Development and reproducibility of a tool to assess school food-purchasing practices and lifestyle...

ORIGINAL RESEARCH

Development and reproducibility of a tool to assessschool food-purchasing practices and lifestyle habitsof Australian primary school-aged children

Meghan FINCH,1,2 Andrea BEGLEY,3 Rachel SUTHERLAND,1,2 Michelle HARRISON4 andClare COLLINS2

1Hunter Population Health, Wallsend, Schools of 2Health Sciences and 4Mathematics and Physical Sciences,University of Newcastle, Newcastle, New South Wales, and 3Nutrition and Dietetics Program, School of PublicHealth, Curtin University of Technology, Perth, Western Australia, Australia

AbstractObjective: To describe the development and reproducibility of a self-report instrument, for use with children inyears 4–6, to identify sources of food eaten during the day, and type and frequency of food purchases at school.Design: Tool development stages included formulation of content and format, expert review, piloting and atest–retest study.Subjects/setting: The pilot study included school students (n = 20) in years 4 and 5 (seven girls, mean age9.7 � 0.7 years) attending an Australian public primary school. The test–retest study was performed in a largemetropolitan public primary school (n = 245 children, 52% female, mean age 10.7 � 0.91 years) including childrenfrom years 4 (n = 88), 5 (n = 84) and 6 (n = 73).Statistical analysis: A Kappa statistic was used to assess level of agreement between the two time periodsseparated by 1 week. The results were analysed using SAS version 8.2 with each question compared at time 1 and 2.Results: The mean kappa was 0.529 using pairings from 17 questions. Values ranged from 0.18 to 0.71 (CI0.46–0.60).Conclusions and applications: The School Eating Habits and Lifestyle Survey has been developed and pilot-testedin primary school-aged children and shown to have moderate stability over time. The results show that each phaseof development, particularly those spent in consultation and testing, led to progressive improvement of thisinstrument. This process improved the quality of information produced and gave insights to self-report of dietaryintake and behaviours among children.

Key words: children, food habit, nutrition survey, purchasing behaviour, school canteen.

INTRODUCTION

Changes in the physical eating environment of schoolstogether with the increasing prevalence of childhood obesityhave prompted many nutrition experts and public healthadvocates to question whether the current school environ-ment supports and promotes the development of healthy

eating as normative childhood behaviour.1–3 In schools,efforts can be directed to improving food intake through amultisectorial approach, incorporating the school foodservice and catering facilities.4 Recognition of this opportu-nity has resulted in a worldwide trend towards the develop-ment of guidelines and standards for provision of healthyfood choices in schools.5–8

Unlike the USA where a National School Lunch programprovides lunch to approximately 59% of all public schoolchildren, most children in Australia (86%) bring their lunchfrom home.9,10 Australian school food services are usuallylimited to an on-campus canteen that provides the opportu-nity to purchase food and drinks without leaving the schoolgrounds.9 While they most commonly operate during themorning tea and lunch breaks, each differs in their manage-ment systems, operating hours, price and range of productsoffered for sale.9

M. Finch, MPH, Public Health Nutritionist, Conjoint Lecturer in Nutri-tion and DieteticsA. Begley, MPH, APD, LecturerR. Sutherland, MPH, APD, Nutrition Program Manager, Conjoint Lec-turer in Nutrition and DieteticsM. Harrison, GradDipMedStat, Lecturer/TutorC. Collins, PhD, APD, Senior Lecturer in Nutrition and DieteticsCorrespondence: C. Collins, Mail Box 38 Hunter Building,Callaghan, Newcastle, NSW 2308, Australia. Email:[email protected]

Nutrition & Dietetics 2007; 64: 86–92 DOI: 10.1111/j.1747-0080.2007.00148.x

© 2007 The AuthorsJournal compilation © 2007 Dietitians Association of Australia

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mailto:[email protected]

In Australia there is considerable government commit-ment to improving foods sold in schools, even though thereare limited published data about children’s school food-purchasing practices.11 A recent study has indicated that91% of primary school children use the canteen.12 Althoughtrend data are lacking it has been suggested that more chil-dren are purchasing lunch, recess and afternoon snacks fromthe school canteen because of busy family lifestyles and thecompeting demands on parents’ time.12 Data from a smallnumber of studies conducted in Australia suggest that chil-dren most commonly use the canteen to purchase lesshealthy convenience foods like hot chips, pies and past-ries.12,13 Evidence also suggests that although Australiancanteen food contributes less to overall energy intake thanfood brought from home, the types of foods commonlypurchased from the canteen are those that are strongly asso-ciated with obesity.9

