5/2/2017 1 Influence of teachers personal health behaviors on - - PDF document

5/2/2017 1

Influence of teachers’ personal health behaviors on

• perationalizing obesity prevention policy in Head Start

preschools: A project of the Children’s Healthy Living Program (CHL).

Esquivel MK, Nigg C, Fialkowski JK, Braun K, Li F , Novotny R. Journal for Nutrition Education and Behavior. 2016; 48 (5)

1

Objectives

• 1. To review the literature on factors that affect the efficacy of

child care center wellness policy implementation on the

• besogenic environment within preschool settings.
• 2. To discuss how the Children's Healthy Living Program child

care wellness policy intervention was designed to address multiple levels of the socioecological model to positively influence the nutrition and physical activity environments in Head Start classrooms.

• 3. To identify key strategies and lessons learned from this

program that could support effective wellness policy implementation in child care centers to address childhood

• besity.

2

Introduction

• State of Emergency Declared in Pacific Region1
• High prevalence obesity-related non-communicable diseases
• High prevalence of adult obesity
• Childhood overweight/obesity (ow/ob) is a risk factor for
• w/ob in adults2
• Childhood prevalence ow/ob in Pacific & Hawai‘i:
• US Affiliated Pacific: 21% to 39% in 2-8 yr olds3
• Hawaii: 28% children entering kindergarten 20074
• Unchanged from 20035
• US Mainland: Recent national study showed decline in obesity in

3-5 year olds Hawai‘i data not included6

3

5/2/2017 2

Children’s Healthy Living Program (CHL)

• USDA grant for childhood obesity prevention in US

Affiliated Pacific7

• Training program
• Community randomized controlled intervention trial based on social

ecologic model and focused on the environment

• 5 jurisdictions and 18 communities
• >25% Native Hawaiian Pacific Islander per US Census
• Target Population: 2-8 year olds children in selected communities
• Data collected (baseline and follow-up)
• Socio-demographics
• Anthropometry
• Dietary intake
• Physical activity
• Sleep
• Screen time

4

CHL Partnership

Determining Childhood Ow/Ob

• Body Mass Index (BMI) compared against reference data
• Classification
• CDC BMI percentile cut points for ow/ob8
• 0 to <5th = underweight, 5th to <85th = healthy weight, ≥ 85th to <95th=
• verweight, ≥ 95th = obese
• Continuous
• BMI z-scores (zBMI)=

5

Mean

• 2 SD
• 1SD

0 SD + 1 SD + 2SD 95th %tile 84th %tile 50th %tile 6th %tile 19th %tile Child BMI – Avg BMI from Reference Population SD of Reference Population

Causes of Obesity

• Energy imbalance
• Socio-Ecologic Model12
• Individual/environment interaction
• Obesogenic Environments13
• Physical- availability & access
• Economic- food cost & income level
• Political- policies or access
• Socio-Cultural- beliefs, traditions

6 Policy Community Organizational Interpersonal Individual

5/2/2017 3

Head Start (HS) and Childhood Obesity

• HS: Federally funded free preschool for children from low-

income families20

• Emphasis on education and health
• Health Requirements: annual physical exam, bi-annual growth

assessment

• Meal Requirements: mandatory participation in Child and Adult Care Food

Program (CACFP)

• CACFP22
• Outlines minimum requirements for reimbursable meal components
• HS or similar Early Childhood Education (ECE) delivered

throughout US Affiliated Pacific Islands & Territories

• HS has shown positive effect on childhood obesity in

Michigan

• Decline in BMI z-score of obese children after 1st year of HS

participation greater than comparison samples, p<0.00121

7

Current HS Nutrition/Health Policy

• Policies from the Office of Administration for Children and

Families- Office of Head Start20

• Identify individual child nutritional needs
• Measure height/weight
• Questionnaires about family eating pattern/cultural food preferences
• Special dietary requirements
• Meal and Snack Provision
• Meals/snacks meet 1/3 to ½ of daily nutrition needs
• Follow USDA child nutrition meal patterns
• Foods are high in nutrients, low in fat, sugar, salt
• Serve a variety of foods to broaden child’s food experiences
• No outside foods/beverages allowed
• Meal Time
• Food is not a punishment/reward
• Staff/volunteers eat the same food, family style to the extent possible

8

Current HS Nutrition/Health Policy

• Policies from the Office of Administration for Children and

Families- Office of Head Start20

• Identify individual child nutritional needs
• Measure height/weight
• Questionnaires about family eating pattern/cultural food preferences
• Special dietary requirements
• Meal and Snack Provision
• Meals/snacks meet 1/3 to ½ of daily nutrition needs
• Follow USDA child nutrition meal patterns
• Foods are high in nutrients, low in fat, sugar, salt
• Serve a variety of foods to broaden child’s food experiences
• No outside foods/beverages allowed
• Meal Time
• Food is not a punishment/reward
• Staff/volunteers eat the same food, family style to the extent possible

9

Opportunities for Improvement

• Strengthen policy

statements

• Additional policies to

improve implementation

5/2/2017 4

10 Table 2.1 Literature review: summary of effective early childhood education policy intervention outcomes measured and intervention activities. Outcomes Measured Intervention Activities Significant Results Author, Location, Study Child Class CBPR EW T/TA Ob SR Lanigan, US EHNAHCE23 x x x x Classroom feeding practices Gosliner, California, Contra Costa County Child Care24 x x Teacher-parent communication Classroom FV availability Benjamin, North Carolina, NAP SACC25 x x Obesity prevention best practices implemented Drummond, Arizona, NAP SACC26 x x Obesity prevention best practices implemented Lyn, Georgia, DECAL27 x x Environment and Policy Assessment and Observation score De Silva-Sanigorski, Australia, Romp N Chomp28 x x x Obesity prevalence Juice consumption Alkon, US, NAP SACC29 x x x x BMI z score Ob= Observed, SR= Self-Report, CBPR=Community Based Participatory Research, EW= Employee Wellness, T/TA= Training and Technical Assistance

Summary/Problem Statements

• Multi-level interventions are needed for childhood ow/ob

prevention and treatment within preschool settings

• ECE-based policy interventions have the potential to

support prevention efforts but have not been tested on Native Hawaiian and Pacific Islander populations

• Increased ow/ob in HI and Pacific but lack of system to

monitor progress

• HS may be a potential partner for monitoring young child growth

but validation of program measurements is needed

• Child growth assessments differ by reference data (CDC

vs WHO), both are used in US Affiliated Pacific and difference has not been assessed in NHPI sample

