promoting healthy eating and physical activity in school
TRANSCRIPT
The Journal of Middle East and North Africa Sciences 2015; 1(6) http://s-o-i.org/1.18/Jomenas.2015.6
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Promoting Healthy Eating and Physical Activity in School Age Children and
Adolescents in Jordan: Public Health Project
Affaf Attar
Community Health Nursing, Faculty of Nursing, Al-Zaytoonah University, Jordan
Abstract: This document present a public health project concerned with promotion of health and wellness
among school age children and adolescents in Jordan, the focus of this project will be the eating behaviors and
physical activity among this group. Poor diet and physical inactivity among younger persons can lead to an
increased risk for certain chronic health conditions, including high blood pressure, type 2 diabetes, and obesity. By
the utilization of the Omaha system model as an assessment approach for this important group of the population, two
major health-related behavior domains were identified. These domains are the nutritional status and the physical
activity among school age children and adolescent. The school is a vital and conducive environment to enhance and
support this group of population to promote the optimal health conditions using a variety of resources. The Omaha
system identifies the problem signs and symptoms, and blueprints the intervention scheme for each health related
issue which may include; surveillance, teaching, guiding, and counseling. A detailed comprehensive plan guided by
a MAP-IT approach is used as an interventional approach to promote healthy eating and physical activity among
school age children and adolescents in Jordan. Finally, the MAP-IT approach describes the step-by-step approach
through the identification of the mission and vision of the people and organizations involved, establishing a
community coalition of stakeholders, identifying the resources and limitations, setting action plan based on priorities
and feasibility, and then implement and evaluate the progress of the plan, the action plans regarding the nutrition and
physical activity is blueprinted hereunder.
[Attar, A. (2015). Promoting Healthy Eating and Physical Activity in School Age Children and Adolescents in
Jordan. J. Middle East North Afr. sci, 1(6), 15-30]. (p-ISSN 2412- 9763) - (e-ISSN 2412-8937).
http://www.jomenas.org. 5
Keywords: Healthy Eating – Public Health Project- Physical Activity.
1. Introduction
Health promotion has been defined as “All of
the individual and community – wide strategies that
include communication, education, legal regulations,
changes in service organizations and public
development to increase individual’s control over
their own health to improve their health” (Selekman,
2006).
Health promotion or wellness promotion
aimed to the reduction of health problems and
disease, as well as lead to the enhancement of mental
and physical wellbeing (Mcloughlin & Kubick,
2004). It seems that health promotion look beyond
the physical body, it considered the physical,
psychological and mental health as integral parts;
changes in one consequently will lead to changes in
the other (Peterson, 2006).
Healthy or unhealthy lifestyles are developed
early in life and thereafter are very difficult to
change. Adults who do not have healthy and
balanced lifestyles are not good role models for
children. For this reason it is very important for
children to be taught how to live healthy lives during
their formal schooling (Selekman, 2006).
Healthy eating and regular physical activity
play a substantial role in preventing chronic diseases,
including heart disease, cancer, and stroke, the three
leading causes of death among adults aged >18
years. Poor diet and physical inactivity among
younger persons can lead to an increased risk for
certain chronic health conditions, including high
blood pressure, type 2 diabetes, and obesity (The
Surgeon general's call to action to prevent and
decrease Overweight and obesity, 2001).
2. Rationale for Choosing the Project Idea
As of 2009, the majority of children and
adolescents aged 5–17 years were enrolled in
schools. Schools have direct contact with students
for approximately 6 hours each day and for up to 13
critical years of their social, psychological, physical,
and intellectual development.
The health of students is strongly linked to
their academic success, and the academic success of
students is strongly linked with their health.
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Therefore, helping students stay healthy is a
fundamental part of the mission of schools
(Shephard, 1996). School health programs and
policies might be one of the most efficient means to
prevent or reduce risk behaviors, prevent serious
health problems among students, and help close the
educational achievement gap (Allensworth,
Nicholson, &Wyche, 1997).
Schools offer an ideal setting for delivering
health promotion strategies that provide
opportunities for students to learn about and practice
healthy behaviors. Schools, across all regional,
demographic, and income categories, share the
responsibility with families and communities to
provide students with healthy environments that
foster regular opportunities for healthy eating and
physical activity. Healthy eating and physical
activity also play a significant role in students’
academic performance.
3. Project Purpose The purpose of our project is to promote
healthy eating and physical activity in school age
children and adolescents in Jordan by utilization of
the Omaha system model as an assessment approach
for the schools’ competencies related to healthy
eating and physical activity in school age children
and adolescent in Jordan and by creating an
integrated comprehensive plan guided by a MAP-IT
approach as an interventional approach to promote
healthy eating and physical activity in school age
children and adolescents in Jordan.
