Healthy Schools Colorado

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Center for Research Strategies Page 1

Healthy Schools Colorado

Evaluation Findings

Web-Enabled Database Tracking System

Report Prepared by:

Center for Research Strategies Karrie Witkind, M.S.

Kaia Gallagher, Ph.D.

225 East 16^th Avenue, Suite 1150 Denver, Colorado 80203

(303) 860-1705

Report Prepared for:

Karen Connell

Colorado Department of Education

September 2010

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Healthy Schools Colorado

Web-Enabled Database Tracking System

Executive Summary

The goal of the Healthy Schools Colorado Project (HSC) is to help children become healthy and be ready to learn through school policy changes that support healthy living choices. In particular, school health policies should provide opportunities for students to engage in physical activity as well as to have access to fruits, vegetables, healthy meals and healthy vending choices while they’re in schools. The HSC Project is also designed to increase the knowledge of school nurses on asthma and diabetes management.

For the first year of the project (the 2009-2010 academic year), 78 schools were recruited from 10 school districts. Collectively these schools educate nearly 49,000 students. As part of their grant requirements, school teams and coordinators collected school level data regarding their physical education, physical activity, nutrition and school health service policies and programs. Highlights from the first year of reporting are provided below.

Physical Education / Activity

Quality physical education promotes lifelong healthy living skills related to physical activity and fitness.

Database reporting shows that a majority of HSC schools implement each of the seven guidelines related to best practices in physical education. We estimate that 26,000 to 35,000 students benefit from receiving quality physical education that utilizes these best practices.

HSC schools were found to offer fewer annual hours of physical education to students than is recommended by NASPE. Likewise, schools provide fewer minutes per week of physical activity breaks than NASPE recommends.

Nutrition Services

Nutrition policy is typically established at the district level and is in accordance to state and federal guidelines.

Findings reveal that most schools had many of the six guidelines related to best practices in nutrition services in place.

These practices impact over 42,000 students who have access to fresh fruits and vegetables during the school day and nearly 41,000 have restricted access to foods of minimal nutritional value in vending machines, school stores and other venues.

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Center for Research Strategies Page 3 While these results are encouraging, more work needs to be done to require that healthy food choices are available to students at every school function where food is served.

School Health Services

Schools nurses play a critical role in promoting student health and wellness.

Nurses in HSC schools have identified 3,801 students without health insurance and have referred 2,101 eligible students to state health insurance programs.

Screening and referral services are provided to students for vision, hearing, oral health and their height and weight. Over eight percent of students screened for vision were referred to health care providers as were nearly 11% of those screened for oral health.

Additionally, school nurses are managing over 2,400 students with asthma and diabetes and providing these students, staff and family with disease management education.

Unfortunately school nurses are limited by high caseloads. According to our estimates, the school nurse to student ratio is .93 full time equivalent school nurse for every 2,206 students;

which far exceeds the recommended caseload of 1:750 for well students.

In one study, an inner city school district that decreased its school nurse to student ratio to the

recommended 1:750 experienced an annual cost savings that far exceeded the salary of a school nurse.¹ Thus, at a time when the budgets of school districts are in a state of crisis, districts may actually save money by hiring school nurses.

Summary

While student health and wellness can be impacted through a wide variety of school-based

programming, policies have the potential to provide a universal reach to all students and once in place can be more easily sustained than other funding-based interventions. As demonstrated in the first year of the Healthy Schools Colorado Project, policies can also be a powerful tool in reaching a large number of students.

1 Charting Nursing’s Future. A Publication of the Robert Wood Johnson Foundation. August 2010.

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Healthy Schools Colorado

Web-Enabled Database Tracking System

Background

The Healthy Schools Colorado Project (HSC), funded by The Colorado Health Foundation, is designed to create healthy school environments that encourage students to adopt healthy living choices. Using the Coordinated School Health Model, the HSC funds school district and regional coordinators to recruit and train school teams. School teams use the School Health Index to assess their school’s health and safety policies and programs in each of the eight components of the Coordinated School Health Model. The teams then develop School Health Improvement Plans (SHIPs) that define goals for improving physical education, physical activity, or nutrition policies and/or programs. The SHIPs may also target the other components of Coordinated School Health as well.

