Evaluation of a school-based intervention aimed at increasing the nutritional awareness of 7-10 year olds using performing arts.

H.R. Lees and Dr. P. Mani Das Gupta

Psychology and Mental Health, Faculty of Sciences, Staffordshire University, Stoke-on-Trent, England

Address for correspondence: Dr. P. Mani Das Gupta. Email m.dasgupta@staffs.ac.uk

(Received ....; final version received ....)

Despite a number of interventions aimed at children, research continues to highlight increasing evidence of the detrimental short and long-term health implications of obesity in childhood. One reason why childhood interventions do not seem to be making a huge impact may be the use of developmentally inappropriate educational material.

The current study investigated the effectiveness of Active participation within a drama workshop for delivering existing health education material in contrast with Observation of Drama, and a No Drama intervention. In addition to a scored meal depiction questionnaire, the meal choice justifications of the 219 participants, aged between 7 to 10 years, were explored using thematic analyses.

The results indicated a developmental difference in the effect of the intervention type. Specifically, the 7-9 year olds use of the 'Balance of Good Health Model' (BGHM) themes to justify their meal choice, was supplemented by drama observation as appose to a reverse in this trend by the age of 10, when active participation in drama was more effective. These finding are discussed in relation to Piagetian research, criticism of the BGHM’s use with younger children and suggestions for future investigation.

Both the quantitative and qualitative findings suggested that older children were more able to depict a ‘healthy meal’, and justify their reasoning in accordance with the intervention themes following a drama intervention. Therefore, drama could be an effective way of supporting the education of 9-10 year olds when using themes from the Balance of Good Health Model (BGHM; FSA, 2001). However, 7-8 yr olds understanding of the model was not found to be supplemented by drama participation or observation. This finding is discussed in relation to criticism of the BGHM’s use with younger children and suggestions for future research.

Introduction

Childhood Obesity; The Issues

“We are in the midst of an obesity epidemic and must use all the weapons in our armoury to

prevent the next generation of British children being the most obese and unhealthy in

history” Dr Vivienne Nathanson, Head of Science and Ethics at the British Medical

Association (2006)

The increase of childhood obesity in Britain between 1995 and 2007 (NHS, 2009a)

has been the cause of much alarm considering the strengthening evidence of its detrimental

effects. Reilly & Wilson’s (2006) review of the literature, for instances, describes the ‘major

health burden’ obesity can cause at any age, including cardiovascular risk factors, diabetes,

cancers, arthritis, and psychological ill health .

Dietary imbalance has been highlighted as an influential factor with regards

increasing obesity rates in childhood. The National Dietary Survey (2000) investigating the

eating habits of 4-18 years olds, reported a worrying increase in the consumption of high

energy-dense foods such as white breads, crisps and confectionary snacks by Britain’s young

people, and reduced intake of fruit and vegetables. Of further concern is the evidence that

these dietary trends appear to be unaffected by national nutritional awareness campaigns such

as “5 a Day” and “Change for Life” (DOH, 2009; NHS, 2009b), with the latest NHS statistics

suggesting that still only one in five children between 5 and 15 yrs are meeting their

recommended daily fruit and vegetable allowance (NHS, 2010). These worrying dietary

trends are particularly noticeable in the North Staffordshire region where the overweight and

obesity prevalence amongst the under 12s is higher than the National average. Consequently,

this region has been targeted as of ‘high priority’ for receiving intervention (Staffordshire

Children’s Trust, 2007).

Interventions

A number of interventions have been used to tackle imbalance in children’s diets.

