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PREVENTING DIABETES AND OTHER
CHRONIC DISEASES THROUGH ASCHOOL-
BASED BEHAVIOURAL INTERVENTION IN
FOUR CARIBBEAN COUNTRIES
FINAL PROJECT REPORT (Project # WDF05-139
Prepared by
Caribbean Food and Nutrition Institute (CFNI/PAHO/WHO)
For The World Diabetes Foundation (WDF)
August 1, 2012
i
TABLE OF CONTENTS
Page
ACKNOWLEDGEMENTS … … … … … … … vii
ABBREVIATIONS … … … … … … … … viii
1.0 PROJECT BACKGROUND … … … … … ... 1
1.1 Introduction … … … … … … … ... 1
1.2 Project Title … … … … … … … ... 5
1.3 Project Goal … … … … … … … ... 5
1.4 Project Objectives ... ... ... ... ... ... ... 5
1.5 Project Outcomes … … … … ... ... ... 5
2.0 METHODOLOGY … … … … … … … ... 6
2.1 Study Design … … … … … … … ... 7
2.1.1 Phases of the Project … … … … ... 8
2.1.2 Targeted Behaviours ... ... ... ... 8
2.1.3 Project Components … … … … ... 9
2.1.4 Management of the Project … … … ... 16
2.2 Data Collection and Analysis … ... ... ... .... 17
2.3 Project Monitoring and Evaluation ... ... ... ... ... 20
2.4 Constraints/Challenges to Methodology ... ... ... … 22
2.5 Preparatory Activities (Phases 1 and 2)... ... ... ... ... 24
2.5.1 Sensitization ... ... ... ... ... ... 24
ii
2.5.2 Needs Assessment … … … … ... 25
2.5.3 Curriculum Development Workshop ... ... ... 34
2.5.4 Orientation of Country Co-ordinators ... ... ... 35
2.5.5 Development of Materials ... ... ... ... 35
2.5.6 Training of Teachers ... ... ... ... ... 37
2.5.7 Identification of project co-ordinators ... ... 39
2.6 Lifestyle Intervention (Implementation with students - Phase 3) ... 39
2.6.1 Collection of baseline data
(including 24 Hour Recalls and KAP Year 2) ... ... 40
2.6.2 Implementation of the Four Components ... ... 40
2.6.3 Process Evaluation ... ... ... ... ... 42
2.6.4 Final Data Collection ... ... ... ... 43
3.0 RESULTS … … … … … … … … ... 46
3.1 Demographics and Profiles ... ... ... .... ... 47
3.2 Eating Behaviours ... ... ... ... ... .... ... 53
3.2.1 Knowledge of Nutrition ... ... ... ... ... 53
3.2.2 Food Consumption Patterns ... ... ... ... ... 55
3.3 Physical Activity Behaviours … … … … … 65
3.3.1 Knowledge of Physical Activity ... ... ... ... 66
3.3.2 Physical Fitness ... ... ... ... ... ... 69
3.3.2.1 Flexibility ... ... ... ... ... 69
3.3.2.2 Muscular Strength ... ... ... ... 70
iii
3.3.2.3 Muscular Endurance ... ... ... ... 71
3.3.2.4 Aerobic Capacity ... ... ... ... 73
3.4 Health Status of the Children Studied ... ... ... 73
3.4.1 BMI for Age ... ... ... ... ... ... 73
3.4.2 Blood Pressures ... ... ... ... ... 74
3.5Components I to IV ... ... ... ... ... ... .. 78
3.5.1 Behaviour Curricula on Nutrition/Diet and
Physical Activity (lessons) ... ... ... ... 78
3.5.2 School-wide Promotional Activities ... ... ... 84
3.5.3 Building Supportive Environments at School ... 88
3.5.4 Building Supportive Environments at Home
and Community ... ... ... ... ... 94
4.0 DISCUSSION AND RECOMMENDATONS ... ... ... ... 100
5.0 CONCLUSION … … ... ... ... ... ... ... 113
6.0 BIBLIOGRAPHY ... ... ... ... ... ... ... ... 116
7.0 ANNEXES (Separate document attached)
List of Figures
Figure 1: Obesity Prevalence (Selected Age Groups and Countries
Figure 2: Crude Mortality Rates (Deaths /100,000) in the Caribbean for
iv
Selected Diseases
Figure 3: WDF Project Components
Figure 4: Target Behaviours and Components of the Lifestyle Intervention
Figure 5: Project Management
Figure 6: Teacher Training Sessions, Trinidad and Tobago
Figure 7: Co-operative Learning Groups, Trinidad
Figure 8: Physical Fitness Assessments, Grenada
Figure 9: Weight, Height, Blood Pressure Measurements, Grenada
Figure 10: Focus Group Discussions, Grenada and Tobago
Figure 11: 24 Hour Recall, Grenada and Trinidad
Figure 12: Age Distribution by Type of School
Figure 13: Age Distribution by Country
Figure 14: Students attending Intervention and Control Schools by Country
Figure 15: Daily Consumption by Type of School, Year 1
Figure 16: Daily Consumption by Type of School, Year 2
Figure 17: Flexibility by Intervention and Control Schools
Figure 18: Muscular Strength by Intervention and Control Schools
Figure 19: Muscular Endurance by Intervention and Control Schools
Figure 20: Aerobic Capacity by Intervention and Control Schools
Figure 21: Mean Change in Pulse rate by BMI-for-Age, Year 1
Figure 22: Mean Change in Pulse rate by BMI-for-Age, Year 3
Figure 23: Comparison of Overweight and Obesity Among Year 1 and 3 Students
Figure 24: Comparison of Overweight and Obesity Among Year 1 and 3 Students by
Intervention and Control Schools
Figure 25: Systolic Status by Schools
Figure 26: BMI by Systolic Status, Year 1
Figure 27: Systolic Status by School, Year 3
Figure 28: Diastolic Status by School, Year 1
Figure 29: Teacher Evaluation, Year 1
Figure 30: Project Teachers Self-Assessments
v
Figure 31: Anglican High School Students, Grenada enjoying Physical Activity on a
Promotional Day
Figure 32: Poster Competition for Students at SFESS, Trinidad
Figure 33: Students in a Healthy Lunch Competition in Grenada
Figure 34: Hiking Club, Nevis
Figure 35: Teachers Modelling Behaviour: Eating a Variety of Fruits Daily
Figure 36: Students Participating in Fruit day
Figure 37: Minor Physical Activity Equipment Donated by the Project
Figure 38: Parents‟ Involvement in Project Activities
Figure 39: Changes Made to Encourage Physical activity
Figure 40: GFNC Educating Students on the Amounts of Sugar, Fat, and salt that are
in common foods eaten
Figure 41: Student getting Blood Pressure Checked at a Parent Activity
List of Tables
Table 1: Intervention and Control Schools per Country
Table 2: List of Monitoring and Evaluation Tools used in the Project
Table 3: Distribution of Students Sample of the Population
Table 4: Daily Food Consumption by Students
Table 5: Sources of Students‟ Information and Lunch
Table 6: Students‟ Physical Activity and Practices
Table 7: Students‟ Knowledge versus Practice
Table 8: Group Distribution of Teachers by Country
Table 9: Nutrition Topics Taught
Table 10: Health and Nutrition Programmes
Table 11: Demography Characteristics of Year 1 Students
Table 12: Participation of Parents in Intervention Schools, Year 3
Table 13: Independent Samples Test of Mean Scores between Intervention an
Table 14: Mean Scores by School Type, Year 2
Table 15: Total Nutrition Scores by School Type, Year 3
vi
Table 16 Once or More per day Consumption by Gender
Table 17: Consumption of Foods Once or More Daily, Year 1 vs. Year 3
Table 18: Distribution of Year 2 and Year 3 Samples (Food Record-Assisted 24
Hour Recalls) by Intervention and Control Schools and Gender
Table 19: Meeting the Recommended Dietary Allowances (RDA)
Table 20: Meeting Population Goals
Table 21: Eating a Variety of Foods Daily (Targeted Behaviour)
Table 22: Percentage of Students who were able to correctly answer questions on
Physical Activity in Section 4.1
Table 23: Percentage of Students who were able to correctly answer questions on
Physical Activity in Section 4.2
Table 24: Mean Scores by School Type, Year 2
Table 25: Percentage of Year 3 Students who were able to correctly answer
questions on Physical Activity
Table 26: Mean Scores by School Type, Year 3
Table 27: Diastolic Pressure by BMI
Table 28: Minor PA Equipment Donated to Intervention Schools
Table 29: Parents‟ Recollection of the Take-Home Assignments
Table 30: Ways in which Parents helped with Project Activities
vii
ACKNOWLEDGEMENTS
The Caribbean Food and Nutrition Institute (CFNI) would like to acknowledge the funding by
The World Diabetes Foundation for the conduct of the research and the critical roles played by
the Principals, Teachers, Students, Curriculum Officers and Senior Ministry Personnel from the
Health, Education and Sports Sectors over the four year period.
A special thanks to the Director and staff of CFNI and all the Data Collectors who contributed in
some form to the research for their excellent work.
Those who participated in the focus group discussions and the key informant interviews were
willing and enthusiastic to participate and for this we especially thank them.
viii
ABBREVIATIONS
AHS - Anglican High School
BMI - Body Mass Index
CC - Country Co-ordinator
CFNI - Caribbean Food and Nutrition Institute
GDP - Gross Domestic Product
GFNC - Grenada Food and Nutrition Council
GHS - Gingerland High School
GRE - Grenada
NCDs - Non-communicable Diseases
NGOs - Non-Governmental Organizations
PA - Physical Activity
PAHO - Pan American Health Organization
PBSS - Petit Bordel Secondary School
PE - Physical Education
PTA - Parent Teachers Association
RDAs - Recommended Dietary Allowances
RSS - Roxborough Secondary School
SBA - School Based Assessments
SFESS - San Fernando East Secondary School
SFP - School Feeding Programme
SKN - St. Kitts and Nevis
SMSS - St. Mark's Secondary School
ix
TRT - Trinidad and Tobago
TSSS - Thomas Saunders Secondary School
WAHS - Washington Archibald High School
WDD - World Diabetes Day
WDF - World Diabetes Foundation
WHO - World Health Organization
1
PROJECT
BACKGROUND
2
1.0 PROJECT BACKGROUND
1.1 Introduction
The correlation between nutrition, physical fitness and learning is well documented.
Healthy lifestyle patterns are essential for students to achieve their full academic
potential, physical and mental growth, and lifelong health and well being. Healthy diet
and physical activity are demonstrably linked to reduced risk for mortality and
development of many chronic diseases as adults. Obesity and its co-morbidities, non-
communicable diseases (NCDs), are the region‟s main public health problems, and are
linked to food intakes and lifestyle. The region is experiencing a nutrition transition
reflected in a shift in diets away from indigenous staples (Cereals and Starchy roots,
fruits and tubers), locally grown fruits, vegetables, legumes, and limited foods from
animals, to diets that are more varied and energy-dense, consisting of foods that are more
processed (including processed beverages), more from animals, more added sugars, high
in fats/oils and sodium, and often more alcohol. This shift in diets is ultimately reflected
in the increasing prevalence of overweight and obesity, a main risk factor in NCDs, such
as diabetes, hypertension, stroke, heart diseases and some forms of cancers. These NCDs
are the main public health problems in the region.
It is now generally recognized that obesity and NCDs constitute the leading causes of
deaths and illnesses in developing countries. The developed countries are currently
facing the full brunt of these disease burdens and are a good proxy of how their disease
burden patterns will soon be repeated in countries such as in the Caribbean. The silent
epidemic of obesity has increased rapidly in the last two decades in the Caribbean. About
25% of adult Caribbean women are obese, almost twice as many as their male
counterparts. Child and adolescent obesity is also high. Moreover, adult obesity is
associated with child obesity and this risk increases when either parent is also obese
(Henry, 2004c). After adolescence there is a clear and consistent increase in obesity
through to older adults (Figure 1).
3
Figure 1: Obesity Prevalence (Selected Age Groups and Countries).
Source: Henry, 2004c.
Obesity is the main risk factor in several major NCDs, such as heart diseases, diabetes,
hypertension, stroke and cancers. NCDs are the main public health problem and account
for more than 65 percent of the top seven causes of death and illness in the region (Fig.
2).
Figure 2: Crude Mortality Rates (Deaths/100,000) in the Caribbean for Selected
Diseases
Source: CAREC, 2007.
0
10
20
30
40
50
%
St Kitts/Nevis Trinidad Belize Jamaica Guyana
18-24 yrs 25-34 yrs 35-44 yrs 45-54 yrs 55+ yrs
All Sexes
0
20
40
60
80
100
120
140
2000 2001 2002 2003 2004
Cru
de M
ort
ali
ty R
ate
s
Heart Disease Cancers Diabetes Stroke Injuries Hypertension HIV Disease
4
Obesity and NCDs have significant negative impacts both on individual and national
budgets. At the individual level, these diseases are twice as costly to treat compared to
infectious diseases (World Bank, 2006). The author also estimates that if everyone
affected with diabetes and hypertension were to be treated, then the direct cost to the
Caribbean region will be US$691 million annually (2.08 percent of Gross Domestic
Product, GDP), which is about 66% of what the region currently spends on public health.
Moreover, almost half of the direct cost of these diseases are attributable to obesity.
Obesity and NCDs are preventable lifestyle diseases and are caused mainly by
unbalanced diets and sedentary lifestyles. The escalation of these diseases in the
Caribbean are aggravated by: insufficient awareness among policy makers of the
problem; ready availability and more affordability of highly processed foods, high in salt,
fat, trans fats and sugar; unavailability and relatively high prices for fruits and vegetables,
and a general lack of knowledge among households of the nutritional and health-
enhancing value of these food groups.
However, since the formative years of childhood are where most lifestyle and health
behaviours are learnt, schools have the responsibility to help students as well as staff to
establish and maintain lifelong, healthy lifestyle patterns. All students should have the
opportunity to obtain the knowledge and skills necessary to make nutritious and
enjoyable food choices for a lifetime.
This project is aimed at preventing diabetes and other chronic diseases through a school
based behavioural intervention. Through this project the adoption of healthy lifestyle
behaviours were actively promoted and supported. It was funded by the World Diabetes
Foundation and e conducted over the period 2007-2011 in four countries: St. Kitts and
Nevis (SKN), Trinidad and Tobago (TRT), Grenada (GRE) and St. Vincent and the
Grenadines (SVG). The project targets, students in Form 1 (Grade 7), were followed
through to Forms 2 and 3 (Grades 8 and 9).
5
1.2 Project Title
“Preventing Diabetes and other Chronic Diseases through a school-based behavioural
intervention in four Caribbean Countries”.
1.3 Project Goal
The goal of the project was to prevent diabetes and other chronic diseases through a
school-based behavioural intervention.
1.4 Project Objectives
The purpose of this project was to promote the adoption of healthy lifestyle behaviors of
Secondary school children through a school based intervention in (Grades 7-9) students
in four countries of the Caribbean. The specific objectives of the project are:
1. To improve the diet and physical activity patterns among students.
2. To determine the effectiveness of the intervention to improve diet and physical
activity behaviours in students.
1.5 Project Outcomes
The main outcomes proposed for the project were:
1. Improved diet and physical activity patterns starting at the secondary school
level.
2. Sustainable lifestyle intervention programme for secondary schools.
6
METHODOLOGY
7
2.0: METHODOLOGY
2.1 Study Design
This project followed the Form 1/Grade 7 students in the selected intervention schools for
three years up to Form 3/Grade 9. The schools were selected based on the criteria
developed to meet the scientific requirements of the project. In each country, two schools
served as intervention schools and two as control schools, except for St. Kitts and Nevis
which had three control and two intervention schools. Selections were made from both
urban and rural locations (Table 1).
Table 1: Intervention and Control Schools/Country
COUNTRY LOCATION INTERVENTION
SCHOOLS
N CONTROL
SCHOOLS
N
Grenada
(GRE)
Urban Anglican High School
(Girls) (AHS)
119 St. Joseph‟s Convent
(Girls)
130
Rural St. Marks‟ Secondary
School
(Co-ed) (SMSS)
113 St. David‟s Catholic
Secondary School
(Co-ed)
114
St. Kitts and
Nevis
(SKN)
Urban Washington Archibald
High School (St. Kitts,
Co-ed)(WAHS)
178 Basseterre High
School
(St. Kitts, Co-ed)
Charlestown High
School
(Nevis, Co-ed)
166
120
Rural Gingerland High
School
(Nevis, Co-ed) (GHS)
84 Cayon High School
(St. Kitts, Co-ed)
126
St. Vincent
and the
Grenadines
(SVG)
Urban Thomas Saunders
Secondary School
(Co-ed)(TSSS)
77 Campden Park
Secondary School
(Co-ed)
154
Rural Petit Bordel Secondary
School
(Co-ed)(PBSS)
57 Georgetown
Secondary School
(Co-ed)
143
Trinidad
and Tobago
(TRT)
Urban San Fernando East
Secondary
(Trinidad, Co-ed)
(SFESS)
123 Belmont Junior
Secondary School
(Trinidad, Co-ed)
92
Rural Roxborough Secondary
School
(Tobago, Co-ed)(RSS)
57 Goodwood High
School
(Tobago, Co-ed)
63
8
The intervention was implemented as follows:
In 2008, the focus was on Grade 7/Form 1.
In 2009/2010 the focus was on Grade 8/Form 2.
In 2010/2011 the focus was on Grade 9/Form 3.
2.1.1 Phases of the Project
This project was conducted in four phases:
Phase 1: Problem Assessment and Awareness-Raising.
Phase 2: Development of Programme Materials and Training of Project teachers.
Phase 3: Implementation of a Lifestyle Intervention though Classroom teaching and
building support in the school and home environments.
Phase 4: Evaluation of the Intervention – process and outcome.
2.1.2 Targeted Behaviours
Seven targeted behaviours (five on Diet and two on physical activity) were selected for
intervention:
1. Eating a Variety of Foods Daily;
2. Eating Breakfast Daily;
3. Eating Fruits and Vegetables Daily;
4. Reducing Daily Intake of Fats and Salts;
5. Reducing Daily Intake of Sugary Snacks and Drinks;
6. Engaging in at least Moderate Physical Activity (PA) for a Minimum of 60
minutes at least 5 days Weekly;
7. Engaging in a Variety of Physical Activity Daily.
These behaviours were supported by a series of Core Concepts and Sub-concepts (Annex
I) for the adoption of the behaviours in the children. Three behaviours were addressed
through fourteen lessons in Year 1:
Eating a Variety of Foods Daily (Diet).
