utilizing the school health index to build collaboration between a university and an urban school...

RE S E A R C H AR T I C L E

Utilizing the School Health Index to BuildCollaboration Between a University and anUrban School DistrictJAMES BUTLER, DrPH, MEda,b CRAIG S. FRYER, DrPH, MPHc,d ERNESTINE A. REED, MEde STEPHEN B. THOMAS, PhD, FAAHBf,g

ABSTRACTBACKGROUND: Insufficient attention has been paid to the process of conducting the Centers for Disease Control andPrevention’s School Health Index (SHI) to promote collaboration between universities and urban school districts whendeveloping adolescent health promotion initiatives. This article provides an overview of the real-world contextual challenges andopportunities this type of collaboration can pose.

METHODS: The SHI and selected collaboration principles were used to facilitate partnership and increase stakeholder buy-in,which led to developing and implementing an 8-year health promotion campaign.

RESULTS: The focus on planning brought together key stakeholders to allow for health promotion programming to take place,despite the competing demands on the schools. The SHI allowed for input from stakeholders to develop campaign activities andinform school- and district-wide policy. Universities and school districts desiring to develop and implement school-based,adolescent health promotion programs should (1) identify the hierarchical structure of the school district, (2) establish credibilityfor the program and the university staff, (3) emphasize the benefits to all partners, (4) maintain a cooperative partnership withteachers and administrators, (5) appreciate the need for planning, and (6) provide as many resources as possible to aid analready overburdened school system.

CONCLUSIONS: Promoting healthy behaviors among students is an important part of the fundamental mission of schools.The significance of collaboration using the SHI, with direct input from students, teachers, administrators, and universitypartners, is critical in the development of institutional support for implementation of adolescent health promotion initiatives.

Keywords: adolescent health; school health; School Health Index; collaboration; physical activity; nutrition.

Citation: Butler J, Fryer CS, Reed EA, Thomas SB. Utilizing the School Health Index to build collaboration between a universityand an urban school district. J Sch Health. 2011; 81: 774-782.

Received on February 2, 2010Accepted on March 1, 2011

Adolescence is a critical time for the developmentof lifestyle practices, attitudes, and beliefs related

to health and well-being.1 Many adolescent healthbehaviors, including dietary practices, physical activityhabits, and weight control have been previouslydescribed.2-4 Yet evidence suggests there may because for concern, not only about the current healthstatus and behaviors of adolescents, but also abouttheir future health status as adults.1 Comprehensiveschool-based initiatives that target these behaviors

aAssistant Professor, ([email protected]), Department of Behavioral & Community Health, School of Public Health, University of Maryland College Park, 2320 SPH Building 255,College Park, MD 20742-2611.bAssociate Director, ([email protected]), University of Maryland Center for Health Equity, School of Public Health, University of Maryland College Park, 2320 SPH Building 255,College Park, MD 20742-2611.cAssistant Professor, ([email protected]), Department of Behavioral & Community Health, School of Public Health, University of Maryland College Park, 2324 SPH Building 255,College Park, MD 20742-2611.dAssociate Director, ([email protected]), University of Maryland Center for Health Equity, School of Public Health, University of Maryland College Park, 2324 SPHBuilding 255, CollegePark, MD 20742-2611.eExecutive Director (retired) of Middle Schools Operations, ([email protected]), Board of Public Education, School District of Pittsburgh, 341 South Bellefield Avenue, Pittsburgh,PA 15213-3552.

can help sustain healthy lifestyles through theadolescent years and after the initiatives have ended.5

However, insufficient attention has been paid to theprocess of conducting the Centers for Disease Controland Prevention’s (CDC) School Health Index (SHI)to promote collaboration between a major publicuniversity and an urban school district to developan adolescent health promotion campaign, and thereal-world challenges and opportunities this type ofcollaboration can pose.

774 • Journal of School Health • December 2011, Vol. 81, No. 12 • © 2011, American School Health Association

The social and physical environments of schoolsare considered significant factors that affect ado-lescent food consumption habits, physical inactiv-ity practices, and subsequent obesity rates6-8 thatare all risk factors for adult-onset conditions amongadolescents (eg, cardiovascular disease, hypertension,and type 2 diabetes).1 This, in turn, may suggestthat (1) adolescents are not receiving or implement-ing health promotion messages designed to con-tribute to optimal health throughout the lifespan,1

(2) their communities lack resources to maintainareas and facilities to promote physical activity,9 and(3) adolescents lack access to healthy foods in theirschools and neighborhood.7,10

In recognition of the growing prevalence of obe-sity and to promote the overall health and well-beingof adolescents, the CDC’s Division of Adolescent andSchool Health developed the SHI. The SHI is an adoles-cent and school health assessment tool designed to helpschools and school districts evaluate and improve theirhealth policies and programs in the context of a Coor-dinated School Health Program (CSHP). The SHI cur-rently addresses several adolescent health behaviorsincluding physical activity and nutrition education.11

In this article, we describe use of the SHI as a road map,guided by selected collaboration principles (building onpartners’ strengths and resources, reciprocal learning,cultural humility, and long-term commitment),5,12 tobuild collaborations between an urban school districtand a public university to plan a comprehensive healthpromotion campaign, which is designed to impact theschool environment, school policy, and potentially thehealth behaviors of students.

