Health literacy and the determinants of obesity: a population-based survey of sixth grade school children in Taiwan

BACKGROUND: Health literacy has become an important health policy and health promotion agenda item in recent years. It had been seen as a means to reduce health disparities and a critical empowerment strategy to increase people's control over their health. So far, most of health literacy studies mainly focus on adults with few studies investigating associations between child health literacy and health status. This study aimed to investigate the association between health literacy and body weight in Taiwan's sixth grade school children.

METHODS: Using a population-based survey, 162,209 sixth grade (11-12 years old) school children were assessed. The response rate at school level was 83%, with 70% of all students completing the survey. The Taiwan child health literacy assessment tool was applied and information on sex, ethnicity, self-reported health, and health behaviors were also collected. BMI was used to classify the children as underweight, normal, overweight, or obese. A multinomial logit model with robust estimation was used to explore associations between health literacy and the body weight with an adjustment for covariates.

RESULTS: The sample consisted of 48.9% girls, 3.8% were indigenous and the mean BMI was 19.55 (SD = 3.93). About 6% of children self-reported bad or very bad health. The mean child health literacy score was 24.03 (SD = 6.12, scale range from 0 to 32). The overall proportion of obese children was 15.2%. Children in the highest health literacy quartile were less likely to be obese (12.4%) compared with the lowest quartile (17.4%). After controlling for gender, ethnicity, self-rated health, and health behaviors, children with higher health literacy were less likely to be obese (Relative Risk Ratio (RRR) = 0.94, p < 0.001) and underweight (RRR = 0.83, p < 0.001). Those who did not have regular physical activity, or had sugar-sweetened beverage intake (RRR > 1.10, p < 0.0001) were more likely to report being overweight or obese.

CONCLUSIONS: This study demonstrates strong links between health literacy and obesity, even after adjusting for key potential confounders, and provides new insights into potential intervention points in school education for obesity prevention. Systematic approaches to integrating a health literacy curriculum into schools may mitigate the growing burden of disease due to obesity.

The population cost-effectiveness of delivering universal and indicated school-based interventions to prevent the onset of major depression among youth in Australia

AIMS: School-based psychological interventions encompass: universal interventions targeting youth in the general population; and indicated interventions targeting youth with subthreshold depression. This study aimed to: (1) examine the population cost-effectiveness of delivering universal and indicated prevention interventions to youth in the population aged 11-17 years via primary and secondary schools in Australia; and (2) compare the comparative cost-effectiveness of delivering these interventions using face-to-face and internet-based delivery mechanisms. METHODS: We reviewed literature on the prevention of depression to identify all interventions targeting youth that would be suitable for implementation in Australia and had evidence of efficacy to support analysis. From this, we found evidence of effectiveness for the following intervention types: universal prevention involving group-based psychological interventions delivered to all participating school students; and indicated prevention involving group-based psychological interventions delivered to students with subthreshold depression. We constructed a Markov model to assess the cost-effectiveness of delivering universal and indicated interventions in the population relative to a 'no intervention' comparator over a 10-year time horizon. A disease model was used to simulate epidemiological transitions between three health states (i.e., healthy, diseased and dead). Intervention effect sizes were based on meta-analyses of randomised control trial data identified in the aforementioned review; while health benefits were measured as Disability-adjusted Life Years (DALYs) averted attributable to reductions in depression incidence. Net costs of delivering interventions were calculated using relevant Australian data. Uncertainty and sensitivity analyses were conducted to test model assumptions. Incremental cost-effectiveness ratios (ICERs) were measured in 2013 Australian dollars per DALY averted; with costs and benefits discounted at 3%. RESULTS: Universal and indicated psychological interventions delivered through face-to-face modalities had ICERs below a threshold of $50 000 per DALY averted. That is, $7350 per DALY averted (95% uncertainty interval (UI): dominates - 23 070) for universal prevention, and $19 550 per DALY averted (95% UI: 3081-56 713) for indicated prevention. Baseline ICERs were generally robust to changes in model assumptions. We conducted a sensitivity analysis which found that internet-delivered prevention interventions were highly cost-effective when assuming intervention effect sizes of 100 and 50% relative to effect sizes observed for face-to-face delivered interventions. These results should, however, be interpreted with caution due to the paucity of data. CONCLUSIONS: School-based psychological interventions appear to be cost-effective. However, realising efficiency gains in the population is ultimately dependent on ensuring successful system-level implementation.

