PEDIATRICS Vol. 120 No. 4 October 2007, pp. e1059-e1068 (doi:10.1542/peds.2006-3003)
ARTICLE |
Healthy Buddies: A Novel, Peer-Led Health Promotion Program for the Prevention of Obesity and Eating Disorders in Children in Elementary School
Endocrinology and Diabetes Unit, Department of Psychology, British Columbia's Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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OBJECTIVE. We designed and tested a novel health promotion program for elementary schools that was based on peer teaching from older to younger schoolchildren ("Healthy Buddies").
SUBJECTS AND METHODS. This prospective pilot study compared the effect of our program (2–3 hours/week, 21 weeks) in 2 Canadian elementary schools (intervention: n = 232 children, the whole school implementing the program; control: n = 151). Older students (4th through 7th grade) were given direct instruction from 1 intervention teacher and were paired with younger students (kindergarten through 3rd grade) for the whole school year. Students in 4th through 7th grade then acted as teachers for their younger "buddies." All lessons included 3 components of healthy living: nutrition, physical activity, and healthy body image. The students first learned how to be positive buddies and learned the 3 components of a healthy life. Thereafter, they learned how to overcome challenges to living a healthy life. Outcome measures (intervention and control schools at the beginning and end of the school year) included validated questionnaires that assessed healthy-living knowledge, behavior and attitude, a 9-minute fitness run, self-competence, body satisfaction, disordered eating symptoms, and anthropometry (BMI, blood pressure, and heart rate).
RESULTS. Compared with control students, both older and younger intervention students showed an increase in healthy-living knowledge, behavior, and attitude scores and a smaller increase in systolic blood pressure. BMI and weight increased less in the intervention students in 4th through 7th grade and height more in the intervention students in kindergarten through 3rd grade.
CONCLUSIONS. Our student-led curriculum improved knowledge not only in older schoolchildren but also in their younger buddies. It also decreased weight velocity in the older students. Student-led teaching may be an efficient, easy-to-implement way of promoting a healthy lifestyle from kindergarten to 7th grade.
Key Words: Healthy Buddies • elementary school • prevention • lifestyle • peer-led promotion program • nutrition • physical activity • body image
Abbreviations: HLQ—Healthy Living Questionnaire • ChEAT—Children's Eating Attitude Test • EAT—Eating Attitude Text • CI—confidence interval • NS—not significant
Since 1981, there has been a secular trend toward an increase in BMI of 0.1 kg/m2 per year among Canadian children,1 and more than one quarter of 2- to 17-year-old Canadian children and adolescents are overweight or obese.2 Once established, the treatment of childhood and adolescent overweight is difficult and poorly effective.3 Early intervention can potentially modify environmental risk factors for the development of weight excess in childhood, such as decreased activity and poor nutritional habits.4
The incidence of anorexia nervosa and bulimia nervosa among adolescent females approaches 1% and 5%, respectively.5 In addition, up to 29% of adolescents also exhibit behaviors (eg, restrictive eating, binging, purging, generalized food preoccupation, distorted body image) on the eating disorder spectrum, without meeting the strict criteria for anorexia nervosa and bulimia nervosa.6,7 These behaviors may be associated with significant health morbidity and mortality.8 As is often the case for obesity, the treatment of eating disorders is complex and often ineffective.9 Attempts to change unhealthy eating attitudes and behaviors at an early stage are essential.10
Children spend a significant amount of time at school. Therefore, the classroom has long been considered an ideal setting for effective prevention and health promotion.11 Intervention in elementary school–aged children can impact critical periods for obesity onset, such as adiposity rebound and puberty.12 Concerns about weight and shape are already present in elementary school–aged children, 13 and early attitudes and behaviors about food and body image predict later problems with disordered eating.14 In addition, food and lifestyle preferences and patterns tend to become entrenched as children progress to adolescence.15 There is a need for efficient, cost-effective, easy-to-implement programs for the prevention of both obesity and eating disorders. A review by the World Health Organization found that school-based health promotion interventions are more likely to be effective when they are multifactorial, intensive, involve the whole school, and are at least 1 year in duration.16
