Placing students at the center: the Whole School, Whole Community, Whole Child model

The Commit to Be Fit framework: a community case study of a multi-level, holistic school-based wellness initiative in rural Virginia

Background

Public health interventions that target children's physical, mental, and emotional health will enhance their ability to learn and grow. Although more complex, school initiatives that address multiple ecological levels and take a holistic view may be more effective and likely to lead to lasting change.

Aims

This article presents the framework of Commit to Be Fit (C2BF) as an example of how schools can integrate multi-level and holistic approaches for health. This innovative school-based intervention includes activities addressing individual, home, school, and community to create a culture of wellness. We describe the implementation of C2BF and its basis in ecological models and give examples of activities across three components: cafeteria, classroom, and community. We discuss challenges and note that leadership engagement and alignment were critical elements for C2BF's success thus far.

Discussion

C2BF uses a school-based multi-level approach to creating a culture of wellness and holistic health for students, teachers, and community members. C2BF is unique compared to other school-based programming and includes activities that address all eight domains posited for program sustainability within public health. Built to be flexible and adaptive, C2BF was able to successfully pivot during the COVID pandemic and also follow new science.

Conclusion

C2BF and other multi-level holistic approaches are more likely to achieve long-term change by utilizing strategies across the multiple levels of the ecological model to improve health and wellbeing.

Implementation of CDC Guidelines for Recess: A Formative Research Study

The American Academy of Pediatrics recognizes recess as an essential part of overall child development in schools, impacting children's cognitive, socioemotional and physical health and development. However, recess is often removed from the school curriculum in exchange for more classroom activities. The Centers for Disease Control and Prevention (CDC) and SHAPE America developed Strategies for Recess in Schools to promote high-quality recess through specific actions, yet is not known how these are successfully implemented, particularly, in underserved settings. This formative research study examined the implementation of the CDC strategy in an urban, inner-city charter elementary school to identify barriers and facilitators to successful recess implementation from the perspective of various stakeholders. Thirteen in-depth interviews and focus group discussions were conducted with parents, teachers, recess monitors, and school administrators. Interviews were recorded, transcribed, and coded for thematic analysis, supported by group discussion and analytic memos. Results suggested that although stakeholders recognized the importance of recess, the implementation of the CDC strategy was neither uniformly understood nor implemented, suggesting that additional frameworks may be helpful in implementing the CDC strategy in schools in underserved communities.

Use of Private, Parochial, and Public Schools in Baccalaureate Nursing Programs for Pediatric Practicum

BACKGROUND

Clinical sites are increasingly difficult to secure due to shorter hospital stays, increased clinical site competition, and limited practicum sites. Little is known about the use of schools for pediatric clinical practicum.

PURPOSE

To explore utilization of private, parochial, and public primary and secondary schools for pediatric clinical practicum sites.

METHODS

Faculty (n = 108) completed a 38-item online survey.

RESULTS

Twenty-seven faculty members (25%) reported using schools for pediatric practicum. Most nursing students (85.1%) spent 23 total hours or less in schools obtaining anthropometric measurements, reviewing immunizations, and providing health education to children, parents, and teachers.

CONCLUSION

Using schools for the pediatric practicum is thought to be a common practice; our findings suggest otherwise. School-based practicums provide students with skills beyond acute care competencies. Nursing faculty need to seriously consider which pediatric clinical settings provide the best experience to prepare future nurses.

Evaluation of a Large-Scale School Wellness Intervention Through the Consolidated Framework for Implementation Research (CFIR): Implications for Dissemination and Sustainability

Background

Numerous studies have tested school-based interventions promoting healthy behaviors in youth, but few have integrated dissemination and implementation (D&I) frameworks. Using D&I frameworks can inform if and how an evidence-based intervention is implemented and maintained and provide strategies to address contextual barriers. Such application is necessary to understand how and why interventions are sustained over time. We evaluated a school wellness initiative called SWITCH® (School Wellness Integration Targeting Child Health) to (1) assess implementation outcomes of adoption, fidelity, and penetration, (2) discern implementation determinants through the Consolidated Framework for Implementation Research (CFIR), and (3) examine differences among inexperienced and experienced schools and influential factors to sustainment.

Methods

A total of 52 schools from Iowa, United States enrolled in the 2019-2020 iteration of SWITCH (22 inexperienced; 30 experienced). The CFIR guided the adaptation of mixed methods data collection and analysis protocols for school settings. Specific attention was focused on (1) fidelity to core elements; (2) adoption of best practices; and (3) penetration of behavior change practices. Determinants were investigated through in-depth qualitative interviews and readiness surveys with implementation leaders. A systematic process was used to score CFIR domains (between -2 and +2) indicating positive or negative influence. Independent t-tests were conducted to capture differences between samples, followed by a cross-case analysis to compare determinants data. Inductive coding yielded themes related to sustainment of SWITCH beyond formal implementation support.

