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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptNIH Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
Am J Prev Med. Author manuscript; available in PMC Dec 1, 2010.
Published in final edited form as:
PMCID: PMC2921547
NIHMSID: NIHMS164176
School Site Visits for Community-Based Participatory Research on Healthy Eating
Anisha I. Patel, MD, Laura M. Bogart, PhD, Kimberly E. Uyeda, MD, Homero Martinez, MD, PhD, Ritamarie Knizewski, RD, Gery W. Ryan, PhD, and Mark A. Schuster, MD, PhD
From the Department of Pediatrics, University of California at Los Angeles (Patel), Los Angeles, California; RAND Health (Bogart, Martinez, Ryan, Schuster), Santa Monica, California; Los Angeles Unified School District (Uyeda, Knizewski), Los Angeles, California; and the Department of Medicine, Children’s Hospital Boston and Harvard Medical School (Bogart, Schuster), Boston, Massachusetts
Address correspondence and reprint requests to: Anisha I. Patel, MD, Department of Pediatrics, University of California at San Francisco, 3333 California Street, Suite 245 San Francisco CA, 94143-0503. patela/at/peds.ucsf.edu
Background
School nutrition policies are gaining support as a means of addressing childhood obesity. Community-based participatory research (CBPR) offers an approach for academic and community partners to collaborate to translate obesity-related school policies into practice. Site visits, in which trained observers visit settings to collect multilevel data (e.g., observation, qualitative interviews), may complement other methods that inform health promotion efforts. This paper demonstrates the utility of site visits in the development of an intervention to implement obesity-related policies in Los Angeles Unified School District (LAUSD) middle schools.
Methods
In 2006, trained observers visited four LAUSD middle schools. Observers mapped cafeteria layout; observed food/beverage offerings, student consumption, waste patterns, and duration of cafeteria lines; spoke with school staff and students; and collected relevant documents. Data were examined for common themes and patterns.
Results
Food and beverages sold in study schools met LAUSD nutritional guidelines, and nearly all observed students had time to eat most or all of their meal. Some LAUSD policies were not implemented, including posting nutritional information for cafeteria food, marketing school meals to improve student participation in the National School Lunch Program, and serving a variety of fruits and vegetables. Cafeteria understaffing and cost were obstacles to policy implementation.
Conclusions
Site visits were a valuable methodology for evaluating the implementation of school district obesity-related policies and contributed to the development of a CBPR intervention to translate school food policies into practice. Future CBPR studies may consider site visits in their toolbox of formative research methods.
The prevalence of overweight among U.S. children tripled between 1963–1970 and 1999–2000.1 Since students spend a large proportion of their time in schools, it is not surprising that schools have been targeted for obesity prevention activities at federal, state, and local levels.2 Students consume 35% of their daily energy intake at school,3 so many of these obesity prevention efforts have specifically focused on policies to improve the healthfulness of the school food environment.4
In 2004 the federal Child Nutrition and Women, Infants, and Children Reauthorization Act required that school districts participating in the National School Lunch Program (NSLP, a federally funded program that provides nutritionally balanced, low-cost or free lunches to eligible school children) create wellness policies that outline nutritional guidelines for school food.5 From 2003–2005, states adopted 122 bills and 71 resolutions related to obesity prevention, most covering changes to school food.6 School districts have also worked to ensure that nutritious food and beverage offerings are available in schools. For example, the Los Angeles Unified School District (LAUSD), the second-largest district in the U.S. (with >800 schools) and the site of the present study, has been active in creating policies aimed at reducing childhood obesity, with many of its policies subsequently enacted at the state level. In 2002, LAUSD implemented the Motion to Promote Healthy Beverage Sales, which banned the school sales of soft drinks and other beverages with high sugar content.7 An Obesity Prevention Motion, passed in 2003, provided nutrient standards, portion sizes, and restrictions for food sold on LAUSD campuses.8
Implementing school nutrition policies at the local level is often challenging due to budgetary constraints, understaffing, and lack of school staff, parent, and student acceptance.911 Community-based participatory research (CBPR) is a research approach in which academic researchers, community members, and organizations equitably participate in all phases of research, including identification of community health concerns, intervention design, study implementation, data analysis, and the interpretation and dissemination of study results.12 CBPR may be an effective means to formulate school-based obesity prevention programs and policies due to the large number of stakeholders involved and the complexity of the problem.13
Ethnography, the study and systematic recording of culture, may be a useful means in CBPR for helping researchers to understand community context and to determine community priorities for research.14 Ethnographers often use a variety of methods (e.g., observations, document collection, qualitative interviews), to gain rich cultural understandings of communities or groups of individuals. Drawing on ethnographic techniques, site visits involve trained observers in gathering information through multiple methods (e.g., observations, document collection, qualitative interviews) from settings relevant to the research.1517 Although typically employed for evaluative purposes, site visits can be formative, helping communities and researchers to jointly understand the culture and community context of research settings. The present paper describes how site visits informed the development of a middle school–based intervention to promote healthy eating practices through translation of policy into practice.
