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Volume
2:
No. 1, January 2005
COMMUNITY CASE STUDY
The School Health Index as an Impetus for Change
Lisa K. Staten, PhD, Nicolette I. Teufel-Shone, PhD, Victoria
E. Steinfelt, MS, Nohemi Ortega, Karen Halverson, Carmen
Flores, Michael D. Lebowitz, PhD
Suggested citation for this article: Staten LK, Teufel-Shone NI, Steinfelt VE, Ortega N, Halverson K, Flores C,
et al. The
School Health Index as an impetus for change.
Prev Chronic Dis [serial online] 2005 Jan [date cited].
Available from: URL:
http://www.cdc.gov/pcd/issues/2005/
jan/04_0076.htm.
PEER REVIEWED
Abstract
Background
The increase in childhood obesity and prevalence of chronic
disease risk factors demonstrate the importance of creating
healthy school environments. As part of the Border Health
Strategic Initiative, the School Health Index was implemented in
public schools in two counties along the Arizona, United States-Sonora,
Mexico border. Developed in 2000 by the Centers for Disease Control and
Prevention, the School Health Index offers a guide to
assist schools in evaluating and improving opportunities for
physical activity and good nutrition for their students.
Context
Between 2000 and 2003, a total of 13 schools from five school
districts in two counties participated in the School Health
Index project despite academic pressures and limited
resources.
Methods
The Border Health Strategic Initiative supported the hiring
and training of an external coordinator in each county who was
not part of the school system but who was an employee in an
established community-based organization. The coordinators worked
with the schools to implement the School Health Index, to develop
action plans, and to monitor progress toward these goals.
Consequences
The School Health Index process and school team participation
varied from school to school. Individual plans were different but
all focused on reducing in-school access to unhealthy foods, identified as high-fat and/or of low nutritional value. Ideas for
acting on this focus ranged from changing the content of
school lunches to discontinuing the use of nonnutritious foods
as classroom rewards. All plans included recommendations that
could be implemented immediately as well as those that would
require planning and perhaps the formation and assistance of a subcommittee
(e.g., for developing or adopting a district-wide health
curriculum).
Interpretation
After working with the School Health Index, most schools made
at least one immediate change in their school environments. The
external coordinator was essential to keeping the School Health
Index results and action plans on the agendas of school
administrators, especially during periods of staff turnover.
Staff turnover, lack of time, and limited resources resulted in
few schools achieving longer-term policy changes.
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Background
Adult U.S. Hispanic populations living along the Arizona, United States-Sonora,
Mexico border experience type 2 diabetes prevalence rates that
are double the rate of the general U.S. population (1,2). The rate of
type 2 diabetes is also rising among youth, especially in
Mexican American children (3,4). School nurses in the border region report that
the number of children with diabetes in their schools is increasing rapidly.
Risk factors contributing
to these rates are ethnicity, family history, obesity, physical
inactivity, and poor nutrition (5).
Increases in rates of diabetes are closely associated with
obesity rates. Obesity rates among U.S. children have been
escalating rapidly over the past three decades (4,6,7). Data from
the 2003 Centers for Disease Control and Prevention (CDC) Youth
Risk Behavior Surveillance System show that 14% of Arizona high school
students were at risk for becoming overweight, and 11% were
overweight. While this was slightly lower than the U.S. estimates
of 15% at risk and 14% overweight (8), no data are available for
children living along the border. If extrapolations are made from
adult data from the region (1,2), more children living along the
border are at risk and are overweight than the general U.S.
population. To reverse this trend of increasing obesity and
diabetes in youth along the U.S.-Mexico border, interventions must
target two modifiable risk factors: physical inactivity and poor
nutrition.
Schools are ideal environments for promoting physical activity
and good nutrition (9,10). Unfortunately, U.S. schools face many
barriers to having healthy environments. The reduction or
elimination of physical education (PE), the transfer of school food
service to outside vendors, and reliance on vending machine
revenues for extracurricular activities all contribute to a
less-than-optimal health environment for children. In addition,
these factors may be contributing to the dramatically increasing
rate of childhood obesity in the United States (4). Policies and
resources shaping the school environment impact students’
patterns and levels of physical activity (9,10) and patterns of
food and nutrient intake (11).
