Abstract
BackgroundChildhood obesity is a major public health issue in the Gulf Cooperation Council countries (GCC) and effective prevention initiatives are much needed. This study aimed to co-develop, with stakeholders, a school-based intervention for obesity prevention among adolescent girls in Jeddah, Kingdom of Saudi Arabia (KSA). A social-ecological framework and co-development and participatory approaches were used to understand the drivers of adolescent obesity in KSA and to develop and assess the acceptability of the co-developed intervention.
Design and Methods
The PhD programme of research was conducted over three phases. Ethical approval was obtained from the Ministry of Education (MoE) in KSA and also from King’s College London Research Ethics Committee (REC number: 3727).
Phase 1: focused on evidence building to understand the burden of adolescent overweight and obesity in KSA and other GCC countries.
Phase 2: focused on partnership building, co-identifying intervention priorities and co-developing intervention content and mode of delivery using a participatory approach. Specifically, during this phase, I examined school readiness using a 17-item questionnaire which assessed the school environment, policies and practices related to diet and physical activity, and the capacity of the school to promote the intervention. Also, I assessed students health behaviours (N=100 per school) using a 22-item health behaviour questionnaire. Group concept mapping was used to obtain adult and students stakeholder perspectives on important and feasible intervention opportunities for obesity prevention in two secondary schools. Photovoice was integrated into the concept mapping with students. Adult stakeholders included staff from the Ministry of Education (MoE) and schools, school canteen suppliers and mothers (N=19). Student stakeholders (N=15) were from two girls’ schools (one secondary, ages 13-15 years and one high school, ages 16-18 years) that were purposefully identified with the support of the Ministry of Education. Both stakeholder groups identified a school-canteen based intervention as an important and feasible intervention. Prior to intervention development, an evidence synthesis on school canteen interventions was undertaken to understand the impact as well as the enablers and barriers associated with such interventions.
Phase 3: focused on further developing the ideas for a school-based canteen intervention and on small scale piloting. Firstly, intervention modelling workshops were conducted with stakeholders (10 students, 11 MoE and school staff) drawn from Phase 2 to identify the content and mode of delivery of the canteen intervention. Students also conducted canteen food-scaping to identify current provisions and assess healthfulness. Semi-structured questionnaires during workshops were used to identify common themes related to school food provision. The nutrient profile of existing and intervention food and drinks in both school canteens was assessed using the Food Safety Authority traffic light system for nutrient quality where red indicates high (unhealthy), amber (moderate) and green (healthy).
Next, a two-day uncontrolled pilot was conducted in both schools. Two classes from each school were randomly selected (N=116 - 60 secondary school students aged 13-15 years; 56 high school students aged 16-18 years). The intervention canteen provisions were provided by the existing food suppliers and aligned with both the students’ preferences and the MoE guidelines for canteen food provision. Pre-post intervention assessment of the small-scale pilot was undertaken using a 20-item questionnaire. All consultations/ surveys were conducted by MA in Arabic, orally and/or in print. Data were then translated into English by MA for analysis and reporting.
Results
Phase 1: In the KSA, there was an increase in the prevalence of both overweight and obesity in the 2000s. The 2011 national survey gives the most recent estimates with about 1 in 3 boys and 1 in 4 girls aged 12-18 years old being overweight or obese. In Kuwait and the UAE, the levels of overweight declined whilst that of obesity increased. The levels were highest in Kuwait, with obesity levels of 37% for boys and 25% for girls aged 6-18 years in 2013. Qatar had the lowest rates with obesity level of 5% for boys and girls aged 6-18 years old in 2010. Across all GCC countries, poor dietary habits and low levels of physical activity were associated with overweight and obesity. The prevalence of overweight and obesity was higher in those with higher socio-economic circumstances (SEC) compared with those in lower SEC groups. Only one school-based intervention study in the GCC was identified and the study quality was poor.
Phase 2:
a) The readiness assessment of the school reflected a nutrition-poor environment. Access to healthy food was reported by the school staff but researcher observations found that canteen foods were nutritionally poor. The foods available were mainly highly processed and high in fat and salt, including croissants and pizza. There was a lack of facilities to prepare food in the canteen. A poor level of priority and support for physical activity was reported in addition to poor access to outdoor play areas, sporting equipment and facilities for outdoor games. The adolescents’ health behaviour assessments (response rate 95%) found that 29% of mothers and 48% of fathers were educated to degree level, and 16% of mothers and 67% of fathers worked in full-time employment. Poor dietary habits (37% had daily breakfast, < 5% consumed ≥ 5 portions of fruits and vegetables per day and high sedentariness (90%) were reported among students.
b) 6 workshops (3 workshops with 15 students; 3 workshops with 19 adult stakeholders) were undertaken with stakeholders. Concept mapping identified a school-based intervention as the most feasible and actionable intervention for this context. There was correspondence across stakeholder groups, adults and students, in several areas including a strong emphasis on improving access to healthy, affordable foods in the canteen. The meta-analysis from the review of the school canteen interventions showed a positive, though small, impact on total energy intake (pooled mean difference between intervention and control group -32.49 kcal/day, 95% Confidence Interval -48.22 to -16.76), and on fruit, vegetable and fibre (+0.97 g/day, +0.51 to +1.44).
Phase 3: intervention modelling workshops with both students and adults identified improved canteen provisions, specifically more healthful and reasonably priced foods. Teachers emphasised that healthy food would promote better academic performance; the Ministry of Education was insistent that the new additions of food and drink must align with school food policies and students wanted their food preferences reflected and an improvement in nutritional quality compared with the existing canteen foods. Pre-intervention, the nutrient profile of existing food and drinks in both school canteens was poor with a high proportion of the items being coded as ‘red’ (high levels of fat, saturated fat, sugar or salt). The intervention items had a significantly more healthful nutrient profile, with a high proportion of items being coded as ‘green’. For example, snacks such as Kinder and Twix chocolate bars were replaced with fruit salad (banana, kiwi, apple, grapes, strawberry, cantaloupe melon),
The intervention was a non-controlled pilot study and was conducted in both schools across two days among 116 students, with 69% of participants completing the pilot assessment pre- and post-intervention questionnaires. During the pilot intervention, all canteen provisions were consumed and post-intervention acceptability and overall satisfaction was reported for intervention foods (6% pre-intervention vs 34% post-intervention, p=0.001) and drinks (11% vs 32%, p= 0.011).
Conclusions
Using a social-ecological framework and participatory approaches throughout the research process, an acceptable school-based canteen intervention was co-developed with students, school and MoE staff. The intervention was tested successfully during a pilot study and has potential for a larger evaluation study. Some key issues that need consideration in future larger scale work include improved parental engagement, intervention timing so that examination periods are avoided, and development of a framework for cost-effectiveness in the context of complicated canteen provision arrangements. The co-development approach was an effective method for engaging students and adults in intervention design and evaluation and should also be considered for future research in this context.
| Date of Award | 1 May 2021 |
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| Original language | English |
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| Supervisor | Seeromanie Harding (Supervisor), Majella O'Keeffe (Supervisor) & Trevor George (Supervisor) |