Abstract and facilitators for the intake of healthy


Obesity is a rapidly growing problem, concerning
children in West European countries. Obesity during childhood may lead to
various cardiovascular diseases later on in life. The sufficient intake of
fruits, healthy snacks and water is an important factor in the prevention of
obesity and cardiovascular diseases. The Krachtvoer project aims to increase
the 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 improve
the Krachtvoer project regarding the needs of the students, by analyzing barriers
and facilitators for the intake of healthy nutrition. With the use of photo
voice, a qualitative research method, these barriers and facilitators will be
mapped. The results of this study will contribute to the Krachtvoer project in
order to gain a better effect on increasing the intake of healthy nutrition,
regarding Dutch 12-14 year olds. The theoretical framework of this study will
include the EnRG framework, developed by Kremers et al. During the research, students
from lower vocational schools will be asked to participate in this photo voice
project. During the research, students will be recruited by contacting the
director or the board of education of schools. Two to three classes will be
recruited to participate in the study. During two lessons the students will be
asked to take photos of their school and home environments, regarding barriers
and facilitators for the intake of healthy nutrition and participate in a photo
voice discussion. During this discussion, which will be tape recorded, the photos
will be explained. The discussion will make use of photo discussion questions
(PHOTO). An analysis of the collected data will be included in the research

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Keywords: Photo voice –
Krachtvoer – Obesity and overweight – Healthy nutrition – Qualitative research


obesity is a rapidly growing problem in West European countries (Wang &
Lobstein, 2006), including the Netherlands (Frederiks et al., 2005). This
increase in overweight and obesity is due to insufficient intake of healthy
foods (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, is
linked to high fat diets (Martens et al., 2007).  High fat diets do not only contribute to the
prevalence of overweight children, but also to the development of the metabolic
syndrome, certain cancers and cardiovascular diseases, which increases the
mortality rate of the children later in life (Aballay et al., 2013). To tackle
this increase in the prevalence of overweight and obese children in the first
two years of Dutch lower vocational schools, it is important to improve healthy
eating in the 12-14 year old high school students. Proper nutrition during
their youth can have positive effects of their dietary intake in the future.
The Krachtvoer project is a Dutch educational program, developed for Dutch
12-14 year olds with a low socio economic status, which seeks to improve the
intake of fruits, vegetables and decrease the intake of snacks that are
containing a high amount of fat. The Krachtvoer project also aims to increase
the daily breakfast intake and quality of children in lower vocational schools
in the Netherlands (Martens et al., 2006). 
This study will contribute to the Krachtvoer project by gaining
information on the needs of the children. By making use of photo voice, this
research will gain insights in the perception of 12-14 year old students from
lower vocational schools. Photo voice is a method of CBPR (Community-based
participatory research), which increases the knowledge of researchers regarding
the problem, in order to adjusting the community to the needs of the population.
Photo voice is a qualitative research method, making use of the term
constructivism and documentary photography. Constructivism is defined as
learning by individual interaction and through the experiences of this
interaction (Hergenrather & Rhodes, 2008). The process of photo voice
includes identification of issues, recruitment of participants, training in photo
voice, instruction and distribution of camera equipment, photo assignment
identification, photo assignment discussion, analysis of the data, action plan
development and program evaluation (Wang et al., 1998).  By taking photographs, the participants of
this research can visualize benefits and barriers of participating in health
promoting behavior, within the environment. The theoretical framework that will
be included in this study is the EnRG framework (Kremers et al., 2006). This
framework includes environmental factors, moderators and cognitive mediators to
study energy balance related behaviour.   


Objectives and Research Questions:

Objectives of this research will be: 1) improving the
Krachtvoer project with new gained information on children’s needs, 2) gaining insight in the perceptions of
Dutch 12-14 year old high school students (lower vocational level) on barriers
and facilitators of home and school-based
nutrition factors promoting or preventing health promoting behaviours
(healthy nutrition); and 3) to analyse if there are differences in
these perceptions between children on demographical levels (e.g. gender/ethnicity).  With these
research objectives, research questions for the study can be formed. The
research questions for this study will be: 1) what are the perceptions of
Dutch high school students aged 12-14 on barriers and facilitators of health
promoting behaviours (food/physical activity) within the school environment?
And 2) are there differences in perceptions between boys and girls or in ethnicities? By answering
these research questions, a better understanding in the barriers and facilitators
of participating in health promoting behaviour is achieved and if the
Krachtvoer project should be adjusted to demographic variables. With the
results of these research questions, the Krachtvoer project can be improved to
have better effects on healthy eating of Dutch 12-14 year olds.


Because high fat diets are present in a high amount of
12-14 year old children with a lower vocational level, it is important to
increase their intake of fruits, healthy snacks and water (Martens et al.,
2007).The increased intake of healthy nutrition is important to decrease the
risks of cardiovascular diseases and cancers later on in the lives of the
children. Implementing interventions in younger age is helpful in decreasing
the rapidly growing prevalence of adolescent overweight and obesity, in the
future. This is caused by healthy nutrition in your younger years having
beneficial 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 of
fruits, healthy snacks and water, by contributing to the Krachtvoer project.
This study will gain insight in new information that can be used to improve the
project, which contributes to a better participation in the Krachtvoer project
by Dutch 12-14 year olds with, in lower vocational schools. It will also
contribute to the implementation of new educational material for the project,
which can improve the project.


