Development and Validation of a Physical Activity Educational Module for Overweight and Obese Adolescents: CERGAS Programme
, Denise Koh 2, Razalee Sedek 3, Ahmad Taufik Jamil 4, Alvin Lai Oon Ng 5, Abu Saad Hazizi 6, Abd. Talib Ruzita 1 and Bee Koon Poh 1,*Round 1
Reviewer 1 Report
This is a well-written development and validation study, describing the development of an educational module to adolescents on physical activity and its importance on staying healthy and preventing disease. The need for the study and the material developed is well-defined in the introduction and the methodology used is sound. The development process is conducted and reported in three phases: needs assessment (I), development of the module (II) and content and face validation (III). All the phases have been performed rigorously by using justified methods, such as focus group discussions (Phase I) and content validity index (CVI). The authors have critically reflected all stages of the development process and reported the process precisely. The conclusion is justified. However, a few more specific definitions are needed to help the reader in putting the study in context.
Firstly, as the definition of adolescence in the literature varies, the definition or age range used in this study should be defined.
Secondly, it is not described in the manuscript (only in the conclusions) that where and how will the developed module be used or incorporated. This should be described in short.
Thirdly, the C.E.R.G.A.S Programme is mentioned already in the title, however the concept of the programme is not described in the manuscript.
A few minor comments:
Focus groups:
it is normal to conduct pilot discussions to test the pre-defined questions and their suitability. Was this done in the current study?
was there any other way provided for the adolescents to report their thoughts, f. ex. post-it notes? This is also quite common way to make sure that all the information is gathered.
Table 4:
in the columns reporting the n of the participants reporting the items as relevant or not relevant, perhaps the n should be included in the column heading to increase readability.
Author Response
Dear Editor,
We thank you and the reviewers for the constructive comments and thoughtful recommendations. Enclosed please find the revised version of our article Manuscript ID IJERPH-464835. Below are our point-by-point responses to the comments.
No. | Reviewer’s Comments | Authors’ Response |
1. | Firstly, as the definition of adolescence in the literature varies, the definition or age range used in this study should be defined.
| Subjects were boys and girls aged 13 to 15 years old recruited from secondary schools.
We have now defined the age of the adolescent subjects in Line 127. |
2. | Secondly, it is not described in the manuscript (only in the conclusions) that where and how will the developed module be used or incorporated. This should be described in short.
| C.E.R.G.A.S participants will receive PA education in a two-day camp at a training centre. This PA education module can serve as the main education material for C.E.R.G.A.S’s participants and facilitators in the education camp.
We have added this information at Lines 106-107.
|
3. | Thirdly, the C.E.R.G.A.S Programme is mentioned already in the title, however the concept of the programme is not described in the manuscript.
| C.E.R.G.A.S is a 12-week programme, in which participants receive additional nutrition and PA education delivered by health professionals in a two-day camp, apart from the standard Physical and Health Education modules offered in the school curriculum. Participants also took part in exercise training sessions twice weekly for 12 weeks at school (90 minutes per session).
This information is included in Lines 62-68.
|
4. | It is normal to conduct pilot discussions to test the pre-defined questions and their suitability. Was this done in the current study? | The FGD interview protocol was reviewed by expert panel comprising dietitian, nutritionist and qualitative research expert. Suggestions from expert panels were reviewed and amendments were done accordingly.
Lines 142-143.
|
Was there any other way provided for the adolescents to report their thoughts, f. ex. post-it notes? This is also quite common way to make sure that all the information is gathered. | Before FGD sessions end, participants were given a chance to provide brief personal commentary by writing on a piece of notes paper. Researcher collected back the notes and incorporated these responses into module preparation.
Lines 148-150.
| |
5. | Table 4: In the columns reporting the n of the participants reporting the items as relevant or not relevant, perhaps the n should be included in the column heading to increase readability. | The total number of expert panel members is stated in the Title to Table 4.
Line 366 |
Reviewer 2 Report
Thank you for the opportunity to read and review your article. The topic of content, adolescent PA participation, is important. You have shown that you have undertaken a thorough process in the development of the educational tools.
You present a sound summary of key literature that supports the need for inquiry into interventions that may increase adolescent participation in PA. However, the introduction section in the article lacks any discussion of the literature concerning the design and development of pedagogically sound intervention programmes in schools; the importance of integrating interventions into the core work of schools; and the need for partnership with education to develop and implement such interventions. It is important that you demonstrate in the introduction and follow through in the methods and discussion with more information about how and why partnership with the experts in the field (i.e. teachers) is established and how your programme designed supports the potential maintenance of this intervention as a sustainable programme for schools.
