The equitable reach of a universal, multisector childhood obesity prevention program (Live Life Well @ School) in Australian primary schools March 2020, Volume 30, Issue 1

Introduction

Childhood obesity is a global public health issue, which has profound health, economic and social impacts.¹ In Australia, approximately one-quarter of school children (aged 5–17 years) are overweight or obese.² In the state of New South Wales (NSW), Australia, the proportion of school children who are overweight or obese is 24.7%.³ The proportion of school children who are overweight or obese is significantly higher in children from low socio-economic areas (35%).⁴

Population-level, long-term interventions in the school setting that encourage healthy eating and increased physical activity can reduce the prevalence of childhood obesity.¹ The World Health Organization recommends whole-of-school programs that include healthy eating and physical activity in the school curriculum, vegetable and fruit breaks, quality physical education (including development of fundamental movement skills), availability of adequate facilities, and support for school teachers and staff to implement health promotion initiatives with all children.¹ It is important to ensure that such interventions can also be delivered and adopted by schools in disadvantaged communities to address health inequities.

The NSW Government is implementing a suite of universal health promotion programs in different settings to reduce childhood overweight and obesity by 5% by 2025.⁵ The primary school-based program is known as Live Life Well @ School (LLW@S). This paper examines LLW@S monitoring data to provide practical insights into LLW@S adoption and changes in primary school environments across NSW, particularly in schools characterised as disadvantaged.

Live Life Well @ School

LLW@S is a joint initiative between NSW Government agencies – the Ministry of Health and Department of Education – and the Catholic and independent (private) school sectors, implemented state-wide since 2011. LLW@S focuses on the school curriculum, the school food and physical activity environment, and teacher professional development to influence the food and physical activity behaviours of primary school children (5–11 years old).

The program’s health promotion messages align with the Australian national guidelines for nutrition and physical activity.^6,7 The program promotes whole-of-school physical activity and nutrition initiatives that are consistent with the World Health Organization’s Health Promoting Schools Framework.^1,8 Key components of the program include:

• A guiding framework of measurable ‘desirable practices’, developed in consultation with the education sector, and from previous research⁹ (Table 1)
• Free accredited professional development for teachers, delivered face to face and online
• A health promotion workforce to recruit, develop school relationships, and support the school to implement a LLW@S Action Plan through site visits, phone calls and emails
• Funding for schools to develop and implement their LLW@S Action Plan (available between 2011 and 2014), and to support teacher attendance at training
• Access to free nutrition and physical activity programs and resources.

Table 1.     Live Life Well @ School (LLW@S) program desirable practices

To monitor program implementation, health promotion staff routinely gather data during their contact with the schools to provide support and advice on program implementation. Data is collected on the number of LLW@S trained schools and number of desirable practices achieved by schools according to defined protocols, and stored in a purpose-built online database, the Population Health Intervention Management System.¹⁰ The data are also used to provide schools with feedback, tailor support to achieve LLW@S desirable practices and inform quality improvements to LLW@S.⁵

Program reach

To ensure equity of program uptake and reduce the risk of widening the health differential for NSW children, program reach is monitored by indicators of disadvantage, specifically schools located in geographically remote and socio-economically disadvantaged areas, or with high Aboriginal populations. These schools are offered support and resources tailored to meet their needs to engage in the program. For example, health promotion staff provide schools that have a high number of students from culturally and linguistically diverse backgrounds with translated written resources. Since the program’s inception in 2011 to June 2017, schools located in disadvantaged areas (n = 1121; 85.8%), in geographically remote areas (n = 46; 86.8%) and with at least 10% of students from Aboriginal backgrounds (n = 643; 85.8%) have received proportionately more LLW@S training than all NSW primary schools (n = 2126; 82.7%).

Program adoption

Program adoption is indicated by the proportion of the 10 desirable practices achieved by a school (Table 2). Between 2012 and June 2016, the NSW Ministry of Health deemed that a school was considered to have adopted the program when it was achieving 70% or more (seven or more) desirable practices. In June 2016, 79% of all participating schools were adopting the program. Thereafter, the target rate for program adoption was revised by 10% to extend health promotion action to LLW@S desirable practices that were less well adopted. By the end of June 2017, 72.9% of participating schools in NSW had reached the new 80% target of achieved desirable practices, increasing impact in the setting.

