Running head: HEALTHY CHANGE FOR HEALTHY GAINS

Healthy Change for Healthy Gains Program Grant Proposal

Harry Ta

Health Science 405

Theodora Papchristou

California State University, Long Beach

December 16, 2016

HEALTHY CHANGE FOR HEALTHY GAINS Ta 1

Table of Contents

Specific Aims2

Background and Significance.....................2

Importance of Topic..2

Critical Review on Similar Programs4

Linking Goals and Objectives to their Theoretical Relevance..5

Hypotheses....8

Description of Population and Method of Sample Selection...8

Design of Experimental Methodology9

Operationalization of Concepts.11

Formative Evaluation Methods Pilot Testing Procedures...12

Process Evaluation Monitoring of Program Implementation.....13

Rationale for Choice of Statistical Techniques....14

Descriptive Statistics Univariate Analysis........14

Inferential Statistics Bivariate Analysis........15

Timeline......16

Appendix.....17

References.......22
HEALTHY CHANGE FOR HEALTHY GAINS Ta 2

Specific Aims

Latino children and adolescents are at high risk for obesity, and obesity can further lead

to more complications. Programs had implemented physical activity and nutrition education

interventions to change the current lifestyle and behaviors of Latino youth. The Healthy Change

for Healthy Gains program will adopt the methods and interventions of the successful programs

on changing behaviors in Latino children to reduce obesity rates. The Healthy Change for

Healthy Gains program will utilize the Transtheoretical Model and classical experimental design.

The program will need a focus group to pilot test methods. Once the program has taken the

necessary recommendations to change the process and methods the program will begin.

The program will start in January 2017 and end in December 2017. The target population

of the program will be Latino youth between ages 5-17 in Los Angeles County. The program will

get a representative sample by comparing interventions between two elementary schools and two

high schools. The implementation process and persons who implement will be monitored to

ensure the program is progressing as predicted. The Healthy Change for Healthy Gains program

will aim to increase knowledge about physical activity, diabetes, heart disease, healthy eating and

healthy choices; increase positive attitudes toward healthy eating and physical activity; and

increase changing of old behavior to a healthier behavior. A pre- and post-test will be

administered to assess the change.

Background and Significance

Importance of the Topic

Obesity poses a large problem in the United States for children and adolescents,

especially among Latino/Hispanic children and adolescents. Although, being obese does not
HEALTHY CHANGE FOR HEALTHY GAINS Ta 3

mean death, being obese will increase risk for diabetes and heart disease. Approximately 80% of

Latino men and 75% of Latino women are overweight or obese, and about 13% of Latino men

and 11% of Latino women have diabetes (American Heart Association, 2015). In addition, heart

disease is the number one leading cause of death for all Americans (American Heart Association,

2015). If Latino children and adolescents do no change their current behaviors, they will be at

high risk for being overweight or obese. This will result in more complications in life such as

heart disease and diabetes.

The prevalence rate of obesity is approximately 17% or 12.5 million of the children and

adolescents in the United States (CDC, 2011). The incidence rate for obesity among children and

adolescents have doubled and quadrupled in the past 30 years, respectively (CDC, 2015). Latino

children and adolescents are in a worse condition. Approximately 22.4% of Latino children and

adolescents are obese (State of Obesity, 2014). This statistic is even larger than the national

prevalence rate of 17%. In addition, the rate of obesity among Latino children and adolescents is

6.6% (State of Obesity, 2014). Although there is a difference in numbers, the risk factors for

obesity among the general population and the Latino children and adolescents are almost the

same. Risk factors include a combination of physical inactivity, consuming less nutritious food,

and the type of environment the children and adolescents live in.

