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Effects of an Adolescent Obesity Management Educational Program on Middle and High School Teachers in South Korea

Open AccessPublished:April 20, 2017DOI:https://doi.org/10.1016/j.anr.2017.03.006

      Summary

      Purpose

      This study aimed to examine the effects of an adolescent obesity management educational program (AOMEP) on middle and high school teachers.

      Methods

      A quasiexperimental, pretest post-test design was performed to test primary variables, including adolescent obesity management knowledge, attitudes, perceived behavioral control, and behavioral intention based on the concepts presented in the Theory of Planned Behavior.

      Results

      A total of 61 teachers participated. The experimental group (n = 30) received 15 hours of AOMEP, whereas the control group (n = 31) did not receive any. The experimental group showed significant improvement in knowledge (t = 2.53, d = .65, p = .014) and attitude (t = 2.77, d = .71, p = .008) toward adolescent obesity management compared to the control group. However, there were no significant differences in perceived behavioral control or behavioral intention between the groups.

      Conclusions

      AOMEP may be utilized as an effective obesity management program for adolescent students in schools.

      Keywords

      Introduction

      During the past few decades, obesity has become a major health problem globally. To reduce its incidence, a “war on obesity” has been declared in some countries [
      • Showell N.N.
      • Fawole O.
      • Segal J.
      • Wilson R.F.
      • Cheskin L.J.
      • Bleich S.N.
      • et al.
      A systematic review of home-based childhood obesity prevention studies.
      ]. However, despite governmental efforts, the obese population is significantly increasing. Further, children and adolescents are not an exception to this trend. To outline the scope and severity of the problem, it has been reported that more than 42 million adolescents are either overweight or obese worldwide [
      • World Health Organization
      Obesity and overweight [Internet].
      ]. In South Korea, a web-based survey of youth risk behaviors [
      • Korea Centers for Disease Control and Prevention
      Eleventh Korea youth risk behavior web-based survey statistics.
      ] found that 10.9% of adolescents were obese. Specifically, Gangwon province accounted for the highest level of obesity, at a rate of 12.4% [
      • Korea Centers for Disease Control and Prevention
      Eleventh Korea youth risk behavior web-based survey statistics.
      ].
      A major issue associated with childhood obesity is that it may lead to metabolic disease and a dangerous constellation of cardiac risk factors in later adult life [
      • Lloyd L.J.
      • Langley-Evans S.C.
      • McMullen S.
      Childhood obesity and risk of the adult metabolic syndrome: a systematic review.
      ]. Metabolic disease induces higher rates of cardiovascular disease, stroke, and type 2 diabetes mellitus [
      • Lloyd L.J.
      • Langley-Evans S.C.
      • McMullen S.
      Childhood obesity and risk of the adult metabolic syndrome: a systematic review.
      ,
      • Ivey F.M.
      • Macko R.F.
      • Ryan A.S.
      • Hafer-Macko C.E.
      Cardiovascular health and fitness after stroke.
      ]. Thus, management of obesity at an early age may be a key component against obesity related adulthood diseases [
      • Lofton S.
      • Julion W.A.
      • McNaughton D.B.
      • Bergren M.D.
      • Keim K.S.
      A systematic review of literature on culturally adapted obesity prevention interventions for African American youth.
      ]. Adolescent obesity also affects physical, psychological, and social problems [
      • Lloyd L.J.
      • Langley-Evans S.C.
      • McMullen S.
      Childhood obesity and risk of the adult metabolic syndrome: a systematic review.
      ,
      • Ivey F.M.
      • Macko R.F.
      • Ryan A.S.
      • Hafer-Macko C.E.
      Cardiovascular health and fitness after stroke.
      ,
      • Ben-Sefer E.
      • Ben-Natan M.
      • Ehrenfeld M.
      Childhood obesity: current literature, policy and implications for practice.
      ]. Obese adolescents may possess a negative body image, which can lead to lower self-esteem [
      • Showell N.N.
      • Fawole O.
      • Segal J.
      • Wilson R.F.
      • Cheskin L.J.
      • Bleich S.N.
      • et al.
      A systematic review of home-based childhood obesity prevention studies.
      ,
      • Ben-Sefer E.
      • Ben-Natan M.
      • Ehrenfeld M.
      Childhood obesity: current literature, policy and implications for practice.
      ] that could cause these individuals to display depressed and even nervous behaviors when referring to their obesity issue [
      • Ben-Sefer E.
      • Ben-Natan M.
      • Ehrenfeld M.
      Childhood obesity: current literature, policy and implications for practice.
      ,
      • Sormunen M.
      • Tossavainen K.
      • Turunen H.
      Parental perceptions of the roles of home and school in health education for elementary school children in Finland.
      ]. In addition, obesity in adolescents may result in other negative consequences, such as distant peer relationships and passive participation in school activities [
      • Ben-Sefer E.
      • Ben-Natan M.
      • Ehrenfeld M.
      Childhood obesity: current literature, policy and implications for practice.
      ,
      • Kim H.G.
      The effect of perceived parental abuse and neglect and peer attachment on school life adjustment according to children's gender.
      ]. Therefore, the management of obesity for adolescent students is essential for promoting overall health.
      School-based health education has been widely implemented and is considered fundamental for promoting the health of students [
      • Sormunen M.
      • Tossavainen K.
      • Turunen H.
      Parental perceptions of the roles of home and school in health education for elementary school children in Finland.
      ]. In Korea, adolescents typically spend the majority of their time at school [
      • Kim H.G.