Results

Experienced schools had higher scores on fidelity/compliance (t = -1.86 p = 0.07) and adoption (t = -2.03 p = 0.04). CFIR determinants of innovation source, culture, relative priority, and leadership engagement were positive implementation determinants, whereas tension for change and networks and communications were negative determinants. Distinguishing factors between experienced and inexperienced schools were Readiness for Implementation and Self-efficacy (experienced significantly higher; p < 0.05). Strategies to enhance sustainability were increasing student awareness/advocacy, keeping it simple, and integrating into school culture.

Conclusions

Findings provide specific insights related to SWITCH implementation and sustainability but more generalized insights about the type of support needed to help schools implement and sustain school wellness programming. Tailoring implementation support to both inexperienced and experienced settings will ultimately enhance dissemination and sustainability of evidence-based interventions.

Comprehensive Prevention of Campus Sexual Violence: Expanding Who Is Invited to the Table

There are calls for sexual violence prevention to be more comprehensive and align with a socio-ecological approach. However, there is lack of models with specificity on how to engage additional stakeholders. Whole School Approach (WSA) frameworks have been used to address health promotion and bullying prevention and can be a useful model for guiding campus sexual violence prevention work. WSA models situate violence as a community issue and one where all community members have a role to play in prevention. Rather than focusing on addressing individual behavior, WSA frameworks address the role of the larger school environment in serving as a protective factor against violence, abuse, and harassment. A review of the literature on WSA frameworks in other disciplines reveals a number of potential ways to translate key elements of WSA models to the field of campus sexual violence prevention. In particular, mechanisms can be applied to expand the role of students, faculty, staff, parents/significant adults, institutional leadership, and the larger community.

State Laws Matter When It Comes to District Policymaking Relative to the Whole School, Whole Community, Whole Child Framework

BACKGROUND

The Whole School, Whole Community, Whole Child (WSCC) framework supports the "whole child" across 10 domains. This study assessed state law and district policy WSCC coverage.

METHODS

Primary legal research was used to compile relevant district policies and state laws for a stratified random sample of 368 public school districts across 20 states for school year 2017-18. Policies/laws were evaluated on 79 items across the WSCC domains (range: 3-14 items/domain). Multivariable regressions examined the relationship between state laws and district policies, controlling for district characteristics, and weighted to account for the sample design and non-response.

RESULTS

On average, district policies and state laws addressed 53% and 60% of the 79 items, respectively. State law predicted district policy WSCC attention across items (coeff. = 0.26, 95% CI = 0.14, 0.38) and 4 domains: physical activity (coeff. = 0.57, 95% CI = 0.29, 0.86); health services (coeff. = 0.50, 95% CI = 0.39, 0.62); social and emotional climate (coeff. = 0.34, 95% CI = 0.23, 0.45); and family engagement (coeff. = 0.41, 95% CI = 0.28, 0.54). State law was associated with lower district-level coverage in 3 domains (health education; counseling, psychological, and social services; and community involvement).

CONCLUSIONS

Although WSCC implementation is locally-driven, states have an active role to play in setting a policy "floor" for guiding district WSCC attention.

Community-Based System Dynamics for Mobilizing Communities to Advance School Health

BACKGROUND

Frameworks such as the WSCC model provide evidence-based guidance for addressing school health at the school, district, and regional level. However, frameworks do not implement themselves; they require the mobilization and collaboration of stakeholders within communities and an understanding of the unique resources and barriers within each context. Furthermore, addressing school health presents a complex systems problem.

METHODS

Community-based system dynamics (CBSD) is a participatory approach for engaging communities in understanding and changing complex systems. We used a descriptive multiple case study design to evaluate how and why CBSD was used as a tool for stakeholders to engage with the complexity of school health.

RESULTS

We analyzed 3 cases to understand how these methods were used to enhance collaboration, analysis, and community action at multiple levels, including in 2 school districts, with a city-wide stakeholder committee, and with a group of high school students.

CONCLUSIONS

Community-based system dynamics presents a promising approach for building shared language and ownership among stakeholders, tailoring to local community contexts, and mobilizing stakeholders for action based on new system insights. We close with a discussion of unique opportunities and challenges of expanding the use of CBSD in the field of school health.

