Do parents, teachers and health professionals support school-based obesity prevention?

Abstract

Objective: This study aimed to investigate the attitudes of parents, teachers and health professionals on factors contributing to childhood obesity and the role of the school in preventing childhood obesity. The prevalence of overweight and obesity was also assessed to compare to current national figures.

Design: A large primary school concerned about childhood obesity approached the local area health service for assistance in developing appropriate health promotion strategies. This research was carried out as a formative approach to strategy development. A cross-sectional random sample of classes representing each grade (Kindergarten to Year 6) in the school participated. The parents of children in randomly selected classes made up the parent sample. All school staff and health workers currently working with schools were invited to participate.

Subjects: A total of 170 parents (85%), 31 school staff (89%) and 40 (80%) health workers completed the attitude survey. There were 167 (83.6%) school children, from randomly selected classes representing Kindergarten to Year 6, who had their height and weight measured.

Setting: The study was conducted in one primary school on the Central Coast of NSW.

Main outcome measures: Attitudes were assessed via a 21-item attitude survey based on a literature review. Content validity and test retest reliability (k = 0.61-0.85) were assessed prior to the study. Overweight and obesity was assessed using the Cole et al. (35) cut-off points which are the equivalent of adult Body Mass Indices of 25 (overweight) and 30 (obese).

Statistical analyses: Kruskal-Wallis (P = < 0.05) was used to determine where attitudes differed between the three groups.

Results: Of the 167 children who had their height and weight measured, 37.7% (n = 63) were either overweight (n = 43, 25.7%) or obese (n = 20, 12.0%). The most noticeable differences in opinion related directly to weight. Health professionals are clearly in support of the school taking a leading role in obesity prevention, with teachers displaying the least support (P = 0.014).

In light of teachers' current stance, providing support is crucial if obesity prevention is to become a school role. More research is needed to determine if providing continuing professional development along with up-to-date resources improves teachers' support for school-based prevention.

Key words: childhood obesity, school, prevention, attitudes

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Introduction

Childhood obesity has rapidly become one of the most alarming public health issues in the developing world (1). In Australia, the rate of childhood obesity tripled while overweight doubled in the 10-year period 1985-95, with 26% of boys and 23% of girls overweight or obese (2-4). The significance of the childhood obesity epidemic has provided the impetus for calls for urgent action with much attention focusing on prevention (5-7). Due to the complex nature of the obesity epidemic, evidence describing which strategies are likely to prevent childhood obesity is currently limited.

Of the evidence currently available, school-based interventions have been successful in positively influencing health behaviours such as increasing fruit and vegetable consumption (8), increasing healthy food choices (9,10) increasing intensity (11-13) and length of physical activity (11-15), decreasing sedentary activity (16), as well as directly impacting on weight (11, 15-22). School-based interventions have also been highlighted in numerous reports as one of several settings needing investment and resources to control the obesity epidemic (5-7,23,24).

The school setting appears attractive for preventive activities for many reasons. No other setting, other than the home environment, has as much continual contact with children for the first two decades of their life (25), resulting in the potential for continuous reinforcement of health promoting behaviours within a supportive environment (26). Compulsory school attendance allows preventive strategies to impact on almost all children, including those at highest risk of overweight and obesity, without singling out any particular child (26,27). Factors impacting on overweight and obesity such as nutrition and physical activity are already components of the formal school curriculum, resulting in the opportunity to enhance what is currently taught in school. Importantly, schools also provide a valuable avenue to access parents and families (26).

Despite the attractive nature of the school setting, limitations exist. The curriculum is currently extremely full, leaving little time to implement additional programs, teachers receive limited training in nutrition and physical activity and the increasing nature of litigation and theft has resulted in reduced access to sporting equipment and free play (41). Based on these limitations, school-based strategies should build on the existing school curriculum and environment, be based on a comprehensive framework and also be supported by the school community.

