No. 3, July 2004
Focus Groups to Develop a Bone Health Curriculum for After-school Programs
Sara C. Folta, MS, Jeanne P.
Goldberg, PhD, RD, Lori P. Marcotte, MPH, MS, RD, Christina D. Economos, PhD
Suggested citation for this article: Folta SC,
Goldberg JP, Marcotte LP, Economos CD. Using focus groups to develop a bone
health curriculum for after-school programs. Prev Chronic Dis
[serial online] 2004 Jul [date cited]. Available from: URL:
Childhood behaviors influence peak bone mass and osteoporosis risk in later
life. The after-school environment provides an opportunity to enrich a
child’s learning and experience. Our objective was to gain a better
understanding of the knowledge of, attitudes and beliefs about, and barriers
to achieving bone health among children, parents, and after-school program
leaders from low-income, ethnically diverse communities. Findings led to the
development, implementation, and evaluation of a bone health curriculum in
the after-school setting.
Eight focus groups were conducted in three representative communities. Focus
group participants included children aged six to eight years, parents of
children aged six to eight, and after-school program staff. Transcripts and
written notes from each session were reviewed and common themes were
identified within each group.
Most adults had some understanding of osteoporosis, but did not recognize
that childhood behaviors had a role in developing the disease.
Program leaders raised concerns about their ability to implement a health
program and recommended a flexible format. Parents and program leaders
recognized the importance of maintaining a fun atmosphere.
It is feasible to create a curriculum for a bone health program that meets
the unique needs and interests of children and program leaders in the after-school setting. Addressing the needs, interests, and
common barriers of the target population is an essential first step in curriculum
Back to top
Osteoporosis is a childhood disease with adult consequences. Childhood
behaviors, including diet and physical activity (1-4), have a major
influence on the attainment of peak bone mass and the primary prevention
of osteoporosis (5-11). The higher the peak bone mass in childhood, the more an
individual can afford to lose in adulthood (12-14). The long-term benefits
of increasing bone mineral density during childhood are compelling
(15,16). A change in one negative standard deviation in bone mass may double
fracture risk (17,18).
In the United States, there is a large gap between childhood behaviors
known to help maximize bone health and what children actually do. National
survey data estimate that more than half of girls aged six to 11 years are
not meeting 100% of the 1989 Recommended Dietary Allowance for calcium, and
nearly half of boys are not meeting this requirement (19). The gap between
recommendations and intakes is difficult to reverse as children age (20,21).
Of equal importance is that children of all ages do not obtain adequate
levels of physical activity (22-25). Studies show that sedentary behavior
increases and moderate physical activity decreases as children advance
through elementary school (26,27) and that this decline continues into
adolescence (27,28). Furthermore, girls are less likely to engage in
physical activity than boys (27-29), and black children are less active than
white children (28,29). The gap between the long-term effect of modifiable
influences on bone health and the behaviors of millions of children suggests
that cost-effective interventions to promote bone health in children are urgently needed.
After-school programs are ideal for complementing the school day with
health education and physical activity. Several million children participate in after-school
programs, and demand outstrips supply by a rate of approximately two to one (30). Furthermore, many
adequate funding, and quality is highly variable (30). Curriculum-based
interventions may enhance existing enrichment activities and provide
structure to programs that are not highly developed. Reviews of nutrition
and physical activity education curricula indicate that they can contribute
to significant improvements in students’ knowledge, skills, and behavior,
but that they must have certain characteristics to be effective (31-33). A health
curriculum should be theory driven and should address children’s needs,
interests, and concerns, in addition to their knowledge, attitudes, and beliefs
(31-33). Addressing barriers to change is also important. This paper
describes the design of a curriculum to promote bone health based on data
obtained from focus group research to identify motivating factors,
preferences, and barriers to change among children, parents, and after-school program leaders.
