Brittany Kaczmarek

PH1113
EXAM ONE: NEEDS ASSESMENT
Introduction
Obesity has become one of the greatest epidemics of this generation. Where once
infectious disease used to be the top public health concern, chronic disease has taken its place.
Obesity has played a major role in this shift, leading to greater risks for other chronic diseases
later in life. One of the most concerning aspects of the growth of obesity across the nation is the
increase in childhood obesity (CO). The World Health Organization (WHO) has classified CO as
one of the top global public health concerns of the 21st century (Langley-Evans & Moran, 2014).
Focusing on improving the health of children and adolescents who are obese should be a priority
for preventing future morbidity and premature mortality. In the following sections, determinants
putting school-age (SA) youth living in a low-income community of Houston, TX at greater risk
for CO will be identified and, from this information, methods will be developed to prevent and
reduce this health problem in this population.
Question 1A: Development of Planning Group
Establishing a planning group that will provide a variety of expertise in addressing the
health problem is essential to implementing an effective intervention. The planning group will
include developers, implementers and participants of the intervention. Involving the participants
in the planning group is important to gain the perspective of those who will actually be receiving
the intervention. SA youth involved will be classified as obese and non-obese, so youth from
both classifications can give personal insight to the intervention. Parents of obese and non-obese
SA youth will also be included in the planning group. Parent involvement promotes discussion
about differences in home life and lifestyle behaviors between the children.
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As implementers of the intervention, school representatives will be included in the
planning group. School administrators, principals, nurses, teachers, coaches and counselors of
the Houston Independent School District (HISD) are an important addition to the planning group.
Involving implementers will give sufficient insight to what is being done in the organization
currently and what can be improved to better the health problem. Representatives from local and
national organizations will also be involved in the planning group for the intervention.
Employees from The City of Houston Health and Human Services, commonly involved in the
fight against CO, will represent leaders in policy and health promotion programs in the Houston
area. Representatives from The Academy of Nutrition and Dietetics and The Academy of
Pediatrics will also contribute to the planning group, in which policy and common practices of
addressing CO will be the focus. As developers of the intervention, professionals from academia
and the health field will be essential in providing expertise in prevention and reduction of CO.
Such professionals include researchers from the University of Texas School of Public Health in
Houston as well as pediatricians, dietitians, nurses, and health educators from a local UTHealth
weight management clinic.
Each member of the planning group will have a specific role in the intervention. For
example, the health care workers will be involved in defining CO and the health risks associated
with the health problem. The participants, on the other hand, will be involved in identifying the
importance of quality of life factors due to CO. However, it is essential to have a cohesive
planning group rather than individual members with their own responsibilities. Every member
will be involved in each aspect of the intervention, in order for the planning group to work as an
interdisciplinary team.
Question 1B: Priority Population and Intervention Setting
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In the last 40 years, obesity rates among children and adolescents have tripled resulting in
approximately 13 million obese youth in the United States today (National Conference of State
Legislatures [NCSL], 2015). In Texas alone, the state prevalence of CO was approximately 19%
from 2003 to 2011 (NCSL, 2015). In 2011 to 2012, approximately 18% of 6 through 11-year olds
and 21% of 19-years olds were classified as obese (CDC, 2015a). These high percentages of
obesity in youth were found within the ages of 5 through 18. Therefore, this intervention will
focus on youth in this age group, referred to as SA youth.
Obesity not only affects more youth every year, but is an even greater threat to specific
populations within SA youth. Minority youth, especially African American and Hispanic
populations, have been found to have a greater occurrence of CO. The National Health and
Nutrition Examination Survey (NHANES) found the prevalence of obesity was higher in nonHispanic black and Mexican-American youth as compared to non-Hispanic white youth (Ogden,
Carroll, Curtin, McDowell, Tabak, & Flegal, 2006). These findings were reinforced by the
Centers for Disease Control and Prevention (CDC) (2015a), in which a study from 2011 to 2012
found the prevalence of obesity among children and adolescents was 22.4% for Hispanics, 20.2%
for non-Hispanic blacks and 14.1% for non-Hispanic whites. With such a difference in obesity
prevalence evident between ethnicities, the minority populations of Hispanics and non-Hispanic
blacks will be additional criteria for the priority population.
The final criteria for the priority population will be low-socioeconomic status. The CDC
(2015a) has reported greater CO prevalence among households with an income at or below the
poverty threshold. Research shows as income status decreases, CO rates increase (CDC, 2015a).
Therefore, the priority population will encompass SA youth who come from a low-income
family. This criterion for the priority population helped determine the setting for where the
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intervention will take place. An urban low-income community of Houston, TX, known as the
Greater Third Ward, is where the intervention will be implemented.
Within the community of the Greater Third Ward, the public schools run by HISD will be
the ultimate setting for the intervention implementation. SA youth spend a lot of time in the
school setting, approximately 1,260 hours in a school year (Desilver, 2014). This amount of time
spent in one setting creates an environment that can make a substantial impact on SA youth.
With this in mind, the three public HISD primary and secondary schools located in the Greater
Third Ward community will serve as the setting for the intervention.
Question 2:
Health Problem: Entry to PRECEDE Model
This intervention will be entering the PRECEDE Logic Model of Risk at the health
problem, which is identified as CO. CO is formally defined by using a youths Body Mass Index
(BMI) percentile based on age and gender. Unlike the measurement of obesity in adults,
assessing obesity in a child requires evaluating the measured BMI percentile on a growth chart
developed by the CDC. If a child is at or above the 95th percentile, then the child can be
classified as obese (CDC, 2015d). Many factors are involved in the growing prevalence rates of
CO. Some factors of CO are unchangeable by interventions, such as genetics and socioeconomic
status, while lifestyle and environmental factors can be modified to improve the health problem.
There are both short- and long-term effects of CO. In the short-term, obese youth are at
increased risk for health problems such as high blood pressure, high cholesterol, insulin
resistance and joint issues (Freedman, Mei, Srinivasan, Berenson, & Dietz, 2007; Whitlock,
Williams, Gold, Smith , & Shipman, 2005; Han, Lawlor, Kimm, 2010). Breathing difficulties,
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such as sleep apnea and asthma, have also been found to occur more often in obese youth (Han et
al., 2010; Sutherland, 2008). The health problems associated with obesity are not just physical
but mental and emotional as well. Obese youth are found to have higher rates of depression,
occurrence of behavioral difficulties and trouble in school (CDC, 2015b). The long-term effects
of CO further disrupt the quality of life of the youth in adulthood with increased risk for
morbidity and mortality. Obesity increases risk of chronic diseases including cardiovascular
disease (CVD), type 2 diabetes mellitus (T2DM), stroke, hypertension and types of cancers
(NCSL, 2015). If progressed further, obese youth are at greater risk for premature mortality. The
World Health Organization (WHO) (n.d.) reports approximately 2.6 million individuals die every
year due to being overweight or obese.
Quality of Life
CO puts SA youth at greater risk for a number of poor quality of life indicators. Youth
who are obese as youth have been found to have an 80% likelihood of being obese as an adult
(NCSL, 2015). Obesity is then a major risk factor for many other chronic illnesses which
decrease an individuals quality of life. As a result of an increase in health conditions related to
obesity, health care costs increase as well. The average medical cost for an obese individual is
$1,429 greater than an individual of a normal weight (CDC, 2015c). In 2008, the annual medical
cost of obesity in the United States was $147 billion dollars (CDC, 2015c). These health care
costs can increase stress and play a significant role in decreasing an obese individuals quality of
life.
Low self-esteem is a quality of life issue proven to be common among youth who are
obese. Obese youth have been found to be at greater risk for poor self-regard and diminished

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quality of life due to their perceived physical appearance, athletic capability and how they
function in social settings (Griffiths, Parsons, & Hill, 2010). A quality of life factor in reducing
self-esteem among obese youth is the stigmatization of this population. Social stigma commonly
suggests obese individuals are accountable for their condition (Griffiths et al., 2010; Puhl &
Latner, 2007). Due to stigmatization, obese youth commonly experience social rejection,
seclusion and judgement (Mustillo, Hendrix & Schafer, 2012). Feelings of negative self-image
and self-esteem tend to be internalized, thus affecting the emotional health of the individual
(Mustillo et al., 2012).
As a part of the needs assessment, evaluating the quality of life indicators among
participants is essential to understanding the importance of these factors within the population.
Surveys and focus groups will be the methods utilized to determine importance of quality of life
indicators among SA youth. This intervention will be working with a younger population,
therefore stigma and low self-esteem will be addressed using surveys. This method was selected
to collect anonymous feedback about this delicate issue. The SA youth might feel shy or fearful
to express their feelings about these sensitive topics to others but feel more obliged to be truthful
if they can answer the questions on a survey. The survey will have statements the participants
will rate on a five-point Likert scale. Such statements will include I am happy with my physical
appearance, I have a high self-esteem, and My fellow peers speak negatively about obesity.
The complexity of the statements will depend on the age of the participant completing the
survey. The second method utilized to determine importance of quality of life indicators within
the population will be focus groups. Focus groups will be conducted to measure how important
physical health and prevention of chronic disease is to the priority population. There will be
open discussion about the importance of preventing obesity into adulthood. This method was
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chosen to expose participants to their peers perceptions on the topic while being able to openly
express their own. This will create an open environment for the SA youth to discuss the impact
this health problem has on their lives as well as others.
Risk Factors for Childhood Obesity
Similar to adult obesity, CO has many factors contributing to the increased prevalence of
the health problem. There is no single factor that can be identified in causing CO (Langley-Evans
& Moran, 2014). Three behavioral risk factors playing a significant role in CO are poor food
choices resulting in high intake of energy-dense foods, lack of physical activity and high
consumption of sugar-sweetened beverages (SSBs). Environmental risk factors for CO can be
found at the interpersonal, organizational, community and society levels.
Behavioral Risk Factors
CO has been found to be associated with improper nutrition of youth, especially from
consumption of energy-dense foods. Energy from food is essential for life; however the excess
consumption of energy leads to excess weight. A balance of energy between what is consumed
from food and beverages and what is expended is essential to prevent excess weight. A healthy
diet rich in fruits and vegetables will be less energy-dense than a diet thriving on fast food and
sweets. The Dietary Guidelines for Americans 2010 recommends a healthy diet involving whole
grains, fruits, vegetables, lean protein and low-fat dairy products (United States Department of
Agriculture [USDA], 2010). Despite these recommendations, research has found children are
consuming large portions, excess calories and fewer vegetables (Colapinto, Fitzgerald, Taper, &
Veugelers, 2007). A study by Scerri and Savona-Ventura (2011) found overweight and obese
children were less likely to eat fruit and vegetables and more likely to consume meats and chips.
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Additionally, one-third of American SA youth consume fast food on a daily basis, increasing
their weight by six pounds every year (St-Onge, Keller, & Heymsfield, 2003).
A behavioral risk factor that is closely associated with poor food choices in increasing
CO is high consumption of SSBs. SSBs are drinks with little to no nutrients and include any
beverages that contain added sugar in the form of high fructose corn syrup or sucrose (CDC,
2010). Examples of SSBs include soda, fruit drinks, energy drinks and sweetened milk (CDC,
2010). SSBs, similarly to excess of energy-dense foods, provide empty calories to youth which
can be turned into excess weight when consumed in high amounts (Vartanian, Schwartz, &
Brownell, 2007). SSBs have been found to be the most common source of sugar and a significant
contributor of calories in the American youths diet (Reedy & Krebs-Smith, 2010). Between the
1970s and 1990s, there was a 123% increase in consumption of SSBs among children and
adolescents (French, Lin & Guthrie, 2003). By the mid-1990s, SSB consumption among youth
was double the amount of milk consumed (Harnack, Stang & Story, 1999; Yen & Lin, 2002).
Among youth in the United States, consumption of SSBs has reached an average of 224 calories
per day, contributing to 11% of daily caloric intake (CDC, 2010; Troiano, Briefel, Carroll, &
Bialostosky, 2000). Research has found 80% of youth consume SSBs on any given day (Wang,
Bleich, & Gortmaker, 2008). In particular, youth who consume the most SSBs are non-Hispanic
black, Hispanic, low-income and obese (CDC, 2010). There are several proposed mechanisms
linking SSB consumption and obesity, with the most common acknowledging that energy
obtained in the liquid form is less satisfying than energy obtained from solid foods (CDC, 2010;
Pereira, 2006). This can lead to overconsumption of calories and increased portion sizes, thus
increasing risk for obesity (Pereira, 2006). A cross-sectional survey evaluated SSB intake and
body fat among 385 SA youth attending school in Santa Barbara, California (Giammattei, Blix,
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Marshak, Wollitzer & Pettitt, 2003). The study found the odds of having a heavier weight was
46% greater among students who consume three SSBs per day than students who consume fewer
amounts (Giammattei et al., 2003). With this amount of evidence linking high consumption of
SSBs to CO, there is confidence in classifying this behavior as a risk factor.
Lastly, inadequate physical activity has also been found to be a behavioral risk factor for
CO. The Physical Activity Guidelines for Americans 2008 recommends children engage in
physical activity for at least 60 minutes every day (United States Department of Health and
Human Services [DHHS], 2008). However, only 22% of American youth are meeting these
physical activity guidelines and 25% of youth are classified as living a completely sedentary
lifestyle (Troiano, 2002). These high rates of physical inactivity have been found be associated
with youth increasing their screen time rather than exercising (Gable, Chang, & Krull, 2007).
Youth spending more time watching television rather than being active has been found to be
directly linked to CO (Proctor, Moore, Gao, Cupples, Bradlee, Hood, & Ellison, 2003). Youth
who watch at least five hours of television per day is at 8.3 times greater risk for obesity than
youth who watch only up to two hours per day (Proctor et al., 2003). Studies have also found
overweight and obese youth are less active than non-obese youth. A recent study found
overweight and obese youth reported less average physical activity time as compared to their
leaner peers (Scerri & Savona-Ventura, 2011). Physical inactivity has become a major issue
among American youth; an issue continuing to increase the rates of CO if unaddressed.
Environmental Risk Factors
Personal behaviors are not the only contribution to increase risk of CO. Environmental
risk factors play a role in influencing youth to act on risky behaviors leading to obesity. These

