RESEARCH ARTICLE

Collaborative School-Based Obesity

Interventions: Lessons Learned From 6
Southern Districts*
ANJALI JAIN, MDa CASEY LANGWITH, BAb

ABSTRACT
BACKGROUND: Although studies have shown that school-based obesity interventions can be effective, little is known about
how to translate and implement programs into real-world school settings.
METHODS: Semistructured interviews were conducted in spring 2012 with 19 key informants who participated in a multifaceted
childhood obesity intervention involving school nurses and wellness coordinators in 6 school districts and over 100 schools.
RESULTS: The intervention changed form according to the needs and interests of the school districts. Despite funding support,
schools and nurses had little capacity to address childhood obesity without the help of the coordinator. Initiating programs at
the beginning of the school year was particularly difcult for schools. Applying for grants from internal and external sources and
assisting with planning and logistics for wellness activities were signicant activities of the coordinator. Although some school
personnel and families preferred a focus on wellness rather than obesity, those working with individual at-risk children and
families found the experience especially gratifying.
CONCLUSIONS: In contrast to controlled studies, real-world implementation of obesity interventions in schools that are
intended to create sustained change requires exibility in intervention design, timing, and personnel. A single change agent
focused on obesity-related activities was essential to success.

Keywords: school nurses; organization and administration of school health programs; nutrition and diet.
Citation: Jain A, Langwith C. Collaborative school-based obesity interventions: Lessons learned from 6 southern districts. J Sch
Health. 2013; 83: 213-222.

Received on June 28, 2012

Accepted on September 28, 2012

obesity interventions.5-7 Interventions have the poten-

A lthough recent data suggest that growth in the
rates of childhood obesity may be leveling off,
the proportion of US children who are overweight or
obese remains high.1 Obesity is linked to increases in
the risk of adverse comorbid health conditions, such as
type 2 diabetes and hypertension, and corresponding
increases in health spending.2,3 Children who are
obese are likely to remain so as adults.4 As awareness
of the health and economic implications of childhood
obesity spreads, stakeholders from various sectors are
searching for effective interventions.
Schools have been identified by policymakers and
experts as favorable environments for childhood
tial for broad reach as nearly all US children ages 5-18
are enrolled in school,8 and the school day provides
ample opportunities for children to learn and prac-
tice health behaviors.9 Previous studies have shown
that school-based obesity interventions can be effec-
tive in improving health behaviors, such as reducing
caloric intake and increasing physical activity, with
mixed evidence about the effectiveness of interven-
tions on physiologic measures such as body mass
index (BMI).6,10-12 However, the school environment
is not without challenges. Schools function as com-
plex bureaucracies and often face significant fiscal and

a
Managing Consultant, (anjali.jain@lewin.com), The Lewin Group, Fairview Park Drive, Suite 500, Falls Church, VA 22042.
b
Research Consultant, (casey.langwith@lewin.com), The Lewin Group, Fairview Park Drive, Suite 500, Falls Church, VA 22042.
Address correspondence to: Anjali Jain, Managing Consultant, (anjali.jain@lewin.com), The Lewin Group, Fairview Park Drive, Suite 500, Falls Church, VA 22042.
Support for this research was provided by UnitedHealth Group. We thank the wellness coordinators, school nurses, and district personnel who shared their experiences for this
study. We also wish to thank Claire Haskell and Reed Tuckson of UnitedHealth Group and Shirley Schantz of the National Association of School Nurses for their insightful comments
on drafts of the article with special thanks to Shirley for her assistance in conducting the interviews.
Indicates CHES and Nursing continuing education hours are available. Also available at: http://www.ashaweb.org/continuing_education.html