Peer teaching is defined as education of young people by young people.17 Interventions using a peer-teaching model for health promotion have shown positive effects and studies show participating students highly value the peer-teaching experience.18 Healthy Buddies is a peer-led health promotion program that we designed for use with elementary school students from kindergarten to 7th grade. Older "buddies" (4th through 7th grade) first receive a healthy-living lesson from their schoolteachers. These older buddies then act as peer teachers to deliver that lesson to their younger buddies (kindergarten through 3rd grade). Schoolteachers do not conduct separate lessons with the younger buddies. Healthy Buddies is implemented in the entire school with all paired classes progressing through the 21 (weekly) healthy-living lessons concurrently, bringing awareness about health promotion into the school milieu. We hypothesized that Healthy Buddies would be a powerful tool to promote and improve health for both younger and older elementary students. The objective of this study was to pilot Healthy Buddies in 1 elementary school and evaluate the effect of the program on students' health knowledge and behaviors, self-competence, body satisfaction, disordered eating behaviors and fitness, as well as physical characteristics of height, weight, BMI, blood pressure, and heart rate. Another school served as a control.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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The pilot study involved 2 public elementary schools (kindergarten through 7th grade) located along the Sunshine Coast of British Columbia, Canada. Population for both schools is predominantly white; the area has an annual family income slightly lower than the average for British Columbia ($57052 vs $64821) and is considered middle class socioeconomic status.19 Both the intervention and the control schools are located in the same school district but are geographically distant to minimize influence of the intervention school on the control school population. Selection of the 2 schools was based on expressed interest and school district superintendent support. The intervention school was selected because it had an even number of classes, which made buddy pairing more efficient for this pilot study. The Healthy Buddies program was implemented in the intervention school, whereas no intervention took place in the control school. Ethics approval was obtained from the ethics review boards from the University of British Columbia and from Children's and Women's Health Centre of British Columbia. Informed consent was received from parents/guardians and assent from students. Families/students from the intervention school who did not provide consent/assent received the intervention in their classroom but were excluded from all measurements.
Program
Our Healthy Buddies program20 was developed around the prescribed learning outcomes from the British Columbia Ministry of Education. The program's content is based on 3 main components of healthy living: being physically active, eating healthy foods, and having a healthy body image. The program's slogan ("Go Move!", "Go Fuel!", and "Go Feel Good!") emphasizes these 3 themes. Twenty-one healthy-living lessons were designed and taught over the course of the study school year.
At the beginning of the school year, students in 4th through 7th grade were paired with kindergarten through 3rd-grade buddies. Each week, students in 4th through 7th grade at the intervention school received a 45-minute healthy-living lesson through direct instruction from the intervention teacher. Students in 4th through 7th grade then acted as peer educators, teaching a 30-minute lesson to their kindergarten through 3rd-grade buddy. Buddy lessons were delivered using a variety of techniques (eg, presentations, games, art activities, etc). In the first half of the year, the buddy pairs learned how to be positive buddies and learned about the 3 components of a healthy life. In the second half of the year, they learned about the challenges to living a healthy life (eg, the media) and how to overcome these obstacles. Each buddy pair also spent two 30-minute structured physical activity sessions per week in the gymnasium, which allowed both classes (paired buddies) to participate simultaneously. Several steps were taken to decrease the potential variability in the performance between buddy pairs and to ensure that all younger buddies receive a similar experience. For instance, buddy pairs were changed once during the year, buddies away because of illness would be replaced by other buddies, and older buddies still developing in their leadership abilities would be paired with a more capable older buddy.
A brief description of the 3 themes of the Healthy Buddies program is provided below.
Regular Physical Activity: "Go Move!"
The buddy pairs spent 2 sessions per week doing 30-minute structured aerobic fitness sessions, called fitness loops. Each fitness loop incorporated a circuit, with a series of stations, designed around a theme (eg, transportation fitness loop). Students were encouraged during the fitness loops to exercise vigorously, using self-measured parameters of physical exertion (eg, sweating, red in the face, etc). The intervention school also participated in a school-wide healthy-living theme day, midway through the year. Each classroom prepared an activity and buddy pairs rotated through the different activities.
Healthy Eating: "Go Fuel!"
