Implementation process and acceptance of a setting based prevention programme to promote healthy lifestyle in preschool children

Objective: Evaluation of the implementation process of a kindergarten-based intervention ('TigerKids') to promote a healthy lifestyle. Design: Questionnaire survey among kindergarten teachers about programme implementation and acceptance. Setting: Kindergartens in Bavaria, Germany. Methods: Two hundred and fifteen kindergartens were included; 96.3 % returned informative questionnaires. `TigerKids' is a multi-approach behavioural intervention programme to increase physical activity level and to promote healthy eating in preschool children. Project elements and materials are designed for kindergarten teachers, children, and their parents. The main outcome measures of the study are implementation, acceptance, and estimated effectiveness of the intervention programme. Results: The elements for promoting healthy lifestyle were implemented regularly in the participating kindergartens: 94.2 % used the drinking station daily, 75.8 % prepared the magic fruit plate daily, and 63.3 % carried out the activity programme at least two times per week. The educators reported that the children ate more fruits and vegetables, drank more non-sugared beverages, and were more active. The designed materials and elements for the children, the educators, and the parents were also evaluated positively by the kindergarten teachers. Conclusion: The `TigerKids' programme is a suitable instrument for health promotion in the kindergarten setting

Implementation process and acceptance of a setting based prevention programme to promote healthy lifestyle in preschool children

Objective: Evaluation of the implementation process of a kindergarten-based intervention ('TigerKids') to promote a healthy lifestyle. Design: Questionnaire survey among kindergarten teachers about programme implementation and acceptance. Setting: Kindergartens in Bavaria, Germany. Methods: Two hundred and fifteen kindergartens were included; 96.3 % returned informative questionnaires. `TigerKids' is a multi-approach behavioural intervention programme to increase physical activity level and to promote healthy eating in preschool children. Project elements and materials are designed for kindergarten teachers, children, and their parents. The main outcome measures of the study are implementation, acceptance, and estimated effectiveness of the intervention programme. Results: The elements for promoting healthy lifestyle were implemented regularly in the participating kindergartens: 94.2 % used the drinking station daily, 75.8 % prepared the magic fruit plate daily, and 63.3 % carried out the activity programme at least two times per week. The educators reported that the children ate more fruits and vegetables, drank more non-sugared beverages, and were more active. The designed materials and elements for the children, the educators, and the parents were also evaluated positively by the kindergarten teachers. Conclusion: The `TigerKids' programme is a suitable instrument for health promotion in the kindergarten setting

Applying the Intervention Mapping protocol to develop a kindergarten-based, family-involved intervention to increase European preschool children's physical activity levels: the ToyBox-study

Although sufficient physical activity is beneficial for preschoolers' health, activity levels in most preschoolers are low. As preschoolers spend a considerable amount of time at home and at kindergarten, interventions should target both environments to increase their activity levels. The aim of the current paper was to describe the six different steps of the Intervention Mapping protocol towards the systematic development and implementation of the physical activity component of the ToyBox-intervention. This intervention is a kindergarten-based, family-involved intervention implemented across six European countries. Based on the results of literature reviews and focus groups with parents/caregivers and kindergarten teachers, matrices of change objectives were created. Then, theory-based methods and practical strategies were selected to develop intervention materials at three different levels: (i) individual level (preschoolers); (ii) interpersonal level (parents/caregivers) and (iii) organizational level (teachers). This resulted in a standardized intervention with room for local and cultural adaptations in each participating country. Although the Intervention Mapping protocol is a time-consuming process, using this systematic approach may lead to an increase in intervention effectiveness. The presented matrices of change objectives are useful for future programme planners to develop and implement an intervention based on the Intervention Mapping protocol to increase physical activity levels in preschoolers

Developing the intervention material to increase physical activity levels of European preschool children: the ToyBox-study

Early childhood is an important period for adopting positive health-related behaviours. More than 95% of European preschool children attend kindergartens, making these settings ideal for the implementation of health promotion interventions. The ToyBox-intervention addressed preschool children, their parents/caregivers and teachers. The aim of the intervention was to improve four energy balance-related behaviours (i.e. healthy snacking, water consumption, physical activity and sedentary behaviour) by implementing a kindergarten-based, family-involved intervention in six European countries (Belgium, Bulgaria, Germany, Greece, Poland and Spain). The intervention material was developed following the intervention mapping protocol, taking into account local and cultural differences among the intervention countries. The present paper focuses on the development of the physical activity component of the intervention. Parental involvement was addressed by providing parents/caregivers with two newsletters, two tip cards and a poster. Teachers received a handbook with guidance on environmental changes in the classroom, 26 physical education sessions and suggestions for fun, interactive classroom activities aiming at total class participation to increase preschoolers' physical activity levels. The ToyBox-intervention material was distributed according to a standard time frame. Teachers received their material prior to the start of the intervention and parents/caregivers received their material during the intervention when each energy balance-related behaviour was implemented

Tools, harmonization and standardization procedures of the impact and outcome evaluation indices obtained during a kindergarten-based, family-involved intervention to prevent obesity in early childhood: The ToyBox-study