9
Eating Breakfast Daily (Diet).
Engaging in a Variety of Physical Activity Daily (Physical Activity).
In the second and third years, all of the seven behaviours were addressed. Eighteen
lessons were developed and scheduled to be taught in Year 2 and sixteen in Year 3.
2.1.3 Project Components
There were four components to the intervention (See Figure 3). These are:
I. Behaviour Curricula on Nutrition/Diet and Physical Activity (Lessons)
II. School-wide Promotional Activities (Programmes)
III. Building Supportive Environments at School (Environment)
IV. Building Supportive Environments at Home and Community (Environment and
Family Support)
Figure 3: WDF Project Components
Guidance
Counseling
Lessons
Environment
Programmes
Family Support
Diet
Physical
Activity
Conflict resolution
Self Esteem
Self-assessment
Monitoring
Promotional
Days
Extra-
curricular
Core days (3)
Additional (2)
Diet (E.g. cooking)
Physical (E.g.
cheerleading)
Home/
School
Projects
PTA
Talks/
Activities
Summer/
Maintenance
Projects
Peer
Health
ServicesHealthy
School
Meals
Options
Cooperative
learning
Dietitian
School Nurse
Lifestyle Intervention
Multiple
Intelligences
Constrcutivism
Physical
Actiivity
Facility
10
Component I - Behaviour Curricula on Nutrition/Diet and Physical Activity
The overall objective of the behavioural curriculum was to ensure that all students in
project intervention schools were exposed to the elements of a behavioural curriculum
fundamental to the knowledge and skills base required to consciously practice the
targeted behaviours in their school, home and community environments. The theoretical
framework for the behavioural-oriented lessons is shown in Annex II.
The behaviour curriculum consisted of 48 (40-minute) straight lessons on diet and
physical activity taught directly to the children (“straight” lessons). Additionally, lessons
where relevant nutrition and physical activity concepts are infused into the curricula of
selected subjects were also taught to reinforce the behaviours. Both the straight lessons
and the infused lessons emphasized self-assessment and monitoring; goal setting; and the
development of the relevant cognitive, affective and behavioural skills required for the
voluntary adoption of the targeted behaviours. This was supported by teacher training to
facilitate a behavioural change orientation in delivery of lessons, and in the development
of assignments and activities.
The activities related to conflict resolution and self-esteem were woven into the physical
activity and nutrition sessions. The theoretical framework that underpinned the project
lessons embraced three key teaching and learning approaches:
1. Constructivist Approach
2. Cooperative Learning
3. Multiple Intelligences Approach
The breakdown and spread of the lessons (see Annex III, IV and V) allowed for minimal
disruption of the normal curriculum teaching. Training of the teachers was conducted
over a three to five day period during the Summer Vacation prior to the opening of each
new school year to allow teachers to internalize the materials and get clarifications. A
sample agenda is attached as Annex VI and the presentations used at each training
session are attached as Annex XIX. All teachers for the particular Grade were invited to
11
the training so no individual teacher would be overburdened with more than one lesson
per term. A manual with the lessons and all the relevant materials required for the
teaching was developed for each school year. In addition to the direct concept lessons,
teachers were trained to develop infused lessons based on selected concepts for each of
the seven behaviours. This provided added reinforcement and support for the selected
behaviours. For this training, a manual on infusion was developed that took teachers
through a series of processes from the lesson plan for their lesson topic to an infused
version. This did not require timetabling since the infused lessons were based on topics
that were on the syllabus. After training it was left up to the individual subject matter
teachers to teach the infused lessons with which they were comfortable.
Apart from the lessons, teachers were also exposed to presentations and discussions on
how to motivate students, teaching methods; and classroom management to name a few
that enhanced the teachers‟ capacity and ability to ensure learning of all students. This
component also asked teachers to do a self-evaluation (Annex VII) of the lessons taught
and the Country Co-ordinator (CC) conducted a peer evaluation (VIII). This component
was implemented together with the other three components over the three year period.
Component II: School-wide Promotional Activities
School nutrition programmes provide opportunities for children to learn real-life
strategies for evaluating food options and making healthy choices. Many such
programmes have developed creative ideas for giving children the skills and information
they need in order to build healthy and nutritious eating habits. Physical activity can have
an enormous impact on improving a child‟s physical and emotional well-being. Research
has shown that increased physical activity can help children maintain a healthy body
weight, enhance their self-confidence, and offer “opportunities for social contact,
nurturing, and maturational guidance.
This component focused on nutrition and physical activity programmes though
promotional and extracurricular activities such as special days, after-school clubs and
12
other events related to the target behaviours and the concepts being taught in the
classroom.
Promotional Days
There are several important health related days/events recognized across the region and
internationally which will provide an opportunity for schools to participate by
showcasing and highlighting good nutrition and physical activity to the school
community. These included:
o World Diabetes Day
o Caribbean Nutrition Day
o Caribbean Wellness Day
o Sports Day
Under the project, it is mandatory for all intervention schools to observe, plan for and
participate in at least three of these events annually. Schools were allowed to observe
other special days, e.g. fruit days.
As part of observing promotional days, schools prepared posters and charts with
messages encouraging healthy lifestyle and increased physical activity. Schools also
hosted open days offering education material to members of staff, student and members
of the community as well as healthy foods. Collaboration with local organizations such
as the Diabetes Association and Nutrition Departments in Countries were done. For fruit
days, children were asked to bring fruits to school and share. Sometimes these were
included in healthy baked snacks.
Other Activities included:
Formation or revitalization of clubs such as Nutrition Club, Wellness Club,
Walking or Cycling club.
After-school physical activity programmes such as hiking and aerobics.
13
Dissemination of information through creation of bulletin boards and poster style
newsletters highlighting planned nutrition activities at school.
Healthy lunch contests providing prizes to students observed to have that day‟s
category of low fat/low salt/low sugar food.
Field days with physical activity teacher
Creation of a school gardens
Component III: Building Supportive Environments at School
Building supportive environments in the school involves providing support to the school
environment through working with canteens, vendors and other teachers to make changes
in the food choices available to the students. This component focussed on the school
resources and to equitably serve the needs and interests of all students and staff, taking
into consideration differences in cultural norm and physical limitations.
School principals were encouraged to support a healthy eating and physical activity
environment in schools. Ways of doing these were documented in the Manual” Manual
for Healthy Lifestyle Projects in Schools” Some suggestions which were implemented
included:
Encouraging staff members to model healthy eating and physical activity as a
valuable part of daily life, e.g. making healthy food selections.
Creating opportunities, in addition to the structured PE curriculum, for physical
activity (e.g. recess, movement, walkathons, cheer leading, sports team/clubs and
other extracurricular activities). These were supported and strongly encouraged.
Including physical activity as a part of celebrations, meetings and other special
events.
Making available facilities that enable students‟ participation in physical activity, e.g.
access to sports equipment, playing fields, games courts, shower facilities, etc. Some
basic equipment was donated to each intervention school.
Encouraging canteen staff and vendors to increase the availability and sale of
nutritious selections and discourage the sale and consumption of beverages and foods
of low nutritional value during regular school hours.
14
Communicating with parents/guardians in order to accomplish the development of a
supportive school environment, The school teams were asked to educate the school
community on trends and information related to health and wellness. Community
partnership was also encouraged to continue learnt behaviour at home and in
community.
Schools were encouraged to partner with the community to assist in the support of an
active, healthy community of learners.
Component IV: Building Environments at Home and In the Community
Parents and family play an all important role in sending the right messages to foster the
development of healthy eating and lifestyle behaviours. Parents control most food choices
available at home, so changing parents‟ eating behaviours may be one of the most
effective ways to influence their children‟s eating behaviours.
In this component, building supportive environments in the home were carried out
through family support education programmes. Activities were designed to inform
parents about the goal and objectives of the intervention and also to involve them in
activities not only through take home assignments, but through talks and involvement in
promotional days at the school. Parents will be encouraged to work with children on take
home activities and to seek out the school team for advice and referral on healthy
lifestyle-related issues. Summer/maintenance activities were also included. To involve
parents and other family members in promoting healthy eating and physical activity,
some of the following were done:
Worked with parent teacher associations to include serving/selling healthy foods
at fundraisers and school events.
Used nutrition education materials for giving information on healthy eating
Offered nutrition education services that students shared with their families, such
as reading and interpreting food labels, reading nutrition related newsletters and
preparing healthy recipes
15
Facilitated interactive meetings with parents and teachers to discuss the
relationship with overweight and health, physical activity and healthy food.
Encouraged parents and students to work together to pack healthy lunches for
students who bring lunch to school and identify stores in their communities
where students can purchase healthy snacks on the way to and from school.
Encouraged parent and child activities on nutrition and physical activity. Gave
students summer or other vacation activities.
Planned parent and organized fruit and vegetable events, where dishes are served
and parents learn more about the project.
Encourage children and parents to develop a more active lifestyle such as
replacing television viewing and other inactive pursuits with chores, outdoor
activities, sports and projects. Family members were engaged in simple physical
activities while performing everyday tasks.
Plan parent and child exercise challenges, relays, races and games.
Encouraged students and family members to set exercise goals.
Figure 4: Target Behaviours and Components of the Lifestyle Interventions
16
2.1.4 Project Management
Figure 5 below depicts the project hierarchy. CFNI was responsible for overall
management of the project, which was implemented through the Ministries of Education
in each country. A Country Coordinator (CC) in each country liaised with the country
team and CFNI to plan and organize activities in the participating schools as directed.
Organization of project activities in each intervention school was done by a school team,
led by a school liaison teacher in each school who acted as the focal point for the project
within the school. The school teams undertake the day to day implementation of the
intervention in their respective schools through interaction with members of the school
community – teachers, parents, canteen staff and vendors around the vicinity of the
school, who in turn participated in activities planned for students, who were the main
beneficiaries of the project.
Figure 5: Project Management
Responsibilities of project players are detailed in Annex IX attached.
STUDENTS
PARENTS TEACHERSCANTEEN/
VENDORS
CFNI & WDF
COUNTRY COORDINATOR
SCHOOL TEAM
COUNTRY TEAM
FOCAL
POINT
MOE
17
2.2 Data Collection and Analysis
Both qualitative and quantitative data were collected. Outcome Evaluation/Indicators
focussed on: Knowledge test; Skills development; Classroom and take home
assignments/projects done; BMI; and Fitness. Process evaluation/Indicators focussed
on: Number of hours or time spent on sessions; Number of concepts taught; Exposure of
students (attendance records); and Number and details of other intervention strategies
carried out. Impact evaluation/Indicators focussed on: comparative analysis of
behaviour changes pre and post intervention and control vs. intervention.
In order to determine which children were exposed to what lessons, Project Registers
were used (Annex X). A CC, assigned to each country, also gave monthly updates on the
progress with the lessons and the challenges faced. These reports also gave status reports
on the other three components of the project so the timely adjustments could be made to
ensure the lifestyle intervention was implemented as scheduled. These monthly updates
were prepared based on a CFNI template particularly for that purpose so that the desired
feedback would be obtained from all the countries. The CC was in constant contact with
the CFNI project team.
Data were collected on all students except for the Food Record-Assisted 24 Hour Recalls
(Annex XIVk) where a sample was used from each school (both Control and
Intervention). These data collected (Annex XIVj contains the Manual used for this data
collection) included:
1. Fitness levels (Aerobic Capacity, Muscular Strength; Muscular Endurance; and
Flexibility).
2. Anthropometric measurements- weight and height (BMI calculated) and Blood
Pressure.
3. Knowledge, attitude and behaviour related to diet and physical activity using
survey questionnaires and topic guides for the qualitative data: Focus Group
Discussions and Key Informant Interviews (For Process evaluation and Year 3
only: not done at baseline or Year 1).
18
4. Food intakes using single food-record assisted 24-hour recalls at baseline and
follow-up.
These non-invasive measurements were taken at the beginning of Grade 7/Form 1 and
again at the end of Grade 9/Form 3. A second questionnaire was administered in Grade
8/Form 2 to gather information on the behaviours that were not introduced in
Grade7/Form1. The collection of dietary intake data by means of 24 hour Recalls was
proposed as part of the monitoring and evaluation of this project. These were done in
Grade 8/Form 2 (Year 2) and Grade 9/Form 3 (Year 3) only. In Year 2 of the Lifestyle
Intervention with the students, a sub sample of 849 students from both Intervention and
Control Groups were selected for administration of the dietary recall. It was planned that
these same students would again be interviewed in Year 3 and comparisons made in their
intake patterns. However, in Year 3 only 497 Students were found that were common to
both years and it was those students who were used in comparing intakes between Years
2 and 3.
The purpose of the twenty-four-hour recall method is to provide information on the
respondent‟s exact food intake during the preceding day. The objectives of the 24-hour
dietary recall are:
1. To collect information on the respondent‟s total food consumption over the
preceding day
2. To use the information to determine the mean consumption of population groups
In this case the Recalls were used to determine if there were differences in the mean
consumption of nutrients between the intervention and control students in Years 2 and 3
of the project. Two tools were used in collecting data on the participants‟ eating habits:
Food Record Form (Annex XIVc) and a 24-Hour Food Recall Form (Annex XIVd). All
of the children selected were asked to complete the self-reported food record form two
days before the 24-hour recall was conducted. The completed self-reported food record
form was used as a prompt during the assisted 24-hour recall to ensure that the
information collected was thorough and as accurate as possible. The purpose of the 24-
19
hour recall method was to provide thorough information on a respondent‟s food intake in
terms of portions during the preceding day. Trained data collectors (Training Manual
attached as Annex XIVk) guided participants through the questionnaire going through a
3-stage process by reading each question aloud, and then giving them time to provide a
response. Portion sizes were estimated with units familiar to the respondent such as
tablespoons, teaspoons, bowls, cups, or by standard foods units such as one slice of
bread, one medium apple, or one medium potato. For foods that did not have standard
measuring units and were difficult to estimate with cups or bowls, the serving size was
estimated by using the food models provided. These food models were developed
specifically for each country. The 3-stage process used by the interviewers to collect the
information for the 24-hour recall were as follows:
Stage 1: Recall of Foods and Beverages Consumed
At this first stage, the respondent was asked to recall his/her exact food/drink intake
during the previous day. For example, if the interviewer visited the person being
interviewed on Friday, the information should cover food and beverage intake from
Thursday beginning at 12:01 a.m. until Thursday night at 12:00 p.m. (midnight). the
recall included all the foods and drinks taken during the time the respondent was awake.
Each food was recorded on a separate line. To get a clear description of foods/drinks
consumed, data collectors were asked to probe for details including types, brand names,
cooking methods, additions, time and place consumed.
Stage 2: Estimation of Amounts
In the second stage, the amounts were determined by working back from the first food,
down to the last food recorded on the list. The utensils and models were used to help the
respondent estimate amounts consumed. Interviewers were to ensure that they got how
much the respondent actually ate, not how much they were served.
Stage 3: Review of Interview Data
At the end of the interview, the interviewer was expected to review the recall form to
ensure that complete information had been recorded for each item (type, amounts, brand,
20
etc.). Finally, they had to use the check list to ensure that no foods or drinks were
overlooked during the recall.
Data Entry and Analysis
Statistical analysis was performed using SPSS. Frequency distributions, medians, means
and standard deviations were used to describe the data. Cross-tabulations and chi-squared
tests were performed to evaluate the strength of association between categorical
variables. For continuous variables (such as BMI and dietary intake data), t-tests and one-
way analyses of variance were used to determine differences in consumption at follow-up
due to site, sex and also condition by site and condition by sex, among other variables. In
all cases, p < 0.05 was used as the cut-off for statistical significance.
For the 24 Hour Recalls, the data were analyzed using the CERES software. The
Physical Fitness levels were determined using the Prudential FITNESSGRAM Reference
Standards for the four Health Fitness Components: Aerobic Capacity, Muscular Strength;
Muscular Endurance; and Flexibility.
Comprehensive process evaluation procedures were included and these evaluation
activities were integral to programme implementation. Ongoing process evaluation were
carried out to monitor the planning and implementation process at the school level,
including innovations/adaptations and potential confounding influences. The process
evaluation sought to determine how well the intervention was implemented both in terms
of fidelity to suggested procedures as well as the adequacy of the children‟s exposure to
the programme‟s curricular inputs, in view of the integrated approach that was used in the
classroom teaching.
2.3 Project Monitoring and Evaluation
Several tools were used to monitor the project. A list of the tools used are detailed below.
21
Table 2: List of Monitoring and Evaluation Tools used in the Project
FORM DESCRIPTION
Teacher Self-Evaluation Form Completed by teachers after every lesson
Project Lesson Register Completed by teachers at each lesson.
Country Coordinator Monthly
Report
Used by country coordinator to describe progress of
all activities in the country
Country Coordinator Monthly
Chart
Planning tool for Country Coordinators. Completed
Monthly.
Food Availability Checklist Used by observer to evaluate whether foods are
available at school to support desired behaviours.
Completed on agreed schedule.
Physical Activity Checklist Used by observer to evaluate physical activity
facilities, equipment and schedule in schools.
Completed on agreed schedule.
Foodservice Operations Checklist Used by observer to evaluate standard of foodservice
at school. Completed on agreed schedule.
Physical Activity School Profile Used to evaluate physical activity facilities,
equipment and schedule in schools. Completed on
agreed schedule.
Students‟ Sources of Foods Administered to key informants (principal/teacher)
to evaluate food availability and food service at
school
Evaluation of the project was carried out by the administration of knowledge, attitude and
practice (KAP) questionnaires to students each year, and by monitoring fitness, blood
pressure, dietary intake and anthropometric status on a planned schedule. A selection of
students‟ portfolios with completed worksheets were retrieved periodically and reviewed.
Focus group discussions with teachers were also used to get feedback to use in planning.
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2.4 Constraints/Challenges to Methodology
All the components of the project called for commitment by teachers, students,
parents, principals and the Ministries and NGOs in order to achieve the project
objectives. The Behavioural Curriculum was a critical component of the project and
most of the constraints/challenges were associated with it. These included:
Commitment of teachers and lack of ownership of projects
Lack of motivational incentives. Teachers not motivated
Scheduled timing for training of teachers. Time for training – difficult to get
teachers to train during the vacation and during the school term: Some
countries have set policies for training during the term (no training) while in
others the teachers refuse to turn out even if the Principals insist (lack of
respect for principals)
Paucity of trained and motivated teachers in Physical Education
Inappropriate and inadequate teaching material (Remedial Children?)
