Creating a student-led health magazine with an urban, multicultural, resource-restricted elementary school: Approach, process and impact

Abstract

BACKGROUND:

Health magazines effectively deliver health information. No data regarding student-led magazines to promote health exist.

OBJECTIVE:

To evaluate whether children’s health knowledge, interests and lifestyle choices improve following distribution of a student-led health magazine.

METHODS:

Elementary students worked with teachers and paediatric residents to publish a health magazine. A healthy lifestyle challenge page promoted reduction in soda pop consumption. Pre- and poststudent questionnaires explored knowledge, interests and behaviours related to health.

RESULTS:

Sex and grade distributions were similar in pre- and post-questionnaires. Ninety-seven percent of children reported the magazine helped them learn about health. Pre- and postknowledge scores did not differ (P=0.36). Following distribution, the percentage of students who reported drinking no soda increased from 43% to 67% (P=0.004), and those who reported drinking <2 glasses of soda per day increased from 66% to 85% (P=0.01).

CONCLUSIONS:

A student-led health magazine was effective in motivating short-term student-reported behavioural change.

Advocacy and preventive medicine are important aspects of health care. The concept of partnering with communities has gained momentum because many social determinants of health are not easily addressed solely in a clinic or hospital setting (1). Health promotion programs targeted and delivered to populations within their own environment facilitate access to care and health information (2). For school-age children, this environment is within the school setting. Therefore, collaborative school health initiatives may serve as invaluable catalysts to health promotion.

Health newsletters and magazines have been shown to encourage healthy behaviours among both adults and children (3–6). Currently, no data regarding the use of student-led health magazines to promote health outcomes exist. In the present study, elementary school students, in collaboration with paediatric resident facilitators, created a health magazine that was distributed to their peers. The primary objective of the present study was to evaluate whether child-reported health knowledge, interests and lifestyle choices improved following the distribution of the health magazine. The secondary objective was to describe the development of this resident-facilitated, student-led health magazine.

METHODS

Formation of the community-academic partnership

This was a collaborative project facilitated by paediatric residents from the University of Toronto who were affiliated with The Hospital for Sick Children (Toronto, Ontario). Building on previous community service projects at one inner-city elementary school, the residents partnered with key educational team stakeholders (including the principal, school social worker, psychologist, teachers and teaching aides) to assist students in creating their own health magazine to be distributed to peers to promote health knowledge, interest and healthy behavioural choices in an at-risk paediatric population.

Target population

The target population comprised children from an inner-city public elementary school in Toronto, Ontario. Census data for students from this school (compared with aggregate data for students province wide) revealed several social risk factors: 32% (versus 17%) resided in low-income households; 48% (versus 23%) did not have English as their first languange; and 20% (versus 3%) were new immigrants to Canada (7,8).

Participants in the present project included 20 ‘producer’ students (fifth and sixth grade elementary school students who created the magazine) and 74 ‘consumer’ students (fourth to sixth grade students who received the magazine, but did not actively participate in the development). The producer students were part of an after-school program designed to build leadership skills.

Study design

The present study consisted of three parts with a mixed methodology study design, including a preliminary hypothesis-generating approach, characterized by focus-group style small group sessions with students for magazine theme derivation, followed by development and administration of questionnaires. These methods were guided by participatory action research principles (9–13). Participatory action research is based on involvement of community members as active participants at all stages of the research including reflecting on problems, ‘brainstorming’ strategies for change, assisting the change and evaluation (10,11).

The questionnaires were distributed pre- and postmagazine release, and results were analyzed using descriptive statistics with T tests, χ² and Fisher’s exact tests.

The study was approved by The Hospital for Sick Children Research Ethics Board, and families of all involved students were informed about the project as per school policies. During each study phase, students were informed that the data collected were anonymous and participation was voluntary.

Intervention development

Focus group principles were used to conduct a health needs assessment at the elementary school (10). Four paediatric residents facilitated four concurrent group sessions with students (five in each group) from the student leadership team. The facilitators asked the same lead questions, with a goal to have an open discussion, enabling the students to explore their perceptions about health issues and their own health education priorities as well as their ideas on how to best disseminate information about health in a meaningful way. Each child was given the opportunity to speak on each topic and to interact with other students in their group as they brainstormed. The discussions were transcribed from facilitator notes and analyzed initially by two team members through repeated readings, followed by consensus discussions with all team members to derive emergent themes surrounding these topics (10,13). As a form of member checking to enable data verification and feedback during data analysis, initial themes were also presented to the producer students and teaching team (14).

