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Best practice in childhood obesity screening

VOL: 103, ISSUE: 15, PAGE NO: 28-29

Felicity Duncan, MA, RGN, DN cert, SN cert

practice educator and development manager for school nurses at Brighton and Hove Children and Young People?s Trust

ABSTRACT Duncan, F. (2007) Best practice in childhood obesity screening. nursingtimes.net.

ABSTRACTDuncan, F. (2007) Best practice in childhood obesity screening. nursingtimes.net.

In preparation for the government campaign to collect data on the size of all 11-year-olds, Brighton and Hove school nurses ran a pilot for an audit in summer 2006 that aimed to examine best practice. We gathered information from 188 children, their teachers and nurses, and evaluated the reactions of parents/carers.

Childhood obesity has tripled in a decade (Rigby et al, 2003). The government, in an initiative to halt this trend, is instructing trusts across the UK to begin a five-year programme of measuring 11-year-olds (Every Child Matters).

Brighton and Hove school nurses conducted a pilot studyto explore the issues that could arise in collecting personal information from pubescent young people during school time. The aim was to learn how we may do this sensitively and efficiently, causing least possible harm.

Objectives

The specific aims were:

  • To explore the feelings of the children being measured;
  • To quantify the reaction of parents and carers;
  • To consider the views of teachers;
  • To learn from the observations of nurses.

The study was not concerned with the sizes of the children; the results on this were sent directly to the government and were not used by the trust.

The audit

There are three school nursing teams in the area and each was asked to select two schools that would reflect the wide range of need within their populations. They chose three inner-city schools with children from a broad range of social backgrounds; one village school from a mainly affluent area; one school from a mainly deprived area; and one large school with a varied catchment area. These schools agreed to take part and 230 children were screened.

We asked head teachers to arrange class lists including names, dates of birth and gender of year-six pupils and we requested they send a letter (written by us) to parents. This explained what we were proposing to do, invited parents to contact us (through the school) if they had concerns and asked them to inform the school if they did not want their child to be measured. In this way 'negative consent' was obtained if parents did not reply.

Nurses were asked to measure children individually and discreetly but were given no other guidelines. Depending on the size of the school, there were two to three people per team, mainly experienced school nurses working with two student nurses.

Questionnaires

Two questionnaires were devised for children and teachers:

  • Children had a sheet with words to circle, which would elicit gender and their feelings about being measured. They could circle as many or as few comments as they wished; positive and negative results were counted separately. They were also invited to write their own comments (Box 1);
  • Teachers were given a sheet asking how the session affected them and how the class behaved before and after the session and were also invited to write comments.

Box 1. Pupil evaluation questionnaire

1.Please circle the words or sentences that describe you:

girl boy

2.How did you feel about being measured?

OK I liked being weighed I didn't care

Something different I liked my height being measured

I liked being measured with my class mates

OR

Not OK Uncomfortable I didn't want to be weighed

I didn't like being measured with my classmates

I didn't like my height being measuredEmbarrassed

3.Please write other comments about how you felt. Thank you.

Evaluation of questionnaires

The named nurse for each school filled in a form to collect numbers of children screened, those absent or refusing measurement and numbers of parent/carer refusals, requested nurse contacts and/or appointments.

For the children's questionnaire, the results of the pre-given descriptions are shown first and then the children's own comments are described and analysed. Ninety-six boys and 92 girls (a total of 188) completed the questionnaire.

Positive results

As children could circle as many comments as they wished, we had a total of 234 positive comments (from 188 children) with boys' and girls' findings similar in most areas (Fig 2). More than half 'didn't care' (equally spread between boys and girls); nearly 40 children thought it was 'OK'; and few objected to their classmates being nearby. The only difference of note between boys and girls was that more boys liked their height and (to a lesser degree) their weight being measured.

Negative results

More than a quarter of those who filled in the questionnaire disliked the process. Some 51 children (27%) circled negative comments and, of these, 10 children circled two negative comments (Fig 3). Noticeably more girls than boys were less happy in every way. Nurses observing the children would surmise that obesity affects boys and girls equally (this of course has yet to be proved). Although it was mainly overweight children who appeared to feel uncomfortable, a significant number of 'shorter than average' children also disliked being measured. There was also a noticeable number of girls who, despite looking slim, told the nurses that they 'knew they were overweight'.

Possible explanations for girls' discomfort could be earlier onset of puberty and the demand by society for women, in particular, to be thin.

