The effectiveness of the health promoting school intervention model in reducing overweight and obesity among school children in indonesia: a mixed-methods protocol study

The effectiveness of the health promoting school intervention model in reducing overweight and obesity among school children in indonesia: a mixed-methods protocol study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Study protocol The effectiveness of the health promoting school intervention model in reducing overweight and obesity among school children in indonesia: a mixed-methods protocol study Rosdiana Rosdiana, Toto Sudargo, Fitri Haryanti This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5300191/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : Childhood obesity is a growing public health concern in Indonesia, with potential long-term health consequences. Despite various interventions, the prevalence of overweight and obesity among school-aged children continues to rise. This study aims to develop, implement, and evaluate a comprehensive school-based intervention to reduce overweight and obesity in Indonesian school children through improved health literacy, nutrition education, and physical activity promotion. Methods : This mixed-methods study will employ a three-phase design: pre-intervention, intervention, and post-intervention. The study will be conducted in three districts of South Sulawesi, Indonesia: Makassar, Gowa, and Maros. The intervention, based on Bandura's Social Cognitive Theory, will include capacity building for teachers, canteen workers, and school principals; implementation of health promoting schools; and parental engagement. Quantitative data will be collected through anthropometric measurements, questionnaires assessing knowledge, self-efficacy, and health literacy. Qualitative data will be gathered through focus group discussions with key stakeholders. The effectiveness of the intervention will be evaluated using various statistical analyses, including ANOVA, t-tests, and ANCOVA, while qualitative data will undergo thematic analysis. Results : We anticipate that this intervention will lead to significant reductions in BMI, improvements in health literacy, increased knowledge about nutrition and physical activity, and enhanced self-efficacy among participating school children. Conclusion : By integrating nutrition education, physical activity promotion, and the Health Promoting School model, this research aims to provide valuable insights for developing effective strategies to combat childhood obesity. The findings are expected to inform health and education policies in Indonesia and contribute to the global effort in addressing childhood obesity. Trial registration : Current Controlled Trial NCT06601348 pediatric obesity school health services health promotion health literacy Indonesia Figures Figure 1 Figure 2 Background Data from WHO and UNICEF indicate that Indonesia ranks among the top 10 countries with the highest obesity rates globally [ 1 ]. The prevalence of obesity in Indonesian children is increasing rapidly, with 18.8% of children aged 5–12 years experiencing severe overweight, comprising 10.8% who are obese and 8.8% who are overweight [ 2 ]. This trend is part of a global increase in childhood obesity, with the percentage of overweight children under 5 years rising from 6.2% in 1990 to 7.5% in 2020, affecting approximately 4 million children worldwide [ 3 ]. This translates to an increase of 400,000 overweight children, bringing the total to around 4 million by 2021 Childhood obesity has significant negative health impacts, both immediate and long-term. These include increased risks of high blood pressure, high cholesterol, type 2 diabetes, breathing problems such as asthma and sleep apnea, and various psychosocial issues [ 4 ]. Moreover, childhood obesity often persists into adulthood, contributing to the rising prevalence of non-communicable diseases (NCDs). It is estimated that by 2020, lifestyle-related NCDs will account for 60% of the disease burden and 70% of deaths worldwide if adequate preventive measures are not implemented [ 5 ]. In Indonesia, there is a persistent cultural perception that associates obesity with prosperity. This misconception poses a significant challenge to public health efforts aimed at preventing and reducing childhood obesity [ 6 ]. Obesity in children can impact health status, educational achievement, and quality of life, and is associated with a range of negative but preventable physical, social, and emotional health impacts with improved health literacy [ 7 ]. Schools are increasingly recognized as ideal environments for promoting health and preventing childhood obesity. Globally, various school-based interventions have shown promise in addressing this issue. Studies from 18 European countries have demonstrated positive effects on fruit and vegetable consumption, although not always statistically significant. Other interventions, such as the YOG obesity model [ 8 ], the Prevention of Obesity in American Indian School Children [ 9 ], and the Alberta Project Promoting Active Living and Healthy Eating (APPLE) have reported improvements in BMI, body fat percentage, dietary habits, and physical activity levels [ 10 ]. In Indonesia, however, school-based obesity prevention interventions are limited. One notable previous study implemented a healthy program comprising nutrition education and physical activity, which showed significant improvements in knowledge, attitude, and behavior [ 11 ]. However, this study had limitations, including the lack of structured physical activity interventions and the need for more comprehensive nutrition education materials. Given the rising prevalence of childhood obesity in Indonesia and the limited implementation of comprehensive school-based interventions, there is a critical need for effective and sustainable strategies tailored to the Indonesian context [ 12 ]. This study aims to evaluate the effectiveness of a school-based intervention model in reducing overweight and obesity among school children in Indonesia. By adopting a mixed-methods approach, we seek to not only assess the quantitative outcomes but also understand the qualitative aspects of implementation and acceptability within the Indonesian school system. Our study will address the gaps in existing research by implementing a comprehensive school-based model specifically designed for the Indonesian context, utilizing a mixed-methods approach to provide a holistic understanding of the intervention's effectiveness, and focusing on sustainable and culturally appropriate strategies for long-term impact. The findings of this study will contribute to the development of evidence-based policies and practices for childhood obesity prevention in Indonesia, with potential implications for other low- and middle-income countries. Methods Study Design This study employs an exploratory sequential mixed methods design, as outlined by Creswell & Clark [13]. The approach combines qualitative and quantitative research methodologies, beginning with an exploratory needs assessment using a cognitive social theory framework. The study unfolds in three phases: a qualitative exploration of needs assessment, a three-month trial implementing the Health Promoting School model, and a six-month quantitative Multi-center Cluster Randomised Controlled Trial to evaluate the effectiveness of school-based interventions. The research aims to address three primary questions: 1) What is the effectiveness of school-based physical activity in reducing overweight and obesity in children aged 9-12 years? 2) How do school-based interventions combined with health promoting school programmes contribute to reducing overweight and obesity in children aged 9-12 years? 