Literature focusing on school-based obesity prevention emphasise the importance of a comprehensive multi-strategy approach based on the Health Promoting School (HPS) framework (28-30). There was a systematic review of effectiveness, 'Health promoting schools and health promotion in schools: two systematic reviews' by Database of Reviews of Effectiveneness (DARE) in 2000. The HPS framework was shown to be a promising approach to addressing health issues in schools. To prevent obesity, evidence suggests that modifications of the school environment are as important as classroom curriculum. A combination of environmental, curriculum and family strategies have also been shown to be sustainable (29,31). Lastly, comprehensive interventions sustained for long periods of time rather than short-term, single strategy programs are more effective at sustaining a healthy lifestyle (29). In light of the evidence, teachers, parents and health workers are therefore critical stakeholders in the success of school-based obesity prevention (32).

Given their key role in school-based obesity prevention it is surprising that the attitudes of teachers, parents and health workers towards the school's role in obesity prevention has not been reported in Australia. Limited studies, conducted in the early 1990s, in the USA focused on principal and school nurse attitudes towards obesity and the school's role in treatment (33,34). One study conducted with teachers and health workers indicated a high level of support for prevention programs in schools, however school principals showed opposition believing teachers and parents would not be supportive (32,33). Current literature focusing on key stakeholder attitudes to school obesity prevention is lacking.

In light of the current call for action to prevent childhood obesity, determining these attitudes is critical in predicting the success of future strategies. This study aimed to investigate the attitudes of parents, teachers and health professionals regarding the role of the school in preventing childhood obesity. The prevalence of overweight and obesity was also assessed in one school community to compare to current national figures.

Methods

Sample

The study was conducted within the school community associated with a large primary school on the Central Coast of New South Wales, Australia. A random sample of classes representing each grade (Kindergarten to Year 6) in the school was invited to participate. The parents of children in randomly selected classes made up the parent sample.

All teaching and administrative staff at the school were invited to participate following an explanation of the study and the issues of childhood obesity at a staff meeting. Health workers were recruited to the study from within the Central Coast Health Services that were currently working with schools (including school health nurses, nutritionists, dental therapists and health promotion officers). A total of 50 were recruited through staff meetings and email.

Consent

Parents completed a consent form on behalf of their children, to have their height and weight measured. Teachers distributed the consent forms and parents were given one week to complete and return the form. Verbal consent was also sought from children on the day of measuring. Written consent for the attitude survey was not sought from parents, teachers and health professionals. Consent was assumed through completion of the survey. Participation was voluntary. Ethics approval was received from the Central Coast Area Health Service Ethics Committee (03/06). Approval was also sought from the school principal as required by the NSW Department of Education.

Confidentiality

Responses were anonymous with no names or identifying elements required. All surveys were coded. Children's height and weight was recorded on the parent survey to avoid names being taken.

Measures

Attitude

Parents', teachers' and health professionals' attitudes regarding the school's role in obesity prevention were determined through a 21-item attitude survey. The attitude survey was divided into two subsets of questions. Subset 1 (Table 1. Questions 1-9) was designed to determine attitudes towards the factors contributing to childhood obesity while subset 2 (Table 2. Questions 10-21) assessed attitudes towards the school's role in preventing obesity. Attitudes were assessed via a five-item Lickert scale.

Overweight and obesity

Overweight and obesity was assessed using the international cut-off points defined by Cole et al. (36). These cut-off points are set by tracking Body Mass Index (BMI) percentiles equivalent to a BMI of 25 and 30 at age 18 years of age back through adolescence and childhood. This is the preferred standard definition of childhood overweight and obesity for epidemiological use in Australia (36).

Survey design and analysis

A literature search was conducted to guide survey development. The attitude component of the survey featured in all groups to allow for direct comparison between the three groups. The survey was constructed using a combination of items from published studies (30,33). Test retest reliability of the survey was determined by sampling teachers, parents and health professionals from areas similar to the study population. Kappa statistic was used to assess level of agreement between the two time periods (k = 0.61-0.85). A period of two weeks between testing was used for all groups. Content validity was determined from a childhood obesity expert. Statistical Package for Social Sciences version 11.0 (SPSS Inc, Chicago, SPSS for Windows version 11.0 2001) (37) was used to analyse the survey. Statistical significance was assessed at P < 0.05.

