Evaluation of implementation and effect of primary school based intervention to reduce risk factors for obesity

Intervention programme

The active programme promoting lifestyle education in school (APPLES) was designed as a multidisciplinary, multiagency programme using a population approach that was underpinned by the Health Promoting Schools philosophy.14 This philosophy aims to link the school with family and community and focuses on the whole school ethos, including its policies, management style, and attitudes of staff, so that consistent health messages are given and received.

The programme's team included a dietitian (project manager), a community paediatrician, a health promotion specialist, a psychologist, an obesity physician, and a nutritional epidemiologist. The programme targeted the whole school community including parents, teachers, catering staff, and the school environment. It was designed to take place over one academic year and was based on the concept of school action plans, which were to be developed by the individual schools on the basis of their perceived needs. The programme was intended to influence dietary and physical activity behaviour and not simply knowledge in the school children.

The team provided training for teachers and some resources, and the project manager also provided input and contacted the schools regularly throughout the year to give support. The underlying approach was to be non-prescriptive and to ensure ownership of the programme by the schools.

Participants

Ten state primary schools in Leeds were enrolled into the project as described in the accompanying article.13 Sociodemographic measures suggested that they were somewhat advantaged schools, with 1-42% of children from ethnic minorities and 7-29% entitled to free school meals (compared with 11% and 25% for Leeds children as a whole).

Children in years 4 and 5 (8-10 year olds) received the programme. This age group was chosen because the prevalence of overweight increases at around this age, the children were able to cooperate with questionnaires, and collection of data could be completed before they left primary school.

In 1996, the schools were randomised to receive the programme or serve as controls for that year. The five control schools received the intervention the following year. To evaluate the implementation and effect of the programme, we pooled data from the 10 schools.

Design and development of intervention

To inform the design and development of the intervention, questionnaires were administered to all school staff, including secretarial and catering staff, and parents of year 4 and 5 pupils. The questionnaire asked for views about the importance of education on nutrition and physical activity and whose responsibility that should be. In addition, parents were asked about changes they would like to see in school and information they would like to receive. The responses from these questionnaires were used by schools to develop the school action plans. The progress towards these targets was monitored by regular staff meetings and surveys of packed lunches, breaktime snacks, and playground activities

Response rates to these questionnaires were taken to reflect the support of parents and teachers for the programme. We also used the completion of diaries by children as a measure of commitment by children and parents, and data on growth and 24 hour recall of diet and activity questionnaires as a measure of commitment by the schools.

Changes regarding school meals were discussed with the local education authority catering organisation, which agreed that the team would work directly with the catering staff in schools. Meals were monitored by discussions with staff, collection of monthly menus, and observation of lunches on offer. We assessed whether quality had improved over the year.

An anonymous questionnaire was administered to teachers at the end of the intervention to evaluate the quality of the teachers' training, the usefulness and appropriateness of the resources, and the adequacy of support offered and to ascertain whether the programme had had an effect in the schools. We also collected information on support taken up by the schools over the year.

Focus groups

To determine the effect on children's levels of knowledge and attitudes towards healthy living, we held focus groups in schools at the end of the first year. Details are available in the accompanying paper.14

Response rates

Table 3 shows that data were available for over 90% of pupils for most measures, indicating excellent participation in the programme by schools and staff. Response rates for the three day diet and activity diaries were satisfactory and indicated a good level of commitment by both children and parents.

Support and training

Nineteen out of 20 teachers attended the training sessions. In anonymous questionnaires at the end of the intervention, all reported that they found the training useful, that the resources were useful and they would continue to use them, that support during the project was good, and that they had an increased awareness of healthy eating and physical activity among pupils.

The project manager offered a variety of ways that she could support the schools in implementing their action plans. Table 4 shows the types of activity offered and the uptake by the schools. All opted for direct input in the classroom, competitions, and involvement in a food awareness week.

School action plans

All schools elected to incorporate nutrition education into the curriculum, with additional sessions supplied by the project manager (table 5). They also included a “fit is fun” programme in physical education lessons and undertook to improve their health resources. In total, there were 85 action points with six to 14 points per school plan; 76 (89%) of these points were successfully achieved. Reasons for not achieving action points included shortage of time, staff sickness, and impending inspection by government teaching standards officers.

School meals

Given the emphasis on healthy eating, school meals were an important aspect of the assessment. Positive changes were seen in all schools (table 6).

Focus groups

Compared with other children, children who had received the intervention showed greater understanding of the health benefits of diet and physical activity; sophistication of ideas and vocabulary expressed; willingness and confidence to share their ideas as well as basic knowledge. They also reported behaviour changes and were more able to recollect topics learnt and activities in school linked to diet and physical activity.

Ways to tackle obesity

Schools provide an excellent opportunity for preventing and treating obesity.7–9 They offer continual regular contact with children and opportunities for nutrition education and promotion of physical activity both within the formal curriculum and informally through a supportive environment such as healthy school meals and breaktime snacks.

To date, information on effective programmes for prevention of obesity as well as results are largely missing.11 Although a healthy diet and exercise are probably unique components for such preventive programmes, currently there is no knowledge on how they should best be implemented.

Our programme used a population based approach underpinned by the Health Promoting Schools philosophy.14 The population approach ensured that all children including those at risk of developing obesity were included. As the prediction for adult obesity from childhood measures is poor,5 a population approach should have more effect at the public health level than targeting children who are already obese. Furthermore, behavioural and environmental conditions that contribute to the development and maintenance of obesity might be modified.

The Health Promoting Schools philosophy14 is an approach that teachers can relate to, and which respects the professionalism and contribution of school staff while also viewing the child as part of a wider community. It extended beyond the classroom and ensured participation by schools, teachers, parents, caterers, and pupils in the development of the programme. This helped to ensure ownership and successful implementation.

This systematic evaluation has shown that risk factors for obesity can be successfully targeted in primary schools and that change can be achieved in the school environment and in children's knowledge base with relatively few additional resources. Given the positive effects achieved in all 10 schools, we believe the programme could be successful in other primary schools.