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environmental risk factors influence the individual on many levels, ranging from relationships to
policies. No level is more important or significant than another. These levels of the environment
work cohesively to influence youth and produce CO as a result.
At the interpersonal level, family environment can play a key role in promotion of CO.
Eating dinner together has been found to have an impact on CO rates. Families who eat dinner
together three or more times per week have been found to be at decreased risk for obese children
(Veugelers & Fitzgerald, 2005). At the organizational level, the school environment has a strong
influence on CO. Many schools are now offering many SSB options in vending machines (Miller
& Silverstein, 2007). The majority of SSB availability in school is from non-soda beverages such
as juice (Terry-McElrath, O'Malley, & Johnston, 2012). However, the vending machines allow
for increased availability of sodas in schools (Terry-McElrath et al., 2012). Providing options for
sodas or other SSBs promotes these beverages to youth and encourages high consumption of
SSBs.
At the community level, accessibility of good nutrition sources and opportunities to be
physically active makes a significant impact on risk for CO. It is evident that a youths built
environment shapes their access to nutrient-dense foods and physical activity (Rahman, Cushing,
Jackson, 2011) Higher socioeconomic communities have been found to have access to three
times as many supermarkets than lower socioeconomic communities (NCSL, 2015). Availability
of supermarkets increases access to fresh fruits and vegetables as well as a greater selection of
healthy food options (NCSL, 2015). Individuals living in rural, minority and low-income
communities typically have less access to stores selling healthy foods they can afford (Larson,
Story & Nelson, 2009). Additionally, these areas tend to have an overabundance of convenience
stores and fast food restaurants selling energy-dense foods and beverages to families (Larson et
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al., 2009). Communities with access to high-caloric options and convenience stores increase the
risk for heavier youth, while supermarkets and farmers markets present in the community is
associated with decreased child BMI and risk for increased weight status (Rahman et al., 2011).
Low-socioeconomic communities also tend to have a built environment providing fewer
opportunities to be physically active (NCSL, 2015). In some communities, the environment may
be built where it is difficult for youth to be physically active (CDC, 2010). The Centers for
Disease Control and Prevention (CDC) (2010) report half of youth in the United States do not
have a park, community center or sidewalk in their neighborhood. A healthy lifestyle of good
nutrition and physical activity have been found to prevent obesity, but individuals wont
participate in these healthy behaviors if the community environment doesnt provide its
inhabitants with the ability to accomplish them (NCSL, 2015).
Lack of accessible potable drinking water has an effect on risk of obesity as well. In
2008, 8% of the United States population did not have access to clean drinking water (U.S.
Environmental Protection Agency [EPA], 2008). Those with a lack of access to potable drinking
water may consume more SSBs to replace water (CDC, 2010). A study in Alaska found a
community with little access to clean drinking water had 58% of 2 year-olds consuming two or
more SSBs per day as compared to 21-26% in communities with potable water access
(Fenaughty, Fink, Peck, Wells, Utermohle, & Peterson, 2009).
Societys impact on CO is more prominent than expected. The food and beverage
industry, along with media, influences risky behaviors for CO on a daily basis. Portion sizes have
not only doubled in the past 20 years, but fast food restaurants now offer portions up to 20%
larger (Colapinto, Fitzgerald, Taper, & Veugelers, 2007). Studies have found children eat these
larger portions without even realizing it, which in turn increases risk for CO (Fisher, Rolls, &
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Birch, 2003; McConahy, Smiciklas-Wright, Mitchell, & Picciano, 2004). Media and the
entertainment industry contribute to CO through advertisements. Foods high in calories, fat,
sugar and sodium are advertised much more heavily towards youth than nutrient-dense foods
(CDC, 2015b; Institute of Medicine [IOM], 2005). Batada & Wootan (2007) found Nickelodeon,
a popular television channel for youth, aired commercials for foods of poor nutritional value for
94% of food advertising. Additionally, the study found food preferences of the youth can be
influenced by exposure to a 30 second television commercial (Batada & Wootan, 2007).
Advertisements for energy-dense snacks and beverages even reach youth within the school
environment. Approximately half of all middle and high schools in the United States allow
advertisements of unhealthy foods to the students (CDC, 2011). These advertisements influence
students to choose unhealthy food options rather than their more nutritious counterparts.
Federal and local policy is a societal level environmental risk factor that has the power to
make a true public health impact on CO (Kristensen et al., 2014). One of the most controversial
policies aimed at reducing obesity is taxation on SSBs. Taxation of SSBs has been the topic of
much debate, but has been passed in select states such as California (Robert Woods Johnson
Foundation [RWJF], 2014). A microsimulation was performed to estimate the effective ness of an
SSB excise tax on CO after 20 years of implementation (Kristensen et al., 2014). An SSB excise
tax was found to reduce CO, especially in the 13 to 19 year-old population (Kristensen et al.,
2014). The policy would decrease obesity the most in non-Hispanic blacks as well as decrease
obesity disparities overall (Kristensen et al., 2014). Therefore, taxation on SSBs can reduce CO,
especially among individuals belonging to the priority population. However, without a national
requirement of implementing such a tax, the youth of the country are not reaping the benefits.
Question 3: Prioritizing Behavioral and Environmental Risk Factors
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Prioritization of the risk factors is essential to determine the focus of the present
intervention. Interventions focusing on nutrition education alone have been found to be
ineffective in significantly reducing CO (Summerbell, Waters, Edmunds, Kelly, Brown, &
Campbell, 2005). Interventions implementing programs focusing on physical activity made only
minor reductions in overall weight status of youth (Summerbell et al., 2005). Combining diet
education and physical activity components made positive impacts on BMI, but no significant
results (Summerbell et al., 2005). Focusing on overconsumption of SSBs in interventions has
been found to decrease consumption among youth (van de Gaar, Jansen, van Grieken, Borsboom,
Kremers, & Raat, 2014). Currently, there is a gap in the literature for effectiveness of SSB
interventions and their effect on CO. Due to great amounts of interventions already focusing on
nutrition and physical activity among obese youth, this intervention will aim to be more
innovative and focus on the behavioral risk behavior of high consumption of SSBs. An extensive
analysis found the relationship between SSB consumption and obesity has been found to have
temporality, strength, consistency, biological plausibility, experimental evidence and a doseresponse relationship (Hu, 2013). Therefore, an intervention focused on this behavioral risk
factor in reducing CO is promising.
The environmental risk factors must also be prioritized to narrow the scope of focus of
environment factors this intervention will address. Family influence and school environment are
two environmental risk factors that have been utilized in interventions often. Including parents in
an intervention for CO has been found to have positive effects. Langley-Evans & Moran (2014)
encourages parental involvement in interventions because youth require the entire family to
make lifestyle changes. Many school interventions geared towards CO have been completed, all
exhibiting mixed results. However the MATCH program, which made SSBs less available in
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schools, found the intervention to be effective in reducing mean zBMI and was sustainable after
a year of implementation (Lazorick, Fang, Hardison & Crawford, 2015). The environmental risk
factors of the built environment and accessibility have been used in interventions and have
showed promising effects on obesity. A study found change in built environment allowing better
transportation and accessibility was correlated with an average reduction in BMI and odds of
becoming obese (MacDonald, Stokes, Cohen, Kofner , Ridgeway, 2010). Policy has not been
implemented as often in interventions, but when used has exhibited little effect on BMI (Mayne,
Auchincloss, & Michael, 2015). Few interventions have been conducted addressing the food and
beverage industrys effects on CO. When a 10% sales tax was added to fast food purchases in
Australia, there was a 10% decrease in sales (Stanton, 2008). However, the customers
disregarded the increased price soon after initial implementation and sales recovered (Stanton,
2008). Therefore, more evidence is needed to determine if methods such as price interventions
are effective. For media, social marketing campaigns have been utilized to promote healthy
behaviors and in turn decrease obesity. There is little evidence on the benefit of the use of social
marketing campaign interventions against CO; however they are most effective when
implemented on children because behavior is more easily changed (Walls, Peeters, Proietto, &
McNeil, 2011). After careful prioritization of this evidence, the intervention will focus on the
environmental risk factors involving availability of SSBs and potable drinking water as well as
use of media through a social marketing campaign in the school environment. Table 1, as seen
below, prioritizes all behavioral and environmental risk factors for CO by relevance and
changeability. The factors to be utilized in the intervention are in italics.
Table 1. Priority Behavioral and Environmental Risk Factors for Intervention
Behavioral Risk Factors

Relevance

Changeability

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High-consumption of SSBs
Poor food choices resulting in an
energy-dense diet
Inadequate physical activity
Environmental Risk Factors
Availability of SSBs in school
environment
Availability/accessibility of potable
drinking water
Media
Family environment
Built environment (healthy options
& physical activity opportunities)
Food & beverage industry
Government policy

+++
+++

+++
++

+++
Relevance
+++

++
Changeability
+++

+++

+++

+++
+++
+++

++
++
++

+++
++

+
+

Question 4. Program Objectives

There are few interventions with measurable objectives focusing on decreasing SSB
consumption among SA youth in the school environment available in the current literature.
However, an intervention encouraging consumption of water rather than SSBs found a
significant 23% decrease in mean daily intake of SSBs by the end of the school year (Sichieri,
Trotte, de Souza, & Veiga, 2008). Another study used education and environmental strategies by
providing greater access to water in the school environment (Muckelbauer, Libuda, Clausen,
Toschke, Reinehr, & Kersting, 2009). This study found a decrease in the risk of being
overweight by 31% (Muckelbauer et al., 2009). These interventions were conducted over one full
school year, therefore determining the length of this intervention. Due to lack of available data in
the literature, the objectives for obesity reduction and availability of SSBs in schools were
determined using Healthy People 2020. Healthy People 2020 targets a 10% improvement in
obesity among children and adolescents ages 2 through 19 by the year 2020 (DHHS, 2010). The
objective for this intervention was carefully structured around this data. The Healthy People
2020 target for proportions of schools offering or selling SSBs was also utilized to create this
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interventions environmental impact objective of availability of SSBs in schools. The measurable
objectives for this intervention are as follows:
Health Outcome:
1. Reduce the amount of participating children and adolescents ages 5 to 18 years old
attending school in the Greater Third Ward who are classified as obese by 5% within a
school year, as compared to a control group.
2. Reduce risk for being overweight by 30% among participating children and adolescents
ages 5 to 18 years old attending school in the Greater Third Ward within a school year, as
compared to a control group.
Behavioral Impact:
3. Reduce consumption of total daily caloric intake from sugar-sweetened beverages by
participating children and adolescents ages 5 to 18 attending school in the Greater Third
Ward by 25% within a school year, as compared to a control group.
Environmental Impact:
4. Increase the amount of schools operating within the Greater Third Ward that do not offer
or sell sugar-sweetened beverages to students by 5% within a school year, as compared to
a control group.
5. Children and adolescents ages 5 to 18 years old participating in the intervention
implemented in schools within the Greater Third Ward will report a significant (p<0.05)
increase in potable water availability in school, as compared to a control group.
6. Children and adolescents ages 5 to 18 years old participating in the intervention
implemented in schools within the Greater Third Ward will report a significant (p<0.05)
increase in media focused on healthier beverage choices, as compared to a control group.
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Question 5. Determinants
There are a variety of determinants associated with the risk factors leading to CO. These
determinants must be understood in order to identify what needs to be changed for the
intervention to be effective.
Determinants for Behavioral Risk Factors
From Social Cognitive Theory (SCT), self-efficacy plays a significant role in determining
behavioral risk factors for CO. Self-efficacy is defined as an individuals confidence in their
ability to perform a behavior (Bandura, 1997). Low self-efficacy for drinking water as well as eating
fruits and vegetables was found in an African American community of 222 students using a validated
questionnaire (Elmore, Shakeyrah, Sharma, Manoj, 2013). Research has also found low self-

