Obesity is now become an epidemic among school going young adolescence in developed countries. The prevalence rate of childhood obesity is considerably high in developed countries. Similarly, prevalence rate of obesity is increasing in developing countries too (James 2004). It is estimated that there are 250 million adult obese people live worldwide (Seidell 1999). Obesity is associated with many chronic diseases like hypertension, heart diseases, diabetes type 2 and even cause cancer. So, increase prevalence of obesity means increase global burden of chronic diseases which indirectly affects the status of global economy. Obesity caused about 9% of total annual medical expenditure in the US in 1998 (Finkelstein, Fiebelkorn and Wang 2003). According to Ogden et al. (2006), 19% of children aged 6 to 11 years are obese and 18% are overweight in the US. Given the wide array of devastating health, social and economic consequences of obesity, the continuing escalating rates of childhood obesity, not least among rural dwellers in the USA, is a great public health concern. Consequently, lot of attention has been paid to the need for effective preventions programmes. Of such programmes is “Winning with Wellness” programme in Appalachia- a rural area in the US. Based on the evaluation report of the programme by Schetzina et al (2009), this paper reviews activities, approach, framework and theories of the programme. ‘Winning with Wellness’ Programme
The school-based health programme “Winning with Wellness” was introduced as a pilot project in an elementary school in rural Appalachia as a way to promote healthy eating and physical activity for elementary school children (Schetzina et al. 2009). The programme was based upon the coordinated school health (CSH) approach that was developed in 1988 (TN Gov 2010). The aim of the pilot programme was to prevent obesity which is a major problem, particularly in rural areas in the US (Schetzina et al. 2009). The programme was supported financially by community collation and it was implemented together with the school based programme in Tennessee (TN Gov 2010). There are eight different components to improve the lifestyle of students and their families: health education; health services; counselling, psychological and social services; nutrition; physical education; school staff wellness; healthy school environment, and student, parents and community involvement (CDC 2008). The school authority established indoor and outdoor walking trails to enhance physical activity among students. Teachers received a training to guide the students properly in such physical activity. A proper nutrition service to promote healthy eating among students was installed such that a registered dietician was assigned to develop ‘Go, Slow and Whoa’ programme which categorized the foods according to their nutritional value and advised the school food service coordinator to supply light diets. Teachers were responsible to provide information about the ‘Go, slow and Whoa’ to students to improve their knowledge about nutritional value of the food and this kind of lesson enable a student to identify healthy and unhealthy diet. School administration also encouraged parents to help their children to choose the healthy diet during lunch in school or at home. Besides students, this health promotion intervention also advocated teachers and staffs to lead a healthy life by increasing physical exercise and taking healthy diet. A counselling and psychological service was available to develop personal skill among the students about physical exercise and active lifestyle. This health promotion intervention maintained all kind of ethical issues such as consent were taken from both students and parents to participate into this pilot project (Schetzina et al. 2009). Third and fourth graders participated in the programme, in total 114 children. Model
As stated before in the evaluation report by Schetzina et al. (2009) ‘Winning with Wellness’ Programme was based on the Co-ordinated School Health (CSH) model. The latter was based on the traditional three-component model, where a school health program is defined in terms of health instruction, health services, and a healthful environment. This model was expanded and eight essential components were suggested: nutrition services, health education, physical, education, school health services, counselling and psychological services, healthy school environment, health promotion for school staff and participation of community. Diane Allensworth and Lloyd Kolbe first proposed
a health promotion model for school health in a professional literature in 1987 which is now known as Coordinated School Health (CSH) model (CDC 2008). This model placed emphasis on creating supportive environments for students by different measures and the new version has been used and adopted in many health prevention programmes (Schetzina et al. 2009). The CSH model is not based upon the Tannahill Model of Health Promotion where health promotion is defined in terms of health education, health protection, and ill-health prevention. Similarly, CSH model is not based upon the Tones Model of Health Promotion which considers empowerment as the main theme of health promotion practice. According to the Ottawa Charter for Health Promotion (WHO 1986), health promotion strategies should be adapted to the local needs, although there are similarities with the CSH, this approach was not based upon the Ottawa Charter. The CSH offered a way to change the school and ideas were explored and alternative solutions and approaches could be examined in the classroom. Teachers understood and examined the realities of children’ circumstances and choices and the understanding provided a change to bring and implement better choices for the children.