Students learned about nutritious and nonnutritious foods and beverages and were exposed to numerous examples of healthy foods throughout the program. Students' learning was reinforced through exercises such as memory card games and visual art projects. Students learned about why we eat, about how the body uses fuel and about energy balance.
Healthy Body Image, Self-esteem, and Social Responsibility: "Go Feel Good!"
Students first learned about valuing themselves and others based on who they and others are on the inside. The Healthy Buddies program also addressed body-image and disordered eating issues by teaching kids about healthy growth and development and media literacy. Fitness loops were designed for every level of fitness so that the physical activity component aids in healthy body-image development. The peer-led structure was designed to facilitate social skills development as well as self-esteem and social responsibility through role modeling.
A more comprehensive description of the Healthy Buddies program can be obtained from our Web site.20
Measures
Participating students in both the intervention and control schools were evaluated during the same week at the beginning (September) and at the end (June) of the study school year.
Anthropometric Evaluation
Height and weight were measured in light clothing with shoes removed to the nearest 0.1 cm and 0.1 kg, respectively, using a portable stadiometer (model 225 1821009; Seca, Birmingham, England) and scale (model 987; Salter, Tonbridge, England). Blood pressure (mmHg) and heart rate (beats per minute) were measured on the right arm of the participants using a Dinamap Pro300 (Critikon, Tampa, FL). All data were collected by trained volunteer physicians. These volunteers only participated in the collection of the data and were blinded to the status of the students.
Fitness Assessment
Fitness was measured by the 9-minute run, a validated measure of fitness in children in elementary school.21 In short, a track with 4 designated quarter marks was delineated on an outdoor school playing field at each of the intervention and control schools. To avoid competition between students, runners started from different quarter marks. The distance run during a 9-minute period was measured by a group of secondary-school student volunteers.
Questionnaires
Healthy Living Questionnaire
Primary (kindergarten through 3rd grade) and intermediate (4th through 7th grade) Healthy Living Questionnaires (HLQs) were designed by our study team to measure knowledge about and behaviors toward various aspects of healthy living. The self-report questionnaire assessed body image, food preoccupation, self-competence, knowledge about nutrition/physical activity, and frequency of healthy eating, exercise, and healthy-living behaviors. It also included questions about general health attitudes and emotional health. Kindergarten through 3rd-grade students received 1-on-1 assisted administration by trained undergraduate volunteers. Students in 4th through 7th grade received in-class group assisted administration by the assessment coordinators. Both age-appropriate versions of the HLQ were piloted in a nonparticipating school before study onset. Kindergarten and grade-4 students received the questionnaire on 2 occasions, 2 weeks apart, to test reliability of the measure. Several of the questions (5 of 9 on the intermediate HLQ, and 5 of 8 on the primary HLQ) showed excellent test-retest reliability (r = 0.7–0.9). Those questions that had r < 0.7 were modified or simplified. To obtain a valid questionnaire, we used questions from previously published questionnaires in the literature that used similar school-based intervention studies.22,23 The questions were then reviewed with experts in the field (eg, elementary school teachers, students).
Harter Self-competence Scales
Two age-appropriate scales were used. Students in 3rd through 7th grade received the Perceived Competence Scale for Children.24 This scale is a 28-item self-report instrument for children 8 to 14 years old, assessing children's perceptions of self-competence within 3 distinct skill-based domains: cognitive (emphasizing academic performance), social (emphasizing peer relationships), and physical (emphasizing sports and outdoor games). A fourth subscale measures general self-worth as a superordinate construct, independent of specific skills. Items are scored on a 4-point scale, with averages calculated for each of the 4 domains. Students from kindergarten to 2nd grade received a downward extension of the intermediate scale. The pictorial scale of Perceived Competence and Social Acceptance for Young Children was administered immediately after the HLQ.25. The instrument is composed of 24 items, pictorially representing 4 domains: cognitive competence, physical competence, maternal acceptance, and peer acceptance loading on 2 factors: general perceived competence (composed of subscales of cognitive and physical competence) and social acceptance (composed of maternal and peer acceptance subscales).