Development of effective strategies to improve children’sfood choices requires an understanding of their eatingbehaviours and factors that influence this in the school envi-ronment.14 A more comprehensive understanding of schoolfood-purchasing patterns could provide a means for inform-ing development of intervention strategies, monitoringtrends and evaluating the effectiveness of healthy schoolfood programs. To do this specific tools are required tomeasure canteen purchasing practices. In addition, the valid-ity and reliability of the assessment method must be reportedin order to provide an assessment of reliability.15 Currently,evaluation of school-based interventions for primary schoolchildren is hampered by the dearth of valid, reliable andacceptable methods for gathering self-reports of dietaryintake and behaviours within a school setting.16

The present study describes the development, pilotingand reliability testing of the School Food Eating Habits andLifestyle Survey (SEHLS). The aim of the study was to reporton the development and validation of a research tool capableof measuring influences on children’s food choices andeating behaviours in the school environment, focusing onschool food purchases.

METHODS

Phase 1—content and format

The initial content of the research tool was guided by a set ofresearch questions generated from a review of relevant lit-erature. A self-report instrument was required and thisguided format and terminology in order to aid comprehen-sion and interpretation by the target age groups. Questionswere developed to assess practices and behaviours associatedwith key aspects of the Australian primary school food-purchasing environment. In the present survey the schoolfood-purchasing environment is defined as foods eaten orpurchased during the school day from the canteen, vendingmachines and external sources such as local shops and take-away outlets.

Given there were no existing published tools with contentrelating to food-purchasing practices of school-aged chil-

dren, the development of new questions was necessitated.Items relating to food-purchasing habits were structured tofollow a logical sequence throughout the day. The responseoptions for items related to canteen food purchases wereincluded based on a review of 50 local primary schoolcanteen menus. Common menu items were identified andgrouped in the review and used as the basis for both the typeof foods included and the terminology used to describethem. Similarly, items relating to vending machines and foodpurchases from sources outside school grounds were identi-fied via a review of common options available. Items wereincluded in the questionnaire relating to frequency of foodpurchasing from the canteen, vending machine use and foodfrom sources external to the school. The time of day mostlikely to purchase food was based on the known availablewindows of opportunity for students.

Phase 2—expert review

This phase involved content validation both from a method-ological and practical perspective by field experts. Thisincluded two experienced nutrition researchers (CC, RS), astatistician and data entry programmer all of whom haveexpertise in the field of survey development, measurementand evaluation. A primary school teacher also reviewed thetool to ensure that the survey would be easily understood,did not appear leading and was appropriately structured tofacilitate interpretation.

The reviewers provided comments on the formulation ofspecific items, exclusiveness of items, presentation andwording, and the choice of response options. Items were alsochecked to ensure they were written clearly, complied withthe format criteria, used familiar words, offered a plausiblerange of response options and were suitable for data entry.

Phase 3—pilot test

After expert review the revised survey was pilot-tested toassess the suitability of the tool for what it was intended tomeasure; to assess the feasibility of the proposed method ofdata collection and to provide experience in logistics ofcompletion such as, time taken for administration and levelof assistance required, as well as data management andanalysis. The final aim of the pilot was to ensure that allquestions were easily comprehensible to all respondents.

The pilot test was conducted at a local governmentprimary school (n = 20, seven girls, mean age9.7 � 0.7 years). School selection and recruitment of thesubjects were opportunistic. Subjects were recruited by theirteacher who identified eligible students giving consent withpermission from the school Principal and parents. Thesurvey was administered in class time by the teacher. Sub-jects were in years 4 and 5, with at least half representing thelowest level of English language literacy estimated to be ableto functionally self-complete the questionnaire. The subjectsalso represented the lowest age group intended to self-complete the survey. After completion, the teacher was inter-viewed about perceptions of student comprehension, time

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taken for administration and statements that the studentsfound difficult to respond to or that needed clarification.

