Title: Evaluation of a School Nurse-led Intervention for Children with Severe Obesity in New York City Schools
Description: Background and Significance: Severe childhood obesity, the fastest growing subcategory of childhood obesity, affects 4-6% of youth. Children from racial/ethnic minority groups and low income households are disproportionately affected. Severe obesity increases risk for metabolic syndrome, cardiovascular disease, non-alcoholic fatty liver disease, musculoskeletal problems, poor health-related quality of life, bullying, low self-worth, absenteeism, and adult obesity. One method of addressing childhood obesity is through school-based interventions. School nurses may be well-suited to lead obesity interventions because of their healthcare expertise, long-term relationships with students and families, and availability to students without financial burden. Purpose: The overarching aim of this mixed methods dissertation was to evaluate the implementation and efficacy of the Healthy Options and Physical Activity Program, a school nurse-led intervention for children with severe obesity attending New York City schools.

This evaluation focused on the 2012/2013 school year, the first full year of program implementation. Methods: Aims 1 and 2 were conducted to prepare for the Healthy Options and Physical Activity Program evaluation. Aim 1 included conduct of a systematic review and meta-analysis of existing literature to examine the role and impact of nurses in school-based obesity interventions. Aim 2 studied application of 3 propensity score methods to the observational Healthy Options and Physical Activity Program data set to determine which best removed significant differences in 11 potential confounders between the 1,054 kindergarten through fifth grade children who participated in the program in 2012/2013 and the 19,464 children who were eligible but did not participate. Aims 3-6 comprised the Healthy Options and Physical Activity Program evaluation. Aims 3, 4, and 5, utilized a retrospective cohort design to examine program implementation and its one year impact on body mass index percentile, school absences, and walk-in school nurse visits.

Analytic methods included descriptive statistics, Wilcoxon signed rank tests, McNemar’s test, and logistic regression. Aim 6 qualitatively explored perceived barriers to and facilitators of implementing the Healthy Options and Physical Activity Program from the perspective of school nurses, using individual semi-structured interviews. Interview data were analyzed using content analysis. Results/findings: Of 11 studies eligible for systematic review, 8 met inclusion for meta-analysis. Pooled findings suggest that school nurse led interventions decreased BMI percentile by -0.41 (95%CI: -0.60, -0.21; I2=0, Cochrane Q=2.0). The comparison of propensity score methods demonstrated that only propensity score matching removed all significant differences between children who received the Healthy Options and Physical Activity Program and children who were eligible for but did not receive the program. The program evaluation demonstrated that the program had limited reach (5% of eligible children) and low intensity (median 1 session/year, parent attendance at 3.2% of sessions).

Factors associated with selection for program enrollment included attending a school with low school nurse workload (OR 2.4, 95%CI 2.0-2.8), low school poverty (OR 1.6, 95%CI 1.3-1.9), and lack of chronic illness comorbidity (OR 0.5, 95%CI 0.5-0.6). After propensity score matching, program participants failed to decrease body measures, school absences, or school nurse visits at 1 year. Themes of interviews with 19 school nurses suggest that nurses encountered barriers to program implementation: parental and administrative resistance, heavy workload, and obesogenic environments. Despite barriers, nurses implemented the program to the best of their ability using creativity and teamwork. Conclusion: As implemented, the Healthy Options and Physical Activity Program was not effective in reducing body mass index percentile, absences or school nurse visits in youth with severe obesity. Barriers such as limited time and lack of parental and administrative support prevented nurses from fully implementing the program.

However, school nurses with their clinical knowledge base, cost-free accessibility to children and families, and long-term relationship with students may be able to successfully employ other school-based obesity interventions. Therefore future research should use rigorous methods to develop and test school-based interventions implemented by school nurses, with a focus on intervention feasibility and sustainability. Implications for the Profession: This dissertation has implications for nursing practice, health policy, and nursing science. Findings of this mixed methods evaluation suggests that nurses may not have the resources necessary to implement intensive school-based obesity interventions. Nurses who are planning to implement such an intervention may want to carefully consider program intensity and feasibility. In addition, careful attention to increasing parent buy-in and ensuring administrator support are key. In addition, policy that supports adequate school nurse staffing can support appropriate nursing workload and may allow nurses time to implement health promotion programs and obesity interventions.

During the qualitative portion of this dissertation, nurses reported the obesogenic environment as a barrier to healthful living that impacted the program’s effectiveness; obesogenic environmental factors (e.g., unhealthy school meals) will need to be addressed via legislation. Lastly, nurse scientists can work to increase the literature surrounding school-based obesity interventions, particularly with randomized controlled trials of interventions and qualitative work with nurses, parents, school administrators, and children. In addition, school-based obesity interventions must be developed and tested that consider the challenges faced by vulnerable children such as children living and attending school in high poverty neighborhoods.