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PACIFIC OBESITY PREVENTION IN

COMMUNITIES PROJECT (OPIC)

FIJI COUNTRY REPORT

A collaborative project of: Fiji School of Medicine and Deakin University. 2004-2009

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OBESITY PREVENTION IN COMMUNITY (OPIC) PROJECT – FIJI REPORT 2004 - 8

Report prepared by Dr Timaima Tuiketei, Dr Wendy Snowdon, Gade Waqa, Dr Peter Kremer, Jimaima Schultz and Nola Vanualailai, on behalf of the OPIC Team

August 2010

ISBN 978-982-515-057-2

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Table of Contents

Foreword ............................................................................................................................................... 3

List of Tables ......................................................................................................................................... 4

List of Figures ........................................................................................................................................ 6

Abbreviations ........................................................................................................................................ 8

Acknowledgements ............................................................................................................................... 9

Executive Summary ............................................................................................................................. 11

1.0 Objectives.............................................................................................................................................. 13

2.0 OPIC Methodology and Research design .............................................................................................. 15

3.0 The Healthy Youth Healthy Communities Intervention Study .............................................................. 17

4.0 Socio-cultural Component .................................................................................................................... 63

5.0 Policy Component ................................................................................................................................. 71

6.0 Economic Component ........................................................................................................................... 83

7.0 Conclusions and Recommendations ..................................................................................................... 88

References .................................................................................................................................................. 90

Annex 1: Background information on Fiji ................................................................................................... 92

Annex 2: Community and School interventions ......................................................................................... 99

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Foreword As the Dean of the Fiji School of Medicine (FSMed) and now the College of Medicine, Nursing and Health Sciences, I am pleased to share a few thoughts in regard to the OPIC project. Obesity is a major public health problem not only in Fiji but in the Pacific region as a whole. It is responsible for significant social and economic costs to individuals, families, communities and nations. Despite many local, national & regional prevention and control programmes, obesity-related disorders continue to cause major challenges and more effective interventions are needed. The Pacific Obesity Prevention In Communities (OPIC) Project which was implemented in four countries: Fiji, Tonga, Australia and New Zealand, and was conducted as a collaboration between Fiji School of Medicine, Deakin University (Melbourne/Geelong) and the University of Auckland (Auckland). This was a challenging project to implement across four diverse sites, and involving multiple components. It represents an important and unique study focused on the prevention of obesity, and has the potential to help our understanding of the complex interplay between various factors in the community. While unhealthy diets and reduced physical activity levels are well known risk factors for obesity, there is limited information on the interactions between the various factors which shape availability and choice of food, and opportunities for physical activity. Challenges within the environment need to be better defined before effective interventions can be tested. This Fiji report documents the main processes that were implemented within the four components of the study, and their key findings, which have been compiled and consolidated from all the various reports and documents that were made during the study period from 2004-8. The revelations from this study provide some baseline information and insights specifically for obesity prevention in young people at the different school and community settings in Fiji. Together with the findings of other previous NCD and nutritional studies such as the 2002 NCD STEPS survey, the 2004 National Nutritional survey and many others, these additional research outcomes will further consolidate, advocate and strengthen the multisectoral response to NCD prevention and control strategies in Fiji. Recommendations made in this report needs to be to be taken up and followed through by the Fiji government through the Ministry of Health, Ministry of Education, Ministry of National Planning and other government agencies. In particular, the 22 policies recommended will definitely provide an appropriate framework for further policy development and decision making processes to improve obesity prevention in Fiji to another level. This study also provided an opportunity for capacity building and academic advancement for the Fiji OPIC project team at the Fiji School of Medicine and those that were closely involved in the execution of this research. I thank and commend all those who were involved in this Fiji OPIC project. Professor Ian Rouse Dean - College of Medicine, Nursing and Health Sciences August 2010

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List of Tables

Table 1: Action Plan for the Fiji ‘Healthy Youth Healthy Communities ..................................................... 19

Table 2: Demographics of Intervention and Comparison groups ............................................................... 22

Table 3: Height, weight, fat percent, BMI and BMI-z score measurements by ethnicity ........................... 23

Table 4: Weight classification by gender .................................................................................................... 26

Table 5: Height, weight, fat percent, BMI and BMI-z score measurements by gender .............................. 27

Table 6: Waist circumference and waist-to-height ratio by ethnicity ........................................................ 28

Table 7: Waist circumference and waist-to-height ratio by gender ........................................................... 28

Table 8: Weight perceptions and weight control behaviours by ethnicity ................................................. 29

Table 9: Weight perceptions and weight control behaviors by gender ..................................................... 30

Table 10: Breakfast consumption behaviours by ethnicity......................................................................... 32

Table 11: Breakfast consumption behaviours by gender .......................................................................... 34

Table 12: Morning tea consumption behaviours by ethnicity .................................................................... 35

Table 13: Morning tea behaviours by gender ............................................................................................. 36

Table 14: Lunch behaviours by ethnicity .................................................................................................... 36

Table 15: Lunch consumption behaviours by gender ................................................................................. 37

Table 16: Consumption of fruit, vegetables and takeaway foods by ethnicity ......................................... 38

Table 17: Consumption of fruit, vegetables and takeaway foods by gender ............................................ 39

Table 18: Soft drink consumption by ethnicity ........................................................................................... 41

Table 19: Soft drink consumption by gender .............................................................................................. 42

Table 20: Fruit drink consumption by ethnicity .......................................................................................... 42

Table 21: Fruit drink consumption by gender ............................................................................................. 43

Table 22: After school snack consumption by ethnicity ............................................................................. 43

Table 23: After school snack consumption by gender ................................................................................ 44

Table 24: Snack food purchasing behaviours by ethnicity .......................................................................... 44

Table 25: Snack food purchasing behaviours by gender ............................................................................ 45

Table 26: Physical activities and television use by ethnicity ....................................................................... 45

Table 27: Physical activities and television use by gender ......................................................................... 47

Table 28: Family meals and home availability of foods by ethnicity .......................................................... 49

Table 29: Family meals and home availability of foods by gender ............................................................. 52

Table 30: Parental support for healthy eating by ethnicity ........................................................................ 53

Table 31: Parental support for healthy eating by gender ........................................................................... 53

Table 32: Parental support for physical activity by ethnicity ...................................................................... 54

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Table 33: Parental support for physical activity by gender ........................................................................ 54

Table 34: Home availability of televisions, video games and computers by ethnicity ............................... 55

Table 35: Home availability of televisions, video games and computers by gender .................................. 55

Table 36: School support for healthy eating and physical activity by ethnicity ......................................... 56

Table 37: School support for healthy eating and physical activity by gender ............................................ 56

Table 38: Neighbourhood and community factors by ethnicity ................................................................. 57

Table 39: Neighbourhood and community factors by gender .................................................................... 57

Table 40: Pediatric Quality of Life by ethnicity .......................................................................................... 58

Table 41: Pediatric Quality of Life by gender .............................................................................................. 59

Table 42: Awareness of OPIC messages ...................................................................................................... 59

Table 43: Summary of Findings on the social cultural issues in schools ..................................................... 64

Table 44: Summary of interview results for gender & cultural differences in food & eating .................... 67

Table 45: Summary of findings in the cultural & gender differences in physical activity ........................... 68

Table 46: Cultural & gender differences in body image ............................................................................. 68

Table 47: List of policies recommended ..................................................................................................... 77

Table 47: School participation for time trade-off ....................................................................................... 86

Table 49: Fiji’s key health indicators ........................................................................................................... 93

Table 50: Selected regional comparative indicators .................................................................................. 94

Table 51: The ten major causes of morbidity and mortality in 2007 .......................................................... 95

Table 52: Action plan objectives for school and community ...................................................................... 99

Table 53: Action plan for the Fiji ‘Healthy Youth Healthy Communities ................................................. 102

Table 54: Interventions implemented in the 7 schools ............................................................................ 103

Table 55: Interventions in Communities ................................................................................................... 104

Table 56: Activities undertaken for social marketing ............................................................................... 104

Table 57: Activities undertaken for capacity building .............................................................................. 106

Table 58: Activities undertaken for nutrition objectives ......................................................................... 108

Table 59: Activities undertaken for physical activity objectives ............................................................... 109

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List of Figures Figure 1: Overall structure of OPIC project ................................................................................................. 15

Figure 2: Flow diagram showing participation in the Fiji, Healthy Youth Healthy Communities intervention study ....................................................................................................................................... 20

Figure 3a: Cumulative overweight and obesity – All ................................................................................. 24

Figure 3b: Thinness - All .............................................................................................................................. 24

Figure 4a: Cumulative overweight and obesity – Indigenous ..................................................................... 24

Figure 4b: Thinness - Indigenous ................................................................................................................ 24

Figure 5a: Cumulative overweight and obesity - Indo-Fijian ...................................................................... 25

Figure 5b: Thinness - Indo-Fijian ................................................................................................................. 25

Figure 6a: Cumulative overweight and obesity - Other .............................................................................. 25

Figure 6b: Thinness - Other ......................................................................................................................... 25

Figure 7a: Cumulative overweight and obesity – Males ............................................................................. 26

Figure 7b: Thinness - Males ........................................................................................................................ 26

Figure 8a: Cumulative overweight and obesity - Females .......................................................................... 27

Figure 8b: Thinness - Females ..................................................................................................................... 27

Figure 9a: Proportion trying to lose weight – All ........................................................................................ 29

Figure 9b: Proportion trying to lose weight by ethnicity ............................................................................ 29

Figure 10a: Proportion trying to lose weight – Male .................................................................................. 30

Figure 10b: Proportion trying to lose weight - Female ............................................................................... 30

Figure 11: Proportion of adolescents who skipped breakfast – by group .................................................. 31

Figure 12: Proportion of adolescents reporting home as their source for breakfast ................................. 32

Figure 13: Proportion of adolescents who skipped breakfast – by ethnicity ............................................. 33

Figure 14: Proportion of adolescents reported having breakfast ............................................................... 33

Figure 15a: Proportion who skipped breakfast - Males .............................................................................. 34

Figure 15b: Proportion who skipped breakfast – Females ......................................................................... 34

Figure 16a: Proportion who obtained breakfast from home- Males.......................................................... 35

Figure 16b: Proportion who obtained breakfast from home - Females ..................................................... 35

Figure 17: Proportion having recommended fruit and vegetable consumption by group......................... 37

Figure 18: Proportion having recommended fruit and vegetable consumption by ethnicity .................... 38

Figure 19a: Proportion having recommended fruit and vegetable consumption – Males ........................ 39

Figure 19b: Proportion having recommended fruit and vegetable consumption- Females ...................... 39

Figure 20: Proportion of frequent consumption of takeaway food consumption by group ...................... 40

Figure 21: Proportion of frequent consumption of takeaway food consumption by ethnicity ................. 40

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Figure 22a: Proportion of frequent consumption of takeaway food consumption - Males ...................... 41

Figure 22b: Proportion of frequent consumption of takeaway food consumption - Females ................... 41

Figure 23: Proportion of adolescents reporting more than two hours total screen time/day according to group....................................................................................................................................................... 46

Figure 24: Proportion of adolescents reporting more than two hours total screen time/day according to ethnicity .................................................................................................................................................. 46

Figure 25a: Proportion of adolescents reporting more than two hours total screen time/day – Males ... 47

Figure 25b: Proportion of adolescents reporting more than two hours total screen time/day – Females ....................................................................................................................................................... 47

Figure 26: Proportion of adolescents reporting having family meals on most days .................................. 48

Figure 27: Adolescent perceptions of availability of different foods and beverages in the household according to group ...................................................................................................................................... 49

Figure 28: Family meals and home availability of foods by ethnicity ......................................................... 50

Figure 29a: Adolescent perceptions of availability of different foods and beverages in the household – Indigenous ................................................................................................................................................ 50

Figure 29b: Adolescent perceptions of availability of different foods and beverages in the household - Indo-Fijian ................................................................................................................................................. 50

Figure 30a: Adolescent perceptions of availability of different foods and beverages in the household according to group – Males ........................................................................................................................ 51

Figure 30b: Adolescent perceptions of availability of different foods and beverages in the household according to group - Females...................................................................................................................... 51

Figure 31a: Family meals and home availability of foods – Males ............................................................. 52

Figure 31b: Family meals and home availability of foods - Females .......................................................... 52

Figure 32: Awareness of OPIC messages .................................................................................................... 61

Figure 33: Problem tree for low vegetable intake ...................................................................................... 74

Figure 34: Solution tree for low vegetable intake ...................................................................................... 75

Figure 35: Map of Fiji .................................................................................................................................. 92

Figure 36: Distribution of deaths in Fiji by cause groups, 2007 .................................................................. 96

Figure 37: OPIC community interaction process model ........................................................................... 100

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Abbreviations

AQOL Adjusted Quality of life

CEA Cost effective analysis

CUA Cost utility Analysis

DMO Divisional Medical Officer

Food Refers to all food and drinks

FPAN Fiji Plan of Action for Nutrition

FSM Fiji School of Medicine

MOH Ministry of Health

NCDs Non communicable diseases

OPIC Obesity Prevention in Communities project

PA Priority Area (s)

PedsQL™ Pediatric Quality of Life Inventory

Policy Laws & regulations, enforceable actions, precise policies which require action

QALY Quality adjusted life year

QoL Quality of Life

SDMO Sub Divisional Medical Officer

TTO Time trade off

UNDP United Nations Development Program

VAT Value added tax applied to all services and products in Fiji

WHO World Health Organization

WTO World Trade Organization

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Acknowledgements The Fiji OPIC component formed part of the Pacific Obesity Prevention in Communities project, and was managed by the Fiji School of Medicine. The support and involvement of both past and present members of the OPIC team is appreciated. The research was funded by Wellcome Trust, the New Zealand Health Research Council and the National Health and Medical Research Council of Australia. Funding contributions from the Ministry of Health Fiji are hereby acknowledged. The involvement of the members of the following government agencies, non-governmental organisations and the many stakeholder groups were critical to the completion of the study and the following are acknowledged for their active participation and contributions: Ministry of Health: Permanent Secretary for Health, Medical Officer & staff Valelevu Health Centre, SDMO Suva and team, DMO Central and staff, and staff of MOH HQ Ministry of Education: The Permanent Secretary for Education, Director TVET. The Principals, teachers, school project focal points, students and parents from the following: Assemblies of God High School, Ahmadiyya Muslim College, Ba Provincial High School, Bhawani Dayal Arya College, Central College Lautoka, Cuvu College, Drasa Secondary School, Lautoka Andra Sangam College, Natabua High School, Nadi College, Nadi Muslim College, Nasinu Secondary School, Nakasi High School, Nasinu Muslim College, Rishikul Sanatan College, Swami Vivekananda College, Sigatoka Methodist College and St. Thomas High School Community settings: Faith Base Organizations in Valelevu Medical Area: Assemblies of God; AGOFI, Catholic; Hindu ; Methodist, ; Muslim; SDA; World Harvest Centre Other public sector: Fijian Affairs Board, Fisheries Department, Department of Agriculture, Department of Public health and Primary Care; Trading Standards, Ministry of External Trade and Foreign Affairs; Ministry of Finance, Suva City Council, Ministry of Commerce and Industry Private Sector: Ram Sami & Sons Fiji Limited Rooster Chicken; Rewa Corporative Dairy Company; Acquifer Water company; Coca Cola Fiji Amatil Fiji; Nestle Fiji Ltd. Other NGOs: Consumer Council of Fiji. The OPIC Team: Fiji:

Jan Pryor, Graham Roberts, Sitaleki Finau, Jimaima Schultz, Gade Waqa, Anjileena Dev, Vani Fifita, Nola Vanualailai, Anaseini Raikoti, Sunil Chand, Vula Utonivaya, Epi Coriakula, Andrew Prasad, Joanna Kenny, Arleen Sukhu, Savaira Leweniqila, Wendy Snowdon

New Zealand: Sarah Carne, Ofa Dewes, Dudley Gentles, Shirin Foroughian, Gavin Faeamani, Maea Hohepa, Fa’asisila Savila, David Schaaf, Robert Scragg, Lois Shaw, John Sluyter, Tasileta Teevale, David Thomas, Jennifer Utter, Jody Warbrick Tonga: Laukau ‘Aholova, Tilema Cama, Fatai Faingata’a, Hekisou Fifita, Kalesita Fotu, Popi Latu Fotu, Litiola Kava, Ichikawa La’akulu, Lote Lautaimi, Fine Lolohea, Sisilia Moala, Nancy Palu, Siosifa Pomana, Siosi Soakai, ‘Inoke Taufa, Paula Vivili

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Australia: Colin Bell, Rob Carter, Anita Chia, Max de Courten, Jisheng Cui, Catherine Keating, Peter Kremer, Mark Lawrence, Caryn Kave, Louise Mathews, Helen Mavoa, Marita McCabe, Lynne Miller, Marj Moodie, Lina Ricciardelli, Mary Malakellis, Michelle Rowland, Andrea de Silva Sanigorski, Anne Simmons, Wendy Snowdon, Boyd Swinburn, Anne-Marie Thow, Lauren Williams, Nadine White, Laurie Meade, Kate Scalzo, Narelle Roberston.

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Executive Summary

Background The Pacific region including Fiji has the highest rates of obesity in the world. The Pacific OPIC Project was established in 2004 to evaluate the effectiveness of whole-of community obesity prevention programs for youth (ages 12-18 years) in New Zealand, Fiji, Tonga and Australia. There is limited information on the lifestyle and obesity patterns among youth in the South Pacific region. This Fiji report documents the main processes that were implemented, and the key findings.

Methods The quasi experimental design included several components: intervention and data collection in schools, food policy analysis, socio-cultural studies and economic studies.

In the schools-based component of OPIC, information was collected from 17,150 high school students from 7 different schools in Nasinu area alongside the Suva – Nausori corridor and 11 schools in the western division as a comparison group. The response rate for the 7 Nasinu Schools was 75% and the follow up rate was 32.7%. The response rate from the comparative schools was 73% and the follow up rate was 45.1%.

The food policy component included an analysis of existing policies, along with the identification of recommended policy changes to create a healthier food environment. Utilizing participatory methods, along with informant interviews and economic modeling this component worked with key sectors and agencies in Fiji.

The socio-cultural component included in-depth interviews with 48 students in the selected schools. The interviews included collection of information on body image, physical activity and diet.

The economic component of OPIC, included an assessment of the quality of life among adolescents in the interview schools. Assessments of the cost-effectiveness of interventions were also included.

Results and findings • The prevalence of overweight/ obesity was 26% females and 17% males in the OPIC study population. • More than 30% of Indo-Fijian students were classified as thin. • Approximately half of females and one third of males were trying to lose weight, while 13% of females and 24% of males were trying to gain weight. • Approximately 30% of students drank soft drinks on 4 or 5 days in the past 5 school days. • Multiple opportunities exist for increasing physical activity during the school day, yet less than one-third of students played actively • Less than 30% of students reported that food & drinks available at school were mostly healthy. The intervention resulted in no significant changes in the measures of overweight. While there was some improvement in body fat % in the intervention group, this was not reflected in the other anthropometric measures.

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The food policy component identified considerable barriers to healthy eating in Fiji. The existing mutton flap ban was having some effect on food supply, but was not sufficient. Twenty-one policy change recommendations were identified by stakeholders focused on reducing the cost of healthy foods and increasing the cost of less healthy foods, along with reduced access to less healthy foods such as fatty meats and control of food advertising and consumption of foods in schools and public buildings.

The socio-cultural component identified important influences on diet, physical activity and body image. Indo-Fijians had a diet that was high in vegetables, while indigenous Fijians had more complex carbohydrates. Many of the differences found in this study cut across cultural group and gender. For example, Indo-Fijian females appeared to be less interested in being physically active than either indigenous Fijians or Indo-Fijian males. Indo-Fijian females also appeared to have fewer opportunities than indigenous Fijian girls to engage in recreational physical activity. Indo-Fijian males wanted to increase weight and/or muscle, while indigenous Fijian females wanted to lose weight.

The economic studied component of OPIC found a large variation in mean AQoL scores by ethnic group. Quality of life decreased with excess weight for Indo-Fijians, but increased in Indigenous Fijian adolescents. The Indo-Fijians experienced a bigger loss in quality of life amongst the overweight (3%) than the obese group (1%). In contrast, both overweight and obese Indigenous Fijian adolescents, experienced 2% higher quality of life scores than their healthy weight peers. Conclusions & Recommendations Fiji now has extensive data on the diets, physical activity and weights of a large sample of adolescents. This data highlights the considerable problems in this group with regard to overweight, underweight, poor diets and low physical activity. The factors affecting diet and physical activity levels in adolescents include multiple factors such as the school, home and community environment, including sociocultural values and national policies. Improving the health of adolescents is therefore unlikely to be a simple process. The multiple planned actions that took place within the HYHC aspect of OPIC in Fiji delivered few impacts on the intervention groups. This is a highly significant finding. It demonstrates that multiple actions are likely required over sustained time periods to effect change. It also demonstrates the importance of this type of research, and of programme evaluation. It is essential that efforts to improve health are targeted and effective. Recommendations are to: 1) Create supportive environments

2) Utilise multiple, sustained interventions and activities to target obesity.

3) Schools to adopt comprehensive health-promoting approach

4) Clear guidance on healthy eating, physical activity and body weight 5) More research, monitoring and evaluation to identify effective approaches to combat obesity

and NCDs.

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Fiji OPIC Study

1.0 Objectives 1.1 AIM

The overall aim of the four-country Pacific OPIC Project (Obesity Prevention in Communities) was to build the evidence for obesity prevention in young populations. The research questions for Fiji were:

1. What is the overall impact (including cost-effectiveness) of comprehensive, community-based programs on overweight/obesity prevalence in young populations?

2. What is the feasibility of the specific intervention components and what are their impacts on eating and physical activity patterns?

3. What are the socio-cultural factors (community attitudes, perceptions, beliefs, values) that promote obesity and how can they be influenced?

4. What are the effects of national and international food-related policies and policy changes on the supply of foods in Fiji that might influence obesity prevalence?

5. What is the overall burden of childhood obesity (including loss of quality of life, disease impacts and health system costs) and how can resources be best allocated to prevent obesity?

The research objectives were:

1. To develop, implement and evaluate the impact of comprehensive community based programs in settings relevant to the identified target groups.

2. To compare the costs, impacts and outcomes of the programs with the comparison communities.

3. To identify the reasons for the successes and failures of the individual intervention components in each project using quantitative and qualitative methodologies.

4. To increase the capacity of health professionals and the community to plan, implement and evaluate nutrition and physical activity programs

5. To link the intervention programs with monitoring programs (such as WHO STEPS Survey)

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1.2 RATIONALE

Overweight and obesity are the seventh leading predicted cause of avoidable global disease burden for 2010 and 2020 (WHO, 2002), with prevalence rates rapidly increasing in both developed and developing countries. It is of serious concern that the Pacific region has the highest rates of obesity in the world (Coyne, 2000). Chronic diseases contribute significantly to the global burden of disease, and are particularly devastating for low and middle income countries, both socially and economically (WHO 2005).

