Initial Findings of a Multicomponent School Health Intervention in Rural Appalachia: The Greenbrier CHOICES Project

Abstract

Background. Schools are an important setting for health promotion because they afford children and adolescents numerous opportunities to accumulate the recommended physical activity (PA) minutes and make other health-related decisions, including healthy eating. Unfortunately, there is little evidence of coordinated school-based health interventions in rural Appalachia. The Greenbrier Children’s Health Opportunities Involving Coordinated Efforts in Schools Project was a federally funded, 3-year, multicomponent school-based health intervention focused on PA, healthy eating, and weight management. Aims. The purpose of this study was to evaluate the impact of Greenbrier Children’s Health Opportunities Involving Coordinated Efforts in Schools on adolescent PA, dietary behaviors, and weight status. Method. Measures of PA, dietary behaviors, and body mass index were collected across 14 data points throughout the intervention (including a baseline in Year 1). Results. Participants included 4,633 randomly selected middle school students (M = 2,289, F = 2,344) across the intervention. Baseline to Year 3 findings revealed a 12.8 percentage point increase in students achieving 60 minutes of daily PA. There were no significant differences in either dietary behavior or body mass index. Discussion. Findings provide evidence of the positive impact comprehensive school-based health interventions can have on middle school student health-related behaviors. Conclusion. Schools remain an ideal setting for health promotion. Initiatives targeting more than one level of influence on health-related behaviors are more likely to succeed.

Keywords

adolescents diet physical activity/exercise quantitative methods rural health

Schools are an important setting for health promotion because they afford children and adolescents numerous opportunities to accumulate the recommended physical activity (PA) minutes and make other health-related decisions including healthy eating (Hills, Dengel, & Lubans, 2015). Numerous professional organizations and government agencies highlight schools’ role in promoting PA through various position statements (e.g., American Academy of Pediatrics, American Heart Association, Centers for Disease Control and Prevention [CDC], Society for Health and Physical Educators). Collectively these position statements acknowledge the potential health concerns associated with childhood physical inactivity, reinforce the critical contribution that schools can make from a public health perspective, identify the challenges or impediments to PA promotion, and recommend strategies for schools to implement effective programs (Carson, Castelli, Beighle, & Erwin, 2014). Unfortunately, there is little evidence that those recommendations are used in a coordinated manner within schools in rural Appalachia, particularly West Virginia.

Adolescent physical inactivity and associated health concerns are not foreign to citizens in West Virginia (Jones et al., 2014; Kristjansson et al., 2015). Eighteen years of statewide surveillance from the West Virginia Coronary Artery Risk Detection in Appalachian Communities (CARDIAC) project has demonstrated a high rate of overweight and obesity among the over 200,000 school-age children screened for body mass index (BMI). Cumulative data results across all grade levels and years grew from 33.9% in kindergarten students to an alarming 47.1% in fifth graders (Elliott et al., 2017). These numbers are particularly disconcerting because overweight children are at higher risk for developing chronic disease risk factors and tend to be less physically active than their normal-weight peers (Bai et al., 2016). Longitudinal CARDIAC data provide convincing evidence of problematic trends concerning health indicators among children that, if not addressed in the immediate future, will have a profound impact on the quality of life of many West Virginians.

Population Health

Greenbrier County is located within the Appalachian Mountains, in southeastern West Virginia, with a population of 35,373 (51% female). The median household income in Greenbrier County is $43,182, below the state average of $51,064. School-age children make up 14.7% of the population, with 27.7% older than 65 years (U.S. Census Bureau, 2010). Forty-six percent of the school-age children within Greenbrier County are eligible for free lunch. According to the Robert Wood Johnson’s 2014 Health Rankings, Greenbrier County ranked 30th out of 55 in the state relative to health outcomes (how healthy a county is) and 15th relative to health factors (what influences the health of the county). Premature death rate of Greenbrier County citizens (9,267 per 100,000) is substantially higher than the national benchmark (5,466). Thirty-four percent of residents are reported physically inactive and 30% of adults rated as obese (University of Wisconsin Population Health Institute, 2014). Only 31% of Greenbrier County citizens have access to locations to be physically active—which is due in part of the mountainous terrain and the fact that over 70% of the population live in rural areas (Chenoweth & Galliher, 2004).

Surveillance of student health indicators, health knowledge, and health behaviors across the state shows alarming trends. Data from the CARDIAC project show that many chronic disease risk factors are already prevalent in elementary age children including high BMI and abnormal blood lipid profiles. 2010 CARDIAC data from Greenbrier County showed 24.5% of fifth graders were obese (BMI above the 95th percentile) and 5.1% were morbidly obese (BMI above the 99th percentile). Additionally, 19.1% of fifth graders were hypertensive and over 25% of the children had abnormal blood lipid profiles. These numbers appear to be consistent with data from the state-mandated fitness test data (Fitnessgram®). In 2010, only 56% of Greenbrier County middle school students were in the Healthy Fitness Zone for body composition (as measured by BMI) and 67% of students achieved the Healthy Fitness Zone for aerobic capacity (measured by the Fitnessgram protocol for the Mile Run or the 20-meter shuttle run/PACER).