Nutritional Education through schools is seen as an effective option. , Aldinder & Jones

(1998) in their Health Promotion in Schools review, suggested that the school environment ,

is particularly effective for passing on information not only to a large number of pupils, but

also to school staff, families and whole communities . Past multidisciplinary school

interventions, such as that implemented by Sahota et al (2004), have been relatively

successful in positively impacting children’s dietary behaviour, specifically their vegetable

consumption. This improvement in early behaviour is all the more important in light of

findings that some aspects of dietary behaviour, particularly fat intake, remain reasonably

stable between childhood and adulthood (Bertheke Post et al, 2001)

During a review of school-based nutritional interventions, Perez-Rodrigo and

Aranceta (2003) identified a number of characteristics which appeared important for an

effective interventions. Those found to be key included the need for a theory driven strategy

that is developmentally appropriate, creative and engaging. In addition to exploring these

suggestions in greater detail, the current article will also aim to investigate the extent to

which Perez-Rodrigo and Aranceta’s findings are fulfilled by using Theatre in Education

(TIE) as a creative and engaging approach to health education.

Theatre in Education: A creative and engaging approach

Theatre in Education (TIE) derived in the mid 1960s from a desire to facilitate social

change by encouraging greater interaction between theatre and the community. More

recently, Theatre in Health Education (THE) has emerged as a distinct form of TIE concerned

specifically with health education. A major advantage of THE interventions is their success in

engaging children who are not responding well to conventional teaching methods. Amongst

the sources reporting this outcome, is the teachers involved in the Starbites performing arts

intervention by Perry & May (2006). The aim of the research was to increase pupils

awareness of healthy eating from 7 primary schools in Cheshire, which the teaching staff felt

was achieved. In addition self-esteem and team building skills also increased as a result of

this intervention.

The success of unconventional approaches to teaching, such as THE, is arguably

because of their employment of Intrinsic motivations. Intrinsic motivations, or the enjoyment

gained purely from performing a certain behaviour, was found by Parker and Lepper (1992)

to be a more effective educational tool than extrinsic motivations (external rewards received

as a result of certain behaviours). Parker and Lepper used fantasy or non fantasy embellished

computer programs to teach children about geometric shapes, and found that understanding

and retention of knowledge was significantly better in the group using the, intrinsically

motivating, fantasy computer program.

Furthermore, a literature review of school-based drug prevention programmes by

Cuijpers, (2002), also found that ‘interactive delivery methods’ were ‘superior’ to non-

interactive programmes. Relating this to THE , it has been shown that while observation of a

drama performance can positively impact children’s nutritional awareness, active

participation with the subject matter (linked to intrinsic motivation) has a stronger impact

upon behaviour. For example, while Perry et al’s (2002) ‘Alls Well That Eats Well’ school

tour production produced a significant effect on knowledge, the interventions effect on actual

eating behaviour in the short-term was not significant. However, despite Perez-Rodrigo and

Aranceta’s recommendations for using creative and engaging material, the effectiveness of

employing intrinsic motivations through participation in THE, and the insertion of ‘fun’ into

health education, are under investigated (Perry & May, 2006).

Developmental appropriateness

Developmental appropriateness of educational material is another characteristic

highlighted by Perez-Rodrigo and Aranceta as essential for successful interventions. Hart,

Bishop, & Truby (2002) investigation the nutritional awareness of 7-11 year olds and found

the majority grouped foods in terms of concrete ideas, such as eaten for main meal, rather

than abstract concepts, such as nutrients. They therefore, questioned the emphasis upon

abstract ideas in current educational material, such as that based upon the Balance of Good

Health Model (BGHM; FSA, 2001). This model advocates the importance of eating a

“balanced” diet, i.e. a diet containing a variety of the right amounts of foods from each of the

5 food groups, and is currently taught as part of the UK National Curriculum (NC) from

around the age of 5 years (British Nutrition Foundation, 2008).

Based on their research, Hart et al, suggested that cognitive barriers determine

children’s understanding more than quality or quantity of educational information provided.

Hart et al’s (2002) findings are in line with a body of developmental research, which argues

that younger children are more able to deal with concrete rather than abstract thinking (Piaget

& Inhelder, 1969). This is also supported by more recent research that demonstrates age-

related development in children’s health concepts (Zeinstra et al, 2007; Contento, 1981).

Working with 5-11 yr olds, Contento (1981) for example, reported that younger children

(pre-operational stage -aged about 2-6years) were able to name healthy foods but not give

reasons as to why they considered these foods healthy. The older, (concrete operational

stage- age 7-11years) children, understood that foods change in the body to produce effects

such as strength and growth, but were not able to explain how this occurred.

