Effect of School-based Wellness Intervention in 7th Graders on Stage of Change for Lifestyle Behaviors: The MATCH Program

Objective: For the MATCH intervention, assess concurrent validity of a single item Stage of Change (SOC) measure and association with effectiveness. Methods: Observational pre, post intervention study in 17 schools in North and South Carolina. Subjects included 908 youth with all measures (908/1,468=62%) who participated in an interdisciplinary seventh grade wellness program called Motivating Adolescents with Technology to Choose Health (MATCH). Measures included: Pre and Post-MATCH self-reported SOC, frequency of fruit and vegetable intake (F/V) and Physical Activity (PA) and measured Body Mass Index z-score (zBMI). Concurrent validity was assessed using Wilcoxon rank tests (pre-action vs. action SOC category for F/V and PA at preand post-MATCH) and Spearman correlations (between change in SOC, F/V and PA). Change in SOC category distribution was assessed with McNemar’s test; association between change in SOC and change in zBMI was investigated with multiple regression. Results: Both PA and F/V were found to be statistically significantly higher for students in the action SOC category (p<0.0001). Greater increase in SOC was weakly associated with a greater increase in PA (correlation 0.1069, p=0.0013). Participation demonstrated a shift in SOC post-MATCH (% in “action” SOC 47% pre, 53% post; p=0.003). ZBMI decreased significantly from preto post-MATCH (p<0.0001). A significant association existed between baseline SOC and change in zBMI: students with higher baseline SOC tended to have more decrease/less increase in zBMI (all overweight subgroup, b=-0.040, p=0.0108). Limitations: lack of a control group, survey questions not validated for individual behavior change. Conclusion: The SOC measure appears to be valid. Participation in MATCH may improve SOC and baseline SOC may predict increased effectiveness; however this result must be considered cautiously in this observational study.


Introduction
Childhood obesity is a major public health problem in the United States. Even though the rates of obesity among youth have not changed significantly between 2003-2004 and 2011-2012, the reported prevalence rates remain considerably high at 17% [1]. Combating childhood obesity requires modifying behaviors on both sides of the energy equation, dietary intake and Physical Activity (PA) [2]. The public school system can serve as an effective medium for behavioral interventions to reach large numbers of students. There is increasing evidence to suggest school-based interventions, especially in elementary grades, targeting dietary and PA behaviors contribute to a Body Mass Index (BMI) reduction in children [3], although less is known about the effectiveness of school-based intervention in middle and high school grades [4,5].

Transtheoretical model
The transtheoretical model (TTM) provides a reasonable framework for designing school-based interventions. The TTM was described and applied originally for behavior change in adults for addictive and specifically smoking behaviors [6].
considering change in the next 6 months. Those in the preparation stage have a plan to change within the next month and are therefore, the ideal candidates for recruitment into a behavioral intervention [12]. Since adolescence is commonly referred to as a period of growth and change, a SOC-based intervention implemented during middle school is particularly appropriate as adolescents are likely to identify with the change process [13].
Furthermore, SOC incorporates an individual's attitude and motivation to change, important factors for behavior change [14]. Despite SOC being especially appropriate for adolescents, to date there have been few school-based interventions based on the construct. A review of 11 interventions between 1999 and 2004 yielded only one intervention based on TTM [15] and it did not study SOC associations with BMI [8]. To our knowledge, SOC in adolescents participating in a school-based, educational-behavioral intervention with BMI z-score as an outcome has not been reported previously.

Intervention
Motivating Adolescents with Technology to CHOOSE Health (MATCH) is a school-based interdisciplinary obesity intervention designed to improve nutrition and PA habits in seventh grade students. Key components of MATCH have been described previously [16]. MATCH leverages constructs from both Social Cognitive Theory (SCT) [17] and Self-Determination Theory [18,19].
Also a key component of MATCH, self-efficacy is a shared construct between SCT and TTM. In MATCH self-efficacy develops through learning behavior modification strategies, such as self-monitoring and goal setting, integrated with lessons on nutrition, PA, and technology that align with the Standard Course of Study [16,20]. After findings from a pilot study of MATCH in a single school with high rates of obesity demonstrated improved BMI measures in both short and long term results when compared to a national comparison group [16,21], the MATCH intervention expanded to include more schools. In the 2013-14 year of MATCH in 17 schools, a new question (described in detail below and in Table 1) was added to the pre/post lifestyle behavior survey completed by students that assessed SOC for nutrition and PA behaviors.

