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

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

Reliability of primary caregivers reports on lifestyle behaviours of European pre-school children: The ToyBox-study

Reliable assessments of health-related behaviours are necessary for accurate evaluation on the efficiency of public health interventions. The aim of the current study was to examine the reliability of a self-administered primary caregivers questionnaire (PCQ) used in the ToyBox-intervention. The questionnaire consisted of six sections addressing sociodemographic and perinatal factors, water and beverages consumption, physical activity, snacking and sedentary behaviours. Parents/caregivers from six countries (Belgium, Bulgaria, Germany, Greece, Poland and Spain) were asked to complete the questionnaire twice within a 2-week interval. A total of 93 questionnaires were collected. Test-retest reliability was assessed using intra-class correlation coefficient (ICC). Reliability of the six questionnaire sections was assessed. A stronger agreement was observed in the questions addressing sociodemographic and perinatal factors as opposed to questions addressing behaviours. Findings showed that 92% of the ToyBox PCQ had a moderate-to-excellent test-retest reliability (defined as ICC values from 0.41 to 1) and less than 8% poor test-retest reliability (ICC<0.40). Out of the total ICC values, 67% showed good-to-excellent reliability (ICC from 0.61 to 1). We conclude that the PCQ is a reliable tool to assess sociodemographic characteristics, perinatal factors and lifestyle behaviours of pre-school children and their families participating in the ToyBox-intervention

The effect of a kindergarten-based, family-involved intervention on objectively measured physical activity in Belgian preschool boys and girls of high and low SES: The ToyBox-study

Background: The ToyBox-study developed an evidence- and theory-based intervention to improve preschoolers' energy balance-related behaviours - including physical activity (PA) - by targeting the kindergarten environment and involving their parents/caregivers. The present study aimed to examine the effect of the ToyBox-intervention on increasing Belgian preschoolers' objectively measured PA levels.Methods: A sample of 472 preschoolers (4.43 ± 0.55 years; 55.1% boys) from 27 kindergartens (15 intervention, 12 control kindergartens) in Flanders, Belgium were included in the data analyses. Preschoolers wore an ActiGraph accelerometer for six consecutive days and were included in the data analyses if they had a minimum of two weekdays and one weekend day, both at baseline and follow-up (one year later). Preschoolers' PA outcomes were estimated for an average day, weekday, weekend day, during school hours, and during after school hours. To assess intervention effects, multilevel repeated measures analyses were conducted for the total sample, and for sub-groups (according to sex, kindergarten levels of socio-economic status (SES) and risk groups (low levels of PA at baseline)) of preschoolers.Results: Small intervention effects were found in the total sample. Most intervention effects were found in boys and in preschoolers from high SES kindergartens. Boys from the intervention group had an increase in vigorous PA (ß = 1.47, p = 0.03) and moderate-to-vigorous PA (ß = 1.27, p = 0.03) from baseline to follow-up, whereas PA levels in boys from the control group stagnated or decreased. In preschoolers from high SES kindergartens, the largest effects were found for PA outcomes during school hours and during after school hours.Conclusion: The results from the Belgian sample demonstrate that effects of the PA-component of the ToyBox-intervention on objectively measured PA were found in preschool boys and in preschoolers from high SES kindergartens, which means that the ToyBox-intervention was mainly effective in those sub-groups. Future interventions should search for alternative strategies to increase preschoolers' PA levels in preschool girls and preschoolers from low SES kindergartens, as these are the most important at-risk groups regarding PA

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

Designing and implementing a kindergarten-based, family-involved intervention to prevent obesity in early childhood: The ToyBox-study

The development of the ToyBox-intervention was based on the outcomes of the preliminary phase of the ToyBox-study, aiming to identify young children's key behaviours and their determinants related to early childhood obesity. The ToyBox-intervention is a multi-component, kindergarten-based, family-involved intervention with a cluster-randomized design, focusing on the promotion of water consumption, healthy snacking, physical activity and the reduction/ breaking up of sedentary time in preschool children and their families. The intervention was implemented during the academic year 2012-2013 in six European countries: Belgium, Bulgaria, Germany, Greece, Poland and Spain. Standardized protocols, methods, tools and material were used in all countries for the implementation of the intervention, as well as for the process, impact, outcome evaluation and the assessment of its cost-effectiveness. A total sample of 7,056 preschool children and their parents/caregivers, stratified by socioeconomic level, provided data during baseline measurements and participated in the intervention. The results of the ToyBox-study are expected to provide a better insight on behaviours associated with early childhood obesity and their determinants and identify effective strategies for its prevention. The aim of the current paper is to describe the design of the ToyBox-intervention and present the characteristics of the study sample as assessed at baseline, prior to the implementation of the intervention