Over a lifetime, a child with obesity will cost an estimated $19,000 worth of medical

treatment (Duke Global Health Institute, 2014). The number also accounts for comorbidities of

obesity. The Duke Global Health Institute (2014) estimated that it will cost nearly $14 billion to

treat all 10-year-olds in the United States. With the total of 12.5 million obese children and

adolescents in the United States, the total medical cost to treat obesity would accumulate to $237

billion in a lifetime.
HEALTHY CHANGE FOR HEALTHY GAINS Ta 4

Critical Review on Similar Programs

There had been many programs interventions to reduce the risk of obesity among

childhood obesity, specifically obesity among Latino youth. Crespo et al. (2012) made

noteworthy results with Latino children and adolescents through community and school

intervention programs. Other community interventions were also implemented among the Latino

youth population (Mirza et al., 2013) as well as among the general children and adolescent

population (Jurkowski et al., 2013; Griffin et al., 2014; Berge et al., 2016). These community

interventions included either a physical education or physical activity component, a nutrition and

diabetes education component, or a combination of physical and nutritional education. School

interventions also had a significant effect on the young population using physical and nutrition

education. Davis et al (2010), Kilanowski and Gordon (2015) and Evans et al (2016) also had

physical and nutritional components in their school intervention program for Latino children and

adolescents as well as Marcus et al. (2009) and Elder et al (2014) in their school intervention

program for the general youth.

The difference between the Crespo and colleagues (2010) community intervention

component with Mirza and colleagues (2013) community intervention for Latino youth is that

Crespo and colleagues focused more on changing the environment to reduce obesity rates while

Mirza and colleagues focused more on changing diets to reduce obesity rates. The success of

Crespo and colleagues (2010) community intervention was due to educating the Latino family

on healthy eating, diabetes, and importance of physical activity as well as provide new

equipment for public parks. The success of Mirza and colleagues (2013) intervention was due to

educating and changing the diet of Latino families, especially Latino youth. Although there is a

difference between the two interventions, the similarity between the two interventions is that
HEALTHY CHANGE FOR HEALTHY GAINS Ta 5

family plays an important role with reducing obesity rates among Latino children and

adolescents.

The community interventions implemented for the general youth are different in the kind

of method used. Rather than just changing the environment or changing diets, the community

interventions consisted of mainly physical activity with families (Jurkowski et al., 2013; Griffin

et al., 2014; Berge et al., 2016). All three community interventions had been successful in

reducing obesity rates among the general youth. The studies had shown that being more

physically active can reduce risk of obesity.

Unlike the community interventions, the interventions conducted in a school setting for

the Latino children and adolescents (Davis et al., 2010; Kilanowski and Gordon, 2015; Evans et

al., 2016) are similar to the interventions administered for the general youth in a school setting

(Marcus et al., 2009; Elder et al., 2014). In the research, the children and adolescents are

provided with a special physical education that focuses on aerobic exercises and strength

training, and a curriculum for healthy eating, avoiding sweetened foods, and the consequences of

diabetes. The programs were successful in changing habits and reducing risk of obesity, but it

was discovered that physical activity had a more profound change in the youths lives and results

than with dietary changes and education.

Both community and school interventions that were administered had been successful in

changing behaviors and reducing risk of obesity among children and adolescents, especially

Latino youth. Many different types of interventions were implemented, but the most reoccurring

and most effective method was physical activity.

Linking Goals and Objectives to their Theoretical Relevance

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The theoretical model that will be used for the Healthy Change for Healthy Gains

program is the Transtheoretical Model. This model explains the process of behavior change

through six stages. The six stages of change in the Transtheoretical Model are the pre-

contemplation, contemplation, planning, action, maintenance, and termination.

The first stage of the Transtheoretical Model is the pre-contemplation stage. This stage

suggests that the individual is not ready for any action or behavior change. Before Healthy

Change for Healthy Gains is implemented Latino youth in the community, the children and

adolescents are at the pre-contemplation stage where the youth are just living with their current

behaviors. Once Healthy Change for Healthy Gains has been implemented, the first step of the

program is to have health educators administer a pre-test for the participants to assess their

attitudes of healthy meals and physical activities, and record participants body mass index

(BMI) to measure change. The second step of the program is to have health educators conduct

physical and nutrition education for Latino children and their families at local parks or

community centers. This education will discuss diabetes, the risk, long-term consequences;

consequences of foods high in sugar and fat, its link to diabetes and heart disease, healthy food

options, better alternatives, smaller portions; and importance of physical activity, the benefits of

being physically active, and types of exercises the Latino youth and their families can perform.