11 12

Wellness Policy Intervention Development Implementation Teacher Assessment1 Classroom Outcomes2 Child Outcomes3, 4 Long-term Outcomes HS teacher focus groups to inform intervention Esquivel MK, et al. J Family Med Community

• Health. 2016

Teacher nutrition misconceptions, efficacy, priorities, & knowledge PA & Nutrition Environment Esquivel MK, et al. Childhood Obesity. 2016 BMI Fruit & vegetable intake Evaluating HS data for child BMI monitoring in Pacific Implementation Fidelity & Teacher reported health behaviors, indicators, skills, & knowledge related to nutrition & PA5 Esquivel MK, et al. Journal for Nutrition Education and Behavior. 2016 Assessment Tools: 1Child Care Provider Healthy Eating and Activity Survey, 2Environment and Policy Assessment and Observation Tool

a.Nutrition and b.Physical Activity, 3Observed Plate Waste, 4CDC 2000 Growth Charts, 5Monthly Implementation Survey

Mediator Moderator

Conceptual Framework for Head Start Policy Intervention in Hawai‘i

5/2/2017 5

Background

• Policy interventions have made positive effects on CCC

environments

• Policy goals: create classroom environments that support energy

balance (calories in=calories out)

• Few studies have assessed effect on child outcomes
• BMI: 2 studies found positive effect on child BMI28, 29
• Diet: Improved F/V availability24, decreased juice consumption29
• Interventions that included teacher/staff activities:
• Correlation between center staff and classroom meal time feeding

practices, classroom nutrition education and parent-family communication23

• Positive effect of teachers’ self-efficacy on communicating nutrition

information to parents and frequency of fruits and vegetables served at centers23

13

Hypotheses

Classroom

• Improved nutrition &

physical activity (PA) classroom environment

• Mediated by teachers’

beliefs, misconceptions, knowledge, and priorities

• Moderated by

implementation fidelity & teacher behaviors and status Child

• Decrease child zBMI &

increase child fruit/veg consumption

• Mediated by teachers’

beliefs, misconceptions, knowledge, and priorities

• Moderated by

implementation fidelity & teacher behaviors and status

14

HS cluster CHL randomized community

Methods: Design, Participants

• 7 month intervention within

CHL randomized community trial

• Pre- Post Assessment
• Monthly intervention

activities

• Dissertation Study Sample
• HS clusters containing CHL

randomized communities

• Intervention: 11 HS classrooms
• 220 children sampled
• Control:12 HS classrooms
• 240 children sampled
• Ages: 3-5 years
• Low-income

15

5/2/2017 6

Methods: Recruitment for Intervention

• Honolulu Community Action Program (HCAP) Head Start

Agency agreed to participate

• Local agency that delivers HS program on Oahu
• HS teachers were consented at cluster/area meetings
• Children and parents from HS classrooms were recruited

at:

• HS program orientation meetings
• Start and end of school day at HS classrooms
• By MKE, HS staff
• Parents/guardians completed informed consent, socio-

demographic questionnaire, information release and received $5 Long’s gift card for remuneration

16 17

Table 4.1 HI HS Teacher Informed Policy Intervention as Related to the Three Focus Group Themes Policy Intervention Intervention Activities Focus Group Theme Integration of Nutrition & PA Promotion

Incorporate nutrition and PA promotion at regular monthly HS meetings Examples: 1) Provide nutrition & PA materials for classroom, family, & employee wellness 2) HS staff and teachers training on nutrition & health Theme 1: Supports teachers’ ability to be positive influence on child Theme 2: Support teacher role modeling Theme 3: Provide classroom resources

Employee Wellness

Deliver employee wellness activities that coincide with HS classroom nutrition & PA activities at monthly meetings Theme 1: Supports teachers’ ability to be positive influence on child Theme 2: Support teacher role modeling

Foods and Beverages Served

Create nutrition standards to improve the dietary quality of foods and beverages served Examples: 1) Eliminated 100% fruit juice to increase availability of fruit 2) Limit high energy, low nutrient menu items, such as fried noodles and potatoes Theme 1: Supports program’s positive influence on child by offering fruit and

• ther nutrient dense foods.

Theme 2: Support teacher role modeling as teachers consume the same foods and beverages as children.

Community Partnerships

Pursue partnerships to ensure sustainability of monthly activities Examples: 1) Local farmers for vegetables for employee taste testing 2) Local health centers/professionals to provide information about PA 3) Meal vendors provide nutrition training and education Theme 3: Addressing gaps in resources to nutrition and health promotion

Figure 4.1 HI HS T eacher informed policy intervention within social ecologic model.

18 Policy Community Organizational Interpersonal Individual

Wellness policy implementation Engaging HS teachers in policy development T/TA, worksite wellness Changing meal service and food served Supporting teachers as role models Classroom health curriculum

5/2/2017 7

Figure 4.2 HI HS T eacher Informed Policy Intervention Activities & Obesogenic Environment

19 Political Social Physical Economic

HS teacher informed wellness policy implementation Supporting teachers as role models Monthly group worksite wellness Changing meal service style, foods served Implementing classroom curriculum T/TA HS improves accessibility of FV to children of low-income households

Outcome Variables

Classroom

• Environment and Policy

Assessment and Observation (EPAO):

• Nutrition and physical activity

environment13

• Monthly Implementation

Survey23

• Child Care Provider Healthy

Eating and Activity Survey (CCPHEA):

• Child nutrition priorities,

knowledge, efficacy, & misconceptions11

Child

• Servings of FV consumed
• Observed plate waste: Fruit and

vegetable consumed at lunch

• zBMI using CDC 2000 reference
• Predictor variables (pre-

intervention)

• Demographics
• Age (years), race, sex

20

Classroom Variables

• Environment: EPAO (pre- and post-)35
• Validated tool & protocol to quantitatively score nutrition & PA

environment (Ward)

• Nutrition Score (mean of nutrition sub areas) (Range 0-20)
• Physical Activity (PA) Score (Range 0-20)
• Total Score (mean of nutrition and PA) (Range 0-20)
• Monthly Implementation Survey (monthly)34
• Created by Yin et al
• Implementation fidelity- # classroom activities/month (Range 0-4)
• Teachers’ change in health status and health behaviors (Range 0-7)
• Teacher Child Nutrition Survey: CCPHEA (pre- and post-)23
• Validated tool & protocol to assess teachers’ child nutrition
• Efficacy (Range 3-12)
• Priority (Range 3-12)
• Misconceptions (Range 3-12)
• Knowledge (Range 5-20)