Similarly, Zeinstra et al (2007) demonstrated that 4-5 yr olds relied upon concrete

concepts, such as colour, while 12 yr olds were able to categorised food using abstract

concepts like food groups. In light of this research, THE could be employed to give a

physical aspect to abstract concepts in support of younger children’s understanding. Indeed,

Ulas (2008) noted during an investigation into the use of dramatic activities in the

development of primary school children’s oral skills, that the variety available meant drama

is a method of education which lends itself well to accommodating for the needs, interests

and developmental level’s of individuals. Such research emphasises the need to use material

that is not only engaging but also appropriate to a child’s cognitive level in order to deliver

effective health promotions.

Research Aims

In light of these observations, the primary aim of the current study is to investigate if

Active participation in a drama workshop will increase 7-10 yr olds ability to depict a healthy

meal as outlined in the BGHM in comparison to that of participants Observing the drama (as

in Perry et al, 2002), and a Control group who will not be exposed to drama at all. Reviewing

the literature suggests that THE’s ability to depict/ ‘give flesh’ to abstract concepts as well as

promote intrinsic motivation will result in active participation in the drama having the

greatest impact on children’s knowledge of what a ‘healthy meal’ contains. A secondary aim

of this study is to investigate the developmental progression of children’s nutritional

understanding, especially with regards observing any age differences in the justifications

given by children regarding their dietary choices.

The Research Project

This study was designed to compare children’s ability to depict a ‘balanced’ meal and

the reasons for their choices, both before and after an intervention. Therefore, a mixed

before-after design was used, with 2 independent variables (age and intervention), and 2

dependant, within-subject variables (Healthy meal descriptions before and after intervention).

There were four age groups (7, 8, 9 and 10 yrs) and three intervention techniques were used

(Active participation in drama, Observation of drama and Control – no drama). The

dependant variable was assessed by obtaining an annotated depiction of a healthy meal before

and after intervention that was scored in accordance with the BGHM.

Who took part

A total of 219 children (both males and females) from community groups and primary

schools in the Newcastle-under-Lyme area of North Staffordshire took part. They were all

being taught at KS2 and aged between 7 and 10 yrs. , Both a group/school representative and

parent/guardian supplied informed consent for participation. Equal sample sizes and at least

20 participants in each group according to age, sex and intervention condition were found to

be required to maintain the robust nature of the multivariate technique being used to analyse

the data (Stevens, 2009). However, time and school attendance constraints meant that this

was not possible (as shown in Table 1), therefore, compensations were made during analysis.

Materials used

Questionnaire

Pre and post intervention dietary awareness was measured using an identical ‘Draw

and Write’ questionnaire (DWQ) shown in Figure 1, requesting the depiction of a ‘healthy

meal’ as well as written reason for meal choices drawn. The DWQ was based on previous

research as well as current NC KS2 assessment of nutritional knowledge (QCDA, 1999). It

was used to enable the children to express their food choices in a more ‘fun’ way than simply

writing text. The drawings were scored in conjunction with the written responses, used to

explain their choices, so as to avoid misinterpretation.

Figure 1. Draw and Write Questionnaire

The Action!!

Firstly, for identification purposes, the participants consent forms (collected

beforehand) were assigned individual numbers to correspond with the subsequent material

each participant would receive during the project. These were also used to randomly assign

the participants into one of the three conditions done on the day to allow for absences.

Secondly, a scripted introduction was delivered to the participants to introduce the

researchers, and to inform them of the procedure. All participants were then given their

appropriately numbered pre-test DWQ receiving verbal explanations on how to complete the

questionnaire before being pretested as a group in exam style conditions.

Then, all participants were taken to the drama room to participate in a group warm up

designed to be fun, motivate and prepare those who were to take part in the drama. All

participants were then read the intervention material (BGHM information) in the form of a

complex scenario written especially for the research (Box 1; Figure 2). information adapted

from the BGHM.

