Effects of a Promotor Training on Local School Wellness Advocacy Capacity

Abstract

There is gap between the enactment and implementation of local school wellness policies. Building the capacity of promotores to engage parents in strengthening local school wellness policy implementation is an innovative strategy. This evaluation study examines the effects of 6 hours of promotor advocacy training to improve local school wellness policy implementation. Consistent with psychological empowerment theory, the training and the related toolkit were designed to increase promotores’ knowledge and self-efficacy to engage parents in advocating for improved local school wellness policy implementation. Pre–post training questionnaires (n = 74), five posttraining participant focus groups, and four staff member focus groups explored changes in promotor and participating organization capacity. Findings show increased participant self-efficacy, knowledge, and attitudes to advocate for improved local school wellness policy implementation. Participating organizations reported intention to continue supporting promotor local school wellness policy advocacy. Findings illuminate strategies to strengthen promotor capacity to engage parents in local school wellness policy advocacy.

Keywords

lay health promoters school policies parent advocacy nutrition physical education

Introduction

Background/Literature Review

School settings play a key role in shaping children’s eating and physical activity patterns (Kubik, Lytle, Hannan, Perry, & Story, 2003). School campuses provide educational and real-life opportunities for students to learn about and adopt healthy eating and activity patterns (Koplan, Liverman, & Kraak, 2003). For example, school lunches provide about one third of children’s weekday calorie intake (U.S. Department of Agriculture, 2004b). Children can expend about 50% of their calories during a school day (Koplan et al., 2003).

Policy Implementation

In recent years, government and health advocacy organizations have articulated the need for school environments to promote healthful eating and active living (Koplan et al., 2003; Sallis, Story, & Orleans, 2007; Waxman & Norum, 2004). To use the influential role school settings play in shaping children’s eating and physical activity patterns, the U.S. Congress required school districts participating in the national school lunch or breakfast programs to establish local school wellness policies (LSWP) by the beginning of the 2006-2007 school year (U.S. Department of Agriculture, 2004a).

Whereas the majority of U.S. school districts have enacted LSWP, research indicates that the policies tend not to be comprehensive and frequently are not implemented (Belansky, Chriqui, & Schwartz, 2009; Chriqui, Schneider, Chaloupka, Ide, & Pugach, 2009; Moag-Strahlberg, Howley, & Luscri, 2008; Seo, 2009). To date, enacted school wellness policies have produced modest results (Belansky, Cutforth, et al., 2009; Gittelsohn & Kumar, 2009; Vecchiarelli, Takayanagi, & Neumann, 2006). Two national surveys of school administrators and board members found that lack of funding and staff time were the top challenges to the successful implementation of LSWP (Agron, Berends, Ellis, & Gonzalez, 2010; Chriqui et al., 2009). Other challenges were inadequate implementation and monitoring tools and insufficient efforts to garner school community support for LSWP (Agron et al., 2010).

Parents’ Role

School parents can potentially play a key role in helping a school community overcome the challenges of implementing LSWP (Agron et al., 2008). For example, parents can participate in decision making, governance, and advocacy (Epstein & Salinas, 2004; U.S. Department of Education, 2004). Parents can also share in the implementation work, thereby addressing the challenge of lack of school staff time.

However, formative research revealed that many parents in low-income California communities did not know that school districts are required to have LSWP (Agron et al., 2008). Although many resources on school parent engagement exist, none of these resources are designed to build parent capacity to navigate the school-based advocacy process related to LSWP implementation (Agron et al., 2008). Therefore, we need more research on how to implement a support system that empowers parents to advocate for improved LSWP implementation.