Back to top
Eight focus groups were conducted in three low- to moderate-income,
multiethnic Massachusetts communities in the three months from November 1999 through January
2000. In total, 66 individuals participated. Participants included three groups of
children aged six to eight years (N = 26; 70% white, 30% African American;
61% male); three groups composed of parents with children aged six to eight (N = 24;
80% white, 20% African American; 8% male); and two after-school program
staff groups (N = 16; race and ethnicity not specified; 19% male). Of the
program staff who participated, two oversaw staff and program development
and 14 taught. Focus groups took place at the after-school program sites and
were led by two professional focus-group facilitators with expertise
in conducting groups with children. Sessions typically lasted two hours and
included six to 11 participants. Each adult participant received $30 and
each child received a $20 gift certificate to a local toy store. Each session
was recorded on audiotape for subsequent transcription; focus-group
facilitators took additional notes.
Focus-group facilitators provided a brief introduction and invited parents and
leaders to offer general opinions and comments about health education and
strategies for engaging children in desired behaviors in after-school
programs. Facilitators told children that the purpose of the meeting was to
learn about what children like to eat and play. All groups were told
there were no right or wrong answers. Facilitators explored knowledge,
attitudes, beliefs, preferences, and barriers related to bone health and to
the potential implementation of a curriculum that focused on bone health in
the after-school environment.
The two facilitators systematically analyzed transcripts. Each one read
the original transcripts to identify themes of each topic of discussion
before collaborating on the summary report and submitting the report to an
independent investigator. The investigator reviewed the transcripts and
final report and recoded key phrases into a matrix constructed to conform to
the project’s conceptual framework. Recoding key phrases into the matrix
allowed for a more detailed understanding of the key themes identified by
the facilitators and provided the ability to incorporate these themes into
the project development.
The Institutional Review Board at Tufts University gave human subjects
research approval for this project.
Back to top
Knowledge and awareness
As expected, the children had limited knowledge about bone health and the
factors that affect it. Some understood the connection between bone health
and drinking milk. Not surprisingly, they were generally aware of something
called “calcium” but did not understand that it is a mineral or know where
it is found in the diet: “It’s a kind of vitamin and cereal has it” was a
typical response. After calcium was defined
for them, many children commented, “Calcium makes you stronger, smarter, and helps
As expected, none of the children understood “osteoporosis.” Among
parents, knowledge of osteoporosis was mixed, whereas most after-school
program leaders had a basic knowledge of what osteoporosis is and how to
prevent it. In general, both parents and after-school program staff were
aware of the effect of calcium and exercise on bone health and development.
Attitudes, perceptions, and beliefs
Children showed little interest in understanding osteoporosis, but some
interest in knowing how to make bones healthy and strong. Children
appropriately associated bones with certain foods: “Bones make you think
about dairy products.” Parents felt that nutrition played a critically
important role in their child’s development. Among their chief concerns
were getting their children to eat enough fruits and vegetables and limiting
their intake of sweets and other “junk foods”: “I worry about the
long-range effect of nutrition on them in their twenties, what will have
been done by then.” “I like to make sure my kids get their vitamins
every day…because I know they don’t eat right. They don’t eat enough
vegetables.” “Other than genetics, nutrition is the number-one thing for
your child’s health.”
Parents were less concerned that their children’s diets had enough
calcium and did not consider osteoporosis a major health threat: “As long
as they’re eating from the basic four food groups, I’m not worried.”
“I always think of osteoporosis as an adult issue.” “I think I need
the bone help more than them.”
Parents and after-school program leaders were both concerned about the
amount of physical activity the children were getting. One parent
commented, “He doesn’t get enough exercise — never. He’s healthy, but he
has an interest in video games and anything electronic. I’m worried about
down the road.” An after-school program leader observed, “If you talk to a
gym teacher or watch a class, these kids aren’t in any shape at all. In my
class, there are four or five kids who can’t run around the bases without
stopping and huffing and puffing.”
Most children said they liked or drank milk. The perspectives of children
and parents differed on the subject of physical activity. Children said that
if given a choice, they would prefer physical activity, games, or
sports during their free time: “I like to play tag and play games like
when you pretend to be monsters and things…I’d rather play outside.”
