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This study examined the feasibility of implementing an innovative theater-based after-school program, ‘Ready. Set. ACTION!’, to reach ethnically diverse and low-income children and their parents with obesity prevention messages. The study population included 96 children and 61 parents. Children were in fourth to sixth grade and 41% were overweight at baseline. Program impact was evaluated with a pre/post-randomized controlled study design, but a major focus was placed on the process evaluation conducted in the intervention schools. Intervention children and parents reported high program satisfaction and that they had made changes or intended to make positive changes in their behaviors due to program participation. However, few meaningful differences between the intervention and control conditions were found at follow-up. Thus, the combined process and impact evaluation results suggest that the intervention was effective in leading to increased awareness of the need for behavioral change, but was not powerful enough on its own to lead to behavioral change. From this feasibility study, we concluded that Ready. Set. ACTION! offers promise as a creative intervention strategy. The next research step may be to incorporate theater-based programs into more comprehensive school-based interventions, with both educational and environmental components, and evaluate program impact.
The high prevalence of obesity among children is of concern given its physical, behavioral and psychosocial consequences [1–3]. Of particular public health concern, are the disparities in obesity across ethnicity and social class, with high prevalences among ethnically diverse and low-income populations [4–6]. Given the challenges inherent in changing behaviors of relevance to obesity, the complexity of providing messages that are appropriate for diverse cultural groups, and the importance of ensuring that messages do not harm a child’s developing body image and self-esteem, creative intervention strategies are needed to reach children at greatest risk for obesity. Furthermore, given the importance of families in helping children engage in healthy behaviors and the difficulties often encountered in involving parents in school-based health promotion initiatives , it is imperative that novel strategies to reach parents are developed and evaluated.
One promising and creative strategy for reaching children and their families with health-related messages is through the use of theater [8, 9]. The performance of a play offers children a peer leadership opportunity in which they get to teach others, possibly increasing their sense of self-empowerment and ownership of the messages. Additionally, theater, or more specifically a play production in which children are the actors, offers a unique tool to bring behavioral messages into the home by getting parents to pay attention to those messages. A needs assessment done by our team suggested that low-income parents may be more likely to attend an event in which their children are participants (e.g. in a play) than an educational event, even if it involves fun activities (e.g. eating and joint parent–child classes) .
While most theater-based programs have focused on influencing the youth participants in the program (versus attempting to reach parents) [e.g. 11–13], theater has been explored as an educational and behavior change strategy for children and their parents on health-related issues, such as seat-belt safety  and substance use . Previously, we utilized theater to reach children and their parents in attempt to reduce weight-related teasing among children within a more comprehensive school-based program and found a decrease in reported weight teasing among the children . While decreasing weight teasing may have implications for obesity prevention , interventions primarily aimed at obesity prevention probably need to address a broader scope of risk factors. We are unaware of any evaluations of theater interventions that target children and their parents with obesity prevention messages.
‘Ready. Set. ACTION!’ is an after-school theater program designed to reach ethnically diverse and low-income elementary school children and their parents with messages of relevance to obesity prevention. Our primary aim was to develop and test the feasibility of implementing Ready. Set. ACTION!, developed in partnership between researchers at the University of Minnesota and artists/educators from Illusion Theater, a Minneapolis-based theater company with experience in educational theater. A secondary study aim was to examine if participation in this program resulted in changes in the children’s weight-related behaviors and their home environments that might facilitate the adoption of healthier eating and physical activity behaviors of relevance to weight management. This paper describes the intervention, evaluation, key findings and implications for future directions.
The study was conducted in four urban schools in St Paul, MN, USA, in which ~90% of the students qualified for free or reduced price lunch . Baseline evaluation was done in the fall 2006 and follow-up evaluation was done in the spring 2007. The intervention was implemented in two of the schools and program feasibility was assessed among participating children and their parents at these two schools. In addition, other students at the intervention schools who saw the play completed a brief viewer survey. Program impact was evaluated using a pre/post-group-randomized controlled trial with two conditions, intervention and control, with two schools in each condition. The intervention condition received the Ready. Set. ACTION! theater-based educational program. The control condition also participated in a theater-based intervention, which involved performing a play focused on environmental health issues using a prepared script. This study design allowed for the similar recruitment of children across conditions, as all children were recruited into an after-school theater health-related intervention. The use of a theater-based control condition also allowed for the assessment of program impact above and beyond the experience of participating in a play. Although the main purpose of the study was to examine program feasibility, we were interested in carrying out a full evaluation with a study design and assessment tools that could be used in a future larger scale study. Ethical approval for the study was received from the Institutional Review Board of the University of Minnesota and the Saint Paul Schools Research Committee.
