Improving Student Access to Tap Water for
Transcription
Improving Student Access to Tap Water for
Improving Student Access to Tap Water for Better Health Results, Lessons Learned and Recommendations From a David Douglas School District Pilot Project MAY 2012 Dr. Tia Henderson, Upstream Public Health Stephanie Manfre, David Douglas School District Oregon’s children need better access to filtered tap water to promote health where they learn, eat and play. Upstream Public Health, a non-profit organization, is dedicated to creating the social and environmental conditions where all Oregonians can thrive. David Douglas School District, home to the largest high school in the state, prioritized improving water access for its students through policy and program initiatives. In collaboration with David Douglas School District, with funding from Multnomah County, Upstream Public Health set out to support the District’s policy efforts by providing filtered tap water to students. The partnership successfully piloted a project with multiple elements including water stations, a poster contest, nutrition education and water bottles. This document summarizes the lessons learned in implementing the pilot project in order to help other school districts learn from the experience. JUNE 2012 Improving Student Access to Tap Water for Better Health ______________________________________________________________________________ Table of Contents Acknowledgements iii EXECUTIVE SUMMARY iv Background Water and Health: Why Access is Important for Children Water Stations Policy and School Water Access Addressing Health Disparities 1 1 2 2 2 Approach Increasing Student Water Access: School Selection for Water Stations Water Station Selection Water Station Locations and Installation Evaluating Water Station Use Encouraging Student Water Consumption Student Media and Promotion Program Providing Free Water Bottles to Students Water and Beverage Related Education School Water Policy Evaluating Consumption 3 3 4 6 6 7 7 7 7 8 8 Project Challenges and Lessons Learned Water Station Siting and Installation Water Filter and Equipment Issues Water Consumption 10 10 10 11 Conclusions 12 References 12 Appendix 1 - Survey Appendix 2 - Permission Slip Appendix 3 - Poster Contest Info Appendix 4 - Poster Contest Entry Form i iv vi viii Improving Student Access to Tap Water for Better Health ______________________________________________________________________________ Acknowledgements Project Staff: Dr. Tia Henderson, Research Manager, Upstream Public Health Stephanie Manfre, Healthy Active Schools Coordinator, David Douglas School District Project Supported By: Teachers Rachel Wagner, Andrew Locke, Steve Benner, Angela Nurre Principals and Administrators John Bier, Mark Gaulke, James Johnston, Charlene Bassine, Mark Haner Project Advisors Raquel Bournhonesque, Upstream Public Health Barbara Kienle, David Douglas School District David Callaway, David Douglas School District Frank Bruno, David Douglas School District Funding Upstream Public Health, a community-based public health organization, worked with the David Douglas School District on this project. Upstream received a grant through the Healthy People Healthy Places Grant, part of Multnomah County’s Health Department’s comprehensive approach to obesity prevention funded through the Centers for Disease Control and Prevention’s (CDC) Communities Putting Prevention to Work (CPPW) Program. The David Douglas School District received a Healthy Active Schools (HAS) grant through the same Multnomah County program. Donations CamelBak, Elkay and the Oaks Amusement Skating Park For questions, contact: Dr. Tia Henderson, [email protected] Barbara Kienle, [email protected] Floyd Light Middle School - Poster Contest, Runner-Up ______________________________________________________________________________ iii Improving Student Access to Tap Water for Better Health ______________________________________________________________________________ Executive Summary Policy efforts to address the childhood obesity epidemic are more effective with on-the-ground support. Upstream Public Health partnered with the David Douglas School District (DDSD) to increase children’s access to, and consumption of, free filtered tap water during the 2011 and 2012 school years. While the focus of the pilot project activities were centered on three schools, David Douglas High School, Floyd Light Middle School and Alice Ott Middle School, this project benefitted eight total schools. The pilot components included 1) upgrading old water fountains with new water stations (see picture on page two), 2) conducting a water education and promotion campaign with a student art contest, 3) providing free water bottles in three schools, 4) gathering water volume monitoring data on water station use (pre and post), and 5) conducting a pre and post beverage consumption recall survey in the three schools to evaluate student water and other beverage intake changes. Health teachers at each school also taught nutrition units during the project’s implementation phase. The project was successful in increasing student access to, and consumption of, water. While this pilot project only studied three schools, through collaboration and funding from two grants, the project installed twelve water stations in eight schools, and dispersed 4,940 BPA-free water bottles to students. Needless to say, the water stations and bottles were a big hit with students, teachers, staff and administrators alike. The water volume data results showed that all schools increased their use of the new water stations over the project period. While the recall survey showed an increase in student water consumption for some groups, it was not across the board. Latino and White high school students reported drinking significantly more water three months after the beginning of the project. White high school survey participants reported drinking significantly fewer sugary drinks at the end of the project. Middle school survey participants did not report significant changes in water or sugary drink consumption after one month of implementing the project elements. The project encountered technical and logistical challenges including: space restrictions, old asbestos in walls, and problems with water station filters clogging from pipe sediment. Project collaborators modified initial decisions to upgrade fountains only in cafeterias and gymnasiums to a decision of being as close as possible to these locations to address space issues and have electrical access. Asbestos was safely removed following required protocols. The partners worked with various filter types and