In contrast, parents consistently said that if left on their own, children
would choose television and video games rather than physical activity.
Parents demonstrated an awareness of the importance of physical activity and
of their role in promoting it: “I do make them go outside, but it’s like
kicking and screaming — they don’t like to go.”
After-school program leaders were concerned about the amount of planning
required to implement a curriculum. Said one participant, “I’m a second-grade teacher. I have
enough planning to do all day long. I don’t have the time.” Some
after-school program leaders also
expressed a desire for flexibility: “I think ideas would be better,
because if you disagree with the format, then you’re going to come to some
conflict with ‘Oh, I have to do this?’ Make it more optional. ‘You may
want to do this, or you could do A, B, and C.’” “[It] just depends on
the mood of the children what I’m going to do that day. If they’re
fidgety, we go out and run around the park.”
While after-school program leaders recognized the need to provide
guidance for children about healthy eating and exercise, they did not
perceive health education as a priority: “I think health education is
important but as [another participant] said, they get a lot of it during the
day at school, and we’re more geared toward their social and emotional
growth, socializing with other children and interacting with adults.”
Both parents and after-school program leaders expressed some concerns
about the nutrition education component of the curriculum. They worried that
the activity would replace the children’s already limited time for
play and fun. One after-school program leader stated, “I don’t want it to be a
bore for them. Especially since they’ve been in school all day long. I do
think it’s important, but when they come to us, it’s time to let loose
some steam.” A parent said, “I’m hoping they’ll come home and say
‘I had fun doing this and that today.’ If he says, ‘I have to go
here,’ then he’s in the wrong place.”
Parents also expressed a concern that the nutrition education activity
might be too academic: “It needs to be addressed for children as not so
medical. It needs to be presented as fun.” “I think the calcium-focused
activity would get old fast. You know: ‘Calcium again, I’m so sick of
Despite wanting their children to enjoy a break from academics, getting
homework done during the after-school time was a high priority for parents.
After-school program leaders felt pressure to make sure homework was
complete by the time parents arrived to pick children up. One parent
commented, “Homework has to be the first priority. I get home too late to
get it done with him.” An after-school leader said, “I know my parents:
they want [their children] to get their homework done.”
After-school program leaders consistently and poignantly expressed their
concern that they might not know enough to effectively teach the bone-health
curriculum. They were afraid they would be embarrassed if they could
not answer a child’s question. “I’m not saying I’m ignorant about
osteoporosis, but I’m not as knowledgeable as I’d like to be.” “[I
would want] more knowledge about osteoporosis, questions the kids would ask
us, so we could have answers for them.” Parents also expressed concern
about the ability of the after-school program leaders to implement the
curriculum: “The after-school teachers would need training. They’re
capable, but need training.” While an extensive training program was
proposed, most after-school program leaders suggested that only minimal
training would be possible because of limited available time. Because of
high staff turnover rates in the after-school setting, they also voiced an
interest in ongoing oversight and support so the curriculum could
continue even if trained leaders left the after-school program.
Shaping the curriculum
Curriculum development relied heavily on information obtained in the
focus groups. To respond to the needs of program leaders in the after-school
setting, short and simple lessons were designed with alternate activity
options, tips for implementation, and ideas for modifying games. Curriculum
components could complement regular program activities without interfering
with priorities such as homework. Ongoing support was offered via
newsletters, and research staff were available to assist new leaders during
From the outset of the project, the objective was to package both a
physical-activity component and a nutrition education component so that the
children would have fun while learning. The children know the project as
“The Bones Club.” To address the desire expressed in focus groups to
allow children to use after-school time for fun activities that would enable
them to socialize and “let off some steam” and to fulfill the objective
of offering simple, non-academic language, the physical activity component
was named “Let’s Play.” Activities identified as favorites with the
children were adapted to weight-bearing activities (similarly titled
“Let’s Run” and “Let’s Jump”). Because after-school program
leaders indicated that they operate in a wide variety of physical
environments, all games included simple modifications to accommodate play in
Likewise, the nutrition education component was named “Let’s
Explore” to reflect some of the preferred activities of children and to
emphasize both teamwork and fun. During the focus groups, children indicated
an interest in reading, and after-school program leaders reported “circle
time” as a common component of the after-school day. Age-appropriate books
were provided to support the learning themes of the
“Let’s Explore” lessons. Many after-school program leaders expressed
concern that they may not know enough about bone health to teach
the curriculum effectively. To begin to address this, an appendix was included with each
section of the written curriculum that answered commonly asked questions and
provided a quick reference guide for additional resources.