According to the 2017 Youth Risk Behavior Surveillance System (YRBSS), 19.5% of high school students in West Virginia are obese compared to the national average of 14.8%. 2017 YRBSS data also reveal that high school students in West Virginia were less likely to engage in healthy dietary behaviors than high school students across the United States. For example, 76.9% of students in West Virginia reported drinking soda in the week prior to the survey compared to the national average of 72.2%. Likewise, 26.2% of adolescents in West Virginia reported drinking one or two sodas per day compared to the national average of 18.7% (Kann et al., 2018). YRBSS indicators of PA and sedentary behaviors also revealed that adolescents in West Virginia were less likely to be physically active than adolescents across the country (Kann et al., 2018). Therefore, given the health-related challenges facing children and adolescents within rural Appalachian communities, greater efforts are needed to counteract sedentary behaviors and poor dietary habits in these areas. Schools are ideal settings to provide support, education, and interventions focused on health promotion. Yet little is known about the effectiveness of such interventions in rural Appalachian settings. The purpose of this study was to evaluate the impact of a 3-year, multicomponent, school-based initiative on adolescent health–related behaviors (PA and dietary) and weight status (BMI).

Method

The Greenbrier CHOICES Intervention

The Greenbrier Children’s Health Opportunities Involving Coordinated Efforts in Schools (CHOICES) Project was a 3-year initiative focused on adolescent health. The project used integrated intervention settings (school, community, and health care) to address PA and dietary behaviors of adolescents living in a single county in West Virginia. The ecological model of health behavior (McLeroy, Bibeau, Steckler, & Glanz, 1988) provided a framework for Greenbrier CHOICES. Ecological models acknowledge that adolescent health behaviors are complex and highly influenced by multiple factors across different levels (i.e., interpersonal, organizational, community, and policy). The Greenbrier CHOICES project consisted of a comprehensive intervention aimed at reaching multiple levels of influence on adolescents’ PA and dietary behaviors through three components: school, community, and health care.

School

Regarding PA behavior, the school component of Greenbrier CHOICES incorporated elements of a Comprehensive School Physical Activity Program (CSPAP; Erwin, Beighle, Carson, & Castelli, 2013). CSPAP aims to increase access and opportunities for students to meet the recommended 60 minutes of daily PA. Greenbrier CHOICES included the following CSPAP components: quality physical education (PE), before- and after-school programs, family and community engagement, and faculty/staff involvement (see Table 1). Given that quality PE is the cornerstone of CSPAP, the design of a middle school standards-based PE curriculum was at the center of Greenbrier CHOICES. Four PE teachers from the county designed the curriculum in collaboration with content and pedagogy experts across the 3-year intervention. The curriculum focused on culturally and geographically relevant PA. That is, the units of instruction in the curriculum introduced PA congruent with students’ way of life and the environment in which they live (Braga & Elliott, 2018). This process involved seeking and responding to students’ feedback, providing continuous professional development for teachers, procuring varied and adequate equipment, and building partnerships with community members and organizations. The newly designed PE curriculum included 12 units of instruction aiming to provide students in Grades 6, 7, and 8 the skills, knowledge, and dispositions to participate in various PA types (e.g., mountain biking, archery, disc golf, etc.). PE teachers implemented the curriculum in the two middle schools within the county across the regularly scheduled 225 minutes of PE each week. Full description and outcomes of the curriculum design implementation process were published elsewhere and are beyond the scope of this study (Braga, Elliott, Jones, & Bulger, 2015; Braga, Jones, Bulger, & Elliott, 2017).

Table 1.

Overview of School Intervention Components.

CSPAP category	Greenbrier CHOICES component	Implementation
New physical education units (3-week units)	Mountain biking	Years 2, 3
	Archery	Years 2, 3
	Slack-lining	Years 2, 3
	Disc golf	Years 2, 3
Before- and after-school programs	Walking	Years 3 (2×/wk, Fall)
	Mountain biking	Years 2, 3 (2×/wk, Fall/Spring)
	Zumba	Years 2, 3 (2×/wk, Fall/Spring)
	Gladiator training	Years 2, 3 (2×/wk, Fall/Spring)
	Gardening/healthy cooking	Years 2, 3 (1×/wk, Fall/Spring)
During-school PA	Gardening and farm-to-school program	Years 2, 3
During-school PA	Fresh food prep and tastings	Years 2, 3
Family and community engagement	Cycle De Mayo Festivities on the Greenbrier River Trail	Year 2
	Fruity 5 km race	Year 2
	AmeriCorp volunteer and physical activity promotion	Year 3
Staff involvement	Zumba (after-school)	Years 2, 3 (2×/wk, Fall/Spring)
	Gladiator training (after-school)	Years 2, 3 (2×/wk, Fall/Spring)
	Mountain biking (after-school)	Years 2, 3 (2×/wk, Fall/Spring)

Note. CSPAP = Comprehensive School Physical Activity Program; CHOICES = Children’s Health Opportunities Involving Coordinated Efforts in Schools; wk = week; PA = physical activity.

