Are School Nurses an Overlooked Resource in Reducing Childhood Obesity? A Systematic Review and Meta-Analysis

Building Healthy Families: Outcomes of an Adapted Family Healthy Weight Program Among Children in a Rural Mid-Western Community

Background: This study aimed to evaluate the effectiveness of implementing an adapted, evidence-based 12-week Family Healthy Weight Program (FHWP), Building Healthy Families, on reducing BMI metrics and clinical health indicators in a real-world community setting. Methods: Ninety child participants with a BMI percentile greater or equal to the 95th percentile for gender and age and their parents/guardians (n = 137) enrolled in the program. Families attended 12 weekly group-based sessions of nutrition education, family lifestyle physical activity, and behavior modification. A pre-post study design with a 6-month follow-up was used. Results: Nine cohorts of families between 2009 and 2016 completed the program with 82.1% retention at 12 weeks and 53.6% at 6 months. Participants had statistically significant improvements at 12 weeks in BMI z-score, %BMIp95, body mass, body fat, fat mass, fat-free mass, and systolic blood pressure with greater improvement at 6 months in body mass, BMI metrics, body fat, fat mass, fat-free mass, and systolic blood pressure. Parents/guardians of the participants had similar statistically significant body composition and blood pressure improvements (p < 0.05). In addition, children had significant improvements in high-density lipoprotein (HDL) cholesterol and aspartate aminotransferase (AST) liver enzymes at 6 months. Conclusions: Overall, this study demonstrated that an evidence-based FHWP can result in statistically meaningful declines in BMI z-score and accompanied clinically meaningful changes in health risk. Participants lost ∼4% of their body mass in 12 weeks, while their parents/guardians lost closer to 7% of their body mass, which supports previous literature suggesting body mass changes influence health.

School Health Infrastructure and Students' Elevated Body Mass Index

School-age children with overweight or obesity continue to be problematic in the United States, and are associated with many health, social, and financial problems. Schools provide an excellent venue in which to promote healthy weight in students, and school nurses are well-positioned to play an essential role in controlling obesity. The number of studies reporting relationships among school health infrastructure and prevalence of elevated Body Mass Index (BMI) is limited. The present study explored associations between three components of school health infrastructure (staff, services, budget) and the proportion overweight or obese 1st, 3rd, and 6th grade students, after controlling for selected factors (race, county education level, county poverty level, rurality). Study results supported an independent association between elevated BMI and school health staff. Additionally, independent associations between elevated BMI and the following covariates were supported: household income, race, and parents' educational level. There is an ultimate need for well-designed studies addressing these associations.

Short-term lifestyle education on obesity reduction in adolescents

Backgrounds

Obesity is increasing in adolescents in China. However, the awareness of obesity and prevention on related risk factors were not well known. We aim to assess the effectiveness of short-term health education intervention on obesity in Chinese adolescents.

Methods

In this study, 42 primary and secondary schools from Qingdao were randomly divided into the education and control groups. A total of 11,739 adolescents was included in the current study. The logistic regression was employed to assess odds ratio (OR) of education intervention on overweight and obesity prevalence adjusting for covariates.

Results

The baseline prevalence of overweight and obesity was significantly higher in urban than in rural areas and in boys than in girls. After 1 year lifestyle intervention, the proportion of students with awareness of obesity was higher, meanwhile age-adjusted mean values of weight, body mass index, duration of watching TV and doing homework were lower in education group than control group. The corresponding figures were 43.6 [95% CI (confidence intervals); 43.3-43.9] kg versus 44.3 (95% CI; 44.0-44.6) kg, 18.6 (95% CI; 18.5-18.7) kg/m2 versus 18.9 (95% CI; 18.8-19.1) kg/m2, 1.3 (95% CI; 1.2-1.3) hours/d versus 1.4 (95% CI; 1.3-1.4) hours/d, and 1.5 (95% CI; 1.4-1.5) hours/d versus 1.8 (95% CI, 1.7-1.8) hours/d. The multivariable adjusted OR for combined prevalence of overweight and obesity was 0.85 (95% CI, 0.76-0.96) in education group as compared with control group.

Conclusion

Short-term health education intervention results in significantly higher reductions in obesity parameters and improvement in awareness in Chinese adolescents.

What Are the Challenges of School Nurses in South Korea in Managing Obese Children From Low-Income Households?