Context of Partnership
The UCLA/RAND Center for Adolescent Health Promotion (a Prevention Research Center funded by the CDC) has a history of conducting CBPR within Los Angeles (LA) communities.18 The Center established two advisory boards to inform community priorities for research: a community advisory board (CAB) made up of school teachers, parents, community leaders, and other key stakeholders from Carson and Wilmington (adjacent communities in southwestern LA County), and a youth community advisory board (YCAB) made up of Los Angeles Unified School District (LAUSD) high school students. In response to the advisory boards’ requests for the Center to study school-based obesity prevention, the Center partnered with LAUSD to develop a CBPR intervention to address obesity among middle school students. To guide all phases of the research study, the Center established a Healthy Living Advisory Board (HLAB) made up of LAUSD administrators, school board representatives, and community leaders with expertise in child obesity issues (e.g., representatives from the public health department, food policy organizations, and community-based organizations).
Through semi-structured interviews with key stakeholders and focus groups with parents and students about community priorities for obesity prevention programming,19 the community–academic team determined that the middle school–based obesity intervention should include a focus on bringing LAUSD nutrition policy into practice. Although 79% of LAUSD students qualify for free and reduced-price lunches through the NSLP,20 a daily average of only 43% of 6th–12th graders participate in the NSLP.21
The specific focus of the present research was on the Cafeteria Improvement Motion, which was passed in December of 2005 by LAUSD’s Board of Education and which directed district leaders to implement changes to improve school nutrition. The Cafeteria Improvement Motion requires the district to work with researchers, parents, and students to improve the nutritional content of foods offered (e.g., through lower fat, sugar, and sodium) and reassess all aspects of foodservice operations in an effort to increase NSLP participation.22 Specific components of the Cafeteria Improvement Motion include increasing NSLP participation by incorporating student and parent input about school meals, ensuring that students have sufficient time to eat their meals, developing a comprehensive program to market cafeteria meals to students based on student and parent feedback, increasing the variety of fresh fruits and vegetables offered, and posting point-of-sale nutritional information about foods and beverages so students can make healthier choices.
At the time of this study (in 2006), LAUSD had not yet implemented all of the Cafeteria Improvement Motion policies. In order to develop specific intervention components and further understand the context and culture of middle school food environments, the community–academic research team and CAB selected four of the ten middle schools in Carson and Wilmington (the regional focus of the CAB) to participate in this study based on geographic location and contacts with administrators in these schools. The sociodemographic characteristics of the schools, as well as the characteristics of LAUSD as a whole, are shown in Table 1.23
Table 1
Table 1
Sociodemographic Characteristics of Site Visit Schools a
Community Involvement
In line with CBPR principles, the three Center community advisory boards and the main community partner, LAUSD, were active participants throughout the research.24 While partners contributed to the various research activities (e.g., development of site visit protocols and observation checklists, analysis and interpretation of results), some community partners played particularly large roles. Specifically, the director of LAUSD Student Medical Services, who served as Co-Principal Investigator of this study, attended weekly study team meetings, helped to select site visits as a methodology for intervention development, assisted with protocol development and direct observations, helped with manuscript development, and participated in presentations of site visit results to community members. The senior administrator of LAUSD’s Food Services Branch also participated in most phases of the research (e.g., site visit protocol development, school recruitment, site visit observations, dissemination of results to the community, and manuscript development). Another main community partner (the Director of the Carson Family Resource Center, who was a CAB member) helped the team establish relationships with schools, participated in site visit protocol development, and was a site visit observer.
Representatives from the broader LA community also played an important role in this research. Site visit goals, procedures, and results were presented to the three community advisory boards and to school staff at the four study sites. Advisory board members and school staff from the four study sites helped to interpret data and to determine how the data could inform development of a middle school–based obesity prevention intervention to translate LAUSD nutrition policy into practice.