3) What is the comparative effectiveness of piloting a health promoting school model with nutrition education and physical activity in reducing overweight and obesity in children aged 9-12 years? Recruitment of School Participant and Setting The recruitment process began with a preliminary study in several schools in South Sulawesi, focusing on institutions meeting specific criteria such as A and B accreditation. School principals and health practitioners were contacted, and the study's objectives were explained, emphasizing the goal of reducing childhood obesity and its long-term health implications. It was stressed that the study aimed to implement school health promotion without burdening staff with additional work. Upon agreement, parents were invited to learn about the study's purpose and benefits for their children. Parents were offered weekly health education sessions on obesity, its causes, and prevention measures throughout the study. Upon agreement, all schools and parents signed informed consent forms. From an initial pool of 15 identified schools, cluster randomization was used to select eight schools from three districts with varying economic levels that met the study criteria. Sampling Inclusion/Exclusion Criteria Inclusion criteria for schools encompassed: 1) non-boarding school status; 2) obesity prevalence above 10% based on routine physical examination records; 3) provision of school lunch to over 50% of students. Individual participant inclusion criteria included: a) male and female gender; b) children aged 9-12 years at the time of initial data collection; c) children who are overweight or obese; d) children willing to participate as respondents, complete the intervention, and provide informed consent; e) full-day school attendance. Exclusion criteria included: a) children with clinical conditions or health disorders such as heart disease; b) children absent during the pretest; c) children who left or moved schools; d) children who did not complete the intervention. Intervention The intervention comprised three components implemented over a 6-month period: nutrition education, physical activity, and a Health Promoting School model. These interventions were designed to reduce childhood overweight and obesity through education, improved health literacy, and implementation of government-designated healthy school curricula. The description related to the intervention outlined in Table 1. Nutritional education intervention This component involved developing a nutrition handbook module through piloting the health promoting school model. The content combined the government's "healthy school" program and WHO cartoon pamphlets, distributed to each school/student in the intervention schools. Nutrition and health education was provided six times for students, twice for parents, and four times for teachers and UKS officers. Topics included the proportion of three healthy meals, choosing drinks and snacks, reducing consumption of Western ready meals, and promoting local food. Nutrition professionals first gave talks to teachers and parents, after which trained teachers were responsible for teaching students. Each talk lasted a minimum of 40 minutes. "My Plate Diet" posters were displayed in all participating classrooms, and a handbook of balanced nutrition modules was distributed to all participants in the nutrition education groups. Physical Activity Intervention The "Happy in School Children" program was implemented as the physical activity intervention. This school-based program, originally developed and promoted in urban Beijing since 2004 [14], was adapted for Indonesian school children. The intervention aimed to increase physical activity by offering three 10-minute segments of moderate-intensity physical activity daily. Activities included games, dance, rhythmic gymnastics, and customized exercises, designed to encourage enjoyable forms of physical activity and improve overall fitness levels among participants. Health Promoting Shool (HPS) Model Trials Based on WHO guidelines, this model covered six key areas adapted to local needs: 1) healthy school policies, 2) school physical environment, 3) school social environment, 4) community links, 5) action competencies for healthy living, and 6) school health services. The model focused on creating a healthy environment, promoting behavior change, and improving health services through the implementation and strengthening of school health efforts. This comprehensive approach aimed to create a supportive environment for healthy behaviors and reinforce the messages delivered through the nutrition education and physical activity interventions [15]. Table 1. Overview of participant, intervention, measure description, and time frame Participant Intervention/Treatment Measure Description Time Frame Children School Nutrition education Process and learning methods through training and seminars involving class teachers, sports teachers, and distribution of posters in each class. Nutrition education is provided twice a week in the classroom through video screenings and posters on the introduction and causes of overweight and obesity status, from the consumption of junk food, foods and drinks high in sugar Measuring tools: 1) Chek list; 2) FFQ Measuring scale: ratio and categorical measuring results: conducted trials with the team. Health literacy, the ability of children, orangutans and schools to apply and use information, health promoting school approach measurement tool, in-depth interview and questionnaire distribution. 3 months trial, 3 months implementation of health promoting school (HPS) model Physical Activity “A school-based physical activity programme for students called "Happy in school children" was used in the physical activity intervention. The Happy programme was developed as a school-based intervention to promote physical activity in primary school children. The Happy programme, which has been implemented and promoted in urban Beijing since 2004, will be piloted with school children in Indonesia. As a strategy to increase physical activity. To be offered 3 times during the school day, Happy in school children will be organised by professional instructors and teachers to perform 10-minute segments of moderate-intensity, physical activity. Other forms of physical activity include games, dance or rhythmic gymnastics, such as jumping rope, and squatting, or as customised by the curriculum. The 10-minute session consists of four parts: 1) the teacher or students choose cards to determine the activity; 2) some children are chosen to model the exercise in front of the class and other students follow suit (one to three activities are performed at each session); 3) a cool-down period is conducted after the activity; and 4) students are taught health messages. The average energy expenditure for 10 minutes of physical exercise ranges from 25.0-35.1 kcal.33, the goal being that students are encouraged to develop different forms of physical exercise that they enjoy.” 6 months Health Promoting Shool (HPS) Model Trials “WHO has developed a set of guidelines covering six areas to be adopted by member states, each country will need to develop detailed indicators and evaluation frameworks to meet their local needs. Indicators and guidelines should be selected based on evidence and theory, with multiple objectives that are relevant, adaptable and achievable, to develop good practice. Indicators and guidelines for selection are based on the following criteria: (1) should be theory-based and evidence-based - based on the concept of HPS and consistent with the values and objectives of the government programme "Healthy Schools"; (2) with broad objectives - to cover all dimensions of HPS and healthy schools; (3) useful and helpful to develop health literacy providing useful and relevant information to assist in school strengthening, and to identify good practices and actions for improvement; (4) relevant and achievable applicable in the local school context; and (5) flexible and adaptable. The healthy school evaluation framework has taken these criteria into consideration. For each of the six key areas, a number of components and checkpoints have been developed to reflect the key elements of a Healthy School, with targets for schools to achieve. Points are awarded if the checkpoint criteria are met. An overall score and scores under each key area can then be calculated. Following the development of the indicators, a series of questionnaires were designed as an assessment tool for schools to evaluate HPS based on the piloted indicators. To ensure the validity and applicability of the newly developed content, it was trialled in schools, through questionnaires. The process of developing content for healthy schools will be in the process of piloting the HPS.” 6 months Parents children (mediators based on SCT) Parental self-efficacy Parental behavioural capability Parental outcome expectations and expectancies Parental role modelling observational learning Parent’s motivation “Healthy environment for healthy foods and physical activity monitoring of behaviours role modeling Involvement encouragement in healthy behaviours restriction of unhealthy foods and sedentary behaviours.” 