Demonstrate a breadth of knowledge of how the discipline of health psychology can address significant areas of theory and practice within the context of promoting positive health behaviour change.
Illustrate the ability to communicate effectively to the discipline of health psychology and report practical procedures in a clear and concise manner in a variety of formats.
Answer
Introduction
In UK obesity is the burning problem among children and adolescents. The adverse conditions of obesity are manifested in adolescence and adulthood. Obesity is the multifactorial disease because it is caused by genetic, environmental and lifestyle factors (Poti et al. 2014). Hence its management requires healthy lifestyle modification. An important part of lifestyle choices is diet adjustment. Researchers have found that increasing the consumption of the fruits and vegetables prevents obesity and other debilitating conditions (Reilly et al. 2003). The report deals with proposed intervention for increasing fruit and vegetable consumption of adolescents in school. The objective of the proposed intervention is to estimate any change in Body Mass Index or BMI with increase in fruits and vegetables intake. This in turn helps to determine decrease in obesity prevalence. The report discusses the benefits associated with the intervention, study design used for this purpose and methodology. The report details the process of delivering the intervention in school setting. It discusses the plan of evaluating the outcomes of the intervention.
Background and need of the proposed intervention
Obesity
Obesity is prevalent in teenagers and is increasing at an alarming rate. In UK it is the “significant contemporary” health concern because it has been identified as one of the leading cause of death. Obesity refers to the state of extreme fatness. The rising rate of obesity has been declared as “national emergency” and it is preventable cause of death (Reilly 2003). As per the reports of Poti et al. (2014), one third of population in UK could be obese by 2020. As per the data of WHO in 2014 the percentage of the adult obesity in UK was 28.1. In the population aged between 2-19 years, 30.4% of the girls and 33% of the boys were overweight or obese.
The long term and the short term effects of obesity includes cardiovascular disease, prediabetes, sleep apnoea and social-psychological problems (Fedewa 2015). People with obesity have lower life expectancy and poor quality of life according to Wang and Veugelers (2008). Adolescents are more likely to devolve obesity related diseases. Sometimes school canteens have lower accessibility to fruits and vegetables which promotes the children to eat unhealthy snacks and increase their preference for junk food rich in calories. Eventually this leads to poor diet and weight gain among children. Therefore, it is necessary to develop healthy eating behaviour in childhood stage.
Effect of fruit and vegetable consumption
According to Grannner and Evans (2011) when children enter into the adolescent phase the consumption of fruits and vegetables decreases. The paper showed that 80% of the children do not eat enough fruits and vegetables during their adolescence. The results from several epidemiological studies conducted in several states showed beneficial effect of consuming diet rich in fruits and vegetables. These benefits include reducing the risk of heart disease, stroke, and cancer (Bes-Rastrollo et al. 2006). Other benefits include prevention of risk factors for chronic health condition such as chronic obstructive pulmonary disease, cataracts, hypertension and diverticulosis. The mechanism of the positive action is the nutrient present in the fruits and vegetables such as sulphides in vegetables. They act synergistically for preventing the risk factors for these health conditions. Sulphides are known to stimulate anticancer enzymes. Antioxidants in vegetables such as phytoesterols and Phytoestrogens detoxify carcinogens and also functions in lowering the blood cholesterol. Fruits contain antioxidative flavinoids which are protective against cancer and heart diseases. Vegetables and fruits consumption also increases fibre content which increases the motility of the substances through the digestive tract and aids in excretion of fats and cholesterol (Reichmann 2009).
Rationale Outcome and Objectives
The rationale for targeting adolescent for the proposed intervention that is increasing the fruit and vegetable consumption is due to the fact that at this age children tend to make healthy eating choices for themselves (Campbell et al. 2007). Various benefits identified in consumption of fruits and vegetables is the rationale for this proposed intervention. Since the adverse outcomes of chronic health conditions are manifested in adulthood it is imperative for children to cultivate positive heating habits. The more this is implemented at this age the more they are likely to carry them on through adulthood. The purpose of targeting adolescents for the proposed intervention at schools is due to higher influence of school in modifying behaviour. It is possible to reach lots of adolescents at the same time. Moreover, when adapting a new behaviour peers play a great role. Children tend to develop new behaviours developed by their peers which is also called as peer to peer effect (Dudley, Cotton and Peralta 2015). In addition, a little is known about the relationship between the increased accessibility to fruits and vegetables and its impact on consumption via other variables such as preferences and group norms. This relationship will be known using various theories and models underlying the relationship and will be used for delivery of proposed intervention.