Stage of Change Question Category
Which statement best describes your intentions regarding your health?
A. I have no interest in starting to become more physically active or eating healthier in the next 6 months. Precontemplation B. I am thinking about starting to become more physically active and eating healthier within the next 6 months. Contemplation C. I am planning to start becoming more physically active and eating healthier in the next 30 days. Preparation D. I have been more physically active and eating healthier in the past few months (less than 6 months). Action E. I have been more physically active and eating healthier for more than 6 months now. Maintenance

Fruit and Vegetable Question
How many servings of fruits or vegetables do you eat daily? Do not count french fries.

Staging algorithms
An important component in an SOC-based intervention is identifying a staging measure to accurately classify participant SOC. However, a common challenge with assessing interventions based on stage theories is the lack of valid staging algorithms [22]. A variety of approaches for measuring SOC have been described and the most commonly studied are multi-item algorithms [23]. Multi-item staging based on specific behaviors related to weight loss is thought to have greater reliability and utility than staging based on single items related to global constructs [24]. However, the incorporation of lengthy, complex algorithms that measure SOC for just a few behaviors into established questionnaires is not always feasible due to time and length constraints. In adults regarding staging for PA, a few studies have demonstrated promising results that a single-item format with 5-choice responses, each choice representing a SOC, has been effective [25,26]. The lack of consensus for measuring SOC for PA and dietary behaviors in adolescents underscores the need to examine the validity of a single-item SOC measure that identifies intentions towards becoming more physically active and eating healthier.

Study objectives
According to TTM, self-reported engagement in PA and consumption of fruit and vegetable intake should be higher for those in "action" (action and maintenance) stages of change than those in "pre-action" (precontemplation, contemplation, and preparation) stages because those in the latter stages are actually modifying their behaviors in an attempt to change. This assumption has been supported by several published studies [23,26,27] and served as the rationale for this study design aimed at determining the validity of the SOC survey question in assessing readiness to change dietary and PA behaviors. Therefore, the purpose of this study in young adolescents participating in the MATCH intervention is three-fold; to determine 1) the validity of the single-item SOC survey question, 2) if MATCH participation was associated with a change in SOC, and 3) associations with baseline and changes in SOC and changes in BMI z-score.

Methods
Design: Observational cohort pre, post intervention study.
Sample: During the 2013-2014 school year, 13 North Carolina (NC) and 4 South Carolina (SC) middle schools with a high prevalence of obesity implemented the MATCH intervention. All students enrolled in regular seventh-grade classes were exposed to MATCH in regular school activities. Sample size was predetermined by the number of students in seventh grade at each school; however, only data from students with both parental consent and student assent were included in the study.
Measures: MATCH outcome measures and procedures have been described previously [20,28]. Birth date, gender, and ethnicity were obtained from school files. Age was determined from date of birth and date of measurement. Height and weight measurements were obtained privately by trained school staff following a protocol and after viewing a training tutorial on accurate measurement. For all measures students were dressed in school uniforms or standard school attire with shoes off. Weight was measured using a calibrated scale (HealthOMeter 349KLX, ScalesGalore) and height was measured to the nearest ¼ inch with a constructed, wall mounted stadiometer. Stadiometers were constructed by attaching a commercially available construction-grade measuring (1/8" increments) stick to a piece of lumber (2" x 6") that was mounted to a wall in each school flush with the floor. A groove adjacent to the stick was milled into the wood so that a carpenter's "speed square" fit into the groove, allowing the square to easily slide and rest on the head of a student being measured and maintain a right angle from the stick. BMI was calculated from height and weight measurements. Standardized Center for Disease Control (CDC) charts were used to determine BMI z-score and BMI percentile for age and gender [29]. Weight category (underweight <5%ile; healthy weight 5-<85%ile; overweight 85-<95%ile; obese ≥ 95%ile) was determined using current CDC definitions. All students were provided a 35-item Sleeping, Eating, Activity, and Technology (SEAT) online survey at baseline and postintervention. Responses to three of the SEAT questions are the focus of this paper and are investigated in this analysis. The first question assesses PA and is a validated question that comes from the 2007 Youth Risk Behavior Survey. The other two questions were created de novo for MATCH; one queries fruit and vegetable intake, [30] and the other assesses SOC and was a new question added during the 2013-14 MATCH year. The singleitem SOC question and response options can be found in Table 1 and is described in more detail below.

