Journal of Public Health Advance Access originally published online on November 27, 2007
Journal of Public Health 2008 30(1):30-37; doi:10.1093/pubmed/fdm078
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Primary prevention of type-2 diabetes and heart disease: action research in secondary schools serving an ethnically diverse UK population
K. Khunti, Professor of Primary Care Diabetes and Vascular Medicine1,
M. A. Stone, Senior Research Fellow1
J. Bankart, Medical Statistician1
P. Sinfield, Research Associate1
A. Pancholi, Research Associate1
S. Walker, Nutritionist2
D. Talbot, Dietician, Director of Services2
A. Farooqi, General Practitioner3
M. J. Davies, Professor of Diabetes Medicine4
1 Department of Health Sciences, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
2 Leicestershire Nutrition and Dietetic Service, Leicester LE19 4SA, UK
3 The East Leicester Medical Practice, Leicester LE5 4BP, UK
4 Department of Cardiovascular Sciences, University of Leicester and University of Leicester Hospitals NHS Trust, Leicester Royal Infirmary, Leicester LE1 5WW, UK
Address correspondence to K. Khunti, E-mail: kk22{at}le.ac.uk
Background Escalating rates of childhood obesity are likely to have an impact on the prevalence of coronary heart disease and type-2 diabetes. We aimed to identify barriers to healthy lifestyles and evaluate the effectiveness of an action research approach to lifestyle modification in secondary schools.
Methods An action research partnership between schools and university researchers involved pupils aged 11–15 in five inner-city secondary schools serving a predominantly South Asian population in Leicester, UK. Data collection included baseline and follow-up diet and physical activity questionnaires. Focus groups and observational visits were used to identify barriers, assist with developing tailored interventions and review the impact of the study.
Results Working with secondary schools presented challenges but a useful partnership was sustained. Qualitative feedback suggested that this had raised awareness of healthy lifestyle issues in participating schools. Barriers in pupils included low prioritization of health when making lifestyle choices. Sub-optimal diet and activity habits were identified at baseline. Overall, these persisted at follow-up, although some limited positive changes were identified.
Conclusions Using action research methods in this context is challenging but can facilitate useful data collection and may have a modest impact on lifestyle behaviours.
Keywords: cardiovascular disease, primary prevention, Schoolchildren, South Asian, type-2 diabetes
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Introduction |
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There has been much recent concern about the rising prevalence of overweight and obesity in children and young people in both the USA1 and the UK.2 An increased prevalence associated with ethnic origin has also been identified amongst children living in England.3 The escalation in childhood body size has important implications for risk of morbidity and mortality in adulthood,4,5 in relation to the emergence of cases of type-2 diabetes in young people.6–8 In people of South Asian origin living in Western countries, the risk of developing type-2 diabetes and coronary heart disease may be further exacerbated through higher levels of insulin resistance associated with ethnic origin9 and there is evidence that this association may begin in childhood.10
In the Schools Acting in Leicester Against Diabetes (SALAD) and heart disease project, we adopted an approach based on action research.11,12 The study involved inner-city secondary schools serving an ethnically diverse population within which South Asians of Indian origin are the dominant group. Our choice of this approach was based on the assumption that involving the study population in identifying interventions would increase the likelihood of achieving an impact. Detailed baseline results have been previously presented;13,14 this paper aims to describe and reflect on the action research process and present some of our findings regarding attitudes and barriers to promoting and adopting healthy lifestyles, and the impact of the project. Key features of action research include participation, democratic practice facilitated by reflective working and contribution to both change and scientific knowledge.11 We actively involved schools throughout the research process, from the application for funding to consideration of results and we hoped to contribute to change in our study population as well as furthering knowledge.
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Methods |
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Box 1 summarizes the stages of the project, which was reviewed informally by the local research ethics committee but did not require formal approval. The active stages of collaborative working with schools were conducted during 2003–05. Schools were invited to participate in the study on the basis of city location and a high proportion (>60%) was of South Asian pupils. Pupils in years 7–10 (ages 11–15) in the five participating schools were included. For baseline data collection we used a Food Intake Questionnaire,15,16 which had previously been modified for use in the local ethnically diverse population. This instrument identifies consumption of any amount of specific items on the previous day, including positive and negative markers which dieticians would generally recommend or discourage. Pupils also completed a questionnaire about active and inactive behaviours derived from the Four by One-Day Recall Physical Activity Questionnaire17 and the Youth Risk Behaviour Survey18 as used in the Modifiable Activity Questionnaire for Adolescents.19 Each school was actively involved in planning and administering the survey and an explanation of the study including confidentiality and the importance of accurate responses was given to pupils during an assembly or in class. We also conducted a brief questionnaire survey of staff attitudes to healthy lifestyle promotion in schools, including a question about perceived levels of responsibility for pupils' health in different stakeholder groups (pupils, parents, individual schools, local education authority and government).