6 monhts School principle, sport teacher, and school canteen keeper Training Modelled lesson Program into the school curriculum “School canteen keeper bers from the cooperation center for five days. Teachers, usually classroom tutors and/or health educators had attended a two-days training session conducted by the staff of their center with the training slides and videos provided by Chinese CDC. They had learned how to inte- grate the program into the school curriculum, and how to perform the activities. Slides and videos about nutrition, childhood obesity, risk factors, health consequences, and prevention were prepared by Chinese CDC and provided to school teachers. Teachers modelled the lessons to ensure that they understood the recommended tech- niques and strategies for implementation.” 6 monhts Assessment of Intervention Effects Anthropometric measurements were taken at baseline (October-November 2024) and post-intervention (May-June 2025). These included height (measured to the nearest 1 mm using a stadiometer), weight (measured to the nearest 0.1 kg using a calibrated electronic scale), BMI and BMI-z scores (calculated using the World Health Organisation growth reference), and waist circumference (measured to the nearest 0.1 cm using a non-elastic tape). All measurements followed standardized procedures to ensure accuracy and reliability. The comprehensive data collection allowed for a thorough evaluation of the interventions' effectiveness in reducing overweight and obesity among the participating children. The outcome measure description outlined in Table 2. Table 2. Overview of outcome measure, measure description, and time frame Outcome Measure Measure Description Time Frame BMI Z-score Where weight will be measured using a body composition meter (Seca 804) to 0.1 kg, and height measured with a stadiometer to 0.1 cm. BMI (kg/m2) will be converted to the Weight and height measurements will be taken twice to obtain accuracy and correct averages. Body mass index (BMI) for age Z score, according in 2007 WHO Growth Standards for children, will be used to classify the risk of being overweight with a Z SD score of 1, overweight with a Z SD score 1, and overweight: BMI Z-score ≤ 3, obesity BMI Z- score ≥ 3. 6 months intervention combining health promoting school Children knowledge Children knowledge, the ability to give appropriate answers to questions about nutrition, physical activity, causes of overweight and obesity and how to prevent them. The measuring instrument uses a questionnaire, a ratio measuring scale, the measurement result is determined from the total score set, the correct answer score is given 1) if it is wrong 0) 6 months intervention combining health promoting school Self-efficacy Self-efficacy, a person belief in their ability to perform a behaviour, the behaviour is obesity prevention, measured using a 3-point Likert scale, namely 1) agree, 2) disagree, and 3) disagree. Answer score for favourable questions: Agree: 3) Undecided: 2) Disagree:1) Unfavourable question answer score: Agree: 1) Undecided: 2) Disagree: 3) 6 months intervention combining health promoting school Health Literacy Health literacy, the ability of children, orangutans and schools to apply and use information, health promoting school approach measurement tool, in-depth interview and questionnaire distribution. 6 months intervention combining health promoting school Study phase This study will be conducted in three phases as illustrated in Figure 2, encompassing pre-intervention, intervention, and post-intervention stages. A detailed explanation of each phase follows. Phase I - Pre-Intervention This phase focuses on assessing the current state of health promotion in schools across three districts (Makassar, Gowa, and Maros). It involves evaluating children's knowledge about nutrition and exercise, their diet and physical activity patterns, and their attitudes, cultural beliefs, visions, and ideas about obesity. Additionally, we will determine the extent to which health promotion related to nutrition and physical activity has been implemented in schools. The phase also includes identifying facilitators and barriers to health promotion in schools within these districts, according to key stakeholders such as the Primary Education Office, Health Office, Youth and Sports Office, Health Promotion Coordinator, District Nutrition Coordinator, and School Health Teams. Phase II - Intervention The intervention phase, estimated to last 6 months, is conceptualized using Bandura's social cognitive theory (SCT) approach. School-based interventions will be designed to improve health literacy, reduce BMI, enhance knowledge, and increase self-efficacy, aiming to reduce overweight and obesity in schools. Key components include capacity building for teachers, canteen workers, and school principals; implementation of health promoting schools; development of a pilot model for school-based capacity building; and capacity building for parents to facilitate children's knowledge adaptation. The intervention is based on SCT's three main constructs influencing health behavior change: self-efficacy, goals or intentions, and outcome expectations, with a primary focus on self-efficacy and outcome expectancy constructs. Phase III - Post-Intervention This phase will determine the effectiveness of the school-based intervention by measuring changes in BMI, knowledge, self-efficacy, and health literacy. Additional activities include pilot testing of the health promoting school model on children, parents, and teachers; collection of mothers' and teachers' perceptions on model implementation; exploration of respondents' perceptions of the intervention's influence on reducing overweight and obesity; and pilot inspection of the health promoting school model to ensure improved health literacy. Throughout all phases, researchers will conduct random site visits to monitor data collection and intervention implementation, with feedback shared with the field team to ensure adherence to protocols. Planned Statistic Analysis Sampel size The sample size will be determined using the hypothesis test formula for the difference in means between the overweight/obese group and the intervention group with normal weight, as per Lemeshow et al. [16]. Quantitative Statistics Data will be presented as mean (SD), median, range, or percentage for categorical variables. Statistical analyses will be performed using SPSS, including normality tests, ANOVA, independent t-tests, paired t-tests or Mann-Whitney tests, repeated ANOVA, and ANCOVA. Effect size will be measured using Cohen's D. Qualitative Analysis Thematic analysis of focus group transcripts will be conducted independently by two researchers, following a six-step approach: data familiarization, initial coding, theme search, thematic map creation, theme definition and naming, and final analysis. This qualitative data will contextualize results and investigate participants' perceptions and attitudes towards the intervention. Discussion This research aims to develop a knowledge base and application for improving early healthy living behaviors through nutrition education and physical activity, packaged within a health promoting school framework. The study has the potential to influence health and education policy by providing a comprehensive evaluation of a combined approach to reducing overweight and obesity in school children. The unique aspect of this study lies in its mixed-methods design, combining a Randomised Controlled Trial with qualitative approaches to trial the Health Promoting School (HPS) model. This combination of nutrition education, physical activity, and the HPS model offers a holistic strategy for addressing childhood obesity in Indonesia. Abbreviations HPS: Health Promoting School; WHO: Word Health Organization; UNICEF: United Nations Children’s Fund; NCDs: non-communicable diseases; FFQ: Food Frequency questionnairy; SCT: Social Cognitive Theory SPIRIT: Standard Protocol Items Recommendations for Interventional Trials. Declarations Declartion of interest The outhers declare no conflict of interest Clinical Trial Number Not Applicable Acknowledgements Not Applicable Availability of data and material Not applicable, Due to the timeframe for recruitment and outcome assessment, there was no opportunity to conduct an interim analysis and therefore no role for separate analysis. Author’s contributions RD, TS, FH contributed to the study concept and design. All authors participated in drafting, reading, and approving the manuscript. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Ethics approval and Consent to participate Ethics approval was obtained from University Gadjah Mada, Medical and Health Ethics Committee (MHREC) Faculty of Medicine, Public Health and Nursing Universitas Gajah Mada-Dr. Sardjito General Hospital reference number: KE/FK/1235/EC/2024. Informed written consent will be obtained from participants, namely the principal, students, parents, including all other participants in the study. Consent for publication Not applicable References Sulistiadi W, Kusuma D, Amir V, Tjandrarini DH, Nurjana MA. Growing Up Unequal: Disparities of Childhood Overweight and Obesity in Indonesia’s 514 Districts. Healthcare. 2023;11. Kementerian Kesehtan RI. Riskesdas. 2018. https://kesmas.kemkes.go.id/assets/upload/dir_519d41d8cd98f00/files/Hasil-riskesdas-2018_1274.pdf. Accessed 6 Nov 2023. Unicef. Childhood Overweight. 2021. De Pauw R, Claessens M, Gorasso V, Drieskens S, Faes C, Devleesschauwer B. Past, present, and future trends of overweight and obesity in Belgium using Bayesian age-period-cohort models. BMC Public Health. 2022;22:1–14. Almutairi N, Burns S, Portsmouth L. Barriers and enablers to the implementation of school-based obesity prevention strategies in Jeddah, KSA. International Journal of Qualitative Studies on Health and Well-being. 2022;17. Widiastuti I, Widyawati IY, Wahyuni ED. Perubahan antropometri anak usia sekolah yang mengalami obesitas paska pemberian terapi bermain: gobak sodor. Critical Medical and Surgical Nursing Journal (CMSNJ). 2016;4:29–39. Pradhan NA, Mughis W, Ali TS, Naseem M, Karmaliani R. School-based interventions to promote personal and environmental hygiene practices among children in Pakistan: protocol for a mixed methods study. BMC public health. 2020;20. Wang Z, Xu F, Ye Q, Tse LA, Xue H, Tan Z, et al. Childhood obesity prevention through a community-based cluster randomized controlled physical activity intervention among schools in china: the health legacy project of the 2nd world summer youth olympic Games (YOG-Obesity study). International journal of obesity (2005). 2018;42:625–33. Giralt M, Albaladejo R, Tarro L, Moriña D, Arija V, Solà R. A primary-school-based study to reduce prevalence of childhood obesity in Catalunya (Spain) - EDAL-Educació en alimentació: study protocol for a randomised controlled trial. Trials. 2011;12:54. Xu H, Li Y, Zhang Q, Hu X, Liu A, Du S, et al. Comprehensive school-based intervention to control overweight and obesity in China: a cluster randomized controlled trial. Asia Pac J Clin Nutr. 2017;26:1139–51. Kurniawan F, Astiarani Y, Santi BT, Kristian K, Satya R, Fitriah N. Health Screening for the Primary School Students in Penjaringan District. MITRA: Jurnal Pemberdayaan Masyarakat. 2022;6:148–57. Brown T, Moore TH, Hooper L, Gao Y, Zayegh A, Ijaz S, et al. Interventions for preventing obesity in children. The Cochrane Database of Systematic Reviews. 2019;2019. Creswell JW, Clark VLP. Third Edition: Designing and conducting mixed methods research approarch. 2017;:520. Spiga F, Davies AL, Tomlinson E, Moore THM, Dawson S, Breheny K, et al. Interventions to prevent obesity in children aged 5 to 11 years old. The Cochrane Database of Systematic Reviews. 2024;2024. Langford R, Bonell CP, Jones HE, Pouliou T, Murphy SM, Waters E, et al. The WHO Health Promoting School framework for improving the health and well-being of students and their academic achievement. Cochrane Database of Systematic Reviews. 2014;2014. Lemeshow et al. 1997. Open Access - Journals - Scientific Research Publishing. 1997. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5300191","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Study protocol","associatedPublications":[],"authors":[{"id":369793576,"identity":"1cdff1f3-78ec-4736-8540-4af1f8d87227","order_by":0,"name":"Rosdiana Rosdiana","email":"","orcid":"","institution":"Universitas Gadjah Mada","correspondingAuthor":false,"prefix":"","firstName":"Rosdiana","middleName":"","lastName":"Rosdiana","suffix":""},{"id":369793578,"identity":"552c73a6-9f1b-4466-8706-c0b3aa90d184","order_by":1,"name":"Toto Sudargo","email":"","orcid":"","institution":"Universitas Gadjah Mada","correspondingAuthor":false,"prefix":"","firstName":"Toto","middleName":"","lastName":"Sudargo","suffix":""},{"id":369793580,"identity":"6cb3cd19-52ec-4adc-939a-8f23527f1c58","order_by":2,"name":"Fitri Haryanti","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+0lEQVRIiWNgGAWjYBAC9mYgkdgA5SVUwMQNmHFq4TnMDNfC2JBwhhgtB5hBaqFaGNvgEni0sPMf+/Bwh12+wfGzxx88nHfYbm0D88MPDAXWuLUwMzPPSDyTbLnhTF5iQ+K2w8nbDrAZSzAYpOPUYg/UwpDYxmxgcCDHEKzF7ACDGdAvh/HaAtRSb2Bw/g1QyxyQFvZvxGg5bGBwA2RLw2E7swM8BG0xBmo5biB5443hjIRj6Qlmh3mKJRLw+IWH/+Bjxp9t1QZ853MMPv6osbY3O96+8cOHP7hDDA4UDkDoxAZQjCQQ1sDAIN8Aoe2JUTwKRsEoGAUjCwAA3+VS//5YVqUAAAAASUVORK5CYII=","orcid":"","institution":"Universitas Gadjah Mada","correspondingAuthor":true,"prefix":"","firstName":"Fitri","middleName":"","lastName":"Haryanti","suffix":""}],"badges":[],"createdAt":"2024-10-21 00:08:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5300191/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5300191/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":67455039,"identity":"4d7d9734-b4b3-4948-aa60-c2cc30ece952","added_by":"auto","created_at":"2024-10-25 08:32:01","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":62214,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eProposed Study Flow\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5300191/v1/9267500c5b98268cb1218dc2.png"},{"id":67455040,"identity":"dd71f724-c796-43a1-a943-6e553be22483","added_by":"auto","created_at":"2024-10-25 08:32:01","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":93842,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eResearch stages and time frame\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5300191/v1/bab7a96a1dbf8cd5631dc99f.png"},{"id":71668468,"identity":"ca3a7b10-e7bc-4d85-a5a8-d1fd18a451a9","added_by":"auto","created_at":"2024-12-17 14:39:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":585755,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5300191/v1/de37e4b5-b1c0-4b0d-8584-4eaee7dbc9b0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The effectiveness of the health promoting school intervention model in reducing overweight and obesity among school children in indonesia: a mixed-methods protocol study","fulltext":[{"header":"Background","content":"\u003cp\u003eData from WHO and UNICEF indicate that Indonesia ranks among the top 10 countries with the highest obesity rates globally [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The prevalence of obesity in Indonesian children is increasing rapidly, with 18.8% of children aged 5\u0026ndash;12 years experiencing severe overweight, comprising 10.8% who are obese and 8.8% who are overweight [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This trend is part of a global increase in childhood obesity, with the percentage of overweight children under 5 years rising from 6.2% in 1990 to 7.5% in 2020, affecting approximately 4\u0026nbsp;million children worldwide [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This translates to an increase of 400,000 overweight children, bringing the total to around 4\u0026nbsp;million by 2021\u003c/p\u003e \u003cp\u003eChildhood obesity has significant negative health impacts, both immediate and long-term. These include increased risks of high blood pressure, high cholesterol, type 2 diabetes, breathing problems such as asthma and sleep apnea, and various psychosocial issues [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Moreover, childhood obesity often persists into adulthood, contributing to the rising prevalence of non-communicable diseases (NCDs). It is estimated that by 2020, lifestyle-related NCDs will account for 60% of the disease burden and 70% of deaths worldwide if adequate preventive measures are not implemented [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Indonesia, there is a persistent cultural perception that associates obesity with prosperity. This misconception poses a significant challenge to public health efforts aimed at preventing and reducing childhood obesity [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Obesity in children can impact health status, educational achievement, and quality of life, and is associated with a range of negative but preventable physical, social, and emotional health impacts with improved health literacy [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSchools are increasingly recognized as ideal environments for promoting health and preventing childhood obesity. Globally, various school-based interventions have shown promise in addressing this issue. Studies from 18 European countries have demonstrated positive effects on fruit and vegetable consumption, although not always statistically significant. Other interventions, such as the YOG obesity model [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], the Prevention of Obesity in American Indian School Children [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], and the Alberta Project Promoting Active Living and Healthy Eating (APPLE) have reported improvements in BMI, body fat percentage, dietary habits, and physical activity levels [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Indonesia, however, school-based obesity prevention interventions are limited. One notable previous study implemented a healthy program comprising nutrition education and physical activity, which showed significant improvements in knowledge, attitude, and behavior [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, this study had limitations, including the lack of structured physical activity interventions and the need for more comprehensive nutrition education materials.