Statistical analysis

Kruskal-Wallis (P = < 0.05) was used to determine where parents, teachers and health professionals attitudes differed. A non-parametric test was chosen due to ordinal data, non-normal distribution and unequal groups which do not meet the assumptions for ANOVA.

Results

Response rate

A total of 170 parents out of 200 (85%) completed the attitude survey and returned the consent form allowing their child's height and weight to be measured. Of these, 167 children (83.6%) were at school on the day that height and weight was measured. Response rate for teachers and health professionals was 89% (n=31) and 80% (n=40) respectively.

Height and weight measurements

Of the 167 children who had their height and weight measured, 63 (37.7%) were classified as either overweight (n=43, 25.7%) or obese (n=20, 12.0). Fifty-four percent (54%) of the overweight and obese children were male, while the remaining 46% were female.

Parents', teachers' and health professionals' attitudes

Attitudes towards the factors contributing to childhood obesity (Subset 1)

Data in Table 1 represent the responses by parents, teachers and health professionals to the factors contributing to childhood obesity. The majority of responses were similar across the three groups.

There were 30% of parents who were unsure if obese children would outgrow their obesity, compared with 9.7% of teachers and 10% of health professionals (P = 0.597). The majority of parents (87.6%,), teachers (96.7%) and health professionals (100%) agreed or strongly agreed that what children eat directly affects their weight (P = 0.631) and also their health (P = 0.260). When asked the same questions in relation to physical activity, 90.4%, 96.8% and 87.5% of parents, teachers and health professionals respectively agreed that being physically active influences a child's weight (P = 0.817). However, significantly more health professionals (85%) agreed that physical activity influences a child's risk of health problems in the future, followed by teachers (72.4%) and then parents (55%) (P = 0.003).

When asked if reducing the amount of time children watch television can help control a child's weight, 27.1% of parents, 29.0% of teachers and 25% of health professionals were either unsure, disagreed or strongly disagreed with this statement (P = 0.799). All teachers (100%) and health professionals (100%) disagreed or strongly disagreed that children breastfed for four months or more are more likely to be obese when they become teenagers. Almost 30% of parents were unsure if breastfeeding influences risk of obesity in later life (P = 0.085).

Attitudes towards the school's role in preventing childhood obesity (Subset 2)

Data in Table 2 represents responses by parents, teachers and health professionals to the school's role in preventing childhood obesity. The majority of parents, teachers and health professionals agreed or strongly agreed that it is important for schools to play a major role in promoting the health of children. Health professionals were most supportive (100%) followed by parents (92.4%) and then teachers (83.9%) (P = 0.019).

Parents, teachers and health professionals displayed consistently strong support regarding the school's role in encouraging children to be physically active (P = 0.983) and providing opportunities for physical activity at school (P = 0.474). More than 90% of health professionals (92.5%) disagreed that only families are responsible for encouraging children to be more active compared with 80% of parents and 71% of teachers (P = 0.031).

Both parents (92.4%) and health professionals (92.5%) supported an emphasis on teaching at school about balanced eating. Although 77.9% of teachers also supported this statement, 9.7% disagreed (P = 0.006).

Over a third of parents (30.6%) and teachers (35.5%) agreed that only family is responsible for the food habits of children compared to 10% of health professionals (P = 0.020). When asked if schools should be restricted to selling only healthy food, 95% (n=38) of health professionals supported this action compared to 54.7% of parents and 67.7% of teachers (P = 0.011).

When asked questions relating directly to weight and the role of the school, health professionals were again most supportive. Approximately half of the parents (48.2%) and teachers (54.8%) surveyed disagreed or strongly disagreed with the statement 'schools are not doing enough to prevent childhood obesity' compared with less than a quarter (22.5%) of the health professionals (P = 0.006). Almost 40% of health professionals agreed with this statement. Seventy-five percent of health professionals agreed school would be an ideal place to prevent weight problems in children compared with 43.2% of parents and 33.3% of teachers (P = 0.014).