In addition to creating an infrastructure within the schools that supports and sustains the Coordinated School Health Model, the HSC Project also supports a cadre of Physical Education and School Nurse Trainers who provide professional development training to Physical Education Instructors and School Nurses. These professional development opportunities are designed to increase the capacity of school personnel to utilize best practices in physical education instruction and chronic disease management.

While the ultimate program goal of the HSC Project is for all Colorado children to be healthy and ready to learn, the long-term outcomes of the grant include changes in school policy and implementation to support youth in adopting healthy living choices such that there are:

Increased opportunities for youth to engage in physical activity Increased student access to fruits and vegetables

Increased student access to healthy meals and vending choices for youth in schools, and Increased knowledge of school nurses on asthma and diabetes management.

The HSC Project utilizes a web-enabled data tracking system to collect and monitor school level data related to policies and practices in the areas of school health services, physical education/activity and nutrition. Data are collected and entered by district / regional coordinators, school teams and school nurses annually. This report summarizes the baseline data from the 2009-10 academic year collected through the online HSC database.

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Demographics

The HSC Project consists of five grantees that represent a total of 10 school districts within Colorado.

Three grantees represent large metropolitan school districts, while two grantees are regions that include two to five smaller school districts. During this first academic year, the five grantees recruited 10 to 26 schools each for a total of 78 schools.

As depicted in Table 1, the schools participating in the HSC Project educate nearly 49,000 students. In the 2009-2010 academic year, the majority of schools (62%) are represented by the Poudre District and the Pikes Peak Region.

Table 1. District Characteristics: School & Student Figures

Grantees/School Districts ^{No. of} Schools

Percent of Schools

No. of Students

Percent of Students Grantee Districts

Douglas County District 10 12.8% 8,178 16.7%

Jefferson County District 10 12.8% 4,688 9.6%

Poudre District 22 28.2% 14,606 29.8%

Grantee Regions

Adams County Region: 10 12.8% 6,239 12.7%

Adams District 14 10 12.8% 6,239 12.7%

Adams District 50* - - - -

Pikes Peak Region: 26 33.3% 15,273 31.2%

Academy D20 7 9.0% 5,136 10.5%

Colorado Springs D11 4 5.1% 1,706 3.5%

Falcon D49 4 5.1% 2,739 5.6%

Harrison D2 7 9.0% 4,326 8.8%

Manitou Springs D14 4 5.1% 1,366 2.8%

Total 78 100.0% 48,984 100.0%

*Adams District 50 will join the grant during the 2010-2011 academic year.

Figure 1 and Table 2 illustrate that the majority of participating schools are elementary schools. These schools educate approximately 21,000 students.²

2 This figure excludes K-8 and K-12 students.

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Table 2. Student Figures by School Type No. of Students

Percent of Students

K-8 1,060 2.2%

K-12 1,775 3.6%

Elementary 20,795 42.5%

Middle 13,299 27.1%

High 12,055 24.6%

Total 48,984 100.0%

School Health Index

Each school team received training from the Rocky Mountain Center for Health Promotion and Education on utilizing the School Health Index to assess their school’s health policies and programs related to each of the eight Coordinated School Health components. Each component was assessed by the teams using an index that created an implementation score ranging from 0 to 100%, where 100%

infers that the component is fully in place within the school.

Figure 2 displays the mean school health index scores for each component across the schools. On average, schools assessed their Physical Education and Physical Activity Programs as being more fully implemented based on the School Health Index criteria than the other seven components of

Coordinated School Health. The components of Coordinated School Health that received the lowest average implementation scores were Health Promotion for Staff, Health Education and Community Involvement.

2 1

43

20

12

0 10 20 30 40 50

K-8 K-12 Elementary Middle High

Figure 1. Number of Schools by Type (N=78)

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School Health Improvement Plan (SHIP)

School teams use their School Health Index Scores to guide their decision on which of the eight

components of Coordinated School Health they should target in their School Health Improvement Plans (SHIPs). School teams were required to create two SHIPs where at least one of the SHIPs targeted Physical Education, Physical Activity or Nutrition.

