meals and vending, and increase knowledge of school nurses on asthma and diabetes were achieved using the Coordinated School Health (CSH) Model. The CSH Model guides schools through steps, following Colorado’s Roadmap to Healthy Schools, related to bringing together a school team, using the School Health Index to assess school health needs, and developing and implementing School Health Improvement Plans (SHIPs) that target school health needs. The HSC project creates the infrastructure within regions, school districts, and schools to support and sustain CSH efforts. This section will highlight the process learning of school health team co-leaders and the district/regional coordinators, gained over the length of the three-year grant initiative. Leadership Support School-Level Findings The support of administrators is frequently cited as essential for successful implementation of CSH programs. Principal support helps to reinforce health and wellness programming in the schools and move school teams to sustain their efforts.

In some schools, the school health team is now a standing school committee that teachers can choose from as part of their teaching assignment.

Many schools have a principal as an active member of their school wellness team. District and

regional coordinators agreed that when a principal sits on the school wellness teams, these teams have greater successes.

Other ways school principals offer support is through communicating with staff, parents, and the community, making time for teams to meet, participating in school wellness activities, and providing additional money to support their school’s health and wellness efforts. In addition to directly supporting the efforts of their school health teams, it is equally important for school leadership to create an environment where these efforts are embraced by the school community and sustained. Figure 4 shows the perceived support for health and wellness by school health team co-leaders. There is greatest perceived support and participation from school staff for school wellness.24

                                                                                                                         24  Data reflects results of all cohorts on the end of the 2011-2012 school co-leader survey.        

   

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Figure 4. Support for School Wellness

District and Regional Coordinator Findings At the district and regional level, leadership support from the health advisory council and the superintendent play key roles. Each district and region’s health advisory council met a minimum of four times and as many as nine times. Linkages have been made with other school and district accountability committees, parent and student groups, and community programs and organizations. All of the health advisory councils reviewed and revised, as needed, their district’s wellness policy. Other identified successes for the health advisory councils for each district and region include:

Pikes Peak o Recruited representatives from all of the districts in the region as well as

representatives from four surrounding districts to participate on the council. o Maintained partnerships with school and community health initiatives to build

awareness and support across the region.

Jefferson County o Aligned CSH work with the district’s Comprehensive Health Plan. o Required schools to include health and wellness goals in their accountability plans. o Developed a Wellness Goal guidance document.

   

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Douglas County

o Revisited the district coordinator’s role and after not having an active role on the district’s Health Advisory Council, the coordinator was invited in year three to participate in the district’s principal meetings and attend council meetings.

Adams 50

o Changed wellness and physical activity policies to align with HB1069. o Developed a communication plan to inform families about health and wellness

offerings in the community.

Adams 14 o Increased communication strategies by developing a wellness tab on the district

website. o Improved representation on the Council to include parent/family and employee

wellness.

Poudre o Added three new wellness goals to the district policy and language about wellness

expectations in the district’s strategic direction document. o Distributed monthly newsletters to co-leaders about the wellness policy with

specific strategies that could be implemented at the school level to impact policy. Policy Leadership Support School-Level Findings School co-leaders have used district wellness policies as justification to others for schools to focus on wellness programs and activities. School co-leaders can point to the policy both as guidance and to increase recognition and buy-in from the school community and administration that health and wellness need to have a bigger role in schools. For example, in Douglas County, the wellness policy is reviewed with every school team, and in Jefferson County, the wellness policy is reviewed at the principal meetings. Schools keep policy at the forefront of their work in what they decide to implement as their SHIPs. For example, in Poudre, elementary schools emphasize that soda should not be sent to school. This focus is directly from the district’s policy. Overall this type of relationship between the district wellness policy and the school wellness team’s efforts has positively shifted the type and extent of changes that teams are able to ask for at their school. Once policy changes are embraced, schools are able to develop an environment where school health is the norm. Most districts have wellness policies or guidelines that address increasing physical activity and having healthy choices available to students. These components of the wellness policy are the easiest to implement and

   

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produce tangible results. Schools often addressed these policy components with the following common school-level strategies:

Increase student activity o Before and after school programs o Recess before lunch o Classroom brain breaks o Increased minutes of PE instruction o PE programming and curriculum o Fitness challenges

Offer healthy and alternative snacks for celebrations/parties/fundraisers o Reduced candy as rewards o Alternative celebrations such as treasure box instead of cupcakes o Healthy fundraisers that have been approved by the wellness committee o Fresh fruits and vegetables snack program o Breakfast programs o School gardens o Student and parent education about healthy eating

District and Regional Coordinator Findings Policy was a strong focus for districts and regions over the three years of the initiative. Each district’s wellness policy covered physical activity, physical education, school meals, competitive food and beverages, and nutrition and education. All coordinators worked to identify and revise, if needed, the wellness policy in their district(s). On the end-of-year coordinator survey, coordinators were asked a series of questions about how they communicate and implement their district wellness policy. Coordinators devoted a great deal of time and attention to communicating policy information.