According to Schetzina et al. (2009), community-based participatory research (CPBR) approach was used in ‘Winning with Wellness’ health promotion programme. CBPR is a collaborative approach and this approach is now seen as an alternative to the traditional research approach (Tandon et al. 2007). In this programme, a collaboration of teachers, health care providers, parents, community members and researchers was established to make the following obesity prevention programme effective and evaluate outcome of the programme precisely (Schetzina et al. 2009). Some researchers suggest that in rural areas, parents and community involvement in an important element in an obesity intervention (Hawley, Beckman and Bishop 2006) because of scarcity of resources for health promotion in rural elementary schools (Nelson et al. 2006). To compensate the shortness of healthcare facilities, it is obviously a good decision to choose CPBR which ensures multiple level of influence from individual behaviours to family settings, local community and health care services to decrease rate of overweight and obesity among children (Filbert et al. 2009).
The approach of this school health promotion encourages children into taking action, and it brings materials and information into the classroom (Collins et al. 2002). The idea of involving parents, families, and school is described as a way of increasing the commitment and ensuring positive educational and health outcomes (TN Gov 2010). Approaches that use several different strategies and include several different people are more successful than an approach that relies on health information and instruction (Collins et al. 2002). The approach created a new cultural norm where healthy and physical activity was promoted and encouraged. The approach also included many different people and resources. The approach opened up ways for new ideas about how to make health promotion a part of changes in school and improvements in the school environment (Veugelers and Fitzgerald 2005). Furthermore, it lowered the risk for chronic disease in adulthood, and helped to promote healthy behaviour that might lead to life-long habits. This health approach can also reduce absenteeism, reduce classroom behaviour problems, improve performance, and prepare students to be productive members of the community (TN Gov 2008). In addition, the approach supports teacher and staff to improve their health and act as role models for the children. However, such kind of programme requires extensive planning and funding and cannot be considered as a short-term approach (TN Gov 2010). Moreover, the success of a school-based programme relies on the cooperation and positive attitude of several groups of professional, as well as parental involvement in the ‘Winning with Wellness’. Programme was more expensive when compared to health promotion programmes that solely focus on health information and instruction (Schetzina et al. 2009). However, changes are not easy to achieve and there is no simple formula. The approach might need to be adapted and changed to suit the needs of specific communities (Summerbell et al. 2005). Though this approach has many advantages, it takes longer to implement in new schools, and preparations are needed in order for the approach to be successful in new areas. Theory
A theoretical framework helps an individual to focus and clarify intentions and desires with a certain health promotion approach (Naidoo and Wills 2000). Furthermore, a theoretical framework offers a foundation upon which to explain the approach and the benefits that can be expected from a certain
approach. Theory of Planned Behaviour (TBP) was used in this programme (Schetzina et al. 2009). This theory is often used to predict positive health behaviours, and it is based on cognitive processing and level of behaviour change. The TBP is used for assessing factors influencing behavioural motivation and action that may be used to exploring and predicting intention related to diet (Conner et al. 2003). Analysis of factors related to beliefs underlying diet and health choices can be examined, and the model can be used for explaining human behaviour (Ajzen and Fishbein 2005). Three different predictors of health behaviour are used: attitude, subjective norm, and perceived behavioural control (Nejad, Wertheim and Greenwood 2005). Health behaviours are influenced by the individuals’ personal emotion and affect-laden nature; however, a weakness of the TBP theory is that it does not take emotions into account (Dutta-Bergman 2005). Nevertheless, the TBP can be used to understand people’s volitional behaviour, and it can explain the relationship between behavioural intention and actual behaviour. Furthermore, it has improved the predictability of exercises and diet (Baranowski et al. 2003). The theory also takes into account the individual’s social behaviour by considering social norm. Research suggests that this theory is good at explaining intention, and perceived behavioural control (Godin and Kok 1996).