In accordance with the grant guidelines, all school teams targeted Physical Education, Physical Activity or Nutrition. A total of 59 school teams targeted either Physical Education or Physical Activity Programs.

Of these, 19 teams (all within the Pikes Peak Region) targeted Physical Education while another 40 teams focused on Physical Activity Programs. Additionally, 46 school teams directed their efforts toward making improvements in Nutrition Services. Figure 3 displays the number of schools targeting each component.

74.8%

68.0% 67.9%

60.0% 56.7%

46.1% 43.7% 40.8%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Figure 2. Mean School Health Index Scores

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Center for Research Strategies Page 8 While school teams were required to develop two SHIPs, the two SHIPs could target the same

component of the School Health Index. However, as depicted in Fig. 4, the majority teams chose to target more than one component in the School Health Index with their SHIPs, while a few teams developed SHIPs that targeted all eight components of Coordinated School Health.

59

46

29 25 22

18

9 8

0 10 20 30 40 50 60 70

#

o f

S c h o o l s

Figure 3. # of Schools Targeting Each Respective SHI Module (N=75)

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Physical Education & Physical Activity Policies

According to the National Association for Sport and Physical Education (NASPE) quality physical

education helps all students develop health-related fitness, physical competence, cognitive understanding, and positive attitudes about physical activity so that they can adopt healthy and physically active

lifestyles. To build capacity among physical education instructors to deliver quality physical education, the Colorado Department of Education developed a cadre of physical education trainers to provide professional development on best practices guidelines for quality physical education to physical

educators across the state. During the first year of the HSC Project, this cadre of instructors provided seven professional development trainings across the state that promoted best practices in physical education.

At the school level, coordinators and teams were asked to evaluate whether their school implemented seven guidelines related to best practices in physical education as detailed in Table 3 below. Findings reveal that a majority of schools reported implementing each guideline (68% to 88%) impacting approximately 26,000 to 35,000 students based on school census data. Using these guidelines we may infer that a majority of students are receiving quality physical education that will help them learn skills that contribute to lifelong healthy living that includes physical activity and fitness.

4

52

2 3 6

2 0

6 0

10 20 30 40 50 60

1 2 3 4 5 6 7 8

#

o f

S c h o o l s

# of SHI Modules Targeted in SHIPs

Figure 4. Total # of SHI Modules Targeted in SHIP by School (N=75)

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Table 3. Number of Schools Implementing these Guidelines:

Student census in all reporting schools = 41,777 Percent “Yes”

(#)

# of Students Impacted Are all staff who teach PE are certified, licensed or endorsed by the state in PE? 86.2%

(56) 35,049

Did any PE teachers or specialists receive professional development on PE during this school year?

87.7%

(57) 37,457

Are those who teach PE provided with goals, objectives & expected outcomes? 84.6%

(55) 34,751

Are those who teach PE provided with a chart describing the annual scope &

sequence of instruction?

70.8%

(46)

29,355

Are those who teach PE provided with plans for how to assess student performance?

67.7%

(44) 28,855

Are those who teach PE provided with a written PE curriculum? 67.7%

(44)

25,897

Does the school offer opportunities for all students to participate in intramural activities or PA clubs?

72.3%

(47) 29,915

Coordinators and school teams were also asked to estimate the amount of physical activity breaks and physical education hours received by students at each grade level. Physical activity may include recess or a structured physical activity that increases the heart rate of students. NASPE recommends that school age children accumulate at least 60 minutes of physical activity per day or 300 minutes per week.

A 2009 study compared third grade students who received little or no daily recess with those that received more than 15 minutes per day (or 75 minutes plus per week). Students who received more opportunities for recess were found to behave better in the classroom and to be more likely to learn.³ As depicted in Table 4, most HSC schools fell short of NASPE’s recommendation for physical activity.