Assessing the sustained impact of a school-based obesity prevention program for adolescent boys: the ATLAS cluster randomized controlled trial

BACKGROUND: Obesity prevention interventions targeting 'at-risk' adolescents are urgently needed. The aim of this study is to evaluate the sustained impact of the 'Active Teen Leaders Avoiding Screen-time' (ATLAS) obesity prevention program.

METHODS: Cluster RCT in 14 secondary schools in low-income communities of New South Wales, Australia. Participants were 361 adolescent boys (aged 12-14 years) 'at risk' of obesity. The intervention was based on Self-Determination Theory and Social Cognitive Theory and involved: professional development, fitness equipment for schools, teacher-delivered physical activity sessions, lunch-time activity sessions, researcher-led seminars, a smartphone application, and parental strategies. Assessments for the primary (body mass index [BMI], waist circumference) and secondary outcomes were conducted at baseline, 8- (post-intervention) and 18-months (follow-up). Analyses followed the intention-to-treat principle using linear mixed models.

RESULTS: After 18-months, there were no intervention effects for BMI or waist circumference. Sustained effects were found for screen-time, resistance training skill competency, and motivational regulations for school sport.

CONCLUSIONS: There were no clinically meaningful intervention effects for the adiposity outcomes. However, the intervention resulted in sustained effects for secondary outcomes. Interventions that more intensively target the home environment, as well as other socio-ecological determinants of obesity may be needed to prevent unhealthy weight gain in adolescents from low-income communities.

More active pre-school children have better motor competence at school starting age: an observational cohort study.

BACKGROUND: Almost half of young children do not achieve minimum recommendations of 60 daily minutes in physical activity. Physical activity is potentially an important determinant of the development of motor competence in children. This study is one of very few longitudinal studies in this area and the first to investigate early childhood physical activity as a predictor of subsequent motor skill competence. METHODS: Children were assessed as part of the Melbourne InFANT Program longitudinal cohort study at 19 months, 3.5 years and 5 years. Moderate-to-vigorous physical activity (MVPA) (accelerometry) was assessed at each time point. At age 5, children were also assessed in actual (Test of Gross Motor Development-2) and perceived motor competence (Pictorial Scale of Perceived Movement Skill Competence). General linear models were performed with all 12 skills (six object control and six locomotor skills), both actual and perceived, at age 5 as the respective outcome variables. Predictor variables alternated between MVPA at 19 months, 3.5 years and 5 years. RESULTS: Based on standardized TGMD-2 scores most children were average or below in their skill level at age 5. MVPA at 19 months was not a predictor of actual or perceived skill at age 5. MVPA at 3.5 years was associated with actual locomotor skill (B = 0.073, p = 0.033) and perceived total skill at 5 years of age (B = 0.059, p = 0.044). MVPA was not a predictor of actual or perceived object control skill at any age. CONCLUSION: Parents and preschool staff should be informed that more time in MVPA as a preschool child contributes to locomotor skill and to perceptions of skill ability in a child of school starting age. Understanding this relationship will assist in intervention development.

Investigation of community factors associated with child and adolescent depression

The purpose of the thesis was to establish whether community-level variables accounted for an important share of the potentially modifiable factors that predict child and adolescent depression in order to inform prevention efforts in this field.

Pathway to justice: Examining the attrition of child sexual abuse cases

The attrition of child sexual abuse cases from the criminal justice process was explored. Recommendations to prevent attrition included: more effective communication between stakeholders; enabling connections between children and adults to facilitate disclosures; introduction of peer support programs to prevent withdrawal; and educating children about sexual victimisation to reduce withdrawal.

The influence of mother-child interactions on preschoolers' eating and weight.

The investigation of maternal and child factors influencing the socialization of children’s eating and weight, including the validation of an observational coding system for assessing dyadic mother-child feeding interactions, revealed a range of shared maternal and child mealtime behaviors potentially associated with preschoolers’ willingness to accept parent’s healthful feeding guidance.