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Kanchanachitra M, Angeles G. Impact of a School-Based Nutrition Intervention in Preventing Overweight and Obesity in Children in Thailand. THE JOURNAL OF SCHOOL HEALTH 2023; 93:140-147. [PMID: 36217922 PMCID: PMC10092697 DOI: 10.1111/josh.13253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 08/03/2022] [Accepted: 09/15/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND This study evaluated the impact of a school-based nutrition program on preventing overweight and obesity in children in Thailand from 2014 to 2019. METHODS We used difference-in-differences with matched comparison group to evaluate program impact. Treatment schools were categorized into those that participated in phase 1 only, and those that participated in phase 1 and 2. We matched 311 treatment schools in phase 1 only with 1504 comparison schools, and 75 treatment schools in both phases with 216 comparison schools. Administrative data from Thailand Office of Basic Education Commission were used from 2014 (baseline), 2016 (first follow-up), and 2019 (second follow-up). RESULTS Program resulted in a 0.6-1.1 percentage point reduction in the students' probability of overweight by the end of phase 1, and 1.7 percentage points by the end of phase 2. Impact on obesity was found only for schools participating in both phases (0.4 and 0.9 percentage points by the end of phase 1 and 2, respectively). IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY Program continuity and intensity are key to achieve a reduction in overweight and obesity in schoolchildren. CONCLUSIONS The program was successful in reducing overweight and/or obesity given appropriate level of continuity and intensity.
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Affiliation(s)
- Manasigan Kanchanachitra
- Institute for Population and Social ResearchMahidol University999 Phuttamonthon Sai 4, Salaya, PhuttamonthonNakhon Pathom73170Thailand
| | - Gustavo Angeles
- Department of Maternal and Child Health, Gillings School of Global Public HealthUniversity of North Carolina at Chapel Hill400 Meadowmont CircleChapel HillNC27599
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Said L, Gubbels JS, Kremers SPJ. Effect Evaluation of Sahtak bi Sahnak, a Lebanese Secondary School-Based Nutrition Intervention: A Cluster Randomised Trial. Front Nutr 2022; 9:824020. [PMID: 35369051 PMCID: PMC8966668 DOI: 10.3389/fnut.2022.824020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 02/21/2022] [Indexed: 11/13/2022] Open
Abstract
Objective To evaluate the effectiveness of Sahtak bi Sahnak on dietary knowledge and adherence to dietary guidelines in Lebanese adolescents. Design/setting A cluster randomised controlled trial was conducted in public and private secondary schools located in urban and rural regions in Lebanon. Participants Sixteen secondary schools including 1,572 adolescents were randomly assigned to the intervention (n = 739) or control group (n = 833). Intervention Sahtak bi Sahnak is an educational school-based intervention dedicated to improving dietary adherence to nutritional guidelines, increasing the level of dietary knowledge, and preventing the development of obesity during adolescence. It was systematically designed based on the Intervention Mapping framework. The total length of the intervention was around seven educational sessions, until all of the 11 lessons were covered. Each education session lasted 20-40 min. Main Outcome Measures Dietary knowledge and adherence levels were measured at baseline and post-intervention using validated questionnaires. Statistical Analysis Multivariate multilevel regression models were used to examine intervention effects on outcomes, controlled for background characteristics (i.e., age, gender, location, type of school, grade, BMI z-score). Results The intervention group showed significant improvements in total dietary knowledge (B = 12.74, p < 0.001) and intake of healthy items (B = 1.89, p < 0.001), compared to the control group. Intake of unhealthy items decreased significantly (B = -1.43, p < 0.001), compared to the control group. These results were adjusted for age, gender, type of school, location, BMI z-score, study group, and score at baseline. Conclusion and Implications Sahtak bi Sahnak is an effective and culturally appropriate school-based intervention for targeting diet among a variety of Lebanese adolescents.
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Affiliation(s)
- Liliane Said
- Department of Health Promotion, NUTRIM School of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, Netherlands
- Department of Nutrition and Food Sciences, Faculty of Arts and Sciences, Lebanese International University, Bekaa, Lebanon
| | - Jessica S. Gubbels
- Department of Health Promotion, NUTRIM School of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Stef P. J. Kremers
- Department of Health Promotion, NUTRIM School of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, Netherlands
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3
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Seral-Cortes M, De Miguel-Etayo P, Zapata P, Miguel-Berges ML, Moreno LA. Effectiveness and process evaluation in obesity and type 2 diabetes prevention programs in children: a systematic review and meta-analysis. BMC Public Health 2021; 21:348. [PMID: 33579237 PMCID: PMC7881469 DOI: 10.1186/s12889-021-10297-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 01/20/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Obesity in children is one of the most severe public health challenges of the current century and Type 2 Diabetes Mellitus (T2DM) frequency is also escalating. More so, the importance of process evaluation (PE) in complex interventions is increasingly recognized. The present review, aims to identify the effectiveness in terms of body composition parameters in a generation of articles to prevent obesity and T2DM in children. We hypothesise that those studies reporting PE applying the latest implementation guidelines suggested by the researchers would potentially show positive changes in body composition compared to those not reporting it. Additionally, we will evaluate the implementation degree of PE in those articles considering it and describe the PE subcomponents. Lastly, we aim to assess the intervention target used and its results. METHODS A literature review was performed in parallel by 2 independent reviewers. A final number of 41 studies were selected for inclusion criteria. RESULTS Meta-analysis of BMI and zBMI found non-significant effects of the proposed interventions. Sub-group analysis revealed only a significant effect in studies which performed PE. Moreover, PE was reported in 42% effective studies and 57% non-effective studies. Fidelity and satisfaction were the most implemented PE subcomponents, although there was a generally low grade of PE use (7/41). The highest proportion of effectiveness (83%) was shown in interventions of physical activity alone while the intervention most used was 3-arm target (diet, PA and BS). CONCLUSIONS Overall, obesity and T2DM prevention studies included in this review are not effective in terms of BMI and zBMI. Those studies performing PE reported to be effective in terms of BMI, while studies not reporting PE did not have positive results in terms of BMI and zBMI. In addition, none of the intervention studies included all PE indicators and most studies, which included PE in their interventions, did not provide full report of the PE components, according to the guidelines used for the present review. PROSPERO registration number: CRD42018093667.