Given that the obesity rate among school-age children is increasing, school nurses can play a vital role in managing obesity and encouraging healthy living in school settings. Obese children from low-income backgrounds are more vulnerable than other students and require more careful attention and intervention. This qualitative study aimed to explore and understand the barriers recognized by school nurses in managing obesity in low-income household children. A focus group interview was conducted with 17 school nurses working at an elementary school. Children, home, school, political and structural, and social areas were revealed as intricate factors in obesity management. This study can help understand school nurses' obstacles in managing obese children from low-income families and can help them prepare practical measures to overcome these obstacles.

Skill-Mix Changes Targeting Health Promotion and Prevention Interventions and Effects on Outcomes in all Settings (Except Hospitals): Overview of Reviews

Objectives: Skill-mix changes to step up health promotion and prevention are increasing, but there is limited evidence on their effects. Methods: Overview of reviews, based on a protocol. The search was carried out in six databases, screening was performed ensuring high interrater reliability. All countries, health professions and lay workers in all settings (except hospitals) were included, quality appraisals performed. Results: A total of 31 systematic reviews were included. Expanded roles performing outreach (e.g., home visits) had mostly positive effects on access and health outcomes, primarily for hard-to-reach groups. Task-shifting in colorectal or skin cancer screenings (performed by advanced practice nurses) were suggested effective; supporting roles (by community health workers) increased uptake in screenings, but based on limited evidence. Expanded roles of various professions focusing on lifestyle modification showed promising effects in most reviews, including weight, diet, smoking cessation and physical activity. Reviews on cost-effectiveness were based on limited evidence. Conclusion: Promising skill-mix changes included expanded roles providing lifestyle modifying interventions, task-shifting, and outreach roles for hard-to-reach groups, whereas evidence on costs was limited.

The current state of international research on the effectiveness of school nurses in promoting the health of children and adolescents: An overview of reviews

OBJECTIVE

School nurses are engaging worldwide to promote and protect children's health. Many researchers who examined the effectiveness of the school nurse criticized the inadequate methodology employed in many of the studies. We therefore carried out an evaluation on the effectiveness of school nurses based on a rigorous methodological approach.

METHODS

In this overview of reviews we performed an electronic databank search and global research results on the effectiveness of school nurses were sought. We identified 1,494 records through database search. Abstracts and full texts were screened and summarized using the dual control principle. We summarized the aspects of quality criteria as well as the significance of the effectiveness of the school nurse. In the first step, k = 16 systematic reviews were summarized and evaluated following the AMSTAR-2 guidelines. In a second step, j = 357 primary studies included in these k = 16 reviews were summarized and assessed following the GRADE guidelines.

RESULTS

Research results on the effectiveness of school nurses show that school nurses play a key role in improving the health of children with asthma (j = 6) and diabetes (j = 2), results on combating obesity are less certain (j = 6). The quality of identified reviews is mostly very low with only six studies of medium quality, of which one identified as a meta-analysis. A total of j = 289 primary studies were identified. Approximately 25% (j = 74) of identified primary studies were either randomized controlled trials (RCT) or observational studies, of which roughly 20% (j = 16) had a low risk of bias. Studies with physiological variables such as blood glucose or asthma labeling led to higher quality results.

CONCLUSION

This paper represents an initial contribution and recommends further evaluation of the effectiveness of school nurses, particularly in the areas of mental health or children from low socioeconomic backgrounds. The general lack of quality standards in school nursing research should be integrated into the scientific discourse of school nursing researchers to provide robust evidence for policy planners and researchers.

Influence of pilot and small trials in meta-analyses of behavioral interventions: a meta-epidemiological study

BACKGROUND

Pilot/feasibility or studies with small sample sizes may be associated with inflated effects. This study explores the vibration of effect sizes (VoE) in meta-analyses when considering different inclusion criteria based upon sample size or pilot/feasibility status.

METHODS

Searches were to identify systematic reviews that conducted meta-analyses of behavioral interventions on topics related to the prevention/treatment of childhood obesity from January 2016 to October 2019. The computed summary effect sizes (ES) were extracted from each meta-analysis. Individual studies included in the meta-analyses were classified into one of the following four categories: self-identified pilot/feasibility studies or based upon sample size but not a pilot/feasibility study (N ≤ 100, N > 100, and N > 370 the upper 75th of sample size). The VoE was defined as the absolute difference (ABS) between the re-estimations of summary ES restricted to study classifications compared to the originally reported summary ES. Concordance (kappa) of statistical significance of summary ES between the four categories of studies was assessed. Fixed and random effects models and meta-regressions were estimated. Three case studies are presented to illustrate the impact of including pilot/feasibility and N ≤ 100 studies on the estimated summary ES.