efficacy for physical activity is common among obese youth compared to their leaner
counterparts ( Deforche , De Bourdeaudhuij, Tanghe, Hills, De Bode, 2004). Additionally, obese
youth exhibit more perceived barriers, a construct from the Health Belief Model (HBM), to be
physically active and are less confident to act on these barriers (Trost, Kerr, Ward, Pate, 2001).
Finally, obese youth exhibit low intentions to eat healthy foods as compared to underweight or
normal weight youth (Mohd, 2011). Intention to perform a behavior originates from the Theory
of Reasoned Action (TRA) and Theory of Planed Behavior (TPB) and is linked to attitude,
subjective norm and perceived control about a behavior (Motao & Kasprzyk, 2008). All of these
determinants contribute to SA youth participating in risky behaviors that can lead to CO.
Determinants for Environmental Risk Factors
Many of the determinants for the environmental risk factors of CO originate with the
youths parents. For example, the weight status of a parent alone affects whether or not their
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child will be obese. If both parents are obese, the risk for obesity in the child is 11 times greater
than a child with non-obese parents (Kleiser, Schaffrath Rosario, Mensink, Prinz-Langenohl, &
Kurth, 2009). Even youth with only one obese parent are at greater risk for CO (Kleiser et al.,
2009). Parental stress and feelings of safety has been found to negatively affect the ability of
families to eat dinner together. As parental stress and feelings of being unsafe in either their
home or neighborhood, family dinners per week decreased (Hearst, Martin, Rafdal, Robinson &
McConnell, 2013). Parents feelings of lack of street safety also influenced whether theyd let
youth go outside to be physically active (Rodrguez-Oliveros, Haines, Ortega-Altamirano,
Power, Taveras, Gonzlez-Unzaga, & Reyes-Morales, 2011). Parents of youth who are obese
have also been found have a lack of nutrition knowledge leading to preparation of unhealthy
meals (Rodrguez-Oliveros et al., 2011; Hearst et al., 2013). Cultural beliefs influence the way a
parent feeds their children as well as how children are taught to select food for themselves
(Kumanyika, 2008). These cultural beliefs of food will vary among ethnicities and communities,
leading to the greater burden of CO in low-income, minority populations (Kumanyika, 2008).
Social norms play a large role in a youths environment, especially outside the home. To
meet the current social norm, youth have greater difficulty decreasing rather than increasing their
BMI (Wang, Bleich, & Gortmaker, 2008). For example, vending machines at schools have
become a social norm by providing products such as SSBs and sweets in approximately 90% and
80% of schools, respectively (W van den Berg, Mikolajczak, & Bemelmans, 2013). Nutrition
standards for what is provided in vending machines helps shape social norms as well as influence
government agencies and food industries (National Alliance for Nutrition and Activity, n.d.).
Lastly, funding for schools allows food and beverage companies to market unhealthy food
products to students on school grounds. Schools receive funding for placing vending machines in
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schools selling SSBs, desserts, and high-fat snacks (Miller & Silverstein, 2007). Pouring-rights
contracts give permission to companies to exclusively sell products in vending machines and at
school events in exchange for funding for the school district (Nestle, 2012). Schools then are
promoting specific brands by advertising and selling competitive foods such as SSBs (Nestle,
2012). If SA youth are purchasing these competitive foods, they are less likely to be consuming
more nutritious foods offered by the school. This phenomenon favors profit over nutrition,
leading to health problems such as CO (Nestle, 2012).

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Question 6: PRECEDE Logic
Model of Risk

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EXAM TWO: OUTCOMES, OBJECTIVES, MATRICES, METHODS AND PRACTICAL

APPLICATIONS
Question 7: Behavioral and Environmental Outcomes
To develop an intervention properly, it is essential to assess not only the behavioral and
environmental risk factors of a health problem but also the factors leading to health promoting
behavior. For this intervention, the health promoting behavior will reduce the risk of childhood
obesity in school-age (SA) youth. After prioritizing risk factors from the needs assessment,
health promoting behavioral and environmental outcomes which reduce risk of childhood obesity
were established. To reduce the risk of childhood obesity, SA youth will reduce consumption of
sugar-sweetened beverages (SSBs). Decreasing daily consumption of SSBs and replacing these
beverages with water is correlated with lower total caloric consumption and decreased
prevalence of obesity (Popkin, 2010; de Ruyter, Olthof, Seidell, & Katan, 2012). Therefore,
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students in the intervention will: Select water, rather than SSBs, as their beverage of choice
[BO1].
Water is calorie-free and individuals who replace SSBs with water are able to maintain a
healthy weight (Muchelbauer, Libuda, Clausen, Toschke, Reinehr, & Kersting, 2009). Two
studies indicate drinking water rather than SSBs assists in prevention of obesity among SA youth
(Ebbeling, Feldman, Osganian, Chomitz, Ellenbogen, & Ludwig, 2006; Wang Ludwig,
Sonneville, & Gortmaker, 2009). One study found replacing SSBs with water was related to
significant decreases in total energy intake of approximately 200 calories per day (Stookey,
Constant, Gardner, & Popkin, 2007). Tate and colleagues (2012) observed the effect of replacing
caloric beverages with water for 6 months in overweight and obese individuals. Participants who
did not consume calories from beverages experienced a significant weight reduction over a six
month period and were twice as likely to accomplish a 5% weight loss. While adults who replace
SSBs with water have increased weight loss, youth who replace SSBs with water have reduced
energy intake and risk of obesity (Tate et al., 2012; Popkin, D'Anci, Rosenberg, 2010; Briefel,
Wilson, Cabili, Hedley Dodd, 2013). One study used a healthy lifestyle education program which
aimed to reduce SSB intake among SA youth by encouraging selection of water as a beverage
(Sichieri, Trotte, de Souza & Veiga, 2008). The program found students in the intervention who
focused on drinking water instead of SSBs exhibited a greater reduction in both SSBs and BMI
than the control group (Sichieri et al., 2008).
Environmental conditions play a role in reducing risk of obesity in SA youth as well. The
needs assessment established how the school environment plays a key role in influencing health
behaviors of SA youth. The school environmental factors that influence SSB consumption
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include the availability of SSBs and clean drinking water as well as exposure of students to
media. Therefore, the school environment is the focus of this intervention and the school will:
Not offer or sell SSBs [EO1]; Make clean drinking water readily available [EO2]; Not
advertise for any SSBs [EO3]; and Promote beverages that do not fall into the SSB
category, specifically water [EO4].
There is a correlation between foods offered by schools and foods purchased by students
(Mazur et al., 2008). Beverage products offered or sold by schools also influence dietary choices
among students. The HEALTHY school-based intervention evaluated the effects of eliminating
all SSBs from vending machines, a la carte lines, school stores, and the cafeteria (Siega-Riz,
2011). Students at the intervention schools reported an increase in water consumption by two
fluid ounces higher than students in the control schools (Siega-Riz, 2011).
SA youth spend a majority of their day at school so it is essential to ensure that water
provided at the school is safe and clean (Patel & Hampton, 2011). Additionally, studies have
shown providing access to clean water at school can reduce SSB consumption among SA youth
(Patel, Bogart, Uyeda, Rabin, & Schuster, 2010; Wang, Ludwig, Sonneville, & Gortmaker, 2009;
Ebbeling, Feldman, Osganian, Chomitz, Ellenbogen, & Ludwig, 2006). Enhancing the
availability of healthful beverages, such as water, in schools is related to improved dietary intake
among students (Cullen, Hartstein, Reynolds, Vu, Resnicow, Greene, White, 2007; TerryMcElrath, O'Malley, Delva, Johnston, 2009). A study by Elbel and colleagues (2015) evaluated
the influence of drinking water dispensers on water consumption in New York City schools.
Three months after installing the water dispensers, water taking was tripled as compared to
schools without access to clean drinking water (Elbel et al., 2015). After one year of
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implementation, 80% of students in intervention schools reported noticing the water dispensers
and 50% of students who noticed the jets reported drinking more water due to the availability of
the dispensers (Elbel et al., 2015). Therefore, this study found providing clean drinking water to
students through use of water dispensers was related to an increase in the amount of students
who drink water (Elbel et al., 2015). A similar study assessed how offering clean, filtered tap
water using dispensers in a middle school influenced students water consumption (Patel, Bogart,
Klein, Schuster, Elliott, Hawes-Dawson, Lamb, & Uyeda, 2011). The dispensers had a
significant positive influence on water consumption among students (Patel et al., 2011). Students
from schools with increased availability of clean drinking water through dispensers had higher
adjusted odds of drinking water at school as compared to students who do not (Patel et al., 2011).
Research concludes enhancing drinking water infrastructure, modernizing water fixtures, and
improving clean water accessibility can increase water intake among students in school (Kenney,
Gortmaker, Carter, Howe, Reiner, & Cradock, 2015).
SA youth are influenced by a variety of media on a daily basis which makes a significant
impact on their behavior. School environments are sources of advertising when allowed by
policymakers, administrators, and other stakeholders involved in the school (Larson, Davey,
Coombes, Caspi, Kubik, & Nanney, 2014). Food and beverage marketing in schools are
presented in various forms such as products, promotional materials, messaging, logos,
sponsorship of school events and incentive programs (Story & French, 2004). Banning
advertising of SSBs in the school environment shows promise of reducing SSB consumption
among students. Current research evaluating effectiveness of banning SSB advertising in schools
is scarce, however findings of a particular study found a change over time in the amount of
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schools banning advertising for unhealthy products in an attempt to improve student dietary
choices (Larson et al., 2014). The results of this study suggest schools recognize the need to ban
advertising for products, such as SSBs, to reduce obesity risk among SA youth (Larson et al.,
2014).
Replacing advertisements endorsing SSBs with messages promoting water consumption
will further improve SA youth beverage selection behavior. There are various studies within
empirical literature supporting the strategy of promoting water through media to improve water
intake among SA youth. Loughridge and Barratt (2005) compared the effect of promoting water
consumption along with improved water access to only improving water access within the school
environment. The study concluded adding the promotion of water consumption in schools
increased water intake among students more than just enhancing water access (Loughridge &
Barratt, 2005). Springer and colleagues (2013) developed the CATCH social marketing get ur
H2O campaign to increase water intake and reduce consumption of SSBs among students. Get ur
H2O involved messaging within the school environment to increase student water consumption
(Springer, Kelder, Byrd-William, Pasch, Ranjit, Delk, & Hoelscher, 2013). Water promotion
messaging strategies included posters and messages on water bottles given to students (Springer
et al., 2013). The greatest increase in water intake among students was found in schools with the
social marketing condition (Springer et al., 2013).
Different forms of promotion for water consumption have been utilized and been
successful in previous studies. One study used reusable water bottles as the strategy to promote
water consumption in a German elementary school (Muckelbauer, Libuda, Clausen, Toschke,
Reinehr, & Kersting, 2009). There were planned daily schedules to fill-up water bottles and
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teachers assisted students in filling up their water bottles every morning (Muckelbauer et al.,
2009). The study found an overall improved water intake and reduction in risk of overweight
among students from the intervention school as compared to those in the control group
(Muckelbauer et al., 2009). Kenney and colleagues (2015) utilized signage suggesting water as a
primary beverage choice and provided disposable cups near water sources as promotion methods
(Kenney, Gortmaker, Carter, Howe, Reiner, & Cradock, 2015). The amount of students who
drank water during lunch doubled from baseline as compared to control students (Kenney et al.,
2015). Additionally, the amount of students seen with SSBs was reduced after implementation of
the intervention (Kenney et al., 2015).
Question 8: Priority Population Differentiation
When developing an intervention using the intervention mapping approach, it is essential
to determine whether or not the priority population determined in the needs assessment should be
differentiated before proceeding further. In determining whether or not to differentiate the
intervention population, it is important to understand the population is made up of individuals
with varying attributes and needs which will not be able to be addressed by a single intervention
if the variation is too great (Bartholomew, Parcel, Kok, Gottlieb, & Fernandez, 2011). Major
differences in age, gender, ethnicity, education, geographic location, and socioeconomic status
are important aspects to consider when determining whether or not to differentiate the
intervention population (Bartholomew et al., 2011). The priority population for this intervention
was sufficiently narrowed concerning ethnicity, geographic location and socioeconomic status
with the target population being low-income African-American and Hispanic SA youth attending
school in the Third Ward of Houston, TX. However the age gap set for this intervention, SA
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youth ages five through eighteen, is too broad and leaves variations in knowledge level. The age
and education level of the target population needs to be narrowed to an age group based on
school level. Despite the wide age gap, there is no evidence suggesting there is a difference in
determinants of behavior between the age groups. Therefore, rather than differentiating the
priority population, the targets will only be narrowed to middle school students ages 11 through
13. This age group would benefit from the intervention the most because the prevalence of SSBs
has tripled among adolescents 11 through 19 years old and behaviors of middle school students
are more likely to be changeable than high school students (Han & Powell, 2013).
Some studies have also found a difference in genders in response to water promoting
interventions. For example, a nutrition education program aimed at improving water
consumption behaviors in SA youth found a significant difference in increased water
consumption and resulting BMI reduction in girls (Sichieri, Trotte, de Souza, & Veiga, 2008).
However, difference in determinants of the health promoting behavior between genders was not
found in the literature. There was no other contributing evidence within the literature to suggest
differentiation was necessary for this intervention. Therefore, there will not be a differentiation
of the priority population.
Question 9: Performance Objectives
Understanding the specific steps in which the SA youth and schools will have to take to
achieve the outcomes determined is essential in constructing an effective intervention. The
creation of performance objectives for both the individual and the environment describes the
process of how to accomplish the desired result. Table 1 presents the performance objectives for
the individual, the student, selecting water as their beverage of choice rather than SSBs. These
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performance objectives, with the exception of cleaning the water bottle when empty, were
previously utilized in various interventions effective at reducing SSB consumption and
increasing water intake in SA youth. Muckelbauer and colleagues (2009) structured an
intervention with objectives for students to obtain a reusable water bottle, obtain water from
fountains, drink water, and refill the water bottle with water when it is empty. With these
objectives, the intervention was effective in reducing the risk of overweight in students by
increasing water consumption (Muckelbauer, Libuda, Clausen, Toschke, Reinehr, & Kersting,
2009). Another intervention using the objectives for students to make the decision to drink water
and refuse SSBs was also successful in increasing student water consumption (Kenney,
Gortmaker, Carter, Howe, Reiner, & Cradock, 2015). The objective of cleaning the water bottle
when empty was added as a behavioral performance objective because bacteria will accumulate
in reusable water bottles if they are not disinfected properly between uses.
Table 1. Behavioral Performance Objectives
Behavioral Outcome 1: Students will select water, rather than SSBs, as their beverage of choice
Students will:
PO1.1 Make the decision to drink water
PO1.2 Obtain a reusable water bottle
PO 1.3 Obtain water from a water station or purchase water if reusable bottle is unavailable
PO1.4 Drink water
PO1.5 Clean reusable water bottle when empty
PO1.6 Refill reusable water bottle with water when empty
PO1.7 Refuse alternative beverages including SSBs

