Rebecca Lynch

Validation of a self-completion measure of breakfast foods, snacks and fruits and vegetables consumed by 9- to 11-year-old schoolchildren

Objective:To evaluate the validity and reliability of a dietary recall questionnaire, designed for group-level comparisons of foods eaten at breakfast and intake of fruits, vegetables, sweet items and crisps.Design:Validity was assessed relative to 24-h dietary recall interviews, and reliability by comparing the baseline data with 4-month follow-up data.Subjects and setting:Fifty-eight schools took part in the validity assessments, with 374 children completing both measures. Reliability was assessed using 29 schools, with 1233 children at baseline and 1033 at follow-up. Children were aged 9–11 years and schools were located in socio-economically deprived areas of Wales.Results:Results indicated moderate to substantial agreements for most foods eaten at breakfast on the day of reporting and fair to moderate agreements for breakfast foods the previous day. For items throughout the rest of the previous day, agreement was fair to substantial during school hours, but slight after school. Correlations were moderate in terms of ‘healthy’ items and ‘unhealthy’ items consumed at breakfast on the day of reporting, but weaker for the previous breakfast. Correlations between measures in terms of fruits, vegetables, sweet items and crisps throughout the rest of the previous day were fair to moderate. The measure demonstrated fair to substantial group-level reliability.Conclusions:The questionnaire, while subject to a number of limitations, gives an adequately valid and reliable overview of selected aspects of childrens diet. It is likely to be of value at group-level in randomized controlled trials of school-based interventions.Sponsorship:The research was funded by the Public Health Improvement Division of the Welsh Assembly Government.

Free healthy breakfasts in primary schools: a cluster randomised controlled trial of a policy intervention in Wales, UK

OBJECTIVE The present study evaluated the impact of a national school programme of universal free healthy breakfast provision in Wales, UK. DESIGN A cluster randomised controlled trial with repeated cross-sectional design and a 12-month follow-up. Primary outcomes were breakfast skipping, breakfast diet and episodic memory. Secondary outcomes were frequency of eating breakfast at home and at school, breakfast attitudes, rest-of-day diet and class behaviour. SETTING Primary schools in nine local education authority areas. SUBJECTS A total of 4350 students (aged 9-11 years) at baseline and 4472 at follow-up in 111 schools. RESULTS Students in intervention schools reported significantly higher numbers of healthy food items consumed at breakfast and more positive attitudes towards breakfast eating at 12 months. Parents in intervention schools reported significantly higher rates of consumption of breakfast at school and correspondingly lower rates of breakfast consumption at home. No other significant differences were found. CONCLUSIONS The intervention did not reduce breakfast skipping; rather, pupils substituted breakfast at home for breakfast at school. However, there were improvements in childrens nutritional intake at breakfast time, if not the rest of the day, and more positive attitudes to breakfast, which may have implications for life-course dietary behaviours. There was no impact on episodic memory or classroom behaviour, which may require targeting breakfast skippers.

Free breakfasts in schools: design and conduct of a cluster randomised controlled trial of the Primary School Free Breakfast Initiative in Wales [ISRCTN18336527]

BackgroundSchool-based breakfast provision is increasingly being seen as a means of improving educational performance and dietary behaviour amongst children. Furthermore, recognition is growing that breakfast provision offers potential as a means of addressing social inequalities in these outcomes. At present however, the evidence base on the effectiveness of breakfast provision in bringing about these improvements is limited.Methods/DesignThis paper describes the research design of a large scale evaluation of the effectiveness of the Welsh Assembly Governments Primary School Free Breakfast Initiative. A cluster randomised trial, with school as the unit of randomisation was used for the outcome evaluation, with a nested qualitative process evaluation. Quantitative outcome measures included dietary habits, attitudes, cognitive function, classroom behaviour, and school attendance. The study recruited 111 primary schools in Wales, of which 56 were randomly assigned to control condition and 55 to intervention. Participants were Year 5 and 6 students (aged 9–11 years) in these schools. Data were collected for all 111 schools at each of three time points: baseline, 4 month and 12 month follow-up. This was achieved through a repeated cross-sectional survey of approximately 4350 students on each of these occasions. Of those students in Year 5 at baseline, 1975 provided data at one or both of the follow-ups, forming a nested cohort. The evaluation also included a nested process evaluation, using questionnaires, semi-structured interviews and case studies with students, school staff, and local authority scheme coordinators as key informants.DiscussionAn overview of the methods used for the evaluation is presented, providing an example of the feasibility of conducting robust evaluations of policy initiatives using a randomised trial design with nested process evaluation. Details are provided of response rates and the flow of participants. Reflection is offered on methodological issues encountered at various stages through the course of the study, focusing upon issues associated with conducting a randomised trial of a government policy initiative, and with conducting research in school settings.Trial registrationCurrent Controlled Trials ISRCTN18336527