RESULTS

A total of 1602 effect sizes, representing 145 reported summary ES, were extracted from 48 meta-analyses containing 603 unique studies (avg. 22 studies per meta-analysis, range 2-108) and included 227,217 participants. Pilot/feasibility and N ≤ 100 studies comprised 22% (0-58%) and 21% (0-83%) of studies included in the meta-analyses. Meta-regression indicated the ABS between the re-estimated and original summary ES where summary ES ranged from 0.20 to 0.46 depending on the proportion of studies comprising the original ES were either mostly small (e.g., N ≤ 100) or mostly large (N > 370). Concordance was low when removing both pilot/feasibility and N ≤ 100 studies (kappa = 0.53) and restricting analyses only to the largest studies (N > 370, kappa = 0.35), with 20% and 26% of the originally reported statistically significant ES rendered non-significant. Reanalysis of the three case study meta-analyses resulted in the re-estimated ES rendered either non-significant or half of the originally reported ES.

CONCLUSIONS

When meta-analyses of behavioral interventions include a substantial proportion of both pilot/feasibility and N ≤ 100 studies, summary ES can be affected markedly and should be interpreted with caution.

Sonographic Markers Are Useful for Detection of Early Vascular Deterioration in Children with Overweight/Obesity: Effect of a 1-Year Combined Nutritional Education and Physical Exercise Program

As in adults, childhood obesity is associated with several metabolic disorders; however, there is little information regarding complex obesity-derived complications such as hepatic steatosis or endothelial dysfunction at early ages. Therefore, the objective of the present study was to analyze the effect of a nutritional and physical exercise program on obesity comorbidities in the form of subclinical atherosclerosis and non-alcoholic fatty liver in young children. A total of 148 children completed the study. For nine months (one academic year), children carried out a nutritional and physical activity program of 3 h/week. Anthropometric, clinical, liver ultrasound and carotid intima-media thickness (cIMT) parameters were evaluated. Our results showed that the program significantly improved anthropometrical parameters, especially regarding BMI and body fat (p < 0.001 and p = 0.004, respectively). The effect on metabolic parameters was limited, although a significant reduction on triglycerides was observed (p = 0.009). The education program had a great influence on the echogenic parameters, since the percentage of children with light steatosis decreased from 35% to 4% at the end of the study. In addition, cIMT also decreased significantly in both groups, although there was no statistically significant differences between groups. In conclusion, detection of early complications of obesity through sonographic parameters may allow early intervention, as in the present study, to prevent obesity co-morbidities in children.

School Nurses Matter: Relationship Between School Nurse Employment Policies and Chronic Health Condition Policies in U.S. School Districts

The increasing prevalence of chronic health conditions (CHCs) in school-aged children highlights the need to better understand school health services’ role regarding CHCs. Using U.S. nationally representative district-level data from the 2016 School Health Policies and Practices Study, we examined whether having policies on school nurses’ employment was associated with having policies on CHCs and whether having such policies varied by geographic location. Compared to districts without such employment policies, districts with such policies (52.3%) were significantly more likely to have CHC management policies. For each CHC policy examined, more than 20% of school districts did not have the CHC policy, with Northeast districts having the greatest proportion of such policies and West districts having the least. Thus, many students’ CHC needs may not be met at school. It is important for school nurses to play a key role in advocating for the development of school-based policies on CHCs.

Interventionen der Schulgesundheitspflege in Deutschland

Zusammenfassung. Hintergrund: Das international etablierte Berufsbild der Schulgesundheitspflege ist in Deutschland noch nicht flächendeckend implementiert. In ersten Modellprojekten und einigen internationalen Schulen kann bereits die Umsetzbarkeit des Konzepts und der Arbeitsalltag von Schulgesundheitspflegenden in Deutschland beobachtet werden. Drängende und derzeit oft ungelöste Aufgaben im Setting Schule sind die Inklusion chronisch kranker Schüler_innen und die Gesundheitsförderung in der Lebenswelt. Ziel: Ziel dieser Arbeit ist die Beschreibung der Interventionen von Schulgesundheitspflegenden im Schulalltag. Methode: Mittels eines standardisierten Onlinefragebogens wurden Schulgesundheitspflegende in Deutschland hinsichtlich ihrer durchgeführten Tätigkeiten und zu deren Häufigkeit befragt. Die Tätigkeiten wurden basierend auf der Nursing Intervention Classification (NIC) erhoben. Die Daten wurden mittels deskriptiver Statistik ausgewertet. Ergebnisse: Die Befragten ( n = 25) sind schwerpunktmäßig in der Akutversorgung und der Gesundheitsedukation bzw. -förderung tätig. Pflegeinterventionen, die einen familiären oder populationsbezogenen Ansatz haben, werden lediglich alle 2–3 Monate oder seltener von dem Durchschnitt der Befragten angewandt. Schlussfolgerungen: Die tägliche intensive Inanspruchnahme diverser Pflegeinterventionen deutet auf einen dringenden Bedarf an pflegerischer Expertise in der Schule hin.