Phase 4—reliability testing

Reliability testing measured the stability of responses overtime using a test–retest methodology. This included 245children in years 4 (n = 88), 5 (n = 84) and 6 (n = 73)from a large metropolitan primary school (mean age10.7 � 0.91 years, 52% female). The survey was completedin class by children whose parents gave informed consent,with teacher supervision on two occasions, separated by oneweek. Approval to conduct the research was granted by theHunter Area Research Ethics Committee, the University ofNewcastle Human Research Ethics Committee and the NSWDepartment of Education and Training. These school yearsrepresented the full range of ages for future studies. Resultswere analysed using SAS statistical software, Version 8.2 ofthe SAS System for Windows, 2005, SAS Institute Inc., Cary,NC, USA. The frequencies of the categorical data from eachquestion were compared between the first and secondadministration of the survey. A Kappa statistic was used toassess level of agreement between the two time periods. Theresulting reliability coefficient is commonly expressed as anumber between 0 and 1, with 0 indicating no reliability and1 indicating perfect reliability.17,18 For survey tools, values of0.4 or above are considered to indicate moderate agreementand values of 0.8 or higher indicate excellent agreement.19,20

RESULTS

Phase 2—expert review

Feedback on the initial version of the SEHLS resulted in anumber of modifications to achieve content validity. Table 1presents a summary of modifications and rationale for thechanges. An item relating to motivation for student foodpurchasing was added (question 12).

Phase 3—pilot testing

Further revisions were made after reviewing responses madein the pilot study and feedback from teachers. Teacher rec-ommended modifications related to the interpretability andcomprehension of items requiring changes to some wordingand layout of items in the tool. The younger students andthose with lower literacy ability also took longer to fill outthe survey and required support, that is, someone wasrequired to introduce and explain how to answer it and to beavailable to answer any questions. Time taken to completethe questionnaire was longer than anticipated and tookabout half an hour at the most. Modifications as a result ofstudent responses led to the addition of new responseoptions identified from responses written under the ‘other,please specify’ category. Inclusion of these was based on thelikelihood of these options being used by the larger studytarget population. Table 1 summarises the resulting surveymodifications.

Version 3.0 of the SEHLS comprises a total of 35 items,of which 25 focus on assessing food habits (questions4–12), seven relate to activity and sedentary pursuits (ques-tions 13–19) and three identify demographic variablesincluding self-reported gender and date of birth (questions1–3). Items relating to food habits assess usual canteen pur-chasing times and purchasing frequency, canteen spending,frequency of canteen use, sources of food eaten at schooland at breakfast, and, types of foods purchased. One item isincluded for children to suggest influences on canteen pur-chases (question 12, ‘If you buy food at school, what is themain reason why you would choose a particular food?’). Allquestions are multiple choice and categorical in nature. Forsome of the questions there is also the option for respon-dents to specify a response that is not given as an option. Afull copy of version 3.0 of the SEHLS is available from theauthors (MF).

Phase 4—reliability testing

Table 2 presents the results of the test–retest reliabilityassessment. The mean value was analysed excluding thequestions allowing multiple responses due to the presence ofvery small sample sizes leading to unstable values. A smallnumber of responses with perfect agreement (k = 1), due tosmall samples, were also removed. The resulting mean kappavalue is thought to be a conservative estimate. From theremaining correlations using pairings from 17 questions,the kappa values ranged from 0.18 to 0.71. Table 2 presentsthe results for each of the 17 included questions.

DISCUSSION

The aim of the present study was to report on the develop-ment and validation of a research tool capable of measuringinfluences on children’s food choices and eating behavioursin the school environment, focusing on school food pur-chases. The development of the SEHLS incorporated a meth-odology, adapted from similar studies addressing contentvalidity and reliability, in the context of operational andpractical efficiency.15–17 The results clearly show that eachphase of development, particularly those spent in consulta-tion and testing, provided valuable feedback, progressivelyenhancing the instrument and increasing the viability of itsfuture use.

The results from the developmental phase confirm theimportance of these steps in survey tool development.Indeed the modifications made at this stage addressedseveral limitations inherent in the initial version. Theseincluded limited incorporation of data entry coding, unnec-essary respondent burden, and ambiguity and lack of clarityin some items. Modifications improved the quality of datacollected and generalisibility of results through addition andmodification of questions and response options. The expertreview phase, and specifically the inclusion of reviewers,with expertise spanning a variety of areas, improved thecontent validity both from a methodological and practical

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Table 1 Summary of the types of modifications to the School Eating Habits and Lifestyle Survey

Reason underlyingchange Example of change

Item(s) or response(s)prior to modification

Item(s) or response(s)post modification

Expedite dataentry purposes

Pre-coding added alongsideresponse options. For examplerespondents now asked toindicate chosen responseby circling number instead ofshading in circle

NA NA

Address formatting Layout of questions on the pagechanged from having up to threerunning from left to rightacross a page to singlequestions running downthe page

NA NA

Ease respondentburden

Addition of filter questionsfor consumption of breakfast,recess and lunch. Prior toitems asking about particularsof breakfast consumption

Where do you usually eatbreakfast?How often do you usuallyeat breakfast?