Table 2.     Adoption of Live Life Well @ School program by trained schools between 2013 and 2017 by Aboriginal status, socio-economic status and remoteness

^a All schools that attended training, less schools that opted out of the program
^b Schools with 10% or more students from Aboriginal background, reported by the Australian Curriculum, Assessment and Reporting Authority
^c Schools located in the two most disadvantaged quintiles, as measured by the Socio-economic Indexes for Areas^13
d Schools located in remote and very remote areas, as measured by remoteness classifications^14
e Target was increased by 10% or one practice to extend health promotion impacts.

Equitable LLW@S practice achievement

Across all schools, desirable practices 1–4 were well achieved, especially in remotely located schools (Table 3). The high level of achievement of desirable practices addressing curricular activities (1 and 2) may be partially due to their association with the mandatory NSW school curriculum requirements.

Desirable practices addressing the food and physical activity environment (3–6) were successful when supported by specific government programs. Desirable practice 3 (opportunity for students to eat vegetables and fruit, and drink water) was supported by the Crunch&Sip® program, which provides designated class time for students to eat fruit and vegetables, and drink water.¹¹ Achievement of desirable practice 4 (physical activity during recess and/or lunch) is likely to be related to the provision of recreation space during class breaks and programs such as the NSW Premier’s Sporting Schools – Sporting Schools Challenge, which provides school grants for physical activity equipment.¹² Health promotion staff encourage schools to participate in complementary programs and may provide additional support in disadvantaged areas to implement Crunch&Sip, including supplying free fruit and vegetables. Alternatively, schools may support student-led programs to encourage physical activity during recess and lunch, which meet both the school educational student leadership objectives and LLW@S desirable practices concurrently.

The proportion of all primary schools achieving desirable practice 5 (providing a supportive environment for healthy eating – canteens, school activities involving food and drink) was much lower than for other desirable practices. Provision of such a supportive food environment is complex and continues to be a key priority. The NSW Government’s NSW Healthy Canteen Strategy, launched in 2018, outlines the type and proportion of food and drinks suitable for sale in NSW school canteens. Local health promotion staff support schools to implement the NSW Healthy Canteen Strategy and tailor the food environment for healthy eating, often in partnership with licensed canteen operators. Progress towards improving the food environment in the school requires sustained support and perhaps could be further investigated in the small proportion of schools that have achieved desirable practice.⁵

The remaining desirable practice relating to the food and physical activity environment (desirable practice 6: providing information to families on healthy eating, healthy lunchboxes, physical activity and limiting screen time) had lower achievement (60.5%) in geographically remote schools, although these schools achieved the highest proportion of desirable practices 1–4. Schools in geographically remote areas may frequently use face-to-face contact with families rather than distributing information sheets and newsletters, which makes achieving this practice difficult in remote areas.

Desirable practices 7, 9 and 10, regarding professional development, planning, monitoring and reporting, were less well achieved than the other desirable practices in all schools, and particularly in remote areas. This may be due to the tyranny of distance, including lack of transport, and lack of a supplementary budget for relief staff to enable teachers to attend professional development courses. Achievement of desirable practice 8 (an identified team or committee to support LLW@S implementation) indicates that staff are interested in planning actions in the school that align with LLW@S; more needs to be understood about the barriers that limit the implementation of action plans.

Table 3.     Desirable practices achieved by trained schools in June 2017, by Aboriginal status, socio-economic status and remoteness

^a All schools that attended training, less schools that opted out of the program, less schools whose practice achievement data was not collected during scheduled reporting period
^b Schools with 10% or more students from Aboriginal background, reported by the Australian Curriculum, Assessment and Reporting Authority
^c Schools located in the two most disadvantaged quintiles, as measured by the Socio-economic Indexes for Areas^13
d Schools located in remote and very remote areas, as measured by remoteness classifications¹⁴

Limitations

The data include only schools that have participated in LLW@S training because data are not available for schools not participating. Data on program adoption was collected by mulitple health promotion staff who also were responsible for providing support to schools to implement the program. The study reports on participating schools as a whole and does not differentiate between government and nongovernment schools. This presents an opportunity for further research that reports on the differential impact of LLW@S based on type of school.

Conclusions

Collaboration between the health and education sectors is essential to promote healthy lifestyles in school settings. The comprehensive, universally delivered LLW@S program achieves high reach and adoption in primary schools across NSW, which should inform international practice for whole-of-school approaches to addressing childhood obesity. This approach is feasible and acceptable for influencing school environments to promote healthy lifestyles, and does not contribute to widening the health differential for children.

Acknowledgements

The authors acknowledge those involved in the development, implementation and monitoring of LLW@S.

Peer review and provenance

Externally peer reviewed, not commissioned.