| Box 1 Stages of the SALAD action research project Pre-study
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As this was an action research project, there were no pre-set interventions. The aim was to identify interventions that could be implemented in other schools without specific financial or other assistance, so schools were not offered funding for implementing changes, or any help apart from advice and facilitation from the research team. Following the baseline survey, focus groups were conducted with pupils and staff and preliminary survey results were fed back to schools. Focus groups were organized by school staff members, who were given guidance about including a range of pupils in terms of age, gender, ethnic background and educational ability. They were facilitated by members of the academic team using flexible topic guides designed to elicit barriers, and facilitators related to healthy lifestyles and to gather ideas for interventions. Staff focus groups were tape-recorded, but it was felt that recording might restrict pupils' willingness to contribute and notes were therefore taken by a member of the research team. Key findings from preliminary content analysis of pupil focus groups were used in staff focus groups and planning meetings, including consideration of the practicality of implementing interventions suggested by pupils. Members of the research team also made an observational visit to each school and recorded written field notes about food and physical activity provision. In addition, an active dialogue was established with the organization providing meals to participating schools.
The study included a period of approximately 1 year during which it was hoped that schools would implement some changes. Efforts were made to maintain links between the schools and the research team through meetings and telephone calls during this period, at the end of which a smaller scale follow-up survey using the same questionnaires was conducted with one class in each of school years 7–10. Follow-up focus groups were also conducted with staff and pupils.
Since we were evaluating the action research approach rather than specific interventions, we conducted baseline and follow-up comparisons in the five schools as a whole rather than making comparisons between schools. Potential dietary changes were considered in terms of the proportion of pupils reporting consumption of the 18 positive and 21 negative markers on the previous day. Physical activity levels were compared for proportions using an active method of travel to and from school (walking or cycling); average hours spent viewing television or videos or playing computer games; frequency of aerobic and non-aerobic exercise and proportions engaging in any active behaviour during school breaks or in the evening. To maximize the number cases for analysis, there was no attempt to match individual pupils' responses when comparing baseline and follow-up data. Multivariable analyses using SAS v9.1 were conducted to determine significance levels after adjustment for the potential confounding influence of age, gender, ethnic group and school attended. School lunch consumption and physical education (PE) at school on the previous day were also investigated as potential confounders for diet and physical activity analyses respectively. Descriptive statistics were obtained from responses to the staff survey, using SPSS v14.0. Analysis of combined qualitative data from focus groups and observational visits involved initial open coding using QSR N6 free nodes, allowing ideas to emerge from the data in line with the basic principles of grounded theory.20 A process of progressive focussing was subsequently used to develop a thematic framework bearing in mind our aim of identifying barriers to healthy lifestyle promotion and adoption, also allowing scope for other emerging ideas.
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Results |
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Participating schools and demography of pupils
All six eligible schools initially agreed to participate, but one withdrew before the start of the study, citing other commitments. The five participating schools were all mixed-sex and located in the city of Leicester, which was ranked 31 of 354 local authorities in the 2004 Indices of Multiple Deprivation, where 1 was the most deprived area and 354 the least deprived.21 Pupils in years 7–10 were in almost all cases aged 11–15 and in the overall sample of five schools there were 4763 registered pupils of whom 3650 (77%) were of South Asian, mainly Indian, origin.
Research process
Schools initially expressed a strong interest in participating, but working with secondary schools was challenging. Key contacts changed at least once in all schools, and communication was difficult since contacts could not be reached by telephone while teaching and many did not use e-mail. Curriculum and other staff commitments made it difficult to maintain links and organize meetings. In spite of the enthusiasm of key staff involved in the project, it was difficult to gauge overall levels of interest and involvement and there was clearly a lack of dedicated staff time for this type of activity. However, none of the five participating schools withdrew from the study and each managed to plan and successfully complete two questionnaire surveys and organize focus groups and observational visits.
Data collected
At baseline, we obtained 3418 diet and 3601 physical activity questionnaire responses, from a total of 4763 eligible pupils (response rate 72 and 76% respectively). For the sampled follow-up survey we obtained 503 and 509 responses respectively for diet and physical activity (15 and 14% of the number of responses at baseline). We obtained 309 complete staff survey responses for the question about perceived levels of responsibility for pupils' healthy lifestyles. One observational visit, one baseline and one follow-up staff focus group were conducted in each school. Eighteen baseline focus groups were conducted with pupils (range two to four per school and five to eight pupils per group). One to two follow-up focus groups were held with pupils in each school (eight groups in total, 8–16 pupils per group).