the manufacturer of the water station to arrive at a working set of filter options. There were concerns about students carrying opaque reusable water bottles, but school principals responded with a suggestion to use clear bottles. The DDSD school board also addressed concerns about water access and updated its wellness policy’s administrative rules to promote student water consumption. The policy now permits students carrying reusable water bottles at school and providing access to free water at all district facilities. All of the initial technical and logistical challenges were overcome. This project was supported by a Healthy People Healthy Places grant from Multnomah County to Upstream Public Health and a Healthy Active School (HAS) grant to the David Douglas School District. Both grants were from the Centers for Disease Control and Prevention’s (CDC) Communities Putting Prevention to Work (CPPW) Program. ______________________________________________________________________________ iv Improving Student Access to Tap Water for Better Health ______________________________________________________________________________ Background In the spring of 2010, the David Douglas School District (the district) received a Healthy Active Schools (HAS) program grant from Multnomah County. The HAS program worked in partnership with schools, community members and SUN Community Schools in Multnomah County to create policy, environmental and system changes to support healthy eating and physical activity for students. During an initial assessment of district schools and facilities related to HAS grant objectives, district staff brought up water access and availability frequently as a challenge. Because of the age of many district buildings, old pipes contributed to poor tasting water and many fountains were aged, some beyond repair. Most principals wanted increased water access as a priority goal related to the Healthy Active Schools grant. In the fall of 2010, the district began developing wellness policy language and selected a Multnomah County Health Department’s Healthy Active Schools Action Plan objective, “policies and practices that increases and promotes the availability of drinking water for students,” as part of their policy efforts. The district HAS coordinator, Stephanie Manfre, began engaging school communities to assess water access sites and needs. During this time, Upstream Public Health, an Oregon non-profit that advocates for health policy, was working to promote student tap water consumption instead of sugary drinks in schools to reduce student excess calorie intake as part of environmental efforts to address obesity. The district and Upstream formed a partnership (the partners) to increase student access to better tasting, filtered tap water through installing water stations. Additionally, Upstream worked to support the district’s development of a related to water access to incorporate into their wellness policy. The goals of this project were to: 1. Increase student and school water access, 2. Increase student water consumption, 3. Increase district-wide support for adopting wellness policy language centered on increasing water access, and 4. Develop a best practices document regarding water station installation linked to wellness policies. Upstream applied for a Healthy People Healthy Places Grants mini-grant from Multnomah County to support the district in reaching their water access goals. The project included evaluation elements to ensure the different goals were met, covered later in this report. This document on lessons learned is intended to be a tool used for Oregon school districts to extend water access for other student communities. Water and Health: Why Access is Important for Children In 2010, Section 203 of the federal Healthy Hunger Free Kids Act required that all schools participating in the national school lunch program provide children access to free, potable water during meal times. This policy is part of a national trend to turn the tide on the obesity epidemic affecting children. Childhood obesity rates have more than tripled in the last thirty years1,2. Currently one in three children and adolescents in the U.S. are overweight or obese3. In the Tri-county region, including Multnomah County, nearly one out of every four youth in 8th and 11th grade are overweight or at risk of being overweight4. Obesity is a serious problem affecting youth because these individuals are more likely to develop obesity-related chronic health issues as adults1,5. Obesity is one of the leading causes of preventable death in the U.S.6. Obesity is also a health equity issue. Children from communities of color may be more at risk of being obese, as African American, Latino and Native American adults experience a higher prevalence of obesity7. Obesity has a public cost as well as an individual one. The estimated medical costs related to adult obesity in Oregon were estimated as $781 million per year in 2004 and are most likely well over $1 billion today8. Promoting the consumption of healthy foods and beverages, such as water, is included in recommended strategies to combat obesity9. Recent studies indicate that student intake of sugary drinks such as soda contributes to weight gain10–13. Adolescents ages 12 to 19 are the largest consumer of sugary beverages, drinking an average of 220 kilocalories a day 14 . Encouraging students to drink water in place of sugary drinks can reduce the potential for child weight gain15. ______________________________________________________________________________ 1 Improving Student Access to Tap Water for Better Health ______________________________________________________________________________ Consumption of soda is also a leading contributor to dental decay16–18. Low-income children, Black/African American, non-Hispanic and Hispanic children have more than twice the rates of untreated dental decay compared to their White, non-Hispanic peers 19 . Dental problems are one of the leading causes of school absenteeism in the U.S., more common than asthma or hayfever20. Water consumption can also reduce child dental decay when children choose it over sugary drinks21–23. Beyond the obesity challenge and dental decay, all people need water to promote health. Water supplies every cell in our bodies with oxygen to thrive. Water clears out colds and other illnesses through lymph fluid, carries enzymes to digest food in the stomach and flushes toxins out of the body. Dehydration affects cognitive ability, physical performance and motor skills 24,25 . Dehydration can reduce mental performance and has most recently been tied to feeling cranky26,27. Children