This step will start in March 2017. The education component of the Healthy Change for Healthy

Gains program will assist the Latino children and adolescents in transitioning from the pre-

contemplation stage to the contemplation stage where the Latino youth have decided to change

their current behaviors to a more beneficial and active behavior to reduce their risk of obesity

soon.
HEALTHY CHANGE FOR HEALTHY GAINS Ta 7

The third stage of the Transtheoretical Model is the planning stage. This stage explains

that the individual is ready to plan his or her actions to change his or her behavior. After the

education component of the program, the health educators will discuss and recommend an

exercise routine and certain calorie diet to guide Latino youth. This planning process will start in

April 2017. This step addresses the planning stage by preparing the Latino children and

adolescents for a healthier behavior.

The fourth stage of the Transtheoretical Model is the action stage. This stage explains that

the individual is ready to put his or her plans into action to change his or her behavior. Activities

will begin in May 2017. Every first week of the month health educators and Latino children will

meet at local parks and community centers to follow up on the physical and nutrition education.

Every third week of the month, the Latino youth and their families can join health educators at

local parks or community centers to play and perform the Latino childrens exercise routine.

Healthy meals will also be provided for the Latino children and their families. This program

activity addresses the action stage by having the participants perform their planned exercises and

eating healthy meals to change his or her behavior.

These follow-up activities will be held every month for eight months, until November

2017. This part of the program will address maintenance, the fifth stage of the Transtheoretical

Model. The maintenance stage indicates that the individual is not just able to perform actions to

change behavior but maintain their new actions as well. These follow-up activities address the

maintenance stage by having the Latino youth manage the information provided at month one

and continue following their exercise routines and healthy eating.

The last stage of the Transtheoretical Model is the termination stage. This stage suggests

that the individual has stopped his or her old behavior and has implemented the new behavior
HEALTHY CHANGE FOR HEALTHY GAINS Ta 8

from the program into his or her life. The Healthy Change for Healthy Gains program will

determine whether the new behavior has been successfully implemented by administering a post-

test and measuring BMI at the last phase of the program.

Hypotheses to be Examined

Objective #1: By December 2017, the Latino children and adolescents will increase their

knowledge on the risks and protective factors of obesity by 10%, as measured by questions 1-10

on the post-test.

Objective #2: By December 2017, the Latino youths attitude towards physical activity and

healthy eating will be 10% more positive, as measured by questions 11-20 on the post-test.

Objective #3: By December 2017, the Latino children and adolescents will increase physical

activity and healthy eating by 10%, as measured by questions 21-25 on the post-test.

Description of Population and Method of Sample Selection

The target population of the Healthy Change for Healthy Gains program will be Latino

children and adolescents ages 5-17 attending school in Los Angeles County. The program will

accept both males and females with a maximum BMI of 29.9. The program will be administered

in areas near schools of the Latino youth participants.

A stratified random sample will be used to select a representative sample of the target

population. A stratified random sample is the best sampling method because the list of Latino

students from public schools can be used. Once a public school has been selected the Healthy

Change for Healthy Gains program will need to ask permission of selected public schools in the

Los Angeles County to provide and gain access to a list of Latino children and adolescents
HEALTHY CHANGE FOR HEALTHY GAINS Ta 9

attending that school. If a school declines to allow permission to their list of Latino students, then

another school will be selected from the Los Angeles County. Latino students randomly selected

from two elementary and two high schools will be provided with an application form that needs

to be signed by the student and his or her parent to consent to the Healthy Change for Healthy

Gains program.

Sample size needs to be calculated in order to gain enough participants to show a

significant impact of the Healthy Change for Healthy gains program on the Latino youth. Type I

error is interpreted as alpha. The program is a behavioral program, meaning alpha is always set at

0.05. Type II error is represented as beta and beta is determined by the formula B= 1-4(alpha).

Since alpha is 0.05 for this program, beta will be 0.80. The effect size is calculated by using the

smallest percent of change in the measured objectives. The lowest percent of change was 10%,

so 0.10 is used to determine the number of participants on the sample size table. The sample size

would have been 219, however; the program will need to double the amount because of an

experimental and control group, and an additional 20% of participants due to Latino children and

adolescents refusing to participant in activities, dropping out of the program, and unable to locate

or contact. With the addition of the 20% to the original 219, the sample size would be n=526.