      The effect of perceived parental abuse and neglect and peer attachment on school life adjustment according to children's gender.
      ]. As such, school is considered the optimal place to teach obesity management. Most children acquire knowledge and attitudes involving issues related to health in school [
      • Jo E.J.
      8A study on finding protective factors which affect children's school adjustment from parental abuse: comparison between abused children and normal children.
      ]. School is an important environment for the prevention of risky health behaviors and improvement of overall health promotion behavior [
      • Russell-Mayhew S.
      • Nutter S.
      • Ireland A.
      • Gabriele T.
      • Bardick A.
      • Crooks J.
      • et al.
      Pilot testing a professional development model for preservice teachers in the area of health and weight: feasibility, utility, and efficacy.
      ]. Howard-Drake and Halliday [
      • Howard-Drake E.J.
      • Halliday V.
      Exploring primary school headteachers' perspectives on the barriers and facilitators of preventing childhood obesity.
      ] have insisted that school is a crucial setting for the implementation of obesity prevention programs. Thus, school-based obesity management programs are an important part of child and adolescent health promotion [
      • Fairclough S.J.
      • Hackett A.F.
      • Davies I.G.
      • Gobbi R.
      • Mackintosh K.A.
      • Warburton G.L.
      • et al.
      Promoting healthy weight in primary school children through physical activity and nutrition education: a pragmatic evaluation of the CHANGE! randomised intervention study.
      ].
      As a role model of adolescent students, teachers may have a powerful impact on the behavior influencing attitudes of students [
      • Russell-Mayhew S.
      • Nutter S.
      • Ireland A.
      • Gabriele T.
      • Bardick A.
      • Crooks J.
      • et al.
      Pilot testing a professional development model for preservice teachers in the area of health and weight: feasibility, utility, and efficacy.
      ,
      • Yager Z.
      Issues of teacher training in the prevention of eating disorders and childhood obesity in schools.
      ]. Regarding obesity management, teachers can provide direct or indirect messages about body weight and shape, eating behavior, and physical exercise [
      • Russell-Mayhew S.
      • Nutter S.
      • Ireland A.
      • Gabriele T.
      • Bardick A.
      • Crooks J.
      • et al.
      Pilot testing a professional development model for preservice teachers in the area of health and weight: feasibility, utility, and efficacy.
      ]. Therefore, obesity management programs initiated by teachers may result in positive outcomes for adolescent students. Adolescent obesity is an important health problem of concern, not only for school nurses, but also for other teachers. Currently, the Ministry of Education in Korea [
      • Ministry of Education
      Basic directions for student health promotion [Internet].
      ] encourages teachers to participate in obesity management educational programs.
      However, unlike health professionals, some teachers are unprepared for performing such a role in the management of obesity programs, and may have difficulties in managing the problems of obese students [
      • Howard-Drake E.J.
      • Halliday V.
      Exploring primary school headteachers' perspectives on the barriers and facilitators of preventing childhood obesity.
      ,
      • Heo Y.Y.
      • Hwang J.A.
      The status, importance and performance of the school obesity education in elementary school.
      ]. To increase the ability of the teachers to manage adolescent obesity, more specialized obesity management educational programs are urgently needed [
      • Howard-Drake E.J.
      • Halliday V.
      Exploring primary school headteachers' perspectives on the barriers and facilitators of preventing childhood obesity.
      ].
      Few studies have focused on obesity management programs for educators in South Korea, and these studies have been limited to school nurses and nutritionists in elementary schools [
      • Heo Y.Y.
      • Hwang J.A.
      The status, importance and performance of the school obesity education in elementary school.
      ,
      • Choo J.
      • Yang H.M.
      • Kim H.J.
      • Oh S.W.
      • Kim S.
      • Jeong M.
      • et al.
      School-based obesity prevention and management programs as perceived and experienced by elementary school health teachers.
      ]. Although studies from other countries have suggested that obesity educational programs for teachers are an important factor in obesity management of children and adolescents [
      • Lofton S.
      • Julion W.A.
      • McNaughton D.B.
      • Bergren M.D.
      • Keim K.S.
      A systematic review of literature on culturally adapted obesity prevention interventions for African American youth.
      ,
      • Russell-Mayhew S.
      • Nutter S.
      • Ireland A.
      • Gabriele T.
      • Bardick A.
      • Crooks J.
      • et al.
      Pilot testing a professional development model for preservice teachers in the area of health and weight: feasibility, utility, and efficacy.
      ,
      • Howard-Drake E.J.
      • Halliday V.
      Exploring primary school headteachers' perspectives on the barriers and facilitators of preventing childhood obesity.
      ,
      • Yager Z.
      Issues of teacher training in the prevention of eating disorders and childhood obesity in schools.
      ], to date, no studies exist examining obesity management educational programs targeting teachers of adolescents in Korea.
      If proper obesity management education for teachers is provided in schools, it can contribute to the success of this type of program, ultimately improving the attainment of health promotion behaviors in adolescents. Therefore, this study aimed to conduct an adolescent obesity management educational program (AOMEP) for teachers and to evaluate whether the program was effective in improving knowledge, attitude, perceived behavioral control, and behavioral intention of teachers.

