The Journal of School Nursing
2021, Vol. 37(3) 157-165
ª The Author(s) 2019
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DOI: 10.1177/1059840519850881
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Sugar-sweetened beverages (SSBs) are a large source of added sugar in teenagers’ diets, comprising 20–25% of daily calories. Despite efforts, teens in rural and southern states continue to have the high SSB consumption rates. Using Teen Advisory Councils (TAC), students designed and delivered school-specific interventions at five Tennessee schools. Using repeated measures models with Bonferroni correction, data were collected on SSBs and water consumption at baseline and 30 days postintervention. The 573 participants ranged from 13 to 19 years; mean age 15.97 years (SD = 1.4). Daily SSB servings decreased from a mean of 2.37 (SD = 2.06) to 1.87 (SD = 1.89; p = .024). Weekly SSB behaviors decreased 10%. Daily water consumption increased 19.5% to 4.46 (SD = 2.97) servings (p = .03). Student-led efforts supported behavioral changes. TACs were effective at changing lifestyle behaviors. Community-driven solutions may result in manageable changes to sustain behaviors.
health education, health/wellness, high school, collaboration/multidisciplinary teams, community
Obesity is a complex health problem caused by a multitude of factors. Epidemiological and clinical evidence indicates that multiple factors each exert modest effects on daily energy balance and weight control (Hu, 2008, 2013; Ogden, Yanovski, Carroll, & Flegal, 2007). Although no simple solution exists to the obesity epidemic, especially among high-risk populations such as Appalachian youth, decreasing intake of added dietary sugar has been shown to reduce body weight. (Delpier, Giordana, & Wedin, 2013; TeMorenga, Mallard, & Mann, 2012). About one third of the U.S. youth are overweight or obese, with some geographical regions disproportionately higher such as southern states and rural regions (Cheung, Cunningham, & Kramer, 2016; Singh, Kogan, & van Dyck, 2010).
Recent trends suggest that U.S. youth are consuming less soda; however, sugar-sweetened beverages (SSBs) remain the single largest source of added sugar in the U.S. adolescent diet (Centers for Disease Control and Prevention [CDC], 2011; Hu, 2013; Keller & Bucher Della Torre, 2015; Miller, Merlo, Demissie, Sliwa, & Park, 2017). Despite recent declines in soda consumption among adolescents, intake of other SSBS including energy drinks, sports drinks, and coffee drinks is increasing (Kit, Fakhouri, Park, Nielsen, & Ogden, 2013; Mesirow & Welsh, 2015). Consequently, the overall consumption of SSBs remains high among adolescents (Rosinger, Herrick, Gahche, & Park, 2017).
SSBs comprise close to 10% of U.S. adolescents’ daily caloric intake with nearly 20–25% of adolescents consuming more than 350 calories per day from SSBs (Hu & Malik, 2010; Rosinger et al., 2017). The CDC estimates that over 70% of adolescents consume at least one SSB daily (CDC, 2011). In addition to a well-established link to obesity, SSB consumption has been linked to other comorbidities such as metabolic syndrome, high blood pressure, and type 2 diabetes (Bermudez & Gao, 2010; Hu & Malik, 2010; Jayalath et al., 2015; Kavey, 2010; Malik & Hu, 2015). Using nationally representative data with children, increased SSB consumption has also been found to be independently related to cardio-metabolic risk factors (Kosova, Auinger, & Bremer, 2013).
The 2015-2020 Dietary Guidelines for Americans recommend consuming more calorie-free beverages such as water (U.S. Department of Health and Human Services & U.S. Department of Agriculture, 2015). Schools and local communities have recently promoted water consumption to youth (Malik & Hu, 2015). Other efforts to reduce SSB consumption include taxation of SSBs, limiting Supplemental Nutritional Assistance Program benefits for the purchase of SSBs, better labeling of SSBs, and limiting availability of SSBs in schools such as vending machines and cafeteria purchases (Kavey, 2010; Malik & Hu, 2015). Despite these recent efforts, adolescents residing in rural regions have disproportionately high SSB consumption rates compared to adolescents residing in other geographical regions such as urban or suburban areas (Sharkey, Johnson, & Dean, 2011). Furthermore, daily water consumption in rural regions is not well understood (Sharkey et al., 2011). These policy efforts are not working in rural areas, especially among the adolescent population. In regions where policy efforts have not succeeded in reducing SSB consumption and increasing water consumption, community-driven solutions are needed.