Barriers to adopting and promoting healthy lifestyles
Table 1 summarizes barriers to adopting and promoting healthy lifestyles. Similar issues were cited during baseline and follow-up focus groups, often supported by observations during visits to the schools. Although pupils demonstrated some basic knowledge of healthy lifestyles they acknowledged low prioritization of impact on health when making choices about their lifestyle, particularly when selecting food. They were more likely to be influenced by cost, taste and hunger satisfaction. Image and peer pressure were also important, as illustrated by a focus group participant who pointed out that it would not be ‘cool’ to eat an apple at school, although he would eat fruit at home.
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Some issues raised by staff were considered by them to be outside their control, leading to feelings of frustration. Examples included lack of PE facilities and external barriers such as competition from local food retail outlets (Box 2). Staff focus group participants also demonstrated some attitudes likely to have a negative impact on the intensity of efforts to promote healthy lifestyles in their schools. These included a degree of defensiveness in relation to providing opportunities for physical activity, with PE staff generally feeling that provision was already good and that they were working to capacity given current staffing levels (Box 3). Staff also cited the high importance given to delivering a very full curriculum and achieving good exam results, pressures which reduced prioritization of healthy lifestyle promotion. Staff survey results suggested that staff attributed high levels of responsibility for encouraging healthy lifestyles to all stakeholder groups under consideration, but results also suggested that staff regarded parents as having the highest level of responsibility (mean score out of 5: 4.33, 95% Confidence Interval (CI): 4.22–4.43) and schools the lowest (mean score: 3.72, 95%CI: 3.66–3.92).
Some broad issues were raised by both staff and pupils, but from a different perspective (Table 1), for example, cost was viewed by staff in relation to the commercial basis of school meals provision as well as its influence on pupils' food choices. Pupils suggested that they generally had limited money to spend and did not want to risk wasting it on a new food choice. They also regarded less healthy options such as chips as better value for money in terms of satisfying their hunger compared to more healthy items like fruit. In other areas there was greater similarity in the views expressed, for example, both groups suggested that engaging interest in physical activity may be more difficult in girls than boys. This view was supported during observational visits during which significant numbers of boys were observed playing football during breaks, with few girls engaging in any form of physical activity. Both groups also cited a specific cultural barrier relating to religious commitments such as attending faith schools in the evenings, which impacted on time available for physical activity.
Box 2 Examples of diet and physical activity interventions suggested and discussed by pupils and staff during focus groups
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| Box 3 The staff perspective: quotations from baseline and follow-up focus groups A. Barriers causing frustration: lack of resources and competition from local food retail outlets ‘... we've only got one gym that is it. We've got an all weather pitch which is called an all weather pitch but that's about as far as it goes and it floods... ‘[baseline staff focus group] ‘...for all the work (the cook supervisor) is doing on providing healthy eating for children, suddenly the children are going across the road (to ‘burger van’ parked directly outside school) for burgers and chips and they have no idea of the fat content and I have tried the legal route and I have tried everything and apparently I can't challenge that because they aren't doing anything illegal' [follow-up staff focus group] B. Defensiveness leading to reluctance to acknowledge need for change ‘I wouldn't say (there have been) many changes because I think what was being done was a good job anyway ... we have always had such a supportive staff here that are willing to give up time to encourage students to participate (in PE activities)’ [follow-up staff focus group] C. Impact of the action research project ‘I think it has helped us to focus, it's something that happens (change) and it's an ongoing process, but in terms of this school it has helped us to focus on this issue which we may not have focused on in this way. We don't always meet as one group ... it's brought together that this is the kind of thing we might continue doing’ [follow-up staff focus group] ‘I think it has had an impact because the children who did the questionnaires took it very seriously and every question raises your awareness in any case ...I think it's had a little ripple effect.’ [follow-up staff focus group]
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Identification and implementation of interventions
Identifying interventions that would be realistic in terms of implementation was difficult in all schools and the changes made were therefore modest (Box 2). A useful dialogue between the local school meals provider and the schools led to a number of changes in the foods offered, including removal of vending machines, reduction in the availability of salt, introduction of ‘no chip days’ and offering ‘combination meals’ or ‘grab-and-go’ bags including at least one healthier item. However, changes sometimes lacked nutritional validity, for example, in one school ‘chip cobs’ were replaced by cheese pasties with a probable higher fat content. Other interventions included poster displays and increased efforts to incorporate healthy lifestyle messages throughout the curriculum through project work in subjects such as languages and mathematics. Physical activity interventions were particularly difficult to identify but there were some efforts to increase the choice of activities, for example, to include a dance option which might appeal to girls. One school introduced an incentive scheme aimed at both diet and activity; this involved stamping a passport-style card for healthy food choices and participation in extra-curricular physical activity, with a prize draw for those with fully stamped cards. Some changes that occurred over the study period, such as developing or being provided with new facilities or seeking or gaining specialist sports college status, were not a result of the project, but were monitored and encouraged.