      Conceptual framework

      The concepts presented in Icek Ajzen's Theory of Planned Behavior (TPB) [
      • Wyer Jr., R.S.
      • Srull T.K.
      Handbook of social cognition.
      ] were used as a conceptual framework to examine the effects of AOMEP in this study (Figure 1). This theory explains human behavior and has been widely applied in health-related fields for the purposes of health behavior modification. It states that attitudes toward behavior and perceived behavioral control influence behavioral intention and actual performed behaviors. TPB has previously been used in school-based interventions for health behavior modification in overweight and obese adolescents [
      • Chatzisarantis N.
      • Kamarova S.
      • Kawabata M.
      • Wang J.C.
      • Hagger M.S.
      Developing and evaluating utility of school-based intervention programs in promoting leisure-time physical activity: an application of the theory of planned behavior.
      ,
      • Slawson D.L.
      • Dalton W.T.
      • Dula T.M.
      • Southerland J.
      • Wang L.
      • Littleton M.A.
      • et al.
      College students as facilitators in reducing adolescent obesity disparity in Southern Appalachia: team up for healthy living.
      ].
      Figure 1
      Figure 1Conceptual framework in this study. Note. AOM = adolescent obesity management; AOMEP = adolescent obesity management educational program.
      Therefore, based on the concepts presented in this theory [
      • Wyer Jr., R.S.
      • Srull T.K.
      Handbook of social cognition.
      ], we shaped a model comprising (a) knowledge, (b) attitudes, (c) perceived behavioral control, and (d) behavioral intention toward adolescent obesity management (AOM). Unlike the original TPB [
      • Wyer Jr., R.S.
      • Srull T.K.
      Handbook of social cognition.
      ], we did not consider that variables such as knowledge, attitude, perceived behavioral control would affect behavioral intention. Additionally, actual behaviors were not measured in the current study, due to the short-term implementation of the AOMEP. The current study assumed that an AOMEP may increase AOM behaviors, which may lead to the ultimate achievement of decreasing adolescent obesity. This is why the TPB was considered a conceptual framework within the current context, rather than as a theoretical framework.
      Knowledge concerns levels of understanding and deals with the amount of correct information individuals hold regarding AOM. Attitudes refer to the degree of value placed on the performance of AOM. Therefore, this definition of attitudes was utilized in the current study. Perceived behavioral control means the perception of the ease or difficulty in performing a particular behavior, and is regarded as the most important precondition for behavioral change. In the current study, perceived behavioral control may facilitate or impede implementation of AOM. This measure, in combination with behavioral intention, can be used to predict the behavior of an individual. Behavioral intention is an indication of readiness to perform a given behavior and is assumed as an immediate antecedent of behavior. Therefore, it may predict the implementation of AOM. The main focus of this study framework was to lead successful AOM implementation by teachers, in an effort to attain adolescent health promotion.

      Methods

      Study design

      The current study was a quasiexperimental design, using a pretest/post-test nonequivalent control group, to examine the effects of AOMEP on school teachers (Figure 2).
      Figure 2
      Figure 2Flow diagram in this study. Note. AOMEP = adolescent obesity management educational program. aAge, gender, marital status, career, etc. bKnowledge of adolescent obesity management (10 items). cAttitude of adolescent obesity management (6 items). dPerceived behavioral control of adolescent obesity management (8 items). eBehavioral intention of adolescent obesity management (3 items). fExperimental group only (9 items).