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Affiliation(s)
- M Seral-Cortes
- Growth, Exercise, NUtrition and Development (GENUD) Research Group, Instituto Agroalimentario de Aragón (IA2), Instituto de Investigación Sanitaria, Aragón (IIS Aragón), Universidad de Zaragoza, 50009, Zaragoza, Spain
- Department of Psychiatry and Nursing, Faculty of Health Sciences, Universidad de Zaragoza, Zaragoza, Spain
| | - P De Miguel-Etayo
- Growth, Exercise, NUtrition and Development (GENUD) Research Group, Instituto Agroalimentario de Aragón (IA2), Instituto de Investigación Sanitaria, Aragón (IIS Aragón), Universidad de Zaragoza, 50009, Zaragoza, Spain.
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, Madrid, Spain.
| | - P Zapata
- Growth, Exercise, NUtrition and Development (GENUD) Research Group, Instituto Agroalimentario de Aragón (IA2), Instituto de Investigación Sanitaria, Aragón (IIS Aragón), Universidad de Zaragoza, 50009, Zaragoza, Spain
- Departamento de nutrición y dietética, Universidad de Antioquia, Medellín, Colombia
| | - M L Miguel-Berges
- Growth, Exercise, NUtrition and Development (GENUD) Research Group, Instituto Agroalimentario de Aragón (IA2), Instituto de Investigación Sanitaria, Aragón (IIS Aragón), Universidad de Zaragoza, 50009, Zaragoza, Spain
- Department of Psychiatry and Nursing, Faculty of Health Sciences, Universidad de Zaragoza, Zaragoza, Spain
| | - L A Moreno
- Growth, Exercise, NUtrition and Development (GENUD) Research Group, Instituto Agroalimentario de Aragón (IA2), Instituto de Investigación Sanitaria, Aragón (IIS Aragón), Universidad de Zaragoza, 50009, Zaragoza, Spain
- Department of Psychiatry and Nursing, Faculty of Health Sciences, Universidad de Zaragoza, Zaragoza, Spain
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, Madrid, Spain
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Prevention of Childhood Obesity: A Position Paper of the Global Federation of International Societies of Paediatric Gastroenterology, Hepatology and Nutrition (FISPGHAN). J Pediatr Gastroenterol Nutr 2020; 70:702-710. [PMID: 32205768 DOI: 10.1097/mpg.0000000000002708] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Global childhood obesity increased more than 8-fold over 40 years, inducing a very large personal, societal, and economic burden. Effects of available treatments are less than satisfactory; therefore, effective prevention is of high priority. In this narrative review, we explore preventive opportunities. The available evidence indicates large benefits of improving nutrition and lifestyle during early life, such as promoting breast-feeding and improving the quality of infant and early childhood feeding. Promoting healthy eating patterns and limiting sugar-containing beverage consumption from early childhood onwards are of great benefit. Regular physical activity and limited sedentary lifestyle and screen time alone have limited effects but are valuable elements in effective multicomponent strategies. The home environment is important, particularly for young children, and can be improved by educating and empowering families. School- and community-based interventions can be effective, such as installing water fountains, improving cafeteria menus, and facilitating regular physical activity. Reducing obesogenic risk factors through societal standards is essential for effective prevention and limiting socioeconomic disparity; these may comprise food, drink, and physical activity standards for day cares and schools, general food quality standards, front-of-pack food labeling, taxation of unhealthy foods, restriction of food advertisements to children, and others. Effective prevention of childhood obesity is not achieved by single interventions but by integrated multicomponent approaches involving multiple stakeholders that address children, families, and societal standards. Pediatricians and their organizations should be proactive in supporting and empowering families to support their children's health, and in promoting societal measures that protect children.
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Fetter DS, Linnell JD, Dharmar M, Bergman JJ, Byrnes M, Gerdes MA, Ruiz LD, Pang N, Pressman J, Scherr RE. Using Theory to Develop Healthy Choices in Motion, a Comprehensive, Experiential Physical Activity Curriculum. Front Public Health 2020; 7:421. [PMID: 32039132 PMCID: PMC6989426 DOI: 10.3389/fpubh.2019.00421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 12/31/2019] [Indexed: 12/03/2022] Open
Abstract
Background: Research has shown that engaging in regular physical activity supports physiologic, metabolic, and immunologic processes, as well as quality of life. However, few youth in the United States meet the U.S. Department of Health and Human Services recommendation of 60 min of moderate-to-vigorous physical activity every day. School-based programs can be an effective avenue for engaging youth in physical activity, particularly when the design of the health education is based on theory, research, and practice. The purpose of this study was to design, implement, and evaluate a theory-driven physical activity curriculum for the Shaping Healthy Choices Program (SHCP) using a systematic approach. Methods: The experiential, inquiry-based physical activity curriculum, Healthy Choices in Motion (HCIM), was developed with an optional technology enhancement using Backward Design. A questionnaire to assess the curriculum's effect on physical activity knowledge was developed and assessed for content validity, internal consistency (α = 0.84), and test-retest reliability (r = 0.73). The curriculum was piloted in two phases among upper elementary-aged youth: to ensure the learning goals were met (Pilot I) and to determine the curriculum's impact on physical activity knowledge, behavior, and self-efficacy (Pilot II). Pilot II was implemented among eight 4th and 5th-grade classrooms participating in the UC CalFresh Nutrition Education Program: (1) Comparison (no intervention) (n = 25); (2) SHCP only (n = 22); (3) SHCP + HCIM (n = 42); (4) SHCP + HCIM with technology enhancement (n = 47). Analyses included unadjusted ANOVA and Bonferroni for multiple comparisons and paired t-test (p < 0.05). Results: Through the use of a methodical design approach, a comprehensive physical activity curriculum, called HCIM, was developed. Youth participating in HCIM improved physical activity knowledge compared to youth receiving no intervention (+2.8 points, p = 0.009) and youth only in the SHCP (+3.0 points, p = 0.007). Youth participating in HCIM with technology enhancement demonstrated improvements compared to youth only in the SHCP (+2.3 points, p = 0.05). Conclusion: Improvements in physical activity knowledge in youth participating in HCIM may contribute to improvements in physical activity and should be further explored in conjunction with behavioral measurements.