4. Background
Engaging children and adolescents in healthy
eating and regular physical activity can lower their
risk for obesity and related chronic diseases
(Daniels, et al., 2005).The dietary and physical
activity behaviors of children and adolescents are
influenced by many sectors of society, including
families, communities, schools, child care settings,
health-care providers, faith-based institutions,
government agencies, the media, and the food and
beverage industries and entertainment industry. Each
of these sectors has an important, independent role to
play in improving the dietary and physical activity
(Daniels, et al., 2005).
The school is an important area for health
promotion and enhancing positive health behavior.
Kolbe (2005) noted that ‘‘not all school health
programs are effective. Importantly, programs that
are not specifically designed and organized to
achieve a given goal should not be expected to attain
that goal”. The modern school health programs could
be one of the most efficient means for improving the
health and achievements of our children.
4.1. Impact of Healthy Eating and Physical
Activity
Healthy eating and physical activity have
been associated with increased life expectancy,
increased quality of life, and reduced risk for many
chronic diseases. Healthy living through healthy
eating and regular physical activity reduces the risk
for the top three leading causes of death in the
United States (heart disease, cancer, and stroke), as
well as for certain chronic conditions, such as high
blood pressure and type 2 diabetes (Kushi, et al.,
2012).
A healthy diet and regular physical activity
can prevent and reduce metabolic risk factors that
cause CVD, including hyperlipidemia (e.g., high
cholesterol and triglyceride levels), high blood
pressure, obesity, and insulin resistance and glucose
intolerance. For example, dietary fiber can decrease
the cholesterol concentration in the blood, and
physical activity can help maintain normal blood
glucose levels (Thompson, et al., 2003).
Some types of cancer can be prevented
through regular physical activity and a diet
consisting of various healthy foods with an emphasis
on plant sources (e.g., fruits, vegetables, and whole
grains) (Kushi, et al., 2012). Physical activity might
contribute to cancer prevention through its role in
regulating the production of hormones, boosting the
immune system, and reducing insulin resistance.
Healthy eating and physical activity also can
contribute to cancer prevention by preventing
obesity. Overweight and obesity are associated with
increased risk for numerous types of cancer,
including cancer of the breast, colon, endometrial,
esophagus, kidney, pancreas, gall bladder, thyroid,
ovary, cervix, and prostate, as well as multiple
myeloma and Hodgkin’s lymphoma (Kushi, et al.,
2006)
Poor diet and physical inactivity are risk
factors for numerous conditions that affect overall
health and quality of life, and many of these
conditions can lead to chronic diseases. Intermediate
outcomes such as obesity, metabolic syndrome, and
inadequate bone health, under nutrition, iron
deficiency, eating disorders, and dental caries can
begin in childhood, leading to earlier onset of disease
and subsequent premature death. Healthy eating and
physical activity control body weight through a
balance of energy expenditure and caloric consump-
tion. Weight gain occurs when persons expend less
energy through physical activity than they consume
through their diet. As this imbalance continues over
time, the risk for overweight and obesity increases
(Kopla, Liverman & Kraak, 2005).
Overweight is defined as having excess body
weight for a particular height from fat, muscle, bone,
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water, or a combination of these factors. Obesity is
the condition of excess body fat. Obesity in children
and adolescents is associated with numerous
immediate health risks, including high blood pres-
sure, high blood cholesterol levels, type 2 diabetes,
metabolic syndrome, sleep disturbances, orthopedic
problems, and social and psychological problems,
such as discrimination and poor self-esteem (Krebs,
et al., 2007).
These immediate health risks can have long-
term consequences for children and adolescents,
affecting them into adulthood. Insufficient public
health and education efforts to decrease or minimize
these health risks will affect both health-care and
education systems. Increasing rates of obesity among
children and adolescents are of particular concern
because those who are obese are more likely to
become overweight or obese adults and have related
chronic diseases. The probability of childhood
obesity persisting into adulthood increases as
children enter adolescence. Even obesity during
early childhood (ages 2–5 years) increases the risk
for adult obesity (Benjamin, 2010).
4.2. Factors Influencing the Eating Behaviors
among Children and Adolescent
Multiple factors including demographic,
personal, and environmental factors influence the
eating behaviors of children and adolescents. Male
adolescents report greater consumption of fruits and
vegetables and higher daily intakes of calcium, dairy
servings, and milk servings than females. Black
adolescents are more likely than white or Hispanic
adolescents to report eating fruits and vegetables five
or more times per day (Eaton, et al., 2010).
Children and adolescents from low-income
households are less likely to eat whole grain foods.
Taste preferences of children and adolescents are a
strong predictor of their food intake. Taste
preference for milk, among both males and females,
is associated with calcium intake (Zabinski, et al.,
2006).
Taste preferences for fruits and vegetables
are one of the strongest reported correlates of fruit
and vegetable intake among males and females.