LITERATURE REVIEW

Health promotion has been concerned with pro-gram settings for many years—most commonly interms of carrying out comprehensive health promo-tion initiatives within a particular setting, for example,the workplace, community, and in schools.13 Theschool-based setting offers opportunities for healthpromotion initiatives to be directed at individual healthbehavior change, as well as environmental change toachieve improved health outcomes for school-agedyouth, school administrators, and school staff.14 Inaddition, by using a ‘‘settings approach’’ to adolescenthealth promotion provides an all-inclusive framework

fProfessor, ([email protected]), Department of Health Services Administration, School of Public Health, University of Maryland College Park, 3302E SPH Building 255, College Park, MD20742-2611.gDirector, University of Maryland Center for Health Equity School of Public Health, University of Maryland College Park, 3302E SPH Building 255, College Park, MD 20742-2611.

Address correspondence to: James Butler, Assistant Professor, ([email protected]), Department of Behavioral & Community Health, University of Maryland Center for Health EquitySchool of Public Health, University of Maryland College Park, 2320 SPH Building 255, College Park, MD 20742-2611.

This work was supported by a grant fromthe Heinz Endowments and the National Institute on Minority Health and Health Disparities (Grant PG60MD000207) to Dr. Thomas.Dr. Butler was supported, in part, through his Mentored Career Development Award to Promote Diversity (K01CA134939; PI: Butler). Dr. Fryer was supported, in part, through hisMentored Research Scientist Development Award to Promote Diversity (K01CA148789; PI: Fryer).

within which to work, encourages multi-stakeholderownership of health, and is suitable for collaborationsbetween universities, public school districts, and indi-vidual schools.15

Most US public schools provide some type of nutri-tion and physical activity programs; however, multiplecountervailing pressures (eg, budget cuts, increasingdemands on teachers’ time, and political pressures toimprove student performance on standardized tests)act on school leaders to impede a sustained focus on thehealth of students.16 For example, due to budgetaryconcerns and testing requirements, the transfer ofschool food services to outside vendors, the reliance onvending machine revenues for extracurricular activi-ties, and the elimination of physical education activitieshave all contributed to a less-than-optimal schoolenvironment where adolescents spend their formativeyears.17-20

Nonetheless, schools still remain ideal settingsfor implementing comprehensive health promotioninitiatives20 including physical activity and nutritioneducation as they are an important context in whichadolescents develop, grow, and spend time.17 In addi-tion, school-based interventions that focus on healthyeating and exercise have been shown to significantlyimpact adolescent health behaviors.21,22 These inter-ventions are especially relevant in racial and ethnicminority communities characterized by social and eco-nomic disadvantage.22

Originally proposed in 1987, Allensworth andKolbe23,24 provided a model with an ‘‘expanded’’perspective, encouraging linkages, and coordinationamong a broader number of supports to ensureachieving healthy students. Thus the CDC’s CSHPmodel consists of 8 interrelated components thatconstitute a CSHP, including systematic communi-cation and collaboration between students, families,teachers, and school administrators in an effort toimpact the overall school environment as well asschool health policies.11 The CSHP model asserts thatschools by themselves cannot—and should not beexpected to—solve the nation’s most serious healthproblems that affect students. Still, schools couldprovide a facility in which university faculty mightwork together with parents and school personnel todevelop programs aimed at maintaining the health andwell-being of adolescents.12,25,26 This type of intera-gency cooperation between a university and a school

Journal of School Health • December 2011, Vol. 81, No. 12 • © 2011, American School Health Association • 775

district harnesses the imagination, innovation, andmutual support that can come from working acrossprofessional and organizational boundaries.13,27 As aresult, a CSHP that works meets the health needs of thestudents and increases the use of actions that improvestudent health, while also making better use of healthpromotion and disease prevention tools like the SHI.11

Recognizing the potential for schools to providemore healthful nutrition and physical activity envi-ronments for the nation’s young people, the SHIenables schools to identify and evaluate the strengthsand weaknesses of their health education, safety poli-cies, and related programs.25,26 In addition, the SHIenables schools to develop action plans for improv-ing student health and promotes the engagement ofteachers, parents, students, and the community inadvancing healthy behaviors.4,16,28 Although researchdemonstrates the use of the SHI in the assessment ofadolescent school health promotion,4,16,28,29 there is adearth of literature about the processes employed byuniversity faculty and external collaborators to engageteachers, parents, students, and the community in theplanning of health promotion initiatives. More impor-tantly, to our knowledge, this process has less oftenbeen examined in urban public school settings.