Body-Image Perception
Students in 4th through 7th grade received a modified version of the Figural Rating Scale to assess body-image perception and satisfaction.26 Students received sets of 7 differently sized nonlinear adult figures, 2 sets matching gender of respondent and 1 of opposite gender. Students were asked to rate their Current Self, Ideal Self, and Ideal Other. Students in kindergarten through 3rd grade received a modified version of Schematic Figures (Child/Adolescent Version) to assess body-image perception and satisfaction.27 Kindergarten through 3rd-grade students received the same instructions and scale layout as the 4th- through 7th-grade students, with 2 sets of 7 nonlinear matched gender child figures and 1 set of 7 nonlinear opposite gender child figures.
Children's Eating Attitude Test
The Children's Eating Attitude Test (ChEAT) is a validated measure of children's eating attitudes used for screening symptoms of disordered eating.28 It is a modified version of the adult Eating Attitude Test (EAT, EAT-26), a self-report inventory measuring bulimia and anorexia nervosa, dieting, preoccupation with food and body weight. The ChEAT is validated for children ages 8 through 13 years and was reproduced with permission for the intermediate questionnaire battery. For the students in kindergarten through 3rd grade, our study team modified the ChEAT for comprehensibility. This modified version was piloted before study onset, in conjunction with the piloting of the HLQ. Test-retest reliability was established by administration to kindergarten children at 2 intervals, 2 weeks apart.
Statistical Evaluation
Baseline characteristics are reported as mean ± SD and changes in the variables under study over the 10-month study are provided as mean (95% confidence interval [CI]). We used a 2-tailed paired t test to evaluate the significance of the changes in the various parameters over the 10-month study. Considering potential correlation within school class, the effect of the intervention was assessed by using mixed-effects model analysis with class as the cluster, after controlling for gender and grade. A P value of <.05 was considered statistically significant. Data were analyzed with SAS 9.1 (SAS Institute Inc, Cary, NC).
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RESULTS |
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Physical Characteristics
Ninety-five percent (intervention) and 79% (control) of the eligible schoolchildren participated in the study. The baseline characteristics of the participants are reported in Table 1.
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Kindergarten Through 3rd Grade
As expected, weight and height increased significantly in students in both the intervention and control schools during the 10-month study (P < .001). However, there was a greater height increase in the students in the intervention group (mean: 4.9 cm; 95% CI: 4.6 to 5.2 cm) compared with the students in the control group (mean: 4.1 cm; 95% CI: 3.8 to 4.3 cm; F = 13.2; P < .001; Fig 1A). The increase in systolic blood pressure was significantly lower in the students in the intervention group (mean: 1.0 mm Hg; 95% CI: –1.1 to 3.1 mmHg; P not significant [NS]) compared with the students in the control group (mean: 5.4 mm Hg; 95% CI: 2.6 to 8.1 mmHg; P = .005; F = 5.2; P = .025; Fig 2A). Diastolic blood pressure did not significantly change over the school year and was not affected by the intervention. Changes in weight, BMI, and heart rate between baseline and follow-up measures were not significantly affected by the intervention.
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4th Through 7th Grade
Similarly, weight and height increased significantly in students in 4th through 7th grade during the 10-month study period (P < .001). However, there was a smaller increase in body weight and BMI in students in the intervention group (mean: 2.9 kg; 95% CI: 2.5 to 3.3 kg and mean: 0.4 kg/m2; 95% CI: 0.2 to 0.5 kg/m2, respectively) compared with students in the control group (mean: 3.9 kg; 95% CI: 3.2 to 4.6 kg and mean: 0.7 kg/m2; [95% CI: 0.5 to 0.9 kg/m2; F > 7.1; P < .008; Fig 1B). Systolic blood pressure remained unchanged in the students in the intervention group (mean: 0.0 mm Hg; 95% CI: –2.5 to 2.5 mmHg; NS), contrasting with an increase of 4.0 (1.3 to 6.8) mmHg (P < .001) in students in the control group (F = 7.7; P = .006; Fig 2B). Diastolic blood pressure did not significantly change over the school year and was not affected by the intervention. Changes in height and heart rate between baseline and follow-up measures were not significantly affected by the intervention.
