An evaluation of the Rashaka Initiative: a school-based obesity intervention in Makkah City, Saudi Arabia

Abstract

Background: Childhood overweight and obesity are public health issues worldwide. In Saudi Arabia, in 2016/2017 the Rashaka Initiative, a national school-based, multicomponent, weight-related intervention, was launched to decrease the prevalence of obesity among students by 5% within five years. Neither the development stage of the initiative nor its implementation has been evaluated to explore its processes and outcomes. Aim: This study was aimed at evaluating the implementation of the Rashaka Initiative in intermediate and secondary schools in Makkah City, Saudi Arabia, covering both process and outcome. To this end, the following objectives were pursued: (1) to develop an evaluation framework that can be used to assess the processes and outcomes of the initiative, (2) to determine whether there was a change in students’ body mass indices (BMIs) during the implementation period, and (3) to explore the knowledge and attitudes of the Rashaka stakeholders regarding the perceived barriers and facilitators of implementation in their schools. Methods: This retrospective study, conducted after the implementation of the Rashaka Initiative, was completed in three phases. In phase I, a conceptual framework called the school-based weight-related intervention evaluation framework (SWIEF) was developed by integrating some elements of the program evaluation framework used by the US Centers for Disease Control and Prevention (CDC) with the components of a logic model. In phase II, secondary data from the Rashaka Initiative were analysed. Phase III was a cross-sectional exploration of the Rashaka stakeholders’ knowledge and attitudes as well as what they perceive as facilitators and barriers to implementing the intervention at their schools. Results: The comprehensive literature review yielded a published systematic review (Banany et al. 2024, Systematic Reviews). This systematic review found 11 school-based weight-related intervention studies in the six Gulf Cooperation Council countries (GCC). Despite the methodological limitations of some of these studies, there is preliminary evidence of the possible benefits of school-based interventions on students' weight and associated lifestyle factors in these countries. A review of the literature also facilitated the development of the SWIEF. The analysis of the secondary data revealed a significant reduction in BMI (p<0.001) across schools that participated in the Rashaka Initiative over two school years (2016/17 and 2018/19). However, this reduction was not associated with the school environmental factors attributed to the initiative. The study findings found that students’ BMIs decreased more considerably in girls’ and intermediate schools than in boys’ and secondary schools (p<0.001 and p=0.031, respectively). The cross-sectional study indicated that significantly better knowledge of risk factors and interventions for childhood obesity was exhibited by female Rashaka stakeholders (vs their male counterparts), stakeholders who completed tertiary education (vs those with lower education levels) and stakeholders engaged in the initiative for more than two years (vs participants who joined more recently) (p<0.001, p<0.007 and p<0.033, respectively). School health counsellors had more positive attitudes towards children’s health and weight than principals (p<0.008). Significantly more favourable attitudes towards the Rashaka intervention were also found among female stakeholders (p<0.011) and those with better knowledge of the initiative’s objectives, components, activities, and outcomes (p<0.049). Among the stakeholders, 73% perceived collaboration with different government and private sector institutions as the most common facilitator of the Rashaka implementation at their schools, while 69% perceived a lack of time as the main barrier. Conclusions: Addressing childhood obesity is a public health priority that requires substantial efforts from all relevant key stakeholders in Saudi Arabia. The evidence derived in this thesis revealed that the Rashaka Initiative has yet to satisfy its objectives. Future studies should be more rigorous, theory-based, and holistic to tackle obesity among school students. Evaluations of school-based obesity interventions should use control groups, validated and reliable measures and rigorous data analysis. Long-term monitoring of the implemented interventions is highly recommended for their improvement and sustainability.