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Performance objectives for the environment are also necessary to consider the steps the
schools will take to decrease the availability of SSBs while increasing the availability of clean
drinking water and changing media messages about beverages in the school environment. The
performance objectives for the school environment in this intervention are shown in Table 2.
These objectives were also previously utilized in studies aiming for similar environmental
outcomes as the present intervention. The study by Muckelbauer and colleagues (2009)
implemented environmental objectives such as installing water stations, supplying reusable water
bottles, and allowing water in class. The objective of discontinuing advertising of SSBs in the
school environment was supported in a study by Larson and colleagues (2014), while the
objective of promoting water consumption was used in an effective intervention by Kenney and
colleagues (2015). Finally, replacing SSBs from places of purchase in the school environment
with water was an objective used in an intervention known as The Zuni High School Diabetes
Prevention Program (Ritenbaugh et al., 2003). The intervention found availability of SSBs was
significantly related to consumption among students (Ritenbaugh et al., 2003). After three years
of implementation, the students consumed nearly no SSBs at school. SSBs were substituted by
approximately 24 ounces of water per week by each student (Ritenbaugh et al., 2003).
Table 2. Environmental Performance Objectives
Environmental Outcomes 1-4: Schools will not offer or sell SSBs; make clean drinking water
readily available; not advertise for any SSBs; and promote beverages that do not fall into the
SSB category, specifically water
PO 2.1 Food and nutrition staff will replace all SSBs from places of purchase (cafeteria, vending
machines etc.) with bottled water
PO 3.1 Principals will order installation of water stations to supply potable drinking water
PO 3.2 Principals will order reusable water bottles to supply to students
PO 3.3 Teachers will allow water in class
PO 4.1 Principals will discontinue advertising for SSBs including logos, posters and videos
PO 5.1 Principals and teachers will promote drinking water using various forms of media

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Multiple strategies will be used to validate both the behavioral and environmental
performance objectives. For the behavioral performance objectives, observation of students
completing objectives would be useful in visualizing the steps being taken to accomplish the
behavioral outcome. Additionally, key informant interviews with students discussing how they
accomplish the desired behavioral outcome would assist in validation of the behavioral
performance objectives. For the environmental performance objectives, similar strategies will be
utilized for validation. Observation of school staff completing tasks on site and key informant
interviews with the staff will be conducted. The interviews with school staff will include
principals, teachers, and food and nutrition staff. Additional interviews can be conducted with
others involved in the objectives such as vendors who supply beverages to the school as well as
the water station installation company. These validation strategies for the environmental
performance objectives will assist in confirming the proper steps are being taken to accomplish
the desired environmental outcomes of the intervention.
Question 10: Determinants
Assessing the determinants of both the individual and the environment are essential in
understanding why SA youth engage in the health promoting behavior of drinking water instead
of SSBs. Within existing literature, there are specific determinants for the individual and
environment recognized as important in influencing the health promoting behavior among SA
youth.
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Brittany Kaczmarek
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Individual Determinants
Knowledge: Knowledge is derived from communication theory and is defined as the
information leading to understanding and engaging in informed action (Finnegan Jr. &
Viswanath, 2008). Knowledge, particularly nutrition knowledge, impacts dietary choices of SA
youth (Taylor, Evers, & McKenna, 2005). Wardle and colleagues (2000) found existing nutrition
knowledge was related to better dietary quality. Another study examining the association
between knowledge of daily calorie recommendations and SSB consumption found similar
results (Gase, Robles, Barragan, & Kuo, 2014). Results indicated participants who could
correctly identify the recommended daily calorie needs drank an average of nine fewer SSBs per
month than participants who did not know the recommended daily calorie needs (Gase et al.,
2014).
Skills and Self-Efficacy: Self-efficacy is a construct of the Social Cognitive Theory
(SCT) and is defined as an individuals confidence in their ability to accomplish a desired
behavior (Bandura, 1997). A study by Shannon and colleagues (1990) examined self-efficacy as
a primary factor in dietary behavior. Data was collected from 170 women who participated in a
10 week course at pre-intervention, post-intervention, and two months afterward (Shannon,
Bagby, Wang, & Trenkner, 1990). Self-efficacy significantly determined dietary behavior at preand post-intervention (Shannon et al., 1990). Another study evaluating 350 children ages 11 or
12 years old as a cohort for 6-month time intervals found self-efficacy to be positively associated
with healthy dietary behaviors among youth (Masui, Sallis, Berry, Broyles, Elder, & Nader,
2002).

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Skills are a part of self-efficacy and involve an individuals expertise influencing their
ability to perform a behavior. A study conducted within high schools looked at the relationships
between cognitive beliefs, healthy lifestyle choices, and healthy lifestyle behaviors among
adolescents (Kelly, Melynk, Jacobson, & OHaver, 2011). The study found a significant
correlation between behavioral skills and healthy lifestyle choices (Kelly et al., 2011). Therefore,
both self-efficacy and skills are important determinants in SA youth choosing water rather than a
SSB.
Attitudes: Attitudes are from the Theory of Planned Behavior (TPB) and are a direct
determinant of an individuals behavioral intention determining behavior (Montano & Kasprzyk,
2008; Fishbein & Ajzen, 1975). Attitudes and intentions were found to be a correlate of dietary
behavior among multiple samples of SA youth (McClain, Chappuis, Nguyen-Rodriguez, Yaroch,
& Spruijt-Metz, 2009). Patel and colleagues (2014) also discuss the influence of attitude on
drinking water at school among middle school students. The study found attitudes toward school
drinking fountains were associated with intentions to drink water at school and intentions to
drink water at school were related to total water intake (Patel, Bogart, Klein, Cowgill, Uyeda,
Hawes-Dawson, Schuster, 2014). Therefore, positive attitudes about drinking water among SA
youth are essential determinants in whether or not this population will drink water instead of
SSBs.
Outcome Expectations: Outcome expectations are another construct from SCT and are
defined as the beliefs about the probability and significance of what will occur due to performing
a specific behavior (McAlister, Perry, & Parcel, 2008). Outcome expectations have been found to
be linked with health behaviors such as increased water consumption. A study by Sharma and
38

Brittany Kaczmarek
PH1113
colleagues (2006) evaluated specific SCT constructs in predicting four health behaviors,
including increased water consumption, among 159 elementary school students. The study found
amount of water consumed per day was determined by expectations for drinking water (Sharma,
Wagner, & Wilkerson, 2006). Positive outcome expectations for drinking water were found to be
a significant determinant of students obtaining the recommended amount of eight glasses of
water per day (Sharma et al., 2006).
Environmental Determinants
There are also determinants of the school environment influencing SA youth to
participate in the health promoting behavior. Determinants for these environmental conditions
include knowledge, attitudes, and self-efficacy and skills. Hughes (2010) found the principals
knowledge plays a key role in the success of students. Therefore, behavior of students can be
determined by the knowledge of leaders in the school environment and how these leaders apply
such knowledge within the environment to influence the students (Hughes, 2010). A study
conducted by Chen and colleagues (2010) looked at whether teachers are resources and role
models for students with respect to healthy dietary behavior. The study evaluated knowledge of
the teachers and how this knowledge influences the behavior of the students they teach (Chen,
Yeh, Lai, Shyu, Huang, & Chiou, 2010). Better dietary behaviors were found to be correlated
with classrooms whose teachers had more nutrition knowledge (Chen et al., 2010).
Attitudes of school staff toward drinking water rather than SSBs can also play a role in
influencing students behavior. A cross-sectional study evaluating the Healthy School Canteen
Program, a program aimed at improving student dietary behaviors in schools, assessed
determinants for schools choosing to participate in the program (Milder, Mikolajczak, van den
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Brittany Kaczmarek
PH1113
Berg, van de Veen-van Hofwegen, & Bemelmans, 2015). Attitudes of school staff were classified
as a determinant for why a school chose to promote healthier dietary behaviors such as drinking
water (Milder et al., 2015). School staff at intervention schools encouraged healthier dietary
behaviors, believed overweight among students is a health problem and had a sense of
responsibility in preventing overweight among their students (Milderet al., 2015). Therefore, the
staff at intervention schools had attitudes leading to the promotion of healthier dietary behavior
among students.
Finally, self-efficacy and skills are considered environmental determinants of the health
promoting behavior among SA youth as well. Domsch (2009) studied the relationship between
effective behaviors and efficacy by evaluating practices of principals and teachers. This
relationship was measured using surveys in which the participants self-reported self-efficacy
scales and student achievement (Domsch, 2009). Instructional skills were also included in the
analysis for teachers (Domsch, 2009). Higher skill level among teachers was related to principal
efficacy (Domsch, 2009). Additionally, the study indicated principal efficacy scores were
positively correlated with student achievement (Domsch, 2009). These finding suggest school
staff are key in influencing changes in the environment to encourage health promoting behaviors
among students.
New Research
The behavioral and environmental determinants for the health promoting behavior found
in the literature need to be confirmed in order to indicate whether these determinants are
sufficient for the target population. Therefore, new research will be done to conclude if
determinants properly represent why SA youth are drinking water rather than SSBs or if other
40

Brittany Kaczmarek
PH1113
theoretical determinants are more influential. This research would be conducted using focus
groups and key informant interviews with SA youth who are actually participating in the health
promoting behavior as well as interviews with school staff.
Question 11: Change Objectives
Refer to Matrix 1 for the changes objectives of the behavioral outcome and Matrix 2 for
the changes objectives of the environmental outcomes.

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Brittany Kaczmarek
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Matrix 1. Behavioral Outcome: [BO1]
Determinants
Performance
Objectives
PO1.1 Students will make the
decision to drink water rather than
a SSB

Knowledge

PO1.2 Students will obtain a

reusable water bottle

K.1.2 Describe how to receive a

reusable water bottle

PO 1.3 Students will obtain water

from a water station or purchase
water if reusable bottle is
unavailable

K.1.1 Explain how the health benefits SSE.1.1. Have confidence in the
of drinking water is a deciding factor ability to choose water as a beverage
in selecting water as a beverage
over other options
SSE.1.2a Have confidence in the
ability to obtain a reusable water
bottle for use
SSE.1.2b Demonstrate the ability to
obtain a resuable water bottle
K.1.3 Explain how to locate water
SSE.1.3a Have the confidence in the
station or vending machines to obtain ability to find a water station or
water
vending machine to obtain water
SSE.1.3b Demonstrate the ability to
find a water station or vending
machine to obtain water

PO1.4 Students will drink water

PO1.5 Students will clean water

bottle when empty

PO1.6 Students will refill bottle

with water when empty

Skills and Self-efficacy

SSE.1.4 Have confidence in the

ability to drink water

K.1.5a Explain the importance of

cleaning reusable water bottles in
preventing water-borne illnesses
K.1.5b Explain proper procedures of
how to clean reusable water bottle

SSE.1.5a Have confidence in the

ability to properly clean resuable
water bottle
SSE.1.5b Demonstrate the ability to
properly clean reusable water bottle
SSE.1.6a Have confidence in the
ability to refill water bottle when
empty
SSE.1.6b Demonstrate the ability to
refill water bottle when empty

Attitudes

Outcome Expectations

A.1.1 Express positive belief about

the importance of deciding to drink
water

OE.1.1 Expect that making the

decision to drink water will reduce
consumption of sugar-sweetened
beverages
OE.1.2 Expect that obtaining a
reusable water bottle will increase
water consumption

OE.1.3 Expect obtaining or

purchasing water will decrease sugarsweetened beverage consumption

A.1.4 Express positive attitudes about OE.1.4 Expect drinking water will
drinking water rather than sugardecrease sugar-sweetened beverage
sweetened beverages
consumption and improve overall
health
OE.1.5 Expect water to be free of
impurities or contaminants

OE.1.6 Expect refilling water bottle

when empty will increase water
consumption

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Brittany Kaczmarek
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PO1.7 Students will refuse
alternative beverages including
SSBs

K.1.7a Explain refusal of alternative SSE.1.7 Have the confidence in the

A.1.7 Express positive feelings about OE.1.7 Expect refusing alternative
beverages is due to health benefits of ability to refuse alternative beverages refusing any beverages other than
beverages will decrease sugarwater
water
sweetened beverage consumption
K.1.7b Explain characteristics of an
effective refusal

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Brittany Kaczmarek
PH1113
Matrix 2. Environmental Outcomes: [EO1-4]
Determinants
Program Objective
Knowledge
PO 2.1 Food and nutrition staff will
K.2.1 Explain all locations students could
remove all SSBs from places of purchase access SSBs
(cafeteria, vending machines etc.) and
replace with bottled water

Skills and Self-Efficacy

SSE.2.1a Express confidence in promoting
water through removing sugar-sweetened
beverages from places of purchase
SSE.2.1b Demonstrate ability to work with
vendors on replacing SSBs with water