District wellness policies were communicated in a variety of ways. Most commonly, information was shared via newsletters, principal meetings, school staff trainings, staff meetings, parent meetings, wellness webpages, and face-to-face meetings with school teams. The district and regional coordinators took on the responsibility of communicating the policy.

While districts seemed to be communicating with staff, families, parents and students, and the

community about the wellness policy, there were minimal resources available to schools on how to implement the policy. District coordinators often developed resources or newsletters with practical ideas for how schools can impact district wellness policies.

The districts and regions have each experienced positive results from their policy implementation efforts despite some challenges. Notable examples of success include:

The Douglas County district coordinator lacked district-level support at the beginning of the initiative (due to a change in district superintendent) and, at the end of the grant, still lacked the authority to oversee policy implementation. Despite the lack of influence over policy in this

   

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district, the existing policy was strong and well written. In addition, other district factors such as a health-conscious community and wellness-driven parents resulted in more monitoring of the policy through the voice and clear expectations of staff and parents.

In the Adams region, the coordinator struggled with making policy language stronger. Even

though there was some push-back with semantics, the coordinator successfully added a school health team requirement for every school.

As with any kind of change, policy changes take time. For example, one school at the end of three years has 100% of its staff using alternatives to food/candy as rewards in their classrooms. It took the coordinator three years of work to reach this goal, each year having to get more staff educated, bought-in, and enforcing the new policy. And with change come challenges. Many districts struggled with changing policy language to make the policy stronger. Then there was the challenge of enforcement. The district/regional coordinators and school health team co-leaders often were limited to how much “emphasis” or enforcement could be given to a policy. Coordinated School Health Professional Development and Technical Assistance School-Level Findings The partners of Healthy Schools Colorado use a professional development model to train district and school staff on CSH best practices, curricula, and assessments in physical activity, healthy eating, asthma management, and diabetes management, and on school policies related to all of these topics. Schools participating in HSC have benefitted greatly from the professional development opportunities. In fall 2011, each district and region conducted trainings for their school teams with assistance from RMC Health staff. The common goal of these trainings was to meet schools where they were in the CSH process and provide them with information, tools, and support.25 Each site had very successful trainings and evaluations immediately following the trainings showed positive results related to meeting training objectives, training facilitation, and materials provided. Eighty-six percent of the respondents on the 2011-12 end-of-year survey said they attended a fall 2011 training and, more importantly, the majority of school co-leaders (82%) indicated they applied what they learned from the fall 2011 CSH training during the school year. Figure 5 depicts the extent participants’ ability increased as a result of the CSH training they attended.

                                                                                                                         25 CDE’s PE and nurse training evaluation results were discussed in the Performance Measure Results section.

   

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Figure 5. CSH Training Results

Specific examples of skills and knowledge learned from the trainings include:

Instructional and facilitation strategies How to write good SHIPs and plan effective activities Lessons learned from other school health teams: inexpensive ideas to implement SHIP,

keep it simple, manageable goals, and collaboration is key Using the Roadmap as a CSH guide for schools Budget for SHIP Data collection tips and strategies to show success

The following statements highlight the positive responses from school co-leaders about the CSH training they attended.

“We knew exactly what to do with staff and administration. We received tons of ideas from other school teams that helped us with our own plan. We really concentrated on teacher buy-in and used the skills from the training to do this”.

“We were able to create attainable goals that benefit the overall health of our school. We were given examples of how to easily implement a plan and we were able to execute it.” “Always going back and looking at the steps and go through them. I used the materials on-line quite frequently. I am always using the information on highly effective teams to continue principal and classroom teacher buy-in.”

   

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District and Regional Coordinator Findings Healthy Schools Colorado has demonstrated that the experiences of school teams differ markedly depending on whether they receive help from a district/regional coordinator. School co-leaders and district-level administrators attribute much of their success to the work of the coordinators. School teams are better at completing the School Health Index in a collaborative way, creating action plans, and working as a team to implement health promotion initiatives. In addition, the involvement of a coordinator supported schools in undertaking more complex tasks with a greater degree of collaboration across the school and local communities in order to achieve goals. Figure 6 shows how much district/regional coordinators supported school teams. 26 Figure 6. Coordinator Support to School Teams

In turn, to support the district and regional coordinators, RMC Health held regular coordinator meetings for networking, professional development, and to share information, tools, and resources. All five HSC coordinators “agreed” or “strongly agreed” that the coordinator meetings:27

Had clear goals Were an effective use of time Provided opportunities to learn from others