To extend the PE curriculum, Greenbrier CHOICES introduced before- and after-school programs aligned with the new units of instruction (e.g., after-school mountain biking, after-school archery, etc.). School-level personnel including a project director, physical educators, classroom teachers, AmeriCorp volunteers, and/or interscholastic coaches coordinated and delivered the extended PA opportunities to students. In addition, Greenbrier CHOICES established partnerships with community members and organizations to extend the curriculum units beyond the school setting. For example, as a culmination of the mountain biking PE unit, the local bike shop personnel organized an event in which families and students participated in a bike ride along a bike trail in the community.

Regarding dietary behaviors, the school component of Greenbrier CHOICES focused on changing the offerings within the cafeteria and presenting food in a more appealing style. Food school personnel participated in ongoing professional development focusing on the changes within the meals served to students such as fresh food preparation and offering the school-grown vegetables on a salad/garden bar within the lunchroom (see Table 1). In addition to changes within the cafeteria Greenbrier CHOICES supported the establishment of a school garden to provide gardening education to middle school students. Finally, healthy-cooking classes and healthy food–tasting events were provided within the school for students and their families.

To support the integration of the CSPAP components, regular, ongoing professional development; instructional resources; equipment upgrades; and clinical supervision were provided for school food service personnel, health and PE teachers, school staff, health care providers, and the gardening coordinator within the county (Table 2). Professional development sessions occurred during regularly scheduled in-service days throughout the academic year for school personnel and staff. Introductory and follow-up booster sessions were scheduled in response to staff and personnel feedback throughout the grant program. The sessions were tailored for the content delivered and the audience, and the structure of each session included a combination of introducing evidence-based practices, structured group work and feedback opportunities, consultation with content experts, and peer instruction and information sharing. University faculty and regional consultants with expertise in designated content areas provided professional development sessions (Braga et al., 2017). School-level personnel including a project director, physical educators, classroom teachers, AmeriCorp volunteers, and/or interscholastic coaches coordinated and delivered the extended PA opportunities to students.

Table 2.

Overview of Professional Development Offerings in CHOICES School Component.

Participants	Professional development topic and contact hours	Implementation
PE and health educators	• Comprehensive school PA programming (3 hours)	Years 1, 2
	• Standards-based PE and health curriculum (12 hours)	Years 1, 2, 3
	• Value-added PE and health content	Years 1, 2, 3
	○ Mountain biking PE and after-school clubs (12 hours)
	○ Slack-lining (6 hours)
	○ Archery (9 hours)
	○ Disc golf (3 hours)
	○ Take Charge! Be Healthy! (3 hours)
	• FITNESSGRAM® test administration and data management (3 hours)	Years 2, 3
	• Curriculum analysis procedures (6 hours)	Years 2, 3
	• Curriculum development sessions (16 hours)	Years 1, 2, 3
All School staff	• Let’s Move West Virginia (2 hours)	Year 1
Food service personnel	• Lunchroom redesign (3 hours)	Year 2
Food service personnel	• Fresh food preparation and health food tasting (3 hours)	Year 2
Health care providers	• BMI and motivational interviewing (6 hours)	Year 2
Gardening coordinator	• High Rocks farm-to-school grant training (5 hours)	Year 2
	• Site visit for farm-to-school (5 hours)	Years 2, 3

Note. CHOICES = Children’s Health Opportunities Involving Coordinated Efforts in Schools; PE = physical education; PA = physical activity; BMI = body mass index;

Community

The community component of Greenbrier CHOICES extended the health and PE curricula by increasing student access to healthy eating and culturally relevant PA. Collaborations with existing community partners, resources, experts, and facilities allowed middle school students and their families affordable and accessible community-based PA programming. Of primary significance was a partnership with the local AmeriCorp program and personnel. An AmeriCorp volunteer became integral to the intervention team and offered gardening education to middle school students and their families within and outside of school hours. During- and after-school gardening programs were developed and efforts extended to the local farmers’ market. Additional activities such as Greenbrier River Trail biking event, walk-run events, guided forest hikes, cooking classes, and gardening seminars were coordinated and hosted within the community to stimulate and reinforce local resources, partnerships, and programs that promoted PA and health behaviors.

Health Care

The health care component of Greenbrier CHOICES complemented the school and community efforts by identifying and supporting overweight and obese students through prevention, treatment, and referral. School-based health centers located in each middle school allowed close monitoring of chronic disease risk factors, PA engagement, and nutritional counseling for families and adolescents experiencing weight management challenges. The chronic care medical home model (Barlow, 2007), a standardized national referral protocol recommended by the American Academy of Pediatrics, provided the framework for connecting these families to a network of qualified regional health professionals (e.g., dietitians, pediatricians, exercise physiologists, physical therapists, etc.) for the purposes of obesity management and prevention. Ongoing professional development and support provided to school-based health center personnel and regional health care providers were vital to the clinical component success (see Table 2). Regional health care providers and experts in pediatric obesity and pediatric cardiology conducted professional development sessions for onsite school-based health center nurse practitioners and health care consultants on motivational interviewing, implementation of the chronic care medical home model, and identification of local allied health professionals available for obesity management and prevention referrals.