The aim of the research is to estimate if change in BMI can be achieved with the increase in fruits and vegetables intake.
The objective of the intervention is to increase the fruits and vegetables consumption of the adolescents in school in a school setting and track BMI and self efficacy level to identify and reduction in prevalence of obesity.
The proposed outcomes of the intervention include reduction in the obesity rates with continuation of this intervention for a prolonged period of time. Implementing this intervention for a long period (nine months in this case) will reduce the prevalence of obesity, which can be tracked by the BMI and self-efficacy level. Further, there is a need of having a clear specification of obesity preventing goals. It helps to shape the plan and aid in evaluating the success.
Research questions
- Could increased consumption of fruits and vegetables decrease BMI?
- What is the association between the self efficacy level and increasing the consumption of fruits and vegetables among adolescents?
Research funding
The funding for this research will be obtained from “Big lottery fund” (Fund 2011). It is a charity board that supports community groups and charitable projects with money. It also supports people who work towards improving the quality of life of people. The money for the organisation is obtained from national lottery and 40% of its is distributed to the projects related to health, environment, education, and other charitable projects. The intervention design for this research is covered by the lottery fund as this research aims for targeting health related behaviour in educational environment. This research meets the criteria set by the big lottery fund for giving their support. These include alignment of the intervention with the local health and social policies and involvement of community for proposed intervention. The research study involves school, students, teachers and canteen staff. The delivery of intervention involves the feedback and support of school authorities. The lottery fund wants projects to implement strategic thinking and well know the beneficiaries. This is covered by the researchers as the input and opinions of the participants on intervention is collected. Further, the researcher has already developed the evaluation plan, which is mandated by the lottery fund (Fund 2011). The intervention design is flexible in terms of length and type of fruits and vegetables as flexibility is additional criteria for the big lottery fund. The lottery fund expects the intervention to be sociable and fun, which the researcher has already covered. As the research materials include use of app it is sure to grab the attention of the adolescents as it is popular technology in this age group. (See Appendix for budget allocation).
Theoretical framework and behaviour change techniques
The theoretical framework is important in research study as it provides a structure to support theory underlying a particular study. Theories are formulated to explain and understand particular phenomena. The theories related to fruits and vegetable consumption among children gives the way to develop the intervention. The set of concepts and its definitions in reference to the relevant scholarly literature constitute theoretical framework (Mohr et al. 2014). For these research applicative theories related to the fruit and vegetable consumption is discussed in subsequent sections. Review of such theories is vital to ensure the efficacy of the strategies that will be used for increasing the consumption among adolescents.
The theory of planned behaviour formulated by Ajzen in 1985 emphasises on the role of intention in the “behaviour performance” (Ajzen 2015). The theory is based on the concept that attitude of an individual help to predict the spontaneous unplanned behaviour of an individual. Identifying an individual’s attitude towards a particular behaviour explains the underlying intention. Since this theory links beliefs to behaviour, it can be implemented in the project of promoting increased intake of fruits and vegetables to decrease weight. If children are made to believe that the action has positive outcomes they are sure to develop a positive attitude. Further, if children belief the importance of this healthy eating behaviour and learns its effectiveness in combating serious health conditions, it will significantly affect adopting the new behaviour of having more fruits and veg diet. If children can see that the influential people around them including peers have adopted this behaviour and if they feel that they are able to access more fruits and veg it will lead to intention and then behaviour. The study conducted by Riebl et al. (2015) showed that the nutrition related behaviour in youth has strongest relationship with attitude. The study has used theory of planned behaviour for nutrition related interventions and was found to have positive outcomes.
The strategy to deliver the proposed intervention follows the principles of social cognitive theory proposed by Albert Bandura in 1986. According to this theory, a behaviour change in an individual is determined by personal, behavioural, and environmental elements (Lee et al. 2015). Environment influences the development of personal characteristics and behaviour. Similarly, thinking and feeling of an individual have an impact on the environment. Hence, it is the reciprocal interaction between an individual and the social environment that guides the behavioural change. The idea behind implementing this theory is the fact that children in school setting engage in observational learning (Bjorklund and Causey 2017). Hence promoting consumptions of fruits and vegetables among schools children will help others also to imitate same behaviours as their peers. The reason behind imitating is rewards or praises given by the teacher to a particular child. The child develops positive feelings due to the action which in turn triggers emotional reactions among other observers (Barry 2005). Consequently, all the children in school tend to increase the consumption of fruits and vegetables. This theory has been predominant in understanding how new behaviours are developed. The strategy for using this social cognitive model is the involvement of self-efficacy. Adolescents in school with higher self-efficacy have positive effect on fruits and vegetable consumption. This theory is built on the child’s belief that he or she can execute a particular behaviour to a certain level enough to attain the desired outcome (Cullen et al. 1998).