Lifestyle projects involve complex social, economic and family issues -
schools alone cannot sustain
No National policies holding schools accountable for providing students with
behavioural skills,
knowledge and attitudes necessary for positive health lifestyles
Trade Unions play a key role in school activities
Teachers accustomed to vertical as opposed to integrated programmes -
intervention programmes seem like extra work unrelated to their school
curricula. Teachers not willing to teach “outside the box”
Rate of teacher turnover/staff changes
Disruptions due to natural disasters, Trade Union disputes, elections/change in
administration/alteration of political climate, teacher continuing education
Frequent changes in national administration pose constant threat to
sustainability
Remedial children and data collection and classroom teaching
Teachers negative approach to teaching remedial children
23
Targeted population – sometimes have drastic changes which can affect the
data analysis.
Financial: After the Needs Assessment the project phases were adjusted to include
the development of more materials and training of teachers. Even though the key
stakeholders in all the participating countries agreed to the project and confirmed
their commitment, data collection was marred with data collectors demanding
payment for their efforts. This increased costs and during the final data collection,
after meetings with the stakeholders, data collectors (e.g. Sports Specialists and
Nurses) were offered gratis. Although venues were budgeted, it was difficult to find a
suitable venue at reasonable cost. To borrow or loan multi-media to conduct
workshops were embarrassing and inconvenient. Photographs could not be taken at
times since persons had to use their personal cameras. Transportation costs to and
from schools were high in some countries. Even though the Ministries of Education
facilitated the clearing of packages from the Customs Departments, CCs sometimes
experienced difficulties and delays which greatly affected scheduled teaching times
and targets.
Teacher Training: It was difficult to get teachers to attend training . Some of those
who attended were transferred from the intervention schools after training. Even the
trained teachers were not prepared to deliver the lessons as planned. The lack of
interest, poor work ethics and negative attitude after training, were major blunders of
success of the objectives of this project.
Reading Levels: A large percentage of students than expected were unable to read
and comprehend materials used in the project and thus became frustrated and
displayed disruptive behaviours. They were "remedial" and as such lessons that were
developed and pre-tested for 40 minutes took 80 minutes and more in some instances.
The problem was further exacerbated by the fact that many teachers lacked classroom
management skills. Training in this area had to be included during the first Refresher
Training in 2009 (during Grade 7/Form 1 -Year 1). .
24
2.5 Preparatory Activities (Phase 1 and Phase 2)
2.5.1 Sensitization
Sensitization meetings were held before the project was implemented and once per year
thereafter with key stakeholders and Ministry personnel in all four project countries.
Presentations were done for the different categories of stakeholders:
Ministry Personnel (Health, Education and Sport); and
Principals and Teachers; in order to:
discuss the implementation Strategy;
discuss the schools selected and the criteria used;
discuss the roles and responsibilities of the stakeholders;
discuss the benefits to the country; and
discuss the status of syllabuses.
Based on those meetings there was widespread enthusiasm for the project all but two of
the seventeen schools wanted to be Intervention Schools. The teachers of the schools that
opted to be Control Schools were all enthusiastic but the principals were realistic and
objective and felt that with their current activities they would not be able to do justice to
the project. There was also widespread support and commitment from the key Ministries
(Health, Education and Sport). Official approval to implement the project was obtained;
confirmation on the schools selected; approval given to meet with school personnel; and
the syllabuses were made available.
After the Needs Assessment (see details below) several sensitization meetings were held
again with:
Ministry Personnel (Health, Education and Sport).
Health Personnel, Principals and Teachers.
Teachers – Control Schools.
Parents, Canteen Staff and Principals.
The meetings were held to:
25
give an overview of the project;
present key findings of the Needs Assessment Survey;
discuss the Implementation Strategy;
discuss the roles and responsibilities of the stakeholders; and
discuss the project logistics and timeline .
The additional sensitization meetings were held based on the results of the process
evaluation and the concerns of the key implementers. It was also used to get
confirmation on the sustainability of the project after the donors were gone. It was
stressed that the Ministry of Education had to be the lead player and that staff should be
so assigned as to allow for continuity. The presentations at each sensitization sessions
are documented in Annex XIX.
2.5.2 Needs Assessment
PHASE 1 of the project looked at “Problem Assessment and Awareness Raising”. To
ensure that the target population was adequately supported, a Needs Assessment was
conducted specifically to:
determine knowledge of nutrition in relation to selected core concepts;
ascertain current practices in teaching nutrition concepts;
determine attitudes towards the infusion of nutrition concepts in their
particular subject area;
determine current practices in teaching Physical Education; and to
identify factors which may facilitate or hinder the incorporation of nutrition
and physical activity concepts in subject curriculum.
Data were collected from the seventeen selected secondary schools in the four countries:
St. Kitts and Nevis; St. Vincent and the Grenadines; Grenada; and Trinidad and Tobago
using:
1. Focus group discussions – Students (Grade 7/Form 1 boys and girls); Teachers of
Forms 1-3/Grades 7-9. The boys' sessions were separate from that of the girls'.
26
2. Key Informant Interviews with Principals, Physical Education Teachers and
Curriculum Officers.
3. Self-administered Questionnaires for teachers and students. The questionnaires
focussed on knowledge, attitudes and practice.
Copies of the Needs Assessment evaluation tools are attached a s Annex XIII. The
survey population is shown in Table 3 below.
Table 3: Distribution of Student Sample Population by Country
Survey questionnaires used were divided into three main sections: Demographics;
Nutrition Knowledge, Skills and Behaviour; and Physical Activity Knowledge, Skills and
Behaviour. Focus Group discussions and Key Informant Interviews were conducted to
support the quantitative findings. These discussions and interviews were all conducted
over a period of 2 months during September and October, 2007. The main objectives of
the student focus group discussions related to physical activity were to:
1. Examine overall perceptions of nutrition and physical activity
2. Identify students‟ preferences for certain types of food physical activity and
factors that facilitate involvement in these activities.
3. Identify factors influencing eating habits and involvement in physical activity
both at school and away from school (perceived social, cultural, and
environmental factors),
Country # Schools N
Grenada 4 593
Nevis 2 296
St Kitts 3 428
St Vincent and the Grenadines 4 600
Tobago 2 301
Trinidad 2 425
Total:
17 2643
27
Key Informant Interviews were conducted with Physical Education (PE) teachers and
Principals. The main objectives of the interviews were to:
1. Determine perceptions of students‟ attitudes towards healthy eating and physical
activity.
2. Determine teachers‟ perceptions of barriers to students selecting healthy foods
and participating in physical activity.
3. Determine current practices and attitudes in teaching/promoting healthy eating
and physical activity in general.
4. Determine facilities and resources in school which hinder/facilitate students‟
selection of healthy foods and involvement in physical activity.
A full report of the qualitative data is attached as Annex XVIIa. The findings are based
on both the quantitative and qualitative data and are listed below under:
1. Students‟ Dietary Practices (Daily Consumption and School Purchases
2. Students‟ Sources of Information and Meals (Lunch)
3. Students‟ Physical Activity Practices
4. Students‟ Knowledge versus Practice/Attitude
5. Nutrition Topics Taught
6. Health and Nutrition Programmes (Reported by Teachers).
STUDENTS DIETARY PRACTICES
Based on discussions with the students, they knew about the Caribbean Six Food Groups
and what a balanced diet entailed. They were quite aware of what is "healthy eating" and
why it was important to do so. Some benefits they cited include: "To keep the body fit; to
give long lasting energy; and to help the body to function properly". However, there was
an imbalance in foods eaten from the food group. There was a concern about the amount
of the sugar and sodium content of foods purchased at school. Snack foods and soft
drinks were consumed on a daily basis more frequently than milk, fruits, vegetables, or
peas/beans/nuts (Table 4).
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Table 4: Daily Food Consumption and Food Purchases by Students
Students admitted to consuming a lot of "junk foods" but they had varied understanding
and in some cases misconceptions of the term. This was revealed when they listed what
foods they considered junk and the reasons for naming them such. The most common
food purchased at school was soda/soft drinks and the least purchased: fruits. The impact
of food availability at school on overall consumption is unclear. Grenada had the highest
proportion of fruit consumption on a daily basis, yet the lowest proportion of students
buying fruit at school. Students seem to be obtaining their fruits from other sources so it
was clear that the intervention had to extend beyond the school environment.
STUDENTS SOURCES OF INFORMATION AND MEALS
Both the qualitative and quantitative data revealed that the Home was an important
environment in diet and activity behaviour since most students got lunch from home.
Parent seemed to be the primary source of nutrition information to students so it was
Daily Consumption
Food Category %
Food From Animals 75.0
Milk Products 43.7
Staple Foods 72.1
Vegetables 28.6
Peas/beans/Nuts 11.3
Fruits 27.0
Snack Foods 49.1
Soda/Soft Drinks 26.3
School Purchases
Type of Food %
Soda/Soft Drinks 41.0
Fruit Juice 32.9
Fruits 5.4
Fried Chicken 22.6
Pastry/Sweets 26.3
Cooked lunch 23.8
Other Foods 32.7
29
clear that they had to be targeted as well. The discussions on meals did not bring out
where they got lunch but they did indicate that they were not able to eat healthily at
school due to a variety of reasons including peer pressure; availability; cost and taste.
Most felt that they ate healthier meals at home. From the quantitative data collected,
67.3% seemed to be having lunch at home (Table 5).
Table 5: Sources of Students’ Information and Lunch
Discussions with the Curriculum Officers for Food and Nutrition and Physical Education
brought out the fact that any subject including food and nutrition were not offered to all
levels at the schools and PE, if offered was only one day per week for a maximum of 80
minutes and the focus was on sports.
STUDENTS PHYSICAL ACTIVITY PRACTICES
In an ideal world you will want 100% physical activity. In these school children, only
15% are participating in the PE Classes Except for chores, most students were not
involved in regular physical activity (Table 6).
Sources of Lunch
Source %
Home 67.3
School Canteen 2.9
Tuck Shop 23.1
Vendor 1.2
Other 5.5
Sources of information
Source %
Parents 86.8
School 79.1
Books 62.9
Friends 32.2
Internet 25.6
Magazines 16.4
Other 12.3
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Table 6: Students’ Physical Activity and Practices
STUDENTS KNOWLEDGE VS PRACTICE/ATTITUDE
There was some level of disparity between what students knew and what they did. Many
students could report on what was good or bad but that knowledge did not translate to
them enjoying doing what was good for them. A large portion of the students knew that
eating high fibre foods was good for them, but yet a much lower proportion enjoyed it
(Table 7).
Physical Activity % All countries
Chores 66.6 57.0
Walking 52.1 41.7
Dancing 33.8 31.3
Stretching/Strengthening 22.0 20.6
Physical Education Class 15.1 19.9
Cycling 10.1 13.9
Swimming 5.2 8.4
Sedentary Activities
TV/Video Games 52.1 53.6
Sitting/Reading 38.4 31.6
31
Table 7: Students’ Knowledge versus Practice
Variable %
Good Enjoy
More High Fibre 96.4 63.3
Fruits and vegetables Daily 99.3
Breakfast Daily 98.3 87.1
Fast food often 12.2 69.1
High Fat Snacks Often 10.9 70.5
Exercise Daily 98.3 73.0
Participating in PE 96.6 83.7
Taste has a major impact on enjoyment levels of food. It is therefore important to teach
about how food makes you feel physically, and link it into sports nutrition, because sport
are is so popular among the youth. Even students who said they did not enjoy daily
exercise knew that it is good for them. Students seemed to understand the benefits of
daily physical activity but simply did not enjoy it. Something beyond education may
need to be done to improve the enjoyment levels of physical activity. Just over 50% of
students reported that eating a variety of foods at home was up to them. Less than 25%
of students were unsure or disagreed with the statement that “eating fruits and
vegetables will protect them from chronic diseases”: most of whom were unsure.
Students believed that they were strong enough to withstand peer pressure.
A target sample size of approximately 20 teachers from Grades 7-9 (Forms 1-3) at each
school was used for the teacher survey. The teacher questionnaire (self-administered)
included six sections: Personal Profile; Teaching of Nutrition in Schools; Nutrition and
Health Knowledge, Perceptions and Behaviour; Physical Activity Knowledge,
Perceptions and Behaviour; Teaching Approaches/Techniques; and Teachers‟
Perceptions of Students‟ Nutrition and Activity.
32
Teachers were grouped into either Group A or Group B based on whether or not they
taught a subject directly related to health, nutrition, or physical activity then basic
percentages were computed. Group A consisted of teachers who reported teaching
Integrated Science, Home Economics, Physical Education, and Health and Family Life
Education. Any teacher not teaching one of those subjects was assigned to Group B. In
total, Group A consisted of 68 teachers, and Group B, 189 (Table 8).
Table 8: Group Distribution of Teachers by Country
Group A Group B
Country N % N %
Grenada 15 22.1 39 20.6
St. Vincent and the Grenadines 22 32.4 47 24.9
Trinidad and Tobago 17 25.0 59 31.2
St Kitts 7 10.3 29 15.3
Nevis 7 10.3 15 7.9
Total 68 100.0 189 100.0
The findings are listed below under:
1. Nutrition Topics taught
2. Health and Nutrition Programmes
NUTRITION TOPICS TAUGHT
Several nutrition topics are taught but for the majority of subject teachers report that most
students were not exposed to the information (Table 9). Many students were unsure if
they would like to eat vegetables every day because they (vegetables) are good for them.
The findings raised questions as to why students are unsure about eating vegetables. This
added another behavior to the intervention.
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Table 9: Nutrition Topics Taught
Topics Taught GRE % All countries
Nutrients 63.2 50.0
Caribbean Food Group 60.7 41.4
Benefits of Fruits and Vegetables 54.5 36.8
Dangers of Fats and Sugars 46.5 28.8
Benefits of Breakfast 45.9 28.6
What is healthy eating 40.8 28.0
Preventing Overweight 30.9 21.8
Other 8.0 7.6
HEALTH AND NUTRITION PROGRAMME (REPORTED BY TEACHERS)
What is being done for health and nutrition in schools – not as much as we would like.
Teachers also have disparity between their perception and their actions (Table 10).
Table 10: Health and Nutrition Programmes and Teachers in Health Promotion
Health and Nutrition Programme
Programme % Total
None 9.3 10.5
School Lunch 46.3 42.4
Involving Community
and parents
7.4 1.6
Physical activity for all 16.7 30.4
Physical activity for
some
46.3 28.8
Teachers in Health and Nutrition
Promotion
What is done Think Do
Role model 15.9 53.3
Educate/Teach
nutrition
46.8 46.7
Promote healthy
lifestyle/Adviser
31.8 50.0
Provide/disseminate
information
5.5
34
Teachers thought that they could not be role models or that they disseminated
information to the students. Due to the fact that teachers are not expected to be away
from their classes for long periods, the Needs Assessment also tried to get an ideal of
when was the best time for training. Most teachers agreed to the summer vacation but
within the first two weeks of July and the last week in August. The teachers indicated
that the Lesson plans should be prepared to suit the educational and learning
characteristics of the students, so that they are more able to recall specific topics and
apply them to their behaviour. Beyond providing information, teachers must play a role
in motivating and encouraging students. Teachers made suggestion on factors for the
successful implementation of the schools. Training, ownership and available resources
emerged as the most important factors. This together with parents as a primary source of
information and the trend in many students reporting on what is good or bad but that
knowledge not translating into them enjoying doing what is good for them (for e.g. high
sugar and sodium consumption), emphasized the need to take a holistic approach to
address the current nutrition situation at the schools.
2.5.3 Curriculum Development Workshop
Based on the findings of the Needs Assessment, the seven behaviours studied were
selected (See Methodology) as well as topics/concepts. These formed the framework for
the Regional Curriculum Review Workshop which followed to:
agree on which subjects the broad nutrition and physical activity concepts could
be infused;
fit/incorporate all the concepts into the different subject areas to facilitate target
behaviours.
At the end of the workshop a matrix of the subjects into which the nutrition and physical
activity concepts could be infused by target behaviours was developed; and differences in
curricula for the four countries were identified.
The workshop was also used to get suggestions for materials that would facilitate the
application of infusion of nutrition and physical activity concepts. These included the use
of media technology, food charts, thematic events, the provision of adequate facilities,
35
and giving in-depth explanations to teachers so that they could convey the information
with accuracy. For teacher training sessions the following were suggested:
further reading on methods for infusion;
engendering confidence among teachers to carry out the process;
providing systematic, deliberate, and synchronized information across the region.
core teachers who had a genuine interest should be targeted;
The need for sufficient monitoring and feedback to guide evaluation and follow-up was
mentioned. With respect to the implications of project strategies and the role of teachers,
it was suggested that the appropriate literacy competitions among schools should be
encouraged; and an effort made to influence behaviour towards Physical Education and
other physical activities; and the inclusion of early training, monitoring, and follow-up.
Participants believed that it was important that parents were made to see the benefits of
the project for themselves. Other suggestions for parents with respect to project strategies
included, conducting several workshops and home visits if possible, having direct
involvement by the parents, food exhibitions, advertisements, training and practical
cooking classes. A full report is attached as Annex XVIIb. These suggestions were
considered during Phase II of the project which focused on “Development of Programme
Materials and Training of Project Teachers”.
2.5.4 Orientation of Country Co-ordinators
An Orientation manual (Annex XXIII) was prepared for the Country Co-ordinators and
an Orientation session given via the UWIDEC (University of the West Indies Distance
Education Centre) prior to the start of the Lifestyle Intervention Implementation with the
students. A second was done prior to Year 2 as well.