Stage of change:
The SOC survey question and response choices are depicted in Table 1. Students were asked "Which statement best describes your plans regarding your health?" Students had the opportunity to respond with one of the five multiple choice answers (letters A-E). The following algorithm was used to evaluate responses. Responses A-E were assigned values as follows: A=0, B=1, C=2, D=3, E=4. The scoring from 0-4 corresponded to the following stages: pre-contemplation, contemplation, preparation, action, and maintenance, respectively. Responses were further categorized as "pre-action" for scores 0-2 or "action" for scores 3-4.
Fruit and vegetable intake: Fruit and vegetable intake was measured with a question created for MATCH. The question and response choices are shown in Table 1. The multiple choice responses (letters A-G) were converted to reflect average servings per week as follows: A=0, B=1, C=3, D=5.5, E=7, F=17.5 and G=20.
Physical activity: A question from the Youth Risk Behavior Survey was used to assess PA [30]. The question and response choices (letters A-H) are illustrated in Table 1.

Intervention
The MATCH intervention was initially developed and implemented by a middle school teacher in a school in rural, eastern NC with high obesity prevalence [16]. Since inception in one school in 2006, MATCH has expanded to include 17 schools in the 2013-2014 school year.
Prior to implementation of MATCH, one school teacher is identified as the school coordinator and is responsible for monitoring lessons taught, while all seventh grade teachers are trained to teach MATCH lessons in their subject areas. Current training procedures include school coordinators' training at a one-day training with remaining teachers being trained during a 45-minute group meeting time at their school. Approximately 15 or more lessons are delivered over five to six months with the highest concentration of lessons taught in health or science classes.
Students track their progress in workbooks and are provided with small incentives (e.g. water bottles, pens, drawstring bags) periodically or after accomplishing goals [20]. In the first expansion year lesson materials were provided on a CD-ROM requiring printing of materials by teachers and storage by students in notebooks. Since 2010 the lessons (slide sets, guiding materials, etc.) are all available to teachers in a central, password-protected web-based resource system and students are each provided a printed workbook with all lesson materials. The pre-printed notebook has helped with more consistent lesson sequencing and completion.

Analysis
Concurrent validation of staging algorithms utilizing constructs of the TTM model as a standard of comparison has been described [23,26]. Concurrent validity of this single-item stage algorithm was determined through two-steps: 1) Wilcoxon rank tests were used to cross-sectionally analyze data collected pre and post-MATCH to assess if those in the "action" vs. "preaction" category reported higher amounts of fruit and vegetable consumption and PA; 2) Spearman correlation analyses were subsequently performed to determine if a higher increase in stage score is associated with a higher increase in reported fruit and vegetable consumption and PA participation.
Descriptive statistics (means, standard deviation) were calculated for baseline participant characteristics. BMI z-score changes from pre to post MATCH were tested for significance using t-tests. Only those participants with BMI measures and completed SEATS at both pre-and post-MATCH were included in the SOC analysis.
Wilcoxon signed-rank test was used to test for change in SOC scores from pre-to post-MATCH. Wilcoxon rank test was used to compare reported frequencies of PA and F/V intake between SOC categories. McNemar's test was used to compare the SOC categories pre-vs. post-MATCH, by gender, ethnicity, and weight category.
Multiple regression analyses were conducted to determine association between change in SOC and change in BMI z-score from pre to post intervention.
Additional multiple regression analyses controlled for baseline weight category to determine association of level of SOC at baseline with BMI z-score change. This study was approved by the University Medical Center Institutional Review Board (#07-0741) at East Carolina University.