The Pacific region has the highest rates of obesity in the world. There is limited information on the lifestyle and obesity patterns among youth in the South Pacific region. However, it is only recently that governments have been seeking evidence on what does and does not work for obesity prevention; and unfortunately this current evidence base is very limited. The Pacific Islands Ministers of Health two yearly meetings resolutions were committed to this initiative as such. This was reflected in the 2003 Tonga Commitment, 2005 Samoa Commitment and the 2007 Vanuatu (WHO 2003, WHO 2005, WHO 2007) Commitment of their governments’ undertaking. Systematic reviews of the literature have identified less than 30 intervention studies to prevent childhood or adolescent obesity (Summerbell et al., 2005). Most studies have been conducted in primary schools, have been short term and have had modest results at best. Much more intervention research is required, especially for highly susceptible populations. For these reasons, the Pacific OPIC Project (Obesity Prevention In Communities) was established to measure the effectiveness and cost-effectiveness of whole-of-community obesity prevention programs for youth (ages 12-18 years) in New Zealand, Fiji, Tonga and Australia. The Pacific OPIC Project was funded for five years by three research funding bodies: the Wellcome Trust (UK), the National Health and Medical Research Council (Australia), and the Health Research Council (New Zealand) as part of an International Collaborative Research Grants scheme.

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2.0 OPIC Methodology and Research design 2.1 OVERALL PACIFIC OPIC PROJECT STRUCTURE The overall structure of the project and the main inter-connections are shown in Figure 1.

Figure 1: Overall structure of OPIC project

The rationale for the study designs was:

• The use of multiple intervention strategies across several settings to achieve a high enough ‘dose’ of interventions to affect eating patterns and physical activity;

• The strong community focus and linkages with existing or proposed government and NGO programs to increase the ownership and sustainability of the interventions;

• Linkages with monitoring and surveillance programs where possible to increase sustainability and cost efficiencies (using monitoring data as the comparison population);

• The use of community participation, including through ANGELO workshops, to increase community engagement in the research process and outcomes and to ensure the relevance and sustainability of the interventions;

• The analysis and incorporation of environmental factors (physical, economic, policy and socio-cultural) into the intervention programs to address the underlying causes of obesity;

Effects of comprehensive

community interventions

Burden of childhood

obesity

Research

Research

Analytical Studies

Intervention Studies

Analytical Studies

Feasibility and effects of specific

interventions

Effects of policies and policy changes

on food supply Policy

Studies

Aus

NZ

Fiji

Tonga

Economic Studies

QoL

Socio-cultural Studies

Allocative efficiency for interventions

QoL in adolescent obesity

S-C promoters and protectors

for obesity * Inform Interventions, Cost effectiveness, QoL = Quality of Life

*

*

*

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• Measuring costs so that cost-effectiveness of the intervention programs can be determined;

• Measuring the effects of the interventions on socio-cultural factors and quality of life indicators so that these important program impacts can be documented;

• Maximising the opportunities to grow the research capacity through PhD and Masters

training programs linked with the research projects.

As shown in Figure 1, the OPIC study in Fiji had 4 different components which were: 1. Community and School Intervention Component (Intervention Study, known as

Healthy Youth Healthy Communities Study in Fiji) 2. Socio-cultural Component 3. Policy Component 4. Economic Component

The objectives, methods and findings for each component are detailed in separate sections in this report.

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3.0 The Healthy Youth Healthy Communities Intervention Study The Healthy Youth Healthy Communities (HYHC) study was the Fijian arm of the broader OPIC intervention study. Details of the development, implementation and evaluation of the HYHC component are detailed in this section. Health promotion action at a community level needs to become embedded in the organizations working in that community and need to ensure that the community owns and embraces the action. The challenges are considerable, particularly in achieving a sufficiently high and sustainable ‘dose’ of intervention and evaluating the process, impacts and outcomes to a sufficiently high standard given all the constraints associated with such projects. While these challenges are recognized, the problem of obesity, especially in Pacific populations, needs to be addressed at all levels – community, national, and global. The HYHC utilized a community-based approach which incorporated a health promotion approach that aimed to build community capacity to change adolescent behavior and reduce unhealthy weight gain. 3.1 METHODS

Study Design, Communities and Participants

The HYHC intervention study was based on a quasi-experimental study design, with intervention schools chosen from the Nasinu community, and the comparison schools in the west of Fiji. Specifically, seven intervention secondary schools in Nasinu were chosen based primarily on the ethnic mix of students involving 67% indigenous Fijians and 33% Indo-Fijians. Other criteria for selection include geographical locations, community setup and the ease of access to carry out intervention activities. Similar criteria were used to select the control schools from three areas in the west of Fiji, namely, Sigatoka, Nadi and Lautoka. In these areas 11 schools that matched the profiles of the intervention schools were selected from 35 secondary schools. Students between the ages of 13 and 19 in forms 3 to 7 participated in the study. In the seven identified Nasinu schools, the total enrolment was 3530 of which 2670 consented to participate – giving the response rate of 75%. In the lost to follow up, 373 children were not available for their measurements to be taken and 1418 children moved out elsewhere. Hence the follow up rate was 32.7%. For the 11 Comparison schools in Sigatoka, Nadi and Lautoka, 6255 children were enrolled and 4567 consented to the data collection. The response rate was 73%. In the lost to follow up, 2 children refused, 431 children were not available for their measurements to be taken and 2075 of them moved elsewhere. Hence the follow up rate for the comparison schools was 45.1% The overall follow-up rate was therefore 41%. The overall participation and follow-up rates for the Intervention and Comparison groups are summarized in Figure 2.

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The overall sample at baseline comprised more females (53%) than males (47%) and 84% of students were between the ages of 13 and 16 years (41% aged 13 to 14; 43% aged 15 to 16). Approximately 50% of students were in Year 9 and 35% of students were in Year 11 at school. 43% of students identified their ethnicity as Indigenous Fijians, 52% as Indo-Fijian, and 5% as other ethnicity (Other) group. 3.2 THE HYHC INTERVENTION

There were 2 phases in the HYHC Intervention: a. Phase 1 – Preliminary assessment of socio-cultural factors At each intervention site, preliminary interviews were conducted with the 12-18 year olds to determine the perceptions of potential socio-cultural barriers related to three areas: barriers that facilitate or hinder healthy eating, regular physical activity and a healthy body size. Findings from the interviews informed and shaped the community workshops and baseline questionnaire and indicated that youth:

• knew about healthy food and drinks, • often buy junk food with spending money that was not monitored by adults, • identified mothers as a key messenger about food while fathers provided more

messages about exercise & physical activity, • thought boys had more freedom than girls to exercise and in Fijians, Indo- Fijians

prioritize study over exercise, • identified media, peers and sports stars as important messengers relating to body

size, shape and muscularity. Overall they identified approximately 15-20 potential behaviors, knowledge and skills gaps, and 10-25 environmental barriers in each of the settings. The findings of the socio-cultural interviews were included in the materials developed for the community workshops. b. Phase 2 – Community workshops to develop the draft action plans The phase 1 findings were presented at a 2-day workshop with community stakeholders, including the youth. The participants then prioritized the components to develop a draft action plan which was later consolidated through further community consultation. The community workshop used the ANGELO framework based on an Analysis Grid for Elements Linked to Obesity. Each action plan developed for the school and the community had two overall aims:

• to build community capacity • to promote healthy weight through capacity building, social marketing messages,

evaluation and environmental change The action plan developed is in Table 1.

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Table 1: Action Plan for the Fiji ‘Healthy Youth Healthy Communities

Behavioral & Innovative Objectives

Key Strategies

1. To significantly reduce the proportion of adolescents who skip breakfast on school days.

• Promote breakfast with students and parents – pamphlets & school assembly morning talks • School canteen providing breakfast

2. To improve the healthiness of food at school by significantly decreasing the consumption of high sugar drinks and promoting the consumption of water and by significantly increasing fruit and vegetable consumption

• Develop school policies for canteens to support water, fruit and vegetable consumption • Curriculum development with Home Economics and Agricultural Science

3. To significantly decrease the consumption of energy dense snacks and significantly increase consumption of fruit as afternoon snacks

• Social marketing [include fruits (& vegetables) for snacks and benefits of F & V; what constitutes healthy snack • Student information on healthy snacks, F & V snacks

4. To significantly increase the proportion of adolescents living within walking distance to school to walk to and from school with a sense of safety

• “Walking buddies” • Road safety skills

5. To support physical education teachers to conduct physical education classes effectively

• School policy on physical education classes • Partnership with organizations to provide sports equipment such as, hoops, ropes & others

6. To significantly increase the amount of active play after school/ weekends; significantly decrease time spent watching TV & playing computers or electronic games

• House rules on screen time and outside play time • School walkathon

7. To develop a program for promoting healthy eating & physical activity within churches, mosques & temples

Food Preparation Skills • Budgeting skills

Further details regarding the interventions are provided in Annex Two.

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Figure 2: Flow diagram showing participation in the Fiji, Healthy Youth Healthy Communities intervention study

Nasinu area selected as intervention region (target group children 13-19 yo).Secondary schools (n=7)

Three towns on western VitiLevu (Sigatoka, Nadi, Lautoka) selected as comparison region. Secondary schools (n=11)

Intervention Comparison

All children in Nasinu area received intervention.2670 of 3530 children consented to data collection (response rate: 75%)

Children from comparison towns received background activities only.4567 of 6255 children consented to data collection (response rate: 73%)

First exit survey:440 children surveyed

First exit survey:644 children surveyed

Final exit survey:439 children surveyed

Final exit survey:1425 children surveyed

Lost to follow-up:Child refused (n=0)Child not available for measurement (n=373)Child moved elsewhere (n=1418)

Lost to follow-up:Child refused (n=2)Child not available for measurement (n=431)Child moved elsewhere (n=2075)

Intervention analysed: n=879; follow-up rate: 32.7%

Comparison analysed: n=2069; follow-up rate: 45.1%

Excluded from analyses:- All follow-up analyses because child moved into comparison area (n=5)- Anthropometric measures because of equipment problems, measurement or data entry error (n varies)- Knowledge, attitudes, behaviours and quality of life measures because of equipment problems (n varies)

Excluded from analyses:- All follow-up analyses because child moved into intervention area (n=7)- Anthropometric measures because of equipment problems, measurement or data entry error (n varies)- Knowledge, attitudes, behaviours and quality of life measures because of equipment problems (n varies)

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3.3 SURVEY METHODOLOGY

In order to identify problems and also monitor the impacts of interventions, surveys were conducted of the students involved. Students were surveyed in 2005 (baseline) and again in 2008 (follow-up). Data were collected via paper questionnaires and Personal Digital Assistants (PDAs). Paper questionnaires were used to record demographic information, and PDAs were used for administration of the knowledge, attitudes and behaviours (KAB) survey. The KAB survey consisted of items focusing on nutritional-related issues, with a total of 20 variables, physical activity issues with 19 variables, and behavioral issues with a total of 42 variables. A stadiometer was used to measure the height to the nearest 0.1 (cm), during which students removed their socks and shoes. Weights to the nearest 0.05 (kg) were measured by feeding the information, with no adjustment for clothing, into the Bioelectrical Impedance Analysis (BIA). A Figure Finder tape was used to measure waist circumference at the level of umbilicus. Standardized protocols were used to ensure consistency during recording and all research staff received training in relation to measurement and sensitivity issues. 3.4 DATA TREATMENT Anthropometric measures included: waist (cms), waist/height ratio (cms), body composition (percentage body fat), as well as body mass index (BMI, weight in kg/height in m2) and standardized body mass index (BMI-z score, calculated using the WHO Reference 2007 the Stata macro) (www.who.int/growthref/en/). The WHO Reference 2007 age-specific BMI cut-offs were also used to classify children’s weight status as either thinness grades 1-3, healthy weight, overweight or obese. 3.5 RESULTS The results of the intervention study are reported according to key sections: demographics, body size and attitudes, behaviors and perceptions and quality of life.

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a. Demographics Demographic information for the intervention and comparison groups across baseline and follow-up are summarized in Table 2. Table 2: Demographics of Intervention and Comparison groups

Intervention Comparison Baseline Follow up Baseline Follow up Fijian Indo-

Fijian Other All Fijian Indo-

Fijian Other All Fijian Indo-Fijian Other All Fijian Indo-

Fijian Other All

Total 174 680 20 874 174 680 20 874 775 1141 145 2061 775 1141 145 2061 Gender Male 44.3 47.2 25.0 46.1 44.3 47.2 25.0 46.1 43.1 44.1 40.0 43.4 43.1 44.1 40.0 43.4 Female 55.8 52.8 75.0 53.9 55.8 52.8 75.0 53.9 56.9 55.9 60.0 56.6 56.9 55.9 60.0 56.6 Age 12 yrs & <

0 0 0 0 0 0 0 0 0.1 0.1 0 0.1 0 0 0 0

13 to 14 yrs

24.1 39.0 30.0 35.8 0 0 0 0 45.0 50.4 54.5 48.7 0.1 0 0 0.1

15 to 16 yrs

62.6 58.4 70.0 59.5 14.4 26.5 15.0 23.8 47.5 48.5 43.5 47.7 35.7 40.8 40.0 38.9

17 yrs & >

13.2 2.7 0 4.7 85.6 73.5 85.0 76.2 7.4 1.1 2.1 3.5 64.1 59.2 60.0 61.1

School year Form 3 29.8 35.5 25.0 34.2 0 0 0 0 51.9 53.1 59.4 53.1 0 0 0 0 Form 4 54.6 44.1 55.0 46.3 0 0 0 0 0 0 0 0 0 0 0 0 Form 5 12.8 20.3 20.0 18.9 1.4 1.1 0 1.2 48.1 46.9 40.6 46.9 31.8 27.3 31.5 29.3 Form 6 2.8 0.2 0 0.6 72.3 64.6 70.0 66.1 0 0 0 0 46.2 43.2 42.0 44.2 Form 7 0 0 0 0 26.2 34.3 30.0 32.7 0 0 0 0 22.0 29.5 26.6 26.5 Living with one or two parents during the school week 78.9 98.3 77.8 94.2 77.3 97.6 88.9 93.6 81.5 97.4 94.3 91.5 78.9 96.2 91.9 89.6 Living with other adult relatives during school week 58.6 24.7 50.0 31.6 55.5 26.9 38.9 32.5 53.4 24.0 40.7 35.8 55.6 25.6 39.8 37.5 Number of people living at home 1 to 4 people

18.8 37.8 11.1 33.5 21.9 39.0 16.7 35.3 17.6 42.0 27.6 32.2 20.8 46.8 28.5 36.0

5 to 6 people

24.2 46.8 38.9 42.4 34.4 45.5 27.8 43.0 37.7 45.2 38.2 42.0 37.7 42.2 39.0 40.3

7 or > people

57.0 15.5 50.0 24.1 43.8 15.5 55.6 21.8 44.7 12.8 34.2 25.9 41.6 11.1 32.5 23.7

The Intervention group had a higher proportion of Indo-Fijian and male adolescents than the Comparison group. Furthermore, the Intervention group had a higher proportion of children who were older reflecting the different proportion of children sampled from each of the different year levels among the

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Intervention and Comparison groups. There were few differences between the two groups for living arrangements; approximately equal proportions of adolescents reported living with one or two parents, or with other adults during the school week, as well as numbers of other people living at home. At follow up there were few differences between the two groups however again the distribution of year levels and ages varied, which is not surprising given the structure of the two groups at baseline.

b. Body size and Attitudes Information about body size and attitudes to body size are summarized in this section of the report. Mean (and standard deviation, SD) values for the key anthropometric measures for the Intervention and Comparison groups at baseline and follow-up are summarized in Table 3, and shown in Figures 3 to 6. Table 3: Height, weight, fat percent, BMI and BMI-z score measurements by ethnicity

Intervention Comparison Baseline Follow up Baseline Follow up Fijian Indo-Fijian Other All Fijian Indo-Fijian Other All Fijian Indo-Fijian Other All Fijian Indo-Fijian Other All Height Mean 166.0 161.1 163.3 162.2 169.8 164.0 165.6 165.2 165.8 160.8 164.4 163.0 170.1 164.2 167.8 166.7 SD 7.1 8.2 4.6 8.1 8.0 9.1 5.1 9.1 7.7 8.5 7.6 8.5 8.1 9.1 8.6 9.1 Weight Mean 62.5 51.1 57.6 53.5 69.0 55.4 61.2 58.2 62.2 50.7 61.1 55.8 69.2 54.9 66.4 61.1 SD 9.6 12.8 11.9 13.0 10.4 14.5 12.0 14.8 12.2 12.3 14.9 13.7 11.8 13.0 15.5 14.5 Fat percent Mean 24.0 25.0 27.6 24.9 24.0 23.7 26.6 23.8 22.5 24.0 26.6 23.6 24.5 24.4 27.6 24.7 SD 10.6 10.5 8.3 10.5 12.0 12.3 11.3 12.2 9.9 10.6 9.9 10.4 11.8 12.0 10.7 11.9 BMI Mean 22.7 19.6 21.5 20.2 23.9 20.5 22.3 21.2 22.5 19.5 22.5 20.9 23.9 20.3 23.5 21.9 SD 3.1 4.2 3.8 4.2 3.2 4.7 4.0 4.6 3.6 4.0 4.6 4.2 3.5 4.1 4.5 4.3 BMI-z score Mean 0.59 -0.55 0.16 -0.32 0.67 -0.59 0.12 -0.34 0.62 -0.50 0.58 -0.02 0.69 -0.57 0.52 -0.03 SD 0.88 1.42 1.22 1.41 0.85 1.45 1.22 1.44 0.92 1.41 1.18 1.36 0.89 1.38 1.15 1.35

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Figure 3a: Cumulative overweight and obesity – All

Figure 3b: Thinness - All

Figure 4a: Cumulative overweight and obesity – Indigenous

Figure 4b: Thinness - Indigenous

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Figure 5a: Cumulative overweight and obesity - Indo-Fijian

Figure 5b: Thinness - Indo-Fijian

Figure 6a: Cumulative overweight and obesity - Other Figure 6b: Thinness - Other

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The same indicators are also shown by gender in Tables 4 and 5 and Figures 7 and 8. The combined overweight and obesity prevalence at baseline was

17.8% in the intervention group and 22.3% in the comparison group. At follow-up, the rates were 18.3% and 21.5% respectively.

Table 4: Weight classification by gender

Intervention Comparison Baseline Follow up Baseline Follow up Male Female All Male Female All Male Female All Male Female All Weight Classification Thin 13.3 9.4 11.2 14.3 11.6 12.8 11.5 4.9 7.7 10.8 6.0 8.1 Healthy weight 69.6 72.2 71.0 66.6 70.9 68.9 68.2 71.4 70.0 71.3 69.8 70.4 Overweight 9.6 15.0 12.5 12.1 14.1 13.2 14.1 18.1 16.4 11.5 17.7 15.0 Obesity 7.5 3.4 5.3 7.0 3.4 5.1 6.2 5.7 5.9 6.4 6.5 6.5

Figure 7a: Cumulative overweight and obesity – Males

Figure 7b: Thinness - Males

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Figure 8a: Cumulative overweight and obesity - Females Figure 8b: Thinness - Females

Detailed findings on anthropometric measures are given in Table 5.

Table 5: Height, weight, fat percent, BMI and BMI-z score measurements by gender

Intervention Comparison Baseline Follow up Baseline Follow up Male Female All Male Female All Male Female All Male Female All Height Mean 167.3 157.8 162.2 172.3 159.1 165.2 167.8 159.2 163.0 173.8 161.2 166.7 SD 7.2 5.9 8.1 6.3 6.3 9.1 8.6 6.3 8.5 6.9 6.5 9.1 Weight Mean 56.2 51.2 53.5 63.5 53.7 58.2 57.9 54.1 55.8 65.4 57.8 61.1 SD 13.8 11.9 13.0 15.0 13.0 14.8 14.8 12.5 13.7 14.8 13.4 14.5 Fat percent Mean 18.4 30.3 24.9 14.6 31.5 23.8 16.5 28.6 23.6 13.8 32.2 24.7 SD 9.7 7.6 10.5 10.2 7.6 12.2 9.6 7.6 10.4 8.9 6.9 11.9 BMI Mean 20.0 20.5 20.2 21.3 21.1 21.2 20.4 21.2 20.9 21.5 22.1 21.9

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Intervention Comparison Baseline Follow up Baseline Follow up Male Female All Male Female All Male Female All Male Female All SD 4.2 4.2 4.2 4.6 4.6 4.6 4.2 4.1 4.2 4.2 4.3 4.3 BMI-z score Mean -0.39 -0.26 -0.32 -0.37 -0.32 -0.34 -1.16 0.09 -0.02 -0.19 0.09 -0.03 SD 1.50 1.33 1.41 1.53 1.36 1.44 1.47 1.26 1.36 1.42 1.29 1.35

Information on the students’ waist circumference is given in tables 6 and 7. There are no specific cut-offs for adolescents.