PO 3.1 Principals will order installation K.3.1a Describe benefits in providing

of water stations to supply potable
clean drinking water to students through
drinking water
water station installation
K.3.1b Describe steps required to install
water stations
PO 3.2 Principals will order reusable
K.3.2 Describe how reusable water bottles
water bottles to supply to students
will be supplied with budget, sources and
storage information
PO 3.3 Teachers will allow water in class K.3.3 Describe importance of allowing
SSE.3.3 Have confidence in the ability to
water in class for students to increase
permit students to drink water in the
water consumption and stay hydrated
classroom

Attitudes
A.2.1 Express positive attitudes about
eliminating all sugar-sweetened beverages
from the school environment and replacing
them with water to benefit the students
health
A.3.1 Express positive attitudes towards
increasing water access in the school
environment by installing water stations

A.3.2 Express positive beliefs in supplying

students with reusable water bottles to
increase water consumption
A.3.3 Express positive feelings towards
students being allowed to drink water in
the classroom

PO 4.1 Principals will discontinue

advertising for SSBs including logos,
posters and videos

K.4.1 Describe risk of SSB advertising

SSE.4.1a Have confidence in the ability to A.4.1 State belief that advertising for SSBs
towards students and the health benefits of cease SSB advertising within the school
in the school have negative health outcome
discontinuing advertising
environment
for students
SSE.4.1b Demonstrate the ability to
remove advertising for SSBs in the school
environment

PO 5.1 Principals and teachers will

promote drinking water using various
forms of media

K.5.1a Describe health benefits of drinking

water instead of SSBs used in promotions
K.5.1b Describe different ways to promote
drinking water

SSE.5.1a Have confidence in the ability to A.5.1 Express positive attitudes towards
promote drinking water through media
media promoting water consumption
SSE.5.1b Demonstrate the ability to
geared toward students to change behavior
promote drinking water by using media as
a source

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Brittany Kaczmarek
PH1113
Question 12: Methods and Practical Applications
Theoretical methods are utilized to influence changes in determinants of behavior within
the target population or environmental condition (Bartholomew, Parcel, Kok, Gottlieb, &
Fernandez, 2011). The methods are matched to a change objective from the matrices and are
linked by the determinant (Bartholomew et al., 2011). The practical applications are the
strategies used by the intervention to implement a particular method. Methods and practical
applications are used for both the behavioral outcomes as well as environmental conditions of the
intervention.
Methods chosen for the behavioral outcome of this intervention include belief selection,
persuasive communication, facilitation, imagery, modeling, counter-conditioning, repeated
exposure, and cultural similarity (Bartholomew, Parcel, Kok, Gottlieb, & Fernandez, 2011).
Belief selection utilizes messages aimed at supporting positive beliefs, weakening negative
beliefs, and introducing new beliefs (Bartholomew et al., 2011; Fishbein & Ajzen, 2010). This
method was found to be effective in a healthy lifestyle education program utilizing messages to
encourage positive beliefs about water consumption in place of SSBs (Sichieri, Trotte, de Souza
& Veiga, 2008). The primary approach of the intervention was to teach students the message that
drinking water is positive (Sichieri et al., 2008). On average, the consumption of sodas per class
decreased by four times the amount in the intervention group as compared to the control group
(Sichieri et al., 2008). Additionally, the intervention group exhibited a greater reduction in BMI
status than the control group (Sichieri et al., 2008). The intervention also successfully utilized
imagery, persuasive communication, repeated exposure, and cultural similarity as methods.
Imagery utilizes objects with a resemblance to a particular subject (Bartholomew et al., 2011).
For imagery, Sichieri and colleagues (2008) used a pyramid of drinking showing water at the
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Brittany Kaczmarek
PH1113
base of the pyramid and SSBs at the top of the pyramid to encourage water consumption.
Persuasive communication, which directs individuals to adopt a desired behavior by utilizing
arguments, was used in the intervention by creating the center of the campaign around the health
benefits of choosing water over SSBs (Bartholomew et al., 2011; Sichieri et al., 2008). Repeated
exposure is a method aimed at ensuring a stimulus is continuously available to the individuals
senses (Bartholomew et al., 2011; Zajonc, 2001). The intervention utilized this method by
exposing the students continuously to the message and lessons promoting water consumption.
Finally, within this intervention, cultural similarity was used to create an intervention relatable to
the target population. Cultural similarity is defined as the utilization of features of the targets in
source, message and channel (Bartholomew et al., 2011; Kreuter & McClure, 2004). Cultural
similarity was used in the intervention by previously analyzing the messages for understanding
in two groups of students who were the same age and socio-economic status as the participants
of the study (Sichieri et al., 2008). With the significant success of this particular study, these
methods were determined to be suitable for this intervention.
Facilitation is defined by Bandura (1986) as the creation of an environment conducive to
performing an action (Bartholomew, Parcel, Kok, Gottlieb, & Fernandez, 2011). Facilitation is
used as a method in many effective water promotion programs because an actual alteration of the
intervention environment occurs. For example, a study that installed water fountains and had
school teachers present classroom lessons to promote water consumption resulted in a reduced
risk for overweight among students (Muckelbauer, Libuda, Clausen, Toschke, Reinehr, &
Kersting, 2009). Counter-conditioning, defined as learning healthy behaviors used to substitute
risky behaviors, have also been found to be an effective method in similar interventions
(Bartholomew et al., 2011; Prochaska, Redding, & Evers, 2008). A recent study had participants
46

Brittany Kaczmarek
PH1113
replace two or more servings of SSBs per day with noncaloric beverages (Tate et al., 2012).
Participants had significantly greater reductions in calories per day when they
Change Objectives
K.1.1, K.1.7a, SSE.1.1,SSE.1.4,
SSE.1.7, A.1.1, A.1.4, A.1.7,
OE.1.1, OE.1.3, OE.1.4

Methods
Belief Selection (TPB/TRA)

K.1.1, K.1.7a, SSE.1.1, SSE.1.7, Persuasive Communication

A.1.1, A.1.4, A.1.7, OE.1.1,
(SCT)
OE.1.3, OE.1.4
K.1.2, K.1.3, SSE.1.1, SSE.1.2a,
SSE.1.2b, SSE.1.3a, SSE.1.4,
SSE.1.6a, SSE.1.6b, OE1.2,
OE.1.3

Facilitation (SCT)

SSE.1.1, SSE.1.4, SSE.1.6a,

Imagery (Theories of
SSE.1.7, OE.1.1, OE.1.3, OE.1.4 Information Processing)

K.1.2, K.1.3, K.1.5a, K.1.5b,

Modeling (SCT)
K.1.7a , K.1.7b , SSE.1.1,
SSE.1.2a, SSE.1.2b, SSE.1.3a,
SSE.1.3b, SSE.1.4, SSE.1.5a,
SSE1.5b, SSE.1.6a, SSE.1.6b,
SSE.1.7, OE.1.2, OE.1.5, OE1.6,
OE.1.7

Practical Applications

Parameters

Posters hung in school hallways

and near water stations with
messages of positive beliefs
toward drinking water rather than
SSBs
Video advertisements shown
during morning announcements
emphasize the health benefits of
drinking water rather than SSBs
Installation of water fountains
dispensing potable drinking water
for students along with
distribution of free reusable water
bottles

Research students existing

attitudinal, normative and
efficacy beliefs before
intervening

Recognition of logos printed on

posters, water stations, reusable
water bottles and featured in
advertisements helps students to
remember to drink water
Role models in video
advertisements provides strategies
for deciding to drink water,
locating water, how to
obtain/use/properly clean reusable
water bottle, and how to refuse
SSBs

Water messages should be

applicable to students
beliefs; includes surprise,
replication and arguments
Requires changes be made
in the school environment;
recognizes barriers and
implementers; intervention
should be at a higher
(organizational) level
Accustomed images used
in media act as a parallel to
a less accustomed practice

Use of attention,
remembrance, self-efficacy
and skills; students must
be able to identify with
role models; model must
be reinforced; use of
coping rather than mastery
model
SSE.1.1, SSE.1.4, A.1.7
Counter-Conditioning (TTM)
Replace all SSBs in places of
Accessibility of clean
purchase with water so students
drinking water, the
will substitute risky behavior with substitute for SSBs
a healthier behavior
K.1.1, K.1.7a, SSE.1.1, SSE.1.4, Repeated Exposure (Theories of Various forms of mass media
Impartiality of original
SSE.1.7, A.1.1, A.1.4, A.1.7,
Learning)
(posters on walls, advertisements attitude toward drinking
OE.1.1, OE.1.2, OE.1.4, OE.1.7
in classrooms) constantly expose water
students to messages encouraging
drinking water rather than SSBs
K.1.1, SEE.1.1, SSE.1.2a,
Cultural Similarity (Persuasion- Media delivering messages
Uses basic characteristics
SSE.1.3a, SSE.1.4, SSE.1.7,
Communication Matrix)
promoting water consumption
of SA youth to improve
A.1.1, A.1.4, A.1.7, OE.1.1,
will be culturally relevant to
receptiveness of water
OE.1.3, OE1.4, OE.1.7
African-American and Hispanic message; uses socialmiddle school students residing in cultural characteristics to
a low socioeconomic urban
further increase
community
receptiveness of water
message

substituted SSBs with a healthier beverage (Tate et al., 2012).

Table 3. Methods and Practical Applications for Behavioral Outcome

47

TPB/TRA: Theory of Planned Behavior/Theory of Reasoned Action, SCT: Social Cognitive Theory, TTM: Trans-theoretical Model;
Parameters adapted from Bartholomew, Parcel, Kok, Gottlieb, & Fernandez (2011).

Brittany Kaczmarek
PH1113
Methods for the environment include advocacy, modeling, mass media role-modeling and
mobilizing social networks (Bartholomew, Parcel, Kok, Gottlieb, & Fernandez, 2011). Advocacy
is a method used to give active support to a desired cause (Bartholomew et al., 2011). This
method has been found to be effective in previous studies similar to the present intervention. A
specific study advocated with schools to improve the infrastructure of the environment in an
attempt to increase water consumption for obesity prevention among students (Laurence,
Peterken, & Burns, 2007). By one year, the amount of students with filled water bottles increased
by 25%. Modeling is another effective method to be used in addressing the environment in this
intervention. Modeling was utilized in a water campaign with the statements Water is the best
thing I can give to my child! from caretakers of students (van de Gaar, Jansen, van Grieken,
Borsboom, Kremers, & Raat, 2014). This social marketing campaign emphasized the importance
of the adult influencing the childs healthier behaviors and reflected this message onto caregivers
viewing the media (van de Gaar et al., 2014). After implementation of the intervention, average
SSB consumption as well as average SSB servings decreased in the intervention students (van de
Gaar et al., 2014). Caregivers in the social marketing campaign were also shown being
reinforced for encouraging water consumption among SA youth, which is a method known as
mass media role-modeling (van de Gaar et al., 2014). Mass media role-modeling is a method
using models shown being reinforced for a desired action using mass media (Bartholomew et al.,
2011; Bandura, 1997; Rogers, 2003). The final method being used within the environment is
known as mobilizing social networks. Mobilizing social networks is a method involved in
encouraging the social networks of the target population in providing various forms of support to
make acting on a desired action easier for the targets (Bartholomew et al., 2011; Heaney &
Israel, 2008). This method has been effective in many interventions with a SA youths social
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Brittany Kaczmarek
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network including parents telling stories about the importance of drinking water, teachers
repeating the health message of drinking water during lessons, and teachers assisting children
with retrieving water from accessible sources (van de Gaar et al., 2014; Sichieri, Trotte, de Souza
& Veiga, 2008; Muckelbauer, Libuda, Clausen, Toschke, Reinehr, & Kersting, 2009).
Table 4. Methods and Practical Applications for Environmental Outcomes
Change Objectives

Methods

Practical Applications

K.3.1a, K.3.1b, K.3.2,

K.3.3, K.4.1, SSE.2.1a,
SSE.4.1a, SSE.4.1b, A.2.1,
A.3.1, A.3.2, A.4.1, A.5.1

Advocacy (Stage Theory of

Organizational Change)

K.5.1b, SSE.2.1b, SSe.5.1a,

SSE.5.1b

Modeling (SCT)

K.3.1a, K.3.3, K.4.1,

SSE.2.1a, SSE.4.1a,
SSE.5.1a, A.2.1, A.3.1,
A.3.2, A.3.3, A.5.1

Mass Media RoleModeling (Diffusion of

Innovations Theory, SCT)

K.2.1, K.3.3, K.5.1a,

K.5.1b, SSE.3.3, SSE.5.1a,
SSE.5.1b, A.3.3, A.5.1

Mobilizing Social Networks

(Theories of Social
Networks and Social
Support)

Students issue letters to

school administrators urging
the removal of both SSBs
and media for SSBS in the
school environment,
installing water stations to
provide clean drinking
water to students, and
implementing a water
campaign to improve health
of students.
Video advertisements
presented during morning
announcements show how
school staff can assist
students in choosing water
as their beverage instead of
SSBs
A story printed in the school
newspaper about how the
schools involvement
benefited the decrease in
SSB intake by students
through improving water
consumption
School staff are trained in
assisting students with
utilizing water stations and
how to use provided media
for promotion of water
consumption among
students

Parameters
Advocacy for water must
equate style of the students
and schools represented;
comprises policy advocacy
message tailored toward
water consumption

Models specific to school

environment and staff
(principals, teachers, food
and nutrition staff)

Intervention circumstances
include modeling and
persuasive communication

Accessibility of social
network and potential
supporters (principals,
teachers, food and nutrition
staff)

SCT: Social Cognitive Theory; Parameters adapted from Bartholomew, Parcel, Kok, Gottlieb, & Fernandez (2011).