Design of Experimental Methodology

The Healthy Change for Healthy Gains program will adopt the classical experimental

design as the experimental method. The reason for using this experimental design is because the

classical experimental design is the strongest design due to three important components: an

experimental and control group, randomization of Latino students on the two selected elementary

and high schools population list, and a pre- and post-test. Two elementary schools and two high

schools in the Los Angeles County with equal characteristics in terms of number of Latino
HEALTHY CHANGE FOR HEALTHY GAINS Ta 10

students, BMI of the Latino youth, and the type of community environment the schools are

located in will be selected as the focus of the program. One elementary school will be the

experimental group, and the other will be the control group; one high school will be the

experimental group, and the other will be the control group.

The classical experimental design controls for eight threats to internal validity: history,

maturation, testing, instrumentation, regression to the mean, selection, attrition, and interaction.

The classical experimental design controls for these eight threats to internal validity is because of

randomization; two groups, experimental and control; and a pre-and post-test. The threats to

internal validity that the classical experimental design cannot control for are diffusion,

compensation, compensatory rivalry, and demoralization. The reason that the classical

experimental design cannot control for these four threats to internal validity is because the threats

are more participant- and staff-related.

Diffusion is the when the experimental and control group interact with each other.

Information is shared between the two groups. When this happens, the control group will change

and cannot function as designated by design. The Healthy Change for Healthy Gains program

will control for this threat by separating the experimental elementary school group and the

control elementary school group, as well as separating the experimental high school group and

the control high school group so that the two groups do not interact.

Compensation is when the persons who implement the standard treatment for the control

group feels empathy for the control group because the control group is not receiving the new and

improved program. They will give more attention to the control group than the standard

treatment entails, thus; the control group will change and cannot function as designated by

design. Compensatory rivalry is when the persons who implement the standard treatment to the
HEALTHY CHANGE FOR HEALTHY GAINS Ta 11

control group get competitive with the persons who implement the new treatment to the

experimental group, so they put higher demands on the control group than entailed to motivate

the participants. The Healthy Change for Healthy Gains program will control for the

compensation and compensatory rivalry threats by training the persons who implement the

standard treatments to the control groups to be more aware of not straying away from the

standard treatment. The implementation process will also be monitored to document any

unintended changes in the protocol.

Demoralization is when the persons who implement standard treatment to the control

group quit because they feel that they cannot earn better results than the experimental group.

This feeling of deprivation will lead to not administering the standard treatment to the control

group. Thus, the control group will change and cannot function as designated by design.

Unfortunately, there is not action to counteract demoralization. However, the Healthy Change for

Healthy Gains program will monitor the implementation process and document any unintended

changes to the protocol.

Operationalization of Concepts

The Healthy Change for Healthy Gains program will use self-administered questionnaires

as the data collection method. Since the target population of the program are children and

adolescents, a self-administered questionnaire is the best form of data collection method; this

will allow the Latino youth time to finish the survey and ask questions to clarify. Having a face-

to-face interview, observing the Latino children and adolescents, and telephone interviews will

make some participants nervous and will not allow enough time for the children and adolescents

to provide an accurate response.