Table 6: Waist circumference and waist-to-height ratio by ethnicity

Intervention Comparison Baseline Follow up Baseline Follow up Indigenous Indo-

Fijian Others All Indigenous Indo-



Fijian Others All

Waist circumference Mean 76.3 71.4 74.1 72.4 79.7 74.6 76.1 75.6 76.3 71.3 76.2 73.6 77.9 72.1 77.8 74.7 SD 7.0 10.3 7.1 9.9 7.6 11.0 8.3 10.6 8.6 10.1 10.7 9.9 7.9 9.8 10.7 9.6 Waist-to-height ratio Mean 0.46 0.44 0.45 0.45 0.47 0.45 0.46 0.46 0.46 0.44 0.46 0.45 0.46 0.44 0.46 0.45 SD 0.05 0.06 0.04 0.06 0.05 0.06 0.05 0.06 0.05 0.06 0.06 0.06 0.05 0.06 0.06 0.06

Table 7: Waist circumference and waist-to-height ratio by gender

Intervention Comparison Baseline Follow up Baseline Follow up Male Female All Male Female All Male Female All Male Female All Waist circumference Mean 72.7 72.3 72.4 77.0 74.5 75.6 73.8 73.4 73.6 75.7 73.9 74.7 SD 10.2 9.6 9.9 11.1 10.0 10.6 10.5 9.4 9.9 9.6 9.6 9.6 Waist-to-height ratio Mean 0.43 0.46 0.45 0.45 0.47 0.46 0.44 0.46 0.45 0.44 0.46 0.45 SD 0.06 0.06 0.06 0.06 0.06 0.06 0.06 0.05 0.06 0.05 0.05 0.06

Information was also gathered on students’ perceptions of their own weight and body size. The findings are shown in Tables 8 and 9, and Figures 9 and 10

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Table 8: Weight perceptions and weight control behaviours by ethnicity

Intervention Comparison Baseline Follow up Baseline Follow up Indigenous Indo-Fijian Others All Indigenous Indo-Fijian Others All Indigenous Indo-Fijian Others All Indigenous Indo-Fijian Others All Weight Perception Underweight 29.1 31.8 33.3 31.2 13.6 28.9 13.3 24.7 19.8 21.2 14.2 20.1 16.8 22.0 18.1 19.7 About the right weight

42.7 48.1 40.0 46.5 57.3 52.0 60.0 53.5 57.7 60.2 58.3 59.1 61.7 58.9 54.3 60.0

Overweight 28.2 20.1 26.7 22.3 29.1 19.2 26.7 21.8 22.5 18.5 27.6 20.7 21.5 19.1 27.6 20.6 Body weight Happy/very happy 44.7 42.9 33.3 43.0 36.9 41.2 26.7 39.7 52.2 46.0 42.5 48.1 52.2 48.5 41.7 49.4 Body shape Happy/very happy 52.4 52.7 46.7 52.4 45.6 49.7 40.0 48.3 57.9 52.4 41.7 53.7 59.6 54.5 50.4 56.1 Weight control behaviours Trying to lose weight

36.9 25.3 33.3 28.4 43.7 34.4 46.7 37.1 49.1 40.1 41.7 43.7 44.4 36.5 36.2 39.5

Trying to gain weight

42.7 43.2 40.0 43.0 26.1 36.4 20.0 33.3 23.8 29.1 18.1 26.2 26.7 30.0 22.1 28.1

Not trying to change weight

20.4 31.5 26.7 28.6 30.1 29.2 33.3 29.6 27.2 30.8 40.2 30.1 28.9 33.6 41.7 32.4

Trying to gain muscle 43.7 52.3 66.7 50.7 48.5 49.7 60.0 49.8 63.7 55.0 64.6 59.1 54.2 52.1 59.1 53.4

Figure 9a: Proportion trying to lose weight – All

Figure 9b: Proportion trying to lose weight by ethnicity

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Table 9: Weight perceptions and weight control behaviors by gender

Intervention Comparison Baseline Follow up Baseline Follow up Male Female All Male Female All Male Female All Male Female All Weight Perception Underweight 32.0 30.6 31.2 26.0 23.7 24.7 19.6 20.5 20.1 21.7 18.3 19.7 About the right weight 47.5 45.7 46.5 54.1 53.1 53.5 63.4 55.9 59.1 63.1 57.0 60.0 Overweight 20.4 23.7 22.3 19.9 23.3 21.8 17.0 23.6 20.7 15.3 24.7 20.6 Body weight Happy/very happy 43.7 42.5 43.0 50.3 31.8 39.7 55.3 42.5 48.1 57.8 43.0 49.4 Body shape Happy/very happy 55.6 50.0 52.4 57.3 41.7 48.3 59.1 49.5 53.7 60.9 52.5 56.1 Weight control behaviours Trying to lose weight 23.8 31.8 28.4 27.1 44.5 37.1 34.7 50.5 43.7 28.5 48.0 39.5 Trying to gain weight 54.1 34.7 43.0 48.6 22.0 33.3 36.2 18.6 26.2 42.4 17.2 28.1 Not trying to change weight 22.1 33.5 28.6 24.3 33.5 29.6 29.0 31.0 30.1 29.2 34.8 32.4 Trying to gain muscle Trying to gain muscle 77.9 30.6 50.7 87.9 21.6 49.8 85.4 38.9 59.1 84.2 29.8 53.4

Figure 10a: Proportion trying to lose weight – Male

Figure 10b: Proportion trying to lose weight - Female

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c. Eating and Diet

This section summarises information about adolescents’ behaviours – specifically pertaining to eating and diet. Physical activity and sedentary behaviours and adolescents’ perceptions of their household, school, and community/neighbourhood environments are reported in sections after this. The proportion of adolescents who skipped breakfast is summarized for the two groups in Figure 11. This indicates that nearly all adolescents reported eating breakfast; only around 5 percent reported not eating breakfast. This was generally consistent for the Intervention and Comparison groups at both baseline and follow-up.

Figure 11: Proportion of adolescents who skipped breakfast – by group

The proportion of adolescents who reported obtaining breakfast from home is summarized in Figure 12. This shows that of those adolescents who reported eating breakfast, most indicated that this was obtained from home.

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Figure 12: Proportion of adolescents reporting home as their source for breakfast

Table 10: Breakfast consumption behaviours by ethnicity





Fijian Others All

Source of breakfast Home 93.9 94.2 85.0 93.9 94.7 91.0 95.0 91.8 89.5 92.5 89.0 91.1 92.6 91.8 89.0 91.9 School canteen/tuckshop

0.8 1.0 0.0 0.9 0.8 2.2 0.0 1.9 3.4 1.5 2.4 2.3 1.9 1.0 0.8 1.3

Shop (outside school) 2.3 0.2 5.0 0.7 1.5 0.0 0.0 0.3 4.2 0.3 0.8 1.8 2.5 0.7 3.2 1.5 I don’t eat breakfast 3.1 4.7 10.0 4.5 3.1 6.8 5.0 6.1 2.9 5.7 7.9 4.8 3.1 6.5 7.1 5.3 Ate breakfast in past 5 school days 0 to 1 day 4.9 4.7 11.1 4.9 7.4 6.5 0.0 6.5 8.8 5.2 3.5 6.5 4.6 6.5 6.1 5.7 2 to 3 days 15.6 9.1 27.8 10.8 19.7 12.9 11.1 14.1 15.5 11.6 22.8 14.0 20.7 14.6 21.9 17.6 4 to 5 days 79.5 86.2 61.1 84.3 73.0 80.6 89.9 79.4 75.7 83.2 73.7 79.5 74.7 78.8 71.9 76.7

The proportion of adolescents who skipped breakfast is summarized for the two ethnicities in Figure 13. This indicates that higher proportions (approximately double) of Indo-Fijian adolescents reported that they skipped breakfast when compared with Indigenous adolescents.

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Figure 13: Proportion of adolescents who skipped breakfast – by ethnicity

The proportion of Indigenous and Indo-Fijian adolescents who reported obtaining breakfast from home is summarized in Figure 14. This Figure indicates that of those Indigenous and Indo-Fijian adolescents who reported eating breakfast, most adolescents from both ethnic groups indicated that this was obtained from home.

Figure 14: Proportion of adolescents reported having breakfast

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Table 11: Breakfast consumption behaviours by gender

Intervention Comparison Baseline Follow up Baseline Follow up Male Female All Male Female All Male Female All Male Female All Source of breakfast Home 95.5 92.5 93.9 93.4 90.4 91.8 94.1 88.7 91.1 94.1 90.2 91.9 School canteen/tuckshop 0.9 1.0 0.9 2.1 1.7 1.9 1.2 3.1 2.3 1.5 1.2 1.3 Shop (outside school) 0.3 1.0 0.7 0.3 0.2 0.3 1.9 1.8 1.8 1.2 1.8 1.5 I don’t eat breakfast 3.3 5.5 4.5 4.2 7.7 6.1 2.7 6.4 4.8 3.1 6.9 5.3 Ate breakfast in past 5 school days 0 to 1 day 5.8 4.1 4.9 9.3 4.1 6.5 6.0 6.9 6.5 6.7 4.9 5.7 2 to 3 days 8.0 13.2 10.8 9.0 18.4 14.1 10.6 16.7 14.0 12.9 21.4 17.6 4 to 5 days 86.2 82.7 84.3 81.7 77.5 79.4 83.4 76.4 79.5 80.4 73.7 76.7

The proportion of adolescents who reported skipping breakfast is summarized in Figures 15a and 15b. A higher proportions of females (approximately double) reported that they skipped breakfast than their male counterparts. Again these trends were generally consistent across baseline and follow-up surveys.

Figure 15a: Proportion who skipped breakfast - Males Figure 15b: Proportion who skipped breakfast – Females

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The proportions of male and female adolescents who reported obtaining their breakfast from home is summarized in Figure 16. There was a small but consistent trend for males to more often obtain their breakfast from home when compared with females.

Figure 16a: Proportion who obtained breakfast from home- Males

Figure 16b: Proportion who obtained breakfast from home - Females

Table 12: Morning tea consumption behaviours by ethnicity





Fijian Others All

Source of morning tea Home 22.1 44.8 30.0 40.4 13.7 19.6 10.0 18.4 18.1 37.5 23.6 29.0 13.6 23.0 11.8 18.6 School canteen/tuckshop

73.3 49.9 45.0 53.9 74.8 74.5 60.0 74.2 70.8 52.2 59.8 59.9 70.7 63.9 55.9 65.9

Shop (outside school)

3.1 0.5 10.0 1.2 4.6 0.5 10.0 1.5 6.0 2.3 3.9 3.8 6.3 2.7 11.8 4.8

I don’t eat breakfast

1.5 4.8 15.0 4.5 6.9 5.3 20.0 6.0 5.1 8.1 12.6 7.3 9.4 10.4 20.5 10.8

Ate morning tea in past 5 school days 0 to 1 day 7.6 7.5 20.0 7.8 5.9 5.4 0.0 5.4 7.4 8.5 7.5 8.0 7.0 6.2 9.7 6.8 2 to 3 days 33.1 21.5 20.0 23.6 34.8 24.8 26.7 26.6 32.5 19.9 30.1 25.5 39.7 30.5 51.6 35.5 4 to 5 days 59.3 71.0 60.0 68.7 59.3 69.9 73.3 68.0 60.1 71.6 62.4 66.5 53.3 63.2 38.7 57.7

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Table 13: Morning tea behaviours by gender

Intervention Comparison Baseline Follow up Baseline Follow up Male Female All Male Female All Male Female All Male Female All Source of morning tea Home 46.9 35.3 40.4 19.4 17.5 18.4 33.8 25.3 29.0 19.8 17.6 18.6 School canteen/tuckshop 48.7 58.0 53.9 72.5 75.5 74.2 54.4 64.1 59.9 61.6 69.2 65.9 Shop (outside school) 0.9 1.4 1.2 1.2 1.7 1.5 5.0 2.9 3.8 6.5 3.4 4.8 I don’t eat breakfast 3.6 5.3 4.5 6.9 5.3 6.0 6.8 7.6 7.3 12.1 9.7 10.8 Ate morning tea in past 5 school days 0 to 1 day 8.3 7.4 7.8 4.8 5.8 5.4 5.8 9.7 8.0 5.6 7.7 6.8 2 to 3 days 22.5 24.4 23.6 22.2 30.1 26.6 22.4 27.8 25.5 31.4 38.6 35.5 4 to 5 days 69.2 68.2 68.7 73.0 64.1 68.0 71.8 62.5 66.5 63.0 53.8 57.7

Data on lunch-related behaviour are provided in Tables 14 and 15.

Table 14: Lunch behaviours by ethnicity



Fijian Others All Indigenous Indo-Fijian Others All Indigenous Indo-Fijian Others All

Source of lunch Home 85.5 89.9 85.0 89.0 77.9 84.7 60.0 82.9 86.3 86.7 83.5 86.3 86.3 85.6 75.6 85.1 School canteen 12.2 6.0 15.0 7.3 17.6 8.8 30.0 10.9 11.3 7.1 15.0 9.3 9.7 7.6 19.9 9.3 Shop (outside school) 2.3 1.0 0.0 1.2 3.1 1.7 10.0 2.1 1.2 0.9 1.6 1.1 2.9 1.2 3.9 2.1 I don’t eat b/fast 0.0 3.2 0.0 2.5 1.5 4.8 0.0 4.1 1.2 5.3 0.0 3.4 1.1 5.6 1.6 3.5 Ate lunch in past 5 school days 0 to 1 day 6.4 7.8 5.0 7.5 4.8 4.4 5.0 4.5 5.1 10.3 4.8 7.8 2.7 6.1 2.4 4.4 2 to 3 days 13.5 10.8 25.0 11.7 19.1 12.9 5.0 13.8 10.8 10.3 12.8 10.7 11.7 11.3 10.4 11.4 4 to 5 days 80.2 81.4 70.0 80.9 76.2 82.7 90.0 81.7 81.2 79.5 82.4 81.6 85.6 82.7 87.2 84.2

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Table 15: Lunch consumption behaviours by gender

Intervention Comparison Baseline Follow up Baseline Follow up Male Female All Male Female All Male Female All Male Female All Source of lunch Home 90.5 87.8 89.0 86.0 80.3 82.9 89.7 83.7 86.3 86.8 93.8 85.1 School canteen/tuckshop 7.5 7.2 7.3 10.2 11.5 10.9 7.9 10.3 9.3 9.0 9.5 9.3 Shop (outside school) 0.6 1.7 1.2 1.8 2.4 2.1 1.0 1.2 1.1 2.5 1.8 2.1 I don’t eat breakfast 1.5 3.4 2.5 2.1 5.8 4.1 1.5 4.8 3.4 1.8 4.9 3.5 Ate lunch in past 5 school days 0 to 1 day 6.3 8.5 7.5 4.4 4.5 4.5 5.8 9.4 7.8 4.2 4.6 4.4 2 to 3 days 9.5 13.5 11.7 9.5 17.5 13.8 6.3 14.2 10.7 8.2 14.0 11.4 4 to 5 days 84.2 78.0 80.9 84.1 78.0 81.7 87.9 76.4 81.6 87.6 81.4 84.2

The recommendation for a healthy diet is to have at least 5 serves of fruits and vegetables (combined) a day. The findings of OPIC for this recommendation are shown in Figure 17 and Table 16. The adolescents from the Comparison group were more likely to report meeting this target at both baseline and follow-up surveys when compared with the Intervention group. There was no evidence of change in fruit and vegetable intake for either group.

Figure 17: Proportion having recommended fruit and vegetable consumption by group

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Table 16: Consumption of fruit, vegetables and takeaway foods by ethnicity

Intervention Comparison Baseline Follow up Baseline Follow up Indigenous Indo-Fijian Others All Indigenous Indo-Fijian Others All Indigenous Indo-Fijian Others All Indigenous Indo-Fijian Others All Fruit/Vegetables 5 or more servings per day

24.4 19.6 40.0 21.0 21.4 21.1 25.0 21.3 27.6 20.9 33.9 24.5 27.0 21.2 37.0 24.6

Takeaways 2 or more times per week

9.9 7.2 15.0 7.9 9.2 6.2 10.0 6.8 13.6 8.3 7.9 10.3 8.2 9.2 6.3 8.6

Takeaways for dinner More than once a week

10.7 7.1 0.0 7.8 8.7 6.5 0.0 6.8 8.3 6.1 3.2 6.7 7.3 6.1 5.5 6.5

Consumption of recommended levels of fruit and vegetable intake by ethnicity is summarized in Figure 18. Generally there was a small but consistent trend indicating that higher proportions of Indigenous adolescents consumed the recommended levels of fruit and vegetables.

Figure 18: Proportion having recommended fruit and vegetable consumption by ethnicity

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Table 17: Consumption of fruit, vegetables and takeaway foods by gender

Intervention Comparison Baseline Follow up Baseline Follow up Male Female All Male Female All Male Female All Male Female All Fruit/Vegetables 5 or more servings per day 25.7 17.3 21.0 22.4 20.4 21.3 26.2 23.2 24.5 25.9 23.7 24.6 Ate takeaways 2 or more times per week 8.7 7.2 7.9 7.5 6.2 6.8 9.4 11.0 10.3 10.1 7.4 8.6 Ate takeaways for dinner More than once a week 9.9 6.1 7.8 9.4 4.9 6.8 6.7 6.8 6.7 6.5 6.5 6.5

Consumption of recommended levels of fruit and vegetable intake for male and female adolescents is summarized in Figures 19a and 19b. Generally there was a small but consistent trend indicating that there higher proportions of male adolescents consumed recommended levels of fruit and vegetables when compared with their female counterparts. Figure 19a: Proportion having recommended fruit and vegetable consumption – Males

Figure 19b: Proportion having recommended fruit and vegetable consumption- Females

High consumption of a take-away foods, is an indicator of a diet high in fat, sugar and salt, and therefore students were questioned on this. Frequent (≥ twice a week) consumption of takeaway food is summarised according to group in Figure 20. There were only slight differences between groups (Comparison reporting higher proportion) for frequent consumption of takeaway. Generally, these levels remained consistent from baseline to follow-up.

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Figure 20: Proportion of frequent consumption of takeaway food consumption by group

Consumption of take-away foods is shown by ethnicity in Figure 21. There is a small but consistent trend for Indigenous adolescents to more frequently consume takeaway foods for dinner when compared with their Indo-Fijian counterparts.

Figure 21: Proportion of frequent consumption of takeaway food consumption by ethnicity

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Frequent (≥ twice a week) consumption of takeaway food is summarised according to gender in Figure 22. This indicates that a small but significant (~6-11%) proportion of both male and female adolescents reported that they consumed takeaway foods for dinner. There were no reliable differences between males and females for frequency of takeaway food for dinner. Figure 22a: Proportion of frequent consumption of takeaway food consumption - Males

Figure 22b: Proportion of frequent consumption of takeaway food consumption - Females

Soft drinks and fruit drinks are important contributors of sugar and energy in many diets, and the levels of intake in the study population is shown in Tables 18-21. Levels overall are high.

Table 18: Soft drink consumption by ethnicity

Intervention Comparison Baseline Follow up Baseline Follow up Indigenous Indo-Fijian Others All Indigenous Indo-Fijian Others All Indigenous Indo-Fijian Others All Indigenous Indo-Fijian Others All Regular (non-diet) soft drink consumption in past 5 school days 0 to 1 day 32.1 30.5 30.0 30.7 29.0 25.6 30.0 26.3 26.7 20.7 25.2 23.3 33.8 29.6 32.3 31.4 2 to 3 days 46.6 46.3 55.0 46.5 40.5 46.1 50.0 45.2 44.3 43.9 37.8 43.6 42.1 43.3 43.3 43.0 4 to 5 days 21.4 23.3 15.0 22.7 30.5 28.3 20.0 28.5 29.0 35.4 37.0 33.1 24.1 26.8 24.4 25.6 Soft drink consumption on previous school day None 15.2 19.8 20.0 19.0 25.6 16.2 25.0 18.1 19.9 17.3 26.8 19.0 26.4 22.7 37.8 25.2 One can or less 46.4 47.8 50.0 47.6 40.0 46.6 25.0 44.8 44.4 47.8 37.0 45.7 42.4 44.0 29.1 42.3 Two cans or more 38.4 32.4 30.0 33.4 34.4 37.2 50.0 37.1 35.7 34.9 36.2 35.3 31.2 33.3 33.1 32.5

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Table 19: Soft drink consumption by gender

Intervention Comparison Baseline Follow up Baseline Follow up Male Female All Male Female All Male Female All Male Female All Regular (non-diet) soft drink consumption in past 5 school days 0 to 1 day 26.0 34.5 30.7 16.7 34.1 26.3 21.4 24.8 23.3 26.2 35.5 31.4 2 to 3 days 48.7 44.8 46.5 46.6 44.1 45.2 43.9 43.4 43.6 43.2 42.9 43.0 4 to 5 days 25.4 20.6 22.7 36.7 21.8 28.5 34.7 31.8 33.1 30.7 21.7 25.6 Soft drink consumption on previous school day None 15.6 21.9 19.0 14.1 21.4 18.1 17.9 19.9 19.0 23.3 26.7 25.2 One can or less 42.8 51.5 47.6 36.7 51.5 44.8 39.5 50.5 45.7 36.9 46.4 42.3 Two cans or more 41.6 26.6 33.4 49.2 27.1 37.1 42.7 29.6 35.3 39.8 26.9 32.5

Table 20: Fruit drink consumption by ethnicity

Intervention Comparison Baseline Follow up Baseline Follow up Indigenous Indo-Fijian Others All Indigenous Indo-Fijian Others All Indigenous Indo-Fijian Others All Indigenous Indo-Fijian Others All Fruit drink consumption in past 5 school days 0 to 1 day 46.6 49.9 50.0 59.3 47.3 43.8 35.0 44.2 36.7 37.4 31.5 36.7 46.0 44.8 34.7 44.5 2 to 3 days 43.5 38.1 35.0 39.0 38.9 42.6 45.0 42.0 40.0 40.6 10.2 40.3 38.0 38.3 44.1 38.6 4 to 5 days 9.9 12.0 15.0 11.7 13.7 13.6 20.0 13.8 23.3 22.0 28.4 23.0 16.1 16.9 21.3 16.9 Fruit drink consumption on previous school day None 7.5 10.1 25.0 10.1 6.0 13.1 8.3 11.7 6.0 9.3 11.6 8.3 6.8 9.5 11.6 8.6 One glass 23.9 23.2 25.0 23.3 16.4 18.1 16.7 17.8 12.0 18.8 19.8 16.3 14.0 20.9 10.5 17.5 Two glasses or more 68.7 66.8 50.0 66.6 77.6 68.8 75.0 70.6 82.0 71.9 68.6 75.4 79.2 69.7 77.9 73.9

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Table 21: Fruit drink consumption by gender

Intervention Comparison Baseline Follow up Baseline Follow up Male Female All Male Female All Male Female All Male Female All Fruit drink consumption in past 5 school days 0 to 1 day 48.7 49.9 59.3 43.3 44.8 44.2 36.8 36.6 36.7 40.5 147.6 44.5 2 to 3 days 40.0 38.1 39.0 42.1 42.0 42.0 38.3 41.9 40.3 38.7 38.5 38.6 4 to 5 days 11.3 12.0 11.7 14.6 13.2 13.8 26.9 21.5 23.0 20.8 13.9 16.9 Fruit drink consumption on previous school day None 10.4 9.8 10.1 12.3 11.2 11.7 8.6 8.0 8.3 8.3 8.9 8.6 One glass 17.2 28.0 23.3 16.6 18.7 17.8 15.0 17.4 16.3 15.4 19.1 17.5 Two glasses or more 72.4 62.2 66.6 71.2 70.1 70.6 76.5 74.5 75.4 76.3 72.0 73.9

While snacking itself is not of concern, the types of snack chosen are often a problem in children. Results are shown in tables 22-25. Overall snacking is common, with bread-based snacks the most popular, but biscuits, chips, noodles and chocolates/sweets are also common.