Testing the "Zero-Sum Game" Hypothesis: An Examination of School Health Policies and Practices and Inequalities in Educational Outcomes

BACKGROUND

Health and education are intrinsically linked, while both are significantly patterned by socioeconomic status throughout the life course. Nevertheless, the impact of promoting health via schools on education is seen by some as a "zero-sum game"; ie, focusing resources on health improvement activity distracts schools from their core business of educating pupils, potentially compromising educational attainment. There is emerging evidence that school health improvement interventions may beneficially influence both health and attainment. However, few studies have examined the relationship between school health improvement activity and socioeconomic inequalities in educational attainment.

METHODS

Wales-wide, school-level survey data on school health policies and practices was linked with routinely collected data on academic attainment. Primary outcomes included attendance and academic attainment at age 14 (Key Stage 3) and 16 (Key Stage 4). Linear regression models were constructed separately for high and low Free School Meal (FSM) schools, adjusting for confounders. Interaction terms were fitted to test whether there was an interaction between FSM, health improvement activity, and outcomes.

RESULTS

There were positive associations between almost all school health variables and KS3 attainment among high, but not low FSM schools. Similarly, for attendance, there were positive associations of several health variables among high but not low FSM schools. There were no associations for KS4 attainment.

CONCLUSIONS

Our findings did not support the "zero-sum game" hypothesis; in fact, among more deprived schools there was a tendency for better attendance and attainment at age 14 in schools with more embedded health improvement action.

School Climate as an Intervention to Reduce Academic Failure and Educate the Whole Child: A Longitudinal Study

BACKGROUND

Preventing student academic failure is crucial to student health and life success. Previous studies suggest a positive school climate may reduce students' risk for academic failure and contribute to academic success. The purpose of this study was to determine the longitudinal associations between school climate and academic grades in a group of middle school students who transition into high school.

METHODS

Parallel latent growth curve modeling was used to examine changes among study variables longitudinally using a sample of 2604 in 6th, 7th, and 8th-grade students across 16 regional schools located in 3 counties in West Virginia.

RESULTS

Students with higher perceptions of a positive school climate exhibited sustained or improved academic achievement over time (β = 0.22 to 0.30, p < .01). Higher positive perceptions of school climate appear to sustain students who earn As/Bs (β = 0.20 to 0.27, p < .01) and strengthen students who earn Cs/Ds/Fs (β = -0.16 to -0.46, p < .05).

CONCLUSIONS

Positive student perceptions of school climate may sustain high academic performance while strengthening students who earn Cs/Ds/Fs. School climate may be useful as an intervention to support school-based health promotion to reduce the achievement gap in the United States.

Defining Food Education Standards through Consensus: The Pilot Light Food Education Summit

BACKGROUND

Consistent with the Whole School, Whole Community, Whole Child Approach, food education encompasses nutritional status, culture, community, environment, and society. Unifying standards are needed to support food education integration in K-12 curricula. Pilot Light, a Chicago-based nonprofit, sought to generate such standards. This study reports a formative evaluation research process that led to the development of Food Education Standards (FES).

METHODS

Nine FES were drafted within the context of the National Health Education Standards. The 2-day Pilot Light Food Education Summit convened 26 experts and community members to review draft FES. A facilitated, consensus-building process generated refined FES and K-12 competencies. Drawing on Summit outcomes and expert feedback, a team of teachers subsequently drafted final FES. Summit participants completed pre- and post-Summit surveys to assess changes in food education priorities.

RESULTS

The initial 9 FES were refined to 7. Comparison data indicated shifts in endorsed priorities for food education, moving from prioritizing specific knowledge, such as "categorizing food into food groups," toward "students having a conscious decision-making process around food."

CONCLUSIONS

Developed with input from experts across multidisciplinary fields, the evidence-based Pilot Light FES can be feasibly implemented in multiple subjects across all school types and community socio-demographic levels.

Breast Cancer in San Francisco: Disentangling Disparities at the Neighborhood Level

BACKGROUND

This study uses a novel geographic approach to summarize the distribution of breast cancer in San Francisco and aims to identify the neighborhoods and racial/ethnic groups that are disproportionately affected by this disease.

METHODS

Nine geographic groupings were newly defined on the basis of racial/ethnic composition and neighborhood socioeconomic status. Distribution of breast cancer cases from the Greater Bay Area Cancer Registry in these zones were examined. Multivariable logistic regression models were used to determine neighborhood associations with stage IIB⁺ breast cancer at diagnosis. Cox proportional hazards regression was used to estimate the hazard ratios for all-cause and breast cancer-specific mortality.