need filtered water to support their health for learning in school. Water Stations In this project, the partners chose to replace outdated water fountains with water stations. A water station combines a chilled, filtered water source with a water fountain and up to three water bottle filler spouts. Figure 1 shows the type used in this project. This design increases the number of physical water access sites youth can use to quickly obtain adequate servings of Figure 1: Water station water. This design improves water access in two ways. In addition to getting a drink from the bubbler fountain, youth can also fill a water bottle and keep water with them throughout the day. Policy and School Water Access Federal, state and local laws intersect in relation to water access requirements in public schools. Chapter 29 of the Oregon Structural Specialty Code Section 2903 requires that schools have one drinking fountain for each floor, regardless of school population. Oregon schools, especially larger facilities, may lack adequate water access for students. Prior to this project, the David Douglas School District wellness policy did not contain language related to water access. Under the federal 2010 Healthy Foods for Healthy Kids Act, schools are required to provide access to water during meals times. The 2004 federal Child and Nutrition and WIC Reauthorization Act required all school districts participating in federal meal programs establish a local wellness policy by the 2006 school year. These wellness policies address water access in school. Addressing Health Disparities The goals of this project were implemented in order to address health disparities and support health equity. The David Douglas School District is in an area of Multnomah County, Oregon (see Figure 2) where populations carry a disproportionate burden of poverty and health issues and communities have historically felt exclusion from accessing resources. The number of people in mid Multnomah County who meet federal poverty guidelines increased by 53 percent from 2000 to 200828. More than 70 percent of students at each school site are eligible for free and reduced lunches (see Table 2). Nearly one quarter of the student population in the district are limited English proficient and more than half are people of color (see Tables 1 and 2). Additionally, 74.1 percent of District students in 2010-2011 were eligible for free and Figure 2: Multnomah County, OR ______________________________________________________________________________ 2 Improving Student Access to Tap Water for Better Health ______________________________________________________________________________ Table 2. 2011-2012 School demographic information29,30 Table 1. 2011 - 2012 DDSD demographics29,30 David Douglas District SCHOOL Children FRL Student of Color Eligible Enrollment Total student enrollment 10,642 Total children of color 54.5% David Douglas H.S. 53.5% 70.2% 3,219 District Limited English Proficient 23.7% Alice Ott M.S. 45.3% 73.6% 739 Floyd Light M.S. 54.4% 78.9% 824 60.2% 86.9% 842 31.4% 44.2% 156 53.7% 80.1% 447 62.8% 82.2% 411 54.2% 79.9% 603 42.9% 69.4% 641 64.3% 88.5% 641 55.6% 77.8% 491 63.7% 91.1% 586 56.5% 84.8% 547 54.8% 89.3% 458 reduced meals and the district has the largest high school in the state29. The partners wanted to ensure more vulnerable students from low-income families or communities of color could have greater access to good tasting, filtered tap water and increase their water intake along with their peers. This was part of the project goal of increasing student water consumption. Based on this goal, the partners selected schools with high populations of children from diverse backgrounds. The impacted student community includes over 4700 students at three schools: David Douglas High School (DDHS), Alice Ott Middle School (AOMS) and Floyd Light Middle School (FLMS) (see Table 2). A fourth school, Ron Russell Middle School (RRMS) was compared to the participating middle schools for evaluation purposes. Each water station was located in an accessible location to ensure that all students, regardless of race, ethnicity or income, would have access to filtered water at each school. The third goal of developing a district policy related to water access also helped meet a longer-term equity goal of expanding water access to all schools across the district. Approach Increasing student water access: School Selection for Water Stations The David Douglas School District had established in previous water testing that school water was safe to drink and posed no health risks from contaminants. Although safe, feedback from students and school staff indicated that water from most fountains had a metallic taste. The district and Upstream selected three schools Ron Russell M.S. Arthur Academy Cherry Park Elem Earl Boyles Elem Gilbert Heights Elem Gilbert Park Elem Lincoln Park Elem Menlo Park Elem Mill Park Elem Ventura Park Elem West Powellhurst Elem to receive new water stations with the pilot project’s grant funds using the following criteria: 1) School had reported lack of good tasting water access. 2) S c h o o l s e r v e d l a r g e r s t u d e n t populations. 3) School had higher numbers of students eligible for free and reduced meals. 4) School had older buildings with fountains that needed to be updated. 5) School had administrative support for the other components of the project. Based on the criteria, the partners decided to use funds from both grants to install new ______________________________________________________________________________ 3 Improving Student Access to Tap Water for Better Health ______________________________________________________________________________ hydration stations with cold, filtered water at eight schools: Alice Ott Middle School, Floyd Light Middle School, Ron Russell Middle School, David Douglas High School, West Powellhurst Elementary, Menlo Park Elementary, Ventura Park Elementary, and Cherry Park Elementary. Overall, through the collaboration and funding from two grants, twelve Elkay water stations were installed. In addition to the water stations, the district’s HAS grant also supported purchasing water containers and reusable plastic cups for all ten elementary school cafeterias, along with the Fir Ridge Campus, an alternative high school. Another HAS coordinator at a neighboring district had made similar purchases for schools and was able to share lessons learned. Prompted by the new federal School Lunch Program (SLP) requirement that all students have access to water during meal times, and given the fact that not all district schools had water fountains located within cafeterias (or if they did, the fountains were old and students did not have day-long access), the purchase of water containers allowed for all students to have access to fresh water in the cafeteria during the school day. Each cafeteria was provided with a rolling cart, refillable water containers that could be stored in the kitchen or in walk-in refrigerators to keep water cool, and 100 washable plastic cups. Water Station Selection The project team considered three potential types of water stations for this project (see Figure 3). Project partners wanted the stations to be compliant with the American Disabilities Act to ensure all students could have access. Affordability was also a factor in deciding on which station to use. The concept of affordability included the initial price of the unit, price of replacement filters, price to hire any out of district contractors, costs of new infrastructure changes and the cost of installation in labor and other parts. The David Douglas School District has an electrician and a plumber that can complete installation, but all new sewage drains have to be permitted through the City of Portland. This permitting can involve time delays and require out of district contractors, which might cost more than in-district staff. The district wanted to limit additional costs where possible. Figure 3: Water station options in this project All fourteen schools in the David Douglas School District have water fountains in a hallway or classroom and seven have them in a cafeteria. The quality and age of the water fountains varies. There are 43 water fountains in the high school campus including north and south buildings, the performing arts center and the district offices. Alice Ott Middle School has six fountains. Floyd Light Middle School has nine fountains. Ron Russell has seven fountains. The water fountains in all schools range in type from old-style ceramic bubblers without filtration or cooling units to modern steel bubblers (see Figure 4). Prior to this project, none had water bottle fill options and few were filtered and chilled. The discussion built on previous district efforts examining water quality at different school sites and making upgrades, such as Figure 4: Older water installing water filters or chiller fountains in David units in other buildings. Douglas School District ______________________________________________________________________________ 4 schools. Improving Student Access to Tap Water for Better Health ______________________________________________________________________________ The district operations partners wanted to be able to retrofit or replace existing water fountains rather than install new plumbing in new locations on school campuses to use resources efficiently. Another factor contributing to ongoing maintenance costs is if water station units or components that could be easily tampered with, and if so, could be easily replaced for low cost. Upstream partners wanted a design that would provide both a water fountain and a water Criteria ADA compliant? bottle filler option so that students could carry water with them and reduce waiting time in lines. Each of the three water stations were reviewed based on these and other criteria presented in Table 3. The project partners chose the Elkay EZ H2O unit, as it fit the best with project goals. Table 3 Water station selection and criteria Elkay EZ H2O Bottle Filling Station Brita Hydration 2000 Multi-Faucet or water fill w/ Single Sink ✓ ✓ Would need to install foam padding beneath sink and put chiller in cabinet Requires additional plumbing or a drain? no no Each separate sink requires its own drain; this requires permits from the city; any city permitted process requires hiring a non-district contractor (higher costs) Requires electricity? ✓ ✓ ✓ Has filtration unit w/reasonable gallon capacity? ✓ (1.1 gal/minute chilled; change every 3000 gals) ✓ ✓ Has chiller unit w/ reasonable gallon capacity? ✓ ✓ 2 gallons/minute Are the parts likely to be vandalized? Similar to existing fountains Plastic housing in wall Are breakable parts easy to replace? Similar to existing Spigots – could be a challenge Yes, but may be frequent Water monitor? Built in (12 oz counter) None Add-on Accessibility of filter? Under unit Behind wall Under unit Approximate Estimate Costs Unit ~ $1040, replacement filters $100, installation and materials $500 ~ $1640 Unit $2150, chiller $945, replacement filters $80, installation $500 =~ $3675 $640 infrastructure, initial filter $150, replacement filters $62, chilling unit $700 (12 gallons/hour), labor $500= ~ $2052 Final choice Selected this one Price higher than we could pay Can’t install new drain – this is out Narrow ¼” drain easy to clog; plastic spigot lever can break off ______________________________________________________________________________ 5 Improving Student Access to Tap Water for Better Health ______________________________________________________________________________ Water Station Locations and Installation Before being awarded the grant, the partners identified a few potential sites near school cafeterias and gymnasiums that would provide all day access to children and potentially at meal times or during physical activity before being awarded the grant. After Upstream received a grant, the district plumber and electrician completed extensive walkthroughs of various sites at each of the three schools with photos to help the partners better understand the best potential sites at each school. The plumber and electrician provided cost estimates for replacing or retrofitting existing water fountains with the new water stations based on supplies, materials and labor. installed additional fountains at the DDHS; the Alice Ott, Floyd Light and Ron Russell middle schools, and the Cherry Park, Menlo Park, Ventura Park, and West Powellhurst elementary schools. In total, twelve water fountains were installed in eight schools from the Upstream Public Health and David Douglas School District collaboration and two grants. Ron Russell received a water fountain as a thank you for participating as a comparison control school in this project. Measuring Water Station Use Water monitors measured large increases in water use. The partners installed HM Digital water monitors in each water line in existing water fountains at FLMS, the DDHS, AOMS and RRMS to record fountain water use. The monitors remained when the old fountains were replaced with the water stations. Upstream collected water volume data approximately every two weeks for one month before and several months after the water stations were installed. In conducting the walkthroughs and completing