Promotores’ Role

A promising strategy to build the capacity of school parents to strengthen LSWP implementation is using a promotor (e.g., lay health advisor, community health worker) approach (Centers for Disease Control and Prevention [CDC], 2011). Promotores provide their time and social networks to positively affect their communities’ health (Rosenthal et al., 2010). Promotor interventions have improved individual-level health behaviors (Forst et al., 2004) and access to health services (Aguilar-Gaxiola et al., 2002; Plescia, Groblewski, & Chavis, 2008). Promotores have been instrumental in successful community-level advocacy efforts related to poverty, employment, housing (Ingram, Sabo, Rothers, Wennerstrom, & de Zapien, 2008), environmental justice (Takaro, Krieger, &Song, 2004), and health care services coverage (CDC, 2011). Despite a CDC (2011) policy brief noting the importance of promotores engaging in the school wellness policy work, our review of the literature did not reveal reports of promotores advocating for policy implementation within schools.

Intervention Description

To address this gap, California Project LEAN (Leaders Encouraging Activity and Nutrition [CPL]) developed a multilevel strategy to build the capacity of school parents to strengthen LSWP implementation. First, CPL developed the Parents in Action! Toolkit targeted to school parents. The topics include the following: how to navigate the school system, why parents should be concerned and involved with LSWP development, general health and wellness, and parent advocacy strategies. Then, to disseminate and diffuse the Parents in Action! Toolkit and to address the gap in existing promotores training resources, CPL developed a 6-hour training curriculum (in English and Spanish) to strengthen the capacity of promotores and their supporting organization to engage parents in strengthening LSWP implementation. Promotor training topics include the following: importance of engaging parents in the implementation, monitoring, and evaluation of LSWP; assessing the foods and beverages available on the school campus; and advocacy action steps.

Theoretical Guidance

Psychological empowerment (PE) theory (Zimmerman, 1995) provided the theoretical basis for the Toolkit and the promotor training curriculum. PE refers to how individuals gain mastery over issues that concern them. PE theory has three components (i.e., Intrapersonal, Interactional, and Behavioral). The Intrapersonal Component relates to beliefs that goals can be achieved. The Interactional Component relates to awareness about how to mobilize resources to achieve goals. The Behavioral Component includes action steps toward those goals.

Consistent with the Intrapersonal Component of PE, the school nutrition and physical activity fact sheets in the Toolkit were designed to enhance promotores’ and parents’ self-efficacy (SE) to improve their children’s school food and physical activity conditions. The Interactional Component is reflected in how the training curriculum provided promotores with step-by-step guidance on how to mobilize parents to influence LSWP implementation. For the Behavioral Component, promotores applied the advocacy skills and tools acquired during the training to real-life situations.

This article presents the findings from an external evaluation of the piloting of the promotor training. The evaluation focused on key indicators of capacity building at the individual and organizational levels (Flaspohler, Duffy, Wandersman, Stillman, & Maras, 2008). Specifically, the evaluation sought to (a) assess the extent to which promotores experienced a change in their knowledge, perceived attitude, or SE related to working with parents to use an advocacy approach to strengthen LSWP implementation and (b) explore participating school/community organizations’ intention to support subsequent promotor LSWP advocacy activities.

Methods

Participants

A total of 79 participants were recruited through four Los Angeles–based organizations that used a promotor approach. Two organizations were school-based and two were community-based. Five training groups were formed. Participants attended 4 weekly 1.5-hour training sessions. The participants resided in Los Angeles County and were predominantly women (n = 77 women and 2 men), between the ages of 30 and 78 years. The mean age was 47 years (±11 years). Four of the five training groups were conducted in Spanish. Although race data were not collected, based on course facilitator observation, the English-speaking group was made up of Whites and African Americans and was predominantly the latter. Based on observation, there were no other racial groups represented in the study.

A total of 11 staff members from the four school-/community-based organizations participated in the telephone focus groups to explore organizational intention to support promotores’ to engage parents in LSWP advocacy activities. Staff members included promotor coordinators and organization administrators. The participants were predominantly Latino women (n = 8 Latinas, 1 African American woman, 1 non-Hispanic White male, and 1 male of unknown ethnicity). The data collection protocol was reviewed and approved by the Public Health Institute Institutional Review Board in Oakland, California. Participants verbally consented after reading or hearing the study procedures in questionnaire and focus group introductions.