9-Minute Run
In both the intervention and control schools, there was a statistically significant increase in the distance covered during the 9-minute run between the beginning and the end of the 10-month study, an effect that could be attributed to the maturation or the training of the subjects (P < .001). This increase was however similar in intervention and control schools, both for kindergarten through 3rd grade (mean: 147 m; 95% CI: 102 to 192 m in intervention and mean: 108 m; 95% CI: 56 to 160 m in the control school) and students in 4th through 7th grade (mean: 75 m; 95% CI: 32 to 118 m in intervention and mean: 81 m; 95% CI: 43 to 118 m in the control school; F = 0; NS).
HLQ
Baseline HLQ scores for knowledge, behavior, and attitude are reported in Table 1.
Health Knowledge
The maximum score for these questionnaires is 47, with a higher score reflecting better knowledge of nutritious versus nonnutritious foods and beverages and physically exertive versus nonexertive activities.
Kindergarten Through 3rd Grade
There was a significant increase in health knowledge scores for both the intervention (mean: 6.1; 95% CI: 5.3 to 6.8; P < .001) and the control students (mean: 1.9; 95% CI: 1.1 to 2.7; P = .004). However, intervention students showed a markedly greater increase in health knowledge scores (F = 33.9; P < .001, Fig 3A).
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4th Through 7th Grade
Statistically significant improvements in health knowledge scores were found for the intervention students (mean: 6.8; 95% CI: 5.7 to 7.8; P < .001) only. Students in the control group showed minor improvements (mean: 0.8; 95% CI: –0.8 to 2.0; NS; F = 37.1; P < .001; Fig 3B)
Health Behavior
The maximum score for these questionnaires is 94, with a higher score given to those reporting good health practices such as increased report of healthy eating and physical activity.
Kindergarten Through 3rd Grade
There was a significant increase in health behavior scores between baseline and follow-up for students in the intervention group (mean: 5.6; 95% CI: 3.2 to 7.9; P < .001) and students in the control group (mean: 2.8; 95% CI: 0.9 to 4.7; P = .004). There was a trend toward a higher increase in health behavior scores in students in the intervention group compared with students in the control group (F = 2.9; P = .093) but the difference was only significant for female students in the intervention group compared with female children in the control group (school x gender interaction; F = 6.4; P = .013; Fig 3A).
4th Through 7th Grade
Health behavior scores increased significantly in the children in the intervention group (mean: 6.4; 95% CI: 4.4 to 8.5; P < .001) but not in the children in the control group (mean: 0.8; 95% CI: –0.7 to 2.4; NS). Mixed-model analysis revealed that the magnitude of the change was significantly greater for students in the intervention group compared with students in the control group (F = 4.5; P = .025; Fig 3B)
Health Attitudes
The maximum health attitudes score is 34 for the kindergarten through grade-3 questionnaires and 80 for the grade-4 through -7 questionnaires; higher scores are given to those reporting healthier attitudes.
Kindergarten to 3rd Grade
Statistically significant improvements in the scores were observed in children in the intervention group (mean: 1.8; 95% CI:0.8 to 2.7; P < .001) but not children in the control group (mean: 0.3; 95% CI: –0.8 to –1.4; NS). Accordingly, the magnitude of the changes in health attitude score was significantly greater in children in the intervention group compared with those in the control group (F = 4.2; P = .043; Fig 3A).
4th Through 7th Grade
Similarly, health attitudes scores increased significantly in the older intervention group (mean: 4.7; 95% CI: 2.7 to 6.6; P < .001) but not students in the control group (mean: 1.9; 95% CI: –0.1 to 3.9); P = .062; F = 4.5: P = .035: Fig 3B).
Body-Image Perception, ChEAT, and Harter Self-competence Scales
Kindergarten to 3rd Grade
Cognitive and physical competence subscale scores increased similarly in both children in the intervention group and in the control group (P < .04). Body-image perception, ChEAT, and Harter scores were not significantly affected by the intervention.
