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Holistic health promotion for adolescent girls in an alternative school setting: lessons learned.

Introduction

Teens in alternative school programs engage in more risky health behaviors (Grunbaum, Lowry, & Kann, 2001) and are at greater risk of obesity (Sherlock, 2011) than teens in mainstream schools. Because healthy students are able to learn better than unhealthy students (Basch, 2011), these health disparities only exacerbate the academic disadvantage that students in alternative schools already experience. Good health supports academic success (Basch, 2011).

Meta-analytic evidence suggests that school-based health education programs can reduce obesity and increase positive health behaviors among adolescents (Stice, Shaw, & Marti, 2006). However, almost no studies have assessed healthy lifestyle programs in alternative school settings. Alternative schools pose particular challenges and opportunities for health promotion. Studies of other health-related programs such as HIV prevention in alternative schools have shown low levels of success (O'Hara, Messick, Fichtner, & Parris, 1996) and documented a greater number of barriers to implementation compared to mainstream school settings, such as poor attendance rates (Sherlock, 2011) and environmental limitations (Wisner, 2013).

Alternative schools--or alternative education programs--provide individualized services for youth who struggle to succeed in traditional schools and who may be at risk for academic failure (Foley & Pang, 2006). Although there is a great need for health promotion in alternative schools, these settings are often overlooked as potential research or program implementation sites for many reasons including the geographic dispersion of students, complicated consent procedures when many students are in foster care, short-term alternative school placements and attrition, and chronic attendance problems (Kubik, Lytle, & Fulkerson, 2004). In fact, many students are referred to alternative schools precisely because of truancy or school anxiety problems that interfere with attendance.

In addition, a meta-analytic review of barriers and facilitators for successful implementation of general school-based mental health programs in regular schools found that barriers included low parent engagement, unwieldy logistics, and poor support from administrations and teachers (Langley, Nadeem, Kataoka, Stein, & Jaycox, 2010). Facilitators to successful implementation included having adequate funding, professional support, and positive perceptions of the program (Langley et al., 2010). In a qualitative description study, administrative staff in Minnesota reported that inconsistent student attendance would interfere with the feasibility of conducting health research in alternative school settings (Kubik et al., 2004). However, key informants also identified potential facilitators: attention to building trust and rapport with students, avoiding stereotypical assumptions about students at alternative schools, and minimizing demands on staff time (Kubik et al., 2004).

It is increasingly clear that healthy behaviors (e.g., nutrition, exercise, sleep, and positive coping) enable academic success and that compromised health and coping among students at alternative schools can interfere with their academic progress. Nevertheless, few health intervention studies have explored how to best reach this population. To address this gap in the literature, the authors conducted a study to examine the feasibility and acceptability of implementing a holistic healthy lifestyle and body image program among adolescent girls in an alternative school setting. To overcome some of the implementation barriers noted above and to ensure relevance to a challenging population, we incorporated community-based participatory research elements into all phases of the project, as described below.

Methods

Recruitment and Sample Demographics

Recruitment Procedure. This study was conducted in a small alternative school setting, designed to serve students in grades six to twelve who struggle to succeed in mainstream schools due to social and behavioral difficulties. In line with principles of community-based participatory research (CBPR; Israel, Schulz, Parker, & Becker, 1998), the research team worked collaboratively with the administration at the alternative school and a school-affiliated community gardening program to identify students who met eligibility criteria and who might benefit from the program. Although administrators did not use specific criteria for selecting students, they identified students who were at risk for either general emotional and behavioral problems or for body image problems specifically. In participatory research programs, allowing community representatives to provide guidance regarding study recruitment is essential for fostering long-term ownership and investment in the program (Community-Campus Partnerships, 2006). No boys were recruited because the school administration identified creating a safe space for adolescent girls to discuss topics related to health and well-being as a significant priority. Nine eligible adolescent girls were identified by the school social worker and principal for recruitment into the study and to participate in an eleven-week elective health class. Two of the nine girls did not return consent, assent, or pre-test surveys, which excluded them from participating. Seven girls were enrolled in the Healthy Eating and Achieving by Teens (HEAT) Program, but two were absent from all but the first class and were dropped from analyses. Five girls completed the program. The HEAT Program was approved by the institutional review board at the authors' institution.