the estimates, the partners determined some of the potential sites were unworkable because they required opening solid or brick walls, which would be too costly. The final location of each water station was based The water readings were on 1) proximity to high traffic challenging to collect as the areas with day-long access such monitor sometimes stopped as the cafeteria or the gym, 2) working, batteries were taken access to existing plumbing, Figure 5: Example locations of new from the units and the water drainage and electricity, and 3) water stations at FLMS and AOMS station filters suffered technical space to accommodate the problems. Upstream did not chiller unit without having to open solid walls. include inaccurate monitor readings before The grant project budget included funding for conducting Wilcoxon Rank Sum tests on the data repairs and a year’s worth of replacement water at FLSM, AOMS and the HS. The water monitor filters to help the district cover intermediate results indicate the school populations at the upkeep of the water stations. high school and at FLMS used the new water stations significantly more than the previous The district staff installed water fountains at water fountains (p< 0.01). At AOMS, the average AOMS and FLMS in April of 2011 and one at water usage from this fountain doubled after DDHS in the summer of 2011 (see Figure 5). The installation, but the difference was not first DDHS fountain was located near the north statistically significant, likely due to technical cafeteria, the first AOMS fountain was in a challenges with the monitor. The control school hallway, and the FLMS fountain was near the monitor readings did not show changes in water front office that children pass on the way to the fountain volume flow during the project. cafeteria. Using the HAS grant, the district ______________________________________________________________________________ 6 Improving Student Access to Tap Water for Better Health ______________________________________________________________________________ Student Perceptions The water stations were a big hit with students, teachers, staff and administrators alike. As one high school student said, "there's a huge crowd of students around every lunch who want to get the clean, filtered water and not the zinc-y, metal-y water." This project used multiple strategies, all of which support student water consumption. The project provided technical assistance for policy development, installing water stations, a water-bottle give-away and an education campaign that included youth developing media and water slogans that were displayed above each new water station. Student Media and Promotion Program During the spring of 2011, Upstream Public Health worked with principals, teachers and staff at AOMS, FLMS and DDSD to hold a water poster contest to generate and promote youth-oriented messages about health and water consumption (see Figure 6). Upstream staff presented contest forms and educational materials to several student classes and to staff to encourage participation (see Appendices 1 and 2). Figure 6: Winning entry from Upstream staff, the DDHS: “I got that H2O that district HAS Coordinator future flow”, FLMS: “Start with and teachers judged the tap”, and collage of entries entries to select winners and runners up. Upstream received donations from the Oaks Amusement Park Skating Rink and purchased Jamba Juice gift cards for winners and runners up. Students at AOMS and FLMS used other entries to create large collages that they hung in the cafeteria and hallways. Upstream posted winning entries on banners above the new water stations in spring and fall of 2011 (see Figure 6). Providing Free Water Bottles to Students Upstream ordered water bottles for AOMS and FLMS from American Promotions. The company was able to print a one-color designed version of each winning student artwork on the bottles at each school (see image Figure 7). Students, administrators and teachers who worked on the project received the new water bottles. The bottles and water stations were well received. One viceprincipal remarked “I was amazed how many of our s t u d e n t s appreciated getting the bottles and how nice they were – thanks again.” Figure 7: Water bottles with winning art from DDHS and Floyd Light MS (left, right). Water and Beverage Related Education This project integrated promotion and health education into environmental and policy change elements because research indicates that adding these elements significantly improves youth water consumption through hydration stations31. The water poster contest included educational information and winning entries were also supportive of water and health messages (see Appendix 3). The poster contest and display of winning entries corresponded with nutrition curriculum in the schools. In the 2010-2011 school year, seventh grade health students learned about water and health during the spring of 2011 as part of the nutrition health curriculum. In the fall of 2011, high school health students learned about nutrition, obesity and the health risks of soda consumption. One health teacher is also the chair of the David Douglas High School health department and thus had influence on translating the program on the ground to other faculty. ______________________________________________________________________________ 7 Improving Student Access to Tap Water for Better Health ______________________________________________________________________________ School Water Policy In August, 2011, the Healthy Active School Coordinator Stephanie Manfre presented new policy language based on best practices to the school board. The school board made changes to their administrative rules language related to water and other wellness areas. Elements of the new language that support water access are italicized below: The district recognizes that children need an ongoing water supply to keep their bodies functioning optimally and to avoid dehydration. Therefore, the district will promote the consumption of water as an essential nutrient that plays a role in overall health and will provide all students and employees with access to clean and safe drinking water free of charge at all district facilities. Students will be permitted to carry water bottles while at school. While not a defined policy, kids are generally not allowed to have opaque water bottles at school. We showed principals images of a transparent and slightly tinted water bottle and many found this acceptable. One principal preferred a completely clear water bottle to ensure that inside contents were easily identifiable. Student Beverage Consumption