All protocols, procedures and intervention materials were developed and written by the Behavior Committee, which included investigators with relevant expertise from the entire study group. The committee formed smaller working groups to address specific tasks. FLASH modules were written by a working group that included investigators and intervention staff from all seven study centers, as well as experts in nutrition and physical activity. FLASH development involved an iterative design and review process accomplished through weekly conference calls and face-to-face meetings. A total of five FLASH modules were created, one for each semester of the intervention, and each took ~6months to complete. Module development for the latter semesters took place once the intervention was underway, and formative feedback that reflected implementation concerns reported by classroom teachers and other personnel in the field was considered in the development of subsequent modules.
Other behavior intervention elements were the family newsletter and school-break challenge packages. There were seven newsletter issues distributed. School-break challenge packages were distributed for the summer break between the seventh and eighth grades and for the winter holiday break for the eighth grade. The packages included materials to get the families involved in making healthy behavior changes, as well as supporting changes that the student was making. These elements were designed by the Family Outreach Working Group. The working groups revised the materials on the basis of input from across the study group and worked closely with media and print production companies to incorporate appealing graphics and images that reflected the diversity of the HEALTHY study schools. Overall, this design process contributed to study-wide integration of the behavior intervention with the nutrition, physical activity and communication intervention components.3–5
Each center hired a full-time staff member to serve as the health promotion coordinator and three HEALTHY assistants. The health promotion coordinator oversaw the implementation of the behavior intervention component and its integration into other aspects of the intervention. The health promotion coordinator trained both the classroom teachers and the HEALTHY assistants on each FLASH module, and monitored and guided teacher performance.
Structure of FLASH sessions
Each FLASH session was a self-contained learning unit with clearly stated objectives. The basic FLASH materials were a teacher manual and a student workbook, available in English or Spanish and written at a fifth grade reading level. Other materials, described below, were provided to enhance session delivery and promote behavior change. There were 10 sessions in modules 1−4 and 8 in module 5, designed to be delivered one session per week. Each session began with a statement of the session goal(s). The FLASH teacher manual provided a scripted introduction, main talking points and conclusion for each activity. Multiple settings, including homeroom, science and other academic classes, study halls, health and electives, were used. FLASH sessions were designed to be completed in no more than 30 min from the time of distribution of materials to their collection and storage. However, teachers could opt to fill the entire class period, and the study provided suggestions for supplemental activities.
Overview of FLASH cumulative learning sequence
Across all FLASH modules, there was a common format and sequencing of learning activities organized according to a progression of health behavior change themes. summarizes the dimensions of the five FLASH in-class modules. A specific behavior change theme was identified for each of the five semesters of the intervention, starting in the second half of the sixth grade and continuing through the seventh and eighth grades. The themes served as a common focus and point of integration for all intervention components in the HEALTHY study, and were designed to reflect the increasing cognitive complexity and social awareness of middle school students. The fifth and last FLASH module provided an opportunity to integrate and review learning and skills acquired across all previous FLASH modules.
As the learning content progressively built a core health sciences knowledge base and skills across the five semester themes, modules were also designed to build enthusiasm for the behavior change through enjoyable, grade-appropriate learning activities with increasing levels of peer interaction, involvement and feedback. Each student completed a brief self-assessment checklist in the first session of each module, which established a baseline level of awareness for an array of nutrition and physical activity choices and behaviors that were the primary targets of intervention during the semester. Initial activities used to enhance knowledge acquisition included puzzles, cryptograms, true–false questions and interactive games. The middle sessions of FLASH were designed to help students become more skilled in direct observation or self-monitoring (for example, keeping track of eating/beverage consumption and physical activity behaviors both in and out of school), problem solving and goal setting while keeping them engaged through an interactive peer-learning approach. The final sessions were reserved for the production and presentation of a student project, such as posters, public service announcements, a marketing campaign for a new healthy snack product, movement routines and other creative group activities with a health behavior change focus or message. These creative products were presented in the FLASH class and shared later with other classes and even with other schools at other centers. Students also completed the same brief self-assessment checklist in the final session as they did in the first session as a means of measuring personal progress. They could check back to the beginning of their workbook and compare their responses at the start and at the end of the FLASH module.