Sampling Procedures

Greenbrier County School District enrolls approximately 5,200 students annually. Within the two middle schools, approximately 1,200 students enroll each year (624 males, 576 females).

The predominant ethnicity within the two middle schools is Caucasian white, accounting for approximately 93% of the student body. Seventy-two percent of the middle school students qualify for free or reduced lunch.

All enrolled middle school students received the intervention at their respective schools, which included participating in the newly designed 3-week PE units (e.g., mountain biking, archery, slacklining, disc golf, etc.), and newly designed after-school PA programming. The garden club was open to all students, including school-supported transportation home (e.g., mountain biking club, archery club, disc golf club), fresh food tastings and preparation during science classes, enhanced offerings in the school cafeteria (e.g., garden bar with school-grown produce). Elements of the intervention were implemented progressively across all three years of the program. Rationale for the progressive rollout was to ensure that teachers, staff, and school personnel who were responsible for implementing the programs had adequate professional development related to CSPAP and various aspects of the project and had sufficient time and resources to implement the programs. A significant portion of project Year 1 was spent building capacity, hiring program personnel, and collecting baseline data, whereas Years 2 and 3 included regular and ongoing PD, implementation of enhanced PE units and before- and after-school PA clubs/programs, launch of the school gardening program, and enhanced lunchroom offerings (see Table 1). The project components were available to all students, yet beyond the required PE attendance (225 minutes/week) and interactions with the enhanced PE units, participation in all other the CSPAP offerings provided through the project were not mandated or required.

For evaluation purposes, a systematic equal probability sampling protocol was used at baseline and at each data collection window across the intervention period (total of 14; see Table 3). Equal probability sampling protocol was used to capture a representative sample of the participants across the period of the project. At each data collection window, 30% to 31% of the total population were sampled using the sampling protocol. The following steps were taken to draw the probability sample prior to each data-collection window: (1) after the opt-out period, eligible participants were assigned a unique eight-digit identification number; (2) eligible participants were sorted alphabetically by school, classroom, last name, first name, and birth date and assigned the unique identification number based on school, classroom, and last name sequentially starting within each category at one; (3) the list of eligible participants was placed into the “PEP Sampling Spreadsheet” and the detailed instructions from “Sampling Guidance for PEP Grantees” were followed; (4) the selected sample of participants were contacted by grant personnel for involvement in data collection procedures.

Table 3.

Meeting Physical Activity, Dietary Behavior, and BMI Results (Percentage Met Established Criteria) Among Randomly Selected Participants Across the Collection Periods.

	60-Minute moderate/vigorous physical activity (3DPAR)^a		5+ Daily fruit/vegetable dietary behaviors (SPAN)^b		Normal/underweight BMI^c
Variable	% Met	p	% Met	p	% Met	p
Gender		.78		.67		.03
Female (n = 1,442)	36.7		36.3		74.9
Male (n = 1,432)	37.1		37.1		72.1
School		.39		.16		.03
Eastern (n = 2,126)	37.4		35.8		74.4
Western (n = 748)	35.7		39.1		71.05
Grade		.10		.0002		.06
6 (n = 957)	38.4		40.3		75.6
7 (n = 990)	34.2		38.4		72.0
8 (n = 927)	38.0		30.3		72.8
Data collection window		<.0001		.94		.50
Baseline (n = 309)	27.8		—		—
Year 1 (n = 1,022)	30.0		—		56.9
Year 2 (n = 810)	41.8		36.6		56.1
Year 3 (n = 1,042)	40.6		36.8		58.7

Note. 3DPAR = 3-Day Physical Activity Recall; SPAN = School Physical Activity and Nutrition; BMI = body mass index; PA = physical activity. Dietary behaviors collected at baseline and Year 1 were not included due to a change in response options from Year 1 to Year 2. Data reported reflect only SPAN Year 2 and Year 3.

PA data were collected on the following time points: baseline: February; Year 1: March, April, May, September; Year 2: October, February, March, April; Year 3: September, November, March, April. ^bSPAN data were collected on the following time points: Year 2: October, February, March, April; Year 3: September, November, March, April. ^cBMI data were collected on the following time points: Year 1: March; Year 2: November; Year 3: September.

Prior to data collection, institutional review board approval was obtained. Participants in this study included 4,633 (M = 2,289, F = 2,344) randomly selected middle school students in Grades 6, 7, and 8 enrolled across the 3-year intervention. At the beginning of each school year, parents and students were provided a 2-week period to opt out of the project. Across the 3-year intervention, a total of 315 participants (8.47%) opted out of the project.

Data Sources

Physical Activity

The paper/pencil version of Human Kinetics Activitygram (Welk, Mahar, & Morrow, 2013) measured adolescents’ PA behavior. Participants used Activitygram to recall type, duration, and intensity of PA engagement across a 3-day period, including 2 weekdays and 1 weekend day. Validation studies provided evidence that the recall is a valid instrument for assessing overall, vigorous, and moderate to vigorous PA in adolescent girls (Pate, Ross, Dowda, Trost, & Sirard, 2003). Previous research has indicated, however, that using self-report instruments among adolescent populations can overestimate PA when compared to accelerometer data (Hearst, Sirard, Lytle, Dengel, & Berrigan, 2012). Grant requirements for meeting goals included accumulating at least 60 minutes of daily moderate to vigorous PA.

