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Service Delivery Innovation Profile

Fun, Interactive Classes Emphasize Easy-to-Understand Messages, Leading to Enhanced Knowledge About Healthy Behaviors in Elementary School Children


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Summary

ProMedica Health System offers a series of classes free of charge to elementary school children and their parents to promote adoption of healthier behaviors related to nutrition and physical activity. Known as the Conversation Map Education Program, classes consist of fun, interactive activities (including a colorful map-based game) that emphasize easy-to-understand, positive information and messages. Separate courses exist for young children (grades 1 through 3), older children (grades 4 through 6), and parents, with classes being taught in the schools and community organizations, including YMCA daycare sites. The courses, which more than 2,000 elementary school children have completed to date, have increased knowledge about healthy behaviors related to diet and physical activity.

Evidence Rating (What is this?)

Moderate: The evidence consists of results from a short questionnaire assessing knowledge levels in children before and after completing the course.
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Developing Organizations

ProMedica
Toledo, OHend do

Date First Implemented

2009
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Patient Population

Age > Child (6-12 years)end pp

Problem Addressed

The prevalence of childhood obesity has increased significantly over the last several decades and has now reached epidemic proportions. Untreated obesity has adverse effects on children's health as they age, often leading to serious health problems. Many children become obese due to poor lifestyle choices (e.g., unhealthful diet, not enough regular physical activity) that stem in part from a lack of understanding about how to make appropriate choices.
  • A growing epidemic: The prevalence of obesity (defined as a body mass index above the 94th percentile) among children and adolescents has increased rapidly in recent decades. Nationwide, between 1976 and 1980 and 2007 and 2008, the prevalence of childhood obesity more than tripled, rising from 5.0 to 19.4 percent in 2- to 5-year-olds, from 6.5 to 19.6 percent in 6- to 11-year olds, and from 5.0 to 18.1 percent in 12- to 19-year-olds.1 Among ProMedica's health plan members, about one-third of children and 65 percent of adults are obese.
  • Severe health consequences: Overweight and obesity put children at current and future risk of many serious health problems, including cardiovascular disease, type 2 diabetes, and mental health conditions such as anxiety and depression.2
  • Poor lifestyle choices: The chief causes of childhood obesity include lack of regular physical activity and poor nutritional habits. Only about 35 percent of high school students report that they participate in at least 60 minutes of physical activity on 5 or more days of the week, and only 30 percent of students report that they attend physical education class daily.3 In 2009, only 22 percent of high school students reported eating fruits and vegetables five or more times daily (when fried potatoes and potato chips are excluded) during the past 7 days, and less than 40 percent of children and adolescents in the United States meet the U.S. dietary guidelines for saturated fat.4
  • Driven by lack of understanding: Many children make poor lifestyle choices because they do not understand important concepts of physiology and nutrition that could help them develop healthy habits and maintain a healthy weight. Teaching these complex topics in a manner that children and parents understand can be challenging, and many efforts to do so (e.g., media messages) have proven to be confusing to and/or have not resonated with their target audience.

What They Did

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Description of the Innovative Activity

