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Health Education Research Advance Access originally published online on October 23, 2006
Health Education Research 2006 21(6):884-895; doi:10.1093/her/cyl123
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© The Author 2006. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oxfordjournals.org

V.I.K. (Very Important Kids): a school-based program designed to reduce teasing and unhealthy weight-control behaviors

Jess Haines1,*, Dianne Neumark-Sztainer1, Cheryl L. Perry1, Peter J. Hannan1 and Michael P. Levine2

1 Division of Epidemiology and Community Health, University of Minnesota, 1300 South Second Street, Suite 300, Minneapolis, MN 55454, USA
2 Department of Psychology, Kenyon College, Gambier, OH 43022-9623

* Correspondence to: J. Haines. E-mail: haines{at}epi.umn.edu


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Conclusions
 Conflict of interest statement
 Acknowledgements
 References
 
The purpose of this study was to evaluate the feasibility and effectiveness of V.I.K. (Very Important Kids), a school-based, multi-component intervention designed to prevent teasing and unhealthy weight-control behaviors among fourth through sixth grade students. The effectiveness of the V.I.K. intervention was evaluated using a pre–post quasi-experimental design with one school assigned to each condition: intervention and assessment-only control. Data were collected at baseline and at 8-month post-test among 63 students at the intervention school and 57 students at the control school. The V.I.K. intervention included an after-school program, a theater program, school environment components and a family component. Process data suggest that the V.I.K. program can feasibly be implemented within a school setting and can effectively engage students, school staff and parents. Analysis of impact data revealed that the percentage of students reporting being teased decreased significantly in the intervention school relative to the control school, after controlling for baseline levels of teasing, body mass index z score and demographic factors (odds ratio = 0.22; 95% confidence interval = 0.06, 0.88; P = 0.03). These findings provide promising evidence that multi-component, school-based interventions may effectively reduce teasing in elementary schools. Future research of interventions aimed at preventing teasing using a larger sample of schools is warranted.


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Conclusions
 Conflict of interest statement
 Acknowledgements
 References
 
Weight-based teasing is prevalent among school-aged youth. A large population-based study of adolescents found that 19% of average-weight girls and 13% of average-weight boys reported being teased about their weight at school at least a few times a year, while >45% of overweight girls and boys report this frequency of teasing [1].

Weight-related teasing is associated with psychosocial and behavioral factors that may put youth at risk for developing eating disorders and obesity. Retrospective [2], cross-sectional [3, 4] and prospective studies [5] have found that being teased about weight is associated with body dissatisfaction, an established risk factor for eating disorders [6–8]. Prospective research has also shown that being teased about weight predicts weight-related behaviors that are associated with both eating disorders and obesity, including use of unhealthy weight-control behaviors and binge eating [9–11]. Thus, intervention programs aimed at reducing teasing among youth have the potential to impact the development of eating disorders and obesity.

Few studies targeting the prevention of weight-related disorders have specifically addressed teasing. In one study, conducted in an elite ballet school, students worked with research staff to establish school-wide norms that precluded any weight-related teasing. Although teasing was addressed within the intervention, changes in teasing behavior were not evaluated [12]. A second study used a puppet program to communicate messages about harmful effects of teasing to elementary schoolchildren [13]. This program, evaluated using a non-controlled design, was shown to be effective in communicating the message that teasing about weight was wrong in a small sample of elementary students [13]. Although two other intervention studies, one implemented among fifth grade students [14] and a second among middle school students [15], had some positive outcomes regarding body image, they did not achieve their goal of significantly reducing weight-related teasing.

The present study builds upon previous research by empirically testing the feasibility and effectiveness of V.I.K. (Very Important Kids), a theory-based, multi-component intervention designed to prevent teasing in an ethnically diverse, primarily low-income sample of fourth through sixth grade students. The specific aims of this study were to (i) assess the feasibility and acceptance of the V.I.K. program by students and school staff, (ii) evaluate V.I.K.'s impact on level of teasing and unhealthy weight-control behaviors reported by students using a controlled pre–post design and (iii) examine the extent to which intervention effects could be explained by significant changes in the key theoretical constructs addressed in the V.I.K. intervention, such as self-efficacy to impact teasing norms or peer weight-related norms/behaviors.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Conclusions
 Conflict of interest statement
 Acknowledgements
 References
 
