Assessing a novel application of web-based technology to support implementation of school wellness policies and prevent obesity
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- Wright, P.M., Li, W., Okunbor, E. et al. Educ Inf Technol (2012) 17: 95. doi:10.1007/s10639-010-9146-4
Childhood obesity is one of the most pressing public health concerns in the United States. Because schools are a critical site to promote wellness and prevent obesity, extensive policy and legislative efforts have focused on school-based food services, nutrition education, physical education, and overall physical activity. Unfortunately, research indicates that most of these policies prove ineffective due to insufficient implementation. A small number of web-based programs have emerged that are designed to support the implementation of school wellness policies. The purpose of the current study is to present and interpret findings from an evaluation of the web-based portion of a program implemented throughout the state of Pennsylvania. In total, 192 registered users completed a survey designed to evaluate their utilization and perceptions of the web-based features of the Health eTools for Schools program. Participants represented the following stakeholder groups: school nurses, teachers, wellness coordinators, administrators, and food service directors. Findings indicate the web-based portion of the Health eTools for Schools program is comprehensive, well-designed, and has the potential to support implementation of school wellness policies geared toward obesity prevention. At present, the web-based features are most effective in providing school nurses with tools and resources to execute their roles related to obesity prevention. Applications supporting other groups such as teachers and food service directors require further development to be equally effective. The number of programs with this focus is likely to increase and further research is needed to address other aspects of these programs as well as their impact on student level outcomes such as eating habits, body mass index, physical activity levels, and physical fitness.
KeywordsObesity Web-based technology School Wellness policy
Trends for overweight and obesity in the United States (US) have taken on epidemic proportions in all segments of society (Center for Disease Control and Prevention CDC 2006; Racette et al. 2003). Among children and adolescents, the prevalence of obesity has tripled in recent decades (Hedley et al. 2004; Ogden et al. 2006). A wealth of epidemiological research has demonstrated that overweight and obesity are major risk factors for a multitude of psycho-social consequences in youth (Williams et al. 2005) as well as physical health consequences, such as type 2 diabetes, high blood pressure, and cardiovascular disease (Williams et al. 2005; World Health Organization (WHO) 2006). It is projected that obesity will become the leading cause of preventable morbidity and mortality, and may contribute to a decrease in life expectancy in the US (Olshansky et al. 2005; van Baal et al. 2006). Gender and race/ethnicity both serve as predictors of obesity. In general, females have a higher body mass index (BMI; the most common indicator of overweight and obesity) than males and both Mexican American and African American girls tend to have higher BMI than Caucasian girls (Center for Disease Control and Prevention CDC 2005; Felton et al. 2002; Ogden et al. 2008; Swallen et al. 2005). Over the last 30 years, the greatest increases in the prevalence of overweight in the US have been reported in African-American girls (Troiano et al. 1995). Among boys, a recent report indicates Mexican Americans are significantly more likely than Caucasians to have higher BMI. While such trends are important in helping us develop targeted interventions, it is clear that childhood overweight and obesity is a major public health concern that must be addressed systemically (Anderson and Butcher 2006). The current study evaluates a novel application of web-based technology to support schools in promoting student health and preventing obesity.
1.1 Obesity prevention in schools
While research has demonstrated that factors such as parental influence and the built environment (features such as parks, sidewalks, and biking paths) influence obesity, increasing physical activity levels and improving eating habits are commonly viewed as two of the most effective and actionable strategies to obesity prevention (Anderson and Butcher 2006; Sallis and Glanz 2006; Lindsay et al. 2006). It is also widely recognized that schools provide an important and highly efficient setting for obesity prevention interventions targeting children (Story et al. 2006; USDHHS 2001). Following this logic, many state and federal policies have been enacted in recent years to increase physical activity levels and improve the nutritional value of food that children consume in school. In fact, a recent review of policy activity between 2003 and 2005 revealed that 717 new bills related to childhood obesity prevention were introduced in 49 states (Boehmer et al. 2008). Perhaps the most significant piece of federal legislation on this issue is the Child Nutrition and WIC Reauthorization Act of 2004 (Public Law 108-265: Section 204) that mandated district level policies by the start of the 2006 school year to promote school-wide wellness. To address this mandate, many states and districts have adopted the Coordinated School Health Program model promoted by the Centers for Disease Control (CDC; Allensworth and Kolbe 1987; Institute of Medicine 1997; Marx et al. 1998). The Coordinated School Health Program model addresses eight interconnected components that, if working synergistically, have strong potential to impact student health. These eight components are physical education, health education, health services, nutrition services, counseling, psychological and social services, healthy school environment, health promotion for staff, and family/community involvement. Unfortunately, despite the intuitive appeal of school-based policies targeting childhood obesity, most prove ineffective (Trust for America’s Health 2009). Due to competing pressures such as mandated achievement testing, limited resources within schools, a lack of guidelines for implementation or accountability, and the fact that a number of these mandates are unfunded, many of these policies are not fully enacted (Vardaman 2009).