      Setting and samples

      The study was conducted in Gangwon province, South Korea, with 61 middle school and high school teachers. After approval of the relevant institutional review board, teachers were recruited to participate in the study. The Department of Education announced the AOMEP to each school in the study area, and teachers that applied were classified as the experimental group. The control group was selected using a table of numbers comprising those who were enrolled at the Department of Education as a teacher. These teachers had received no educational program regarding obesity management at any point. The researchers contacted prospective participants via e-mail and provided them with comprehensive information about the study, including its purpose, methods, and procedures as well as their right to withdraw from the study at any time. In addition, participants were notified that there was no disadvantage in nonparticipation, and that data would be reported as a whole and not individually. After the participants had contacted the researchers stating their interest in the study, they were then asked to provide informed consent.
      All participants completed the pretest questionnaire 1 week prior to the AOMEP. In the experimental group, eight participants withdrew from the study, and two participants had incomplete responses. Six participants in the control group withdrew, and three questionnaires were incomplete. A total of 61 individuals participated in the study, with 30 in the experimental group and 31 in the control group.
      Using G*Power version 3.1.7 [
      • Faul F.
      • Erdfelder E.
      • Buchner A.
      • Lang A.-G.
      Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses.
      ], we found that 30 participants per group would satisfy an effect size of .65, and that two groups with 80% power were required for one-tailed independent t tests at a significance level of .05. With this information considered, the total sample of 61 participants was deemed appropriate.

      Ethical considerations

      Ethical approval of the study was granted by the institutional review board of Hallym University (IRB no. HIRB-2016-040), to which one of the researchers is affiliated. The board confirmed that the study did not violate human rights, and that all contents and processes conformed to the conduct of appropriate research ethics.

      Measurements

      Knowledge

      Knowledge was measured using a questionnaire the researchers developed based on the Obesity Guidelines by the Korean Society for the Study of Obesity [
      • Korean Society for the Study of Obesity
      Obesity treatment guidelines [Internet].
      ]. It was comprised of 10 dichotomous questions asking for true or false response regarding adolescent obesity criteria, causes, prevention, and management. The correctness of a response was scored dichotomously as 1 (correct) and 0 (incorrect). The total scores ranged from 0–10. Higher scores signified more knowledge related to AOM.

      Attitudes

      Attitudes were measured by a scale developed by Heo and Hwang [
      • Heo Y.Y.
      • Hwang J.A.
      The status, importance and performance of the school obesity education in elementary school.
      ] and revised by the authors, so that it was appropriate for the purpose of the current study. Specifically, the instrument was revised to examine the main items required for the management of obesity in adolescents. This scale consisted of six items and assessed values regarding AOM. Items of the questionnaire were scored on a 4-point Likert scale (1 = not at all, 2 = a little, 3 = moderately so, 4 = very much). Total scores ranged from 6 to 24, with higher scores indicating positive attitudes toward AOM. Cronbach α was not reported in the original study [
      • Heo Y.Y.
      • Hwang J.A.
      The status, importance and performance of the school obesity education in elementary school.
      ], but was calculated to be .86 in the current study.

      Perceived behavioral control

      Perceived behavioral control was measured by a scale developed by Choo et al [
      • Choo J.
      • Yang H.M.
      • Kim H.J.
      • Oh S.W.
      • Kim S.
      • Jeong M.
      • et al.
      School-based obesity prevention and management programs as perceived and experienced by elementary school health teachers.
      ], and revised by the researchers to reflect the role of a school teacher. We revised the instrument to assess components of AOM controllability. A total of eight items were measured on a 4-point Likert scale (1 = not at all, 2 = a little, 3 = moderately so, 4 = very much). Total scores ranged from 8 to 32. A higher score indicated increased confidence in achieving AOM. Cronbach α was not reported in the original study [
      • Choo J.
      • Yang H.M.
      • Kim H.J.
      • Oh S.W.
      • Kim S.
      • Jeong M.
      • et al.
      School-based obesity prevention and management programs as perceived and experienced by elementary school health teachers.
      ], but was calculated to be .90 for the current study.

      Behavioral intention

      Behavioral intention was measured by a scale developed by the authors based on previous studies, and constructed to be appropriate for the purposes of the current study. This instrument included items to determine whether participants displayed the intention to play an active role in AOM. A total of three questions, such as “How often do you think you will participate in AOM?” were utilized. Responses were scored on a 4-point Likert scale (1 = not at all, 2 = a little, 3 = moderately so, 4 = very much), with possible scores ranging from 3 to 12. Higher scores indicated a stronger behavioral intention toward AOM. Cronbach α was calculated to be .91 for this measure.

      Satisfaction

      Satisfaction of teachers was assessed with an instrument based on the satisfaction scale developed by Otieno et al [
      • Otieno O.G.
      • Toyama H.
      • Asonuma M.
      • Kanai-Pak M.
      • Naitoh K.
      Nurses' views on the use, quality and user satisfaction with electronic medical records: questionnaire development.
      ]. The instrument revision was made not only for cultural fit but also for contextual fit, and translated from English to Korean. This measurement consisted of nine, 4-point Likert scale items (1 = not at all, 2 = a little, 3 = moderately so, 4 = very much). The scale assessed satisfaction with the AOMEP, feelings related to knowledge improvement, and feelings associated with the importance of the program. The higher the score, the greater the level of satisfaction. Cronbach α was not reported in the original study, but was calculated to be .93 in the current study.

