A mixed methods study investigating the role of primary schools in reducing childhood obesity

Y Al-Shammary, H Mahmood, C Mulhern, E McGee, M Singh

Schools and childhood obesityBackground- why did we do it?Methodology- and how?FindingsConclusions and recommendationsLimitationsNext steps- so what? How can we use this?

Background National Child Measurement Programme (NCMP) established in 2005-6

All children measured in reception year (age 4-5) and year 6 (aged 10-11)

Childhood obesity prevalence increasing – complex and multi-factorial

“Opt out” consent, so majority of children should be included, good sample size

Obesity increases over the life course, so not surprising that obesity rates increase between reception year and yr 6

Data shows 1 in 10 children in reception are obese, rising to 1 in 4 children in year six

Long term impacts on health: tracks into adult life; raised blood pressure and cholesterol even in childhood; “adult onset” T2 diabetes found in number of Birmingham school children, due to obesity

2006/08 2008/10 2010/12

Background

Children’s obesity in year six, since 2006 (the darker areas highlight rising rates of obesity):

BackgroundSchools provide an opportunity to intervene, and

perhaps alter the trend of increasing obesity during primary school years

Much work both locally and nationally to improve food provision in schools and access to physical activity since NCMP set up, including some specific local initiatives funded by Public Health

Not always easy to get schools to take up even free programmes

Only robust measure of impact is NCMP, which shows an increase in obesity in year 6 in Birmingham

Birmingham trends2006-7 2013-14 Change (%)

School year

England Birmingham England Birmingham England Birmingham

Reception 9.9 % 11.3% 9.5% 11.3% -0.4% 0.0%

Yr 6 17.5% 21.5% 19.1% 23.9% 1.6% 2.4%

While obesity rates are dropping or stabilising in England as a whole, in Birmingham they have stabilised in reception, but increased faster than the average for England in year 6

Methodology Quantitative: Statistical Process Control (SPC)

(Funnel Plot)

Used to identify “outliers”, either more or less obesity than expected

MethodologyQualitative:

One-to-one semi-structured interviews with Senior School Staff in target schools

Interviews audio recorded and transcribed

Analysis using the Thematic Method-transcriptions coded by 2 independent team members, themes identified

Interview structureGeneral questions on awareness of childhood obesityAwareness of NCMP programme and how their

school is doingKnowledge of relevant current services and

programmesBarriersSchool needs

SampleDemographics

Findings- sample8 schools approached: 3 no response

5 schools:3 schools with higher obesity prevalence levels – 35%, 33%,

37%2 schools with lower obesity prevalence levels – 14%, 13%

(NB. W Midlands average 20.6%, Eng average 18.9%)• 3 deputy heads (1 via email), 1 sports teacher and 1 head

teacher

Findings-themes identifiedLack of awareness/acceptance of problem of childhood obesity, and the role or point of NCMP“not sure” “not much”“if we had results and had guidance on what we should be doing, then it may be more useful”

Recognise childhood obesity but attribute it to ‘out of school’ factors (sometimes cultural)“how much they eat at home” “takeaways” “sleeping patterns, eat late at night”

Parentsa) Bad influence/barrier to healthy lifestyle“they fill children’s lunchboxes” “not being addressed by parents”b)Potential way to achieve change“parents need to be targeted” “parent workshop” “work with parents”

… themes, continuedLack of willingness, capacity or resources to prioritise the problem“I won’t lose my job if the kids are obese but I will if they don’t do well in their SATS”“schools are overloaded” “not at the top of our list of priorities”

Recognition of free support available to schools and families“FoodNet are really good” “Villa Vitality – kids loved it” “Change4Life – helpful”

Priority – school taking initiative“we build it into our school, talking about healthy lifestyle” “we’ve got 4 times as many clubs as

we had last year, they’re all free” “… want to increase the number of girls participating

Model showing major themes from teacher interviews

ConclusionsSchools struggle to make obesity a priority, not what

they are judged on (SATS, Ofted)Many believe the responsibility lies outside of schoolParents are seen as both potential facilitators of change,

and as barriers to schools influencing changeRequest for list of services available to schools approved

by Public HealthSuggestion that healthy lifestyles should be part of

teacher training

RecommendationsMultilevel approach by Public Health- 3 Ps

Policy - Wider approach, tackle obesogenic environment e.g. limit on number of takeaways per “local area”; max of 10%

Progression over time – use data to reinforce dialogue with schools so that they know whether they are doing well or not; potential research to track individual children within NCMP

Professional training – try to influence teacher training (healthy lifestyles); links with BEP to ensure obesity is on their agenda

LimitationsLimitations – small sample (generalisability)Did not manage to include all schools approached (3

“bad”, 2 “good”)SPC – suitable tool?Could this be made more sophisticated: schools which

have higher or lower obesity rates than expected for demographics such as deprivation and ethnicity?

What next?Partnership needs developing: Schools- parents-public

health, underpinned by evidencePublic Health can:

Use feedback to modify how schools are informed about their NCMP results (has been done, positive feedback)

Ensure commissioned services are evidence-based & focus on both school and family, empower schools to reach families

Schools can: feedback on what works for them, take up services when offered

Model for PublicationDifficult to publish research in non-academic institutions

such as NHS or Local government Currently in stage 3 – Write Up

Childhood Obesity multifactorial, multiagency and multi-determinant issue

Can only be tackled through integrated and coordinated approach

Childhood Obesity steering group with various working groups

Schools, NHS, planning, physical activity, nutrition and public health

Partnerships

ContactsFor further information please contact

Hashum Mahmood hashum.mahmood@birmingham.gov.uk

Charlene Mulhern charlene.mulhern@birmingham.gov.uk

Eleanor. Mcgee@bhamcommunity.nhs.uk