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

1. 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

2. Schools and childhood obesity • Background- why did we do it? • Methodology- and how? • Findings • Conclusions and recommendations • Limitations • Next steps- so what? How can we use this?

3. 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

4. Background Children’s obesity in year six, since 2006 (the darker areas highlight rising rates of obesity): 2006/08 2008/10 2010/12

5. Background • Schools 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

6. Birmingham trends 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

7. Methodology • Quantitative: Statistical Process Control (SPC) (Funnel Plot) • Used to identify “outliers”, either more or less obesity than expected

8. Methodology • Qualitative: • 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

9. Interview structure • General questions on awareness of childhood obesity • Awareness of NCMP programme and how their school is doing • Knowledge of relevant current services and programmes • Barriers • School needs

10. Sample • Demographics

11. Findings- sample • 8 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

12. Findings-themes identified Lack 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” Parents a) 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”

13. … themes, continued Lack 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

14. Model showing major themes from teacher interviews

15. Conclusions • Schools struggle to make obesity a priority, not what they are judged on (SATS, Ofted) • Many believe the responsibility lies outside of school • Parents are seen as both potential facilitators of change, and as barriers to schools influencing change • Request for list of services available to schools approved by Public Health • Suggestion that healthy lifestyles should be part of teacher training

16. Recommendations • Multilevel 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

17. Limitations • Limitations – 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?

18. What next? • Partnership needs developing: Schools- parents-public health, underpinned by evidence • Public 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

19. Model for Publication • Difficult to publish research in non-academic institutions such as NHS or Local government • Currently in stage 3 – Write Up

20. Partnerships • 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

21. Contacts • For further information please contact • Hashum Mahmood hashum.mahmood@birmingham.gov.uk • Charlene Mulhern charlene.mulhern@birmingham.gov.uk • Eleanor. Mcgee@bhamcommunity.nhs.uk