4th Through 7th Grade
Similar to the primary results, no significant intervention effect was found for any of these measures.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Our study demonstrates that students can be successful teachers in the classroom and that older students can effectively promote health to younger students, resulting in positive changes in both populations. Implementation of our 10-month (1 school year) intervention improved health knowledge, health attitudes, and health behaviors not only in older schoolchildren (4th through 7th grade), who were taught by the intervention teacher, but also in younger schoolchildren (kindergarten through 3rd grade), who received the healthy-living lessons from their older buddies. We also provide preliminary evidence that the Healthy Buddies program can optimize height and weight parameters in all students. In addition, we show that comprehensive health promotion can be achieved in elementary schools within the prescribed provincial curriculum.
Our study used peer-led education, defined as education of young people by young people,17 as a vehicle to disseminate the information. Thus, it is a student-led, not a teacher-led, program. Although there is a scarcity of rigorous evaluations of such programs, studies that evaluate health-related peer-education suggest that these programs may be more effective, resulting in greater positive changes in knowledge, attitudes, and behavior, than teacher-led interventions.29 In addition, peers have a strong influence on eating behavior and body esteem.30 The proposed advantages of student-led programs over adult-led programs are thought to be their cost-effectiveness, the fact that they empower the students doing the teaching, and that they give the student-teachers the opportunity to be positive role models.31 To our knowledge, there has been only 1 study that used peer-led teaching to promote healthy lifestyle in a school setting.29 The peer-leaders were elected by the students in the same classroom (7th grade), and the intervention focused on healthier nutrition. The effectiveness of the intervention was not reported, but the results suggest that such an approach was very well received by both the students and the teachers.
Our intervention program, entitled "Healthy Buddies: Children Teaching Children to Go Move, Go Fuel, and Go Feel Good" is innovative for a number of reasons. First, it includes not only older children in elementary school (4th through 7th grade) but also children in the younger grades (kindergarten through 3rd grade). Our program clearly demonstrates that peer-led education of the youngest schoolchildren is feasible and can be effective.
Second, we engage the school as a unit through cross-grade pairing of every class. Many Canadian elementary schools already use pairing of intermediate students with primary students for educational purposes (eg, reading groups, tutoring), and it was, therefore, logical to design a program with a similar structure. The pairing of older and younger grades makes it possible to involve all students. Having classroom teachers partnering to facilitate their buddy student sets can increase fidelity and embed support. By engaging the school as a unit (instead of focusing on just a few grades), we expect increased awareness and enthusiasm about the program. This aspect was not formally tested in our study. However, many teachers spontaneously reported a subjective decrease in bullying issues at the intervention school. This aspect will be formally tested in our expansion project.
Third, unlike previous prevention studies, our program considers obesity and eating disorders together, along a continuum of disordered eating. In agreement with Irving and Neumark-Sztainer32, we feel that it is potentially deleterious to focus a global prevention strategy on just 1 end of this spectrum. For instance, a significant percentage of adolescents, mainly girls, wrongly perceive themselves as overweight and engage in inappropriate dieting behaviors.33 Our prevention program focuses on promoting healthy attitudes and behaviors toward body image, nutrition, and activity combined with education about healthy growth and development.34 We did not observe a significant effect of the intervention on body-image perception, ChEAT, or Harter Self-competence Scales scores. This may be because of the fact that most students in kindergarten to 3rd grade and 4th through 7th grades had normal scores at baseline. The sample size in our pilot study was too small to determine whether students with extreme scores would more specifically benefit from the intervention and this will need to be addressed in larger studies.
Although weight and BMI increased in schoolchildren in both the control and intervention 4th- through 7th-grade groups, the increase was significantly lower in the students in the intervention group. This suggests that the increase in healthy knowledge, health attitude, and health behavior and/or the increase in physical activity achieved through the implementation of the Healthy Buddies program may have caused a smaller increase in weight and BMI. This needs, however, to be confirmed in a larger study. The greater increase in height velocity in kindergarten through grade-3 intervention students compared with students in the control group is more surprising. We do not believe that in a population of normal schoolchildren a program such as Healthy Buddies could positively affect longitudinal growth, and this aspect of the study needs to be reevaluated in a larger study.
Healthy Buddies was specifically designed around the provincial prescribed elementary school curriculum so that the program could be implemented in the intervention school within the time frame of regular classroom lessons. It comes as a comprehensive kit that includes physical activity materials, memory cards, and other games for reinforcing healthy-living lesson content, and resource binders with 21 lesson plans prepared. Lesson content meets learning outcomes in physical education, visual art, personal planning, leadership and social responsibility. The pairing of classes allows for safe and structured sharing of gym and outdoor recreational spaces reducing the demand on schools with limited spatial resources.