21

5/2/2017 8

Classroom Variables

• Environment: EPAO (pre- and post-)35
• Validated tool & protocol to quantitatively score nutrition & PA

environment (Ward)

• Nutrition Score (mean of nutrition sub areas) (Range 0-20)
• PA Score (Range 0-20)
• Total Score (mean of nutrition and PA) (Range 0-20)
• Monthly Implementation Survey (monthly)34
• Created by Yin et al
• Implementation fidelity- # classroom activities/month (Range 0-4)
• Teachers’ change in health status and health behaviors (Range 0-7)
• Teacher Child Nutrition Survey: CCPHEA (pre- and post-)23
• Validated tool & protocol to assess teachers’ child nutrition
• Efficacy (Range 3-12)
• Priority (Range 3-12)
• Misconceptions (Range 3-12)
• Knowledge (Range 5-20)

22

Classroom Variables

• Environment: EPAO (pre- and post-)35
• Validated tool & protocol to quantitatively score nutrition & PA

environment (Ward)

• Nutrition Score (mean of nutrition sub areas) (Range 0-20)
• PA Score (Range 0-20)
• Total Score (mean of nutrition and PA) (Range 0-20)
• Monthly Implementation Survey (monthly)34
• Created by Yin et al
• Implementation fidelity- # classroom activities/month (Range 0-4)
• Teachers’ change in health status and health behaviors (Range 0-7)
• Teacher Child Nutrition Survey: CCPHEA (pre- and post-)23
• Validated tool & protocol to assess teachers’ child nutrition
• Efficacy (Range 3-12)
• Priority (Range 3-12)
• Misconceptions (Range 3-12)
• Knowledge (Range 5-20)

23

Monthly Implementation Survey34

• Teacher personal

health behaviors and status assessment

• Yes= “1”
• No= “0”
• Sum for each month
• Average of 7 months

24

Table 4.2 Monthly teacher health indicator and behavior survey items, “yes” responses were scored 1 and “no” responses were scored 037. Have you seen an improvement in your knowledge and skills of physical activities? Have you seen an improvement in your knowledge and skills of nutrition and healthy eating? Have you seen an increase in physical activity? Have you been choosing water over soda and sugary drinks? Have you been eating more vegetables and fruits? Have you been reducing your portion size? Have you seen an improvement in your overall physical health? Have you seen any loss of body weight? Have you seen any improvement in your cholesterol? Have you seen any improvement in your blood pressure? Have you seen any improvement in your mental health? Questionnaire adapted from Yin et al37.

5/2/2017 9

T eacher Child Nutrition Survey: Priority Questions

25

4 1 3 2 4 1 3 2 4 1 3 2

Research Questions & Analytic Plan

2) Is the relationship between wellness policy implementation and the classroom environment (EPAO) mediated by changes in teacher priority, knowledge, misconceptions, or efficacy about child nutrition (CCPHEA survey)?

Analysis: Series of linear regression models Control: Baseline values, study group

26

Mediation (Baron and Kenny, 1986)

27

5/2/2017 10

Mediation (Baron and Kenny, 1986)

28

Step 1: Confirm that the independent variable is a significant predictor of the dependent variable.

Mediation (Baron and Kenny, 1986)

29

Step 1: Confirm that the independent variable is a significant predictor of the dependent variable. Step 2: Confirm that the independent variable is a significant predictor of the mediator.

Mediation (Baron and Kenny, 1986)

30

Step 1: Confirm that the independent variable is a significant predictor of the dependent variable. Step 2: Confirm that the independent variable is a significant predictor of the mediator. Step 3: Confirm that the mediator is a significant predictor of the dependent variable, while controlling for the independent variable*.

5/2/2017 11

Mediation (Baron and Kenny, 1986)

31

Step 1: Confirm that the independent variable is a significant predictor of the dependent variable. Step 2: Confirm that the independent variable is a significant predictor of the mediator. Step 3: Confirm that the mediator is a significant predictor of the dependent variable, while controlling for the independent variable*. *when the mediator and the independent variable are used simultaneously to predict the dependent variable, the previously significant path from Step #1 is now greatly reduced, if not non-significant

Mediation (Baron and Kenny, 1986)

32

Step 1: Confirm that the independent variable is a significant predictor of the dependent variable. Step 2: Confirm that the independent variable is a significant predictor of the mediator. Step 3: Confirm that the mediator is a significant predictor of the dependent variable, while controlling for the independent variable*.

Policy Intervention Teacher Child Nutrition Survey Classroom Environment

*when the mediator and the independent variable are used simultaneously to predict the dependent variable, the previously significant path from Step #1 is now greatly reduced, if not non-significant

Research Questions & Analytic Plan

3) Does the relationship between policy implementation and

Classroom environment (EPAO) depend on (moderated by) the level of

policy implementation or change in teachers personal health behaviors and indicators related to nutrition and PA?

Analysis: Series of multiple regression models, testing the interaction between intervention and moderating variable Control: baseline value and study group

33

5/2/2017 12

Moderation (Baron and Kenny, 1986)

34

Independent Variable Moderator* Independent Variable x Moderator Dependent Variable A B C If “C” is significant then there is a

moderating effect of the I.V. and moderating variable. *Affects direction or strength of relationship “A”. Interaction is product of I.V. and moderator

Moderation (Baron and Kenny, 1986)

35

Independent Variable Moderator* Independent Variable x Moderator Dependent Variable A B C If “C” is significant then there is a

moderating effect of the I.V. and moderating variable. Interaction is product of I.V. and moderator

Policy Intervention

Classroom Environment *Affects direction or strength of relationship “A”.

Moderation (Baron and Kenny, 1986)

36

Independent Variable Moderator* Independent Variable x Moderator Dependent Variable A B C If “C” is significant then there is a

moderating effect of the I.V. and moderating variable. Interaction is product of I.V. and moderator

Policy Intervention Teacher health behaviors/indicators

Classroom Environment *Affects direction or strength of relationship “A”.

