| Objective: Childhood obesity has become one of the most serious public health problems in the world.The increasing rate of obesity in China has exceeded the global average,which becomes the second largest-scale obese country following the United States.Childhood obesity has greatly increased the probability of adulthood obesity,which has become a high-risk factor for many chronic diseases such as type 2 diabetes and cardiovascular disease.As a result,it has brought a heavy economic burden to society.In the latest "Implementation Plan for the Prevention and Control of Obesity in Children and Adolescents",Liaoning Province has been classified as an area with a high prevalence of childhood obesity across the country,and Shenyang as the capital of Liaoning,the prevalence of childhood obesity is not optimistic.This research focuses on how to solve the child obesity epidemic in Shenyang,and conducts scientific research.The research explored how to apply the Transtheoretical Model into children’s health education,and how to combine health education technology with theoretical models in order to guide the improvement of children’s health behaviors.It aims to form a comprehensive prevention and control plan to provide a scientific basis for government departments to carry out child obesity prevention and control work.Therefore,this study aims are: 1.predict the development trend of Shenyang children’s weight status under natural conditions,look for the transfer characteristics of weight status in different age groups,and provide real-world basis for the development of intervention programs and the determination of intervention objects;2.Based on the the Transtheoretical Model,carry out a formative research to form a "multi-level multi-component comprehensive prevention and control plan for childhood obesity";3.Based on this plan to carry out a cluster randomized controlled trials experiment,evaluate the effectiveness of this prevention and control program in reducing childhood obesity,improving children’s health behaviors,and improving parenting behaviors.Methods:In this study,we first constructed a multistate Markov model of weight state transition from primary school grade 1 to senior high school grade 3 based on the Shenyang Children and Adolescents Health Examination Database from 2003 to 2018.RStudio software was used to estimate the transfer probability and transfer law among three weight statuses of children of different ages and genders.Taking the weight status of children in grade 1 of Shenyang primary school in 2018 as the initial status to predict the weight status of their natural development in 18 years old(high school grade 3).Secondly,based on formative research,the intervention measures and strategies of childhood obesity in different intervention places at home and abroad were collected by the literature method,and the item pool of intervention measures was formed.Interviews were conducted on the stakeholders of childhood obesity intervention in Shenyang,including the staff of primary healthcare institutions,the administrators of primary-school,teachers,children and parents,in order to realize the current situation of obesity among children,intervention needs,difficulties and obstacles,besides,the effectiveness and feasibility of intervention measures of the item pool were inquired.Based on the transtheoretical model,the data results were summarized to develop a multi-level multi-component comprehensive obesity prevention and control program for children in Shenyang,the contents needed to be developed include intervention objectives,intervention implementation plans,intervention evaluation programs and intervention materials.Finally,carried out a cluster randomized controlled trial program.The intervention group consisted of 4 classes and 157 children,while the control group consisted of 4 classes and 160 children from the same school.The children in the intervention group were intervened according to the "multi-level multicomponent comprehensive prevention and control plan for childhood obesity".Children,parents and school were taken as the three-level intervention objects.Five behaviors related to childhood obesity including children’s vegetables and fruits,sedentary behavior,physical activity,meat intake and sugar-sweetened beverages intake were chose as multiple intervention components to conduct research.Using the statistical analysis methods such as generalized estimating equations,Student’s t test and chi-square test to contrast the different between intervention group and control group in children weight status,children’s health behavior,children’s Stage of Change of the Transtheoretical Model,parents’ parenting behavior,parents’ parenting self-efficacy in order to evaluate the effectiveness of the intervention program.Process evaluation was carried out throughout the whole intervention project,participants’ interviews were carried out to evaluate the feasibility of the intervention program.Results: 1.For children of different genders and ages,overweight status is a relatively unstable weight status.Compared with the other two status,overweight status is more likely to transfer to the other two weight status.The probability of overweight children staying in the original state was 49.3%-69.1%,the probability of obese children staying in the original state was 75.9%-85.3%,and the probability of healthy weight children staying in the original state was 91.6%-95.4%.2.The probability for children to stay in the original weight status increases with age.The rate for boys staying in the overweight status increased from 55.86% in grade 1 of primary school to 69.1% in grade 3 of high school,and girls increased from 49.3% to 66.0%.3.The obesity status of boys is more stable than that of girls.The probability of boys staying in obese status is 81.4%-85.3%,and that of girls is 75.9%-81.4%.The probability of boys staying obese is about 1.04-1.11 times that of girls in the same age group.4.Under the condition of natural development without external intervention,in 2018,the overweight rate of Shenyang boys