HEALTHY CHANGE FOR HEALTHY GAINS Ta 12

The pre- and post-test will have 10 questions to assess knowledge, 10 questions to assess

attitudes, and five questions to assess behavior change. These questions on the pre- and post-test

will evaluate any increase or decrease in knowledge, attitude, and behavior for the Latino

children and adolescents due to the Healthy Change for Healthy Gains program. The knowledge-

based questions will be in true/false format. These questions will assess whether the education

components of the program had been successful in educating the Latino youth about diabetes,

heart disease, healthy eating, and physical activity. The level of measurement for the knowledge-

based questions will be nominal. A five-point Likert Scale will be used for the attitudinal

questions. The attitudinal questions will determine any changes in attitude towards physical

activity and eating healthy due to the program. The level of measurement of the attitudinal

questions will be ordinal. The last five questions will determine whether the program was

effective in changing the behavior of the Latino children and adolescents. The level of

measurement of the behavioral questions will be interval. These answers to these questions will

be in intervals so that if the Latino youth forget the exact answers, they will be able to give a

proper estimate.

Formative Evaluation Methods Pilot Testing Procedures

A pilot test is needed to test for feasibility and efficiency of the Healthy Change for

Healthy Gains program. Feedback from the community and experts in the field will be

mandatory for the program to succeed. Community members and community leaders will be

asked about the type of environment the Latino neighborhood is and how to gain the trust of the

community. The community members and leaders will also provide insight on the Latino culture

so that the program and staff can be adapted to be more culturally competent and trusting.
HEALTHY CHANGE FOR HEALTHY GAINS Ta 13

Experts in the field will be health care providers in local clinics and hospitals around the

elementary and high schools, local health departments, and researchers that have performed

behavioral programs on Latino children and adolescents. Health care providers in local clinics

and hospitals will be able to answer questions regarding obesity among Latino youth in the

community, and discuss any barriers that the target population have that prevents them from

changing behaviors. The local health departments will be able to provide information on obesity

rates among youth, especially Latino youth. The local health department can also establish the

reason obesity rates among Latino children and adolescents differ from other ethnicities and help

link that reason to interventions of the pilot test. Researchers from previous successful behavioral

programs on Latino youth reducing obesity rates are very important. These researchers can

provide details on the reason for their success, any barriers to their program, methods that they

could have taken into considerations, and another perspective on the Healthy Change for Healthy

Gains pilot test.

Once all the feedback from the community and experts in the field are collected and

evaluated, a focus group will be made. The focus group will include approximately 20 Latino

children and adolescents. The focus group will test the interventions made from the data

collected from the community and experts in the field, and will offer their views and opinions on

what kind of recommendations can be made to ensure that the actual program will be successful

in changing behavior.

Process Evaluation Monitoring of Program Implementation

The staff of the Healthy Change for Healthy Gains program will be monitoring the

recruitment and retention of participants, implementation process, and the program budget

throughout the program. To monitor the recruitment and retention of participants, a sign-up sheet
HEALTHY CHANGE FOR HEALTHY GAINS Ta 14

will be presented at the start of the programs. This sign-up sheet will be used to compare with

how many of Latino youth have attended the activities. If the participants are not attending the

activities or participants are not participating in the activities, then the staff needs to contact the

participants parents or guardian to ask for an explanation for why the Latino children and

adolescents are not attending the activities or participating in the activities. The program

directors will use the explanations to improve the program.

To monitor the implementation process, program staff will be needed to observe persons

who implement the treatment for the experimental and control groups. The persons who

implement treatment to the experimental and control groups must be trained to implement the

program in the correct method and have to be monitored. The program staff is also recommended

to hold regular meetings with those who implement to document progress and barriers. Any

unintended observations in the implementation process will be documented to improve methods

of implementing and to improve the program.

To monitor the program budget, a budget has to be made before the program is

implemented. The program staff have to determine how much of the funding budget needs to be

distributed into certain areas and components of the program. Once a budget has been settled and

the program implemented, the persons who implement the program will report back to the

program staff to discuss what areas need more money, and which areas do not need as much

money. This will ensure the program will stay within the budget.

Rationale for Choice of Statistical Techniques

Descriptive Statistics Univariate Analysis

HEALTHY CHANGE FOR HEALTHY GAINS Ta 15

Any percentages and frequencies gathered from variables in the program will be reported

as nominal data. These percentages and frequencies will include data from bar graphs and

histograms. The mode will be reported to show the significance of that score.