Dietary Behaviors

The School Physical Activity and Nutrition (SPAN) survey instrument was selected to measure fruit and vegetable consumption. The complete 91-item SPAN survey is a surveillance system used to measure food choice behaviors, food selection skills, weight perceptions and practices, nutrition knowledge, attitudes about food and eating, and PA behaviors. Reliability and validity measures of the SPAN survey have been documented within elementary school–age children (Penkilo, George, & Hoelscher, 2008; Thiagarajah, et al., 2006). Eleven closed-ended questions were selected from the complete survey (2009-2010 version—8th and 11th Grade Questionnaire SPAN survey). Participants reported the number of times certain foods and drinks were consumed the previous day. Criterion for meeting nutrition guidelines was consumption of at least five fruits and vegetables per day.

Weight Status

Trained health care personnel within the school-based health center collected height and weight measurements using research-appropriate instruments (SECA Road Rod stadiometer-78” for measurement of height in inches; and SECA 840 Personal Digital Scale to measure weight in pounds). BMI was electronically calculated and plotted on CDC growth charts using Epi Info software (CDC, 2017b). Percentile ranges were used to establish weight status. Children were characterized as follows: 85th to 94.9th percentile, overweight; >95th percentile, obese (CDC, 2017a). Grant requirement for meeting goals was defined as those who were less than the 85th percentile for BMI.

Data Analysis

Data were stored in Microsoft excel and analyzed in IBM SPSS Statistics Version 21 and SAS Version 9.4. Descriptive data analysis was conducted with valid percentage reported of students meeting PA and nutrition guidelines, with p values for meeting grant requirements reported using chi-square tests. Due to a measurement change in SPAN response options at the end of Year 1, only Year 2 and Year 3 results are presented here for consistent reporting purposes. Finally, modeling appropriate for the longitudinal nature of the data collection was run; for BMI percentile, linear mixed models were run with a variety of both random effects and repeated measures covariance matrixes; the best fitting model was selected via smallest Akaike information criterion. For meeting PA requirements and fruits and vegetables, repeated measures generalized estimating equations were run with a binomial distribution and logit link.

Results

Demographics

Eligible participant demographics from Eastern and Western Greenbrier Middle School across the 3-year grant period (2012-2014) are reported in Table 4. The distribution of participants across sex (F = 50.6%, M = 49.4%) and grade (Grade 6: 35%, Grade 7: 33.5%, Grade 8: 31.5%) were fairly equal. However, representation from Eastern was nearly three times that of Western (74.5% and 25.4%, respectively).

Table 4.

Participant Demographics: Frequencies (Valid %) and Means (SDs) for the Total Sample and by Year.

Variable	Total	Baseline	Year 1	Year 2	Year 3
Data collection window
Baseline^a	309 (6.7%)
Year 1^a	1,365 (29.5%)
Year 2^a	1,402 (30.3%)
Year 3^a	1,557 (33.6%)
Gender
Female	2,344 (50.6%)	148 (47.9%)	682 (50.0%)	712 (50.8%)	802 (51.5%)
Male	2,289 (49.4%)	161 (52.1%)	683 (50.0%)	690 (49.2%)	755 (48.5%)
School
Eastern	3,448 (74.4%)	232 (75.1%)	989 (72.5%)	1,031 (73.5%)	1,196 (76.8%)
Western	1,185 (25.6%)	77 (24.9%)	376 (27.6%)	371 (26.5%)	361 (23.2%)
Grade
6	1,622 (35.0%)	107 (34.6%)	477 (35.0%)	513 (36.6%)	525 (33.7%)
7	1,546 (33.4%)	101 (32.7%)	436 (31.9%)	491 (35.0%)	518 (33.3%)
8	1,465 (31.6%)	101 (32.7%)	452 (33.1%)	398 (28.4%)	514 (33.0%)
Age
Years	12.6 (1.0)	12.6 (1.0)	12.7 (1.0)	12.5 (0.99)	12.4 (1.1)
Height^b
Inches	62.3 (3.6)	—	63.2 (3.5)	62.2 (3.6)	61.6 (3.6)
Weight^b
Pounds	126.1 (37.6)	—	131.1 (37.8)	126.5 (38.8)	120.8 (35.7)

At each data collection window 30% to 31% of the total student population was sampled (BL one data collection window [spring], Years 1 to 3 four data collection windows each year [two fall, two spring]). ^bBMI data were collected on the following time points: Year 1: March; Year 2: November; Year 3: September.