Evidence shows that nutrition education programs and curricula targeted
at elementary-aged children are more effective when they include a family
component (33). Some parents received newsletters that corresponded to
curriculum units to reinforce after-school program lessons at home. Newsletters included quick and easy recipes and physical
activity tips that took into account the time constraint that was mentioned
as a barrier in the focus groups. Parents also were given a directory that
allowed them to leverage their own limited resources by using nutrition,
physical activity, and health resources available in their communities.
Back to top
This study demonstrates how focus groups can be used to shape a
curriculum to meet the needs of after-school program leaders, parents, and
children so that maximum buy-in and learning can occur. Of particular
importance, focus groups can identify key barriers to implementing the
curriculum that might otherwise go unnoticed. Perhaps the most important
barrier was that health education was not considered a priority by either
parents or after-school program leaders. To succeed, the curriculum would
need to focus on fun for the children and ease of implementation for the
program leaders. The curriculum was designed to be short and flexible so it would not replace activities that were considered a priority.
Parents and program leaders indicated limited confidence in promoting
health, particularly nutrition, to children. Still, program leaders believed
they could incorporate such a program into their existing after-school
program structure and implement it as long as they are given
Not surprisingly, children were not interested in osteoporosis the
disease, but they did want to learn about how bones move and what they
could do to grow big and strong. This perception confirmed that it is possible to
engage even very young children in a health topic if the topic is presented
at their level of comprehension and if it appeals to their interests.
The children who participated in the focus groups were young.
Sometimes they were wonderfully direct and open, and at other times their
responses were colored by the need for peer acceptance. In this series of
focus groups, their responses about likes and dislikes differed from those
of their parents. For instance, children overwhelmingly expressed a
preference for active games or sports over video games, but parents reported
difficulty in engaging children in outdoor play. This
observation confirms the need to conduct focus groups that include both children and
parents to obtain a more balanced picture of preferences and
The inconsistency between children’s reported desire for physical
activity and parents’ reports that children engage in sedentary behaviors
if given a choice is difficult to reconcile. Possibly, while
children may like the idea of physical activity, they are reluctant to
engage in it
once they have started other activities. Several factors may draw children
to activities that are more sedentary. In the focus groups, parents noted
the ubiquity of televisions and computer games in their homes. In addition,
cold weather and early darkness were also mentioned as serious barriers to
outdoor play. Regardless of these perceived barriers, children participated
willingly when provided with the types of physical activities in the after-school programs that both the children and the program leaders agreed were
Focus groups do not provide data that are generalizable to other
populations, but they can be a time-efficient and cost-effective method for
identifying attitudes, beliefs, and barriers toward health behaviors among
defined target populations. Through an interactive discussion led by trained
professionals, it is possible to identify information that is critical to
program success and that might not be uncovered in survey research. For
example, the permissive environment allowed after-school leaders to openly
describe their perceptions of their limited knowledge about osteoporosis and
bone health, which, if not addressed, could limit their ability to implement
the curriculum and could consequently hinder the success of the program.
Response to the bone-health curriculum has been enthusiastic. More than 50 after-school programs in
Massachusetts and Rhode Island have implemented it successfully, and it has been well-accepted by after-school program leaders, parents, and children. After-school program leaders
report that the curriculum has enhanced their programs and has had the
unexpected benefit of improving their relationships with the children. They
indicate that children enjoy being in the “Bones Club” and having something to call their own. Participation is optional, but
remains at a high level, and dropout rates related to dissatisfaction are
extremely low (less than 1%). Dropout is linked almost exclusively to
children leaving the after-school program or the school district itself.