To raise awareness about the health effects of SSBs and benefits of water consumption, a school-based project was conducted at five high schools in Tennessee. This study is part of a larger project targeting 11 schools in Tennessee. Findings from a related study focusing on elementary aged children and their parents are published elsewhere (Smith & Baumker, 2019). The purpose of this study was to examine the impact of a high school-based, student-led project aimed at limiting short-term SSB consumption behaviors and increasing daily water consumption behaviors. For this study, SSB behaviors, daily servings, and the number of days per week of SSB consumption were analyzed in a sample of high school students. To understand daily water consumption behaviors, daily servings and the preference of water as a beverage of choice were also explored. For this high school-based intervention, our research questions were the following: (1) Do daily SSB servings differ from baseline to postintervention? (2) Does the number of days per week that SSBs are consumed differ from baseline to postintervention? (3) Does daily water consumption (servings) change from baseline to postintervention? and (4) Does water as a preferred beverage change from baseline to postintervention?
The project’s theoretical foundation was a communitybased participatory research approach. Key principles from this approach framing this project are (a) building trust and fostering an environment of shared decisionmaking with school and community stakeholders, (b) empowering parents and teachers while fostering colearning to design our research questions, and (c) actively involving agency partners in the dissemination of research findings (Israel et al., 2005).
For example, classroom teachers, school administrators, parents, students, and project leaders who worked directly with the students from the Tennessee Clean Water Network led the project from the beginning. This community-based team identified the need for the project, schools interested in participation, recruitment plans and procedures, designed and delivered the school-based interventions, and worked closely with the lead investigator to develop the research questions and analysis plan. Community stakeholders gained support for the project through local coalitions.
Lead by project leaders from the Tennessee Clean Water Network, student advisory councils at each school designed and delivered a social marketing campaign for their school to promote water consumption and reduce SSB consumption. At least two classroom teachers served on the advisory councils at each school for administrative support.
Messaging varied by school but included “tag lines,” posters and signs, water bottle logos, and using popular social media platforms such as Snapchat, Facebook, and/or Instagram. Schools also sent out student-designed newsletters to update parents on study progress. Community members actively collaborated with academic partners to design and distribute the project newsletters. This process allowed community members to be involved in the authorship of the newsletters by helping to decide content and presentation of the content.
The Social and Behavioral Human Subjects Committee at The Ohio State University approved this study as “Exempt” (Institutional Review Board Exemption # 2017E0121); it is an expansion project piloted by Smith and Holloman as “Sodabriety” (Smith & Holloman, 2014). Facilitators were trained in the methods and implementation approach of Sodabriety.” The schoolbased intervention began with the creation of a Teen Advisory Council (TAC) at each of the five high schools. Each TAC designed specific components of the intervention: “Bringing Tap Back: A 30-Day Challenge.” Similar to Smith and Holloman (2014) for Sodabriety, each TAC consisted of 12 members with two teachers and student representation from each grade.
Each TAC designed a campaign to promote a month-long challenge. Each TAC shared facts about the benefits of limiting SSBs with the student body via daily announcements and promoted the month-long challenge to drink more unsweetened beverages such as water or unsweetened tea. Each TAC met weekly over the course of 3 months to plan and deliver the intervention. About half of the meetings were for preparation and planning; TACs met weekly during the challenge and once at the conclusion of the intervention to debrief and talk about the overall experience with the lead facilitator.
To gather baseline data, sources of SSB purchased were assessed. Data were collected at baseline and within 2 weeks after the 30-day challenge concluded. SSBs were regular soda or pop, sweetened tea, sweetened coffee drinks, fruit drinks, juice, sports drinks, and energy drinks. One serving of SSBs or water was 8 ounces or 1 cup.
All five high schools were located in Tennessee: three schools were in the midregion and two schools were in the west region. Four of the five schools were in rural counties. Most schools (N = 3) were economically “distressed” counties that are the poorest counties based on unemployment, per capita income, and poverty (Appalachian Regional Commission, 2018).