Site Visit Protocol
Researchers and community partners worked together to develop the site visit protocol. The conceptual model for this study drew from social–cognitive theories of health behavior change and ecologic influences.25 Within this model, students’ eating behaviors are influenced by their background (e.g., demographics, culture), beliefs, attitudes, social norms, self efficacy, skills, abilities, intentions, and environmental factors.25 The community–academic team conducted focus groups with students to examine influences such as student beliefs, attitudes, and peer norms;19 site visits were selected to gain insight regarding environmental influences on students’ eating behaviors. The specific framework for the protocol was based on the flow of food through the school environment. To inform the framework for the site visit protocol, the community–academic team observed two different cafeteria settings to examine how food moved through cafeterias. Specifically, observers noted that food was delivered to the cafeteria, prepared in the school kitchen, presented to students in cafeterias, and then selected by students who ate, discarded, or traded food items. This framework helped the community–academic team define activities that could be conducted in the school food environment, including mapping of school cafeteria layout, listing of food and beverage offerings, document collection, making observations, and conducting field interviews. After the protocol was developed, an LAUSD Food Services representative led a mock site visit to a district middle school outside of the study area. The mock site visit helped the community–academic team refine the observation protocol and determine the number of observers and time necessary for conducting school cafeteria observations.
Site visit observers were members of the community–academic partnership and included CAB and HLAB members, nutritionists, pediatricians, an anthropologist, and research assistants. Site visit observers underwent a 3-hour training led by the first author of this study to review site visit procedures, observational checklists, and templates, which are described in detail below.
Site Visit Activities
From September to October of 2006, site visit observers used multiple methods, including mapping of cafeteria spaces, listing of food and beverage offerings, collection of documents, direct observations of students in cafeterias at lunch, and field interviews, to gain a greater understanding of the middle school food environment in LAUSD. At each school, site visits occurred over a 2-day period to account for variability in entrée offerings and school schedules (i.e., shortened days). Site visit dates were selected based on school preferences and observers’ availability. Table 2 shows site visit mapping, listing, and observation activities; corresponding checklist categories; field note descriptions; and examples from site visits.
Table 2
Table 2
Checklist Categories and Field Note Descriptions for Site Visit Activities
Observers arrived at the school about 1 hour prior to lunch to collect relevant school documents (e.g., school schedule and menu) and to map cafeteria spaces and list school food and beverage offerings using a semi-structured checklist. Following site visits, research assistants compared food and beverages sold in middle school stores and vending machines to an online list of food and beverages that meet LAUSD Beverage Resolution and Obesity Prevention Motion policies for saturated and total fat, added sugar, sodium, and portion size.
Site visit observers also conducted direct observations of students in the middle school cafeterias at lunch using semi-structured observation templates. For consistency, a core group of six observers recorded the same observations across sites. Four additional trained observers, who were not available for all site visits, helped supplement observations in heavy volume areas. Observers were instructed to spread out to different parts of the eating area to capture variation in student consumption patterns and behaviors (e.g., close to vending machines/school stores and cafeteria lunch lines). Observers were not instructed to spend a particular amount of time on each observation, but rather to continue the observation until little new information was emerging.
To further understand decision making processes that may affect students’ food and beverage choices (e.g., lunch line arrival times, peer influences), one or two study team members observed students (n=73) as they purchased their food from cafeteria buffets and windows, school stores, and vending machines. One to two study team members also observed student consumption patterns by observing students (n=84) while they were eating; observations included amounts of foods and beverages consumed, whether students ate with friends, pace of eating (i.e., slow, average, rushed), and notes on student behavior during lunch (e.g., socializing, exercising). To assess the waiting times in lines, another observer recorded cafeteria line wait times with a stopwatch. One to two observers were also stationed by trashcans, where they described food and beverages that were discarded.
During site visits, observers also engaged school staff and students in impromptu, unstructured field interviews. Instead of relying on interview guides, observers used cafeteria observations to shape discussions with school staff and students; they were instructed to handwrite field notes to document conversation content and student and staff quotations.
Data Analysis
The first author used inductive coding to examine observation checklists, school documents, and handwritten field notes for common themes. From these observation records, 9 major (e.g., structure and timing of lunch) and 70 minor (e.g., number of lunch periods) themes were identified. These themes were used to develop a mutually exclusive and exhaustive codebook that was used by two research assistants to manually code all observation records. The first author and research assistants discussed any disagreements in coding and then recoded relevant sections of site visit documents in which there were discrepancies. Cohen’s Kappa, a robust measure of interrater reliability, was used to examine the consistency between the two coders for all categoric observations.26 Intraclass correlation was used to calculate interrater reliability for continuous ratings such as line length.27 Of 68 categoric observations, inter-rater consistency was perfect (Kappa =1.0) for 83% (58 observations). For the remaining 10 categoric ratings, Cohen’s Kappas averaged 0.65. The two continuous ratings had intraclass correlations of 1.0.