Discussion

This study indicates a high level of awareness and concern about childhood obesity among parents, teachers and health professionals. The large proportion of children found to be overweight or obese, together with 30% of parents indicating they were unsure if an obese child would outgrow their obesity, raises concern regarding parents' ability to recognise that their children's weight has become a problem. Studies by Wake et al. (37) and by Baughcum et al. (38) confirm this, in finding the majority of parents with overweight children did not recognise when their child was overweight nor feel concerned about their weight. This may a have serious impact on the willingness of parents to obtain treatment and implement behaviour change strategies in the home. Acknowledging the home environment as the most influential in shaping children's health behaviours (39,40), this places greater importance on the need for schools to work in partnership with parents to prevent obesity.

To date, of the few strategies known to be successful in addressing childhood obesity, both promoting breastfeeding and limiting sedentary activity have shown potential (16,24,41,42) but a large proportion of parents were unaware of this. Breastfeeding can decrease the risk of childhood obesity (41-43). In addition, a significant proportion of parents, teachers and health professionals were also unaware or disagreed with reported evidence (16) that decreasing sedentary behaviour can decrease obesity. These findings highlight the need to develop mechanisms to disseminate practical strategies to parents, through which schools provide a valuable avenue.

Attitudes towards school-based obesity prevention were positive overall, however some differences were evident. Traditional school-based activities such as providing opportunities for physical activity, were consistently supported. All three groups agreed schools have a major role in encouraging children to be more active. Despite support for schools to play a major role, evidence suggests the amount of time devoted to physical activity and health is decreasing (7). Simple strategies known to be effective and easily implemented within schools include encouraging physical activity in break times and providing children with sports equipment (44-50). There was a strong perception that controlling the food and eating environment is primarily a parental responsibility. With this in mind, interventions that attempt to share this role may be seen as beyond the role of the school and meet with resistance.

The development of an 'obesogenic' environment which hinders rather than encourages the uptake of healthy eating and exercise behaviours has been linked to epidemic of obesity (51). Therefore, not only is it logical, but also consistent with the HPS framework, that changes within the school environment are necessary to bring about population-level changes and complement what is taught in the curriculum (52). Implementing school nutrition and physical activity policies provide substantial opportunities for students to engage in appropriate levels of physical activity and healthy eating (50), yet support for such strategies were mixed. Health professionals were more supportive of restricting schools to selling only healthy food despite all three groups acknowledging the important role school canteens play in supporting classroom messages. Restricting the sale of high fat and high sugar foods in school has been highlighted as an important strategy to prevent childhood obesity, but is yet to be implemented in Australia (52). However, strong advocacy in some US states has resulted in the total ban of soft drink sales within schools indicating it is possible to implement such strategies to protect public health (53).

The most noticeable differences in opinion across the groups related directly to weight. Health professionals are clearly in support of the school taking a lead role in obesity prevention. Consistent with a study by Price et al. (33), teachers displayed the least support, suggesting that although teachers acknowledge the seriousness of childhood obesity there is reluctance for schools to play a major role in prevention. This may come as no surprise due to the overloaded curriculum and pressure by society to solve all problems within the school environment. As successful implementation of school-based programs is dependant on support from school staff, a concerted effort will be needed to convince teachers to see obesity prevention as their core business.

In light of the current stance presented by teachers in this study, providing training and support is crucial if obesity prevention is to become a school role. Evidence suggests training increases the extent to which teachers implement the curriculum (15,55). Further, advocating for specialist physical education teachers has additional merit, with studies showing that specialist teachers teach longer lessons, spend more time on developing skills, impart more knowledge and provide more moderate to vigorous physical activity than class teachers do (46). The dissemination of accurate nutrition and physical activity information is urgently needed, with a study of Australian teachers revealing popular media as the most widely consulted source of nutrition information (56). Ideally, training should begin when teachers commence their initial training. Mechanisms for the provision of continuing professional development also need to be explored. Finally, more research is needed to determine if providing additional teacher support improves support for school-based prevention. Such strategies would act to further enhance the role that schools can play in addressing the obesity epidemic.

