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Best practice in screening for obesity in childhood.

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Brighton and Hove school nurses conducted a pilot study to explore issues that could arise in collecting personal i…


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

Felicity Duncan, MA, RGN, DN cert, SN cert, is practice educator and development manager for school nurses at Brighton and Hove Children and Young People’s Trust

Brighton and Hove school nurses conducted a pilot study to explore issues that could arise in collecting personal information from 11-year-old schoolchildren. The aim was to learn how to do this sensitively and efficiently. The specific aims were:



- To explore the feelings of the children being measured;



- To quantify reactions of parents and carers;



- To consider the views of teachers;



- To learn from the observations of nurses.



Data on the sizes of the children was sent directly to the government and not used by the trust.





The area has three school nursing teams, each of which selected two schools. They chose three inner-city schools with children from a broad range of social backgrounds, one village school from a mainly affluent area, one from a mainly deprived area and one with a varied catchment area.



We asked head teachers to send an explanatory letter (written by us) to parents. This invited parents to contact us 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.





Two questionnaires were devised:



- Children had a sheet with words to circle that would elicit gender and their feelings about being measured;



- 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.





Out of a total of 230 pupils who were screened, 96 boys and 92 girls completed the questionnaire.



Positive results


As children could circle as many comments as they wished, we had a total of 234 positive comments, with boys’ and girls’ findings similar in most areas. More than half ‘didn’t care’; nearly 40 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 children who filled in the questionnaire disliked the process and 51 (27%) circled negative comments. Noticeably more girls than boys were less happy in every way. 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 nurses that they ‘knew they were overweight’.



Children’s comments


Some 45 boys and 46 girls wrote comments, approximately two-thirds of which were positive. Of the negative comments, noticeably more were by girls.



Many positive comments reflected the ways in which the nurses handled the screening process:



- ‘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 and many were clearly already anxious about being overweight and were seeking 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 nurses’ handling of the process. For example:



- ‘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’.



Negative comments demonstrated children’s low self-esteem. For example:



- ‘Terrible, horrible, sad, upset, hated it, made me feel fat’;



- ‘I felt embarrassed if anyone thought I was fat or a midget’.



Views of staff, parents and carers


Nine teachers completed the questionnaire. There was a common thread about wanting to avoid further intrusion into lesson time, although six teachers said children were measured at a convenient time when they were working independently. The children’s behaviour before and after being measured was not affected. Two parents withheld consent and two girls (from different classes) refused to be weighed. Two parents requested contact with the school nurse.



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, there was 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 that encountered the most difficulty consisted of experienced school nurses, new into post and not known to the children. Also this school was in the midst of an exciting 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 and two refused.



Comments from nurses included:



- Nurses had to cajole many children into being weighed;



- They had to work individually with some who had poor body images;



- Overweight children disliked the process most of all;



- Some children were tearful about being weighed;



- Nurses became aware of other health issues that 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 but more than a quarter (27%) did not like the process;



- Children felt more comfortable being measured by someone they knew and were more 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’;



- Almost inevitably children saw their measurements, even though this was not the purpose of the exercise. 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 meant nearly all the cohort was screened.



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 a number of issues. For example, nurses need clear guidelines. Two of the teams included health promotion or transitional work that provided an unintended but informative extra dimension (the children preferred these approaches). A scientific approach would require all nurses to adopt the same methods.



On 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 include only three or four comments for each category. Finally, 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 undermined the study; it was thought parents of obese children were more likely to opt out (Crowther et al, 2006).



Implications for practice


- Nurses need to be aware that some children will feel uncomfortable about being measured and will require 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



- Combine data collection with a learning activity such as a health promotion topic offered by nurses



- Include clear messages that people are designed to be different sizes and that any form of bullying is unacceptable



- Offer reassurance to children who may have observed their height and weight or already have concerns



- Offer families follow-up care and support through schools or via community-based projects



- Consider the issue of ‘negative consent’, which poses an ethical dilemma - it may be viewed as an infringement of rights but if parents have to ‘opt in’ the data may be less comprehensive and the drive against childhood obesity no further advanced





- Childhood obesity has tripled in a decade (Rigby et al, 2003)



- The government is instructing trusts across the UK to begin a five-year programme of measuring 11-year-olds (Every Child Matters, 2007)



- NICE (2006) emphasises that schools and local government should share responsibility with the NHS in the management of obesity



This article has been double-blind peer-reviewed

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