The Effectiveness and Acceptability of Comprehensive and Multicomponent School Health Services: A Systematic Review

PURPOSE

Comprehensive school-based health services were reviewed as part of preparing World Health Organization guidelines.

METHODS

Six databases were searched for controlled trials with schoolchildren aged 5-19 years, involving school-linked health services incorporating 4 of 7 health areas.

RESULTS

Seventeen quasi-experimental studies conducted in high-income countries found school health services associated with reductions in suicide planning (male: 7.1% vs. 7.7%, p < .01), hospitalization (relative risks 3.403, 95% confidence interval [CI] 1.536 to 8.473, p < .05), emergency department visits (odds ratio .85, 95% CI .75 to .95, p = .006), school absence (odds ratio .78, 95% CI .69 to .87, p < .0001), carrying weapons (male: 16.1% vs. 25.1%, p < .01), fighting (male: 32.6% vs. 43.1%, p < .01), sexual activity (53.5% vs. 60.5%, p < .05), drinking alcohol (60.1% vs. 70.5%, p < .001), using drugs (28.0% vs. 38.3%, p < .001), and physical activity (female: 57.4% vs. 50.4%, p < .01). They can be cost-saving, were also associated with smoking and less contraceptive use, and had no effect on depression prevalence. Acceptability/satisfaction was good. The certainty of evidence was low to moderate. Heterogeneity was high for some outcomes.

CONCLUSIONS

Results suggest moderate desirable and trivial undesirable effects of school health services in high-income countries. This article compiles evidence on effectiveness, cost-effectiveness, and acceptability into one review, enabling decision-makers to consider all essential factors.

The effectiveness of nurse-led interventions to prevent childhood and adolescent overweight and obesity: A systematic review of randomised trials

BACKGROUND

Obesity among children and adolescents continues to rise worldwide. Despite the efforts of the healthcare workforce, limited high-quality evidence has been put forward demonstrating effective childhood obesity interventions. The role of nurses as primary actors in childhood obesity prevention has also been underresearched given the size of the workforce and their growing involvement in chronic disease prevention.

AIM

To examine the effectiveness of nurse-led interventions to prevent childhood and adolescent overweight and obesity.

DESIGN

A systematic review of randomised trials.

DATA SOURCES

Medline, CINAHL, EMBASE, Cochrane (CENTRAL), ProQuest Central and SCOPUS were searched from inception to March 2020.

REVIEW METHODS

This review was informed by the Cochrane handbook for systematic reviews of interventions.

RESULTS

Twenty-six publications representing 18 discrete studies were included (nine primary prevention and nine secondary prevention). Nurse-led interventions were conducted in diverse settings, were multifaceted, often involved parents and used education, counselling and motivational interviewing to target behaviour change in children and adolescents' diet and physical activity. Most studies did not determine that nurse-led interventions were more effective than their comparator(s) in preventing childhood and adolescent overweight and obesity.

CONCLUSIONS

Nurse-led interventions to prevent juvenile obesity are feasible but have not yet determined effectiveness. With adequate training, nurses could make better use of existing clinical and situational opportunities to assist in the effort to prevent childhood obesity.

The role of the nurse in the obesity clinic: a practical guideline

Obesity is a major public health problem, and its trend is increasing worldwide. Interventions to effectively treat obesity and its related diseases are advocated. Given the complexity of obesity management, nurses need specific core skills to work in the Obesity Clinic and can act as key players in the multidisciplinary team of the Obesity Clinic. To provide practical guidelines for nurses working in Obesity Clinic for effective management of obesity and its related diseases, the current evidence on the role nurses in the obesity clinic was reviewed. Nurses can play a pivotal role in the management of patients with obesity and associated diseases that may require a stricter follow-up than usual care. Given the complexity of the treatment of obesity and its comorbidity, nurses should receive a specific training for: 1) methods and tools to effectively treat obesity and obesity-related disease, 2) patients and families education on nutrition, lifestyle changes, and prevention/management of obesity-related diseases; 3) motivation of patients towards adherence to treatment to achieve their specific goals. This manuscript highlights the need of specific core skills for nurses working in the Obesity Clinic.