All children in fourth to sixth grades at the intervention and control schools were eligible to participate and were selected on a first come, first served basis. The baseline study population included 108 children and 73 parents. The follow-up study population included 96 children (overall response rate: 89%; intervention: 91%, n=51; control: 87%, n=45) and 61 parents (overall response rate: 84%; intervention: 81%, n=30; control 86%, n=31). Approximately 75% of the surveys were completed by mothers; other primary caregivers who participated were fathers, stepmothers, grandmothers, aunts and uncles. Primary reasons for child attrition included moving schools and/or a change in contact information and primary reasons for parent non-response or attrition included inability to contact parent or language barriers. Table I shows the baseline characteristics for all children and separately for children who responded at follow-up. No response bias was found for any of these characteristics utilizing t-tests and chi-square tests as appropriate.
Social Cognitive Theory (SCT) guided the development of Ready. Set. ACTION! [17, 18]. As described below and outlined in Fig. 1, the intervention included three components: (i) theater sessions, (ii) booster sessions and (iii) family outreach. Each of these components addressed constructs from the domains of child behaviors, personal factors and the home environment.
Fourteen 2-hour after-school theater sessions were conducted. Each session included (i) a ‘check-in’ in which children were given an opportunity to share any behavioral changes they had made over the past week such as eating more fruits and vegetables and talk about how take-home packages were received by families; (ii) easy-to-prepare healthy snacks; (iii) a movement component with activities that are fun, easy and require minimal resources (e.g. dancing or walking) and (iv) theatrical ACTivities. For the initial sessions, the ACTivities component included exercises to introduce the children to theater techniques and to build trust and co-operation. In later sessions, the ACTivities focused on enhancing knowledge and skills related to physical activity and healthy eating, as well as promoting a positive body image, through interactive activities. During these activities, the children were asked to share their personal experiences related to being active and eating healthfully. It was from these explorations that the content of the script for the Ready. Set. ACTION! play developed. Some examples of how intervention messages were transformed into play scenes include the following: (i) the message of reducing soda pop became a song/dance called ‘Stop the Pop’, (ii) adopting healthier eating and physical activity patterns became a coach’s pep talk to his team, (iii) limiting television viewing developed into a humorous horror spoof in which too much time in front of the television turned children into zombies and (iv) promoting self-esteem and body image led to a song called ‘I love myself, I love my body’. During the final sessions, children were introduced to the script and began to rehearse for the play performance. The theater program sessions culminated with an evening play performance at Illusion Theater in downtown Minneapolis and a daytime performance at school.
Children participated in eight weekly after-school booster sessions. These sessions included activities such as creating advertisements for fruits and vegetables, having the children paint positive affirmations (e.g. I am special) on a mirror to take home, and brainstorming ways to be active while watching television such as doing jumping jacks during commercials. Participants also furthered their physical activity skills by teaching dance and strength training exercises to their classmates and by learning exercises to do at home with their families. In addition, booster sessions included rehearsals for the school performance of the Ready. Set. ACTION! play and for songs and selected play scenes to be performed at the final family get-together.
The family component aimed to enhance home support for behavioral changes through positive reinforcement of healthy behaviors, parent–child participation in physical activities and availability of healthy foods. Weekly Fun and Fitness packs were sent home that included a healthy food with a simple recipe or fitness incentives for the family (e.g. pedometers; two of each incentive were sent to families). A CD of the Ready. Set. ACTION! songs was also sent home to foster dance at home. Each pack also had a parent postcard with information and interactive activities on a topic addressed in the after-school program (parent postcards are available at http://www.obesityprevention.umn.edu/obp/Parents/readysetaction.html). There were also two family events. The first was the performance of the play by the students at Illusion Theater. The second family event was held at the school following the booster sessions. This event was a ‘Ready. Set. ACTION! DVD Release Party’, which involved a family viewing of the DVD recording of the play production, a short performance by the children and a communal family dinner. Each family received a copy of the DVD.
