Underlying Theory: The Out of School Nutrition and Physical Activity (OSNAP) Initiative’s strategies to increase drinking water access uses theoretical constructs from the social-ecological model and Community-Based Participatory Research (CBPR) principles. To prepare the participating sites for program implementation, the OSNAP research team used the model for collaborative quality improvement. This collaborative quality improvement model is based on the Breakthrough Series (BTS) developed by the Institute for Healthcare Improvement and uses learning communities as the vehicle for helping programs to select and implement goals.
Strategies Used: The OSNAP initiative to increase drinking water access includes strategies that target:
- Changing Access and Availability to Favor Healthy Foods and Beverages
The primary focus of this policy and environmental change effort was to work with the Boston Public School system (BPS), the afterschool programs, and the BPS Food and Nutrition Services to create and implement afterschool program-based policies through the learning communities to increase access to water and decrease access to sugar sweetened beverages at afterschool snack time. This was done in a variety of ways to fit the circumstances of individual schools but primarily involved replacing juices with water on the menu and providing pitchers/coolers of water with recyclable cups during snack time.
- Food and Beverage Marketing to Favor Healthy Foods and Beverages
Social marketing and education strategies were used to emphasize the value of water as a substitution for sugar sweetened beverages during the learning community (reaching teachers and staff). In some sites, students were engaged in art activities and weekly water helper duties to increase their enthusiasm for drinking water, and the beverage changes were communicated to families as part of school program events and newsletters.
- Social Support for Healthy Eating
The social marketing and education strategies described above were designed to increase social support for water consumption from parents, school staff, and other children. Also, because this effort was part of a larger learning community, there was a greater sense of ownership of the larger project to improve nutrition and physical activity at the programs.
Research Findings: The OSNAP intervention was tested in a randomized controlled trial.
Twenty afterschool programs in Boston were randomly assigned to the intervention group or a delayed intervention control group (10 sites in each group). Sponsoring agencies responsible for the afterschool programs included the YMCA, Boys & Girls Club, and Boston Center for Youth and Families. Prior to randomization, sites were matched on the type of agency overseeing the afterschool program, snack provider, physical activity facilities, and school-level race/ethnicity, and socio-demographic composition. Sites assigned to the control group were given the opportunity to participate in the intervention the following school year.
Primary and secondary outcomes of the OSNAP intervention related to drinking water access included average changes in: 1) ounces of water served at snack per day (primary); 2) beverage calories served at snack per day (secondary); 3) ounces of juice and milk served at snack per day (secondary); and 4), number of times each beverage was served at snack per day (secondary). Trained observers (blinded to the study group assignment) observed snack serving on 5 consecutive days at both baseline and follow-up. All sites completed the study.
Of the planned observation days (100 total), 97 were completed (3 sites were observed for 4 days instead of 5 because of holiday schedules). After 6 months, the comparison of afterschool programs in the study intervention vs. control sites showed:
- increased volume of water served by a mean of 3.6 oz. per day per child;
- decreased calories from beverages served by a mean of 60.9 kcal per day; and
- increased frequency of water being served to children by a mean of 0.6 times (or 3 additional times over a 5-day school week)
All of these outcomes were statistically significant. Milk servings decreased by a mean of 0.3 servings per day, but this change achieved only borderline statistical significance. Servings of juice were not significantly reduced with a mean change of 0.2 servings per day.