\u003c/p\u003e \u003cp\u003eGiven the rising prevalence of childhood obesity in Indonesia and the limited implementation of comprehensive school-based interventions, there is a critical need for effective and sustainable strategies tailored to the Indonesian context [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This study aims to evaluate the effectiveness of a school-based intervention model in reducing overweight and obesity among school children in Indonesia. By adopting a mixed-methods approach, we seek to not only assess the quantitative outcomes but also understand the qualitative aspects of implementation and acceptability within the Indonesian school system.\u003c/p\u003e \u003cp\u003eOur study will address the gaps in existing research by implementing a comprehensive school-based model specifically designed for the Indonesian context, utilizing a mixed-methods approach to provide a holistic understanding of the intervention's effectiveness, and focusing on sustainable and culturally appropriate strategies for long-term impact. The findings of this study will contribute to the development of evidence-based policies and practices for childhood obesity prevention in Indonesia, with potential implications for other low- and middle-income countries.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy Design\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study employs an exploratory sequential mixed methods design, as outlined by Creswell \u0026amp; Clark [13]. The approach combines qualitative and quantitative research methodologies, beginning with an exploratory needs assessment using a cognitive social theory framework. The study unfolds in three phases: a qualitative exploration of needs assessment, a three-month trial implementing the Health Promoting School model, and a six-month quantitative Multi-center Cluster Randomised Controlled Trial to evaluate the effectiveness of school-based interventions. The research aims to address three primary questions: 1) What is the effectiveness of school-based physical activity in reducing overweight and obesity in children aged 9-12 years? 2) How do school-based interventions combined with health promoting school programmes contribute to reducing overweight and obesity in children aged 9-12 years? 3) What is the comparative effectiveness of piloting a health promoting school model with nutrition education and physical activity in reducing overweight and obesity in children aged 9-12 years?\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eRecruitment of School Participant and Setting\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe recruitment process began with a preliminary study in several schools in South Sulawesi, focusing on institutions meeting specific criteria such as A and B accreditation. School principals and health practitioners were contacted, and the study\u0026apos;s objectives were explained, emphasizing the goal of reducing childhood obesity and its long-term health implications. It was stressed that the study aimed to implement school health promotion without burdening staff with additional work. Upon agreement, parents were invited to learn about the study\u0026apos;s purpose and benefits for their children. Parents were offered weekly health education sessions on obesity, its causes, and prevention measures throughout the study. Upon agreement, all schools and parents signed informed consent forms. From an initial pool of 15 identified schools, cluster randomization was used to select eight schools from three districts with varying economic levels that met the study criteria.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSampling Inclusion/Exclusion Criteria\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInclusion criteria for schools encompassed: 1) non-boarding school status; 2) obesity prevalence above 10% based on routine physical examination records; 3) provision of school lunch to over 50% of students. Individual participant inclusion criteria included: a) male and female gender; b) children aged 9-12 years at the time of initial data collection; c) children who are overweight or obese; d) children willing to participate as respondents, complete the intervention, and provide informed consent; e) full-day school attendance. Exclusion criteria included: a) children with clinical conditions or health disorders such as heart disease; b) children absent during the pretest; c) children who left or moved schools; d) children who did not complete the intervention.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eIntervention\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe intervention comprised three components implemented over a 6-month period: nutrition education, physical activity, and a Health Promoting School model. These interventions were designed to reduce childhood overweight and obesity through education, improved health literacy, and implementation of government-designated healthy school curricula. The description related to the intervention outlined in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNutritional education intervention\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis component involved developing a nutrition handbook module through piloting the health promoting school model. The content combined the government\u0026apos;s \u0026quot;healthy school\u0026quot; program and WHO cartoon pamphlets, distributed to each school/student in the intervention schools. Nutrition and health education was provided six times for students, twice for parents, and four times for teachers and UKS officers. Topics included the proportion of three healthy meals, choosing drinks and snacks, reducing consumption of Western ready meals, and promoting local food. Nutrition professionals first gave talks to teachers and parents, after which trained teachers were responsible for teaching students. Each talk lasted a minimum of 40 minutes. \u0026quot;My Plate Diet\u0026quot; posters were displayed in all participating classrooms, and a handbook of balanced nutrition modules was distributed to all participants in the nutrition education groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePhysical Activity Intervention\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe \u0026quot;Happy in School Children\u0026quot; program was implemented as the physical activity intervention. This school-based program, originally developed and promoted in urban Beijing since 2004 [14], was adapted for Indonesian school children. The intervention aimed to increase physical activity by offering three 10-minute segments of moderate-intensity physical activity daily. Activities included games, dance, rhythmic gymnastics, and customized exercises, designed to encourage enjoyable forms of physical activity and improve overall fitness levels among participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHealth Promoting Shool (HPS) Model Trials\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBased on WHO guidelines, this model covered six key areas adapted to local needs: 1) healthy school policies, 2) school physical environment, 3) school social environment, 4) community links, 5) action competencies for healthy living, and 6) school health services. The model focused on creating a healthy environment, promoting behavior change, and improving health services through the implementation and strengthening of school health efforts. This comprehensive approach aimed to create a supportive environment for healthy behaviors and reinforce the messages delivered through the nutrition education and physical activity interventions [15].