1.2 Web-based technology supporting academic and health outcomes
The use of web-based technology to support academic outcomes in schools is not new. For example, Discovery Education Assessment provides assessment tools that align with individual states’ high-stakes exams (see http://discoveryeducation.com/products/assessment/index.cfm). In addition to assessing students’ knowledge and predicting performance, this program also provides streaming video content for remediation. Study Island (see http://www.studyisland.com/) is aligned with specific states’ educational standards and offers web-based instruction, practice, assessment and reporting applications. Regarding the support of health outcomes, some programs exist to support specific areas, such as physical education (see http://www.pecentral.com/) and nutrition (http://www.mypyramid.gov/index.html). There are few examples of web-based programs that provide a broad range of resources that address student health outcomes and support school wellness policies. Perhaps the most well-established it is the Healthy Schools Program sponsored by the Alliance for a Healthier Generation (http://www.healthiergeneration.org/schools.aspx). The focus of the Healthy Schools Program is to help schools make healthy living an educational priority. The program is offered nationwide and currently has over 2,000 schools in its network and is represented in all 50 states. Most resources focus on the school level and relate to creating a healthy environment and supporting policy changes and programs that will promote physical activity and healthy eating for students and staff. Unlike the academically based programs noted above, the Healthy Schools Program is not tailored to meet state specific guidelines or standards and does not include customized student level reporting functions.
1.3 Health eTools for Schools
Health eTools for Schools is a program made possible through funding by Highmark Healthy High 5 which is an initiative of the Highmark Foundation, and also supported by Independence Blue Cross, and Blue Cross of Northeastern Pennsylvania in their respective service regions. The goal of the Highmark Foundation is to improve the health and well-being of children ages 6 to 18 years. The Health eTools for Schools program was developed by InnerLink, Inc. to support school and district level attempts to enact school wellness policies and prevent childhood obesity in the state of Pennsylvania. According to the Trust for America’s Health (2009), obesity rates in the state of Pennsylvania are characteristic of the national epidemic with 26.7% of adults being obese and 29.7% of children being overweight or obese. The Health eTools for Schools program is research-based and is aligned with Pennsylvania educational standards. It is customized to meet the needs of Pennsylvania schools and is based on the Coordinated School Health Program model, which was adopted state-wide in Pennsylvania in 2006.
The Health eTools for Schools program is designed to provide teachers, administrators, and other school/district personnel with resources to enhance student attitudes, knowledge and behavior regarding nutrition, physical fitness, and overall wellness. The program consists of web-based database applications that are supported in the field by a team of Coordinated School Health Consultants and implementation specialists. This approach to deployment, which the Health eTools for Schools Program refers to as coordinated school health extension services, is modeled after agriculture extension services provided by the United States Department of Agriculture (USDA; see http://www.csrees.usda.gov/). The web-based database applications offer numerous downloadable resources, information management applications, and reporting functions for school nurses, food service professionals, teachers, and administrators. The program provides them with interactive tools that help measure, record, and report changes in student health indicators, such as BMI, and competitive food policies. School nurses can conduct and record physical health screenings, including BMI, in a short period of time. Physical education and health teachers have access to innovative lesson plans and hands-on activities to use with students. Nutrition service personnel can access resources for food choices. Administrators have access to tracking of wellness policy implementation as well as best-practice approaches to wellness policy creation, and implementation.
The current study draws from the 2008–2009 Health eTools for Schools evaluation project. The first author was contracted by the American Association for Physical Activity and Recreation (AAPAR) to serve as the external evaluator for Health eTools for Schools. The specific aims of the evaluation project were to 1) Develop and validate a customized survey to assess the web-based features of the Health eTools for Schools program, 2) Administer the survey online to a representative sample of registered users, 3) Describe background of the respondents and the contexts in which they work, 4) Identify areas of relative strength and weakness that may guide program improvement, and 5) Establish baseline measures for future comparison and monitoring of program improvement efforts. The purpose of the current study is to present and interpret findings from that evaluation to assess the potential of web-based technology in supporting implementation of school wellness policies and contributing to obesity prevention.