Our study had several limitations. First, this was a pilot study investigating the feasibility of our program. As such, it included only 2 schools and a limited number of schoolchildren. Therefore, although very promising, some of the differences observed between the control and intervention schools, such as the differences in the BMI, weight, and height changes need to be confirmed in a study that includes more participants. Second, the control school had a somewhat lower percentage of participation to the assessment part of the study. This could be because of a lower motivation of the parents/students to go through the assessment process (measurement, questionnaires) after hearing that they were not an intervention school. Third, we did not assess pubertal stage, information that is ethically difficult to collect in normal schoolchildren in North America. Although pubertal development is unlikely to affect the results of the younger children (kindergarten through 3rd grade), this could conceivably be different in the older participants. However, the height velocity during the 10 month-intervention was similar in the students in 4th through 7th grade in the control and intervention schools, suggesting that the pubertal growth did not introduce bias. Fourth, we cannot comment on whether our student-led intervention is more effective than a traditional teacher-led intervention. However, our program has the advantage of being integrated within the existing prescribed curriculum and of not requiring additional staffing. Last, whether the improvements in health knowledge and behavior are sustained beyond the school year remains to be demonstrated. However, because this intervention is designed to fit the prescribed school curriculum, it could easily be implemented on a continuous basis throughout the elementary school.
We have now received additional funding to implement our program in 40 elementary schools in British Columbia between 2006 and 2008 (20 schools during the 2006–2007 school year and 20 during the 2007–2008 school year). There are small differences with the program piloted in the present study. First, determination of the approximate age (±1 month) of the students (not only the grade they are in) has been approved by the ethics committee and is now being formally recorded, making possible the determination of BMI z scores although the importance of using BMI z scores over absolute BMI values was recently challenged.35 Second, the program will be implemented by the local school teacher, and not anymore by an external teacher. The program is being provided as a comprehensive kit and is demonstrated at 2 training sessions delivered by our Healthy Buddies team before program launch. This step is taken to promote sustainability of the program. Finally, a validated measure of empathy and a measure of social responsibility is now included in our program evaluation to formally assess the effect of the program on bullying.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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This pilot study suggests that peer-led teaching can be an effective tool to increase health knowledge, health behaviors, and health attitudes in children in elementary school as young as 5 years. Involving children this young captures an important population often neglected in other interventions. Pairing classes and classroom teachers for the duration of the program can increase fidelity and provide support. Having all students and teachers involved for the duration of the school year can impact the ethos of the school. Social responsibility may increase through structured buddy relationships as spontaneously reported by intervention school staff. Preliminary evidence that our program may have a positive influence on weight gain in the overall population of student-teachers needs to be confirmed in a larger study.
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ACKNOWLEDGMENTS |
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This study was supported by Toronto Sick Kids Foundation grant XG03-024. Dr Stock was supported by the Hoffmann La Roche Canadian Pediatric endocrinology fellowship.
We thank Valerie Ryden (coauthor of the Healthy Buddies program and the pilot study intervention teacher) for expertise and unwavering commitment; Min Gao (senior biostatistician) for advice and expert statistical help; and Jessica Reiser (baseline testing coordinator) and Ryan Ishkanian (follow-up testing co-coordinator). The enthusiastic support from Stewart Hercus (school superintendent, School District 46) and the staff and schoolchildren at our intervention and control schools is also very gratefully acknowledged.
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FOOTNOTES |
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Accepted Mar 14, 2007.
Address correspondence to Jean-Pierre Chanoine, MD, PhD, Endocrinology and Diabetes Unit, Room K4-213, British Columbia's Children's Hospital, 4480 Oak St, Vancouver, British Columbia, Canada V6H 3V4. E-mail: jchanoine{at}cw.bc.ca
Financial Disclosure: Dr Stock has intellectual property rights as an author of the Healthy Buddies Program. There is no financial relationship between Dr Stock and the Healthy Buddies Program. The other authors have indicated they have no financial relationships relevant to this article to disclose.
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