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Overview of participant, intervention, measure description, and time frame\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1414%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipant\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2323%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntervention/Treatment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44.4444%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMeasure Description\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime Frame\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1414%;\"\u003e\n \u003cp\u003eChildren School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2323%;\"\u003e\n \u003cp\u003eNutrition education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44.4444%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eProcess and learning methods through training and seminars involving class teachers, sports teachers, and distribution of posters in each class.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eNutrition education is provided twice a week in the classroom through video screenings and posters on the introduction and causes of overweight and obesity status, from the consumption of junk food, foods and drinks high in sugar\u003c/li\u003e\n \u003cli\u003eMeasuring tools: 1) Chek list; 2) FFQ Measuring scale: ratio and categorical measuring results: conducted trials with the team. Health literacy, the ability of children, orangutans and schools to apply and use information, health promoting school approach measurement tool, in-depth interview and questionnaire distribution.\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e3 months trial, 3 months implementation of health promoting school (HPS) model\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1414%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2323%;\"\u003e\n \u003cp\u003ePhysical Activity\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44.4444%;\"\u003e\n \u003cp\u003e\u0026ldquo;A school-based physical activity programme for students called \u0026quot;Happy in school children\u0026quot; was used in the physical activity intervention. The Happy programme was developed as a school-based intervention to promote physical activity in primary school children. The Happy programme, which has been implemented and promoted in urban Beijing since 2004, will be piloted with school children in Indonesia. \u0026nbsp;As a strategy to increase physical activity. To be offered 3 times during the school day, Happy in school children will be organised by professional instructors and teachers to perform 10-minute segments of moderate-intensity, physical activity. Other forms of physical activity include games, dance or rhythmic gymnastics, such as jumping rope, and squatting, or as customised by the curriculum. The 10-minute session consists of four parts: 1) the teacher or students choose cards to determine the activity; 2) some children are chosen to model the exercise in front of the class and other students follow suit (one to three activities are performed at each session); 3) a cool-down period is conducted after the activity; and 4) students are taught health messages. The average energy expenditure for 10 minutes of physical exercise ranges from 25.0-35.1 kcal.33, the goal being that students are encouraged to develop different forms of physical exercise that they enjoy.\u0026rdquo;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e6 months\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1414%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2323%;\"\u003e\n \u003cp\u003eHealth Promoting Shool (HPS) Model Trials\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44.4444%;\"\u003e\n \u003cp\u003e\u0026ldquo;WHO has developed a set of guidelines covering six areas to be adopted by member states, each country will need to develop detailed indicators and evaluation frameworks to meet their local needs. Indicators and guidelines should be selected based on evidence and theory, with multiple objectives that are relevant, adaptable and achievable, to develop good practice. Indicators and guidelines for selection are based on the following criteria: (1) should be theory-based and evidence-based - based on the concept of HPS and consistent with the values and objectives of the government programme \u0026quot;Healthy Schools\u0026quot;; (2) with broad objectives - to cover all dimensions of HPS and healthy schools; (3) useful and helpful to develop health literacy providing useful and relevant information to assist in school strengthening, and to identify good practices and actions for improvement; (4) relevant and achievable applicable in the local school context; and (5) flexible and adaptable. The healthy school evaluation framework has taken these criteria into consideration. \u0026nbsp;For each of the six key areas, a number of components and checkpoints have been developed to reflect the key elements of a Healthy School, with targets for schools to achieve. Points are awarded if the checkpoint criteria are met. An overall score and scores under each key area can then be calculated. Following the development of the indicators, a series of questionnaires were designed as an assessment tool for schools to evaluate HPS based on the piloted indicators. To ensure the validity and applicability of the newly developed content, it was trialled in schools, through questionnaires. The process of developing content for healthy schools will be in the process of piloting the HPS.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1414%;\"\u003e\n \u003cp\u003eParents children (mediators based on SCT)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2323%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eParental self-efficacy\u003c/li\u003e\n \u003cli\u003eParental behavioural\u003cbr\u003e\u0026nbsp;capability\u003c/li\u003e\n \u003cli\u003eParental outcome expectations and expectancies\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eParental role modelling observational learning Parent\u0026rsquo;s motivation\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44.4444%;\"\u003e\n \u003cp\u003e\u0026ldquo;Healthy environment for healthy foods and physical activity monitoring of behaviours role modeling\u003cbr\u003e\u0026nbsp;Involvement encouragement in healthy\u003cbr\u003e\u0026nbsp;behaviours restriction of unhealthy foods and sedentary behaviours.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e6 monhts\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1414%;\"\u003e\n \u003cp\u003eSchool principle, sport teacher, and school canteen keeper\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2323%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eTraining\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eModelled lesson\u003c/li\u003e\n \u003cli\u003eProgram into the school curriculum\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44.4444%;\"\u003e\n \u003cp\u003e\u0026ldquo;School canteen keeper bers from the cooperation center for five days. Teachers, usually classroom tutors and/or health educators had attended a two-days training session conducted by the staff of their center with the training slides and videos provided by Chinese CDC. They had learned how to inte- grate the program into the school curriculum, and how to perform the activities. Slides and videos about nutrition, childhood obesity, risk factors, health consequences, and prevention were prepared by Chinese CDC and provided to school teachers. Teachers modelled the lessons to ensure that they understood the recommended tech- niques and strategies for implementation.