Site Visit Observations Relevant to the Cafeteria Improvement Motion
Site visit results, described below and in Table 3, are framed with regard to three major LAUSD Cafeteria Improvement Motion aims—(1) increasing student participation in the NSLP, (2) facilitating students’ ability to make healthier food and beverage choices, and (3) eliciting student input about cafeteria programs.
Table 3
Table 3
Role of site visit observations in translating policy into practice in the school food environment
Increasing Student NSLP Participation
One aim of the Cafeteria Improvement Motion is to ensure that students have sufficient time to eat in LAUSD school cafeterias. At the four schools in the study, the lunch period lasted 30 minutes. Although observers noted that cafeteria lines appeared to be long at most schools, the line length averaged 4.2 minutes at three of the four schools. One school had longer lines, with an average wait time of 9.3 minutes (range = 4 minutes–14.5 minutes). Despite perceptions that the lunch period is too short for students, nearly all students who were observed finished most or all of their meal.
According to the LAUSD Cafeteria Improvement Motion, another commonly mentioned reason for low NSLP participation is the perception that food is unhealthy and of poor quality.22 Such perceptions were also heard by the research team when speaking with students during site visits. As one student remarked during the site visits, “The cafeteria food is gross because it is sometimes still frozen and greasy.” Another student said, “The food here is why we are fat like this. ”
The Cafeteria Improvement Motion recommends that student and parent input be used to develop a comprehensive program to market school meals to students in efforts to increase NSLP participation. Signs were posted in windows at two schools to alert students to available NSLP food options, but observers noted that signs were small, handwritten, difficult to read, and not posted for food items such as yogurt parfaits and salads (newer items specially formulated to meet the Cafeteria Improvement Motion’s revised nutrition standards). Observers noted that students needed to select a cafeteria food window before they were close enough to see the food options at the window. At one school a student said, “I wish the signs were larger so I can see them from the end of the line. ”
Facilitating Students’ Ability to Make Healthier Food and Beverage Choices
The Cafeteria Improvement Motion also mandates that a variety of fresh fruits and vegetables be available throughout the meal period. During the site visits, a limited variety of fresh fruits and vegetables was observed. A small number of prepackaged salads were available at two of the four schools, and only one of the four schools had a salad bar. At three of the four schools, fresh fruit was mainly available as whole fruit (e.g., whole apples, oranges, peaches, pears). In trashcan observations, uneaten whole fruit was repeatedly observed being discarded. According to a group of students at one school, students may prefer presliced fruit over whole fruit because eating whole fruit is awkward in front of friends (especially for students who wear dental braces), and peeling some fruit like whole oranges can make hands sticky.
Although school administrators expressed enthusiasm for ensuring that a variety of fresh fruit and vegetables were available at mealtimes, many said that implementing programs (e.g., providing a salad bar) would be difficult due to such barriers as staffing shortages, cost, and administrative burden. At three of the four schools, food services employees said that they felt they were short-staffed. Solutions to employee shortages included substitute and student employees; at one especially short-staffed school, the assistant principal regularly worked in the cafeteria. At one school, the cafeteria manager said that he ordered presliced fruit to decrease the prep time for a fruit and salad bar.
Although the Cafeteria Improvement Motion also states that nutritional information should be posted for all entrees and a la carte items in the cafeteria, such information was not posted at any of the four school sites.