      Content validity

      The first author of this article and two other nursing faculty members discussed the lucidity of the expressions utilized and revised the items as necessary for all the instruments. A content validity test on all instruments used was conducted by an expert panel to identify suitability of the questionnaires. The panel was composed of seven experts. Among them, three experts were child and adolescent health nursing professors, two were school nurses working at a middle school and high school, and two were physicians specialized in obesity. In this study, the content validity indices of all instruments exceeded 80%, which was considered acceptable. Through this process, the suitability of these three instruments was ensured.

      Data collection

      Data was collected from August 25, 2016 to September 13, 2016. The first author oriented the research assistants regarding the study processes prior to the commencement of this study. The research assistants were master's degree candidates, and were blinded to the assignment groups of the teachers. To maintain confidentially, the researchers used ID numbers for teachers to match and measure changes in scores between the tests.
      The pretest was conducted to examine the homogeneity of the participants, and to measure baseline knowledge, attitudes, perceived behavioral control, and behavioral intention toward AOM. The pretest was completed 1 week before starting the AOMEP intervention, and the post-test was performed 1 week later, after the completion of the program, using the same questionnaire that was used for the pretest. In addition, satisfaction with the AOMEP was evaluated at the post-test only for the experimental group. Pretest and post-test questionnaires were administered at the same time for the control group via e-mail. A small gift (worth approximately US$5) was given to each of the participants who completed the questionnaire as a token of appreciation.

      Educational intervention

      After obtaining written informed consent, an AOMEP was administered to participants. The AOMEP was designed by the authors and five specialists (including a physician, a nutritionist, a pediatrician, an exercise specialist, and an educationist). The program contents were based on the textbook published by the Korean Society for the Study of Obesity [
      • Korean Society for the Study of Obesity
      Obesity treatment guidelines [Internet].
      ]. Following confirmation through several in-depth discussions among the authors regarding the applicability and feasibility of the AOMEP within the school setting, the intervention was initiated. The AOMEP consisted of four sessions and was conducted in 15 hours over 4 consecutive workdays (3–4 hours per session), from September 1st to September 6th (Figure 3). The rationale for the duration and frequency of the intervention was twofold. First, educational programs for teachers offered by the Department of Education were regulated to a maximum of 15 hours per program. Second, the frequency was chosen considering the number of postwork hours typically available to teachers.
      Figure 3
      Figure 3Educational contents. Note. AOMEP = adolescent obesity management educational program.
      Eight AOMEP topics were addressed during the four sessions: “importance of AOMEP in schools”, “disease prevention”, “nutrition”, “counseling”, “exercise”, “exercise practice”, “school curriculum”, and “role of teachers”. The “importance of AOMEP in schools” and “disease prevention” session involved instruction on the importance of obesity management, current adolescent obesity issues, and potential benefits of the AOMEP in adolescents. The “nutrition” and “counseling” session focused on the formation of healthy dietary habits, modifying healthy food choices, and counseling psychological problems. In particular, to reinforce positive attitudes, perceived behavioral control, and behavioral intention toward AOM, teachers were exposed to elements such as diet diaries, role playing, applied counseling techniques, and discussions about the problems of obese adolescents, using real cases. In addition, each specialist gave teachers guidance and feedback in their area of expertise. The “exercise” and “exercise practice” session focused on appropriate exercise for adolescents that can be performed within the school setting, such as a jumping rope. Teachers were informed about the necessary intensity of exercise, a regime for obese students, and types of exercise that could be performed with peers. Finally, the “school curriculum” and “role of teachers” session involved planning and evaluation of an AOMEP within the school, the plan for the activation of an AOMEP, and the importance of a teacher's role in this program. In this session, as a role model, teachers discussed their beliefs regarding obese adolescents.
      In an effort to ensure that sessions were retained, lectures and graphics representing the statistics, and video clips were used as educational methods and materials, to stimulate learning motivation and attention in teachers [
      • Walthouwer M.J.L.
      • Oenema A.
      • Lechner L.
      • de Vries H.
      Comparing a video and text version of a web-based computer-tailored intervention for obesity prevention: a randomized controlled trial.
      ]. In addition, to share their opinions and experience and to induce active participation, discussion was incorporated into the AOMEP.

      Data analysis

      Data analyses were performed using SPSS version 21.0 (IBM Inc., Chicago, IL). To test homogeneity, a t test and chi-square test were used. To examine the effects of the AOMEP between the two groups, a t test of the mean differences (i.e., post-test minus pretest score) was used. To test the satisfaction level of the program, mean and standard deviation were used. The statistical significance level was set at .05.