Over the past several years, increased nationalattention has been given to issues of overweightand obesity among children.7,8 According to the USDepartment of Health and Human Services, 9 millionchildren, or 16%, were overweight and the rateof overweight children in Pennsylvania was 18%.30

These statistics were particularly alarming for urbanyouth, as many were already overweight or at riskfor overweight, and gender, age, race, and individuallevels of poverty were associated with their increasedweight gain.31,32

THE SHI AS A PLANNING TOOL: GETTING STARTED

The Pittsburgh, Pennsylvania school district alongwith its 18 middle schools and 10 high schools facedunique challenges related to its limited resources as itattempted to address the overweight epidemic amongits students. Having firsthand knowledge of these chal-lenges and a positive prior working relationship, theSchool District Superintendent requested formation ofa collaborative effort with the university to addressthis critical health issue. Identifying and addressingthese challenges while modifying school policies andcurricula13 related to school-based health promotioninitiatives became essential. Thus, the SHI was used asa planning tool and roadmap for developing collabo-rations and solidifying relationships between a publicuniversity and the school district to help the districtlaunch a comprehensive health promotion campaign.

From September to December 2002, the SchoolDistrict Superintendent held a series of meetings

with district administrators, teachers, and principalsto introduce the SHI in all 18 middle schools. The pri-mary aim was to select which SHI modules would beincluded in the planning process, and to gain buy-infrom these key stakeholders. University faculty werealso invited and attended these meetings to gain fur-ther understanding of the SHI and how it can be usedto foster collaboration when planning comprehensiveadolescent health initiatives.

The initial activity of these meetings was having thestakeholders engage in a collaborative process to cre-ate healthier students and schools by completing the8 SHI self-assessment modules, which correspond tothe 8 components of a coordinated school program,11

with special attention paid to the Physical Educationand Nutrition Services modules. Completion of themodules provided the framework for utilizing a ‘‘wholeschool approach’’15 for engaging the schools in the pro-cess of planning regarding healthier school environ-ments. In addition, the SHI provided the framework fora ‘‘whole child approach,’’33 which we addressed bycreating school health teams and identifying studentrole models to participate in leadership development,an important component of a CSHP’s sustainability.34

After completing the 8 SHI self-assessment modules,the stakeholders posed the question, ‘‘How can weaddress physical activity and nutrition education in ourschools?’’ From this simple question and its subsequentdiscussion, the concept of a health promotion and dis-ease prevention campaign was born specifically withthe idea of following a cohort of students scheduledto graduate in the year of 2010, using Healthy People2010 as a beacon. More importantly, this approach wasinclusive of the entire school district and directly tiedthe campaign to the 2010 graduation.

Using the SHI recommendations for establishingschool-level health advisory boards,11,33 the schooldistrict administrators, teachers, parents, students, anduniversity faculty worked collaboratively to identifyexisting school health policies’ and programs’ strengthsand weaknesses as the initial step in developing andimplementing a new comprehensive school healthcampaign. According to the SHI, these boards can pro-mote lifelong wellness by supporting a healthy learningenvironment, which impacts adolescent health andwell-being; enabling the students to become healthyand productive adults.11,33 Thus, we instituted 3 advi-sory boards to guide the implementation of the SHI:(1) a Planning and Advisory Committee comprised ofschool district representatives and university faculty;(2) School Health Teams composed of teachers, staff,and parents; and (3) a Peer Health Council (studentrepresentation from each school).

In September 2003, activities derived from the SHIprocess were officially launched as a health promo-tion campaign and ambitiously targeted all sixth-grade


Table 1. A Description of the 10 Pittsburgh Public High Schools

School Description Total Enrollment African American (%) White (%)

A The largest of the 10 schools offers programs at the gifted, scholars, and standardacademic levels.

1402 37 56

B This school provides comprehensive academic programs to accommodate studentneeds.

1124 38 55

C Students receive a quality education in an atmosphere that nurtures their individualartistic talents.

551 32 61

D The school provides special programs in business and health technology. 918 37 58E A teaching, horticulture/landscaping, health, and robotics academies are located

within this school.493 67 29

F The law and public service and the Junior Reserve Officers’ Training Corps (ROTC)are 2 magnet programs offered to students.

575 82 13

G The Robotics Technology and Public Safety programs and the health careers,Information Technologies and Culinary Arts academies are housed here.

492 93 4

H This school provides students with opportunities to learn scientific researchprocedures through its mathematics and science program.

736 63 32

I The school is home to 2 magnet programs: the International Baccalaureate andRobotics Technology.

684 70 23

J The only school with a 100% African American population. Students can receiveprofessional certifications and science and mathematics academy scholarshipson completion of 4 years of school.

335 100 0

students (approximately 2000) attending the 18 Pitts-burgh middle schools. To jump-start the campaign,‘‘Back-to-School Rallies’’ were organized at everyschool. During the rallies, presentations were givenby both university faculty and school teachers on theimportance of healthy eating and physical activity andstudents were provided with pedometers and strate-gies to build these activities into their daily lives. Theaim was to introduce concepts of healthy eating andphysical activity and spark the students’ interest inthe campaign, and stress the importance of havingthem as collaborators with the university-school dis-trict partnership. After graduation, these same studentswere then followed as they transitioned from middleschool to the 10 Pittsburgh Public High Schools listedin Table 1.