Journal of School Health March 2013, Vol. 83, No. 3 2013, American School Health Association 213
resource constraints.13,14 Furthermore, school envi-
ronments are changeable and thus generally not
conducive settings for evaluating the impact of inter-
ventions through randomized controlled trials,15 and
little is known about how to translate and sustain
school-based programs that have shown promise in
studies into real-world settings.16-18
School nurses, whose charges typically include
health promotion and disease prevention within the
school setting, appear to be well suited to address
obesity prevention.19,20 However, few studies have
examined how and if a school nurse, as part of a
school-based intervention, can play a significant role
in ameliorating obesity.19-21 Previous studies have
reported that nurses perceive barriers to obesity-
related education and communication with families,
including lack of knowledge and resources, lack of
institutional support, and time constraints.20-22 Prior
evaluations of nutrition-related interventions have
also found district-level coordinators to be important
in helping schools overcome barriers by facilitating
communication, providing guidance and supporting
materials, and keeping the intervention prominent
in stakeholders minds.23,24 Others have found that
dedicated school health coordinators were associated
with improvements in school policies and resulting
student health behaviors.25 The purpose of this
paper is to provide lessons learned from the 1st
year of implementation of Activate for Kids (AFK),
an innovative multifaceted intervention that was
designed to address these barriers by providing training
and support to school nurses, including the placement
of a district wellness coordinator to supplement nurses
efforts. This paper describes the implementation of the
intervention and does not report the outcomes or
effectiveness of the intervention on the childs health
except as examples in a few anecdotal reports.
The initiative, AFK, was conceived, developed, and
led by UnitedHealth Group (UHG), a diversified health
benefits and services company that offers a broad
array of products and services including its largest
business as an insurer, UnitedHealthcare (UHC). UHGs
interest in childhood obesity stemmed from concerns
about the rising costs of obesity, with the intention
to use the companys existing clinical, technological,
and operational expertise in chronic care management
to help address the problem. UHGs corporate social
responsibility approach, of which this project is a part,
seeks to engage organizations from multiple sectors,
which is consistent with recommendations from
expert and policymaking bodies regarding obesity, and
integrate philanthropy with business products and
services.6,26,27 UHG thus recruited several partners
for the initiative: 6 school districts; United Health
Foundation (UHF), a not-for-profit, private foundation
funded by UHG that provides grants to advance clinical
knowledge and promote community health; and the
214 Journal of School Health March 2013, Vol. 83, No. 3
National Association of School Nurses (NASN), a not-
for-profit specialty nursing organization focused on
developing and providing leadership to school nurses.
UHG approached 6 school districts in 3 states,
Florida, Georgia, and Texas, where the prevalence
of overweight and obesity among children is higher
than the national average.28 Four of the 6 districts
had an existing relationship with UHC/UHG as UHC
provided health insurance for the districts employees,
whereas the remaining 2 had previously been insured
by UHC. Table 1 presents baseline student enrollment
data and demographic information for the 6 districts
that participated in AFK.
UHG leadership held a series of in-person meetings
with district administrators to invite districts to partic-
ipate in the initiative. In addition, within each district,
at least 2 focus groups were conducted with district-
and school-level leadership to identify priorities, con-
cerns, and opportunities for the initiative. Additional
focus groups in some districts included representatives
from the local community, medical professionals, and
parents.
The goal of AFK was to support school nurses to (1)
identify overweight and obese children through BMI
screening and notification; (2) provide counseling,
resources, and/or referrals for intervention to the
families of overweight and obese children, if desired;
and (3) work with school officials, teachers, and food
services personnel to advocate for and implement
evidence-based school policies related to obesity
prevention. To support the school nurses and facilitate
district-level changes, a wellness coordinator solely
dedicated to obesity prevention and treatment was
recruited and hired within each district. The role
of the wellness coordinator was modeled on UHGs
approach to care coordination for individuals with
complex medical needs. The wellness coordinators
were thus employees of UHG, but were hired locally
and worked onsite within district administrative
offices.
Table 2 below provides an overview of the main
components of AFK, which consisted of mixed funding
streams and administrative structures among the
partners. UHG, UHF, and NASN specified the basic
components of AFK, but district and school leaders
were able to tailor activities to suit local needs and
interests. The design of AFK offered schools the
opportunity to engage in both primary and secondary
prevention activities.6 Primary prevention, which
focuses on preventing the incidence (ie, new cases) of
obesity within the whole population, was incorporated
through special school programming that initiated
and/or promoted healthier nutrition and increased
physical activity. BMI screening, as a secondary
prevention activity, aimed at early detection of obesity
with appropriate referral to weight management
resources to reduce the prevalence of obesity and its
2013, American School Health Association
Table 1. School District Characteristics and Demographics*