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e6 monhts\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAssessment of Intervention Effects\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnthropometric measurements were taken at baseline (October-November 2024) and post-intervention (May-June 2025). These included height (measured to the nearest 1 mm using a stadiometer), weight (measured to the nearest 0.1 kg using a calibrated electronic scale), BMI and BMI-z scores (calculated using the World Health Organisation growth reference), and waist circumference (measured to the nearest 0.1 cm using a non-elastic tape). All measurements followed standardized procedures to ensure accuracy and reliability. The comprehensive data collection allowed for a thorough evaluation of the interventions\u0026apos; effectiveness in reducing overweight and obesity among the participating children. The outcome measure description outlined in Table 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Overview of outcome measure, measure description, and time frame\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1717%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome Measure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59.596%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMeasure Description\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2323%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime Frame\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1717%;\"\u003e\n \u003cp\u003eBMI Z-score\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59.596%;\"\u003e\n \u003cp\u003eWhere weight will be measured using a body composition meter (Seca 804) to 0.1 kg, and height measured with a stadiometer to 0.1 cm. BMI (kg/m2) will be converted to the Weight and height measurements will be taken twice to obtain accuracy and correct averages. Body mass index (BMI) for age Z score, according in 2007 WHO Growth Standards for children, will be used to classify the risk of being overweight with a Z SD score of 1, overweight with a Z SD score 1, and overweight: BMI Z-score \u0026le; 3, obesity BMI Z- score \u0026ge; 3.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2323%;\"\u003e\n \u003cp\u003e6 months intervention combining health promoting school\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1717%;\"\u003e\n \u003cp\u003eChildren knowledge\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59.596%;\"\u003e\n \u003cp\u003eChildren knowledge, the ability to give appropriate answers to questions about nutrition, physical activity, causes of overweight and obesity and how to prevent them. The measuring instrument uses a questionnaire, a ratio measuring scale, the measurement result is determined from the total score set, the correct answer score is given 1) if it is wrong 0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2323%;\"\u003e\n \u003cp\u003e6 months intervention combining health promoting school\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1717%;\"\u003e\n \u003cp\u003eSelf-efficacy\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59.596%;\"\u003e\n \u003cp\u003eSelf-efficacy, a person belief in their ability to perform a behaviour, the behaviour is obesity prevention, measured using a 3-point Likert scale, namely 1) agree, 2) disagree, and 3) disagree. Answer score for favourable questions: Agree: 3) Undecided: 2) Disagree:1) Unfavourable question answer score: Agree: 1) Undecided: 2) Disagree: 3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2323%;\"\u003e\n \u003cp\u003e6 months intervention combining health promoting school\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1717%;\"\u003e\n \u003cp\u003eHealth Literacy\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59.596%;\"\u003e\n \u003cp\u003eHealth literacy, the ability of children, orangutans and schools to apply and use information, health promoting school approach measurement tool, in-depth interview and questionnaire distribution.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2323%;\"\u003e\n \u003cp\u003e6 months intervention combining health promoting school\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy phase\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study will be conducted in three phases as illustrated in Figure 2, encompassing pre-intervention, intervention, and post-intervention stages. A detailed explanation of each phase follows.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePhase I - Pre-Intervention\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis phase focuses on assessing the current state of health promotion in schools across three districts (Makassar, Gowa, and Maros). It involves evaluating children\u0026apos;s knowledge about nutrition and exercise, their diet and physical activity patterns, and their attitudes, cultural beliefs, visions, and ideas about obesity. Additionally, we will determine the extent to which health promotion related to nutrition and physical activity has been implemented in schools. The phase also includes identifying facilitators and barriers to health promotion in schools within these districts, according to key stakeholders such as the Primary Education Office, Health Office, Youth and Sports Office, Health Promotion Coordinator, District Nutrition Coordinator, and School Health Teams.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePhase II - Intervention\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe intervention phase, estimated to last 6 months, is conceptualized using Bandura\u0026apos;s social cognitive theory (SCT) approach. School-based interventions will be designed to improve health literacy, reduce BMI, enhance knowledge, and increase self-efficacy, aiming to reduce overweight and obesity in schools. Key components include capacity building for teachers, canteen workers, and school principals; implementation of health promoting schools; development of a pilot model for school-based capacity building; and capacity building for parents to facilitate children\u0026apos;s knowledge adaptation. The intervention is based on SCT\u0026apos;s three main constructs influencing health behavior change: self-efficacy, goals or intentions, and outcome expectations, with a primary focus on self-efficacy and outcome expectancy constructs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePhase III - Post-Intervention\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis phase will determine the effectiveness of the school-based intervention by measuring changes in BMI, knowledge, self-efficacy, and health literacy. Additional activities include pilot testing of the health promoting school model on children, parents, and teachers; collection of mothers\u0026apos; and teachers\u0026apos; perceptions on model implementation; exploration of respondents\u0026apos; perceptions of the intervention\u0026apos;s influence on reducing overweight and obesity; and pilot inspection of the health promoting school model to ensure improved health literacy. Throughout all phases, researchers will conduct random site visits to monitor data collection and intervention implementation, with feedback shared with the field team to ensure adherence to protocols. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePlanned Statistic Analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSampel size\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe sample size will be determined using the hypothesis test formula for the difference in means between the overweight/obese group and the intervention group with normal weight, as per Lemeshow et al. [16].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eQuantitative Statistics\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eData will be presented as mean (SD), median, range, or percentage for categorical variables. Statistical analyses will be performed using SPSS, including normality tests, ANOVA, independent t-tests, paired t-tests or Mann-Whitney tests, repeated ANOVA, and ANCOVA. Effect size will be measured using Cohen\u0026apos;s D.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eQualitative Analysis\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThematic analysis of focus group transcripts will be conducted independently by two researchers, following a six-step approach: data familiarization, initial coding, theme search, thematic map creation, theme definition and naming, and final analysis. This qualitative data will contextualize results and investigate participants\u0026apos; perceptions and attitudes towards the intervention.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis research aims to develop a knowledge base and application for improving early healthy living behaviors through nutrition education and physical activity, packaged within a health promoting school framework. The study has the potential to influence health and education policy by providing a comprehensive evaluation of a combined approach to reducing overweight and obesity in school children. The unique aspect of this study lies in its mixed-methods design, combining a Randomised Controlled Trial with qualitative approaches to trial the Health Promoting School (HPS) model. This combination of nutrition education, physical activity, and the HPS model offers a holistic strategy for addressing childhood obesity in Indonesia.