Male and female adolescents who reported frequent
fast-food restaurant visits (three or more visits in the
past week) were more likely to report that healthy
foods tasted bad, that they did not have time to eat
healthy foods, and that they cared little about healthy
eating (Zabinski, et al., 2006).
The home environment and parental
influence are strongly correlated with youth eating
behaviors. Home availability of healthy foods is one
of the strongest correlates of fruit, vegetable, and
calcium and dairy intakes. Family meal patterns,
healthy household eating rules, and healthy lifestyles
of parents influence fruit, vegetable, calcium and
dairy, and dietary fat intake of adolescents
(Neumark-Sztainer, Wall, Perry, & Story, 2003).
4.3. Factors Influencing the Physical Activity
among Children and Adolescent
Physical activity is defined as “any bodily
movement produced by the contraction of skeletal
muscle that increases energy expenditure above a
basal level”. Examples of physical activity include
walking, running, bicycling, swimming, jumping
rope, active games, resistance exercises, and
household chores.
Regular participation in physical activity
among children and adolescents is related to
demographic, personal, social, and environmental
factors. Gender is correlated with physical activity
levels, with males participating in more overall
physical activity than females. This trend continues
through adulthood, with females remaining less
physically active than males.
Adolescent males also report a greater
intention to be physically active in the future than
females. Children and adolescents who intend to be
active in the future and who believe physical activity
is important for a healthy lifestyle engage in more
activity. Overall, personal fulfillment influences the
motivation both of boys and girls to be physically
active (Trends in leisure-time physical inactivity by
age, sex, and race/ethnicity--United States, 1994-
2004, 2005).
Dowda, Dishman, Pfeiffer & Pate (2007),
defined the parent and family support for physical
activity can as a child’s perception of support (e.g.,
perceiving parents will do physical activity with
them and sign them up for sports or other physical
activities) to a parent’s reported support (e.g., regular
encouragement of physical activity or regularly
placing value on being active).
Youth perceptions and parent reports of
support for physical activity are strongly associated
with participation in both structured and non-
structured physical activity among children and
adolescents (Dowda, Dishman, Pfeiffer & Pate,
2007).
The physical environment can be both a
benefit and a barrier to being physically active.
Environmental factors that might pose a barrier to
physical activity include low availability of safe
locations to be active, perceived lack of access to
physical activity equipment, cost of physical
activities, and time constraints. The school
environment can also influence the participation of
children and adolescents in physical activity (Motl,
Dishman, Saunders, Dowda, & Pate, 2007).
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4.4. Impact of Television Viewing on the Eating
and Physical Behaviors among Children and
Adolescents
Television viewing, non-active computer use,
and non-active video are all considered sedentary
behaviors. Television viewing among children and
adolescents, in particular, has been shown to be
associated with childhood and adult obesity
(Hancox, Milne & Poulton, 2004). Potential
mechanisms through which television viewing might
lead to childhood obesity include: Lower resting
energy expenditure, displacement of physical
activity, food advertising that influences greater
energy intake, and excess eating while viewing
(Epstein, Roemmich & Robinson, 2008).
The American Academy of Pediatrics (2001)
recommends no more than 2 hours of television and
video viewing per day for children aged ≥2 years.
Overall, persons aged 8–18 years spend an average
of 7 hours and 11 minutes per day watching
television, using a computer, and playing video
games. In 2009, 33% of 9th- through 12th-grade
students reported watching ≥3 hours of television on
an average school day, and 25% reported using a
computer ≥3 hours on an average school day (Center
for Disease Control, 2010).
4.5. School Health in Jordan
In Jordan the Global School-based Student
Health Survey (GSHS), (2007) has been used to
periodically monitor the prevalence of important
health-risk behaviors and protective factors related to
the leading causes of mortality and morbidity among
students aged 13-15 years; dietary behaviors,
hygiene, mental health, physical activity, protective
factors, sexual behaviors that contribute to HIV
infection, tobacco use, and violence and
unintentional injuries.
A representative sample of students in 8th
through 10th grades was selected from 25 schools;
seventy classrooms were randomly selected intact
from each school to participate. The sample of
students eligible to participate was 2243 students.
The results regarding physical activity was 14.3% of
students were physically active for a total of at least
60 minutes daily for 7 days, while 83.5% of students
participated in insufficient physical activity, on the
other hand 39.3% of students spent three or more
hours per day doing sitting activities, and 76.6% of
students usually took less than 30 minutes to get to
and from school each day.
