Discussion
obesity
OBESITY, CHILDHOOD OBESITY, STAGGERED, APPENDIX, BROWN
The Ajyal Salima intervention is the first of its kind to be implemented in the Eastern Mediterranean region. Indeed, efficacy data on nutrition education programmes are very scarce in this region, with the only other intervention studyAlthough our intervention was successful overall, there were differences amongst countries in the impact of the programme on dietary and physical activity behaviours, while knowledge and self-efficacy were improved across the board. Saudi Arabia and Palestine were the countries where the intervention had a strong impact on every aspect of dietary and physical activity behaviour. Amongst driving factors, identified through the qualitative analysis, are motivational incentives such as rewarding and recognising students and teachers, and actively involving parents in the programme, both particularly observed in Palestine.It is challenging to pinpoint unique success factors in the current study as the effect of each component was not tested independently and the reason for success is most likely multifaceted. However, by investigating how each country implemented the programme and gathering qualitative data from the feedback of programme coordinators, specific themes were extracted which could partly explain the success of the intervention, as well as the differences in results across the five study countries. First, the experiential or hands-on nature of the intervention was mentioned as the driving force behind the students’ motivation and eagerness to learn nutritional and physical activity concepts. In 2017, DeCosta et al have highlighted the importance of hands-on experience such as gardening and cooking programmes in increasing healthy food consumption in similar educational interventionsFinally, for students to apply the knowledge acquired through the educational part of the programme, access to healthy foods and activities in the school environment is fundamental but unfortunately, not always optimal. The extracted theme of budget constraints was especially present in the feedback of programme coordinators in Lebanon and Palestine and encompasses availability of fruits and vegetables on school grounds and accessibility to areas for physical activity. This could partly explain the lack of effect on physical activity behaviours in Lebanon despite the high rate of parents’ encouragement to engage in physical activity. Budget constraints and accessibility to extracurricular activities should be explored as an improvement opportunity reported in our qualitative data (Appendix). In their systematic review of interventions targeting childhood obesity prevention, Brown et al conclude that interventions targeting individual behaviour to prevent obesity are moderately successful, also suggesting that having upstream targets such as policymakers and school management would lead to a greater impact on obesityOur study has multiple strengths as well as some limitations. Strengths include the use of a randomised controlled intervention design and the sampling of public schools in different countries that are representative of the region. On the other hand, questionnaire-based methodology can be of concern in terms of internal validity, which is usually threatened by external confounding factors. For this reason, we have used random assignment of schools into control and intervention groups to minimise the effect of potential confounders such as social desirability bias, year of study and differences in implementation between countries. In addition, the Ajyal Salima study purposely used questionnaires and not interview assessments, shown to be less influenced by social desirability in children (40). Another limitation of the study is the different years of implementation for study countries. The Ajyal Salima project required the buy-in from ministries of each country, from the pilot country Lebanon to the rest of the region. Countries were rolled into the programme as soon as the ministries’ approvals were secured. This has led to a staggered implementation over 6 years. The presence of control schools matched for year of implementation in each country minimises the confounding effect of time on the main effect of the intervention. In addition, all statistical analyses were adjusted per ‘country’ to control for country-specific confounders such as year of implementation.Findings from this study show that the Ajyal Salima intervention, a school-based multi-component educational intervention, leads to significant improvements in dietary and physical activity habits when rolled out in five Middle Eastern countries. These changes are likely to occur via an increase in knowledge and self-efficacy also shown to improve as a result of the intervention. Countries were not equally successful at implementing the intervention or observing behavioural changes; however, modulating factors were identified which could be tackled to enhance the efficacy of the intervention. These factors were parent involvement, accessibility to healthy foods and activity on school grounds and the hands-on aspect of the intervention. Based on previous research, ensuring these three factors are optimised is best accomplished by having upstream targets such as public health policy and school board governance. Indeed, since the first implementation of Ajyal Salima, most countries have put in place school policies with nutrition and physical activity standards set by the ministries, encouraging healthy habits at the individual (nutritious choices) and school (canteens and shops) levels. There is also a need to engage families and communities through conveying the right messages in terms of nutrition and health. In this respect, digitalisation of the programme and its communication can help reach the extended network of students for a more sustainable change in behaviour.