Once the students transitioned into high school, theadvisory board membership changed and new advi-sory boards had to be developed and reestablished.The former administration of the middle schools thatcomprised the initial advisory boards requested toremain involved with the SHI process. As a result,university faculty worked diligently to find tangibleways for them to remain connected to the process andits activities. An important component of the transi-tion was that former advisory board members’ (eg,administrators and teachers from the middle schools)testimony regarding the importance of the SHI processgarnered interest from the high school administratorsand teachers. The former middle school administra-tors played a pivotal role in obtaining buy-in from thenew high school administrators and teachers. Thus,their assistance created a more prudent process inthe development of the new advisory boards and thetransition of the campaign.

The advisory boards continually met and engagedits members, especially the students, in collaborativepartnerships with the university to develop SHI activi-ties. For example, the university conducted mini-grantwriting workshops with the students and teacherson how to write and submit a competitive grantapplication. Subsequently, each school applied to theuniversity for a mini-grant of $1500 each year to designtheir own health-related initiatives (eg, purchasing amicrowave to heat lunch meals brought from homeand exercise equipment to increase physical activ-ity during after school programs). Table 2 presentsselected activities derived from the SHI implemen-tation process. Some of which focus on increasingphysical activity and nutrition practices during an aca-demic school year.

BUILDING COLLABORATION WITH THE SCHOOL DISTRICT

The Pittsburgh Public School District is the largest of43 school districts in Allegheny County and the secondlargest in Pennsylvania. The district serves approx-imately 28,000 students in Kindergarten throughgrade 12 in 65 schools, and is composed of 10high schools each with unique academic programs(Table 1). Although the university and the school dis-trict had a prior positive work relationship, district pol-icy mandated that formal administrative approval mustbe obtained before any university-initiated health pro-motion program could be implemented. This processnecessitated understanding the levels within the hier-archical framework of the Pittsburgh School Districtthat included a Superintendent of Schools, Develop-ment Coordinators—who serve as liaisons betweenthe district and external organizations who enter


Table 2. Selected Activities From the SHI Implementation Process

Date Activity Description

September 2003 Pedometer distribution to track physical activity >3000 pedometers provided to students attending the 18 public middle schools.October 2004 and 2005 Let’s just PLAY day A local park was the site of physical activity sessions (eg, trail walks, relay races,

dancing) to encourage students to make some extra time in their day to PLAYand celebrate PLAY based on the Nickelodeon© Television Channel’s annualWorld Wide Day of Play.

April-May 2006 Writing anthology project The anthology of student work represented an effort to highlight the schooldistrict’s commitment to integrating health and wellness across the curricula.

October-December 2006 High school mini-grant proposals Eight proposals were approved. Students from1 high school used a portion of theirfunding to develop an Afro-Latino Dance Troupe to promote physical activity.

January 2007 Art poster contest Winning posters were converted into billboards, providing increased visibility in thecity of Pittsburgh for the SHI priority goals of physical fitness and nutritioneducation.

February 2007 Evening cooking classes The first of 5 evening cooking classes for parents and students was held to promotehealthy food choices.

February 2007 High school mini-grant proposals These proposals focused on nutrition education and increasing physical fitness. Oneschool used part of their mini-grant funding to rent bikes for their students to useon a local bike trail.

May 2007 ‘‘Be active’’ and ‘‘be healthy’’ day This event was planned by the Advisory Committee and Peer Health Councils andheld at a local amusement park to promote awareness of the importance of dailyphysical activity.

October-December 2008 Meetings Meetings were held at each school to continue and maintain the collaborationprocess and engage teachers and students.

November 2009 Poster presentation A poster, based on using the SHI and certain collaboration principles, was presentedat a national public health meeting.

January-May 2010 Yearbook ads High school yearbook ads were taken out to congratulate the 2010 graduates.May-June 2010 T-shirts Final distribution of health promotion/disease prevention campaign T-shirts to

students.

SHI, School Health Index.

into collaboration with the district, Coordinator ofHealth Services, and the Institutional Review BoardOffice. Considering the school district receives numer-ous requests from outside agencies for programmingand other activities, several efforts, including a formalletter describing the prior endeavors and the desire forcollaboration using the SHI, were made to ensure thecollaboration would become firmly established.35

Additional meetings with specific district personnel(eg, Coordinator of Health Services and the Develop-ment Coordinators) were arranged during the fall of2002 to ensure activities derived from the SHI planwere consistent with district policy. At this time, a for-mal application of request to conduct a health initiativein the school district was submitted and approved bythe school district’s and the university’s institutionalreview boards. This endorsement was based on per-ceived validity of the SHI, scientific merit, consistencywith district objectives for collaboration with outsideagencies, potential benefit to the students, and the uti-lization of an experienced liaison, who worked directlywith the school district and the university.36

Collaborating With the High SchoolsAn early sustained focus on the school district liaison

was critical to ensure that district needs and interestswere gauged correctly.37 In districts with several highschools, communication with outside agencies usually

requires trained school-based personnel to act as adesignated intermediary.37 Our school district liaisonfilled an important role in providing a communicationlink between the university faculty and staff, the schooldistrict administration, and the schools.