5/2/2017 13

Moderation (Baron and Kenny, 1986)

37

Independent Variable Moderator* Independent Variable x Moderator Dependent Variable A B C If “C” is significant then there is a

moderating effect of the I.V. and moderating variable. Interaction is product of I.V. and moderator

Policy Intervention Teacher health behaviors/indicators Policy Intervention x Teacher health behaviors/indicators

*Affects direction or strength of relationship “A”. Classroom Environment

Manuscript: Classroom Results

Table 4.3: Baseline mean scores for classroom level variable by group and paired t-test results (n=23). Intervention (n=11) Control (n=12) Variable Mean (SD) Mean (SD) P-value

Environment and Policy Assessment and Observation (EPAO) range 0-20

Nutrition 14.92 (1.5) 14.30 (0.96) 0.246 Physical Activity 14.52 (1.5) 14.33 (1.3) 0.755 Total 14.72 (1.3) 14.32 (0.59) 0.351

38 39

Table 4.5 Covariate adjusted means of Post-Intervention class-level EPAO nutrition, physical activity (PA) and total scores and CCPHEA misconception, priority, knowledge and efficacy related to child-nutrition, comparing the treatment and control classrooms*

Variables Intervention Group

Mean (SE)

Control Group

Mean (SE)

P value** EPAO- Nutrition 14.9 (0.40) 14.9 (0.39) 0.98 EPAO- PA 16.5 (0.45) 14.3(0.43) 0.002 EPAO- Total 15.7 (0.33) 14.6 (0.32) 0.039 CCPHEA-Misconceptions 6.5 (0.20) 6.4 (0.21) 0.847 CCPHEA- Priority 9.8 (0.37) 9.5 (0.40) 0.641 CCPHEA- Knowledge 9.7 (0.41) 10.0 (0.43) 0.534 CCPHEA- Efficacy 6.1 (0.35) 5.6 (0.38) 0.321

* General linear regression model adjusted for baseline values; ** Global F test that at post-intervention, the difference in means between the two groups is zero.

2.1 Did policy implementation result in a significant improvement in the classroom environment as measured by EPAO scores?

5/2/2017 14

40

Table 4.6 Model testing teacher priority of child nutrition mediation on the intervention effects for post intervention class-level Physical Activity EPAO and Total EPAO. Variables Treatment Group Control Group Difference p valuee Mean (SE) Mean (SE) Post-intervention Post-intervention EPAO- PA

Original regression model a

16.5(0.45) 14.3(0.43) 2.2 0.002

Teacher Priority mediation model b

16.3 (0.42) 14.4 (0.42) 1.9 0.005 EPAO- Total

Original regression model c

15.7 (0.33) 14.6 (0.32) 1.1 0.039

Teacher Priority mediation model d

15.6 (0.32) 14.7 (0.32) 0.9 0.077

a adjusted for pre-intervention EPAO-PA score b adjusted for pre-intervention EPAO-PA and CCPHEA- priority c adjusted for pre-intervention EPAO-Total score d adjusted for pre-intervention EPAO-Total and CCPHEA- priority e global F test that at post-intervention, the difference in the means between the two intervention

groups is zero

2.1a Is the relationship between wellness policy implementation and the classroom environment mediated by changes in teacher priority, knowledge, misconceptions,

• r efficacy about child nutrition as measured by CCPHEA survey?

41 Table 4.7: Multiple regression model results for moderating effect of teacher health behaviors/status on the intervention effect on the classroom EPAO total and EPAO PA.

Parameter Estimate (SE) t Value Pr > |t| Total EPAO Intercept 7.05 (3.12) 2.26 0.0366 group intervention (reference: control) 2.17 (0.53) 4.10 0.0007 EPAO- Total baseline 0.63 (0.22) 2.91 0.0094 Health behavior/ indicator <mean (reference: >mean)

• 1.07 (0.57)
• 1.87

0.0786 Study Group x Health behavior/ indicator

• 2.47 (0.78)
• 3.15

0.0055 PA EPAO Intercept 14.65 (3.16) 4.63 0.0002 group intervention (reference: control) 3.46 (0.79) 4.36 0.0004 EPAO- PA baseline 0.16 (0.22) 0.76 0.4574 Health behavior/ indicator <mean (reference: >mean)

• 1.22 (0.83)
• 1.46

0.1615 Study Group x Health behavior/ indicator

• 2.65 (1.15)
• 2.30

0.0338

2.1b Does the relationship between policy implementation and EPAO scores depend on (moderated) the level of policy implementation or change in teachers personal health behaviors and indicators related to nutrition and PA? (Multiple Regression) 42

10 11 12 13 14 15 16 17 18 19 20

Health indicator below mean Health indicator at or above mean

EPAO Score

EPAO-PA Intervention Group EPAO-PA Control Group EPAO-Total Intervention Group EPAO-Total Control Group

Figure 4.6 Linear model results exploring moderating effect of teacher health behavior/indicators on Environment and Policy Assessment and Observation- Physical Activity (EPAO PA) scores by intervention and control group.

5/2/2017 15

43

10 11 12 13 14 15 16 17 18 19 20

Health indicator below mean Health indicator at or above mean

EPAO Score

EPAO-PA Intervention Group EPAO-PA Control Group EPAO-Total Intervention Group EPAO-Total Control Group

Figure 4.6 Linear model results exploring moderating effect of teacher health behavior/indicators on Environment and Policy Assessment and Observation- Physical Activity (EPAO PA) scores by intervention and control group.

44

10 11 12 13 14 15 16 17 18 19 20

Health indicator below mean Health indicator at or above mean

EPAO Score Figure 4.1 Moderating effect of teacher health behavior/indicators on Environment and Policy Assessment and Observation- Physical Activity (EPAO PA) scores by intervention and control group.

EPAO-PA Intervention Group EPAO-PA Control Group EPAO-Total Intervention Group EPAO-Total Control Group

Figure 4.6 Linear model results exploring moderating effect of teacher health behavior/indicators on Environment and Policy Assessment and Observation- Physical Activity (EPAO PA) scores by intervention and control group.