ProMedica Health System offers a series of classes free of charge to elementary school children and their parents to promote adoption of healthier behaviors related to diet and physical activity. Known as the Conversation Map Education Program, classes consist of fun, interactive activities (including a colorful map-based game) that emphasize easy-to-understand, positive information and messages. Separate courses exist for young children (grades 1 through 3), older children (grades 4 through 6), and parents, with classes being taught in the schools and community organizations, including YMCA daycare sites.
  • Program marketing: A ProMedica representative contacts schools and independent organizations (or responds to a school or organization that has contacted ProMedica), explaining what the classes entail and seeking permission to deliver them. To minimize disruption to the school, ProMedica encourages schools to offer the class as part of the school's existing gym or health curriculum. In most cases, after the school principal agrees to the plan, school gym teachers help to coordinate the classes. ProMedica also offers classes at other organizations where children have group activities, such as churches, community groups, and YMCA daycare sites. To maximize interest, ProMedica provides the classes at no cost within a 27-county service area in northwest Ohio and southeast Michigan.
  • Children's courses: A ProMedica representative usually teaches the children's courses, although in some cases school teachers or representatives of independent organizations hosting the classes can teach the course after completing a training program (see the Planning and Development Process section for more details). The 2-hour course for grades 1 through 3 typically consists of four half-hour sessions, while the 3-hour course for grades 4 through 6 is typically delivered in six half-hour sessions. Between October 2009 and March 2011, more than 1,000 children completed the courses in elementary schools, with hundreds more having taken them through community organizations; as of September 2012, more than 2,000 children have completed these courses. Key elements of the children's courses include the following:
    • Curriculum focused on key concepts: Classes focus on a few key topics, including how the body works, understanding food groups, reading food labels, media literacy, portion control, grocery shopping, preparing healthy meals, and the importance of physical activity.
    • Emphasis on easy-to-understand, positive messages: Information about food choices can be confusing, especially for children, so the program emphasizes easily understood concepts and positive messages. For example, the class materials categorize foods as either "strong" or "lazy"—strong foods include fruits, vegetables, and whole-grain bread, while lazy foods include high-calorie snacks such as cookies, potato chips, and soft drinks.
    • Learning through fun, interactive activities: The presenter uses scripted guides that emphasize fun, interactive activities instead of lectures. Teachers use a Socratic teaching style designed to get all children to participate by asking questions and sharing their own experiences. The centerpiece of the class is a colorful, interactive map-based game that includes a board, game pieces, and cards representing different types of foods. Children advance through the map by finding the "three and a half keys" to good health each day, which include getting an hour of physical activity, engaging in 2 hours or less of screen time (e.g., watching television, playing video games, using the computer), drinking three cups of low-fat milk or dairy, and filling half the plate with fruits and vegetables at each meal. The guide includes additional handouts that can be used in the classroom or at home to reinforce learning.
    • De-emphasis on weight, obesity: To avoid drawing attention to overweight or obese students (which can lead to bullying), the classes make little mention of weight or obesity. Instead, the curriculum stresses the importance of following healthy behaviors for everyone.
  • Parent class: ProMedica offers a single 1- to 2-hour class for parents, which schools may offer as part of parents' nights, parent-teacher association meetings, or other activities that attract parents. Parent classes can also be offered at church gatherings. The class teaches similar subject matter and uses similar teaching methods to empower parents and caregivers to help their children make good decisions about eating and physical activity. To date, several dozen parents have attended the course.
  • Conversation map: Information provided in September 2012 indicates that an additional conversation map has now been developed for adults of all ages ("Healthy Eating in the Real World") to address eating at fast food restaurants, buying food at convenience stores, and other topics.

Context of the Innovation

ProMedica is a nonprofit health care system based in Toledo, OH, with locations in northwest Ohio and southeast Michigan. The system includes a health education and research center, health maintenance organization, nursing homes, local network of 2,900 private practice physicians, and several hospitals. The impetus for this program came out of ProMedica's Fields of Green initiative, which targets obesity and food access in the organization's service area. ProMedica introduced Fields of Green in 2008 after identifying obesity as a critical health issue. The courses for students and parents fit within this initiative's overall goals, which include raising awareness about proper nutrition and exercise, reducing the incidence of obesity, and increasing knowledge about and access to healthier foods, especially for underserved populations.

Did It Work?

