Impact evaluation of “Have Fun — Be Healthy” program: A community based health promotion intervention to prevent childhood obesity

1 BACKGROUND

Childhood obesity is a global public health concern and is predicted to rise in prevalence over the coming years.1 In Australia, 25.7% of children are obese or overweight2 with 28% of children reported overweight or obese in Queensland.3 Obese children are predisposed to higher risks of numerous cardiovascular and metabolic complications in their adulthood. Unhealthy, energy dense diets and sedentary lifestyles with lack of physical activity are identified as the principal risk factors leading to obesity in childhood.1 Parents and primary carers play a key role in preventing their children from being exposed to these unhealthy lifestyle behaviours and thus reducing their risk of being overweight or obese.4 The preschool life stage is recognised as a critical age for intervention since obesogenic habits are still malleable at this period.4 Interventions implemented at community settings (eg Play groups, child care) engaging primary carers have shown to substantially support learning and development in children.5, 6

Social cognitive theory, the most frequently used paradigm in health promotion, describes human behaviour as a three-way, dynamic, reciprocal model where personal factors, environmental influences and behaviour interact constantly.7, 8 They collectively indicate that creating an environment which encourages behaviour change at the outset can largely facilitate the adoption of healthy behaviours.9 Observational learning (acquiring specific behaviours through observing actions of others and the outcomes of their behaviours), self efficacy (a person's confidence in performing a specific behaviour) and reinforcement are some of the key constructs of social cognitive theory which could be effectively applied in childhood obesity prevention.7, 9

This study aimed to evaluate the impact of the Have Fun - Be Healthy project (HFBH) which is a novel, community-based health promotion intervention implemented by Playgroup Queensland and funded by Queensland government. Playgroup Queensland aims to provide low cost, supportive environments for families with preschool children. A Supported Playgroup, a major initiative of Playgroup, aims to empower primary carers in supporting the development of their children utilising community partnerships.10 First piloted in 2008, it was implemented in 2012 in a group of conveniently selected Supported playgroups in Queensland (in Central, Far North, South, South east Queensland, North Coast and Brisbane) delivering 150 programs and reaching an estimated 1655 children. This project aimed to improve the dietary and physical activity behaviours of children (aged 0-5). It also aimed to improve the self efficacy (SE) of their primary carers to guide these behaviours in their children. The objectives of this study were to assess the short term changes in dietary, physical activity and sedentary behaviours of children following participation in the HFBH project. It also aimed to assess the short term effects on the SE of primary carers. The results generated from this study may assist in developing recommendations for effective future programs.

2 METHODS

An impact is an immediate or short term effect brought about by a particular health promotion program on individuals which would influence their health determinants.11 Enhanced knowledge, skills, attitudes, efficacy and motivation on health related behaviours and actions would be among the key immediate effects on individuals.11, 12 The impact evaluation HFBH project was based on a descriptive research design and evaluated the impact of this intervention from its inception to 2014.

The target population consisted of preschool children (up to 5 years of age) and their primary carers from socio-economically disadvantaged backgrounds in Queensland.10 The intervention consisted of four structured cooking and four structured physical play sessions (each session lasting 1-2 hours) delivered weekly by locally trained facilitators over a period of 8 weeks in a Playgroup setting (4 roll outs/terms per year). Data collection was carried out prior to and following the intervention (10 weeks apart) using questionnaires administered to parents and primary carers of preschool children (aged up to 5 years) who participated in the HFBH intervention. All participants (parents or primary carers) were recruited by convenience sampling following informed consent. In addition to participation in HFBH sessions, they were given resource packs to be used at home which included information booklets and cards describing physical play ideas and healthy food recipes which were introduced at the HFBH sessions. More detailed description of a typical HFBH session can be accessed from the website.13

The questionnaires were developed through collaboration between Griffith University, Playgroup Queensland and Queensland Health based on the parent proxy Eating and Physical Activity Questionnaire (EPAQ) for preschool children.14 They were used to determine children's physical activity levels in previous week and dietary intake and screen time (duration of time the child was engaged in viewing TV, DVD, Video, using computer or playing video games) in previous day. They also included close-ended questions on socio-demographic details of the families of the children. In addition, they included questions on SE of carers on promoting healthy foods, limiting unhealthy foods, promoting physical activity as well as limiting screen time. These SE measures were adopted from the work of Campbell et al (2010) and responses were scored on a five-point Likert scale from 1 (not at all confident) to 5 (extremely confident).4 The Eating and Physical Activity Questionnaire (EPAQ) used in our study was previously validated and had good reliability14 while the SE measures had high reliability.4

Matched pairs were included in the impact evaluation analysis. Paired t-test (for parametric data), Wilcoxon signed rank test (for non-parametric data) and Spearman rank order correlation analysis were performed using Statistical Package for Social Sciences (SPSS) version 20.0. Ethical clearance for this project was obtained from the Griffith University Human Research Ethics Committee.

3 RESULTS

A total of 640 pre intervention surveys and 312 post intervention surveys were returned with a matched response rate of 45.5%. Majority (333, 59.2%) of the carers were in the age group of 30-39 years. Most (316, 57.6%) were involved in a home based carer role. Nearly a quarter of the total participants (137, 24.9%) were employed. Most of the children were from English speaking (537, 95.4%), two parent households (478, 87.1%). Their mean age was 3.84 years (SD: 1.6).

