A participatory parent-focused intervention promoting physical activity in preschools: design of a cluster-randomized trial

Freia De Bock, Joachim E Fischer, Kristina Hoffmann, Herbert Renz-Polster, Freia De Bock, Joachim E Fischer, Kristina Hoffmann, Herbert Renz-Polster

Abstract

Background: With rates of childhood obesity increasing, physical activity (PA) promotion especially in young children has assumed greater importance. Given the limited effectiveness of most interventions to date, new approaches are needed. The General Systems theory suggests that involving parents as intervention targets may be effective in fostering healthier life styles in children. We describe the development of a parent-focused participatory intervention and the procedures used to evaluate its effectiveness in increasing daily PA in preschoolers.

Methods/design: Thirty-seven South German preschools were identified for this study and agreed to participate. Using a two-armed, controlled cluster-randomized trial design we test a participatory intervention with parents as the primary target group and potential agents of behavioural change. Specifically, the intervention is designed to engage parents in the development, refinement and selection of project ideas to promote PA and in incorporating these ideas into daily routines within the preschool community, consisting of children, teachers and parents. Our study is embedded within an existing state-sponsored programme providing structured gym lessons to preschool children. Thus, child-based PA outcomes from the study arm with the parent-focused intervention and the state-sponsored programme are compared with those from the study arm with the state-sponsored programme alone. The evaluation entails baseline measurements of study outcomes as well as follow-up measurements at 6 and 12 months. Accelerometry measures PA intensity over a period of six days, with the mean over six days used as the primary outcome measure. Secondary outcomes include childrens' BMI, a sum of averaged skin fold thickness measurements across multiple sites, and PA behaviour. Longitudinal multilevel models are used to assess within-subject change and between-group differences in study outcomes, adjusted for covariates at the preschool and individual levels. Teacher qualitative interviews monitor the intervention implementation process.

Discussion: Participatory approaches that actively involve parents have the potential to promote PA in ways that might be better tailored to local needs and more sustainable. Our mixed methods approach to assess the intervention efficacy and implementation employing both quantitative and qualitative measures within a cluster-randomized controlled trial may serve as a framework for evaluating public health interventions in preschool settings.

Trial registration: clinicaltrials.gov No: NCT00987532.

Figures

Figure 1
Figure 1
Study design. Notes: n = number of preschools, N = number of children, SES = socioeconomic status.
Figure 2
Figure 2
Evaluation design accounting for seasonal differences and using a waiting list control. CONT = gym lessons (existing state-sponsored programme). INT = participatory parent-focused intervention plus simultaneous gym lessons. X1 and X2: randomization time points, X1 = autumn, X2 = spring. ---- children enrolled and measured, but no intervention/gym lessons.
Figure 3
Figure 3
Preschool children happily presenting their accelerometer.