Inferential Statistics Bivariate Analysis

Objective #1: By December 2017, the Latino children and adolescents will increase their

knowledge on the risks and protective factors of obesity by 10%, as measured by questions 1-10

on the post-test. The independent variable will be group membership, two categories:

experimental and control. The level of measurement of the independent variable is nominal. The

dependent variable will be one nominal variable. A Chi-square test will be conducted using

group membership as the independent variable and the question as the dependent variable, with a

significant level of alpha = 0.05.

HEALTHY CHANGE FOR HEALTHY GAINS Ta 16

Timeline

Activity Jan Feb Mar Apr May Jun July Aug Sept Oct Nov Dec

201 201 201 201 201 201 201 201 201 201 201 201

7 7 7 7 7 7 7 7 7 7 7 7
Needs X

Assessment
Program X

development
Pilot testing X
Sampling X
Pre-test X
Program X X X X X X X X X

implementatio

n
Process X X X X X X X X X

Evaluation
Post-test X
Data Analysis X X X X X X X X X X
Report X

Writing

Appendix

Pre- and Post-test/ Questionnaire

HEALTHY CHANGE FOR HEALTHY GAINS Ta 17

1) Watching TV is a good exercise. (True/False)

2) Drinking water is good for the body. (True/False)
3) Being overweight or obese can lead to heart disease and diabetes. (True/False)
4) Eating fruits is good for you. (True/False)
5) It is important to exercise every day. (True/False)
6) Playing sports is an example of exercise. (True/False)
7) Soda has lots of nutrients and vitamins the body needs. (True/False)
8) A BMI of at least 30 is considered overweight. (True/False)
9) A BMI between 25-29.9 is considered overweight. (True/False)
10) Lack of physical activity and nutritious food will result in being overweight or obese.

(True/False)
11) Exercising regularly is good for you.
a. Strongly agree
b. Agree
c. Neither agree or disagree
d. Disagree
e. Strongly disagree
12) Exercise can only be done indoors.
a. Strongly agree
b. Agree
c. Neither agree or disagree
d. Disagree
e. Strongly disagree
13) Walking is a form of rigorous exercise.
a. Strongly agree
b. Agree
c. Neither agree or disagree
d. Disagree
e. Strongly disagree
14) Having heart disease is harmful to the body.
a. Strongly agree
b. Agree
c. Neither agree or disagree
d. Disagree
e. Strongly disagree
15) Being overweight or obese can lead to complications in life.
a. Strongly agree
b. Agree
c. Neither agree or disagree
d. Disagree
e. Strongly disagree
16) Diabetes is not manageable.
a. Strongly agree
b. Agree
c. Neither agree or disagree
HEALTHY CHANGE FOR HEALTHY GAINS Ta 18

d. Disagree
e. Strongly disagree
17) Eating over the daily recommended calorie intake is fine.
a. Strongly agree
b. Agree
c. Neither agree or disagree
d. Disagree
e. Strongly disagree
18) Diabetes and heart disease are preventable.
a. Strongly agree
b. Agree
c. Neither agree or disagree
d. Disagree
e. Strongly disagree
19) A meal should consist of dairy, grains, protein, fruits, and vegetables.
a. Strongly agree
b. Agree
c. Neither agree or disagree
d. Disagree
e. Strongly disagree
20) Sugar is not addictive.
a. Strongly agree
b. Agree
c. Neither agree or disagree
d. Disagree
e. Strongly disagree
21) How often do you exercise daily?
a. Not at all
b. 1-10 minutes
c. 11-20 minutes
d. 21-29 minutes
e. 30+ minutes
22) What is your BMI?
a. 19-22
b. 23-25
c. 26-29
d. 30+
23) How many glasses of water do you drink a day?
a. None
b. 1-3
c. 4-6
d. 7-8
e. 8+
24) How often do you snack/eat junk food a day?
a. None
b. 1-2 times
HEALTHY CHANGE FOR HEALTHY GAINS Ta 19

c. 3-4 times
d. 5+ times
25) How many hours do you spend sitting, watching TV, or on the computer daily?
a. None
b. 1-2 hours
c. 3-4 hours
d. 5-6 hours
e. 7+ hours

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