Per school teams estimates elementary students averaged 141 minutes of physical activity per week with some students receiving as few as 20 minutes per week while a few others met the recommended 300 minutes per week. The estimates for middle and high school students averaged 73 minutes per week with some students not receiving any physical activity breaks.

3 The State of Play. Robert Wood Johnson Foundation Publication. February 2010.

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Table 4. Estimated Minutes of Physical Activity Breaks / Week

Grade No. of Schools

Minimum

# of Minutes

Maximum

# of Minutes

Mean # of Minutes

Mean # of Students / School

Estimated Total # of Students⁴

K 35 30 300 149.2 70.4 2,463

1 37 30 275 160.3 74.5 2,756

2 37 20 275 160.0 72.9 2,697

3 37 20 275 141.3 71.2 2,633

4 37 20 230 130.7 71.7 2,652

5 37 20 230 127.4 69.4 2,566

6 25 20 300 116.4 108.1 2,703

7 20 0 300 72.8 226.0 4,519

8 20 0 300 70.0 208.1 4,162

9 7 0 275 66.3 114.4 801

10 7 0 275 75.4 62.3 436

11 7 0 275 75.4 51.1 358

12 7 0 275 75.4 72.3 506

NASPE recommends 150 minutes per school week for elementary school children and 225 minutes for middle and high school students for physical education. Assuming a 36 week school year, this translates into 90 hours of PE for elementary age students and 135 hours for middle and high school students per school year.

As depicted in Table 5, our estimates indicate that elementary students receive an average of 45 hours of physical education per year, while middle and high school students average 61 hours per year. While it was challenging for the coordinators and school teams to collect these estimates, we believe that these data help to estimate the extent to which Colorado schools typically fall short in offering physical education to students.

4 The estimated total number of students receiving PA breaks represents nearly all students in grades K-9; in grades 9-10, these estimates represent approximately less than half of the students.

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Table 5. Estimated Hours of Physical Education / School Year

Grade No. of Schools

Minimum

# of Hours

Maximum

# of Hours

Mean # of Hours

Estimated Total # of Students⁵

K 35 0 72 37.7 71.3 2,569

1 36 24 75 45.1 76.6 2,910

2 36 24 75 45.4 74.4 2,828

3 36 24 75 45.4 73.6 2,780

4 36 24 75 45.3 73.5 2,792

5 36 24 75 45.3 71.5 2,716

6 26 1 110 49.4 141.2 3,670

7 20 1 120 60.5 267.6 5,620

8 20 1 120 60.5 252.8 5,308

9 5 15 75 61.6 180.4 1,443

10 5 15 75 61.6 121.9 975

11 5 15 75 61.6 98.1 785

12 4 15 75 60.0 120.2 721

Nutrition Services

Access to Healthy Foods

Coordinators and school teams were asked to evaluate whether their school implemented six guidelines related to best practices in nutrition services. Data reveal that in most schools many of these guidelines are in place. Nineteen percent of schools (14) met all six guidelines.

All schools reported complying with USDA regulations and state policies for food and beverages as well as ensuring that every student has access to healthful food choices in appropriate portion sizes. As depicted in Table 6, over 42,000 students have access to fresh fruits and vegetables during the school day and nearly 41,000 have restricted access to foods of minimal nutritional value in vending machines, school stores and other venues. While it is promising to note that the parents of nearly 36,000 students are encouraged to provide a variety of nutritious foods from home for lunch and snack, only 31% of the schools require that healthy food choices are available to students at every school function where food is served.

5 The estimated total number of students receiving PE represents nearly all students in grades K-9; in grades 9-10, these estimates typically represent more than half of the students.

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Table 6. Number of Schools Implementing these Guidelines:

Student census in all reporting schools = 47,113 Percent “Yes”

(#)

# of Students Impacted Ensure that all foods & beverages comply with USDA regulations & state

policies.

100%

(74) 47,113

Encourage parents to provide a variety of nutritious foods if students bring lunch or snacks from home.

71.6%

(53) 35,569

Require that healthy food choices are made available to students at every school function that includes foods.

