Volume 2: Special Issue, November 2005
From Concept to Practice: Using the School Health Index to Create Healthy School Environments in Rhode
Island Elementary Schools
Deborah N. Pearlman, PhD, Elizabeth Dowling, MPH, Cheryl Bayuk, Kathleen
Cullinen, MS, RD, Ann Kelsey Thacher, MS
Suggested citation for this article: Pearlman DN, Dowling E, Bayuk C,
Cullinen K, Thacher AK. From concept to practice: using the School Health Index to create healthy school
environments in Rhode Island elementary schools. Prev Chronic Dis [serial
online] 2005 Nov [date cited]. Available from: URL: http://www.cdc.gov/pcd/issues/2005/
The prevalence of childhood obesity is increasing, and schools are ideal places
to support healthy eating and physical activity. In 2000, the Centers for
Disease Control and Prevention (CDC) developed the School Health Index, a
self-assessment and planning tool that helps schools evaluate and improve
physical activity and nutrition programs and policies. Although many state
education agencies, health departments, and individual schools have used the
School Health Index, few systematic evaluations of the tool have been performed.
We examined the physical activity and nutrition environments in Rhode
Islandís public elementary schools with high and low minority student
enrollments and evaluated a school-based environmental and policy intervention
that included implementation of the School Health Index.
As part of a CDC Division of Nutrition and Physical Activity cooperative
agreement awarded to the Rhode Island Department of Health, we conducted a needs assessment of 102 elementary schools and
implemented an intervention in four inner-city elementary schools. In phase 1,
we analyzed the Rhode Island Needs Assessment Tool (RINAT), a telephone survey
of principals in approximately 50% of all Rhode Island public elementary schools
in the state during the 2001–2002 school year (n = 102). Comparisons of the
nutrition and physical activity environments of schools with low and high
minority enrollment were calculated by cross-tabulation with the chi-square test.
In phase 2, we used process and outcome evaluation data to assess
the use of the School Health Index in creating healthier environments in schools. Our intervention —
Eat Healthy and Get Active! ó involved implementing three of the eight
School Health Index modules in four Rhode Island elementary schools.
Survey data revealed that schools with high minority enrollment (student
enrollment of ≥10% black, ≥25% Hispanic, or both) offered
few programs supporting healthy eating and physical activity (P <
.05). Schools with high and low minority enrollment both offered nonnutritious
foods and beverages. Process evaluation data revealed that 1) principals play a
pivotal role on School Health Index teams, 2) schoolwide validation of a
teamís small successes is crucial for sustaining a commitment to healthy lifestyle policies and programs, and 3) external
facilitators are essential for implementation success. Outcome data showed that
all schools developed at least one policy or environmental strategy to create a
healthy school environment. Only two schools implemented immediate changes.
Needs assessment, external facilitation, and evaluation are the foundation for
sustainable school-based policies. Although the
School Health Index is universally perceived as a user-friendly assessment
tool, implementation is likely to be less successful in schools with low staff
morale, budgetary constraints, and inconsistent administrator support.
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U.S. children today are more likely to be overweight than children in previous
decades, and the upward trend in the prevalence of childhood obesity is
continuing (1). Between 1980 and 2000, the prevalence of obesity doubled among
children aged 6 to 11 years (2). The increase is particularly evident among
non-Hispanic black and Hispanic youth (3).
Schools are ideal places to support healthy eating and physical activity (4).
However, the 2000 national School Health Policies and Programs Study (SHPPS) found that only 8% of elementary schools provided daily physical education;
71.4% provided regular recess for elementary school children (5). In 43% of
elementary schools, food and beverages of little or no nutritional value were readily
available (5). Many national initiatives call for strengthening school-based
policies and environments (6-12). In 2000, the Centers for Disease Control and
Prevention (CDC) developed the School Health Index (SHI), consisting of eight
modules drawn from the CDCís Coordinated School Health Program model. The model describes
a healthy school environment as one in which the integration of policies,
practices, and programs promote healthy lifestyle behaviors and reduce
health-related risk behaviors (13). Using the SHI, teams composed of
administrators, teachers, food service personnel, and other members of the
school community assess the schoolís strengths and weaknesses in eight areas
and then plan for improvement (14).
