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Addressing the national obesity epidemic through program planning and evaluation: A proposed program to encourage healthy eating habits in the University of Virginia Health System cafeterias
Allen Strickler PhD, Joyce Green Pastors RD MS CDE, Barbara Yager RD MEd, Wendy Cohn PhD, Arthur Garson Jr MD MPHUniversity of Virginia Department of Public Health Sciences P.O. Box 800717Charlottesville, VA 22908-0717
Background
Intervention
Logic Model Evaluation
Summary
References and Acknowledgements
AbstractWe are currently experiencing a national obesity epidemic. To help battle this epidemic at the local level, a Community Obesity Task Force (COTF) was established in the Charlottesville/Albemarle area in 1999. The COTF is currently conducting a community wide assessment using the nationally validated ENACT tool developed by the Prevention Institute/Strategic Alliance. Within the Health Care Environment assessment portion of ENACT, a high priority is the comprehensive food policy strategy to develop nutrition guidelines for hospital cafeterias. Our objective was to develop a theory-based program plan and evaluation to apply this to the UVA Health System cafeterias. Our focus involves a proposed expansion of the Signals program in the cafeterias, which uses point of sale information to designate cafeteria food items as green (enjoy normally), yellow (eat in moderation), or red (eat sparingly) based on nutritional content. Data from a Signals program pilot showed moderate (non-significant) changes in healthy purchasing habits that we hypothesize are due to behavioral factors. Based on behavioral and causal theory, we developed a program with a logic model, to guide planning and evaluation. The proposed program includes educational and motivational materials based on the transtheoretical model of change as an important component. We feel an effective educational/motivational campaign based on cafeteria patrons' current stage (e.g., pre-contemplation, contemplation) will raise awareness of healthier eating habits and subsequently encourage utilization of Signals program information. Based on constructs in the logic model, we propose the use of point of sale data and cafeteria patron survey results to evaluate our program. We believe our program plan serves as an effective model to address the complex behavioral factors involved in healthy eating and motivate those who utilize the UVA cafeterias to make food choices that promote heath and weight control.
We developed an intervention model that includes an educational component, a motivational component, and a facilitation component.
●By combining all three of these components into the intervention plan, we feel that the overall intervention will prove much more successful than implementation of any of the components alone.
●We used these components as a basis for developing an intervention model (Figure 7), designated Healthy Choices Cafeteria (HCC).
●Educational Component:The educational component consists of healthy eating information.
1. Displays that provide general guidelines for daily and meal specific caloric intake.2. Displays that teach individuals about the food pyramid and portion sizes.3. Displays that relate food consumption to physical activity via caloric intakes and expenditure
●Motivational Component:The motivational component of the model consists of motivational information.
1. Displays alerting individuals to the positive aspects of losing weight (through healthier eating).
2. Displays alerting individuals to the numerous health risks that are caused by obesity.3. Displays that mention obesity health risks linked with risk reduction through weight loss.
●Facilitation Component:This component includes the Signals program information as seen in Figure 7.
1. Displays that explain the Signals program and how it is applied to individual food items.2. Brochures that can be handed out to individuals explaining how the Signals
program works. 3. The actual signage cards with Signals color/nutritional information that are placed near their specific food items.
As the motivational component causes individuals to progress to the preparation and action phases, they will be primed to implement the educational components of the intervention. These will hopefully synergize to cause them to utilize the facilitation component (Signals information) to help them make healthier food choices.
We relied on the transtheoretical health behavior theory to serve as the basis for our proposed intervention (Figure 5).
●We believe that the limited success of the Signals program to date has been a result of a large proportion of hospital cafeteria patrons who are in the pre-contemplation or contemplation stages.
●We designed our proposed interventions to prompt individuals to progress through the preparation phase to the action phase. Ideally, these individuals will continue to progress to the maintenance and termination stages of the model.
We formulated a logic model to serve as a framework for the program plan and as a guide for development of our evaluation.
●With the problem of obesity in mind, we have identified the important aspects of each category of the model and how they are interconnected. This is depicted in Figure 6.
●The intended population and underlying problem constructs affect the issues of obesity, which in turn motivates the design of our intervention strategy as mediated through causal theory and transtheoretical health behavior theory.
●We expect the outcomes to cause a long term positive impact of reduced obesity and related health issues in the community, which feed back to the constructs of the original problem and issues. ●The constructs included in the Logic Model served as a basis for the development of our intervention and evaluation
Transtheoretical Health Behavior Model
Figure 8: The evaluation planning table
Finally, we created an evaluation plan to assess the efficacy of the intervention.
●We utilized our logic model to formulate specific evaluation questions, designated as either process or outcome in the form of an evaluation table (Figure 8).
●We developed specific methods and tools to facilitate data collection and reporting.