You have presented key anthropometric evidence relevant to the study in the introduction but have omitted to describe relevant educational evidence. Please consider revising the introduction to include a section outlining the nature of the Health and Physical Education curriculum in Malaysian schools, available resourcing, learning objectives within the core curriculum with regard to PA/Exercise and national assessment evidence demonstrating understanding of the baseline you are working with (in the same way as you have provided this for the health aspects of your study (O/O rates etc). This will assist to enable readers to understand the context and implications of the evidence you present in the results section (e.g. section 3.2.1)
Finally, this is a paper about the design of an educational intervention, yet the introduction lacks any discussion of learning theory. Please outline the theoretical underpinnings of the pedagogical design that you have used and present an argument demonstrating why this design was considered appropriate to meet the stated aim of the intervention in the context of Malaysian schools.
In line 59 (and in the abstract) you refer to the C.E.,R.G.A.S programme. Could you please ensure that you define this acronym in line 50, and refrain from using the acronym (i.e. use the full name) in the abstract.
Your description of the methods that you have used is clear.
Can you please clarify in the methods section who implemented the modules in this development period and who will be implementing the modules once they are validated.
What period of class time is required for the intervention and how is this intended to be integrated into the core learning programmes of schools?
Your intervention development committee is strongly weighted towards expertise in health. In section 2.3.1 we see that 2 of the 10 people are non-educators. In section 2.4.1 you state that your interdisciplinary panel consists of five people - one of whom was an educator. You then go on to describe a process of CVI which does not seem to account for the imbalance in the group. How did you address the fact that education expertise was under-represented in the scoring system that you used? This is a very important issue to address. If you did not address this, can you please include this in your limitations section and discuss the potential impact that this issue may have had on the evidence that you are presenting.
Your reporting of the focus group evidence is sound. In your limitations section you may want to consider adding in a discussion regarding why you did not conduct FDGs with teachers in phase 1 and 2.
Section 3.3 - Module content.
Could you please include in this section information about the expected learning time required to complete the units of work.
In Table 3 you have defined the Learning Outcomes (LOs) for the module (i.e. all 5 units). It is most unusual that you have repeated these in each unit and have not identified how each unit contributes to the overall LOs with specific LOs. A more usual way to present a learning module overview would be to identify the specific LOs that are relevant to each unit. Learning involves the development of capabilities (knowledge, attitudes, skills and values) that are required to understand an issue or concept and potentially take action resulting from this understanding (i.e. developing capabilities associated with health literacy in the context of PA). Can you please expand table 3 to demonstrate more clearly the section you have labelled ‘content’ so as from an educational perspective readers are able to identify where attitudinal and value development is supported in these modules.
Please add a limitations section following the discussion and address the potential implications of the limitations of your methods - in particular the lack of evidence from the education sector.
Please conduct a final check of your article for minor grammatical errors. In particular you move between tenses in several places.
Author Response
Dear Editor,
We thank you and the reviewers for the constructive comments and thoughtful recommendations. Enclosed please find the revised version of our article Manuscript ID IJERPH-464835. Below are our point-by-point responses to the comments.
1. | Lacks any discussion of the literature concerning the design and development of pedagogically sound intervention programmes in schools | Instead of school setting, the present study employed residential education camp setting to improve adolescents’ PA behaviors. The relevant discussion was added in introduction section. Lines 62-82 |
2. | The importance of integrating interventions into the core work of schools | The information is added in Lines 83-94. |
3. | The need for partnership with education to develop and implement such interventions. | The information is added in Lines 83-94. |
4. | It is important that you demonstrate in the introduction and follow through in the methods and discussion with more information about how and why partnership with the experts in the field (i.e. teachers) is established and how your programme designed supports the potential maintenance of this intervention as a sustainable programme for schools. | Instead of school setting, present study employed residential education camp setting to improve adolescents’ PA behaviors. The relevant discussion is now added in introduction section. Lines 69-82 |
5. | Include a section outlining the nature of the Health and Physical Education curriculum in Malaysian schools, available resourcing, learning objectives within the core curriculum with regard to PA/Exercise and national assessment evidence demonstrating understanding of the baseline you are working with (in the same way as you have provided this for the health aspects of your study (O/O rates etc). | The information is added in Lines 83-94. |
6. | Lacks any discussion of learning theory. Please outline the theoretical underpinnings of the pedagogical design that you have used and present an argument demonstrating why this design was considered appropriate to meet the stated aim of the intervention in the context of Malaysian schools. | Social Cognitive Theory was used. The information is added in Lines 191-198. |
7. | In line 59 (and in the abstract) you refer to the C.E,R.G.A.S programme. Could you please ensure that you define this acronym in line 50, and refrain from using the acronym (i.e. use the full name) in the abstract. | C.E.R.G.A.S is the Malay acronym of CEria (cheerful), Respek (respect), Gigih (persistent), Aktif (active) and Sihat (healthy).