      Results

      Homogeneity test between two groups

      No significant differences in general characteristics were found between the experimental and control groups (Table 1). The homogeneity test showed no differences in age, gender, marital status, career, having an obesity management program in school, types of AOM program in school. In addition, baseline scores of main variables (knowledge, attitudes, perceived behavioral control, and behavioral intention) were not significantly different. Therefore, the two groups were considered homogenous.
      Table 1Homogeneity Test between Two Groups (N = 61).
      CharacteristicsClassificationEG (n = 30)CG (n = 31)Total (n = 61)χ2/tp
      n (%) or M ± SDn (%) or M ± SDn (%) or M ± SD
      General characteristics
       Age (yr)43.43 ± 7.9242.63 ± 8.4443.03 ± 8.130.38.706
       GenderMale5 (16.7)3 (9.7)8 (13.1)0.65.419
      Female25 (83.3)28 (90.3)53 (86.9)
       Marital statusMarried24 (80.0)24 (77.4)48 (78.7)0.06.806
      Single6 (20.0)7 (22.6)13 (21.3)
       Career (month)163.52 ± 107.77155.26 ± 124.99159.25 ± 116.070.27.786
       Having an obesity management program in schoolYes23 (76.7)25 (80.6)48 (78.7)0.14.704
      No7 (23.3)6 (19.4)13 (21.3)
       Types of AOM program in school
      Multiple choice.
      Physical activity20 (66.7)13 (58.1)38 (62.3)0.48.488
      Diet control16 (53.3)13 (41.9)29 (47.5)0.79.373
      Counselling19 (63.3)21 (67.7)40 (45.6)0.13.717
      None3 (10.0)4 (12.9)7 (11.5)0.13.722
       Degree of awareness in AOM by oneself3.37 ± 0.563.32 ± 0.753.34 ± 0.660.26.795
      Main variables
       Knowledge6.77 ± 1.196.86 ± 0.886.81 ± 1.040.35.728
       Attitude20.37 ± 2.5020.06 ± 2.6920.21 ± 2.580.45.652
       Perceived behavioral control21.30 ± 1.7421.77 ± 1.9421.54 ± 1.851.00.321
       Behavioral intention9.77 ± 1.369.87 ± 1.439.82 ± 1.380.29.771
      Note. AOM = adolescent obesity management; CG = control group EG = experimental group.
      a Multiple choice.

      Effects of AOMEP

      An independent t test of mean difference (post-test score minus pretest score) showed that the AOMEP had significant effects on knowledge (t = 2.53, d = .65, p = .014) and attitudes (t = 2.77, d = .71, p = .008) in the experimental group. The effect sizes (d) were between medium and large [
      • Cohen J.
      Statistical power analysis for the behavioral sciences.
      ]. However, there were no significant differences on perceived behavioral control (t = 1.60, d = .41, p = .115) or behavioral intention (t = 0.83, d = .21, p = .412) between the two groups (Table 2). Further examination of the group scores discovered positive changes in the experimental group, while the control group exhibited negative changes for all variables.
      Table 2Effects of AOMEP on Main Variables (N = 61).
      VariablesNo. of itemsEG (n = 30)CG (n = 31)t
      t refers to the t value of mean difference.
      d
      d refers to effect size.
      p
      M ± SDM ± SD
      PrePostMean differencePrePostMean difference
      Knowledge106.77 ± 1.197.17 ± 1.260.40 ± 1.456.86 ± 0.886.55 ± 1.03−0.38 ± 0.822.53.65.014
      Attitude620.37 ± 2.5021.47 ± 2.221.10 ± 2.4120.06 ± 2.6919.58 ± 2.80−0.48 ± 2.052.77.71.008
      Perceived behavioral control821.30 ± 1.7421.33 ± 1.470.03 ± 1.4521.77 ± 1.9421.23 ± 1.94−0.55 ± 1.521.60.41.115
      Behavioral intention39.77 ± 1.369.80 ± 1.270.03 ± 1.459.87 ± 1.439.65 ± 1.25−0.23 ± 0.960.83.21.412
      Note. AOMEP = adolescent obesity management educational program; CG = control group; EG = experimental group.
      p < .05.
      a t refers to the t value of mean difference.
      b d refers to effect size.

      Satisfaction of AOMEP in experimental group

      We evaluated the satisfaction about the intervention program in the participants who received the AOMEP, the results of which are shown in Table 3. The mean scores of all categories were over 3.40 (out of 4) and the overall mean score was 3.47 (± 0.41). Therefore, the experimental group was deemed satisfied with the AOMEP.
      Table 3Satisfaction toward AOMEP in Experimental Group (N = 30).
      CategoryM ± SD
      Usefulness3.51 ± 0.43
      Effectiveness3.40 ± 0.48
      Worthiness3.42 ± 0.42
      Helpfulness3.48 ± 0.44
      Overall satisfaction3.57 ± 0.50
      Total3.47 ± 0.41
      Note. AOMEP = adolescent obesity management educational program.