The high school principals provided the schooldistrict liaison with a list of teachers to serve as SHIprocess facilitators responsible for initiating contactwith their fellow teachers, the students, and staff fromtheir respective schools. The facilitators were biology,health, and physical education, and English teacherswho were interested in partnering with the universityand ensuring the SHI health theme of physical activityand nutrition education would be integrated acrossthe curricula. At this time, an initial meeting ateach school, arranged by the facilitator, included theprincipal, vice principal, interested teachers, and theuniversity faculty. Its purpose was to obtain buy-inand to determine SHI-specific activities. The facilitatorsfurther arranged meetings between the universityfaculty and the students to begin developing health-related activities (eg, evening cooking classes withstudents and their parents).

COLLABORATION PRINCIPLES

The literature describes principles to identify andguide collaborations between universities, school


district personnel, schools, and communities.5,12,13,15,37

These principles are congruent with the SHI, whichstresses the need for people interested in adolescenthealth to become involved and work together to createhealthier students and healthier schools.11,15 Althoughmany of these principles can be applied to interactionswith both participants and partners, our focus wason collaborations with our partner organizations—theschools and school district. For the purposes of thisarticle, we chose to focus on 4 particular collabora-tion principles that are consonant with the settingsapproach to health promotion13 building on partners’strengths and resources, reciprocal learning, culturalhumility, and long-term commitment.

Building on Partners’ Strengths and ResourcesThis principle encourages university faculty to

build on partners’ strengths and maximizes the equi-table exchange of resources rather than focus ondeficits.13,38 In our case, the school district providedaccess to the students, school facilities, and the invest-ment of various school staff members with dedicatedtime and effort devoted to implementation of the SHIas part of their jobs. The university provided dedi-cated staff support, professionally designed campaignmaterials, and financial resources for each school inthe form of a $1500 mini-grant to develop innova-tive health promotion initiatives driven by each schooland designed to increase physical activity and advancenutrition education to increase consumption of fruitand vegetables.

In addition to a mutually valued goal and a favor-able exchange of resources, another significant aspectof readiness to collaborate is the characteristics of thepartner’s leadership.39 The school district was led byexperienced administrators committed to finding waysto better respond to adolescent health issues. More-over, these administrators embraced the universityassistance as a means to address the challenges froma public health perspective. These district administra-tive strengths were important assets facilitating thecollaboration.

Reciprocal LearningThrough the process of reciprocal learning,40 the

university faculty and the school district gaineda deeper understanding of each other and thefundamental issues of nutrition education and physicalactivity among adolescents. The process requiredfaculty to understand the culture of the school district,each individual school,36 and orient the partners tothe culture of a public university.41

Advisory boards are a mechanism increasingly usedby universities in collaboration with targeted groupsto reciprocally learn from one another.42,43 As notedabove, 3 advisory boards guided the SHI process that

represented the views and interests of the students,teachers, parents, school district representatives, anduniversity faculty. These advisory boards informedthe university faculty about culturally sensitive andeffective recruitment strategies. The boards also pro-vided insight into the development of materials andhow to obtain district-wide support and overcomebarriers via conflict resolution.13,44 Currently, the lit-erature describing advisory boards tends to place moreemphasis on 1-way information flow, from advisers touniversity faculty.5 Our experience is best describedas a 2-way, reciprocal, communication, and learningmodel between both partners.

Cultural HumilityUniversity faculty should demonstrate what Ter-

valon and Murray-Garcia45 refer to as cultural humil-ity, which involves respecting the strengths, expertise,and organizational culture of collaboration partners.Practicing cultural humility serves to minimize poten-tial power imbalances between faculty and partners.Although a university and an urban school district areinstitutions of education, it was clear from the outsetthat each institution had its own unique culture ofoperation. We tried to demonstrate cultural humilityby consulting with the advisory boards to learn abouteach school’s practices that may impact the implemen-tation of the SHI. For example, university faculty hadto humble themselves and respect the existing meet-ing culture of the school district and not push its ownmeeting agenda based on convenience. As a result,one direct outcome from this experience was that SHIplanning meetings were integrated into the standingBoard of Education meetings with principals.

Long-Term CommitmentCollaboration calls for a strong commitment by uni-

versity faculty to the long-term, iterative processes ofhuman and social capital development in school dis-tricts and to sustaining effective school-based healthinitiatives.13,44 The first year of the SHI collabora-tion process began with limited resources. However,a grant from a local philanthropic organization waslater received. Our experiences indicated the philan-thropic organization gained confidence in our strategyof collaborating with the school district and providedus with a substantial multiyear grant, which is longerthan their traditional 1-year-at-a-time grant funding.Notwithstanding, our school district partners contin-ued to demonstrate their commitment to the SHIprocess by informing us of culturally sensitive prac-tices, effective implementation strategies, developmentof materials, and solutions to overcoming barriers inthe achievement of our goals.