                                                                                                                         26  This  data  reflects  responses  from  the  2011-­‐12  End-­‐of-­‐Year  Co-­‐leader  Survey  

27  This  data  reflects  responses  from  the  2011-­‐12  End-­‐of-­‐Year  District  and  Regional  Coordinator  Survey  

   

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Met the needs of their program Increased knowledge and skills around health issues

As a result of the capacity building that coordinators received they reported that they were:

Confident in their ability to provide support to schools to implement CSH Able to establish linkages and partnerships with other district and school programs Able to establish a formal system to communicate with school health teams Able to establish linkages and partnerships with community organizations

Sustainabil ity School-Level Findings When asked, 81% (N=144) of the schools said they had established a plan to sustain, expand, or enhance components of their CSH program.28 Most teams, after the first year of implementing their SHIP, chose to continue the same SHIP with a few additions or small changes for the following school year. School experiences show it takes more than a year for schools to make sustainable changes and school teams have learned that it is better to promote small and gradual changes at the beginning to create a large and lasting impact.

“[We are] building upon an established healthy schools team by recruiting new staff, parents, and community partnerships.” “We are continuing with both SHIPs with minor modifications to meet the changing needs of students and staff.” “We will continue working on both of our goals that we set for our SHIP. We feel that we have a good solid foundation laid out now and good data to work with and we are going to try to improve the participation in both of our SHIP goals.”

When asked what elements of the SHIP will be continued beyond the school year, the majority of schools identified examples specific to their individual SHIPs. Some common and noteworthy examples of SHIP elements that will be continued include:

Pedometer challenges Healthy classroom snacks and celebrations School garden Salad bars Healthy newsletters Classroom activity breaks Great Body Shop (curriculum)

                                                                                                                         28 This data reflects responses from all cohorts on the 2011-12 End-of-Year Co-Leader survey

   

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Staff wellness programs District and Regional Coordinator Findings District and regional coordinators spent the last three years building infrastructure, programs, support, and policy that will sustain their CSH efforts. Specific examples of sustainability efforts from the districts and regions include:

Jefferson County o Aligned and required health and wellness goals in the district’s overall strategic

plan. o Leveraged funds with other district programs to support health and wellness (e.g.,

partnering with Food and Nutrition Services on salad bars.) o Created a guidance document for schools interested in school gardens.

Adams Region o Required a school wellness team in every school. o Collaborated with district and community programs (e.g., Flat 14ers, LiveWell

coalitions, Kaiser, CO Youth Matters, etc.)

Douglas County o Developed resources such as CSH Sustainability Workboxes (materials, resources,

Roadmap, video, district contact info.)

Pikes Peak o Sustained a strong regional Health Advisory Council, which paved way for

individual district successes. o Schools received funding from other sources. For example, three schools received

Colorado Legacy funding for their wellness efforts.

Poudre o Helped schools that were not funded under HSC begin to work on health and

wellness needs in their school. This was attributed to the overall district push and success for health in wellness through HSC.

o Provided additional services and resources that support HSC through its partnerships with community organizations (e.g., a chiropractic practice originally wanted access to the schools to share their own information and resources but, through guidance and education from the coordinator about school needs and direction, these individuals have become strong advocates for school health and volunteer regularly at the school).

   

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District Sustainability Success Story, Jefferson County

At the beginning of the HSC Initiative many schools in Jefferson County were interested in starting a school garden. However, no information or resources were available. Soon these inquiries were funneled through the district coordinator. Following a district staff newsletter on one school garden and its youth farmers market, approximately 14 schools reached out to the Healthy Schools Coordinator expressing interest in starting a garden. The coordinator, not knowing anything about school gardens, set out to gather information and resources about the cost, logistics, and process for starting a school garden. The Coordinator worked to bring together district-level stakeholders to develop comprehensive support and guidance for school gardens, including representatives from Denver Urban Gardens, Slow Food Denver, CU Extension, LiveWell Wheat Ridge, Jeffco Public Health, Jeffco Food and Nutrition Services, Jeffco Legal Services, Risk Management, Facilities, and the Community Superintendent’s Office. A school garden manual was developed and approved. Multiple school gardens broke ground in the spring of 2012.

Successes and Challenges School-Level Findings Successes Schools experienced successes throughout the three years of the HSC Initiative. Schools have increased minutes of student physical activity, promoted staff wellness, implemented health curricula and lessons, improved healthy options at parties and celebrations, improved vending choices and nutrition for school lunches, improved and created new policies or school guidelines that support health and wellness, and increased knowledge and awareness of staff, students, families, and the community around health. These changes have impacted targeted areas of school health but have also created culture changes in many schools. The school success stories submitted over the course of the project illustrate the breadth, reach, and impact that these schools have made. See Appendix B for exemplary success stories.

