Oswego County Healthy Highway Program

State: NY Type: Promising Practice Year: 2020

Oswego County, New York is a rural community located on the southeastern shore of Lake Ontario with a population of 120,000. As in many rural communities across the country, the ongoing economic hardship of the county fuels many poor behavioral choices that result in poor health outcomes. Obesity is one of them.

Obesity has reached epidemic proportions across the United States and New York State, and Oswego County is not an exception. It finds overweight and obesity plaguing its residents, especially among school children. Childhood obesity rates in Oswego County were the second highest among all counties in New York State according to school surveys in 2010-2012.

Obesity and overweight are the second leading cause of preventable death in the United States and threaten to overtake tobacco use as the single most preventable cause of premature death. According to the Institute of Medicine, if action is not taken to reverse the obesity and overweight trend, this generation runs the risk of being the first generation that does not have a longer lifespan than their parents. Obese and overweight children and adolescents are at risk for multiple health problems during their youth and as adults. Obese children and adolescents are more likely to become obese as adults. Research has shown that children who are obese between the ages of 10 and 13 have an 80% chance of becoming obese adults (American Academy of Child and Adolescent Psychiatry). Obese and overweight youth are more likely to have risk factors associated with cardiovascular diseases, such as high blood pressure, high cholesterol, and Type 2 diabetes. Losing weight helps to prevent and control multiple chronic conditions and improves the quality of life.

To address school children's obesity and overweight, Oswego County Health Department (OCHD) strives to explore new ways to motivate school and broader communities to improve elementary school students' health knowledge and behavior. First, OCHD worked with local higher education and piloted the Health Highway Program (HHP) in two schools in the county.  HHP aims to reduce childhood obesity by increasing food literacy among elementary school children to help them make more healthy choices when it comes to food and physical activity. The pilot showed that HHP improved students' knowledge of healthy eating and changed their food choices in the school lunch cafeteria compared with those students who had not been trained with the HHP curriculum. Then, OCH built a broad community collaboration and promoted the HHP in all elementary schools with a multiple year plan in Oswego County.

The HHP is still promoted in the schools in Oswego County. The outcomes of the first year's survey of the students in HHP are positive. We present how OCHD mobilizes limited local resources and collaborates with community partners to address childhood obesity and overweight in the county in this application.

Realizing that poor eating habits, including inadequate intake of vegetables, fruit, and milk, and eating too many high-calorie snacks, play an essential role in childhood obesity and overweight, OCHD sought to work on children when they were young and building eating habits. In response to the concerning statistics and the deep connection between poor food choices and obesity and overweight, Oswego County sought to target elementary school children and to teach the importance of making healthy choices related to increasing physical activities. The Healthy Highway Program came to OCHD's attention.

HHP is a set of flexible and versatile curriculum developed by a retired elementary school physical education teacher in New York State. The teacher owns the copyright of the curriculum. HHP uses traffic themes and traffic metaphors to categorize foods into red light, yellow light, and green light” foods, similar to other programs like We Can! and CATCH, and to teach students a common language regarding healthy choices in diet and physical activity. At the same time, HHP leaves room for teachers and students to be creative in adapting the languages and concepts in their various activities. The program encourages children to make at least one healthy choice a day, targeting food choices and increasing physical activity. It uses common traffic metaphors such as equating foods with a traffic light, with some foods being red light, yellow light or green light” foods.  Students are taught the importance of balancing red, yellow, and green light” food choices in order to keep their engines” working at optimum levels.  It offers fun activities to help students understand that it takes more physical activity to burn off the calories found in red light” choices compared to yellow or green light” choices and that the balance can help achieve or maintain a healthy weight. The program provides a basic vocabulary to help facilitate discussions of food choices and physical activities.

With a local philanthropy's financial support and a local state university faculty's technical assistance, OCHD engaged two elementary schools to pilot HHP back in 2015.  This collaborative pilot was successful. Student's pre- and post-intervention questionnaires indicated an increased knowledge in healthy foods.  Also, surveys between schools with and without the intervention showed significate behavioral changes in food choices in the school cafeteria. Specifically, after the HHP intervention, the rates of students correctly identifying healthy foods improved ranging from 4%-20% and students in food choices on vegetables and sweetened-chocolate milk were 57% vs 39% and 42% vs 72% in the schools with intervention and without HHP. The outcomes of the pilot were presented at the New York State IV Population Health Summit and published in the International Journal of Health Promotion and Education.

According to the 2014-2016 Student Weight Status Category Reporting System, Oswego County has the highest percentages of the combined student weights among elementary, middle, and high school students in New York State, with 22.6% falling in the obese weight status and 41.7% of students in the overweight or obese status. Thirty-eight percent of elementary schoolchildren in Oswego County were overweight or obese.