45 Table 2.1 Literature review: summary of effective early childhood education policy intervention outcomes measured and intervention activities. Outcomes Measured Intervention Activities Significant Results Study, Study Child Class CBPR EW T/TA Ob SR Lanigan, EHNAHCE23 x x x x Classroom feeding practices Gosliner, Contra Costa County Child Care24 x x Teacher-parent communication Classroom FV availability Benjamin, NAP SACC25 x x Obesity prevention best practices implemented Drummond, NAP SACC26 x x Obesity prevention best practices implemented Lyn, DECAL27 x x EPAO score De Silva-Sanigorski, Romp N Chomp28 x x x Obesity prevalence Juice consumption Alkon, NAP SACC29 x x x x BMI z score Ob= Observed, SR= Self-Report, CBPR=Community Based Participatory Research, EW= Employee Wellness, T/TA= Training and Technical Assistance Similar intervention activities; teacher efficacy, misconceptions, knowledge associated with classroom feeding practices, parent-teacher communication, classroom nutrition education Improved teacher efficacy in communicating with parents and increased likelihood for fruits and vegetables to be served Self reported improved nutrition environment (70.08 to 77.15, p<0.001) and PA environment (34.23 to 41.00, p<0.001) Nutrition best practices increased from 25-30 (p=0.003) and PA 10-14 (p=0.0014) Significantly improved EPAO nutrition and PA scores, greater proportion of PA sub-score improvements (5/8) vs nutrition (2/8) Significantly different decrease in ow/ob prevalence intervention vs. control and decreased fruit juice consumption Similar time frame; significantly larger sample Significantly lowered zBMI in 209 children, intervention included parent/family intervention component

5/2/2017 16

Limitations

• Inclusion of HS classrooms outside of CHL randomized

communities

• Significantly different race distribution (controlled for in analysis)
• EPAO- repeated measures in account for day-to-day

variation

• Lack of individual level physical activity assessessement

46

Discussion

• Teacher priority about child nutrition
• Mediated relationship between policy and environmental changes
• bserved & child fruit consumption
• Interventions should focus on how to increase priority of childhood
• besity prevention
• Teachers’ health behaviors and status moderation effect
• Supports inclusion of employee wellness activities to increase

intervention effect

• Fruit juice and family style meal service and Nutrition EPAO
• Changes might not have been large enough to shift EPAO score
• Elimination of fruit juice increased fruit availability & contribute to

increased consumption in this intervention

• Family style meal service interrupted on measurement day
• PA EPAO larger increase in other studies
• Lyn et al able to improve 5/8 PA EPAO sub-scores vs 3/8 nutrition in

this study27

47

Conclusion

48

Head Start teachers can play an important role in

• besity prevention interventions and monitoring in

preschool settings. They should be included in policy level interventions to address the physical activity environment in HS classrooms.

5/2/2017 17

Acknowledgements

• Funding: CHL Program
• USDA Grant No: 2011-68001-30335 from the USDA National

Institute of Food and Agricultural Science Enhancement Coordinated Agricultural Program

• CHL Intervention Staff and Admin team
• Committee members
• HCAP Head Start staff, teachers, and families

49

References con’t

• 14. IOM. Evaluating obesity prevention efforts: A plan for measuring progress. Washington DC: National Academy of Press; 2013.
• 15. U.S. Department of Education National Education Surveys Program. Child care: percentage of children ages 3-6, not yet in

kindergarten, in center-based care arrangmenets by child and family characteristics, and region, selected years 1995-2007. Available at: http://www.childstats.gov/americaschildren/tables/fam3b.asp?popup=true. Accessed February 6, 2013.

• 16. Nicklaus S, Boggio V, Chabanet C, Issanchou S. A prospective study of food preferences in childhood. Food Quality and
• Preference. 2004;15(7-8):805-818.
• 17. Serdula MK, Alexander MP, Scanlon KS, Bowman BA. What are preschool children eating? A review of dietary assessment. Annu

Rev Nutr. 2001;21:475-498.

• 18. Administration for Children and Families: About Head Start. [cited 2014 April 4]; Available from:

http://www.acf.hhs.gov/programs/ohs/about/head-start

• 19. Benjamin SE, Cradock A, Walker EM, Slining M, Gillman MW. Obesity prevention in child care: a review of U.S. state regulations.

BMC Public Health. 2008;8:188.

• 20. Code of Federal Regulations (CFR) 45 Head Start, Part 1304 Head Start Program Performance Standards, Section 1304.23 Child

Nutrition (Pages 98-115).

• 21. Lumeng JC, Kaciroti N, Sturza J, et al. Changes in Body Mass Index Associated With Head Start Participation. Pediatrics. 2015 Jan

12.

• 22. US Department of Agriculture Food and Nutrition Services: Code of Federal Regulations Chapter II Part 226 Child and Adult Care

Food Program pgs 180-287. Accessed on February 22, 2015 from http://www.fns.usda.gov/cacfp/regulations.

• 21. Lanigan JD. The relationship between practices and child care providers' beliefs related to child feeding and obesity prevention. J

Nutr Educ Behav. Nov-Dec 2012;44(6):521-529.

• 24. Gosliner WA, James P, Yancey AK, Ritchie L, Studer N, Crawford PB. Impact of a worksite wellness program on the nutrition and

physical activity environment of child care centers. Am J Health Promot. Jan-Feb 2010;24(3):186-189.

• 25. Benjamin SE, Ammerman A, Sommers J, Dodds J, Neelon B, Ward DS. Nutrition and physical activity self-assessment for child care

(NAP SACC): results from a pilot intervention. J Nutr Educ Behav. May-Jun 2007;39(3):142-149.

• 26. Drummond RL, Staten LK, Sanford MR, et al. A pebble in the pond: the ripple effect of an obesity prevention intervention targeting

the child care environment. Health Promot Pract. Apr 2009;10(2 Suppl):156S-167S.

50

Current HS Nutrition/Health Policy

• Policies from the Office of Administration for Children and

Families- Office of Head Start20

• Identify individual child nutritional needs
• Measure height/weight
• Questionnaires about family eating pattern/cultural food preferences
• Special dietary requirements
• Meal and Snack Provision
• Meals/snacks meet 1/3 to ½ of daily nutrition needs
• Follow USDA child nutrition meal patterns
• Foods are high in nutrients, low in fat, sugar, salt
• Serve a variety of foods to broaden child’s food experiences
• No outside foods/beverages allowed
• Meal Time
• Food is not a punishment/reward
• Staff/volunteers eat the same food, family style to the extent possible

51

Opportunities for Improvement

• Strengthen policy

statements

• Additional policies to

improve implementation

5/2/2017 18

Intervention Planning: Research Questions

1.1 What are HS teachers’ recommendations for policy change to improve nutrition and physical activity promotion in the HS classrooms? 1.2 What are HS teacher strategies for implementing new and improving compliance with existing policies for promoting nutrition and physical activity in the HS classrooms?