As part of an overall community strategy, schools can have a significant impact on promoting positive eating and physical activity behaviours, as well as preventing obesity in children. Acknowledging that obesity is multifactorial in nature, the most significant gains in obesity prevention will be seen when efforts are also directed towards addressing the broader determinants at a macro-environment level (51).

Conclusion

A school should provide the physical and social environment that encourages and enables safe and enjoyable physical activity and healthy eating (6). A whole of school approach to obesity prevention needs to incorporate strategies across the HPS framework, ensuring nutrition and physical activity are addressed within the curriculum, the wider school ethos and in each school's community. Teaching the importance of improved diet and physical activity impacts on knowledge, but may not be translated into behavioural outcomes unless there is an opportunity to practice those skills within a supportive school environment.

Clearly, childhood obesity is an important issue for parents, teachers and health professionals. The support for school-based prevention is currently not consistent across the three groups with health professionals clearly advocating for schools to play a major role. Strong and consistent support exists for traditional curriculum-based activities. This provides an opportunity to support teachers and enhance the effectiveness of current classroom and structured physical activity. While acknowledging the strength of the HPS framework in supporting health behaviours, environmental changes to support classroom curriculum remain the challenge. The child's home is likely to have the greatest influence on a child's eating and physical activity behaviours. Supportive school interventions can only reinforce and complement any effort to prevent obesity that happens in the home.

Table 1. Parents', teachers' and health professionals' attitudes towards
factors contributing to childhood obesity

Question                              Parents  Teachers    HP     P
          Response                    n    %   n    %    n    %   value

A child's weight is important to their health.
          Agree/Strongly agree        164  96  31  100   38   95
          Unsure                        1   1   0    0    2    5  0.470
          Disagree/Strongly disagree    5   3   0    0    0    0
Childhood obesity is a serious health issue.
          Agree/Strongly agree        168  99  31  100   40  100
          Unsure                        2   1   0    0    0    0  1.00
          Disagree/Strongly disagree    0   0   0    0    0    0
Most obese children will outgrow their obesity.
          Agree/Strongly agree         13   8   1    3    2    5
          Unsure                       51  30   3   10    4   10  0.597
          Disagree/Strongly disagree  106  62  27   87   34   85
What children eat directly affects their health.
          Agree/Strongly agree        148  88  29   97   40  100
          Unsure                       11   6   0    0    0    0  0.260
          Disagree/Strongly disagree   10   6   1    3    0    0
Being physically active influences a child's risk of health problems in
  the future.
          Agree/Strongly agree         93  55  21   72   34   85
          Unsure                       12   7   2    7    1    2  0.003
          Disagree/Strongly disagree   64  38   6   21    5   13
The type of food eaten directly affects a child's weight.
          Agree/Strongly agree        137  81  29   93   31   77
          Unsure                       12   7   0    0    4   10  0.631
          Disagree/Strongly disagree   21  12   2    7    5   13
Being physically active influences a child's weight.
          Agree/Strongly agree        151  90  30   97   35   88
          Unsure                        6   4   0    0    3    7  0.817
          Disagree/Strongly disagree   10   6   1    3    2    5
Reducing the amount of time children watch television can help control
  their weight.
          Agree/Strongly agree        124  73  22   71   28   70
          Unsure                       24  14   6   19    8   20  0.799
          Disagree/Strongly disagree   22  13   3   10    4   10
Children who are breastfed for 4 months are more likely to be obese when
  they become teenagers.
          Agree/Strongly agree          0   0   1    3    1    3
          Unsure                       50  29   7   22    0    0  0.085
          Disagree/Strongly disagree  120  71  21   75   39   97

Table 2. Parents', teachers' and health professionals' attitudes towards
the school's role in preventing childhood obesity