2.1 Procedures and instrumentation
The Health eTools for Schools Survey was developed specifically for this project in consultation with the leadership at InnerLink, Inc. as well as representatives of the Highmark Foundation. The input of these key stakeholders as well as a review by a panel of registered users was intended to ensure a high level of content validity in the survey. After multiple rounds of revision and approval by the researchers’ Institutional Review Board, the content of the survey was finalized. In February 2009, an online version of the survey was administered. The survey was sent to a list of 1,300 registered users who had logged on to the program in the past 2 years. An initial introduction letter and explanation of consent procedures was sent to these users by the research team via e-mail. Upon sending these materials and a link to the survey, 76 of the registered users’ e-mail addresses prompted an undeliverable message. Therefore, the number of potential respondents was reduced to 1,224. Multiple follow-up messages were sent by the research team and by InnerLink, Inc. to bolster response rates. The survey was completely voluntary and anonymous in nature. Respondents were assured that no identifying information would be shared with individuals outside the research team. The survey was available online through the end of May 2009. The survey contained sections on participants’ background as well as their school/district context. The remaining sections contained items specifically related to participants’ perceptions and utilization of the web-based portion of the Health eTools for Schools program. Many items are general in nature and completed by all participants, however, some items are role-specific and targeted to Wellness Coordinator/Administrators, Food Service Directors, School Nurses, or Teachers. To balance the forced choice rating scale (most evaluative items are rated on a Likert scale, i.e. Strongly Agree through Strongly Disagree) the survey ends with several open response items that allow participants to make qualitative comments regarding program strengths and areas for possible improvement.
2.2 Participants and setting
In total, 192 registered users completed the survey, representing 15.7% of the 1,224 potential respondents. While this percentage is lower than expected, it is not uncommon for electronic survey response rates, which are consistently lower than mailed paper surveys (Leung and Kember 2005; Shannon and Bradshaw 2002). For example, Moss and Hendry (2002) demonstrated that response rates on electronic surveys can vary widely, ranging from 6% to 76%, for a number of reasons. Cook et al. (2000) conducted a meta-analysis of response rates for 56 web- or internet-based surveys administered across 39 different studies and calculated an average response rate of 34.6%. Possible explanations for the relatively low response rate in this study include system protections such as firewalls and spam blockers as well as the lack of any incentives offered to participants (Alessi and Martin 2010; Deutskens et al. 2004).
The vast majority of respondents in this study were White (96.4%) females (93.8%) and three-quarters (75.5%) were between the ages of 40 and 59. Most (85.4%) reported working in the field of education for four years or more and just over two-thirds (69.8%) had been at their current school for four years or more. All professional roles specified in the survey were represented in the following proportions: School Nurses, 81.3%; Teachers, 13.5%; Wellness Coordinators, 5.2%; Administrators 4.7%; and Food Service Directors, 1.6%. Representatives from InnerLink, Inc. confirmed this sample was representative of their user population.
Respondents in the current study worked in schools and districts across the state of Pennsylvania and represented the three regions providing the Health eTools for Schools program in the following proportions: Highmark Foundation (56.3%); Independence Blue Cross (37.5%); and Blue Cross of Northeastern Pennsylvania (3.6%). Respondents reported enrolling in the Health eTools for Schools program between 2005 and 2009 but the majority (80.2%) enrolled in 2007 and 2008. Respondents represented the full range of school levels serving the grades for compulsory education in the US, kindergarten through 12. Most (87.5%) worked in public schools, 8.9% worked in private schools, and only 2.6% worked in charter or alternative schools. Just over one-half (53.6%) of respondents described their school/district context as suburban, followed by rural (30.7%), and urban (15.6%). The majority (78.9%) estimated that their school served less than 1000 students and 41.1% estimated enrollments below 500.
2.3 Data analysis
All analysis was done at the item level, i.e. no scales were created. Item level analysis made use of descriptive statistics including frequencies, means, and standard deviations. Within each section of the survey, points of strength and weakness were identified through relative comparison as this was a baseline survey with no comparison group. Open response comments were analyzed using inductive content analysis strategies that allowed us to identify patterns and categories of responses (Patton 2002). Qualitative and quantitative data sources were triangulated to assess the degree to which findings were reinforcing or conflicting (Lincoln and Guba 1985).
3.1 General items for all respondents
Level of agreement with general evaluation items
% Strongly Agree & Agree Combined
Mean (Standard Deviation)
I understand the full range of tools and resources available through eTools.
The eTools program has helped us address state and federal mandates related to nutrition and physical activity.
Materials and resources from eTools have been incorporated into our curriculum.
The staff at my school has received sufficient training and support to effectively use the eTools program.