Eliciting Student Input about Improving Cafeteria Programs
One major suggestion mentioned by students in site visit field interviews was to increase beverage offerings as a part of the NSLP. Beverages offered through the NSLP included 100% juice in cartons at three schools, and nonfat plain and chocolate sweetened skim milk in plastic bags across the four sites. At the four schools, two to five porcelain drinking fountains in outdoor seating areas located outside of the cafeteria. Observers noted that fountains had candy wrappers, leaves, or debris in them, and none of the fountains at the schools had chilled water. Only a few students were seen drinking water from the fountains at mealtimes. In compliance with the LAUSD Motion to Promote Healthy Beverage Sales, beverages for purchase ($1.00–$1.25/item) through vending machines or school stores included 100% fruit juice, sports drinks, flavored sweetened milk, and bottled water. Unopened bags of cafeteria milk were seen discarded at each school in trashcan observations. In employee observations, cafeteria staff were seen giving students milk; they explained that they needed to make sure that meals contain three food or beverage components (milk, fruit/vegetable, grains/bread, or meat/meat alternative) so schools could be reimbursed through the NSLP. Students said they threw away milk because it was packaged in unappealing plastic bags and was warm. At three of the four schools, students requested that water be offered in addition to juice and milk as a part of the standard lunch or available for free somewhere in the cafeteria. At one school, students were observed pushing in line to purchase water from a vending machine during a class break; observers interpreted this pushing to be due to short breaks between classes and too few bottled water vending machines at the school. Some students also remarked that bottled water was expensive.
In this study, information gathered from site visits enabled the community–academic research team to determine priorities for a school-based obesity prevention program that would help LAUSD to translate district obesity prevention policy (e.g., the Cafeteria Improvement Motion) into practice within schools. Specifically, site visits helped the community–academic research team generate ideas to increase NSLP participation, envision programs to assist students to make healthy food and beverage choices, and gather input about cafeteria programs from students, cafeteria staff, and school administrators.
Although an increasing number of states and school districts have adopted policies to improve the healthfulness of school food environments, such policies may not be implemented at the local school level. As evidenced by this study, site visits can provide researchers, policymakers, schools, and communities with a useful tool for assessing whether obesity-related policies are being implemented in schools as intended.
In addition to its utility in assessing the implementation of school obesity-related policies, site visits can also help researchers and policymakers, stakeholders who typically work outside of the school realm, to gain an understanding of the school food environment. For example, after speaking with cafeteria staff at the four schools during site visits, the community–academic team had a greater knowledge of barriers, such as cost and understaffing, that many schools face when trying to provide nutritious and palatable meals to students. The team therefore sought to design an intervention that would bring LAUSD obesity policy into action, while also taking into account such concerns and increasing intervention feasibility and sustainability. For example, based on student feedback, the community–academic team decided to offer an additional variety of presliced fruit or vegetable in the cafeteria daily. Rather than asking already understaffed cafeteria employees to manually slice fruit or vegetables for the intervention, presliced fruit was ordered from cafeteria distributors.
This study has limitations. The qualitative nature of the study limits the extent to which the current findings can be quantified, even though terms such as “most” or “the majority” are sometimes used to describe results. Because site visits were limited to only four schools within one region of Los Angeles, specific observations may be less applicable outside of LA or even beyond the areas of LAUSD where they were collected. For example, even though the four schools included in this study were in compliance with LAUSD policies regarding foods and beverages that can be sold in district schools, in 2008, when auditors from LAUSD’s Inspector General’s Office visited 70 randomly selected schools in the district, many schools were found to be noncompliant with some LAUSD food and beverage policies, such as LAUSD nutritional specifications for competitive food and beverages (i.e., food and beverage items sold outside of the NSLP), that are permitted to be sold in schools.28
This paper highlights how site visits were used to translate a specific policy (LAUSD Cafeteria Improvement Motion) into practice within schools in one geographic area of LA. Site visit methodology may be applied to other settings targeted in CBPR efforts. For example, site visits may prove useful in workplaces, which have served as the setting for recent CBPR studies.2931 In one study, site visits helped researchers identify useful practices to promote healthy weight among employees of small and medium-sized U.S. worksites.32 Other potential contexts for applying site visit methodology to develop interventions could, for example, include partnerships with faith-based organizations, parks and recreation centers, tribal communities, or neighborhood housing developments.
Conclusion
This paper provides a description of how site visits were a useful CBPR tool for planning an intervention to translate policy into practice within the school food environment. Future CBPR studies may want to consider including site visits in their toolbox of formative research methods.
Acknowledgments
Supported by U48/DP000056 from the CDC (MA Schuster, PI), R24 MD001648-01 from the National Center for Minority Health and Health Disparities (MA Schuster, PI), and the Robert Wood Johnson Foundation UCLA Clinical Scholars Program #61603. The authors would like to thank Bessie Ko Sipple-Asher, Jennifer Hawes-Dawson, Josefina Dhungana, Ying-Ying Goh, Sandra Paffen, and Cynthia Schuster for their assistance with data collection and Burt Cowgill, Jacinta Elijah, and Jennifer Patch for their assistance in data collection and analysis.
Footnotes
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
No financial disclosures were reported by the authors of this paper.
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