Instruments and Procedures

A one-group pre- and posttest evaluation design (Issel & Handler, 2009) was used to assess changes in promotores’ knowledge, attitudes, and SE to engage parents in LSWP implementation work. The pre–post questionnaire SE questions were adapted from the validated scale developed to investigate SE of elementary school teachers to teach nutrition (Brenowitz & Tuttle, 2003). The pre–post knowledge and perceived attitude questions were developed using the U.S. Department of Agriculture Community Food Project Evaluation Toolkit (Community Food Security Coalition, 2006). The questionnaire contained 9 perceived attitude questions, 20 knowledge questions, and 5 SE questions formatted using Likert-type scales, multiple-choice questions, and true–false questions. The attitude-related questions focused on promotores’ perceived relevance of the training topics. Knowledge-related questions dealt with school food and physical activity practices and policies. SE questions assessed promotores’ confidence to partner with other parents to improve LSWP implementation.

The draft questionnaire was piloted with five promotores from a community-based agency in San Jose, California. The questionnaire vocabulary was revised to reflect areas for improvement revealed in the piloting.

Bilingual facilitators administered the Spanish or English questionnaires to training participants. Tables 1 and 2 and Figure 1 collectively include all the questionnaire items. Of the 79 trainings participants, 74 completed the pre- and posttraining questionnaires during the first and fourth sessions.

Table 1

Knowledge Responses Results (n=74)

	% Correct Pre	% Correct Post	p Value
Please check if the following statements are true or false:
• The School Lunch and School Breakfast Programs are the only way students can get food on campus.	58.97	85.29	.013
• In order to successfully implement a school food practice or policy, you only have to work with the school food service department.	68.18	75.76	.466
• School districts can set their own nutrition and physical activity standards that go above and beyond state standards.	48.78	50.00	.916
• Once a practice is written into school district policy, the schools in that district are then obligated to follow the policy.	44.12	25.58	.088
The school setting has a strong influence on children’s behavior for the following reasons: (Check as many as apply)
• Children spend a lot of time at school during the week.	54.55	79.41	.022
• Schools can control what type of food is sold in the surrounding neighborhood off of school campus.	20.45	29.41	.361
• Schools are solely responsible for preventing childhood obesity.	84.09	88.24	.602
• Schools can provide students with the opportunities to learn and practice healthy behaviors that they can adopt for life.	86.36	88.24	.806
Local school wellness policies must set goals for: (Check as many as apply)
• Nutrition education	86.36	91.18	.509
• Physical activity	86.36	88.24	.806
• All foods and beverages sold on campus	61.36	61.76	.971
• School-based activities designed to promote student wellness	88.64	97.06	.166
School districts are required to: (Check as many as apply)
• Provide middle and high school children with a minimum amount of 400 minutes of PE (physical education) per 10-day period.	25.00	72.73	<.0001
• Provide elementary school children with a minimum amount of 200 minutes of PE per 10-day period.	20.45	75.76	<.0001
• Have physical activity goals as part of their local school wellness policy.	77.27	79.41	.820
• Ensure that all children get 60 minutes of activity every day.	70.45	82.35	.225
When parents are involved in their children’s schools, the children are more likely to: (Check as many as apply)
• Earn higher grades and test scores and enroll in more advanced academic programs.	9.09	12.12	.666
• Be embarrassed by the presence of their parents.	86.05	93.75	.285
• Attend school regularly.	22.73	28.12	.592
• Have better social skills, show improved behavior, and adapt well to school.	88.64	91.18	.714

Table 2

Perceived Attitude Results (n=74)