A Type III Hybrid Effectiveness-Implementation Pilot Trial Testing Dissemination and Implementation Strategies for a Pediatric Weight Management Intervention: The Nebraska Childhood Obesity Research Demonstration Project

Background: Several family-based efficacious pediatric weight management interventions (PWMIs) have been developed to reduce child weight status. These programs are typically based in larger cities delivered by an interdisciplinary team in a hospital or medical center. The degree to which these efficacious PWMIs have been translated to, and are feasible in, rural or micropolitan areas is unclear. This study protocol describes a pilot Type III hybrid effectiveness-implementation (T3HEI) trial testing a multilevel strategy that focuses on the adoption, implementation, and sustainability of a PWMI online training program and resource package designed for implementation in micropolitan and rural areas. Methods: The trial design employed the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework to evaluate outcomes and the Promoting Action on Research Implementation in Health Services framework to specify potential mechanisms of adoption, implementation, and sustainability. The study will test the feasibility of a fund and contract dissemination strategy in the adoption of a PWMI in four to eight rural communities, compare a learning collaborative implementation strategy including embedded training and sustainability action planning with communities who receive the PWMI online program and resources alone, and determine whether the PWMI reach, effectiveness, and maintenance are of magnitude similar to previous effectiveness trials. The dissemination and implementation process focused on an integrated research-practice partnership process model that includes a systems-based approach with multiple sectors and vertical decision-making representation. Conclusions: Our pilot T3HEI study has the potential to inform how best to move and sustain evidence-based PWMIs into practice. The findings will inform larger scale dissemination, implementation, and sustainability efforts in medically underserved areas across the country. Trial registration: This protocol is registered with clinicaltrials.gov (NCT04719442).

Effect of Mobile Health Technology on Weight Control in Adolescents and Preteens: A Systematic Review and Meta-Analysis

Childhood obesity is a crucial public health concern. In recent years, numerous studies have employed mobile health technology applications for weight control in children but obtaining varying effects. We conducted a meta-analysis to discuss the effectiveness of mobile health technology in reducing the body mass index (BMI) of obese children. The standardized mean difference (SMD) in BMI between the intervention and control groups was employed to measure the effect of mobile health technology intervention on weight control. The Comprehensive Meta-Analysis Version 3 software was employed for meta-analysis, and the results are presented in a forest plot. This study included nine randomized control trials, which featured a total of 1,202 participants. The meta-analysis revealed that mobile health technology intervention did not have a significant weight loss effect on subjects with obesity. However, by using ethnicity as a moderating variable for subgroup analysis, we discovered that the BMI of ethnic Chinese groups who received mobile health technology intervention was significantly lower than that of the control group. This effect was not significant in the non-ethnic Chinese subgroup. Therefore, the use of mobile health technology intervention for weight control in ethnic Chinese children resulted in significantly lower BMI in these children; however, the use of mobile health technology intervention for weight control is unsuitable for non-ethnic Chinese children.

School-based interventions for the treatment of childhood obesity: a systematic review, meta-analysis and meta-regression of cluster randomised controlled trials

OBJECTIVE

Schools offer an ideal setting for childhood obesity interventions due to their access to children and adolescents. This review aimed to systematically review the impact of school-based intervention for the treatment of childhood obesity.

DESIGN

Eight databases were searched from inception till 30 May 2020. A revised Cochrane risk-of-bias tool and the Grading of Recommendations, Assessment, Development and Evaluations criteria were used to evaluate the risk of bias and overall evidence. Meta-analysis and meta-regression were performed on Stata software using the random effects model. Overall effect was evaluated using Hedges' g, and heterogeneity was assessed using Cochran's Q and I2.

SETTING

Cluster randomised controlled trials (cluster-RCT) delivered in school.

PARTICIPANTS

Children and adolescents (6-18 years of age) with overweight and obesity.

RESULTS

Twelve cluster-RCT from seven countries with 1755 participants were included in the meta-analysis. School-based interventions for the treatment of childhood obesity reduced BMI and BMI z-scores with a medium effect (g = 0·52). Subgroup analyses showed greater effectiveness of brief school-based interventions and the interventions conducted in lower-middle to upper-middle economies. Meta-regression assessed the heterogeneity and the final model, with covariates of the type of economies and trial duration, accounted for 41·2 % of the variability. The overall quality of evidence was rated low because of the high risk of bias and inconsistency.

