Diet and Physical Activity Environments in Primary Schools in Brunei Darussalam Siti Rohaiza Ahmad Bsc (Nutrition), Msc (BIOTECH)
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Diet and Physical Activity Environments in Primary Schools in Brunei Darussalam Siti Rohaiza Ahmad BSc (Nutrition), MSc (BIOTECH) A thesis submitted for the degree of Doctor of Philosophy at The University of Queensland in 2016 School of Public Health Abstract The challenges in trying to achieve population-level lifestyle changes have seen researchers and policymakers shift towards a focus on environmental improvements to support health-related behaviours. School environments are dynamic food and policy environments that have the capacity to change both the risks and protective factors for healthy eating and physical activity in children. The essential focus of this thesis has been to explore childhood-obesity prevention policies at a country level, and to explore the increasing problem of obesogenicity in primary school settings in Brunei Darussalam. To achieve this, three methods were adopted: a policy analysis of nutrition and physical activity initiatives, targeting the prevention of obesity in primary school settings among children aged 8 to 11 years old in Brunei, Malaysia and Singapore; case studies in five primary school settings; and a stakeholder analysis, providing insight into the perspectives of those with an interest in children‘s health, including policymakers, teachers, school administrators, and the children themselves. The key research findings are that the Brunei Darussalam‘s childhood-obesity prevention response can be strengthened by increasing the attention to upstream approaches, using school settings and school neighbourhoods, and that school community members including school administrators and teachers can play an important role in contributing to the obesity-prevention programs in the school settings, but are currently under resourced to play this role. Further, continuing to primarily blame parents for their children being overweight and obesity is a limited way of understanding the problem and is a barrier to policy innovation and community acceptance of environmental measures. The outcomes of this study are intended to benefit students and school community members through improved country-level and school-level policies that create environments to support dietary and physical activity behaviours in children. Specific policy recommendations for Brunei Darussalam include a more systematic approach to data collection, monitoring and surveillance of childhood obesity, as well as a strengthening of evidence-based obesity prevention at the environmental level. My research makes an important contribution to knowledge in the field by adopting a more holistic approach to policy research examining the various aspects of the built and food i environments and the policies that support these environments. New methods are proposed for describing, analysing, and improving environments that are important settings for obesity prevention; and the importance of engaging key stakeholders as leaders of change is highlighted. ii Declaration by author This thesis is composed of my original work, and contains no material previously published or written by another person except where due reference has been made in the text. I have clearly stated the contribution by others to jointly-authored works that I have included in my thesis. I have clearly stated the contribution of others to my thesis as a whole, including statistical assistance, survey design, data analysis, significant technical procedures, professional editorial advice, and any other original research work used or reported in my thesis. The content of my thesis is the result of work I have carried out since the commencement of my research higher degree candidature and does not include a substantial part of work that has been submitted to qualify for the award of any other degree or diploma in any university or other tertiary institution. I have clearly stated which parts of my thesis, if any, have been submitted to qualify for another award. I acknowledge that an electronic copy of my thesis must be lodged with the University Library and, subject to the policy and procedures of The University of Queensland, the thesis be made available for research and study in accordance with the Copyright Act 1968 unless a period of embargo has been approved by the Dean of the Graduate School. I acknowledge that copyright of all material contained in my thesis resides with the copyright holder(s) of that material. Where appropriate I have obtained copyright permission from the copyright holder to reproduce material in this thesis. iii Publications during candidature Ahmad, S. R., Schubert, L., and Bush, P. R. (2013). Primary school nutrition and physical activity environment: A case study in Brunei Darussalam. Obesity Research and Clinical Practice, (7), 22- 23. doi:10.1016/j.orcp.2013.08.065. Ahmad, S. R., Schubert, L., and Bush, P. R. (2015). Measuring the obesogenicity of an environment: using an audit (assessment) tool. 9th Malaysia Indonesia Brunei Conference Abstract Book. Ahmad, S. R., Schubert, L., and Bush, P. R. (2016). Primary School Obesogenic Environment Model: Case study in Brunei Darussalam. 