Project facilitators recruited potential student TAC members by contacting those suggested by teachers or counselors. Teachers nominated students who had an interest in health coaching, developing leadership skills, and consistent attendance at school. Teacher TAC members were health teachers, physical education teachers, or others who volunteered. School TACs developed school-wide campaigns using flyers, daily announcements, and posters. Personal messaging helped recruit intervention participants at each school. In total, high school students who participated in the intervention numbered 573 or nearly half of the students enrolled in the schools. Excluded students were those who were home-schooled, expected to move from the host school during the intervention, or attended vocational training.
Descriptive variables including gender, age, and grade in school were assessed by self-report during the baseline data collection. Age was reported in years.
Beverage survey. A 7-item beverage survey was completed at baseline and 30 days postintervention. Content and predictive validities for use with adolescents have been demonstrated (Smith & Holloman, 2014; Wang, Bleich, & Gortmaker, 2008). Using an adapted survey (Smith and Holloman, 2014), the frequency of SSBs consumed during the week (How many days a week do you consume SSBs?) is assessed. Responses ranged from daily to than once a week or never (I do not drink sweetened beverages). The number of sweetened drinks consumed per day was assessed. Examples of SSBs provided were regular soda or pop, sweet tea, fruit drinks (not 100% fruit juice), sport drinks, energy drinks, flavored or sweetened milk, coffee with sugar, other coffee drinks, and other. A third item asked about the SSB that they drank most often.
Two items asked about water consumption: the number of daily water servings and their usual source of water such as the “tap” or sink, drinking fountains, and/or bottled water. Participants were asked to rank their favorite drinks among water, low-fat or skim milk, diet or sugar-free soda/pop, fruit juices, iced tea or sweet tea, sports drinks, regular soda, energy drinks, or other. Their most highly favored drink was scored as 1, next favorite as 2, and so on, with the least favorite being the final number ranked. Lastly, participants were asked whether drinking healthy beverages was important to them and whether healthy drink options were available at school. Each of these 2 items was dichotomized with yes coded as 1 and no coded as 0.
As part of this project, schools had 2–4 metered water bottle refill stations installed in hallways and gymnasiums. The number of “refills” for each station was recorded from baseline to postintervention. Each “refill” was from the time the machine was activated to fill a water bottle until the bottle was removed. All students, regardless of project participation, could use the water bottle refill stations.
The project was completed over two academic years: Two high schools completed the project during the 2015–2016 academic year and three schools completed the project during the 2016–2017 academic year. Recruitment was completed in two phases: The first phase recruited TAC members and the second phase recruited school-wide students to participate in the “Bringing Tap Back” challenge.
Homeroom teachers distributed TAC information packets with parent permission forms and child assent forms. Tennessee Clean Water Network project staff and school administrators reviewed returned forms for possible selection as a TAC member. TAC members were selected based on project need(s) and nominations of school advisors or administrators.
Two students led each TAC; the Project Facilitator provided guidance. Each meeting concluded with TAC members having responsibility for planning activities and follow-up. Following the procedures of Smith and Holloman (2014) each TAC had subgroups to work on project recruitment and data collection; school-wide promotion, messaging, and media; and providing support every week to students, celebration activities, and supplies.
To kick off school-wide recruitment, each TAC planned and conducted a “Pledge Day” that included pep rallies, pledge signings to reduce SSBs, and “drink more water.” Informational flyers were available for students to enroll in the campaign. During Pledge Day, TAC members distributed water bottles, hung infographics and posters throughout their school, and prepared classroom educational materials such as “facts about SSBs” for teachers to use in health courses. TAC members attended homeroom periods or made school-wide announcements to encourage students to take home information packets and promote the project. Schoolwide recruitment lasted 1–2 weeks. Written child assent and parent permission were obtained.
The messaging from each TAC was important and had to be consistent at each school. Because metered water bottle refill stations were purchased and installed at each school, each TAC strived to promote water consumption. Other messaging regarding SSB consumption was an important choice for each TAC. For example, deciding whether to promote reducing SSB consumption or promoting abstinence was important consideration. Each TAC decided to focus their school’s SSB messaging on reducing SSBs rather than on abstinence.
During the month-long challenge, each TAC met weekly to discuss problems, needs, and support or messaging needed. For example, during daily announcements, TAC members may deliver a “daily fact about SSBs.” Media included school newsletters, signage at schools, and graphic art to display messages. Each project was tailored to each school and was designed and delivered by the school-based TAC.