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Affiliation(s)
- Deborah S Fetter
- Department of Nutrition, University of California, Davis, Davis, CA, United States.,Department of Nutrition, Center for Nutrition in Schools, University of California, Davis, Davis, CA, United States
| | - Jessica D Linnell
- Oregon State University Extension Service, Corvallis, OR, United States
| | - Madan Dharmar
- Betty Irene Moore School of Nursing, University of California, Davis, Davis, CA, United States
| | - Jacqueline J Bergman
- St. Mary's College of California, Allied Health Sciences Program, Moraga, CA, United States
| | - Michele Byrnes
- CalFresh Healthy Living, University of California, Davis, Davis, CA, United States
| | - Melanie A Gerdes
- Department of Nutrition, University of California, Davis, Davis, CA, United States.,Department of Nutrition, Center for Nutrition in Schools, University of California, Davis, Davis, CA, United States
| | - Lyndsey D Ruiz
- Department of Nutrition, University of California, Davis, Davis, CA, United States.,Department of Nutrition, Center for Nutrition in Schools, University of California, Davis, Davis, CA, United States
| | - Natalie Pang
- Department of Nutrition, University of California, Davis, Davis, CA, United States.,Department of Nutrition, Center for Nutrition in Schools, University of California, Davis, Davis, CA, United States
| | - Jona Pressman
- Butte County Cluster, University of California Agriculture and Natural Resources, Oroville, CA, United States
| | - Rachel E Scherr
- Department of Nutrition, University of California, Davis, Davis, CA, United States.,Department of Nutrition, Center for Nutrition in Schools, University of California, Davis, Davis, CA, United States
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Andrade A, Correia CK, Coimbra DR. The Psychological Effects of Exergames for Children and Adolescents with Obesity: A Systematic Review and Meta-Analysis. CYBERPSYCHOLOGY BEHAVIOR AND SOCIAL NETWORKING 2020; 22:724-735. [PMID: 31697604 DOI: 10.1089/cyber.2019.0341] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The systematic review and meta-analysis were conducted to analyze the psychological effects of exergames for children and adolescents with overweight or obesity. In August 2018, the electronic databases searched were PubMed, Scopus, Web of Science, SPORTDiscus, Science Direct, CINAHL, and PsycINFO. The eligibility criteria were defined according to the population, intervention, comparison, outcome, and study design. In relation to the population, only studies with children or adolescents with overweight or obesity and without any other comorbidities were analyzed. Only publications in English were considered. Nine studies were selected. The comparisons identified were in relation to weight, type of activity, and play style versus control and preintervention. The magnitude of effect size suggests that the practice of exergaming has a small effect on psychological outcomes. Furthermore, cooperative games produced greater attraction to the game (g = 4.71, 95% confidence interval [CI] = 3.23-6.19) and greater intrinsic motivation (g = 5.29; 95% CI = 3.68-6.90). It was verified that self-esteem (standard mean difference [SMD] = 0.37; 95% CI = 0.09-0.66), and self-efficacy (SMD = 0.42; 95% CI = 0.06-0.79) improved after playing an exergame. This systematic review and meta-analysis suggest that exergames may be effective in improving psychological aspects of children and adolescents with overweight or obesity. Given the limited number of studies, it is essential to increase scientific research in this area.
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Affiliation(s)
- Alexandro Andrade
- Laboratory of Psychology of Sport and Exercise, Department of Physical Education, Center of Health Sciences and Sports, Santa Catarina State University, Florianópolis, Brazil
| | - Clara Knierim Correia
- Laboratory of Psychology of Sport and Exercise, Department of Physical Education, Center of Health Sciences and Sports, Santa Catarina State University, Florianópolis, Brazil
| | - Danilo Reis Coimbra
- Laboratory of Psychology of Sport and Exercise, Department of Physical Education, Center of Health Sciences and Sports, Santa Catarina State University, Florianópolis, Brazil
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7
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Fetter DS, Dharmar M, Lawry-Hall S, Pressman J, Chapman J, Scherr RE. The Influence of Gain-Framed and Loss-Framed Health Messages on Nutrition and Physical Activity Knowledge. Glob Pediatr Health 2019; 6:2333794X19857405. [PMID: 31276023 PMCID: PMC6598332 DOI: 10.1177/2333794x19857405] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 04/29/2019] [Accepted: 05/17/2019] [Indexed: 11/28/2022] Open
Abstract
Background. Research remains inconclusive about the most effective frame for encouraging health preventative behaviors. Aims. To examine the impact of gain- and loss-framed health messages on nutrition and physical activity (PA) knowledge in fourth-grade youth participating in the Shaping Healthy Choices Program (SHCP), a multicomponent nutrition program. Methods. Youth were recruited to participate in this 9-month quasi-experimental study and divided into 3 groups: (1) comparison (n = 50), (2) loss-framed (n = 76), and (3) gain-framed (n = 67). All youth participated in the SHCP, and the gain- and loss-framed groups also viewed weekly health messages. Paired t tests or Wilcoxon signed-rank test, ANOVA (analysis of variance), and Bonferroni for multiple comparisons were used for analysis. Results. Youth who participated in the SHCP improved nutrition knowledge (+2.0 points; P < .01) and PA knowledge (+1.8 points; P < .01). Nutrition knowledge improved in the comparison group (+1.3 points; P = .04), loss-framed group (+1.9 points; P = .01), and gain-framed group (+2.6 points; P = .01). Improvements in PA knowledge were also demonstrated in the comparison group (+1.6 points; P < .01), the loss-framed group (+1.3 points; P < .01), and the gain-framed group (+2.5 points; P = .01). There were no significant differences between groups. Youth in the loss-framed group reported a decrease in self-efficacy (-1.2; P = .05), while this was not observed in the other groups. Discussion. The SHCP improves nutrition and PA knowledge, and the positive reinforcement further strengthens some of these improvements, while loss-framed messaging can contribute to undesirable outcomes. Conclusions. Incorporating positive reinforcement through gain-framed messages can be a relatively low-cost avenue for supporting beneficial outcomes.