Study design and population
The effectiveness of the V.I.K. intervention was evaluated using a pre–post quasi-experimental design with one school assigned to each condition: intervention and assessment-only control. The control and intervention schools were well matched in average school enrollment, race/ethnicity of student body, academic achievement scores and socio-economic status [16]. At both schools, ~90% of the students qualified for free or reduced lunch [16]. All fourth through sixth grade students at the intervention and control schools were eligible to participate. Parents or guardians provided signed written consent for their children to participate in the study. Ethical approval for this study was received from the Institutional Review Board of the University of Minnesota and the Saint Paul Schools Research Committee.

Description of the V.I.K. intervention
V.I.K. is a school-based, multi-component intervention designed to reduce teasing and use of unhealthy weight-control behaviors among elementary schoolchildren. Development of the V.I.K. intervention was informed by social cognitive theory [17] and by insight from key stakeholders at the intervention school, obtained via an in-depth formative assessment with students, parents, school staff and a V.I.K. advisory board comprising various members of the school community. During the formative assessment, teasing, not only about weight but also about ‘any difference’, emerged as a key issue affecting the students [18]. Staff, students and parents also identified poor body image and the impact of media's promotion of the thin ideal as important issues affecting students at the school. As a result of these findings, the primary aim of the V.I.K. intervention was to reduce teasing. The V.I.K. intervention employed a general no-teasing message to ensure that students learned that all teasing, including weight-based teasing, was not acceptable. In addition to activities focused on teasing, the V.I.K. intervention included activities to impact students' level of body satisfaction, internalization of the media's messages, use of unhealthy weight-control behaviors and key theoretical constructs associated with teasing behavior (e.g. self-efficacy to impact teasing norms). Activities implemented at the individual level focused on changing the student's behavioral and personal factors influencing teasing and disordered eating behaviors (Table I). The intervention also included environmental-level strategies that focused on changing social norms regarding teasing and weight at the school and in the student's home environment (Table I).


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  		Table I Description of V.I.K. intervention components

 
Program evaluation
Due to the pilot nature of this study, emphasis was placed on evaluation of the feasibility and acceptance of the V.I.K. intervention. Research staff documented attendance at and implementation of each of the program activities. Individual interviews of fourth through sixth grade teachers at the intervention school (n = 5, 83% of fourth to sixth grade teachers) were conducted and process evaluation surveys of the after-school program were completed by intervention school students (n = 42, 70% of the students who participated in the program).

Impact of the V.I.K. program on the primary outcome (teasing), secondary outcomes (media internalization, body satisfaction and unhealthy weight-control behaviors) and key theoretical constructs addressed in the intervention (e.g. self-efficacy and behavior of role models) was assessed using data from the impact survey that was completed by students at baseline and post-intervention. Measures included in the impact evaluation survey and their respective psychometric properties are described in Table II.


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  		Table II Impact evaluation measures for V.I.K.

 
Analytic methods
Qualitative data obtained from detailed notes taken during process evaluation interviews with school staff were reviewed using content analysis [26] for consistent themes across interviews. Frequencies (e.g. number and percentage of those who would recommend program to a friend) were calculated for the quantitative data collected from the student process surveys.

For impact evaluation, analyses were conducted using an intention-to-treat protocol, which involves analyzing the participants' data in their baseline condition (intervention or control), without regard to the number of intervention sessions attended. Two-sided tests of significance were performed, with P ≤ 0.05 considered statistically significant.

Regression analyses were conducted to assess between-group differences in the outcome measures at post-intervention. Logistic regression was used for binary outcome variables and linear regression was used for continuous outcome variables. In regression models, the dependent variable was the subject's response at post-intervention, with the baseline value of the measure entered as a covariate. This was done to adjust for any imbalances at baseline and increase precision of the estimate [27]. The independent variable of interest was intervention status (treatment versus control). Gender, grade, race/ethnicity and body mass index (BMI) z score were included in the models to balance the level of these covariates across conditions.