Table 22: After school snack consumption by ethnicity





Fijian Others All

Fruit after school Most days/daily 23.7 33.3 10.0 31.0 24.4 32.1 15.0 30.3 31.6 44.3 51.2 40.0 27.5 38.7 44.9 34.9 Ate bread-based snack after school Most days/daily 44.3 29.8 45.0 32.7 50.4 29.8 40.0 33.6 46.8 29.5 52.8 37.9 50.5 34.0 49.6 41.5 Ate biscuits, potato chips, noodles after school Most days/daily 39.7 37.4 55.0 38.3 35.1 36.4 15.0 35.6 39.2 32.7 33.1 35.2 27.9 36.3 26.8 32.4 Ate pies, takeaways, hot chips after school Most days/daily 12.2 10.7 10.0 10.9 9.2 11.7 20.0 11.4 9.9 10.4 7.1 9.9 8.8 13.1 10.2 11.2 Ate chocolates or sweets after school Most days/daily 24.0 33.2 20.0 31.1 14.7 25.0 20.0 23.0 22.8 25.6 19.7 24.1 17.3 25.4 16.5 21.6

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Table 23: After school snack consumption by gender

Intervention Comparison Baseline Follow up Baseline Follow up Male Female All Male Female All Male Female All Male Female All Fruit after school Most days/everyday 34.0 28.5 31.0 33.7 27.6 30.3 40.9 39.3 40.0 37.7 32.6 34.9 Ate bread-based snack after school Most days/everyday 33.4 32.1 32.7 36.4 31.4 33.6 39.5 36.6 37.9 42.9 40.4 41.5 Ate biscuits, potato chips, noodles after school Most days/everyday 36.4 39.8 38.3 36.4 35.0 35.6 38.2 33.0 35.2 30.4 33.9 32.4 Ate pies, takeaways, hot chips after school Most days/everyday 11.0 10.8 9.2 11.9 10.0 9.9 10.1 9.8 9.9 10.5 11.8 11.2 Ate chocolates or sweets after school Most days/everyday 25.6 35.5 31.1 19.8 25.4 23.0 18.5 28.4 24.1 15.8 26.1 21.6

Table 24: Snack food purchasing behaviours by ethnicity

Intervention Comparison Baseline Follow up Baseline Follow up Indigenous Indo-Fijian Others All Indigenous Indo-Fijian Others All Indigenous Indo-Fijian Others All Indigenous Indo-Fijian Others All Bought snack food from shop/takeaway in past 5 school days 0 to 1 day 29.8 44.8 50.0 42.3 36.6 53.2 35.0 49.9 38.7 53.2 48.0 47.3 38.4 50.4 43.3 45.3 2 to 3 days 44.3 32.1 30.0 34.2 45.8 31.0 45.0 33.9 36.3 31.2 33.1 33.3 40.4 34.8 37.0 37.1 4 to 5 days 26.0 23.1 20.0 23.5 17.6 15.8 20.0 16.2 25.0 15.7 18.9 19.5 21.1 14.8 19.7 17.6 Money spent on food on last school day None 17.1 19.8 15.4 19.0 17.1 16.9 15.4 16.9 14.8 22.1 35.4 20.3 15.3 18.9 29.9 18.3 $1 to 4 67.1 64.5 76.9 65.6 64.5 64.1 53.9 63.8 65.6 60.8 49.6 61.8 62.2 59.6 49.6 59.8 $5 to 9 13.2 11.3 7.7 11.6 14.5 14.9 23.1 15.1 14.8 12.6 11.0 13.4 17.3 15.3 12.6 15.8 $10 or more 2.6 4.4 0.0 3.9 4.0 4.0 7.7 4.2 4.8 4.5 3.9 4.6 5.3 6.3 7.9 6.0

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Table 25: Snack food purchasing behaviours by gender

Intervention Comparison Baseline Follow up Baseline Follow up Male Female All Male Female All Male Female All Male Female All Bought snack food from shop/takeaway in past 5 school days 0 to 1 day 42.7 42.0 42.3 50.2 49.6 49.9 50.5 44.7 47.3 48.2 43.1 45.3 2 to 3 days 34.3 34.1 34.2 34.3 33.6 33.9 34.6 32.2 33.3 36.9 37.2 37.1 4 to 5 days 23.0 24.0 23.5 15.5 16.8 25.0 14.9 23.0 19.5 14.9 19.7 17.6 Money spent on food on last school day None 15.3 21.8 19.0 9.7 22.3 16.9 20.4 20.2 20.3 18.3 18.4 18.3 $1 to 4 61.8 68.4 65.6 67.4 61.1 63.8 61.2 62.3 61.8 58.6 60.8 59.8 $5 to 9 14.6 9.3 11.6 16.7 14.0 15.1 12.9 13.7 13.4 15.0 16.5 15.8 $10 or more 8.3 0.5 3.9 6.3 2.6 4.2 5.5 3.9 4.6 8.2 4.4 6.0

d. Physical activity and sedentary behaviours

Levels of physical activity are of interest, along with related variables such as television use. Findings on these indicators are provided in this section. Table 26: Physical activities and television use by ethnicity





Fijian Others All

Morning recess/interval Mostly active 23.1 14.7 16.7 16.2 14.5 8.1 5.7 9.1 14.4 11.2 7.1 12.1 8.8 7.0 3.9 7.4 Lunch break Mostly active 19.5 13.9 22.2 15.1 14.4 6.4 5.6 7.8 9.9 9.7 11.0 9.9 7.7 7.1 7.1 7.3 Did physical activities after school, past 5 school days 0 to 1 day 42.4 31.3 38.9 33.4 24.6 30.5 44.4 29.9 23.6 25.9 22.8 24.8 19.8 27.8 17.3 23.9 2 to 3 days 28.0 37.3 16.7 35.2 42.4 42.1 27.8 41.8 29.0 36.7 29.1 33.2 29.3 36.5 26.0 33.0 4 to 5 days 29.7 31.4 44.4 31.5 33.1 27.4 27.8 28.4 47.4 37.4 48.0 42.0 50.9 35.7 56.7 43.1 Total screen time (television and computer) ≤2 hours 42.9 28.2 12.5 30.3 40.5 28.6 38.5 30.6 37.5 37.8 44.3 38.2 45.2 37.0 34.6 39.4 >2 hours 57.1 71.8 87.5 69.7 59.5 71.4 61.5 69.4 62.5 62.2 55.7 61.8 54.8 63.0 65.4 60.6

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The proportion of adolescents who reported high levels of screen time (> 2 hours) each day is summarized according by group in Figure 23. This indicates that higher proportions of adolescents from the Intervention group reported higher levels of total screen time when compared with adolescents from the Comparison group.

Figure 23: Proportion of adolescents reporting more than two hours total screen time/day according to group

The proportion of adolescents who reported high levels of screen time (> 2 hours) each day is summarized according to ethnicity in Figure 24. A higher proportions of Indo-Fijian adolescents reported spending more time on screen based activities when compared with Indigenous adolescents.

Figure 24: Proportion of adolescents reporting more than two hours total screen time/day according to ethnicity

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Table 27: Physical activities and television use by gender

Intervention Comparison Baseline Follow up Baseline Follow up Male Female All Male Female All Male Female All Male Female All Morning recess/interval Mostly active 19.1 13.8 16.2 12.5 6.4 9.1 14.4 10.3 12.1 10.0 5.5 7.4 Lunch break Mostly active 19.0 12.0 15.1 9.8 6.1 7.8 13.4 7.2 9.9 9.8 5.4 7.3 Did physical activities after school, past 5 school days 0 to 1 day 33.8 33.1 33.4 22.0 36.3 29.9 21.5 27.3 24.8 16.2 29.8 23.9 2 to 3 days 34.4 35.7 35.2 37.1 45.6 41.8 26.7 38.2 33.2 24.9 39.1 33.0 4 to 5 days 31.8 31.2 31.5 41.0 18.1 28.4 51.8 34.5 42.0 58.9 31.1 43.1 Total screen time (television and computer) ≤2 hours 26.1 34.4 30.3 27.1 34.4 30.6 35.0 41.2 38.2 35.0 43.2 39.4 >2 hours 73.9 65.6 69.7 72.9 65.6 69.4 65.0 58.8 61.8 65.0 56.8 60.6

The proportion of male and female adolescents who reported more than two hours screen time/day is summarized in Figures 25a and 25b. There was a small but consistent trend where higher proportions of males spent more time on screen based activities when compared with female adolescents. There was little evidence of change from baseline to follow-up survey for both males and females. Figure 25a: Proportion of adolescents reporting more than two hours total screen time/day – Males

Figure 25b: Proportion of adolescents reporting more than two hours total screen time/day – Females

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d. Perceptions of the household environment The environment at home has important impacts on childrens’ attitude and behaviour. The proportion of adolescents reporting having family meals on most days (ie. 4-5 days from the past 5 days) is summarized according to group in Figure 26. Just over 60% of adolescents from both the Intervention and Comparison groups reported having family meals on most days and that there was a slight reduction in this proportion for both groups.

Figure 26: Proportion of adolescents reporting having family meals on most days

Adolescent perceptions of the availability of different foods and beverages in the home are summarized according to group in Figure 27. This indicates that fruit was generally available in home of both Intervention and Comparison adolescents. Furthermore, this availability increased substantially for the Intervention group at follow-up while the Comparison was unchanged. Adolescents from both groups also reported that chips, chocolates and soft drinks were also generally available in the household (range: 27-52%).

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Figure 27: Adolescent perceptions of availability of different foods and beverages in the household according to group

Table 28: Family meals and home availability of foods by ethnicity





Fijian Others All

Frequency of family meals in past 5 school days 0 to 1 day 8.7 12.6 16.7 12.1 8.7 13.7 5.6 12.7 13.0 11.2 15.8 12.2 11.6 14.1 18.1 13.4 2 to 3 days 22.1 22.6 16.7 22.3 16.4 26.4 22.2 24.7 204 25.0 15.8 22.5 21.6 25.8 18.1 23.6 4 to 5 days 69.2 64.9 66.7 65.6 75.0 59.9 72.2 62.6 66.7 63.8 68.5 65.3 66.8 60.1 63.8 63.0 Fruit available to eat at home Most days/everyday 40.8 63.3 33.3 56.8 47.6 75.7 53.3 68.1 62.2 82.2 78.7 74.3 58.2 80.9 75.6 71.8 Potato chips available to eat at home Most days/everyday 42.7 45.1 46.7 44.6 14.6 40.6 26.7 33.8 54.5 51.1 47.2 52.1 14.4 42.3 27.6 31.7 Chocolates available to eat at home Most days/everyday 17.2 37.5 14.3 31.8 15.2 37.5 21.4 30.1 16.4 35.4 18.1 26.8 13.1 37.3 23.6 27.0 Soft drinks available to eat at home Most days/everyday 10.5 42.6 23.1 34.6 17.1 46.2 15.4 38.5 19.0 43.5 18.1 32.2 13.9 42.1 17.3 29.4

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The proportion of Indigenous and Indo-Fijian adolescents who reported having family meals on most days is summarized in Figure 28. This Figure shows that there was a small but consistent trend for Indigenous adolescents to have family meals than their Indo-Fijian counterparts.

Figure 28: Family meals and home availability of foods by ethnicity

Adolescents from the two ethnic groups reported on availability of different foods and beverages in the household. These results are summarized in Figures 29a and 29b. There was considerable variation between food and beverage availability within the households by ethnic groups.

Figure 29a: Adolescent perceptions of availability of different foods and beverages in the household – Indigenous

Figure 29b: Adolescent perceptions of availability of different foods and beverages in the household - Indo-Fijian

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The availability of different foods and beverages in the household is shown by gender in Figures 30a and 30b. Generally there were few reliable gender differences in relation to perceived availability of different foods and beverages in the household.

Figure 30a: Adolescent perceptions of availability of different foods and beverages in the household according to group – Males

Figure 30b: Adolescent perceptions of availability of different foods and beverages in the household according to group - Females

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Table 29: Family meals and home availability of foods by gender

Intervention Comparison Baseline Follow up Baseline Follow up Male Female All Male Female All Male Female All Male Female All Frequency of family meals in past 5 school days 0 to 1 day 12.8 11.5 12.1 13.1 12.3 12.7 11.2 13.0 12.2 11.6 14.8 13.4 2 to 3 days 22.6 22.5 22.3 25.5 24.1 24.7 21.0 23.7 22.5 23.0 24.1 23.6 4 to 5 days 65.1 66.0 65.6 61.4 63.6 62.6 67.9 63.3 65.3 65.4 61.1 63.0 Fruit available to eat at home Most days/everyday 58.0 55.9 56.8 73.5 64.1 68.1 74.1 74.5 74.3 75.2 69.2 71.8 Potato chips available to eat at home Most days/everyday 45.3 44.1 44.6 34.3 33.5 33.8 53.7 50.9 52.1 32.3 31.2 31.7 Chocolates available to eat at home Most days/everyday 32.6 31.2 31.8 28.6 31.2 30.1 25.2 28.1 26.8 25.5 28.2 27.0 Soft drinks available to eat at home Most days/everyday 38.2 32.0 34.6 42.4 35.6 38.5 33.0 31.6 32.2 28.3 30.2 29.4

The proportion of male and female adolescents who reported having family meals on most days is summarized in Figures 31a and 31b. About 2/3 of male and female adolescents reported having family meals on most days and that there was no reliable gender difference.

Figure 31a: Family meals and home availability of foods – Males

Figure 31b: Family meals and home availability of foods - Females

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Table 30: Parental support for healthy eating by ethnicity





Fijian Others All

Maternal support for healthy eating A lot 64.1 66.9 60.0 66.0 66.0 76.0 73.3 73.5 79.2 80.2 78.7 79.7 75.9 77.6 79.5 77.1 Some/a little 30.1 27.9 33.3 28.7 27.2 21.4 20.0 22.8 14.5 18.0 18.1 16.7 17.9 19.7 15.8 18.8 None 3.9 4.2 0.0 4.0 1.0 1.3 6.7 1.4 2.2 0.5 0.8 1.2 2.2 1.1 0.0 1.4 Don’t live with mother 1.9 1.0 6.7 1.4 5.8 1.3 0.0 2.4 4.2 1.3 2.4 2.5 4.0 1.6 4.7 2.8 Paternal support for healthy eating A lot 54.4 52.0 66.7 53.1 56.3 62.0 73.3 61.0 70.8 66.8 63.0 68.0 67.8 66.9 61.4 66.8 Some/a little 29.1 34.1 20.0 32.4 28.2 30.2 13.3 29.1 19.6 27.7 23.6 24.3 22.2 26.0 22.8 24.3 None 7.8 7.5 6.7 7.5 1.9 3.6 0.0 3.1 2.2 1.9 5.5 2.2 2.5 2.5 3.9 2.6 Don’t live with father 8.7 6.5 6.7 7.0 13.6 4.2 13.3 6.8 7.4 3.7 7.9 5.4 7.6 4.6 11.8 6.3

Table 31: Parental support for healthy eating by gender

Intervention Comparison Baseline Follow up Baseline Follow up Male Female All Male Female All Male Female All Male Female All Maternal support for healthy eating A lot 66.9 65.3 66.0 75.7 71.8 73.5 79.7 79.7 79.7 77.3 77.0 77.1 Some/a little 29.3 28.2 28.7 21.6 23.7 22.8 16.5 16.8 16.7 18.1 19.2 18.8 None 1.7 5.7 4.0 0.6 2.0 1.4 1.0 1.4 1.2 1.4 1.5 1.4 Don’t live with mother 2.2 0.8 1.4 2.2 2.5 2.4 2.9 2.2 2.5 3.3 2.4 2.8 Paternal support for healthy eating A lot 53.6 52.7 53.1 61.3 60.8 61.0 68.5 67.7 68.0 68.1 65.8 66.8 Some/a little 36.5 29.4 32.4 32.0 26.9 29.1 24.9 23.7 24.3 23.6 24.9 24.3 None 3.9 10.2 7.5 1.7 4.1 3.1 1.6 2.7 2.2 2.2 2.9 2.6 Don’t live with father 6.1 7.8 7.0 5.0 8.2 6.8 4.9 5.8 5.4 6.1 6.4 6.3

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Table 32: Parental support for physical activity by ethnicity





Fijian Others All

Maternal support for physical activity A lot 35.4 47.0 35.7 43.8 48.5 48.3 42.9 48.2 50.2 58.5 54.3 55.0 51.7 55.1 45.7 53.1 Some/a little 54.6 46.6 57.1 48.9 42.4 46.0 42.9 45.0 41.5 38.5 39.4 39.7 40.6 40.4 46.5 40.9 None 6.1 4.7 0.0 4.9 3.0 4.7 14.3 4.7 3.6 2.1 3.2 2.7 3.7 2.9 3.9 3.3 Don’t live with mother 4.0 1.7 7.1 2.4 6.1 1.0 0.0 2.2 4.8 1.0 3.2 2.6 4.0 1.5 3.9 2.6 Paternal support for physical activity A lot 47.4 51.0 61.5 50.6 44.7 54.2 30.8 51.2 54.6 65.0 49.6 29.9 55.1 60.6 53.5 57.9 Some/a little 38.2 37.8 23.1 37.3 34.2 35.3 53.9 35.8 34.1 29.2 40.2 31.9 32.9 31.1 31.5 31.8 None 7.9 4.4 7.7 5.3 4.0 6.8 7.7 6.2 3.4 2.0 2.4 2.5 4.3 4.6 4.7 4.0 Don’t live with father 6.6 6.8 7.7 6.8 17.1 3.6 7.7 6.8 7.9 3.8 7.9 5.7 7.7 4.8 10.2 6.3

Table 33: Parental support for physical activity by gender

Intervention Comparison Baseline Follow up Baseline Follow up Male Female All Male Female All Male Female All Male Female All Maternal support for physical activity A lot 45.1 42.7 43.8 46.3 49.6 48.2 51.8 57.5 55.0 51.6 54.2 53.1 Some/a little 48.0 49.6 48.9 47.4 43.2 45.0 42.2 37.8 39.7 42.2 39.9 40.9 None 4.6 5.1 4.9 3.4 5.6 4.7 2.9 2.6 2.7 3.0 3.6 3.3 Don’t live with mother 2.3 2.6 2.4 2.9 1.7 2.2 3.1 2.2 2.6 3.1 2.3 2.6 Paternal support for physical activity A lot 64.6 40.2 50.6 61.8 43.3 51.2 66.2 55.1 29.9 64.7 52.8 57.9 Some/a little 26.4 45.4 37.3 31.3 39.2 35.8 26.6 36.0 31.9 27.4 35.1 31.8 None 2.8 7.2 5.3 2.1 9.3 6.2 1.6 3.2 2.5 1.6 5.7 4.0 Don’t live with father 6.3 7.2 6.8 4.9 8.3 6.8 5.6 5.7 5.7 6.3 6.4 6.3

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Table 34: Home availability of televisions, video games and computers by ethnicity





Fijian Others All

Has a television at home Yes 84.7 94.8 100 92.6 89.4 96.8 92.3 94.8 92.3 97.1 96.1 95.2 96.0 97.5 97.6 96.9 Has a television in bedroom Yes 21.1 21.0 16.7 20.9 11.3 21.9 25.0 19.6 13.8 21.5 18.2 18.4 12.8 21.8 22.3 18.5 Has video games, electronic games or computer at home Yes 41.5 71.4 53.3 63.8 52.1 78.8 80.0 72.7 51.7 77.8 85.8 68.4 54.0 81.1 83.5 70.9 Parent limit television use Strict limits 60.0 40.1 38.5 45.2 42.2 32.2 30.8 34.8 40.9 39.5 33.1 39.6 43.7 36.3 33.1 38.9

Table 35: Home availability of televisions, video games and computers by gender

Intervention Comparison Baseline Follow up Baseline Follow up Male Female All Male Female All Male Female All Male Female All Has a television at home Yes 94.0 91.5 92.6 96.0 94.0 94.8 96.1 94.5 95.2 97.0 96.9 96.9 Has a television in bedroom Yes 30.9 13.0 20.9 27.3 13.6 19.6 20.8 16.6 18.4 24.7 13.7 18.5 Has video games, electronic games or computer at home Yes 69.8 59.5 63.8 79.3 67.9 72.7 71.5 66.0 68.4 71.8 70.2 70.9 Parent limit television use Strict limits 47.3 43.7 45.2 34.9 34.7 34.8 40.3 39.0 39.6 37.1 40.3 38.9

e. Perceptions of the school environment

Similarly the school environment will impact on behaviours and attitudes. Perceptions of support are shown in this section. While many students considered that their school was supportive of healthy eating, few felt that the canteen supported this. Support for physical activity was seen to be quite low, although teachers were often seen as good role models in this area.

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Table 36: School support for healthy eating and physical activity by ethnicity

Intervention Comparison Baseline Follow up Baseline Follow up Indigenous Indo-Fijian Others All Indigenous Indo-Fijian Others All Indigenous Indo-Fijian Others All Indigenous Indo-Fijian Others All School support for student’s healthy food choices A lot 46.6 56.0 33.3 53.8 56.0 54.0 38.9 53.9 46.6 53.2 29.9 48.9 40.9 44.9 22.8 41.7 Food and drinks in the school canteen Mostly healthy 9.4 9.4 16.7 9.6 12.0 11.4 0 11.2 15.6 13.3 4.7 13.5 11.0 9.5 2.4 9.5 Teachers as role models for healthy eating Good/excellent 49.6 58.9 45.0 56.9 46.6 54.7 20.0 52.4 64.8 67.0 37.0 63.9 46.8 53.3 24.4 48.6 Teachers as role models for being physically active Good/excellent 67.2 66.4 50.0 66.1 44.3 55.6 20.0 52.7 66.8 67.9 42.5 65.6 53.7 54.7 27.6 52.3 School support for all students to play organised sports A lot 32.8 53.7 30.0 49.5 53.4 59.6 35.0 57.9 61.6 70.4 67.7 66.8 56.6 63.9 52.0 60.3 School encouragement for all students to be active at lunchtime A lot 15.3 31.6 15.0 28.3 22.9 33.3 35.0 31.5 26.5 39.7 15.0 32.8 21.1 34.3 10.2 27.5

Table 37: School support for healthy eating and physical activity by gender

Intervention Comparison Baseline Follow up Baseline Follow up Male Female All Male Female All Male Female All Male Female All School support for student’s healthy food choices A lot 48.0 58.5 53.8 50.0 57.1 53.9 47.1 50.3 48.9 40.9 42.3 41.7 Food and drinks in the school canteen Mostly healthy 8.6 10.4 9.6 14.8 8.3 11.2 15.3 12.2 13.5 11.2 8.2 9.5 Teachers as role models for healthy eating Good/excellent 53.1 60.0 56.9 52.2 52.5 52.4 63.2 64.4 63.9 48.2 48.9 48.6 Teachers as role models for being physically active Good/excellent 61.2 70.0 66.1 53.7 51.8 52.7 61.3 68.8 65.6 51.8 52.7 52.3 School support for all students to play organised sports A lot 41.2 56.1 49.5 48.7 65.2 57.9 59.7 72.3 66.8 54.8 64.4 60.3 School encouragement for all students to be active at lunchtime A lot 20.3 34.8 28.3 28.1 34.3 31.5 30.8 34.3 32.8 25.2 29.2 27.5

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f. Perceptions of neighbourhood and community The wider environment and community will also impact on behaviour. Perceptions of key factors are shown in Tables 38 and 39. Table 38: Neighbourhood and community factors by ethnicity

Intervention Comparison Baseline Follow up Baseline Follow up Indigenous Indo-Fijian Others All Indigenous Indo-Fijian Others All Indigenous Indo-Fijian Others All Indigenous Indo-Fijian Others All Neighbourhood at night Safe 63.3 64.8 55.6 64.3 76.1 76.4 72.2 76.3 66.8 69.6 61.4 67.9 75.8 74.1 75.6 74.8 Parental perception of neighbourhood at night Safe 45.3 38.9 16.7 39.4 44.4 54.7 55.6 53.0 43.7 42.5 28.4 41.9 50.6 48.6 37.0 48.5 Bothered by dogs when walking in neighbourhood Somewhat/a lot 42.7 33.3 16.7 34.5 35.9 35.4 16.7 35.0 33.6 40.9 30.7 37.3 41.5 41.7 42.5 41.7 Bothered by traffic when walking in neighbourhood Somewhat/a lot 37.6 25.1 27.8 27.3 31.6 30.9 22.2 30.8 27.6 26.1 17.3 26.1 30.4 25.7 24.4 27.4 Bothered by other people when walking in neighbourhood Somewhat/a lot 43.6 23.9 16.7 27.1 35.0 28.4 27.8 29.5 29.8 26.4 18.1 27.1 31.3 26.9 24.4 28.4 Best friends provide support for physical activity A lot 82.9 75.1 69.2 76.6 86.8 77.5 76.9 79.6 87.0 84.6 78.7 85.1 89.8 82.0 88.2 85.5

Table 39: Neighbourhood and community factors by gender

Intervention Comparison Baseline Follow up Baseline Follow up Male Female All Male Female All Male Female All Male Female All Neighbourhood at night Safe 79.0 52.4 64.3 90.5 64.7 76.3 83.2 56.2 67.9 88.8 64.1 74.8 Parental perception of neighbourhood at night Safe 50.3 30.5 39.4 69.1 39.8 53.0 56.4 30.8 41.9 63.9 36.7 48.5 Bothered by dogs when walking in neighbourhood Somewhat/a lot 41.1 29.1 34.5 41.8 29.4 35.0 41.0 34.5 37.3 45.2 39.0 41.7 Bothered by traffic when walking in neighbourhood Somewhat/a lot 27.0 27.5 27.3 34.9 27.5 30.8 26.8 25.4 26.1 28.1 26.9 27.4 Bothered by other people when walking in neighbourhood Somewhat/a lot 24.0 29.7 27.1 29.9 29.1 29.5 24.5 29.0 27.1 24.9 31.1 28.4 Best friends provide support for physical activity A lot 85.4 70.1 76.6 90.3 71.7 79.6 91.4 80.3 85.1 91.4 80.9 85.5

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g. Quality of Life

This section summarises information for the assessment of quality of life (Pediatric instrument only). Again information is presented for both the Intervention and Comparison groups at baseline and follow-up.