Sample Demographics. Three of the five girls in the study were in eighth grade, one was in ninth grade, and one was in tenth grade. Two students identified as African American/black, and three students identified as white. Three students noted that they lived only with their mothers, one student only with her father, and one student with a foster family. Surveys asked for self-reported height and weight in order to calculate body mass index (BMI) percentiles; however, only three girls provided complete information in order to calculate it. Two of these girls were above the ninety-fifth percentile based on height, weight, age, and gender, and one girl was below the fiftieth percentile. In addition to the HEAT class, three students were receiving health-related education from other sources: two students reported being in a physical education class offered by the school, two in one-on-one meetings with a school nurse to discuss weight-related health, and one in a traditional health education course.

Measures

Pre- and Post-intervention Survey Measures

General Self-efficacy. Self-efficacy is an individual's belief in his or her ability to meet the demands of a given situation (Chen, Gully, & Eden, 2001). Higher self-efficacy is associated with more positive body image (Kololo, Guszkowska, Mazur, & Dzielska, 2012). General self-efficacy was measured using the eight-item New General Self-Efficacy Scale (NGSE; Chen et al., 2001), which has been used previously to assess self-efficacy among at-risk adolescents with good internal consistency (a = 0.86; Hasking, Scheier, & Abdallah, 2011). Items were assessed on a four-point Likert scale, from strongly disagree (1) to strongly agree (4). Higher scores indicate higher self-efficacy.

Academic Self-efficacy. Academic self-efficacy was measured using the three-item Student Report of Academic Self-Efficacy scale (SRAS; Hoover-Dempsey & Sandler, 2005). Items were assessed on a four-point Likert scale, from not true (1) to very true (4). The SRAS has been validated among preadolescents with adequate internal consistency (a = 0.71; Hoover-Dempsey & Sandler, 2005). Higher scores indicate higher academic self-efficacy, which is associated with better academic performance (Hoigaard, Kovac, 0verby, & Haugen, 2015).

Body Weight. Items from the Youth Risk Behavior Surveillance Survey (Brener et al., 2002) were used to assess student perceptions of weight, as well as their weight-related eating behaviors. Students were asked "How do you describe your weight (very underweight to very overweight)?" and "Which of the following (lose, gain, do nothing, or stay the same) are you trying to do about your weight?" Students were also asked whether they had fasted; taken diet pills, powders, or liquids without medical advice; and whether they had vomited or used laxatives to lose or keep from gaining weight in the last thirty days.

Depressive Symptoms. Depressive symptoms were assessed using the ten-item Center for Epidemiologic Studies Depression scale (CESD-10; Andresen, Malmgren, Carter, & Patrick, 1994). The CESD-10 has been validated among adolescents with good internal reliability ([alpha] = 0.85; Bradley, Bagnell, & Brannen, 2010). The CESD-10 is scored using a four-point Likert scale, with students indicating whether items represented their feelings rarely or none of the time (0) to all of the time (3). Depressive symptoms are related to both body image and school performance (Marcotte, Fortin, Potvin, & Papillon, 2002). Depression is also associated with a number of problematic behaviors--such as attempted suicide, heavy drinking, and risky sexual practices (Hallfors et al., 2004)--all of which are more common among alternative school youth than their peers in mainstream schools (Grunbaum et al., 2001).

Body Image and Weight Teasing. Five subscales from the McKnight Risk Factor Survey IV (Shisslak et al., 1999) were used to assess body image: appearance appraisal (AA, three items), the degree to which students were bothered by body changes (BC, two items), overconcern with weight and shape (OWS, five items), and weight-related teasing from peers and adults (WT-P, eight items, and WT-A, three items, respectively). Each had moderate to excellent internal reliability when tested among adolescents (Lynch, Heil, Wagner, & Havens, 2007). These sub scales were used to assess students' body image perception and experiences with weight-related teasing.