The behaviour choice model highlighted in the study of Goldfield and Epstein (2002) is based on the concept of individual’s preferences, actions and assumptions. It helps to determine an individual’s allocation of choices. This model acts as an important framework for modelling social and economic behaviour. The model is focused on the determinants of individual choices. The theory explains that why an individual prefers one specific option among several different alternatives and the rationale behind acting consistently in choosing “self determined best choice of action”. The study conducted by Moore and Tapper (2008) showed that when multiple choices are not given to the children in school they are bound to prefer best one from the given choices. In this study, the researcher found that when the school children were deprived of unhealthy snacks during break time, it increased their willingness to have fruits instead of snacks. The intervention thus uses this model as a strategic option to promote increased fruit and vegetable consumption among adolescent in schools.
According to Michie, Atkins and West (2014) behaviour modification is the outcome of capability, motivation and opportunity. All the four are interrelated to each other. This acts as framework for delivering the proposed intervention to the adolescents in school. In this case, the capability refers to physical and psychological capability. If the fruits and vegetables are available to the children at prices cheaper or same as that of unhealthy snacks. Greater the display of fruits salad or in form of custard or attractive vegetable soups, higher will be the capability to purchase. Similarly, more the children are aware of the benefits of the new behaviour the more they are likely to adopt it. This refers to psychological capability. Opportunity in this case refers to chance or means to develop new behaviour. Physical opportunity is the accessibility of fruits and vegetables in school. Social opportunity is the ability of the children to prefer fruits while other peers are having junk food. It in turn gives the social opportunity to others to prefer the healthier options. Lastly, motivation plays a vital role behind any human action. The same applies for this intervention. Reflective motivation develops from prompts and cues to purchase a product. Just as an attractive advertisement prompts a person to buy that product, watching fruits and vegetables regularly on school campus and in posters will automatically prompt the children to eat. Reflective and automatic motivation influences the decision-making (Michie et al. 2011).
Considering the above theories and concepts the procedure for successful delivery of the intervention is designed which is discussed in the methodology section. (See appendix for Behaviour Change Technique Taxonomy Codes (BCT’s) for the intervention).
Methodology and ethics
Design
The method of implementing this intervention involves quasi experimental study design. It includes both control and experimental group. This study design is selected because the aim of the research is to estimate the casual impact of the proposed intervention on the adolescents in school (target population). It is similar to the randomised control trial except for the element of random allocation to the control or treatment group. The dependent variable in this case is the change in BMI of children with increased consumption of fruits and vegetables. The independent variables are age and height used to confound the dependent variables and change in self-efficacy levels. The design of the intervention is replicated from the paper of Kok et al. (2004) and Bartholomew et al. (2011). The rationale for using the mixture of both the designs was appropriateness of the protocol to complete each step of the research. This gives the understanding of the how the change in behavior takes place.
Participants
The number of participants selected for applying this intervention is 500 (due to heterogeneous population in school)school students who are adolescents of age 11-18. The total strength of the school was 5000 therefore 10% is chosen for obtaining precision as recommended by (Hoffmann et al. 2014). The control group and the experimental group will contain 250 participants each. The control group will be given app and the questionnaire. The experiment group will be given the same materials but also have to revise them by input of data. The control group will not be given any intervention. For this study the participants do not undergo random assignment. The rationale for this strategy is that taken as a group it can be implemented more frequently than the randomised cousins (Bartholomew et al. 2011).
Material
The materials that will be used for implementing the plan are- posters, Questionnaires (quantitative self-report technique), App, School canteen, tape measures and scales.