Following the intervention, there was an increase in consumption of vegetables, fruits and plain milk. A reduction in fruit juice, cordial, soft drink, flavoured water, flavoured milk and packaged snacks intake was also noted. There was an improvement in the physical activity and reduction in the screen time. However, none of these differences were statistically significant (P > .05). Carer SE in promoting healthy eating and limiting screen time showed statistically significant improvements (Table 1).

Following the intervention, a lesser proportion of children spent their leisure time engaged in viewing TV, DVD, video, using computer or playing video games (pre-intervention 10.4%, post-intervention 4.8%, percentage difference -5.6%). Highest level of carer SE (proportion of carers who were confident or extremely confident) was reported for promoting physical activity (pre intervention 91.1%, post intervention 94.9%). The lowest level of SE (proportion of carers who were not at all confident or slightly confident) was reported for limiting screen time (pre intervention 41.1%, post intervention 46.4%) (not shown in tables).

As in table 2, consumption of plain water, vegetables and fruits in children increased with higher levels of carer SE in promoting healthy foods (positive correlation) (P < .01). The consumption of unhealthy foods including cordial and other sweet drinks (P < .01), flavoured milk (P < .05), packaged snacks (P < .01), lollies (P < .01), chocolates (P < .01) and other sweets (P < .05) decreased with higher levels of carer SE in restricting unhealthy foods (negative correlation). The number of days a child was physically active for more than 3 hours increased with higher levels of carer SE in promoting physical activity (P < .01) (positive correlation). Furthermore, children's screen time decreased with higher levels of carer SE in limiting screen time (P < .01) (negative correlation).

4 DISCUSSION

The HFBH intervention was designed based on the social cognitive theory and its’ key constructs: observational learning, self efficacy, and reinforcement.7, 8, 16 The intervention involved active participation of carers and their children in cooking and physical play sessions which promoted observational learning and parental role modelling. These in turn could have led to behaviour change in the participants (to be more physically active and adopt healthy dietary habits).8, 9 It has been noted that people often benefit from witnessing others from similar backgrounds achieve successful behaviour change.16 The HFBH sessions also provided the participants with an opportunity to gain mastery experience in cooking skills and physical play activities. In addition, they were able to learn and practice these skills in a supportive environment guided by a trained facilitator. These skills may have improved their self efficacy and reinforced the practice of healthy behaviours (initially learnt at Playgroup) at home. The resource packs given to the participants were also useful in this regard.

The overall aim of the HFBH project was to improve healthy dietary and physical activity behaviours in preschool children and improve SE of their primary carers in guiding these behaviours. The results of the impact evaluation showed that this intervention has been successful in achieving these aims. Although some of these improvements were not statistically significant, the direction of the results shows positive changes. This may be due to more accurate reporting of children's behaviours based on improved parental attention on these elements following the intervention.

Similar to the findings of Campbell et al (2010), physical activity levels (the number of days the child was active) were lower than Australian national recommendations for this age group, while the screen time exceeded the recommendations.4, 17 We also found that milk and vegetables intake was below the recommended limits.18 These findings highlight the need for interventions to improve diet and physical activity in this age group.

Carer SE is a key focus in health promotion interventions targeting specific behaviour changes in children, and its role in preventing childhood obesity has been documented in previous studies in association with both dietary and physical activity behaviours.19-22 In our study, carer SE in promoting healthy eating was positively correlated with children's intake of water, vegetables and fruits and this was consistent with previous evidence.4, 20 Similarly, there was a negative correlation between carer SE in limiting unhealthy foods and child's intake of these foods.4, 19, 20 In line with previous evidence, carer SE in limiting screen time negatively correlated with the screen time of children4, 19 while SE in promoting physical activity positively correlated with physical activity levels of children.20

Lowest carer SE was reported for limiting screen time and was consistent with previous evidence4, 19 highlighting the need for more effective interventions to improve parental SE in this regard. However, we found that highest levels of SE was for promoting physical activity in contrast to Campbell et al (2010) who reported highest SE in relation to promoting healthy eating⁴.

Our findings emphasise the importance of improving the SE of carers which may effectively contribute towards reducing the screen time and intake of unhealthy food while improving the intake of healthy foods and physical activity in preschool children. Carer training programs have been shown to be effective in improving SE leading to improved parenting and disciplinary relationships with their children.23 During our intervention, carers got the opportunity to actively participate and contribute to the cooking and physical play sessions with their children. Parental participation has been shown improve outcomes in childhood obesity prevention interventions.22, 24 These activities as well as the resource packs may further enable carers to translate the knowledge and skills they gained at the HFBH sessions into useful practice in their home settings.25 Furthermore, they were encouraged to become role models by participating in these sessions. Parental role modelling has shown to positively impact on child's behaviours.26, 27

It is acknowledged that the lack of a control group, convenience sampling and relatively low matched response rate could limit generalisation and internal validity of the findings.

5 CONCLUSIONS

Overall, the HFBH project is a novel health promotion intervention, being amongst the first of its’ kind in Australia. Although conclusions based on its findings need to be interpreted with caution due to the limitations in study design, the consistent pattern of the results suggests that the HFBH project could be a promising intervention which has been successful in meeting most of its objectives. These include improving healthy dietary and physical activity behaviours in preschool children and also improving carer SE. These findings may be instrumental in developing and implementing similar future health promotion interventions in comparable settings which aim to address the growing public health crisis of childhood obesity.

CONFLICT OF INTEREST

The authors declare that there are no conflicts of interest in connection with this article.