Context
This study took place at Dubai, UAE. With close to three million (a third of the country’s population) inhabitants, Dubai is the most populated Emirate of the UAE (8). In the Academic Year 2018–2019, Dubai reported 280,979 registered students in private schools and 29,387 students in public ones (8).
In 2017 and 2018, the prevalence of obesity among UAE in-school children was 13.7% and 13.4%, respectively (9). The target of the national agenda indicator is to reduce this value to 12% by the year 2021 (9).
Multiple organizations and authorities in the country are working to achieve this indicator including: the Ministry of Health and Prevention (MOHAP), Department of Health- Abu Dhabi, Dubai Health Authority (DHA), Dubai Municipality, and the Ministry of Education (MOE). While each of these entities has its own programs, activities, and strategies, they all acknowledge that the reduction of school children obesity, and the enhancement of their health and well-being would not be optimally realized without the proper implementation of a nationally endorsed SNP. Anecdotal evidence reveals inconsistencies in the implementation of SNPs in Dubai schools with no clear information on the enablers and barriers to such implementation.
The UAE has several school nutrition guidelines generated by differing federal and Emirate level governing bodies, including the MOE, DHA, Dubai Municipality, MOHAP, and the Health Department-Abu Dhabi. The UAE does not have a national policy specific for school nutrition, but rather a national Nutrition Strategy that has a few subsections related to schools (10). Although all the entities are working to achieve UAE vision 2021 indicator of reducing the prevalence of childhood obesity, there remain major discrepancies across the guidelines that are affecting the planning, implementation, and monitoring and evaluations of SNPs. In Dubai, public schools are following the MOE guidelines, while private schools are following the DHA and Dubai Municipality guidelines, along with the Knowledge and Human Development Authority of Dubai (KHDA) recommendations. Public schools end-up having similar programs as they are centrally managed by the MOE, while plans in private schools are quite varied, and depend on the curriculum that the respective school offers.
School canteen suppliers must be approved by the MOE and the Dubai Municipality. For the public schools in Dubai, the MOE is responsible of deciding upon the food suppliers. The role of the school is only supervision, where they only control for the food safety. Private schools, however, have the freedom to choose their suppliers and then get the approval from Dubai Municipality. At the time of this study, several prominent initiatives, in relation to SNPs, were taking place (Table 1).
Table 1
Program-based SNPs initiatives that were taking place at the time of the study
Program
|
Description
|
Responsible Authority
|
Level of influence
|
School canteen standards and guidelines
|
A guiding manual for schools to improve the nutritional standard of food served or sold in their premises
|
Dubai Municipality and Dubai Health Authority
|
This policy needs to be signed by the school administration and permanently displayed in school canteens
|
Food labelling
|
Guidelines to ensure that children have access to nutritious, safe, and wholesome food during their school time
|
Food Safety Department of Dubai Municipality (Started in 2017)
|
All schools in Dubai
|
Happy Schools Initiative
|
An award to recognize schools that have made achievements in supporting the health and wellbeing of students
|
KHDA (Started in 2017)
|
Focusing on the wellbeing of Dubai private schools’ students between the ages of 10 and 14 years old
|
Health Awareness Campaigns
|
Periodic campaigns to boost awareness about healthy eating among students
|
MOHAP
|
Public schools and corresponding community
|
Guidelines and requirements for food and nutrition in Dubai
|
Raise awareness of students about the nutrient quotient in foods
|
Food safety department- Dubai Municipality
|
Provides all stakeholder with an overview of the health status, nutrition information, nature and effects of foods provided in schools, and common set of nutritional guidelines that would help promote healthy eating in schools in the Emirate of Dubai
|
Research Design
The study relied on a qualitative design, based on semi-structured key informant interviews. The design enabled the development of an in-depth insight into the perspective of the participants (11). Ethical approval for the study was obtained from the International Review Board (IRB) at the Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU), Dubai, UAE, under the reference number MBRU-IRB-2018-029.