CONCLUSIONS

School-based interventions are a possible approach to provide universal healthcare for the treatment of childhood obesity, and further well-designed cluster-RCT with longer follow-up are needed. This study is registered with PROSPERO (CRD42020160735).

Investigating the effectiveness of school health services delivered by a health provider: A systematic review of systematic reviews

Schools are the only institution regularly reaching the majority of school-age children and adolescents across the globe. Although at least 102 countries have school health services, there is no rigorous, evidence-based guidance on which school health services are effective and should be implemented in schools. To investigate the effectiveness of school health services for improving the health of school-age children and adolescents, a systematic review of systematic reviews (overview) was conducted. Five databases were searched through June 2018. Systematic reviews of intervention studies that evaluated school-based or school-linked health services delivered by a health provider were included. Review quality was assessed using a modified Ballard and Montgomery four-item checklist. 1654 references were screened and 20 systematic reviews containing 270 primary studies were assessed narratively. Interventions with evidence for effectiveness addressed autism, depression, anxiety, obesity, dental caries, visual acuity, asthma, and sleep. No review evaluated the effectiveness of a multi-component school health services intervention addressing multiple health areas. From the limited amount of information available in existing systematic reviews, the strongest evidence supports implementation of anxiety prevention programs, indicated asthma education, and vision screening with provision of free spectacles. Additional systematic reviews are needed that analyze the effectiveness of comprehensive school health services, and specific services for under-researched health areas relevant for this population.

Perceptions of Obesity Prevention Policies: Socioeconomic Assessment in the Turkish Capital

PURPOSE

The purpose of this study was to inform public policy opportunities to reduce childhood obesity by identifying parents' perceptions of factors contributing to childhood obesity, attribution of responsibility, and the extent of their support for public prevention policies with attention to socio-economic status.

DESIGN AND METHODS

In 2015, 2066 parent-child dyads across socio-economic strata from 43 randomly selected schools in Ankara completed surveys and measurements to examine perceptions, attribution, and prevention policies related to childhood obesity.

RESULTS

Parents across the socio-demographic spectrum recognized obesity as a serious problem. Unhealthy food availability was identified as the leading cause of while industry and media were credited with having the greatest responsibility for childhood obesity. There was strong public support for policy strategies targeting schools, marketing, and the built environment, though support tempered as socio-economic status and parental education decreased.

CONCLUSIONS

This survey provided insight into parents' knowledge and beliefs surrounding childhood obesity as well as their endorsement of related prevention strategies. Educational messages that address variations in SES to describe the causes of childhood obesity and connect those causes to actionable community prevention strategies may improve community support for enhanced policy actions within and beyond school settings.

Body Mass Index Screening and Follow-Up: A Cross-Sectional Questionnaire Study of Pennsylvania School Nurses

Background

Childhood overweight and obesity health concerns can affect a student’s academic performance, so it is important to identify resources for school nurses that would help to improve self-efficacy, knowledge, and confidence when approaching parents with sensitive weight-related information and influence overall obesity prevention efforts in the school setting.

Objective

The purpose of this study was to conduct a Pennsylvania (PA) state-wide 29-item survey addressing school nursing barriers and practices, supplementing information already known in this area. Although the survey covered a range of topics, the focus was body mass index (BMI) screening and its related practice within the schools.

Methods

We conducted a state-wide Web-based survey of school nurses in PA to understand current areas of care, find ways to address child health through school BMI screenings and follow up, and identify current educational gaps to assist school nurses with providing whole child care within the realm of weight management. Chi-square test of independence was conducted to determine the relationship between BMI screening follow up and interest in a BMI toolkit.

Results

Nurse participants (N=210), with a 42% (210/500) response rate, represented 208 school districts across PA. Participants were asked about their current process for notifying parents of BMI screening results. The majority (116/210, 55.2%) send a letter home in the mail, while others (62/210, 29.5%) send a letter home with students. A small number (8/210, 3.8%) said they did not notify parents altogether, and some (39/210, 18.6%) notify parents electronically. More than one-third (75/210, 35.7%) of nurses reported receiving BMI screening inquiries from parents; however, under half (35/75, 46.7%) of those respondents indicated they follow up with parents whose child screens overweight or obese. Overall, the vast majority (182/210, 86.7%) do not follow up with parents whose child screens overweight or obese. The majority (150/210, 71.4%) of the nurses responded they would benefit from a toolkit with resources to assist with communication with parents and children about BMI screenings. A significant association between respondent follow up and interest in a BMI toolkit was observed (P=.01).