      Discussion

      This study evaluated the effects of the AOMEP, based on the concepts presented in the TPB, to determine whether it affected changes in the knowledge, attitudes, perceived behavioral control, and behavioral intention of teachers toward AOM in middle and high school settings. We conducted four sessions of an educational program, including illustration of the importance of AOM, disease prevention, nutrition, counseling, exercise, exercise practice, curriculum, and the role of teacher.
      This study showed that the major benefits of the AOMEP were that it significantly influenced knowledge of, and attitudes toward, obesity management in teachers. The effect sizes of knowledge and attitudes in the AOMEP were between medium and large (.65 and .71, respectively). Thus, the AOMEP was effective in enhancing AOM knowledge and attitudes. Generally, a prerequisite of behavior change in all health educational programs is an improved level of knowledge [
      • Zendehtalab H.R.
      The effect of intervention based on the theory of planned behavior on improving nutritional behaviors of students.
      ]. The results of this study are consistent with the findings of others, which found that a focus on increasing the level of knowledge held by individuals may motivate these individuals to perform the desired behavior in health-related issues [
      • Sharma M.
      Theoretical foundations of health education and health promotion.
      ]. Additionally, it has been shown that an increased level of knowledge also has a positive impact on attitudes toward the behavior [
      • Polonsky M.J.
      • Renzaho A.
      • Ferdous A.S.
      • McQuilten Z.
      African culturally and linguistically diverse communities' blood donation intentions in Australia: integrating knowledge into the theory of planned behavior.
      ].
      In our study, we speculated that various teaching methods, such as video clips, discussion about cases, practice, and counseling would elicit a greater increase in knowledge in the experimental group. This is because the utilization of interactive features leads to improved knowledge acquisition [
      • Muzaffar H.
      • Chapman-Novakofski K.
      • Castelli D.M.
      • Scherer J.A.
      The HOT (Healthy Outcome for Teens) project. Using a web-based medium to influence attitude, subjective norm, perceived behavioral control and intention for obesity and type 2 diabetes prevention.
      ]. It has been reported that knowledge and attitudes were the strongest predictors of behavioral intention in an obesity program [
      • Sharma M.
      Theoretical foundations of health education and health promotion.
      ,
      • Muzaffar H.
      • Chapman-Novakofski K.
      • Castelli D.M.
      • Scherer J.A.
      The HOT (Healthy Outcome for Teens) project. Using a web-based medium to influence attitude, subjective norm, perceived behavioral control and intention for obesity and type 2 diabetes prevention.
      ]. Therefore, an educational intervention may help improve knowledge and attitudes of participants toward the target behaviors.
      In the current study, the AOMEP included a session emphasizing the role of the teacher. Although this study was designed to gain positive findings, the results revealed that significant differences in perceived behavioral control and behavioral intention toward AOM did not occur. However, most studies reported that the obesity educational intervention significantly improved the perceived behavioral control and behavioral intention on obesity management [
      • Chatzisarantis N.
      • Kamarova S.
      • Kawabata M.
      • Wang J.C.
      • Hagger M.S.
      Developing and evaluating utility of school-based intervention programs in promoting leisure-time physical activity: an application of the theory of planned behavior.
      ,
      • Zendehtalab H.R.
      The effect of intervention based on the theory of planned behavior on improving nutritional behaviors of students.
      ,
      • Muzaffar H.
      • Chapman-Novakofski K.
      • Castelli D.M.
      • Scherer J.A.
      The HOT (Healthy Outcome for Teens) project. Using a web-based medium to influence attitude, subjective norm, perceived behavioral control and intention for obesity and type 2 diabetes prevention.
      ]. Additionally, other studies examining educational programs based on TPB for obese individuals found that the improved knowledge and attitudes observed had a significant relationship with perceived behavioral control and behavioral intention [
      • Zendehtalab H.R.
      The effect of intervention based on the theory of planned behavior on improving nutritional behaviors of students.
      ,
      • Polonsky M.J.
      • Renzaho A.
      • Ferdous A.S.
      • McQuilten Z.
      African culturally and linguistically diverse communities' blood donation intentions in Australia: integrating knowledge into the theory of planned behavior.
      ]. This could have occurred because we did not consider the possibility that there may not be enough time for significant changes to appear. The duration of the intervention in previous obesity studies using TPB [
      • Zendehtalab H.R.
      The effect of intervention based on the theory of planned behavior on improving nutritional behaviors of students.
      ,
      • Muzaffar H.
      • Chapman-Novakofski K.
      • Castelli D.M.
      • Scherer J.A.
      The HOT (Healthy Outcome for Teens) project. Using a web-based medium to influence attitude, subjective norm, perceived behavioral control and intention for obesity and type 2 diabetes prevention.
      ], in which perceived behavioral control and behavioral intention were significantly improved in the experimental group, was between 1 week and 2 weeks, compared to the 4-day program period of this study. These results suggest that it may take more time for significant changes, such as perceived behavioral control and behavioral intention toward AOM to be seen. Results from the current study also suggest that an obesity educational program for teachers must focus more on reinforcement of their perceived behavioral control and behavioral intention toward AOM.
      Through the AOMEP, teachers may gain the various skills needed to manage obese students and to prevent adolescent obesity in schools. In addition, results suggest that the contents of an obesity management program should be incorporated into the school curriculum. Jourdan et al [
      • Jourdan D.
      • Samdal O.
      • Diagne F.
      • Carvalho G.S.
      The future of health promotion in schools goes through the strengthening of teacher training at a global level.
      ] emphasized that training intended for teachers was an important factor in the successful implementation of health promotion in schools. Yager [
      • Yager Z.
      Issues of teacher training in the prevention of eating disorders and childhood obesity in schools.
      ] proposed that prevention efforts would be successful if teachers gained adequate knowledge and as long as both weight-related attitudes and behaviors of teachers were concurrently targeted. Therefore, an educational program targeting teachers was also crucial for effective outcomes of obesity management.
      Moreover, Howard-Drake and Halliday [
      • Howard-Drake E.J.
      • Halliday V.
      Exploring primary school headteachers' perspectives on the barriers and facilitators of preventing childhood obesity.
      ] reported that there was a strong demand for teachers to have awareness, knowledge, and skills related to the general obesity agenda of students. Actually, the issue of obesity management places a stressful burden on teachers. This is because they typically have no specialized knowledge of obesity management. In this study, although the mean length of teaching in both groups was greater than 12 years, teachers had little experience receiving obesity educational programs for their students. Therefore, providing specialized education, guidance, and resources from health professionals is essential. Through the results of this study, we predict that support for teachers, such as an AOMEP or other obesity management programs presented by school nurses in the school setting, may be effective in helping obese adolescent students.
      In the current study, we adopted Ajzen's TPB as a conceptual framework. This is because the concepts of this theory have been effective in explaining the behavioral intentions and actual behaviors toward educational strategies, and have been shown to be a successful framework for developing educational programs for teachers [
      • Lambert L.G.
      • Chang Y.
      • Varner J.
      • Monroe A.
      Allowing and using foods of low nutritional value in elementary school classrooms: the implications of teachers' beliefs.
      ]. In particular, when educational programs are intended for teachers to attain the educational goal, TPB may be used as a successful educational strategy. From the results of this study, further research based on TPB is needed, and for a longer period, to evaluate the effects of the program.