Within Oswego County, we have approximately 9,800 elementary school students in 24 schools spread on the county's territory that is slightly larger than the State of Rhode Island. It is a challenge for a rural county like Oswego.

Taking the preliminary success of the pilot and the new data about student overweight and obesity in the County, OCHD widely shares the collaboration and the outcomes of the pilot and challenges of the obesity in the community. Then, came an unexpected new partner, a local hospital who was interested in addressing rooted chronical diseases in the community via behavior modifications. With the support of the County Legislature, a three-way agreement was set up among OCHD, the local hospital, and the local philanthropy to commit a long-term investment in implementing HHP in all 24 elementary schools in Oswego County. Many other agencies joined the efforts, and close to $100,000 were committed for the expansion of the HHP throughout the county, and other partners came to joint the expansion with their expertise. A countywide rollout started in the school year of 2018-2019.

Within any segment of the school, Are you feeling like a racecar or a wreck?” can be a question asked for a morning check-in.  The nurse's office can be designated as the body shop.”  What did you fuel your engine with?” is a fun way to discuss food choices. Once adopted in a school, these concepts and metaphors are flexible enough to be integrated into the existing curricula to meet the diverse needs from classroom to classroom and school district to school district. Schools have used the HH program concepts to develop HH cartoons in library classes, invited the local SUNY Oswego ice hockey team to discuss how they fuel their bodies” for collegiate hockey, held a lunchbox derby, adopted water at snack time policies, and hosted Walk to School Day events.

The program's languages and concepts are proven easily transferred from classrooms to the cafeteria, the gem, the nurse station, the library, and even the community. The program creates a fun way to discuss food choices and physical health, such as Are you feeling like a racecar or a wreck?” becomes a question asked for a morning check-in, the nurse's office is designated as the body shop,” What did you fuel your engine with?” leads a popular way to talk about food choices. Once adopted in a school, these concepts and metaphors are flexible enough to be integrated into the existing different subject curricula to meet the diverse needs from classroom to classroom and school district to school district. Schools have used the HHP concepts to develop HH cartoons in library classes, invited the local college ice hockey team to discuss how they fuel their bodies,” held a lunchbox derby, adopted water at snack time policies for classroom parties, and hosted Walk to School Day events. The HHP impacts even spilled over” to families' discussions on meals and physical activities, for example, grandmothers reporting her grandchildren stopped drinking soda; children requesting to hike or bike” to dance class as mom is frantically getting them in the car so they won't be late; children warning their parents in the fast food restaurant that this is a red light meal,” and a 3 yr old telling mom that cookies are a red light choice” and he wanted to leave Santa a green light” choice for a snack. 

In addition, education about the HHP was delivered to childcare providers, the local YMCA, and Americorp members working with youth over the summer.  These additions enhanced the connections between school and home and the schools and the community.

Despite many agencies held nutrition, physical activity, and health education programs for school children and other community members in the county, prior to HHP being introduced to elementary schools, there were no consistent efforts and streamlined messages at the County level to address childhood obesity.  Oswego County Health Department led some ways in innovatively address community's childhood obesity and overweight:

  • Firstly, leading by example – the successful pilot in two local elementary schools. The pilot did not just show the success in statistics but also found a common theme and language for the community to address childhood obesity and overweight collaboratively. In the meantime, the success of the pilot earned the trust and attracted many partners to form a solid long-term community health improvement project.
  • This project addresses the critical link between health behaviors and health outcomes - healthy food choices and increasing physical activity to reduce childhood obesity and overweight. Also, this project created a consistent and easy to understand message about eating, physical activities, and overweight and obesity in the community.
  • It is an approach to motivate teachers', school staff's, and students' expertise and talents to make the HHP languages and concepts permeating to each corner of the school campus and beyond, for example: using the back of lunch menus to highlight healthy kid friendly recipes and opportunities for family physical activity, sending out the Pit Stop Newsletter to all the drivers” in the school to share success stories from other schools or offer ideas for the coming month such as tasty Tuesday” food tastings or fitness Fridays” to provide extra physical activity time.  These kinds of creativity promote the HHP languages and concepts and inspire families to adopt the messages children brought homes.
  • This is a true community collaboration. In addition to OCHD and the local hospital have divided the schools in half and act as a mentor for each school in implementation and evaluation, many other agencies joint the HHP as they can and like, an agency from the land grant college promoting nutrition education, the rural health network offering organizing inter-school competition and providing small grants as incentives, the local higher education providing critical assessment and evaluation tools, and so on and so forth.