Changes The project was successful in changing some student’s water and soda consumption based on survey responses. Upstream gave an adapted version of beverage consumption questions from the Oregon Youth Risk Behavior Survey (YRBS) to a sample of health students at FLMS and DDHS (see Appendix 1). Middle school students took the pre surveys in early April and the follow up in late May; high school students took the pre survey in early October and the follow up in midDecember of 2011. Upstream added modified YRBS format questions to better understand the quantity of water students consumed. Ron Russell Middle School agreed to administer the pre and post survey to their students during the same time period to help the evaluation as a control school. Upstream provided the school board with a description of the project, the survey and a parent permission form to follow best human subjects practices (see appendix 2). Upstream performed Pearson chi-square or Fisher’s exact tests on student survey response "There's a huge crowd of students around every lunch who want to get the clean, filtered water and not the zinc-y, metal-y water." - high school student data to see if there were any differences in beverage consumption before and after the intervention. Upstream used three categories of beverage consumption frequency as outcome variables: low (1-3 times in past 7 days), medium (4-6 times in past 7 days), and high (at least once a day). Middle school student responses did not show a change in overall student water intake among participants. Student responses showed pre-existing differences in water consumption between the schools. Survey participants at Floyd Light were 1.9 times more likely to report consuming water at least once a day compared to their peers at Ron Russell M.S. both before and after the project elements were in place. There were no significant reported changes in consumption of any beverage in the middle school survey participants. This may be due to the pre and post survey being spaced only one month apart. When all high school students were grouped together, there were no significant changes in student reported water consumption in the three months between the pre and post surveys. However, when we examined student reported behaviors among different populations, Pearson chi-square analysis found the number of Hispanic and white high school students drinking at least 8 oz of water a day increased significantly (P<.05) from pre to post survey. Other students did not report a significant change in daily water consumption including Asian/American Asian, Black/African American, or Native Hawaiian and Pacific Island adolescents. Strangely, the number of American Indian/Alaskan Native students reporting daily water consumption decreased between the pre and post surveys; however this ______________________________________________________________________________ 8 Improving Student Access to Tap Water for Better Health ______________________________________________________________________________ those who reported not drinking lowsugar flavored beverages in the past 7 days increased from 53% to 62%. The number of Hispanic and white high school students drinking any amount of soda decreased significantly (p<0.01). The findings are most likely related to the combination of messages students received through the promotion contest materials and existing nutrition curriculum in health classes. Contest participants used art to show linkages between health and water consumption. Many entries focused on how water is related to obesity through displacing sugary drink intake. The increase in the number of high school Hispanic/Latino and White students reportedly drinking water and less of them drinking soda is a positive indication the project helped increase water consumption while also potentially lowering some student’s intake of calories from soda. The reduction of calories from soda is related to weight gain, and the sugar in soda is associated with diabetes and dental decay – two pressing health issues for children in Multnomah County. Survey responses did not show significant changes in the number of African American/Black, Native Hawaiian and Pacific Islander, or Asian/American Asian students changing daily water or soda intake . Students with water bottles and poster finding should be interpreted with caution as the the sample size was very small (less than 20). Overall, the number of high school students reporting drinking any soda or at least one soda a day, any or daily consumption of other sweetened beverages, and any consumption of low-sugar flavored drinks significantly decreased after the project elements were in place (p<.001, p,<.01, p<.001; p<.02, p<.01 respectively). The share of high school students who reportedly did not drink soda in the past 7 days increased from 25% to almost 39% at follow up; those who reported not drinking sweetened beverages in the past 7 days increased from 47% to 61%; and There are other factors beyond this pilot project that can affect student reported intake of beverages such as household income and access to healthy options. While we could not look at all factors, Upstream used multiple logistic regression models to examine how student race, time, and container size were associated with the frequency of student intake of four drinks. After controlling for potentially confounding variables, Hispanic/Latino and African American students had a lower odds of drinking water every day (OR 0.86 not sig., 0.49 p<0.01, respectively). Although not significant, Asian/American Asian, Native Hawaiian and Pacific Islander and American Indian/Alaskan Native had a higher odds of drinking water every ______________________________________________________________________________ 9 Improving Student Access to Tap Water for Better Health ______________________________________________________________________________ day (OR 1.03 - 1.10). Students drinking soda every day was not strongly related to time (OR 0.41, P<0.01). Time was associated with the potential for students to report drinking water every day (OR 1.27, p,0.12) although it was not significant. Students drinking soda from a 20oz container had a greater odds of drinking soda every day (OR 2.41, p<0.01) than if they did not use this larger portion size. This is important because if students could reduce their intake of by 110-165 calories a day it can help them stay at a healthy weight or lose pounds (based on a 3,500 calorie diet leading to one pound of weight a day)32,33. Students drinking caffeinated drinks or low sugar flavored drinks every day had a greater odds (OR 3.30, 3.72 p<.01 