	Pre Mean (SD)	Post Mean (SD)	p Value
The goal of this project is to improve school food and physical activity practices in schools. To accomplish this goal, how useful do you think it would be to train parents in the following areas:
• How to get involved in influencing school wellness policies to improve student health	3.84 (0.43)	3.94 (0.24)	.2397
• The different ways students can obtain foods and beverages on campus (e.g., school lunch, vending machines, etc.)	3.12 (1.13)	3.03 (1.33)	.7524
• The challenges of providing healthy food on campus	3.41 (1.06)	3.21 (1.24)	.4570
• The school’s nutrition standards	3.68 (0.64)	3.76 (0.66)	.6138
• The benefits of daily physical activity	3.86 (0.35)	3.91 (0.29)	.4931
• How to gather information from his/her child about physical activity on campus	3.63 (0.54)	3.91 (0.38)	.0108
• How to advocate for improved nutrition and physical activity in their child’s school or school district	3.86 (0.52)	3.91 (0.29)	.6051
• How to work with schools to implement school wellness policies	3.72 (0.45)	3.88 (0.33)	.0850
• How to develop an action plan to improve school food and physical activity practices	3.80 (0.46)	3.85 (0.56)	.6199

NOTE: SD = standard deviation.

Figure 1

Promotor Improvements in Self-Efficacy for Advocacy Skills (n = 74)

The promotor focus groups were also conducted on the last training day in order to improve access to participants. Key focus group instructions and questions included the following: Please draw an image that represents the most useful or helpful part about the training. What part of the training seemed useful?

One to 3 months after the completion of the training sessions, a CPL curriculum developer/facilitator and an external evaluator conducted four staff member focus groups via telephone, one for each of the four participating organizations. Key questions included the following: What aspects of the trainings were most useful to members of your organization? What skills, materials, or strategies from the trainings, if any, have members in your organization started to use? What skills or materials do you plan to use?

Data Analysis

This evaluation involved a three-phase mixed-methods data collection and analysis process. The first phase involved statistical analysis of the de-identified questionnaires. STATA (10.0) statistical software was employed to conduct chi-square tests and analysis of variance to detect significant (p ≤ .05) changes in proportions and means of promotores’ perceived attitudes, knowledge, and SE to engage parents in LSWP work.

In the second phase, the emergent themes from promotor focus groups were analyzed and compared with the questionnaire results. By conducting mixed-methods analyses, the evaluators gained insight into the meaning of the questionnaire responses. The third phase of evaluation involved (a) identifying the themes from the four staff member focus groups and (b) exploring the implications of these for sustaining the subsequent promotor advocacy efforts.

Results

Advocacy Process Knowledge

In the focus groups, when promotores were asked to identify something that represented the most useful part of the training experience, some promotores listed the four key advocacy steps to strengthen LSWP implementation presented in the training: identify the problem and solution(s), identify policy players, develop an action plan, and review how we did. One promotor explained, “I have a better feel for what advocacy is.”

Questionnaire analysis revealed significant knowledge gains related to whether the school meal programs were the only sources of food available to students on school campuses (p = .013), a school’s influence on children’s eating behaviors (p = .022), and the amount of physical education time school districts are required to provide for elementary, middle, and high school students (p < .0001).

All nonsignificant knowledge items moved in the positive direction except for one item regarding whether schools are obligated to follow district-level wellness policies (p = .088). See Table 1. The decrease in the percentage of correct answers for this item may reflect promotores’ increased awareness and multiple reports that their schools were out of compliance with LSWP. For instance, one focus group participant shared, “We have a policy but they [schools] are not following it.”

Attitude and Relevance of Training Topics

The promotor focus groups revealed interest in learning how to engage other parents in the use of an advocacy approach to strengthen LSWP implementation. This theme was corroborated by the baseline questionnaire responses, which indicated that, at pretraining, the majority of promotores already saw the relevance of using an advocacy approach to improve LSWP implementation. This response pattern remained high at posttraining. Promotores’ perceived attitude regarding how useful they thought it would be to assess their child’s physical activity in school showed significant (p = .01) improvement. Except for two items (sources of school food/beverages and challenges of providing healthy school food), all nonsignificant perceived attitude items moved in the positive direction (see Table 2).