The IBM SPSS Version 24 statistical software was used to conduct all analyses. Data were analyzed using both descriptive and inferential methods. Descriptive data were analyzed by calculating frequency, means, standard deviations, and ranges of values. Pearson correlations, paired t tests, and multivariate analyses with tests of between-subject effects were conducted. Consumption behaviors from baseline (Time 1) were compared to immediately postintervention (Time 2). Effect sizes (ES) were calculated using Cohen’s d to also measure the magnitude of the treatment effect. ES account for large sample sizes. If standard deviations were not similar, Glass’s delta technique was used to calculate ES. Small ES was defined as <.2, medium ES = .3–.5, and large ES = .6 or above. Mean difference was significant at p = .05 level (Becker, 2000; Ialongo, 2016). To construct a model for weekly consumption of SSBs, an ordinal scale was converted to an analogous interval scale as follows: I do not drink SSBs = 0, less than once a week = 1, 1–2 times a week = 2, 2–3 times per week = 3, at least 5 days per week = 5, and every day = 7.
This study was completed during the 2015–2017 academic years. As shown in Table 1, most students (56.5%) were female and in the 12th grade (34.2%). The students’ ages ranged from 13 to 19 years, with a mean age of 15.97 years (SD = 1.4). At baseline, most students drank bottled water only (56.3%); less than one fourth drank tap, sink, or drinking fountain water (24.7%) and 19% drank bottled or tap water sources. At baseline, most students (84.2%) felt that drinking healthy beverages was important to them and their school had healthy beverage options available (90.5%). As shown in Table 2, these results did not differ by school, grade, or gender.
Only 4.6% of students did not consume SSBs at baseline. At postintervention, 7.4% of students reported that they did not drink SSBs, a 60.8% increase in abstainers. As shown in Table 3, the brief intervention reduced daily SSB servings from an average of 2.37 (SD = 2.06) to 1.87 (SD = 1.89; p = .024). The reduction was one half serving per day. The ES of .25 indicates a small–medium effect on daily SSB consumption. Likewise, weekly consumption of SSBs was reduced. At baseline, participants reported consuming SSBs an average on 4.72 (SD = 2.43) days per week. Weekly consumption decreased to 4.24 (SD = 2.52) days per weeks at postintervention, a reduction of nearly ½ day or 10% of weekly consumption. Although trending in the hypothesized direction, the reduction in weekly SSB consumption was not significant (p = .078). The ES of .19 indicates a small, meaningful effect on weekly SSB consumption. Results did not differ by gender, grade level, or school that the participant attended.
In this student population, sweetened tea was the favorite beverage at baseline (43.7%) followed by regular soda or pop (37.5%). Sports drinks were only favored by 6.2% and energy drinks were the favorite of only 1.4% of students. These trends did not change at postintervention; sweetened tea was the overwhelming favorite drink (59.7%) followed by regular soda/pop (25%).
Water consumption increased 19.5% from baseline to postintervention. Participants reported consuming 3.73 daily servings of water (SD = 2.62) at baseline and 4.46 (SD = 2.97) servings of water at postintervention. The increase in water consumption from baseline to postintervention was significant (p = .037). The ES of .26 indicates that the short intervention had a small-to-medium effect on water consumption. These results did not differ by school, grade, or gender. The number of water bottle refills ranged from 2,209 to 5,327 during the 30-day campaign. The schools averaged between 110 and 266 daily water bottle refills. The effect of the water refill stations on campaign participants could not be determined since all students could access the stations. Water was ranked as a favorite drink in over one third of participants at baseline (33.3%) and follow-up (30.7%). Over half of participants ranked water as either their favorite or second favorite beverage at baseline (56.8%) and at follow-up (53.3%). Water preference did not change from baseline to follow-up.
Nationally, beverage consumption patterns among American adolescents have changed over time (Miller et al., 2017). Downward trends in soda consumption among many subpopulations have been attributed to policy and educational approaches to promote healthier beverage options instead of SSBs. Community-based educational programs focusing on reducing SSBs have been implemented in some states and local communities (Miller et al., 2017). Despite these trends, SSBs remain disproportionately high in some regions such as rural areas and Appalachia. Therefore, the CDC recommends that policy and educational efforts should continue to address SSBs and promote healthier beverage options such as increasing water consumption (Miller et al., 2017). Programming efforts should occur in multiple community settings, including schools.