Georgia Florida Texas

Characteristic District A District B District C District D District E District F
Total number of students (PK-12) 25,777 28,444 40,613 64,457 69,374 44,824
Total number of schools 33 34 62 64 74 43
Elementary schools 20 20 31 37 45 29
Middle schools 6 9 9 12 14 7
High schools 7 5 7 9 11 5
Other 0 0 15 6 4 2
Number of school nurses 33 34 46 20 74 49
Number of nurse assistants/health technicians 0 0 48 42 79 42
Student demographics
Eligible for free or reduced lunch 57.0% 37.0% 59.6% 39.2% 34.8% 36.1%
White 55.2% 67.6% 52.6% 57.1% 22.4% 42.9%
Black 4.8% 20.1% 36.3% 13.6% 31.4% 15.5%
Hispanic 36.1% 7.2% 3.1% 18.5% 24.1% 32.5%
Asian/Pacic Islander 1.7% 0.9% 2.8% 4.0% 21.8% 8.9%
American Indian/Alaskan native 0.2% 0.4% 0.8% 0.2% 0.2% 0.3%
Two or more races 1.9% 3.8% N/A N/A N/A N/A
Urban-centric locale Rural: Fringe Rural: Fringe Suburb: Large Suburb: Large Suburb: Large Suburb: Large
* Source: Information on the number of schools and nurses was obtained from district Web sites and confirmed by key informants. Information on the total number of students,
eligibility for free/reduced-price lunch, student race/ethnicity, and urban-centric locale was obtained from the National Center for Education Statistics, Common Core of Data,
2009-2010. Available at http://nces.ed.gov/ccd/bat/. Accessed May 9, 2012.
Rural: fringe districts are census-defined rural territories within 2.5 or 5 miles of an urban area (depending on the population of the urban area).
Suburb: large districts are located outside a principal city and inside an urbanized area with population of 250,000 or more.

adverse consequences among the population. To date,
studies have shown mixed success for BMI screening
and parental notification, and recommendations from
expert bodies differ on whether to endorse screening
in schools.29-31 As a result, AFK used safeguards to
prevent potential harm from BMI screening, including
training school nurses on proper collection methods
and privacy, introducing stakeholders to the program
through focus groups and informational materials, and
providing resources for follow-up.31
Through information from key informant inter-
views, this paper discusses participants perceptions
of barriers and enabling factors in implementing AFK,
which may be useful to future researchers and organi-
zations seeking to establish school-based interventions;
it is not intended to assess the efficacy or appropriate-
ness of the interventions or to rigidly define a single
intervention.
METHODS
Study Participants
As part of the agreement to join, the districts
consented to participate in studies evaluating the
initiative and its impact and outcomes. To collect
information about perceived impact and lessons
learned in the first year of implementing the initiative,
we conducted semistructured interviews with key
informants.
The UHG project director and wellness coordinators
nominated 4 district administrators and 6 school nurses
to serve as key informants, who were contacted via
email. All 4 of the administrators and 3 of the school
nurses responded and agreed to contribute within
the study time frame. A total of 19 interviews were
conducted in April and May 2012 (Table 3).
Study Instruments, Procedures, and Data Analysis
For each type of key informant, a semistructured
interview guide with open-ended questions was
developed. The interview guide included questions
about the key informants role in the initiative, the
districts or schools policies and activities related to
wellness, and changes in the content or number of
policies during the time period of the initiative. Key
informants were also asked about their perspectives
on the effectiveness of the various components of the
initiative and about any changes in the responsibilities,
mission, or engagement of participants as the initiative
progressed. Questions about the successes, challenges,
facilitators, and barriers to implementing the initiative
were also posed. Interviews lasted from approximately
30 to 90 minutes.
Interviews were audiotaped and detailed notes were
taken as well as exact transcription of direct quotations.
Notes were reviewed to identify common themes. The
authors, who were also the interviewers, met to discuss
common themes and agree upon key findings.
RESULTS
Establishing the Initiative
There were differences in the districts levels of
engagement in wellness activities prior to the start
of AFK. For example, some of the districts had

Journal of School Health March 2013, Vol. 83, No. 3 2013, American School Health Association 215
Table 2. Components and Funding of AFK Interventions