49

Brittany Kaczmarek
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EXAM 3: PROGRAM DEVELOPMENT, ADOPTION, IMPLEMENTATION, &
EVALUATION
Question 13: Program
The proposed intervention, titled H2O My Health: Here to Own My Health, is aimed at
reducing risk of childhood obesity among middle school students by decreasing sugar-sweetened
beverage (SSB) consumption by increasing intake of water. The program aims to accomplish
these outcomes by reducing access to SSBs, eliminating all media promoting SSBs, initiating a
media campaign for drinking water, and increasing accessibility to clean drinking in the school
environment. H2O My Health will be based in Jackson Middle School located in the Third Ward
district of Houston, Texas. Participants will include middle school students attending Jackson
Middle School. School staff assisting the facilitation of the intervention will include the
principal, teachers, and Food and Nutrition Services (FNS) employees. Delivery channels to be
utilized by the intervention to convey messages include print media, videos containing peer
models, and interpersonal discussion about the importance of drinking water with homeroom
teachers. The main theme of H2O My Health emphasizes the importance of drinking water rather
than SSBs to promote optimal health. H2O My Health aims to reduce central challenges of
selecting water over SSBs, such as lack of access to clean drinking water and the negative
influence of media promoting SSBs in a youths environment. H2O My Health creates a
supportive environment for middle school students to make the healthier choices concerning
beverage selection. The title of the program, meaning here to own my health, aims to empower
students in taking control of their own health by choosing water over SSBs.
The program will begin a month before the start of the school year, between the months
of July and August. During this time, preparation for the intervention to be implemented during
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Brittany Kaczmarek
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the school year will begin. The principal will participate in train the trainer sessions, in which
they will learn how to train employees for the program. These sessions will be two hours a day
for one work week. The principal will learn about the purpose of the program, the tasks that must
be completed for the program to be properly implemented, and who among the school staff must
complete specific tasks. Following the principal training week, the teachers and FNS employees
will be trained by the school principal about the H2O My Health program. Both teachers and FNS
staff will attend an overall training session educating the employees on the purpose of the
program and why it is important for the health of the students. The employees will then be split
up into training sessions for the teachers and FNS staff on following days. The teachers will be
trained on how to assist students with obtaining water from the water stations, the importance of
replacing SSB advertisements with program posters in classrooms and nearby hallways, how to
utilize program videos, and how to actively promote drinking water to the students. The FNS
staff will be trained on how to remove SSB products and advertisements from places of purchase
as well as the importance of promoting the consumption of water to students. Training sessions
for both the teachers and the FNS staff will be over the course of one day for three hours. After
the completion of training, the principal will order the water stations and reusable water bottles
as well as observe the proper installation of the water stations in the schools. The principal will
also personally approve all program media before use. The FNS staff will then remove all SSBs
from places of purchase and replace the SSBs with water products. The FNS staff will also
replace all advertisements of SSBs from places of purchase with posters promoting water
consumption among students. The teachers will also assist in replacing advertisements for SSBs
in school hallways and classrooms with program posters. Before the school year begins, students

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of Jackson Middle School will receive schools newsletters at home including information about
H2O My Health and the health benefits of drinking water instead of SSBs.
The second phase of the implementation of the H2O My Health program comprises the
entire nine month school year, from the end of August to the following May. At this time the
water stations, which will be called hydration stations, will be installed and no SSB products
will be offered or sold anywhere in the school environment. Advertisements for SSBs will not be
displayed and an active pro-water media campaign will be established in the school environment.
This media campaign will include educational videos promoting water consumption shown
during the first homeroom class of every month as well as promotional posters located in all
classrooms and school hallways. The focus of the educational component of the program will be
based in homeroom class, in which the teachers conduct group discussions once a month about
the importance of drinking water after the program video is shown. There is not a formal
education curriculum for the homeroom teachers, but active participation from the students on
the topic addressed in the video should be encouraged. Homeroom teachers will distribute
reusable water bottles as well as present locations of hydration stations to students during the
first homeroom class of the year. Outside of homeroom class, all teachers should assist students
with obtaining water from the hydration stations when needed and encourage student water
consumption in class. The principal will be responsible for ensuring employees are implementing
the program with fidelity. This follow-up by the principal will be accomplished through monthly
meetings with all teachers and FNS staff of the middle school. In the meetings, the principal will
go over employee responsibilities, check in with each employee, and allow the opportunity for
the staff to ask questions concerning the program. Refer to Table 1 for the overall scope and

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Brittany Kaczmarek
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sequence of the H2O My Health program and Table 2 for further description of the nine program
videos shown in homeroom class.

Table 1. Overall Scope and Sequence of the H2O My Health Intervention

Months:

Principal

-Train the trainer

sessions
-Order and
oversee
installation of
hydration stations
-Order reusable
water bottles
-Approve
educational videos
and promotional
posters promoting
water
consumption
-Trained about
program
-Replace any
advertisements for
SSBs with
promotional
posters in
classroom and
hallways
-Trained about
program
-Removes all
SSBs from places
of purchase and
replace with water
products
-Removes all
advertisements of
SSBs from
cafeteria and
vending machines
to replace with
promotional
posters
-Receive school
newsletter about
program

Teachers

FNS Staff

Students

10

-Ensure all tasks are being completed by employees in monthly meetings

-First day of homeroom class:

Provides free reusable water
bottles and demonstrates
location of all hydration stations
to students

-First homeroom class of every month: shows monthly

educational video promoting water consumption among
students
-Active involvement in the promotion of drinking water
during homeroom including group discussions about
monthly video
-Assists students in locating and utilizing hydration stations
-Supports drinking water in class

-Ensures proper products are available for purchase (no SSBs are available)

- First day of homeroom class:

Given free reusable water
bottles and sown location of
hydration stations

-Open group discussion in homeroom class about monthly

videos and the importance of drinking water rather than
SSBs

-Access to hydration stations located in various areas of the school

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Brittany Kaczmarek
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Table 2. Scope and Sequence of Monthly 10-Minute Homeroom Promotional Videos

Video Number

Video Title

Description & Topics

Covered

Channel/Vehicle

Participant

H2O and Your Body

Videotape

Students

Nutrition of H2O

Videotape

Students

The Many Sources of

H2O

Videotape

Students

H2O and Performance

Videotape

Students

Staying Hydrated with

H2O

Videotape

Students

H2O On the Go

Videotape

Students

Saying No When Not

H2O

Videotape

Students

H2O at Home

Videotape

Students

H2O Your Health

Discusses the anatomy and

physiology of the body
and how water hydrates
and nourishes the body
Discusses how water
purely hydrates the body,
without adding empty
calories like alternative
beverages
Discusses the many
sources of clean drinking
water one can acquire and
how water can be free
versus alternative
beverages
Discusses the importance
of water in the role of
performing physically in
sports and mentally in
school
Discusses why drinking
water throughout the day
is important and how its
the only beverage to keep
the body properly hydrated
Discusses how to prepare
to stay hydrated by
drinking water when not
at home or school
Discusses how to properly
refuse alternative
beverages that are not
water
Discusses how to ask
parents to buy water,
rather than alternative
beverages, for the home
environment
Gives an overview of what
was previously discussed
and also goes into further
detail about how drinking

Videotape

Students

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Brittany Kaczmarek
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water, rather than
alternative beverages,
maintains an overall
healthy lifestyle

Question 14: Design Document

Design documents are essential in the creation of important materials for the H2O My
Health program such as the educational videos and promotional posters. Table 3 represents how
the design documents for the H2O My Health program will be formulated. The following
example is a sample design document for promotional posters displayed in classrooms and
school hallways.
Table 3. Sample Design Document
Product: Promotional poster
Theme: H2O My Health: Here to Own My Health- encouraging students to take ownership
of their health by making healthier beverage selections
Channel/vehicle: Display print
Audience: Middle school students ages 11-13
Theoretical Methods: Belief selection, imagery, repeated exposure, cultural similarity
Change Objective: Students will have confidence in the ability to choose water as a beverage
over other options. Posters should increase self-efficacy about drinking water.
Sample Description: Poster will be 18 x 24 dimensions with an ocean blue, white and grey
color scheme. A picture of a water droplet as the back drop of the poster is preferred. The chosen
font for the poster is Comic Sans MS. Poster should have the name of the program, H2O My
Health: Here to Own My Health, in the center and have surrounding pro-water slogans. Please
refer to the following section for examples of slogans promoting water consumption among
students. The overall message of the poster is to encourage students to drink water rather than
other, calorie-laden beverages. Have poster emphasize that students are in charge of their own
health. Instill the feeling of empowerment for the students to make the healthier beverage choice.
Sample Slogans:
Be in the know and drink H2O
Water: A bodys best friend
When offered drinks with fizz and caffeine, say no. Just drink H2O
Water: the healthiest drink youll never have to pay for
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Brittany Kaczmarek
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Question 15: Pretesting
Pretesting is defined as the method of analyzing messages conveyed by program products
among the target population before the final production of the program (Bartholomew, Parcel,
Kok, Gottlieb, & Fernandez, 2011). Pretesting is essential in the determining whether or not the
planning of the program to this point has resulted in clear, engaging messages as well as if the
program can actually be implemented (Bartholomew et al., 2011). The pretesting will evaluate if
the program materials and implementers meet the cultural needs of the target population
(Bartholomew et al., 2011). It is important for the program to be comprehensible and inoffensive
to the culture it is addressing as well as utilize concepts of the culture when making program
changes to increase community capacity once the program is complete (Bartholomew et al.,
2011). The pretesting phase is also a period for checking parameters of theoretical methods
(Bartholomew et al., 2011). This review is important in assessing if methods were
operationalized appropriately (Bartholomew et al., 2011). For the H2O My Health program, it is
imperative for the middle school students of Jackson Middle School to accept the messages of
the program in order to see a response to the program. Therefore, the slogans and media utilized
to covey the program messages will first be pretested in focus groups with middle school
students. The focus groups will present the various promotional posters and videos to the group
of middle school students and receive feedback on the vernacular and attractiveness of the
program material. Questions addressed in the focus group are as follows: Do you like the
poster? Can you understand the message of the poster? How do you feel about the design of
the poster? Do the posters appeal to you? How or how not? Do these posters encourage you
to drink water rather than other beverages? If you could change the poster, what would you
change? How do you feel about the videos? Did you understand the message of the video?
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Brittany Kaczmarek
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Were you interested in the message? Are the peer models in the video like you and others your
age? If not, what would you change about them? If you could change the video, what would
you change?
The qualitative data collected in these focus groups will assist in deciding whether or not
to alter program materials. If the majority of the responses are positive, then the program
materials can remain the same for actual program implementation. However, if there are many
negative responses to the program materials in the focus groups then changes to the materials
will be made to better suit the target population. If any changes are made to the program posters
or videos, proper operationalization of theoretical methods will need to be assessed again. A pilot
test of the H2O My Health program within Jackson Middle School will occur after the pretesting
phase is complete. Pilot testing is a method in which the program is conducted with the
implementers and participants preceding actual implementation (Bartholomew, Parcel, Kok,
Gottlieb, & Fernandez, 2011). The pilot test will assist in confirming whether or not the H2O My
Health program is ready for complete implementation (U.S. Department of Health and Human
Services (HHS), n.d.).
Question 16: Cultural Relevance
As previously mentioned, the H2O My Health program is based in Jackson Middle School
located in the Third Ward district, an area of Houston, Texas with a high minority population.
The Third Ward was specifically chosen for implementation of the program because the needs
assessment found the prevalence of childhood obesity to be higher in non-Hispanic black and
Mexican-American youth as compared to non-Hispanic white youth (Ogden, Carroll, Curtin,
McDowell, Tabak, & Flegal, 2006). Although the focus of this intervention is on minority middle

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Brittany Kaczmarek
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school youth, non-Hispanic white students are still likely to attend Jackson Middle School.
Therefore, the H2O My Health program needs to be culturally relevant to various ethnic
backgrounds. It is essential for the program to also be applicable to all genders, religions, and
ages present within the target population. Relevance to the middle school students is important
for overall acceptance of the program; therefore taking all major cultural differences into
consideration is critical for H2O My Health. Cultural variation will be primarily addressed within
the planning group. Those within the planning group are familiar with the community and the
variety of cultures making up the target population. Therefore, members of the planning group
are essential in creating materials appropriate for the cultural background of the target
population. Ensuring cultural relevance will also be addressed in the focus groups conducted
during the pretesting phase.
Question 17: Linkage for Adoption and Implementation
In the needs assessment for the H2O My Health program, a planning group involving a
variety of professionals was established as a step in implementing an effective program. The
planning group established in the needs assessment includes school-age (SA) youth, parents of
obese and non-obese SA youth, Houston Independent School District (HISD) Board of
Education, principals, nurses, teachers, coaches, counselors, employees from The City of
Houston Health and Human Services, representatives from The Academy of Nutrition and
Dietetics and The Academy of Pediatrics, researchers from the University of Texas School of
Public Health in Houston, pediatricians, dietitians, nurses, and health educators from a local
UTHealth weight management clinic.