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003eHPS: Health Promoting School; WHO: Word Health Organization; UNICEF: United Nations Children\u0026rsquo;s Fund; NCDs: non-communicable diseases; FFQ: Food Frequency questionnairy; SCT: Social Cognitive Theory SPIRIT: Standard Protocol Items Recommendations for Interventional Trials.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDeclartion of interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe outhers declare no conflict of interest\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable, Due to the timeframe for recruitment and outcome assessment, there was no opportunity to conduct an interim analysis and therefore no role for separate analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRD, TS, FH contributed to the study concept and design. All authors participated in drafting, reading, and approving the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and Consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval was obtained from University Gadjah Mada, Medical and Health Ethics \u0026nbsp;Committee (MHREC) \u0026nbsp;Faculty of Medicine, Public Health and Nursing Universitas Gajah Mada-Dr. Sardjito General Hospital reference number: KE/FK/1235/EC/2024. Informed written consent will be obtained from participants, namely the principal, students, parents, including all other participants in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eSulistiadi W, Kusuma D, Amir V, Tjandrarini DH, Nurjana MA. Growing Up Unequal: Disparities of Childhood Overweight and Obesity in Indonesia\u0026rsquo;s 514 Districts. Healthcare. 2023;11.\u003c/li\u003e\n \u003cli\u003eKementerian Kesehtan RI. Riskesdas. 2018. https://kesmas.kemkes.go.id/assets/upload/dir_519d41d8cd98f00/files/Hasil-riskesdas-2018_1274.pdf. Accessed 6 Nov 2023.\u003c/li\u003e\n \u003cli\u003eUnicef. Childhood Overweight. 2021.\u003c/li\u003e\n \u003cli\u003eDe Pauw R, Claessens M, Gorasso V, Drieskens S, Faes C, Devleesschauwer B. Past, present, and future trends of overweight and obesity in Belgium using Bayesian age-period-cohort models. BMC Public Health. 2022;22:1\u0026ndash;14.\u003c/li\u003e\n \u003cli\u003eAlmutairi N, Burns S, Portsmouth L. Barriers and enablers to the implementation of school-based obesity prevention strategies in Jeddah, KSA. International Journal of Qualitative Studies on Health and Well-being. 2022;17.\u003c/li\u003e\n \u003cli\u003eWidiastuti I, Widyawati IY, Wahyuni ED. Perubahan antropometri anak usia sekolah yang mengalami obesitas paska pemberian terapi bermain: gobak sodor. Critical Medical and Surgical Nursing Journal (CMSNJ). 2016;4:29\u0026ndash;39.\u003c/li\u003e\n \u003cli\u003ePradhan NA, Mughis W, Ali TS, Naseem M, Karmaliani R. School-based interventions to promote personal and environmental hygiene practices among children in Pakistan: protocol for a mixed methods study. BMC public health. 2020;20.\u003c/li\u003e\n \u003cli\u003eWang Z, Xu F, Ye Q, Tse LA, Xue H, Tan Z, et al. Childhood obesity prevention through a community-based cluster randomized controlled physical activity intervention among schools in china: the health legacy project of the 2nd world summer youth olympic Games (YOG-Obesity study). International journal of obesity (2005). 2018;42:625\u0026ndash;33.\u003c/li\u003e\n \u003cli\u003eGiralt M, Albaladejo R, Tarro L, Mori\u0026ntilde;a D, Arija V, Sol\u0026agrave; R. A primary-school-based study to reduce prevalence of childhood obesity in Catalunya (Spain) - EDAL-Educaci\u0026oacute; en alimentaci\u0026oacute;: study protocol for a randomised controlled trial. Trials. 2011;12:54.\u003c/li\u003e\n \u003cli\u003eXu H, Li Y, Zhang Q, Hu X, Liu A, Du S, et al. Comprehensive school-based intervention to control overweight and obesity in China: a cluster randomized controlled trial. Asia Pac J Clin Nutr. 2017;26:1139\u0026ndash;51.\u003c/li\u003e\n \u003cli\u003eKurniawan F, Astiarani Y, Santi BT, Kristian K, Satya R, Fitriah N. Health Screening for the Primary School Students in Penjaringan District. MITRA: Jurnal Pemberdayaan Masyarakat. 2022;6:148\u0026ndash;57.\u003c/li\u003e\n \u003cli\u003eBrown T, Moore TH, Hooper L, Gao Y, Zayegh A, Ijaz S, et al. Interventions for preventing obesity in children. The Cochrane Database of Systematic Reviews. 2019;2019.\u003c/li\u003e\n \u003cli\u003eCreswell JW, Clark VLP. Third Edition: Designing and conducting mixed methods research approarch. 2017;:520.\u003c/li\u003e\n \u003cli\u003eSpiga F, Davies AL, Tomlinson E, Moore THM, Dawson S, Breheny K, et al. Interventions to prevent obesity in children aged 5 to 11 years old. The Cochrane Database of Systematic Reviews. 2024;2024.\u003c/li\u003e\n \u003cli\u003eLangford R, Bonell CP, Jones HE, Pouliou T, Murphy SM, Waters E, et al. The WHO Health Promoting School framework for improving the health and well-being of students and their academic achievement. Cochrane Database of Systematic Reviews. 2014;2014.\u003c/li\u003e\n \u003cli\u003eLemeshow et al. 1997. Open Access - Journals - Scientific Research Publishing. 1997.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"pediatric obesity , school health services , health promotion , health literacy , Indonesia ","lastPublishedDoi":"10.21203/rs.3.rs-5300191/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5300191/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Childhood obesity is a growing public health concern in Indonesia, with potential long-term health consequences. Despite various interventions, the prevalence of overweight and obesity among school-aged children continues to rise. This study aims to develop, implement, and evaluate a comprehensive school-based intervention to reduce overweight and obesity in Indonesian school children through improved health literacy, nutrition education, and physical activity promotion.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: This mixed-methods study will employ a three-phase design: pre-intervention, intervention, and post-intervention. The study will be conducted in three districts of South Sulawesi, Indonesia: Makassar, Gowa, and Maros. The intervention, based on Bandura's Social Cognitive Theory, will include capacity building for teachers, canteen workers, and school principals; implementation of health promoting schools; and parental engagement. Quantitative data will be collected through anthropometric measurements, questionnaires assessing knowledge, self-efficacy, and health literacy. Qualitative data will be gathered through focus group discussions with key stakeholders. The effectiveness of the intervention will be evaluated using various statistical analyses, including ANOVA, t-tests, and ANCOVA, while qualitative data will undergo thematic analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: We anticipate that this intervention will lead to significant reductions in BMI, improvements in health literacy, increased knowledge about nutrition and physical activity, and enhanced self-efficacy among participating school children.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: By integrating nutrition education, physical activity promotion, and the Health Promoting School model, this research aims to provide valuable insights for developing effective strategies to combat childhood obesity. The findings are expected to inform health and education policies in Indonesia and contribute to the global effort in addressing childhood obesity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration\u003c/strong\u003e : Current Controlled Trial NCT06601348\u003c/p\u003e","manuscriptTitle":"The effectiveness of the health promoting school intervention model in reducing overweight and obesity among school children in indonesia: a mixed-methods protocol study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-25 08:31:57","doi":"10.21203/rs.3.rs-5300191/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"00f9ac33-19b5-4fc8-b635-1eea0308cdd5","owner":[],"postedDate":"October 25th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-17T14:39:20+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-25 08:31:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5300191","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5300191","identity":"rs-5300191","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}