Our study expands on the evidence-based work of Smith and Holloman (2014) that tested a student-designed and student-delivered intervention to reduce SSB within school communities. To our knowledge, this is the first study that rigorously tested Smith and Holloman’s (2014) communitydriven approach in a broader school-based population. The applicability of the intervention approach and findings to other schools of similar infrastructure or resources and identified health needs are supported by the size and scope of the schools that participated in this expansion project. Schools ranged in size from 641 students to nearly 1,200 students. Most schools were located in rural regions of the State of Tennessee, and other schools were located in comparatively large cities. For this expansion project, some schools (n = 2) were more racially/ethnically diverse compared to the Smith and Holloman’s pilot work. However, three important findings emerged from this study.
First, student-designed and student-led programs that facilitate peer support are effective for short-term behavioral change. At the conclusion of the month-long challenge, students reduced their daily SSB servings and the days per week that they drank SSBs. A half serving per day reduction in SSB consumption (found in this study) would equate to approximately a net reduction of 75 kcal/day if other dietary factors remained constant. If sustained over time, an estimated 6–7.5 pounds/year could be lost, effecting the prevalence of overweight, obesity, and other comorbidities such as high blood pressure and high cholesterol in this adolescent population (Jayalath et al., 2015; Kosova et al., 2013; Malik & Hu, 2015). Further, although school TACs did not promote abstaining completely from SSB consumption in their media campaigns, results indicate that participants who completely abstained from SSBs increased 60% from baseline to postintervention, indicating steps toward a lifestyle behavioral change.
Second, increasing water consumption, especially water from tap and water fountain sources, was a focus of this project. At each participating school, metered water bottle refill stations were installed for student use prior to the start of the school year. Each TAC was charged with creating “messaging” to promote water consumption. At baseline and follow-up, water was a beverage ranked highly by the majority of participants. However, at baseline, average daily SSB consumption (2.4 servings per day) was slightly lower than water consumption servings of only 3.7 servings per day. At follow-up, SSB consumption was reduced to 1.8 servings per day while water consumption increased to 4.5 servings per day. These findings support that participants may be replacing SSBs with water as beverages, a healthier lifestyle choice.
Third, this adolescent subpopulation differs from other adolescent populations in important ways. National data reveal that daily soda consumption among U.S. high school students decreased from nearly 34–20% from 2007 to 2015 (Kann et al., 2016; Miller et al., 2017). At baseline, daily consumption of SSBs exceeded 30% in this sample. Further, national trends indicate that adolescents are consuming less regular soda but higher amounts of energy drinks and sports drinks (Kann et al., 2016; Kit et al., 2013; Mesirow & Welsh, 2015). Our results reveal that sweetened tea (43.7%) is by far the preferred sweetened beverage followed closely by regular soda (37.5%). Less than 8% of our participants prefer energy drinks or sports drinks. These trends remained constant at postintervention. One explanation may be the higher cost to purchase energy drinks and sports drinks, compared to sweetened tea and regular soda. In communities with limited financial resources, purchasing more expensive SSB options may not be feasible. Finally, national trends show that males tend to consume more SSBs compared to females and older adolescents drink more SSBs compared to younger adolescents (Miller et al., 2017). Our results revealed that SSB consumption patterns did not differ by gender or age. Our findings support that reliance on national data may not reveal unique trends within subpopulations. Rural areas have environmental, economic, and social characteristics that influence health problems (Moy et al., 2017).
Health programming to reduce SSB consumption among rural Appalachian teens has shown promise when using culturally acceptable approaches including peer mentoring models that stress self-reliance and helping others in the community. Smith and Holloman (2014) used a teen advisory approach that produced a significant and sustainable reduction in daily SSB consumption. Health programming should be tailored to meet the needs of adolescent subpopulations. To provide personalized interventions, geographical differences must be understood and incorporated into health programs. The use of student-designed and student-led tailored campaigns to promote “Bringing Tap Back” within each school aligns with current recommendations to reduce SSB consumption. For example, the intervention was school based and community driven. The TACs may address other school or community-identified health needs. Finally, TACs can also provide peer-based health coaching to students.