5. Application of the Omaha System Theory
5.1. Rationale for Using Omaha System Theory
Omaha system theory is a research-based,
comprehensive, standardized taxonomy that exists in
the public domain. It is designed to enhance practice,
documentation, and information management. It is
intended for use across the continuum of care for
individuals, families, and communities who
represent all ages, geographic locations, medical
diagnoses, socio-economic ranges, spiritual beliefs,
ethnicity, and cultural values. We decided to use this
theory because it has terms that are arranged in a
hierarchy (i.e. from general to specific), and are
intended to be easily understood by health care
professionals and the general public. It provides a
structure to document children and adolescents needs
and strengths, describe multidisciplinary practitioner
interventions, and measure children and adolescent
outcomes in a simple and user-friendly, yet
comprehensive, manner. Furthermore, it enables
collection, aggregation, and analysis of clinical data.
It supports quality improvement, critical thinking,
and communication. It fosters research involving
best practices/evidence-based practice. It links
clinical data to demographic, financial,
administrative, and staffing data.
5.2. First Domain: Health Related Behavior
Problem: Nutrition:
Problem signs and symptoms:
1) Overweight: BMI 25.0 or more.
2) Underweight: BMI 18.5 or less.
3) Lacks established standards for daily caloric/fluid
intake.
4) Exceeds established standards for daily
caloric/fluid intake.
5) Unbalanced diet.
6) Improper feeding schedule for age.
7) Does not follow recommended nutrition plan.
8) Unexplained/progressive weight loss.
9) Unable to obtain/prepare food.
10) Hypoglycemia/hyperglycemia.
Intervention Scheme
The following table will illustrate the general
guide line that will be established in Promoting
healthy Eating in School Age Children and
Adolescents in Jordan according to Omaha system
theory (see Appendix A).
Based on the Omaha system care plan above,
we will screen the school age children and
adolescent for healthy eating and obesity using the
following surveillance technique: measuring body
mass index, measuring waist circumference,
assessing risk factors in children and adolescent,
assessing life style (dietary recall& eating habit), and
assess the readiness to change. Body mass index can
be calculated by dividing the weight on the square
tall in meter and compare it to the normal range
which lies between18.5 – 24.9. Assessing the waist
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circumference is a good way in assessing abdominal
fat among children and adolescent and this will help
us to know the level of risk for disease onset.
Assessing life style risk factors may include
assessing tobacco use, cholesterol level, physical
inactivity, and impaired fasting glucose (110-
125mg/dl). The desire of the children and adolescent
to change will be assessed by asking them the
following question: does he\she want to lose weight?
What are the reasons and motivation for weight loss?
and did he\she has any previous attempt to lose
weight?
As we know the Omaha system theory has
teaching, guiding, and counseling category beside
the surveillance category. During our assessment
process, we can provide teaching and counseling
about the weight loss benefits versus obesity risks
for children and adolescents. In addition, we can
provide them a recommendation for a healthy weight
loss and recommendation for physical activity level.
Because we established the Omaha system as an
assessment tool, we will illustrate more about the
teaching and guiding interventions using the MAP-
IT theory as an interventional tool in the intervention
part.
5.3. Second Domain: Health Related Behavior
Problem: Physical activity Problem signs and symptoms:
1) Sedentary life style
2) Inadequate/inconsistent exercise routine
3) Inappropriate type /amount of exercise for age/
physical condition.
4) No scheduled physical activities.
Intervention Scheme The following table will illustrate the general
guide line that will be established in promoting
physical activity in school age children and
adolescents in Jordan according to Omaha system
theory (See Appendix B).
Based on the Omaha system care plan above,
we will screen the school age children and
adolescent for adequacy and appropriateness of
physical activity using the following surveillance
technique: assessing life risk factors, assessing the
daily life routine exercise, and assessing attitudes
toward physical activity.
Many technological advances and
conveniences that have made our lives easier and
less active, many personal variables, including
physiological, behavioral, and psychological factors,
may affect our plans to become more physically
active. In fact, there are many reasons for not
adopting more physically active lifestyles as Don’t
have enough time to exercise, lack of self-
motivation, finding exercise boring, low self-
efficacy, fear of being injured, and lack of
encouragement and support from family and friends.
Understanding common barriers to physical activity
and creating strategies to overcome them may help
in making physical activity part of children and
adolescent daily life. These recommendations will be
addressed in the interventional guideline by utilizing
the MAP-IT model.
6. Mobilize, Assess, Plan, Implement, Track
(MAP-IT)
MAP-IT is a framework that can be used to
plan and evaluate public health interventions in a
community. Both seasoned and new public health
professionals can utilize the steps in MAP-IT to
create a healthy community. This process involves
time, effort, and a series of steps to ‘map out’ the
path toward the desired change in a community.