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Before adoption and implementation of the H2O My Health program, any potential
additions to the planning group need to be considered. A useful addition to the planning group
who would be helpful in the adoption and implementation of the H2O My Health program are
beverage sales representatives for HISD. Negative pushback on breaking vendor contracts and
funding by removing SSBs and related advertisements from the school environment is likely.
However, if beverage sales representatives are members of the planning group, discussions about
using the companys water products will settle any uncertainty. Removal of the beverage
companys advertisements within the school environment will also be discussed.
Another group to be added to the planning group includes the Texas branch of Clean
Water Action. Clean Water Action is an organization dedicated to protecting not only the
environment but also the health of individuals through ensuring clean and affordable drinking
water to communities (Clean Water Action, n.d.). Involving members of this organization in the
planning group could be vital in the selection of the best water station devices responsible for
supplying the students with clean drinking water as a part of the program.
Question 18: Adoption, Implementation, Maintenance Performance Objectives
As the intervention transitions from the development phase to actual implementation,
specific steps need to be taken to ensure proper adoption, implementation and maintenance of the
program. For H2O My Health, the program must be adopted by the HISD Board of Education,
implemented in Jackson Middle School by school personnel, and maintained within the middle
school to determine institutionalization of the program. Program objectives are essential in
guiding the adoption, implementation, and maintenance process of the H2O My Health program.

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The following performance objectives describe the steps taken to accomplish desired outcomes
for the adoption, implementation, and maintenance of the H2O My Health program.
Adoption Outcome: The Board of Education of the Houston Independent School
District decides to adopt the H2O My Health obesity prevention program as indicated by the
superintendent signing the form for program adoption.
Performance Objectives for Adopters
The HISD Board of Education will:
PO1.1 Assess the target populations need for a program such as H2O My Health
PO2.1 Review the H2O My Health program materials
PO3.1 Consider the H2O My Health program objectives, methods, and overall advantages
PO4.1 Acquire reactions to the program from the participating principal, teachers, FNS staff, and
student parents
PO5.1 Collect current evidence on the effectiveness of other school districts using a similar
program
PO6.1 Note any potential obstacles of utilizing the H2O My Health program
PO7.1 Approach the linkage system for ideas and solutions on how to undertake program
obstacles
PO8.1 Acquire support for program adoption from the principal, teachers and FNS staff
PO9.1 Formulate an announcement including an endorsement for the adoption of the program
PO10.1 Finalize the form for adoption of the H2O My Health program
PO11.1 Have the completed adoption form signed by the HISD superintendent and returned
Implementation Outcome: Jackson Middle School will implement the H2O My Health
obesity prevention program including clean water accessibility, use of a pro-water media
campaign as well as removal of all SSB products and advertisements from the school
environment.
Performance Objectives for Implementers
PO1.2 The Jackson Middle School principal will order hydration stations and reusable water
bottles needed for the implementation of the H2O My Health program
PO2.2 The Jackson Middle School principal, teachers and FNS Staff will undergo training in
preparation for the implementation of the H2O My Health program
PO3.2 The Jackson Middle School FNS will remove all SSBs from places of purchase within the
school environment and replace the SSBs with water products
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PO3.2 The Jackson Middle School teachers and FNS Staff will remove any advertisements for
SSBs within the school environment and replace with H2O My Health promotional posters
PO4.2 The Jackson Middle School teachers will show students all locations of hydration stations
and distribute free reusable water bottles to students during the first homeroom class of the
school year
PO5.2 The Jackson Middle School teachers will integrate the nine H2O My Health program
videos, and a discussion about topics from the videos, into the first homeroom class of every
month throughout the school year
PO6.2 The Jackson Middle School principal, teachers, and FNS Staff will implement the H2O
My Health program as trained and will be follow-up during monthly meetings
Maintenance (Sustainability) Outcome: Jackson Middle School will institutionalize the
H2O My Health obesity prevention program into the organizations practices.

Performance Objectives for Maintenance (Sustainability)

PO1.3 The Jackson Middle School principal will train future teachers and FNS staff on how to
properly implement the H2O My Health program every year
PO2.3 The Jackson Middle School principal will order any needed material for the
implementation of the H2O My Health program (e.g. hydration stations, reusable water bottles,
promotional posters and videos)
PO3.3 The Jackson Middle School principal will include implementation of the H2O My Health
program in teacher and FNS staff job responsibilities
PO4.3 The Jackson Middle School principal will announce yearly program outcomes to the
HISD Board of Education to maintain adequate funding
PO5.3 The Jackson Middle School principal will include the H2O My Health program in the
yearly budget
PO6.3 The Jackson Middle School principal will sustain an open communication channel with
all members of the linkage system concerning any inquiries

Question 19: Adoption and Implementation Matrix

Refer to Matrix 1 for the change objectives for the adopters of the program and Matrix 2
for the change objectives for the implementers of the program.

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Matrix 1. Change Objectives for Program Adopters

Determinants:

Knowledge and Awareness

Attitudes (A)
(K)
PO1.1 Assess the target populations need K1.1 Explain needs of the target population A1.1 Express that meeting the needs of the
students is important for the students health
for a program such as H2O My Health
and why H2O My Health is essential in

Self-Efficacy (SE)

Outcome Expectations (OE)

SE1.1 Have confidence in the ability to assess OE1.1 Expect that assessing the needs of the
target population will be beneficial to the
the target populations need for the H2O My
students health
Health program

improving the students health

K2.1 Describe the H2O My Health program A2.1 Express that the H2O My Health program SE2.1 Have confidence in the ability to review
the H2O My Health program materials
program materials
materials and their purpose in the H2O My materials should be easily utilized in the
middle school environment
Health program
PO3.1 Consider the H2O My Health
K3.1 Describe the objectives, methods and A3.1 Express that the objectives, methods and SE3.1 Have confidence in the ability to study
program objectives, methods, and overall advantages of the H2O My Health program advantages of the H2O My Health program will all objectives, methods, and advantages of the
H2O My Health program
advantages
benefit the target population
PO2.1 Review the H2O My Health

OE2.1 Expect that materials are appropriate for

the target population
OE3.1 Expect that the H2O My Health program

objectives, methods, and advantages are

appropriate for the target population
PO4.1 Acquire reactions to the program K4.1 Describe the different reactions as well A4.1 Express that obtaining reactions about the SE4.1 Have confidence in the ability to obtain OE4.1 Expect that obtaining reactions about the
from the participating principal,
as the overall consensus of the H2O My
H2O My Health program is important in
reactions about the H2O My Health program program will result in a positive consensus
teachers, FNS staff, and student parents Health program
deciding whether or not to adopt the H2O My
Health program
PO5.1 Collect current evidence on the
K5.1 Describe other school districts who
A5.1 Express that reviewing effectiveness of SE5.1 Have confidence in the ability to
OE5.1 Expect that reviewing effectiveness of
effectiveness of other school districts
used a similar program and the effectiveness similar programs in other districts is essential in determine whether or not similar programs
similar programs in other school districts will
using a similar program
of these programs
deciding whether or not to adopt the H2O My were effective in other school districts
assist in the decision to adopt the H2O My
Health program
Health program
K6.1 Describe any potential obstacles of the A6.1 Express that identifying potential
SE6.1 Have confidence in the ability to identify OE6.1 Expect that identifying potential
obstacles of the program is important in the
H2O My Health program
any potential obstacles of the H2O My Health obstacles will assist in preparing for such
obstacles in the future
preparation for adoption of the H2O My Health program
program
PO7.1 Approach the linkage system for K7.1 Describe solutions for addressing the A7.1 Express that solutions will prevent
SE7.1 Express confidence in the ability to come OE7.1 Expect that the linkage system will be
ideas and solutions on how to undertake program obstacles
able to assist in overcoming program obstacles
obstacles from hindering utilization of the H2O up with ideas and solutions for program
program obstacles
obstacles
My Health program
PO6.1 Note any potential obstacles of
utilizing the H2O My Health program

PO8.1 Acquire support for program

K8.1 Explain who supports program
adoption from the principal, teachers and adoption
FNS staff

A8.1 Express that support from school

personnel is important for program adoption

SE8.1 Express confidence in the ability to

acquire support for program adoption from
school personnel

OE8.1 Expect that support for program

adoption from school personnel will assist in
the decision of adopting the H2O My Health

PO9.1 Formulate an announcement

including an endorsement for the
adoption of the program

A9.1 Express that endorsing the program is

important for the organization to support the
adoption of the H2O My Health program

SE9.1 Express confidence in the ability to

endorse the adoption of the H2O My Health

program
OE9.1 Expect that endorsing the program will
gain overall support for the adoption of the
H2O My Health program

K9.1 Explain reasons why the adoption of

the H2O My Health program is being

endorsed
PO10.1 Finalize the form for adoption of K10.1 Describe components on the adoption A10.1 Express that completing the form is
the H2O My Health program
form that were completed for the H2O My important for the adoption of the H2O My

program
SE10.1 Express confidence in the ability to
complete the adoption form for the H2O My

Health program
PO11.1 Have the completed adoption
K11.1 Explain the reasons why the HISD
form signed by the HISD superintendent superintendent must sign and return the
and returned
form in order to adopt the H2O My Health

Health program
SE11.1 Express confidence in the ability to
have the HISD superintendent sign and return
the program adoption form

program

Health program
A11.1 Express that having the adoption form
signed and returned by the HISD
superintendent is essential for the adoption of
the H2O My Health program

OE10.1 Expect that completing the form will

lead to the final steps for adopting the H2O My
Health program
OE11.1 Expect that having the HISD
superintendent sign and return the form will
result in adoption of the H2O My Health
program

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Matrix 2. Change Objectives for Program Implementers
Knowledge and Awareness
Attitudes (A)
(K)
PO1.2 The Jackson Middle School
K1.2 Identify what needs to be ordered A1.2 Express that the purchased materials are
principal will order hydration stations and how much of the budget will
essential to the implementation of the H2O
and reusable water bottles needed for contribute to the purchases
My Health program
the implementation of the H2O My
Health program

SSE1.2a Express confidence in the ability to OE1.2 Expect that ordering the needed
order needed materials for the
materials will assist in the proper
implementation of the H2O My Health
implementation of the H2O My Health

PO2.2 The Jackson Middle School

K2.2 Describe what the training for the A2.2 Express that training is important in
principal, teachers and FNS Staff will H O My Health program will cover
order to properly implement the H2O My
2
undergo training in preparation for
Health program
the implementation of the H2O My
Health program

SSE2.2a Express confidence in the ability to

attend the program training
SSE2.2b Demonstrate the ability to perform
specific skills learned from program training
sessions

Determinants:

Skills & Self-Efficacy (SSE)

Outcome Expectations (OE)

program
program
SSE1.2b Demonstrate the ability to order
needed materials for the implementation of
the H2O My Health program
OE2.2 Expect that attending program
training sessions will increase likelihood of
proper implementation of the H2O My
Health program

PO3.2 The Jackson Middle School

K3.2 Describe all locations in which
FNS will remove all SSBs from places SSBs are sold and will be replaced
of purchase within the school
with water products
environment and replace the SSBs
with water products

A3.2 Express that replacing SSBs with water SSE3.2a Express confidence in the ability to OE3.2 Expect that replacing all SSBs sold in
will assist the students in making healthier
replace all SSBs sold with water products
the school environment with water products
beverage choices
SSE3.2b Demonstrate the ability to replace will increase water consumption among
all SSBs sold in the school environment with students
water products

PO4.2 The Jackson Middle School

teachers will show students all
locations of hydration stations and
distribute free reusable water bottles
to students during the first homeroom
class of the school year

A4.2 Express that presenting all locations of

hydration stations and distributing free
reusable water bottles to students during the
first homeroom class of the school year will
encourage students to actively utilize
hydration stations
A5.2 Express that showing and discussing
H2O My Health program videos each month

K4.2a Describe all locations of

hydration stations
K.42b Describe when to retrieve
reusable water bottles from principal
and how to properly distribute the
bottles to the class
K5.2 Describe the nine H2O My

PO5.2 The Jackson Middle School

teachers will integrate the nine H2O Health program videos and the main
My Health program videos, and a
topics for discussion each month
discussion about topics from the
videos, into the first homeroom class
of every month throughout the school
year
PO6.2 The Jackson Middle School
K5.2 Describe tasks and
principal, teachers, and FNS Staff will responsibilities for proper
implement the H2O My Health
implementation of the H2O My Health
program as trained and will be follow- program
up during monthly meetings

will encourage students to make healthier

beverage selections

SSE4.2a Express confidence in the ability to

assist students in locating hydration stations
and obtaining their reusable water bottle
SSE4.2b Demonstrate the ability to show
hydration stations and distribute reusable
water bottes
SSE4.2a Express confidence in the ability to
show and discuss all nine program videos
SSE4.2b Demonstrate the ability to present
and discuss topics of each program video
with the first homeroom class of every
month

OE4.2 Expect that presenting hydration

stations and distributing reusable water
bottles will increase use of hydration stations
among students

OE5.2 Expect that presenting and discussing

program videos will result in increased water
consumption among students

A6.2 Express that following up on employee SSE6.2a Express confidence in the ability to OE6.2 Expect that having monthly meeting
responsibilities of the H2O My Health
discuss proper implementation of the H2O will ensure fidelity of the H2O My Health
program will ensure fidelity of
implementation

My Health program

program

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PH1113
Question 20: Promotion of Adoption and Implementation Methods and Applications
Utilization of health promotion programs within an organization entails respect of various
factors such as the organizations goals, structure of authority, roles within the organization,
regulations, and relationships (Beyer & Trice, 1978; Goodman, Steckler, & Kegler, 1997; Riley,
Taylor, & Elliott, 2003; Rogers, 1983). Therefore, the H2O My Health program needs to
encourage the adoption decision as well as implementers to take ownership towards tasks of
program operation (Batholomew, Parcel, Kok, Gottlieb, & Fernandez, 2011). Within this process,
the planning team of the H2O My Health program will utilize theoretical methods and practical
applications to encourage program adoption and implementation (Bartholomew et al., 2011).
Methods utilized by the H2O My Health planning team to design practical applications to
accomplish adoption and implementation of the program originate from theories including Social
Cognitive Theory, Theories of Information Processing, Health Belief Model, and Theories of
Goal Directed Behavior (Bartholomew et al., 2011).
Table 4. Methods and Practical Applications for Adoption and Implementation
Determinants

Methods

Attitudes, Outcome
Expectations

Persuasive Communication (SCT) A: Video encouraging adoption of Messages need to be applicable to

program through use of arguments individuals beliefs; includes
about how drinking SSBs
surprise, replication and arguments
increases a students risk for
childhood obesity and therefore
the H2O My Health program will
reduce such risk among students.
Video will include school
principals, teachers, FNS staff, and
students discussing the benefits of
such a program in the school
environment.
I: Video shown during staff
training discussing the importance
of the H2O My Health program
implementation in reducing risk
for childhood obesity among
students. Video uses arguments
from school principals, teachers,
and FNS staff for why the
implementation in the school is
important for the health of the
students.