To address physical activity and nutrition in the school
environment, the CDC developed the School Health Index for
Physical Activity and Healthy Eating: A Self-Assessment and
Planning Guide (SHI) in 2000 (12). The SHI enables schools to 1)
identify strengths and weaknesses of physical activity and
nutrition policies and programs; 2) develop action plans for
improving student health; and 3) involve teachers, parents,
students, and the community in improving school services. The SHI
manual consists of eight modules drawn from the CDC Coordinated
School Health Program model. The SHI is a team-based
assessment process. Recommended team members include
administrators, teachers, school health workers, food service
personnel, parents, and community health agencies. Team members
respond to a series of questions in each module, and the
questions are scored to yield an index reflecting their
school’s strengths and weaknesses. The SHI also includes a
planning section that helps schools use the index scores to
develop action plans (12).
Between 2000 and 2003, the SHI was implemented in 13 schools
in two Arizona-Sonora border counties as part of the
Border Health Strategic Initiative (Border Health ¡SI!) (13). Border Health ¡SI! was a
legislative appropriation for a comprehensive diabetes prevention
and control program in Cochise, Santa Cruz, and Yuma, Arizona
counties. Border Health ¡SI! consisted of policy coalitions and interventions targeting
providers, people with diabetes, their families, the general community, and schools
in two of the border counties. This
paper describes the schools component of Border Health ¡SI!. It provides a case
study of the SHI implementation process for seven elementary schools and the barriers to change encountered in the school environment.
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Context
Schools were recruited from the Nogales area of Santa
Cruz County and the communities of Somerton and San Luis in Yuma
County, Arizona. Nogales had a population of approximately 21,000 in
2001 and is predominantly Hispanic (97%) (14). The majority of
individuals (64%) had incomes less than 200% of the federal poverty
level. Most adults (52%) did not have a high school diploma, and 17% were unemployed (14).
Border Health ¡SI! recruited eight schools from three public school districts
in the Nogales area. Combined, these districts serve approximately
9256 students and have 10 elementary schools, three middle
schools, and three high schools. Of these 16 schools, six did not meet the federal Leave No Child
Behind criteria in 2003, and two were underperforming (15-17). No schools were classified as
excelling. During the first two years of Border Health ¡SI!, one district was
on a year-round calendar. In 2002, this district resumed a traditional
calendar. A small district (made up of one school) kept the year-round
schedule.
In the Yuma area, five schools were recruited from the
communities of Somerton and San Luis, which are 100% Hispanic. Combined, the two communities had a population of approximately 24,610 in
2001 (18,19). Between 63% and 78% of the population had incomes less
than 200% of the federal poverty level. The majority of adults
(62%–65%) did not have a high school diploma, and a large percentage (44%–66%)
was unemployed (18,19).
Border Health ¡SI! worked with two public school districts in Yuma County.
At that time, the districts served approximately 6524 students
from K–12, with six elementary schools, two middle schools, and
one high school. Of the nine schools, four were ranked by the
state of Arizona as underperforming, and four did not meet the
federal Leave No Child Behind criteria in 2003 (20,21). No schools
were classified as excelling. Because of exploding population
growth, two schools in one district were running double sessions
(7:00 AM–12:25 PM and 12:30
PM–6:00 PM) with two sets of principals
and teachers. This schedule did not allow time for extra
activities or even a vacant meeting room.
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Methods
Selection of SHI
The community-based agencies involved with Border Health ¡SI!, along with
technical assistance from the Mel and Enid Zuckerman Arizona College of Public Health (MEZACOPH),
selected the recently released SHI as a tool that would enable
schools to start thinking about creating healthier environments.
Despite the lack of published evaluation results, the Border Health ¡SI! group
felt that it was a reasonable tool to focus schools on physical
activity and nutrition policy. The SHI and follow-up were the
only school-based interventions as part of Border Health ¡SI!.
Project design
The University of Arizona Cooperative Extension in Yuma County and
Southeast Arizona Area Health Education Center (SEAHEC) in Santa Cruz
County facilitated implementation of the SHI. These
two community-based agencies had strong existing relationships
with local schools. SEAHEC was involved in a variety of school nutrition
education programs, and Cooperative Extension was responsible for
the 4-H clubs for children and thus also worked closely with area
schools.
The community agencies and others
involved in Border Health ¡SI! expressed concern that the schools were overburdened and that
health promotion and chronic disease prevention might not be high
priorities. We believed, however, that an outside advocate could
discuss the serious issues related to chronic disease and how they impact children.
We also believed that resource-stressed schools
would accept external coordinators from established and
trusted agencies to provide assistance and support. Cooperative Extension and SEAHEC identified staff members who could serve as external
coordinators to assist schools in completing the SHI assessment
and planning process and in coordinating and compiling the SHI
materials. MEZACOPH staff provided education to external coordinators on the SHI and the
relationship between adolescent health and chronic disease. External coordinators were responsible for
documenting recruitment efforts, the SHI process within the schools,
team member activities, and action plans.
