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It’s in Your Hands

Stella Ho
California State University, Long Beach
Theodora Papachristou
HSC 405
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Background and Significance

Importance of the Topic

Obesity, also known as adiposity, is increasing common among citizens of the United States.

Weight gain can be caused by an imbalance of energy in the body (higher intake than output),

medical conditions, and the result of different types of medicine (NIH, 2017) According to the

State of Obesity, obesity is a factor that causes more than 10,000 premature deaths each year

(State of Obesity, 2018). Of the 15 leading causes of death in 2015, the CDC reported that heart

disease, cancer, stroke, and diabetes are among the top ten killers. These conditions are all

related in some way to being obese and over weight (CDC, 2017). Childhood obesity is now the

number one health concern for parents. Weight gain at young age can lead to obesity-related

diseases and even death as the child grows into adulthood (AHA, 2018).

Those who are obese can experience high blood pressure, heart disease, high cholesterol,

some cancers, and atherosclerosis, type 2 diabetes, liver disease, kidney disease, dementia,

gallbladder disease, and stroke. Some risk factors cannot be changed, this includes age, family

history, genetics, race and ethnicity, and sex. Risk factors that can be changed are lifestyle habits

and the environment. Obesity and overweight is preventable and treatable with healthy lifestyle

changes, such as changing eating habits and increase physical activity (NIH, 2017). Based on the

World Health Organization (WHO, 2017), the rate of obese infants and children will increase to

70 million by 2025. According to the CDC,

During 2010–2014, the prevalence of obesity decreased significantly overall, among non-

Hispanic whites, non-Hispanic blacks, Hispanics, American Indian/Alaska Natives and

Asians/Pacific Islanders, and among 34 (61%) of the 56 WIC state agencies in states, the
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District of Columbia, and U.S. territories. Despite these declines, the obesity prevalence

among children aged 2–4 years in WIC remains high compared with the national

prevalence of 8.9% among children aged 2–5 years in 2011–2014. (CDC, 2017).

Adiposity is the most costly in terms of healthcare expenditures. In 2013, California spent

$475-571 per capita for obesity related costs in healthcare. A meta-analysis found that healthcare

costs exceed $150 billion a year. Type 2 diabetes, the seventh leading cause of death and a risk

factor of obesity, costs $245 billion a year in medical bills alone (ADA, 2017). The CDC

predicts that by 2050, one in three adults would be diagnosed with diabetes. Weight gain can

attribute to heart disease and hypertension, meaning there would be an increase in deaths in

United States (NHLBI, 2017). A study found that obesity alone costs Medicaid programs $8

billion a year (Wang, 2015).

Critical Review on Similar Programs

Obesity and overweight programs have been a major focus for many decades. With

childhood obesity on the rise, those in public health have been trying to make an effort to

increase awareness, provide knowledge, and decrease childhood obesity in a variety of

environments. After critical reviews of similar programs in attempt to decrease childhood obesity

amongst a variety of ethnicity and age groups, the focus has involved those of low SES, ages 5-

11 (which is grade kindergarten to 5th grade), and persuading parents to be involved. The

majority of the programs highlighted the significance of social support coming from authority

figures like their teachers and parents. All of the programs that were critically reviewed were

implemented in school settings, because children at the specific age spend more time at school

than they do at home. Parental involvement is a popular intervention for the programs because

they are the primary care takers of the children and they are the ones who will be able to
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implement the changes in diet and food variety for the child. King et al 2014 was the only

program, the HEROES program, who focused on implementation purely on the school site.

School wellness coordinators, the principal, and the cafeteria manager were the main people

involved in implementation of this program. Funders of these programs have been specific into

what community they want to fund, in other words categorical funding. Struempler et al 2014

recruited children of families who were receiving SNAPed and free/reduced lunch as their target

population, so did Bayer et al 2009 and Centeio et al 2018.