Method Components Primary Funding Source

SCOPE training and micro-grants
BMI screening and parental notication
Wellness coordinators
JOIN for ME Intervention (JOIN) (Optional)
Deliver School Nurse Childhood Obesity Prevention Education (SCOPE), a NASN, funded by UHF
comprehensive, full-day continuing education program developed by NASN to
provide school nurses with the knowledge, tools, and resources needed to:
Screen and refer children appropriately for comprehensive interventions for
overweight and obesity
Identify opportunities for policy and environmental interventions within their
schools
Invite nurses to apply for micro-grants of approximately $2500 for projects that NASN, funded by UHF
nurses would initiate, coordinate, or lead ($60,000 available in total)
Conduct screening and parental notication, in accordance with applicable state School districts
and/or district policies and procedures
Serve as a resource hub for district, campus, and community partners by: UHG/UHF
Cultivating and facilitating relationships among district, campus, and community
partners and initiative sponsors
Providing school nurses, faculty, and personnel with resources and strategies for
promoting school wellness
Assisting with planning and implementation of special activities and events, such
as wellness nights and 5K runs
Facilitating JOIN for ME intervention (if applicable)
Reporting program outcomes
Prepare application for $25,000 grant to district or nonprot community partner for UHF/UHG
projects that would enhance the districts work on childhood obesity
Offer community-based lifestyle intervention for overweight or obese children ages UHG
6-17. Children and their families who participate:
Attend 16 weekly 1-hour group sessions, with monthly follow-up sessions
thereafter
Learn strategies to improve health behaviors such as reducing consumption of
unhealthy foods and drinks, increasing physical activity, and managing screen
time

Table 3. Composition of the Key Informants
Wellness coordinators in each district (6)
UHG and UHF project leadership (4)
School district administrators (4)
School nurses (3)
Joint interview with mother and son participating in JOIN (2)
been conducting height/weight or BMI screening
for a number of years (with some variation among
the practices of individual school campuses), and
one of the districts was already involved in the
Healthy Schools Program as part of the Alliance
for a Healthier Generation, a nationwide partnership
founded by the American Heart Association and the
William J. Clinton Foundation. Initial receptivity and
enthusiasm about the initiative also varied. In-person
visits between UHG and district leadership helped
resolve any initial questions or concerns regarding
the purpose of initiative. The focus groups were also
useful in learning about the districts unique priorities
and readiness for change. Through these discussions,
2 different approaches to AFK emerged: some
districts wanted to engage primarily in wellness (ie,
primary prevention) activities, whereas other districts
expressed interest in supplementing those activities by
connecting individual overweight and obese students
to resources and interventions. Informants indicated
that districts with robust screening policies in place
were more interested in secondary prevention (ie,
individually based interventions) than the others.
UHG initially implemented AFK as a pilot in 1
school district in Georgia early in 2011, hiring the
wellness coordinator and delivering the School Nurse
Childhood Obesity Prevention Education (SCOPE)
training in March 2011. In the other 5 districts,
AFK was launched in the summer of 2011, hiring
the wellness coordinators and delivering the SCOPE
training just prior to or early in the 2011-2012
academic year. At each site, the superintendent
identified a district lead that was responsible for
overseeing the wellness coordinator and AFK initiative
activities.
Delivery of SCOPE Training
NASN, with funding from UHF, delivered the
SCOPE training program to a total of 294 school nurses
in the 6 school districts. The nurses who participated
were registered nurses (RN), licensed practical nurses
(LPN), or licensed vocational nurses (LVN).