The eTools program is regularly utilized by multiple staff members at my school.
My school’s administration believes time and effort devoted to using eTools is well spent.
I believe the content of the eTools program represents current research and best-practice.
I believe the eTools program is easy to access and utilize.
I believe technical support and assistance related to eTools is sufficient.
I believe training and professional development related to eTools has been sufficient.
I believe the content of eTools aligns with our state educational standards.
I believe eTools is facilitating implementation of our school wellness policy.
I would recommend that other schools and districts adopt the eTools program.
The eTools program has improved the level and speed of communication that I can provide to parents about their children’s health.
It is important for eTools to link directly into the state reporting requirements from the Pennsylvania Department of Health and Department of Education.
3.2 Role-specific items
Depending on their professional role(s), participants were asked to respond to more specific items to provide additional context for the evaluation and feedback on the program. Regarding Administrators/Wellness Coordinators and Food Service Directors, the role specific items focused on contextual factors relevant to the broader evaluation project but not the current study. Several items completed by teachers did relate directly to the purpose of the current study and are therefore shared below. As school nurses are the primary target audience of the program and the largest user group, most of their role-specific items are presented below as they speak directly to the purpose of the current study.
Use by teachers of potentially relevant features (N = 26)
% At least once per year
% Have not used
How often do you use the eTools Lesson Plans/Curricula feature?
How often do you use the eTools Links to Other Websites feature?
How often do you use the eTools Professional Development Resources feature?
How often do you use the eTools Collaboration Station feature?
How often do you use the eTools Resources for Coordinated School Health feature?
How often do you use the eTools Fitness Assessments feature? (PE teachers only)
School nurses’ perception of use and impact
% Strongly Agree & Agree Combined
Mean (Standard Deviation)
We use the eTools program to monitor and report on our students’ health status.
We use the eTools program to identify and intervene with students at risk of obesity related health problems.
The eTools program is contributing to an increase in student activity levels.
The eTools program is contributing to improvements in student fitness levels.
The eTools program is contributing to students’ health awareness.
The eTools program is contributing to increased nutrition knowledge for our students.
The eTools program is contributing to improved eating habits for our students.
The eTools program is contributing to healthier lifestyle behaviors for our students.
The eTools program has reduced the amount of time I spend in daily record keeping responsibilities.
School nurses’ time spent on record keeping responsibilities (N = 106)
% 1 h or less
% 1–2 h
% 2–3 h
% More than 3 h
Prior to using eTools, the average amount of time I spent a day on record keeping responsibilities was...
Currently, the average amount of time I spend a day on record keeping responsibilities is...
School nurses’ utilization of specific features
How often do you use the…
% At least once per year
% Have not used
Daily Log feature?
Medication Log feature?
Health Screenings feature?
Progress Notes feature?
School Health Record feature?
Immunization Log feature?
Handheld Computer feature?
BMI Reporting feature?
3.3 Open responses
To compliment the quantitative findings reported above, three open response items were included at the end of the survey. These items were directed at all respondents and not restricted to specific roles. Respondents were asked to describe what they considered the strongest and weakest aspects of the program as well as suggestions for improvement. Inductive analysis of these responses was conducted to identify strong patterns or themes. Regarding strengths of the program, many respondents noted particular features such as “BMI reporting”, “daily logs”, and “health screening”. For instance, one respondent wrote, “BMI feature saves time hand writing and calculating BMI”. Another stated, “I love the daily log and how I can look up a student’s history to see if there is a link to their medical issues”. These responses are consistent with quantitative ratings described above.
Another area of strength had to do with reporting. Many respondents were positive about the program’s alignment with state reporting requirements. A typical comment was, “Correlates to the Pennsylvania School Health Record and reporting requirements”. Several respondents were equally positive about the parent reports that could be generated. Another broad category of strength was efficiency. Many responses fell under this category as they mentioned “ease of use”, “organization of information”, and “time saving”. Some of these comments referenced particular features and others referred to the overall program.
Regarding weaknesses in the program and areas for improvement, many comments related to technical difficulties. Typical complaints included, “program sometimes freezes or off line” and “The program is slow”. Many respondents noted that they had difficulty navigating the various screens. One wrote, “Please make it easier to go from one screen to the other without having to wander through”. Regarding the content of the system and the various features, many respondents mentioned additional features they would like to see to help with including issues like dental records and generating lists of students needing immunizations. As indicated by the sample in this study, school nurses are the most frequent users of this system. Perhaps related to that is the fact that several respondents representing other roles felt the functions related to them were less well developed. Given the relatively small number of respondents in these categories it is noteworthy that this pattern emerged. Sample quotes related to this issue include: “Food service section – there is nothing to speak of”; “system is not compatible with Fitness program”; “not functional for daily PE record keeping”; “Need more lessons on a variety of health subjects”; and “Not enough training in the other features which relate to nutrition & Phys Ed.”.