References

    1. Wilkinson KM. Increasing obesity in children and adolescents: an alarming epidemic. JAAPA. 2008;21:31–36.
    1. Andersen LB, Harro M, Sardinha LB, Froberg K, Ekelund U, Brage S, Anderssen SA. Physical activity and clustered cardiovascular risk in children: a cross-sectional study (The European Youth Heart Study) Lancet. 2006;368:299–304. doi: 10.1016/S0140-6736(06)69075-2.
    1. Pietilainen KH, Kaprio J, Borg P, Plasqui G, Yki-Jarvinen H, Kujala UM, Rose RJ, Westerterp KR, Rissanen A. Physical inactivity and obesity: a vicious circle. Obesity (Silver Spring) 2008;16:409–414. doi: 10.1038/oby.2007.72.
    1. Stevens J, Murray DM, Baggett CD, Elder JP, Lohman TG, Lytle LA, Pate RR, Pratt CA, Treuth MS, Webber LS. Objectively assessed associations between physical activity and body composition in middle-school girls: the Trial of Activity for Adolescent Girls. Am J Epidemiol. 2007;166:1298–1305. doi: 10.1093/aje/kwm202.
    1. Ekeland E, Heian F, Hagen KB. Can exercise improve self esteem in children and young people? A systematic review of randomised controlled trials. Br J Sports Med. 2005;39:792–798. doi: 10.1136/bjsm.2004.017707. discussion 792-798.
    1. Williams HG, Pfeiffer KA, O'Neill JR, Dowda M, McIver KL, Brown WH, Pate RR. Motor skill performance and physical activity in preschool children. Obesity (Silver Spring) 2008;16:1421–1426. doi: 10.1038/oby.2008.214.
    1. Reilly JJ. Physical activity, sedentary behaviour and energy balance in the preschool child: opportunities for early obesity prevention. Proc Nutr Soc. 2008;67:317–325. doi: 10.1017/S0029665108008604.
    1. Telama R, Yang X, Viikari J, Valimaki I, Wanne O, Raitakari O. Physical activity from childhood to adulthood: a 21-year tracking study. Am J Prev Med. 2005;28:267–273. doi: 10.1016/j.amepre.2004.12.003.
    1. Kamath CC, Vickers KS, Ehrlich A, McGovern L, Johnson J, Singhal V, Paulo R, Hettinger A, Erwin PJ, Montori VM. Clinical review: behavioral interventions to prevent childhood obesity: a systematic review and metaanalyses of randomized trials. J Clin Endocrinol Metab. 2008;93:4606–4615. doi: 10.1210/jc.2006-2411.
    1. van Sluijs EM, McMinn AM, Griffin SJ. Effectiveness of interventions to promote physical activity in children and adolescents: systematic review of controlled trials. BMJ. 2007;335:703. doi: 10.1136/.
    1. Hannon JC, Brown BB. Increasing preschoolers' physical activity intensities: an activity-friendly preschool playground intervention. Prev Med. 2008;46:532–536. doi: 10.1016/j.ypmed.2008.01.006.
    1. Stock S, Miranda C, Evans S, Plessis S, Ridley J, Yeh S, Chanoine JP. Healthy Buddies: a novel, peer-led health promotion program for the prevention of obesity and eating disorders in children in elementary school. Pediatrics. 2007;120:1059–1068. doi: 10.1542/peds.2006-3003.
    1. Trost SG, Fees B, Dzewaltowski D. Feasibility and efficacy of a "move and learn" physical activity curriculum in preschool children. J Phys Act Health. 2008;5:88–103.
    1. Campbell R, Starkey F, Holliday J, Audrey S, Bloor M, Parry-Langdon N, Hughes R, Moore L. An informal school-based peer-led intervention for smoking prevention in adolescence (ASSIST): a cluster randomised trial. Lancet. 2008;371:1595–1602. doi: 10.1016/S0140-6736(08)60692-3.
    1. Stone EG, Morton SC, Hulscher ME, Maglione MA, Roth EA, Grimshaw JM, Mittman BS, Rubenstein LV, Rubenstein LZ, Shekelle PG. Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med. 2002;136:641–651.
    1. Braziller G. General System Theory: Foundations, Developments, Applications. New York. 1968.
    1. O'Connor TM, Jago R, Baranowski T. Engaging parents to increase youth physical activity a systematic review. Am J Prev Med. 2009;37:141–149. doi: 10.1016/j.amepre.2009.04.020.
    1. McAllister CL, Green BL, Terry MA, Herman V, Mulvey L. Parents, practitioners, and researchers: community-based participatory research with early head start. Am J Public Health. 2003;93:1672–1679. doi: 10.2105/AJPH.93.10.1672.
    1. Bruss MB, Michael TJ, Morris JR, Applegate B, Dannison L, Quitugua JA, Palacios RT, Klein DJ. Childhood Obesity Prevention: An Intervention Targeting Primary Caregivers of School Children. Obesity. 2010;18:99–107. doi: 10.1038/oby.2009.111.
    1. Giles-Corti B, Salmon J. Encouraging children and adolescents to be more active. BMJ. 2007;335:677–678. doi: 10.1136/bmj.39345.679514.80.
    1. Fitzgibbon ML, Stolley MR, Schiffer L, Van Horn L, Kaufer Christoffel K, Dyer A. Two-year follow-up results for Hip-Hop to Health Jr.: a randomized controlled trial for overweight prevention in preschool minority children. J Pediatr. 2005;146:618–625. doi: 10.1016/j.jpeds.2004.12.019.