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Results

Pre- and post-test questionnaires were used to evaluate student understanding of the main health and nutrition messages. For consistency in delivery, one ProMedica representative conducted testing. Data was collected on 254 children in grades 1 to 3 and on 522 children in grades 4 to 6. Chi-square analysis shows that children in both grade groups enhanced their knowledge about healthy behaviors related to diet and physical activity. Gains in knowledge include the following:
  • Greater understanding of healthy eating habits: In both age groups, the percentage of children who could tell the difference between "strong" and "lazy" foods increased significantly. In grades 1 to 3, the percentage rose from 70% to 86%, while the 4 to 6 grade children went from 82 to 94%. The percentage of children in grades 4 to 6 who could correctly state the number of servings of low-fat milk or dairy products they should consume each day increased significantly, from 36 percent to 56 percent, and the percentage knowing that half their plate should consist of fruits and vegetables also rose significantly, from 51 percent to 85 percent.
  • Greater understanding of healthy exercise habits: In grades 1 to 3, the percentage of children knowing that they should be physically active for at least 2 hours per day went from 61 to 72 percent, but this increase was not statistically significant. In grades 4 to 6, the increase in knowledge of recommended physical activity increased significantly, from 38 to 64 percent. In grades 1 to 3, the percentage of children who knew that screen time should be limited to less than one hour a day went from 60 to 80 percent, while the rate went from 22 to 60 percent in grades 4 to 6; both of those changes were significant.

Evidence Rating (What is this?)

Moderate: The evidence consists of results from a short questionnaire assessing knowledge levels in children before and after completing the course.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Forming committee: In 2008, leaders of ProMedica's Fields of Green formed a committee that developed the concept and then the courses, and that later worked with schools to implement them.
  • Partnering with outside organization: ProMedica approached Healthy Interactions Inc., a health education company, to develop conversation maps and other course materials, following a previous implementation of this model to educate adults about managing diabetes. In late 2008, the committee decided to work with Healthy Interactions to develop the specific course materials for grades 4 through 6.
  • Making key decisions on content delivery: Early on, the committee decided that classes should be designed to allow anyone with a strong interest in health to present the material (after appropriate training), rather than requiring someone with a teaching or medical background. The committee also decided to structure the course to be taught in short (30-minute) sessions so that it could be integrated into existing school classes, and to emphasize interaction with students (rather than lectures) so as to enhance retention.
  • Designing curriculum for grades 4 through 6: In 2009, the committee consulted with Healthy Interactions to develop the course content and materials for grades 4 through 6, using national subject matter experts. Part of this effort involved development of a kit with five conversation maps, with corresponding game pieces and playing cards, as well as a parent map and activities.
  • Conducting focus groups to test, refine curriculum: In the summer of 2009, ProMedica ran a series of focus groups to test the curriculum with children. Staff from ProMedica and Healthy Interactions monitored the classes and interviewed children and parents afterward. Their findings led to some changes in content and presentation. For example, because children became overly excited by the game pieces and playing cards, the curriculum was modified to introduce them in smaller batches instead of all at once. In addition, the committee decided to make the cards out of sturdier cardboard to increase their durability.
  • Adapting curriculum to grades 1 through 3 and parents: In the fall of 2009, ProMedica worked with Healthy Interactions to develop a similar course for younger children and a single-session class for parents. The key messages for this group were to eat strong, play hard (2 hours per day), and get lots of sleep (10 hours).
  • Training presenters: During the curriculum development phase, ProMedica circulated e-mails to employees to gauge their interest in presenting the courses. Those who volunteered participated in 4 hours of training that included a review of course materials and simulated sessions to practice leading the classes. To date, about 70 Promedica staff have completed training. In addition, more than 120 community members (teachers, teacher's aides, and volunteers) have been trained to lead or help lead the course, including more than 100 daycare staff from the YMCA of Greater Toledo (which presents the course at its daycare sites).
  • Approaching schools: In November 2009, ProMedica staff began contacting schools about their interest in offering the courses. The effort focused initially on the Toledo Public School System, the largest school system in ProMedica's coverage area. Because the system is largely decentralized, ProMedica contacted each school individually. Regional schools and academies were then included in this program offering.
  • Approaching community groups: In 2010, ProMedica began contacting community groups about offering the courses. Organizations expressing an interest included YMCA sites, Boy Scouts of America, churches, and other religious groups.
  • Launching parent program: At the same time, ProMedica began working with school officials and community groups to identify opportunities to offer the class to adults.

