Exercise as it relates to Disease/A Cultural Influence on Knowledge and Attitude towards Diet and Physical Activity in Children

This is a critique of the article 'Evaluation of the Good Start Program: a healthy eating and physical activity intervention for Maori and Pacific Islander children living in Queensland, Australia' by Mihrshahi et al. (2017).

What is the background to this research?
Obesity can be defined as an abnormal accumulation of body fat that can lead to the development of other chronic illnesses, cancer, and even death. This dangerous phenomenon is affecting countless children in Australia and worldwide, for example, 'an estimated 20 to 25% of children and adolescents in Australia are overweight, and a quarter of this group is obese'. Childhood obesity is a major concern in Australia as it is directly linked with a shortened life. Thus, it is important to consider employing strategies to ensure children can live a long and healthy life and curtail the obesity epidemic. Physical inactivity and poor diet are equally important risk factors, of obesity, that have been addressed by the research. More importantly, the research highlights how culturally appropriate methods were used to improve knowledge, attitudes and practices related to diet and physical activity (PA) in the target population.

Where is the research from?
The research features a school based intervention called the Good Start Program which took place in Queensland, Australia, in 2013 and 2014. The Good Start Program was driven by a concern for the prevalence of obesity in Maori and Pacific Islander communities and, in particular, the children of these communities. The evaluation indicates that the intervention was delivered by a group of trained multicultural health workers (MHWs) who were all of Maori and Pacific Islander descent. The guidelines for ‘Queensland Multicultural Health Policy Implementation’ outline that the delivery of health care to culturally and linguistically diverse communities is by a culturally competent workforce. For instance, an employee who has the knowledge and understanding of Maori and Pacific Islander culture, and the ability to overcome a language barrier, is culturally competent. The article dedicates a chapter to discussing intervention delivery to enhance the readers insight on the cultural appropriateness of the research which ultimately strengthens it as educational literature.

What kind of research was this?
The research involved an outcome of interest, a target group, and no control group which classifies it as a Case Series/Case Report. Because the research consists of reports of cases and uses no control groups to compare outcomes, it provides little statistical validity. Data was collected from students each school term using pre and post questionnaires in order to identify changes in knowledge, attitudes and practices relating to PA and healthy eating.

What did the research involve?
Approximately 375 students (aged 6–19yo) across 19 public schools participated in the program. It was required of the students to engage in a set of activities, every day for a year, that were educational and physically active in nature. A meaningful message relating to healthy eating and PA was focused on during these activities. The program uniquely connected students with the culture of Maori and Pacific Islander people to improve their knowledge and attitude towards diet and PA. Below is a list of the Good Start Program class activities.
 * 'Challenge Book': a diary given to students to take home and report their daily PA and nutrition intake.
 * 'Can you Dance?': a dance session featuring a mix of hip hop and cultural dance styles.
 * 'Eat Well': a classroom based nutrition education program where key messages are learnt through interactive games and fun activities.
 * 'Got Talent?': a role play scenario the students create and perform that represent healthy lifestyle behaviours.
 * 'Junior Chef': an activity where the children develop basic cooking skills and gain basic nutrition knowledge using culturally tailored resources.
 * 'Power Up': a one-hour session broken up into a nutrition segment and a PA segment.
 * 'Power Up Leadership': a leadership program.
 * 'Island Flavour': physically active and fun games where students learn about health, PA and cultural heritage.

A notable limitation of the research is found in the self-administrated method of pre-post questionnaires as data can be susceptible to being over-reported. However, the evaluation explains how the self-administrated method adapted to an interviewer administrated method to accommodate children at earlier stages of learning which may of encouraged the extraction of more accurate information. Another limitation of the research is that some of the data was collected by the MHWs who were responsible for implementation of the program, hence this was not a blinded evaluation and may have introduced bias.

What were the basic results?
This section will focus solely on the changes in knowledge, attitudes and practices relating to PA of the target group. The Good Start Program was successful in improving the students’ knowledge to do with the positive impact of PA on health and wellbeing. Remarkably, knowledge of PA recommendations increased from pre-intervention to post-intervention by 44% (as shown in Table 1 ). Attitudes towards PA received changes that were good and bad, for example, children reported that they were more interested in playing sport and felt fit enough to play sport, post-intervention. On the other hand, the percent of children who strongly agreed with the statements 'playing sport costs too much' and 'there is no time to do sport' increased post-intervention (as shown in Table 2 ). Fortunately, regular engagement with all practices increased after carrying out the program, particularly 'walking' and 'non-organised sport' received the most percent difference (as shown in Table 3 ).

Table 3. Practices
The results presented in the evaluation match the reality of change in the data. There is no element of exaggeration to the results and they are made clear to the reader through qualitative and quantitative analysis. An 'adjusted odds ratio for change from pre- to post-test, adjusted for age and gender of the children' is provided by the research.

What conclusions can we take from this research?
The Good Start Program had a positive influence on the knowledge, attitudes and practices related to healthy eating and PA. Although there were changes from pre- to post-intervention, the results favoured knowledge over attitudes and practices. The intervention was exposed to the target population in a unique and appropriate way by acknowledging and collaborating with the culture of the Maori and Pacific Islander people. This is a major strength of the program and may prove to be an effective method in the prevention of childhood obesity if it is extended and targets participation in non-organised sport.

Promoting the adoption of healthy lifestyle habits at a young age is at the heart of most preventive health strategies for childhood obesity. There is evidence supporting the use of physical education (P.E.) as a strategy for increasing PA levels in children and adolescents. However, in Australia, schools are not dedicating enough time to P.E. and children are not meeting recommended daily PA guidelines. Because children spend most of their time at school it should be made a priority that schools are utilising methods to increase PA levels in children.

Practical advice
The Good Start Program may only be relevant to the Maori and Pacific Islander people, however culturally appropriate methods are applicable to anyone with a cultural background. There is an opportunity to utilise the ideas, customs and social behaviours of a society to educate and inspire people on PA and the benefits of PA. Another essential point is that children are more likely to respond to being exposed to the potential options for engaging in PA, rather than just being instructed to do it. Children in Australia could learn about Indigenous Australia and experience the traditional tools of song and dance of the Indigenous people during school based activities with the goal to influence their knowledge, attitudes and practices toward diet and physical activity for the better.