In addition to the innovations listed above, one more point OCHD wants to bring the reader's attention. The prevailing weather of public health practice stresses evidence-based programs, HHP has not been recognized as an evidence-based program at this time, even though its concepts and approaches are very similar to other evidence-based programs.  Taking advantage of collaborating with higher education, OCHD is working hard to enhance assessment and to get academic publications to meet the evidence standards despite the reality of limited resources in a rural community. The evaluation section will further discuss the evaluation methods that are being used and the success documented in the pilot program and year one roll out to all elementary schools in Oswego County and the facts of short of resources.         

As a rural, large county, Oswego is short of many resources but never short of the spirit of collaboration because residents and agencies are aware that no one agency can do it alone, and to solve identified problems they have to pull limited resources together.

With so many behavior-associated health problems in the county, how to get the community together to focus on childhood obesity was a question for OCHD, which chose childhood obesity as one of two top priorities to address. From selecting a program to pilot to the expansion of the program, OCHD took the lead with increasing community collaborators.

OCHD reviewed over a dozen evidence-based programs and found a handful or less from rural settings but none of them fit Oswego needs. At this time, HHP, developed by a physical education teacher with some rural experiences, caught OCHD's attention.

Mindful in community collaboration and determined to test something new, OCHD reached out to a few schools and the state university's local campus, then contacted a local charity foundation for the funding. That was how the pilot started.

When the pilot was still on its way, OCHD started a broader outreach to invite other agencies to join. The rural health network was one of the first that provided incentives to the participating schools. A local non-profit participated in many community events in the piloted schools with OCHD.

After the pilot showed the intervention's effectiveness in improving students' food health literacy and changing their food choice behaviors, OCHD quickly disseminated the pilot's outcomes locally, in the state, and in the academic circle. Additionally, OCHD shared local obesity data with the community and related the burdens of obesity with not just health risks but also economic development and educational obstacles. The connection hit many ears. OCHD's intention of expanding HHP throughout the county started to gain the community's support.

Like all other outreaches, the process requires two-way communication. As OCHD was talking with superintendents to sell the pilot outcomes, some superintendents pointed out that rural poverty would prevent learned students from practicing eating healthy as many parts of the county were short of fresh food accessibility. After this alarming feedback, OCHD did some homework and found that a third of the county territory was a food desert.” Then OCHD contacted a regional food bank to ask for help with stress on the vision of combating childhood obesity while benefiting the whole families. The food bank promised to have a mobile truck to go to the food deserts in the county regularly.

OCHD's efforts got a local hospital's attention and desire to join the expansion of the HHP. Then the leaders of OCHD and the hospital went to talk with all superintendents. After the superintendents learned that OCHD was serious in addressing their concerns over food deserts in the county, all nine superintendents signed an agreement on the multiple-year plan of the expansion of HHP. Additionally, OCHD reached out to two private schools in the county. A retired high school principal who spent his life-long education career in the county said, It never happened before that something was even signed (and agreed) by all nine districts for a community project.”

To secure the expansion's financial needs, the County Legislature supported a three-way investment in the expansion. The County, the hospital, and the local foundation jointly invested the HHP to all elementary schools for three years, aiming at reducing childhood obesity by establishing a school-based, community-relevant education program to improve food literacy and food choices among elementary school students.

This program has been an increasingly more extensive in collaboration,  in addition to OCHD, the hospital, the state university faculty, the regional food bank, all school districts and private schools in the county, the federal qualified rural healthcare center in the county, the land-grant university, the rural health network, Headstart, the local YMCA, the AmeriCorp, and other non-profit service agencies joined the collaboration. Also, an uninvited but important partner came on board – local newspapers. As HHP languages became common, a reporter caught and published a story that a three-year-old boy wanted to prepare the green-light” food for the Santa. Since then, the newspapers have been closely following the HHP and other local health improvement projects.

The increased collaboration in the community to expand and improve the HHP has helped to enforce the existing partnership. The state university faculty has been working with OCHD on many projects, and he has committed to staying with OCHD through a thorough evaluation of the HHP expansion. Despite limited resources, we look forward to generating robust data to earn an evidence-based program status if possible.

HHP aims to reduce childhood obesity by increasing food literacy among elementary school children to help them make more healthy choices when it comes to food and physical activity. This is done by:

  • Introduction (introducing program vocabulary and traffic theme)
  • Implementation (introducing nutrition concepts)
  • Integration (integrating the theme into classroom projects like recipe development and math problems)
  • Inspiration (expanding the theme into broader activities such as, trips to farmer's markets and creating snacks and healthy meals)

The effectiveness of the Healthy Highway Program, for improving healthy eating knowledge and healthy food choice behavior among elementary school students was evaluated. Adopting the key aspects of social cognitive theory into the healthy eating promotion strategies at school, the program helped students raise the value of good health and nutrition, identify the benefits of adopting healthy eating patterns, develop practical skills for reading food labels and make healthy food choices through observation and hand-on experiences.