Results
MATCH study participants included 1,468 of 1,601 (92%) seventh graders enrolled at the school. No significant difference in gender, ethnicity, age, baseline BMI or BMI z-score was found between the MATCH participants (N=1,468) and excluded group (N=133). Baseline characteristics of the 1,468 participants are shown in Table 2.
More than half of the students identified as non-white and were overweight or obese at baseline. Of the 1,468 participants, 1,308 had post-MATCH measurements. Of these, 908 (62%) students in 13 schools had pre and post SEATs and were included in the SOC analysis.
Students with all pre-and post-measures (pre and post BMI; pre and post SEAT; N=890) differed somewhat in racial distribution (p=0.024), with higher percentage Caucasian (51% vs. 48%) and other race (10% vs. 6%), and lower percentage African American (39% vs. 46%) from those with missing measures (N=356) ( Table 2). Statistically significant differences were found between the two stage categories ("pre-action" vs. "action") in regard to amounts of PA and fruit and vegetable consumption reported pre-and post-MATCH.
Summary results for self-reported servings of F/V consumption by SOC category (pre-action vs. action) and weight category (all Overweight or Healthy Weight) pre-MATCH and post-MATCH are shown in Table 3. When comparing the pre-action vs. action group, selfreported median servings of fruit and vegetable consumption was significantly higher for the students in the action category at both pre-MATCH (p=0.0001) and post-MATCH (p<0.0001).  Summaries for self-reported days of PA by SOC category and weight category are reported in Table 3. When comparing the pre-action vs. action groups, self-reported median days of PA were significantly greater for the students in the action category pre-MATCH (p<0.0001) and post-MATCH (p<0.0001). When controlling for baseline weight category, students in both weight subgroups ("All Overweight," a combination of obese and overweight, and HW) reported significantly more median days of PA than those in the pre-action category pre-MATCH (p<0.0001 and p<0.0001 respectively) and post-MATCH (p<0.0001 and p<0.0001 respectively).

Journal of Childhood Obesity
Results from Spearman correlation analyses revealed a statistically significant but weak association between changes in reported PA frequency and changes in SOC score. A greater increase in stage score was associated with a greater increase in PA days (spearman correlation=0.1069, p=0.0013). No association was found between changes in fruit and vegetable consumption and changes in SOC score.
Results for change in self-reported SOC score from pre to post intervention are depicted in Table 4. Self-reported SOC category ("pre-action" vs. "action") improved for participants post-MATCH, with the percentage of participants in the "action" stage increasing from 47% to 53% (p=0.0030). The median (IQR) SOC score increased from 2.  (Table 4). Change in BMI z-score from pre to post-MATCH is shown in Table 5. For all participants, there was an overall decrease in BMI z-score from pre to post intervention (-0.051, p<0.0001). There was a decrease in BMI z-score by state as follows: NC (-0.067, p<0.001), SC (-0.031, p=0.0042). The change in BMI z-score reached statistical significance for both sexes and for all weight categories in both states ( Table 5). The decrease in BMI z-scores reached statistical significance for all ethnicities in NC schools, but was not statistically significant for the black and other ethnicity subgroups in SC. Although no significant association was found between change in SOC and change in BMI z-score, multiple regression analyses controlling for baseline weight category showed there were differences in the relationship of baseline SOC and change in BMI z-score by baseline weight category. In the HW subgroup, for each unit of increase in baseline SOC score, the change rate of BMI z-score increased slightly (0.025, p=0.0219), while in the All Overweight the change rate was slightly negative (-0.040, p=0.0108).