Formal projects in which representatives from pub-lic schools and universities work together to resolve


common problems is critical in planning school districtand university collaborations.46,47 These collaborationscan pose several challenges especially in terms of the‘‘sweat equity’’ time investment, the tension betweenconducting research versus providing service, adher-ing to state laws and school district policies, and thelimits of time in a school day where ‘‘no child leftbehind testing’’ shapes school priorities. In our case,the SHI was the mechanism that allowed for inclusionof all stakeholders48 —from school district administra-tors to students—to make meaningful contributions,strategically plan and implement the SHI, and build asolid relationship from collaborations with universityfaculty.

DISCUSSION

Brener et al28 found that few schools nationwideare addressing the entire breadth of SHI items and amore coordinated approach to school health is neededto reinforce health messages. Moreover, Staten et al29

reported that most schools have made 1 immediatechange in their school environment, yet requireplanning and perhaps the assistance of subcommitteesin the development of district-wide health curricula.Our work highlights the process and the use of the SHIin the formation, development, and implementationof an adolescent health promotion campaign. Thus,our work fills a gap in the literature by examininghow to collaborate and form important partnerships.Furthermore, this work demonstrates how the SHIcan be used both at the micro-level (students) withemphasis on the planning process and collaborationinstead of just at the macro-level (schools); where themajority of published literature has limited it focus.28,29

The successful collaboration reported here would havebeen nearly impossible without the use of the SHIas an organizing tool through which the planningprocess could flow and adapt to the cultural normspresent within a school district.

Urban school districts are complex organizationscomplete with public debates over policy and fundingpriorities. During the course of our work, the schooldistrict went through a major reorganization withschool consolidations, closings, and staff reductions.This resulted in political controversy, public demon-strations, and charges of racism and discrimination thatspilled out into the social and political environment.49

This was the real-world context in which we collabo-rated with an urban school district and its implemen-tation of an adolescent health promotion campaign.For example, programs that appeared to detract from‘‘academic areas of study’’ were viewed by the teachersand administrators as being of ‘‘marginal importance.’’Use of the SHI, however, provided a framework fromwhich to address these and other challenges.

We discovered that the focus on planning putteachers, students, parents, and the university facultyon the same level of mutual respect for the SHI process,as they collectively had control. The SHI also allowedfor flexibility to use input—from the school districtadministrators to the students in the classroom—todevelop activities and to inform district wide andlocal school policy related to health promotion anddisease prevention. We also believe that the mini-grantprogram added value to the process so that schoolsreceived financial support to implement their sharedvision on how best to improve the school environment.This approach resulted in the integration of healthpromotion activities across the school curriculaincluding, but not limited to, English, math, socialstudies, and health and physical education classes.

IMPLICATIONS FOR SCHOOL HEALTH

Creating a school environment conducive topromoting healthy behaviors among students is animportant part of the fundamental mission of schoolsto provide young people with the knowledge andskills they need to become healthy and productiveadults.3 Improving student health can lead to increasedcapacity to learn, reduced absenteeism, and improvedphysical fitness and mental alertness.11 Use of the SHI,underscored the significant need for an adolescenthealth promotion campaign that specifically addressedphysical activity and proper nutrition.

Moreover, using the SHI as a planning instrument,rather than an assessment tool, facilitated the adop-tion of the 4 collaboration principles: building onpartners’ strengths and resources, reciprocal learning,cultural humility, and long-term commitment. The SHIhighlighted the importance of developing a carefullyorganized plan to build collaborations and solidify rela-tionships that were necessary to effectively implementthis school-based campaign across the entire schooldistrict. The school district, its schools and studentstook ownership of the SHI processes and outcomes tosuccessfully implement the campaign. Furthermore,the SHI helped ensure that the health promotionactivities launched across the school district were notfragmented, but became branded as a district-wide (ie,across all 10 high schools in the system) campaignknown as the Healthy Class of 2010.

To guide future university and school district col-laborations, we recommend addressing the follow-ing critical areas when developing and implementingschool-based, adolescent health promotion initiatives.First, determine the hierarchical structure of the schooldistrict before approval is sought. Second, establishcredibility for the initiative and the university facultyand staff. Third, emphasize the benefits of the pro-gram to the school district, schools, parents, and stu-dents. Fourth, maintain a cooperative partnership with


teachers and administrators to ensure effective imple-mentation of the initiative. Fifth, appreciate the needfor meticulous schedule planning and changes thatwill affect program implementation. Finally, provideas many resources as possible rather than makingrequests on an already overburdened and underfundedschool system.

By utilizing the SHI and selected collaborationprinciples, we believe there are useful strategies andlessons learned that may benefit urban school districts,and outside organizations seeking to work togetherto potentially change student health behaviors, theschool environment and policies. In our case, the needfor district-wide changes in the types of food optionsoffered at the schools was stressed by the studentsvia mini-grants and the Peer Health Councils thatinformed policy. This led to overall changes in foodservice by providing healthier food and drink optionsin the cafeteria and vending machines. It is both thestudents’ and partners’ ownership of the process thatmakes use of the SHI a tool that continues to yieldpositive results.