An environment that fosters the development of behaviors to promote bone
health can contribute to positive habits that children will adopt before
entering their preteen years, when peer influences gain power. After-school
programs have been an underused setting for health interventions. As they
grow in number, they provide an opportunity to use time that traditionally
has been difficult to fill consistently with appropriate physical and
cognitive activities for all children who attend them. Health interventions
that include an academic and a physical-activity component are difficult to
implement given the varied experience of leaders and the lack of funds for
training and technical support. Limited staff, high turnover rates, and
competing demands on program time are major barriers. Curricula based on
formative research can overcome these barriers, help to improve the
health of children, and prevent chronic disease later in life.
Back to top
This research was supported by a grant (NIH/1RO1 HD 37752-01) and is
based on work supported by Grant P01-DK42618 from the National Institutes of
Health, and the U.S. Department of Agriculture (USDA), under
agreement number 58-1950-9-001. Any opinions, findings, conclusions, or
recommendations expressed in this publication are those of the author(s) and
do not necessarily reflect the view of the USDA.
Back to top
Corresponding author: Christina D. Economos, PhD, Associate Director,
John Hancock Center on Physical Activity and Nutrition, Gerald J. and
Dorothy R. Friedman School of Nutrition Science and Policy, Tufts
University, 150 Harrison Ave, Boston, MA 02111. Telephone:
617-636-3784. E-mail: firstname.lastname@example.org.
Author affiliations: Sara C. Folta, MS, Jeanne P. Goldberg, PhD, RD, Lori
P. Marcotte, MPH, MS, RD, Gerald J. and Dorothy R. Friedman School of
Nutrition Science and Policy, Tufts University, Boston, Mass.
Back to top
- Bonjour J, Theintz G, Law F, Slosman D, Rizzoli R.
Peak bone mass.
Osteoporosis Int 1994;4 Suppl 1:7-13.
- Deal C. Osteoporosis: Prevention, diagnosis, and management. Am
J Med 1997;102 (1A):S35-9.
- Lysen V, Walker R.
Osteoporosis risk factors in eighth grade students.
J Sch Health 1997;67 (8):317-21.
- Anderson J, Rondano P, Holmes A.
Roles of diet and physical activity
on the prevention of osteoporosis. Scand J Rheumatol Suppl, 1996;103:65-74.
- Teegarden D, Proulx WR, Martin BR, Zhao J, McCabe GP, Lyle RM, et al.
Peak bone mass in young women. J Bone Miner Res
- Recker RR, Davies KM, Hinders SM, Heaney RP, Stegman MR, Kimmel DB.
gain in young adult women. JAMA 1992;268 (17):2403-8.
- Slemenda C, Reister TK, Hui SL, Miller JZ, Christian JC, Johnston CC
Influences on skeletal mineralization in children and adolescents:
evidence for varying effects of sexual maturation and physical activity.
J Pediatr 1994;125:201-7.
- Matkovic V.
Nutrition, genetics and skeletal development. J Am
Coll Nutr 1996;15 (6):556-69.
- Bailey D.
The Saskatchewan Pediatric Bone Mineral Accrual Study: bone
mineral acquisition during the growing years. Int J Sports Med
1997;18 Suppl 3:S191-4.
- Barr S, McKay H.
Nutrition, exercise, and bone status in youth.
Int J Sport Nutr 1998;8:124-42.
- French SA, Fulkerson JA, Story M.
Increasing weight-bearing physical
activity and calcium intake for bone mass growth in children and
adolescents: a review of intervention trials. Prev Med 2000;31:722-31.
- Ribot C, Tremollieres F, Pouilles JM.
Late consequences of a low peak
bone mass. Acta Paediatr Suppl 1995;411:31-5.