    1. Manios Y, Kafatos I, Kafatos A. Ten-year follow-up of the Cretan Health and Nutrition Education Program on children's physical activity levels. Prev Med. 2006;43:442–446. doi: 10.1016/j.ypmed.2006.06.001.
    1. Saakslahti A, Numminen P, Varstala V, Helenius H, Tammi A, Viikari J, Valimaki I. Physical activity as a preventive measure for coronary heart disease risk factors in early childhood. Scand J Med Sci Sports. 2004;14:143–149. doi: 10.1111/j.1600-0838.2004.00347.x.
    1. Benjamin SE, Haines J, Ball SC, Ward DS. Improving nutrition and physical activity in child care: what parents recommend. J Am Diet Assoc. 2008;108:1907–1911. doi: 10.1016/j.jada.2008.08.018.
    1. Dwyer J, Needham L, Simpson JR, Heeney ES. Parents report intrapersonal, interpersonal, and environmental barriers to supporting healthy eating and physical activity among their preschoolers. Appl Physiol Nutr Metab. 2008;33:338–346. doi: 10.1139/H07-195.
    1. Oliver M, Schofield GM, Schluter PJ. Parent influences on preschoolers' objectively assessed physical activity. J Sci Med Sport. in press .
    1. Kleiser C, Schaffrath Rosario A, Mensink GB, Prinz-Langenohl R, Kurth BM. Potential determinants of obesity among children and adolescents in Germany: results from the cross-sectional KiGGS Study. BMC Public Health. 2009;9:46. doi: 10.1186/1471-2458-9-46.
    1. Economos CD, Irish-Hauser S. Community interventions: a brief overview and their application to the obesity epidemic. J Law Med Ethics. 2007;35:131–137. doi: 10.1111/j.1748-720X.2007.00117.x.
    1. Hawe P, Shiell A, Riley T. Complex interventions: how "out of control" can a randomised controlled trial be? BMJ. 2004;328:1561–1563. doi: 10.1136/bmj.328.7455.1561.
    1. Burdette HL, Whitaker RC, Daniels SR. Parental report of outdoor playtime as a measure of physical activity in preschool-aged children. Arch Pediatr Adolesc Med. 2004;158:353–357. doi: 10.1001/archpedi.158.4.353.
    1. Moher D, Schulz KF, Altman DG. The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomized trials. Ann Intern Med. 2001;134:657–662.
    1. Campbell MK, Elbourne DR, Altman DG. CONSORT statement: extension to cluster randomised trials. BMJ. 2004;328:702–708. doi: 10.1136/bmj.328.7441.702.
    1. Dowda M, Brown WH, McIver KL, Pfeiffer KA, O'Neill JR, Addy CL, Pate RR. Policies and characteristics of the preschool environment and physical activity of young children. Pediatrics. 2009;123:261–266. doi: 10.1542/peds.2008-2498.
    1. Tucker P, Gilliland J. The effect of season and weather on physical activity: a systematic review. Public Health. 2007;121:909–922. doi: 10.1016/j.puhe.2007.04.009.
    1. Beighle A, Alderman B, Morgan CF, Le Masurier G. Seasonality in children's pedometer-measured physical activity levels. Res Q Exerc Sport. 2008;79:256–260.
    1. Brage S, Brage N, Franks PW, Ekelund U, Wareham NJ. Reliability and validity of the combined heart rate and movement sensor Actiheart. Eur J Clin Nutr. 2005;59:561–570. doi: 10.1038/sj.ejcn.1602118.
    1. Corder K, Brage S, Mattocks C, Ness A, Riddoch C, Wareham NJ, Ekelund U. Comparison of two methods to assess PAEE during six activities in children. Med Sci Sports Exerc. 2007;39:2180–2188. doi: 10.1249/mss.0b013e318150dff8.
    1. Trost SG, McIver KL, Pate RR. Conducting accelerometer-based activity assessments in field-based research. Med Sci Sports Exerc. 2005;37:531–543. doi: 10.1249/01.mss.0000185657.86065.98.
    1. Rowlands AV, Eston RG, Ingledew DK. Measurement of physical activity in children with particular reference to the use of heart rate and pedometry. Sports Med. 1997;24:258–272. doi: 10.2165/00007256-199724040-00004.
    1. Brage S, Brage N, Ekelund U, Luan J, Franks PW, Froberg K, Wareham NJ. Effect of combined movement and heart rate monitor placement on physical activity estimates during treadmill locomotion and free-living. Eur J Appl Physiol. 2006;96:517–524. doi: 10.1007/s00421-005-0112-6.
    1. Stolzenberg HKH, Bergmann KE. Körpermaße bei Kindern und Jugendlichen in Deutschland. Ergebnisse des Kinder- und Jugendgesundheitssurveys (KiGGS) Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz. 2007;50:659–669. doi: 10.1007/s00103-007-0227-5.
    1. Roswall J, Bergman S, Almqvist-Tangen G, Alm B, Niklasson A, Nierop AF, Dahlgren J. Population-based waist circumference and waist-to-height ratio reference values in preschool children. Acta Paediatr. 2009;98:1632–1636. doi: 10.1111/j.1651-2227.2009.01430.x.
    1. Ashwell M. Obesity risk: importance of the waist-to-height ratio. Nurs Stand. 2009;23:49–54. quiz 55.
    1. Nambiar S, Truby H, Abbott RA, Davies PS. Validating the waist-height ratio and developing centiles for use amongst children and adolescents. Acta Paediatr. 2009;98:148–152. doi: 10.1111/j.1651-2227.2008.01050.x.