This study examined a novel application of web-based technology to support schools in promoting student health and preventing obesity. Findings presented here indicate the Health eTools for Schools program is a comprehensive, well-designed program that has the potential to support implementation of school wellness policies geared toward obesity prevention. More specifically, qualitative and quantitative findings indicate that the web-based features of the program are effective in providing school nurses with tools and resources to execute their role. School nurses are increasingly looked to as key players in the fight against childhood obesity but many require additional knowledge, support, and professional development to do this effectively (Hendershot et al. 2008; Moyers et al. 2005; Nauta et al. 2009; Price et al. 1987). Relative to the school nurses’ role, the alignment with state reporting requirements, overall efficiency, and comprehensive nature of Health eTools for Schools are areas of particular strength. Features relating to BMI, health screening, and daily logs are among the most popular and address some of functions school nurses can play in obesity prevention as suggested in the literature (Hendershot et al. 2008; Nauta et al. 2009). One of the most compelling findings in this report related to impact has to do with the reduction in time spent on record keeping by school nurses.
The integration of this program into the school curriculum and applications for users other than school nurses are areas for potential improvement. School wellness policies mandated by the Child Nutrition and WIC Reauthorization Act of 2004 were to focus on nutritional guidelines, nutrition education, physical activity, and other school-based activities to support wellness. It is too early to determine the impact of such policies, but research from across the nation has already demonstrated a wide range in their strength and implementation (Belansky et al. 2009; Metos and Nanney 2007; School Nutrition Association 2007). Programs providing additional support and resources to the key players at the school level and policy makers at the district level could enhance the formulation, interpretation, and enactment of such policies (Vardaman 2009).
While the role of school nurses is important, the integration of these policies with the curriculum would require involvement by health education and physical education teachers. Results reported here indicate that a greater number of educational resources and strategies to support curriculum integration are called for if web-based technologies are going to impact the student learning and outcomes. The same can be said regarding the resources and involvement on the part of food service directors, wellness coordinators and administrators. It is these individuals who are in the best position to influence school and district wellness policies. In addition to providing more web-based features for these groups, the support provided by the Coordinated School Health Consultants may provide a means to get them more involved. It should be noted that the focus of the current study was on the web-based features of the program and did not address field support directly. Future evaluations should describe and systematically assess field support in conjunction with the web-based component of the program. It is likely that robust implementation will require a coordination of these efforts.
Direct assessment of student outcomes was beyond the scope of the current study, however, perceptions of impact on student fitness and activity levels were low. This stands to reason as such impact would require greater utilization by teachers, integration of resources into the curriculum, coordination with other efforts, and less time spent on record keeping. While impact on student outcomes is the ultimate aim of the program, such change will not likely be realized until all aspects of the program are on par with the school nurse components and working synergistically. Therefore, the current study is best viewed as the first step in a line of research. This study has established the feasibility of using web-based technology as part of a comprehensive program to support implementation of school wellness policies and prevent obesity. Based on these findings, it is hoped the program will not only increase web-based resources for the groups currently lagging behind, but also offer them targeted field support. Following these program improvements, future studies should assess the implementation of all aspects of the program as well as student level outcomes such as eating habits, BMI, physical activity levels, and physical fitness.
Given the increasing use of web-based programs in the field of education and the growing emphasis on school-based obesity-prevention strategies, we anticipate an increase in programs like Health eTools for Schools. This particular program was created to align with the various components of the Coordinated School Health Program model (Allensworth and Kolbe 1987; Institute of Medicine 1997; Marx et al. 1998). With targeted improvements to shore up areas of current weakness, programs like this could be an important resource in any state or district that has adopted the Coordinated School Health Program model to guide wellness policies mandated by the Child Nutrition and WIC Reauthorization Act of 2004. A current strength of the web-based portion of this program is the reporting features and their alignment with the State of Pennsylvania Department of Health and Department of Education guidelines. However, educational resources and teacher-friendly applications must be further developed to achieve a comprehensive and well-balanced program. In sum, our findings indicate that web-based applications can make significant contributions to programs designed to support obesity prevention policies and their implementation in schools provided they serve a range of functions and support change at multiple levels ranging from pedagogy and learner assessment to health screening, policy development, and state-level reporting.
We gratefully acknowledge the American Association for Physical Activity and Recreation for funding this study.