2.5.5 Development of Materials
Based on the Needs Assessment findings and the input for the Curriculum Development
Workshop, the identified behaviours and concepts were used to formulate the lifestyle
36
intervention. A Project Procedures Manual was developed along with Teacher Training
Manuals for each Grade (Annex XVIIIa,b,c) over the three year period. The Lesson
Plans developed within the manuals were based on the core concepts and sub-concepts
for the seven behaviours and contained: Worksheets; Posters; Flyers and other teaching
aids. Other materials developed included:
Instruments to assess food and physical activity facilities (Annex XIV e-i)
Data Collectors Manual for Anthropometric Measurements, Blood Pressures and
Fitness Assessments (Annex IV j)
Manual for Training in 24 Hour Recalls (Annex XIV k)
Booklets on Physical Activity (Annex XVIII d)
Manual for Infusion (Annex XVIII e)
Resource Manual for Healthy Lifestyle Projects in Schools (Annex XVIII f)
Newsletters (Annex XVIII g)
Project Brochure (Annex XIV h)
All the monitoring and evaluation tools (Table 2) were developed for the Lifestyle
Intervention. Monitoring and evaluation tools for the Process Evaluation were developed
during Year 1 of the intervention. All of the project materials developed for the three
years of the Lifestyle Intervention, including the manuals, were distributed to all of the
control schools of the WDF Project Countries. A comprehensive list of the materials
distributed are shown in Annex XXIV.
Process and resources
Specialists in the area of Nutrition and Dietetics; Curriculum Development; Sport and
Summer Secondary School Teachers were used in the development of materials. All
materials used for teacher training and for monitoring and evaluation were pre-tested
before finalization for use in the implementation.
37
2.5.6 Training of Teachers
Before the start of each school year, teachers of students in the Grades/Forms targeted
that year were trained by CFNI Technical Officers in a one week workshop. Training was
done in each project country. Refresher training workshops were also conducted during
the second term (January to April) of each school year except for Year 3 (Grade 9/Form
3) when final data collection was done.
The objectives of the training were to:
1. orient the teachers to the project.
2. delineate the role of the teachers in the lifestyle intervention in project schools.
3. Equip the teachers to effectively deliver the behavioural curriculum of the lifestyle
intervention i.e. Component 1.
4. foster ownership of the intervention among teachers of the study group (cohort) in
project schools.
5. engage the teachers, the school community and ministry personnel in
maximizing/expanding their roles to include the primary prevention of chronic
diseases to their primary target audience (starting from the early/youthful years).
All teachers from the appropriate Grade/Form were invited to attend the workshop with
specific instructions that the Physical Education teachers for that Form should attend. It
was helpful to suggest that some key subject teachers be present: Science; Integrated
Science; Agricultural Science; Language Arts; Social Studies; Mathematics; Food and
Nutrition; and Home Economics to name a few (Table 6). The Principals confirmed
attendance.
38
Figure 6: Teacher Training Session Trinidad and Tobago
Tobago (Implementation/Summer) Trinidad (Refresher)
Before project lessons were assigned, an initial listing which paired teachers with lessons
were done by the implementers with a view to matching subject matter with lesson
content. If the subject teacher was absent, then other subject teachers were used. In
essence, any well-trained teacher could teach any project lesson.
All the teachers were asked to prepare infused lessons since it involved the teaching of
the subject area in an infused form. The teachers decided which Unit Topic (and lesson
for that topic) they would be infusing and were guided through a systematic process. The
infused lesson was expected to be taught as timetabled.
The content of the training included:
1. Overview of the project.
The Behavioural Curriculum: Motivating Students; Teaching and Delivery;
Classroom Management; The Infusion Process.
2. Review of project („straight‟) lessons, which were prepared beforehand and
distributed.
3. Development of infused lessons by participating teachers.
4. Presentation of lessons by teachers (micro teaching, summaries and full lessons).
39
5. Review and discussion of other aspects of the curriculum, including the personal
reflection, take home assignments and portfolios.
6. Discussion of other components of the project:
Component 2 – Building Supportive Environments at School;
Component 3 – School-wide Promotional activities;
Component 4 – Building Supportive Environments at Home and Community.
Both the summer/implementation teacher training workshops and the Refresher Teacher
Training Workshops were evaluated (Evaluation forms attached as Annex XXI and
XXII). At the end of each school year teachers were presented with Certificates of
Participation and the Liaison teacher received an additional Certificate of Appreciation.
2.5.7 Identification of key project implementation co-ordinators
These persons who assisted with project implementation were selected by the relevant
Ministries and principals of the participating Project Schools. For specific roles of the
co-ordinating team see Annex IX.
2.6 Lifestyle Intervention (Implementation with students)
All the students from Grade 7/Form 1 of the Intervention Schools were selected to
participate. The cohort of students was then followed for three years. The seven
behaviours and the four components were integrated to form the complete intervention.
2.6.1 Collection of baseline data (including Food Record-Assisted 24 Hour Recalls
and KAP Year 2)
Baseline data (See section 2.2) were collected from all students at the beginning of the
first school year. Both qualitative and quantitative data were collected. All the Data
Collectors were trained using prepared Training Manuals for the Anthropometric
Measurements and Fitness Assessments as well as the Food Record-Assisted 24 Hour
Recalls (Baseline Evaluation Forms shown in Annex XIV). A self-administered
questionnaire was administered to each student based on three of the seven targeted
40
behaviours: eating a variety of foods daily; eating breakfast daily; and doing a variety of
physical activity daily to determine knowledge, attitudes and practices. Measurements of
weight, height and blood pressures were done and Body Mass Index (BMI) determined.
Fitness levels were recorded as they relate to the Health Fitness Components: Aerobic
Capacity, Muscular Strength, Muscular Endurance and Flexibility. The 24 Hour Recalls
were intended to be conducted in Year I and Year 3 but was done in Year 2 and Year 3.
A second self-administered questionnaire was administered in year 2 to cover the
additional targeted behaviours that were not done in Year 1. These findings were used to
compare with the findings in Year 3 (see Section 3.0).
Observations of the supportive school environment were done using pre-tested
checklists. These included:
Physical Activity Checklist;
Food Availability Checklist;
Food Service Operations Checklist;
Physical Activity School Profile;
Students Sources of Food.
Evaluation forms are in Annex XIV.
2.6.2 Implementation of the Four Components
Classroom teaching (Component #1) commenced immediately after the baseline data
collection followed by the activities of the other three components. The trained teachers
delivered the assigned lessons as scheduled (Annex III, IV, V) each year. The lessons
were assigned for each year after each Implementation/Summer Teacher Training
Workshop and adjusted, if necessary, after the Refresher Training Workshops. Teachers
completed self-evaluation forms (Annex VII) for each lesson taught and to document
student attendance on Project Lesson Register Forms (Annex X). The Country Co-
ordinator was expected to observe at least one lesson delivery for a Grade/Form (each
Grade/Form had between 3-5 classes) and document observations in the Country Co-
41
ordinator Observation Form (Annex VIII). The teaching in the classroom embraced three
key teaching and learning approaches:
1. Constructivist Approach
2. Cooperative Learning
3. Multiple Intelligences Approach
Table 7 below captures a teacher using one such approach.
Figure 7: Co-operative Learning Groups, Trinidad
Students were asked to keep portfolios and binders and standardized forms and
instructions given. These portfolios were done as a means of students documenting their
thoughts, goals, challenges and achievements towards the targeted behaviours. Teachers
were also given portfolio documents with all the materials that were expected to be in the
portfolios for each Grade/Form. This helped when periodic checks were made.
42
Components #2, 3, and 4 were implemented as stipulated in section 2.1.3 using the
“Resource Manual for Healthy Lifestyle Project in Schools” as a guide to school, home
and community activities. Suggestions were also made for school policy development
and the involvement of canteen staff, vendors and parents in training activities. Some of
these activities were supported financially and otherwise and students rewarded
periodically. Visual (Annex XX) and electronic documentation of some of the activities
were done. All activities in all four components were continued for the three years of the
project with the same cohort of children as they advanced from Grade 7/Form 1 to Grade
9/Form 3.
2.6.3 Process Evaluation
After the first year was completed it was necessary to conduct a process evaluation. This
was done in 2009 in all eight schools in the four countries. In this evaluation the focus
was on: teachers, students, parents, the school team, the country team, Ministry
personnel, and the Country Co-ordinator. The objectives varied according to the group.
With the students the researchers wanted to get an idea of their current eating and
physical activity behaviours after one year of intervention; the kind of supportive
environments they had as well as their knowledge of the new information received. For
the teachers, there was a need to find out if they had a clear understanding of the project;
whether they had received adequate information; their thoughts about the
implementation; some key issues and challenges; and if they benefitted in any way from
the project.
For the parents the team needed to find out how involved they were with the project and
their basic understanding of what was happening with their children; their views on
healthy eating and physical activity. Survey instruments were used with the other
categories of stakeholders and implementers to determine mainly the progress to date as
well as any major challenges. It was also necessary to learn how the support was being
given to the students and teachers for the successful implementation. The full report is
attached as Annex XVIIc.
43
2.6.4 Final Data Collection
At the end of year 3 with the students, a comprehensive assessment was done as
stipulated in section 2.2 (Annex XVI- Evaluation Forms). For the final data collection
the following were done:
(a) Physical Fitness Assessments: Aerobic Capacity, Muscular Strength, Muscular
Endurance and Flexibility on all students 9Figure 8).
Figure 8: Physical Fitness Assessments, Grenada
PUSH-UPS (STRENGTH) SIT-UPS (ENDURANCE)
TRUNK LIFT (FLEXIBILITY) JUMPING JACKS (AEROBIC CAPACITY)
(b) Weight, height (BMI determined from these measurements) on all students
(Figure 9).
44
Figure 9: Weight, Height and Blood Pressure Measurements, Grenada
WEIGHT AND HEIGHT BLOOD PRESSURE
(c) Knowledge, attitudes and behaviour related to diet and physical activity using a
survey instrument as well as qualitative measures for all students. The qualitative
data were collected using Focus Group Discussions (one group of boys and one of
girls in all schools for each school except for Anglican High School in Grenada
which is an all-girls school); and Key Informant Interviews.
Figure 10: Focus Group Discussions, Grenada and Tobago
TEACHERS (Grenada) STUDENTS (Tobago)
(d) Food intakes using single food-record assisted 24-hour recalls were done on a
selected number of students (see section for 2.2 for details).
45
Figure 11: 24 Hour Recalls, Grenada and Trinidad
GRENADA TRINIDAD
46
RESULTS
47
3.0 RESULTS
3.1 Demographics and Profiles
Students
The lifestyle intervention project with the school children started in 2008 (Year 1) with 1,
916 students. Of the 1,916 persons surveyed 44% were males and 56% females with a
mean age of 12 years. For the purpose of analysis, age was grouped into three categories;
11 years and under, 12years old and 13 year and over. From this grouping, results showed
29% of students were 11 years and under, 47% were 12 years old and 24% in the group
13 years and over. There were 244 more females than males in the study (Table 11). The
sample distribution by country showed that Grenada and St. Kitts accounted for almost
half of the sample at 49%; followed by St. Vincent and the Grenadines at 22.5%; Nevis
and Trinidad with 11%; each and Tobago 6.3%.
Table 11: Demography Characteristics, Year1 Students
n %
Gender
Male 836 43.6
Female 1080 56.4
Age
11years and under 550 28.9
12years 897 47.1
13years and over 458 24.0
Country
Grenada 476 24.8
St. Kitts 470 24.5
Nevis 204 10.6
St. Vincent and the Grenadines 431 22.5
Trinidad 215 11.2
Tobago 120 6.3
48
The distribution by type of school showed that 58% of students attended Intervention
Schools and 42% were enrolled at the Control schools. Across both types of schools the
gender ratio was equivalent, that is, approximately 43% males to 56% females. When
making the comparison by age as seen in Figure 12, the majority of students 45% and
48% from Intervention and Control schools respectively were 12 years of age.
Figure 12: Age Distribution by Type of School
A further breakdown of gender by country, showed that apart from Grenada and Nevis
where 75% and 60% of respondents respectively were females, the distribution was
proportionate (or almost) 50:50 within the other countries. On the other hand, the age
distribution by country (Figure 13) indicated that 60% of students from Trinidad and
Tobago were 13 years and over, while there was as many as 41% of students from
Grenada who were 11 years and under (bearing in mind these were all Grade 7/Form 1
students).
Figure 13: Age Distribution by Country
0
20
40
60
80
100
<=11yrs 12yrs >=13yrs
InterventionControl
0
20
40
60
80
100
Grenada St. Kitts Nevis SVG Trinidad Tobago
<=11y
12y
>=13y
49
A total of 1,727 students participated in the second year of the intervention. The class
registers were used to track collection/response rates across all countries. The gender
distribution of the cohort was 43% males and 57% females. This distribution remained
unchanged when disaggregated by intervention and control schools. Results by country
showed that 37% of students were from St. Kitts and Nevis, 26.5% from St. Vincent and
the Grenadines, 23.5% from Grenada and 13% from Trinidad and Tobago. There were
generally more students attending (based on questionnaire completion) control than
intervention schools (60% and 40% respectively) within all counties but more so from St.
Vincent than any other country Figure 14.
Figure 14: Students attending Intervention and Control Schools by Country
Class registers show movement of students between Grades/Forms. It was determined
that there were missing data from a majority of students in Trinidad and Tobago. The
movement of 52 students attending RSS (Tobago) were tracked from Form 1 to Form 2,
with an additional 4 new students. However, yet we only 21 questionnaires were
received: a collection/response rate of only 37.5%. The results were similar for SFESS,
Trinidad with only 75 of 118 students (63.6%) completing questionnaires. In Year 3, a
total of 1,711 students consisting of 41% males and 59% females participated in the
survey. The representation by intervention and control groupings was 43% and 57%
respectively. The country representation was GRE (26%); SKN (38%); St. Vincent
0
10
20
30
40
50
60
70
80
Grenada St. Kitts & Nevis St. Vincent Trinidad & Tobago
Intervention Control
50
(23%); and Trinidad & Tobago (13%). Students‟ ages ranged from 12-18years with a
mean age of 15.
Teachers
Data were collected from teachers of the nine control schools and the eight intervention
schools in the project. In the control schools, the majority of teachers were females (73%)
and fell in the 20-39 year age group (65.5%). Forty-five percent (45%) of teachers who
reported they had a university degree or with (51%) being in the profession for ten or
more years. In the intervention schools, the majority of teachers (65%) were within the
age range 20-39 years and 29% were between 40-59 years old. There were no teachers
60 year or older. The gender ratio (male to female) was 38:62. Just under one-third of the
teachers indicated that their academic background was Teacher Training College and
28% had university or other degree. Further analysis of the teachers (13%) who indicated
they had secondary school education only, revealed that they were from Grenada (4), St.
Kitts (2), St. Vincent and the Grenadines (2) and Trinidad (1). Regarding the length of
time being a teacher, 42% of respondents have been teaching for 10 or more years; 20%
for 6-9years; and 19% 2-5years. However, in looking at the length of time teaching at the
respective schools, 1/3 of respondents indicated 2-5 years and 29% were teaching at their
named school for less than 2 years.
The Teachers and students in the Intervention schools were all aware of the project but
were involved in varying ways. A little less than one-third of teachers (32%) in the
control school surveyed were aware of the project in their schools. Most of the teachers
reportedly obtained information about the project from other teachers (64.5%) and
relayed that it impacted their teaching (31%). The impact the project had on their
teaching included; the ability to incorporate the benefits of eating fruits and vegetables
and the need to exercise regularly (healthy living) into the lessons (47%); and to educate
students about diabetes (13%). Thirteen percent (13%) of teachers reported that during
the past three years projects were implemented at their school which involved the
promotion of diet and physical activity. These projects included health and fitness
programmes (27%) with canteen operators being asked to serve nutritious meals (18%).
51
All teachers thought it was important for students to eat healthily and to be physically
active.
Parents
A total of 92 parents across the seven intervention schools provided responses (Table 12).
More than half of the parents (56.5%) were between the ages of 31-45 and over one third
(34.8%) between 46 and 60 years. Eight-eight percent (88%) of the parents who
participated were females and 83% reported their relationship as being the mother of a
child in the project.
Table 12: Participation of Parents by Intervention School
Schools N %
Washington Archibald High 8 8.7
Gingerland High 8 8.7
Petit Bordel Secondary 27 29.3
Thomas Saunders Secondary 14 15.2
Anglican High 15 16.3
San Fernando East Secondary 13 14.1
Roxborough Secondary 7 7.6
Total 92 100
Parents of students attending intervention schools were asked about their knowledge,
involvement, perception and support regarding the project. There were 90% of parents
who were aware of the project in their child‟s school: a little over half of them (51%)
knew about the project from the year it was initiated (2008) and a mere 6% only found
out in the final year (2011). Parents‟ source of information about the project included
their child (68%); PTA meetings (57.5%); a letter (20%); and a teacher (17.5%). The
majority of parents thought the purpose of the project was to improve the diet and
physical activity pattern among students (68%). It was also felt by parents that the project
would strengthen Health and Family Life Education (HFLE) programmes (48.8%);
52
promote Food and Nutrition in Caribbean schools (47.5%) and develop an effective diet
and activity intervention for students (45.5%)
Country Co-ordinators
There were 6 country co-ordinators at any one time in the project. There was constancy
Grenada, in St. Vincent and the Grenadines and in St. Kitts and Nevis. However there
were quite a few changes in Trinidad and Tobago. These persons were sourced mainly
from the Ministry of Education in countries to ensure sustainability and continuity after
the project was over. All the Co-ordinators had university or equivalent levels of
education and were in supervisory positions at their respective Ministry Departments.
One of the Co-ordinators was a retired Curriculum Officer in Home Economics at the
Ministry of Education so she was quite familiar with the educational system. The
breakdown of the CCs in respective countries were as follows:
GRE - Curriculum Officer Home Economics, Ministry of Education;
School Feeding Director, Ministry of Education
SVG - Retired Curriculum Officer, Home Economics, Ministry of
Education
St. Kitts- Senior Officer, Ministry of Education
Nevis - School Health Nurse for the both project schools, Ministry of
Health
Trinidad- Medical Student; Nutritionists (freelance); Curriculum Officer,
Food and Nutrition, Ministry of Education
Tobago Director, SFP, Department of Education; Director, School Health;
Former Teacher, Ministry of Education (now Evangelist); Retired
Chief Education Officer, Ministry of Education.