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Affiliation(s)
| | - Madan Dharmar
- University of California, Davis Health System, Sacramento, CA, USA
| | | | - Jona Pressman
- Cooperative Extension, Butte County, Oroville, CA, USA
| | - Jamie Chapman
- Cooperative Extension, Butte County, Oroville, CA, USA
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8
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Fetter DS, Scherr RE, Linnell JD, Dharmar M, Schaefer SE, Zidenberg-Cherr S. Effect of the Shaping Healthy Choices Program, a Multicomponent, School-Based Nutrition Intervention, on Physical Activity Intensity. J Am Coll Nutr 2018. [PMID: 29533146 DOI: 10.1080/07315724.2018.1436477] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Physical activity has been shown to have a wide range of beneficial health effects, yet few youth meet the United States physical activity recommendation of 60 minutes of moderate-to-vigorous physical activity (MVPA) everyday. The objective of this study was to determine whether physical activity patterns improved in a subsample of fourth-graders participating in the multicomponent intervention, the Shaping Healthy Choices Program (SHCP). METHODS At pre- and post-intervention assessments, youth at the control and intervention schools wore a Polar Active monitor on their nondominant wrist 24 h/d for at least 2 consecutive days. Multiple linear regression was used to evaluate change in physical activity by adjusting for covariates and other potential confounders, including ethnicity/race, household income, and sex. Statistical significance was set at p < 0.05. RESULTS Mean minutes of MVPA significantly increased at the intervention school (22.3 + 37.8; p = 0.01) and at the control school (29.1 + 49.5; p = 0.01). There were no significant differences in the change in MVPA between the schools. Youth at the intervention school significantly decreased mean minutes in sedentary activity compared to the controls (p = 0.02). CONCLUSIONS Youth who participated in the SHCP decreased time spent in sedentary activity and increased very vigorous physical activity from pre- to post-intervention, while these changes were not observed at the control school. The overall small physical activity intensity pattern shift supports that physical activity is an important area to target within a multicomponent nutrition intervention aimed at preventing childhood obesity.
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Affiliation(s)
- Deborah S Fetter
- a University of California, Davis, Nutrition , Davis , California , USA.,b University of Califonria, Davis, Center for Nutrition in Schools , Davis , California , USA
| | - Rachel Erin Scherr
- a University of California, Davis, Nutrition , Davis , California , USA.,b University of Califonria, Davis, Center for Nutrition in Schools , Davis , California , USA
| | - Jessica D Linnell
- c Oregon State Extension Service, Family and Community Health, Tillamook and Lincoln Counties , Tillamook , Oregon , USA
| | - Madan Dharmar
- d University of California, Davis , Department of Pediatrics , Sacramento , California , USA.,e University of California, Davis, Betty Irene Moore School of Nursing , Sacramento , California , USA
| | - Sara E Schaefer
- f University of California, Davis, Foods for Health Institute , Davis , California , USA
| | - Sheri Zidenberg-Cherr
- a University of California, Davis, Nutrition , Davis , California , USA.,b University of Califonria, Davis, Center for Nutrition in Schools , Davis , California , USA
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Saint-Maurice PF, Bai Y, Welk GJ, Bandelli LN, Allums-Featherston K, Candelaria N. Impact of NFL PLAY 60 Programming on Elementary School Children's Body Mass Index and Aerobic Capacity: The NFL PLAY 60 FitnessGram Partnership Project. THE JOURNAL OF SCHOOL HEALTH 2017; 87:873-881. [PMID: 29023836 DOI: 10.1111/josh.12561] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 02/20/2017] [Accepted: 02/23/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND We examined the impact of the Fuel Up to Play 60 (FUTP60) program on children's body mass index (BMI) and aerobic capacity (AC). METHODS Participation in the FUTP60 and both BMI and AC profiles were collected through the NFL PLAY 60 FitnessGram Partnership Project involving over 100 schools from 22 US states. We specifically examined the distributions of BMI and AC among participating versus nonparticipating schools in the 2012-2013 school year. Hierarchical linear models tested the impact of participation and availability of additional funding for program implementation on the proportions of youth meeting FitnessGram health-related fitness standards (ie, Needs Improvement-Health Risk [NIHR] and Healthy Fitness Zone [HFZ] categories). RESULTS After 1 year implementing the program, participating schools had lower proportions of boys (-4.1 ± 2.0%, p = .04) and girls (-4.5 ± 2.0%, p = .03) in the NIHR for BMI, and lower proportion of girls (-9.7 ± 4.0%, p = .02) in the NIHR for AC. There were no differences in the distributions for the HFZ and the availability of additional funding did not alter the relationships (p > .05). CONCLUSIONS This study provides preliminary evidence that participation in the FUTP60 is associated with improved profiles of health-related fitness.