Observations, Key Informant Interviews, and Student Reflections

There were three qualitative data collection methods: observational field notes, key informant interviews, and student reflections. While one member of the research team led the lesson, the three other facilitators took observational field notes, which were discussed at weekly team meetings. Field notes focused on participants' attention toward and perceptions of curriculum materials and conversations that arose from lesson content. Second, key informant interviews were conducted after the fifth week of the program and again after program completion. Informants were interviewed for their perceptions of the facilitators and barriers to implementation of a holistic health curriculum in an alternative school setting. Last, participants' written reflections after each lesson were collected. Students were asked to respond in writing to three open-ended questions at the end of each lesson:

1. What did we do today?

2. Why did we do that?

3. How did that make you feel?

Observations, key informant perceptions, and students' written reflections were de-identified, compiled, and analyzed for factors related to implementation and feasibility. Pseudonyms were used in place of real names prior to analysis.

Community Partnership Model

The HEAT Program was developed by using guiding principles of community-involved or CBPR frameworks (Israel et al., 1998). Sometimes used interchangeably, community-involved and community-based research programs follow a set of guiding and evolving principles designed to emphasize the social and cultural elements in a community and the central role of community stakeholders in implementing and evaluating research programs. These principles are outlined in Table 1. Like many CBPR programs (Braun et al., 2011), the HEAT Program had limited financial resources and was designed as a pilot program in order to assess what additional resources might be needed for a full-scale intervention. Additionally, the HEAT Program was conceived in response to an invitation from stakeholders of the community garden and the alternative school. By attending to the needs of the community--as identified by the community--with the strengths and resources available to stakeholders and researchers, this program followed many of the key principles of CBPR. Integration of these principles is discussed in the context of other implementation and feasibility factors.

Curriculum

Several curricula were evaluated and discussed with community stakeholders. The Healthy Bodies: Teaching Kids What They Need to Know curriculum (Kater, 2012) offered students an opportunity to develop health-related psychosocial skills by empowering them to cope with stressful circumstances--such as weight teasing or pubertal development--using critical thinking and emotion regulation strategies. Due to a focus on holistic health rather than size or weight, administrators and the research team identified the Healthy Bodies curriculum as the most appropriate program.

The Healthy Bodies curriculum is an evidence-based program designed to ameliorate shared risk factors for eating disorders and obesity in children and teens (Kater, 2012). Over the span of ten lessons, students build healthful emotional, physical, intellectual, and social skills in order to develop a healthy body image and the foundation for positive behaviors. Kater's curriculum uses a model called the Healthy Body Building Blocks to track progression through the program; each block represents the main takeaway from an individual lesson. The blocks are stacked in three tiers that represent the contributions of biology, behavior, and cognition for building and maintaining healthy body image and weight. Healthy Bodies has been empirically evaluated in classrooms from fourth (Kater, Rohwer, & Levine, 2000) to sixth grade (Kater, Rohwer, & Londre, 2002); however, the curriculum is also designed to be adaptable for adolescents (Kater, 2012). School administrators identified low literacy levels among students as a potential barrier to implementation. Therefore, community partners and the research team adapted any written materials for students to a fourth grade reading level.

Lessons occurred once a week; lasted approximately one hour; and were conducted in a small classroom, conference room, or media room, varying week to week depending on space availability. A team of undergraduate and graduate students in Social Work and Public Health implemented the lessons, and either a school social worker or other staff person was present.

Before each lesson, the research team met to discuss the curriculum's script, activities, and objectives. In order to meet these objectives while attending to the needs of the students, substantial culture- and literacy-related adaptations were introduced to make the content more accessible, relatable, and developmentally appropriate. To ensure that the adapted lessons continued to address the core goals of the curriculum, no adaptations were made in the order or the objectives of individual lessons. Adaptations to the curriculum were made only after discussion and planning of alternate content, verbiage, and activities among members of the research team, and adaptations were checked to ensure that they addressed curriculum objectives.

Results and Discussion

Pre- and Post-intervention Survey Descriptive Information

Pre- and post-intervention assessments of the prevalence of overweight, trying to lose weight, and unhealthy weight loss methods are provided in Table 2. The goal of this research was to examine the feasibility of implementing a holistic health curriculum in an alternative school; no statistical tests were performed due to sample size limitations. However, mean scores of appearance appraisal, general self-efficacy, and academic self-efficacy were more positive on average at post-intervention than at pre-intervention. Further, post-intervention mean scores of body change perception, overvaluation of weight and shape, and weight teasing from peers were improved (less negative) compared to pre-intervention. Depressive symptoms were slightly higher on average at post-intervention.