Process evaluation included an assessment of program participation, satisfaction and perceived impact among children and parents in the intervention condition. Sign-in sheets for parents at the play performance, attendance records for children at the after-school program and survey questions on child and parent reported use of take-home items (e.g. pedometers) were used to assess program participation. Program satisfaction and perceived impact were assessed with child and parent process surveys. The child survey included 17 close-ended items (e.g. ‘Overall, how happy were you with the Ready. Set. ACTION! program?’ with the responses ‘very happy’, ‘happy’, ‘unhappy’ and ‘very unhappy’) and four open-ended questions (e.g. ‘What are the main things you learned in Ready. Set. ACTION!?’). The parent survey included 17 close-ended items (e.g. Overall, how satisfied are you with the Ready. Set. ACTION! program? with the responses ‘very satisfied’, ‘satisfied’, ‘unsatisfied’ and ‘very unsatisfied’) and six open-ended items. Children completed process surveys at the end of the booster sessions and parents completed surveys at the final family event. Since not all parents attended this event, surveys were also sent home with the post-intervention impact surveys. Process surveys were completed by 51 children and 39 parents. Additionally, following the play performances done for the student body, children who viewed the play completed a brief survey where they were asked what they learned from the play and how they could implement these lessons into their daily life.
Children and parents in the intervention and control groups completed impact surveys at baseline and following the booster sessions. Constructs included in the child and parent impact surveys were guided by SCT [17, 18] and intervention aims (Table II [19–30]). For variables on the family/home environment, similar questions were asked of both children and parents. Efforts were made to identify suitable questions/tools that have been used in previous studies and have been pre-tested for comprehension, reliability and/or validity, and were adapted as needed [14,19–33]. The child survey was piloted with a convenience sample of nine fourth to sixth grade students to assess readability, comprehension, and time required to complete the survey. The parent survey was tested with four adults over the phone, to test the feasibility of following up with parents who did not respond to the mailed version with phone interviews.
Trained research staff administered the child impact surveys at after-school sessions, assessed height and weight in a private area in the school using standardized equipment and procedures , and carried out individual interviews with the children to assess dietary intake via a 24-hour dietary recall and physical activity using the Past Day Physical Activity Recall . Data collection with parents (or other caregivers) was done via mailed surveys and telephone interviews. Surveys were first sent home to parents for them to complete and return using a postage paid envelope. Research staff then called any parents who did not return their survey by mail to provide them with the opportunity to complete the survey over the phone.
This feasibility study involves two control schools and two intervention schools and is not powered for formal statistical testing of program impact . In reporting the results of this pilot study, we focus on presenting estimates of program implementation, satisfaction with the program, and program impact on a variety of health-related behaviors and other outcomes for both children and parents.
Data analysis to determine if the program is feasible to implement and acceptable to children and parents is largely descriptive. For close-ended questions on process surveys that children and parents completed, frequencies and percentages were calculated. For open-ended questions, all responses were compiled into one document and reviewed by research team members and theater artists/educators for major themes using principles of content analysis . Frequencies and percentages were also calculated for items on the survey completed by students who viewed the play performance.
For examining program impact, we acknowledge our inability to conduct a formal statistical analysis given the low power of this study and instead report estimates of impact with standard errors reflecting only individual variability. Outcome analysis uses baseline-adjusted analysis of covariance for the intervention effect, with covariate adjustment for child age, gender and for race (black/white/other). Overall impact is summarized through the number of outcomes for which our estimates are in the hypothesized direction.
Satisfaction with the program was reported by 75% of the children and 90% of the parents in the intervention condition. The vast majority (86% of children and 92% of parents) said they would recommend the program to others (Table III). In response to an open-ended question on why they would recommend Ready. Set. ACTION!, parents commented on both how much their children had enjoyed the program and how much they felt that the program had influenced their children’s eating and activity attitudes and behaviors. For example, one parent noted, ‘My daughter is learning new activities everyday. She can express herself through acting and dance. She wants to be healthy by eating better and exercising.’