Impact of the action research study
Comparison of baseline and follow-up survey results suggested that pupils' lifestyle habits remained poor after the intervention period (Tables 2 and 3). Nevertheless, of the 21 negative and 18 positive foods considered for comparison at the two time points, there were significant changes for seven and five items respectively (Table 2). In all but one instance (ice cream) changes suggested improved dietary habits. There were also significant changes (all suggesting improvement) for five of the eight physical activity indicators (Table 3).
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Focus group feedback suggested that pupils generally perceive little change over the intervention period. Staff acknowledged that interventions had been difficult to identify and implement and that any changes which had occurred were not necessarily attributable to the study. Nevertheless, they expressed the view that the project had raised awareness of and focused efforts on lifestyle issues (Box 3).
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Discussion |
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Main findings of the study
The action research project involving secondary schools was considered to be a useful but challenging collaboration. Pupils' sub-optimal lifestyle habits included high levels of television viewing and low consumption of more healthy foods. Barriers to healthy lifestyles in pupils included lack of motivation and the influence of factors such as cost and image. Staff barriers to healthy lifestyle promotion included competing priorities and perceived resource limitations. Schools were able to identify and implement some modest interventions, including changes to the food provided. Although pupils' lifestyle habits remained poor overall, some limited changes were indicated when comparing baseline and follow-up results for both diet and physical activity. In addition, qualitative feedback suggested that involvement in the action research project had contributed to raising awareness of lifestyle issues.
What is already known on this topic
A randomized controlled trial involving a combined diet and exercise intervention in the USA indicated some promise for school-based approaches to the problem of childhood obesity, although pupils were younger than those involved in our study and positive results for obesity reduction were obtained in girls only.22 A study in primary schools in Leeds, UK, reported some success in terms of implementing an intervention to reduce risk factors for obesity and demonstrating improvements in knowledge, attitudes and self-reported behaviour.23 A community health promotion project in the UK24 failed to show any impact on lifestyle risk factors in schoolchildren and a systematic review of interventions for preventing obesity in children25 suggested mixed results overall.
What this study adds
We identified a lack of studies involving young people of secondary school age and ethnic minority populations. Our action research experience in a multi-ethnic inner-city secondary school population indicates that implementing effective interventions in this context is likely to be challenging. We have demonstrated the feasibility of increasing our understanding of the problem by using collaborative action research to collect cross-sectional and qualitative data and we successfully involved schools in developing and implementing tailored interventions. Barriers identified by our study may help to inform the design of future interventions. Our experience suggests that to have a realistic prospect of being able to achieve greater impact in secondary schools, interventions would need to include provision of implementation resources including an appropriate level of dedicated staff time.
Limitations of this study
We included five of the six eligible schools; although there is no reason to suppose that results would have differed in the sixth school, we are unable to confirm this. We involved a sample of only one class per school year for the follow-up survey, but there was no selection of pupils between classes in participating schools and we can therefore surmise, but not confirm, that we used a representative sample. Our action research approach included wide involvement of the school community, but the scope of the study did not include active involvement of parents in selecting or implementing interventions and we cannot therefore comment on whether this would have had any impact. The limited timescale of the project means that we are also unable to comment on the sustainability of changes and our study design without a control group means that we cannot assume that the limited changes identified can be attributed to the study rather than to other potential influences. These included intense media interest in childhood obesity during the study period. In addition, some of our results relating to lifestyle changes are in themselves difficult to interpret: for example, increased consumption of low fat sausages and burgers and diet fizzy drinks was not matched by a significant decrease in reported consumption of the standard versions of these products, making it difficult to be sure that changes for the better are indicated. Similarly, although the analysis included adjustment for some potential confounders, the increase in consumption of ice cream and active travel to school could be due to seasonal variation rather than indicating real levels of change.
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Funding |
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This study was funded by the British Heart Foundation.
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Acknowledgements |
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We wish to acknowledge with gratitude the contribution of the five schools with which we worked in partnership in conducting the study and thank Dr Nick Taub for additional statistical advice.
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References |
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