Another emergent promotor focus groups theme was that the knowledge about the advocacy steps was seen as a potential catalyst for action. “Sometimes one has a lot of ideas, but does not know which path to take—where to start. Participating in this training opened my mind and the door of where I can start.” Promotores also articulated connections between the training program and the health of children, schools, and their community. For example, one promotor explained, “I hope that these programs continue; they help parents to keep helping our children so that in the future we can have a better life for all.” Other promotores expressed motivation in working toward a broader common goal. “To see and hear other women united with the same goal, which is our community wellness.”

Some promotores differentiated the training experience to their previous experiences with nutrition education because of the advocacy skills training. “I thought it was just another nutrition class, but you surprised me because it is something very beneficial.”

Self-Efficacy

The most dramatic improvements were made in SE. Significant improvements were seen in four of the five SE questionnaire items (see Figure 1). Promotores reported feeling more confident in (a) providing guidance to parents on how to work with schools to improve school nutrition and physical activity practices, (b) engaging parents to advocate for improved healthy eating and physical activity options in their child’s school, (c) answering parents’ questions related to nutrition and physical activity practices in their school, and (d) supporting parent efforts to use existing or potential LSWP to improve healthy eating and physical activity options at schools. However, participants did not feel significantly more confident to train a group of parents to improve opportunities for healthy eating and physical activity at a school.

Consistent with the Intrapersonal and Interactional Components of PE theory, various promotores explained their confidence and their awareness of how to improve LSWP implementation. For example, one promotor expressed her confidence as, “The more we are trained, the better advocacy we do.” Another promotor used a metaphor to explain how she could make a difference using a social networks approach (Eng, Parker, & Harlan, 1997) to extend the reach of the training curriculum. “We are like roots. What we learn can spread to other people that we come in contact with.”

Applying the Training Skills

During the 4-week training, four of the five training groups reported using the school nutrition and physical activity advocacy approach delineated in the training to strengthen their school food improvement efforts. By putting the training content into practice, the promotores (a) demonstrated the gains in advocacy knowledge, perceived attitude, and SE described above and (b) exemplified the Behavioral Component of PE theory.

In one example, a promotor explained how he used a fact sheet from the Parents In Action! Toolkit to prevent junk food fundraisers at his son’s school, which he learned was contrary to the LSWP. “I shared my concern with the director and left a copy [of the healthy fundraiser handout] with the secretary. [The director] must have thought I was an expert. . . . [She] decided to ban all junk food fundraisers.” This example highlights the importance of written advocacy tools (such as fact sheets) to support promotores’ advocacy behaviors. Existing global health agencies have articulated the usefulness of advocacy tools to hold organizational decision makers accountable (McCaffery, 2011).

In another example, two training groups from one participating community organization decided to modify their focus in order to find a common advocacy goal, such as implementing school breakfast during student testing days. The vice principal explained how the community members’ common advocacy goal influenced his decision to prioritize school breakfast funding. “Money is very tight right now, but school breakfast during testing was a clear priority for the school community so we made sure we found the money.” This example speaks to the important role the community organizations have at the Behavior Component stage to facilitating working alliances among school community groups.

Organizational Support

CPL invited participating organizations to recruit promotores for the pilot training. Beyond expectation, all the participating organizations reported plans to continue building the capacity of the members within their organization. Two of the organizations planned to continue to allocate staff to advance the advocacy efforts initiated by promotores during the training period—even though facilitating a promoter-led community intervention was beyond the scope of the pilot project. The two other organizations planned to integrate parts of the advocacy approach within the training of promotores. In organizational leader interviews, key suggestions were to have more training time and longer-term support mechanisms for promotores to compare advocacy experiences with each other.