Theory is a big part of program development. Commonly used behavioral theories

throughout these programs are the socio-ecological model (Centeio et al 2018, Cloutier et al

2015, King et al 2014, & Meyer et al 2014), learning theories (Greening et al 2011 & Struempler

et al 2014), and the Theory of Planned Behavior (Angelopoulos et al 2009 & Davidson &

Vidgen 2017). With the theories applied to the programs, most of the programs focused on

nutrition, specifically fruit and vegetable consumption, and physical activity. The other programs

also incorporated the downside of sedentary life, decreasing the amount of screen time,

neighborhood programs, and overall wellness.

Although the programs were all coordinated school health programs and many were only

eight to twelve months long, King et al 2014 had a three-year long program and Meyer et al 2014

had a nine-month program with a follow up three years later. Meyer’s program was successful

for the nine months and once the three-year mark was up, the follow up check in was not as

successful as they thought. Many participants were not around the area anymore or did not want

to participate in the follow up. With the responses that they received, Meyer was able to

conclude that the early exposure to the importance of physical activity and good nutrition did

help those who were part of the experimental group after three years.
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Linking goals and objectives to their Theoretical Relevance

My program will be called “It’s in Your Hands” with a focus of bringing parents,

teachers, and student together to form healthy habits at a young age. The goal of the program is

to educate and help parents and students integrate proper nutrition and a healthy lifestyle with

physical activity into their daily lives. Since the program aims to change behavior, the Theory of

Planned Behavior (TPB) will be used to change attitudes, intentions, and beliefs of control and

what the norm is. “It’s in Your Hands” will be a year –long coordinated school program that

involves monthly activities that promote and correlate with other community or school events

that are going on. Monthly activities will involve moderately active activities where winners

would have a chance to win gift cards for groceries. Materials and curriculum will be given to

teachers to integrate into their lessons to promote an active lifestyle. Bi-weekly a health educator

would come into the classroom and provide lessons on nutrition.

The Theory of Planned Behavior focuses on attitude towards the behavior, perception of

norms, and belief about the ease or difficulty of changing the behavior. The first component is

attitudes toward action, this is the belief about the outcome of changing a lifestyle and evaluation

of the expected outcome, which is decrease in weight gain. The program, “It’s in Your Hands”

will be attacking this problem by educating parents and students on the statistics of weight gain,

the short and long term effects of weight gain, and the ease of how to prevent further weight gain

in an individual. Every other week, a health educator who is trained and knowledgeable in

nutrition and dietetics will be going on site to give lessons to the students about the importance

of diet and nutrition, how to change diet and nutrition, and how to maintain a healthy diet.

Students will be sent home with the worksheets and other flyers that will be given during the

session and will be asked to share them with their parents. Every fourth meeting will be an
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assessment for the students to check on their knowledge and skill on the prior lessons. On the

same day of the assessment, a meeting will be held after school for parents to receive the same

information their child has been receiving for the past two months. The second component is

subjective norm. Subjective norm encompasses the normative belief and motivation to comply.

“It’s in Your Hands” will address these issues by focusing on the parents and teachers. As a child

attending school, the adult the child sees the most other than their parents is their teacher. Having

the teacher incorporate physical activity in between lessons every other day and integrating

healthy foods into the lesson plan and rewards system would allow the student to see that if their

teacher and incorporate nutrition and physical activity into school, they can do it when they are

not at school. On the months that nutrition lessons do not take place, Family Days will be held

where health educators and volunteers will be hosting and directing moderately physical

activities for the entire family to participate in. Activities such as family soccer games, handball

tournaments, and baseball games will be played and the winners will be given gift cards for

groceries. This shows both parents and students how easy and fun it is to be active. Perceived

behavioral control is the last component of TPB that must be addressed. The reason why the

program is called “It’s in Your Hands” because the goal is to instill into the students and parents

head that they have the power and control to change their lifestyle and diet. We, as the program,

are here to give them the resources and encouragement and knowledge they need to achieve that.

This would be through the lessons, the gift cards, and the meetings.

