The South African National Educator Wellness Study (SA-NEWS)
Background: Previous studies have shown that South African (SA) teachers are a population at risk for non-communicable diseases. Health screening, primarily through wellness days, is a popular strategy to improve health by identifying risk factors or disease. In addition, studies show the effectiveness of tailored letters and SMS text message-based interventions for weight loss, physical activity (PA), glycaemic control and hypertension management. Aim: To investigate whether the addition of a tailored print letter and SMS-text communication intervention, in addition to the standard-of-care feedback following a wellness day, would result in greater changes in health risk factors than the standard-ofcare. The feasibility and acceptability of the SMS-text messages was explored and the school health environment analysed to ascertain the impact of school environments and policies on teachers’ health risk status. Finally, the feasibility and helpfulness of employing an adapted intervention mapping (IM) approach to a complex health behaviour change intervention was reported. Methods: Twenty seven schools were selected from a list provided by the Department of Basic Education’s provincial educational authorities. Schools were grouped according to socioeconomic status and geographic location and randomly assigned to either intervention (n=13) or control (n=14) groups. A total of 571 teachers participated in the first set of the wellness days. At the completion of the wellness day, teachers in the intervention schools were asked to select one of 5 health goals they wanted to manage and to rank their top 3 (of 6) barriers preventing them from achieving the goal. In addition to the targeted wellness day feedback, teachers in the intervention group received a single printed tailored letter with advice relating to their goal and barriers. This was followed by at least 8 tailored advice SMS-text messages over 5 months. All teachers were invited to attend the second wellness day after the 5-month intervention. Three hundred and forty nine teachers (59.4%) attended the second set of wellness days. Teachers in the intervention group were asked to evaluate the acceptability of the SMS-text messages. Principals at all schools were also asked to complete an audit of the schools’ policies and built environment. The intervention was developed using an adapted IM approach. Results: This study confirmed that SA teachers are an ‘at risk’ population for developing NCDs. Overweight and obesity rates were found to be 27.3% and 50.3% respectively. Overall 82% of teachers did not meet the recommended PA guidelines and only 11% consumed the recommended 5 fruit and vegetable servings per day. Employing an as per protocol (APP) analysis, the use of a tailored print letter and SMS campaign resulted in significantly greater (p=0.004211) reductions in the proportion of teachers who were overweight and obese as well as those who were hypertensive. The intervention group showed a greater relative percentage decrease in body mass, BMI and in the percent who were overweight or obese compared to the control group (8.9% vs. 1.1% relative change). The intervention also resulted in a significantly higher (p=0.000793) proportion of individuals meeting PA guidelines and an almost double relative percentage increase compared to the control group (21.3 minutes/week vs. 12.3 minutes/week). Due to the high dropout rate in both groups, an intention to treat (ITT) analysis was conducted, only time effects for self-reported physical activity and Kessler Psychological Distress Scale scores remained, all group and time interaction effects were no longer significant (p>0.05). A high degree of acceptability of the SMS-text messages was found. The standard-of-care wellness day with immediate feedback also resulted in significant changes (p<0.05) in most of the clinical and anthropometric measures as well as lifestyle risk factors. This study found that generally, school environments, particularly in the lower quintiles, are not conducive to healthy eating, sufficient physical activity or the promotion of health intervention. The SMS campaign was found to be effective and had a high level of acceptability, with an overwhelming number of participants perceiving the messages to be of use and the level of contact to be appropriate. The findings of this study suggest that SMS-text based interventions are feasible, efficacious and have a high degree of acceptability to the recipients. However, the cost of upscaling the SMS messages to all teachers in SA may be a barrier. The study also highlighted the need to find strategies to minimise dropout in future interventions. Lastly, applying an adapted IM approach is a feasible and helpful method for providing an evidence based and theoretical structure to a complex health behaviour change intervention. Conclusion: Overall, the results appear to indicate that individuals who were exposed to the tailored letter and SMS campaign showed greater health benefits and improved health risk status compared to individuals who were exposed to the standard-of-care wellness day with targeted feedback. Results of this study also highlighted that a wellness day is an effective entry-into-care intervention. As these types of interventions are scalable, low-cost, behaviourally appropriate, autonomously supportive, and exert effects on multiple risk factors, the potential for population health benefit is apparent for policy makers and publicly or privately run health and education systems. An opportunity exists to roll out wellness days to all schools as an entry into care intervention. Including an ongoing SMS communication strategy to the wellness day could provide a simple, low-cost means of providing an additional support programme and perceived continuation of care.
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