   

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Shepardson Elementary, Poudre Taking Steps to a Healthier Future

Shepardson Elementary has maintained successful programs from years past and established new traditions. They are a leader in PE, health, and wellness. To kick off the year, the school hosted the 9thAnnual 4K Fun Run, which had more than 300

participants and raised over $1,000 for wellness. In 2010-11, the school started the Galaxy Travelers Mileage Club. The club meets outside on Mondays

and Wednesdays, and students earn plastic feet for every mile they travel. There are more than 100 participants. Students proudly make necklaces from their feet.

Food has been re-routed in the cafeteria so that students can fill their trays first with vegetables and fruit.

A fit-track was installed for the playground and a garden was added. The school purchased a TV and Xbox Kinect system, and instead of sugary treats for celebrations,

students have the opportunity to move. Together these changes have truly altered the culture of Shepardson to one that is all about health and wellness.

Documenting success is important, as is knowing how you got there. On the 2011-12 end-of-year survey, co-leaders were asked what specific factors facilitated their school’s CSH efforts. Common factors cited include:

Administrator buy-in and support o Administrator support was “essential,” “worthwhile,” and “reliable.”

Parent support Buy-in from students and staff

Funding to implement activities at the school Strong and committed health team members

o “Having a team which represented the different parts of the school and the dedication of a leader to spearhead the effort. The leader depended upon the support, reliability, and creativity of the team.”

Support of district coordinator

o “Our district mentor did a great amount of support and work for us that lead to our success in beginning this process.”

Time, including meeting time, modified school schedules to accommodate activities and new

programs, and time to plan, implement, and communicate SHIP

   

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Access to resources and trainings and innovative ideas from other school teams

o “Funding and support from our district coordinator and Healthy Kids Club. Also sharing between schools at the training was very beneficial.”

Challenges Success was not achieved without some challenges. While administrator buy-in was cited as a factor in schools’ success, lack of it was a barrier. Schools that lacked leadership support for their health efforts also struggled with garnering staff buy-in, participation, parent support, and keeping the momentum of their health efforts going. Likewise, time is a factor linked to the success of schools and lack of time was a barrier. Some schools had limited time available for teams to meet. In some schools, teachers and school team members had so many other responsibilities that there just wasn’t time to focus on the health aspects of the school, especially when there was a perception that other issues needed to take priority.

“Time is always a barrier. We would always love to have more time to plan and communicate with important people involved in the health and wellness environment.”

Staff turn-over was also a barrier for many schools. This can be a change in principal leadership or the loss of a team co-leader or team members. Staff turnover can slow down the momentum of a program, change the level of support and follow-through, and force school health teams to backtrack and re-focus their efforts. In some cases, a new SHIP was written to reflect changes in direction due to turn-over. In one school, the loss of a co-leader or school “champion” forced the school to drop out of the HSC program. Many schools had SHIP objectives around healthy snacks or alternatives to food for class parties, celebrations, and fundraisers. Many schools commented that there was initial push-back from staff and parents on this type of objective because candy and treats, such as cupcakes, have been such a mainstay in schools for rewards and celebrations. In schools where there was resistance to these new guidelines, classroom teachers were encouraged to reduce the amount of candy, etc., instead of eliminating it all at once.

“As with all new processes and procedures, there is always resistance at first to the “new way.” We are working hard to encourage moderation, not banning of items such as cupcakes.”

District and Regional Coordinator Findings Successes As discussed in previous sections, district administrator support, time, funding, and the role of coordinators were all factors for success. The coordinator model was essential for the changes and sustained impacts made in districts and schools. The coordinator drives the Health Advisory Council, policy work, communication and awareness at the district and school levels, and is the primary support for school health teams. When coordinators were asked about specific factors that facilitated their district or region’s CSH efforts, their answers varied as each district and region had different structures, challenges, and supports.

In Poudre, the number of schools working on wellness created a momentum and expectation for all schools to get involved. The health and wellness changes in the schools kept staff encouraged and involved. This district had significant collaboration across departments such as

   

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PE, Child Nutrition, Health Services, Mental Health and Facilities. This collaboration created a common message and direction for schools and facilitated sharing resources across the district.

Douglas County struggled with district-level support and structures and had to use alternative

strategies. The momentum in this district came from the schools and “bubbled up” to the district level. The efforts of the coordinator in this district kept schools involved and motivated.