The ToyBox-intervention is a kindergarten-based, family-involved intervention targeting multiple lifestyle behaviours in preschool children, their teachers and their families. This intervention was conducted in six European countries, namely Belgium, Bulgaria, Germany, Greece, Poland and Spain. The aim of this paper is to provide a descriptive overview of the harmonization and standardization procedures of the baseline and follow-up evaluation of the study (and substudies). Steps related to the study's operational, standardization and harmonization procedures as well as the impact and outcome evaluation assessment tools used are presented. Experiences from the project highlight the importance of safeguarding the measurement process to minimize data heterogeneity derived from potential measurement error and country-by-country differences. In addition, it was made clear that continuing quality control and support is an important component of such studies. For this reason, well-supported communication channels, such as regular email updates and teleconferences, and regular internal and external meetings to ensure smooth and accurate implementation were in place during the study. The ToyBox-intervention and its harmonized and standardized procedures can serve as a successful case study for future studies evaluating the efficacy of similar interventions

Effect and process evaluation of a kindergarten-based, family-involved intervention with a randomized cluster design on sedentary behaviour in 4- to 6-year old European preschool children: The ToyBoxstudy

Background: The aim of the present study evaluated the effect and process of the ToyBox-intervention on proxy-reported sedentary behaviours in 4- to 6-year-old preschoolers from six European countries. Methods: In total, 2434 preschoolers' parents/primary caregivers (mean age: 4.7±0.4 years, 52.2% boys) filled out a questionnaire, assessing preschoolers' sedentary behaviours (TV/DVD/video viewing, computer/video games use and quiet play) on weekdays and weekend days. Multilevel repeated measures analyses were conducted to measure the intervention effects. Additionally, process evaluation data were included to better understand the intervention effects. Results: Positive intervention effects were found for computer/video games use. In the total sample, the intervention group showed a smaller increase in computer/video games use on weekdays (β =-3.40, p = 0.06; intervention: +5.48 min/day, control: +8.89 min/day) and on weekend days (β =-5.97, p = 0.05; intervention: +9.46 min/day, control: +15.43 min/day) from baseline to follow-up, compared to the control group. Country-specific analyses showed similar effects in Belgium and Bulgaria, while no significant intervention effects were found in the other countries. Process evaluation data showed relatively low teachers' and low parents' process evaluation scores for the sedentary behaviour component of the intervention (mean: 15.6/24, range: 2.5-23.5 and mean: 8.7/17, range: 0-17, respectively). Higher parents' process evaluation scores were related to a larger intervention effect, but higher teachers' process evaluation scores were not. ConclusionsL The ToyBox-intervention had a small, positive effect on European preschoolers' computer/video games use on both weekdays and weekend days, but not on TV/DVD/video viewing or quiet play. The lack of larger effects can possibly be due to the fact that parents were only passively involved in the intervention and to the fact that the intervention was too demanding for the teachers. Future interventions targeting preschoolers' behaviours should involve parents more actively in both the development and the implementation of the intervention and, when involving schools, less demanding activities for teachers should be developed

Establishing a method to estimate the cost-effectiveness of a kindergarten-based, family-involved intervention to prevent obesity in early childhood. The ToyBox-study

Overweight and obesity in children are recognized as a major health problem. The ToyBox-intervention was developed with the aim of preventing obesity in pre-schoolers. Because it is increasingly important to inform policy makers not only on the effects of prevention interventions, but also on their costs and cost-effectiveness, our purpose was to establish a method to estimate the cost-effectiveness of the ToyBox-intervention. In order to estimate the long-term impact of the ToyBox-intervention on health and societal costs, extrapolations of the intervention effect will be conducted to predict children's weight status (based on the body mass index) at adult age. Effects of the adult weight status on the prevalence of obesity-related complications will be modelled through a Markov model, with a total time horizon of 70 years and a cycle length of 1 year. The model will be conducted in six European countries participating in the ToyBox-intervention, based on country-specific economic and epidemiological data. This study describes the methodological rationale and implementation of an analytic model to examine the cost-effectiveness of the ToyBox-intervention for six European countries, in order to inform decision-makers on the value for money of this intervention in the prevention of obesity in pre-schoolers

Designing and implementing teachers' training sessions in a kindergarten-based, family-involved intervention to prevent obesity in early childhood. The ToyBox-study

Since school-based interventions are mainly delivered by the school staff, they need to be well-trained and familiarized with the programme's aims, procedures and tools. Therefore, the institute, research group, governmental or non-governmental body in charge of the coordination and implementation of the programme needs to devote time and resources to train the school staff before programme's implementation. This is particularly crucial in multi-centre studies where more than one research teams are involved. Both research teams and school staff need to be trained, using standard protocols and procedures, to ensure that the intervention will be delivered in a standardized manner throughout the intervention centres. The ToyBox-intervention, a multi-component, kindergarten-based, family-involved intervention, focusing on water consumption, snacking, physical activity and sedentary behaviours in preschool children, was implemented over the academic year 2012-2013 in six European countries. As part of this intervention, three teachers' training sessions were delivered to motivate and train teachers in implementing the intervention. The local researchers were trained centrally before delivering the training sessions for the teachers and followed a common protocol using standardized presentations and procedures. The aim of the current paper is to describe the protocol and methodological issues related to the teachers' training sessions conducted within the ToyBox-intervention