Keep in mind that there is no “right” way to follow
this approach, and some of the steps will need to be
taken multiple times. Using MAP-IT, a step-by-step,
structured plan can be developed by a coalition that
is tailored to a specific community’s needs
(Community Tool Box, 2013)
In this project we will utilize the MAP-IT
model to make tomorrow's generations healthier and
active and so for the whole community. The project
will address two major health risk-related behaviors;
the physical inactivity and poor nutrition. The
following steps will be followed as an interventional
approach to implement the MAP-IT model.
6.1. Step I: Mobilize Individuals and
Organizations That Care about the Health of
your Community into A coalition.
6.1.1. Building Community Coalition
The first step in the MAP-IT process is to
mobilize key individuals and organizations into a
coalition. Look for partners who have a stake in
creating healthy communities, and who will
contribute to the process. Aim for broad
representation. A coalition will often work with the
health department and other health organizations in
the community. However, it can also help mobilize a
wider range of resources to address health issues
(Community Tool Box, 2013).
It is typically easier to engage potential
coalition members around issues that are already of
special concern to the community, who are involved
and have direct or indirect impact in providing
varied sources of support to bring up the
governmental concern on the issue of healthy eating
and physical activity among school age children
(Community Tool Box, 2013).
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Coalition members can help facilitate
community input through meetings, events, or
advisory groups. They can also develop and present
education and training programs, lead fundraising
and policy initiatives, and provide technical
assistance in planning or evaluation.
The members of our project include:
1) Education representatives: Teachers,
administrators
2) Medical representatives: Medical pediatrics
associations, Child health physicians and nurses.
3) National organization: National Council of Family
Affairs.
4) Children and parents representatives
5) Social activist representatives
6) Media representatives
7) University academics
8) Business representatives
9) Governmental sectors
10) International organization: WHO, UNICEF,
USAID
At this stage, plan to identify the vision and
mission of the coalition, reason for bringing people
together, individuals who should be represented are
potential partners in the community, such as
organizations and businesses. One of the biggest
challenges in creating a healthy community coalition
is to sustain members’ involvement in the process.
This challenge can be overcome in part by agreeing
as early as possible on a vision for the community.
6.1.2. School Health Programs to Promote Healthy
Eating and Physical Activity (CDC, 2011)
Schools have direct contact with students for
approximately 6 hours each day and for up to 12
years of their social, psychological, physical, and
intellectual development. The health of students is
strongly linked to their academic success, and the
academic success of students is strongly linked with
their health. Therefore, helping students stay healthy
is a fundamental part of the mission of schools.
School health programs and policies might be
one of the most efficient means to prevent or reduce
risk behaviors, prevent serious health problems
among students, share the responsibility with
families and communities to provide students with
healthy environments that foster regular oppor-
tunities for healthy eating and physical activity.
Healthy eating and physical activity also play a
significant role in students’ academic performance.
6.1.3. Coalition Vision
Promoting healthy eating and physical activity
among school-age children and adolescents should
be considered a part of routine preventive public
health care, therefore school health programs would
be a good start for this initiatives. Assessment and
counseling for health eating and physical activity
also should be included in a comprehensive
preventive services package for school-age children
and adolescents. We are looking forward to establish
a health community through the emphasizing on
health eating and physical activity among our
tomorrow's leaders.
6.1.4. Coalition Mission
Our mission is to help prevent obesity and
promote physical activity and healthy eating through
school health programs' policies, practices, and
supportive environments. This mission of promoting
healthy eating and physical activity, including
coordination of school policies and practices,
supportive environments, school nutrition services;
physical education and physical activity programs,
health education, and social services ,and family and
community involvement.
6.1.5. Agenda Setting
The public issue of concern to the coalition is
the health of children and adolescent, the importance
of this issue is affecting the whole health care system
in general and the school health in specific. This
issue should gain the attention of policymakers for
addressing it as policy problem, the coalition
members will meet together to identify their
prioritization, goals and values, refine the issue.
The issue definition and mobilization of
support from community members and media
involvement, and full participation of coalition
members and concerned organizations facilitate the
move of the child and adolescent health issue to the
governmental policy agenda.
6.2. Step II: Assess the Areas of Greatest Need in
the Community, as well as the Resources and
Other Strengths.
The coalition should set priorities by
identifying what community members and key
stakeholders see as the most important issues.
Consider feasibility, effectiveness, and measurability
in determining priorities (Community Tool Box,
2013).
6.2.1. Setting Priorities
Setting priorities is a matter of consensus; all
coalition members should agree on which issues
need to be addressed immediately and which can be
postponed to until a later date.
6.2.2. Community and Need Assessment
Successful obesity prevention programs
address the needs and wants of the community. The
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best way to find out what a community needs and
what it wants is to conduct a community assessment
by following the community assessment process
which include; defining the target community
(School-age children and Adolescent), gathering
information and summarizing and reporting (Move
to the Future, 2013).