The use of the SHI during the planning processserved as the foundation for establishing this signif-icant partnership between a public university andan urban school district. Our experience utilizing theSHI and selected principles of collaboration within anurban public school district helped the district launcha comprehensive health promotion campaign that wasdesigned to impact the school environment, schoolpolicy, and potentially the health behaviors of its stu-dents. Moreover, this experience confirms our beliefthat universities can play an important role in shap-ing the healthy behaviors of our youth and impact thesocial and physical environments of the neighborhoodswhere these youth live.

REFERENCES

1. Jessor R, Turbin NS, Costa FM. Protective factors in adolescenthealth behavior. J Person Soc Psychol. 1998;75(3):788-800.

2. O’Dea J. Body basics: A nutrition education program foradolescents about food, nutrition, growth, body image, andweight control. J Am Diet Assoc. 2002;102(3 suppl.):S68-S70.

3. Olson AL, Gaffney CA, Lee PW, Starr P. Changing adolescenthealth behaviors: The healthy teens counseling approach. AmJ Prev Med. 2008;35(5 suppl.):S359-S364.

4. Sherwood-Puzzello CM, Miller M, Lohrmann D, Gregory P.Implementation of Centers for Disease Control’s School HealthIndex in 3 Midwest middle schools: Motivation for change.J Sch Health. 2007;77(6):285-293.

5. Dumka LE, Mauricio AM, Gonzales NA. Research partnershipswith schools to implement prevention programs for Mexicanorigin families. J Prim Prev. 2007;28(5):403-420.

6. Zhang X, Christoffel KK, Mason M, Liu L. Identificationof contrastive and comparable school neighborhoods forchildhood obesity and physical activity research. Int J HealthGeophysics. 2006;5:14.

7. Nestle M. Strategies to prevent childhood obesity must extendbeyond school environments. Am J Prev Med. 2010;39(3):280-281.

8. Committee on Prevention of Obesity in Children and Youth.Preventing Childhood Obesity: Health in the Balance. Washington,DC: Institute of Medicine; 2005.

9. Poston WS, Foreyt JP. Obesity is an environmental issue.Atherosclerosis. 1999;146(2):201-209.

10. Kennedy E, Goldberg J. What are American children eating?Implications for public policy. Nutr Rev. 1995;53(5):111-126.

11. Centers for Disease Control and Prevention. School Health Indexfor Physical Activity, Healthy Eating, and a Tobacco-Free Lifestyle:A Self-Assessment and Planning Guide. Middle School/HighSchool Version. Atlanta, GA: Centers for Disease Control andPrevention.

12. Israel BA, Schulz AJ, Parker EA, Becker AB. Review ofcommunity-based research: Assessing partnership approachesto improve public health. Annu Rev Public Health. 1998;19:173-202.

13. Tsouros AD, Dowding G, Thompson J, Dooris M, eds. HealthPromoting Universities: Concept Experience and Framework for Action.Copenhagen: World Health Press; 1998:21-32.

14. Nutbeam D. Health promotion effectiveness - the questionsto be answered. In: International Union for Health Promotionand Education, ed. The Evidence of Health Promotion Effectiveness.Shaping Public Health in a New Europe. Part Two: Evidence Book.Brussels: ECSC-EC-EAEC; 2000:1-11.

15. Dooris M. Healthy settings: Challenges to generating evidenceof effectiveness. Health Promot Int. 2005;21(1):55-65.

16. Austin SB, Fung T, Cohen-Bearak A, Wardle K, Cheung LW.Facilitating change in school health: A qualitative study ofschools’ experiences using the School Health Index. Prev ChronicDis. 2006;3(2):A35.

17. Datar A, Sturm R. Physical education in elementary schooland body mass index: Evidence from the early childhoodlongitudinal study. Am J Public Health. 2004;94(9):1501-1506.

18. Sallis JF, Conway TL, Prochaska JJ, McKenzie TL, Marshall SJ,Brown M. The association of school environments with youthphysical activity. Am J Public Health. 2001;91(4):618-620.

19. Wharton CM, Long M, Schwartz MB. Changing nutritionstandards in schools: The emerging impact on school revenue.J Sch Health. 2008;78:245-251.

20. Deschesnes M, Martin C, Hill AJ. Comprehensive approachesto school health promotion: How to achieve broaderimplementation?. Health Promot Int. 2003;18(4):387-396.

21. O’Dea J, Maloney D. Preventing eating and body imageproblems in children and adolescents using the HealthPromoting Schools Framework. J Sch Health. 2000;70(1):18-21.

22. O’Dea JA. Gender, ethnicity, culture and social class influenceson childhood obesity among Australian schoolchildren: Impli-cations for treatment, prevention and community education.Health Soc Care Community. 2008;16(3):282-290.

23. Hoyle TB, Bartee RT, Allensworth DD. Applying the processof health promotion in schools: A commentary. J Sch Health.2010;8(4):163-166.