Many state education agencies, health departments, and individual schools
have used the SHI, but systematic evaluations have been rare. Staten et al
evaluated the SHI in seven elementary schools in two Arizona border communities
(15). Although most schools implemented changes using the SHI, staff turnover,
time constraints, and limited resources were barriers to progress (15). Schools
do not exist in a vacuum; school-based programs and policies are likely to
fail if the environment lacks the infrastructure to promote healthy eating and
physical activity (12).
In our study, we address the following two questions:
- What is the difference between the physical activity and nutrition
environments in Rhode Islandís public elementary schools with high
minority student enrollment (≥10% black, ≥25% Hispanic,
or both) and schools with low minority student enrollment (<10% black and <25%
- Does the SHI help schools create healthy school environments?
We describe the results of a needs assessment to
understand the extent to which Rhode Island elementary schools promoted healthy
eating and physical activity and had policies that supported these
behaviors (phase 1). We also provide case studies of four elementary schools that
participated in the Eat Healthy and Get Active! project, an
intervention to help schools develop policies and environmental supports that
promote lifelong physical activity and healthy eating (phase 2). In the intervention
schools, 25% or more of the students were Hispanic or black, and the schools
were located in cities with a relatively low tax base; thus, they had fewer
resources for improving studentsí eating and physical activity behaviors.
School personnel had become interested in healthier environments for their
students in response to recent publicity about the increase in obesity among
children, particularly among minorities (1,2).
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Phase 1: needs assessment
The needs assessment involved three data sources: the 2001Ė2002 Rhode
Island Needs Assessment Tool (RINAT), Rhode Islandís 2002 Information Works!
(16), and the 2000 U.S. census (17,18). Information Works! is a yearly report
that contains detailed information on every public school and school district in
Rhode Island, including standardized achievement scores, demographic information
on students and parents, and data on school spending (16).
RINAT was designed by the Rhode Island Department of Healthís Initiative
for a Healthy Weight Program to assess environmental and policy support for
healthy eating and physical activity in the stateís elementary schools (Appendix). The
sampling frame consisted of all public elementary schools in Rhode Island (N =
212). Recruitment was a two-step process. First, all elementary schools with a
family center were selected. Schools with family centers receive federal and
state funds to work with families in economically disadvantaged communities
(19). Of the 35 family center schools, 32 completed interviews (91%). Of the
remaining schools in Rhode Island, 100 were randomly selected for the study from
five strata based on the telephone exchanges used for the Rhode Island
Behavioral Risk Factor Surveillance System (BRFSS). Ninety-four schools from the second
sampling frame were selected, and 70 completed interviews (75%). The overall
response rate was 79%, and the final sample included 102 schools. School
principals were interviewed by telephone between November 2001 and May 2002.
From Information Works! data (16), we calculated the percentage of black and
Hispanic students enrolled in Rhode Island public schools. To reflect the demographics of Rhode
Islandís overall student population, we defined a high minority school
as one with a student population that was 10% black or greater, 25% Hispanic or
greater, or both. In cities with the highest concentration of minority students,
8% to 23% of students were black, and 24% to 63% of students were Hispanic (16).
Because RINAT did not include questions on family demographics, we used
Information Works! data to obtain the information (16). In 2002, 34% of Rhode
Island elementary school students were eligible for free or reduced-price
lunches, and 10% had one parent who did not complete high school (16).
Therefore, the percentage of students eligible for free or reduced-price lunch
was categorized as either less than 34% or 34% or greater, and the percentage of studentsí parents who did not complete
high school was categorized as less than 5% or 5% or greater because of missing data on this variable.
RINAT variables were coded either no (no = 0) or yes
(yes = 1).
The variables included whether a school 1) had at least one program to promote
healthy eating; 2) served high-fat or high-sugar foods in the cafeteria, vending
machines, or other venues; 3) had one or more programs to promote physical
activity; 4) had a playground, playing field, or track; 5) provided at least 20
minutes of recess per day; and 6) provided at least 60 minutes of physical
education per week. In Rhode Island, no school met the National Association for Sport and Physical
Education recommendation of 150 minutes per week of physical education for elementary
schools (20). Therefore, we
dichotomized responses on minutes of recess and minutes of physical education
classes at the median.