52 53

Assessment Tools: 1Child Care Provider Healthy Eating and Activity Survey, 2Environment and Policy Assessment and Observation Tool a.Nutrition and b.Physical Activity, 3Observed Plate Waste, 4CDC 2000 Growth Charts, 5Monthly Implementation Survey

Conceptual Framework for Head Start Policy Intervention in Hawai‘i

Esquivel MK, et al. Childhood Obesity. 2016 Esquivel MK, et al. Journal for Nutrition Education and Behavior. 2016 Esquivel MK, et

• al. J Family Med

Community

• Health. 2016

Future Directions

• Integrating child nutrition education into preschool teacher

curriculum/training/continuing education programs

• Intervention:
• Tailoring “Healthy Habits for Life” curriculum
• Repeated EPAO/dietary assessments
• Sharing intervention with other HS classrooms, agencies
• Intervention Effect Analysis:
• Effect of specific environment components from EPAO
• Validation of HS measurements:
• Include other data sets (CHL partners)
• Observing HS teachers anthropometric measurement procedures

54

5/2/2017 19

Manuscript: Background

• Policy interventions have made positive effects on CCC

environments

• Policy goals: create classroom environments that support energy

balance (calories in=calories out)

• Few studies have assessed effect on child outcomes
• BMI: 2 studies found positive effect on child BMI28, 29
• Diet: Improved F/V availability24, decreased juice consumption29
• Interventions that included teacher/staff activities:
• Correlation between center staff and classroom meal time feeding

practices, classroom nutrition education and parent-family communication23

• Positive effect of teachers’ self-efficacy on communicating nutrition

information to parents and frequency of fruits and vegetables served at centers23

55

Manuscript Methods: Recruitment for Intervention

• Honolulu Community Action Program (HCAP) Head Start

Agency agreed to participate

• Local agency that delivers HS program on Oahu
• HS teachers were consented at cluster/area meetings
• Children and parents from HS classrooms were recruited

at:

• HS program orientation meetings
• Start and end of school day at HS classrooms
• By MKE, HS staff
• Parents/guardians completed informed consent, socio-

demographic questionnaire, information release and received $5 Long’s gift card for remuneration

56

EPAO Methods

Observe

Day long

• bservation &

document review

• HS graduate student

interns (n=10)

• 2 hour training
• Blinded to study group

Code

EPAO consists of 81

• bservation and

document review items Items are coded to 3- point scale (0, 1 and 2)

• 0= least desirable; 2=

most

• Items coded relative to

meeting Dietary Guidelines for Americans 2005; CACFP

Score

8 Nutrition and PA sub-area scores

• Mean of each sub-area’s items

multiplied by 10

• Perfect score= 20

Total Nutrition score= mean of 8 nutrition sub-area scores Total PA score= mean of 8 PA sub-area scores Total EPAO= mean of the total nutrition and total PA scores 57

• Validated tool & scoring protocol from Ward35
• Assessed at baseline and follow up

5/2/2017 20

EPAO Total Nutrition Score Calculation

SBNutr EPAO Item Score Observation 26 2 Observation 27 1 Observation 28 Observation 29 2 Observation 30, 30a 1 Observation 31 1 Total (mean*10) 7 / 6 * 10 = 11.7

58

Nutrition Sub-Area Score FV 11.7 Grains 15 HSHF 10 SBNutr 11.7 NutrEnv 16.7 Bev 15 NutrTE 10 NutrPol 20 Total Nutrition Score 13.8

CCPHEA (Classroom Teacher Survey)

Who

1-2 teachers per classroom

Categories*

Efficacy 3 questions Misconceptions 3 questions Knowledge 5 questions Priority 3 questions

Coding

Strongly Agree=4 Agree=3 Disagree=2 Strongly Disagree=1

Scoring

Category score= sum of points from category items Range 3-20 Lower score better

59

Conducted pre- and post- intervention Validated tool and scoring by Lanigan11

Observed Plate Waste Methods

60

Plate- Pre Plate- Post

• Children receive standard portion of

each meal component

• ¼ plate method for visual estimation
• f food left on plate
• 100, 75, 50, 25, 0% left
• (Validated against weighed plate

waste)36

• Family style meal service interrupted
• n measurement day
• Children were offered seconds in

standardized portions

5/2/2017 21

Anthropometry Methods

• Pre- and post- intervention Height (cm) and weight (kg)

measured by 1 trained researcher

• Calibrated stadiometer and digital scale
• Height/weight recorded to nearest 0.1 cm or kg
• BMI calculated and BMI z-scores calculated using CDC

2000 Growth Reference Data

61

Baseline Demography Methods

• Parent/guardian completed demographic form after consenting

62

Analytic Plan & Research Questions

2.2 Did policy implementation result in significant change in child FV intake? Analysis: Mixed model; children are nested by classroom Control: baseline F/V intake, child race, group Unit of Analysis: child 2.2a Is the relationship between wellness policy implementation and child FV intake mediated by changes in the classroom nutrition environment, teacher beliefs, attitudes and knowledge about nutrition? Analysis: Series of multilevel mixed regression model; classroom is cluster Control: baseline F/V intake, child race, group Unit of Analysis: child 2.2b Does the relationship between policy implementation and child FV intake depend on the level (moderated by) the level of policy implementation or change in teachers personal health behaviors and indicators related to nutrition and PA? Analysis: Series of multilevel mixed regression models; testing the interaction between intervention and moderating variable; classroom is cluster Control: baseline F/V intake, child race, group Units of Analysis: child

63

5/2/2017 22

Research Questions & Analytic Plan

2.1 Did policy implementation result in a significant improvement in the classroom environment as measured by EPAO scores? Analysis : General Linear Model using post intervention score Control: Baseline scores, group Unit of Analysis: classroom

64

2.1b Does the relationship between policy implementation and classroom EPAO scores depend on (moderated by) the level of policy implementation or change in teachers personal health behaviors and indicators related to nutrition and PA? Analysis: Series of multiple regression models, testing the interaction between intervention and moderating variable Control: baseline value and group Unit of Analysis: classroom 2.1a Is the relationship between wellness policy implementation and the classroom environment mediated by changes in teacher priority, knowledge, misconceptions,

• r efficacy about child nutrition as measured by CCPHEA survey?

Analysis: Series of linear regression models Control: Baseline values, group Unit of Analysis: classroom

Research Questions & Analytic Plan

2.1 Did policy implementation result in a significant improvement in the classroom environment as measured by EPAO scores? Analysis : General Linear Model using post intervention score Control: Baseline scores, group Unit of Analysis: classroom

65

2.1b Does the relationship between policy implementation and classroom EPAO scores depend on (moderated by) the level of policy implementation or change in teachers personal health behaviors and indicators related to nutrition and PA? Analysis: Series of multiple regression models, testing the interaction between intervention and moderating variable Control: baseline value and group Unit of Analysis: classroom 2.1a Is the relationship between wellness policy implementation and the classroom environment mediated by changes in teacher priority, knowledge, misconceptions,

• r efficacy about child nutrition as measured by CCPHEA survey?