If I don't like it then I can choose what I want’: Welsh school children's accounts of preference for and control over food choice

The paper draws on qualitative data collected in focus groups with primary school pupils in years three and five (ages 7-11 years), carried out as part of a wider study evaluating the Primary School Free Breakfast Initiative in Wales. A total of 16 focus groups were carried out across eight schools to examine pupils perceptions of food and food related behaviour. A key finding was the way in which control over choice of food and access to healthy/unhealthy food options differed between younger and older pupils across home, school and eating out settings. While older participants experienced and valued high levels of control over food choice in all three settings, this was not the case for younger participants. Pupils in year three had little choice, particularly at home and school, with other factors (such as security, structure and mealtime companionship) being more important to them than ability to choose what they ate. All participants in the study expressed a general preference for unhealthy as opposed to healthy food items, even when acknowledging health consequences and engaging in some compensatory strategies. The authors suggest that interventions should aim to educate and encourage food providers, such as parents/carers, schools, and food outlets, to produce a range of healthy options, and encourage informed food choice among children at a younger age.

Well London Phase-1: results among adults of a cluster-randomised trial of a community engagement approach to improving health behaviours and mental well-being in deprived inner-city neighbourhoods

Background We report the main results, among adults, of a cluster-randomised-trial of Well London, a community-engagement programme promoting healthy eating, physical activity and mental well-being in deprived neighbourhoods. The hypothesis was that benefits would be neighbourhood-wide, and not restricted to intervention participants. The trial was part of a multicomponent process/outcome evaluation which included non-experimental components (self-reported behaviour change amongst participants, case studies and evaluations of individual projects) which suggested health, well-being and social benefits to participants. Methods Twenty matched pairs of neighbourhoods in London were randomised to intervention/control condition. Primary outcomes (five portions fruit/vegetables/day; 5×30 m of moderate intensity physical activity/week, abnormal General Health Questionnaire (GHQ)-12 score and Warwick–Edinburgh Mental Well-being Scale (WEMWBS) score) were measured by postintervention questionnaire survey, among 3986 adults in a random sample of households across neighbourhoods. Results There was no evidence of impact on primary outcomes: healthy eating (relative risk [RR] 1.04, 95% CI 0.93 to 1.17); physical activity (RR:1.01, 95% CI 0.88 to 1.16); abnormal GHQ12 (RR:1.15, 95% CI 0.84 to 1.61); WEMWBS (mean difference [MD]: −1.52, 95% CI −3.93 to 0.88). There was evidence of impact on some secondary outcomes: reducing unhealthy eating-score (MD: −0.14, 95% CI −0.02 to 0.27) and increased perception that people in the neighbourhood pulled together (RR: 1.92, 95% CI 1.12 to 3.29). Conclusions The trial findings do not provide evidence supporting the conclusion of non-experimental components of the evaluation that intervention improved health behaviours, well-being and social outcomes. Low participation rates and population churn likely compromised any impact of the intervention. Imprecise estimation of outcomes and sampling bias may also have influenced findings. There is a need for greater investment in refining such programmes before implementation; new methods to understand, longitudinally different pathways residents take through such interventions and their outcomes, and new theories of change that apply to each pathway.

Development of a scale to measure 9–11-year-olds' attitudes towards breakfast

Objective:Development and validation of a questionnaire to measure childrens attitudes towards breakfast.Design:A pilot study was used to select questionnaire items and assess test–retest reliability. The questionnaire was then administered to a larger sample of children together with a dietary recall questionnaire. Randomly selected subsets of these children also completed a dietary recall interview or their parents were asked to complete a questionnaire relating to their childs breakfast eating habits.Setting:Primary schools in south, west and north Wales, UK.Subjects:A total of 2495 children (199 in pilot testing, 2382 in the main study) in years 5 and 6 (aged 9–11 years).Results:The 13-item scale showed good construct validity, high internal reliability and acceptable test–retest reliability. Boys displayed more positive attitudes towards breakfast than girls but differences between the two age groups did not reach statistical significance. Children who did not skip breakfast displayed more positive attitudes than children who skipped breakfast. In addition, more positive attitudes towards breakfast were significantly correlated with consumption of a greater number of ‘healthy’ foods for breakfast (i.e., fruit, bread, cereal, milk products), consumption of fewer ‘unhealthy’ foods for breakfast (i.e., sweet items, crisps) and parental perceptions that their child usually ate a healthy breakfast.Conclusions:The breakfast attitudes questionnaire is a robust measure that is relatively quick to administer and simple to score. These qualities make it ideal for use where validity at the individual level is important or where more time-consuming dietary measures are not feasible.