Hypotheses to be examined

“It’s in Your Hands’” goal is educate and help parents and students integrate proper

nutrition and a healthy lifestyle with physical activity into their daily lives. In this program,

participants will increase their knowledge of healthy snacks they can have by 30%, as measured
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at the post test. Halfway through the program, attitudes will change towards incorporating

physical activity into their lives by 20%, as measured by attendance to bi-monthly Family Days.

By the end of the program, the participants will also show an increase of control over their ability

to incorporate an active lifestyle and creating nutritious meals by 5%, as measured by posttest.

Methods

Description of population and method of sample selection

The “It’s in Your Hands” program is targeted for children in elementary school in Los

Angeles County, specifically Service Planning Area (SPA) 3 also known as the San Gabriel

Valley (SGV). SPA 3 includes services: Alhambra, Altadena, Arcadia, Azusa, Baldwin Park,

Claremont, Covina, Diamond Bar, Duarte, El Monte, Glendora, Irwindale, Monrovia, Monterey

Park, Pasadena, Pomona, San Dimas, San Gabriel, San Marino, Temple City, and Walnut. 20.9%

of children in SGV are considered obese and these are children in the 5th, 7th, and 9th grade.

22.2% of the adults are obese. (LADPH, 2018) In this SPA, residents primarily speak English,

Chinese, and Spanish. The program will have volunteers who can speak these languages fluently.

Participants of this program would have to meet a few criteria. Within this population of people,

those who are eligible for free/reduced lunch and have a BMI over 25, which is considered

overweight and will encounter health risks will be considered for participation in the program.

All the elementary schools in SPA 3 will be contacted via email to the principal and

administrative staff with information about the program and the criteria for participating. The

representative sample will be a stratified random sample because those who are able to

participate are those who are eligible for free/reduced lunch and have a BMI of over 25. The
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schools with the highest population that meet those two criteria will be participating in the

program. Once the schools have been chosen based on the criteria met, flyers and emails will be

sent out to the community and displayed at the schools to promote the program. The nutrition

classes will be open to all students of the school as a short assembly but participation of the

Family Days and parental meetings will be voluntary and based on sign ups.

The sample size used for “It’s in Your Hands” will be the smallest possible sample size

so that resources are not wasted, but ensure that it is big enough to show a statistical significance

between pre-implementation and post-implementation. A small effect size will result in larger

sample size. A large effect size will result in a smaller sample size. Type I error would be alpha

equals to 0.05 and type II would be beta equals to 0.8. According to the sample size

determination table, the minimum sample size would be 438. Adding 20% to account for dropout

rate, refusal to participant, and inability to locate, the amount at posttest in the experimental

group would be 263 and control group would also be 263. The total minimum participants

needed to be recruited is n= 526.

Design of experimental methodology

The research design for “It’s in Your Hands” is the non-equivalent comparison group.

This is the best approach because randomization cannot be performed. Even though participants

will have to meet specific criteria, there is no way to have equivalent characterisitics in both the

experimental and control group, but both groups will be grouped into similar characteristics in

other aspects. The experimental group with the schools that are considered north and south San

Gabriel Valley with a minimum of 263 participants and the control group would be those schools

in east and west San Gabriel Valley with a minimum of 263 participants. Recruitment methods

include emails to parents, sending flyers home with students, and on site recruitment by
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volunteers. There is no prefect program, so threats to internal validity must be addressed.

History, maturation, testing, and instrumentation are the first four threats. These are controlled

by the research design due to the fact that the research design has a control group and

experimental group. Both groups would be exposed to the same threats and would be matched by

group characteristics meaning that the only difference between the two groups is that the

experimental group will be getting the treatment and the control group will not be getting

anything. Regression of the mean is an internal threat that cannot be controlled by the research

design. This is why there is a need for recruitment at the beginning of the program so that there

would be enough participants at the end when removing and extremes or outliers. Extremes

would be getting all the questions correct on the post testing, showing an extreme increase in

knowledge in the subject matter or those who show an extreme decrease in BMI due to outside

factors aside from the program. The program will be taking an additional 20% of desired

participants to account for this. Selection, the sixth threat to internal validity is selection. Since

the research design cannot control for this, separation of locations of the participants will control