Box 1. The Golden Lunchbox Story Extract

Scene 1 the golden lunch box

1. Our scene opens to Jo sitting on a bench with his lunch box in the school playground.

2. Thinking to himself, Jo looks up into the sky and begins to wonder what is for lunch

today

3. Another child sits down opposite Jo and opens their lunch box

4. Looking across, Jo watches with intrigue as it falls open to reveal an egg and cress

sandwich, an apple, carrot sticks, a carton of milk and with a small packet of wine gums.

5. Jo closes his eyes, holds his breath and opens his lunch box to reveal a jam sandwich,

packet of crisps a chocolate bar and bottle of cola.

6. Jo shouts “Yes!” (wait for actor to say line) and began to brag how he had gotten all

of the nicest food to the other child

7. The other child says “well your meal is very nice, (wait for actor to say line) but mine

is made to be a tasty balanced meal, (wait for actor to say line) to give me energy and keep

me healthy”

8. Jo doesn’t understand and claims that it’s not that healthy because it includes a small

bag of wine gums which contain a lot of sugar that is bad for you.

9. The other child looks at Jo and says “no foods are bad for if you (wait for actor to say

line) if you eat them in the right amounts. Because it’s important to have a balance of all five

food groups to achieve a healthy meal.”

Figure 2: Story telling at Bursley Way Primary School

Following delivery of the intervention material, the three groups were split up as

follows; The Active and Observation groups remained in the warm up venue. The

Observation group were seated and watched participants from the Active group act out the

‘Golden Lunchbox’ scenario using props and costumes (Figure 3). At the same time, the

Control group was taken to a separate classroom to watch a DVD version of a story (Dahl,

1982) unrelated to the initial ‘Golden Lunchbox’ story.

Figure 3: Photos of children in the Active group at Chesterton and Richard Heathcote

Primary School’s

All participants were then brought back to the original classroom and instructed to

complete a recall questionnaire regarding information from the ‘Golden Lunch Box’ Story as

part of a colleagues research. Following this, all participants were given their appropriately

numbered post-test DWQ (identical to the pre-test DWQ) and debriefed as a group regarding

the research aims after completing the testing.

The Results

Quantitative

Multivariate Analysis of Variance (MANOVA) was used to analyse the effects

between age, condition and pre and post ‘healthy meals’ depiction scores, the assumptions for

which were met in accordance with Pallant (2007). To improve the unevenness of the groups

sample sizes, the 10 yr old quantitative data was not included in the MANOVA analysis

because of the lack of participants in this age group (Table 1). Similarly, although gender was

controlled for by including both sexes, it was not included as a variable during analysis

because of the lack of evidence supporting gender as a factor affecting interventions

promoting healthy eating at KS2.

Table 1 depicts an increase in the post-DWQ mean scores for all three conditions and

across the ages; most markedly for the Active 9 yr olds and interestingly, the Control group

post-scores also showed an increase.

Table 1. Descriptive Statistics

Pre-score Post-score

Age Condition mean SD mean SD N

7 Active 3.81 1.7

2

5.86 2.59 21

Observation 4.59 2.3

2

4.88 2.37 17

Control 4.53 1.6

2

5.35 2.03 17

Total 4.27 1.9

0

5.40 2.35 55

8 Active 4.38 1.8

6

5.24 2.45 21

Observation 4.81 1.7

2

5.32 2.27 31

Control 4.43 1.7

5

5.11 2.18 28

Total 4.56 1.7

6

5.22 2.27 80

9 Active 4.76 1.9

2

7.00 2.78 17

Observation 4.88 2.5

5

6.38 1.98 26

Control 4.17 1.2

9

6.39 2.28 18

Total 4.64 2.0

7

6.56 2.29 61

10 Active - - - - 7

Observation - - - - 2

Control - - - - 14

Total - - - - 23

The MANOVA showed a significant main effect for age (F (4,372)=3.591,p=.007,

η2=.037) indicating that the DWQ scores improved with age. However, the main effect of

age was found to be significant across the post-test (F (2,187)=6.55, p=.002, η2=.065) and

not pre-test scores (F (2,187)=.379, p=.685, η2=.004). This indicates that the pre-test scores

between the age groups were not significantly different, whereas the post-test scores were.