Critical analysis of the programme:
Traditionally, school-health approaches have focused on knowledge rather than attitudes and skills (Naidoo and Wills 2000). The co-ordinated school health approach challenges the view that pupils will change their behaviour when they have information and knowledge. The CSH works on several different levels in order to promote physical activity and healthy eating (TN Gov 2010). The CSH approach is an ongoing process and the success relies on successful communication between the different groups, professionals, and individuals involved in the programme. A common goal and vision is important and the responsibilities and accountability are shared between the participating groups (Fetro 2005). Even though the groups may support each other, they also function independently.
The question is whether a school-based health programmes “go beyond the intended function of schools” (Miller 2003 p.7). It could be argued that knowledge about health lays the foundation for successful schooling (Miller 2003). However, introducing more programmes into the curriculum is always difficult and schools often have problems to link and include health services and the community in their programmes (Miller 2003). The co-ordinator has the ultimate responsibility for implementing the CSH approach, and it is not recommended that this position is held by the school nurse, unless there is a small school system (TN Gov 2010). A school nurse provides an important link between school, home and the community, and he/she also provides counselling to the pupils. However, the co-ordinator has a wide range of responsibilities: liaison; facilitator; partnership-builder; data collector; report writer; public awareness developer; advocate, information sharer, and overall school system organiser (TN Gov 2010). The co-ordinator develops healthy school teams, and facilitates a system-wide school advisory council. Thus, the responsibility for the successful implementation lies mostly on the co-ordinator. The school nurse is responsible for assessment, planning, and direct care of the children. In addition, the co-ordination between the school and community health care professionals ensures early intervention.
The idea is that the health education is implemented into the daily school life, and the education is provided by health educators, teacher, school counsellors, school nurse, dieticians, and community health professionals. During the school years the foundation for lifelong habits are laid, and it is crucial to help children develop healthy habits (Lynagh, Schofield and Sanson-Fisher 1997). An advantage with using school based health approaches is that existing structures and systems are already in place (Miller 2003). Schools have a curriculum into which a health programme can be implemented. Furthermore, using existing structures are cost effective and schools have also been screened for acceptability. Moreover, a school based approach reaches the staff and the people working at school. Teachers and staff may change their own behaviour and become more aware of their eating and exercise habit. School based approaches reach all children in society and the approach can be targeted at specific minority populations.
The nutrient programme is developed in the school; consequently, changes can be implemented when the children, teacher and their families are ready and motivated for the change. Policies regarding vending machines, the food and drink children bring to school, can be discussed and evaluated together with the co-ordinator, nurse, and school board (NICE 2006). Advice and care should be non-discriminatory and culturally appropriate, and the character of the CSH approach allows for schools and communities to implement approaches that are adapted to students with disabilities and from ethnic minorities (Naidoo and Wills 2000). Physical education and fitness activities are planned according to the national curriculum (TN Gov 2010). A recent report suggests that more time spent on physical activity does not impair academic attainment (Murray et al. 2007). The CSH approach is flexible in the sense that more physical activity can be added without changing the curriculum, for example, lunch or morning activities (TN Gov 2010). The role of parents and community is to be involved, and school administrator teachers and school health staff actively try to involve the family in the health promotion (TN Gov 2010). The CSH approaches were developed to be a long-term approach where funding was guaranteed (Warwick, Mooney and Oliver 2009). In some cases it may be difficult to receive funding especially since the success of the programme is difficult to evaluate, partly because there are a wide range of programmes and ways to implement the CSH approach (Warwick, Mooney and Oliver 2009). Teachers could be considered as weak link in the programme; however, research suggests that teachers often support programmes (TN Gov 2010). There might be conflicting interest, and teachers who play a vital role in a school-based health promotion programme, may focus on knowledge that can be gained from including health in the curriculum. In contrast, the school nurse may emphasise reducing health risks associated with overweight and obesity (St Leger et al. 2007). Thus, the approach relies on the co-ordinator, head teachers, and the school to identify and agree on the most useful and fruitful outcomes for their programme (Warwick, Mooney and Oliver 2009). There are likely to be variations in programme implementation; every co-ordinator works together with the school and different solutions to reach the goal may be used (Warwick, Mooney and Oliver 2009).