The group session results were derived using qualitative note-based analysis principles to identify emerging themes. Throughout the transcript, healthy lifestyle topics (‘eating healthy’, ‘exercise’ and ‘hygiene’) were recurrent. These were areas that students identified as the “biggest health problems for kids their age”, as well those that warranted discussion with their friends and families. Other topics of interest included puberty, preventive immunizations and some specific diseases such as asthma and allergies. Students generally reported their health knowledge as “good” (ranging from okay to excellent) but wanted more information on how the body functions, common health problems and emergencies (colds, chicken pox, fractures, cancer) and hygiene. When asked how they learn about health, they reported several sources including friends, advertisements and the Internet specifically as a “fun” source with easily accessible information. Features they desired in a health newsletter included bright interesting pictures, suggestions/advice pages and activities such as quizzes, riddles, jokes and trivia.

These themes were then used to develop a health needs questionnaire, with the targeted goals to further clarify the health topics and features that should be included in a child-oriented health newsletter, and to understand students’ current sources of health information and perceived level of health knowledge. This questionnaire was piloted with 12 students and collaboratively revised by the school and resident teams, primarily to optimize child-friendly language (eg, ‘overweight’ instead of ‘obesity’), and subsequently distributed to all of the other grade 4 to 6 students in the school (n=59). Their classroom teacher read each item of the questionnaire aloud to the students, and time was allotted for them to answer each item to ensure that the questions were clear and to avoid any potential confounding variables such as reading difficulties.

There was a good distribution of fourth, fifth and sixth grade students, with >70 completing the assessment questionnaire. The healthy living topics of greatest interest among the students included healthy eating, personal hygiene and physical fitness. The health issues the students believed they most wanted to learn about included topics such as allergies, cancer, injuries/emergencies, bone health, death and dying. Students believed that the most attractive and effective stylistic magazine features to be used were interviews, comics, health tips, healthy recipes and fun health facts (Table 1).

Table 1).

Health-related topics of greatest interest among students

Healthy living topics	Endorsed	Health issues topic	Endorsed
Healthy eating	74	Bone health	71
Personal hygiene	73	Death and dying	69
Exercise/fitness	71	Allergies	66
Dental care	64	Cancer	64
Homework	58	Accidents and emergencies	59

Data presented as % children interested in the topic

Based on the results of the health needs questionnaire, the producer students met weekly over a 10-week period to research, write and illustrate health articles with guidance from paediatric residents, teachers and a professional graphic designer. They created a 20-page magazine, titled “Kids On Kids’ Health”, with articles that aimed to address their own health educational needs, using their own creativity, wording and stylistic preferences, as well as those of their peers. The decision to use a paper magazine (over one that was Internet based) was made by the resident facilitators with the school team because it offered the overriding benefits of ease of distribution and equal access to the magazine across the student body. A range of health topics were considered, including: head injuries and helmet safety; sports safety; sprains and fractures; healthy food choices and portions; healthy snack recipes; physical activity; cold and ‘flu’ viruses; fun body facts about why humans burp, have gas, nasal mucous and ear wax; interviews with a child cancer survivor and an emergency room doctor; and a comic strip about using a phone service (Kids Help Phone) to talk with counsellors about issues such as bullying (magazine article examples are shown in Figure 1).

Figure 1).

Examples of magazine title page and articles. Upper left panel Magazine cover page. Upper right panel Helmet safety. Lower left panel Healthy eating. Lower right panel Accessing the Kids Help Phone counselling service

A healthy behavioural lifestyle challenge titled “Drop the Pop” was also included in the magazine to promote soda pop reduction among students in this population. This particular challenge was chosen because it enabled the evaluation of a measurable behaviour change that combined the students’ interest in healthy food with an important child health outcome, given the established link between high-sugar drinks and obesity.

The 20-page magazine was distributed in May 2009 to both the producer and consumer students at the school.

Outcomes

Student-reported outcomes were for the following domains: transfer of health knowledge; health interests; and behavioral response to the healthy lifestyle challenge.

Development of survey instruments

Questionnaires were developed based on the content of the magazine. They served to assess health knowledge transfer, health interests, and a healthy lifestyle behavioural response to a soda pop intake reduction challenge. The questionnaires consisted of three components. The first was a series of multiple choice questions that tested health knowledge based on content from the magazine. The second asked the children to rate their health knowledge on a four-point scale from poor to excellent. The final component asked the children to report their soda pop consumption. This project was embraced by the school leadership, and met curricular requirements for health literacy. The school facilitated time to complete the questionnaires. They were administered to students one day before and three days following magazine distribution, and were completed by both producer and consumer groups in the school gymnasium at the same time. Each question was read aloud to the students, and time was made available for them to respond to each question to ensure that the question was clear and to avoid interference from reading difficulties. All students in grades 4 to 6 were invited to participate; children who were absent from school on the day of the questionnaire distribution were excluded.