- Riis B, Hansen MA, Jensen AM, Overgaard K, Christiansen C.
bone mass and fast rate of bone loss at menopause: equal risk factors
for future fractures: a 15-year follow-up study. Bone 1996;19:9-12.
- Seeman E, Tsalamandris C, Formica C, Hopper JL, McKay J.
femoral neck bone density in daughters of women with hip fractures: the
role of low peak bone density in the pathogenesis of osteoporosis.
J Bone Miner Res 1994;9:739-43.
- Johnston CC Jr, Slemenda CW.
Risk assessment: theoretical considerations.
Am J Med 1993;95 (5A):S2-5.
- Matkovic V, Kostial K, Simonovic I, Buzina R, Brodarec A, Nordin BE.
Bone status and fracture rates in two regions of Yugoslavia. Am J
Clin Nutr 1979;32:540-9.
- Hui SL, Slemenda CW, Johnston CC Jr.
Baseline measurement of bone mass
predicts fracture in white women. Ann Intern Med 1989;111:355-61.
- Wasnich R, Ross PD, Davis JW, Vogel JM.
A comparison of single and
multi-site BMC measurements for assessment of spine fracture probability.
J Nucl Med 1989;30:1166-71.
- U.S. Department of Agriculture, Agricultural Research Service.
and nutrient intakes by children 1994-96, 1998. Beltsville (MD): ARS
Food Surveys Research Group;1999.
- Albertson AM, Tobelmann RC, Marquart L.
Estimated dietary calcium intake
and food sources for adolescent females: 1980-92. J Adolesc
- Zive MM, Nicklas TA, Busch EC, Myers L, Berenson GS.
and mineral intakes of young adults: The Bogalusa Heart Study. J
Adolesc Health 1996;19:39-47.
- Simons-Morton BG, O’Hara NM, Parcel GS, Huang IW, Baranowski T,
Children's frequency of participation in moderate to vigorous
physical activities. Res Q Exerc Sport 1990;61(4):307-14.
- Pate R, Long B, Heath G. Descriptive epidemiology of physical activity
in adolescents. Pediatr Exerc Sci 1994;6:434-47.
- Sallis JF. Epidemiology of physical activity and fitness in children
and adolescents. Crit Rev Food Sci Nutr 1993;33 (4-5):403-8.
- Duke J, Huhman M, Heitzler C.
Physical activity levels among children
aged 9-13 years — United States, 2002. MMWR Morb Mortal Wkly
Rep 2003;52 (33):785-8.
- Myers L, Strikmiller PK, Webber LS, Berenson GS.
sedentary activity in school children grades 5-8: the Bogalusa Heart
Study. Med Sci Sports Exerc 1996;28 (7):852-9.
- Trost SG, Pate R, Sallis JF, Freedson PS, Taylor WC, Dowda M, et al.
Age and gender differences in objectively measured physical activity in
youth. Med Sci Sport Exerc 2002;34 (2):350-5.
- Grunbaum J, Kann L, Kinchen SA, Williams B, Ross JG, Lowry R, et al.
Youth risk behavior surveillance — United States, 2001. MMWR
Surveill Summ 2002;51 (4):1-62.
- Andersen RE, Crespo CJ, Bartlett SJ, Cheskin LJ, Pratt M.
of physical activity and television watching with body weight and level
of fatness among children: results from the Third National Health and
Nutrition Examination Survey. JAMA 1998;279 (12):938-42.
- Working for children and families: safe and smart after-school
programs. U.S. Department of Education. U.S. Department of
Justice; Washington (DC): 2000.
- Contento I, Balch GI, Bronner YL, Paige DM, Gross SM, Lytle LA et al.
Nutrition education for school-age children. J Nutr Ed 1995;27:298-311.
- Stone EJ, McKenzie TL, Welk GJ, Booth ML.
Effects of physical activity
interventions in youth. Review and synthesis. Am J Prev Med 1998;15 (4):298-315.
- Lytle L, Achterberg C. Changing the diet of America's children: what
works and why? J Nutr Ed 1995;27 (5):250-60.
Back to top