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Affiliation(s)
| | - Yang Bai
- Department of Rehabilitation and Movement Science, University of Vermont, Rowell 310P, 106 Carrigan Dr, Burlington, VT 05405
| | - Gregory J Welk
- Department of Kinesiology, Iowa State University, 257 Forker Building, Ames, IA 50011
| | - Lorraine N Bandelli
- Health & Wellness Partnerships and Evaluation, GENYOUth, West New York, NJ 07093
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10
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Toussaint LL, Housholder K, Janssen K, Mansfield A, Lynch BA. Slowing BMI Growth Trajectories in Elementary School-Aged Children: The Northeast Iowa Food and Fitness Initiative. FAMILY & COMMUNITY HEALTH 2017; 40:192-197. [PMID: 28525438 DOI: 10.1097/fch.0000000000000151] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
This project examines the Northeast Iowa Food and Fitness Initiative, a policy-, community-, and school-based effort to slow children's body mass index (BMI) growth over 6 years. Kindergarteners (K) to fifth graders (5) from 10 different school districts participated (N = 4101). Students with 0 to 1 years of initiative exposure showed greater growth in BMI compared with children who had 2 to 6 years of exposure, resulting in K-5 BMI savings of 1.5 points (6 lb) for median-height boys and girls. Results suggest that changes to policies, communities, and schools may provide effective obesity reduction in children.
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Affiliation(s)
- Loren L Toussaint
- Luther College, Decorah, Iowa (Drs Toussaint and Mansfield and Mss Housholder and Janssen); and Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota (Dr Lynch)
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11
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Dariotis JK, Mirabal-Beltran R, Cluxton-Keller F, Gould LF, Greenberg MT, Mendelson T. A Qualitative Exploration of Implementation Factors in a School-Based Mindfulness and Yoga Program: Lessons Learned from Students and Teachers. PSYCHOLOGY IN THE SCHOOLS 2016; 54:53-69. [PMID: 28670007 DOI: 10.1002/pits.21979] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Identifying factors relevant for successful implementation of school-based interventions is essential to ensure that programs are provided in an effective and engaging manner. The perspectives of two key stakeholders critical for identifying implementation barriers and facilitators - students and their classroom teachers - merit attention in this context and have rarely been explored using qualitative methods. This study reports qualitative perspectives of fifth and sixth grade participants and their teachers of a 16-week school-based mindfulness and yoga program in three public schools serving low-income urban communities. Four themes related to program implementation barriers and facilitators emerged: program delivery factors, program buy-in, implementer communication with teachers, and instructor qualities. Feedback from students and teachers is discussed in the context of informing implementation, adaptation, and future development of school-based mindfulness and yoga programming in urban settings.
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Affiliation(s)
- Jacinda K Dariotis
- University of Cincinnati, College of Education, Criminal Justice, and Human Services, Evaluation Services Center.,Johns Hopkins Bloomberg School of Public Health, Department of Population, Family, and Reproductive Health, Center for Adolescent Health, Hopkins Population Center
| | - Roxanne Mirabal-Beltran
- Johns Hopkins Bloomberg School of Public Health, Department of Population, Family, and Reproductive Health
| | - Fallon Cluxton-Keller
- Johns Hopkins Bloomberg School of Public Health, Department of Population, Family, and Reproductive Health
| | | | - Mark T Greenberg
- Pennsylvania State University, Department of Human Development and Family Studies, Prevention Research Center
| | - Tamar Mendelson
- Johns Hopkins Bloomberg School of Public Health, Department of Mental Health
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12
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Morgan PJ, Jones RA, Collins CE, Hesketh KD, Young MD, Burrows TL, Magarey AM, Brown HL, Hinkley T, Perry RA, Brennan L, Spence AC, Campbell KJ. Practicalities and Research Considerations for Conducting Childhood Obesity Prevention Interventions with Families. CHILDREN (BASEL, SWITZERLAND) 2016; 3:E24. [PMID: 27834820 PMCID: PMC5184799 DOI: 10.3390/children3040024] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 10/19/2016] [Accepted: 10/25/2016] [Indexed: 12/17/2022]
Abstract
Internationally, childhood obesity is a major public health concern. Given the established difficulties in treating obesity, designing and evaluating effective obesity prevention interventions are research priorities. As parents play a crucial role in establishing positive health behaviours in children, they are a key target for child obesity prevention programs. However, recruiting and engaging parents in such interventions can be a considerable challenge for researchers and practitioners. Members of the 'Parenting, Child Behaviour and Well-being' stream of the Australasian Child and Adolescent Obesity Research Network (ACAORN) have considerable and varied expertise in conducting such interventions and can provide insights into addressing these challenges. This paper aims to highlight considerations regarding the design, implementation, and evaluation of obesity prevention interventions with families and provide practical insights and recommendations for researchers and practitioners conducting family-based research in this area. Case studies of three family-based interventions conducted by ACAORN members are highlighted to provide examples and contextualise the recommendations proposed.