School recruitment
External coordinators initiated the recruitment process by
presenting the SHI to school district superintendents or
assistant superintendents, the school boards, or directly to
principals. In addition, external coordinators contacted schools where they had personal connections. By the end of the
third year, all schools in the area were approached, and any that
expressed interest were contacted. The external
coordinator provided a verbal overview and copy of the SHI, and
if received positively, made a presentation to school personnel.
When schools were hesitant to participate, additional assistance
was sought from two directors of health services, a school board
president, and a registered nurse at a school-based clinic to encourage schools to participate. Schools were offered a
financial incentive of $1500 upon completion of the SHI. The
incentive was provided by Cooperative Extension and SEAHEC. Schools were
encouraged to apply the funds toward their action plans but were
not required to do so. At the end of the three-year period, the
SHI was implemented in 10 elementary schools, two middle schools,
and one high school, about half of the 25 schools approached.
Implementation of the SHI
Once a school agreed to complete the SHI, the principals
identified an internal SHI coordinator. The internal coordinator
recruited team members, and the external coordinator met with the
team to provide materials and an overview and outline the
assessment process. The external coordinator then followed up
with the internal coordinator to ensure that the teams were
meeting, collected scorecards, produced a summary document, and
scheduled and helped conduct the action planning session.
Evaluation plan
Because Border Health ¡SI! was a legislative appropriation and was not
funded as a research project, resources were not available to do
an in-depth study of the SHI. However, the community-based
agencies and MEZACOPH reached an agreement on an evaluation plan.
Documentation of the plan would include information on the interest
schools showed in completing the SHI, the ability of SHI teams to
understand and complete the SHI, the process for completing the
evaluation instrument, whether or not the teams created action plans,
and finally, whether or not schools were able to make any changes suggested in
the action plans.
Detailed quarterly reports by Cooperative Extension and SEAHEC were used
to document school interest and the SHI process. MEZACOPH staff
conducted in-depth interviews with the external coordinators and
with a convenience sample of 14 SHI team members from the first five
schools to complete the SHI. The purpose of the interview was to
identify barriers to implementing the SHI, to find out whether or not SHI
team members believed an external coordinator was necessary, and
to identify changes in the school environment that could be
attributed to the process. The external coordinators were in
frequent contact with the schools after completion of the SHI. A
year after completion of the SHI, external coordinators contacted
the schools to determine whether or not SHI action plans were being
implemented.
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Consequences
The SHI process was different in each of the schools. The time
frame for complete implementation ranged from four weeks to
almost two academic years. Most schools completed the SHI within
one semester. Schools were encouraged to complete the SHI during
the fall semester to allow for time to work on action plans.
Unfortunately, all schools completed the SHI during the spring
semester.
The SHI team composition varied by school. Team size ranged
from six to 34. All schools included at least one parent. As
described earlier, the border communities are predominantly
Hispanic; therefore, at several schools, parents emphasized the
need for a Spanish version of the SHI. A health educator and
social worker were not included for Yuma area schools because these positions do
not exist in these schools.
An in-depth interview with 14 SHI team members revealed that
team members felt that the SHI helped to build awareness of
school commitment, identify changes that do not require
resources, encourage policy and action, bring health issues to
the schools’ attention, and raise awareness of federal
policies. The team members also identified the four key barriers to
implementing the SHI: 1) time, 2) getting people to meetings, 3) initial
buy-in, and 4) perceived lack of expertise. The SHI team members
believed that the key roles played by the external coordinators
were facilitation and guidance. The external coordinators also
assisted in overcoming barriers.
No school included representatives from community health
agencies on the SHI team. Although outside community members were
suggested by SHI guidelines, both internal and external
coordinators felt that these individuals did not have the
in-depth knowledge of the school environment necessary to answer
the detailed SHI questions. The external coordinators frequently
filled this role as representatives of the community. As part of
the Border Health ¡SI!, community coalitions or Special Action Groups (SAGs)
were established to focus on policy change to create healthier
communities (22). The external coordinators regularly updated these coalitions on SHI progress in schools, and
the coaltions served
as resources to the schools. Coalition members included the
external coordinators, school administrators, nurses,
teachers, and a wide variety of community agencies (22).