Evaluation question Evaluation QuestionInformation Needed to Answer
Data Collection & Reporting
type the Question Respondent Methods Instrument Reporting/Frequency
Process Have Signals information signage elementsFood item nutrition info and correct Program Personal HCC/Signals labeling
Day after implementation
been implemented correctly for cafeteria? color designation Planner Observation checklist form then every 6 months Process Has sustainable healthy eating campaign Correct sign placement Program Personal Sign placement Day after information been implemented as signage And tele-monitor Planner Observation checklist Implementation and on tele-monitors? displays then every 6 months
Process Are changes made to the cafeteria List of changes that that have been made Morrisons Personal
Interview protocol and implementation At six month
sustainable? to the cafeteria employees contact of changes checklist. intervals
Outcome Are people aware of the Healthy Choices andCafeteria patron responses Cafeteria Survey HCC/Signals
One month pre- and post- signage
Signals educational information? pre- and post-survey patrons Survey implementation
OutcomeHave motivational and educational materials been successful in prompting advancement
Cafeteria patron responses Cafeteria Survey HCC/Signals
One month pre- and post- signage
through thranstheoretical stages? pre- and post-survey patrons Survey implementation
Outcome Has awareness of healthy eating increased?Cafeteria patron responses Cafeteria Survey HCC/Signals One month pre and
pre- and post-survey patrons survey post-implementation
Outcome Have people implemented Signals programCafeteria patron responses pre- and Cafeteria Survey HCC/Signals One month pre and
information when purchasing foods? post-survey patrons survey post-implementation Outcome Have point-of-sale purchasing habits Point-of-sale data Morrisons Obtain purchasing Raw numbers of One month pre and changed? management information Foods purchased post-implementation
Outcome Are individuals maintaining healthyCafeteria patron responses Cafeteria Survey Survey questions of At one year intervals
eating habits? Patrons opinions after implementation Outcome Are individuals maintaining/losing weight Cafeteria patron Cafeteria Survey Survey questions of At one year intervals responses patrons opinions after implementation
Media Sample 1: Proposed HCC Survey Questionnaire
●Sustainability is important since individuals may require continued exposure to the intervention to remain in the maintenance stage and not revert back to a previous stage.
●We have identified two methods to evaluate success of interventions:1. Point-of-sale data to analyze baseline
purchasing habits and purchasing habits after implementation of the intervention.
2. A survey of cafeteria patrons at baseline and after intervention implementation. (Media Sample 1).
●We will use evaluation data as a ‘feedback’ mechanism to make adjustments and improvements to our processes and outcomes, including sustainability.
●We are using ENACT to assess the community’s strategic readiness to address obesity in seven different environments in order to generate a master plan for the community.
●A causal theory model based on the community obesity problem was developed to serve as a framework for our program and evaluation .
●We returned to ENACT to help develop a proposed intervention than can be implemented in the UVA Hospital cafeterias.
●We based our proposed intervention on the transtheoretical model of health behavior, which integrates educational and motivational materials into the Signals program
●We developed an evaluation strategy to assess both the implementation processes and the outcomes of the intervention.
1. Mokdad, A. H., Marks, J. S., Stroup, D. F., & Gerberding, J. L. (2004). Actual causes of death in the United States, 2000. Journal of the American Medical Association, 291, 1238-1245.
2. http://www.cdc.gov/obesity/data/trends.html
3. http://vaperforms.virginia.gov/indicators/healthFamily/obesity.php
4. http://eatbettermovemore.org/sa/enact/members/index.php
5. Mangweth B, Hudson JI, Pope HG, Oberleit S, De Col C, Kinzl J, Biebl W., Knowledge of calories and its effect on eating behavior in overweight, normal weight and underweight individuals, Eat Weight Disord. 1999 Dec 4 (4): 165-8.
We would like to thank all individuals, both at UVA and in the surrounding community who contributed to the development of this program and evaluation.
The Signals Program
The Signals program, which has already been implemented in one of the UVA Hospital cafeterias, functions by labeling foods at point-of-sale as green (enjoy normally), yellow (eat in moderation), or red (eat sparingly) based on nutritional content. The point-of-sale information consists of small signs near food items alert cafeteria patrons to the ‘color’ of the food as well as providing nutritional content (Figure 3).
In 2007, the Signals program was evaluated for efficacy. The results showed non-significant modest improvements in healthy purchasing habits. We sought to develop a plan and evaluation that integrates educational and motivational materials into the Signals program. We believe this will prompt more individuals to use Signals to make healthy food purchases.
After the initial community assessment using ENACT, we articulated a potential causal theory to identify factors that contribute to obesity as well as resulting outcomes and impacts, as shown in Figure 4.
●The constructs and identified components serve as a general guide for the subsequent planning and evaluation process.
●This framework not only serves as a guide, but also as a source to consult throughout the planning process.
●Be referring back to this framework, we are able to ensure that the components of our intervention address one of the components of our specific causal theory, and thus are in line with our overall goals.
Causal Theory
Because of prior work with the Signals program, a joint venture with UVA and Morisson’s Management, we decided to focus on developing a formal program plan and evaluation to enhance and expand the program in the hospital cafeterias.
As part of a class in Program Planning & Evaluation we followed a systematic process of development:1. Depict causal theory responsible for the health problem2. Apply health behavior theory to guide development of an intervention to address all factors.3. Develop a logic model.4. Develop our proposed intervention and evaluation plan with data collection tools.
Introduction
Obesity is quickly becoming the most common cause of preventable death in the United States (1). The health problems and co-morbidities that result from obesity are also on the rise. Many states, including Virginia, now have obesity rates above 25% (Figure 1) (2). Several areas of the state of Virginia have obesity rates up to 38.5% (3).
ENACT Community Assessment Tool
●ENACT identifies seven environments to address the obesity problem in the community including childcare, schools, after-school, community, workplace, healthcare, and government.
●Our goal, as part of the COTF, was to focus on the healthy foods and food policy strategies of the healthcare environment (Figure 2).
●We decided on a proposed intervention that would help promote healthier food choices and eating habits in the UVA Health System cafeterias.
Goals
The Community Obesity Task Force (COTF) in Charlottesville, VA has been working since 1999 to address childhood obesity and the growing problem of adult overweight and obesity as well. The COTF is using the nationally validated Environmental Nutrition and Activity Community Tool (ENACT) to assess the community’s strategic readiness to address obesity
Figure 1: Obesity Rates by State