Compared to national averages among girls at alternative schools, girls in this sample reported greater prevalence of overweight, desire to lose weight, and use of diet pills to lose or control weight (Grunbaum et al., 1999). Compared to recent national averages among adolescents overall, girls in this sample also reported more depressive symptoms (Perou et al., 2013). Appearance appraisal--which is the degree to which an individual perceives herself as attractive--among girls in this sample was lower on average in comparison with an ethnically diverse sample of children in fifth to tenth grade (Lynch et al., 2007). Compared to a large cohort of predominantly white adolescents, girls in this sample also reported more concern with weight and shape (Field et al., 2001). African American adolescents tend to have a more positive body image during adolescence than white youth (Franko & Striegel-Moore, 2002), although our findings did not replicate this pattern. Overall, Grunbaum and colleagues (2001) found that alternative school youth were at higher risk for suicide, were more likely to engage in unhealthy dieting practices--such as laxative abuse--and were less likely to engage in vigorous physical activity in comparison to their peers in mainstream schools. These findings from the literature were consistent with the high rate of behavioral concerns found among girls in this sample.

Participant Satisfaction with the Program

At the end of the eleven-week program, students were asked to provide their thoughts about what went well and what could have been improved during the course. All except one student provided feedback. Two students explicitly mentioned enjoying learning about media influences. One said, "I learned a lot about health and the media and influences. It was interesting and fun and informative." The other commented, "I learned a lot of things about the media, and how eating certain things can affect you." One student said, "I also learned that being skinny doesn't make you healthy," although she also mentioned wanting to learn more about weight. Another student wanted more information on being vegan while still attending to internal satiety cues and health. Finally, students' perceptions of the program were positive overall, with several students noting that they enjoyed the group dynamic. Tina, an eighth grader, said, "I was able to tell my point of view of things, and I was able to listen and learn new things from others. I liked that people listened to me and made me laugh and happy even when I was down." When asked what went well during the program, Lucy, a ninth grader, said "The whole thing, I normally don't do well in groups. But this went well."

After the program was complete, school administrators and our community partner were asked for their feedback on the HEAT Program as well. Overall, responses were positive. A school administrator and a school social worker appreciated that students had built trust and rapport with people who were unaware of the reasons for students' enrollment at the alternative schools. Our community partner--who served as the director of a community garden and an instructor at the school--reported that the socioemotional focus of the curriculum filled a gap in their services (which focus on nutrition, physical activity, and agricultural business education for at-risk youth) by providing students a safe space for discussion about body image. Finally, a school social worker noted that scheduling the group as an official class, rather than as an elective, may improve future attendance.

Feasibility and Implementation Factors

Trust and Rapport. Building trust and rapport among students in the HEAT Program was imperative for active participation and meaningful discussion. Trust and rapport were built by setting initial ground rules for discourse, facilitators not seeking out the reasons for students' enrollment at an alternative school, consistently using icebreaker activities at the start of each lesson, including only girls in the program, and setting ground rules for a safe space at the start of the course. The Healthy Bodies curriculum encourages facilitators to develop ground rules of discussion for or with participants in order to encourage respectful discourse. We found that empowering students to set and enforce their own rules for discussion promoted active and respectful engagement.

Facilitators were blind to reasons for students' enrollment at an alternative school; therefore, students did not feel the need to discuss these issues in depth. Students were able to focus on normative issues among adolescents, such as navigating media messages about body image, puberty, and health behaviors. This reprieve from focusing on their problem behaviors was facilitated by the nonjudgmental stance of the intervention team that these were girls in tough situations rather than simply tough girls. Future endeavors may want to enlist outside facilitators--such as university students, social workers, or community health workers--who will also focus on contextual factors affecting students' behaviors. Further, focusing on the issues outlined in the curriculum is essential in an alternative school setting; allowing students to develop a safe space focused on discussing normative issues may help build trust and rapport among students and facilitators.

At the beginning of each lesson, students participated in a group icebreaker session. Icebreakers were designed to involve and engage participants before a core activity or discussion by encouraging physical activity, reflection, or teamwork. Consistently providing unique icebreakers forced students to operate outside of their comfort zones while also providing a routine, effective segue into the day's discussion. Student views of icebreakers were mostly positive; students enjoyed the chance to engage in physical activity when provided. However, school social workers implementing similar programs should consider their students' needs; one student chose not to participate in an exercise that required touching other students due to a negative experience with the same activity in the past. Explaining the icebreaker first may allow students to decide if they wish to participate or if the activity will push their boundaries too much.