Physical Activity

Collectively across the intervention, 36.9% (n = 1,125, 36.7% females, 37.1% males) participants reported meeting the national recommendation of at least 60-minutes of daily moderate-to-vigorous PA (American Heart Association, 2014; CDC, 2015; Strong et al., 2005). Of those who met the criteria 51.03% were female and 48.97% were male. Across school sites and grade levels, the percentage of participants meeting the criteria was similar. From baseline to the end of the intervention, there was a 12.8–percentage point increase (27.8% baseline and 40.6% Year 3) in the number of randomly selected participants meeting national PA recommendations (Table 3). A statistically significant increase over the 13 intervention periods persisted when accounting for school, gender, and grade (odds ratio = 1.02, z score = 2.38, p = .017 (Table 5).

Table 5.

Longitudinal Data Analysis.

Outcome	Predictors	Estimate	SE	OR	Z	p
60-minute moderate/vigorous physical activity (3DPAR)^a
	Intercept	−0.64	0.14	0.53	−4.72	<.0001
	Collection period	0.02	0.01	1.02	2.38	.017
	Student grade
	6	0.07	0.10	1.07	0.69	.49
	7	−0.16	0.10	0.85	−1.59	.11
	8 (reference)	0		1.00
	Gender
	Female	−0.01	0.09	0.99	−0.16	.87
	Male (reference)	0		1.00
	School
	Eastern	0.11	0.09	1.12	1.19	.23
	Western (reference)	0		1.00
5+ Daily fruit/vegetable dietary behaviors (SPAN)^b
	Intercept	−0.87	0.23	0.42	−3.76	.0002
	Collection period	0.02	0.02	1.02	0.80	.42
	Student grade
	6	0.48	0.12	1.62	4.11	<.0001
	7	0.42	0.11	1.52	3.74	.0002
	8 (reference)	0		1.00
	Gender
	Female	−0.06	0.11	0.94	−0.57	.57
	Male (reference)	0		1.00
	School
	Eastern	−0.15	0.11	0.86	−1.32	.19
	Western (reference)	0		1.00
Outcome	Predictors	Estimate	SE	df	t	p
BMI percentile^c
	Intercept	72.58	1.40	2342	74.46	<.0001
	Screening date
	Year 1	0.00	0.91	2698	−0.01	.99
	Year 2	0.87	0.61	2601	1.45	.15
	Year 3 (reference)	0
	Student grade
	6	−3.32	0.96	2,711	−3.46	.0006
	7	−1.59	0.62	2521	−2.56	.01
	8 (reference)	0
	Gender
	Female	1.69	1.24	1991	1.36	.17
	Male (reference)	0
	School
	Eastern	−2.08	1.38	2194	−1.51	.13
	Western (reference)	0

Note. OR = odds ratio; 3DPAR = 3-Day Physical Activity Recall; SPAN = School Physical Activity and Nutrition; BMI = body mass index; df = degrees of freedom. N = 1,906. BMI percentile was modeled using linear mixed modeling, and meeting physical activity and healthy eating outcomes were modeled using generalized estimating equation models.

PA data were collected on the following time points: Baseline: February; Year 1: March, April, May, September; Year 2: October, February, March, April; Year 3: September, November, March, April. ^bSPAN data were collected on the following time points: Year 2: October, February, March, April; Year 3: September, November, March, April. ^cBMI data were collected on the following time points: Year 1: March; Year 2: November; Year 3: September.

Dietary Behaviors

Adolescent dietary behaviors were measured by self-reported consumption of fruit and vegetables on the SPAN survey. Across the intervention, 36.7% participants met the criteria of consuming two or more daily servings of fruit and three or more servings of vegetables. From Year 2 to Year 3, dietary behaviors did not change significantly with only a 0.2% increase in the number of randomly selected participants meeting criteria. Collectively across the intervention, a grade-level trend emerged reflecting fewer eighth-grade participants meeting the criteria than their younger counterparts. Grade-level effects persisted after accounting for time and other covariates (Table 5). Although not statistically significant, individuals from Western, the more rural of the two school sites, reported meeting the criteria at a greater percentage than those from Eastern (39.1% and 35.8%, respectively; Table 3).

Weight Status

Fifty-five percent of participants across the intervention were classified as healthy weight and 42.75% as overweight or obese (see Table 6). Of those in the overweight or obese category, 40.9% were female and 44.6% were male. BMI data collected at three points across the intervention (Years 1, 2, and 3) indicate a 1.3% increase in the percentage of students in the healthy weight zone (55.3% at Year 1 and 55.6% at Year 3). Additionally, data reflect a 2.6% decrease (44% at Year 1 and 41.4% at Year 3) in participants classified as overweight or obese across the intervention. Changes to BMI categories were not statistically different.

Table 6.

Body Composition Results (Percentage Within BMI Categories), All Participants.^a

Variable	Underweight	Healthy	Overweight	Obese	p
Gender					.045
Female (n = 1,442)	1.3	57.9	18.2	22.7
Male (n = 1,432)	2.0	53.4	19.0	25.6
School					.22
Eastern (n = 2,126)	1.6	56.8	18.2	23.4
Western (n = 748)	1.7	52.4	19.7	26.2
Grade					.21
6 (n = 957)	2.0	56.6	16.5	24.9
7 (n = 990)	1.8	54.4	18.9	24.9
8 (n = 927)	1.1	56.0	20.4	22.5
Data collection					.54
Year 1 (N = 1,022)	1.7	55.3	17.7	26.3
Year 2 (N = 810)	1.1	54.9	19.9	24.1
Year 3 (N = 1,042)	2.0	56.6	18.4	23.0

Note. BOM = body mass index. BMI data were electronically calculated and plotted by the Centers for Disease Control and Prevention growth charts using the Epi Info software. Percentile ranges used to establish body composition: 85th-94.9th percentile, overweight; >95th percentile, obese.