Children's comments

Some 45 boys and 46 girls wrote comments on their sheets. Although these cannot be neatly divided into positive or negative, it would be fair to say that approximately two thirds of the comments were mainly positive and, of the negative comments, noticeably more were written by girls. Many positive comments reflected the sensitive ways nurses handled the process. Pupils used expressions such as: 'It felt fine', 'It was easy', 'Not so bad', 'Felt OK about it', 'Comfortable'. Two pupils commented:

  • 'The nurses made me feel more comfortable';
  • 'I didn't mind because I knew no one would make fun'.

Some pupils expressed relief at not being overweight (they could, of course, see their own weight in kilograms) and many children were clearly already anxious about being overweight and many wanted reassurance.

  • 'I liked being weighed because I thought I was fat but found I wasn't';
  • 'I sometimes feel worried about my weight but after being checked I felt OK!'

Some positive comments were made alongside negative responses. Again, these appeared to reflect the nurse's careful handling of the process:

  • 'I normally see [nurse's name] so I felt comfortable having it done';
  • 'I was happy that it was quick, which made me feel more comfortable';
  • 'At first I felt nervous because I'm quite self-conscious about my weight';

'I didn't want to be weighed but it wasn't as bad as I thought '';

'...I was a bit scared about being weighed but I felt fine by the end of it'.

Negative comments demonstrated children's low self-esteem:

'I felt a bit worried, please don't tell anyone';

'Terrible, horrible, sad, upset, hated it, made me feel fat';

'I felt embarrassed if anyone thought I was fat or a midget';

'I felt that if everyone saw they would call me fat girl';

'I hate my size!!! So much!!'

Comments from school staff

Nine teachers completed the questionnaire and there were very few differences between them. There was a common thread about wanting to avoid further intrusion into lesson time. Six teachers remarked that children were measured at a convenient time when they were working independently. One added: 'Therefore teaching wasn't interrupted.'

The behaviour of the children, before and after being measured, was not affected at all and responses from teachers and pupils were similar across the range of schools.

Reaction of parents and carers

Our hypothesis that many parents/carers would refuse permission for their children to be measured and/or keep them away from school on measuring days was proved wrong. Some 230 pupils were screened; two parents refused; two girls (from different classes) refused; and there were only 15 absentees across the six schools. Just two parents requested contact with the school nurse and none asked for an appointment.

School nurses' responses

The two teams who felt most positive had combined data collection with another activity. One delivered a health promotion topic and the other provided a forum for discussing transition into senior school. Both felt the children had enjoyed the session and gained knowledge.

In the other four schools, the data was collected quickly with an explanation about what was happening but no additional health promotion. The nurses knew the children well in three of these schools; they were able to offer individual support and the children's comments reflected this.

The group who encountered the most difficulty were experienced school nurses, new into post and not known to the children. Also this school was in the midst of an exciting, week-long project unrelated to health. They began by explaining what they were doing and why and invited questions, which the pupils responded to well. However, when the children arrived individually to be measured, many were unhappy: two children refused and several boys purposely pulled on their hoods as they approached the nurses.

General comments from all the teams were as follows:

  • Nurses had to cajole many children into being weighed;
  • They had to work individually with some who had poor body images (mainly girls wrongly thinking they were fat);
  • Overweight children disliked the process most of all;
  • Several small children also disliked being measured;
  • Some children were tearful about being weighed;
  • Pupils may not realise that weight increases proportionately to height, for example, the taller of two slim girls may worry because she weighs more;
  • Nurses became aware of other health issues which required follow-up;
  • The actual task (weighing and measuring) was repetitive and tiring.

Key findings

  • The majority of children did not appear to mind being measured;
  • More than a quarter (27%) did not like the process. Many of these were overweight; several were short and some were thin girls believing they were fat;
  • Children felt more comfortable being measured by someone they knew and they were more interested and relaxed when data collection was combined with a learning activity;
  • Children enjoyed the 'freebies' they were given: bookmarks, bracelets and stickers promoting 'Five-a-day fruit and veg';
  • It was almost impossible to stop children from finding out their height and weight. Many wanted to know, others wanted reassurance and pupils need to realise that taller people usually weigh more;
  • Schools need to be involved in the initiative. Pure data collection during time designated to another theme is likely to cause frustration to all;
  • Teachers were anxious not to lose lesson time;
  • 'Negative consent' from parents/carers resulted in almost the whole cohort being screened.

Analysis

As our study involved just six schools, nurses were able to offer individual care and we had sufficient free gifts to give out. In addition, we had planned ahead with teachers to minimise lesson disruption. However, even in this small study, cajoling many children to do something they did not want to do was demanding for all concerned.