The same-sex environment may have facilitated students' comfort in expressing views about difficult topics such as puberty. For example, despite age differences, students reported similar experiences with discomfort, ranging from not knowing what to do about changing proportions and weight gain to feeling that menstrual periods could not be discussed with males. However, with reference to unsupportive reactions from male peers, Karen said about her experiences discussing puberty in other classes, "I don't like when we talk about it [puberty] as gross." Students in this program were comfortable discussing difficult topics in a supportive female-only environment, perhaps because they had not interacted closely with each other before the class and thus had no expectations for judgment. Further, at the beginning of the first lesson, the class cocreated a set of rules for engaging in respectful discussion; students largely adhered to these rules and were held accountable by facilitators and each other for breaking them. Future efforts to implement holistic health programs may want to consider limiting enrollment to same-sex peers or creating safe spaces to discuss sensitive topics, such as puberty and weight gain, with enforceable rules.

Participant Selection. For research purposes, having participants selected by school staff is a barrier to unbiased evaluation; however, in applied school settings, this selection procedure is realistic and feasible. Future studies assessing the efficacy of the intervention's ability to improve body image among adolescents should consider using more rigorous recruitment methods while also meeting the needs of the students being served. For social workers interested in implementing the Healthy Bodies curriculum, recruiting students using a prescreening questionnaire about health and body image may help to more objectively identify those with the highest need for health-related education.

Support from Administration/Stakeholders. Support from key stakeholders--such as school social workers, the principal, and the community garden instructor--was essential for effective implementation. It is especially important to note that the alternative school had already taken several steps to create a holistically healthful school environment. For example, the school had transitioned from using standard cafeteria food vendors to making healthy lunches with local fresh produce for students on site. Additionally a partnership with the community garden exposed students to agricultural business education and nutrition. The health and wellness context enveloping the whole school complemented and may have created a strong foundation for students' participation in the HEAT Program.

An argument could be made that positive changes among participants in the HEAT Program cannot be attributed to the course itself due to the school's overall focus on health and wellness. However, at the time of implementation, although students did have opportunities to engage in healthful eating and physical activity, there were few opportunities for them to engage in discussion about the effects of external factors (such as peer beliefs, media, and historical attitudes) on health and body image and even fewer opportunities for students to do so in a safe space. Further, a key principle of CBPR work is that partnerships address community needs given the strengths, assets, and capacities of all collaborators. School stakeholders identified body image issues and inaccurate ideas about health as prevalent problems among their students. By implementing a program that complemented school-wide emphases on health and wellness--but that promoted socioemotional coping, self-esteem, and critical thinking about health behaviors--this program addressed an identified need using the strengths and assets available to the research team, school staff, and students.

Healthy Bodies Curriculum. The Healthy Bodies curriculum is designed to promote health and body size diversity without simultaneously cultivating body dissatisfaction and unhealthful dieting. As a primary prevention program, the curriculum is not designed to target children struggling with disordered eating or body image specifically, but rather to present a universal message about the importance of health over size. The order of lessons in the curriculum allowed students to build a foundation of knowledge about body image, growth, and development in order for them to cope with media and peer influences that might harm positive self-concept. The order of lessons was a particularly important part of Kater's (2012) Healthy Bodies curriculum and was not altered for this pilot study (Kater, 2012). Weekly facilitator meetings focused on ensuring that lesson plans met objectives in the curriculum and were developmentally and culturally appropriate for the students.

Several alterations were made to the activities and scripts for these lessons in order to meet the needs of the population. First, culturally appropriate adaptations were an effective way to help students connect to the material. Facilitators used images of African American and Latina women in presentations about body image and directed conversations about objectification of women in the media toward the intersection of race and gender. Second, several students had attentional difficulties that necessitated using varied types of learning media (such as movie clips, PowerPoint presentations, tactile activities, and group work) to meet the needs of various learning styles. As discussed above, the use of icebreakers allowed students to engage in a small amount of physical activity that may have improved attention (Pontifex, Saliba, Raine, Picchietti, & Hillman, 2013). Finally, facilitators had to adapt activities to unavoidable time and location constraints by using didactic question and answer sessions instead of lectures and short volunteer-led demonstrations instead of long activities that called for a gym or recreational space.

