AbstractObesity is a rapidly growing problem, concerningchildren in West European countries. Obesity during childhood may lead tovarious cardiovascular diseases later on in life. The sufficient intake offruits, healthy snacks and water is an important factor in the prevention ofobesity and cardiovascular diseases. The Krachtvoer project aims to increasethe daily intake of fruits, healthy snacks and water in Dutch 12-14 year olds,enrolled in lower vocational schools. The aim of this research is to improvethe Krachtvoer project regarding the needs of the students, by analyzing barriersand facilitators for the intake of healthy nutrition. With the use of photovoice, a qualitative research method, these barriers and facilitators will bemapped.

The results of this study will contribute to the Krachtvoer project inorder to gain a better effect on increasing the intake of healthy nutrition,regarding Dutch 12-14 year olds. The theoretical framework of this study willinclude the EnRG framework, developed by Kremers et al. During the research, studentsfrom lower vocational schools will be asked to participate in this photo voiceproject. During the research, students will be recruited by contacting thedirector or the board of education of schools. Two to three classes will berecruited to participate in the study. During two lessons the students will beasked to take photos of their school and home environments, regarding barriersand facilitators for the intake of healthy nutrition and participate in a photovoice discussion. During this discussion, which will be tape recorded, the photoswill be explained. The discussion will make use of photo discussion questions(PHOTO).

An analysis of the collected data will be included in the researcharticle. Keywords: Photo voice –Krachtvoer – Obesity and overweight – Healthy nutrition – Qualitative researchBackgroundChildhoodobesity is a rapidly growing problem in West European countries (Wang &Lobstein, 2006), including the Netherlands (Frederiks et al., 2005). Thisincrease in overweight and obesity is due to insufficient intake of healthyfoods (Huang et al, 2010) and low physical activity levels of the children(Hills et al., 2011). A low intake of fruits, healthy snacks and water, islinked to high fat diets (Martens et al.

, 2007).  High fat diets do not only contribute to theprevalence of overweight children, but also to the development of the metabolicsyndrome, certain cancers and cardiovascular diseases, which increases themortality rate of the children later in life (Aballay et al., 2013). To tacklethis increase in the prevalence of overweight and obese children in the firsttwo years of Dutch lower vocational schools, it is important to improve healthyeating in the 12-14 year old high school students.

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Proper nutrition duringtheir youth can have positive effects of their dietary intake in the future.The Krachtvoer project is a Dutch educational program, developed for Dutch12-14 year olds with a low socio economic status, which seeks to improve theintake of fruits, vegetables and decrease the intake of snacks that arecontaining a high amount of fat. The Krachtvoer project also aims to increasethe daily breakfast intake and quality of children in lower vocational schoolsin the Netherlands (Martens et al.

, 2006). This study will contribute to the Krachtvoer project by gaininginformation on the needs of the children. By making use of photo voice, thisresearch will gain insights in the perception of 12-14 year old students fromlower vocational schools. Photo voice is a method of CBPR (Community-basedparticipatory research), which increases the knowledge of researchers regardingthe problem, in order to adjusting the community to the needs of the population.Photo voice is a qualitative research method, making use of the termconstructivism and documentary photography. Constructivism is defined aslearning by individual interaction and through the experiences of thisinteraction (Hergenrather & Rhodes, 2008). The process of photo voiceincludes identification of issues, recruitment of participants, training in photovoice, instruction and distribution of camera equipment, photo assignmentidentification, photo assignment discussion, analysis of the data, action plandevelopment and program evaluation (Wang et al.

, 1998).  By taking photographs, the participants ofthis research can visualize benefits and barriers of participating in healthpromoting behavior, within the environment. The theoretical framework that willbe included in this study is the EnRG framework (Kremers et al.

, 2006). Thisframework includes environmental factors, moderators and cognitive mediators tostudy energy balance related behaviour.    Objectives and Research Questions:Objectives of this research will be: 1) improving theKrachtvoer project with new gained information on children’s needs, 2) gaining insight in the perceptions ofDutch 12-14 year old high school students (lower vocational level) on barriersand facilitators of home and school-basednutrition factors promoting or preventing health promoting behaviours(healthy nutrition); and 3) to analyse if there are differences inthese perceptions between children on demographical levels (e.

g. gender/ethnicity).  With theseresearch objectives, research questions for the study can be formed. Theresearch questions for this study will be: 1) what are the perceptions ofDutch high school students aged 12-14 on barriers and facilitators of healthpromoting behaviours (food/physical activity) within the school environment?And 2) are there differences in perceptions between boys and girls or in ethnicities? By answeringthese research questions, a better understanding in the barriers and facilitatorsof participating in health promoting behaviour is achieved and if theKrachtvoer project should be adjusted to demographic variables. With theresults of these research questions, the Krachtvoer project can be improved tohave better effects on healthy eating of Dutch 12-14 year olds.RelevanceBecause high fat diets are present in a high amount of12-14 year old children with a lower vocational level, it is important toincrease their intake of fruits, healthy snacks and water (Martens et al.,2007).

The increased intake of healthy nutrition is important to decrease therisks of cardiovascular diseases and cancers later on in the lives of thechildren. Implementing interventions in younger age is helpful in decreasingthe rapidly growing prevalence of adolescent overweight and obesity, in thefuture. This is caused by healthy nutrition in your younger years havingbeneficial effects on your nutrition choices in the future (Martens et al.,2007). The results of this study will have a positive effect on the intake offruits, healthy snacks and water, by contributing to the Krachtvoer project.This study will gain insight in new information that can be used to improve theproject, which contributes to a better participation in the Krachtvoer projectby Dutch 12-14 year olds with, in lower vocational schools.