Table 40: Pediatric Quality of Life by ethnicity





Fijian Others All

Physical Mean 77.3 81.5 82.2 80.7 82.4 82.0 80.9 82.0 77.7 79.9 83.9 79.4 83.2 82.8 85.6 83.2 SD 17.6 13.4 11.5 14.2 12.6 12.2 13.1 12.3 18.5 14.3 13.1 16.1 13.6 12.9 11.2 13.0 Emotional Mean 64.2 66.7 67.0 66.3 62.1 63.3 60.8 63.0 64.7 65.2 67.5 65.2 64.1 65.5 67.4 65.1 SD 16.8 16.7 16.2 16.7 16.2 15.8 17.1 15.9 17.6 17.2 17.0 17.3 16.0 16.7 16.5 16.5 Social Mean 73.7 83.9 76.8 82.0 76.1 85.3 78.0 83.5 74.3 82.1 80.0 79.0 77.6 86.1 82.4 82.6 SD 18.9 15.1 14.9 16.3 17.2 14.9 15.0 15.8 18.5 16.8 16.1 17.8 17.2 15.1 14.9 16.4 School Mean 69.6 79.4 68.5 77.4 64.7 72.3 70.5 71.0 68.8 76.7 74.5 73.5 66.6 75.6 69.4 71.7 SD 16.1 15.6 18.4 16.2 16.1 14.9 14.2 15.4 16.5 15.6 14.9 16.3 14.8 15.2 16.1 15.7 Summary Mean 72.0 78.2 74.7 77.0 72.8 76.5 73.6 75.8 72.2 76.5 77.4 74.9 74.2 78.2 77.5 76.6 SD 12.7 11.6 9.7 12.0 11.8 10.8 10.4 11.1 13.5 12.4 11.8 12.9 11.7 11.8 11.4 11.9

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Table 41: Pediatric Quality of Life by gender

Male Female All Male Female All Male Female All Male Female All Physical Mean 85.3 77.1 80.7 86.5 78.4 82.0 83.7 76.0 79.4 87.9 79.6 83.2 SD 13.5 13.8 14.2 11.0 12.0 12.3 15.1 16.0 16.1 11.1 13.2 13.0 Emotional Mean 71.0 62.5 66.3 68.2 58.9 63.0 70.0 61.5 65.2 70.5 61.0 65.1 SD 16.4 16.0 16.7 15.3 15.2 15.9 16.7 16.9 17.3 15.6 15.9 16.5 Social Mean 83.1 81.0 82.0 84.7 82.5 83.5 80.8 77.5 79.0 84.3 81.3 82.6 SD 15.8 16.7 16.3 15.4 16.0 15.8 17.7 17.8 17.8 15.7 16.8 16.4 School Mean 77.2 77.5 77.4 71.1 70.9 71.0 73.9 73.2 73.5 72.1 71.5 71.7 SD 16.7 15.9 16.2 16.1 14.8 15.4 16.2 16.4 16.3 16.2 15.4 15.7 Summary Mean 79.8 74.7 77.0 78.8 73.4 75.8 78.0 72.6 74.9 79.9 74.2 76.6 SD 12.0 11.5 12.0 10.7 10.8 11.1 12.6 12.7 12.9 11.3 11.7 11.9

4.7 AWARENESS OF OPIC KEY MESSAGES

The follow-up question had additional questions included to assess the awareness of adolescents of the HYHC key messages. A yes response indicated that they were familiar with that message (although the message may not have originated from HYHC. This was included in both the intervention and comparison schools. Table 42 and Figure 32. With the exception of fruits and vegetables, the awareness of HYHC messages was higher overall in the intervention schools.

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Table 42: Awareness of OPIC messages

Yes response

Intervention Comparison

Drinking mainly water 86.1 79.2 Eating breakfast regularly 87.6 76.2 Walking/cycling to school 56.9 54 Eating plenty of vegetables 83.1 87.4 Not going on fad diets 52.7 49.1 Eating a healthy school lunch 82.8 79.2 Limiting television viewing time 70.2 69.1 Limiting electronics and television time 61.6 59.4 Limiting sugary drinks 77.7 73.5 Being active during recess/lunchtime 66.6 57.5 Eating plenty of fruit 92.5 91.3 Different body shapes can be healthy 57.2 52.7 Limiting high fat snacks 73.2 69.3 Being active after school/at weekends 75.5 77.1

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Figure 32: Awareness of OPIC messages

4.8 CONCLUSIONS The rates of overweight and obesity amongst the children surveyed were high, and combined with indicators such as diet, physical activity and school and household environments, indicate substantial issues in Fiji which require action. The plans of action for the identified sites of the OPIC project were developed within the context of the local communities. The action plans are living documents to ensure ongoing feedback and participation of key community stakeholders. The preliminary successes in engaging community members to support the OPIC project, development of the action plans and initial strategies undertaken in the intervention communities have reinforced the community interaction process utilized by the project teams.

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Despite the intensive activities in the Intervention sites, no significant impacts were seen for behavioural or health outcomes, with the exception of the body fat measures and quality of life. Effects for the two ethnic groups were similar. The finding that the body fat percentage was lower in the intervention group than the comparative group at follow-up may however indicate that the interventions did have some impacts on the adolescents. The finding that measures of weight/height did not indicate change but that body fat did, is conflicting. While it may be due to fat to muscle mass changes, this needs further research to understand more clearly the changes. The reported changes in body fat should not be regarded as indicating that improvements were seen in health status of these adolescents, due to the need for more research. Findings for the behavioural and (perceived) environment measures generally indicated no group difference. With the exception of: ‘less than or equal to one serve of vegetables/day’ and ‘average time spent watching TV/day’, and ‘potato chips/snacks available at home every day/almost every day’. For each of these indicators, the results showed that there were more positive (healthier) changes in the comparison group relative to the intervention group. The perceptions of the environment failed to show any evidence for impacts on the household or school environments. There was however quite high awareness of most of the HYHC messages, and the awareness was generally higher in the intervention schools. The implementation of HYHC in Fiji had a number of limitations. The design was not based on the sociocultural data and baseline data collected (due to timing issues), and as such targeted areas for action were not based on evidence. For example, intake of breakfast was already quite high, and yet increasing this was a key objective for HYHC. Similarly interventions could not take account of the wealth of sociocultural data which was developed which demonstrated considerable cultural influences on lifestyle. The implementation of HYHC also had some limitations, including insufficient funds for all activities, insufficient intervention staff at times (as the same staff were also heavily involved in data collection) and delays associated with the formalities of implementing the project. These limitations may have affected the impacts of the interventions, and this needs to be considered when interpreting the results. For further information on this aspect of the OPIC study, including published papers, please contact C-POND.

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4.0 Socio-cultural Component

4.1 INTRODUCTION

The socio-cultural component of the OPIC study aimed to identify socio-cultural factors experienced by adolescents that are related to food and eating, physical activity and inactivity, and their ideas about body size. Socio-cultural factors that promote or protect against obesity include community attitudes, perceptions, beliefs, values and practices. It is difficult to change behavioral patterns without addressing underlying socio-cultural factors. Yet, very little is known about socio-cultural values, attitudes and behaviors that either promote or protect against obesity.

The socio-cultural data were collected from adolescents via (1) interviews, (2) questionnaires, and (3) a computer programme to investigate perceptual distortion of the body image.

4.2 METHODOLOGY

In addition to the measures conducted under the ‘intervention’ component of OPIC, additional socio-cultural studies were included in OPIC. The in-depth interviews involved 24 males and 24 females from each cultural group, with equal representation across junior, intermediate and senior students. Participants were from six (6) of the seven (7) secondary schools in the study area, Amadhiya Muslim College, Assemblies of God High School, Bhawani Dayal College, Nasinu Muslim College, Nasinu Secondary School and Rishikul College.

The interview questions were developed from: 1) the OPIC goals, 2) two focus groups conducted in 2004, and 3) a pilot study that was conducted with six males and six females from each of two main cultural groups in August 2004.

The interviews were semi-structured. All participants were asked the same questions but not necessarily in the same order. Interviewers were the same sex as the participant and spoke the same first language. Participants determined whether they were interviewed in their first language, English, or a combination of the two. This interview protocol was selected in order to create a relaxed environment where the youths would be more likely to share their experiences and ideas. The objectives of interviews were to determine youth’s impressions of:

i. Culture-specific values, ideas and practices that influence food, eating, physical activity (PA) and body size.

ii. Important messages about food, eating, physical activity and body size (participants’ ideas and their explanations).

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iii. Messengers – who provided the messages and who appeared to be most important youth messengers (family, adults, older siblings, teachers, religious groups, peers, media).

iv. Ways the messages were delivered (e.g. encouragement, rules, teasing, role models).

v. Which messages/practices can be changed

• Interviews were recorded, transcribed and translated into English when necessary, coded onto N6 software and put into categories or themes. Some categories were predetermined by the specific research questions. Other themes were added as they emerged from the transcripts.

• Data collected were co-analyzed so that local themes and nuances were identified. 4.3 RESULTS OF THIS ASPECT OF RESEARCH

4.3.1 Findings from the interviews were grouped under three main headings: (1) “Food and Eating”, (2)”Physical Activity” (3)“Body Image”; and each with 3 subsections on:

(i) Messages – the messages that participants received, the ideas of participants and their explanations for activities and body size. (ii) Patterns – participants’ reports of their own patterns of eating and physical activity and their body size, as well as the patterns and body size of others.

(iii) Messengers - the key messengers (sources of messages) identified by participants and their means of conveying messages.

4.3.2 The findings are summarized in Table 43.

Table 43: Summary of Findings on the social cultural issues in schools

Issues Food and eating Physical activity Body Image Messages

Many participants knew about healthy foods and explained the value of a balanced diet in terms of being fit, healthy & being able to concentrate at school. One common misconception: was that commercial fruit drinks were healthy.

Participants were accurate in their explanations of the benefits of doing regular physical activity. The main reasons given were, in this order, to become fit, be healthy, and to be alert at school. Many participants observed that peers who were overweight were unable to be physically active as their more normal size peers, and that overweight peers were less able to be skilled at physical activities.

A number of participants suggested that physical activity was for “kids”; this

Many participants indicated that body weight/size was the outcome of the balance between food eaten & energy used. Participants believed obese people could not do physical activities as easily as people of a healthy weight. Many participants

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Issues Food and eating Physical activity Body Image A number of participants believed that their mothers selected family food on the basis of health, and, in the case of indigenous Fijians, economics. Most participants believed that the main meal of the day was either dinner or breakfast.

message appeared to be reinforced by parents.

Male participants explained the purpose of doing weights & training was to build up strength & fitness, respectively. Majority of males & females believed that males had more opportunities to do recreational physical activities than females.

suggested that it was difficult for underweight people to be physically active. Participants believed they would be teased if their body size was outside the norm, that is, either too large or too small.

Eating patterns

Knowledge about healthy food & eating patterns did not always translate to practice. Many participants missed breakfast, especially Indo-Fijian females. School canteens were the main source of food and drinks at recess time. The vast majority of youth had “spending” money. Spending money was used to buy junk food, most often from school canteens. Spending was not monitored by adults. Food that was brought from home was not necessarily eaten only by participants. Food from home and spending money was often shared among friends.

Patterns of physical activity There were culture-specific patterns of physical activity, with indigenous Fijians engaging in more physical activity than Indo-Fijians. Participants from both cultural groups suggested that indigenous Fijians were physically active because, they were more accustomed to physical activity and had a healthier diet compared to Indo-Fijians.

Twice as many Indo-Fijians as indigenous Fijians said that the need to study limited their physical activities. There were also gender differences in physical activities, with males in both cultural groups engaging in more physical activity than females, both at home and at school. Reasons given for this gender difference were that males had fewer household chores than females, and were afforded more freedom to play, especially in the evenings when personal safety was a consideration. Participants suggested there were more resources (facilities and sports) available for males to do recreational physical activity than females, both at school and in the community. Some teachers discouraged Indo-Fijian girls from playing with boys. Many females said that males did more physical activities than females because they were more interested in sport. Remarkably few participants said that their families exercised together.

Body change strategies Many participants were not trying to use physical activity to alter their weight, size or muscle tone. There were clear differences in the body-change strategies of Fijians & Indo-Fijians. More Indo-Fijians were actively trying to increase their weight/size than were indigenous Fijians. No Indo-Fijian males indicated that they were trying to lose weight. There were also gender differences in body change strategies; more females were trying to lose weight than were males. More males were doing weight training to increase their muscles than were females.

Messengers

More mothers provided home messages about food than did fathers. However, friends influenced at-school choices, in terms of shared

There was a wider group of messengers for physical activity than for food and eating. Fathers and older siblings/cousins influenced boys and girls, by teasing, role

Many female participants were influenced by family members. Friends and the media

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Issues Food and eating Physical activity Body Image buying and consumption. While schools provided messages about food and healthy eating via nutrition curricula, the food and drink reported to be available at school canteens did not necessarily reflect those healthy eating messages. Participants believed & described how they had more control of their food & eating outside the home. This increased control translated into the purchase of junk food. Religious beliefs & practices determined food choices, eating patterns at home & at school, esp. for Hindu & Muslim participants.

modeling and creating opportunities for physical activity. Peers also influenced physical activity both positively (encouragement and being available to play) and negatively (criticism about lack of skills). Rugby stars had a major influence on the physical activities of indigenous Fijian boys.

also influenced ideas about actual and preferred body weight, size, shape and muscularity/tone. The media influenced ideals about body weight, size, shape and tone. Indigenous Fijians were influenced by the bodies of sports stars more than Indo-Fijians , especially Fijian boys. However, this influence was more often explained in terms of sporting prowess rather than good looks.

4.3.3 – For more detailed account of the findings on food and eating, physical activity and body image – please refer to the detailed report in Annex 2 4.3.4 Cultural differences & gender differences in food and eating - The summary of the findings is shown in Table 44.

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Table 44: Summary of interview results for gender & cultural differences in food & eating

Issue Cultural Difference Gender Difference Types & quantities of food eaten

All Indo-Fijians ate vegetables at least twice a day. Fijians ate root crop daily

Peers appeared to be more likely to influence female participants than the males

Breakfast Indo-Fijians had roti and one or more curries with cocoa, Milo and milk. Fijians had either bread or pancakes with tea & one to three teaspoons of sugar,

More than 66% of Indo-Fijian females did not have breakfast regularly

Servings Indo-Fijians have smaller servings than Fijians

Sources of food for lunch

More indigenous Fijians than Indo-Fijians reported buying food from school canteens, especially at recess. Indo-Fij perceive that canteen food was not as good as food prepared from home. Indo-Fij mainly drank water

More females reported buying food at school canteens at recess than did males

Evening meal Indo-Fijians have dinner immediately with dessert after arriving home. Fijians ate snacks & leftover bread & tea before main evening meal later.

Meal regularity Indo-Fijians have less regular meals with fasting 1-2 days /week & many females skip breakfast. Fijians have regular meals

Males had breakfast regularly while 60% of female participants skipped breakfast than did males.

Food selection Depend on economy More female than male participants indicated that adult females in their families influenced their eating patterns esp. mothers, grandmothers & aunts.

4.3.5 Physical Activity

Little is known about adolescents’ patterns of physical activity, their reasons for being physically active and the socio-cultural factors that either support or limit these physical activities. In order to gain the perspectives of Fijian youth, participants were asked about their current patterns of physical activity, as well as about the physical activity patterns of their male and female peers. Participants were also asked why they felt that physical activity was important and what factors promoted or limited their own activities as well as those of their peers.

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4.3.6 Cultural & gender differences in physical activity – Summarized in Table 45 Table 45: Summary of findings in the cultural & gender differences in physical activity

Issue Cultural Difference Gender Difference Constraint to Physical activity

Fijians cited chores as a constraint to physical activity compared to Indo-Fijians. More than twice as many Indo-Fijians as indigenous Fijians indicated that the need to study was a major constraint to being physically active. More Indo-Fijians cited poor diet as a constraint on being physically active.

Missing breakfast in Indo-Fijian females is a constraint to be physically active.

Indo-Fijian females said that dress was a limiting factor for taking part in physical activities than indigenous Fijian females. Females indicated that they had more opportunities for physical activity at school than was the case at home

Appearance Fijians appeared to be much more physically active than did Indo-Fijians ,

Positive influence to physical activity

More indigenous Fijians indicated that parents were a positive influence on their physical activities than did Indo-Fijians

Males did more recreational physical activities than did females

Parental restriction

Indo-Fijian females suggested that parental restrictions on their daughters’ physical activities may have been related to a concern for their daughters’ safety, a number of indigenous Fijian females cited personal safety as a constraint to recreational physical activities, especially in the evenings. Males have more freedom to do sports

Interests Males more interested in sports Health perception

Females did less physical activity than males because females were not as interested in sport.

4.3.7 Cultural differences & gender differences in body image –summarized in Table 46

Table 46: Cultural & gender differences in body image

Issues Cultural Difference Gender Difference Weight loss More Fijians wanted to decrease

weight. More Fijians worked on their muscle tone.

All Fiji females want weight loss. Very few females wanted to increase their muscle tone. Females thought overweight & underweight will be teased by their peers.

Participating More Fijians took up sports for their physique & their role models were rugby players. Main role models for Indo-Fijian were Bollywood stars.

The prediction of social commentary appeared to be a powerful mechanism for influencing females. Media stars were role models for female participants than males.

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Other findings include:

• 82% females and 89% males consume lunch prepared from home

• 50% females and 51% males ate fruit at least 2 -3 servings per day.

• 61% males ate 2-3 serves of vegetables than females (52%)

• 15% Indigenous Fijians have more take away food for lunch than Indo-Fijians and other ethnic groups

• 30% of students consume soft drinks in schools and higher amongst males than females.

• 25% of students bought after school snacks from shops everyday

• 80% of students spend between $1-$4 on food on the previous school day.

4.4 CONCLUSIONS

The participants in this socio-cultural component of the Healthy Youth, Health Community project provided invaluable insights into their patterns of eating and physical activity and their preferences regarding food, physical activities and body size and shape. It was clear that participants had a good understanding of healthy food choices, although their understanding of the importance of regular meals was not as clear cut. Sound knowledge did not necessarily translate into good eating patterns. Participants often received conflicting messages about healthy eating. This was highlighted in the frequent opportunities that participants had to consume junk food and soft drinks. These opportunities were facilitated by school canteens, and to a lesser extent, by families. While the majority of participants took part in physical education at school, fewer participants engaged in regular physical activities outside school. Females indicated that opportunities for recreational physical activity were even more limited at home than they were at school. While many participants wanted to lose weight, a few wanted to gain weight and in the case of males, muscle bulk. A number of these respondents were making active efforts to change their weight by eating a balanced diet and/or exercising. The heterogeneity of adolescents living in peri-urban Suva was highlighted by contrasting patterns and concerns for indigenous Fijians and Indo-Fijians, and males versus females. In summary:

• Indo-Fijians had a diet that was high in vegetables, while indigenous Fijians had more complex carbohydrates.

• Indo-Fijians were more likely to prioritize study over recreational physical activities when compared to indigenous Fijians.

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• Many of the differences found in this study cut across cultural group and gender. For example, Indo-Fijian females appeared to be less interested in being physically active than either indigenous Fijians or Indo-Fijian males. Indo-Fijian females also appeared to have fewer opportunities than indigenous Fijian girls to engage in recreational physical activity. Indo-Fijian males wanted to increase weight and/or muscle, while indigenous Fijian females wanted to lose weight.

• The complex cultural and gender differences found in this study underscore the heterogeneity of this peri-urban population in Suva, even within a relatively small age range.

• It is also important that these findings be considered within the specific context of the demographics of peri-urban Suva and not be generalized to other groups within Fiji.

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5.0 Policy Component

5.1 INTRODUCTION

There is long-standing global recognition that health promotion initiatives must include a policy component (WHO 2005), and also that policies are an essential part of strategies to improve diets and tackle the problem of obesity and chronic disease. Policy can be used to create a supportive environment and also to reinforce healthy behaviors, radically change food supply and ultimately diets (Lang & Rayner 2007). Throughout the Pacific Islands, efforts are ongoing to improve both diet and lifestyles, these tend to focus on education, rather than policy, despite recognition that both approaches are needed (Hughes & Lawrence 2005), and that the lack of policy interventions are a key problem (Hughes 2002).

Policies relating to investment, agriculture, trade, urban design, transport, legislation, regulation and money (fiscal policy) all impact on the food environment, and therefore any efforts to tackle obesity, diabetes and other NCDs must include a focus on all of these. Policies may have been developed for other reasons, eg raising revenue, meeting trade agreements, encouraging commercial and economic development – without consideration of their effects on diets and health. There may also be policy gaps where policy controls of areas are not in place. Changing the food environment will require more than one policy change to occur. Diets are complex, and are affected by many factors such as access, availability, cost, preference, attitudes, knowledge and values. In order to create a healthier food environment, actions will be needed to affect all of these factors: lowering the price of healthier options, increasing the access and availability of healthier options and improving understanding of and attitudes to healthy eating. Therefore, a number of policy changes will be needed, and must be supported by community-based and nutrition education initiatives. Educational initiatives will never be enough by themselves, unless implemented alongside environmental changes. This project was intended to identify the priority policy changes needed to prevent and control obesity & NCDs.

This project had two main components:

1. To identify the most effective, sustainable and feasible policy interventions to prevent and control obesity & NCDs for Fiji. By the end of the research a comprehensive list of possible policy interventions was developed (including those in Fiji’s NCD strategic plan) along with projected health & economic impacts, from which it can draw & select future interventions. This part of the research was also to build the capacity of those involved in Fiji, to enable them to undertake similar work in the future.

2. To contribute to local, regional and international understanding of the relationship between macroeconomic policy and population nutrition, as well at the process of developing and implementing cross-sectoral interventions. It focussed on macroeconomic policy, examining historical trends in trade policy and nutrition, and

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also evaluating previously implemented trade and fiscal policies with the potential to improve population nutrition.

5.2 METHODOLOGY

5.2.1 The method for the identification of possible policy interventions was approached using a participatory method. A multi-sectoral stakeholder group met over a year in a series of five, one to two day workshop-style sessions. The group included policy makers, policy advisers and technical staff from Government departments and Ministries (Finance, Commerce, Trade, Education, Health, Agriculture, Fisheries, Prices and Income Board, Council), the private sector (Nestle) and other non-Government groups (Consumers Council). Contact between the research team and the stakeholder group members was maintained throughout the process via email, letters, documents and phone calls.

The process was supported by information sourced from relevant departments and agencies; Department of Statistics, published literature, reports and the internet. The results and conclusions represented consensus decisions by the group members. Comments and information included have not been attributed to any individual, but instead ‘belonged’ to the group as a whole.