These two districts illustrate the two directions that CSH can grow in a district, bottom up from the school level and top down from the district level. As one coordinator stated, neither works on its own. At the end of the three-year grant, each district and region had systems in place to support CSH at the district and school levels. Policy is one of the best ways to institutionalize wellness in districts and schools. It is advantageous to look at existing policies and model policies and then communicate these policies to district and school staff, parents, students, and the community to create a common vision. Having policies in place protects programs from disappearing when there is turnover among key staff members. It also serves as a way to raise the importance of school health issues in the eyes of staff, parents, and community members. Some districts kept their wellness policy as is, and others made small policy changes. School teams have impacted policy at the building level by implementing policy changes such as recess before lunch, healthy vending policies, and healthy parties and meetings. Challenges While each coordinator had regular challenges in their positions, none were detrimental to the success of their program. Each coordinator struggled with politics, “red-tape,” and learning the “ropes” in their district or region. Academics were top priority in all districts so finding the appropriate place for health and wellness was challenging.

Jefferson County is the largest school district in Colorado and the coordinator needed to understand the different levels of approval, what departments needed to be involved in planning, and who needed to be involved in decisions.

In Poudre, the coordinator had to balance politics and priorities in the district as well as wellness advocates in the community that wanted access to schools for programs that were not always aligned with the focus of the schools.

For the regional coordinators, there was an extra layer of complexity with working in multiple districts. Each district had its own structures, levels of support, policies, and ways of operating. Navigating the intricacies of multiple districts took additional time and effort.

In Pikes Peak, the districts are supportive of health and wellness and have established a long-standing regional advisory council. This has enabled more communication among the districts and has been a springboard for individual districts in the region to support health and wellness in ways that work for their district.

   

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In the Adams region, the two districts operated independently of each other. This region was

treated more as two districts and the coordinator suggested that each district would have benefitted from its own 1.0 FTE coordinator.

Lack of support from district administration was a challenge in some districts.

In Douglas County, the change in superintendent at the beginning of the grant shifted support away from school health and wellness. Over the three years, the focus of the coordinator has been on building support starting with the schools and slowly working towards a district-level model. There recently has been some economic difficulty in the district, causing reorganization and staff turnover. However, the coordinator now has access to principals at their district-level meetings and will finally have the opportunity to introduce, guide, and champion them to implement CSH.

Recommendations Thinking ahead about future HSC implementation, keeping in mind the challenges and successes of the HSC partners, districts and regions, and schools, there are several recommendations to guide future HSC work. District and Regional Levels

Get support of district administration. As stated earlier, administrator support is vital for the success of any CSH program at the district and regional levels. Coordinators suggest that learning about the hot topics in the district around health and wellness is a great way to get a foot in the door. Learn what people are most interested in and connect it to what can be achieved through HSC.

Be present. The role of the coordinator in each district and region was imperative. Coordinators

worked hard to meet in person with individual school teams, participate on the district advisory council, network, and participate in community groups, and they were always available to answer questions, provide information and resources, or provide linkages to other services and offerings.

Use the CSH process. The Colorado Roadmap to Healthy Schools outlines a process that works to

implement CSH in schools. Each coordinator used these steps to guide schools as they implemented CSH programs and activities in their schools.

School Level

Extra support during early implementation. Coordinators suggested that new schools and schools that are implementing new SHIPs need the most support, resources, and information to get their programs started off on the right track.

Start small. School co-leaders recommend starting with small, manageable SHIP objectives the first

year. It takes time to bring together a school team, plan, and then implement that plan. If school health is fairly new in a school, small changes are more accepted and easier to implement at the beginning.

   

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Focus on building a solid core school health team. Co-leaders recommended that a school team

have a large number of people on the team. This keeps the workload down and keeps the momentum going in case of staff turnover.

Get administrator buy-in at the school level. This is key and should be done at the beginning of the

grant.

Look for your “champions.” Motivated and committed team members are instrumental in the changes that take place at the school level. Time, thought, and energy should go into recruiting team members that are and will remain committed to the work. Putting in the effort into the team at the beginning pays off in the end when a school has a team that is active, successful, and sustained.

Summary At the end of the three-year Healthy Schools Colorado (HSC) Initiative, all regions and districts had an active and successful advisory council. There was effective policy work in all the districts. Noteworthy policy accomplishments include:

Use of stronger policy language. Written policy additions such as scheduling recess before lunch and requiring health teams in all

schools. Increased awareness and communication of policies. Integration of school wellness policies and guidelines with the larger district accountability

systems.

All districts reported communicating their policy to a variety of audiences and working with schools and administrators to implement policies. Lastly, district and regional coordinators established and utilized more partnerships with community organizations to further school wellness efforts in their districts and regions. As evidenced during the three years of the grant, the Coordinated School Health (CSH) Model can impact the health of schools, staff, and students and affect policies at the district and school levels. The district and regional coordinators have assumed responsibility for and provided leadership for successful implementation of the CSH Model. Each district and region successfully increased the number of schools recruited over the three years to implement CSH. Coordinators have improved their skills and effectiveness working with schools and made progress working with improving, communicating, and implementing wellness policies. Coordinators have worked extensively with their schools’ health teams to complete the School Health Index, to develop School Health Improvement Plans (SHIPs), and to provide technical assistance, resources, and links to professional development opportunities. School staff reported many learnings and positive experiences from the technical assistance and trainings they attended. Schools in turn have been successful in developing strong SHIPs and implementing these plans in their schools.