Three post-hoc t-tests were conducted between the post-test scores for 7-8, 7-9, and 8-

9 yr olds to explore the significant main effect for age upon the DWQ post-test scores. A

Bonferroni correction was used to adjust the alpha level to permit multiple testing (α =.002).

A significant difference was found between the 8 and 9 yr olds post-test DWQ scores (t

(139)=-3.437, p=.001, 2-tailed, d=.88) with a large effect size according to Cohen(1988).

This indicated that the 9 yr olds had scored significantly higher than the 8 yr olds. There was

a verging on significant difference between 7 and 9 yr olds post-test scores (t (114) = -2.681,

p=.008, 2-tailed, d=.76) with a medium to large effect size (Cohen, 1988), signifying the 9 yr

olds had scored better than the 7 yr olds on the DWQ post-tests but not quite significantly so.

Finally, there was no significant difference between the 7 and 8 yr olds post-test DWQ scores

(t (133) = .433, p=.67, 2-tailed, d=.26), suggesting the 7 and 8 yr olds post-test scores were

the least different of the three age-group comparisons.

Qualitative

Thematic analysis was used to report the 7-10 yr old participant’s written responses.

This analysis was used to investigate justifications for meal choices and expand upon the

quantitative data interpretations. In answer to the question (on the DWQ) “Why is the meal

you have drawn healthy?”. Four dominant themes were identified Each dominant theme

accounted for over 10% of the total responses (Table 2).

The theme with the highest overall frequency was found to be the Food-Health link at

34% of the total responses (Table 2), and is exampled in the following extracts, “Because

peas are vegetables, carrot is a vegetable. Broccoli is a vegetable. Chicken is a meat”, (age

7); “It includes vegetables and a healthy drink, you also have some dairy (cheese) plus

potatoes and bread. You also have some meat (chicken)”, (age 10).

Secondly, Food- nutrient links accounted for 13% of the total responses and included

mention of protein, carbohydrates, vitamins and minerals, calcium and one mention of fibre,

“The tuna steak has protein, the potatoes has carbohydrates and the bread has fibre” (age

7); “I think it is healthy because it has vitamins in it”, (age 8); “The spicy chicken leg gets

calcium in you”, (age 9).

Table 2. Four most frequent theme descriptions and frequencies

Themes Description Total frequenc

y %

1. Food-health link ** Considered healthy because it contains a single or combination of foods or food groups

34

2. Food-nutrient link *

Foods or food groups linked to the specific nutrient they provide but not detailing how these are used

13

3. Balance Using the word “balance” or indicating the need for right amount.

12

4. Food-health outcome links*

Food, food groups or nutrient linked to an effect upon the body without detailing mechanism.

12

* Themes from Hart et al, (2002) ** Themes from Zeinstra et al, (2007)

Similarly, the theme of Balance, which is key to the BGHM, accounted for 12 % of

the total responses (Table 2), and is evidenced in the following quotes, “My meal is healthy

because it is a balanced meal”, (age 10); “This is healthy because it has veg in and you need

a little amount of everything but not too much otherwise it is bad”, (age 7).

Food-health outcome links also accounted for 12% of the total responses, featuring a

wide range of ideas including whole body effects such as being good for the body, aiding

growth and strength, and extending life, “Lettuce sandwich is good for your body”, (age 7).

Specific benefits to teeth, bones, the brain and heart were also reported. Furthermore, the

provision of energy was mentioned, and extended in some cases with reference to the use of

energy for activities, “I think that healthy food gives you energy to do things like running

walking and jogging”, (age 9). Finally, healthy and unhealthy foods were discussed in terms

of their capacity to change body weight, “My meal is healthy because that it does not contain

sugar in the inside of it. Because the sugar can cause fat in your body!!!”, (age 9).

The frequency of the top four themes between pre and post-testing for each age group

was also investigated to expose any intervention effect (Table 3).