216 Journal of School Health March 2013, Vol. 83, No. 3 2013, American School Health Association
Micro-Grants
In the fall of 2011, NASN/UHF also opened the
micro-grant application process to the nurses. The
application required the school nurse to describe, in
a few pages, the following: school demographics; any
needs assessment that had been performed; project
description and plan; intended audience; any school
and community partnerships; plan for sustainability;
communication plan; and proposed use of the funds.
Micro-grant applications were reviewed by 2 SCOPE
trainers and 1 NASN board member with some input
from NASN staff and UHF/UHG partners. Overall, 50
grant applications were submitted, ranging from 3-17
per district. The funders distributed a total of $60,000
among 29 applications, with an average allocation of
$2069. Examples of activities funded included building
a multi-purpose fitness trail, developing an integrated
gardening curriculum, and supporting family wellness
evening events.
BMI Screening and Parental Notication
As part of AFK, the districts decided how BMI
screenings and parental notification would be con-
ducted, resulting in a range of approaches. Across
the districts, screenings occurred at different times of
the academic year and were administered to varying
grade levels. The SCOPE training materials included
sample notification letters, which the district could
use if desired. In practice, the content and method of
parental notification varied. About half of the districts
encouraged school campuses to mail the notification to
parents of all students, whereas the other half focused
only on students who were underweight, overweight,
or obese; 1 district had not mailed the notification at
the time of the interview.
Support from Wellness Coordinators
Although the wellness coordinators had different
professional backgrounds and experience, all had
experience in health education, and the majority
had experience working with schools or school-age
children. Five of the 6 coordinators had Masters
degrees, and the sixth was a registered nurse. With
guidance from district leads and the project team,
the wellness coordinators initially planned to focus
primarily on activities with elementary schools due
to a perception that behavior change was more
likely at younger ages and that parents were more
engaged. However, all wellness coordinators had some
or extensive involvement with middle schools and
the majority were also involved with at least 1 high
school in their district. The wellness coordinators
reported that involvement with the higher grades
mainly occurred because of an enthusiastic school
champion within a particular school. Key informants
cited the timing of the kickoff of AFK at the beginning
Journal of School Health March 2013, Vol. 83, No. 3
of the academic year as challenging. They described
the fall as an extremely busy time in schools and
said that it was difficult to work new AFK activities
into event schedules that were already fixed. Some
principals, teachers, and other personnel reacted
to the initiative with disinterest or wariness, even
within districts where there was wide support. In
addition, the wellness coordinators reported poor
levels of initial participation in some activities, with
fewer people attending events than anticipated. One
wellness coordinator found that it was necessary
to offer food (eg, healthy snacks) or giveaways to
parents to encourage attendance. Some nurses also
experienced similar hesitation from schools when
trying to implement new activities. However, over
the course of the initiative, informants reported
that interest in the initiative greatly increased as
relationships were established and successful examples
from individual campuses became visible.
Principals have realized that the initiative is not
intruding or overwhelming. They have seen how
easy and beneficial it is. (District Administrator)
Wellness coordinators spent a substantial amount
of their effort preparing grant applications. For the
SCOPE micro-grants, the wellness coordinators dis-
cussed ideas and reviewed or edited draft applications.
They also helped nurses and teachers identify appli-
cation opportunities for additional external funding.
Nearly all of the wellness coordinators wrote signifi-
cant portions of the grant applications, which had not
been anticipated. The wellness coordinators explained
that nurses often saw the grant applications as intimi-
dating, because of the time and effort involved as well
as their lack of experience and training. With assistance
from the coordinators to build grant-writing skills, key
informants reported that the nurses became more con-
fident about submitting the grant applications. One
nurse credited the wellness coordinators assistance as
a key factor in the success of the submitted applica-
tions. The wellness coordinators also assisted with the
implementation of the grants after award, including
the $25,000 grants from UHF, as well as helped plan
funded activities on school campuses or within the
district. Examples of funded activities included family
wellness nights, district 5K runs, and special health
education seminars for parents. Wellness coordinators
also supported the development of student activities,
such as wellness clubs, weekly Zumba classes, and
building school gardens. The wellness coordinators
worked primarily with a school champion, most often
the school nurse or a physical education (PE) teacher.
The wellness coordinators perceived their role as giv-
ing guidance on the concept initiated by the school
champion and assisting with logistics, such as help-
ing recruit community organizations to be involved,
recommending vendors or, in some cases, securing
2013, American School Health Association 217
additional funding. The wellness coordinators empha-
sized that an activity was more likely to be successful
when the school champion assumed ownership over
the activity.
I always tell [the nurses and teachers] they know
their schools way better than I ever will. I need
them for the ideas. I am just there to enhance what
they are already doing. (Wellness Coordinator)
The frequency and intensity of interactions between
the wellness coordinators and nurses varied in
