NGHC: Childhood Nutrition and Lifestyle Factors (2013)

Citation:
 
Study Design:
Class:
- Click here for explanation of classification scheme.
Quality Rating:
Research Purpose:

To evaluate the implementation process for a school-based health promotion program and evaluate the effect of the intervention at the school level.

Inclusion Criteria:
  • Primary school children aged seven to 11 years; parents of study participants and school staff
  • Study participant enrolled at one of 10 schools in Leeds selected for the intervention.
Exclusion Criteria:

Primary school aged children less than seven years or more than 11 years old.

Description of Study Protocol:

Recruitment

Questionnaire participants were recruited from two groups:

  • Parents of students who attended an APPLES (active program promoting lifestyle education in schools) intervention school before the intervention
  • School staff (teachers, non-teaching assistants, special needs assistants, catering staff and administrative staff) at schools selected for participation in the APPLES trial.

Focus group participants were students who attended an APPLES trial intervention school during Year One of the study. 

Design

This paper is a non-comparative descriptive study evaluating the implementation of the APPLES trial, a group randomized crossover trial. 

Intervention

  • This paper discusses the results of questionnaires received from school staff evaluating the training received during the intervention, results from focus groups with children who had attended a school in the APPLES trial to evaluate knowledge of healthy living and self-reported behaviors and results of questionnaires received from the parents of students participating in the trial.
  • The APPLES trial intervention has been described in separate publications.

Statistical Analysis

Statistical analysis was not used in this non-comparative descriptive study.

Data Collection Summary:

Timing of Measurements

  • The APPLES trial intervention was conducted in a randomized crossover format with half of the 10 primary schools receiving intervention during Year One of the study (1996-1997) and half of the schools receiving intervention during the second year of the study (1997-1998)
  • Focus groups with children were conducted at the end of the first year of the trial in both intervention and non-intervention schools
    • Questionnaires were administered to school staff and parents at the beginning of the school year in which the intervention was completed
    • Another questionnaire was administered to school staff at the end of the intervention to determine the perceived effectiveness of training, resources and support, as well as to ascertain whether the program had an effect in the school.

Dependent Variables

  • Response rates to questionnaires
  • Evaluation of teacher training
  • Perceived content of the school meals
  • Attitudes and beliefs regarding educating children about healthy lifestyle
  • Information requested by parents about what healthy lifestyle changes should be implemented or offered at school
  • Behavior changes and perceived understanding of health benefits reported by students during focus groups.

Independent Variables

Participation in the APPLES trial intervention (focus groups only).

Description of Actual Data Sample:

Initial N

  • Questionnaires: 124 school staff personnel completed a questionnaire (62 teachers, 13 non-teaching assistants, 23 special needs assistants, 17 catering staff and nine administrative staff)
  • 410 parents completed a questionnaire (64% of questionnaires administered were returned)
  • The number of students participating in focus groups was not reported.

Attrition (Final N)

  • 124 school staff questionnaires
  • 410 parent questionnaires and an unknown number of focus group participants.

Age

Students were enrolled in Years Four and Five in primary school (UK); aged seven to 11 years.

Ethnicity

A range of 1% to 42% of the children in each of the APPLES trial schools were from ethnic minorities.

Other Relevant Demographics

Socio-demographic data was not described in this paper, a range of 7% to 29% of the student population at the APPLES trial schools were entitled to free school meals, which is a lower percentage than Leeds children as a whole (11% to 25%), indicating that this was a somewhat advantaged study population. 

Anthropometrics

None reported.

Location

Leeds, UK.

Summary of Results:

Key Findings

Support and Training of School Staff

  • A high level of support for nutrition education and promotion of physical activity was expressed by both teachers and parents
  • 410 (64%) parents responded to the questionnaire concerning changes they would like to see implemented in school
  • 19 out of 20 teachers attended the training and all reported satisfaction with the training, resources and support
  • All teachers reported training, resources and support was useful and helpful during the intervention and all participants reported the intention to continue to use resources in future years
  • All teachers reported an increased awareness of healthy eating and physical activity among students
  • All 10 schools utilized the program manager (a dietitian certified in the UK) to conduct class sessions on healthy eating, to conduct competitions among students and to conduct a food awareness week. Four of the 10 schools opted to have the program manager attend parent's evening or conduct a health week.

School Action Plans

  • 76 (89%) of the action points determined by schools in their school action plans were achieved, along with positive changes in school meals
  • All 10 schools incorporated nutrition education into the curriculum, incorporated a healthy eating class lead by a dietitian, incorporated a "fit is fun" physical education component and updated health resources as a part of the school individualized action plan
  • Fewer schools opted for improved playground facilities (seven of the 10), changed policies regarding snacks and packed lunches (six of the 10) and a number of other health initiatives (five or fewer of the 10).

School Meals

  • After the intervention, 10 schools offered jacket potatoes (baked potatoes) compared with one before the intervention
    • Six schools offered mashed potatoes, compared with four before the intervention
    • 10 schools offered fresh fruit daily, compared with eight before the intervention
    • Seven schools offered salad vegetables, compared with four before the intervention.
  • Vegetarian options were described as good after the intervention and poor before the intervention.

Focus Groups with Students

  • Intervention children showed a higher score for knowledge, attitudes and self-reported behavior for healthy eating and physical activity
  • Children who had received the intervention showed a greater understanding of the health benefits of diet and activity, had a greater sophistication of ideas and vocabulary expressed regarding diet and activity and reported behavior changes to diet and activity levels.
Author Conclusion:
  • Parents and school staff reported a high level of support for nutrition education and promotion of physical activity
  • Teachers reported satisfaction with training, resources and support offered during the intervention
  • Intervention children showed a higher score for knowledge, attitudes and self-reported behavior for healthy eating and physical activity in focus groups than children not receiving intervention
  • Positive changes in school meals were reported with increased healthy options at intervention schools
  • Schools reported a high level of achievement in implementing the action points determined in individualized school action plans.
Funding Source:
Government: Northern and Yorkshire Region Research and Development
Reviewer Comments:
  • Only 10 schools had participated in the APPLES intervention
  • No statistical analysis completed.
Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) Yes
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
 
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? No
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? Yes
  2.2. Were criteria applied equally to all study groups? Yes
  2.3. Were health, demographics, and other characteristics of subjects described? No
  2.4. Were the subjects/patients a representative sample of the relevant population? No
3. Were study groups comparable? N/A
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) N/A
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? N/A
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) N/A
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? N/A
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? Yes
  4.1. Were follow-up methods described and the same for all groups? N/A
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) Yes
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.4. Were reasons for withdrawals similar across groups? N/A
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? N/A
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) N/A
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? Yes
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? N/A
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? N/A
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? N/A
  6.6. Were extra or unplanned treatments described? N/A
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? N/A
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? N/A
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? N/A
  7.6. Were other factors accounted for (measured) that could affect outcomes? N/A
  7.7. Were the measurements conducted consistently across groups? Yes
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? N/A
  8.1. Were statistical analyses adequately described and the results reported appropriately? N/A
  8.2. Were correct statistical tests used and assumptions of test not violated? N/A
  8.3. Were statistics reported with levels of significance and/or confidence intervals? N/A
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? N/A
  8.6. Was clinical significance as well as statistical significance reported? N/A
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes