School and community drivers of child diets in two Arab cities: The SCALE protocol and innovative tools to assess children’s food environments

Abstract

Background In the context of the rapid nutrition transition experienced by middle-income countries of the Arab region, children and adolescent’s food choices and dietary behaviors are early risk factors for the development of non-communicable diseases. Assessment of factors influencing food choices among this age group is challenging and is usually based on self-reported data, which are prone to information and recall bias. As the popularity of technologies and video gaming platforms increases, opportunities arise to use these tools to collect data on variables that affect food choice, dietary intake, and associated outcomes. This protocol paper describes the SCALE study (School and community drivers of child diets in Arab cities; identifying levers for intervention) which aims to explore the environments at the level of households, schools and communities in which children’s food choices are made and consequently identify barriers and enablers to healthy food choices within these environments. Methods Field studies are being conducted in primary schools, among children aged 9–12 years, in Greater Beirut, Lebanon and Greater Tunis, Tunisia. A stratified random sample of 50 primary schools (public and private) are selected and 50 children are randomly selected from grades 4-5-6 in each school. The study includes surveys with children, parents/caregivers, school directors, teachers, and nutrition/health educators to assess individual diets and the contextual factors that influence children’s food choices. Innovative locally adapted tools and methods such as game-based choice experiments, wearable cameras and neighborhood mapping are used to describe the environments in which children’s food choices are made. Discussion The SCALE study will generate contextual knowledge on factors in school and neighborhood environments that influence child dietary behaviors and will inform multi-level interventions and policies to address childhood malnutrition (under-and over-nutrition). By integrating methods from various disciplines, including economics, data science, nutrition, and public health and by considering factors at various levels (home, school, and neighborhood), the study will identify levers for intervention with the potential to improve children’s dietary behaviors. This will help fill existing gaps in research on food systems and consequently guide positive change in Lebanon and Tunisia, with the potential for replicability in other contexts.

Urban school neighbourhoods dominated by unhealthy food retailers and advertisements in Greater Tunis: a geospatial study in the midst of the nutrition transition

“…Intervening at the level of food environments might be more effective in modifying children's diets than individual behavioural interventions that had limited success (55) . This is all the more necessary since findings from the larger SCALE study (35) of which the present study is partrevealed that about three quarters of children living in Greater Tunis tend to walk to school, and around 30 % of them purchased food from stores available on their way to/ from schools in the 24 hours prior to survey administration (unpublished data from SCALE study). Considering the density of obesogenic food retailers and advertising in school neighbourhoods, strategies used in other contexts and for other harmful behaviours, such as tobacco use (56,57) , could inform the development of effective interventions to enable healthy environments around schools in Greater Tunis.…”

“…This study is part of a larger project entitled ‘School and community drivers of child diets in Arab cities; identifying levers for intervention (SCALE)’, which aimed to investigate school and community-level drivers of children’s food choices in two Arab cities: Greater Tunis in Tunisia and Greater Beirut in Lebanon ( 35 ) . In the present study, we focus on the Tunisian part of the project.…”

“…private (30 %)); fifty children were then randomly selected within each school. The sample size of fifty schools was based on the sample size calculation conducted for the SCALE project – further details can be found elsewhere ( 35 ) .…”

“…A cross-sectional survey used a random sample of fifty primary schools proportionally stratified by type of school (public (70 %) v. private (30 %)); fifty children were then randomly selected within each school. The sample size of fifty schools was based on the sample size calculation conducted for the SCALE projectfurther details can be found elsewhere (35) .…”

Capturing children food exposure using wearable cameras and deep learning

“…Our machine-learning-based data-collection system described in the previous section was deployed in a case study in Tunisia and is currently being deployed in Lebanon [43]. In this section, we present the results from the cross-sectional study that was conducted only in Tunisia.…”