Analysis: Series of linear regression models Control: Baseline values, group Unit of Analysis: classroom

Research Questions & Analytic Plan

2.1 Did policy implementation result in a significant improvement in the classroom environment as measured by EPAO scores? Analysis : General Linear Model using post intervention score Control: Baseline scores, group Unit of Analysis: classroom

66

2.1b Does the relationship between policy implementation and classroom EPAO scores depend on (moderated by) the level of policy implementation or change in teachers personal health behaviors and indicators related to nutrition and PA? Analysis: Series of multiple regression models, testing the interaction between intervention and moderating variable Control: baseline value and group Unit of Analysis: classroom 2.1a Is the relationship between wellness policy implementation and the classroom environment mediated by changes in teacher priority, knowledge, misconceptions,

• r efficacy about child nutrition as measured by CCPHEA survey?

Analysis: Series of linear regression models Control: Baseline values, group Unit of Analysis: classroom

5/2/2017 23

Analytic Plan & Research Questions

2.2 Did policy implementation result in significant change in child FV intake? Analysis: Mixed model; children are nested by classroom Control: baseline F/V intake, child race, group Unit of Analysis: child 2.2a Is the relationship between wellness policy implementation and child FV intake mediated by changes in the classroom nutrition environment, teacher beliefs, attitudes and knowledge about nutrition? Analysis: Series of multilevel mixed regression model; classroom is cluster Control: baseline F/V intake, child race, group Unit of Analysis: child 2.2b Does the relationship between policy implementation and child FV intake depend on the level (moderated by) the level of policy implementation or change in teachers personal health behaviors and indicators related to nutrition and PA? Analysis: Series of multilevel mixed regression models; testing the interaction between intervention and moderating variable; classroom is cluster Control: baseline F/V intake, child race, group Units of Analysis: child

67

Analytic Plan & Research Questions

2.2 Did policy implementation result in significant change in child FV intake? Analysis: Mixed model; children are nested by classroom Control: baseline F/V intake, child race, group Unit of Analysis: child 2.2a Is the relationship between wellness policy implementation and child FV intake mediated by changes in the classroom nutrition environment, teacher beliefs, attitudes and knowledge about nutrition? Analysis: Series of multilevel mixed regression model; classroom is cluster Control: baseline F/V intake, child race, group Unit of Analysis: child 2.2b Does the relationship between policy implementation and child FV intake depend on the level (moderated by) the level of policy implementation or change in teachers personal health behaviors and indicators related to nutrition and PA? Analysis: Series of multilevel mixed regression models; testing the interaction between intervention and moderating variable; classroom is cluster Control: baseline F/V intake, child race, group Units of Analysis: child

68

2.3 Did policy implementation result in significant change in child BMI? Analysis: Mixed model; children nested by classroom Control: baseline zBMI, child race, group Unit of Analysis: child 2.3a Is the relationship between wellness policy implementation and child BMI mediated by changes in the classroom environment, teacher beliefs, attitudes and knowledge about child nutrition? Analysis: Series of multilevel mixed regression model; classroom is cluster Control: baseline zBMI, child race, group Unit of Analysis: child 2.3b Does the relationship between policy implementation and child BMI depend

• n (moderated by) the level of policy implementation or change in teachers

personal health behaviors and indicators related to nutrition and PA? Analysis: Series of multilevel mixed regression models; testing the interaction between intervention and moderating variable; classroom is cluster Control: baseline zBMI, child race, group Units of Analysis: child

69

Analytic Plan & Research Questions

5/2/2017 24

2.3 Did policy implementation result in significant change in child BMI? Analysis: Mixed model; children nested by classroom Control: baseline zBMI, child race, group Unit of Analysis: child 2.3a Is the relationship between wellness policy implementation and child BMI mediated by changes in the classroom environment, teacher beliefs, attitudes and knowledge about child nutrition? Analysis: Series of multilevel mixed regression model; classroom is cluster Control: baseline zBMI, child race, group Unit of Analysis: child 2.3b Does the relationship between policy implementation and child BMI depend

• n (moderated by) the level of policy implementation or change in teachers

personal health behaviors and indicators related to nutrition and PA? Analysis: Series of multilevel mixed regression models; testing the interaction between intervention and moderating variable; classroom is cluster Control: baseline zBMI, child race, group Units of Analysis: child

70

Analytic Plan & Research Questions

2.3 Did policy implementation result in significant change in child BMI? Analysis: Mixed model; children nested by classroom Control: baseline zBMI, child race, group Unit of Analysis: child 2.3a Is the relationship between wellness policy implementation and child BMI mediated by changes in the classroom environment, teacher beliefs, attitudes and knowledge about child nutrition? Analysis: Series of multilevel mixed regression model; classroom is cluster Control: baseline zBMI, child race, group Unit of Analysis: child 2.3b Does the relationship between policy implementation and child BMI depend

• n (moderated by) the level of policy implementation or change in teachers

personal health behaviors and indicators related to nutrition and PA? Analysis: Series of multilevel mixed regression models; testing the interaction between intervention and moderating variable; classroom is cluster Control: baseline zBMI, child race, group Units of Analysis: child

71

Analytic Plan & Research Questions

Table 4.6 Mixed model testing intervention effect on child fruit consumption controlling for baseline fruit consumption and race. Parameter Estimate (SE) t Value Pr > |t| Intercept 46.97 (11.49) 4.09 0.0005 group intervention (reference: control) 19.77 (11.57) 1.71 0.0892 Baseline fruit consumption 0.26 (0.06) 4.49 <0.0001 Asian*

• 13.12 (11.61)
• 1.13

0.26 More than one race*

• 10.12 (8.64)
• 1.17

0.24 NHPI*

• 7.59 (9.90)
• 0.77

0.44 Hierarchical Linear Model: controlling for group, baseline fruit intake, and race. * Reference: White

72

2.2 Did policy implementation result in significant change in child FV intake?

5/2/2017 25

Other Behavior Change Theories

• Health Belief Model
• Health-related behavior is influenced by desire to avoid illness or

get well and belief that health action will prevent/cure illness

• Behavior is decided by individual’s perceptions of benefits and

barriers to health behavior

• Limitation: does not account for social, environmental, economic

factors; assumes no disparities in access to health information

• Theory of Planned Behavior
• Behavioral intentions are affected by attitude that the behavior will

have the desirable outcome; Depends on motivation and ability

• Limitations: assumes all have equal opportunities and resources to

make perform behavior

• Ignores environmental, economic influences

73

Other Behavior Change Theories

• Diffusion of Innovation Theory
• Explains how an behavior/idea/product spreads through a social

system resulting in individuals adopting the new behavior

• In promoting new behavior, understanding where the target

population falls within the adopter categories guides strategies needed for adoption (innovator/early adapter/early-late majority/laggards)

• Factors influencing adoption: relative advantage, compatibility,

complexity, ease to try, observability

• Limitations: ignores individual’s resources, social support, works

best for new behaviors, not cessation or prevention, not developed for PH.