Block-group census data were matched to each school based on the schoolís
street address and zip code to measure residential racial segregation, an
indicator of the socioeconomic status of the schoolís neighborhood. Literature
on social inequalities has shown that residential racial segregation is the
single most important factor in creating neighborhoods of concentrated poverty
(21). To reflect the demographics of the three Rhode Island cities with the
highest concentration of minority residents, we defined a racially segregated
neighborhood as 10% black or greater, 15% Hispanic or greater, or both. In the three cities, 5.8% to 14.5% of residents were black, and 13.9% to
47.8% of residents were Hispanic (18).
Phase 2: intervention and case studies
As mentioned previously, Eat Healthy and Get Active! was an intervention to
help schools develop policies and environmental support that promote lifelong
physical activity and healthy eating. Through a competitive process, the Rhode
Island Department of Health selected the nonprofit Kids First, Inc to implement
the intervention. From September 2002 through June 2003, four schools in three
school districts participated in the project. Participating schools received
$500 and training on use of the SHI manual.
Eat Healthy and Get Active! had five components. Each intervention school 1)
established an SHI team, 2) completed three of the eight SHI self-assessment modules (the school policies and environment
module, the physical education and other physical activity
programs module, and the nutrition services module), 3) developed action plans to
implement policies to improve studentsí physical activity and nutritious eating
behaviors, 4) collected process and outcome data, and 5) worked with an external
facilitator who provided continuity and resources. We focused only on the three
SHI modules that included explicit policy recommendations. Getting a school
board to approve and adopt policies was a longer-term process that would have
exceeded our 10-month intervention.
The SHI was implemented differently in each school, but all schools
established an SHI team and identified an internal coordinator for the
intervention. All teams included the principal, a physical education teacher,
and a food service director or manager. Although the intervention ran from
September through June, it took until October to get school teams established.
Process evaluation was designed to assess implementation of the intervention
and external factors that may have affected the interventionís impact on
study outcomes. Methods for monitoring implementation included evaluations of
facilitator trainings on childhood obesity and use of the SHI, responses to
discussion and planning questions from SHI modules, facilitator meeting notes
and observations of team meetings, and pretest and posttest interviews with SHI
team members. Process evaluation methods to monitor external factors affecting
program implementation included an activity report form for tracking educational
activities that were not part of the intervention and a form to record
observations of the school environment, such as food pyramid pictures in the
cafeteria, lunch time plate waste (the quantity of edible food served that is
uneaten), and advertisements for fast foods within a
1-mile radius of the school. We observed each schoolís immediate neighborhood
environment because the CDCís KidsWalk-to-School program (22) sets a 1-mile
radius as ideal for walking to and from school by elementary school children. We
highlight the process evaluation findings from facilitator meeting notes.
The outcome measures were 1) baseline (October 2002) to end-of-year (June
2003) percent change in SHI self-assessment module scores and 2) the number of policies
developed and implemented. The module score was the total number of points
received for each question in a module (0 = not in place, 1 = under development,
2 = partially in place, 3 = fully in place) divided by the highest possible score
for that module, then multiplied by 100.
Comparisons of the nutrition and physical activity
environments of schools with low and high minority enrollment were calculated by
cross-tabulation with the chi-square test (phase 1) using SPSS, version 12 (SPSS
Inc, Chicago, Ill). Two external facilitators independently identified themes
from the process evaluation, and the themes were ranked from most cited to least
cited. Eat Healthy and Get Active! staff members reviewed the pooled results
(phase 2). The Rhode Island Department of Healthís Institutional Review Board
approved both phases of the study.
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Phase 1: needs assessment
In our survey sample, 42.2% of the schools had a high minority student
enrollment (Table 1). In
schools in which 34% or more of the students were eligible for free or
reduced-price lunch, 78.0% had a high minority student enrollment. In schools in
which 5% or more of the studentsí parents did not have a high school diploma,
69.6% had a high minority student enrollment. Racially segregated neighborhoods
were as likely as predominantly white communities to have schools with a high
minority student enrollment, but our
sample of racially segregated neighborhoods was small (n = 12), which limited
Table 2 presents
characteristics of the nutrition and physical activity environments in the
participating schools. Schools with high minority student enrollment were less
likely than those with low minority student enrollment to have programs
promoting healthy eating or physical activity or have a playing field or track
on the school grounds. In high minority schools, the time allotted for recess
was an average of 27 minutes per day, whereas in low minority schools the recess time
was an average of 16 minutes (data not shown). No differences between the two
types of schools were found in the availability of nonnutritious foods and
sweetened beverages that students could purchase during school hours. Only 10%
of all schools reported having written policies on nutrition, physical activity,
or both, excluding policies mandated by the state (data not shown).