Santa Cruz County
By the end of Border Health ¡SI!, four elementary schools, one K-8 school, two middle
schools, and
one high school completed the SHI in Santa Cruz County. During
the final quarter of the project period, the director of health
services for one district (two elementary schools, one middle
school, and one high school) used SHI results to develop the
district’s comprehensive health plan. Results were not
available from the individual schools, and the district health
plan is not complete at this writing. The information reported
here is based on reports from three of the elementary schools
representing two school districts. Overall, half of the schools
in the area completed the SHI. The main reasons for schools
refusing to participate were lack of time and lack of a school
champion. When a school champion was identified, time became less
of a barrier.
The intent of the SHI is for SHI teams to collaboratively
develop action plans based on the results from the eight SHI modules.
In two of the Santa Cruz County schools, the SHI was completed at
the end of the semester, and the teams were unable to develop
action plans. The principals, who had participated on the teams,
created the action plans in isolation. This process was
especially problematic because one of the principals resigned shortly
after creating a plan. In fact, by the beginning of the next academic year,
only two of the seven SHI team members were still at their school (hereafter
referred to as Santa Cruz School 1 [SC1]). The second principal to develop action plans promoted many
school-level changes (Santa Cruz School 2 [SC2]). Unfortunately, she also left her
position.
Case Study 1
SC1 made several changes as it implemented the SHI, including the decision to move all candy sales out of the cafeteria. Most notably, the
school hired a full-time PE teacher and developed
a policy that prohibited the selling of junk food for
fundraisers. The fundraising policy came into question the
following academic year when the loss of almost all members of
the SHI resulted in very little institutional memory. This case
offers an example of how important the external
coordinator’s role is in the process. The remaining SHI
team member was uncomfortable promoting the action plans to the
new principal. The external coordinator contacted the principal
early in the school year to discuss the SHI and action plans. The
long-term goal of the SHI team was to increase the length of the
lunch period. The principal was unfamiliar with the SHI but
expressed verbal support for the action plans. When resistance
developed over the fundraising policy, the principal enlisted the
aid of a remaining SHI team member to explain the policy to the
staff and parent-teacher organization. The policy was upheld. SC1
had a new principal the following year. The external coordinator
continued to follow up and provided the impetus for the principal
to create a new SHI team that completed the SHI a second time.
SC1 has had a full-time PE teacher for three
years. They have not lengthened the school lunch period.
Fundraisers now include gifts, wrapping paper, and magazines as
well as chocolate. Items for sale at lunch include pencils,
notebooks, pickles, oranges, peanut butter crackers, and
salditos (salted dried prunes) instead of baked goods and
junk food.
Case Study 2
The principal/superintendent at SC2 was deeply committed to
the SHI process. The school made several immediate changes. The
school bake sales were converted to healthy snack sales. Graduation cookies and punch were cancelled and replaced with
lemonade and baked chips and salsa. As a result of the SHI, the
school hired a full-time PE teacher and developed
a PE course. The goal was to have a letter grade for the course, not
a pass/fail grade. An existing staff member was certified
as a PE instructor. The school also organized
track and basketball teams for the first time. The following
summer, the school board attempted to drop the program. The
principal called the Border Health ¡SI! coalition for assistance. Coalition
members, teachers, and parents attended the school board meeting.
The principal presented the SHI results, and the teachers and
parents strongly supported the program. The PE
program was not cut. Unfortunately, before the next academic
year, the principal accepted a job as a district superintendent
in another community. In that role, she was able to add PE into all elementary schools. The
PE course is pass/fail. Individual teachers
are offering low-fat snacks and less sweet snacks at parties, but this
is not a coordinated school effort. Carrots, orange juice, milk,
graham crackers, and cheese sandwiches are served at the school
open house.
Case Study 3
The third Santa Cruz school (SC3) to complete the SHI took
one and a half years to complete the process. The school was
undergoing major renovations when it was first contacted and despite expressing
interest, it was unable to commit to the process. Once the school
committed, however, the external coordinator reported that the SC3 SHI
team was the most enthusiastic. The school removed the vending
machine from the cafeteria and decided to remove all other soda
and candy vending machines and replace them with healthier
choices. The beverage machines include fruit juices, water, tea,
and lemonade. The SHI team also recommended removing the school store from the
cafeteria. The SHI team reported their results
to the Border Health ¡SI! coalition. The team was encouraged by the coalition to
write a newspaper article for the local paper describing the
changes they were making. Students were interviewed by a local
television station when the soda was replaced by fruit drinks.
The students said they missed the soda “but juice was okay.”