All schools showed overwhelming support for the water refill stations and campaign. According to the Healthy Hunger Free Kids Act of 2010, schools should provide access to free drinking water throughout the school day (U.S. Department of Agriculture, 2014). During planning visits for this project, we noted that most existing water fountains in schools were old, unkempt, or not usable. The new water bottle refill stations were placed in areas according to student and staff pedestrian flow. The water bottle refill stations coupled with the water bottles provided with our project resulted in increased use of water stations, compared to the old water fountains.
Although nationally many schools restrict the use of refillable water bottles during school hours, all participating schools made policy changes to allow refillable water bottles during the campaign. Due to the success of the water refill stations, school administrators permanently changed policies to allow refillable water bottles for students and staff. Some schools also purchased additional water bottle refill stations with their own funds based on the success of “Bringing Tap Back.”
Participants self-reported a positive impact on their overall health and well-being by drinking more water and less SSBs. Anecdotally, TAC members reported that participants shared that they lost up to 7 pounds of weight, were “feeling better,” had family and significant others join the pledge, and for one type 2 diabetic a “better adherence to diabetic diet plan.” Many participants reported that they no longer consumed SSBs and “lost the taste for SSBs.” TAC members noted that the water bottle refill stations were being accessed at greater frequency compared to the older water fountains. Generally, participants felt that they had more control over beverage choices by participating in the campaign and experienced some health benefits.
This study focused on short-term changes in health behaviors. Future studies should measure longer term behavioral change. Another limitation is the reliance on self-report for SSB measures. However, studies have shown good correlations between dietary self-report and measured dietary intake. Although SSB consumption has been linked to health outcomes such as obesity and cardiovascular disease, we did not measure health outcomes.
Our attrition rate was higher than expected in some schools, it is likely that students who did not complete the follow-up surveys may have been more likely to consume SSBs or not change their SSB behaviors. Participants were eager to receive the free water bottles and kickoff kits but with no financial incentive to sustain enthusiasm. Reasons given for attrition were the following: timing of the campaign and data collection was close to end of semester activities and school breaks, some schools have high absenteeism and high student turnover, and the lack of incentives beyond the water bottles. To sustain and strengthen desired effects, booster messaging may be indicated. Because this was a feasibility study, we did not have a control group. Consequently, there is no way to know whether these same effects may have occurred in a high school with no similar program or intervention.
Including students not participating in the program as a comparison group to determine the effectiveness of the water bottle refill stations would have been an informative measure on their impact. However, the complexity of this approach was not possible in the context of study design. The entire school had access to the refill stations, and there was not a measurement in place to differentiate between participant and nonparticipant refills. Future studies that incorporate a control group could address this concern. Potential sources of bias include social desirability to underreport SSB consumption and overreport water consumption.
Our results show that student-led efforts to support behavioral change are effective and efficient at approaches to changing individual lifestyle behaviors. Small and manageable changes may lead to sustainable lifestyle pattern that result in net gains in health outcomes. For example, reducing SSB servings even by half serving a day and sustaining that change over time may result in a 6–7 pound weight loss per year if all other dietary patterns remain constant. Reliance on national data to understand the personal lifestyle patterns of subpopulations may not uncover the unique characteristics found within certain groups. A better understanding of the unique characteristics of rural adolescent lifestyle choices is warranted.
This study further supports that students can serve as effective health coaches, advocates, leaders, mentors, and role models to individual behavioral change, broader environmental change, and policy changes within schools. The student-designed and student-delivered approach to support the adoption of health lifestyle behavioral change is rooted in evidence-based practice (Petosa & Smith, 2014; Smith & Baumker, 2019; Smith & Holloman, 2014). Adolescents tend to view peers as more credible, having a better understanding of the concerns of young people, and more likely to model the behaviors of peers than adults (Ebberling et al., 2012; Millitello, Kelly, Melnyk, Smith, & Petosa, 2018). Peer mentoring empowers teens by strengthening their social network and social support to plan, regulate, and evaluate their personal activity and dietary plans, thus building self-efficacy to reduce SSB consumption and increase water consumption. With peers as mentors, a campaign to change lifestyle behaviors are more tailored to personal interests, talents, and the school environment (Petosa & Smith, 2014). Peer leaders and student coaches are important but often underutilized advocates for school nurses to utilize in the support of student health and well-being.
