Maha Nubani Husseini (Ph.D. Candidate)

Braun School of Public Health.Hadassah–Hebrew University Medical Center

An Intervention Program for Promoting Healthy Eating & Physical Activity

among Palestinian Female Schoolchildren

Outline• Introduction

• Methodology

• Need Assessment

• The Intervention

• Post intervention results

Problem OverviewHealthy eating and regular physical activity play a powerful

role in preventing chronic diseases among adults.

Obesity has been regarded as an epidemic and one of the public health challenges in the 21st century.

Obesity prevalence among Palestinian adolescent is 16.5%. (HBSC 2004)

Effective preventive measures are needed to address the epidemic of obesity. As well as an intervention programme to promote healthy eating and physical activity among school children. (WHO What Works)

Why Schools?

Children spend most of their day in school .Schools teachers influence students’ eating habits

and physical activity.

Why Parents?

Have important role in their children’s nutrition and physical activity

They affect a child’s knowledge, beliefs, attitudes and practice

Research Goals

To develop, implement and evaluate a school-based intervention program in East Jerusalem.

To increase Knowledge and improve practice among female schoolchildren, their mothers and teachers regarding healthy eating habits and physical activity.

Research Objectives• Baseline assessment

To assess Knowledge and Practices regarding eating habits and physical activity among schoolchildren and their mothers.

To assess teachers’ eating behavior and physical activity. As well as their readiness / capacity to participate and implement the intervention program.

To assess the level of involvement in health promotion and willingness of the school principal to implement the intervention program at the school.

Research Objectives(cont)

• Evaluation

To evaluate the effectiveness of health promotion intervention program in changing school children’s, their mothers’ and their teachers’ eating habits and physical activity in comparison to control schools.

To evaluate the improvement of teachers’ capacity to deal with health promotion intervention program compared to control schools.

Theoretical framework The Ecological Model

Organizational/ Environmental Support for implementing the Health Promotion Program

Teachers’ Training for Health Promotion

Mothers’ education through workshop

Schoolchildren Education program to promote Healthy Eating & Physical Activity

Teacher engagement and leadership

&

Mothers’ engagement in the health promotion in school

Students’ lifestyle related to healthy eating and physical activity.

Hypothesis: The intervention program impact on students’ lifestyle is mediated by teachers and mothers engagement in health promotion and their behavioral changes.

Study design

A randomized control intervention program trial.

• The study has three stages: Assessment.Implementation and Monitoring.Evaluation.

Intervention Program

Intervention Program

End-point Evaluation

Regular School Curriculum

Regular School

Curriculum

End-point Evaluation

Study Design

Need AssessmentSchools: n=14

Period: April-June 2011

Interventionn=7

Controln=7

Sep – June 2012 Sep – June 2013 Feb – April 2013

Process Evaluation

• Sampling was made in two stages: – School Selection: Stratified random sampling

according to the school ownership. Provision: 13% of students in each stratum.

– Students Selection: Grade 4 and 5 randomly selected, one class of each grade irrespective to branches.

• The post intervention sampling:– Another cross-sectional for grades 4 and 5

schoolchildren.

Sampling Method

Sample Size Calculation

- Based on the estimated prevalence of 25% physically active girls >5 days/w in grade 6 (HBSC, 2004).

-Assuming increasing to 40% among intervention schools, and remain at 25% in the control group, with p > 0.05, power of 90% intra class correlation of 0.001 and a cluster size of 34, 7 schools were needed in each of the groups.

Number of Female Students in Grade 4 & 5 by School Ownership

School Type Number of Schoolchildren Number of Mothers #Number of TeachersTotal number of

participants of each type of school

Palestinian Authority 236 195 79 510

Private 125 115 31 271

UNRWA 136 86 48 270

Jerusalem Municipality 400 348 215 963

Total 897 744 373 2,014

Pre intervention assessment stage– Semi Structured interview (School Principal)– Self-administered questionnaire (Teachers, schoolchildren

and their mothers)– Anthropometric measurements (Schoolchildren height &

weight)– Inspection tours (School environment)

Implementation of the intervention stage– Biweekly monitoring of the intervention

schools.

Post intervention evaluation stage– Tools as in the assessment stage 18 months after.

Data Collection

• Equal proportion from grades 4 & 5: 50%• Mean age: 10 years• Mean order in the family: 3.32 ± 2.01• Mean number of siblings: 4.38 ±1.98• Crowding Index: 58.3% are living between 1-2 CI• Religion: 94.3% were Muslims

Socio-demographic characteristics of the study populationSchoolchildren

MothersSocio-demographic characteristics of the study population

• Mean age: 36.3 ±5.75• Number of children: 56.9% have ≥5 children• Religion: Mostly Muslims• Education: 38.2% had less than secondary school

level of education while 34.1% had secondary education and 18.2%% had diploma or higher

• Employment: 3/4 housewives

Teachers

• Mean age: 36.9 ±8.64• Gender: Mostly Females• Years of experience: 12.6 ±8.16• Religion: Mostly Muslims

Socio-demographic characteristics of the teachers in the study population

The Intervention

Though the assessment and evaluation included grades 4 and 5, the intervention encompassed the whole school setting.

