The co-development of a school-based nutrition intervention to prevent childhood obesity in Jeddah, Saudi Arabia

Abstract

Abstract Background Childhood obesity is a major public health issue in the Gulf Cooperation Council countries (GCC) and effective prevention initiatives are much needed. This study aimed to co-develop, with stakeholders, a school-based intervention for obesity prevention among adolescent girls in Jeddah, Kingdom of Saudi Arabia (KSA). A social-ecological framework and co-development and participatory approaches were used to understand the drivers of adolescent obesity in KSA and to develop and assess the acceptability of the co-developed intervention. Design and Methods The PhD programme of research was conducted over three phases. Ethical approval was obtained from the Ministry of Education (MoE) in KSA and also from King’s College London Research Ethics Committee (REC number: 3727). Phase 1: focused on evidence building to understand the burden of adolescent overweight and obesity in KSA and other GCC countries. Phase 2: focused on partnership building, co-identifying intervention priorities and co- developing intervention content and mode of delivery using a participatory approach. Specifically, during this phase, I examined school readiness using a 17-item questionnaire which assessed the school environment, policies and practices related to diet and physical activity, and the capacity of the school to promote the intervention. Also, I assessed students health behaviours (N=100 per school) using a 22-item health behaviour questionnaire. Group concept mapping was used to obtain adult and students stakeholder perspectives on important and feasible intervention opportunities for obesity prevention in two secondary schools. Photovoice was integrated into the concept mapping with students. Adult stakeholders included staff from the Ministry of Education (MoE) and schools, school canteen suppliers and mothers (N=19). Student stakeholders (N=15) were from two girls’ schools (one secondary, ages 13-15 years and one high school, ages 16- 18 years) that were purposefully identified with the support of the Ministry of Education. Both stakeholder groups identified a school-canteen based intervention as an important and feasible intervention. Prior to intervention development, an evidence synthesis on school canteen interventions was undertaken to understand the impact as well as the enablers and barriers associated with such interventions. Phase 3: focused on further developing the ideas for a school-based canteen intervention and on small scale piloting. Firstly, intervention modelling workshops were conducted with stakeholders (10 students, 11 MoE and school staff) drawn from Phase 2 to identify the content and mode of delivery of the canteen intervention. Students also conducted canteen food-scaping to identify current provisions and assess healthfulness. Semi- structured questionnaires during workshops were used to identify common themes related to school food provision. The nutrient profile of existing and intervention food and drinks in both school canteens was assessed using the Food Safety Authority traffic light system for nutrient quality where red indicates high (unhealthy), amber (moderate) and green (healthy). Next, a two-day uncontrolled pilot was conducted in both schools. Two classes from each school were randomly selected (N=116 - 60 secondary school students aged 13-15 years; 56 high school students aged 16-18 years). The intervention canteen provisions were provided by the existing food suppliers and aligned with both the students’ preferences and the MoE guidelines for canteen food provision. Pre-post intervention assessment of the small-scale pilot was undertaken using a 20-item questionnaire. All consultations/ surveys were conducted by MA in Arabic, orally and/or in print. Data were then translated into English by MA for analysis and reporting. Results Phase 1: In the KSA, there was an increase in the