As professionals, we have a duty of care because obesity diminishes the quality of life (Lean et al, 2006). Obesity is associated with numerous chronic diseases including many that are life-threatening (WHO, 2003, 2005; Wanless, 2004). The following are just some of the accompanying miseries:

  • Many in the current generation of children may be outlived by their parents because of diseases associated with obesity (House of Commons Health Committee, 2004; National Audit Office, 2001);
  • From a social perspective, overweight children are bullied, perceived as 'less able' and their employment prospects are likely to be reduced (Thomas, 2005);
  • Psychologically, overweight/obesity diminishes self-esteem and hampers children's ability to reach their full potential (Strauss, 2000);
  • Emotionally, being 'fat' inhibits nearly every facet of development .

There is much research identifying problems and describing multi-factorial causes; what remains absent is evidence of effective programmes to reduce obesity (Foresight, 2007). Data collection informs but we also need the action of community projects such as MEND (Mind, Exercise, Nutrition, Do it!) which tackles childhood obesity in a variety of positive ways through a twice weekly, nine-week programme for child and carer (MEND, 2006).

The pilot as preparation for an audit

The remit of the pilot was to explore best practice before the launch of the five-year screening campaign and it showed the importance of considering the following:

  • To give nurses clear guidelines. Two of the teams included health promotion or transitional work that provided us with an unintended but informative extra dimension (the children preferred these approaches). A scientific approach would require all nurses to adopt the same methods;
  • To improve the children's questionnaire. Positive and negative comments should be mixed to avoid children circling positives first as they work down the page. Also we would reduce the number of comments (see bar charts for most circled comments) to three or four in each category. A landscaped questionnaire (across an A4 sheet) may be preferable;
  • Negative consent from parents/carers is controversial. In a study where parents were given the opportunity to withdraw, only 48% of children were measured. This seriously undermined the study because it was thought that parents of obese children were more likely to have opted out (Crowther et al, 2006).

Recommendations for best practice

  • First, 'do no harm'; be aware that some children will feel unhappy about being measured and will need sensitive handling;
  • Explain what is being done and why to class groups and invite questions;
  • Share the care: investigate possibilities for school staff to be trained and supported in confidentially collecting measurements of children. Recent NICE guidelines emphasise the need for schools and local government to share responsibility with the NHS in managing obesity (NICE, 2006);
  • Combine data collection with a learning activity such as maths or science or a health promotion topic offered by nurses;
  • Include clear messages to children that people are designed to be different sizes and that any form of bullying is unacceptable;
  • Offer appropriate reassurance to children who may have observed their height and weight or already have concerns;
  • Offer families follow-up care in schools or through community-based projects;
  • Consider the issue of 'negative consent', which poses an ethical dilemma. It may be viewed as an infringement of rights, but as we have seen above (Crowther et al, 2006) if parents can 'opt out', more than half are likely to do so causing data to be unsound and the drive against childhood obesity no further advanced.

Conclusion

The summer term for year-six pupils is a crucial period in their lives. They are about to transfer to senior school, start making lifestyle choices and become young adults. Some multi-agency teamwork, collecting data and becoming involved in projects such as MEND could turn a potentially onerous task into a positive experience for all.

References

Every Child Matters(2007) Measuring Childhood Obesity: Guidance to Primary Care Trusts. www.everychildmatters.gov.uk

Foresight(2007) Trends and drivers of obesity: a literature review for the Foresight project on obesity. www.foresight.gov.uk

House of Commons Health Committee(2004) Obesity, Third report of Session 2003-04 Volume 1 Report.. London: Stationery Office

Lean, M. et al(2006) Obesity - can we turnthe tide?BMJ;333: 1261-1264.

MEND(2006) Mind, Nutrition, Exercise. Do it! www.mendprogramme.org

National Audit Office(2001) Tackling Obesity in England: Report by the Comptroller and Auditor General, HC 220 Session 2000-2001 www.nao.org.uk

NICE(2006) Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. www.nice.org.uk/

Strauss, R.S.(2000). Childhood Obesity and Self-esteem. Electronic Article: Pediatrics; 105: 1.

Thomas, D.(2005 )Fattism is the last bastion of employee discrimination . Personnel Today; October 2005. www.personneltoday.com

Wanless, D.(2004) Securing Good Health for the Whole Population- Final report. www.dh.gov.uk

World Health Organization(2003) Fact sheet: Obesity and overweight.. www.who.int

World Health Organization(2005) Preventing Chronic Diseases: A Vital Investment.www.who.int.

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