For social workers and other facilitators, it is important to know the needs, strengths, and limitations of the population of interest. From discussions with school stakeholders, the research team knew to alter some lessons for students with attentional difficulties. However, we learned from direct observation that students were more engaged when we used images that were racially/ethnically diverse. School administrators required the research team to shorten the length of the initial survey due to concerns about student fatigue and literacy demands. Depending on the population of interest, it may be important to prioritize using short-form measures and measures with appropriate literacy levels.

Attendance and Attrition. The average attendance rate of students who completed the pre- and post-survey was 73 percent and ranged from 55 to 100 percent. The number of students attending each week ranged from two to five, with an average of three to four students per week. Lowest attendance rates were recorded during winter months, suggesting that inclement weather could have affected students' ability to make it to school. Further, because the school serves students from seventeen different rural and suburban school districts, some of which are as far as forty miles away from the school, many students rely on their family to provide transport to school. During winter months, the lack of safe transportation to and from school may have reduced school attendance.

Initially, seven students provided pre-intervention surveys, consent, and assent forms, indicating their willingness to participate in the course. Two students dropped the course after one session. Students were not directly surveyed for their reasons for nonattendance. Because many students are referred to alternative schools because of absenteeism and dropout, these issues remain significant (Foley & Pang, 2006; Ruebel, Ruebel, & O'Laughlin, 2001). Moreover, there is evidence to suggest that some students who are absent or truant perceive the consequences (often suspension) as a reward rather than a punishment, thus positively reinforcing their behaviors (Teasley, 2004). Therefore, it is unsurprising that this program experienced high attrition.

Addressing absenteeism and truancy should be a priority among social workers interested in implementing health interventions in alternative schools. We recommend that social workers collaborate with other school personnel to design effective incentives for class participation and attendance. Positive reinforcement--rather than punishment--may be an effective route for reducing absenteeism (Epstein & Sheldon, 2002). Offering an incentive, such as a class party, movie, or gift, may improve attendance rates. It is important to note that, due to the health-related focus of this curriculum, incentives should exclude candy and other low nutrient foods.

Diversity of Participant Experiences: Age, Race, and Body Size. The sample of this pilot study was small but also racially diverse (two students identified as African American and three identified as non-Hispanic white) and included students from age thirteen to sixteen years old. Students were referred to the alternative school for a variety of reasons. Although the curriculum was focused on healthful eating and body image, one lesson was devoted to pubertal development in order to normalize weight gain during puberty. From this lesson and subsequent discussions with key informants, the authors found that students felt under-prepared for normative changes during puberty. From a research perspective, the wide age range could make it difficult to generalize results. However, the students' satisfaction with the curriculum suggests that adaptations may have been effective at prompting discussion, critical thinking, and feedback among a diverse audience of adolescent girls. From an applied perspective, the sample's diversity may have facilitated trust and communication by allowing students to normalize their own experiences through discussion with peers and facilitators. Further, discussions may have given younger students an idea of what to expect-- especially from puberty--and older students the idea that there is a wide range of experiences rather than a normative trajectory.

Conclusions

The aim of the present study was to assess the feasibility of implementing a holistic curriculum for alternative school students in order to ultimately promote health behaviors, critical thinking, and psychosocial and emotional coping skills. By using an established, evidence-based program--the Healthy Bodies curriculum (Kater, 2012)--and tenets of CBPR, the authors found that it is feasible to implement a health education program for adolescent girls in an alternative school. Strengths of this study included building strong trust and rapport with students, support from key stakeholders, and adapting the curriculum with culturally and developmentally appropriate media and teaching strategies. Challenges included absenteeism and attrition, attentional difficulties, sample size for research, and time and space constraints.