RESULTS

There was a 99% response rate for completion of both pre- and postquestionnaires (pre [n=74]; post [n=73]). In health knowledge transfer, 97% of all students in grades 4 to 6 reported that the magazine “helped [them] learn more about health”. The results for aggregate health knowledge showed that the proportion of students attaining 100% correct questionnaire scores did not significantly differ between pre- and postmagazine distribution (77% predistribution compared with 73% postdistribution [P=0.36]).

Regarding health interests, the student responders reported enjoying several health topics presented in the magazine, with the most popular content related to physical activity and healthy eating, and access to telephone counselling services. The top-rated stylistic features were the interviews and recipes (64% and 63%, respectively), followed closely by the fun facts section, comics and health tips (56%, 54% and 54%, respectively).

The results of the “Drop the Pop” challenge revealed a significant improvement in child-reported soda pop consumption: from 43% of students reporting drinking no soda pop before distribution of the magazine, to 67% who reported drinking no soda pop after distribution of the magazine (P=0.004). Furthermore, the results showed a significant improvement in soda pop consumption overall, with 66% reporting drinking ≤2 cups predistribution to 85% reporting drinking ≤2 cups postdistribution of the magazine (P=0.01) (Figure 2).

Figure 2).

Child-reported soda pop consumption before and after magazine distribution. *Statistically significant

DISCUSSION

In the present study, health attitudes, interests and knowledge of elementary students were explored through the production of a student-led magazine. This intervention was, to our knowledge, the first of its kind using a peer-directed health focus among an elementary age cohort. This unique focus provided us with a perspective that may have been different had we used adults to derive topics to include in the magazine. The use of health expert facilitation and oversight to ensure accurate health content was another critical component of the successful collaborative process.

Studies using newsletters to promote parenting practices have been shown to decrease parental stress, decrease inappropriate expectations, and influence parental attitudes (6,15,16). Tyrell et al (3) created a school-based health newsletter on topics selected by teachers and parents of elementary school children, with the content developed collaboratively with public health nurses. Satisfaction of parents, teachers and principals was assessed; however, students themselves were not specifically included in the target readership or evaluation process. Others have used newsletters for direct health promotion, for example, to increase adult patients’ compliance with blood pressure medications (5). In our study, we chose to examine knowledge, health interest and self-reported health behaviour among students themselves through questionnaires that were developed based on the magazine content. The questionnaires were not previously validated. We found a high self-reported perception of increase in knowledge; however, there was no detected quantitative increase in health knowledge following distribution of the magazine. This may be attributed to a ‘ceiling effect’, in that the predistribution knowledge scores on the questionnaire were >75%. Knowledge questions may have shown more change if they were piloted in advance to determine an appropriate difficulty level.

In addition to assessing knowledge translation, another goal was to enable behavioural change within these students. Pearson et al (17) was able to demonstrate that a family based newsletter for children and parents could successfully increase fruit and vegetable intake when compared with controls. Others were unable to demonstrate a change in behaviour with their newsletter (5). In our study, we demonstrated a self-reported decrease in soda pop consumption. This suggests that students can be motivated to make changes, develop an intervention and may follow through into action that affects their peers in a diverse school in an at-risk setting.

The present study had some limitations. First, we used self-reported measures of behaviour change to determine reduction in soda pop intake; thus, social desirability may have biased our results. Although the questionnaires were anonymous and students were not guided in their responses, measured actual behaviour change would have been an improved outcome. This outcome was measured over a very short time period (three days); longer-term follow-up is needed.

Our study used a pre-post design, with aggregate data collection and no control group. These data are hypothesis generating, and next steps may include a larger study using randomized controlled trial design to reduce bias. Finally, these study results are limited to one elementary school and, because participatory research tends to be context-dependent and driven by local participants’ engagement, the findings are not necessarily generalizable to other elementary students. This specific program requires more supportive data regarding impact before the allocation of limited educational resources can be justified.

Innovative strategies to engage students in acquiring health literacy and fostering health promotion among their peers may be important to address health disparities, particularly among at-risk populations, as suggested by previous studies on health literacy (9,18,19). Participatory action projects that build on existing community programs, and are adaptable to community needs merit further study. Future research in this area should focus on student-led approaches to health-related knowledge translation, and integration of education and health initiatives. Results from the present study may lead to the refinement of less resource-intensive approaches to support similar student-led initiatives that could be evaluated using standardized tools in several diverse school settings.