BMI data were collected on the following time points: Year 1: March; Year 2: November; Year 3: September.

Discussion

The purpose of this study was to evaluate the impact Greenbrier CHOICES had on adolescent PA, dietary behaviors, and weight status. The results indicate that the comprehensive school-based health intervention positively affected student health-related behaviors and weight status in middle school settings. While descriptive data suggest positive changes to weight status, no statistically significant differences were reported in participant BMI across the intervention. Previous research has shown that variables such as parental obesity, diet, and family income can be predictive of adolescent BMI, as well as changes to BMI over time (Wang, Ge, & Popkin, 2000). Other studies outline the critical role PA has on BMI over time, particularly in adolescent females (Kimm et al., 2005). Recognizing the contributions both dietary and PA behaviors have on weight status, the current intervention was designed to enhance school-level opportunities for PA and nutrition. Given the multifaceted nature of BMI, school-level changes may be necessary but not be enough to generate significant changes to individual behaviors and resultantly weight status.

Physical Activity Behavior

At the end of the intervention nearly 40% of the adolescents reported meeting the daily-recommended amount of PA (60 minutes of moderate to vigorous activity), reflecting a 12.8–percentage point increase from baseline. While these data are considerably higher than previous reports of adolescents meeting daily PA guidelines, caution may be needed when interpreting these findings due to the use of self-report methodology. Studies have found self-report PA measures can overestimate minutes in MVPA (LeBlanc & Janssen, 2010). Specifically, LeBlanc and Janssen (2010) reported that 65% of youth participants overreported their time spent engaging in MVPA by at least 5 minutes per day, 20% underreported, and 14% reported within 5 minutes per day. Furthermore, descriptive data from LeBlanc and Janssen indicated that median time engaged in MVPA was 3 times greater when self-reported than objective measures were used (42.4 minutes/day vs. 15.0 minutes/day). Using an objective measure of PA, Troiano et al. (2008) reported that only 7.5% of adolescents (12-15 years old) met daily PA guidelines. Yet a more recent review of PA surveillance data indicated values closer to 27% of adolescents meeting the guidelines (Katzmarzyk, Lee, Martin, & Blair, 2017). School-based interventions that integrate CSPAP have documented increases in children’s step counts during the school day (Burns, Brusseau, & Hannon, 2015; Vander Ploeg, McGavock, Maximova, & Veugelers, 2014). A quasi-experimental longitudinal study in Canada found a greater increase in fifth graders’ mean step count enrolled in a 2-year comprehensive school health intervention compared to those from control schools (Vander Ploeg et al., 2014). Although the current study was not comparative to a control site, the CSPAP was seen to produce increased PA levels in adolescents. Further investigation is needed to explore the effects implementing CSPAP components, discretely and in combination, on adolescent PA as they matriculate through middle school years and are provided additional opportunities to engage in school PA programming over time.

Interestingly, data from the current study do not reflect a large discrepancy in gender of those meeting PA recommendations. Previous findings indicate boys are likely to report greater PA levels than girls (Katzmarzyk et al., 2016; Laurson, Lee, & Eisenmann, 2015; Troiano et al., 2008). However, data from this study suggest a roughly equal number of boys and girls meeting the guidelines (48.9% boys and 51% girls). A possible explanation could be that student input was sought with regard to their interest in different types of PA. Student interests were used to inform the selection of innovative, value-added PE content, and before- and after-school PA programs/clubs. Engaging adolescents in the planning process and implementing culturally and geographically relevant PA in schools may create environments that reduce barriers to participation for adolescents typically disengaged from PA (e.g., female, lower skilled, less fit adolescents; Braga & Elliott, 2018; Braga et al., 2015; Spence & Lee, 2003). However, this claim needs to be supported by future research.

Nutrition Behaviors

In contrast to previous population-based dietary recall findings where less than 10% of adolescents meet daily nutrition recommendations (Kimmons, Gillespie, Seymour, Serdula, & Blanck, 2009), 32% of participants in this study reported meeting fruits and vegetables recommendation prior to the intervention. This discrepancy may suggest possible overreporting of dietary data recall or potential misunderstanding of serving values and/or food group classifications. Across the intervention the percentage of participants meeting the fruit and vegetable recommendation ranged from 30% to 46%. This increase may be attributed to the nutrition-related components introduced in the intervention during Year 2; however, it is important to note that no statistically significant changes in dietary behavior were reported across the intervention. Further examination of grade-level trends observed in these data could be of interest. That is, future steps are needed to explore changes to dietary behaviors across adolescence and what effect increased exposure to school-based nutrition programming (e.g., school gardens, fresh food tastings, etc.) has on fruit and vegetable consumption. Recommended strategies to increase fruit and vegetable consumption include education within schools and communities and access to healthier food choices (Jetter & Cassady, 2006; Kimmons et al., 2009; Pothukuchi & Kaufman, 1999). Because comprehensive nutrition services are provided to all U.S.-based schools, organizations such as the American Dietetic Associations, the Society for Nutrition Education, and the American School Food Service Association contend that nutrition services must be integrated with comprehensive school health initiatives (Briggs, Safaii, & Deborah, 2003).