      Application to school nursing practice

      As the rate of obesity among adolescent students continues to rise in Korea, obesity management programs become increasingly important in schools. Students are not the only necessary population of focus for the effective management of adolescent obesity, but teachers and school nurses should also be involved. According to TPB, an educational program increases participant knowledge levels, and influences both attitudes and perceived behavioral control, affecting behavioral intention, and theoretically leading to healthier behaviors.
      Results of the current study identify the AOMEP as an effective method to increase participant knowledge level and positive attitudes toward AOM. When designing an obesity management educational program, school nurses can play a leading role in successful implementation, with support of teachers. Through educational interaction with both teachers and adolescent students, the effects will be doubled. In addition, when school nurses plan the AOMEP, these results may be utilized as a reference. In schools, teachers as well as nurses, may also function as counselors who encourage the obese adolescents to practice healthy behaviors to manage obesity. Educational programs, such as the AOMEP developed in this study, can be used to assess the impact of educational programs for obese adolescents.
      A strength of the current study is that the AOMEP can aid teachers in recognizing potential roles as obesity managers. Additionally, this study may contribute to an increased perception of the importance of an AOMEP as an effective method to educate adolescents in the school setting. Finally, wider implementation of AOMEPs could result in students being able to obtain obesity management through teachers, who may be more easily accessible than other adults.

      Limitations

      The limitations of this study need to be acknowledged. First, participants were selected from only one province. Future studies could address this issue by including samples that cover different geographical regions and districts across the nation. Second, a convenience sampling method was used in the experimental group, rather than random assignment. Third, the questionnaires that we used were developed by the authors, although the reliability and validity was examined. To address this, a new modified questionnaire considering the study purpose may be more reliable for evaluating the effects of the program. Finally, the behaviors of participants after exposure to the AOMEP were not measured. This issue could be addressed by measuring the behavior of participants after the completion of the program. The present results should be evaluated further after continued follow ups, which could yield more noteworthy results.

      Conclusion

      This study was conducted to evaluate the effects of an AOMEP among teachers of middle schools and high schools. The AOMEP brought about positive effects in both knowledge and attitudes of teachers, with the experimental group showing a greater increase in the level of knowledge and positive attitudes, compared to the control group. However, the results of this study showed that significant changes in perceived behavioral control and behavioral intention were difficult to obtain in a short period. Therefore, the importance of perceived behavioral control and behavioral intention following an AOMEP may be emphasized in the future.

      Conflict of Interest

      The authors report no actual or potential conflicts of interests.

      Acknowledgment

      This research was supported by Hallym University (HRF-201701-018).

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