Discussion
This study of SOC in MATCH in seventh grade demonstrated that a single-item SOC question for dietary and PA behaviors was a valid measure of SOC and that it appears to have captured SOC in this population. Although a change in fruit and vegetable consumption was not associated with a change in SOC score, the results demonstrating an association between change in PA and change in SOC score provide support for the concurrent validity of the staging measure. Given the importance of assessing SOC and the paucity of published studies on single-item staging assessments, this result can have implications in future work focused on developing feasible, concise staging measures in young adolescents. In this observational study, self-reported SOC for dietary and PA behaviors in MATCH participants increased from pre-to postintervention. Although an increase in SOC was not associated with a decrease in BMI z-score from pre to post intervention, the results demonstrating an association between baseline SOC score and a change in BMI z-score in the all overweight subgroup are encouraging and suggest improved SOC is a plausible mechanism for the observed long term improvement in BMI measures in MATCH participants. All subgroups exhibited a general trend upward in SOC from pre to post MATCH; however, it is interesting that the effect size was greatest in the all overweight, female, and white subgroups. MATCH was designed to reach disadvantaged, overweight youth in rural areas. A possible explanation for the larger effect size (decrease in zBMI) in the All Overweight subgroup may be that an underlying mechanism of MATCH helped to improve SOC in the target population. Future studies with larger sample sizes and control groups are needed to further explore sub-group analyses.
Originally designed to measure behaviors such as smoking cessation, applying the TTM model to more complex behaviors such as weight loss requires taking into account multiple health behaviors. Therefore, assessing an individual's SOC on each target behavior may be important [24]. For example, an individual may not be willing to consume more fruits and vegetables, but may be willing to increase PA. Another consideration is that the 4-5 month duration of MATCH may not be enough time to capture a change in SOC for multiple health behaviors. One consideration in future studies would be to revise the SOC survey question to differentiate intentions regarding specific behaviors to better capture SOC for a particular change. In addition, longer term follow up with repeated SOC measures may be informative.

Limitations
There are several limitations to this study. MATCH was implemented in select schools in rural areas of NC and SC a with a predominately Caucasian and African American student population. Therefore, results may not be generalizable to more diverse groups in other areas. Of the 17 schools enrolled this school year, only 13 completed the SEAT survey which reduced the participants in the SOC study and there was no control group. Therefore, we cannot conclude definitively that MATCH participation is exclusively responsible for improvements in adolescent SOC. Finally, the questions used to measure dietary and PA behaviors, although validated, were taken from cross sectional population based surveys not designed to detect individual level behavior change, and do not specify types of PA or distinguish it from exercise. There is some emerging evidence that this distinction between PA and exercise behaviors may be important in obesity studies.

Strengths
Strengths of this study include the rural setting, young adolescent population, high participation rate and large sample size from two states. Results are from schools with a high prevalence of obesity and thus represent a high risk population. The validity testing of a single item SOC measure provides a significant contribution to the field. Finally, the MATCH intervention is a practical, feasible intervention to address obesity.
Improved SOC in MATCH participants is an important finding because SOC can be used as an indicator of intervention effectiveness [23]. Therefore, findings from this study provide support for the effectiveness of this feasible, school-based intervention at addressing obesity. Improved SOC may serve as one of several mechanisms responsible for the improved BMI measures observed in MATCH participants. Baseline SOC seemed to predict success with BMI reduction, such that the higher the baseline SOC score, the stronger the association with reduction in BMI measures pre to post MATCH. This suggests then that the intervention is most effective at reaching those with higher SOC. However, without a control group this conclusion should be considered with caution and further studies are warranted.

Conclusions
Schools are an opportune setting for implementing wellness interventions targeting obesogenic behaviors as long as the intervention fits well into the educational priorities and mission. School-based interventions based on TTM may be particularly effective during adolescence. The results of this observational study found that participation in MATCH may improve adolescent SOC for health behaviors which could provide support for the effectiveness of the intervention while providing insight into a possible mechanism contributing to improved BMI measures in participants.