School Liaison Officers
These were all teachers at the respective project schools. They were involved in the
project with this role for the 3 years of the Lifestyle Intervention and there was a good
mix of males and females:
SMSS - Female Teacher
53
AHS - Female Teacher
SFESS - Male and Female Teacher
RSS - Female and Male Teacher
TSSS - Female and Male Teacher
PBSS - Male Teacher
WAHS - Female Teacher
GHS - Female Teacher
3.2 Diet Behaviours
3.2.1 Knowledge of Nutrition
In Year 1, students were asked a number of nutrition related questions to test their
knowledge of diet behaviour. The results indicated that across both Intervention and
Control schools, response rates were high, with more than half of the students identifying
the correct diet behaviour(s) for each nutrition question. The percentage of students that
identified the correct diet behaviour response(s) was higher (though not significantly)
within Intervention than Control schools. Response rates were lowest for those questions
that allowed for multiple responses. The relationship between knowledge of diet
behaviour and school was tested (as seen by the p-values).
In Year 2, out of 25 possible correct responses, there was no student who received all
correct (or 100%). One student received a score of 21 which represented 84%. Within
each section students from intervention schools received a higher mean score than
students from control schools: this remained unchanged when total nutrition scores were
evaluated by intervention and control schools 11.15 and 10.45 respectively. Section 2.1
of the questionnaire tested general nutrition knowledge. For this section, to test whether
the mean score was the same for students from intervention and control schools an
independent sample t-test was conducted and it can be concluded that there is a
significant difference in mean score (t=3.251, p=.001) (Table 13) between students from
54
intervention and control schools; with students from intervention schools having a higher
mean score (4.75) than students from control schools (4.51) (Table14).
Table 13: Independent sample t-test for Equality of Means, Year 2
Table 14: Mean Scores by School Type, Year 2
School type N Mean Std. Deviation Std Error Mean
Intervention 687 4.7496 1.54945 .05912
Control 1040 4.5096 1.46958 .04557
In Year 3, students from control schools received a higher mean score than students from
intervention schools; this remained unchanged when total nutrition scores were evaluated
by control and intervention schools 23.89 and 21.40 respectively (Table 15).
Table 15: Total Nutrition Scores by School Type, Year 3
School Type Mean Std. Deviation N
Intervention 21.40 9.274 732
Control 23.89 7.144 979
Total 22.83 8.215 1711
Levene's Test
for Equality of
Variances t-test for Equality of Means
F Sig. T df
Sig.
(2-
tailed)
Mean
Difference
Std. Error
Difference
95%
Confidence
Interval of the
Difference
Lower Upper
Equal
variances
assumed
1.459 .227 3.251 1725 .001 .24002 .07384 .09520 .38484
Equal
variances not
assumed
3.216 1413.889 .001 .24002 .07464 .09360 .38644
55
3.2.2: Food Consumption Patterns
The behaviour of the students to the targeted diet behaviours was captured in the self-
administered questionnaire completed in Years 1 and 3 respectively as well as from the
Food Record-Assisted 24-Hour Recalls conducted in Years 2 and 3.
Eating a Variety of Foods Daily
Country data for Year 1 showed that almost three quarters of the students in Grenada
consumed meat, fish or eggs once or more daily but this country also had the lowest
intake of peas and nuts. Tobago reported the lowest consumption of fruits and vegetables
daily while the consumption of carbonated beverages in Trinidad stood at 63%, which
was significantly high when compared with the other countries. In Year 1, the frequency
of consumption and type of food(s) showed more than half of the students consumed
meat, fish, chicken or eggs (61.8%) and snacks (51.8%) once or more daily. The break
down by gender, Table 16, showed that gender influenced consumption of meat,
peas/nuts and snacks (p-values <.05), with females being more likely to consume these
foods (except nuts) daily.
Table 16: Once or more per day Consumption by Gender
Male (%)
Female (%) Total (%) p-value
Categories 32.1 29.5 30.6 0.115
Fruits
Vegetables 32.6 31.2 31.8 0.266
Carbonated Beverages 40.8 37.7 39.0 0.094
Milk/Milk Products 40.3 41.6 41.0 0.297
Meat/Fish/Eggs 56.9 65.6 61.8 0.000
Peas/Beans/Nuts 30.4 25.3 27.6 0.008
Snacks 45.6 56.6 51.8 0.000
56
In Year 1 there was no significant difference seen in the consumption pattern by type
of school but more males on average consumed breakfast every day compared to females.
With the exception of milk products, students attending Intervention schools on average
consumed more of the different foods daily (Figure 15).
Figure 15: Daily Consumption by Type of School, Year 1
In Year 2, more than two-third of students (67% from intervention and 62% from control
schools) were aware of the food group from which the fewest servings should be had and
approximately 42.8% knew the food group rich in vitamins and low in energy. Three
quarters of the students (88% from intervention and 69% from control schools) knew that
it was important to eat a variety of foods daily. The trends for Year 1 and 2 were similar
with respect to the percentage of students consuming foods from the different categories
of foods except for sodas which was reduced in Year 2. Again, the children on the
intervention schools reported higher intakes of all the food categories (Figure 16)
0
20
40
60
80
100
Daily Consumption by School Year 1
Intervention Control
57
Figure 16: Daily Consumption by Type of School, Year 2
In Year 2, the intention to eat a variety of food was greater among students attending
intervention than control schools (78% and 72% respectively). The intention to consume
fruits and vegetables among students was greater than 50%. The percentage of students
with intention to eat fruits on the other hand was higher than those who intended to
consume vegetables (86% and 67% respectively). A little over one-quarter of students or
less, reported that friends, vendors and canteens were a source of support for eating a
variety of foods daily. Teachers, on the other hand were the ones students identified as a
major source of support. The breakdown by intervention and control schools was 67%
and 51% respectively.
In Year 3, the consumption of vegetables, meat and peas/beans/nuts was significant
when compared by intervention and control schools. The consumption was higher
among students attending intervention than control schools in all cases. Apart from meat,
snack was one of the highest daily consumed items by almost half of the students (49%).
Fruit and vegetable daily consumption was low at 23% and 27% respectively. Table17
shows a comparison of foods consumed once or more daily in Year 1 and Year 3.
0
20
40
60
80
%
Daily Consumption by Intervention and Control School
Intervention Control
58
Table 17: Consumption of Foods once or more Daily (Year 1 vs Year 3)
Food Grenada St. Kitts St. Vincent Trinidad
Categories %(yr 1) %(yr 3) %(yr 1) %(yr 3) %(yr 1) %(yr 3) %(yr 1) %(yr3)
Fruits 30.1 25.6 23.8 24.0 38.7 36.1 29.3 22.8
Vegetables 33.6 28.5 29.6 34.1 28.1 22.5 34.0 27.4
Carbonated Soft
Drinks
23.7 33.0 35.4 35.1 48.5 50.8 62.6 47.3
Milk or Milk
Products
46.4 43.1 36.0 37.8 46.3 44.4 32.7 35.4
Meat, Fish,
Chicken
73.3 77.9 57.8 64.7 60.5 72.8 56.3 59.5
Peas/Beans/Nuts 22.6 21.7 27.5 31.9 30.7 32.6 29.3 38.6
Snack Foods 51.7 50.6 46.0 42.3 55.7 54.2 56.7 53.6
Eating Breakfast Daily
In Year 1, of the 68% of students who reported that they ate breakfast every morning,
there was no difference by school. However, a gender difference was depicted as more
males (71%) on average had breakfast every morning compared to females (65%). In
looking at the level of support for breakfast, 94% of students who ate breakfast every
morning said „yes‟ parents/guardian encouraged them. Additionally, attitude also
contributed to breakfast behaviour as 93% of those who ate breakfast daily had indicated
that eating breakfast was easy for them. By Year 3, breakfast was consumed every
morning by a little over half of students (52%) in every country except Trinidad and
Tobago where the consumption was only 36%.
A sample of the Year 2 and Year 3 students were used for the Food Record-Assisted 24
Hour Recalls. Table 18 shows the distribution of the sample for Years 2 and 3 by
Intervention and Control School and Gender.
59
Table 18: Distribution of Year 2 and Year 3 Sample (Food Record-Assisted 24
Hour Recalls) by Intervention and Control Schools and Gender
Type of School Year 2 Year 3
Male Female Total Male Female Total
Intervention 165 198 353 94 143 237
Control 224 272 496 88 140 228
Total 379 470 849 182 283 465
In Year 2 there was a total of 849 students but only 465 in Year 3. The significant fall off
in numbers in Year 3 was due to the fact that: some of the children changed schools;
some dropped out of the school system; some did not advance to Year 3 at that time
(repeated year 2); or for other reasons which prevented them from being in the Grades
that were sampled.
Energy Intake
Mean energy intakes for all the students (both intervention and control) in Year 2 was
2484 Kcal with no significant differences by gender and type of school. When intakes
were compared with the Recommended Dietary Allowances (RDAs), fifty five percent
(55%) of the students met and or exceeded the RDA for their age (Table 19). Differences
by gender were significant with 84% of females meeting and exceeding the RDA
compared with 45% of males. Approximately 45% of students fell below the RDA, with
55% of males and 36% of the females falling in this category. There were no differences
in the intervention and control groups with 56% and 55% of the students respectively in
the groups meeting and exceeding their RDAs.
60
Table 19: Meeting Recommended Dietary Allowances (RDAs)
The mean intake of students in Year 3 was 2468 Kcal with male students showing a
slightly higher mean (2550 Kcal) than females (2416 Kcal). When the intakes were
compared with the RDAs approximately 52% of the students met or exceeded their RDA
for energy. Although the differences were insignificant statistically, more females than
males were likely to exceed RDAs while more males than females were likely to fall
below the RDA. There were no differences in mean intakes between the intervention and
control groups.
Protein Intake
Overall, 82% of students in Year 2 met their RDAs with the remainder falling below
recommended levels for age. These proportions were similar for both intervention and
control schools where 82% and 81% of students respectively met their requirements.
There were also no differences by gender. In Year 3, protein intakes averaged 76 grams
with male students having a slighter higher intake (77 grams) compared with females (75
grams). There were no significant differences between males and females with respect to
meeting the RDAs and overall approximately 76% of the students were estimated to be
Nutrient Year 2
Year 3
Change in
Intake in
Intervention
school from
Year 2 to
Year 3
Control (%) Intervention(%) Control(% ) Intervention(%)
Energy 2484 Kcal
(average
consumed)
55% met and
exceeded
RDA
2484 Kcal
(average
consumed) 55%
met and
exceeded RDA
2468 kcal
(average
consumed)
52% met and
exceeded
RDA
2468 kcal
(average
consumed) 52%
met and
exceeded RDA
Reduced
calorie
intake
Protein 81 82 76 76 Reduced
Calcium 48 53 60 53 Same
Iron 54 59 53 61 Increased
Potassium 59 61 58 62 Increased
61
meeting the recommended allowances. There were no significant differences in protein
intake between intervention and control students.
Calcium Intake
The minerals intakes that were assessed were: Calcium, Iron and Potassium. For
Calcium, in Year 2, approximately 50% of the sample (and for male and female) were
estimated to be meeting their RDAs. When Intervention and Control schools were
compared, slightly more children (53%) in the Intervention Group were meeting their
requirements than those in the Control Group (48%), but those differences were not
significant. In Year 3, mean intake of Calcium suggest that less than half of them were
meeting their RDAs as 56% of them fell below the recommended levels and the data
suggest that females were more likely to be deficient in this mineral compared with males
although the differences were not significant. Approximately 60% of the children in the
control group were meeting their requirements compared to 53% in the intervention
schools but these differences were again not significant.
Iron Intake
With respect to iron, approximately 56% of the Year 2 sample met the RDA, but
significantly more females (52%) fell below the RDA than males (33%). Although more
children in the Intervention Schools were meeting their requirements (59% compared to
54%), the differences were not significant. In Year 3, a significant proportion of the
female students (52%) were not meeting their requirements (compared to 29% of the
males) and significantly more students in the Intervention schools (61%) met the RDA
compared with control students (53%).
Potassium Intake
In Year 2, 60% of all the children met their RDAs for Potassium with slightly more
females (61% vs. 56%) than males consuming the recommended levels. There were no
significant differences in the Intervention and Control Groups although more of the
Intervention students(61% vs. 59%) were meeting their requirements. A little less than
two thirds of the sample in Year 3 were meeting the RDA for Potassium and there were
no significant differences by gender or school type although slightly more females fell
62
into this category (42% vs. 38%). Comparison of Intervention and Control groups
indicate that while differences were not significant, more intervention students ((62%)
met this RDA compared to Controls 58%)
Fat Intake
The average fat intake of the Year 3 students was 87 grams. Female students registered a
higher mean intake of 88 grams compared with their male counterparts where intakes
averaged 84 grams. The differences, however, were not significant.
Comparison of Consumption Patterns in the Sample Population with Caribbean
Population Dietary Intake Goals
One of the objectives of this study was to assess the quality of the intervention group‟s
diet. In order to do this, comparison was made between the average intakes of the
intervention and control group and the population dietary intake goals for macronutrients
(protein, fat and carbohydrate), and fruits and vegetables which have been developed for
the Caribbean. These goals which are based on the evidence-based guidelines provided
by the WHO, represent the population average intake that is judged to be consistent with
a relatively low prevalence of diet-related diseases in the population. A summary of the
findings are set out below in Table 20.
Table 20: Meeting Population Goals
Nutrient Caribbean
Population
Dietary Intake
Goals
Year 2
Year 3
Change in
Intervention
school from
Year 2 to
Year 3
Control (%
meeting target)
Intervention
(%meeting
target))
Control(%
meeting
target) )
Intervention
(%meeting
target))
(%meeting
target)
Energy (from
carbohydrates)
65% from
carbohydrates
37 40 46 46 Increased
Protein 10% 69.9 69.8 66 74 Increased
Fat <25kcal 64 65 66 68 Increased
Vegetables 6% 8 12 10 10 Reduced
Fruits 4% 68 73 73 73 Same
63
Protein
In Year 2, 70% of the sample was meeting the recommended contribution of protein to
total energy and there were no significant differences between girls and boys.
Approximately 70% of the students in Year 3 met the population goal for the
contribution of protein to total energy. There were no significant differences by gender.
Significantly more students (74% vs. 66%) in the intervention group were meeting
their protein requirements compared with the controls.
Carbohydrate
In Year 2 approximately 40% of the students met the goal for Carbohydrate with
significantly less males compared to females. A comparison of the Intervention and
Control Schools shows that although more students from the Intervention Group (40%
compared with 37%) met this target, the differences were not significant. In Year 3, less
than half of the Year 3 sample met the population goal for carbohydrate intake with only
46% of the students registering more than 65% of total energy from this macronutrient.
Significantly more males (51%) than females met the target. There was no difference by
intervention or control groups.
Fat
In Year 2, the data indicate that a little over one third of the children were exceeding the
goal for the contribution of fat in the diet to total energy consumption. When the data
were disaggregated by intervention and control groups, these proportions remained
essentially the same with approximately 35% and 36% respectively from Intervention
and Control schools exceeding the goal for fat. The difference again was not significant.
In Year 3, approximately 67% of the sample met the population goal for fat intake while
there were no significant differences by gender and school, slightly more students (68%
vs. 66%) in the intervention group met the goal for fat.
Fruit and Vegetable Consumption
Another of the targeted behaviours was to improve fruit and vegetable consumption in
the intervention schools. Estimates of fruit and vegetable consumption were done based
64
on the reported food items consumed in the recall and compared with population nutrient
intake goals for fruit and vegetable consumption.
Fruits
The population goal is for at least 4% of total energy consumption to come from fruits.
Among the students assessed, approximately 78% of the sample were meeting this target
overall with slightly more females (72%) than males (67%). When consumption was
compared between intervention and control schools, 73% of the intervention students
were meeting the target compared with 68% in the control schools. In Year 3,
approximately 27% of the students did not meet the population goal for fruit consumption
with slightly more females (27% vs. 26%) meeting the recommendation than males. A
comparison of the data from intervention and control schools show that more students
(28%) in the intervention schools met the goal than in the control schools (25%)
although the difference was not statistically significant.
Vegetables
With respect to vegetable consumption, the findings suggest that the vast majority of
students in the sample (90%) were not meeting the target of 6% of total energy
consumption from vegetables. The breakdown by gender indicates that there were no
differences by gender. Approximately 12% of students in the interventions schools met
the intake goal for vegetables compared to 8% in the control schools, however, the
difference was not significant. In Year 3 Vegetable consumption was low with
approximately 90% of the sample not attaining the population goal. As with fruit
consumption, students in the intervention group were more likely to reach the goal
(92%) than those in the control group (89%) although the difference was not
significant.
Table 21: Eating a Variety of Foods Daily (targeted behaviour)
Year 2 Year 3
Control (%) Intervention(%) Control(% ) Intervention(%)
Eating from all 6
food groups daily
27% 30% 26% 26%
65
Although data from 24 hour recalls are not usually a good indicator of usual intake, the
data can be used to assess to some degree if there were differences between Intervention
and Control for some of the targeted behaviours. One such behaviour was to encourage
students to "Eat a variety of foods daily" and was to be measured by their reported
consumption from the six Caribbean Food Groups. In Year 2 the data suggest that
overall only 27% of the students were eating foods from the six food groups on the days
that they were assessed. There were more students from the intervention group (30%
compared to 27%) that reported eating from the 6 food groups but the difference
was not statistically significant. Girls appeared to be more likely to be eating from all
the food groups but again the difference was not significant. For Year 3 there was a
slight decrease in consumption from the six food groups but this time there was no
difference between Intervention and Control Schools.
3.3 Physical Activity Behaviours
In Year 2, less than one-quarter of students (18.7%) reportedly participated in vigorous
physical activity for 7 days. The reported numbers who exercised to strengthen or tone
their muscles were even less at 9.4%. There was no significant difference in the
percentages between students attending intervention or control schools. Approximately
20% of students did not watch TV on an average school day while 27.8% reportedly
watched TV for 1 hr or less. These numbers increased for sedentary activities on a
weekend with as many as 40% of students watching TV for 5 hrs or more compared to
16% on a week day.
In Year 3, a little under one-third of students (30.8%) reportedly participated in vigorous
physical activity for 30 minutes - five or more days per week. The reported numbers who
exercised to strengthen or tone their muscles were even less at 16.6%. There was no
difference in the percentages between students attending intervention or control schools.
On the other hand, the results by country showed that exercise to strengthen the muscles
were practiced more among students attending schools in Trinidad than Grenada (19.5%
66
and 11.9% respectively). Close to half of the students (48%) either did not watch TV or
watched TV for 1 hr or less on an average school day. These numbers decreased on a
weekend with as little as 23% of students reporting that they watch TV for 1 hour or less.