   

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Data from the HSC database indicate that schools are implementing best practices and policies in physical education, physical activity, nutrition, and health services. In particular, Cohort 1 schools (joined HSC in year one), show increased performance measures related to healthy food choices at parties and celebrations, and healthy options in vending, school stores. and other venues. These schools show an increase in the number of minutes of physical activity for students during the school day. Lastly, school nurses in these schools are helping students manage chronic illnesses and applying best practices in delivering school health services. As demonstrated over the three years of the grant, the professional development and technical assistance framework used to implement the CSH Model in Colorado school districts and schools has increased the knowledge and skills of district and school staff and affected school wellness policies to reach a large number of students, family members, and community members to promote and sustain healthy schools.

   

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APPENDICES

   

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APPENDIX A - Methods PERFORMANCE MEASUREMENT RESULTS The HSC Initiative utilized a web-enabled data tracking system to collect and monitor school-level data related to policies and practices in the areas of school health services, physical education/activity and nutrition. Data were collected and entered by district/regional coordinators, school teams and school nurses annually. Schools recruited to participate in the initiative by the district/regional coordinators were added into the database as they initiated their school team activities. Data were monitored and analyzed by the Center for Research Strategies staff. Measurable Result - Number of Students Impacted During 2011-12

o The “Measurable Result” data in the body of this report and the Performance Measurement Data in Appendix B include data from all schools that were active in the HSC Initiative by the last school year (2011-12). Data were analyzed using descriptive statistics. Student population estimates were made by linking schools to the Colorado Department of Education’s (CDE) October Count Census data. However, in the case of physical activity minutes and physical education hours, school teams were asked to estimate the number of students participating in those events, thus, in those cases, the CDE census data were not used.

Change Observed in First Cohort of Schools (2009-10 to 2011-12)

o To examine change in the first cohort of schools that participated during the first year of the HSC Initiative, comparisons were made between the data collected during the 2009-10 school year to the data collected during the 2011-12 school year.

PROFESSIONAL DEVELOPMENT RESULTS Center for Research Strategies staff worked with the PE and nurse cadre of trainers to develop evaluation survey instruments for each of their trainings. These surveys were distributed to participants attending the trainings and collected by the trainers. Center for Research Strategies staff compiled, analyzed and reported results using descriptive and inferential statistics. SUCCESS STORY RESULTS As part of the Healthy Schools Colorado Initiative data base, participating schools were asked each year to upload two success stories, focusing in particular on the progress they had made in implementing their school health improvement plans. In the 2010-11 school year, 169 stories were submitted and downloaded in an EXCEL format. To determine the topics covered, CRS staff used the “find” function in EXCEL to search for stories using key word options in the areas of physical education, physical activity, nutrition, curriculum, training, policy, and sustainability. Summary counts of the number of stories in respective categories were created. In addition, the stories were reviewed for completeness and evidence of well-defined activities and outcomes. Exemplar stories were reviewed by the RMC Health technical assistance coordinators and selected examples were then included in the text of this final report. SCHOOL-LEVEL SURVEY RESULTS AND DISTRICT AND REGIONAL COORDINATOR SURVEY RESULTS RMC Health staff developed a survey for school team co-leaders and a survey for district and regional coordinators to complete at the end of each year. The surveys’ purpose was to assess the process of CSH at

   

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the school level and at the district and regional level. Information on successes and challenges was also collected. Data was analyzed and summarized using descriptive and qualitative analyses. GRANTEE PROGRESS REPORT RESULTS RMC Health developed templates for each grantee to complete on an annual basis. Districts and regions reported progress on their workplan objectives and on the grant assurances including work with the District Advisory Council, using the Roadmap with schools, CDE’s PE and nurse cadre to provide professional development. Information was summarized and successes and challenges highlighted for each grantee.

   

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APPENDIX B – Performance Measures ACCESS TO HEALTHY FOODS Table A1. Schools Implementing Healthy Nutrition Guidelines (All Schools: SY2011-12)

Student census in all 186 reporting schools = 114,669 No. of Schools

Percent of Schools w/

“Yes”

No. of Students Impacted

Ensure that all foods & beverages comply with USDA regulations & state policies.

186 99.5% 114,181

Encourage parents to provide a variety of nutritious foods if students bring lunch or snacks from home.

186 73.1% 76,164

Require that healthy food choices are made available to students at every school function that includes foods.

186 36.6% 38,414

Every student has access to healthful food choices in appropriate portion sizes.

