|1.Please circle the words or sentences that describe you:girl boy2.How did you feel about being measured?OK I liked being weighed I didn't careSomething different I liked my height being measuredI liked being measured with my class mates|
ORNot OK Uncomfortable I didn't want to be weighedI didn't like being measured with my classmatesI didn't like my height being measuredEmbarrassed3.Please write other comments about how you felt. Thank you.Evaluation of questionnairesThe 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 resultsAs 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 resultsMore 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 commentsSome 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:
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.
- 'The nurses made me feel more comfortable';
- 'I didn't mind because I knew no one would make fun'.
Some positive comments were made alongside negative responses. Again, these appeared to reflect the nurse's careful handling of the process:
- '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!'
'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!!'
- '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';
Comments from school staffNine 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 carersOur 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' responsesThe 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.
AnalysisAs 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:
- 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.
- 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);
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 auditThe 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:
- 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 .
Recommendations for best practice
- 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).
ConclusionThe 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.ReferencesEvery Child Matters(2007) Measuring Childhood Obesity: Guidance to Primary Care Trusts. www.everychildmatters.gov.ukForesight(2007) Trends and drivers of obesity: a literature review for the Foresight project on obesity. www.foresight.gov.ukHouse of Commons Health Committee(2004) Obesity, Third report of Session 2003-04 Volume 1 Report.. London: Stationery OfficeLean, M. et al(2006) Obesity - can we turnthe tide?BMJ;333: 1261-1264.MEND(2006) Mind, Nutrition, Exercise. Do it! www.mendprogramme.orgNational Audit Office(2001) Tackling Obesity in England: Report by the Comptroller and Auditor General, HC 220 Session 2000-2001 www.nao.org.ukNICE(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.comWanless, D.(2004) Securing Good Health for the Whole Population- Final report. www.dh.gov.ukWorld Health Organization(2003) Fact sheet: Obesity and overweight.. www.who.intWorld Health Organization(2005) Preventing Chronic Diseases: A Vital Investment.www.who.int.
- 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.