Conclusions

Schools must start recognizing the role school nurses play to monitor and promote children’s health. This goal might include involving them in school-based preventive programs, empowering them to lead initiatives that support whole child health and ensuring opportunities for professional development of interest to them. Nonetheless, the first step in facilitating obesity prevention methods within schools is to provide school nurses with meaningful tools that help facilitate conversations with parents, guardians, and caregivers regarding their child’s weight status and health through a BMI screening toolkit.

School gardening increases knowledge of primary school children on edible plants and preference for vegetables

At least 10% of children worldwide are diagnosed with overweight. Part of this problem is attributed to low vegetable intake, for which preference at a younger age is an indicator. Few studies examined long-term effects of school garden interventions on the knowledge about and preference for vegetables. Therefore, in this study, an intervention period of 7 months (17 lessons) was organized for primary school students (n = 150) of age 10-12 years in the Municipality of Nijmegen (the Netherlands). Surveys were conducted before and after the intervention period to test the ability of students to identify vegetables, to measure their self-reported preference for vegetables, and to analyze students' attitudes toward statements about gardening, cooking, and outdoor activity. The long-term effects were measured by repeating the survey 1 year after the intervention (n = 52). Results were compared with a control group of students (n = 65) with similar background and tested for significance with α = 0.05. School gardening significantly increases the knowledge of primary schoolchildren on 10 vegetables as well as their ability to self-report preference for the vegetables. The short-term (n = 106) and long-term (n = 52) preference for vegetables increased (p < 0.05) in comparison with the control group. The latter did not show a significant learning effect (p > 0.05). This implies that the exposure to vegetables generated by school gardening programs may increase willingness to taste and daily intake of vegetables on the long term. Students' attitudes toward gardening, cooking, and outdoor activity were unaffected by the intervention.

Screening and treatment of obesity in school health care - the gap between clinical guidelines and reality

AIMS

School health care offers a natural setting for childhood obesity interventions. Earlier studies reveal inadequate screening and treatment in primary care. However, longitudinal studies in unselected populations are lacking. We aimed to examine how school nurses and physicians identified obesity, diagnosed it and offered interventions over primary school. We compared the results with Finnish recommendations.

METHODS

From our cohort of 2000 primary school sixth graders (aged 12-14), 172 were obese at least once during primary school. We manually collected retrospective electronic health record (EHR) data of these 'ever-obese' children.

RESULTS

Of the ever-obese children, 96% attended annual nurse assessments more than twice. School physicians met 53% of the ever-obese children at health checks at first grade and 93% at fifth grade. Of overweight-related extra visits to school nurses, 94% took place without parents. Parents were present in 48% of extra school physician visits. Only 29% of the 157 who became obese during the first five school grades received an obesity diagnosis. However, school physicians mentioned weight problems in EHR for 90% of the children and, similarly, school nurses for 99%. The majority received a treatment plan at least once. For 78%, at least one plan was made with the parents. Still, 28% missed nutrition plans, 31% exercise plans and 90% lacked recorded weight development targets.

CONCLUSIONS

The gap between clinical guidelines and reality in school health care could be narrowed by improving diagnosing and parent collaboration. Obstacles in parent involvement and work methods in school health care need further study.

Investigating the effectiveness of webinars in the adoption of proven school wellness strategies

OBJECTIVE

Recent federal legislation in the USA highlights the role schools play in student health by requiring the utilisation of wellness councils for policy development and oversight. One barrier to developing good-quality wellness policies and wellness culture is limited knowledge of resources among school professionals. This article describes an approach to webinar delivery to improve school wellness efforts.

DESIGN

Eight webinars, 30-60 minutes in length, were delivered on topics designed to enhance school wellness environments.

SETTING

Webinars were delivered using an online meeting software platform to school professionals, who participated from their respective school buildings remotely.

METHOD

Webinars featured content experts for the selected topics and were promoted to school professionals and wellness organisations. Attendees were invited to participate in a post-webinar questionnaire regarding satisfaction with the session and intent to act on knowledge gained from participation.