Complaints about dog faeces as a symbolic representation of incivility in London, UK: a qualitative study

During a ‘Well London’ study, residents were asked about their neighbourhood and its environment. Above all other complaints, ‘dog poo’ was mentioned as a key concern. Despite low rates of infection and disease among the human population resulting from contact with canine faecal matter, the concerns of the public continue to rate it as a serious public health issue. Most public health studies, therefore, seek to identify processes of transmission and disease pathology as a method of addressing the problem. This study approaches the issue through a contextualised analysis of residents’ complaints, using anthropological theory to examine the symbolic representation of ‘dog poo’. Analysis of the interviews shows that these specific complaints were located among less easily defined or articulated experiences of social and environmental neglect, where neighbours were estranged from one another and local authorities seen as negligent. This approach has important implications for public health, as it provides not only a strong indicator of the level of dissatisfaction within some of Londons more disadvantaged neighbourhoods, but also identifies a need for policies that are grounded in cross-disciplinary research into the relationship between health, ‘wellbeing’ and experiences of marginalisation among urban populations.

Measures of exposure to the Well London Phase-1 intervention and their association with health well-being and social outcomes

In this paper, we describe the measures of intervention exposure used in the cluster randomised trial of the Well London programme, a public health intervention using community engagement and community-based projects to increase physical activity, healthy eating and mental health and well-being in 20 of the most deprived neighbourhoods in London.10 No earmarked resources to support the development of these measures and associated data collection were provided to either the research team or to those delivering the interventions on the ground. Instead, these were derived from contractually specified performance management information reported quarterly by partners and by inclusion of questions seeking information about participation in the follow-up questionnaires used to measure the main trial outcomes. The exposure measures are consequently considerably less sophisticated than those used in the US studies, where earmarked funding was available.

Evaluating the free school breakfast initiative in Wales: methodological issues

Purpose – The purpose of this paper is to report findings on an initiative set up by The Welsh Assembly Government to provide free, healthy breakfasts to primary school children throughout Wales. Design/methodology/approach – The research employed a cluster randomised controlled trial design with 58 schools in South, West and North Wales. Quantitative measures were taken at baseline, four months and 12 months. Findings – With the injection of more money and effective services it was found that the free school breakfast initiative could help improve health and social inequalities. Originality/value – This paper provides some of the background to the initiative, describes the evaluation and highlights some of the key methodological issues that arose during the course of the research.

'Well London' and the benefits of participation: results of a qualitative study nested in a cluster randomised trial

Background Well London is a multicomponent community engagement and coproduction programme designed to improve the health of Londoners living in socioeconomically deprived neighbourhoods. To evaluate outcomes of the Well London interventions, a cluster randomised trial (CRT) was conducted that included a longitudinal qualitative component, which is reported here. The aim is to explore in depth the nature of the benefits to residents and the processes by which these were achieved. Methods The 1-year longitudinal qualitative study was nested within the CRT. Purposive sampling was used to select three intervention neighbourhoods in London and 61 individuals within these neighbourhoods. The interventions comprised activities focused on: healthy eating, physical exercise and mental health and well-being. Interviews were conducted at the inception and following completion of the Well London interventions to establish both if and how they had participated. Transcripts of the interviews were coded and analysed using Nvivo. Results Positive benefits relating to the formal outcomes of the CRT were reported, but only among those who participated in project activities. The extent of benefits experienced was influenced by factors relating to the physical and social characteristics of each neighbourhood. The highest levels of change occurred in the presence of: (1) social cohesion, not only pre-existing but also as facilitated by Well London activities; (2) personal and collective agency; (3) involvement and support of external organisations. Where the physical and social environment remained unchanged, there was less participation and fewer benefits. Conclusions These findings show interaction between participation, well-being and agency, social interactions and cohesion and that this modulated any benefits described. Pathways to change were thus complex and variable, but personal well-being and local social cohesion emerged as important mediators of change.