After intervention, based on pretestposttest design, statistically significant more students improved their healthy eating literacy by telling ‘healthy (green light) and unhealthy (red light)' foods among their daily food choices. For example, after the intervention, statistically

significant more K2nd graders came to perceive French fries as ‘red light' food (from 41.9% to 61.2%). Similar changes happened among 3-5th graders regarding broccoli, bacon, banana, and green beans. After intervention, more 3-5th graders answered that broccoli, banana and green beans are green light” food, whereas bacon is a red light” food.

An observational study was also conducted in the two pilot schools as well as a control school.  This study utilized trained 6th grade students as food detectives” to observe what foods students were selecting and consuming in the cafeteria when purchasing lunch.  Students in the pilot schools ate more fruits and vegetables then the control school post intervention; as well as chose chocolate milk less often (43.2% vs. 72.2%) and purchased less ice cream (12.8% vs. 21.5%) in the cafeteria.

A similar pretest-posttest design was implemented after the first year roll out to all 24 elementary schools to assess healthy eating literacy.  In the k-2 grades, positive improvements were made on all foods tested: apple, French fries, broccoli, pretzel, ice cream, bagel and cake.  The improvement seen from pretest to posttest were statistically significant and ranged from a 5%-10% increase.  In the 3-6th grade students, positive improvements of healthy food literacy have been found on a few tested foods: French fries, bacon, cheese stick, pretzels. Compared to students in the pre-test, more students in the post-test answered that French fries and bacon are red light foods, and cheese stick and pretzels are yellow light foods in a statistically significant manner. One unexpected finding is that, compared to students in the pre-test, more students in the post-test answered that chocolate milk is more green light food in a statistically significant manner. All other green light foods such as broccoli, banana and green beans were perceived by students as green light foods on both pre- and post- tests without any statistically meaningful differences.

Pretest and posttest were developed by the HHP workgroup and teachers were trained on how to administer the surveys.  The surveys included pictures of foods and required students to identify if they were red, yellow, or green light” foods by either drawing a line to the appropriate color on a traffic light or for older children coloring in the appropriate color on a traffic light.  Surveys were completed by students in school.  Food Detectives” were trained in what to observe and how to document finding on a printed picture of a lunch tray with the day's choices.

Information from the pretest and posttest was analyzed using Statistical Package for Social Sciences (SPSS) by a professor from a local university.  The outcomes of the pilot were presented at the New York State IV Population Health Summit and published in the International Journal of Health Promotion and Education.

Sustainability of the project was a concern following the pilot project and was addressed in the three-year plan developed for the roll out to all 24 elementary schools in the County.  The HHP was initially presented to physical education teachers and school principals in the two pilot schools.  Principals supported the implementation and understood the impact of obesity on health and educational performance.  After a year of implementation, one of the pilot schools that implemented the program successfully, lost both of their physical education teachers (drivers”) due to retirement and the following year the new physical education was not familiar with the program and it became stagnant. 

In planning for the expansion of the program, the first objective was to have staff from the health department and hospital trained in the HHP, so that ongoing mentorship and training on the HHP could be provided in the elementary schools.  As training for the schools was rolled out, multiple staff members were encouraged to attend, including physical education teachers, food service workers, classroom teachers and administrators.  Those attending the training, the drivers” for their schools, were encourage to go back to the schools and build their pit crews”, or teams that could champion the program across the school.  Ongoing training, for three years, with the program developer was also planned for to help train additional personnel. 

Staff from the local hospital and OCHD are available to reinforce and provide ongoing ideas for implementing the concepts and vocabulary taught in the HHP training.  The goal is to utilize the traffic metaphors presented to create an ongoing culture change within the schools.  A condition where healthy choices around nutrition and physical activity become part of the ongoing dialogue withing the school, at home, and in the community. 

Updates on the Healthy Highway project are regular agenda items on several community committees and other agencies have committed some financial support for the program to assist with educational materials that can be used in schools or during community events to keep consistent messages across the County.  In addition, in the summer several agencies come together to present HHP education at community events and use the vocabulary and themes of the HHP to supplement what is happening at the schools.  One sector that has expressed interest in learning more about the program is dental providers.  OCHD is planning to conduct public health detailing around this topic in an effort to get dentist, pediatricians and family medicine doctors to begin using the vocabulary that is taught in schools about red, yellow, and green light” food choices.  Again, wanting to spread a consist and sustainable educational message about increasing green light” choices and limiting red light' choices among our young people in hopes of improving food literacy for a lifetime of benefit.

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