FLASH peer influence approach
All FLASH modules and sessions were designed to foster peer engagement and influence. The learning activities were structured to progress from individual work, to pairs, to small group interactions of 3−5 students. Teachers were directed to adhere to this designated progression of student groups, but were given discretion on regrouping students if misconduct posed barriers to the completion of the session. Typically, at the start of the session, teachers shared the delivery of instructions with students, who either read aloud from the workbook or responded interactively to questions and prompts from the teacher. Activities, such as cryptograms, true-false questions and interactive games, were conducted in pairs and small groups, and permitted students to gain knowledge while having fun. The middle sessions of FLASH, which targeted individual self-monitoring and other challenges, incorporated group problem solving so that students worked together to overcome barriers to healthy eating and activity. Students were provided with a theme ‘enhancer,’ such as a water bottle or pedometer, to assist them in carrying out the behavioral assignments. Participation in these efforts and eventual goal attainment resulted in social recognition and other rewards. In the final sessions, students worked together in their small groups to engage in a creative process that resulted in the production and presentation of group projects, including posters, mock public service announcements, commercials, songs, raps, poems, movement and dance routines. Creative products were presented and acknowledged in the classroom and in other school venues as possible to enhance self-confidence and social competence for healthy behavior change.
Overall, the FLASH modules were designed to build cognitive and cooperative social skills, such as listening, communicating, working together and sharing ideas about health and health behavior change.
Behavioral skills training and practice
Behavioral skills practice, as well as using goal setting, self-monitoring and problem solving, was an important aspect of the FLASH behavior intervention component (see ). These methods were adapted from procedures commonly used in obesity prevention and treatment for broad application to all students as they considered their options to enhance health. Tasks were initiated in the classroom but were aimed at teaching students skills for self-awareness in all environments. Students were initially taught to track pertinent behaviors at school and later away from school, always bringing information back to the small peer group. Self-monitoring tasks began with a simple self-observation (for example, ‘how many cups of water do you drink during one school day?’ or ‘how many steps does it take you to go from your classroom to the gym?’). A more complex self-monitoring assignment was not used until the fourth FLASH module in the first semester of the eighth grade. A tracking booklet introduced a series of four challenges, and social recognition and rewards for these tasks were based on documented attainment of specific behavior change goals.
Implementation of FLASH
The overall HEALTHY intervention was designed as a collaborative effort between centrally trained and supervised study staff interventionists for physical education, school food service and behavior, as well as key school personnel. For the behavior intervention, classroom teachers were selected in concert with school administration, then trained and supported by the staff of the HEALTHY study. Peer-selected student leaders in each classroom (known as student peer communicators) had an integral role in intervention delivery. The principal at each participating school assumed the final discretion in selecting the classrooms and teachers for FLASH implementation. Given the need for standardization of delivery, each FLASH session was formulated to be a self-contained learning unit with specific objectives. The FLASH teacher manual provided explicit, scripted instructions for each section of the lesson with major talking points outlined. The remainder of the session was mainly peer led, but facilitated by the teacher with assistance from the designated HEALTHY study staff.
Family outreach newsletter and break take home challenge packages
The family outreach component of the behavior intervention aimed at providing parents with information and tools for promoting sound nutrition and increased physical activity in the home environment, and for involving families in supporting behavior changes being made by the student. The newsletter content corresponded with the progression of themes and targeted behaviors that characterized the FLASH intervention. Seven one-page, double-sided color newsletters were produced centrally with local customization through photographs by each center. Newsletters were distributed at strategic times, such as during breaks, for maintaining intervention messaging.
Newsletters featured vignettes about parent efforts to promote children's healthy behavior, specifically illustrating the means by which parents had successfully modified nutrition practices or increased physical activity. These vignettes were collected from parent focus groups and interviews conducted at all study centers before the start of the HEALTHY intervention. Each of the first three newsletters contained ‘role model’ stories derived from interviews and written as first-person narratives that depicted, in their own words, the manner by which the parents overcame barriers to raising a healthy family. The newsletters also contained recipes, lists of available opportunities for community activity programs and advice columns aimed at decreasing impediments and increasing self-efficacy for parental support of healthy lifestyle behavior. A Spanish language translation was produced as needed.
In addition to the newsletters, students received two packages of materials intended to be used by the entire family to sustain behavior change during school-break periods. One package was produced for the summer break between the seventh and eighth grades and one for the eighth grade for the winter holiday break. The packages contained instrumental items intended to facilitate healthy behavior outside school (for example, behavior self-monitoring calendars, t-shirts, a heart healthy cookbook, a vegetable cutting board, a ‘TV turn-off’ decal and both a teen- and family-oriented aerobic exercise DVD (digital versatile disc)). Accompanying instructions challenged students and their families to set and meet behavior goals.