in primary school grade 1 will increase from 14.3% to 21.4% by the time of high school grade 3,the obesity rate will decrease from 20.9% to 18.5%,while the overweight rate of girls will increase from 13.3% to 15.7% by the time of high school grade 3,and the obesity rate will decrease from 13.9% to 9.5%.5.The results of the formative research method showed that the intervention research on childhood obesity should take the inter-individual level(family)and organization level(such as school,primary healthcare institutions,communities,etc.)as the common intervention objects,and multi-component intervention measured at the same time to improve the effectiveness of intervention research.At present,most of the primary healthcare institutions in Shenyang have not carried out the prevention and control of childhood obesity yet,main problems included the severe shortage of child healthcare doctors,uneven staffing and diagnosis environment,obvious gap,difficult contact between children and parents,low social recognition and trust,most of the prevention and control methods are not feasible and related work cannot effectively be conducted.Primary school children have less academic pressure,more spare time,teachers including headteachers,physical education teachers,healthcare teachers can play a positive role in the prevention and control of childhood obesity.But the lack of parental support is one of the main obstacles to the prevention and control of childhood obesity in primary schools at the same time.6.For the “multi-level multi-component comprehensive prevention and control plan for childhood obesity” developed based on formative research,we chose children(individual),family(interpersonal)and school(organization)as the three level intervention objects,take improving children’s vegetable and fruit intake,sedentary behavior,physical activity,meat intake,and sugar-sweetened beverages as the intervention goals,implementing multiple intervention measures at the same time.7.The baseline data of the intervention study showed that the prevalence of overweight in the intervention group was21.0%,the prevalence of obesity was 32.5%,and the prevalence of overweight in the control group was 20.4%,and the prevalence of obesity was 40.8%.Intervention improved the score of five behavior-related self-efficacy and perceived benefits for children in the intervention group.The intervention increased intake of vegetables,fruits and meat,increased physical activity,and reduced sedentary time and sugar-sweetened beverage consumption.Compared with before the intervention,the obesity rate of children in the intervention group decreased by 10.3% after the intervention.Compared with the control group,the BMI z-score of the intervention group decreased by 0.275 after the intervention.After intervention,the scores of parents’ parenting behavior,parents’ parenting selfefficacy,parents’ health behavior and parents’ health attitude were improved in the intervention group.After the intervention,the teachers’ health knowledge,awareness,belief and self-efficacy of prevention and control of childhood obesity were improved.Conclusions: 1.Compared with overweight children,obese children are more difficult to transfer to normal weight status,while boys are more difficult to transfer overweight and obesity to normal weight than girls.With the growth of children,the individual’s weight status tends to be stable especially overweight status,making it more difficult to transfer to the healthy weight status.In the natural state without intervention,the prevalence of overweight and obesity among children in Shenyang will continue to increase in the future.2.Then work primary healthcare institutions carried out in the prevention and control of childhood obesity,and there are significant problems in human resources and social recognition.Compared with primary healthcare institutions,using schools as the site is conducive to the development of current childhood obesity prevention and control work,and can be used as an entry point for childhood obesity prevention and control work.3.The multiple levels of intervention targets and multiple components of intervention measures are the successful experience of the prevention and control of childhood obesity in the world,and it is also a method recognized by the prevention and control of childhood obesity in our country.The intervention experiments of this study have verified that this intervention model can achieve better interventions effect.4.The Transtheoretical Model can be better integrated into children’s health education.Children’s health behaviors transformed in accordance with pre-contemplation stage-contemplation stage-preparation phase-action phase-maintenance phase can combine with health knowledge transmission,behavioral goal setting,parental network community activities,and can achieve significant intervention results.The healthy behavior theory represented by the cross-theoretical model can be considered to included in the health Education Curriculum Reform at the Stage of Basic Education in our country.5.The “multi-level multicomponent comprehensive prevention and control plan for childhood obesity” developed in this research can effectively promote the behavioral transition of children’s stage of change of five healthy behaviors,including vegetables and fruits,sedentary behavior,physical activity,meat and sugar-sweetened beverages.,and improved the level of children’s behavior related self-efficacy and decision balance.Besides,the intervention facilitated the changes of five types of behavior,as well as reduced the detection rate of obesity and the Z score of BMI in the intervention group.6.The results show that bringing into a variety of objects including children,parents,schools,designed intervention programs based on the normal behavior model,carrying out fully formative research and investigation on the intervention area and population,and making use of parents’ online communities are the keys to the successful implementation of the intervention. |
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