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Affiliation(s)
- Philip J Morgan
- Priority Research Centre in Physical Activity and Nutrition, University of Newcastle, Callaghan Campus, Newcastle 2308, Australia.
| | - Rachel A Jones
- Early Start Research Institute, Faculty of Social Sciences, University of Wollongong, Wollongong 2522, Australia.
| | - Clare E Collins
- Priority Research Centre in Physical Activity and Nutrition, University of Newcastle, Callaghan Campus, Newcastle 2308, Australia.
| | - Kylie D Hesketh
- Centre for Physical Activity and Nutrition Research, Deakin University, Geelong 3126, Australia.
| | - Myles D Young
- Priority Research Centre in Physical Activity and Nutrition, University of Newcastle, Callaghan Campus, Newcastle 2308, Australia.
| | - Tracy L Burrows
- Priority Research Centre in Physical Activity and Nutrition, University of Newcastle, Callaghan Campus, Newcastle 2308, Australia.
| | - Anthea M Magarey
- Discipline of Nutrition and Dietetics, Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide 5042, Australia.
| | - Helen L Brown
- Centre for Physical Activity and Nutrition Research, Deakin University, Geelong 3126, Australia.
| | - Trina Hinkley
- Centre for Physical Activity and Nutrition Research, Deakin University, Geelong 3126, Australia.
| | - Rebecca A Perry
- Discipline of Nutrition and Dietetics, Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide 5042, Australia.
| | - Leah Brennan
- School of Psychology, Australian Catholic University, Sydney 3065, Australia.
| | - Alison C Spence
- Centre for Physical Activity and Nutrition Research, Deakin University, Geelong 3126, Australia.
| | - Karen J Campbell
- Centre for Physical Activity and Nutrition Research, Deakin University, Geelong 3126, Australia.
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Morgan PJ, Young MD, Smith JJ, Lubans DR. Targeted Health Behavior Interventions Promoting Physical Activity. Exerc Sport Sci Rev 2016; 44:71-80. [DOI: 10.1249/jes.0000000000000075] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Aceves-Martins M, Llauradó E, Tarro L, Moreno-García CF, Trujillo Escobar TG, Solà R, Giralt M. Effectiveness of social marketing strategies to reduce youth obesity in European school-based interventions: a systematic review and meta-analysis. Nutr Rev 2016; 74:337-51. [PMID: 27018054 PMCID: PMC4836715 DOI: 10.1093/nutrit/nuw004] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
CONTEXT The use of social marketing to modify lifestyle choices could be helpful in reducing youth obesity. Some or all of the 8 domains of the National Social Marketing Centre's social marketing benchmark criteria (SMBC) are often used but not always defined in intervention studies. OBJECTIVE The aim of this review is to assess the effectiveness of European school-based interventions to prevent obesity relative to the inclusion of SMBC domains in the intervention. DATA SOURCES The PubMed, Cochrane, and ERIC databases were used. STUDY SELECTION Nonrandomized and randomized controlled trials conducted from 1990 to April 2014 in participants aged 5 to 17 years were included. DATA EXTRACTION After the study selection, the 8 domains of the SMBC were assessed in each included study. RESULTS Thirty-eight publications were included in the systematic review. For the meta-analysis, randomized controlled trials (RCTs) reporting body mass index or prevalence of overweight and obesity were considered. Eighteen RCTs with a total of 8681 participants included at least 5 SMBC. The meta-analysis showed a small standardized mean difference in body mass index of -0.25 (95%CI, -0.45 to -0.04) and a prevalence of overweight and obesity odds ratio of 0.72 (95%CI, 0.5-0.97). CONCLUSION Current evidence indicates that the inclusion of at least 5 SMBC domains in school-based interventions could benefit efforts to prevent obesity in young people. PROSPERO registration number: CRD42014007297.
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Affiliation(s)
- Magaly Aceves-Martins
- M. Aceves-Martins, E. Llauradó, L. Tarro, R. Solà, and M. Giralt are with the Functional Nutrition, Oxidation and Cardiovascular Disease Research Group (NFOC), Medicine and Surgery Department, Universitat Rovira i Virgili, Catalonia, Spain. M. Aceves-Martins, E. Llauradó, L. Tarro, R. Solà, and M. Giralt are with the Health Promotion and Education Research Team, Medicine and Surgery Department, Universitat Rovira i Virgili, Catalonia, Spain. M. Aceves-Martins, E. Llauradó, L. Tarro, R. Solà, and M. Giralt are with the Spanish Research Team at the European Youth Tackling Obesity (EYTO) Project. C.F. Moreno-García is with the Engineering, Computing and Mathematics Department, Universitat Rovira i Virgili, Catalonia, Spain. T.G. Trujillo Escobar is with the Mathematics and Statistics Faculty, Universitat Politécnica de Catalunya, Barcelona, Spain
| | - Elisabet Llauradó
- M. Aceves-Martins, E. Llauradó, L. Tarro, R. Solà, and M. Giralt are with the Functional Nutrition, Oxidation and Cardiovascular Disease Research Group (NFOC), Medicine and Surgery Department, Universitat Rovira i Virgili, Catalonia, Spain. M. Aceves-Martins, E. Llauradó, L. Tarro, R. Solà, and M. Giralt are with the Health Promotion and Education Research Team, Medicine and Surgery Department, Universitat Rovira i Virgili, Catalonia, Spain. M. Aceves-Martins, E. Llauradó, L. Tarro, R. Solà, and M. Giralt are with the Spanish Research Team at the European Youth Tackling Obesity (EYTO) Project. C.F. Moreno-García is with the Engineering, Computing and Mathematics Department, Universitat Rovira i Virgili, Catalonia, Spain. T.G. Trujillo Escobar is with the Mathematics and Statistics Faculty, Universitat Politécnica de Catalunya, Barcelona, Spain
| | - Lucia Tarro
- M. Aceves-Martins, E. Llauradó, L. Tarro, R. Solà, and M. Giralt are with the Functional Nutrition, Oxidation and Cardiovascular Disease Research Group (NFOC), Medicine and Surgery Department, Universitat Rovira i Virgili, Catalonia, Spain. M. Aceves-Martins, E. Llauradó, L. Tarro, R. Solà, and M. Giralt are with the Health Promotion and Education Research Team, Medicine and Surgery Department, Universitat Rovira i Virgili, Catalonia, Spain. M. Aceves-Martins, E. Llauradó, L. Tarro, R. Solà, and M. Giralt are with the Spanish Research Team at the European Youth Tackling Obesity (EYTO) Project. C.F. Moreno-García is with the Engineering, Computing and Mathematics Department, Universitat Rovira i Virgili, Catalonia, Spain. T.G. Trujillo Escobar is with the Mathematics and Statistics Faculty, Universitat Politécnica de Catalunya, Barcelona, Spain