Both the control and the experimental group will be given the app and the questionnaires to evaluate the dietary intake. However, the experiment group will also have to revise the given materials. The purpose of the app is to track the consumption of the food during the phase of intervention. The children in the experimental group are instructed to take the snapshot of the food they are eating to know the degree of fruits and vegetables consumption. A statistician will be employed to convert the collected data into quantitative form by using SPSS (Social Packages for the Social Sciences) (Bourke et al. 2014). Based on the data collection the consumption of fruits at different point of time will be compared. Comparing the results of the control and the experimental group will give the effectiveness of the intervention (Golley et al. 2011).
The purpose of using the app is that it is simple and easy to use for the participants. The simplicity of the app will increase the likeliness of the children to take part in the intervention willingly and be honest with the input of the data that is what they are actually eating. The rationale for providing app at initial phase is to develop the self-monitoring behaviour among children (Duncan et al. 2016). The more they will take photos of the food they are eating the more they will be aware. The questionnaires is designed (close ended) in a manner that measures the self efficacy of the participants, their feelings about eating fruits and changes implemented in its availability at the school canteen. The purpose of using questionnaire is its quick generation of standardised data in short span of time and is thus designed in a manner recommended by Polit and Beck. The questionnaire will consist of three parts A, B and C and each reply will be coded using numbers (1-6) in the normal sense (Moore and Tapper 2008).
Further, after subjecting the participants to the intervention their Body-Mass index or BMI will be checked to monitor the outcomes of the new behavior. Recording the height and weight of the child will help in assessing if the obesity prevalence has reduced. BMI defines overweight and helps to indicate obesity. Obesity is classified as BMI above or equal to 30.0. In the highest class of obesity the BMI is greater than 40 and is common in most obese adults (Poti et al. 2014). After collecting the BMI results of all the participants it will be plotted on the percentile chart (Gosliner 2014). It is taken into account because at this age the participants are still in the growing phase.
Posters on fruits and vegetables consumption will be displayed in the school premises such as canteen and common hall and the classrooms as prompts and cues. School fruits tuck shopkeeper and other canteen workers may recommend the children to purchase more fruits and vegetables. It will act as verbal persuasion (Albuquerque et al. 2017). Further, teachers can motivate children to succeed in their new behaviour by appreciating their efforts. Watching the posters on daily basis will provoke the children to think of healthy eating and pick more fruit pieces during the recess. The strategy employed here again follows observational learning (Moore and Tapper 2008).
Procedures
The first step of implementing the intervention is to inform and aware all the participants before the intervention begins. It makes the participants acquainted with the steps of the data collection and intervention. To obtain desired results and avoid errors it is necessary for the children to have basic concept of how they need to participate. The intake of fruits and vegetables will be categorised as follows: consuming fruits having and not having juice, vegetables excluding potatoes, French fries, and cold drinks (Reichmann 2009).
In the first week of the intervention the participants are given the app to track the current consumption of food. This refers to self monitoring of behaviour using the app. The baseline BMI and other data such as questionnaires are collected. The data collected in the first week indicates the current food choices and preferences of the participants as well as their heights and weights. In addition it also gives the data of the current levels of self-efficacy and feelings associated with the consumption of fruit and vegetables. The data collected in the first week will be used to compare with the data generated after the intervention (Poti et al. 2014).
The intervention will take place in week 2. These phase of the intervention will include providing the participating children with the prompts and cues such as increasing the fruits availability in schools at same price as other unhealthy food options or cheaper price, posters of fruits and vegetables in schools. The app will be used in week 3, 6, 12 and the questionnaires will be filled. This is to get an idea of the effect of the intervention on the consumption of fruits and vegetables and to know any change if occurred in self-efficacy levels or has remain same or dropped after the initial intervention. In week 12, the BMI of the children will be recorded again. This phase will be followed by rewarding the children with non-specific incentive for what they have taken part in for example a day of non-academic activities. It will motivate them for progress they have made (Granner and Evans 2011). After debriefing, children will have an understanding of what had happened and why. After six months, check will be done for all the participants in the experiment group. It includes checking BMI, questionnaires and app (Reichmann 2009). This BMI will be compared with the baseline BMI. This will give the impact of the intervention and any increase in level of fruits and vegetables consumption as well as change in self-efficacy levels.
Ethical consideration
Ethical issues are obvious in any research study particularly when it involves human beings. Ethical issues may crop at any point of research and may become a risk in the progress of research. Researchers must handle the ethical issues as they are in charge for their own ethical conduct according to Bryman (2015).