The school store has not moved, but it is no longer selling
candy. It replaced candy with healthier options, and profits have stayed the same. Bake sales now have oranges,
cucumbers, and carrots. Some sales include candy but only small
candy bars.
Yuma County
A total of five schools, four elementary schools and one middle
school, implemented the SHI as part of the Border Health ¡SI! in the southern Yuma
area. All three elementary schools in one district participated.
In the second district, only one elementary school participated. It was the only
elementary school not running double shifts. Overall, five of the nine schools
in the area completed the SHI. The main reason for refusing to participate was lack of time. In Yuma, the
external coordinators actively facilitated the action planning
process. Documentation from the Yuma area focuses on the
action plans.
Case Study 1
All teachers participated on the SHI teams at the first school (YC1) in the
Yuma area. Not all teachers were enthusiastic. A school policy was developed to
prohibit the use of food as a reward in the classroom, and students were limited
to one snack per day. The SHI team also set goals of 1) teaching more nutrition information,
2) gathering and
disseminating information on all food and drink items sold at
the school, and 3) shifting from selling junk food items
and sports drinks to healthier options. The school offered
granola and fruit bars as alternatives, but they did not sell, and the school reverted to selling junk food. YC1
established walking groups two to three days per week for
students. Teachers organized structured fitness breaks. The
school also implemented an annual field day for staff and
students.
Case Study 2
YC2 also established a school policy prohibiting
nonnutritious food as a reward and limiting snacks to one per day
per student. The SHI team was especially interested in eliminating
outdated health education material and incorporating a sequential health
education curriculum. Teachers began standing at the salad bar to
encourage children to eat more fruit and vegetables. The
school also began to increase use of community facilities and
to offer a swimming class at the local community pool. The
school’s part-time PE teacher left the
school for a full-time position out of the district. The SHI team
presented the SHI results at a staff workshop.
Case Study 3
YC3 established a lengthy list of goals, including requiring
hand washing, adopting a sequential health education curriculum,
and incorporating activity breaks into the classroom. Two years
after implementation of the SHI, no progress has been made.
The three Yuma area elementary schools described here are from
one school district. The superintendent and SHI team members
requested that the external coordinators from Cooperative Extension
present the SHI results to the school board. The perception was that
the board would view the external coordinators as community
members and not as school personnel, and they would thus have a
greater impact. The SHI team members then presented the results
to the Border Health ¡SI! coalition.
Case Study 4
The fourth Yuma area elementary school (YC4) was from the
second school district and focused on similar issues as the other
three schools. This school chose to focus on increasing instruction time for
health and PE, adopting new health education
textbooks, and presenting health-related information to parents
and staff. At this point, no progress has been made toward these
goals.
The action plans of these schools emphasized modifying health-related
curricula and adopting a sequential health education curriculum. Upon exploring
the issue at the district level, it was determined that the district is not
considering modifications to health education curriculum until 2005. To
provide the teachers with resources, Cooperative Extension presented
a resource event where teachers selected educational materials
focusing on health education, nutrition, and physical activity and
provided suggestions on ways to incorporate nutrition messages
and physical activity into the existing curricula. In addition,
Cooperative Extension also provided one school library with more than 50 books on physical activity and nutrition
(fiction and nonfiction).
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Interpretation
Seven Arizona elementary schools along the Arizona-Sonora border assessed their school environments and developed
action plans using the CDC’s SHI. Despite some difficulties resulting from time
constraints and human resources, all schools were able to complete the
assessment. The schools focused their action plan priorities on nutrition and physical activity. School action
plans included items that could be addressed immediately (e.g., a
school policy prohibiting use of candy as rewards) as well as
policies that would necessitate implementation at the district level
(e.g., adopting a sequential health curriculum or seeking funds to
hire a full-time PE instructor). The individual
school action plans varied, but all seven shared one component:
to reduce internal access to unhealthy foods. Plans included
changing the content of school lunches, discontinuing the use of
nonnutritious foods as classroom rewards, moving candy sales and
a snack bar away from the cafeteria, and choosing healthy
alternative fundraisers. Two schools were able to use SHI
results to hire PE teachers.
The goal of Border Health ¡SI! was for schools
to disseminate the results
of the SHI at least to the teachers at each participating
school. In addition, we hoped that the results would be presented
at parent-teacher and school board meetings. High rates of staff
turnover highlight the importance of disseminating SHI results
and action plans to a larger audience. It is crucial for schools
to have an advocate for physical activity and nutrition. The
external coordinator and Border Health ¡SI! coalitions served as those
advocates and were able to keep the issue of school health
prominent in school administrators’ minds.