Data collection and evaluation about the
health issues of healthy eating and physical activity
in the community is important to identify and
analyze the nature of the problem, and this will form
a baseline of the problem and help in making
decisions on the needed interventions.
When no data are available, the coalition may
need to begin collecting data to form a realistic
picture of community needs. The information about
health eating and physical activity can be gathered
using a worksheet that contains the most common
indicators related to this issue, for example; fruit and
vegetables intake, fat intake, fiber intake, calcium
intake, physical activity (minutes per day), TV
viewing, dental caries, low hemoglobin.
Many resources are available in Jordan about
the children and adolescent health indicators;
international organization (WHO, UNICEF), Jordan
department of statistics, ministry of health, ministry
of education, Jordan food and drug administration
and universities and research centers.
6.2.3. Community Resources and Strengths
Once community assessment is completed,
develop a list of strengths and resources within that
community. Resources go beyond financial
resources, every community has a wealth of non-
monetary resources that can be used to address areas
of concern, the resources available in Jordan to
support the program of healthy eating and physical
activity includes the availability of infrastructure,
such as schools, playing yards, parks, sport clubs,
health system, professional expertise, data,
community-based organizations as the National
Council of Family Affairs, and community leaders
(Appendix 1) (Move to the future, 2013).
International organization such as WHO,
UNICEF, and USAID provide adequate support to
the children health programs in many different ways,
experts’ opinions, surveys, policymaking and
organizing implementation.
6.3. Step III: Plan Your Approach
During the planning phase, start with a vision
of where you want to be as a community, then add
strategies and action steps to help you achieve that
vision. Objectives should be specific to each issue or
community, and should address the goal of the
program, what is needed in order to reach the goal,
and a way of measuring progress in order to know
when the goal has been reached. A plan of action
should include: Action steps, assignment of
responsibility, information collection, and a feasible
timeline.
Our action plan to work on the promotion of
health eating and physical activity contains the
following goals, objectives and action steps, for that
a specific template will be used to address this action
plan (CDC, 2011; Community Tool Box, 3013).
6.4. Step IV: Implement Your Plan Using
Concrete Action Steps
Once the action plan is established, coalition
members can begin to implement the action steps
identified in the plan. Coalition members should
work on completing the tasks that have been
assigned to them according to the set timeframe.
Monitoring of events is key to implementation. The
phase of implementation requires attention to
develop a budget, carry out the interventions/actions
and managing the plan timelines.
6.4.1. Develop a budget
To do anything with your plan you need
money. And to get money you need a budget. Grants
require a budget, sponsoring organizations require a
budget, and donors like to know how much the
project will cost before they make a contribution,
which you know from doing a budget. A budget is an
estimate of the money you will receive and the costs
you will incur to implement your program. It is your
best guess at the time you develop the budget but
should be as accurate as possible. A budget should
cover a specific time period such as 9 months, 12
months, or 18 months.
6.5. Step V: Track Your Progress over Time.
Evaluation is the process of collecting data to
determine how well your program is succeeding and
whether changes need to be made. Evaluation data
might be collected during implementation, in which
case the collection process is often called
monitoring. Monitoring is useful to identify
problems so that a program can be improved in mid-
course (Move to the Future, 2013).
Conversely, comprehensive evaluations are
typically done at the conclusion of a program, or at
the conclusion of distinct phases of a program. In
addition to your own desire to create the most
effective program possible, another strong incentive
for evaluating is that many funders require well-
conducted evaluations. Although it is true that much
of your evaluation may be carried out after your
program is completed, do not wait until the
program's completion to plan your evaluation.
The Journal of Middle East and North Africa Sciences 2015; 1(6) http://s-o-i.org/1.18/Jomenas.2015.6
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Successful evaluation is best planned at the same
time you are planning your programs interventions
therefore, evaluation planning should be an integral
part of your program planning (Community Tool
Box, 2013).
Conduct regular evaluations to measure and
track your progress over time. Tracking is a two-part
step that involves analyzing the data and reporting
on progress. Make sure to note to what extent the
plan was followed, any changes that were made, and
whether the goal was reached. The following points
should be considered at time of evaluation:
1) Evaluation and tracking are vital to the long-term
success of the coalition’s efforts.
2) Consider partnering with a local university or
State center for health statistics to help with data
tracking.
3) Data validity and reliability: Watch out for
revisions of survey questions and/or the development
of new data collection systems. This could affect the
validity of your responses over time.
4) Data Availability: Data collection efforts are not
always performed on a regular basis.
5) Documenting the progress and success
6) Remember to share your progress and successes
with your community. If you see a positive trend in
data, issue a press release or announcement.
7) make sure to involve the media so that you’ll be
able to put the word out when you need to.
8) Data Quality: make sure to check for
standardization of data collection, analysis, and
structure of questions.
7. Potential Limitations
The financial support is considered as one of
the most potential problem for the implementation
process since it is required in every step of our plan.
