Assessing the Effectiveness of an Obesity-Prevention Intervention to Improve Healthy Lifestyle among Saudi School Girls Aged 9 to 16: A Feasibility Study Duaa Hasan Hefni Submitted in Partial Fulfilment of the Requirements of the Degree of Doctor of Philosophy University of Salford, Manchester, United Kingdom School of Health and Society January 2017 i Table of Contents List of Tables ........................................................................................................................... viii List of Figures ........................................................................................................................... ix Abbreviations ............................................................................................................................ xi Acknowledgements .................................................................................................................. xii Dedication ................................................................................................................................ xii Abstract ................................................................................................................................... xiii Chapter One: Introduction .......................................................................................................... 1 1.1. Introduction .................................................................................................................... 1 1.2. Overview ........................................................................................................................ 1 1.3. Overview of the Kingdom of Saudi Arabia .................................................................... 3 1.4. Statement of the Problem ............................................................................................... 4 1.5. Significance of the Study ................................................................................................ 5 1.6. Motivation for the Study ................................................................................................ 7 1.7. Research Aim and Objectives......................................................................................... 8 1.8. Research Questions ........................................................................................................ 8 1.9. Structure of this Thesis ................................................................................................... 9 1.10. Summary ..................................................................................................................... 10 Chapter Two: Literature Review .............................................................................................. 11 2.1. Introduction .................................................................................................................. 11 2.2. Search Strategy ............................................................................................................. 11 2.2.1. Searched Databases ............................................................................................ 12 2.2.2. Extra Sources ...................................................................................................... 12 2.2.3. Search Terms ...................................................................................................... 13 2.2.4 Inclusion and Exclusion Criteria ......................................................................... 13 2.2.5. Search Results .................................................................................................... 14 2.2.6 Quality of Studies ................................................................................................ 14 2.3. Causes of Childhood Obesity ....................................................................................... 15 2.4. Health Implications of Childhood Obesity ................................................................... 16 2.5. Global Childhood Obesity Prevalence ......................................................................... 16 2.6. Childhood Obesity Prevalence in Saudi Arabia ........................................................... 18 2.7. Tackling the Childhood Obesity Problem in Saudi Arabia .......................................... 21 2.8. Nutritional Transition and Childhood Obesity ............................................................. 22 2.9. Diet, Physical Activity and Childhood Obesity ........................................................... 24 2.9.1. Diet ..................................................................................................................... 24 2.9.2. Physical Activity ................................................................................................ 26 2.9.3. Relationship of Diet, Physical Activity and Childhood Obesity ........................ 28 2.9.4. Emotions, Social Setting, and Eating Behaviour and Childhood Obesity ......... 29 2.10. Childhood Obesity Prevention Interventions ............................................................. 31 2.11. School-Based Interventions for Preventing Childhood Obesity................................. 32 ii 2.11.1. Culture .............................................................................................................. 34 2.11.1.1 Dietary traditions .................................................................................................. 34 2.11.1.2 Ramadan and Eid .................................................................................................. 35 2.11.1.3 Religiously motivated claims and bans ................................................................ 35 2.11.1.4 Inequality of curriculum between boys’ and girls’ education .............................. 35 2.11.1.5 Housemaids .......................................................................................................... 36 2.11.1.6 Lack of supervision .............................................................................................. 36 2.11.2. The School Setting ........................................................................................... 36 2.11.3. Parent’s and Teacher’s Role ............................................................................. 38 2.11.4. Duration of Intervention ................................................................................... 39 2.11.5. Behaviour Change ............................................................................................ 41 2.11.6 Appraisal and Quality Assessment of Included Studies .................................... 44 2.11.6.1 Study Aims ........................................................................................................... 45 2.11.6.2 Study Design ........................................................................................................ 45 2.11.6.3 Impact of Interventions on Dietary Habits ........................................................... 47 2.11.6.4 Impact of Intervention on Physical activity and Sedentary Behaviour................. 50 2.11.6.5 Reviewed Studies Summary of Key Findings ...................................................... 51 2.11.6.6 Strengths and Limitations of Studies .................................................................... 55 2.12 Theories Used in School-based Obesity Interventions ................................................ 56 2.12.1 Selecting a Health-Behaviour Theory ............................................................... 56 2.12.2 Major Health Behaviour Theories ..................................................................... 57 2.12.2.1 The Health Believe Model .................................................................................... 57 2.12.2.2 (Stages of) Behaviour Change Theory ................................................................. 57 2.12.2.3 Theory of Reasoned Action .................................................................................. 58 2.12.2.4 Social Cognitive Theory (SCT) ............................................................................ 58 2.12.2.5 Health Behaviour Theory ..................................................................................... 58 2.12.3.The Social Cognitive Theory............................................................................. 59 2.12.4 Constructs of Social Cognitive Theory ............................................................. 61 2.12.4.1 Personal Factors ................................................................................................... 61 2.12.4.2 Behavioural Factors .............................................................................................. 61 2.12.4.3 Environmental Factors.......................................................................................... 61 2.13. Gaps in Theory, Knowledge and Practice .................................................................. 62 2.14. Summary ..................................................................................................................... 62 Chapter Three: Methodology ................................................................................................... 64 3.1. Introduction .................................................................................................................. 64 3.2 Research Paradigms and Philosophy ............................................................................. 64 3.3. Paradigms and