24. Allensworth DD, Kolbe IJ. The comprehensive school healthprogram: Exploring an expanded concept. J Sch Health.1987;57:409-412.

25. Centers for Disease Control and Prevention. Guidelines forschool health programs to promote life-long healthy eating.MMWR Recomm Rep. 1996;45:1-41.

26. Centers for Disease Control and Prevention. Guidelines forschool and community programs to promote life-long physicalactivity among young people. MMWR Recomm Rep. 1997;46(RR-6):1-36.

27. Centers for Disease Control and Prevention. Healthy Youth!Coordinated school health program. 2009. Available at:http://www.cdc.gov/ healthyYouth/CSHP. Accessed January25, 2011.

28. Brener ND, Pejavara A, Barrios LC, et al. Applying the SchoolHealth Index to a nationally representative sample of schools.J Sch Health. 2006;76(2):57-66.


29. Staten LK, Teufel-Shone NI, Steinfelt VE, et al. The SchoolHealth Index as an impetus for change. Prev Chronic Dis.2005;2(1):A19.

30. Governor’s Report. Pennsylvania: Receives an ‘A’ in 2006 Uni-versity of Baltimore obesity report card. 2007. Available at:http://www.emaxhealth.com/109/9395.html. Accessed Jan-uary 25, 2011.

31. Trent M, Waterfield G, Jennings J. Socioeconomic status andobesity among urban youth: A geographic analysis. J AdolescHealth. 2006;38(2):119.

32. Ogden CL, Carroll MD, Flegal KM. High body mass indexfor age among US children and adolescents. JAMA.2008;299(20):2003-2006.

33. Marx E, Wooley SF, Northrop D. Health Is Academic: A Guide toCoordinated School Health Programs. New York: Teachers CollegePress; 1998.

34. American School Health Association. ASHA provides CDCprogress report on CSHP. In: The Pulse. Kent, OH: AmericanSchool Health Association; 2008:3.

35. Olds RS, Symons CW. Recommendations for obtainingcooperation to conduct school-based research. J Sch Health.1990;60(3):96-98.

36. Petosa R, Goodman RM. Recruitment and retention ofschools participating in school health research. J Sch Health.1991;61(10):426-429.

37. Wallerstein NB, Duran B. Using community-based participa-tory research to address health disparities. Health Promot Pract.2006;7(3):312-323.

38. Rappoport J. Empowerment as a guide to doing research:diversity as a positive value. In: Trickett EJ, Wans RJ, BirmanD, eds. Human Diversity: Perspectives on People in Context. SanFrancisco, CA: Jossey-Bass; 1994:359-382.

39. Stith S, Pruitt L, Dees J, et al. Implementing community-basedprevention programming: A review of the literature. J PrimPrev. 2006;37:577-617.

40. Bradbury H, Reason P. Conclusion: broadening the bandwidthof validity; issues and choice-points for improving the qualityof action research. In: Bradbury PRH, ed. Handbook of

Action Research: Participative Inquiry and Practice. London: Sage;2001:447-456.

41. Wandersman A, Florin P. Community interventions andeffective prevention. Am Psychol. 2003;59:441-448.

42. Harris KJ, Ahluwalia JS, Okuyemi KS, et al. Addressing culturalsensitivity in a smoking cessation intervention: Developmentof the Kick It at Swope project. J Community Psychol. 2001;29:447-458.

43. Saunders SD, Greaney ML, Lees FD, Clark PG. Achievingrecruitment goals through community partnerships: TheSENIOR Project. Fam Community Health. 2003;26(3):194-202.

44. Israel BA, Schulz AJ, Parker EA, Becker AB, Allen AJ,Guzman JR. Critical issues in developing and following CBPRprinciples. In: Minkler M, Wallerstein N, eds. Community-BasedParticipatory Research for Health: From Process to Outcomes. SanFrancisco, CA: Wiley; 2008:47-62.

45. Tervalon M, Murray-Garcia J. Cultural humility versuscultural competence: A critical distinction in defining physiciantraining outcomes in multicultural education. J Health Care PoorUnderserved. 1998;9(2):117-125.

46. Dickens C. Too valuable to be rejected, too different to beembraced: A critical review of school/university collaboration.In: Johnston PB, Cramer D, Dove T, eds. Collaborative Reform &Other Improbable Dreams: The Challenges of Professional DevelopmentSchools. Albany, NY: State University of New York Press;2000:21-42.

47. Trickett EJ, Espino SL. Collaboration and social inquiry:Multiple meanings of a construct and its role in creating usefuland valid knowledge. Am J Community Psychol. 2004;34(1-2):1-69.

48. Allensworth DD. Improving the health of youth through acoordinated school health programme. Promot Educ. 1997;1:42-47.

49. Lee CJ, Elizabeth J. Foundations yank Pittsburgh school grants.Pittsburgh Post Gazette, July 10, 2002. Available at: http://www.post.gazette.com/neigh_city/20020710foundationcity1p1.asp.Accessed February 9, 2011.


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