186 96.8% 111,144

Students have access to fresh fruits and vegetables during the school day.

186 98.4%

112,758

Put restrictions in place for student access to vending machines, school stores, & other venues that contain foods of minimal nutritional value

186 94.6%

103,200

ACCESS TO HEALTHY VENDING Figure A1. Number of Students By Access to Vending Machines (All Schools: SY2011-12)

39843  

71848  

0  

20000  

40000  

60000  

80000  

Access   No  Access  

Num

ber  o

f  Stude

nts  

   

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Table A2. Student Access to Vending by Type of School (All Schools: SY2011-12)

Type of School No. of Schools

Percent of Schools w/ Student Access

to Vending

No. of Students with Vending

Access K-8 3 0% 0 K-12 3 33% 170 Elementary 121 0% 0 Middle29 32 62.5% 13,913 High 21 100.0% 25,760 Outdoor labs 2 0% 0

TOTAL 182 N/A 39,843 Change in First Cohort of Schools (2009-10SY to 2011-12SY)

One K-8 school and two middle schools no longer allow students access to vending.

                                                                                                                         29  Three  middle  schools  only  sell  bottled  water.  

Table A3. Schools with Vending Machines Accessible to Students (All Schools: SY2011-12) 39,843 students have access to vending machines

Vending machines contain:

Percent of Schools Answering “Yes” K-12 N=1

MS N=20

HS N=21

No. of Students Impacted

-Nuts, seeds, dairy products, fresh fruits or vegetables, dried fruits and vegetables, and packaged fruits in own juices

100.0% 75.0% 66.7% 27,892

-Any other food item containing no more than 35% total calories from fat and no more than 35% of total weight in sugar.

100.0% 80.0% 65.0% 26,878

-Fat free or low fat milk* 100.0% 80.0% 57.1% 25,088

-Fat free or low fat flavored milk up to 150 calories* 100.0% 8.0% 55.0% 23,963

-100% juice, with no added sweeteners* 100.0% 75.0% 61.9% 24,471

-Bottled Water 100.0% 95.0% 95.2% 38,820

-No sodas (neither regular nor diet sodas) 100.0% 90.0% 90.5% 37,007

-No or low calorie beverages with up to 10 calories / 8 oz (e.g., unsweetened or diet teas, low calorie sport drinks, fitness waters, flavored waters, seltzers).

100.0% N/A 85.0% 20,487

-Other drinks, up to 12 oz servings with no more than 66 calories / 8 oz

100.0% N/A 71.4% 18,187

-At least 50% of non-milk beverages must be water and no/low calorie 100.0 N/A 95.2% 25,341

   

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*In age appropriate portion sizes & calories PHYSICAL EDUCATION & PHYSICAL ACTIVITY POLICIES Table A4. Schools Implementing Physical Education Guidelines (All Schools: SY2011-12)

Student census in the 182 reporting schools = 110,816 No. of Schools

Percent of Schools w/

“Yes”

No. of Students Impacted

Are all staff who teach PE are certified, licensed or endorsed by the state in PE?

182 90.1% 96,513

Did any PE teachers or specialists receive professional development on PE during this school year?

182 91.2% 103,616

Are those who teach PE provided with goals, objectives & expected outcomes?

180 89.4% 97,173

Are those who teach PE provided with a chart describing the annual scope & sequence of instruction?

179 75.4% 77,091

Are those who teach PE provided with plans for how to assess student performance?

179 76.5% 82,519

Are those who teach PE provided with a written PE curriculum? 179 68.7% 74,487 Does the school offer opportunities for all students to participate in intramural activities or PA clubs?

182 73.1% 79,662

PHYSICAL EDUCATION HOURS NASPE recommends 150 minutes of physical education per school week for elementary school children and 225 minutes for middle and high school students. Assuming a 36 week school year, this translates into 90 hours of PE for elementary age students and 135 hours for middle and high school students per school year. As shown in Table A5, most schools participating in the HSC Initiative fall short of this recommendation. The mean number of hours of physical education per school year ranges from 38 to 47 hours for primary school students and 67 to 78 hours for secondary school students. PHYSICAL ACTIVITY MINUTES NASPE recommends that school age children accumulate at least 60 minutes of physical activity per day or 300 minutes per week. Physical activity may include recess or a structured physical activity that increases the heart rate of students. Table A6 shows that most schools participating in the HSC Initiative fall short of this recommendation. The mean number of minutes of physical activity per school week ranges from 145 to 171 minutes for primary school students and 96 to 143 minutes for secondary school students. Table A5. Estimated Hours of Physical Education / School Year (All Schools: SY2011-12)

Grade No. of Schools

Mean No. of Hours (Standard

Min – Max No. of Hours

Estimated No. of Students Impacted

options %

   