the districts. Half of the coordinators said they
worked primarily with principals, teachers, and district
personnel rather than school nurses, as had been
originally envisioned. The coordinators level of
involvement with the nurses appeared to be related,
in part, to the nurses responsibilities around wellness
and BMI screening prior to AFK, with coordinators
working more closely with nurses who were already
familiar with conducting BMI screening and follow-
ups. One key informant also thought the variation
could be associated with the education level of the
school nurseswith more educated nurses being more
engagedin the district and the involvement of the
nurse supervisor.
There is so much that schools want to do but dont
know how or dont have the resources to do. [AFK]
is about providing assistance in how to organize,
develop, and get resources for wellness programs.
(District Administrator)
Forming partnerships with local community organi-
zations and medical groups was another responsibility
of the wellness coordinator. Through networking and
research, the wellness coordinators identified local or
national resources for obesity interventions that suited
the needs of particular campuses. Wellness coordina-
tors reported providing educational content, such as
sample health education curricula and healthy tips
for inclusion in school posters or newsletters. They
also recruited organizations that could participate in
school activities by, for example, providing free health
screenings to parents at health fairs. Nearly all key
informants emphasized the importance of this func-
tion of the wellness coordinator and considered the
coordinator to be better suited to perform these tasks
than parents or school personnel, who may lack the
training and time to identify resources efficiently.
I thought I was going to go in like a gangbuster,
and make all these changes, but youve got to get
their trust. They have to know that youre there
and what youre about. (Wellness Coordinator)
All 6 wellness coordinators described that trust
among district, school, and community partners
developed over the course of the school year. In
218 Journal of School Health March 2013, Vol. 83, No. 3
the first few months, the wellness coordinators spent
much of their time reaching out to schools to generate
interest. As the year progressed, however, principals,
teachers, nurses, and community groups often sought
out the wellness coordinators to collaborate on
activities. As a result, the wellness coordinators were
seen to be influential in creating, maintaining, or
renewing interest in wellness activities. For example,
1 district had been involved in the Alliance for a
Healthier Generation (Alliance) for several years, but
the activities had waned due to competing priorities
and budget cuts. The coordinator reported renewed
interest in Alliance activities as a result of AFK.
JOIN Intervention
With the offering of the JOIN program, nurses are
really making an effort to talk to parents about
[obesity] because now they have an alternative.
Before, nurses felt like, What am I going to
offer parents with just these [notification] letters?
(Wellness Coordinator)
Two districts chose to incorporate the JOIN for Me
(JOIN) intervention, an individual weight and wellness
intervention for overweight or obese children, in the
first program year. The program was launched in a total
of 5 school campuses across the 2 districts in spring
2012. School nurses invited families of overweight and
obese children (identified through BMI screening) to
participate, and the wellness coordinators facilitated
the weekly sessions. The key informants involved in
JOIN were very enthusiastic, describing the availability
of the intervention as an important and necessary
motivator for the nurses, who previously felt they
lacked solutions for families who had been identified
as having an obese or overweight child. (A separate
study, not yet published, was concurrently conducted
on the efficacy of the JOIN intervention.)
Individual Assistance to Children and Families
As originally envisioned, the role of the wellness
coordinator included individual care coordination for
families, but only 2 of 6 coordinators said they received
requests from nurses seeking referrals for particular
families. These 2 coordinators were in the 2 districts
that were most advanced in terms of BMI screening
and other obesity-related activities before the launch
of AFK, and were also the districts that received
JOIN. In one of the remaining districts, the wellness
coordinator had minimal interaction with school
nurses, so requests may have gone to someone other
than the wellness coordinator; in another, Department
of Health nurses, rather than school nurses, conducted
BMI screenings; and in a third, the schools had not
yet issued parental notification letters at the time of
2013, American School Health Association
the interviews. The nurses and wellness coordinators
who referred individual families to programs reported
a sense of deep gratification, which was motivating for
continuing their childhood obesity efforts.
School Nurse Engagement
Key informants reported that the overall engage-
ment and effectiveness of the school nurses varied
among districts and schools. Perceived reasons for the
variation included the different personalities, levels of
enthusiasm and education of individual nurses, the
varying support from district leadership, and nurse-to-
student staffing ratios. Barriers to nurse participation
in the initiative included lack of time in the face
of competing responsibilities, inexperience with grant-
writing and implementation, and lack of consequences
for nonparticipation. Further, in 1 district, a significant
number of school nurses faced potential layoffs at the
end of the academic year due to budget shortfalls.
To persuade and encourage others also to join
into this health initiative, especially those who
already feel overwhelmed with daily obligations,
responsibilities, and expectations is . . . difficult.
(School Nurse)
Despite these barriers, there were examples of
nurses who demonstrated extraordinary effort in
initiating and leading new wellness activities within
schools. For example, 1 nurse spearheaded a new