In response to an open-ended question to the children about what they liked best about Ready. Set. ACTION!, many of the children mentioned the dancing, the play performance and the respect they received within the program. For example, one child wrote, ‘That we make up dances and we get to perform and make new friends’. Another child wrote, ‘That they helped us understand being active and respecting you are very important’. A third child wrote that the best part was that ‘no one made fun of me’.
More than half of the children (59%, n=33) had consistent attendance and participated in at least 75% of the initial theater sessions. Only a third of the children attended at least 75% of the booster sessions following the play performance (39%, n=22). Reasons for not attending more consistently and program attrition over time included moving to a different school, suspension from school, involvement in other after-school activities, and homework conflicts.
As part of the family outreach, children performed a play at Illusion Theater for an audience of ~200 people. Many of the children had multiple family members attend including parents, grandparents, aunts, uncles, and siblings. Out of the 45 children who performed in the play, 23 (51%) had at least one parent or guardian present. A few additional parents who could not attend the performance came to see the school-wide performance and some also attended the final family get-together where they saw segments of the play.
Another component of family outreach included family take-home packs. Both children and parents were asked about whether they used the items that were sent home. The most popular items were the water bottles (reported to be used at least weekly by 67% of the children and 56% of the parents) and the pedometers (used at least weekly by 67% of the children and 44% of the parents).
Children also had an opportunity for peer outreach. Approximately 900 first to sixth grade students viewed the school-wide performances of the play. The fourth through sixth grade students who viewed the play (n=366) completed a brief viewer survey.
Children who participated in the theater program were asked a series of questions on whether they thought the program helped them feel better about themselves and make changes in their eating and physical activity behaviors (Table III). Approximately half of the children reported that they felt that the program had helped them ‘a lot’ in making these changes and that they had learned a lot from Ready. Set. ACTION!. Responses to an open-ended question about the main things they learned further indicated that they understood the main messages; for example (in their own spelling):‘to not watch that much TV and to eat a lot of vegitble, water and fruit’ and ‘to fell very good about ur selfs’.
The majority of parents reported their intentions to make changes in the home environment with regard to food, physical activity and weight talk (i.e. making fewer comments about weight or body shape) (Table III). Intentions were higher for positive changes such as encouraging family members to drink more water (97%) than for restrictive behaviors such as reducing the amount of soda pop purchased (72%).
Finally, among the 366 children who viewed the school play, 29% reported learning a lot from the play and an additional 59% reported learning ‘quite a bit’ or ‘some’ from watching the play. Many children indicated that after watching the play, they planned on making behavioral changes such as eating more fruits and vegetables (73%), although numbers were lower for restrictive behaviors such as watching less TV (48%).
Details of baseline-adjusted follow-up results among intervention and control conditions are presented in Table IV. Overall, 13 of 21 outcomes were in the hypothesized direction. Only self-efficacy to be physically active showed a statistically significant difference in the desired direction. Based upon child reports, weight talk (e.g. parent comments about weight and parent dieting) at home was higher among intervention families than among control families; this change was not in the desired direction.
The primary aim of this study was to develop and test the feasibility of a theater-based obesity prevention program for ethnically diverse and low-income elementary school children and their parents. We were interested in determining the feasibility and potential utility of implementing a theater-based intervention with outreach to children’s families. High percentages of children and parents in the intervention condition reported that they enjoyed the program and that they had made changes or intended to make positive changes in their behaviors as a result of program participation. However, the impact evaluation found few meaningful differences between the intervention and control conditions. In interpreting the findings from the impact evaluation, it is important to note that the study was designed as a feasibility study; we did not anticipate that the theater intervention, on its own, would lead to meaningful behavioral changes, nor power the study to detect changes. The combined process and impact evaluation results suggest that the intervention was effective in leading to increased awareness of the need for behavioral change, but was not powerful enough on its own to lead to behavioral change. We concluded that a theater-based school program offers promise as a strategy for reaching diverse and hard-to-reach children and parents with messages of relevance to health promotion. However, given the complexity of behavioral change, in order to actually lead to meaningful behavioral changes that are likely to impact weight status, school-based theater-based programs need to be incorporated into more comprehensive obesity prevention efforts that reach out to children, families and communities and have both educational and environmental components.