Discussion

This mixed-methods evaluation assessed the outcomes of a pilot promotor training to engage parents in LSWP advocacy. Despite the relatively short duration of the training intervention (i.e., 6-hour training), promotores reported a change in their knowledge, attitude, or SE related to working with parents to use an advocacy approach to strengthen LSWP implementation. Participating organizations made progress toward building their capacity to support promotor advocacy efforts. These key findings merit further discussion in the context of relevant promotor training and capacity building literature.

Promotor Training Practice

In prior research with elementary school teachers, SE to teach nutrition functioned as a mediator to implementing nutrition education in the classroom (Brenowitz & Tuttle, 2003). Therefore, the SE gains seen in this pilot training evaluation is an indication that the training curriculum experience contributed to promotores’ capacity to put into practice the skills learned in the training into practice.

The recommendation to have more training and follow-up support is consistent with existing literature on promotor training (Swider, Martin, Lynas, & Rothschild, 2010). In addition, more training and follow-up has the potential to increase the only nonsignificant promotor SE gain (confidence to conduct trainings with school parents).

In the present study, participating organizations helped promotores apply the skills learned in the training, and organizational leaders increased their intention to support promotor LSWP advocacy efforts. These findings add to the existing theoretical and empirical evidence of the importance of having ongoing organizational support for promotores involved in school-based advocacy work (Flaspohler et al., 2008).

Study Design and Transferability

The one-group pre- and posttest evaluation study design that was used with supplementary qualitative methods was appropriate to detect changes in participants’ capacity to advocate for improved LSWP implementation. However, since the design did not include a control group, we cannot be assured that the reported changes were exclusively due to the intervention. To partially address this limitation, and to increase the validity of the findings, a combined quantitative–qualitative analysis approach was used. Participants’ qualitative responses regarding their experiences with the training topics and their child’s school food and physical activity environment were triangulated with their pre–post questionnaire responses and presented.

One evaluation study is not generalizable to all settings. The findings from this study may be most transferable to settings with similar contextual traits. In this pilot study, contextual traits included highly motivated Latino and African American training participants and organizational commitment to support promotor efforts to partner with parents to address their school nutrition and physical activity concerns. This type of evaluation study can also be implemented in communities with different contextual traits to illuminate the reliability of the findings.

Conclusion

This evaluation study examines the effects of a training that aimed to build the capacity of promotores to engage parents in advocacy efforts to strengthen LSWP implementation. The study findings help illuminate three potential implementation strategies and related research topics to further this approach.

Implications

First, based on the findings of this pilot study, the overall approach to build promotores’ capacity to support parent engagement in LSWP implementation using the CPL 6-hour training curriculum is promising. The training curriculum strategy involved providing promotores with (topic-specific and advocacy) knowledge to build their SE to navigate complex school policy environments and hold school stakeholders accountable for promoting healthy school environments. More evaluation research is needed on the potential value of a longer training curriculum.

Second, in addition to promotores’ SE gains to perform the LSWP advocacy tasks, they discussed how to mobilize parents, and they practiced the advocacy skills in a real-life setting. This combination of the three components of PE theory is consistent Popular Education, an adult education philosophy used by many promotor organizations (Werner & Bower, 1982). In Popular Education, knowledge is generated collectively by discussing and analyzing lived experiences to identify and implement problem-solving strategies. Therefore, PE theory may be well suited to provide theoretical guidance on future promotor training and intervention research.

Third, after this pilot training the next key step is to develop and implement a subsequent promotor-led intervention to engage school parents in LSWP implementation advocacy efforts. As seen in this pilot training study, organizational support is useful. Organizational support can take the form of training promotores, convening promotores for follow-up discussions, and linking promotores with other community resources. Further research that illuminates how to strengthen organizational support systems (e.g., training, follow-up, partnership building) for promotores’ school advocacy efforts can add much needed practice-based evidence to this topic area.

Footnotes

Acknowledgements

We acknowledge and appreciate the promotores and promotor agency staff who participated in this research.

This research was supported in part by grants from the Rosalinde Arthur Gilbert Foundation.

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