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Deviation) K 11530 38 (21) 0 - 118 7,745 1 118 45 (16) 18 - 118 8,082 2 118 45 (17) 18 - 120 8,132 3 118 45 (16) 18 - 120 8,160 4 118 45 (16) 18 - 120 7,892 5 117 44 (15) 18 - 120 8,085 6 62 47 (16) 18 - 100 6,445 7 27 67 (23) 30 - 120 7,350 8 27 67 (23) 30 - 120 7,329 9 17 87 (52) 7 - 180 6,176

10 15 78 (50) 7 - 150 5,507 11 15 78 (50) 7 - 150 4,741 12 15 78 (50) 7 - 150 4,079

Table A6. Estimated Minutes of Physical Activity Breaks / Week 31 (All Schools: SY2011-12)

Grade No. of Schools

Min – Max No. of Minutes

Mean No. of Minutes

(Standard Deviation)

Estimated No. of Students Impacted

K 117 30 - 420 163 (76) 7,737 1 119 30 - 420 171(71) 8,026 2 119 30 - 420 169 (71) 8,226 3 119 30 - 345 158 (66) 8,217 4 119 25 - 330 147 (65) 7,910 5 119 25 - 300 145 (63) 7,911 6 68 25 - 300 126 (56) 6,785 7 31 25 - 300 96 (68) 7,321 8 31 25 - 300 96 (68) 7,358 9 9 25 - 270 132 (92) 2,444

10 8 25 - 270 143 (108) 2,125 11 8 25 - 270 143 (108) 1,527 12 8 25 - 270 143 (108) 1,398

SCHOOL HEALTH DATA Table A7. Number of Students with Select Health Conditions (All Schools: SY2011-12)

Students with… No. Of Students

Percent of Student

Mean # of Students / School

                                                                                                                         30  Seven  of  the  115  schools  did  not  offer  PE  for  Kindergarten  students.  31  Data  reflect  schools  that  offer  PA  breaks;  outliers  were  removed.  

   

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Body Asthma 7,292 6.9% 42 ADHD 2,685 2.5% 16 Allergies (life -threatening) 2,871 2.7% 17 Behavioral / mental 1,375 1.3% 9 Traumatic brain injury 710 0.7% 5 Seizure disorder 654 0.6% 4 Gastrointestinal 693 0.7% 4 Orthopedic 609 0.6% 4 Cardiovascular 509 0.5% 3 Diabetes type 1 335 0.3% 2 Diabetes type 2 25 ~0.0% .2

SCREENINGS AND REFERRALS Table A8. Number of Students Screened & Referred (All Schools: SY2011-12)

# Screened # Referred Percent Referred Vision 67,194 5,310 7.9% Hearing 67,069 1,179 1.8% Oral health 2,574 519 20.2% Height & weight 6,691 147 2.2%

# Identified # Referred Percent Referred Students w/out health insurance 3,304 2,422 73.3%

CHRONIC DISEASE MANAGEMENT Table A9. Number of Students with Asthma & Diabetes (All Schools: SY2011-12)

Number of students, who…

# of Students w/ Asthma (N=7,292)

# of Students w/

Diabetes (N=360)

Self-manage 1,782 149 Have a self-carry contract / self-manage agreement 731 120 Have medicine at school 2,097 254 Received information to take home 1,237 152 Received verbal instructions 1,159 338 Referred to providers 208 N/A

SCHOOL NURSE CASELOAD Colorado has a high school nurse to students ratio and is ranked 40th in the nation by NASN in terms of this ratio. While NASN recommends a ratio of 1:750 for well students, the ratio for the entire state of Colorado is a dismal 1:1,788. Among schools participating in the HSC, the estimated ratio is even higher with one full time equivalent school nurse for every 2,397 students. The number of schools assigned to nurses ranged from one to nine schools with an average of five schools per nurse.

   

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ADDITIONAL SCHOOL HEALTH SERVICES DATA

Nurses have conducted 5,392 special education assessments during the 2011-12 school year

which is an average of 32 per school There have been 382,458 visits to health rooms during the school year; this is an average of

2,833 visits per school. SCHOOL HEALTH INDEX Figure A2. Initial School Health Index Scores by Cohort

75  68   68  

60   57  46   43   41  

82  75   71   68   65  

53  40   44  

84  71   73  

62  56  

35  46  

38  

0  

20  

40  

60  

80  

100  

Mean  Scores  

Cohort  1   Cohort  2   Cohort  3  

   

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SCHOOL HEALTH IMPROVEMENT PLAN Figure A3. No. of Schools Targeting Each SHI Module (All Schools: SY2011-12)

137  

78  90  

33  17   19  

2   0  0  20  40  60  80  100  120  140  160  

#  of  Schoo

ls  

(N=170)