student fitness club and created a monthly in-school
broadcast on healthy eating featuring a rotating group
of community leaders. Planning many of the activities
involved an intense time commitment on the part of
these nurses on top of their traditional duties. Key
informants indicated that the nurses and coordinators
valued the mutual encouragement and appreciation
they showed to each other when working together.
Barriers and Facilitators
It just depends on the administration and the
personnel and their passion. If you have a principal
that doesnt see wellness as a priority, then you will
be banging your head against the wall. (Wellness
Coordinator)
Key informants were asked to reflect upon barriers
and facilitators to the successful implementation of
AFK. One frequently cited barrier was the relatively
low interest in wellness among some school and
district partners in the face of competing priorities and
limited resources. Key informants described challenges
faced by schools, including difficult or uncertain
budgetary situations, concerns about overextending
school personnel, and concerns about interfering with
standardized testing timing and schedules. Several key
Journal of School Health March 2013, Vol. 83, No. 3
informants said that demonstrating the link between
academics and health was important to convince
skeptical administrators that school wellness was a
worthwhile pursuit.
Key informants indicated that the level of support
among district leadership was critical for success. Orig-
inally, the superintendent had been envisioned as the
main champion for AFK, although the superinten-
dents involvement turned out to vary across districts.
Still, key informants perceived most district leads, who
were appointed by the superintendents, as influential
in raising the profile of the initiative and encouraging
adoption of the program. Four wellness coordinators
said the district lead provided contacts and advice
about strategies to use within the district. Two coor-
dinators reported a less involved district lead. In 1
case, the district lead narrowly interpreted the scope of
the initiative, confining the activities to those focused
on school nutrition services. This coordinator, how-
ever, was able to obtain support from other district
personnel.
Early Outcomes
They needed someone to do the leg work and be the
motivator or pusher. . . . They had all kinds of ideas
that they wanted to do, but they had no time to do
it. . . . So I helped them and now its contagious -
the school is involved in it so much more. (Wellness
Coordinator)
Despite the challenges, the key informants over-
whelmingly viewed the initiative as successful. In par-
ticular, 3 main successes emerged. First, the key infor-
mants cited anecdotal evidence of increased awareness
of the connection between weight and health and the
beginning of a culture change within the district or
particular campuses. In all cases, the key informants
reported an increased number of wellness activi-
ties compared with previous years. In addition, the
wellness coordinators identified a multitude of fund-
ing opportunities from external organizations, which
helped draw new dollars into the district for school
wellness activities. All of the wellness coordinators
experienced growingeven snowballingsupport
for the initiative over the course of the year, especially
among principals who noticed achievements in other
schools.
Second, key informants reported increases in the
formation and meetings of district- and school-level
wellness committees. In 1 district, the majority of
schools formed school wellness councils as part
of the Healthy Schools Program, participation in
which seemed triggered by the AFK coordinator.
In another case, an administrator reported that
the district wellness committee previously existed
primarily to comply with a state mandate, but had
2013, American School Health Association 219
begun reassessing its mission. Wellness committees in
4 of the 6 districts were planning changes for the next
academic school year. For example, in 1 district, the
committee planned to recommend changing the BMI
screening policy to require students in all grade levels
from kindergarten through 12th grade to be screened,
an expansion of the current policy.
A majority of key informants perceived increases
in the sharing of information and strategies among
partners over the course of the year as a third
benefit of the initiative. In some cases this expansion
was accomplished through formal channels, such as
through meetings of a newly formed district-wide
Task Force in 1 district. The wellness coordinator also
served as an informal conduit between school nurses,
principals, and teachers from different campuses
by sharing examples of successful practices. Several
coordinators reported that learning about what others
were doing fostered motivation among the school
partners. Key informants pointed out that school
nurses traditionally work independently from their
peers, with campuses creating silos that can be
isolating. The wellness coordinator served as a way
for nurses to belong to a community as well as access
information about each others work.
DISCUSSION
This study assessed lessons learned from the
first year of establishing an innovative partnership
among 6 school districts, UHG/UHF, and NASN. The
model conceived by UHG aimed to create change
agents at multiple levels within the school and
district administration, by providing training and
funding to school nurses to implement obesity-related
activities within individual schools and establishing
a wellness coordinator in the district to support
their efforts. Below, lessons learned and resulting
recommendations are offered for future school-based
obesity interventions.
Lessons LearnedPractical Recommendations for
Establishing Productive Partnerships
1. The vision for the initiative had to be flexible and
customized according to local concerns and interests, which
also makes it harder to measure outcomes and show
impact.
At its onset, UHG intended a flexible program
design to allow for variation in district needs.
Accordingly, components of the initiative were
carried out and implemented at different times
in the districts, and in some cases occurred at