Phase 2: intervention and case studies
Table 3 shows the
demographic characteristics of the four schools that participated in the
intervention. The four schools combined included grades prekindergarten through
6: school 1 had grades prekindergarten and kindergarten; school 2, grades
kindergarten and 1; school 3, grades kindergarten through 6; and school 4,
grades 4 through 6. Student enrollments in the various schools
ranged from 118 to 547 students, with Hispanic students comprising 26% to 65% of the student body. Student eligibility for free or reduced-price
lunch ranged from 54% to 93%.
As mentioned, all teams included the principal, a physical education teacher,
and a food service director or manager. Some teams had teachers, the school
nurse, a parent, the president of the parentĖteacher organization, the director
from the schoolís family center, or all of these. In all, the principal played a
pivotal role in team functioning. In three of the four schools, the principalís
support was a key component to the success of the intervention. In the fourth
school, existing tension between the principal and staff was a barrier.
Team size ranged from 5 to more than 20 members. Regardless of a schoolís
team size, getting regular attendance at team meetings was challenging. The team size did not
seem to affect implementation of strategies; for example, the largest team
implemented the fewest strategies. What mattered more than the team size was the
attitude of the team members; smaller teams with members who were enthusiastic,
decisive, and proactive were able to accomplish more than larger teams with
conflicting agendas. Teams had formal meetings from October through June. Three teams were subcommittees of the
School Improvement Team, a team that is mandated for all schools by Rhode
Island statute (23).
All schools completed the SHI assessment early in fall 2002. Team members
were excited to implement changes. Three schools drafted action plans by the end
of fall for implementation during spring 2003. The facilitators encouraged teams
to address one action or policy at a time. Each policy had many steps that
preceded full implementation. Through small successes, SHI teams recognized that
they would have greater support if they recommended one proposal at a time
rather than a long list of changes. It also became clear that some of the
proposed changes would be difficult to implement, either because the policy
required a lengthy process (e.g., changing the schoolís food service vendor,
having an adequate teacher:student ratio for physical education classes) or
because of budget constraints. By the end of the year, all schools had developed
policies, defined problems, and developed language to support healthy eating and
Schools 1 and 2
Two schools in one district established one SHI team for both schools and collaborated to implement a hand washing policy
and a healthy snack policy. The hand washing policy was incorporated into the
school handbooks, so the handbooks now state that all children will wash their
hands before participating in any activity that involves food. The policy on
healthy snacks in all school venues evolved from the district food service
directorís success in forging relationships with vendors to provide healthy
snacks to all elementary schools. The healthy snacks policy was incorporated
into the state’s mandated school improvement plan (23), giving the team’s work greater visibility and
School 3 had a low morale issue, so its team had to build support while
proposing activities to improve the schoolís environment. The team drafted
polices to replace the less healthy foods that were sold during lunch time to
raise money for school events,
such as replacing high-fat ice cream with lower fat yogurt and 100% fruit juice
popsicles. In addition, the parentĖteacher organization attempted to replace
fundraisers involving food with little or no nutritional value with fundraisers
nonfood products. These proposals did not become policies. Sources from the
that school profits generated from ice cream sales were considered a needed
fundraising strategy and were unlikely to be changed. However, the schoolís
SHI team increased awareness about food choices at special events.
Because of this teamís setbacks, facilitators worked with team members to
draft a new policy. The policy stated that at the start of each new school year,
one SHI team member would collect information from teachers and staff members
about the use of curricula or programs that taught children about healthy eating
and physical activity. The collected information would be printed in the parentĖteacher
organization newsletter and school department publications. Although the
drafting of this policy unified the team and gave members a sense of
accomplishment, the draft did not become a formal policy and no additional
progress was made. Despite the teamís resourcefulness in developing health
promotion policies, enthusiasm for Eat Healthy and Get Active!
after attempts to implement changes were thwarted.