respectively) of drinking soda every day than if not consuming those drinks. Project Challenges and Lessons Learned This project would not have been feasible without collaboration among school administration and school district departments. The district Student Services Director, the Operations Manager, and the Healthy Active Schools Program Coordinator thought this project would help build support for the district wellness policy development process. During the water access project, the open communication among the district plumber, electrician, Operations Manager, the HAS Coordinator, school principals, and Upstream staff ensured the project could address challenges as they came up. These individuals worked to make decisions based on feedback from school and district administrators. Water Station Siting and Installation The partners recommend that schools involve principals and maintenance staff early on when developing plumbing, electrical and other cost estimates prior to applying for grants to fund water station installation projects such as this one. An initial challenge the partners faced was finding sites with all day access that met other criteria such as existing electricity, plumbing, drainage, space for a chiller unit and non-solid walls. The partners chose to upgrade existing water fountains so no walls would have to be opened or new plumbing and drainage installed. This helped keep additional installation costs down, however, it also limited new station locations. We created initial estimates based on input from maintenance before applying for the grant and had to revise these significantly based on perspectives from school principals. Two of the locations we were considering turned out to be unfeasible due to infrastructure. We then had to select new sites and create new cost estimates two months into the project. If applying for grant funds, we recommend working through the station siting criteria and getting agreement from district facility staff and school principals before establishing the budget. The partners checked in with each school principal about potential water station sites before finalizing location of water station decisions. These conversations helped ensure the partners were locating each station in a spot that fit with school needs and all day access. This was a successful method and one others should use in the future. It is also beneficial if districts and schools work with in-house specialists as much as feasible for scoping each location, installation and replacement of filters or other broken parts. When the project encountered challenges, being able to work consistently with the same people helped each person build their knowledge base and fostered creative problem solving. The project was affected by school timelines and workload of operations staff. Timelines for installation need to take into account doing major work on days and at times when children would not be exposed to noise and dust (i.e. a hallway outside a cafeteria). During installation, our plumber had to remove asbestos. While this is common for old buildings, it is something to keep in mind in terms of safety and disposal. Water Filter and Equipment Issues The project encountered challenges with water fountain operation. The filters in the units clogged up earlier than expected or as advertised. This resulted in slower water flow and ______________________________________________________________________________ 10 Improving Student Access to Tap Water for Better Health ______________________________________________________________________________ longer student lines to use the fountains. Principals were frustrated with this until the problem was solved. Through trial and error, repeated problem-solving discussions and listening to partner concerns, the grant partners found viable solutions to each of these challenges. We learned that the Elkay units had sensitive filters that were clogged from common, harmless sediment in our public water sources. Old plumbing in buildings and city pipes as well as particulate from the Bull Run Watershed contributed to this challenge. We learned that other school districts installed sediment filters with each Elkay unit. Sediment filters are installed outside of the Elkay unit so that water travels from the main plumbing system, through the new filter, into the Elkay unit. School district staff worked with Upstream Public Health to try several filter options in combination with the existing internal Elkay filter including a sediment sieve, a sediment filter, a separate “pre-filter”, and replacing the original filter with a new Elkay prototype filter. Two of these filtration options worked well: 1) the use of an external presediment filter in addition to the internal original Elkay filter and 2) substitution of the original Elkay filter with a new prototype from the manufacturer. The use of a pre-sediment filter with the internal Elkay filter was considered a secondary option because of the additional infrastructure maintenance (it was housed in a locked wooden box mounted to the wall beneath each unit), added time, and additional cost to change an external filter at a different time than the internal Elkay filter. The external unit used wooden housing and piping subject to student vandalism (e.g. being kicked) that could result in additional repair. In an act of support, the Elkay manufacturer donated all existing prototype filters to David Douglas and Portland Public School Districts. The manufacturer only had twenty left for limited testing, and all were distributed to two local school districts, including David Douglas. The district plans to use these prototype filters on units that structurally cannot accommodate the secondary pre-filter option (e.g. because of a brick wall exterior or lack of space beneath the unit). This grant provided funds to supply original Elkay filters and pre-filters for those models that will continue to use this secondary method for at least one year after the grant ends. When the original Elkay filters run out, the district will switch to purchasing the new prototype filter. The new version is approximately the same price as the original filter. Another unexpected technical challenge is the need for a snubber to accompany the water stations. The snubber keeps the ground fault interrupter from tripping. Without this part installed, the solenoid valves in the fountain and the bottle filler tend to trip the breaker on the outlet. It is not hard to install on site, but if one does not know about it at the onset, it can lead to thinking that there is either a problem with the unit or the outlet. Elkay sent the