31.1%

(23) 12,081

Every student has access to healthful food choices in appropriate portion sizes. 100%

(74) 47,113

Students have access to fresh fruits and vegetables during the school day. 91.9%

(68) 42,333

Put restrictions in place for student access to vending machines, school stores,

& other venues that contain foods of minimal nutritional value

85.1%

(63) 40,991

Access to Healthy Vending Machines

In addition to assessing school nutritional policy, coordinators teams were also asked to indicate whether their schools had vending machines that were accessible to students. With the exception of one K-8 school, none of the schools with elementary age students offered vending machine access to students. In contrast, all of the high schools (12) and 90% of the middle schools (18) had vending machines for student use. Among HSC schools, an estimated 24,769 students have access to vending machines.

Encouragingly, all schools with vending machines sold bottled water and the majority offered 100% juice beverages and food items containing no more than 35% with total calories from fat or 35% of total weight in sugar. Unfortunately over half of the middle schools and about 44% of high schools also sold sodas in vending machines. See Tables 7 and 8 for more details.

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Table 7. Number & Percent of Schools Answering “Yes”

Do vending machines that are accessible to students contain: ^K-8 ^Middle ^High # of Students Impacted -Nuts, seeds, dairy products, fresh fruits or vegetables, dried fruits

and vegetables, and packaged fruits in own juices

100%

(1)

16.7%

(2)

28.6%

(2) 3,454

-Any other food item containing no more than 35% total calories from fat and no more than 35% of total weight in sugar.

100%

(1)

75.0%

(9)

75.0%

(6) 14,992

-100% juice, with no added sweeteners (in age appropriate portion sizes & calories)

100%

(1)

75.0%

(12)

87.5%

(7) 17,247

-Bottled Water 100%

(1)

100%

(15)

100%

(8) 20,231

-No sodas (neither regular nor diet sodas) 100%

(1)

42.9%

(6)

55.6%

(5) 8,322

Table 8. Number & Percent of High Schools Answering “Yes”

Do vending machines that are accessible to students contain: ^High # of Students Impacted -No or low calorie beverages with up to 10 calories / 8 ounces (e.g., unsweetened or

diet teas, low calorie sport drinks, fitness waters, flavored waters, seltzers).

75.0%

(6) 7,900

-Other drinks, up to 12 ounce servings with no more than 66 calories / 8 ounces 87.5%

(7) 8,385

-At least 50% of non-milk beverages must be water and no or low calorie options 25.0%

(2) 1,996

School Health Services

According to the National Association of School Nurses (NASN), school nurses help children learn by assessing student health status and making referrals, identifying vision and hearing problems that impact learning, delivering emergency care, administering medication and vaccines, performing health care procedures, disaster preparedness and providing health counseling and wellness programs. NASN outlines the benefits of hiring school nurses to include:

Helps students manage chronic illness, increasing attendance Improves attendance which translates into academic success

Addresses health concerns and keeps students at school and parents at work Allows teachers to teach instead of providing health care for children

Reduces number of 911 calls, and

Promotes health professional input on wellness programs for the school community.⁶

6 Healthy Children Learn Better! School Nurses Make a Difference. National Association of School Nurses.

February 2010.

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Center for Research Strategies Page 15 Student Health Data

As part of HSC, school nurses and staff were asked to collect and enter data into the online database.

The types of data collected included the number of students whose health care plans identified select health conditions, the number of students requiring various medical procedures, screening and referral activities and the number of students with asthma and diabetes who self managed their disease, kept medicine at schools and received additional instruction. Capturing this information provides insight into not only the magnitude and scope of the school nurse workload but also the volume of students

requiring specialized nursing services.