3.3.1: Knowledge of Physical Activity
Sections 4.1 of the questionnaire examined the students' knowledge of the physical
activity recommendations for their age groups. A mere 3% of students received all 5 PA
questions correct (Table 22). The mean score by intervention and control schools was
not significant.
Table 22: Percentage of Students who were able to correctly answer questions
on Physical Activity in Section 4.1
Frequency Valid Percent
Valid
0 43 2.5
1 299 17.3
2 576 33.4
3 511 29.6
4 243 14.1
5 55 3.2
Total 1727 100.0
Sections 4.2 of the questionnaire examined the students' knowledge on the fitness
components; frequency; duration; intensity; and variety of physical activity. 14 students
got all 15 questions to section 4.2 correct (Table 23).
67
Table 23: Percentage of Students who were able to correctly answer
questions on Physical Activity in Section 4.2
Frequency Valid Percent
Valid
.00 20 1.2
1.00 1 .1
2.00 6 .3
3.00 66 3.8
4.00 269 15.6
5.00 275 15.9
6.00 121 7.0
7.00 144 8.3
8.00 201 11.6
9.00 200 11.6
10.00 130 7.5
11.00 105 6.1
12.00 87 5.0
13.00 52 3.0
14.00 36 2.1
15.00 14 .8
Total 1727 100.0
The mean score by intervention and control school was significant 7.63 and 7.16
respectively (Table 24).
Table 24: Mean Scores by School Type, Year 2
School type Mean Std. Deviation N
Intervention 7.6288 3.36773 687
Control 7.1654 2.83345 1040
Total 7.3497 3.06465 1727
The results for Year 3 were not consistent with Year 2 with respect to school types.
Table 25 below gives the results of Section 4 where there were 19 possible correct
responses.
68
Table 25: Percentage of Year 3 Students who were able to correctly answer
questions on Physical Activity
Frequency Valid Percent
Valid 0 98 5.7
1 1 .1
2 3 .2
3 14 .8
4 69 4.0
5 149 8.7
6 156 9.1
7 116 6.8
8 91 5.3
9 104 6.1
10 120 7.0
11 119 7.0
12 134 7.8
13 140 8.2
14 138 8.1
15 99 5.8
16 82 4.8
17 57 3.3
18 19 1.1
19 2 .1
Total 1711 100.0
The mean physical activity score was significant by school grouping with the control
group receiving a higher mean score than the intervention group (10.04 and 9.11
respectively) (Table 26).
Table 26: Mean Scores by School Type, Year 3
School Type Mean Std. Deviation N
Intervention 9.11 5.058 732
Control 10.04 3.971 979
Total 9.64 4.490 1711
69
3.3.2: Physical Fitness
The Four Health Fitness Components assessed were:
Flexibility (exercise - Trunk Lift)
Muscular Strength (exercise - Push-ups)
Muscular Endurance (exercise - Sit-ups)
Aerobic Capacity (exercise - Jumping Jacks)
3.3.2.1 Flexibility
Year 1 there were significantly more students from control than intervention school
passing this test (56.3% vs. 49.1%). In year 3, though the pass rate declined, it was
slightly higher for students attending intervention schools. Of those students who passed
the test in year 1, there was a significantly higher failure rate in Year 3 among students
attending control schools (53.8% vs. 40.8%). In Year 1 more students in Control schools
passed while in Year 3 (though the pass rate declined) more students in Intervention
schools passed (Figure 17). Overall, there was lower flexibility, but more of those who
passed in Year 1 in control schools, failed (53.8%) in year 3 compared to 40.8% for the
intervention schools.
Figure 17: Flexibility by Intervention and Control Schools
0
10
20
30
40
50
60
fail pass fail pass
Flexibility by Intervention and Control Schools
Intervention Control
70
3.3.2.2 Muscular Strength
In Year 1, the pass rate was significantly higher for students attending intervention than
control schools (62.6% vs. 57.5%). In Year 3 the pass rate was higher for students
attending control school, though not significant (37.5 to 31.9% respectively : p=.013).
Generally, less than 50% of students passed this test. In Years 1 and 3 more children in
Control schools passed (Figure 18)
Figure 18: Muscular Strength by Intervention and Control Schools
3.3.2.3 Muscular Endurance
For Years 1 and 3, the pass rate was higher for students attending control than
intervention schools. There were significantly more students failing in the third year
of the project who were attending intervention than control schools. In Year 1 more
students in Intervention schools passed while in Year 3 more students in Control
schools passed (Figure 19).
0
10
20
30
40
50
60
70
fail pass fail pass
Muscular Strength by Intervention and Control Schools
Intervention Control
71
Figure 19: Muscular Endurance by Intervention and Control Schools
3.3.2.4 Aerobic Capacity
o The mean resting pulse rate was 74.98 beats per minute (bpm)
o The change in mean pulse rate was higher significantly for females (77bpm) than
males (72bpm)
o The pulse rate was also higher for students attending Control Schools (76bpm) versus
those from Intervention schools (74bpm).
Figure 20: Aerobic Capacity by Intervention and Control Schools
0
10
20
30
40
50
60
70
fail pass fail pass
Muscular Endurance by Intervention and Control School
Intervention Control
0
20
40
60
80
fail pass fail pass
Aerobic Capacity by Intervention and Control Schools
Intervention Control
YR 1 YR 3
72
More students from control schools passed this test 60.7% to 57.1% respectively: p=.009.
In Year 1, the change in pulse rate by BMI-for-Age (Figure 21) showed a steady increase
in the mean pulse of students who were normal compared to those who were obese.
Figure 21: Mean Change in Pulse Rate by BMI-for-Age, Year 1
In Year 3, the change in pulse rate by BMI-for-Age (Figure 22) showed fluctuations in
the mean pulse of students who were normal compared to those who were overweight
and obese. The results were more significant when compared to Year 1.
Figure 22: Mean Change in Pulse Rate by BMI-for-Age, Year 3
0
20
40
60
80
100
Thinness Normal Overweight Obese
mean c
hange in p
uls
e r
ate
Mean Change in pulse rate by BMI-for-Age
78,9
75,1 74,0
77,6
70
72
74
76
78
80
Thinness Normal Overweight Obese
Mean Change in Pulse Rate by BMI-for-Age
73
3.4. Nutritional Status of the Children Studied
3.4.1: BMI for Age
BMI information of children collected at the end of Year 2 of the project showed that
there was a significant decline in the overweight and obesity status of children attending
intervention schools when compared to Year 1 (Figure 23).
Figure 23: Comparison of Overweight and Obesity Among Year 1 and Year 3
Students
Further disaggregation of the data showed that approximately 47.2% and 42.5% of
students attending intervention and control schools respectively, and who were
overweight in Year 1 of the project, fell to the category of normal in Year 3 (Figure 24).
There was also a decline in the movement of students who were obese in Year 1 of the
project to overweight in Year 3; 32.4% and 31.1% of students from intervention and
control schools respectively.
Figure 24: Comparison of Overweight and Obesity Among Year 1 and Year 3
Students by Intervention and Control Schools
17
14 16
13
15 11 17 10 0
4
8
12
16
20
Overweight Obese Overweight ObeseYr1 Yr3
0
20
40
60
80
Comparison of Overweight and Obesity among students
Yr1 Yr 3
Intervention Control
74
Height and weight data was not collected in the second year of the project. However,
students were asked about perception of their weight. Approximately 65% of students
felt they were about the right weight; 18% slightly underweight; and 17% slightly
overweight. There were more females than males (16% vs. 12.7%) who felt they were
slightly overweight. On the other hand more males perceived they were very overweight.
These results were not significant between intervention and control schools.
In Year 3, when asked about the perception of their weight, 15.1% of students felt they
were underweight; 2.5% of them severely; and 14.8% thought they were overweight.
More males felt they were underweight whereas more females felt they were overweight:
this was not significant when intervention and control school groupings were compared.
Based on BMI-for-age, 3.2% of students were thin and 26% overweight, 10% of these
being obese. By school grouping this was not significant.
3.4.2: Blood Pressures
Systolic blood pressure is the pressure when the heart beats while pumping blood and
Diastolic blood pressure is the time when the heart is in a period of relaxation and
dilation; that is, when it receives blood. In Year 1, the majority of respondents 95.4%
had normal systolic pressure readings. Of this proportion, 76.8% were below the
midpoint of the normal range and the remaining 23% were at or within the midpoint of
the normal range. 2.2% were pre-hypertensive and 2.4% hypertensive. There was no
difference in normotensive reading by gender, and just a very small percentage more
females were pre-hypertensive than males. Within Intervention schools, 3% of students
were pre-hypertensive or hypertensive (Figure 25) while Control Schools reported a
higher percentage of students with normal blood pressure readings.
75
Figure 25: Systolic Status by School, Year 1
When comparing BMI-for-age with the systolic pressure reading, for the Year 1 cohort,
the results indicated that the greatest numbers of pre-hypertensive and hypertensive
students were those who were overweight (6.8%) and obese (9.2%) respectively (Figure
26). There was also some concern regarding the number of overweight students who also
had high normal and high blood pressure (3% each). Within the other BMI categories,
pre-hypertensive and hypertensive percentages were small; that is, 1.2% or less. In
conducting further analysis, 62% of respondents who were hypertensive exercised for
less than 5 days per week.
Figure 26: BMI by Systolic Status, Year 1
97,7
1,2 1,1
94,5
2 3,5 0
20
40
60
80
100
Normal Pre-hypertensive Hypertensive
Intervention Control
0
20
40
60
80
100
Thinness Normal Overweight Obese
BMI by Systolic Status
Normal Pre-hypertensive Hypertensive
76
In Year 3, the majority of respondents (95.8%) had normal systolic pressure readings,
1.7% were pre-hypertensive and 2.5% hypertensive. Unlike Year 1, there was no
difference in normal systolic pressure reading by gender, and there were significantly
more students from intervention schools with readings within the normal range when
compared to control schools: 97.7% and 94.5% respectively (Figure 27).
Figure 27: Systolic Status by School, Year 3
When comparing BMI-for-age with the systolic pressure reading, the results indicated
that of those who were obese, 7.2% were pre-hypertensive and 13.2% hypertensive.
Diastolic readings for Year 1 indicated that 92% of students were normotensive, 5.3%
pre-hypertensive and 3% hypertensive. These percentages were higher than that reported
for systolic pressure. Additionally, results by type of school showed that within
Interventions schools, there was a lower percentage of students on average with normal
diastolic readings and a higher percentage with pre-hypertension when compared to
students from Control Schools. There were higher percentages of females than males
with pre-hypertensive and hypertensive diastolic readings. There were also 17% of
students who were obese with pre-hypertension and 9% with hypertension, the figure for
overweight students with pre-hypertension stood at 7.2% (Figure 28).
0
20
40
60
80
100
Normal Pre-hypertensive Hypertensive
Systolic Status by School
Intervention Control
77
Figure 28: Diastolic Status by School, Year 1
In Year 3, Diastolic readings indicated that 88% of students were normotensive, 9.6%
pre-hypertensive and 2.3% hypertensive. There was no difference in normal diastolic
pressure reading by gender or intervention and control schools.
When comparing BMI by diastolic pressure it was evident that significantly more persons
in the overweight and obese category were pre-hypertensive and hypertensive.
Table 27: Diastolic pressure by BMI
Diastolic
Pressure
BMI Total
Thinness Normal Overweight Obese
Normal Count 45 990 207 108 1350
% within BMI 91.8% 91.6% 84.1% 70.6% 88.3%
Pre-
hypertensive
Count 3 81 29 31 144
% within BMI 6.1% 7.5% 11.8% 20.3% 9.4%
Hypertensive Count 1 10 10 14 35
% within BMI 2.0% .9% 4.1% 9.2% 2.3%
Total Count 49 1081 246 153 1529
% within BMI 100.0% 100.0% 100.0% 100.0% 100.0%
0
20
40
60
80
100
Normal Pre-hypertensive Hypertensive
Diastolic Status by School
Intervention Control
78
3.5 Components
The implementation of the project activities were done to varying degrees through the
four components of the project. Activities were captured and are attached as Annex XX.
3.5.1 Behaviour Curricula on Nutrition/Diet and Physical Activity (Lessons)
In this component, 48 concepts were used in lessons for delivery to the children in the
intervention schools. These concepts formed the content base for the lessons. Fourteen
(14) lessons were scheduled for Year 1; 18 for Year 2; and 16 for Year 3. In Year 1 all 14
lessons were taught in all intervention schools. By the end of the project the number of
lessons taught ranged from 38-45 of a total of 48. There were 58% of teachers who had
attended the summer workshop before the start of the project. Of this number, 27.5% of
teachers rated the workshop as "very effective", a higher percentage (47.5%) gave a
rating of "effective" and a total of 15% combined indicated "not effective and/or poor".
Even though the workshop was given good ratings, it was a little under one-third (30%)
of teachers who indicated the workshop helped them in teaching the lesson.
Over half of the teachers (58%) taught the project lessons in the classrooms. Their
impression of the classroom teaching was that it had limitations (time constraint and a
lack of fun activities). Additionally, they indicated that there was too much information
for one lesson and the sessions were too long and compact for some students. However,
there were a few teachers who mentioned that students were interested and the lessons
went well.
Even though there was more participation in the second workshop, a total of 73% of
teachers, the ratings given were lower when compared to the summer session (22% gave
a rating of very effective, 44% indicated effective and 18% not effective and/or poor).
There were 58% of teachers who prepared infused lessons (when cross referenced with
those who taught project lesson in classroom, this represented 68% of those teachers)
however; there was only 15% who taught any of those lessons. The diet concept was
79
infused in the following subject areas Mathematics (10%), and Agricultural Science (6%)
among others. The impression of the lessons by the teachers were that they were practical
and effective (12%) and also that it was a good way of teaching the whole concept of
exercise and healthy eating.
Generally, lessons were well constructed and information was relevant. Lessons were
distributed in a timely manner and delivery schedules developed as soon as lessons were
received. This was fine for Year 1 and the teachers filled out the self-evaluation forms.
Based on the data shown in Figure 29 below, most of the teachers were able to deliver the
lessons confidently, business-like, were fair to all, used appropriate language and
included all the students in discussions and activities.
80
Figure 29: Teachers Evaluation, Year 1
Midway through the project the teachers assessed their roles (Figure 30) as follows:
Creating Awareness
Imparting knowledge
Helping to develop skills
Participating in workshops
Motivating students - lessons
Motivating Students -project Activities
Getting Feedback
020406080
100
Confident
020406080
100
Business-Like
020406080
100
Fair to All
020406080
100
Use of Language
020406080
100
Inclusiveness
81
Figure 30: Project Teachers Self-Assessment
0
20
40
60
80
GrenadaSt.Kitts Nevis SVG Trinidad
Imparting Knowledge
Noresponse
Fullyachieved
0
20
40
60
80
GrenadaSt.Kitts Nevis SVG Trinidad
Creating Awareness
Noresponse
Fullyachieved
0
20
40
60
80
GrenadaSt.Kitts Nevis SVG Trinidad
Help Develop Skills
NoresponseFullyachieved
0
20
40
60
80
100
GrenadaSt.Kitts Nevis SVG Trinidad
Participate in Workshops
NoresponseFullyachieved
0
10
20
30
40
50
60
70
GrenadaSt.Kitts Nevis SVG Trinidad
Motivate Students - lessons
NoresponseFullyachievedPartiallyachieved
0
10
20
30
40
50
60
70
80
GrenadaSt.Kitts Nevis SVG Trinidad
Motivate students - project act.
NoresponseFullyachievedPartiallyachieved
0
20
40
60
80
GrenadaSt.Kitts Nevis SVG Trinidad
Feedback
Noresponse
Fullyachieved
82
Year 1 yielded the best results in terms of lesson delivery. As the years went by several
challenges affected the delivery of the lessons and adherence to the schedule. The late
arrival of lessons hindered delivery as it sometimes became difficult to schedule lessons.
Conflicts arose in relation to the School‟s agenda and this resulted in a back log of
lessons to be delivered after Year 1. Year 2 showed some decrease in lesson delivery but
efforts were made to catch up. There was, however, a significant decrease in Year 3
mainly due to the backlog in Year 2 and the fact that students were then pursuing more
subject options and it became difficult to have them together as one class at times. There
was no "catch-up" time for Year 3 so students were not exposed to quite a few concepts.
The following provides a summary of the major constraints in relation to lesson delivery:
Transfer of Teachers
Late arrival of lessons (during mid-term and close to the end of the term).
Lesson delivery clashing with revision period, end of term exams and/or the
premature ending of school.
Difficulty of scheduling lessons after Term One. In the Caribbean the focus of
the Education Sectors is to have students fully prepared for examinable subjects
that would lead to certification and a route to higher education. Completing the
curriculum and completing mid- and end-of-term reports were priority activities.
Term 2 in each country is deemed “Sports Term” and teachers were more
preoccupied with sports. Term One was the only term that teachers were prepared
to do the teaching of the lessons for the project. This was not stated at the times
of training.
Difficulty in obtaining periods for delivery in cases where the project Teacher did
not have a regular schedule with the specific classes.
Lack of preparation by a minute number of teachers (only a few teachers were left
to teach all the lessons).
The CCs felt that the enthusiasm in Year One was diluted because of the above issues as
well as others which were indicated as never addressed although they were repeatedly
brought to the attention of CFNI. One such issue was the perceived volume of written
83
exercises/paper for students during and after each lesson. They also indicated that
students complained bitterly and responded negatively to the volume of paper they
received. It resulted in handouts being thrown away/discarded by the students even
before the lesson was completed. The issue of length of lessons and the number of
handouts were addressed in the second and third year of the project by a drastic
reduction. However, students did not want LESS they wanted NONE and it was difficult
to address since the project materials were prepared long in advance.
Refresher training for the delivery of lessons was not conducted after Year 2 due to:
Administrative matters at CFNI and early final year examinations which started in
May (usually conducted in June). Once examinations begin there are usually no
official classes. The students are supposed to be at school but in reality the
teachers ask them to stay away. This was not a directive from the Education
Administration but it was a regular occurrence at all schools in all the project
countries.
Because of the above, lessons were delivered late, almost mid Term 1 and the
teachers by then indicated that they had no time. The usual Term 2 problem of
one focus (Sports Day) meant very little teaching time even for the time tabled
subjects.
Final data collection had to be completed before the start of the end of year
examinations (May/June).
These combined with the fact that too many lessons from Term 1 were outstanding led to
the decision to forgo the refresher training.