Do you usually eat breakfast onschool mornings?Where do you usually eatbreakfast?How often do you usually eatbreakfast?

Minimise confusion Addition of additional filteroptions in the item asking aboutschool vending machinepurchasing

‘Yes’‘No’

‘Yes’‘No’‘No, my school doesn’t have avending machine’‘I don’t know what a vendingmachine is’

Enhance data quality Addition of please-specifyhandwritten option for‘other’ responses

‘Other’ ‘Other, please specify_____’

Enhance interpretationof results

Rewording and addition ofextra filter options for itemrelating to purchase of foodoutside school grounds

‘Yes’‘No’

‘No, my school does not allow it’‘My school allows it and I don’tbuy any’‘Yes, my school allows this andI do buy some’‘My school doesn’t allow it andI do buy some’

Enhance study quality Items relating to physicalactivity and sedentarybehaviours

NA How much time do you usuallyspend each day on the computeror playing video games?On week days how much timedo you spend watching television?How many times a week do youusually eat your meal at night infront of the television?How much time do you usuallyspend each week playing gamesor doing activities that make yourun around or huff and puff?What do you usually do at recess?What do you usually do at lunchtime?

Boldface indicates changes.



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perspective. The resulting modifications give a clear indica-tion that this was achieved.

The results of the pilot provided valuable informationabout potentially weak areas of the tool with respect to itsadministration and student interpretation. Teacher recom-mended modifications related to the interpretability andcomprehension of items (see Table 1). Conversely, studentresponses led to the addition of new response options withinthe survey items (see Table 1). These findings highlight theimportance of obtaining feedback from the tool administra-tor, in this case the teacher, in addition to subjects, in thiscase students, whose comments are likely to relate to differ-ent but important aspects of a tool.

The review of student responses and teacher interview,post pilot, gave specific insight into subjects’ comprehensionand understanding of what was being asked of them. Bothage and cognitive ability influence the child’s understandingof the method used and the thought processes that contrib-ute to self-reporting of food choices.15 Central to this was theinclusion of subjects in the pilot representing the lowest levelof English language literacy estimated to be able to function-ally self-complete the questionnaire. This increased the

authors’ confidence that the changes made to the SEHLS,version two, were appropriate for children at relevant stagesof their curriculum.

Subar, in a commentary on the development of dietarytools, suggests that extensive piloting or cognitive testing isuseful to be sure that the target population both understandswhat is being queried and is capable of providing theanswers sought by investigators.21 The pilot process, under-taken here, provided valuable information relating to thepractical administration of the SEHLS. Information oncompletion time and level of instruction required is essentialfor the successful future application of the tool in a schoolclassroom or formal research setting. Additionally, rehearsingand testing of surveys and tools can enhance the feasibility offuture studies.21,22

A test–retest technique was employed to measure thetemporal stability of the SEHLS to provide evidence of itsconsistency.17,18,21–23 The SEHLS questionnaire was readmin-istered after one week. The amount of time allowed betweentwo measurements was important because of memory effectsor potential dietary changes that can occur in the interimperiod between administrations.24 The shorter the time gap,

Table 2 Results of test–retest study of the School Eating Habits and Lifestyle Survey by question

Question Kappa Lower 95% CI Upper 95% CI

Q4—Do you ever buy food from the school canteen? 0.53 0.279 0.78Q4a—What time of day do you usually buy food from the school

canteen?0.54 0.45 0.63

Q4b—How often do you buy food from the school canteen? 0.57 0.48 0.66Q5—Do you usually eat breakfast on school mornings? 0.58 0.37 0.79Q6—Do you usually eat recess when you are at school? 0.18 -0.07 0.43Q7—Do you ever buy recess from the school canteen? 0.68 0.58 0.78Q8—Do you usually eat lunch when you are at school? 0.35 0.08 0.63Q9—How often do you buy lunch from the school canteen? 0.52 0.34 0.70Q10—Do you ever buy food or drinks from a vending machine

that is in your school?0.36 0.19 0.53

Q11—Do you ever buy food or drinks from places outside schoolgrounds during school time?