For every child participating the ethical issues involve protecting their rights, privacy, dignity and confidentiality. The general stand taken for this research was taking prior consent from the concerning school authorities, parents and family members. Other considerations will be taken to maintain the purity of the data. The role of the researcher is to make sure that no child is forced to participate against their will. In forming a research design, the research ethics play an important part. Therefore, researcher is committed to adhere to the research ethics in every phase of the research and even while reporting the data (Phelan et al. 2013). To avoid accountability and issues related to the confidentiality of participant’s information the researcher needs to contemplate on the intervention design and treatment of respondent.
For achievement in data collection, it is essential to build trust with the respondents (Phelan and Kinsella 2013). In this research all the participants will undergo checking of DBS and CRB. To ensure that all the participants can participate tablets will be provided to the students who do not have phones. The data will be kept anonymous to eliminate bias such as selecting one person for eating lots of vegetables or having higher BMI. After completing the treatment of experimental group, the control group will also be exposed to the intervention (Reichmann 2009). It would be unethical to avoid the health of other group while improving one group. With the help of potential mentor other complication will be discussed and resolved immediately. Honest efforts will be made to deliver the research following the standard ethics.
Evaluation plan
The researcher has developed an evaluation plan to ensure that the intervention is delivered properly and is working. The evaluation plan is essential for assessing data and checks the adherence to the intervention. For this purpose six step method of Michie et al. (2014) is used, which is discussed below.
Firstly, the stakeholders will be defined (recipients, implementers, supporters of the intervention). School staff will be communicated to display posters in a location that is easily visible to children. Feedback can be collected from project manager staff and the canteen workers to obtain their views on how was the intervention were delivered. Secondly, the researcher will ensure that all the resources were provided to reach the goal. Thirdly, focus is laid on design of intervention such as development of app and questionnaires. Both are designed with the help of skilled team so that it ensures validity of the desired outcomes. Further, checklist will be used to prevent missing any important aspect of intervention (Hoffmann et al. 2014). Fourthly, The researcher will collect the evidence. The baseline data collected before the intervention and at different time points is compared with the control group will give if the intervention is working itself or because of the awareness among the adolescents or due to the use of app. ANOVA or Analysis of Variance will be used to assess the collected data on SPSS. The positive aspect of using this method is it saves using separate T tests. Fifthly, the researcher will draw conclusion from the data the idea of point of difference or changes in the intervention (Tang and Zhang 2013). Analysing the sets of data collected from the control and the experiment groups will give the frequency of each response as percentage. It is the account of the degree of adherence. Lastly, validity will be ensured by incorporating questions that covers all aspects being studied and will be reviewed by expert to check the concepts and common goal of team members before moving into detail (Duncan et al. 2016).
After obtaining the desired outcomes recommendations can be made to the government for making the fruits and vegetables available at cheaper rates. The government can also increase funding for healthy snacks in schools for children aged 7-18 year as the intervention results will prove that this age group have chosen a healthy eating option. Schools are recommended to formulate policies related to healthy nutrition to reduce obesity.
The methodological issues that may arise in the process of intervention delivery are- shorter lunch period that may decrease the odd of student eating fruits and vegetables. Other concerning factors include children consuming high calories diet at home after taking fruits and vegetables in school. This may defeat the purpose of the intervention, as the children are not monitored at home.
Conclusion
It can be concluded from the research and the literature review that the best way to combat obesity is to modify lifestyle choices. There is no single curative method to prevent this chronic condition. Modification in behaviour and the environmental risk factors are vital to prevention and treatment. The important part of this process is eating more fruits and vegetables to produce anti-obesity effect. The primary goal is to teach the adolescents in the schools setting about health eating behaviour and generate awareness of its consequences. The proposed intervention will aid in creating a healthy lifestyle if successful and indicate the interventions through heath training and education.
The implications for this study are greater focus required from educators to improve the self-efficacy of the children and availability of fruits and vegetables in school. Educators should also focus on influencing adolescents to intake fruits and vegetables at home instead of only in school canteen. The study implies for parents to motivate their children to intake more fruits and vegetables and prevent the consumption of high calorie and fat rich food. Since educational institutes play a vital role in life children it is recommended to schools to structure the school meal environment and assist in reducing obesity. Similar step taken by every school will help create a better nation. Future studies may include delivering the intervention to more schools with greater number of participants. If the desired outcomes are achieved and there is a decrease in obesity prevalence.
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