To assess the extent to which intervention effects could be attributed to significant changes in the key theoretical constructs addressed in the intervention (e.g. self-efficacy to impact weight-teasing norms), regression models predicting treatment effect were re-estimated to include both the baseline and post-intervention values of the theoretical constructs for which significant treatment effects were found. A construct was considered to mediate the intervention effect if, when added to the regression model, the intervention effect was reduced and the construct was significantly associated with the outcome variable [28]. All analyses were conducted using SAS 8.2 [29].


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Conclusions
 Conflict of interest statement
 Acknowledgements
 References
 
Participation, follow-up and baseline characteristics
Study design and participant flow is illustrated in Fig. 1. At the baseline assessment in September 2003, the participation rate was 63% at the intervention and 45% at the control school. Major reasons for non-participation at baseline were similar at the intervention and control schools and included lack of parental consent (67% of all non-participants), parent refusal (22%) and school transfer (10%). Among those that participated at baseline, the response rates to the post-intervention survey held in May 2004 were 80% in the intervention school and 79% in the control school. The major reason for lack of post-intervention participation (94%) was school transfer.


Figure 1
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  		Fig. 1 Study design and participant flow for V.I.K. intervention study. *At baseline and post-test evaluations, only those present completed evaluation surveys.

 
Baseline data revealed no significant differences between the intervention and control subjects in gender, age, BMI or the primary and secondary outcome variables (Table III). There were some differences in ethnic composition, with a lower percentage of Asian-American and Hispanic students in the control school than in the intervention school. There was also a higher percentage of fourth grade students in the control school than in the intervention school.


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  		Table III Baseline characteristics of participants in V.I.K. by treatment group

 
Process evaluation
Student participation in the after-school and theater programs was high, suggesting that these programs are effective at reaching and engaging students and they can feasibly be implemented within a school setting. Of the 62 students who attended the after-school program, 65% attended seven or more of the sessions. Approximately 83% of the 18 students who attended the theater program attended all 10 of the theater sessions. The number of students who were able to participate in the theater program was limited to allow for adequate contact with program staff. The feasibility of the V.I.K. intervention is further supported by the program's sustainability. At the request of school staff, since the completion of the study, the V.I.K. intervention has been continued in the intervention school and has been added to the after-school curriculum in a second school. The schools have covered the cost of implementing the program. Given the existing infrastructure for after-school programming, the schools were able to implement the program for ~$450.00 per year (1.5 hours/week for 10 weeks at $10.00/hour per leader for two program leaders, $75.00 for program supplies and $75.00 for 1 hour of staff training).

Student satisfaction with the after-school program was also high: 95% of students reported they were ‘happy’ or ‘very happy’ with the program and 79% of students reported they would recommend this program to a friend. Approximately two-thirds of the students (67%) reported that the program was ‘somewhat’ or ‘definitely’ helpful in ‘making you feel better about yourself’ and ‘reducing the amount of teasing that happens in your school’ (58%).

Parental attendance at the two family nights held in conjunction with the after-school program was low. Less than 15% of the families of students who were in the after-school program attended the first two family nights. A much higher percentage of families (71%) came to watch their child participate in the theatrical production.

Teachers (n = 5) at the intervention school who were interviewed about the V.I.K. program discussed the behavioral changes they noticed among the students. The most apparent behavior change that teachers noticed since the implementation of V.I.K. was in the students' ability to intervene when teasing occurred. One teacher noted, ‘I have seen an increase in confidence [in the students]. They don't put up with much. Won't put up with teasing. They address other students' comments and let them know it is not acceptable’.

When asked what component of the V.I.K. program was most effective, four of the five teachers interviewed mentioned the after-school program. Reasons the after-school program was so effective included that ‘so many students participated’, and it provided a ‘sustained and consistent message’ throughout the semester.

Impact evaluation
Teasing
Prevalence of overall teasing in the control school increased from 21.1 to 29.8% over the study period, while in the intervention school, the level of teasing decreased from 30.2 to 20.6% (Table IV; Fig. 2 depicts prevalence of teasing at each school, adjusted for gender, race/ethnicity, grade level and BMI z score). After controlling for baseline level of overall teasing, BMI z score and demographic factors, the odds of students being frequently teased were significantly lower in the intervention school relative to the control school [odds ratio (OR) = 0.22; 95% confidence interval (CI) = 0.06, 0.88; P = 0.03].