In addition, the weak infrastructure of some schools
could delay or limit the process of implementation.
Furthermore, the absence of school nurse specialty in
our educational system could create a gap in the
professional team that should guide the process of
change in school children and adolescents.
Overcoming the resistance from the students,
families, and teacher is a key factor to succeed in the
implementation of the project.
8. Conclusion Studies showed during the last decades, the
prevalence of obesity has tripled among persons
aged 5-18 years. Multiple chronic disease risk
factors, such as high blood pressure, high cholesterol
levels, and high blood glucose levels are related to
obesity. Schools have a responsibility to help prevent
obesity and promote physical activity and healthy
eating through policies, practices, and supportive
environments.
The promotion of health in the community is
starting from the individuals, families, groups and
society, the school age children and adolescents are a
vital population for the community, maintaining and
promoting them healthy will result in a healthy
community even if later.
The implementation of public health nursing
concepts into the actual community by utilizing the
models as Omaha model and MAP-IT approach to
assess, plan, intervene and evaluate will enable the
public health professional with the necessary tools.
To get a success, the implementation of these
approaches requires the correct identification of
health-related problems, intervention schemes,
mobilize the coalition, set agenda, move the issue to
the governmental table, involve the media, and
parliament members to gain support.
Finally, the studies in Jordan is limited in this
public health issue; the healthy eating and physical
activity, initial research reported the physical
inactivity among school age children, the health
professionals are invited to investigate more in this
issues and establish a national guidelines to promote
the health and wellness for this population.
Corresponding Author: Affaf Attar
Community Health Nursing, Faculty of Nursing, Al-
Zaytoonah University, Jordan
E-mail: [email protected]
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Appendix A. Intervention Scheme
Intervention Scheme
Category Target Care description
Surveillance Physical Sign/Symptom Assess BMI
Surveillance Physical Sign/Symptom Waist Circumference
Surveillance Physical Sign/Symptom Assess for risk factors: co-
morbidities
Surveillance Dietary Management Lifestyle – dietary recall
Surveillance Wellness Assess lifestyle risk
factors
Surveillance Behavior Modification Assess Motivation for change
Teaching, Guiding, &
Counseling
Behavior Modification
Weight loss benefits Versus risks
Teaching, Guiding, &
Counseling
Dietary management
Recommendations for
Healthy Weight Loss
Teaching, Guiding, &
Counseling
Behavior Modification
Attitudes toward physical activity
Appendix B. Intervention Scheme
Intervention Scheme
Category Target Care description
Surveillance Physical Signs / symptoms Assess life risk factors
Surveillance
Physical Signs / symptoms Assess the daily life routine exercise
Surveillance
Physical Signs / symptoms Assessing attitudes toward physical
activity
Teaching, Guiding, and Counseling Exercise Recommendation for exercise
Teaching, Guiding, and Counseling Wellness Life style activities
Teaching, Guiding, and Counseling Behavioral modification Behavior Therapy Combined with
Dietary Adjustments And Routine
Physical Activity
Teaching, Guiding, and Counseling Support system Adequate Support Systems Help
Improve Weight Loss Outcomes
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Appendix C. Action Plan of Promoting Healthy Eating and Physical Activity among
Children and Adolescents
Goal 1: Establish a coordinated approach to develop, implement, and evaluate healthy eating and physical activity
policies and practices.
Objective 1.1: Establish a school health council at each city in Jordan
Action steps Due date Responsibility
Resources
needed
Communicate with representatives from different segments of the
school and community, including health and physical education
teachers, nutrition service staff members, students, families, school
nurses, social service professionals, and religious and civic leaders to
form School health councils
Jan.2015 Program
director
Define the functions and responsibilities of School health council Jan. 2015 Program
director
Objective 1.2: Establish a school health team and designate a school health coordinator at the school level
Action steps Due date Responsibility
Resources
needed
Each school should establish a school health team, representative of
school and community groups, to work with the greater school
community to identify and address the health needs of students.
Jan. 2015 School
director
Identify the responsibility of school health team Jan. 2015 School
director
Objective 1.3: Develop and implement healthy eating and physical activity policies
Action steps Due date Responsibility
Resources
needed
Identify and involve key stakeholders from the beginning of the policy
process.
Jan. 2015 Program
director
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Draft the policy language Jan. 2015 Program
director
Adopt, implement, and monitor healthy eating and physical activity
policies.
Jan. 2015 Program
director
Conduct outcome evaluation of healthy eating and physical activity
policies, programs, and practices.
Jan. 2015 Program
director
Goal 2: Establish school environments that support healthy eating and physical activity
Objective 2.1: Provide access to healthy foods and physical activity opportunities and to safe
spaces, facilities, and equipment for healthy eating and physical activity.