The Greenbrier CHOICES nutrition components included school gardening, healthy food tasting events, lunchroom redesign, and professional development for school food service personnel aimed to increase the quality, diversity, and availability of fresh, locally grown vegetables and herbs for the students. The nutrition components were implemented at the school level and were designed to create opportunities for students to engage with and consume healthy foods during the school day. Findings from this study suggest the school-level nutrition components were not strong enough to lead to individual behavior change. Previous research provides insight to the challenges associated with changing eating behaviors, particularly in child and youth populations (Birch & Davison, 2001). Specifically, dietary behaviors and food preferences evolve during one’s formative years and are reinforced by a variety of societal, cultural, and familial variables (Loth, MacLehose, Fulkerson, Crow & Neumark-Sztainer, 2013; Savage, Fisher, & Birch, 2007). Future school-based interventions may be more effective if parental and family-focused nutrition education are included within program design.

With a growing body of literature surrounding school gardening programs, some evidence suggests positive links between school gardening and vegetable consumption (Morris & Zidenberg-Cherr, 2002; Ratcliffe, Merrigan, Rogers, & Goldberg, 2011). Professional development opportunities for school food service personnel are critical if they are to “take an active role in educating children, parents, and others about nutrition” (Briggs et al., 2003, p. 509). Furthermore, cafeterias need to create attractive displays and appealing healthy options that are nourishing, culturally relevant, and offered in a positive environment with enough time for eating (Briggs et al., 2003; Glanz et al., 2007). Above all, school nutrition policies are needed to promote healthy eating and dietary behaviors through classroom lessons and supportive school environments (CDC, 1996).

Strengths and Limitations

Strengths and limitations of this study need to be considered when interpreting findings. First, given that various school-based PA components were implemented across the 3-year period, it is difficult to determine which CSPAP component(s) had greater or lesser effect on the identified behavior changes. Second, the study sample does not include adolescents who opted out from the study. Hence, participants in this study might include those who are disproportionately more likely to have positive dispositions toward PA and healthy eating behaviors. Furthermore, this study used self-reported data with cutoff values for meeting PA and healthy eating criteria, which may have added bias to adolescents’ responses. Changes in the self-report SPAN survey from Year 1 to Year 2 limited the researchers’ ability to capture the period of possible greatest change. Despite limitations, findings suggest positive outcomes of a comprehensive, school-based, health-related intervention targeting adolescents within a rural Appalachian community. Given the paucity of interventions targeting this population, findings from this study adds to the limited body of literature supporting health behavior change interventions in rural communities.

Implications for Theory and Practice

Findings from this study align with recommendations that whole-of-school approaches can promote health-related behavior change in youth and adolescents (Carson & Webster, 2019; Erwin et al., 2013). Comprehensive interventions based on ecological models of health behaviors have more chances to produce desired outcomes because they target multiple levels of influence on health. Although it is difficult to reach all levels of influence on PA and/or healthy eating through a single intervention, efforts targeting more than one level of influence are more likely to succeed. For example, aligning PE content with before-/after-school opportunities, and community PA events can create additional opportunities for adolescents to engage in PA (Dauenhauer, Stellino, Webster, & Steinfurth, 2019; Welk & Lee, 2019). Likewise, connecting gardening programs with cooking classes, tasting events, and cafeteria offerings can provide opportunities for young people to consume fruits and vegetables during the school day.

This study also supports the school environment as a critical setting for health behavior interventions targeting adolescents. First, schools are ideal settings for health promotion because almost all U.S. adolescents attend school and spend most of their waking hours in this setting regardless of socioeconomic status and where they live. Second, schools already have facilities, personnel, and other resources that can be optimized in health-related initiatives, thus lowering programmatic costs. Third, schools provide opportunities for community involvement through referral models, shared used agreements, and extended hours programming.

Finally, implementation of a CSPAP would be very difficult to achieve without the investment of resources and time spent building capacity and training school staff and personnel (Carson et al., 2019; Webster, Egan, & Brabham, 2019). Therefore, we contend that findings from this study reinforce the value of ongoing professional development for teachers, food personnel, and health-related staff. Although school-based interventions seem promising for youth health promotion, little can be accomplished if individuals delivering interventions do not receive appropriate training. Continuous, meaningful, and participatory approaches to professional development such as the one employed by Greenbrier CHOICES have greater chances to produce desired intervention outcomes.

Footnotes

Authors’ Note

This research was conducted at West Virginia University

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by the U.S. Department of Education Office of Safe and Drug-Free Schools, Carol M. White Physical Education Program Grant 2011 (Q25F110479).

ORCID iD

Emily Jones

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