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  		Table IV Estimated change in frequent teasing from baseline to post-intervention for students in V.I.K. intervention (n = 63) versus control (n = 57) schoola

 

Figure 2
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  		Fig. 2 Percentage of participants in the V.I.K. control and intervention schools reporting frequent teasing at baseline and post-intervention, adjusted for gender, race/ethnicity, grade level and BMI z score.

 
Post hoc analyses were done to examine each component of teasing that made up the overall measure of teasing (teased about appearance, teased about weight and being called names). These analyses revealed that the odds of being frequently teased about appearance were significantly lower in the intervention school relative to the control school, after controlling for baseline level of overall teasing, BMI z score and demographic factors (OR = 0.35; 95% CI = 0.14, 0.93; P = 0.04). Although the prevalence of weight-related teasing decreased from 27.0 to 25.3% over the study period in the intervention school and increased from 21.1 to 29.8% in the control school, this difference was not statistically significant (OR = 0.73; 95% CI = 0.22, 2.30). Similarly, no statistically significant difference was found in the percentage of students who reported being called names at the intervention school as compared with the control.

Secondary outcomes and key theoretical constructs
In general, there were few significant group differences observed for the secondary outcomes and key theoretical constructs addressed in the V.I.K. intervention (Table V). Nevertheless, significant group differences were observed for two theoretical constructs addressed in the V.I.K. intervention. There was an increase in self-efficacy to impact weight-teasing norms (0.71 scale units; 95% CI = 0.3, 1.2; P = 0.002) and a decrease in negative peer weight-related norms (–1.2 scale units; 95% CI = –2.4, –0.2; P = 0.04) in the intervention school relative to the control school, after adjustment for baseline levels of the constructs, BMI z score and demographic factors.


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  		Table V Estimated change in difference in secondary outcome measures and theoretical constructs from baseline to post-intervention for students in V.I.K. intervention (n = 63) versus control (n = 57) schoola

 
Theoretical constructs as mediators for intervention effect
We hypothesized that change in key theoretical constructs, such as self-efficacy, could explain the intervention effect observed for teasing. Regression results indicated that of the theoretical constructs for which significant treatment effects were observed (peer weight-related norms/behaviors and self-efficacy to impact weight-teasing norms) only weight-related norms/behaviors mediated the intervention effect for teasing. When entered into the regression model predicting the treatment effect for teasing that is adjusted for the baseline value of peer norms, peer weight-related norms/behaviors was independently associated with change in teasing (P = 0.05) and the intervention effect was no longer statistically significant (P = 0.10). Thus, the intervention's effect on teasing was mediated by its impact on peer weight-related norms/behaviors (i.e. peer teasing and dieting behaviors).


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Conclusions
 Conflict of interest statement
 Acknowledgements
 References
 
The present study assessed the feasibility and effectiveness of V.I.K., a multi-level, school-based intervention designed to reduce teasing among elementary schoolchildren. Process data suggest that the after-school program, the theater production and the various activities of the family and school outreach components can feasibly, and at a relatively low cost, be implemented within a school setting in ways that effectively engage students, parents and school staff. Impact evaluation results indicate success in reducing the percentage of students who reported being teased at the intervention versus the control school. The percentage of students that reported being frequently teased decreased in the intervention school by 10% over the study period, whereas in the control school, self-reports of being frequently teased increased.

In addition to assessing feasibility and effectiveness of the V.I.K. intervention, we also examined the potential mediating effect of the theoretical constructs for which significant intervention-related changes were observed (peer weight-related norms and behaviors and self-efficacy to impact weight-teasing norms). This examination of potential mediators can help identify components of the intervention that are and are not critical to its success [30]. Only peer norms and behaviors were found to significantly mediate the intervention's effect on teasing, indicating that intervention-related changes to peer norms were critical to the intervention's effect on teasing, whereas intervention-related changes to self-efficacy were not. This finding suggests that researchers and public health practitioners wishing to design interventions to reduce teasing in schools should include activities to change social norms regarding teasing [12, 13]. Similar findings have been found in drug prevention programs aimed at youth; changing social norms has been a consistent and significant mediator of many interventions' effects on alcohol, tobacco, and marijuana use in youth [31]. Environmental-level intervention strategies, such as those used in the V.I.K. intervention to alter social norms at the intervention school (e.g. a school-wide no-teasing campaign and viewing of a theatrical production promoting the no-teasing message), may be useful strategies for program developers to use in attempting to change social norms among elementary schoolchildren.