| | - Carlos Francisco Moreno-García
- M. Aceves-Martins, E. Llauradó, L. Tarro, R. Solà, and M. Giralt are with the Functional Nutrition, Oxidation and Cardiovascular Disease Research Group (NFOC), Medicine and Surgery Department, Universitat Rovira i Virgili, Catalonia, Spain. M. Aceves-Martins, E. Llauradó, L. Tarro, R. Solà, and M. Giralt are with the Health Promotion and Education Research Team, Medicine and Surgery Department, Universitat Rovira i Virgili, Catalonia, Spain. M. Aceves-Martins, E. Llauradó, L. Tarro, R. Solà, and M. Giralt are with the Spanish Research Team at the European Youth Tackling Obesity (EYTO) Project. C.F. Moreno-García is with the Engineering, Computing and Mathematics Department, Universitat Rovira i Virgili, Catalonia, Spain. T.G. Trujillo Escobar is with the Mathematics and Statistics Faculty, Universitat Politécnica de Catalunya, Barcelona, Spain
| | - Tamy Goretty Trujillo Escobar
- M. Aceves-Martins, E. Llauradó, L. Tarro, R. Solà, and M. Giralt are with the Functional Nutrition, Oxidation and Cardiovascular Disease Research Group (NFOC), Medicine and Surgery Department, Universitat Rovira i Virgili, Catalonia, Spain. M. Aceves-Martins, E. Llauradó, L. Tarro, R. Solà, and M. Giralt are with the Health Promotion and Education Research Team, Medicine and Surgery Department, Universitat Rovira i Virgili, Catalonia, Spain. M. Aceves-Martins, E. Llauradó, L. Tarro, R. Solà, and M. Giralt are with the Spanish Research Team at the European Youth Tackling Obesity (EYTO) Project. C.F. Moreno-García is with the Engineering, Computing and Mathematics Department, Universitat Rovira i Virgili, Catalonia, Spain. T.G. Trujillo Escobar is with the Mathematics and Statistics Faculty, Universitat Politécnica de Catalunya, Barcelona, Spain
| | - Rosa Solà
- M. Aceves-Martins, E. Llauradó, L. Tarro, R. Solà, and M. Giralt are with the Functional Nutrition, Oxidation and Cardiovascular Disease Research Group (NFOC), Medicine and Surgery Department, Universitat Rovira i Virgili, Catalonia, Spain. M. Aceves-Martins, E. Llauradó, L. Tarro, R. Solà, and M. Giralt are with the Health Promotion and Education Research Team, Medicine and Surgery Department, Universitat Rovira i Virgili, Catalonia, Spain. M. Aceves-Martins, E. Llauradó, L. Tarro, R. Solà, and M. Giralt are with the Spanish Research Team at the European Youth Tackling Obesity (EYTO) Project. C.F. Moreno-García is with the Engineering, Computing and Mathematics Department, Universitat Rovira i Virgili, Catalonia, Spain. T.G. Trujillo Escobar is with the Mathematics and Statistics Faculty, Universitat Politécnica de Catalunya, Barcelona, Spain.
| | - Montse Giralt
- M. Aceves-Martins, E. Llauradó, L. Tarro, R. Solà, and M. Giralt are with the Functional Nutrition, Oxidation and Cardiovascular Disease Research Group (NFOC), Medicine and Surgery Department, Universitat Rovira i Virgili, Catalonia, Spain. M. Aceves-Martins, E. Llauradó, L. Tarro, R. Solà, and M. Giralt are with the Health Promotion and Education Research Team, Medicine and Surgery Department, Universitat Rovira i Virgili, Catalonia, Spain. M. Aceves-Martins, E. Llauradó, L. Tarro, R. Solà, and M. Giralt are with the Spanish Research Team at the European Youth Tackling Obesity (EYTO) Project. C.F. Moreno-García is with the Engineering, Computing and Mathematics Department, Universitat Rovira i Virgili, Catalonia, Spain. T.G. Trujillo Escobar is with the Mathematics and Statistics Faculty, Universitat Politécnica de Catalunya, Barcelona, Spain
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Expanding a successful community-based obesity prevention approach into new communities: Challenges and achievements. Obes Res Clin Pract 2015; 10:197-206. [PMID: 26166010 DOI: 10.1016/j.orcp.2015.05.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 05/14/2015] [Accepted: 05/29/2015] [Indexed: 11/23/2022]
Abstract
OBJECTIVE A previously successful community-based obesity prevention intervention with a focus on school settings was expanded into new communities with varying contexts. In order to understand the complexities involved in implementing health promotion activities in schools, this study examined experiences of school staff and project officers including barriers, contextual factors and achievements. METHODS School environment assessments were conducted in schools across four Victorian communities with school staff (n=1-5 staff plus a trained researcher per group in 9 primary and 8 secondary schools) 12-18 months post-intervention. Process reports from project officers were also reviewed and analysed (n=4). RESULTS School staff commonly reported time pressures as a barrier to implementation and project officers working within schools reported competing priorities and limited health promotion experience of staff; lack of stakeholder engagement; low participation in some activities and insufficient implementation time. Contextual factors included community socioeconomic status, student ethnicity and living rurally. Achievements included student and staff enjoyment from programme activities, staff capacity building, partnerships, embedding activities into existing infrastructure and programmes, and having consistent health-related messages repeated through a variety of strategies. CONCLUSIONS Community-based interventions with a focus on school settings need to consider system level, organisational and contextual (i.e. socioeconomic, ethnicity, family and town characteristics) factors when expanding previously effective strategies into new communities. Implementation benefits may have added whole of school benefits in addition to child health. Focussing on overcoming the challenges experienced in this complex initiative is required for future interventions. TRIAL REGISTRATION ACTRN12609000892213.