snubbers at our request, we recommend asking for these if they are not included in the purchase of a unit. One middle school has wood floors under the existing water fountain. The principal was concerned that two water sources at the same location (instead of the original bubbler) would increase the likelihood of spills and water damage. At the middle school with a wood floor in the cafeteria, operations staff keep a “caution wet floor” sign up in front of the water fountain at all times and a towel on the ground to absorb any spills. Even with the challenges faced by the installation of the water stations, they proved to be a tremendous success and very popular with students and staff alike. Winning entry from AOMS Water Consumption The main challenge related to water consumption in this project was the need for clear water bottles. School principals were concerned about the potential for students to bring in unsanctioned beverages on campuses. Schools in this project sell water in clear bottles ______________________________________________________________________________ 11 Improving Student Access to Tap Water for Better Health ______________________________________________________________________________ through vending machines. Providing clear water bottles for regular use was a method to address principals’ concerns while also giving students more options for accessing water during the day. Based on results from the water consumption survey, installing water stations and providing students with water bottles can encourage more students to drink water. The promotion program was limited to messages linking health, water and obesity. Other projects building on this work would benefit from tailoring project elements to the unique needs, interests and concerns of specific at-risk youth such as Black/African American or Asian and Pacific Islander students. In the HAS grant project, the new water containers led to a few water spills and unintended student movement during lunchtime at the elementary school level. The Healthy Active Schools Coordinator was able to work with both Nutrition Services and school staff to address these challenges. In addition to being available during lunch, the water containers and cups were also made available at dinner provided by SUN after school programs at several schools. Students created colorful signage and hung them above the water carts to promote the water opportunity. Conclusions This relatively short project successfully helped expand access to chilled, filtered tap water at three schools serving high need students in the David Douglas School District. These simple elements - water fountains, water bottles and policy supporting water access - can help more students drink water for health. This project was successful in encouraging more students to drink water and had the second unexpected benefit of helping students drink less soda. This secondary benefit was likely due to the nutrition curriculum taught in health classes. The involvement of the operations staff, invested school and district administrators, participation of the HAS coordinator, and support from health and leadership teachers at each school, was instrumental for ensuring each project element was in place. This project could not have been realized without support from district operations and administrative staff including Stephanie Manfre and Barbara Kienle’s support at the administrative level. Frank Bruno and David Callaway were critical for problem solving and siting the water stations. Principals John Bier, James Johnston, and Mark Gaulke helped with water station siting and operations issues; and Elkay manufacturing was willing to help us address the Elkay filtration problem. The David Douglas School District understands that many of its students are at risk for obesity and other chronic diseases and potentially lack adequate resources for achieving a healthy lifestyle. Through the participation in the Healthy Active Schools grant, the district has shown a commitment to increasing supports and access to healthy options, including access to filtered, chilled tap water. In addition to the Healthy Active Schools partnership, the district has Multnomah Schools Uniting Neighborhoods (SUN) Programs at nine of fourteen schools, including the two selected middle schools, and David Douglas High School, which provide before and after school, summer, and evening programs including academic support, sports and extra curricular activities, family engagement and health and social services for students and their families. 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Science. 2003 Feb 7; 299 (5608): 853-855 ____________________________________________ Appendices Appendix 1 – Survey Appendix 2 – Permission Slip Appendix 3 – Poster Contest Info Appendix 4 – Poster Contest Entry Form ______________________________________________________________________________ 14 Improving Student Access to Tap Water for Better Health ______________________________________________________________________________ 1. ____________________________________________________________________________ i Improving Student Access to Tap Water for Better Health ______________________________________________________________________________ 1. ____________________________________________________________________________ ii Improving Student Access to Tap Water for Better Health ______________________________________________________________________________ 1. ____________________________________________________________________________ iii Improving Student Access to Tap Water for Better Health ______________________________________________________________________________ 1. ____________________________________________________________________________ iv Improving Student Access to Tap Water for Better Health ______________________________________________________________________________ 1. ____________________________________________________________________________ v Improving Student Access to Tap Water for Better Health ______________________________________________________________________________ 1. ____________________________________________________________________________ vi Improving Student Access to Tap Water for Better Health ______________________________________________________________________________ 1. ____________________________________________________________________________ vii Improving Student Access to Tap Water for Better Health ______________________________________________________________________________ 1. ____________________________________________________________________________ viii