School 4 encountered insurmountable barriers to implementing policies,
including personnel changes (replacement of the food service manager) and the
second-semester announcement that the school was slated to be closed in the near
future. Initially, this school was
enthusiastic about Eat Healthy and Get Active! After completing the SHI
assessment, the team generated and prioritized recommendations. Because the year
for the school closing was uncertain, the team decided not to address issues
relating to the schoolís physical structure. Instead, the team drafted three
policies. The first stated that the school would try to garner resources through
grants and fundraisers for equipment and supplies to increase physical activity
and improve physical education. The second stated that students and families
would receive health information through after-school programs, school
workshops, and other school programs. The third stated that teachers and
administrators would encourage student participation in physical activity
programs in the community. The announcement that the school would close in June
deflated the team’s efforts, and the
school was unable to implement policies generated by the SHI assessment.
External facilitators were an essential component of Eat Healthy and Get
Active! They worked with schools to establish teams,
develop action plans, and monitor progress. In addition, facilitators trained
school personnel to use the SHI manual, attended
SHI team meetings, drafted agendas, took notes, linked teams with resources in
the community, and provided technical assistance. When problems arose, the
facilitators played a key role in maintaining the teamsí focus so that results
of the SHI assessments were translated into action plans and policy
All schools completed baseline assessments for the three SHI modules. Three
schools received high scores for the physical education programs module. Two schools also
received high scores for the nutrition
services module. No school scored high on the school policies
and environment module.
By June 2003, school 3 had completed all three SHI
self-assessment modules. Schools 1 and 2 were unable to complete the physical
education programs module because of staff
turnover. Staff turnover also hampered efforts to complete end-of-study
assessments in school 4, a barrier compounded by time constraints caused by the
school closing. In school 3, the negative change score from baseline to the end
of the study in the nutrition services module was a result of barriers faced by team members as they attempted to
translate their recommendations into approved policies (Table
4). In-depth interviews with two team members revealed that proposals for
healthy food choices needed greater exposure to gain acceptance and overcome
school personnelís reluctance to lose needed revenue from the sale of nonnutritious
ŗ la carte and fast-food offerings.
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Our needs assessment of 102 elementary schools and interventions in four
inner-city elementary schools were undertaken at a time when the prevalence of
obesity among Rhode Island children and adolescents was more than double the
A Healthier Rhode Island by 2010 target prevalence of 10% (24). In 2001,
approximately 28,612 Rhode Island youth were obese (BMI ≥95th
percentile), an overall prevalence rate of 21.5% (25).
One of the challenges in gaining support from school administrators for
policy and environmental changes is the absence of data to support the rationale
for systems-level nutrition and physical activity interventions. Assessment of
policy adoption in school settings is a new area (26); we believe that RINAT is
a valuable tool for collecting information on nutrition and physical activity
policies and programs in elementary schools and can be modified for middle and
Findings from RINAT demonstrated that schools with high minority enrollment had fewer
nutrition and physical activity programs than schools with low minority
enrollment and lacked
the infrastructure to promote physical activity, such as outdoor tracks and
walking paths. These problems were exacerbated in high minority schools situated
in racially segregated neighborhoods. However, our study
included only a small sample of racially segregated neighborhoods with high
minority schools, and the issue of whether a neighborhood’s racial and ethnic
composition and socioeconomic status influence a school’s physical activity and
nutrition environment deserves additional study (4). However,
regardless of the racial and ethnic
composition of the student body, we found that 85% of elementary schools sold
items such as soft drinks, chips, candy, and fast food. All
schools need to have sufficient financial resources to support activities such as field trips and
school enhancement projects or they will continue to rely on the sale of nonnutritious
food items in school venues and at fundraisers to increase revenue and meet
We did not find that schools with high minority enrollment were
less likely than schools with low minority enrollment to perceive childhood
obesity as an important problem. Among principals who reported that childhood
obesity was a problem, 47% were in low minority schools and 53% were in high
minority schools (P = .08; data not shown).
During a 10-month school year, four inner-city Rhode Island elementary schools
assessed their school environments and developed action plans using the CDCís
SHI. Despite intense pressure to focus all efforts on improving studentsí
reading and math scores and limited resources to dedicate to the intervention
project, all four schools completed three of the SHI modules and proposed policies to correct identified problems.