It will alsocontribute to the implementation of new educational material for the project,which can improve the project. MethodsStudy designMore information on the perceptions of Dutch 12-14year old high school students form lower vocational schools is needed. Therefore,the design of this study is going to be a non-experimental, observational,fundamental qualitative study with a constructivist approach. With theinformation obtained from this qualitative study, the Krachtvoer project can beimproved to the needs of the children. Students will be asked to take photos,of their environment, that contain barriers and facilitators of healthynutrition (fruits, healthy snacks and water). The qualitative part will be thediscussion of the photos taken by the students. Study sampleParticipants of the study will include Dutch 12-14year old high school kids from lower vocational schools in the South of Limburg.In order to achieve a participation of at least 50 children, the research willbe conducted within two to three school classes.

The participants will berecruited by recruiting lower vocational schools that are already participatingin the Krachtvoer project. Contact will be made with the director of the schoolor with the board of education (Wang, 2008). Before participation, the studentswill sign a consent form, which is set up by the researcher. The students willhave to participate in two lessons given by the researcher.

These two lessonsinclude an introductory lesson. The first lesson will explain what theobjective and procedure of the two lessons is going to be. The first lessonwill also contain information on the use of the camera for the photo voicemethod. The second lesson will include a discussion on the photos, taken by thestudents.ProcedureBefore the research can take place, the researcherwill be trained in the use of photo voice by participating in a workshop on thephoto voice method. The workshop will help the researcher to conduct theresearch on the recruited schools. Two meetings with the students will takeplace, within the first two weeks of the research period.

In the first meeting,students will be introduced to the photo voice method in order to explain theprocess, ethical issues and to help them sign the informed consent. In thisintroduction, the students will also get to know the researcher(s) that isgoing to conduct the study. The researcher will show some example pictures thatcontain barriers and facilitators, within the school and home environment, ofeating fruits and healthy snacks. After the first meeting, the students will beworking individually. The students will be asked to take pictures of their homeand school environment and these pictures should include barriers orfacilitators of healthy nutrition (fruits and healthy snacks).

For example,photos should be taken of the food in the school canteen if this school canteenonly serves foods and snacks that are a barrier to eating fruits and healthysnacks. The children will be asked to participate in a photo discussion, toanalyze the photos that were taken. During the discussion, questions from thephoto discussion method “PHOTO” will be asked.

This method is derived from thecomponents of the photo discussion method “SHOWED” (Hergenrather et al., 2009).The questions that will be asked during this discussion are “Describe yourPicture.” “What is happening in your picture?” “Why did you take a picture ofthis?” “What does this picture tell us about your life?” “How can this picture provideOpportunities for us to improve life?” The discussion on the photos will berecorded and analyzed. Results will be converted into information for theKrachtvoer project.Data collectioninstruments and measuresCollection of data will take place in the first month(2 weeks of data collection) of the research period.

The first week will beused for an introduction in the photo voice method, while the second week willbe used for discussion interviews, in which the data will be collected. Thediscussion of the photos will be recorded by using a tape recorder. Before thestudent answers he/she will have to say his/her name. Names will not bementioned further on in the study, but will help with making the discussionmore clear when writing out the answers.

Data analysis The recording of the discussion will be transcribedand coded. Coding of the date makes analyzing more manageable. The mostimportant information from the discussion interview will be included in theresearch. This information will be broken down into units; and searching forpatterns in the information will take place (Bogdan & Biklen, 2006). NVivo,qualitative data analysis software, will be used in order to make theinformation more structured and to analyze the transcription of the photodiscussion.  FeasibilityTo guarantee feasibility of the study, the amount oflessons per class will be limited to two; and strict deadlines for conductingthe study will be set. Recruitment of the students will take place before the researchperiod and collection of the data will take place in the first month of theresearch period.

However, even when strict deadlines are set and the amount oflessons per class is limited to two, feasibility problems could occur duringthe execution of the research. Problems in feasibility of this research couldinclude the recruitment of the schools. It is possible that schools do not wantto participate in the research, due to for example lack of time forimplementing the lessons for the research. Because only two to three classesare needed to conduct the study, recruitment of enough students should befeasible.

Another feasibility problem might be that, when recruited viaschools, students might be uncooperative due to a lack of interest. Byconducting the photo discussion within smaller groups, the uncooperativestudents will not influence the entire class and enough useful data will becollected. Another problem, which is easy to solve, is that teachers mightthink that implementing the lessons will cost a lot of preparing time. This isnot the case, due to the researcher giving the lessons him/herself.

Researchethics and integrityThis research includes human subjects, who willparticipate as informants for the researcher. The students will develop theirown data for the data collection by taking photos of their environment and byexplaining the photos according to a photo discussion. To prevent students fromtaking photos that contain private information, students will be asked to signthe informed consent before the start of the data collection. The datacollected will only be stored on one computer, and will be analyzed by only oneresearcher. The data used in the research will not contain names of studentsafter analyzing. The tape recorder that does contain the names of the students,will be handled with care and will not be distributed. After the researchperiod this tape recorder will be emptied.

The data collected from the taperecorder will only be used within this research and will not be distributedamong others. Only the results (research article) of the study will bedistributed. A medical ethical committee will monitor this research proposal onethical concerns (Olde Rikkert et al., 2005).