• Strategy and Structure

Establishing school health steering committee: representatives of teachers, mothers, schoolchildren and the owner of the canteen (8-10 persons), which had periodic meetings (every 4-6 weeks)

School-teacher coordinator who implement and run the program in her school.

• Capacity Building – Teachers

Trained to promote healthy eating and physical activity

Developed a school health promotion program based on the school needs and assets.

Tasks were assigned accordingly.

Trained to integrate healthy terms in the subjects they teach.

• Education and Involvement – Mothers

Educated about the importance of healthy eating and physical activity

Engaged in the schools’ health activities through their participation in preparing healthy meals for schoolchildren.

Participated with their schoolchildren in an open day physical activity program.

Trained to provide their children with a healthy meal including fruits and vegetables on daily bases.

Physical Environment – School Activities

Healthy messages were delivered with the help of a clown.

School morning announcements.

The use of a promoting checklist was introduced.

Healthy messages as part of the wall magazine.

A Healthy corner in each class.

Physical Environment – School Activities Cont.

Schools’ hallways and play grounds were utilized to increase healthy eating and physical activity awareness.

Morning aerobics was introduced.

Utilization of an active break was introduced.School canteens were restricted from selling unhealthy

items.

Characteristics of Students Pre/Post InterventionDifference Between Intervention Schools

Difference Between Control Schools DID (%) p-value

Pre Post Pre Post

n=449 n=446 n=448 n=420

Eating Breakfast (%) 38.5 53.1 34.6 31.7 17.5 0.011

Eating Recommended Quantity F&V (%) 29.8 54.7 25.5 21.0 29.4 0.001

Watching TV≥4 hrs/day (%) 34.7 28.9 31.9 30.0 4.04 0.491

Physical Activity≥5 times/wk (%) 16.5 61.2 13.6 13.1 45.2 <0.001

Overweight & Obesity (%) 27.6 28.5 31.9 34.0 1.27 0.860

Schoolchildren – Pre/Post Intervention Outcome

Baseline End Point0

20

40

60

80

100

Baseline End Point

Eating Breakfast

Eating Rec. F&V

Overweight/Obese

Drinking Milk

P.A.

TV

Intervention Control

Characteristics of Mothers Pre/Post Intervention

Difference Between Intervention Schools

Difference Between Control Schools DID (%) p-value

Pre Post Pre Post

n=368 n=365 n=368 n=360

Preparing Breakfast 66.8 73.7 65.6 61.4 11.0 0.093

Eating Recommended Quantity F&V 37.3 71.6 53.1 41.8 45.6 0.002

Know Daily Recommended Amount of F&V

7.9 20.4 4.6 3.3 13.8 <0.001

Performing P.A. 150min/week 31.0 36.0 24.5 21.1 8.42 0.104

Mothers – Pre/Post Intervention Outcome

Baseline End Point0

20

40

60

80

100

Baseline End Point

Eating b w/t child

Prep bf

Eating Rec. F&V

Perform Rec. P.A.

Know Rec. F&V

Intervention Control

Characteristics of Teachers Pre/Post InterventionDifference Between Intervention Schools

Difference Between Control Schools DID (%) p-value

Pre Post Pre Post

n=177 n=147 n=195 n=195

Formal & Informal Training in HE 43.8 57.1 47.7 46.7 27.9 0.009

Formal & Informal Training in PA 43.8 51.7 41.5 47.2 15.9 0.108

Engagement in HP 39.8 91.2 42.1 47.7 45.6 0.004

Statement 3 “Every teacher should integrate the health promotion field as an integral part of the process of teaching and education”

44.6 72.1 36.1 68.0 4.48 0.713

Eating Breakfast 19.2 34.9 17.4 18.5 14.7 <0.001

Eating Rec Quantity F&V 64.2 77.6 63.9 68.0 9.38 0.866

Engage in P.A. 22.7 29.9 15.9 16.4 7.69 0.194

Teachers – Pre/Post Intervention Outcome

Baseline End Point0

20

40

60

80

100

Baseline End Point

Training HE

Taining P.A.

Eng HP

State 3

Eat Break-fast

East Rec. F&V

Eng P.A.

Perf P.A.

Intervention Control

Learning from success- insights from an interview in one school

• Support and commitment from the schools’ principals is paramount.

• Programme implementation was mainly carried out by physical education and science teachers, who were also active in the schools’ health committee.

• Team spirit among teachers was the major factor.