Although, a flexible approach has its advantages it can also
mean that some schools may integrate concern for health widely across the curriculum, whereas other may choose to focus on specific health issues. As a consequence it is difficult to evaluate the success of the programme. The strength of the approach is that every school has different programmes and services and the solutions and approach are developed to suit a specific school or area. A school can examine their specific needs and resources, although, many programmes are related to the eight components. The full benefit of the CSH approach is perhaps not possible unless you also involve parents (Veugelers and Fitzgerald, 2005). Choices and activities after school influence a child’s chances of becoming obese, and a healthy lifestyle may be difficult for children to change the food and beverage intake at home. Furthermore, if the family is not physically active it may be difficult for children to change the pattern. However, here BMI Index was used as the measurement of obesity of students. There are several problems related to BMI and some of these could be related to the received result in the programme. There are several limitations with the use of BMI index and the index is sometimes combined with a measurement of the waist circumference. The index does not measure fat itself and it does not take into account the skeletal size, amount of body water or muscle mass (EUPHIX 2009). Moreover, the measurement does not reflect body changes when a person is changing his or her height over time. Thus, the index underestimates the degree of overweight in short children and overestimates overweight in tall children. Considering that the programme involved young children it would have been preferable to use some more measurement to examine any changes in body fat percentage. The location of the fat is important, and the children might have lost fat around the waist and gained in muscle strength, which would have an effect on the body fat percentage (BNET UK 2010).
There are several advantages with using the CSH model to health promotion. This model provides a wide range of opportunities for children to learn and experience healthy lifestyle choice and activities by concentrating and integrating a wide range of people and resources both inside and outside the classroom (TN Gov 2010). This type of studies needs to be combined with studies exploring what choices children makes after the school day. By
limiting the intervention and evaluation of the approach to the school day, it is difficult to first of all evaluate the program, but also to determine the best strategies towards helping children. It is possible the children compensated the healthier choices with an increase in unhealthy behaviours after school. A review of health programmes suggests that the most effective programmes involve parents (O’Dea 1993). Working together with parents to promote healthy food choices at school is not always easy; however, it is vital to include parents and many parents pack their children school lunches (KidsHealth 2010). Furthermore, there are problems linked to promoting physical activity with children walking to and from school as parents are reluctant to let their children walk and play outside after school.
Health promotion deals with “raising the health status of individuals and communities” (Ewles and Simnett 2003 p. 23). However, it is often used to refer to planned activities or programmes (Tones and Tilford 2001). This programme was based on theory of planned behaviour, Co-ordinated School health model, and school-setting approach. The programme provided a way to help children to make healthier lifestyle choices, and the children in the study changed some of their choices related to food. They were also more physically active. The CSH model provided a framework for the school health programme in rural Appalachia and the results suggests that this may be valuable. In addition, the approach provides teacher and children with knowledge that can be used to change the school and ideas can be explored and alternative solutions and approaches can be examined in the classroom. Health promotion in school is one step in the right direction to solving problems related to the growth of childhood obesity. A broad holistic approach is recommended which encourage physical, social, spiritual, mental, and emotional wellbeing of both children and the staff at school (LTS 2010).
N.B.: TN Gov – Tennessee Government
CDC – Centers for Disease Control and Prevention
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