Table 3. Pre and post- test % responses by the four most frequent themes and age

Age Response time inrelation to

intervention

1 Food-health

2 Food-nutrient

3 Balance 4 Food-Health

outcome7 Pre 42 13 7 10

Post 39 12 7 11

8 Pre 35 14 10 15

Post 36 20 12 12

9 Pre 28 10 7 11

Post 16 7 33 7

10 Pre 47 10 6 16

Post 16 5 34 10

On the pre-test, the Food-Health theme was the most frequently used by all of the age

groups ( average of 38%). At post-test, frequency remained similar and highest for the 7 and

8 yr olds, however, frequency dropped by 12% for the 9 yr olds and 31% for the 10 yr olds to

become the 2nd most frequent theme after Balance (Table 3). The Food-Nutrient and Food-

Health outcome links were found to follow a similar trend. Responses regarding these two

themes were relatively similar at pre-test across the ages from between 10-16%. At post-test,

use of the themes remained the same for the 7 yr olds, with a relatively small increase in the 8

yr olds use of Food-Nutrient themes. and decrease in the use of both themes by the 9 and 10

yr olds (Table 3). This result supports past research that older children do seem to take

abstract ideas like nutrients into account when making food choices.

The Balance theme was used with a similar frequency across the age groups at pre-

test, with the 7 and 8 yr olds maintaining comparable use at post-test. For 9 and 10 yr olds,

however, the frequency increased by 26% and 28% respectively (Table 3) with an example of

theme change between pre and post-test depicted below (Figure 4 & 5).

Figure 4. Pre-test use of Variety theme

Figure 5. Post-test change to depiction and use of the Balance theme

Breaking this down further, Table 4 represents the frequency of Balance themed post-

intervention responses according to the three intervention conditions. Post-test Balance theme

use, was highest from participants in the Passive condition for 7, 8 and 9 yr olds, but most

notably by the 7 and 9 yr olds. The 10 yr olds from the Active group, by distinction, used the

theme most frequently.

Table 4. Percentage frequency of Balance themed post-intervention responses represented via

age and intervention

InterventionAge Active Passive Control

7 0 75 258 25 42 339 33 67 010 77 15 8

In summary, while 7 and 8 yr olds appeared to maintain relatively similar use of a

range of theme between the pre and post-tests, the 9 and 10 yr olds were found to change the

frequency of theme use in all areas and choose the Balance theme as a justification to a

greater extent following the intervention.

Discussion

Use of active and passive participation in drama to present information about the

importance of eating a balanced meal, had a significant effect on children’s meal choices in

this study. Although there was no difference between the children’s pre-test scores, their

scores improved significantly after the interventions, especially for 9 year olds in the Active

(4.8 To 7.00 meal depiction score average) and Observation groups (4.9 To 6.4). The nine

year olds post-test scores were also significantly higher than the 8 yr olds, suggesting that

they benefited more from the intervention.

According to Piagetian research, the concrete operational stage starts around the age

of 7, though children may achieve this stage a little later. By the age of 9 or 10, children are

nearing the end of the concrete operational stage, and their reasoning is more advanced. The

difference in impact of the concrete (Active) intervention on children’s post-test scores (7

year olds mean score of 5.86 versus 9 year olds mean score of 7.00) is consistent with this

view, as is evidence from the qualitative analysis. Specifically, percentages of pre and post-

test responses of the four most frequent themes by age (Table 3) showed that although some

children are picking up on the connections between food and health, they are not in the

majority and they do not seem to be picking up the theme of balance which is a major driver

in the BGHM initiative. However, the post-test results show that the balance theme

increased a lot after the intervention (7-33% and 6-34% for the 9 and 10 year olds). There

was little or no change in themes for the younger children.

These results may be explained by Table 4 which indicates a developmental

difference in the effect of the type of intervention. The youngest children don’t use the

Balance theme at all if they have been participating in drama, which could be because they

are focusing on the fun aspect and not on the content. According to Piaget, children of this

age find it harder to hold two things in mind simultaneously. However, 7 year olds seem to

absorb Balance knowledge better when watching an enactment (75% use this theme) rather

than simply remembering information from a story (25% used the theme in the Control

group). By the age of ten, this trend is reversed, and children who have actively participated

in the drama use the theme much more (77%) than those who have just watched it (15%).