Lines 25-26 Lines 60-61 |
8. | Can you please clarify in the methods section who implemented the modules in this development period and who will be implementing the modules once they are validated. | The information is added in Line 116-121. |
9. | What period of class time is required for the intervention and how is this intended to be integrated into the core learning programmes of schools? | Participants received additional PA education in a two-day residential camp. This was an intensive education camp and conducted in weekend (Saturday and Sunday) by considering budgetary, time and resources constraints.
In view of the hectic school life, PA education camp which was designed for a two days course covering at least 15 hours of training was considered adequate (Klohe-Lehman et al. 2006; Kabahenda et al. 2011; Inayati et al. 2012). Moreover, researchers can minimize the visit frequency to school to ensure that the school adolescents focusing on academic matters without too many disturbances. Furthermore, intensive education programme might have positive implication as the participants could fully concentrate on learning process without distractions. In addition, the participants can apply the knowledge gained into their daily life immediately. Hence, our C.E.R.G.A.S modules were indicated for two days training.
Lines 72-82
Once the effectiveness is proven, the contents of C.E.R.G.A.S PA education module can be inserted in school physical education (PE) textbook to improve students’ PA knowledge, attitude and practice.
Lines 116-121
|
10. | Your intervention development committee is strongly weighted towards expertise in health. In section 2.3.1 we see that 2 of the 10 people are non-educators. In section 2.4.1 you state that your interdisciplinary panel consists of five people - one of whom was an educator. You then go on to describe a process of CVI which does not seem to account for the imbalance in the group. How did you address the fact that education expertise was under-represented in the scoring system that you used? This is a very important issue to address. If you did not address this, can you please include this in your limitations section and discuss the potential impact that this issue may have had on the evidence that you are presenting.
| We acknowledge that the PA module was reviewed by only two education experts, and have noted this in our Limitation Lines 482-488.
|
11. | Your reporting of the focus group evidence is sound. In your limitations section you may want to consider adding in a discussion regarding why you did not conduct FDGs with teachers in phase 1 and 2. | Instead of putting this as limitation, we explained in the method section why we conduct FGDs with adolescents only.
C.E.R.G.A.S programme is using “adolescent-centred” approach, thus, FGD was employed to explore adolescents’ opinions, ideas, perceptions and concerns in regard to education contents, layout and design.
Line 123 |
12. | Section 3.3 Could you please include in this section information about the expected learning time required to complete the units of work. | We have now added learning time in column 6 of Table 3.
Line 347 |
13. | Section 3.3 In Table 3 you have defined the Learning Outcomes (LOs) for the module (i.e. all 5 units). It is most unusual that you have repeated these in each unit and have not identified how each unit contributes to the overall LOs with specific LOs. A more usual way to present a learning module overview would be to identify the specific LOs that are relevant to each unit. Learning involves the development of capabilities (knowledge, attitudes, skills and values) that are required to understand an issue or concept and potentially take action resulting from this understanding (i.e. developing capabilities associated with health literacy in the context of PA). Can you please expand table 3 to demonstrate more clearly the section you have labelled ‘content’ so as from an educational perspective readers are able to identify where attitudinal and value development is supported in these modules. | We have now added learning outcomes for each topic in Table 3.
Line 347 |
Round 2
Reviewer 2 Report
Thank you for the consideration you have given to the review comments.
The addition of the explanation of CERGAS helps enormously to place the project into context.
In the final sentence of the introduction you state that the PA education module will serve as the main education material in the two-day camp. Can you please clarify as to whether or not you will also employ the 12-week after-school sessions in the future. These after-school sessions would theoretically be very important (and maybe you should test this out) as it is well known that a burst of training or education (such as a two-day camp) without suitable ongoing support is unlikely to produce long-term change in behaviours.