0.48 0.26 0.69

Q13—How much time do you usually spend each day on thecomputer playing video games?

0.59 0.48 0.68

Q14—How much pocket money are you usually given each weekto buy food, includingsnacks and drinks?

0.57 0.46 0.67

Q15—On week days how much time do you usually spendwatching television (TV)?

0.51 0.38 0.64

Q16—How many times a week do you usually eat your meal atnight in front ofthe television (TV)?

0.63 0.56 0.71

Q17—How much time do you usually spend each week playinggames or doing activities thatmake you run around or huff and puff?

0.63 0.53 0.73

Q18—What do you usually do at recess? 0.71 0.62 0.79Q19—What do you usually do at lunch? 0.57 0.46 0.68Overall mean 0.53 0.46 0.60SD 0.13

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the higher the correlation, the longer the time gap, thelower the correlation.15,17,18 The time interval (seven days)between the two administrations was long enough to avoidrecall bias and is sufficiently short to avoid changes in thestudied attributes.18

The SEHLS questionnaire produced a mean one-weektest–retest correlation of 0.529 (CI 0.462–0.596) with arange from 0.18 to 0.71. Values of 0.4 or above are consid-ered to indicate moderate agreement.19 Within the range ofresults for the 17 questions assessed, three had values lessthan 0.4. The lowest value of 0.18 applied to the questionasking about usual recess consumption, followed by thequestion about usual lunch consumption (0.35) and thequestion relating to vending machine use (0.36). The lowkappa values indicate that these questions may need to beremoved or modified in future versions.

Test–retest correlation coefficients from comparative pub-lished studies in child populations using self-completedsurveys of dietary habits range between 0.06 and 0.91.15,25–28

Overall, the reproducibility of the SEHLS is similarto those of other questionnaires for school-aged childrenand represents an acceptable level of agreement in thispopulation.

LIMITATIONS

The instrument is designed to identify school food-purchasing practices and lifestyle habits of school-aged chil-dren based on self-report. Ideally, the reliability study wouldbe complemented with a validation study to give an assess-ment of the accuracy of the tool; however, that was beyondthe scope of the present study. Finally, it is acknowledgedthat the survey is not comprehensive in assessing all factorsassociated with the school food environment. Other impor-tant measures of relevance may include: the types and quan-tities of food sold; price differentials between more healthyand less healthy foods; attitudes to nutrition; and assessmentof indicators of the school policy environment. Furthermore,the proportion of the average child’s food intake sourcedfrom the school canteen in the context of overall dietaryintake was not measured in the present study. This informa-tion is currently lacking in the literature and would providevital insight into the wide range of factors influencing foodchoices of school-aged children in the context of their overalldietary intake.

CONCLUSIONS AND APPLICATION

The eating behaviour of children in the school environmenthas come increasingly under the spotlight in recent times.This is against the background of rising prevalence of over-weight and obesity and a search for settings in which totarget interventions. Development of effective strategiesrequires an understanding of children’s eating behaviour andthe factors that influence behaviour in specific environmentsincluding schools. Insight into food consumption patterns atschool is valuable because it allows public health and edu-cation professionals to develop interventions that are sensi-

tive to the school food setting. Evaluation of school-basedinterventions for primary school children is hampered by theavailability of valid, reliable and acceptable methods forgathering self-reports of dietary intake in a school setting.Furthermore, the use of traditional dietary assessmentmethods such as 24-hour recalls, dietary histories anddietary records are often not suitable. The results from eachstage of development of the SEHLS provide evidence for theimportance of incorporating comparable methodologies inthe development of similar tools in order to avoid many ofthe common pitfalls when such developmental work is notundertaken. This process not only provides gains in thequality of information produced but also contributes to awider understanding of the nature of self-reports of dietaryintake and behaviours among children. Finally, this workallows the authors to conclude that the SEHLS is ready to beused in a representative survey of school food canteen use inAustralian primary schools.

ACKNOWLEDGEMENT

The present study was supported by funding from an AlliedHealth Research Grant from Hunter New England Health.

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