Practical Applications

Parameters

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Self-Efficacy, Skills

Self-Efficacy, Skills

Knowledge

Attitudes, Knowledge

Knowledge

Knowledge, Awareness, SelfEfficacy

Self-Efficacy, Skills, Outcome

Expectations

Self-Efficacy, Skills

Modeling (SCT)

A: Newsletter featuring real stories

from school principals, teachers,
FNS staff, and students about the
positive impact a program like
H2O My Health has on beverage
selection and overall student
health (McAlister, 1995;
McAlister & Fernandez, 2002).
Facilitation (SCT)
I: Installation of hydration stations
and removal of SSB products and
advertisements will aid in the
implementation process of the
program
Imagery (Theories of Information A: Newsletters and examples of
Processing)
promotional posters for the
program will be delivered to the
HISD Board of Education
I: Promotional posters utilized in
training sessions
Discussion (Theories of
A: Scheduled meetings with HISD
Information Processing)
Board of Education in which the
program planning team will give
an oral presentation about H2O
My Health and follow the
presentation with questions and
comments from the audience
Advance organizers (Theories of A: The planning team of H2O My
Information Processing)
Health will present an overview of
the program material in scheduled
meetings with the HISD Board of
Education to encourage adoption
of such a program
I: Educational videos utilized in
training sessions will give an
overview of the H2O My Health
program, why it is important, and
how to properly implement the
program within the school
environment
Consciousness Raising (HBM)
A: Adoption video provides
information about the causes,
consequences for high
consumption of SSBs leading to
childhood obesity among students
Implementation Intentions
I: During training sessions,
(Theories of Goal Directed
Jackson Middle School staff will
Behavior)
undergo role-playing opportunities
in which they will connect
circumstances with responses to
obtain desired outcomes for
implementation
Enactive Mastery Experiences
I: Training sessions will teach
(SCT)
Jackson Middle School principal,
teachers, and FNS staff how to
properly implement the program
through use of educational videos,
role-playing opportunities, and
practice with all program materials

Use of attention, remembrance,

self-efficacy and skills; individuals
must be able to identify with role
models; model must be reinforced;
use of coping rather than mastery
model

Requires changes be made in the

environment; recognizes barriers
and implementers; intervention
should be at a higher level
Accustomed images act as a
parallel to a less accustomed
practice

Listening to those learning to

confirm right schemas are initiated

Representation of content and

what is to be learned

Can utilize feedback and

confrontation but awareness
raising must be followed by
enhancement of problem-solving
capability and self-efficacy
Current positive intention

Reliable source

SCT: Social Cognitive Theory, HBM: Health Belief Model, A; adopters, I: implementers

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PH1113
Question 21: Evaluation
Evaluating H2O My Health is essential for determining if the program has been
implemented with fidelity, is effective in producing desired outcomes and informing stakeholders
about methods for improving childhood obesity (Rossi, Lipsey, & Freeman, 2004). Two types of
evaluation are utilized in the evaluation of a program: process evaluation and effect evaluation.
Process evaluation determines whether a program is delivered to the target population as planned
(Rossi et al., 2004). Process evaluation will assess both the delivery and the coverage of the
program. Outcome evaluation measures the changes in outcomes in relation to the program
(Rossi et al., 2004). Therefore changes in outcomes such as health, environment, behavior, and
risk determinants will be determined in the outcome evaluation for the H2O My Health program.
The quality of life outcomes do not have their own evaluation questions because it is not feasible
to measure these outcomes within the time frame of the program evaluation. The design
proposed for the evaluation of the H2O My Health program is a nonrandomized two-group
quasi-experimental design with pre- and post-tests given to both intervention and comparison
groups. The evaluation design notation for the H2O My Health program is as follows:

NR

O1
X O2
------------------O1
O2

Material from all five steps of intervention mapping is utilized in the development of an
evaluation plan for a program. Steps 4 and 5 are used in process evaluation in which adoption,
implementation and sustainability are assessed. These steps guide process questions concerning
program coverage. Fidelity will be evaluated from step 3, in which theory-based methods and
practical applications selected for the program will be evaluated. Effect evaluation will assess
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Brittany Kaczmarek
PH1113
program impact on outcomes of health, behavior, and environment as well as behavioral and
environmental determinants. These factors originate from steps 1 and 2, the needs assessment
and matrices of change objectives.
Table 5. Evaluation Plan Summary for the H2O My Health program

Type of Evaluation

Evaluation Question

Variable/Indicator

Measure

Source

Data Collection Timing

Effect (Health Outcome) Did H2O My Health make % obese students

an impact on the prevalence
of childhood obesity among
Jackson Middle School
students as compared to the
control group?

The Children's BMI Tool Middle school students

for Schools (Centers for
Disease Control and
Prevention, 2015)

Baseline (August),
follow-up (May), and
second follow-up two
years post-intervention

Effect (Behavioral
Outcome)

Self-report questionnaire

Middle school students

Baseline (August) and

follow-up (May) , and
second follow-up two
years post-intervention

Direct observation

Data collectors

Baseline (August) and

follow-up (May) , and
second follow-up two
years post-intervention

a. Self-report
questionnaire

a. Middle school
students

b. Direct observation

b. Data collectors

Baseline (August) and

follow-up (May) , and
second follow-up two
years post-intervention

a. Self-report
questionnaire

a. Middle school
students

b. Direct observation

b. Data collectors

Effect (Environmental
Outcome)

Effect (Environmental
Outcome)

Effect (Environmental
Outcome)

Did H2O My Health reduce % SSB consumption

SSB consumption among
Jackson Middle School
students as compared to the
control group?
Did H2O My Health reduce % SSBs offered
availability of SSBs to
Jackson Middle School
students as compared to the
control group?
Did H2O My Health
% clean water sources
increase accessibility of
potable drinking water to
Jackson Middle School
students as compared to the
control group?
Did H2O My Health
% media promoting SSBs
decrease media promoting
unhealthy beverage options
to Jackson Middle School
students as compared to the
control group?

Effect (Behavioral
Determinant)

Did H2O My Health

increase knowledge about
the importance of drinking
water among Jackson
Middle School students as
compared to the control
group?

Effect (Behavioral
Determinant)

Did H2O My Health

a. Self-Efficacy (Likert
Scale)
increase skills and selfefficacy of selecting water
b. Skills
rather than SSBs among
Jackson Middle School
students as compared to the
control group?

a. Self-Efficacy: Selfreport questionnaire

(Masui et al., 2002)

Did H2O My Health

Attitudes (Likert Scale)
increase positive attitudes
about drinking water among
Jackson Middle School
students as compared to the
control group?

Self-report questionnaire
(Patel et al., 2014)

Effect (Behavioral
Determinant)

Knowledge (Likert Scale) Self-report questionnaire

(Gase, Robles, Barragan,
& Kuo, 2014)

Middle school students

Baseline (August) and

follow-up (May) , and
second follow-up two
years post-intervention

Baseline (August) and

follow-up (May) , and
second follow-up two
years post-intervention

a. Self-Efficacy: Middle
school students

Baseline (August) and

follow-up (May) , and
second follow-up two
b. Skills: Data collectors years post-intervention

b. Skills: Direct
observation
Middle school students

Baseline (August) and

follow-up (May) , and
second follow-up two
years post-intervention

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Brittany Kaczmarek
PH1113
Effect (Behavioral
Determinant)

Did H2O My Health

Outcome Expectations
increase positive outcome (Likert Scale)
expectations about drinking
water among Jackson
Middle School students as
compared to the control
group?

Self-report questionnaire
(Sharma, Wagner, &
Wilkerson, 2006)

Middle school students

Baseline (August) and

follow-up (May) , and
second follow-up two
years post-intervention

Effect (Environmental
Determinant)

Did H2O My Health

increase knowledge about
the importance of
promoting water
consumption among
Jackson Middle School
personnel as compared to
the control group?
Did H2O My Health
increase skills and selfefficacy to promote
selection of water rather
than SSBs among Jackson
Middle School personnel as
compared to the control
group?
Did H2O My Health
increase positive attitudes
about promoting water
consumption among
Jackson Middle School
personnel as compared to
the control group?

Knowledge (Likert Scale) Self-report questionnaire

(Chen et al., 2009)

Principal, teachers, and

FNS staff

Baseline (August) and

follow-up (May) , and
second follow-up two
years post-intervention

a. Self-efficacy (Likert
Scale)

a. Self-Efficacy: Selfreport questionnaire

(Domsch, 2009)

a. Self-Efficacy:
Principal, teachers, and
FNS staff

Baseline (August) and

follow-up (May) , and
second follow-up two
years post-intervention

b. Skills: Direct
observation

b. Skills: Data collectors

Attitudes (Likert Scale)

Self-report questionnaire
(Midler et al., 2014)

Principal, teachers, and

FNS staff

Baseline (August) and

follow-up (May) , and
second follow-up two
years post-intervention

Process (Program
Coverage)

How many students

participate in the H2O My
Health program activities?

% students reached

Self-report questionnaire

Principal, teachers, and

FNS staff

Throughout
implementation
(Collected first of the
month, August-May)

Process (Program
Coverage)

How many homeroom

Dose delivered
sessions containing
modeling videos and group
discussion are delivered in
each classroom?

a. Direct observation

Data collectors

b. Self-report
implementation logs

b. Principal, teachers,
and FNS staff

Throughout
implementation
(Collected first of the
month, August-May

Process (Program
Coverage)

How many homeroom

Dose received
sessions containing
modeling videos and group
discussion do each student
receive?

In-depth interview

Middle school students

Throughout
implementation
(Collected first of the
month, August-May

Process (Program
Delivery)

Do Jackson Middle School

personnel deliver the H2O
My Health program
components/activities as
intended?
How satisfied are students
with the H2O My Health
program as a whole?

a. Direct observation

a. Data collectors

b. Self-report
implementation logs

b. Principal, teachers,
and FNS staff

Throughout
implementation
(Collected first of the
month, August-May)

In-depth interview

Middle school students

Effect (Environmental
Determinant)

Effect (Environmental
Determinant)

Process (Program
Delivery)

b. Skills

Fidelity

Student satisfaction

Throughout
implementation
(Collected first of the
month, August-May)

73

Figure 1. Evaluation
Logic Model
Brittany Kaczmarek
PH1113

Students will:
-Make the decision to
drink water

Behavioral
Theoretical

-Obtain a reusable
water bottle

Methods:
Implementation of Program

-Belief selection

Activities and Materials:

-Persuasive

-Training for school principal,

communication

teachers, and FNS staff

-Facilitation

-Newsletter sent to students

-Imagery

-Removal of SSBs

-Modeling

Behavioral
Determinants:
-Knowledge
-Skills & Self-Efficacy
-Attitudes
-Outcome Expectations

-Provision of clean drinking water

-Counter-

(hydration stations & water

conditioning

products)

-Repeated exposure

-Removal of SSB media

-Cultural similarity

Students will
select water,
rather than SSBs,
as their beverage
of choice

-Obtain water from a

water station or
purchase water if
reusable bottle is
unavailable
-Drink water

Quality of Life:

-Refill reusable water

bottle with water
when empty

Health
Outcome:
Reduced risk for
childhood
obesity and
sequela (CVD,
T2DM, stroke,
HTN, types of
cancer,
mortality)

-Refuse alternative
beverages including
SSBs

-Program posters
-Distribution of reusable water
bottles
-Modeling videos

Environmental
Theoretical
Methods:

Environmental

Resources:

-Advocacy

Determinants:

-Personnel: Jackson Middle School

-Modeling

Employees (Principal, Teachers, FNS

-Knowledge

-Mass media role-

-Skills & Self-Efficacy

-Attitudes

Staff)

modeling

-Funding allotted from HISD Board

-Mobilizing social

of Education

networks

-Program Materials: hydration

-Principals will install

water stations
-Principals will
provide reusable
water bottles to
supply to students

-Reduced health
care cost
-Improved selfesteem
-Less likely to
be stigmatized

School staff will

support students in
selecting water,
rather than SSBs,
as their beverage of
choice

-Teachers will allow

water in closed
containers in class

stations, reusable water bottles,

videos, posters
-Time for implementation

-FNS staff will

replace all SSBs with
bottled water

-Reduced risk
for being obese
as an adult

Program Inputs

Process Evaluation
Program Outputs

-Principals will
discontinue Logic
advertising for SSBs
including logos,
posters and videos

of Change

Effect Evaluation

Outcomes

74

Brittany Kaczmarek
PH1113
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