In summary, the mode of presentation seems to have different effects at different ages

(Table 4). The results suggest that the youngest children absorb and use more information

when they observe the material presented in an interesting way till about the age of nine. The

ten year olds however, who are capable of holding more than one thing in mind, do much

better in the Active condition. These finding supports the criticism that the BGHM models

traditional use with younger children at the start of KS2 may be developmentally

inappropriate (Hart, Bishop, & Truby, 2002). This trend should be investigated in order to be

able to enhance the presentation of health material to children in the most effective and

developmentally appropriate manner.

Lastly, it is felt important for the improvement of future research to note the current

study’s limitations that are indicationed by both sets of results even though the quantitative

and qualitative results do appear to support each other and correspond with past research. For

example, the lack of significant intervention effect from the quantitative data could be

explained by the unequal group sizes. Though attempts were made to reduce this, the large

number of 8 yr olds especially, could have affected the results. Two further limitations relate

to the procedure. Firstly, the study was conducted with a colleague, which meant all

participants were asked to recall information from the ‘Golden Lunchbox’ story before

completing the post-test DWQ. Consequently, the recall condition could have bolstered

participant’s memory, potentially resulting in the high post-test control group scores observed

particularly in the 9 yr olds. Secondly, fatigue may have been a factor possibly evidenced in

the overall drop in post-test written responses. This may have been due to consecutive

questionnaires, and an entire procedure time of 2 hours.

With regard to subsequent research, these effects could be mediated by obtaining

equal sample sizes and counterbalancing the design to control for memory bolstering and

practice effects (Clark-Carter, 2004). Furthermore, fatigue effects could be controlled for by

presenting the post-test DWQ a few days or even a week after the intervention. This would

also assess the longer-term effect, if any, of the drama intervention, which is suggested to be

an under researched area (Perry & May, 2006). Additional confounding variables noted

during data collection included variability in resources and drama performance between

schools which could have impacted upon the effectiveness of the interventions. The necessity

of getting different children involved in the drama inevitably created differences between the

performances. The observers were therefore watching different productions in different

schools. This flaw could be addressed by separating Active and Observation groups using

pre-recorded drama workshops for the observers to watch in future research.

Conclusion

Observation of drama could be an effective way of delivering nutritional material to 7

and 8 year olds, while active involvement appears more helpful for 9 and 10 year olds.

Ultimately, these findings that the same educational material is understood and/or represented

differently by different age groups, highlights the need to generate developmentally

appropriate nutritional teaching methods for different age groups if health education is to

have a real impact.

References

Aldinder, C., & Jones, J. (1998) Healthy Nutrition: An Essential Element of a Health-promoting School. WHO Information Series on School Health. Document four. Geneva:WHO.

Bertheke Post, G., de Vente, W., Kemper, H.,C., Twisk, J.,W. (2001) Longitudinal trends in and tracking of energy and nutrient intake over 20 years in a Dutch cohort of men and women between 13 and 33 years of age: The Amsterdam growth and health longitudinal study. Br J Nutr, 85(3), 375-85.

British Nutrition Foundation (2008) Food A Fact of Life: Teachers Guide. Available: http://foodafactoflife.org.uk/sheet.aspx?siteId=14&sectionId=61&contentId=43, accessed July 2011.

Clark-Carter, D. (2004) Quantitative Psychological Research: A student’s Handbook. NY: Psychology Press.

Cohen, J. (1988) Statistical Power Analysis for the behavioural Sciences (2nd ed.). New York: Academic Press.

Contento, I., R. (1981) Children's thinking about food and eating – A Piagetian-based study. Journal of Nutritional Education, 13(1), S86-S90.

Cuijpers, P. (2002) Effective ingredients of school-based drug prevention programs: A systematic review. Addictive Behaviors, 27, 1009–1023.