Social workers interested in implementing psychosocial health education programs should consider making curriculum adaptations to reflect the racial/ethnic and neurocognitive diversity of their target population, as well as strategies and incentives to prevent absenteeism. Implementing pre-lesson activities--such as icebreakers or team-building games--to promote trust and collaboration among students may also be helpful. Researchers interested in implementing and evaluating holistic health curricula among alternative school students may want to consider using a CBPR research paradigm to promote stakeholder support and to capitalize on the strengths and resources in the host setting and community. Finally, creating a same-sex and safe space environment to discuss difficult topics such as pubertal development with students appears to be beneficial.

Overall, further research on health promotion among alternative school students is needed. By focusing on health behavior promotion and psychosocial skill development, the Healthy Bodies curriculum may give alternative students the tools they need to cope with an increasingly complex food environment and with unhealthy external influences on body image.

The authors would like to thank the students for participating in this pilot study. We acknowledge the school director, teachers, social workers, community garden director, and staff for their support. We would also like to acknowledge social work undergraduate and graduate students who contributed at various stages of design or implementation, including Xavier Ramirez, Hattie LeNoir-Price, Maria Pineros-Leano, and Meng-Jung Lee. This material is based upon work that is supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture, under award number 2011-67001-30101.

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Jaclyn A. Saltzman, MPH, is a doctoral student, Department of Human Development and Family Studies, University of Illinois, Urbana. Janet M. Liechty, PhD, LCSW, is associate professor, School of Social Work and College of Medicine, University of Illinois. Urbana. Elizabeth A. Badskey, BSW, is a master of social work student, School of Social Work, University of Illinois, Urbana.
Table 1. Principles of Community-Based Participatory Research

1. Recognize the community as a unit of identity

2. Build upon and utilize strengths and resources available in the
   community

3. Facilitate equitable partnership and collaboration throughout
   research phases by empowering and engaging in a power-sharing
   process that attends to social inequalities

4. Promote capacity building and foster co-learning among partners

5. Balance and integrate data generation and intervention foci in
   order to achieve mutual benefits for all partners

6. Focus on public health problems that are relevant locally and on
   ecological perspectives that attend to the many social
   determinants of health

7. Develop systems in a cyclical and iterative process

8. Disseminate results to and with community partners

9. Involve a long-term process and commitment to sustainability

Note. Adapted from "Review of community-based research: Assessing
partnership approaches to improve public health" (Israel et al.,
1998).

Table 2. Pre- and Post-intervention Assessment Scores (N = 5)

Measure                               Pre-test

                            M (SD)       n (%)    Range

Perceived body size
  Overweight                             2 (40)
  About right weight                     3 (60)
  Underweight                            0 (0)
Trying to lose weight                    3 (60)
Fasting to lose weight                   1 (20)
Using diet pills/powders/                1 (20)
  liquids to lose weight
Purging to lose weight                   0 (0)
Depressive symptoms         8.8 (7.7)             0-30
Appearance appraisal        2.7 (0.6)              1-5
Body change perception      2.5 (0.9)              1-5
Overvaluation of
  weight/shape              3.1 (1.4)              1-5
Weight teasing, peers       2.0 (1.3)              1-5
Weight teasing, adults      1.6 (1.0)              1-5
General self-efficacy       20.6 (4.2)            8-32
Academic self-efficacy      8.2 (2.5)             3-12

Measure                              Post-test

                            M (SD)       n (%)    Range

Perceived body size
  Overweight                             2 (40)
  About right weight                     3 (60)
  Underweight                            0 (0)
Trying to lose weight                    3 (60)
Fasting to lose weight                   1 (20)
Using diet pills/powders/                1 (20)
  liquids to lose weight
Purging to lose weight                   0 (0)
Depressive symptoms         11.0 (4.3)            0-30
Appearance appraisal        2.9 (0.7)              1-5
Body change perception      1.9 (0.5)              1-5
Overvaluation of
  weight/shape              2.5 (1.1)              1-5
Weight teasing, peers       1.7 (0.7)              1-5
Weight teasing, adults      1.6 (1.1)              1-5
General self-efficacy       21.6 (5.2)            8-32
Academic self-efficacy      9.6 (1.8)             3-12

Note. M = mean; SD = standard deviation.
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Author:Saltzman, Jaclyn A.; Liechty, Janet M.; Badskey, Elizabeth A.
Publication:School Social Work Journal
Article Type:Report
Geographic Code:1USA
Date:Sep 22, 2015
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