for this. The seventh threat to internal validity is attrition. Since the research design cannot

control for this, the only thing that can be done is to give incentives to keep participants who

continue with the program. Those who attend and win Family Days will be given gift cards for

grocery shopping. The eighth threat to internal validity is interaction. If interactions are

individual, then the design can control for this. The four threats to internal validity that cannot be

controlled by any research design are diffusion, compensation, compensatory rivalry, and

demoralization. Diffusion can be eased because of the geographic separations of the

experimental and control group. Compensation, compensatory rivalry, and demoralization can be
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controlled by thorough training and constant monitor of staff members to ensure equal treatment

is being implemented.

There are twelve threats to internal validity. In contrast, there are two threats to external

validity. The two threats of external validity are moral issues/ethics and artificial environment.

To control for moral issues and ethics, a consent form will be given to the parents to allow the

children to participate in the program, parents will also need to sign a consent form. All

participants will be given information of what and how the program will provide and the services

the program will provide. There are not further controls in the design so the artificial

environment is already controlled. The program will not be performed in any other setting.

Formative Evaluation Methods – Pilot Testing Procedures

“It’s in Your Hands” pilot test will be using the methods of experts’ feedback and

community input in the form of focus groups. An expert for this program would be someone who

has worked with this population before and has experience with programs that are aiming to

decrease BMI and increasing knowledge and attitudes of nutrition and physical activity. To

contact the experts, the “It’s in Your Hands” team will be sending out emails to schedule face to

face interviews. Interviews will be for the team and the expert to know each other and gage if the

interested expert fits the need of the program. A document of questions will be created to ensure

all the same questions are asked. The expert will benefit the program so we can address the

population fairly and equally. An expert would be needed for the Asian population and an expert

would be needed for the Hispanic population to address all of those in SPA 3. The expert will

also look at the content of the program and adjust and give feedback on things that can be

changed, improved or taken out.

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The focus groups will be conducted so that teachers, parents, and students can come and

voice their opinions, concerns, and feedback on the program. There will take place every three

months so that program planners have time to take the feedback into consideration and apply it

and for the participants of the focus group to have time to observe more things they would like to

bring up in the next focus group. The focus group will be run as an open discussion with guided

questions such as “How do you feel about the nutrition component of the program right now?”

They will also be asked to review the upcoming events and content of information for the

program and give any feedback for it. Since they are the ones who are coming and participating,

their opinions and feedback hold more weight. Focus groups are essential for a smooth transition

from the planning stages of the program to implementation of the program.

Process Evaluation – Monitoring of Program Implementation

To ensure that the program is implemented correctly, an expert and the program coordinator

will always be monitoring the health educators and volunteers. To make sure that the program is

reaching the target population, volunteers will be sending out reminder emails about when the

nutrition lessons are, when the parent meetings are, and when the Family Days are. They are also

responsible for recruiting and attracting the students on campus to interest them so they can bring

their families out as well. Health educators will be in contact with all the teachers to make sure

that the curriculum that they are incorporating into their lessons are going smoothly and that they

are available for any questions and suggestions. The health educators will also be helping the

teachers come up with different activities to show the students how easy it is to incorporate into

their daily routine.

In terms of ensuring the program being implemented as outlined, the program coordinator,

expert, the health educators, and the volunteers will have weekly meetings as staff development.
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These will be meetings to ask questions to and from the higher ups of the program, to update

each other about how the program is running. A secretary would be taking notes and

documenting everything said and discussed during these meetings to have record of what

problems, updates, and changes were made during the implementation of the program.

Finances are a very important component for programs like this. The evaluator will be

keeping track and making sure that the resources are being allocated effectively and is used to

better the program. Money should be sent on items that keep the program running and items to

keep the participants in the program.

Timeline

Activity Month 1 Month 2 Month 3 Month 4 Month 5

Needs X
Assessment
Program X
development
Pilot testing x

Sampling X

Pretest x X

Program X
Implementation
Process X x x X
Evaluation
Posttest

Data Analysis X

Report Writing x x x
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