Resources Used and Skills Needed

  • Staffing: The program requires no incremental staff. As noted, more than 70 ProMedica employees can deliver the program as part of their regular job responsibilities, as can the 120 community members (including 100 childcare providers at YMCA-run daycare centers) who also do so as part of their regular jobs.
  • Costs: Upfront development of the course materials cost roughly $150,000. (Other organizations wishing to use the kits and training may obtain them from Healthy Interactions, Inc.)
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Funding Sources

ProMedica Foundation; United Way Grant
The ProMedica Foundation provided a grant to cover the cost of course development. Additional grants from external sources have been obtained to cover the cost of the kits for various community programs.end fs

Tools and Other Resources

More information about the Fields of Green initiative, including the conversation map program, is available on the ProMedica Web site at: http://www.promedica.org/body.cfm?id=217.

A short video explaining several key nutritional concepts to children is available on the Healthy Interactions Web site at: http://www.healthyinteractions.com/media/healthy_kids.html. Information about the company's other educational programs for adults and children is available at: http://healthyinteractions.com/conversation-map-programs.

Adoption Considerations

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Getting Started with This Innovation

  • Make long-term commitment: Developing and implementing this kind of program represents a major undertaking. To succeed, high-level administrators must understand its potential value and support it over the long haul.
  • Structure course to work in existing gym classes: Given the educational system's emphasis on increasing test scores, finding classroom time for courses on diet and exercise can be a major challenge. ProMedica has found that offering the course as part of existing gym or health classes works well, since these represent nonacademic courses and teachers will likely be interested in and supportive of the course content.
  • Structure program to be fun for students: Students will be much more likely to retain the information if they find the course fun and engaging. To that end, make sure that those teaching the course know how to engage all children, and design teaching materials to spark children's interest.
  • Use focus groups to refine curriculum: Before fully rolling out the program, use focus groups to gauge how children respond to it, and make adjustments as needed based on their feedback.

Sustaining This Innovation

  • Be persistent when approaching schools: It may take several calls to reach the principal and gain his or her approval to hold the course. If the principal expresses interest but seems hesitant or too busy to formalize the plan, ask to work with a member of the physical education department to iron out the details.
  • Engage community partners to expand reach: Look for opportunities to offer the courses outside of the school system. By partnering with the YMCA, ProMedica has been able to expand the program's reach to many more children and parents.

More Information

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Contact the Innovator

Gaye Martin
Manager, Community Relations and Advocacy
ProMedica Health System
1801 Richards Rd.
Toledo, OH 43607
Phone: (419) 469-3704
E-mail: gaye.martin@promedica.org

Innovator Disclosures

Mr. Martin reported having no financial interests or business/professional affiliations relevant to the work described in the profile other than the funders listed in the Funding Sources section.

Footnotes

1 Ogden C, Carroll M. Prevalence of Obesity Among Children and Adolescents: United States, Trends 1963–1965 Through 2007–2008. June 4, 2010. Available at: http://www.cdc.gov/NCHS/data/hestat/obesity_adult_07_08/obesity_adult_07_08.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
2 U.S. Centers for Disease Control and Prevention. Overweight and Obesity. Trends by State, 1985–2009. Updated March 3, 2011. Available at: http://www.cdc.gov/obesity/data/trends.html#State
3 Eaton DK, Kann L, Kinchen S, et al. Youth risk behavior surveillance—United States, 2007. MMWR Surveill Summ. 2008 Jun 6;57(4):1-131. [PubMed] Available at: http://www.cdc.gov/mmwr/pdf/ss/ss5704.pdf
4 Centers for Disease Control. National Center for Chronic Disease Prevention and Health Promotion Fact Sheet. Available at: http://www.cdc.gov/HealthyYouth/nutrition/facts.htm
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: July 06, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 04, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: June 02, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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