HealthKick: A Nutrition and Physical Activity Intervention for Primary Schools in Low-income Settings

This 11-page journal article, published by BMC Public Health, shares the experience of HealthKick, a school-based nutrition and physical activity intervention in primary schools designed to reduce diabetes risk factors. This study highlights the key role that educators play in implementing a school-based intervention, but adds that developing capacity within school staff and stakeholders is not a simple or easy task.

The primary goals of HealthKick are to promote healthy eating habits and increase regular participation in health-enhancing physical activity in children, parents and teachers; to prevent overweight, and reduce risk of chronic diseases (particularly type 2 diabetes); as well as to promote the development of an environment within the school and community that facilitates the adoption of healthy lifestyles. The components of HealthKick are: action planning, a toolkit (resource guide, a resource box, and physical activity resource bin), and an Educators' Manual which includes a curriculum component.

The article describes three key phases of the strategy:

Phase 1: Intervention Mapping and formative assessment

Intervention Mapping is a means of systematically applying existing literature, appropriate theories and additional research data in the steps of programme development. The study was used to prioritise key environment and behavioural outcomes regarding nutrition and physical activity, focusing on learners. Key findings from the formative assessment findings showed that overweight and obesity are not imminent concerns among learners from low-income settings in the Western Cape. However, the formative assessment highlighted that the physical activity and dietary behaviour of these children was not optimal and warranted attention. These findings emphasise the need to intervene with educators not only because of their potential role as agents of change within the school environment, but also because of their generally poor health status. Regarding parents, it is likely that the competing priorities relating to substance abuse, poverty, and unemployment have contributed to a culture of limited involvement within these schools.

Phase 2: Intervention development

Based on the analysis of the formative assessment data, and in consultation with educational authorities, sixteen schools were purposively selected to participate in Phase 2. These schools were randomly placed in intervention and control categories. Intervention schools are referred to as 'co-implementation' schools, and control schools as 'self-implementation' schools. Co-implementation schools were asked to nominate a HealthKick 'champion' (an educator or other member of school staff) to act as a focal point for communication with the intervention team. Although the original intention was for this individual to promote healthy lifestyles in their school environment, very few of the champions were able or willing to take on this role. The action planning component of the HealthKick intervention drew heavily on Action Schools! BC Planning Guide for Schools and Teachers. In order to assist schools with implementing strategies selected as part of the action planning process, co-implementation schools were given a HealthKick toolkit. The HealthKick Educators' Manual was developed as an essential component of the intervention. Through Intervention Mapping, it became evident that to ensure sustainability, HealthKick would need to align with Life Orientation (LO). This was supported by formative assessment findings that identified educators' capacity as a barrier to the implementation of school-based health promotion programmes, as well as other research in this area.

Phase 3: Outcome and process evaluation

Testing conducted with Grade 4 learners for the formative assessment was repeated to establish baseline data for the outcome evaluation. This testing will be repeated at 18 (Grade 5) and 24 months (Grade 6) on the same cohort. The sample size for the formative assessment and baseline testing of learners was based on the changes the HealthKick team hoped to be able to detect in response to the intervention. For example, in order to detect changes in leisure time moderate-to-vigorous physical activity (MVPA) similar to those demonstrated in other school-based interventions, the project would require about 90 learners for the intervention and control groups, respectively.

The report shares several lessons learned from the process so far:

• The Intervention Mapping approach provided a useful foundation for the development of the HealthKick intervention, particularly the development of goals. Furthermore, this approach contributed towards the integrity of the study and instruments that have been developed. However, researchers believe that the efficacy of the approach may require further interrogation in light of the time and effort taken to complete the process and the complexity it entailed.
• This study highlight the role that educators' play in implementing a school-based intervention, but developing capacity within school staff and stakeholders is not a simple or easy task. The team was constantly aware of the need to balance educators' sense of autonomy with the need to be prescriptive about what needs to get done.
• Preliminary process evaluation results suggest that the original action planning process proved not to be feasible in co-implementation schools, although later response from schools (in 2010) was more encouraging.
• Parents played a very small role in the HealthKick intervention, although researchers expected this should change as a result of strategies to encourage family and community involvement such as poster events and fun walks. The study notes the need to continue to take cognisance of the influence of the home environment on healthy eating and physical activity, bearing in mind the challenges of substance abuse, poverty, and unemployment and the various health consequences and correlates of these issues.

The article concludes that in spite of the challenges, valuable findings have been produced from this study, especially from Phase 1. Materials developed could be disseminated to other schools in low-income settings both within and outside of South Africa. Owing to the novelty of the HealthKick intervention in low-income South African primary schools, the findings of the evaluation phase have the potential to impact on policy and practice within these settings.