Study design

More information on the perceptions of Dutch 12-14
year 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 the
information obtained from this qualitative study, the Krachtvoer project can be
improved to the needs of the children. Students will be asked to take photos,
of their environment, that contain barriers and facilitators of healthy
nutrition (fruits, healthy snacks and water). The qualitative part will be the
discussion of the photos taken by the students.

Study sample

Participants of the study will include Dutch 12-14
year 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 will
be conducted within two to three school classes. The participants will be
recruited by recruiting lower vocational schools that are already participating
in the Krachtvoer project. Contact will be made with the director of the school
or with the board of education (Wang, 2008). Before participation, the students
will sign a consent form, which is set up by the researcher. The students will
have to participate in two lessons given by the researcher. These two lessons
include an introductory lesson. The first lesson will explain what the
objective and procedure of the two lessons is going to be. The first lesson
will also contain information on the use of the camera for the photo voice
method. The second lesson will include a discussion on the photos, taken by the


Before the research can take place, the researcher
will be trained in the use of photo voice by participating in a workshop on the
photo voice method. The workshop will help the researcher to conduct the
research on the recruited schools. Two meetings with the students will take
place, 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 the
process, ethical issues and to help them sign the informed consent. In this
introduction, the students will also get to know the researcher(s) that is
going to conduct the study. The researcher will show some example pictures that
contain barriers and facilitators, within the school and home environment, of
eating fruits and healthy snacks. After the first meeting, the students will be
working individually. The students will be asked to take pictures of their home
and school environment and these pictures should include barriers or
facilitators of healthy nutrition (fruits and healthy snacks). For example,
photos should be taken of the food in the school canteen if this school canteen
only serves foods and snacks that are a barrier to eating fruits and healthy
snacks. The children will be asked to participate in a photo discussion, to
analyze the photos that were taken. During the discussion, questions from the
photo discussion method “PHOTO” will be asked. This method is derived from the
components of the photo discussion method “SHOWED” (Hergenrather et al., 2009).
The questions that will be asked during this discussion are “Describe your
Picture.” “What is happening in your picture?” “Why did you take a picture of
this?” “What does this picture tell us about your life?” “How can this picture provide
Opportunities for us to improve life?” The discussion on the photos will be
recorded and analyzed. Results will be converted into information for the
Krachtvoer project.

Data collection
instruments and measures

Collection of data will take place in the first month
(2 weeks of data collection) of the research period. The first week will be
used for an introduction in the photo voice method, while the second week will
be used for discussion interviews, in which the data will be collected. The
discussion of the photos will be recorded by using a tape recorder. Before the
student answers he/she will have to say his/her name. Names will not be
mentioned further on in the study, but will help with making the discussion
more clear when writing out the answers.

Data analysis

The recording of the discussion will be transcribed
and coded. Coding of the date makes analyzing more manageable. The most
important information from the discussion interview will be included in the
research. This information will be broken down into units; and searching for
patterns in the information will take place (Bogdan & Biklen, 2006). NVivo,
qualitative data analysis software, will be used in order to make the
information more structured and to analyze the transcription of the photo


To guarantee feasibility of the study, the amount of
lessons per class will be limited to two; and strict deadlines for conducting
the study will be set. Recruitment of the students will take place before the research
period and collection of the data will take place in the first month of the
research period. However, even when strict deadlines are set and the amount of
lessons per class is limited to two, feasibility problems could occur during
the execution of the research. Problems in feasibility of this research could
include the recruitment of the schools. It is possible that schools do not want
to participate in the research, due to for example lack of time for
implementing the lessons for the research. Because only two to three classes
are needed to conduct the study, recruitment of enough students should be
feasible. Another feasibility problem might be that, when recruited via
schools, students might be uncooperative due to a lack of interest. By
conducting the photo discussion within smaller groups, the uncooperative
students will not influence the entire class and enough useful data will be
collected. Another problem, which is easy to solve, is that teachers might
think that implementing the lessons will cost a lot of preparing time. This is
not the case, due to the researcher giving the lessons him/herself.

ethics and integrity

This research includes human subjects, who will
participate as informants for the researcher. The students will develop their
own data for the data collection by taking photos of their environment and by
explaining the photos according to a photo discussion. To prevent students from
taking photos that contain private information, students will be asked to sign
the informed consent before the start of the data collection. The data
collected will only be stored on one computer, and will be analyzed by only one
researcher. The data used in the research will not contain names of students
after analyzing. The tape recorder that does contain the names of the students,
will be handled with care and will not be distributed. After the research
period this tape recorder will be emptied. The data collected from the tape
recorder will only be used within this research and will not be distributed
among others. Only the results (research article) of the study will be
distributed. A medical ethical committee will monitor this research proposal on
ethical concerns (Olde Rikkert et al., 2005).