• The first step involved using problem trees to identify problem areas within policy that could be contributing to an unhealthy food environment. Further information was sought on these issues, to assess more carefully how much of a problem they were.

• The second step identified potential solutions. Each solution was then carefully assessed in step three. This include; scoring of probable effectiveness on NCD problem, scoring of feasibility of policy change (including political and community acceptability, technical and cost feasibility and trade-related feasibility), impact assessment (consideration of side-effects of policy change), modeling (by research team) of the expected impact of policy changes on NCD rates (only undertaken on short-list of solutions, for practical reasons).

• In the final step, stakeholders reviewed all the information and categorized into either: policies for action (most promising), possible policies (show some promise) and policies not recommended for action (little promise).

• The final short-list of policies recommended for implementation, were expected to be effective, cost-effective, targeted, beneficial overall and feasible.

5.2.3 The historical part of the project investigated the interaction between trade policy and population nutrition to improve understanding of the economic and social/political context in which food supply changes are occurring. Processes used included: literature review, data collection, policy analysis methods (to evaluate existing policies, investigating the origin/drivers, implementation & impact of the policies through semi-structured interviews, policy documentation and related reports).

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The research in Fiji examined the genesis, development, implementation & perceived impact of two soft drink taxes & the lamb flap ban. The other countries involved in this comparative research project were Samoa, Tonga, Nauru & French Polynesia.

Interviews: Co-researchers in each country identified initial interviewees in government, the non-government sector and industry, and additional participants were recruited based on policy documents and using snowball sampling. Interviews were semi-structured and tailored to the interviewees' area of expertise. They were kept to less than one hour, were recorded (except for a few where permission was withheld), and summarised in detail and summaries were sent to the interviewees to check. Interviewees were asked for any available policy documentation, archival records and data relating to the policies. Themes were identified using iterative analysis throughout the process of data collection, interview data were triangulated using documented information, and any discrepancies were investigated through additional interviews and locating further policy documentation.

Detailed chronological case studies were then constructed, describing the policy process and impact using interview data, policy documents, media reports and available data regarding policy impact. These detailed case studies were sent to the country co-researchers for verification or correction. The impact of the two trade-related policies on consumers was also assessed. These data had already been collected in Fiji by Gewertz and Errington (2009).

5.3 RESEARCH OUTCOMES FROM POLICY PRIORITISATION COMPONENT

5.3.1 Policy problems and gaps

The process identified that policies across many sectors which could be contributing to an unhealthy food environment. These included policies (and policy gaps) which affected: the pricing of healthier and less healthy foods, advertising and information controls, production levels of local foods and their export, access to healthier foods in different settings and the quality of foods available locally.

The existing policies which were identified as problems included those related to taxation, price control, production levels, agricultural and fisheries support. Overall, existing policies (and policy gaps) were creating a situation where less healthy foods and drinks were widely available, cheaper and more accessible than healthier options.

An example of a completed problem tree is shown in Figure 33.

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Figure 33: Problem tree for low vegetable intake Blue indicates policy problem area

Not eating enough vegetables

Cost

Short supply Preference

Poor knowledge

Alternative foods cheaper

Too lazy to buy, cook

Lack knowledge quick cooking

Too lazy to plant/grow

ImportsLocal supply

Exports high

AMA support

Shortage technical help

Policies/fund shortage

No school food policy or gardens

Climate

Shortage seeds etc

No govt support

Disinterest in farming

Difficulty for getting loans

Transport problems

No govt support

Difficult job

No price control

Tariffs mainly 3%

Transport costs from farms

Storage difficult

No govt support

Charge for market stalls

Land availability

FDB policy

5.3.2 Potential solutions to policy problems After considering which policies were more significant problems, the group identified potential actions (policy solutions) which would alter the current food environment to make it more supportive of healthy eating. These policy solutions were changed to existing policies or new policies where gaps existed. Over 100 potential policy solutions were identified in total. These covered a diverse range of sectors including finance, trade, commerce, agriculture, fisheries, health, planning and media.

Examples are: - changing import and excise duties and VAT exemptions - modifying price control list - provision of subsidies and support to farmers and fishermen, including marketing

support, cool storage - implementing quality controls on products to restrict fat content and type - ban or limiting the import of certain items - restricting marketing, sponsorship and advertising promotions - labeling of foods - controlling retail and vending opportunities - improving school food environments

An example of a completed solution tree is shown in Figure 34

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Figure 34: Solution tree for low vegetable intake (blue indicate potential solutions to the red policy problems)

Not eating enough vegetables

Cost

Short supply Preference

Poor knowledge

Alternative foods cheaper

Too lazy to buy, cook

Lack knowledge quick cooking

Too lazy to plant/grow

ImportsLocal supply

Exports high

AMA support

Shortage technical help

Policies/fund shortage

No school food policy or gardens

Climate

Shortage seeds etc

No govt support

Disinterest in farming

Difficulty for getting loans

Transport problems

No govt support

Difficult job

No price control

Import duty mainly 3%

Transport costs from farms

Storage difficult

No govt support

Charge for market stalls

Land availability

FDB policy

More support

School food policy

School garden policy

Provide free/subsidy seeds

Duty 0%

Loans to get transport

Subsidy transport

Storage facilityPrice control

Bigger markets

5.3.3 Prioritising policy solutions

Implementing all these policy changes would not be possible, and would not be appropriate. Further consideration was needed of which policy changes would have most health benefits, have least negative impacts, be most cost-effective, be technically feasible and be acceptable to the community, political leaders and others. By considering each of these aspects, the group was able to develop a short-list of recommended actions. This process was complemented by some cost-benefit modelling that was undertaken on some of the policies (to predict benefits in terms of deaths averted from NCDs, and the costs of implementation).

Policies were rejected from the short-list if they:

• were unlikely to affect NCD risk,

• costly compared to potential benefits (cost: benefit ratio),

• technically too difficult,

• likely to be rejected by the community and/or political leaders,

• have negative side-effects (such as affecting local businesses or the environment) or

• Were not in line with current national strategies (including membership of the World Trade Organisation).

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The policies were sub-divided into three categories:

o Prioritised for action: Should be implemented as soon as possible o Not prioritised for action: but could be considered for action at a later date, with

more assessment o Not recommended for action: should not be used

The short-list of 22 prioritised policy actions were considered likely to be: effective, cost- effective, feasible and acceptable. Some policy actions would ideally be implemented together for maximum benefit and efficiency.

5.3.4 Recommendations for policy changes in Fiji

The policies summarised below have been recommended by the stakeholder group for implementation. The recommended policy options are expected to be:

o Effective: They are likely to result in a change in the diets of the Fijian population, and to reduce the risk of a range of non communicable diseases. They are cost-effective. Effectiveness will be optimised if the policy is maintained and is full implemented and enforced.

o Feasible: They are likely to be acceptable to a range of stakeholders including the community and various government sectors. They are also practical in regards to local technical capacity and costs.

o Targeted: They will have minimal negative side-effects on areas other than diet. The stakeholder group discussed ways forward to ensure that the policy changes are implemented as soon as possible. They agreed that multi-sectoral collaboration would be essential to the process. This could be mediated via members of the group, and via relevant multi-sectoral groups such as the Healthy food choices subcommittee and the NCD healthy eating subcommittee of the Fiji National NCD Committee.

It is recommended that these policy changes be implemented as soon as possible, and maintained. This will ensure maximum benefits to health in Fiji. They should be:

o incorporated into relevant sector and department strategic documents and action plans

o incorporated into national strategic plans such as the Fiji Plan of Action on Nutrition and the Fiji National NCD Strategic Plan 2004-8

o Communicated to the general community to ensure that they understand the purpose and expected benefits.

5.3.5 List of Policies - The list of policies recommended are listed in Table 47 below.

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Table 47: List of policies recommended

Recommended policy change Expected dietary benefits

Reduce import duty on all vegetables to 0% (except when an item is in season locally)

Lowers the price of imports, enabling more people to buy. (Unlikely to affect local sales).

Reduce import duty on all fruit to 0%.

Add VAT to less healthy oils* only Reduces the use of all oils, especially oils high in saturated fats

5% import duty to be imposed on healthy oils,15% import duty on less healthy* oils

Increase import duty dairy spreads to 15% Encourages shift to healthier margarines

Remove VAT from all bottled water (pure still water only)

Reduces cost of water, so price competitive with soft drinks.

All meats to have import duty 15% regardless of whether for local food processing (no concessionary rate for processors)

Increases the cost of high-fat processed meats compared to unprocessed meats, to facilitate change to leaner meats.

Requirement for all drink vending machines in schools to include either water, unsweetened juice or a sugar-free beverage, at a competitive price

Reduces the intake of soft drinks by children

All schools (government and non-government) to implement school food and nutrition policy (including type of foods/drinks sold, pricing, marketing)

Improves diets, knowledge and attitudes of children

Policy for all schools to have garden by 2012

All divisions to have government F&V storage facilities Reduces waste due to spoiling, so increasing local supply and intake

Cool storage facilities for fish in all divisions

Extend AMA role to include and support domestic supply

Increases availability of local foods to locals, which will increase intake.

Sponsorship sports events by any unhealthy* food or drink related company to be prohibited in events involving children

Reduces the exposure of children to advertising and misleading information regarding less healthy foods and drinks. Resulting in healthier choices and preferences.

Prohibit the use of children, cartoons and misleading images in unhealthy* food and drink related advertisements (all media)

Regulations revised to be clearer and more enforceable regarding misleading advertising claims (including use of words healthy and healthier)

Prohibit advertising unhealthy* food & drinks in

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Recommended policy change Expected dietary benefits

schools, hospitals & other public areas

Prohibit advertising of high fat/sugar/salt food and drinks to children (children’s programmes, those of interest to children) (definition of less healthy foods as UK)

Enforcement of licensing for roadside vendors Reduce the number of vendors selling unhealthy snacks on roadsides, so reducing intake.

Regulation that processed meats sold contain no more than 20 % fat

Reduce the fat content of meats sold locally to be more consistent with other countries. Reduction fat intake.

Sales ban on sale poultry > 15% fat, beef >25% fat, pork > 35% fat, lamb>20% fat

Remove duty and VAT on pre-mix fuel for fishermen

Reduces costs for small-scale fishermen, enabling increased fishing, and increased availability of fish to locals.

* Definition based on a nutrient profiling system.

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5.4 OUTCOMES FROM POLICY ANALYSIS COMPONENT OF RESEARCH

5.4.1 Trade and diet in the Pacific: There have been six key mechanisms through which trade has affected dietary patterns in the Pacific during the past century. These six mechanisms overlap, often reinforce each other, and all relate to specific trade-related policy directions. The first three were initiated in late nineteenth century – the Pacific region’s earlier (for some countries colonial) phase of integration into the global economy, and have had significant and continuing effects on diet. The last three emerged during the post-WWII period. The first factor was the shift from primarily subsistence agriculture to a cash-based economy in response to market development and involvement in international trade. This contributed to reductions in subsistence agriculture and increases in purchased food. Second, the creation of administrative centres required to stimulate trade and commerce in the Pacific Islands catalysed urbanisation, which also reduced capacity for subsistence agriculture. Third, there was significant development of agricultural and fishery commodity production and export, reinforcing the shift away from subsistence agriculture and furthering the use of purchased (often processed) foods. In the post-WWII period, these trade-related shifts in diet continued, and new implications of trade policy for diets emerged. Food imports increased dramatically, facilitating marked dietary change through increasing access to non-traditional foods. Financial integration and investment-related policy liberalisation supported growth in ‘Western-style’ food service, food retail and food processing. This increased the availability and convenience of ‘non-traditional’ foods. Finally, the 1960s rise in development aid, particularly that in the form of food, has contributed to dietary change through reducing the need for investment in local agriculture post-disaster.

A more detailed analysis of the recent period of trade liberalization in Fiji and Samoa suggests that these ongoing policy changes have contributed to the availability of transitional foods in four main ways. Policies of export promotion have reduced land and resources available for production of root crops for domestic consumption. Reductions in import tariffs have reduced the cost of importing transitional foods such as vegetable oil, meat and cereals, likely changing the relative price of foods and energy according to source. Encouragement of domestic meat production through protection has increased availability of locally produced meat, and subsequent liberalization of meat imports has opened these countries to cheap, fatty meat imports – particularly of chicken from the USA and sheep meat from Australia and New Zealand. In addition, investment by multinational food companies has increased availability and consumption of transitional foods. These pathways have intersected at many points with socio-demographic changes including urbanization, the growth of the cash economy, and changing work and leisure patterns. This has meant that such dietary transformations once initiated tend to become embedded through changes in food preferences and lifestyle.

5.4.2 Getting policies on the political agenda

Critical factors in the agenda setting process included advocacy, contextualisation of the issue, and ownership by stakeholders. Advocacy by Ministry of Health staff can help to raise awareness by politicians and staff in other (stakeholder) ministries about the importance of nutrition and possible policy options. Contextualisation can be achieved by identifying current policy debates that relate to food and health, and using these as forums for raising

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the need to improve the food supply (for example, the linking of health concerns regarding fatty meat consumption to concerns over dumping of fatty meats). Ownership can be improved by discussing the benefits to all stakeholders, and by developing a clear justification for the food targeted. Highlighting the benefit of the policy to the administering agency can improve its acceptability.

5.4.3 Policy Implementation and administration

Much of the burden of implementation and administration of economic policies for improving population nutrition falls outside of the Ministry of Health. The findings from the comparative policy analysis suggest that health promotion practitioners can improve the implementation of policies by reducing administrative costs, namely through proposing the use of existing legislative mechanisms. The use of existing legislation also facilitated the implementation of most of the policies in these case studies.

Active ownership by more than one stakeholder also appears to have been critical for policy implementation. It is therefore important for the Ministry of Health to engage the implementing agency and other stakeholders at an early stage. The development of policy documents by the implementing agencies (trade or finance) can result in the selection of a more acceptable and administratively feasible mechanism, which supports policy implementation.

5.4.4 Policy outcomes

The trade and tax policies examined in these studies clearly reduced the supply of the targeted food (trade) and raised significant amounts of revenue (tax). It is also likely that consumers responded to the tax by reducing consumption to some extent. The policies were also effective in raising consumer awareness of soft drinks and fatty meats as contributors to poor health. The use of the lamb flap sales ban in Fiji as a springboard for further public education through the media campaign was particularly effective, and served to raise awareness of specific links between high fatty meat consumption and cardiovascular disease.

However, it is difficult to tell whether these policy initiatives improved the healthfulness of the food supply overall, due to the complexity of the food supply and the lack of time-series dietary data. This highlights the usefulness of the modelling approach undertaken in this study.

5.4.5 International trade law

Under ongoing World Trade Organization, regional and bilateral negotiations, trade restrictions and tariffs (taxes on imports) are being progressively reduced as they form a barrier to trade and discriminate between imported and domestically produced products. Under the principle of ‘national treatment’, countries should not treat imports any less favourably than the same or similar domestically-produced goods once they have passed customs (WTO 2007). Trade restrictions and taxes that affect only imported foods do not comply with this principle. A ban or tax that applies to both domestically produced and imported foods is technically permissible because it is non-discriminatory, however, the WTO requires evidence that it is the ‘least trade restricting measure’ that fulfils the

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objective. It is therefore important that trade restrictions or high taxes on certain foods be clearly justified in order to be acceptable to trade policy makers.

Alternative mechanisms to restrict trade include a mechanism based on percentage of fat in meat imports, or action taken under WTO regulation that allows for imposition of ‘anti-dumping duties’ to bring the price of dumped goods up to an appropriate market value.

5.5 FUTURE ACTIONS

The recommended policy changes have the potential to have considerable impacts on diets and the problems of NCDs in Fiji, through improving the food environment. Without these policy changes, however, Fijians will continue to struggle to meet healthy eating recommendations. Efforts are now needed to turn these recommendations into reality. This will require the support of a wide array of government and non-government departments and agencies. Preventing NCDs must be a priority across all sectors.

Analysis of the policy process behind cross-sectoral policy interventions to improve diets can inform strategies to improve uptake and implementation of future policies. Policy implementation depends on more than just evidence for effectiveness. It is also dependent upon getting the policy intervention on the agenda of the relevant government agency, development of appropriate policy documents or legislation, and provision of adequate resources for implementation.

5.6 LIMITATIONS OF THE STUDY

• The use of only one stakeholder group for component one of the research may have influenced findings, and it is possible that repeating the process would result in slightly different results.

• The policy stakeholders who elected to participate in the study may also have been biased due to self-selection; in particular, there was limited participation by private sector stakeholders.

• The unavailability of data on population food and beverage consumption meant that the impact of the policies on population health was only able to be determined using modeling. The research was also relying on limited data, some of which was quite outdated, for a number of its components.

5.7 CONCLUSION

This unique study has developed a clear picture of how policy has been and can be used in the control of NCDs in Fiji. The in-depth analysis of the factors involved in policy-making across different sectors, combined with the clear identification of specific preferred policy

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changes offers health promoters in Fiji valuable information which they can use to improve the health of Fijians.

It is clear from this research that there is a need for policy across sectors to support a healthy food supply. In particular, trade and finance were highlighted as sectors that have a significant impact on diet in the Pacific, and therefore have great potential to be used as health promotion tools

Further information regarding this component of OPIC are available in a separate policy report for OPIC, and in related journal articles. Please contact C-POND for more information.

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6.0 Economic Component

6.1 Objectives of the economic studies

OPIC included an economic studies component, the objectives of which were: • To measure the net resource costs of the interventions in order to assess their cost-

effectiveness; • To measure the impact of overweight and obesity on the quality of life of adolescents; • To assess the disease and cost burden of overweight and obesity in Fiji. 6.2 Measurement of the intervention costs The aim of this section was to determine the net cost of the intervention. Economic evaluation entails an assessment of costs measured against those in the comparator area. So the net costs of the intervention equal the costs in the intervention area minus those in the comparator area. In economic evaluation, it is quite to employ a health sector perspective when measuring costs. However, in this instance, most of the intervention activities took place in sectors other than health (primarily education). As a consequence, a societal perspective was adopted to the measurement of costs, which means that all costs were measured irrespective of who incurred them. The evaluation was also concerned to measure the full economic costs of the intervention, rather than just the financial outlays incurred. This meant that the costs of all goods and services incurred in the delivery of the intervention activities were measured, even if the goods were not traded in the market. For donated items such as parent and volunteer time or donated goods, a market value was imputed based on current prices. A data collection pro-forma covering data about the nature of the intervention activities (a description of the activity), process (how the activity was conducted), dose (scale/duration of the activity), reach (how many and type of people involved in the activity), frequency (how often the activity was conducted) and associated resource use (for use in the subsequent economic evaluation) was developed, and completed by intervention staff for all activities related to intervention planning delivery. The process evaluation data was supplemented by information drawn from the HYHC intervention reports, meeting minutes, correspondence and communication with the research team staff and other personnel involved in intervention delivery. The data was entered into an Excel database, and more than 600 entries were recorded throughout the 2 year duration of intervention activities. This information is summarised in Tables 56, 57, 58 and 59 .

Costs in the comparator area relate to the cost of ‘current practice’ which was defined as any obesity-prevention activities undertaken in the schools over and above those conducted in all schools in Fiji. Details on activities undertaken and associated resources were compiled from interviews conducted in each of the comparator schools in 2007 and 2008. Generally one person from each school was interviewed, including school principal or vice principal (4), home economics teacher (5), physical education teacher (2), science teacher (1).

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Work to value the identified resources used in the delivery of the interventions or current practice is still proceeding. 6.3 Quality of life analysis The economic studies included the administration of two health-related quality of life (QoL) measures in order to (i) describe the burden of overweight and obesity on the quality of life of Fijian adolescents and (ii) as an outcome measure in a cost-utility analysis (CUA) of the interventions. Whilst the strong association between obesity and mortality and morbidity has been well documented, much less is known about the impact of obesity on quality of life. The impact is both substantial and multi-faceted covering both physical health and social and psychological dimensions. At the broadest level, quality of life refers not only to health status, but also to environmental and economic factors such as income and educational attainment that can have a key influence on well-being.

One of the limitations of cost-effectiveness analysis (CEA), when health effects are measured as survival gains, is that this measure does not take into account the quality of life associated with such survival. Health economists have developed a measure, termed the quality-adjusted life year (QALY) which captures both improvements in the length of life and changes in the quality of those years. CUA is the form of economic analysis which expresses outcomes as incremental costs per QALY gained. QALYs are estimated by assigning every life-year a weight (or utility) between 0 and 1. A weight of 0 reflects a health status that is valued as equivalent to death, with 1 equaling perfect health (Drummond et al. 1997). By converting the effectiveness data to a common measure, the QALY, CUA facilitates comparison of interventions both within and across disease areas.

6.3.1 Measuring quality of life for economic evaluation

A review of the published literature suggests significant cultural variations in health state preferences. Adolescents are also likely to value their health differently to adults, given their social values, support structures, lifestyles and experience. It was therefore important to use adolescent rather than adult values and, more specifically, country-specific adolescent values in the OPIC study. Therefore utility weights needed to be assessed and validated for each site in the OPIC study. They will assess the burden of childhood obesity (in terms of diseases and costs), and its impact on the quality of life of adolescents. These economic studies are dependent on the use of an accepted, validated measure of quality of life. Outcomes will be measured in a common metric of quality-adjusted life-years. This entails individuals attaching a value to the ‘utility’ of any additional years of life gained as a result of an intervention. (QALYs = number of years of life saved multiplied by the ‘utility’ value assigned to their particular health state.)

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6.3.2 Selection of quality of life tools

The starting point for this work was an existing quality of life assessment tool, The AQoL-6D or Assessment of Quality of Life tool (Richardson et al 2004). This is what is termed a ‘utility-based’ instrument suitable for use in an economic evaluation. This means it consists of a generic descriptive questionnaire; plus a scaling system which assigns utility or preference scores to every combination of health states. This provides each respondent with a health state score ranging from 0 (death) to 1 (perfect health). The AQoL-6D consists of 20 items grouped into 6 dimensions (independent living, relationships, mental health, coping, pain and senses), each of which is separately modelled and then combined to obtain a single AQoL-6D utility score. The AQoL was pilot tested for cultural equivalence during two focus groups in Fiji.All secondary students at both the intervention and comparator schools and participating in the OPIC project completed the AQoL at both baseline and follow-up. The questionnaire was self-administered and completed by students in a classroom setting. In order to enhance the credibility of the QoL measurement in the OPIC study, a decision was made to use the AQoL in conjunction with a second instrument, the PedsQL (Varni et al. 1999; 2001; 2002a). The PedsQL is a pediatric general health profile instrument, specifically designed for use with adolescents and children. In the OPIC study, we will be using the generic module for 13-18 year olds. It has been adapted for specific conditions (cancer, asthma, diabetes etc; Varni et al. 2002b; 2003; 2004; Uzark et al. 2003, Laffel et al. 2003), but not as yet for obesity. The questions, however, fit quite neatly with obesity, and we will be using it as a proxy condition specific instrument.

6.3.3 Adapting the tools for Fiji

As the AQoL was originally calibrated with the utility weights or preferences of Australian adults, it was necessary to recalibrate it for adolescents in each of the four countries. This was done using the time trade-off methodology as was employed in the determination of the original adult weights (Moodie et al 2009). AQoL utility scores and dimension scores were calculated for each participant based on the recalibrated algorithm. The recalibration was based upon country-specific time trade-off (TTO) data for 30 multi-attribute health states constructed from the AQoL-6D descriptive system. Senior secondary students, in a classroom setting, responded to 10 health state scenarios each.

A total of 70 individuals from the 6 different schools each completed 10 scenarios, making for a total of 700 scenarios completed in Fiji. The scenarios were divided into three different batches (or sorts). The table 47 below shows the school names, the sort number which each school completed, number of students consented, number participated and the ethnicity distribution.

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Table 47: School participation for time trade-off

School Name Sort number

Number Consented

Number Participated

Ethnicity/Gender

Fijians

Ethnicity/Gender

Indians

Female Male Female Male

Rishikul S College 2 12 11 3 - 5 3

Amadhiya M College 2 11 11 3 1 4 3

Nasinu M College 1 13 13 1 1 5 6

Nasinu Sec School 3 13 13 7 6

AOG High school 3 12 11 3 3 3 2

Nakasi High School 1 11 11 6 1 2 2

TOTAL 72 70 23 12 19 16

The completed data was used to recalibrate the utility weights in the AQoL for use with adolescents in Fiji.

Six schools from the Intervention area were approached and the process of developing new utility weights was explained.

Eleven to thirteen of the senior (form 6) level students were selected by the focal points from each school, in order to take part in the task. Only senior students were selected given the cognitive complexity of the task.

For the results to be reliable, the team considered ethnic distribution and gender equity.

This instrument is now available for use in other economic evaluations conducted with the adolescent group in Fiji.

6.3.4 Results

5,872 adolescents in Fiji completed the AQOL

Across the four OPIC countries, the average AQoL of the total sample was 0.74, ranging from Australia 0.85 to Tonga 0.59. In Fiji, there was a large variation in mean AQoL scores by ethnic group, with the Indigenous Fijians scoring 0.69, and Indo-Fijians 0.78. In general, quality of life was shown to decrease in line with increasing weight status. In other words, overweight or obese adolescents had poorer quality of life than their healthy weight peers. The Indo-Fijians curiously experienced a bigger loss in quality of life amongst the overweight (3%) than the obese group (1%). In contrast, the relationship did not hold for the Indigenous Fijians, who enjoyed higher quality of life as their BMI increased. Both overweight and obese Ethnic Fijian adolescents, experienced 2% higher quality of life scores than their healthy weight peers.

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6.3.5 Conclusion

The economic studies have centered on the adaption of quality of life instruments for use in Fiji and with adolescents, and their use in measurement the relationship between quality of life and adolescent overweight and obesity.

Overall, girls were more sensitive to the effects of overweight and obesity on their quality of life than boys. Amongst overweight adolescents, girls experienced a bigger loss than boys in all ethnic groups. Losses ranged from 1% for overweight Indigenous Fijian girls to over 5% for Indo-Fijians. Likewise Indigenous Fijians experienced quality of life gains except for the overweight girls.

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7.0 Conclusions and Recommendations

The OPIC project was a multi-faceted and complex research project, encompassing multiple activities and areas of research. The project involved both dedicated staff, and the involvement of multiple stakeholders, partners and students. Without the commitment of all those involved, this project would not have been possible. This report has summarised the activities of OPIC in Fiji, over its six years. More detailed reports, journal publications and other materials are available for those who would like further information.

The design and implementation of OPIC in Fiji had limitations, as highlighted in this report, across all the components. In particular, a number of aspects of the HYHC interventions were less than ideal. Many lessons can be learnt from the process of implementing such a complex research project in Fiji, and the research staff involved will ensure that these are considered in future projects.

Fiji now has extensive data on the diets, physical activity and weights of a large sample of adolescents. This data highlights the considerable problems in this group with regard to overweight, underweight, poor diets and low physical activity. There are multiple factors affecting diet and physical activity levels in adolescents, such as the school, home and community environment, sociocultural values and national policies. Improving the health of adolescents is therefore unlikely to be a simple process. The extensive and systematic actions that took place within the HYHC aspect of OPIC in Fiji delivered few impacts on the intervention group. This is a highly significant finding. It demonstrates that multiple actions are likely required over sustained time periods to effect change. It also demonstrates the importance of this type of research, and of programme evaluation. It is essential that efforts to improve health are targeted and effective. More research is planned related to obesity prevention, including on policy change and sociocultural impacts on behaviour change.

Some specific recommendations that are clear from the project are

1. Creation of supportive environment: It is clear that multiple influences impact on adolescent behaviour. Efforts are needed to ensure that these are supportive of a healthy lifestyle. Supportive environments are needed in homes, schools and religious organisations. Additionally higher-level policy change is required to ensure that healthy diets are affordable and accessible; the food policy recommendations made by OPIC are an important aspect of this. Other approaches to increase physical activity are also needed.

2. Multiple, sustained interventions and activities: Unhealthy habits take time to develop, and similarly developing healthier habits will take time, for all sections of the population. Interventions therefore need to be sustained, rather than implemented over short-time periods. Additionally multiple interventions are

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needed across settings to ensure that the same messages are received from all sources. Faith-based, community and school settings are particularly important areas for interventions.

3. Schools need to adopt a comprehensive health-promoting approach: While the contents of the curriculum are important in promoting healthy lifestyles, other actions are needed in the school settings. This should include the health promoting schools approach, student councils, peer support and role modeling. Curriculum may need strengthening in terms of NCDs and healthy lifestyle.

4. Clear guidance on healthy eating, physical activity and body weight: The mix of underweight and overweight present among adolescents is of concern, and highlights the need for balanced approaches to healthy body weight. Guidelines for schools and communities with regards to healthy body weight are needed.

5. Changing attitudes and norms: Attitudes, values and norms around physical activity in girls, body size in girls and aspects of diet, are contributing to the growing health problems seen in adolescents. Change in these areas is critical, and more sociocultural consideration is needed of how to address these without undermining important traditional values.

6. More research, monitoring and evaluation: It is clear that we do not have the solutions to the problems of overweight and NCDs in adolescents, or the wider population. Countries around the world continue to struggle with these problems. Effective solutions are likely context-specific, and therefore it is critical that we continue to work to assess ‘what works’ and ‘what doesn’t work’, and how to improve the effectiveness of interventions. This requires research, along with strong evaluation of activities. Additionally monitoring of obesity levels is needed, to assess trends and factors involved.

Recommendations made in this report should be seriously considered by the Ministry of Education, Ministry of Health, Ministry of National Planning and other government agencies.

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References Coyne T. (2000)Lifestyle Diseases in Pacific Communities. Noumea: Secretariat of the Pacific Community; 2000. Gewertz D, Errington F. (2007)The Alimentary Forms of the Global Life. American Anthropologist;109(3):496-508. Hughes R. (2003) Diet, food supply and obesity in the Pacific. Manila: World Health Organization Regional Office for the Western Pacific;. Hughes R, Lawrence M. Globalisation, food and health in Pacific Island countries. (2005) Asia Pacific Journal of Clinical Nutrition;14(4):298-304. Kremer K, Vanualailai N, Roberts G, Schultz J, Waqa G, Moodie M, Malakellis M, Pryor J, & Swinburn B (2010). Reducing unhealthy weight gain in Fijian adolescents: results of the Healthy Youth Healthy Communities project. Submitted for review. Lang T, Rayner G. (2007) Overcoming policy cacophony on obesity: an ecological public health framework for policymakers. Obesity Reviews;8(Suppl. 1):165-81. McCabe M , Ricciardelli L, Waqa G, Goundar R, Fotu K (2009) Body image and body change strategies among adolescent males and females from Fiji, Tonga and Australia. Body Image, 6: 299-303 McCabe M, Ricciardelli L, Waqa G, Mavoa H, Rowland M, Chila A. (2009) Report on Sociocultural Questionnaires and Perceptual Distortion Measures with Indigenous Fijian and Indo-Fijian Youth Sociocultural Studies in the Healthy Youth Healthy Community Project. Unpublished Ministry of Health (Fiji). (2002). Fiji Non-Communicable Diseases (NCD) STEPS Survey 2002. Suva, Fiji Islands: Ministry of Health Ministry of Health Annual Report (Fiji) 2006. (2006) Suva, Fiji Islands: Ministry of Health Ministry of Health Annual Report 2007. (2007) Suva, Fiji Islands: Ministry of Health Ministry of Health Annual Report 2008. (2008) Suva, Fiji Islands: Ministry of Health, Ministry of Health Annual Report 2009. (2009) Fiji Islands: Ministry of Health Ministry of Health (2004) National Non Communicable Diseases Strategic plan 2004-2008, Ministry of Health (Fiji) Moodie M, Keating C, Mavoa H, Fotu K, Waqa G Faeamani G, Swinburn G The impact of obesity on the utility-based quality of life of adolescents from different ethnic groups in the Pacific: Obesity & quality of life of adolescents. Popkin B. (2001) Nutrition in transition: the changing global nutrition challenge. Asia Pacific Journal of Clinical Nutrition;10 (Suppl.):S13-8. Richardson J, Day N, Peacock S, et al. Measurement of the quality of life for economic evaluation and the Assessment of Quality of Life (AQoL) Mark 2 instrument. The Australian Economic Review. 2004; 37(1): 62-88. Roberts G, Lingham D. (2008) Fiji Health Situational Analysis Report 2008. Fiji School of Medicine. Schultz J, Waqa G, McCabe M, Ricciardelli L, Mavoa H. (2008) Report on Interviews with Indigenous Fijian and Indo-Fijian Youth Socio-cultural Studies in the Healthy Youth Healthy Community Project. Unpublished, Schultz J; Utter J; Mathews L; Cama T; Mavoa H; Swinburn B. (2007) The Pacific OPIC Project: Action Plans and Interventions. Pacific Health Dialogue, 14;2:147-153 Summerbell CD, Waters E, Edmunds L, Kelly SAM, Brown T, Campbell KJ (2009). Interventions for preventing obesity in children. Cochrane Library, 2009 issue 1 Thow, AM & Snowdon, W (2010) Policy interventions to tackle obesity & NCDs in Fiji: Findings from local research. Unpublished UNDP (2008) Human Dev. Report 2007/08, 2. UNICEF: http://www.unicef.org/info by country

http://www.unicef.org/info�

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Utter J, Faeamani G, Malakellis M, Vanualailai N, Kremer P, Scragg R, Swinburn B. (2008) Lifestyle and Obesity in South Pacific Youth, baseline results from the Pacific Obesity Prevention In Communities, (OPIC) project in New Zealand, Fiji, Tonga And Australia, University of Auckland Varni J W (2007) PedsQLQuality of Life measurement in OPIC. Unpublished. Waqa, G. (2007) Annual report Fiji Healthy Youth Healthy Community Project, Unpublished Waqa, G. (2009) Baseline Study – Process Report for Fiji Healthy Youth Healthy Community Project, Unpublished WHO. The World Health Report 2002. (2002) Reducing risks, promoting healthy life. Geneva: World Health Organization. WHO (2003) Vanuatu Commitment 2003, SPC and WHO Pacific islands Ministers of Health meeting, 2003. Manila, WHO. WHO. (2005) Preventing chronic diseases, a vital investment. Geneva: World Health Organization. WHO (2005) Samoa Commitment 2005, SPC and WHO Pacific islands Ministers of Health meeting, 2005. Manila, WHO WHO (2007) Vanuatu Commitment 2007, SPC and WHO Pacific islands Ministers of Health meeting, 2007. Manila, WHO

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Annex 1: Background information on Fiji

Fiji - Demographic and Country overview. Fiji is a small island state at the hub of the south-west Pacific midway between Vanuatu and the Kingdom of Tonga. The 2007 Fiji population census1 was 837,271 comprising 475,739 Indigenous Fijians, 313,789 Indo-Fijians and 47,734 of other ethnic groups. Overall, the rural population was 49% and the urban 51% with urban growth rate being 1.7%2

Figure 35: Map of Fiji

. The average annual growth rate is 0.8% (the natural increase of 1.2% minus migration) with crude growth rates being higher in the Fijian than in the Indo-Fijian population. Areas with noticeably increased population over the past few years are the Western Division (55,266) and Central Division, where the population of the Suva and Nausori urban and peri-urban areas has increased by 32,300. Thirty nine percent of the population is less than 20.

Fiji’s Economic Exclusive Zone contains 332 islands covering a total land area of 18,333 sq km in 1.3 million sq km of the South Pacific. It is a multi-cultural and multi-religious country where different cultures meet and to some extent merge. Literacy rate is around 94%, with English being the official language and Fijian and Hindi the languages of daily use.

Economic Situation. Fiji’s housing and employment crises are pervasive and will be compounded over time by high rates of school drop-out. As land leases expire and food costs rise, squatter settlements now number 200 with an estimated population of 100,000 people. Sixty eight percent of the workforce earns less than $7,000 per year. Main sources of revenue are tourism, sugar, mining, agriculture and bottled water . National GDP at constant price was $3.505 billion in 2000 and had grown to $5.826 billion in 2007.

The country has a relatively good infrastructure to support its development but the overall standard of living is declining. It is rated on the UNDP Human Development Index (HDI) as being one of the 1 Fiji Islands Bureau of statistics Fiji MOH 2008 Annual Report

2 Roberts, Lingham; Fiji Health Situational Analysis report 2008

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medium developed countries, being ranked 92nd among a listing of 177 nations in 2006. However this represents a decline from position 46 in 1995. There is poverty, as reflected by the drop in ranking on the HDI, but it is not overtly apparent as seen in Africa, and some other Melanesian countries. The economy has become increasingly dependent on tourism, remittances from overseas, gold and forestry exports.

The current Interim Government has been in place since December 2006. They have identified certain conditions to be in place prior to Fiji proceeding to a general election. These include adoption of the People’s Charter, within which Pillar 10 addresses issues of the health sector and proposes to ‘increase the proportion of GDP allocated to health by 0.5% per annum for the next 10 years to achieve a level of 7% of GDP’. The achievement of this objective would result in significantly increased funding for the health sector, this will require continued advocacy for health developments in the face of competing demands; and the MoH to demonstrate that it uses its resources effectively.

Estimates of poverty in Fiji are that 29% of the rural population and 40% of the urban population are poor; and that poverty (35% of the overall population) is distributed across the nation. The poor often live in unsafe and overcrowded houses in under-served peri-urban shanty towns where exposure to pollution and other health risks are greatest. They are most likely to indulge in risky behaviors out of circumstances rather than by choice, often going hungry or eating poor quality foods, living stressful lives, indulging in personal habits such as drinking of kava and smoking tobacco to obtain comfort and to socialize. It is estimated that by 2006 the Suva/Nausori corridor will have 15,000 squatter households with a population of 90,000-100,000 people. This will place a large strain on the entire urban infrastructure, such as water supply, sewerage, electricity, roads, traffic congestion and social services.

Key health Indicators A comprehensive set of population health indicators is presented in Table 49 below. Overall the Figures show no real improvement in the health status of the people of Fiji over the past 5 years, although there have been some improvements in areas of post neonatal mortality and contraceptive coverage rates.

Table 49: Fiji’s key health indicators

2003 2004 2005 2006 2007 2008

Population (Census estimates) 866,099 848,647 849,361 868,488 868,107 879,301

Total Live Births 17,910 17,714 17,826 18,394 19,298 18,944

Crude Birth Rate/1,000 Population 20.68 20.87 20.99 21.20 22.2 21.5

Crude Death Rate/1,000 Population 7.06 6.63 7.02 7.1 9.8 7.4

Rate of Natural Increase 1.36% 1.42% 1.4% 1.4% 1.2% 1.4

Under 5 Mortality Rates/1000 live Births

23.73 22.52 25.81 25.8 22.4 23.6

Infant Mortality Rate/1000live Births 18.87 17.84 20.76 19.5 18.4 13.1

Perinatal Mortality (stillbirth and early neonatal deaths/1,000Live Births)

16.4 19.3 22.05 19.4 15.8 15.4

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Early Neonatal Deaths (0-7days)/1,000 live Births

7.54 8.13 10.43 8.0 N/A N/A

Neonatal Mortality (Deaths

0-28days) 1000 Live Births

9.27 10.05 15.37 11.3 11.9 9.0

Maternal Mortality Ratio/100,000 LBs 22.3 33.9 50.5 43.5 31.1 31.7

Source: Fiji MOH Annual Reports 2008

COMPARISON WITH PACIFIC NEIGHBORS.

Table 50 below presents comparative indicators for some pacific states and shows that the Fiji rank in the UNDP Human Development Index, trails behind Tonga and Samoa. There are many other clear differences for example Fiji exhibits double the rate of urbanization than its neighbors; its teenage pregnancy rate (15-19) is high, partly accounted for by the young age of marriage of many Indo-Fijian females.

Table 50: Selected regional comparative indicators

Indicator Fiji Samoa Solomon Is Tonga Vanuatu

Human Dev. Index Rank: 92 77 129 55 120

% population urbanised 51 23 17 24 24

Under 5 mortality rate 2006 18 28 73 24 36

Life expectancy at birth 2006 69 71 63 73 70

% of pop. using improved drinking water sources 2004

47 88 70 100 60

% of pop. using improved adequate sanitation 2004

72 100 18 96 50

Age specific fertility rate (15-19) births per 1000 women

45 23 69 42 38

Sources: 1. UNDP Human Dev. Report 2007/08, 2. UNICEF: http://www.unicef.org/infobycountry

Morbidity and Mortality. Table 51 reveals the triple burden of morbidity in Fiji stemming from injury, infectious diseases and chronic non-communicable diseases. It also shows that non-communicable diseases account for the greatest part of mortality.

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Table 51: The ten major causes of morbidity and mortality in 2007

No MORBIDITY Cause MORTALITY Cause

1 Injury 1 Diabetes mellitus

2 Influenza and pneumonia 2 Other forms of heart diseases

3 Intestinal and infectious disease 3 Ischemic heart diseases

4 Infection of skin & subcutaneous tissues 4 Hypertension

5 Ischemic heart disease 5 Septicaemia

6 Other conditions originating in peri-natal period 6 Cerebrovascular Disease

7 Chronic lower respiratory disease 7 Other conditions originating in perinatal period

8 Other forms of heart diseases 8 Chronic lower respiratory disease

9 Hypertension 9 Renal failure

10 Diabetes mellitus 10 Influenza and pneumonia

Source: Fiji MOH - hospital admission Source: Fiji MOH -Death certificate

Non- communicable diseases such as diabetes, heart disease, high blood pressure and respiratory diseases have now replaced infectious and parasitic diseases as the principal causes of mortality and morbidity in Fiji.

Key Lifestyle and other issues impacting on health of the people

Lifestyle: The socio cultural differences on health, the migration to urban areas and the transition from the consumption of local produce to imported refined food items, has resulted in an increase in obesity and non-communicable diseases in recent decades. Secular fashion and behavioral trends are powerful influences on young people while the breakdown of traditional social controls have allowed behaviours such as binge drinking, cannabis consumption, an active nightclub scene, sexual promiscuity and commercial sex, the consumption of ‘fast foods’ and the increase in street kids and homelessness all of which are readily visible phenomenon of lifestyle change. The greatest challenge is youth unemployment. Young people of productive working age are commonly seen on the urban and suburban streets of Fiji during working hours.

Water and sanitation: Many of the rural water supply systems built during the colonial period are now deteriorated to the degree that village water systems are sources of diarrheal diseases and other water borne diseases.

NCD BURDEN IN FIJI The obesity and non communicable disease problem in Fiji is a serious one. 82% of deaths are now due to heart disease, heart failure, stroke and hypertension, and these have been recognized as an important health problem3

3 Fiji Ministry of Health Report, 2007

. 10% of deaths are due to communicable diseases, maternal & prenatal and 8% due to injury & poisoning.

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Figure 36: Distribution of deaths in Fiji by cause groups, 2007

The last national NCD STEPS Survey 2002 4

The overall population of overweight (BMI 25-29.9) in the Fiji population between the ages of 15-64 years was 29% and for obesity 18%.

found that of the 6783 individuals sampled:

Generally the females had higher BMI than males (mean BMI 26.7 vs 24.2) Fijians more than Indo Fijians There is also a rapid increase in the proportion of overweight/obesity in both genders prior to the age of 30years. By measurement of waist – hip ratio (WHR) there was a significantly higher rate of high risk central obesity among females (45%) than males (4%). The prevalence of diabetes in Fiji among 25-64yrs old was 16 %, & among them the proportion of newly diagnosed cases was 53.2%.There is a much higher proportion of diabetes among the Indo Fijians (21.2%) as compared with Fijians (11.5%) There is also difference in the overall prevalence of diabetes by locality with a prevalence of 24.7% in the urban & 12.8% in the rural. The prevalence of hypertension in the population 15-64years was 19.1% and 63% of them were newly diagnosed. There is a higher proportion of hypertension among Fijians ((21%) as compared with Indo-Fijians (16%) and the proportion of uncontrolled previously diagnosed cases is higher among Fijians (81%) than among Indo-Fijians (58%). There was generally low consumption of fruits and vegetables with 66% of survey participants eating less than one serving of fruit per day and 26% eating less than one serving of vegetables per day. Information from other surveys indicates the range of nutritional problems still being widely experienced (such as iron and iodine deficiency). Reliance on imported foods, poor diet choices and changing lifestyles, with reduced physical activity levels are the underlying problems, and are being seen not only in Fiji but throughout the Pacific Island region.

• There was also a higher proportion of urban males (49%) in the high-risk triglycerides group (>=1.70mmol/L) as compared to either rural males (24%) or urban females (28%). HDL cholesterol levels were used to categorize individuals into a high risk group (<= 0.90 mmol/L) was 31% and for females was 35%, a difference that was not statistically significant.

• 37% currently smoke tobacco,

• There is a low rate of physical activity (25%)

• A high rate of binge drinking (77.3% of current drinkers).

4 Fiji NCD STEPS Survey 2002 Report

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The findings of the NCD STEPS Survey 2002 formed the basis of the development of the Fiji National Non Communicable Diseases Strategic Plan 2004-8, which was formulated in 2003-4. The Ministry of health then also reviewed, strengthened and consolidated its other existing strategies and activities to address non communicable diseases interventions comprehensively as a united front. These included the Fiji Plan of Action for Nutrition (FPAN), Fiji National Health Promotion Council Strategic Plan 2004-8, Micronutrients Survey & Food Fortification of Flour, Food Safety Act 2003, Public Health Act Review and Tobacco Control Act. Interestingly, most of the strategies developed in this NCD Strategic Plan, such as Strengthening of the Food safety Act 2003, Review the Food and Nutrition Policy, Finalise the School health and nutrition Policy, Address non nutritious advertising, Advocate NCD friendly Accreditation of Food, Advocate for taxation according to nutritious values, Advocate Price controls of Nutritious foods, and other activities in Strengthen Community Action, Developing personal skills, Creating supportive Environments and Reorienting health services; were followed through within the components of the Fiji OPIC Research 2004-8. However, there was minimal tangible interaction at the policy level of the Ministry of Health in relation to the implementation and processes taking place at the implementation and intervention results of OPIC. These gaps could have strengthened the implementation of the findings and results of the OPIC study. The Fiji National NCD Strategic Plan is overseen by the national multisectorial NCD Committee which is chaired by the Hon Minister of Health with membership from all stakeholders including representatives from the 3 Divisions; Northern, Western and Central Eastern, who have their own Divisional NCD Committees. The national NCD Committee meets once every quarter and monitors & evaluates the progress of the implementation of this strategic plan at various levels. Following the submission of the NCD Strategic Plan to cabinet in 2004, the Fiji Government also increased its specific NCD budget allocation from 60,000 FJD in 2003 to 280,000 FJD in 2004 and continued annually to date. This reflects the government commitment to address NCD issues and interventions following the World Health Assembly Resolutions and the Pacific Island Ministers of Health meetings culminating the 2003 Tonga Commitment, 2005 Samoa Commitment and the 2007 Vanuatu Commitment. Nutrition: An impressive quantity and range of traditional food such as root crops, fruits and vegetables are grown throughout the country, and along with fish, and are identified as a “hidden strength” of the economy. However it is estimated that only 40% of energy needs come from locally grown food. Nutritional problems for weaning infants, undernourished children and adolescents remain. Kumar (2006) found that one third of teenage schoolgirls in the Western Division were anaemic and that many routinely miss breakfast.