RESULTS

Webinars reached 280 school and wellness professionals (teachers, administrators, nurses, etc.). Participants who completed post-webinar surveys (n = 78) rated the webinar's ability to enhance their knowledge in the respective topic area with an average score of 4.3 out of 5.0 (1 = poor, 5 = excellent). Most respondents (n = 69) intended to share the information gained with a colleague.

CONCLUSION

Webinars provide a viable method of instruction and education for school personnel interested in strategies for improving a school's wellness environment. Further investigation is necessary to determine the best strategies for promoting webinar engagement. Future research should also explore the link between webinar participation and positive changes in school wellness environments.

What Barriers and Facilitators Do School Nurses Experience When Implementing an Obesity Intervention?

A recent evaluation of a school nurse-led obesity intervention demonstrated a 5% implementation rate. The purpose of this study was to explore school nurses' perceived barriers to and facilitators of the intervention in order to understand reasons for the low implementation rate. Methods included semi-structured individual interviews with school nurses. Data were analyzed using content analysis and heat mapping. Nineteen nurses participated and eight themes were identified. Parental and administrative gatekeeping, heavy nurse workload, obesogenic environments, and concerns about obesity stigma were barriers to implementation. Teamwork with parents and school staff was a key facilitator of implementation. Nurses also noted the importance of cultural considerations and highlighted the need to tailor the intervention to the unique needs of their school environment and student population. These findings suggest that for school nurses to play a key role in school-based obesity interventions, barriers must be identified and addressed prior to program implementation.

Implementation of a School Nurse-led Intervention for Children With Severe Obesity in New York City Schools

PURPOSE

The Healthy Options and Physical Activity Program (HOP) is a school nurse-led intervention for children with severe obesity. HOP was developed by experts at the New York City Department of Health and Mental Hygiene and implemented in New York City schools beginning in 2012. The purpose of this study was to evaluate HOP implementation with the goal of informing HOP refinement and potential future HOP dissemination.

DESIGN AND METHODS

This study entailed a retrospective analysis of secondary data. Analytic methods included descriptive statistics, Wilcoxon rank sum and Chi square tests, and multivariate logistic regression.

RESULTS

During the 2012-2013 school year, 20,518 children were eligible for HOP. Of these, 1054 (5.1%) were enrolled in the program. On average, enrolled children attended one HOP session during the school year. Parent participation was low (3.2% of HOP sessions). Low nurse workload, low school poverty, higher grade level, higher BMI percentile, and chronic illness diagnosis were associated with student enrollment in HOP.

CONCLUSIONS

As currently delivered, HOP is not likely to be efficacious. Lessons learned from this evaluation are applicable to future nurse-led obesity interventions.

PRACTICE IMPLICATIONS

Prior to implementing a school nurse-led obesity intervention, nursing workload and available support must be carefully considered. Interventions should be designed to facilitate (and possibly require) parent involvement. Nurses who deliver obesity interventions may require additional training in obesity treatment. With attention to these lessons learned, evidence-based school nurse-led obesity interventions can be developed.

Which Propensity Score Method Best Reduces Confounder Imbalance? An Example From a Retrospective Evaluation of a Childhood Obesity Intervention

BACKGROUND

Propensity score (PS) methods are increasingly being employed by researchers to reduce bias arising from confounder imbalance when using observational data to examine intervention effects.

OBJECTIVE

The purpose of this study was to examine PS theory and methodology and compare application of three PS methods (matching, stratification, weighting) to determine which best improves confounder balance.

METHODS

Baseline characteristics of a sample of 20,518 school-aged children with severe obesity (of whom 1,054 received an obesity intervention) were assessed prior to PS application. Three PS methods were then applied to the data to determine which showed the greatest improvement in confounder balance between the intervention and control group. The effect of each PS method on the outcome variable-body mass index percentile change at one year-was also examined. SAS 9.4 and Comprehensive Meta-analysis statistical software were used for analyses.

RESULTS

Prior to PS adjustment, the intervention and control groups differed significantly on seven of 11 potential confounders. PS matching removed all differences. PS stratification and weighting both removed one difference but created two new differences. Sensitivity analyses did not change these results. Body mass index percentile at 1 year decreased in both groups. The size of the decrease was smaller in the intervention group, and the estimate of the decrease varied by PS method.

DISCUSSION

Selection of a PS method should be guided by insight from statistical theory and simulation experiments, in addition to observed improvement in confounder balance. For this data set, PS matching worked best to correct confounder imbalance. Because each method varied in correcting confounder imbalance, we recommend that multiple PS methods be compared for ability to improve confounder balance before implementation in evaluating treatment effects in observational data.