Table 9 details the number of students identified with select health conditions in their student health care plans for participating schools.⁷ Many of these health conditions require school nurses to maintain competency in medical procedures of varying complexity from glucose monitoring and the

administration of emergency medicine to gastronomy feeding and tracheostomy care. As highlighted in

“Charting Nursing’s Future,” nurses see students with a broader array of disabilities than in the past as students who may have at one time been homebound or institutionalized are now mainstreamed in classes.⁸

Table 9. Number of Students with Select Health Conditions

Number of students with… All Students

Asthma 2,254 30.46

ADHD 872 11.95

Allergies (life -threatening) 768 10.38

Behavioral / mental 621 8.63

Seizure disorder 301 4.12

Orthopedic 223 3.05

Cardiovascular 213 2.96

Gastrointestinal 202 2.77

Diabetes type 1 146 1.97

Diabetes type 2 15 .21

7 Not all students with health conditions have health care plans as parental input is required.

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Center for Research Strategies Page 16 Nurses provide a crucial role in promoting student health and wellness which is essential for learning.

For students without health insurance, school nurses may be their only source of health care services.

In the 2009-10 academic year, school nurses identified 3,801 students being without health insurance and referred 2,102 eligible students to state health insurance. The link between student health and wellness and learning is well documented and has lifelong implication. To quote former U.S. Surgeon General, Dr. Jocelyn Elders: “you cannot educate an unhealthy child and you cannot keep an uneducated child healthy.”⁹

School nurses provided vision, hearing, oral health and height and weight screening to a large number of students. Table 10 provides information on the number of students screened and referred in each area.

Data reveal the while fewer students were screened for oral health, nearly 11% of them were referred.

Eight percent of students who participated in vision screenings were referred as were 2% whose hearing was tested. Nurses also reported conducting 2,508 special education assessments with students and estimated that 190 calls were made to 911emergency services.

Table 10. Number of Students Screened & Referred

# Screened # Referred Percent Referred

Vision 27,934 2,285 8.2%

Hearing 26,808 612 2.3%

Oral health 693 75 10.8%

Height & weight 3,903 159 4.1%

To develop statewide capacity through professional development in chronic disease management, the Colorado Department of Education developed a cadre of school nurse trainers to provide training to school nurses across Colorado. In the 2009-2010 academic year the trainings focused on asthma management and were evaluated using pre- and post-test surveys. Survey results demonstrated significant increases in self-reported confidence by nurse participants in all components of asthma control and nursing expertise within a coordinated school health program as well as gains in their asthma care related knowledge and skills. The cadre of school nurse trainers also developed and disseminated educational tools and newsletters on chronic disease management to and for school nurses.

Within the HSC online database, school nurses estimated the number of students with asthma and Type 1 Diabetes that self-managed their disease, kept medicine at school and received additional instruction for the nurses. Table 11 displays these data. Nurses estimated that among the 2,254 students with

9 School nurses form the link between student health and wellness. Cynthia Hiltz. MSBA Journal. July/August 2008.

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Center for Research Strategies Page 17 asthma, 69% of them self-managed their condition and that 54% of asthmatic students kept medicine at school.

Table 11. Number of Students with Asthma & Diabetes

Number of students, who…

# of Students w/

Asthma (N=2,254)

# of Students w/

Type 1 Diabetes (N=146)

Self-manage 1,545 87

Have a self-carry contract / self-manage agreement 564 82

Have medicine at school 1,215 128

Received information to take home 751 66

Received verbal instructions 683 105

Referred to providers 152 N/A

School Nurse Caseload

Colorado has a high school nurse to students ratio and is ranked 39^th in the nation by NASN in terms of this ratio. While NASN recommends a ratio of 1:750 for well students, the ratio for the entire state of Colorado is a dismal 1:1,931. Among schools participating in the HSC, the estimated ratio is even higher with .93 full time equivalent school nurse for every 2,206 students. The number of schools assigned to nurses ranged from one to ten schools with an average of 4.5 schools per nurse.

When districts improve their school nurse to student ratio impressive gains can be achieved in both health and educational outcomes. For example, when the Milwaukee Public Schools added schools nurses to decrease their school nurse to student ratio to 1:750, the district saved an average of 13 hours a day per school on non-health services staff time for student health concerns for estimated annual savings of $133,000 in salary and fringe benefits which is nearly twice the cost of hiring a school nurse.¹⁰