Dahl, R (1982) Four enchanting stories by Roald Dahl [DVD-Video]. Universal Studios UK Limited.

Department Of Health (2009) Change4Life Campaign - 'Swap It, Don't Stop It'. Available: www.dh.gov.uk/en/Publichealth/index.htm, accessed March 2010.

Food Standards Agency (2001) The Balance of Good Health: Information for educators and communicators. Middlesex: FSA.

Gregory, J., Lowe, S., Bates, C. J., Prentice, A., Jackson, L. V., Smithers, G., Wenlock, R., & Farron, M. (2000) National Diet and Nutrition Survey: Young People Aged 4-18 years, Vol. 1: Report of the Diet and Nutrition Survey. London: The Stationary Office.

Hart, K., H., Bishop, J., A., & Truby, H. (2002) An investigation into school children’s knowledge and awareness of food and nutrition. Journal of Human Nutrition and Dietetics, 15, 129-140.

Nathanson, V. (2006) Junk food ad ban attacked from both sides. Available: www.guardian.co.uk/media/2006/nov/18/advertising.food1, accessed July 2011.

National Health Service (2009a) Statistics on obesity, physical activity and diet: England, 2009: Information Centre for Health and Social Care. Available: http://www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles/obesity/statistics-on-obesity-physical-activity-and-diet-england-february-2009, accessed March 2010.

National Health Service (2009b) Change4life. Available: www.nhs.uk/change4life/Pages/Default.aspx, accessed March 2010.

National Health Service (2010) Statistics on obesity, physical activity and diet: England, 2010: Information Centre for Health and Social Care. Available: www.ic.nhs.uk/default.asp?sID=1265735874472, accessed March 2010.

Pallant, J. (2007) SPSS Survival Manual (3rd ed.). Berkshire: Open University Press.

Parker, L., E., & Lepper, M., R. (1992) Effects of Fantasy Contexts on Children's Learning and Motivation: Making Learning More Fun. Journal of Personality and Social Psychology, 62(4), 625-633.

Perez-Rodrigo, C., & Aranceta, J. (2003) Nutrition education in schools: experiences and challenges. European Journal of Clinical Nutrition, 57(1), 582-585.

Perry, C., & May, S. (2006) Increasing awareness of healthy eating through the use of performing arts: An evaluation of the StarBites Project. Centre for Public Health Research.

Perry, C., Zauner, M., Oakes, J., Taylor, G., & Bishop, D. (2002) Evaluation of a theatre production about healthy eating behaviour of children. Journal of School Health, 72(6), 256-261.

Piaget, J. & Inhelder, B. (1969). The psychology of the child. London: Routlegde & Kegan Paul.

Qualification and Curriculum Development Agency (1999) Diet and Exercise: Sam’s Booklet. Available: http://curriculum.qcda.gov.uk/key-stages-1-and-2/assessment/nc-in-action/items/personal-social-and-health-education/5/1923.aspx, accessed March 2010.

Reilly, J., J., & Wilson, D. (2006) ABC of obesity: Childhood obesity. BMJ, 333, 1207-1210.

Sahota, P., Rudolf, M., Dixey, R., Hill, A., Barth, J., & Cade, J. (2004) Randomised controlled trial of primary school based intervention to reduce risk factors for obesity. British Medical Journal, 323, 1–5.

Staffordshire Children’s Trust (2007) Strategic Needs Analysis 2007-2010. Available: www.staffordshirechildrenstrust.org.uk, accessed March 2010.

Stevens, J. P. (2009). Applied multivariate statistics for the social sciences ( 5th ed.). New Jersey: Lawrence Erlbaum.

Ulas, A., H. (2008) Effects of Creative, Educational Drama Activities on Developing Oral Skills in Primary School Children. American Journal of Applied Sciences, 5 (7), 876-880.

Zeinstra, G., Koelen, M., Kok, F., & Graaf, C. (2007) Cognitive development and children’s perceptions of fruit and vegetables; a qualitative study. International Journal of Behavioural Nutrition and Physical Activity, 30(4), 1-11