74

Other Behavior Change Theories

• Transtheoretical Model (Stages of Change)
• Focus on the decision-making of the individual; model of intentional

change

• Model for behavioral change, other theories can be applied to

stages of TTM to create effective interventions

• Social Norms
• Focuses on environment-interpersonal influences (peer-influence)

to change behavior

• Behavior is influenced by misperceptions of our peers,

interventions focus on correcting misperceptions

• Limitations: Reliable data from sources credible to the target

population are needed; dose of message should be enough to impact population, but not so much that it is “common place”

75

5/2/2017 26

Social Cognitive Theory

• Learning occurs in social context
• Interactions between person-environment-behaviors
• Emphasizes role of social influence
• Takes into account individual’s past experiences and expectations

in engaging in behaviors.

• Limit
• Assumes changes in environment

lead to changes in person

• Focuses on processes of learning

but disregards biologic factors

76

Community Based Participatory Research (CBPR)

77 From Academic Autism Spectrum Partnership in Research and Education: http://aaspire.org/?p=about&c=cbpr

CBPR

Benefits

• Demonstrates respect for

community knowledge

• Can help to overcome past

experiences with researchers

• Intervention effect
• Recruitment
• Retaining participants
• Sustainability
• Capacity building
• Ownership of intervention
• Partnerships

Limitations

• Time
• Building relationships takes

time, planning phases will be lengthy

• Resources
• Adhering to strict research

design and protocols

• ie: lack of control group,

unblinded, “containing” intervention

78

5/2/2017 27

Culturally Appropriate Intervention

• Strengths:
• Developed following some CBPR principles
• Sought knowledge from community (HS teachers) to develop

intervention

• Will seek community input for dissemination
• Intervention was informed via community engagement
• Reinforced teachers as role models for children
• Opportunities:
• Intervention aspects needing to be tailored:
• Curriculum: swap Sesame Street for Na Ki‘i Ola
• Classroom activities to include culturally relevant practices (gardening)

and stories to promote health

• Include traditional foods- kalo, sweet potato- in activities and menus

79

Manuscript: Child Results

Table 4.5 Frequency distribution of child BMI category, zBMI, fruit and vegetable consumption by intervention and control groups, pre- and post- intervention.

Intervention Control BMI Category1 Pre N (%) Post N (%) P Pre N (%) Post N (%) P Underweight 3 (2.0) 3 (2.6) 0.708 7 (4.2) 7 (5.3) 0.660 Healthy weight 105 (68.2) 78 (68.4) 0.967 125 (75.3) 93 (70.5) 0.348 Overweight 22 (14.3) 14 (12.3) 0.634 22 (13.3) 17 (12.9) 0.924 Obese 24 (15.6) 19 (16.7) 0.812 12 (7.2) 15 (11.4) 0.217 Total 154 (100) 114 (100) 166 (100) 132 (100) M (SD), N M (SD), N P M (SD), N M (SD), N P zBMI 0.512 (1.14) 154 0.60 (1.16) 114 0.50 0.252 (1.14) 166 0.35 (1.17) 132 0.48 Fruit consumed4 48.4 (42.3) 143 72.4 (38.8) 104 <0.001 48.1 (43) 161 56.2 (42) 129 0.11

• Veg. consumed4

27.83 (33)118 31.5 (38) 104 0.43 9.93 (22) 161 13 (26) 129 0.28

1= According to CDC BMI Categories 0-4th%tile= underweight, 5-84th%tile= Healthy weight, 85-94th

%tile=overweight, >95th%tile= obese

2= Values are significantly different , p=0.04 3 Values are significantly different , p<0.0001 4 % of serving

80

Mediation Analysis

• Helps to determine mechanism by which intervention is

effective

• Mediating variable (teachers’ beliefs) is intermediate

between exposure (policy implementation) and outcome (classroom environment; child FV intake & BMI)

• Baron & Kenny (1986)
• Confirm significant relationships between IV-DV, IV-mediator,

mediator-DV (controlling for IV)

• MacKinnon
• Regression/Mixed Model Analysis
• Mediators added to model and product of coefficients test mediator

81

5/2/2017 28

Multilevel Mixed Model

• Regression model that takes into account that variation is

not generalizable to IV

• ie: variation differs by classroom
• Allows for IV and DV to be continuous
• Includes both fixed and random effects
• Fixed: child age, sex, race
• Random: classroom
• Data on individuals is grouped (classroom)
• Coefficient or random effects at each level

82

Past Marginalization and Current Health

• Marginalization of Native Hawaiians
• Outcome of colonization
• Removed from land and natural resources
• Prohibited from their traditional lifestyle and practices
• Climate of distrust following
• Act of marginalization (or social exclusion) results in:
• Preventing individuals or communities from participating fully in society
• Characterized by unequal access to care leading to health inequalities
• Effects health directly in seeking treatment, education, prevention
• Material deprivation
• Poverty, emotional/psychological trauma, stress, absenteeism in school

(children), achievement in school

• Policies, practices, and programs can continue to marginalize

groups if not culturally-tailored or relevant & if trust is not established

83

Colonization and Health

• Racism and colonialism can have both direct and indirect

effects on health

• Directly: differentially structure the distribution of power, resources,

and money

• Indirectly: chronic stress
• Racism has been demonstrated to have deleterious

health effects in a number of settings:

• Racial inequities in health in Maori self-reported health
• Aboriginal self-reported psychological and physical health
• Latino post traumatic stress disorder symptoms (Liu, 2011)

84

5/2/2017 29

Example:

85

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