31st Annual Scientific Conference 2016 Abstract Book by the Nutrition Society of Malaysia. Retrieved from: http://nsmconference2016.org.my/post- conference/. Ahmad, S. R., Schubert, L., and Bush, P. R. (2016). Audit tool in assessing obesogenicity on data trustworthiness and community engagement: Lesson learnt from primary school environments in Brunei Darussalam. Malaysia Journal of Nutrition, 22(2), 307 – 315. Retrieved from: http://www.nutriweb.org.my Publications included in this thesis No publications included. Contributions by others to the thesis No contributions by others. Statement of parts of the thesis submitted to qualify for the award of another degree None. iv Acknowledgements I would like to express my special appreciation and thanks to my advisor Dr Lisa Schubert and Professor Robert Bush. They have been tremendous mentors for me. I would like to thank them for encouraging my research and for allowing me to grow as a researcher. I would especially like to thank the Brunei Government for awarding me with the In-Service Training Scholarship. I also would like to thank colleagues at Universiti Brunei Darussalam (especially Dr Anne, Dr Nurol, Dr Ihsan, Dr Sheba and others too) for their continuous moral support. I would also like to thank all of my friends who supported me in writing, and incented me to strive towards my goal. My sincere thanks also go to everyone whom had helped me directly or indirectly in the process of completing my research. A special thanks to my family. Words cannot express how grateful I am to my mother (Mrs Mariam), father (Mr Hj Ahmad), my mother-in law (Mrs Hjh Intan), father-in-law (Mr Sulaiman) , sisters (Mariah, Riza, Adeh, Jamilah, Diana, Mariam, Dina, Seri, Lipah, Lizah, Noraidah, Rina, Zian) and brothers (Zul, Alwis, Sufri, Sahri, Samree, Ramli, Indera, Asrin, Wan, Herman, Sudin and Jofri) for all of their sacrifices, that they have made on my behalf, for being a great company to my children while I am away overseas. Their prayers and support for me had sustained me this far. Special thanks and lots of love also dedicated for Yana, Haiel, Wani, Zara and Izz. Most importantly, I would like to express my thanks and appreciation to my beloved husband, Sateria Sulaiman, for his continuous moral support, encouragement and help throughout my research years. Thank you and lots of love also to my four lovely children, Rania Aleesya, Aaqil Syafee, Daniel Syafee and Sofia Aleesya. My husband and children have been my greatest motivation throughout the journey. v Keywords Obesogenic environment, nutrition, physical activity, primary school, children Australian and New Zealand Standard Research Classifications (ANZSRC) ANZSRC code: 111712, Health Promotion 50% ANZSRC code: 111104, Public Nutrition Intervention 25% ANZSRC code: 160508, Health Policy 25% Fields of Research (FoR) Classification FoR code: 1605, Policy and Administration, 35% FoR code: 1117, Public Health and Health Services 30% FoR code: 1111, Nutrition and Dietetics 35% vi Table of Contents Title page Page no. Abstract i Declaration by author iii Publication during candidature iv Publications included in this thesis iv Contribution by other to the thesis iv Statement of the thesis submitted to qualify for the award of another degree iv Acknowledgements v Keywords vi Table of Contents vii List of Figures ix List of Tables x List of Abbreviations xi Glossary/Units of measurement xii CHAPTER 1 INTRODUCTION AND RATIONALE OF THE PROJECT 1.1 Introduction 1 1.2 Research motivation and significance 2 1.3 Research setting 4 1.4 Chapter structure 6 CHAPTER 2 LITERATURE REVIEW: CHILDHOOD OBESITY AND WHY IS IT A CONCERN? 2.1 Childhood obesity statistics 8 2.2 Childhood obesity: why is it a major concern? 15 2.3 Nutrition Transition in Asia 17 2.4 Conclusions 19 CHAPTER 3 MIDDLE CHILDHOOD: HEALTH BEHAVIOURS INVOLVING DIET AND PHYSICAL ACTIVITY 3.1 Middle childhood – eating patterns and food choices 20 3.2 Middle childhood – physical activity habit 31 3.3 Conclusions 35 CHAPTER 4 LITERATURE REVIEW: OVERVIEW OF POLICY AND SCHOOL-BASED OBESITY INTERVENTION 4.1 Overview of policy 36 4.2 Rationales for schools as a setting for obesity prevention 42 4.3 Components and evidences of school-based obesity prevention 43 4.4 Types of school-based obesity intervention programmes 57 4.5 Stakeholders views on school-based obesity intervention programmes 61 4.6 Critiques and barrier of school-based