a slower pace than originally planned. Some
districts were more interested in general prevention
and wellness, while others wanted more direct
interventions for children at risk. By the end of
220 Journal of School Health March 2013, Vol. 83, No. 3
the year, however, all of the districts identified a
need to provide secondary prevention resources
in addition to implementing primary prevention
activities. Allowing districts to realize this need
at their own pace allowed trust to build between
the partners; however, this approach may not be
practical for other funders or research purposes
where intervention fidelity is essential to showing
impact across different settings.
2. Even free programs may not be initially attractive to
schools as they are already overcommitted and under-
funded.
The initial level of commitment of the partners
appeared to correlate with their underlying atti-
tudes about prioritizing school wellness activities
when facing time and resource constraints. While
more ideal for research, the kickoff of AFK at the
beginning of the academic year placed additional
strain on schools and nurses at a busy time. Fur-
thermore, much of the first year of the initiative was
spent on changing the culture of the schools toward
spurring more interest and ownership of wellness,
meaning that 1 academic year was not long enough
for sustained change. Informants described greater
success when focusing efforts on partners who were
eager to participate at baseline with the number
and level of enthusiasm among participants grow-
ing naturally as word about the initiative spread
and success stories became visible.
3. SCOPE training is useful, but on-the-job support and
assistance were needed.
We found that greater assistance and training were
needed to help school personnel recognize and take
advantage of available resources, both from AFK
as well as other sources. Even though the actual
grant applications were brief documents, nurses and
teachers lacked the time and experience to initiate
applications. In many cases, existing resources from
local or national organizations were available and
could meet the needs of schools, but schools lacked
the knowledge and personnel to access them.
4. The availability of practical interventions fosters motiva-
tion.
Administrators consistently pointed to the impor-
tance of making secondary prevention resources
available. In the 2 districts where the JOIN program
was implemented, its availability was an important
resource for the nurses. Assistance to individual
children and families and resulting success stories
were also reported as the most gratifying aspects of
the initiative.
5. Having a single person, in this case the wellness
coordinator, dedicated to obesity amelioration was critical
in changing culture and practices.
In every district, there were highly enthusiastic
administrators, nurses, and teachers who served
as champions within their school or district. The
2013, American School Health Association
 wellness coordinator, however, emerged as the
central figure driving change, because of the
coordinators ability to work with partners from
various levels of school/district administration and
connect efforts across campuses. The AFK model
required a coordinator who is an independent self-
starter, is able to navigate complex bureaucracies,
and is consistent about following up with partners
to keep them engaged. The coordinators were from
the local communities, able to take advantage of
existing relationships, and familiar with community
dynamics, but, even so, engaging schools and the
community took considerable time and effort.
Limitations
First, the small sample size of key informants means
that views expressed may not be representative of
all participants in the initiative. However, the themes
expressed in this paper were common across districts
interviewed. Furthermore, the district administrators
and nurses who served as key informants were actively
engaged in the initiative and may have a more
favorable view of the initiative than other participants.
To counter a selection bias, all conversations were
confidential and key informants were consistently
probed about the challenges and difficulties with
the initiative. Last, districts were at different stages
of implementation of the initiative at the time
of interviews, which may have affected overall
perception in unpredictable ways.
CONCLUSION
The success of engaging school nurses, who were
often already overcommitted, in AFK was mixed.
There were examples of school nurses who, as a
result of AFK, became champions of the initiative and
instigated a multitude of new wellness activities within
their campuses. The wellness coordinatoralthough
only a single individual within a large school
districtwas able to combine resources from diverse
sources such that the initiative itself became larger in
scope and funding through her/his efforts. Although
advances in school policies were seen in a relatively
short time period, it was the individual success stories
of students and families that seemed to capture the
imagination of those involved in the initiative, and to
motivate further commitment to obesity prevention,
treatment, and wellness.
IMPLICATIONS FOR SCHOOL HEALTH
This study describes lessons learned from the 1st
year of a large-scale childhood obesity initiative
delivered via a multicomponent intervention that
included school nurses and district-level wellness
Journal of School Health March 2013, Vol. 83, No. 3
coordinators. In contrast to controlled research studies,
real-world implementation of obesity interventions
that are intended to create sustained change in schools
requires flexibility in intervention design, timing, and
personnel. A single change agent dedicated solely to
the cause, and thus not able to be pulled in other
directions, is able to provide essential support to school
nurses, teachers, and other school-level personnel to
create and maintain the kind of culture change that is
needed for wellness efforts.
Human Subjects Approval Statement
Permission for school and district personnel to
participate in the study was granted in the agreement
between UHG and the 6 districts.
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