The number of underperforming schools in these districts and
the lack of highly performing or excelling schools results in
stress on the educational system. Principals and school board
members are under pressure to improve the academic
performance of their schools. When approached for funds or
time to implement new programs, school administrators frequently
cite the need for scholastic improvement above all other issues.
External coordinators returned repeatedly to meet with school
administrators to discuss the importance of physical activity and
good nutrition. An additional tactic for educating administrators
was to recruit them to participate in the Border Health ¡SI! SAGs.
The current educational system is responsible for a wide variety of
activities: academic performance, social services, childhood immunizations,
and the nutrition of students through the federal school breakfast and lunch
programs. Involving schools in health promotion and disease prevention
activities is critical, but we must recognize that most school
systems are under extreme pressure to demonstrate academic progress. The fact
that half of schools approached in two low socioeconomic areas
participated in the SHI process indicates the commitment of school personnel to the overall health and well-being of their students
and communities. The support of an external coordinator from a
local agency can assist in removing some logistical
barriers.
While most schools were extremely committed and enthusiastic
about SHI action plans, staff turnover,
time, and limited resources were barriers to progress even with the support of
an external facilitator. Implementation of
new programs is limited further by the low number of certified PE
and health education specialists employed by the districts.
Change in staff in one district occurred during the first year,
and staff had to be educated about the SHI action plans and
school goals. Some schools were undergoing major renovations and
building projects, and in some cases, new schools were built. These schools
found it challenging to take on new projects like the SHI.
One cautionary note is that publicity may present a barrier to acceptance of the
SHI process. In the opinion of the external coordinators, publicity surrounding
the removal of soda machines at one school may have discouraged other schools from participating in the SHI process. When funding for schools is so tight that vending machine
sales are used to support photocopying expenses, field trips,
graduation ceremonies, and extracurricular events, the threat of
losing those funds can deter schools from eliminating this source of revenue,
even though they are interested in improving the
health of their students. The SHI and our project did not push schools to remove
vending machines; instead, we encouraged schools to identify
the best priorities for their own schools. These messages were lost
by the news media. The external coordinator sought advice from the Border Health ¡SI! SAGs on how to
convey our messages. The negative
impressions receded after a brief time, and five more schools
completed the SHI by the end of Border Health ¡SI!.
This project showed the value of having an external
coordinator to help with continuity and with keeping the project
top-of-mind with school officials, especially during periods of high staff
turnover. In addition, the external coordinators acted as a
resource beyond coordination. External coordinators created
resource manuals for alternative ideas for school fundraisers,
linked schools with other community resources, found funds to
provide teachers with educational materials, and volunteered at
school events. Although the SHI process does not include
incentives, we found that monetary incentives for carrying out policy
priorities seemed to encourage participation and gave schools
resources to implement policies. Overall, most schools were
able to implement immediate changes. Policies requiring a
longer-term process and additional resources were more difficult to carry out.
Future projects should focus on documenting whether students
increased their physical activity or improved their eating habits
as a result of SHI policies.
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Acknowledgments
This project was funded by Contract 200-2000-10070 from the Centers for
Disease Control and Prevention. We thank school
personnel and district administrators in the Gadsden, Nogales,
Santa Cruz, Santa Cruz Valley, and Somerton school districts.
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Author Information
Corresponding author: Lisa K. Staten, PhD, Division of Health Promotion Sciences
and Southwest Center for Community Health Promotion, Mel and Enid
Zuckerman Arizona College of Public Health, University of
Arizona, 2231 E Speedway
Blvd, Tucson, AZ 85719. Telephone: 520-321-7777. E-mail: staten@u.arizona.edu.
Author affiliations: Nicolette I. Teufel-Shone, PhD, Division
of Health Promotion Sciences and Southwest Center for Community
Health Promotion, Mel and Enid Zuckerman Arizona College of
Public Health, University of Arizona, Tucson, Ariz; Victoria E.
Steinfelt, MS, and Nohemi Ortega, Cooperative Extension, College of Agriculture and
Life Sciences, University of Arizona, Yuma, Ariz; Karen Halverson and Carmen
Flores, Southeast Arizona Area Health Education Center, Nogales, Ariz; Michael D. Lebowitz, PhD, Arizona Prevention Center and Southwest
Center for Community Health Promotion, Mel and Enid Zuckerman
Arizona College of Public Health, University of Arizona, Tucson,
Ariz.
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