Tipton (2016) corroborates both health promotion messaging and peer coaching as effective, evidence-based strategies for SSB reduction in high school settings. Mentorship and peer coaching fosters a colearning environment between all participants (Smith & Petosa, 2016). Younger students who are coached by older teens may matriculate into a health-coaching role within their schools (Petosa & Smith, 2014). This process helps ensure that health concerns can be addressed within the school environment over time (Petosa & Smith, 2014). Being health coaches and role models, the TACs used peer coaching and personal mentoring to promote school health that resulted in short-term behavioral changes, student collaboration, and team-building to facilitate school-wide policy changes. For example, at the end of the project, all schools implemented new policies allowing students to carry water bottles during the school day.
Schools are important settings to promote healthy lifestyle behaviors (Petosa & Smith, 2014). School nurses may incorporate health programming into a peer-led health coaching approach, moving beyond health education delivered exclusively by teachers or other adults at schools (Petosa & Smith, 2014). In our study, each school had a unique social media presence driven by the school’s culture. Each school’s culture facilitated personalized branding of educational materials by the TAC with the use of hashtags, Snapchat campaigns, Facebook, and/or Instagram into the most popular of students’ communication medium at their school. These communication methods were essential for the TACs to effectively deliver their social marketing campaign as well as effectively implement the program.
With the increasing rates of obesity among adolescent youth, feasible and sustainable mitigation strategies are needed. The National Association of School Nurses (NASN) identifies the school nurse as having the expertise and skills needed for childhood obesity prevention and reduction efforts (NASN, 2018). However, many school nurses cite limited resources and time restraints as a barrier to implementation (Helseth, Riiser, Fagerlund, Misvaer, & Glavin, 2017; Schroeder & Smaldone, 2017). Peer mentorship functions as a solution to overcome these barriers. Utilizing peer mentors as a partner in the development and dissemination of health promotion messaging allows the nurse to delegate components of health program delivery. This task delegation will reduce the workload of school nurses and avoids adding to the workload of other school staff members. Peer mentorship and peer coaching allows the nurse to assume guidance or supervisory role, while trained peer mentors or teen health coaches develop and disseminate health promotion projects.
This study utilized strengths and resources already established within the schools. Thus, the sustainability at participating schools and the initiation of this approach at schools facing similar health barriers is feasible and reasonable. As the leader in health programming, schools look to school nurses for creative yet effective approaches to improve health outcomes of students. The peer-led strategies offer economical, accessible, and evidence-based methods to address the increasing obesity rates or other health concerns among our youth and the barriers cited by school nurses.
Laureen H. Smith and Kimberly Pettigrew conceptualized the manuscript while the draft was prepared by Laureen H. Smith, Courtney Sexton, and Kimberly Pettigrew. Laureen H. Smith, Courtney Sexton, and Sarah Eastburn were involved in the analysis of the data included in the manuscript, whereas only Laureen H. Smith and Sarah Eastburn were involved in the revisions. All authors gave final approval and agreed to be accountable for all aspects of work ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Tennessee Clean Water Network received funding from the Tennessee Department of Health to conduct the original health educational project.
Laureen H. Smith, PhD, RN, FA AN https://orcid.org/0000-0001-8460-0617
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Laureen H. Smith, PhD, RN, FAAN, is an associate professor at The Ohio State University College of Nursing, Columbus, OH, USA.
Courtney Sexton, BS, RN, is a research coordinator at The Ohio State University College of Nursing, Columbus, OH, USA.
Kimberly Pettigrew, MA, BS, is a former director of Community Health Programs at Tennessee Clean Water Network Knoxville, TN, USA.
Sarah Eastburn, BA, is the director of Educational Outreach at Tennessee Clean Water Network, Knoxville, TN, USA.
1 The Ohio State University College of Nursing, Columbus, OH, USA
2 Tennessee Clean Water Network, Knoxville, TN, USA
Corresponding Author:Laureen H. Smith, PhD, RN, FAAN, The Ohio State University College of Nursing, 240 Newton Hall, 1585 Neil Avenue, Columbus, OH 43210, USA.Email: smith.5764@osu.edu