Findings from our process evaluation support evaluation results reported by
Staten et al (15) on implementing the SHI in low-income schools serving
primarily Hispanic students. Like Staten et al (15), we found that
implementation of the SHI is less successful in schools with low staff morale,
budgetary constraints, academic pressures, and inconsistent administrator
support. Also like Staten et al (15), we found that external facilitators were the
key to successful policy interventions. With the pressure to focus on
reading and mathematics test scores, it is easy for school teams working on
nutrition and physical activity policies to lose momentum. Being part of a team
that creates policy recommendations is difficult for administrators, teachers,
and parents, especially when they are not knowledgeable about national
guidelines for healthy eating and physical activity. An outside
facilitator keeps the team on track. External facilitators also provide
continuity by helping teams overcome barriers such as staff turnover and limited
The process evaluation underscored that the principal must understand the SHI
intervention and the school's expectations before agreeing to begin the project.
Furthermore, each team member needs to understand the SHI project objectives and
expected outcomes. In schools 1 and 2, the drafting and implementation of the hand washing and healthy snacks in
school policies was a testament to the essence of an SHI team ó
collaboration. The school superintendent supported the teamsí efforts and
considered their accomplishments to be a model for all schools. A 2005 interview
with the school principal confirmed that both policies continue to be
implemented and are widely accepted by children and parents.
One unique finding from our study was the discovery that although policy
interventions for nutrition and physical activity often positively influence
student behaviors, hands-on, interactive programs and activities incorporated into
policy interventions help schools begin to understand the relationships among policies, behavior change, and a healthy school environment. Including
an individual-level behavior change component in a policy
intervention provides explicit reinforcement for an SHI team promoting
broad-reaching policies that affect all students (12).
Our study has some limitations. Our definition of a high minority school
reflected the demographics of Rhode Island and may not be applicable to other
states. In addition, our intervention was limited to four schools and three
teams. Although many
of our findings were similar to those reported by Staten et al (15), the changes
we documented may not be generalizable to all elementary schools. We also lacked
the funding to evaluate our intervention using a quasi-experimental study
design. Administering our needs assessment survey after the intervention was
complete would have enabled us to gain a better understanding of factors that
influence participation in the SHI process. A postintervention survey also would
have provided an opportunity to
compare the SHI with other strategies schools use to gain support for healthy
eating and physical activity policies. Finally, funding for Eat Healthy and Get Active!
was only available for one school year. Changing a schoolís nutritional and
physical activity environment is a long-term process. A 1-year intervention is
too short to create a sustainable infrastructure.
Our study confirms that the SHI is an effective way to help schools set policies
and standards that meet national health objectives. Although our intervention
was short term, we believe that the school teams established as part of our
intervention will build on their accomplishments and recommend more
controversial and high-impact policies. The political climate in Rhode Island is
becoming more receptive to the concept of policy and environmental changes to
promote healthy eating and physical activity in schools. Obtaining district and
statewide support for these policies will ensure long-term implementation of
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This project was funded by the Centers for Disease Control and Prevention
contract agreement U58/CCU119309-02. The authors thank the school personnel who
agreed to take part in the Rhode Island Needs Assessment Tool (RINAT) survey. We
extend our appreciation to the four elementary schools that participated in the
intervention. This project benefited from the high level of professionalism of
the Brown University students who conducted the RINAT interviews. We also thank
Dorothy Brayley, executive director, and Jennifer Sousa, community liaison, of
Kids First, Inc for their involvement in all phases of the school
intervention. We thank Eliza Lawson, MPH, Rhode Island Department of Health,
Initiative for a Healthy Weight, for her comments on previous drafts of this
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Corresponding Author: Deborah N. Pearlman, PhD, Rhode Island Department of
Health, Division of Disease Prevention and Control, 3 Capitol Hill, Cannon Bldg,
Fourth Floor, Providence, RI 02908. Telephone: 401-222-6817. E-mail: Deborah.Pearlman@health.ri.gov.
Dr. Pearlman is also Assistant Professor of Community Health
(Research), Department of Community Health, Brown University, Providence, RI.
Author Affiliations: Elizabeth Dowling, MPH, Cheryl Bayuk, Kathleen Cullinen,
MS, RD, and Ann Kelsey Thacher, MS, Rhode Island Department of Health,
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