The cost of food: Fiji is a net importer of food and its agricultural potential for food production is largely underutilized. Much of Fiji’s arable land has been devoted to sugar production, but as land leases expire land is left fallow without any plans for further development. For Fiji to develop a viable food export sector, the quality of food produced will need to be increased to meet the expectations of recipient markets. Available survey5

5 Roberts, Lingham (2008).

information suggests that since the 1980’s there has been increased intake of cereals (rice and wheat), animal fats and imported processed foods. This is supported by importation data which reveals clear dramatic increases in the importation of meats and meat products, along with vegetables oils. Overall the availability of calories per capita has been gradually increasing. The contribution of fat to this calorie intake has

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risen from 20% to 30% (from 1964 to 2000). Availability of fish per capita has been declining since the late 1980s, whereas availability of meats has been increasing. Fruit and vegetable availability, from both imports and local sources, has been steadily increasing over recent decades, but still falls well short of the WHO guidelines for a healthy diet.

The main drivers of food choices have been found in a recent study to be cost and convenience. Overall, the food environment is unsupportive of healthy eating for many, particular urban dwellers. Prices for local foods such as fish and root crops are high compared to some meats and rice. There is limited access to healthier options in settings such as restaurants and schools. Marketing is heavily skewed towards the promotion of less healthy foods, and the resources available for health promotion are far outweighed by those available to food manufacturers. While health promotion and education efforts are critical to ensure that the public is well-informed about the importance and constituents of a healthy lifestyle, they are unlikely to follow that advice if the environment does not support them; if it’s difficult to access healthier food, too expensive or they have difficulty identifying the healthier options in stores.

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Annex 2: Community and School interventions Introduction

Overweight and obesity is increasing in most countries but prevalence rates are particularly high and increasing rapidly in Pacific populations. It is likely that socio-cultural factors playa large part in the development of obesity. Any intervention programs, therefore, need to take into account the main behaviors and underlying socio-cultural factors that are contributing to obesity. Health promotion action at a community level needs to become embedded in the organizations working in that community and to ensure that the community owns and embraces the action. The challenges are considerable, particularly in achieving a sufficiently high and sustainable ‘dose’ of intervention and evaluating the process, impacts and outcomes to a sufficiently high standard given all the constraints associated with such projects. While these challenges are recognized, the problem of obesity, especially in Pacific populations, needs to be addressed at all levels – community, national, and global. Development of Action Plans: At each intervention site, preliminary interviews were conducted with youth to identify the potential socio-cultural barriers that facilitators or hinder healthy eating and regular physical activity in order to attain and sustain a healthy body size.

This and other information was presented at a 2-day workshop with community stakeholders, including youth. The participants then prioritized the components for a draft action plan which was later consolidated through further community consultation.

Action Plan objectives: Each action plan had two overall aims:

• to build community capacity and

• to promote healthy weight through capacity building, social marketing messages, evaluation and environmental change.

The Action Plan Objectives that were developed for the school & community are listed in the Table 52.

Table 52: Action plan objectives for school and community

No. Topic Action Plan Objective

1 SOCIAL MARKETING To achieve a high awareness of the Healthy Youth Healthy Community project’s key messages amongst youth and key stakeholders

2 BUILDING CAPACITY To build the Nasinu Community capacity to promote healthy eating and regular physical activity in adolescents and youths

3 EVALUATION To evaluate the project, impact & outcomes of the Healthy Youth Healthy Community Project

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4 BREAKFAST To significantly reduce the proportion of adolescents & youths who skip breakfast and lunch on school days

5 HEALTHINESS OF FOOD AT SCHOOL

[a] WATER VS SWEET DRINKS - To significantly decrease the consumption of high sugar drinks & to promote the consumption of water. [b] FRUIT & VEGETABLES - To significantly increase fruit and vegetable consumption

6 AFTER SCHOOL SNACKS To significantly decrease the consumption of energy dense snacks and significantly increase consumption of fruit

7 WALKING & CYCLING [a] To increase the proportion of school children living within the school area to walk to and from school and have sense of safety for walking around the neighborhood. [b] To significantly increase the healthiness of school food

8 SUPPORT PE CLASSES To support physical education teachers to conduct PE classes effectively.

9 GETTING ACTIVE To significantly increase the amount of active play after school & weekends and significantly decrease time spent watching TV & playing on computers or electronic games

10 GETTING THE COMMUNITY INVOLVED

To develop a program for promoting healthy eating & physical activity within churches, mosques, and temples

Developing the draft action plans

Figure 37 describes the model of the OPIC community interaction process. The steps taken to develop the action plans were conducted within the context of the communities; key community members and stakeholders were involved in all aspects of the process.

Figure 37: OPIC community interaction process model

Preliminary Interviews

COMMUNITY

Preliminary Interviews

In Depth Interviews

Community Readiness

ANGELO Workshop

Intervention Strategies

ACTION PLAN

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Phase 1 – Preliminary assessment of socio-cultural factors Preliminary interviews were conducted to determine the perceptions of 12-18 year olds in terms of three themes: food and eating, activity and inactivity, and preferred body size. Findings from the interviews informed and shaped the community workshops and baseline questionnaire and indicated that youth: • knew about healthy food and drinks, • often buy junk food with spending money that was not monitored by adults, • identified mothers as messenger about food while fathers provided more messages about exercise & physical activity, • thought boys had more freedom than girls to exercise and in Fijians, Indo- Fijians prioritize study over exercise, • identified media, peers and sports stars as important messengers relating to body size, shape and muscularity. The findings of the socio-cultural interviews were included in the materials developed for the community workshops. Phase 2 – Community workshops to develop the draft action plans Once the community consultations and preliminary socio cultural studies took place, each site organized a community workshop with key stakeholders to develop a draft action plan. The community workshop used the ANGELO framework based on an Analysis Grid for Elements Linked to Obesity. The original ANGELO framework centered on obesogenic environments but this was augmented by identifying potential behaviours for targeting, knowledge and skill gaps to fill, in addition to environmental barriers in the homes, schools, churches and communities that needed to be addressed. All the elements were informed by the preliminary socio-cultural interviews prior to each workshop (approximately 15-20 potential behaviors, knowledge and skills gaps, and 10-25 environmental barriers in each of the settings). The environmental barriers were classified as:

• physical (what is or isn’t available), • economic (what are the financial factors), • policy (what are the rules); and • socio-cultural (what are the beliefs, values, attitudes, perceptions & community

practices).

Healthy Youth Healthy Communities’ - A 2-day ANGELO workshop was conducted in August 2004 to develop a plan of action for intervention within the Nasinu community. The students, teachers, and people from the communities and related organizations were updated on the issues related to obesity and available local data on the problem. The participants were then taken through a process of prioritization of the various elements. Individuals first checked, and altered the elements if necessary, and then scored each element for importance and changeability. Group aggregate scores were combined to identify the priority behaviors, knowledge and skill gaps, and environmental barriers that relate to obesity. From these priority elements, a draft action plan was developed. The strategies were congruent with the stage of readiness and were culturally appropriate (the latter was addressed through the in-depth socio-cultural interviews). The draft action plan and behavioral objectives to guide the interventions at was developed for the Fiji Healthy Youth Healthy Community project is described in the Table 53 below:

Aim: To improve the health and wellbeing of individuals and strengthen the Nasinu Community through healthy eating and physical activity

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Table 53: Action plan for the Fiji ‘Healthy Youth Healthy Communities

Ion

Behavioral & Innovative Objectives Key Strategies 1. To significantly reduce the proportion of adolescents who skip breakfast on school days.

• Promote breakfast with students and parents – pamphlets & school assembly morning talks • School canteen providing breakfast

2. To improve the healthiness of food at school by significantly decreasing the consumption of high sugar drinks and promoting the consumption of water and by significantly increasing fruit and vegetable consumption

• Develop school policies for canteens to support water, fruit and vegetable consumption • Curriculum development with Home Economics and Agricultural Science

3. To significantly decrease the consumption of energy dense snacks and significantly increase consumption of fruit as afternoon snacks

• Social marketing [include fruits (& vegetables) for snacks and benefits of F & V; what constitutes healthy snack • Student information on healthy snacks, F & V snacks

4. To significantly increase the proportion of adolescents living within walking distance to school to walk to and from school with a sense of safety

• “Walking buddies” • Road safety skills

5. To support physical education teachers to conduct physical education classes effectively

• School policy on physical education classes • Partnership with organizations to provide sports equipment such as, hoops, ropes & others

6. To significantly increase the amount of active play after school/ weekends; significantly decrease time spent watching TV & playing computers or electronic games

• House rules on screen time and outside play time • School walkathon

7. To develop a program for promoting healthy eating & physical activity within churches, mosques & temples

Food Preparation Skills • Budgeting skills

These names were reviewed by community members during focus groups to identify the most commonly selected one. The choice of name and logo: Healthy Youth Healthy Community participants was developed by the participants during the focus group discussion in the social marketing workshop. Community Engagement and Intervention Strategies The initial behavioral objective targeted by the Healthy Youth Healthy Community intervention addressed the issue of students missing breakfast. Key stakeholders were again consulted to determine the types of strategies that were important and appropriate for their communities in the Action Plan and two working groups were formed to implement the action plan: (1) first group - Local Steering Committee whose membership comprised of representatives of all major stakeholders at Ministerial levels (Health, Education, Women), school focal points for the Healthy Youth Healthy Communities project, local town council, and health centers in the intervention area. The terms of reference for this committee were to advise and support the project team with implementation and act as a link between their respective organizations and the project staff. (2) second group - comprised of the individual School Implementation Committees for each of the intervention schools which included teachers, students, school administration, and canteen managers. The Committee’s terms of reference supported the project by implementing the action

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plan in their school setting. The Committees met fortnightly to plan and monitor project activities. The behavioral objective targeted by the Healthy Youth Healthy Community intervention addressed the issue of students missing breakfast. Schools used multiple strategies to encourage students and to eat a healthy breakfast. Intervention strategies included social marketing through pamphlets targeting students & parents; promotion of breakfast by students during parent interview days; school canteens opening early to sell breakfast before school starts; and education through skills development for students in time management.

• School Intervention - A snapshot of interventions implemented in the 7 schools in 2007 is shown in Table 54.

Table 54: Interventions implemented in the 7 schools

Intervention objectives Implementation by schools & no. of times

Breakfast: To significantly reduce the proportion of adolescents/youths who skip breakfast on school days

Ahmadiyya M College: 3; AOG High School: 3; Bhawani D A College: 3; Nakasi High : 3; Nasinu M College: 2; Nasinu Secondary : 2; Rishikul S College:2;

Lunch: To significantly reduce the proportion of adolescents/youths who skip lunch on school days

Ahmadiyya M College: 1; AOG High School: 2; Bhawani D A College: 2; Nakasi High: 1; Nasinu M College: 1; Nasinu Secondary: 1; Rishikul Sanatan College: 3

Water vs. sweet drinks: To significantly reduce consumption of high sugar drinks & promote consumption of water

Ahmadiyya M College: 6; AOG High School: 3; Bhawani D A College: 2; Nakasi High: 5; Nasinu M College: 5; Nasinu Secondary: 2; Rishikul Sanatan College:- 5

Fruit and Vegetables: To significantly increase fruit and vegetable consumption

Ahmadiyya M College: 3; AOG High School: 1; Bhawani D A College: 3; Nakasi High: 4; Nasinu Muslim College: 3; Nasinu Secondary: 2; Rishikul S College: 2

After school snack: To significantly decrease the consumption of energy dense snacks & significantly increase consumption of fruit

Ahmadiyya M College: 1; AOG High School: 1; Bhawani D A College :2; Nakasi High: 1; Nasinu M College ; Nasinu Secondary :1; Rishikul S College: 1

Physical activity: To significantly increase the no. of students engaged in active play after school & weekends

Ahmadiyya M College: 1; AOG High Sch: 1; Bhawani D A College: 2; Nakasi High: 2; Nasinu M College; Nasinu Secondary :1; Rishikul S College:4

Community Intervention: A total of 1000 people participated in these community activities during the year within faith based organization in the following intervention strategies in Table 55.

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Table 55: Interventions in Communities

Intervention Objectives Implementation by schools & no of times

Breakfast: To significantly reduce the proportion of adolescents/youths who skip breakfast on school days

Assemblies of God: 3; Catholic – 1; Hindu ; Methodist Church: 3; Muslim: 1; SDA: 3; World Harvest: 2

Lunch: To significantly reduce the proportion of adolescents/youths who skip lunch on school days

Assemblies of God: 1; Catholic: 1: Hindu: 1; Methodist Church: 3; Muslim: 2; SDA:- 3; World Harvest: 1

Water vs. sweet drinks :To significantly reduce consumption of high sugar drinks & promote consumption of water

Assemblies of God ; Catholic; Hindu; Methodist Church: 1; Muslim; SDA ; World Harvest: 1

Fruit and Vegetables: To significantly increase fruit and vegetable consumption

Assemblies of God: 2; Catholic; Hindu; Methodist Church : 3; Muslim; SDA ; World Harvest: 2

After school snack: To significantly decrease the consumption of energy dense snacks and significantly increase consumption of fruit

Assemblies of God ; Catholic; Hindu; Methodist Church ; Muslim; SDA ; World Harvest

Physical activity: To significantly increase the number of students engaged in active play after school and on weekends

Assemblies of God ; Catholic; Hindu; Methodist Church : 1; Muslim; SDA; World Harvest: 1

Table 56: Activities undertaken for social marketing

Objective code: M - Multiple objectives, W - Water, FV - Fruits & Vegetables, L - Lunch, B - Breakfast, PA - Physical Activity

Category Description Objective Code

Comments

Media reports and promotions

Television 1x 30 sec TV advertisement, screened 6 times

PA Multiple sponsors, shown live during Fiji-Hong Kong Rugby Sevens match

9 TV news items B - 7, PA - 2 Featured programs at schools; involved 4 teachers and 3 students

2 live TV interviews M - 2 Local church TV station aimed at adolescents and parents; involved project staff and dietician

Radio 10 minutes talk back show, repeated twice

M - 3 On Fijian and Hindi Radio stations; involved 3 project staff

2 x 5 minute Sunday Health Programs

M -3 Project staff on Fijian Radio station

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Comments

4 live radio interviews with Fijian Radio station, replayed 3 times

B- 2, M- 2 Project staff

3 live radio interviews with Radio New Zealand

M - 2, PA - 1 1 student, 2 with project coordinator

Print 10 newspaper articles, 30,000 daily distribution

B - 3, L - 1, M – 4, PA - 2

Targeting whole community and adolescents special newspaper

Developed materials Printed 60 copies DVD on HYHC Jump

Jam aerobics instructors training PA Produced by Ministry of Health

distributed to schools and faith based organizations schools

3 sets posters posted for 3 months

PA - 1, FV -1, W -1

Attached on power poles at 3 different settings

1 set HYHC logo stickers, 2000 copies distributed

W-1 To all schools

1 project newsletter, 100 copies distributed

M-1 To stakeholders

1500 water bottles distributed to 7 schools

M Personalized with school logos

3000 copies of annual school calendars, produced for 2 years

M - 2 3 term calendar, including intervention photos and health messages; distributed to all stakeholders;

Articles in school magazines, 4 schools for 2 years

M Pages devoted to HYHC articles; 2,000 copies distributed

100 certificates of appreciation M Prize giving ceremonies for 2 years, awarded to HYHC champions

3000 project leaflets distributed to students

M-1

3000 copies of breakfast pamphlets

B-2 Separate pamphlets for students and parents

Other 4 billboards erected at 3 different locations

B - 2, PA – 2 Roadside billboards, featuring local students as actors

4 project banners displayed during promotions

PA- 1,B -1,M -2

Displayed at workshops, sports events

Logos on 2 project vehicles M 1000 T-Shirts with project logo M Distributed to students 7 School health notice boards M Distributed to 7 schools for project

health messages One school billboard with project

logo

M Project of the School Health Committee

Sourced materials Printed 1 Fat kit and set of posters M Sourced from New Zealand Heart

Foundation Other 1000 Posters and pamphlets for M Sourced from National centre for

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Comments

distribution Health Promotion 5000 bottles of water distributed

to students and staff W Compliments of local water

company distributed at special events.

70 crates eggs, 26 tins of Milo, 26 bars of cheese, 30 crates of milk used in event catering

B Donated by local business partners

Table 57: Activities undertaken for capacity building Abbreviations: FT - Full Time, M - Multiple objectives, W - Water, FV- Fruits & Vegetables, L - Lunch, B - Breakfast, PA - Physical Activity CSC Community Steering Committee; LSC Local Steering Committee; SSC School Steering Committee; SHC Student Health Committee Category

Description Objective Code

Distribution and comments

Additional Resources Funds $45,000 procured in 3 small

grants. M-2, PA -1 Multiple funding sources

Additional funds procured by 2 schools

W-2 Successful submissions to fund water tanks/fountain

Personnel

2 consultants for Jump Jam Training hired

PA Conducted one week program for 30 teachers and community reps

Leadership Students

200 champions trained in 7 schools x 2 years

M Student members of Student Health Committee (SHC)

168 SHC meetings chaired by students

M At least monthly meetings

Community leaders

60 women attended two 3 day workshops

M 10 faith-based organisations represented

30 members attended monthly CSC meetings

M Few members presented in conferences/meetings as heath champions

30 members of CSC attended training

M Project proposal completed with budget.

Workforce Development Students

48 students attended 1 day training

M Social marketing workshop conducted by HYHC and National Centre for Health Promotion

24 students attended half day training

M Poster making workshop conducted by HYHC

30 students attended 3 days training on COMBI

M Conducted by HYHC and National Centre for Health Promotion.

3 attended 5 day Health Ministers Forum, NZ

M 3 students and 1 community representative

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Category

Description Objective Code


1 student attended OPIC satellite in NZ

M Helped coordinated Fiji displays

3 persons attended 3 day workshop

M 2 students, 1staff presented to 500 participants at Youths Conference

Other Persons

14 school canteen staff attended 2days training

B, L, FV,S Food handlers workshop organized by HYHC and Ministry of Education

14 canteen managers attended 1 day training

B, L, FV,S Canteen managers workshop organized by HYHC and Ministry of Education

40 participants attended 2 x 5 days training

PA Aerobics training for Physical Education teachers and health staff

30 women attended 3 days training

B, L, FV, S Healthy lifestyle workshop organized by HYHC and a church group

25 women attended 3 days training

FV, PA Pot planting workshop organized by HYHC and Ministry of Agriculture

30 participants attended 3 days training

M Pastors and representatives of women’s and youths group; conducted by Health Promoting Churches

Staff 2 staff attended 5 days training and meetings

M Attended by Project Coordinator and other members

5 HYHC staff attended 5 days training

M Social marketing workshop organized by HYHC

Partnerships and Collaborations Government

700 attended 10 x 30 minutes presentations

M Multiple presentations on project to stakeholders

Coordinator attended 14 committee meetings

M Committees jointly organized by Ministry of Education and Ministry of Health

Non-Government Organizations

25 members attend 6 monthly LSC meetings

M Chaired by HYHC

20 members of SSC attend 7 monthly meetings

M Chaired by Ministry of Education

30 members of CSC attend 3 bi- monthly meetings

M Chaired by local church Pastor

55 presentations delivered by HYHC staff

B, L, S Attended by 60 leaders and 300 church members

Organizational Development Schools 5 schools changed menus of

school catering services B, L, FV, Improved school food services for collegial

lunch/tea or teachers meetings Church 2 church groups improved

catering services B, L, FV, More vegetables incorporated into lunch

menu

108

Table 58: Activities undertaken for nutrition objectives

Objective code: M - Multiple/combination of nutrition objectives, W - Water, FV- Fruits & Vegetables, L- Lunch, B - Breakfast S - Snacks, F – Fruits



Policies 2/7 schools developed and implemented school food policy

M Whole school community advised of new policy

3 churches, 5 women’s groups, piloting food policy

M Church members advised of the new policy

7/7 schools implemented fruit policy on Fridays

F Children required to bring own fruit each Friday

2/7 schools implemented school water policy

W Children allowed to bring bottled water to class

Programs 26 breakfast activities in schools, 28 in community

B More than 9000 serves of healthy breakfast provided

29 lunch activities in school, 6 in community

L ~4000 serves of lunch provided to both school and community

36 water activities conducted in schools, 8 in community

W Bottled water provided as incentives during programs

25 fruit and vegetable activities in schools, 3 in community

FV Demonstrated multiple ways of using fruit

Activities 5/7 schools organized programs an annual OPIC day

M A variety of activities during lunch, before or after school

7/7 schools had OPIC information booth at school events

M Events such as career days, parent interview days

2/7 schools organized essay competitions around obesity

M Conducted at class level

7/7 schools organized assembly talks by SHC members

All Up to 6 talks per term per school

1/7 schools, student survey of foods sold in canteen

B, L, S New school food policy mandated as a result

7/7 schools participated in World Food Day

FV Seeds, manure and technical advice provided; students showcase school garden produce

3/7 schools performed plays at non-OPIC schools

M 30 students from 3 schools performed, > 1000 students watched

1 faith based organization organized oratory contest

M Incentives provided. Sunday school children participated.

Infrastructure 4/7 schools installed new water tanks

W SHC prepared and submitted budget proposal

1/7 schools installed new water fountains

W SHC prepared and submitted budget proposal

109



7/7 schools planted a vegetable garden

FV Produce used by school canteen or hostel

2/7 schools built/renovated canteens

M

Table 59: Activities undertaken for physical activity objectives

Abbreviations: PE Physical Education; MoE Ministry of Education; MoH Ministry of Health

Category Description Distribution and comments

Programs 15 physical activity programs organized in the 7 schools

Included walking, traditional dances and aerobics

10 PA programs, >1000 members of religious organizations attended

Included walking, aerobics and soccer

Annual events, > 200 students, 2 new schools joined

Tadra Kahani, cultural dances, Bollywood dances etc

Activities > 2000 students attended International Walk to School Day

Infrastructure and equipment

More than 200 netballs, rugby balls, volleyballs and net were awarded to winning schools for winning PA prizes during Award Nights organized for OPIC schools.

Distributed at annual award nights

Organisational Development

3 PA workshops organized for PE teachers and selected health workers

Jointly organized with MoE and MoH

Report produced August 2010

For information please contact:

C-POND (Pacific Research Centre for the Prevention of Obesity

and Non-communicable Diseases)

Fiji School of Medicine, Tamavua Campus

Suva, Fiji

Telephone 3233255

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