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Al-Yateem N, Attia AKN, AL-Yafei T, Mohammed A, Mahmood B. The impact of a school nurse intervention on adolescents' knowledge about healthy eating. ACTA ACUST UNITED AC 2015. [DOI: 10.12968/bjsn.2015.10.6.280] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Nabeel Al-Yateem
- Assistant Professor, University of Sharjah, College of Health Sciences, Department of Nursing, United Arab Emirates
| | - Amal Kadry Nicola Attia
- Professor of Nursing, University of Sharjah, College of Health Sciences, Department of Nursing, United Arab Emirates
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Williams SL, Mummery WK. We can do that! Collaborative assessment of school environments to promote healthy adolescent nutrition and physical activity behaviors. HEALTH EDUCATION RESEARCH 2015; 30:272-284. [PMID: 25697581 DOI: 10.1093/her/cyv007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Evidence for effectiveness of school-based studies for prevention of adolescent obesity is equivocal. Tailoring interventions to specific settings is considered necessary for effectiveness and sustainability. The PRECEDE framework provides a formative research approach for comprehensive understanding of school environments and identification of key issues/areas to focus resources and energies. No reported studies have tested applicability of the PRECEDE framework in schools in relation to obesity. Adolescents (n = 362), parents (n = 349) and teachers (n = 146) from six secondary schools participated in two quantitative studies and two qualitative studies. Data collected from these studies permitted confirmation of adolescent overweight/obesity a health issue for schools; the need for secondary schools to focus health promotion efforts on healthy nutrition, with inclusion of parents/homes and appreciation for gender differences in developing interventions. Community buy-in and commitment to school-based obesity prevention programs may be dependent on initially addressing what may be perceived as minor issues, and developing policies to guide practices within schools in relation to supply and access to healthy foods, use of sporting equipment and participation in physical activities. The PRECEDE framework allows systematic assessment of school environments and provided opportunity to identify realistic and relevant interventions for promoting healthy adolescent physical activity and nutrition behaviors.
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Affiliation(s)
- Susan L Williams
- School of Medical and Applied Sciences, CQ University, North Rockhampton, QLD 4702, Australia and Faculty of Physical Education and Recreation, University of Alberta, W1-34 van Vliet Centre, Edmonton, AB T6G 2H9, Canada
| | - W Kerry Mummery
- School of Medical and Applied Sciences, CQ University, North Rockhampton, QLD 4702, Australia and Faculty of Physical Education and Recreation, University of Alberta, W1-34 van Vliet Centre, Edmonton, AB T6G 2H9, Canada
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Christian D, Todd C, Davies H, Rance J, Stratton G, Rapport F, Brophy S. Community led active schools programme (CLASP) exploring the implementation of health interventions in primary schools: headteachers' perspectives. BMC Public Health 2015; 15:238. [PMID: 25886398 PMCID: PMC4381418 DOI: 10.1186/s12889-015-1557-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 02/17/2015] [Indexed: 12/03/2022] Open
Abstract
Background Schools are repeatedly utilised as a key setting for health interventions. However, the translation of effective research findings to the school setting can be problematic. In order to improve effective translation of future interventions, it is imperative key challenges and facilitators of implementing health interventions be understood from a school’s perspective. Methods Nineteen semi-structured interviews were conducted in primary schools (headteachers n = 16, deputy headteacher n = 1, healthy school co-ordinator n = 2). Interviews were transcribed verbatim and analysed using thematic analysis. Results The main challenges for schools in implementing health interventions were; government-led academic priorities, initiative overload, low autonomy for schools, lack of staff support, lack of facilities and resources, litigation risk and parental engagement. Recommendations to increase the application of interventions into the school setting included; better planning and organisation, greater collaboration with schools and external partners and elements addressing sustainability. Child-centred and cross-curricular approaches, inclusive whole school approaches and assurances to be supportive of the school ethos were also favoured for consideration. Conclusions This work explores schools’ perspectives regarding the implementation of health interventions and utilises these thoughts to create guidelines for developing future school-based interventions. Recommendations include the need to account for variability between school environments, staff and pupils. Interventions with an element of adaptability were preferred over the delivery of blanket fixed interventions. Involving schools in the developmental stage would add useful insights to ensure the interventions can be tailored to best suit each individual schools’ needs and improve implementation.
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Affiliation(s)
- Danielle Christian
- College of Health and Human Science, Swansea University, Wales, SA2 8PP, UK.
| | - Charlotte Todd
- College of Medicine, Swansea University, Swansea, SA2 8PP, UK.
| | - Helen Davies
- College of Medicine, Swansea University, Swansea, SA2 8PP, UK.
| | - Jaynie Rance
- College of Health and Human Science, Swansea University, Wales, SA2 8PP, UK.
| | - Gareth Stratton
- A-STEM College of Engineering, Swansea University, Wales, SA2 8PP, UK.
| | - Frances Rapport
- College of Medicine, Swansea University, Swansea, SA2 8PP, UK.
| | - Sinead Brophy
- College of Medicine, Swansea University, Swansea, SA2 8PP, UK.
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