The research team identified key stakeholders who are well informed and experienced with the SNPs in Dubai. A snowball sampling technique was utilized to recruit additional key informants. Those included leaders and directors from different institutions with clinical and/ or management backgrounds, decision- and policymakers, nutritionists, nurses and nurse managers, and schools’ principals and vice principals. The interviews were continued until the research team attained saturation, where no new concepts were identified (12).
Out of 48 key informants who were initially recruited, 29 agreed to participate. Those that did not agree to participate attributed this to their busy schedules. When key stakeholders, representing entities, did not agree to participate, they were replaced by other stakeholders from the same entities. Accordingly, semi-structured interviews were conducted with stakeholders from several institutions (Figure 1).
The head of each department, or the person in charge from each institution, received an invitation letter as an attachment to a personalized email. In case of non-response, the team sent an email reminder after two weeks of the invitation. If there was no response, the second and final reminder was through a phone call. All interviewees who were interested eventually replied to the email. After that, a mutually convenient interview timing was set with each key informant, and the interviews were conducted accordingly. One day before the interview, a reminder email, with the consent form and participant information sheet, was sent to each of the interviewees. The school stakeholders were invited with the intention to diversify schools by type of curriculum for private schools (British, Indian, or American), and the type of school in terms of the gender of the students for Public ones (Male only, Female only or mixed gender).
Data Collection
Semi-structured interviews were conducted from January 14, 2019 through April 18, 2019. The interviews focused on common topics, but with the freedom to pursue additional topics of interest as they surfaced. The interviews were anonymous, but the positions of the interviewees were noted. Before the interviews were conducted, a written informed consent in English, which was also translated into Arabic language, was obtained from all the participants. They were informed about the scope of the study and the overall subject of the questions. The interviewees were informed that they could skip any question they do not wish to answer or terminate the interview at any point.
The interview schedule gathered some basic information on the portfolio of the participants and included the following questions:
(1) Please describe your involvement with school nutrition programs in Dubai
(2) Please describe any nutrition plans, policies, or programs in the schools you know of or are engaged with,
(3) In your professional opinion, how well are the SNPs implemented and evaluated in Dubai?
(4) What do you believe are the elements of strength of the SNPs in Dubai?
(5) What do you recommend for improving the planning and implementation of SNPs in Dubai? and
(6) Do you wish to comment on any other areas related to SNPs in Dubai?
(7) Are there any documents you recommend we examine to further understand the SNPs in Dubai?
(8) Are their other experts you recommend that we speak with?
Based on the preference of the participant, interviews were carried out in English or Arabic, and were recorded with written consent of the participants. Interviews, lasted on average 45 minutes, were recorded, transcribed, and (if need be) translated.
Data Analysis
First, the 29 audio-recorded interviews were transcribed verbatim. Interviews in Arabic were translated into English by a member of the research team. A unique alphanumeric identifier was assigned to each participant. This identifier was composed of a unique number for each interviewee, followed by a reference to the level of influence based on the positioning of the corresponding institution (S: School level, ES: Education Sector, E: Emirate, and N: National level), and a reference to the education and development background of the interviewee (C: Clinical, M: Management, and B: Both clinical and management).
Data collected from the interviews were analyzed to identify main themes using the following five-step approach: 1- familiarization, 2- identification of thematic framework, 3- indexing of the transcripts, 4- abstraction and synthesis through charting and 5- conceptual mapping and interpretation (13, 14).
One member of the research team started by identifying prominent themes from the transcribed interviews which were cross-checked by a second member of the team. In case of disagreement on a theme, discussions took place until the two members reached an agreement. In case an agreement was not reachable after discussion, a third member of the research team provided independent opinion and resolved the disagreement.
Relevant quotes were selected from the individual transcripts and placed under the appropriate themes and sub-themes. All team members reviewed and approved the final themes and sub-themes emanating from the data analysis phase.