Can you please check your grammar in lines 115 - 120. Did you intend to state they the validates PA module would serve as reference material in the future? In the last sentence you imply that before you undertook this trial you validated the module? Was that not what you were doing in this trial. I suspect this is simply a case of the sense of the sentence being incorrect? This needs attention as it is very confusing.
Please start line 122 with The......
Thank you for outlining your use of Social Cognitive Theory. As an educator I would be interested in knowing more about your pedagogical approach- but I appreciate that you have made an effort to explain something of the theory that should be underpinning your work.
Thank you for adding in the detail of the Learning Outcomes. It is important that you are realistic in your statements. You cannot actually be sure that at the end of the learning module all students WILL be able to do everything you have listed. In educational literature it is more common to use language that describe what students will do - as until you assess the learning you cannot know that you will get 100% achievement of the expected outcome. For example, you might re-phrase your LOs as:
Participants will
examine different types of physical activity and develop understanding of factors considered essential in a definition of PA
explore the components of physical activity pyramid
explore differences between the types of activities that are categorised as low, medium or high PA
learn about goal setting in relation to PA and experience setting their own PA goals
These represent learning objectives - which you should be measuring to determine the learning outcomes for each student. If you do not change this, could you at least phrase it as expected learning outcomes so that it is clear that you understand that you cannot confirm outcomes until you measure these, and you will see heterogeneity in the outcomes across any class or cohort.
Thank you for addressing the limitation relating to the lack of educational input into the design of the study,
Could you please review the manuscript for grammatical errors. These are minor, and a reader can work with those and understand the work. However, they do detract from the content of your manuscript and make it less accessible.
I look forward to seeing how this work develops in the future and hope you are able to continue with the work and publish the outcomes of the wider implementation phase.
Author Response
Dear reviewer,
We thank you for the constructive comments and thoughtful recommendations. Enclosed please find the revised version (Round 2) of our article Manuscript ID IJERPH-464835. Below are our point-by-point responses to the comments (please see attachment).
No. | Reviewer’s Comments | Authors’ Response |
1 | In the final sentence of the introduction you state that the PA education module will serve as the main education material in the two-day camp. Can you please clarify as to whether or not you will also employ the 12-week after-school sessions in the future. These after-school sessions would theoretically be very important (and maybe you should test this out) as it is well known that a burst of training or education (such as a two-day camp) without suitable ongoing support is unlikely to produce long-term change in behaviours.
| We have added this as recommendation in Lines 483-488.
As an alternative to this intensive programme, we recommend future studies to test the effectiveness of the 12-week after-school sessions employing C.E.R.G.A.S PA module.
|
2 | Please start line 122 with The...... | We have amended accordingly.
Line 120
|
3 | Thank you for outlining your use of Social Cognitive Theory. As an educator I would be interested in knowing more about your pedagogical approach- but I appreciate that you have made an effort to explain something of the theory that should be underpinning your work. | We have added the information in Lines 198-202.
The pedagogical approach we used in present study was constructivism teaching. This method of teaching helps participants to better relate the information learned in the education camp to their lives. In a constructivism classroom, participants work in groups. This helps participants learn social skills, support each other’s learning process and value each other opinion and input.
|
4 | Thank you for adding in the detail of the Learning Outcomes. It is important that you are realistic in your statements. You cannot actually be sure that at the end of the learning module all students WILL be able to do everything you have listed. In educational literature it is more common to use language that describe what students will do - as until you assess the learning you cannot know that you will get 100% achievement of the expected outcome. For example, you might re-phrase your LOs as: Participants will examine different types of physical activity and develop understanding of factors considered essential in a definition of PA explore the components of physical activity pyramid explore differences between the types of activities that are categorised as low, medium or high PA learn about goal setting in relation to PA and experience setting their own PA goals These represent learning objectives - which you should be measuring to determine the learning outcomes for each student. If you do not change this, could you at least phrase it as expected learning outcomes so that it is clear that you understand that you cannot confirm outcomes until you measure these, and you will see heterogeneity in the outcomes across any class or cohort.
| We have now revised each Learning Outcome to reflect more what the student will learn.
Line 343 |
5 | Could you please review the manuscript for grammatical errors. These are minor, and a reader can work with those and understand the work. However, they do detract from the content of your manuscript and make it less accessible.
| We have reviewed for English grammar accordingly. |
Author Response File: 
Author Response.docx