Our findings yielded important lessons regarding parent participation in school-based programs. While it is known that parental involvement in prevention efforts is critical due to their potential to influence their child's weight-related behaviors, parental attendance at intervention events has generally been low [15, 32, 33]. Similar to family events in other school-based interventions, V.I.K.'s first two family nights did not involve students in the planning of the event and were poorly attended. In contrast, >70% of families came to watch their child perform in the V.I.K. student-created play. It is likely that the students, due to their involvement in the play's development, were engaged and excited about the performance and, therefore, helped motivate their families to attend the event. To capitalize on the ability of student-created performance to reach out to parents, future behavior-change interventions could implement student-created plays or other performance works (e.g. cooking shows or demonstrations of various physical activities) in an attempt to communicate messages about the importance of parental influence and support for the desired behavior change.

Strengths and limitations
A major strength of the V.I.K. program was the use of a participatory approach in the development and implementation of the intervention. Use of this approach, which is outlined in the World Health Organization's Health Promoting Schools Framework [34], is recommended when implementing prevention initiatives as a way to ensure the resulting intervention is culturally relevant and reflective of the participants' experiences [12, 35–37]. Another strength of the V.I.K. program was the use of a multi-level intervention that included strategies focused on individual-level factors, as well as school and family outreach. In contrast to interventions focused on individual change, this multi-level approach can be expected to impact students' behavior after the intervention is complete because of its focus on changing norms within the school environment [38–40]. A further strength of the study is the use of a pre–post controlled design.

The pilot nature of this study should be taken into account when interpreting the results of the study. The small sample size is a limitation of the study design. With only one school per condition, we were unable to control for group-level variability because the intervention effect is completely confounded with the school-level component of variance [41]. Thus, it is possible that the inferences are liberal [41]. A second related limitation of V.I.K.'s study design is that the schools were not randomized to conditions. Baseline data suggest that participants in the control and intervention schools were comparable on measured variables. However, given the non-random assignment, it is possible that our observed results may reflect unmeasured baseline differences, although there is no evidence that this was the case. Another limitation of the study design is that not all of the students in the schools participated in the study. It is unknown how participants and non-participants differed regarding demographics or primary or secondary outcomes. The lack of impact on many of the secondary outcomes suggests that a more intensive intervention may be needed to achieve significant changes in these outcomes. These limitations should be addressed in future studies by creating a more intensive intervention, perhaps by including a specific classroom-based component, that is able to adequately address secondary outcomes and by evaluating the intervention using a group-randomized controlled trial with a larger sample of schools.


   Conclusions
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusions
Conflict of interest statement
 Acknowledgements
 References
 
V.I.K. was developed and implemented using a participatory approach that involved collecting input from students, school staff and parents, and empowering students to develop their own intervention strategies. Process data suggest that V.I.K. is feasible and utilizes activities that effectively engage students, school staff and parents. The V.I.K. intervention effectively reduced teasing using a multi-level approach that aimed to influence both individual- and school-level factors influencing weight-related norms and behaviors. Given the high prevalence of teasing among youth [1], the impact teasing has on the physical and psychosocial well-being of youth [4, 11] and the initial success of the V.I.K. intervention in decreasing teasing among elementary schoolchildren, future experimental studies of school-based interventions aimed at preventing teasing using a larger sample of schools are warranted.


   Conflict of interest statement
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusions
 Conflict of interest statement
Acknowledgements
 References
 
None declared.


   Acknowledgements
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusions
 Conflict of interest statement
 Acknowledgements
References
 
This work has been supported by a grant from the Blue Cross and Blue Shield of Minnesota Foundation Grant No. 394029.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusions
 Conflict of interest statement
 Acknowledgements
 References
 
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42. Illusion Theater. Illusion Theater: Education and Outreach. Available at: http://www.illusiontheater.org/education/. Accessed: 15 March 2006.

Received on March 28, 2006; accepted on August 31, 2006


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