Behaviour Change

On determining and evaluating how school-based interventions improve children’s eating habits and thereof preventing childhood obesity using curriculum and extra-curricular activities, Scott’s (2012) study in the UK involving 9 primary schools for a period of 6 months argues that nearly third of 350 participants were either overweight or obese and most exhibited signs of body shape dissatisfaction. Scott (2012) showed that after the intervention there was a change in eating habits with increased vegetable intake and reduced consumption of snacks, however there was no impact on body shape dissatisfaction. Story and colleagues (2006) observed similar findings by claiming that school-based obesity interventions have attained success in modifying eating and physical activity behaviours but have been less effective in changing body weight or fatness. While these studies indicate the impact of improving children’s eating habits, they have not measured the significance or the impact attained by that change in habit relative to weight gain or weight loss, for overweight or obese children.

Kriemler and colleagues (2011) sought to establish the effect of school-based interventions on physical activity and fitness in children and adolescents, by summarising recent reviews

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from 2007 to 2010. The review strongly indicated that 47-65% of trials from the studies were found to be effective, but most effective interventions were those focused on physical activity in school, while the application of multi-component interventions was the most consistent and promising intervention strategy. The study further claims that there was controversy regarding the effectiveness of family involvement, duration and intensity of intervention (Kriemler et al., 2011). The study points out the critical role of school physical activity in preventing childhood obesity as deduced from the studies, however, it does not indicate or recommend the number or range of hours of physical exercise or specific physical activities found to be more significant from the studies. It also does not show if the duration of study had any implication in the trials or if sporting culture and facilities were critical contributors, particularly on those studies that found physical activity to be more effective.

According to Karnik and Kanekar’s (2012) study on childhood obesity as a global public health crisis and ways to prevent that crisis using school-based, community based, play based and hospital based interventions, school-based interventions were found to be targeting physical activity along with diet education. Additionally, the study postulates that childhood obesity can be tackled at population level using education on the prevention of obesity through healthy nutrition practices and physical activity promotion (Karnik and Kanekar, 2012). Another study by Maatoug and colleagues (2015) conducted in Tunisia to evaluate school-based intervention as a component of preventing childhood obesity by improving physical activity and nutrition–related behaviours reported that school-based intervention is successful in increasing healthy dietary habits and in reducing risks of excess weight. Li and colleagues’ (2014) study conducted in China to assess the effectiveness of a 12-week school- based physical activity intervention on obesity used a multi-component physical activity intervention that included improvement of physical education, extracurricular physical activity for overweight or obese children, physical activities at home and health education lectures for children and parents. The study result indicated that a multi-component activity intervention was effective in decreasing levels of BMI and fasting glucose (Li et al, 2014). The findings provide evidence that deploying a multi-component approach that targets eating habits and physical exercises both at home and at school has a higher chance of increasing the effectiveness of an intervention.

Seemingly Sharma’s (2006) study of school-based interventions for childhood and obesity from 1999 to 2004 involving children from kindergarten to high school focused on behaviour change, and found that interventions led to modest change in behaviour, with TV watching

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being the most modifiable behaviour, followed by physical activity and nutrition behaviours. Sharma recommends measures of outcomes to determine the effectiveness of the intervention (Sharma, 2006). Sharma’s (2011) systematic review found out that of 25 interventions analysed, the majority focused on diet and physical activity and about half of the studies focused on behaviour theory. A study evaluating the effectiveness of preventive school-based obesity interventions in low and middle income countries argues that school-based intervention have the potential to improve dietary and physical activity behaviour that are critical in preventing body weights in low and middle income countries (Verstraeten et al., 2012). Hence, this study will apply a behaviour change approach such as attempting to alter school meals and food intake (diet), and improve participation in physical exercises while avoiding sedentary behaviours.

In general, the studies analysed above about prevention of obesity using school-based interventions provided a framework and key components that this study incorporated in planning and designing the school-based intervention programme. The studies identify critical components that influence effectiveness of school-based interventions for preventing childhood obesity, to include involving and educating parents in the intervention programme, the role of teachers as implementers, the benefits of a school setting, and significance of involving the home setting to foster school-based intervention results. The study also borrowed the importance of applying theory such as behaviour or cognitive theory in an intervention programme. Additionally, studies also indicate how critical the duration of educational interventions, behaviour change and measurement of study results are in determining the overall effect realised by an intervention.

The majority of the reviewed studies utilised quasi-experimental designs in estimating the impact of school-based interventions on target populations (Sharma, 2011). Li and colleagues’ (2014) randomised control trial on establishing the effectiveness of a school- based physical activity intervention on obesity in schools used a mixed methods approach in which baseline surveys and experiments were used and qualitative methods like observation and individual interviews were applied. Maatoug and colleagues’ (2015) school-based intervention study reportedly used a mixed-methods approach in collecting data for both pre- intervention and post-intervention, based on physical activity that involved observation methods and nutrition that required surveys. Clarke and colleagues’ (2015) study on parent and child perceptions of school-based obesity prevention in England used qualitative study focus groups. Tarro and colleagues’ (2014) intervention study collected data including BMI every year by measuring and recording, while questionnaires were applied in dietary and lifestyle habits and were completed by parents, children and teachers as implementers. Jones

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and colleagues (2013) argue that mixed methods in most school-based interventions targeting obesity are associated with the need to collect data on adiposity outcomes such as BMI, BMI z-scores, percentage body fat, waist circumference; and behaviour constructs such as physical activity and dietary factors. According to Branscum and colleagues (2013) qualitative and quantitative process data were collected using surveys, open-item questionnaires, field notes considering the programme’s fidelity, reach, recruitment and context, while triangulation of the method was vital for understanding how the programme was implemented and received by teachers, children and parents in the programme. This outlined the effectiveness of selecting a mixed methods approach in completing this study.

The majority of existing studies on childhood obesity in Saudi Arabia are concerned with presenting a descriptive documentation of the epidemic and its prevalence. The most common determinants found within these studies are pertaining to lifestyle, dietary habits and physical activity. As such, most of the studies conducted within the context of Saudi Arabia follow this trend, and thus an effective school-based intervention is still lacking (e.g. Al- Hazzaa, 2007; Al-Dossary, et al., 2009; Al-Enzy, et al., 2014; Saleh, Al-Ghamedi, 2013; Abdulrahman, et al., 2015)

This is surprising given that the obesity issue is already extensively documented and its prevalence is well understood. The majority of these studies determine the trends in body fatness and obesity among Saudi children and adolescents, detail the various causes which lead to its being an increasing concern, as well as offering recommendations for interventions that encourage healthier lifestyles for the children which are needed at the national level. As a result, the present review includes studies from other cultural contexts and hence the results of those studies cannot be readily used to understand the nature of obesity in Saudi Arabia and the attitudes and perceptions of Saudi school girls regarding obesity and overweight. This is especially true for eating habits which are likely to be influenced by variations in cultural practices. Nonetheless many of the findings from other studies found herein can help inform the development and implementation of a more sophisticated and comprehensive school-based intervention programmes in Saudi schools.