Because the CCs were only expected to review one of the many lessons for each
Grade/Form the teachers would only deliver the lessons to one of the Grades/Forms that
the CCs observed but did not deliver that same lesson to the other 3-7 classes of that
Grade/Form. This resulted in an unequal delivery of information to all the cohort
students. As the children and the project advanced, more PA lessons were included and
those were activity-based. However, due to the fact that the PE Teachers were scheduled
for those lessons and their involvement in Sports Term (Term 2), it was virtually
84
impossible to get them to focus on anything else and many of those lessons were not
taught.
The CCs reported that by the time the infused lessons were introduced there was a
general rejection of the project in the schools due to some of the constraints mentioned.
The students observed the teachers reactions and attitudes and began to ignore and
relegate the project. Only a few infused lessons were done at any of the project schools.
Despite the many challenges the majority of the lessons were taught in most of the
intervention schools.
Student Portfolios
Despite the best efforts of the implementers and co-ordinators, students failed to
complete exercises and the majority refused to submit their portfolios. The CCs tried to
hold the portfolios and have students submit exercises when requested but that was
discouraged since the students needed to be assured that they could freely express
themselves and set goals and deal with challenges. Teachers should not understand that
approach. There was a resultant poor response to the portfolios and after Year 1 the
number available for retrieval were not representative.
Registers and Evaluation Forms
These proved to be a challenge although teachers were provided with copies of the
registers before lessons commenced. Teachers seemed to have some aversion to
completing registers and evaluation forms but every effort was made to encourage them
to have forms completed.
3.5.2 School-wide Promotional Activities (Clubs and Promotional Days)
This component included the formation of clubs; the observation of promotional days and
other activities to promote healthy eating and physical activity. The project suggested
three mandatory days:
World Diabetes Day (November 14)
85
Sports Day (Term 2)
Caribbean Nutrition Day (June 1); and any others that were possible during the
school year.
The schools were free to develop with the students the appropriate activities they wanted
to implement. Every effort was made within limits to promote the Project. The CCs
indicated that this was more successful in Year 1 because they had more posters (note
that during the process evaluation all schools asked for less material, including posters)
and material for displays mounted. It must be mentioned however that, as promotional
material decreased, banners, flyers etc were printed at the Ministries of Education. They
believed that efforts to promote the core Days were effectively achieved. CD‟s and other
soft copies of the promotional activities with some of the activities were forwarded to the
Project Co-ordinator at CFNI (Annex XX).
Generally, the entire school population participated in the promotional activities. Figure
31 shows students participating in a dancercise session guided by the Mathematics
Teacher in Grenada who participated in the Teacher Training. This is an example of
whole school approach to the project..
Figure 31: Anglican High School Students, Grenada, enjoying the dancercise
session on one of The Promotional Days
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Activities for World Diabetes Day (WDD) were successful in most of the schools in all
countries. The local Diabetes Associations collaborated with School Teams and
conducted activities sometimes over a period of a week. Poster competitions were also
conducted in some schools. Figure 32 shows the display of posters which were
developed by the students and displayed at the PTA meetings in Trinidad.
Figure 32: Poster Competition for Students at SFESS, Trinidad
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The Promotional Activities for WDD included activities such as walk-a-thons; local Food
Fairs; as well as testimonials by persons with diabetes. The Sports Day Activities
involved the whole school and in some cases parents and the wider communities were
involved as well. Some activities included competition of meals for athletes; blind-
folded taste station; hula hoop Competition; and the serving of healthy snacks to students.
For Caribbean Nutrition Day (June 1), over the 3 year period, activities included Food
Exhibition Competitions among all the Grades/Forms in the school and Poster and Other
competitions.
Figure 33: Students in a Healthy Lunch Competition in Grenada
Many of those activities were not sustained for several reasons ranging from a lack of
commitment at the school level, funds and transportation for persons who wished to work
with schools; and a lack of motivated individuals. Some activities were only completed
after great efforts by the CC and the school liaison teacher.
School Clubs: These were slow in development if they did not exist prior to the
implementation of the project. In one school there was a teachers‟ fitness club and
students were encouraged to join that club: this was short-lived. Figure 34 shows
students and teachers participating in a hiking experience for WDD in Nevis.
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Figure 34: Hiking Club, Nevis
3.5.3 Building Supportive Environments at School
This component attempted to influence the school environment for diet and physical
activity so that the children could adopt the desired behaviours. Modelling by teachers
was also critical as a means of school support.
Figure 35: Teachers Modelling Behaviour: Eating Fruits Daily
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The CCs indicated that it was difficult to assess whether a supportive school environment
had been built. It was felt however, that the ground work had been done and the
Ministries of Education, School Boards, principals and teachers were more aware than
prior to the project. Even though there were no substantial changes as they relate to food
facilities at the school, efforts were made to offer fruits, fruit juice and less fried food to
students.
Figure 36 shows students at the same school as the teachers in Figure 35 participating in
the fruits made available on a "Fruit Day".
Figure 36: Students Participating in Fruit Day
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The individual schools were assessed in two large domains: Assessment of Environment
for Physical Activity and Assessment of Environment for Healthy Eating. In assessing
physical activity the observer was guided by the physical activity checklist (Annex XIV
e) which included activities done in PE classes (swimming, football tennis, etc.). The tool
assessed physical activity facilities available both internal and external (those in close
proximity to school compound) and available equipment. It also explored: the availablilty
of facilities for students' participation in extracurricular or after school
clubs/teams/activities. The second instrument used to assess supportive environment for
physical activity was a physical activity school profile questionnaire (Annex XIV h). The
areas investigated consisted of PE programme, physical activity facilities, and safety and
security.
Assessment of supportive environment for healthy eating was assessed using two
instruments: The foodservice operations checklist (Annex XIV g) and the Students‟
sources of food checklist(Annex XIVi). Annex XIV assessed meal planning, preparation,
documentation, equipment, facilities, training and management of the foodservice
operation (e.g. cafeteria, tuck-shop, vendors). The students‟ sources of food (Annex XIV
i) checklist was used to gather information on enrollment, recess/breaks, location of meal
purchase, subscription to school feeding programme where available, fruit trees
availability, and school gardens (Annex XIV f). It also retrieved information on display
of educational materials in schools and health messages promotions.
Supportive Environment for Physical Activity
The majority of schools had a mandatory PE class which placed emphasis on physical
activity particularly among Grades 7-9/Forms 1-3 students. The PE classes in most of the
project schools were more than 30 minutes in duration. The physical activity classes were
dichotomized into a theoretical section which provides students with knowledge of
sporting activities and benefits of physical activities as well as a practical component
where students participate in a variety of sport/physical activity exercises. There was
however, an imbalance in most schools as it related to the provision or accessibility of
proper playing areas, equipment and protective gears in specialized sports.
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The majority of schools did not have adequate gears and or protective gears. Only three
schools reported having properly maintained facilities such as fields/courts. The SFESS
in Trinidad, which did not have their own facility was the sole school to report adequate
equipment and facilities. They used the community multipurpose facility. All but one
school reported that the majority of students walked to school, no school provided
transportation for students who wished to engage in extracurricular/after school activities.
More than half of schools reported an afterschool activity club of which the majority was
sports-oriented. In most if not all cases, physical activity extracurricular activities were
conducted by regular teachers and not necessarily trained Physical Education Instructors.
As a means of support the project donated a small number of basic equipment for
physical activity. These are listed in Table 28 and depicted in Figure 32 below.
Table 28: Minor PA Equipment Donated to Intervention Schools
Item Amount to Country
Trinidad Tobago St. Vincent
and the
Grenadines
Grenada Nevis St.
Kitts
Pedometers
240 140 270 430 210 330
Floor mats
12 12 12 12 12 12
Cones 12 12 12 12 12 12 12 Skipping ropes 8 8 8 8 8 8 Whistles 6 6 6 6 6 6 Footballs 4 4 4 4 4 4 Windballs, 4 4 4 4 4 4 Basketballs, 4 4 4 4 4 4 Netballs, 4 4 4 4 4 4 Volleyballs, 4 4 4 4 4 4 Cricket Balls 4 4 4 4 4 4 Small dumb bells-
(Either 5lb, 10lb and
20lb) pairs
2 2 2 2 2 2
Blood Pressure Kits 2 2 2 2 2 2 Scales 2 2 2 2 2 2 Stop Watches 2 2 2 2 2 2
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Figure 32: Physical Activity Equipment
Supportive Environment for Healthy Eating
Most schools offered one break period which was on average of 20 minutes, in addition
to the lunch break. Approximately one half of all intervention schools offered a SFP to
provide meals for student but the capacity was, in all cases, just about 10% of the student
population for each school. In schools that operated a SFP, the major sponsor was the
Ministry of Education. More than 30% of schools reported that students main source of
lunch was from the tuck-shop or cafeteria. In the GHS in Nevis, 80% of students obtained
lunch and snacks from a Deli at the supermarket across the road from the school and a
vendor who sold sandwiches and food. The major food groups consumed in most of the
schools were food from animals, staples and fats and oil. In most cases legumes and fruits
were scant especially at lunch time meals.
Beverages available to students were mainly sodas, drinks and juices with milk or milk
products being unavailable in most schools. Pastry and snack items were frequently sold
by vendors, with little or no offerings of fruits. All except the SMSS in Grenada did not
have any food safety operations standards in place. Fruit trees were not commonly
reported on school premises and where they were available only one school reported
accessibility to students, whereas school gardens were operated by five of the eight
intervention schools. The major food cultivated in the school gardens were vegetables,
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legumes and in the case of the SFESS in Trinidad, ducks and chickens were reared. The
products from these gardens were usually sold to the public or utilized in schools. One
half of schools reported having displays of health and lifestyle information in classrooms
and on notice boards.
Facilities for preparation and storage were basically adequate and staff were routinely
monitored and trained. The majority of schools and written recipes, standard serving sizes
and proper sanitation practices with most staff members having a food handler‟s permit
or food badge. All schools had access to piped water within facility except the vendor at
GHS who only had access to a nearby stand pipe. Spaces for dining area were inadequate
or nonexistent for the latter at most schools. In these small areas which are usually prone
to accidents only a minority (3) of schools reported having fire extinguishers. Reports,
record keeping, meal census/register and definition of staff roles were poor in most
schools as the majority of food operators were involved in informal trading with little or
no accountability.
SCHOOL TEAMS
The School Teams were established at the beginning of the project. The members were
sensitized to their roles but there was little support for meetings due to a lack of
commitment at the whole school level. There were only a few individuals on the team
who got together periodically to plan activities. Most school teams only met when
activities had to be planned for the mandatory promotional days. In a few schools the
teams did not:
Encourage stakeholder participation in school wellness efforts.
Ensure that communication with school and community stakeholders was two way,
regular and meaningful.
Collaborate with community partners to provide technical expertise and resources on
pertinent issues.
Create a supportive school environment
Collaborate with community and home to ensure the adoption of the behaviours.
Ownership and commitment to the project were lacking.
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3.5.4 Building Supportive Environments at Home and Community
This component was supposed to encourage parents and the wider community to support
the project and to create environments where the children can move and play as well as to
be able to access safe, affordable and wholesome foods. Support from parents was
minimal and challenging. The communities supported the project by way of NGOs such
as National Diabetes Associations; Nutrition Departments; Sports Departments and
Health professionals.
Based on the surveys conducted with parents, it was apparent that they participated in the
project through attendance at parent talks/meetings (43%); Sports Day (24%); take-home
assignments (15%); and Caribbean Nutrition Day (12%). The main area of their
involvement in organization was with the take-home assignment (30%) (Figure 38).
Figure 38: Parents’ involvement in project activities
Almost all parents (94%) reported they were aware of their child take home assignment,
which covered food groups (eating properly) and the importance of exercise (28%);
choosing healthy foods / developing a healthy lifestyle (25%); and journal entries
(calories consumed/burnt) (12.5%) (Table 29).
0
10
20
30
40
50
Parents Talk Sports Day Assignment CaribbeanNut. Day
WorldDiabetes Day
Clubs
Parents Involvement in Project Activities
Attended Organized
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Table 29: Parents recollection of take-home assignment
Response N %
Different food groups (eating properly and the importance of exercise 9 28.1
Choosing healthy foods/ Developing a healthy lifestyle 8 25.0
Journal entries of calories consumed/burnt 4 12.5
Importance of breakfast 2 6.3
Nutrition and diabetes awareness 2 6.3
Different nutrients found in foods 2 6.3
Baking a cake 1 3.1
Dietary plan and body mass 1 3.1
CFNI 1 3.1
Worksheets 1 3.1
A chart of good eating habits 1 3.1
A little over half of the parents (53%) said their child asked for assistance with
assignments and 80% of parents remembered helping their child to do the activities. The
help extended was in putting foods into food group and providing foods from the
different food groups (23%); gathering information (19%); and helping with ideas for
journal entries (15%) (Table 30). Parents were also of the opinion that they benefited
from the project activities (91%).
Table 30: Ways in which Parents helped with Project activity
Response N %
Put (providing) foods into food group 6 23.1
Gathering information/ Research 5 19.2
Helping with journal entries 4 15.4
Helping to plan meals 3 11.5
Helping to answer assignment questions 3 11.5
Finding out the different kinds of food and its use 2 7.7
Asking child to tell the benefits to her 1 3.8
Exercise program, food to improve diet and drinking water 1 3.8
Went walking together 1 3.8
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All parents thought it was important for their child to eat healthy, be physically active, eat
fruits daily and eat breakfast daily. There were also a high number of parents (98%) who
indicated they would like their child to eat vegetables daily and eat foods from the six
food groups. Seventy four percent (74%) of parents were of the opinion that their
participation in the project made the child more active while an even higher percentage
(84%) were of the belief that it made their child choose healthier foods and snacks.
Parents also expressed an interest in willingness to support their child to make healthier
choices and to be physically active (96%). Ninety percent (90%) of parents reported that
they made changes within the home to encourage their child to be more active. For some
parents these changes included: doing more chores (65%); being more active outside
(48%); and restricting time for television and computer use (43%) (Table 39).
Figure 39: Changes Made to Encourage Physical activity
With respect to dietary behaviours, 90% of parents indicated that during the past three
years they made changes to ensure that their child ate breakfast every morning; 89%
reportedly made changes to reduce fatty, salty foods and snacks; 87% made changes to
reduce sugary foods and drink; 85% made changes to help their child eat from the six
food groups daily; and 70% made changes to encourage their child to snack on fruits and
vegetables daily. These changes were as follows:
Changes made to encourage child to eat from six food groups include:
o Cooking balanced meals (38.5%)
65
48 43
23 20
0
10
20
30
40
50
60
70
Chores Be moreactive
Less TV time Took child toPA
Plan PA forfamily
Changes made to Encourage PA
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o Avoiding cooking and eating too much of everything (30.8%)
o Buying/Eating more fruits and vegetables (23.1%)
o Purchasing the requisite food item (7.7%)
Changes made to ensure child ate breakfast every morning
o Prepared breakfast every morning (55.6%)
o Prepared something that child would like (22.2%)
o Gave child more choices (11.1%)
o Made sure that child ate breakfast (11.1%)
Changes made to encourage child to snack on fruits and vegetables
o Bought fruits and vegetables and give child to carry to school each day
(87.5%)
o Stopped all snacks and give him more fruits (12.5%)
Changes made to reduce sugary foods and drinks
o Bought less (16.7%)
o Drank more water (16.7%)
o Provided home-made juices (50.0%)
o Reduced sugar in meal preparations (16.7%)
Changes made to reduce fatty, salty foods and snacks
o Cooked with less salt (28.6%)
o Prepared food differently, less frying, more boiled and baked meat
(14.3%)
o Made local snacks so child did not have to buy prepackaged ones (14.3%)
At some schools, parents were willing to start kitchen gardens but there was a lack of
resource persons to spearhead the programmes. Nutrition Departments were very
instrumental in educating the students on the levels of salts, fats and sugars in foods and
they made the exercises practical, simple and enjoyable.
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Figure 40 highlights a member of the Grenada Food and Nutrition Council (Nutrition
Department) (GFNC) educating students on the amounts of fats , salts and sugars in some
foods commonly eaten.
Figure 40: GFNC Educating Students on The Amounts of Fat, Salt and Sugar
that are in Common Foods Eaten.
Display showing literal fat content of common snacks and foods
Displays showing literal sugar content of common snacks and foods and drinks
Other activities were co-ordinated with the Departments of Sports and Health.
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Figure 41: Student getting blood pressure checked
COUNTRY TEAM
The project started off with the implementation of a Country Team. Country teams were
officially formed in SVG and GRE. The other project countries, SKN and TRT tried but
could not bring any team together. In TRT and SKN the CCs worked on a one-on-one
basis with persons from the various sectors to get activities implemented. This was done
by phone, e-mails, faxes, and face to face discussions. The teams that officially formed
met no more than twice per term. The work of the Team was never fully realized as the
project‟s work conflicted with personal and professional schedules. Meetings were
conducted at least twice per term. It was a mammoth task to get members to attend
meetings. However, members provided support to the School-based Behavioural
Intervention. Members supported the promotional days. In SVG, it was at the Country
Team level that TSSS received assistance in the school clubs. The nurse on the Country
Team gave tremendous support in the Data Collection process. Members monitored the
implementation of the behavioural curriculum and discussed how the lessons were
progressing and the challenges encountered. This group of persons were very committed
but also very busy professionals and as a result it was sometimes impossible for them to
meet. The country teams mainly encouraged and supplied resources (mainly human) for
school and community activities. Overall the country teams were not as effective as
expected.
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DISCUSSION
AND
RECOMMENDATIONS
101
4.0 DISCUSSION RECOMMENDATIONS AND CONCLUSION
Supportive Environment
Supportive Environment Physical Activity
The supportive environment was critical to the success of the project. The four
components captured the necessary support for the behaviours to be instilled.
Unfortunately a few of the environments were not as supportive as expected. Schools
should endeavour to procure adequate equipment and resources such as balls, skipping
ropes, hoola-hoops, nets, rackets, bats, in order to facilitate an array of fun-filled
activities to which students could be drawn. A way of promoting this process is to
incorporate the community in the planning and development of the school facilities as
part of the community.