A strength of Ready. Set. ACTION! was its innovative use of theater. The artists/educators translated the key messages into words and songs that were understandable and fit the children’s lived experiences, so the program content was personally and culturally relevant to the children and their parents. However, to ease the workload and improve the quality of the final play, our recommendation for the future would be to build from an existing script with a plan to tailor it with the student performers. Additionally, although after-school programs offer an excellent venue for reaching children without interfering with their academic studies, child attendance at the after-school program was not consistent, children sometimes arrived with less than full concentration, and the structure tended to be looser than during the school day. Thus, we would recommend trying to implement the intervention as part of the regular school day.
The high levels of program satisfaction among participating parents and their stated intentions toward making behavioral change are a testament to the value of engaging children in a theater performance as a way to inform parents about health promotion activities in which their children are participating. However, as previously reported [7, 36], it can be difficult to get parents, particularly low-income parents, to attend educational activities. While many of the children had multiple family members present at the evening theater play performance, nearly half of the children’s parents did not attend. The preparation and distribution of the Ready. Set. ACTION! DVD, which documented different aspects of the intervention and included parts of the children’s play performance, provided a way to reach out to parents who could not attend the performance and to reinforce messages among all children and parents.
There were additional benefits of a theater-based program such as Ready. Set. ACTION! that are not related to the goal of obesity prevention, but are worthy of mention. These benefits relate to the introduction of the arts to a population that may only have had minimal exposure to theater. For example, one girl displayed strong dancing skills and was offered a scholarship to a local dancing studio to further her studies. Additionally, for the first time, one of the intervention schools embarked on producing a musical and a boy who participated in Ready. Set. ACTION! (but previously had no acting experience) had the lead role. Furthermore, program leaders perceived that the theater experience had a positive impact on different aspects of the children’s well-being (e.g. confidence and communication).
It is noteworthy, and somewhat disconcerting, that Ready. Set. ACTION! led to an increase in child reports of parental weight talk (e.g. parental comments about their own weight or child’s weight). The program messages were designed to reduce the emphasis on weight and focus on making changes in the home environments to facilitate healthful eating and physical activity behaviors. While it may have been that families engaged in more weight-related discussions following program participation, an alternative explanation for this finding is that the intervention children were more sensitized to weight-related discussions at home. This latter explanation is somewhat supported by the finding that in the process evaluation, 80% of intervention parents reported that they intended to ‘make fewer comments about weight or body shape’ based on the messages learned in the program. Of further note, we do not know the content or tone of the discussions that occurred (e.g. whether it was done in a helpful or non-critical manner). However, since results from previous studies have shown that talking about weight at home can be detrimental to healthy weight management [37, 38], future interventions should be more explicit in emphasizing that weight talk at home is not helpful and may be harmful. Strategies for decreasing weight talk at home should be clearly addressed via the inclusion of specific messages about weight talk in the theater production and take-home newsletters to parents. The negative consequences of talking about dieting and weight should be discussed and alternative strategies for focusing on healthy eating and physical activity should be provided to parents.
Although difficult, it is crucial to develop, implement and evaluate interventions that have the potential to (i) reach hard-to-reach populations at greatest risk for health problems such as obesity and (ii) change hard-to-change behaviors of relevance to obesity. A theater-based program such as Ready. Set. ACTION! provides an innovative strategy for reaching children and families from diverse backgrounds with culturally appropriate messages. Findings from the current study indicate that such an approach is feasible to implement within school settings with the help of community theater groups. However, in order to be effective in behavioral change among children and parents, the program should be incorporated into a more comprehensive family, school and community obesity prevention effort that includes educational and environmental components.
National Institutes of Health (R21 DK072972 to D.N.S.); National Institute of Diabetes and Digestive and Kidney Diseases; The Illusion Theater received additional funding for the theater components from The Medica Foundation, The General Mills Communities of Color Project Grants and The Best Buy Children's Foundation.