Question                       Parents  Teachers    HP    P value
              Response         n    %   n     %   n    %

It is important for schools to play a major role in promoting the health
  of children.
  Agree/ Strongly agree        157  92  26    84  40   100
  Unsure                        12   7   3    10   0     0  0.019
  Disagree/ Strongly disagree    1   1   2     6   0     0
Only the family is responsible for the food habits of their child.
  Agree/ Strongly agree         52  31  11    35   4    10
  Unsure                        19  11   4    13   4    10  0.020
  Disagree/ Strongly disagree   99  58  16    52  32    80
Schools should be restricted to selling only healthy food.
  Agree/ Strongly agree         93  55  21    68  38    94
  Unsure                        38  22   5    16   1     3  0.011
  Disagree/ Strongly disagree   39  23   5    16   1     3
Schools have a major role in encouraging children to be more active.
  Agree/ Strongly agree        147  86  26    84  39    98
  Unsure                        18  11   4    13   0     0  0.983
  Disagree/ Strongly disagree    5   3   1     3   1     2
School would be an ideal place to prevent weight problems in children.
  Agree/ Strongly agree         73  43  10    33  30    76
  Unsure                        53  31   7    23   5    12  0.014
  Disagree/ Strongly disagree   43  26  13    44   5    12
A parent's physical activity and eating habits are an example to
  children.
  Agree/ Strongly agree        152  90  31   100  39    98
  Unsure                         8   5   0     0   0     0  0.335
  Disagree/ Strongly disagree    9   5   0     0   1     2
Schools are not doing enough to prevent childhood obesity.
  Agree/ Strongly agree         21  12   4    13  15    38
  Unsure                        67  40  10    32  16    40  0.006
  Disagree/ Strongly disagree   82  48  17    55   9    22
At school, there should be an emphasis on teaching about balanced
  eating.
  Agree/ Strongly agree        157  93  24    77  37    92
  Unsure                        11   6   4    13   1     2  0.006
  Disagree/ Strongly disagree    1   1   3    10   2     5
At school, there should be an emphasis on providing opportunities to be
  physically active.
  Agree/ Strongly agree        162  95  28    90  39    98
  Unsure                         6   4   2     7   1     2  0.474
  Disagree/ Strongly disagree    2   1   1     3   0     0
The school canteen plays an important role in supporting the healthy
  eating messages taught in the classroom.
  Agree/ Strongly agree        153  90  28     9  40   100
  Unsure                        15   9   2     7   0     0  0.474
  Disagree/ Strongly disagree    2   1   1     3   0     0
Only family is responsible for encouraging children to be more active.
  Agree/ Strongly agree         23  14   2     7   0     0
  Unsure                        11   6   7    22   3     8  0.031
  Disagree/ Strongly disagree  136  80  22    71  37    92
Schools should have a policy about what should not be eaten at school.
  Agree/ Strongly agree         70  42  10    32  29    72
  Unsure                        37  22  10    32   4    10  0.073
  Disagree/ Strongly disagree   61  36  11    36   7    18

Acknowledgments

This study was completed as part requirement for the Master of Public Health. We wish to specially thank Judith Leahy, Jeff Smith, the Community Nutrition Unit and Health Promotion Unit at Central Coast Health for their assistance in data collection and ongoing communication with the school. Acknowledgments also to the health staff, teachers, parents and students participating in this study.

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Hunter Population Health, Hunter Area Health Service, Newcastle, NSW

R. Sutherland, BHSc(Nutr and Diet), Public Health Nutritionist

University of Sydney NSW Centre for Public Health Nutrition

T. Gill, BSc(Hons), PhD, GradDipDiet, RPHNutr, Co-Director

Curtin University of Technology, Perth, WA

C. Binns, MBBS, MPH, PhD, FRACGP, FAFOM, FAFPHM, Professor of Public Health

R. Sutherland designed the survey, carried out the analysis, drafted and revised the paper. T. Gill and C. Binns contributed to the conception of the research, statistical methodology, data interpretation and critical review of the paper.