In addition to adequate equipment, schools should partner with corporate sector to
sponsor school gymnasium, fields, and or sporting centres as a support to student
participation in physical activity programme. Most should aim to have a netball court,
football/cricket field with track and field facilities, an indoor facility for table games as
well as dancing, aerobics and weight exercises. To address and immediate need observed,
lighting of fields and play areas and removal of excess shrubbery are essential to promote
participation and safety. The need may differ according to sporting emphasis and by
culture or preferences in countries.
The initiation of after school activity clubs should be formalized to become regular
scheduled programmes facilitated by trained personnel with the help of other teachers and
or parents and community members. The activities offered at the club can be specialized
or general so that all needs are met. These can include: athletics, football, cricket,
aerobics, dancing, cheerleading, table and lawn tennis, swimming (where possible),
volleyball, dodgeball, jump rope etc. Interschool competitions should be encouraged with
nearby schools in sporting or physical activities. Schools should aim to offer a diverse
cadre of activities in PE periods ranging from netball, jumping rope, shot put, discus,
high jump, long jump, football, cricket, tennis, and racing, hop scotch to lighter activities
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such as taking an adventure walk to a museum or environmental site. Schools can also
organize a grand walkathon against inactivity where students walk showcasing banners
and posters promoting ways to increase physical activity. PE classes may also be
restructured to the end of the school day to accommodate field trips to special activity
centres within the region to introduce students to different sporting activities such as
hockey, water polo, and golf. This also gives students opportunity to meet sport
professionals who can influence physical activity behaviour change and also academics.
The call for simple one- minute exercises in-between classes were not done even though
the teachers indicated that they would. The PE lessons were not delivered totally and
teachers resorted to the accustomed way which did not lend itself to inclusiveness. The
classes were still sports-based and teachers were not always seen as role models with
respect to the physical activity behaviours. Not enough was done at the school and
within the community and with parents to allow children to increase physical activity.
Policies suggested were not put in place and hence very little changes were made. One
or two of the schools did indicated that they included fun sporting activities for the Sports
Day so all categories of individuals could participate without feeling self-conscious or
deficient. The schools needed to involve the wider community and the Ministries more
in assisting with transportation, security and lighting at schools to encourage extra-
curricular activities.
Supportive Environment for Healthy Eating
In light of what has been observed in the schools there are several areas in which
improvement, continued development and in some cases disbanding needs to take place.
The ratio of student to break period and or length of break period observed may prevent
students from selecting healthier meal options as pre-prepared and or fast-food such as
snacks, pastries and or sweets are usually less time consuming to have. Schools should
consider alternate periods for different Forms be have their break or an overall extension
on the time allotted for break period.
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Principals should develop guidelines (based on the Manual submitted) for the offerings at
school canteens, tuck shop and vendors to ensure that there is an increase in the amount
of fruits and vegetables available. It has been noted in European countries that reducing
the product size of juices, drinks and sodas to match individual serving sizes has
positively impacted on health outcomes among adolescents. The schools can attempt to
advocate for the sale of smaller packaged foods. Schools could also promote complex
carbohydrate snack items and increase fibre consumption through tools such and menu
planning activities and cooking competitions.
Through strengthened partnerships between school and private/public sector it would be
advantageous to increase the capacity of the SFP offered by some schools. This not only
encourages but also provide healthy meal options in addition stimulating academic
performance. Schools should encourage the expansion of areas for food service to fully
accommodate students and staff.
At the project schools the vendors/food service staff had the requisite permits, however,
food safety standards were lacking in all but one school. Policy as well as oversight from
the school board should demand accountability from vendors and food service operators
to guard against unsafe food practices. Disseminating educational materials on food
safety is also a simple but efficient way of getting the message across to both vendors and
consumers.
In the Caribbean, parent involvement in school activities is generally lacking and very
few are involved in their children‟s education from a total developmental point of view.
Activities were organized but parents did not participate. More innovative ways were
needed to attract them. Schools were left free to develop this area of the project with
some guidance as given in the Lifestyle Manual developed. However, because there
were not well functioning school and country teams, the necessary networking and
negotiating did not take place with key stakeholders.
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Schools did not deviate from the old way of meeting with the parents at PTA meetings
knowing the history of lack of attendance. Few activities were organized for weekends,
after school and during the vacation. This was unfortunate since the assumption was
made that at the country level teams would have been better able to plan based on culture
and traditions. Even though PTA meetings were used, some additional attractions should
have been included on the agenda to trigger curiosity. This was done at one time at the
WAHS, St. Kitts and there was an overwhelming turn out. The activities included: an
interactive presentation on the targeted behaviours; a few exercises that anyone could do
(the exercises were all matched to specific health components so they were better
appreciated); and the display of healthy snacks. Parents were informed how the snacks
were prepared and were able to sample them at the refreshment break.
Parents should have been allowed to formulate activities based on some basic information
on lifestyle and the link to obesity and diabetes and other NCDs. There needed to be a
better sensitization of parents. Efforts were made, letters sent but as was revealed in the
focus group discussions, the children were not giving their parents the notes. Other
means of communication may have helped.
The community was not as involved as they should have been but it may have been due
to a lack of sensitization and networking on the part of the in-country co-ordinators and
their respective teams. The community was not used effectively and this could have
affected the adoption of certain behaviours. For example, if arrangements were made for
transportation out of schools after the children participated in extra-curricular activities,
maybe more of them would have achieved the fitness levels for their age.
Eating Behaviours
Based on the qualitative and quantitative data, there seem to have been some changes in
the behaviours of the children, though minor. It is difficult to affect change in
adolescents who were not well exposed to healthy lifestyle bahaviours to show major
changes over a three-year period. The targeted children who were followed from Grade
7/Form 1 to Grade 9/Form 3.
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With respect to Nutrition knowledge, the children in the intervention schools had greater
knowledge up to Year 2 and then this changed in Year 3. This could have been due to
reduced classroom sessions and fewer promotional activities. The enthusiasm waned
from Year 1 to Year 3. The shortfall in lesson delivery left many students with the little
information from Years 1 and 2, and more so, the loss of lessons that were more skills
based and hands-on in Year 3. As the project progressed from year 1 to Year 3, students
in the intervention schools were consuming more vegetables, meat, peas, beans and nuts
than the control schools.
Consumption patterns in relation to population goals were positive with mainly increases
in the percentage of students meeting those goals. With respect to “variety of foods” in
year2, more students from the intervention schools reported eating from the six food
groups while no difference was seen in Year 3 even though less were eating the six food
groups. This could have occurred for several reasons:
Availability at school
Availability at home
Little reinforcement in class mid-way in the project
No significant changes in the offerings at the canteens, tuck shops and vendors.
Consumption patterns were assessed using discussions and quantitative surveys and more
particularly Food Record-Assisted 24 Hour Recalls. It must be noted, however, that the
data collected relied on the respondents memory, hence the need for adequate probing by
the interviewers, which was achieved through adequate training. This apart, interviewers
may have also experienced difficulties in recording quantities consumed and assessing
portion sizes. Respondents may have also failed to quantify accurately the amounts of
foods consumed.
Physical Activity Behaviours
The results showed that the children were more active but this was not reflected in all the
health fitness components. Flexibility improved from Year 1 to 3 in the intervention
schools but all other components favoured the control schools, even if the differences
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were not significant. Indications from the parents and students were that they were more
active as a result of the support given via the components of the project. There is a
possibility that if this cohort could be followed for a further two to three years and
policies put in place to ensure supportive environments then more positive outcomes
would be realized.
Health Status
There was a significant decline from Year 1 to Year 3 in the overweight and obesity
status of the children in the intervention schools when compared to the control schools.
Interestingly, perceptions of body size were not as in reality. The children felt that they
were underweight when they were not while there were fewer children thinking that they
were overweight when they actually were based on the BMI-for-Age. This is an
indication that there is still a lack of knowledge and a bit of misconceptions associated
with body size and a lack of information on healthy body weight. This could affect the
behaviours in many ways. The change in health status based on BMI-for-Age where
there was a shift from overweight to normal and from obese to overweight, may have
been due to the intervention but it is not clear that specific goals set by the children
contributed to the shift.
When the blood pressures were correlated to the BMIs, more persons in the overweight
and obese categories were pre-hypertensive and hypertensive respectively as would be
expected. There was just a minor decrease in the percentage of students who were
hypertensive compared to those in the control schools. Overall, the changes were not
significant by school type or gender: in Year 1 a small percentage more females were
pre-hypertensive than males. No definite conclusion can be drawn from the results of the
blood pressures as they relate to the targeted behaviours.
Lessons Learned
The implementation of Lifestyle Interventions to instill healthy eating and physical
activity behaviours in school children generated some useful lessons. Some general
lessons learned from the project include:
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There must be strong buy-in and commitment at the ministerial and stakeholder
level.
There are some challenges in getting teachers to move away from didactic
learning techniques.
Teachers and students must develop a sense of ownership regarding the project
intervention
Parental and community wide support is necessary in order for a supportive
environment to be fostered.
Teacher training must be carried out so that clear, consistent and accurate
messages are delivered to all students.
The development of clubs and creative student activities must be incorporated in
the intervention to ensure that the key target behaviours are reinforced.
In considering the conduct of intervention programmes from conceptualization to
evaluation, several challenges were encountered due to assumptions made on ideal based
on research available at the time and not carefully considering the realities as they exist.
The following lessons were learned and recommendations made.
Conceptualization
Lifestyle projects involve complex social, economic and family issues therefore a
comprehensive approach based on the Health status of children, including promotion
through classroom activities and the creation of conducive environments for behaviour
change need to be encouraged. In conceptualizing school projects these interrelationships
are considered a given but in the Caribbean, "Health Promotion" is discussed at various
levels but governments are still not fully appreciative of prevention programmes.
Usually they are interested in or fund one main component and desire quick results. For
lifestyle projects to be properly conceptualized one should:
Tailor requested programmes to include other key aspects based on resources
Do extensive ongoing sensitization and awareness
Have a constant presence in the schools
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Planning
When planning the project and deciding on the design to use, one may assume that
experimental and control schools are in the various geographical and socioeconomic
areas, but not all schools set out in the criteria are available for study. Many times, the
numbers for power and statistical significance cannot be confirmed during planning. To
address this:
Understand the limits of the region and adjust plans accordingly
Critical to lifestyle projects is the formation of a multidisciplinary team with an
appropriate Steering Committee and there is need for:
a paid Coordinator;
a school management team; and an identified Liaison Officer in Schools with
Principal central to the activity.
With respect to project management, roles and functions for each level a clearly defined
project management team should be defined: Ministry of Education, Health and Sport
should be made responsible for the development of Policy; Schools should be responsible
for administration; Dietitian/Nutritionist/technician should be the persons concerned with
technical standards and procedures; and school personnel(teachers etc) with the daily
supervision and implementation. However, what really exists are roles and functions that
are not consistent; there are limited technical personnel (Nutritionist, Dietitians and
Technicians not in existing organizational structure must be employed through project
funds); and teachers are concerned about encroachment on curriculum To address this
there should be:
Involvement of planners and decision-makers at the highest levels to get buy-in
from principals and the relevant Ministries;
Harmonization and standardization of title and qualifications across the regions;
Regional and International agencies will need to:
collaborate closely with governments to implement programmes due to
limited technical expertise in countries; and
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encourage and support public policy, legislation and regulatory processes for
capacity building, success and sustainability.
Training
Training of teachers is critical to the success of school-based behavioural interventions.
Ideally one would like to see nutrition education and physical activity incorporated into
school curricula using a more integrated and intersectoral approach for lifestyle
programmes. However in reality, teachers are accustomed to vertical as opposed to
integrated programmes and intervention programmes seem like extra work unrelated to
their school curricula. Little emphasis is placed on lifestyle and behavioural outcomes
and more on passing examinations. There is a lack of experience in intersectoral
activities. To address this, training should focus on the use of Infusion Teaching
Methods which are less disruptive. There should be initial training followed by refresher
training on an ongoing basis and monitoring of lessons should be done by both by
teachers and peers. The issue of difficulties in getting teachers out to training is real. In
many cases:
• teachers are not available during the vacation and during the school term;
• others doing professional development training courses;
• Some countries have set policies for training during the term (no training)
• Some teachers do not attend even with time off. To address this: try not to
interfere with the school vacation or activity periods for any substantial activities; and
remember schools have their set schedules per term. Offer Residential training
preferably out of country.
With respect to physical activity, there are opportunities for increased and ongoing
physical activity in schools. However, there is no systematic approach to PE which in all
countries seem to be equated to cricket, football/soccer, netball etc. To take hold of these
opportunities:
Make PE compulsory in schools
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Increase opportunities for physical activity both within and outside of the
curriculum.
In addressing the lifestyle projects in schools there is an assumption assumption that all
children of the same age are at comparable developmental and educational level. In
reality there are special needs and remedial children who are challenged to keep up; and
teachers who are very challenged teaching those special needs children (often due to high
teacher: student ratio). This can be addressed by integrating principles, concepts and
skills training about healthy eating and physical activity at all levels of the school system
and throughout the school environment.
There is a notion that the Education Sector understands the importance and components
of a healthy lifestyle to education and productivity. However, there is a lack of adequate
nutrition training at Teachers‟ Training Colleges; a paucity of trained and motivated
teachers in PE; and inappropriate and inadequate teaching material especially for special
needs children. To address this:
Incorporate basic principles related to positive environments for positive health
lifestyles in Teachers‟ Training Colleges
Schedule time to orient and equip teachers and school personnel to implement
healthy lifestyle programmes.
It is felt universally that there should be ownership of lifestyle interventions by the
Education Sector. However, there is a lack of commitment and ownership of projects by
teachers due to competing priorities; and a lack of motivational incentives. This can
work if:
Teachers basic needs are satisfied first (before initiation of intervention)
Motivational training is done for teachers
There are better compensation packages for teachers and improved physical
facilities and surroundings. This could motivate teachers to support
additional responsibilities.
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Implementation
Theoretically, proper project management calls for the identification of verifiable
indicators and to monitor pre- ongoing and post-implementation. However, in reality
there is limited time and available human resources. The process can be very disruptive
and there is a lack of feedback on findings which can frustrate teachers and students.
This can be addressed by:
making data collection concise and direct – more emphasis on behavioural
outcomes; and
trying other methods such as: review of portfolios; process observation; linking
impact/outcome evaluations with other school initiatives (e.g. the collection of
school health data) and giving feedback to population in a nice setting.
In an ideal world there would be adequate allocation of resources (Time, Facility, Human
resources, funds, Materials) for projects. In reality there is a short specific school year
and planning and implementation time limited; there are less than ideal facilities and
materials; not enough technical resources for daily operations; limited funding for Social
projects; and external funding for short stipulated periods without building capacity for
sustainability. To address these:
Try to get better support (financial) by government and the opposition parties for
ownership and sustainability;
Coordinate resources through multi-sectoral planning
Make judicious use of resources.
Monitoring and Evaluation
Finally, the assumption is made that implementation of lifestyle projects would be
smooth with little disruptions. In reality the targeted population sometimes have drastic
changes which can affect the intervention such as:
Frequent changes in national administration which is a constant threat to
sustainability;
Disruptions due to natural disasters and Trade Union disputes (involve these early in
the planning process);
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Rate of teacher turnover/staff changes;
Lack of political will and buy-in.
Incremental ownership by politicians
Healthy lifestyle issues are usually not incorporated in national education policies. There
are insufficient National policies holding schools accountable. There needs to be:
A review national education sectoral policies to include:
compulsory physical education in schools
compulsory weight management modules and counseling techniques as
part of the education of teachers and health care workers.
Discontinued use of excessive amounts of sugar-and fat-containing foods
offered in cafeterias and school vendors and encourage students to make
healthy diet and lifestyle choices.
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CONCLUSION
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5. CONCLUSION
In this project there were seven behaviours (five on diet and two on physical activity)
targeted:
Eating a Variety of Foods Daily;
Eating Breakfast Daily;
Eating Fruits and Vegetables Daily;
Reducing Daily Intake of Fats and Salts;
Reducing Daily Intake of Sugary Snacks and Drinks;
Engaging in at least Moderate Physical Activity (PA) for a Minimum of 60
minutes at least 5 days Weekly; and
Engaging in a Variety of Physical Activity Daily.
An attempt was made to instill these behaviours in adolescent school children in
secondary schools in selected representative countries of the Caribbean (SKN, TRT, GRE
and SVG). The approach used was to work with these students in the school setting and
supported by the families and communities by focussing activities in the following four
components:
I. Behaviour Curricula on Nutrition/Diet and Physical Activity (Lessons)
II. School-wide Promotional Activities (Programmes)
III. Building Supportive Environments at School (Environment)
IV. Building Supportive Environments at Home and Community (Environment and
Family Support)
In spite of the fact that changes in behaviours were minimal and only slightly significant
in some areas, the approach of changing the environment to affect behaviour change has
great potential for a model to develop Nutrition Policies for Caribbean Schools that focus
on the four components. These, in conjunction with the school and country teams, can
auger well to improve diet and physical activity behaviours in school children. The main
goal of that policy should be to improve the health status of school children and to reduce
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the prevalence of obesity and chronic diseases in the target population. More specifically
the policy should seek to:
Teach knowledge and skills to adopt healthy eating and physical activity
practices.
Have fewer children with modifiable risk factors for NCDs.
Decrease the prevalence of NCDs in children and the population.
Increase physical activity in all schools.
Instill healthy behaviours in children for making healthy food choices.
The following can be possible outcomes of that comprehensive policy:
Individuals (children and staff) making healthier food choices.
Persons (children and staff) engaged in more physical activity.
School gardens and the use of more local foods encouraged.
Food services in operation consistently serve foods from various food groups and
in correct portions.
Appropriate playing areas and space that allow the students to engage in daily
physical activities are provided.
Instruments to systematically collect school health data designed and
administered.
Healthy lifestyle concepts into the delivery of subject of core areas infused or
integrated.
Nutrient requirement for school feeding programme established.
Collaborative research between stakeholders (health) on issues relating to
children‟s health conducted
Working as a team, the various sectors - private and public and NGOs, with the
Ministries of Education playing a key role, can certainly support students in achieving
health and wellness and preventing obesity and associated conditions like diabetes.
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BIBLIOGRAPHY
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6.0 BIBLIOGRAPHY
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3. Dwyer, B. (2002). Training Strategies for the Twenty-First Century: Using Recent
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4. Henry, F (2004c). “The Public Policy Approach to Combat Obesity”. CAJANUS,
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9. World Health Organization, Geneva (1998). Healthy Nutrition: and essential
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ANNEXES (See document attached)