Action steps Due date Responsibility
Resources
needed
Provide adequate and safe spaces and facilities for healthy eating,
establish a place with chairs and tables
2015 School
director
Ensuring sufficient time to receive and consume a meal for eating
breakfast and lunch.
2015 School
director
Providing opportunities for students to wash or sanitize their hands in
a convenient place before eating;
2015 School
director
Schools also should ensure that students have access to safe, free, and
well-maintained drinking water fountains or dispensers during school
meals
2015 School
director
Ensure that spaces and facilities for physical activity meet or exceed
recommended safety standards
2015 School
director
Develop, teach, implement, and enforce safety rules 2015 School
director
Maintain high levels of supervision during structured and unstructured 2015 School
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physical activity programs. director
Increase community access to school physical activity facilities. 2015 School
director
Objective 2.2: Ensure that all foods and beverages sold or served at school are nutritious
Action steps Due date Responsibility
Resources
needed
Implement nutrition standards can be an effective strategy to improve
the nutritional quality of foods offered and purchased in the school
setting
2015 School
director
Market healthier foods and beverages. 2015 School
director
Offer a free fruit and vegetable program 2015 School
director
Train students grow vegetables in a school garden 2015 School
director
Collect suggestions from students and families for meals and snack
items that might be offered
2015 School
director
Goal 3: Implement a comprehensive physical activity program with quality physical education as the cornerstone
Objective 3.1: Provide ample opportunities for all students to engage in physical activity outside
of physical education class
Action steps Due date Responsibility
Resources
needed
The school setting can offer multiple opportunities for students to
enjoy physical activity outside of physical education class and increase
daily amounts of physical activity
2015 School
director
Offer students opportunities to participate in intramural physical
activity programs during after-school hours.
2015 School
director
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Implement and promote walk- and bicycle-to-school programs. 2015 School
director
Objective 3.2: Ensure that physical education and other physical activity programs meet the
needs and interests of all students
Action steps Due date Responsibility
Resources
needed
Promote and ensure inclusion of all students 2015 School health
Nurse (S.H.N)
All students, regardless of sex, race/ethnicity, health status, or physical
or cognitive ability or disability, should have access to physical
education and other physical programs.
2015 S.H.N
Goal 4: Implement health education that provides students with the knowledge, attitudes, skills, and experiences
needed for healthy eating and physical activity
Objective 4.1: Establish health education from kindergarten through grade 12
Action steps Due date Responsibility
Resources
needed
Nutrition and physical activity topics also can be integrated into other
academic disciplines to complement comprehensive health education
and physical education programs
2015 School Health
Nurse (S.H.N)
Integration of health topics throughout the school curriculum should
not replace health education as a course in school; a comprehensive
health education curriculum is necessary
2015 S.H.N
Objective 4.2: Use classroom instructional methods and strategies that are interactive, engage all
students, and are relevant to their daily lives and experiences
Action steps Due date Responsibility
Resources
needed
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Use interactive learning strategies. 2015 School
Teachers &
S.H.N
Use methods and strategies that are developmentally appropriate. 2015 School
Teachers &
SHN
Integrate computer-based instruction into health education. 2015 School
Teachers &
SHN
Goal 5: Provide students with health, mental health, and social services to address healthy eating,
physical activity, and related chronic disease prevention
Objective 5.1: Assess student needs related to physical activity, nutrition, and obesity, and provide counseling and
other services to meet those needs.
Action steps Due date Responsibility
Resources
needed
Assess eating and physical activity behaviors of students. 2015 School
Teachers &
SHN
Schools initiating BMI measurement programs should implement
safeguards.
2015 School
Teachers &
S.H.N
Counsel students on how to achieve healthy eating and physical
activity recommendations.
2015 School
Teachers &
S.H.N
Goal 6: Partner with families and community members in the development and implementation of healthy eating
and physical activity policies, practices, and programs.
Objective 6.1: Encourage communication among schools, families, and community members to
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promote adoption of healthy eating and physical activity behaviors among students.
Action steps Due date Responsibility
Resources
needed
Communicate frequently and use various dissemination methods. 2015 School Health
Nurse
Objective 6.2: Involve families and community members on the school health council
The school health council (SHC) should identify strategies for
establishing partnerships with families and community members.
2015 S.H.C
Objective 6.3: Develop and implement strategies for motivating families to participate in school-
based programs and activities that promote healthy eating and physical activity.
Provide various formats for involving families and offer frequent
opportunities for participation.
2015 S.H.C, S.H.N
Recruit parent, family, and community volunteers to assist with
healthy eating and physical activity initiatives.
2015 SHC, SHN
Appendix D. Community Assessment Sheet
Received November 23, 2015; revised November 30, 2015; accepted December 5, 2015; published online December
16, 2015.