RESULTS

A total of 5,595 invasive primary breast cancers were diagnosed between January 1, 2006 and December 31, 2015. We found neighborhood and racial/ethnic differences in stage of diagnosis, molecular subtype, survival, and mortality. Patients in the Southeast (Bayview/Hunter's Point) and Northeast (Downtown, Civic Center, Chinatown, Nob Hill, Western Addition) areas were more likely to have stage IIB⁺ breast cancer at diagnosis, and those in the East (North Beach, Financial District, South of Market, Mission Bay, Potrero Hill) and Southeast were more likely to be diagnosed with triple-negative breast cancers (TNBC). Compared with other racial/ethnic groups, Blacks/African Americans (B/AA) experienced the greatest disparities in breast cancer-related outcomes across geographic areas.

CONCLUSIONS

San Francisco neighborhoods with lower socioeconomic status and larger minority populations experience worse breast cancer outcomes.

IMPACT

Our findings, which reveal breast cancer disparities at sub-county geographic levels, have implications for population-level health interventions.

Using Elementary Schools for Pediatric Practicum: An Alternative Approach

Securing clinical sites that facilitate achievement of nursing skills to competently care for children is often challenging for nursing faculty. An additional challenge is helping nursing students learn the importance of conceptually driven practice and its application in the delivery of high quality care. This manuscript describes an alternative pedagogical approach that utilizes elementary schools for pediatric practicum, which is framed by the Whole School, Whole Community, Whole Child Model. Our model driven approach not only provides a framework by which baccalaureate nursing students gain the skills necessary to interact with, educate, and care for children, but also one in which they can gain a greater understanding of how the home, school and community influence the overall health and well-being of children. Subsequently, this pedagogy serves as an exemplar of how an alternative site can be utilized to successfully educate nursing students regarding the care of children.

School Health as a Strategy to Improve Both Public Health and Education

Because schools materially influence both health and education, they substantially determine the future well-being and economic productivity of populations. Recent research suggests that healthier children learn better and that more educated adults are healthier. School health is a cross-disciplinary field of study and a fundamental strategy that can be used to improve both health and education outcomes. Modern school health programs include 10 interactive components: health education; physical education and physical activity; nutrition environment and services; health services; counseling, psychological, and social services; physical environment; social and emotional climate; family engagement; community involvement; and employee wellness. This review is written for both health and education audiences. It integrates recent research and developments in relationships among health, education, and economic outcomes; health and education systems; the school health program, its components, and their effectiveness; cross-disciplinary collaboration; local, state, national, and international infrastructures and strategies; implementation science; and relevant academic research, training, and service.

Increasing Social Support for Breakfast: Project BreakFAST

High school students in the United States are known to be frequent skippers of breakfast. Social support is one key element needed to encourage adolescents to consume school breakfast. This article presents an analysis of the influence of a school policy and environment change intervention on the social support of adolescents to eat breakfast.

METHOD

The intervention included school policy changes in 16 schools randomized to intervention and delayed-intervention conditions, in order to allow quick and easy access to breakfast as well as to allow breakfast consumption in classrooms and hallways; a School Breakfast Program marketing campaign to address normative and attitudinal beliefs; and increasing social support and role modeling to encourage breakfast eating. The participants in the study completed an online survey at baseline and again postintervention.

RESULTS

The final analysis included only students who completed the relevant survey (n = 904) items on both the baseline and follow-up surveys. The students in the intervention group showed a higher level of social support post intervention than the control group with a significant adjusted p of .02. Most of the overall social support change was explained by a change in the "other kids at my school" and "other school staff" categories.

CONCLUSIONS

The BreakFAST study shows the benefits of school staff and kids other than friends supporting a behavior change to include breakfast consumption in adolescents.

Not Enough Time in the Day: A Qualitative Assessment of In-School Physical Activity Policy as Viewed by Administrators, Teachers, and Students

BACKGROUND

In recent decades, the alignment of health and education has been at the forefront of school reform. Whereas the establishment of national in-school physical activity (ISPA) recommendations and state-level mandates demonstrates success, there has been less achievement in areas that address health disparities. The purpose of this investigation was to explore barriers and facilitators to implementing state-mandated ISPA policies in the Mississippi Delta.

METHODS

Focus groups or interviews were conducted with district administrators, school principals, teachers, and students. A total of 2 semistructured moderator guides were developed to focus on (1) student ISPA practices and preferences and (2) facilitators and barriers to implementing ISPA policies and practices.

RESULTS

A total of 6 themes were developed. In that, 2 themes addressed participant-described barriers (primary challenges and interferences and excuses). Three themes highlighted participant-described facilitators (compromises, things that work, and being active at school). Finally, 1 theme encompassed the participant-described need to address educating the whole child.

CONCLUSIONS

There is a critical need for meaningful and relevant solutions to circumvent challenges to implementing ISPA policies and practices in the Mississippi Delta. The Whole School, Whole Community, Whole Child model offers a broad means of visualizing rural, low-income, racially concentrated schools to circumvent challenges and foster ISPA policies and practices.