    1. Freedman DS, Wang J, Ogden CL, Thornton JC, Mei Z, Pierson RN, Dietz WH, Horlick M. The prediction of body fatness by BMI and skinfold thicknesses among children and adolescents. Ann Hum Biol. 2007;34:183–194. doi: 10.1080/03014460601116860.
    1. Eisenmann JC, Heelan KA, Welk GJ. Assessing body composition among 3- to 8-year-old children: anthropometry, BIA, and DXA. Obes Res. 2004;12:1633–1640. doi: 10.1038/oby.2004.203.
    1. Bayer O, Bolte G, Morlock G, Ruckinger S, von Kries R. A simple assessment of physical activity is associated with obesity and motor fitness in pre-school children. Public Health Nutr. 2009;12:1242–1247. doi: 10.1017/S1368980008003753.
    1. Bayer O, von Kries R, Strauss A, Mitschek C, Toschke AM, Hose A, Koletzko BV. Short- and mid-term effects of a setting based prevention program to reduce obesity risk factors in children: a cluster-randomized trial. Clin Nutr. 2009;28:122–128. doi: 10.1016/j.clnu.2009.01.001.
    1. Cole CR, Blackstone EH, Pashkow FJ, Snader CE, Lauer MS. Heart-rate recovery immediately after exercise as a predictor of mortality. N Engl J Med. 1999;341:1351–1357. doi: 10.1056/NEJM199910283411804.
    1. Lin LY, Kuo HK, Lai LP, Lin JL, Tseng CD, Hwang JJ. Inverse correlation between heart rate recovery and metabolic risks in healthy children and adolescents: insight from the National Health and Nutrition Examination Survey 1999-2002. Diabetes Care. 2008;31:1015–1020. doi: 10.2337/dc07-2299.
    1. Rikli RE, Petray C, Baumgartner TA. The reliability of distance run tests for children in grades K-4. Res Q Exerc Sport. 1992;63:270–276.
    1. Hollis JF, Sexton G, Connor SL, Calvin L, Pereira C, Matarazzo JD. The family heart dietary intervention program: community response and characteristics of joining and nonjoining families. Prev Med. 1984;13:276–285. doi: 10.1016/0091-7435(84)90084-7.
    1. Anderson SE, Economos CD, Must A. Active play and screen time in US children aged 4 to 11 years in relation to sociodemographic and weight status characteristics: a nationally representative cross-sectional analysis. BMC Public Health. 2008;8:366. doi: 10.1186/1471-2458-8-366.
    1. Muller MJ, Koertzinger I, Mast M, Langnase K, Grund A. Physical activity and diet in 5 to 7 years old children. Public Health Nutr. 1999;2:443–444. doi: 10.1017/S1368980099000609.
    1. Kuepper-Nybelen J, Lamerz A, Bruning N, Hebebrand J, Herpertz-Dahlmann B, Brenner H. Major differences in prevalence of overweight according to nationality in preschool children living in Germany: determinants and public health implications. Arch Dis Child. 2005;90:359–363. doi: 10.1136/adc.2004.052423.
    1. Schenk L, Bau AM, Borde T, Butler J, Lampert T, Neuhauser H, Razum O, Weilandt C. [A basic set of indicators for mapping migrant status. Recommendations for epidemiological practice] Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2006;49:853–860. doi: 10.1007/s00103-006-0018-4.
    1. Ball K, Cleland VJ, Timperio AF, Salmon J, Crawford DA. Socioeconomic position and children's physical activity and sedentary behaviors: longitudinal findings from the CLAN study. J Phys Act Health. 2009;6:289–298.
    1. Semmler C, Ashcroft J, van Jaarsveld CH, Carnell S, Wardle J. Development of overweight in children in relation to parental weight and socioeconomic status. Obesity (Silver Spring) 2009;17:814–820. doi: 10.1038/oby.2008.621.
    1. Reinehr T, Brylak K, Alexy U, Kersting M, Andler W. Predictors to success in outpatient training in obese children and adolescents. Int J Obes Relat Metab Disord. 2003;27:1087–1092. doi: 10.1038/sj.ijo.0802368.
    1. Baron RM, Kenny DA. The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol. 1986;51:1173–1182. doi: 10.1037/0022-3514.51.6.1173.
    1. Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89:1322–1327. doi: 10.2105/AJPH.89.9.1322.
    1. Glasgow RE, Lichtenstein E, Marcus AC. Why don't we see more translation of health promotion research to practice? Rethinking the efficacy-to-effectiveness transition. Am J Public Health. 2003;93:1261–1267. doi: 10.2105/AJPH.93.8.1261.
    1. Kurth B-M, Schaffrath Rosario A. The prevalence of overweight and obese children and adolescents living in Germany. Results of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS) Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2007;2007:736–743.
    1. Lampert T, Mensink GBM, Romahn N, Woll A. Physical activity among children and adolescents in germany. Results of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS) Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2007;2007:634–642.
    1. Reilly JJ, Kelly L, Montgomery C, Williamson A, Fisher A, McColl JH, Lo Conte R, Paton JY, Grant S. Physical activity to prevent obesity in young children: cluster randomised controlled trial. BMJ. 2006;333:1041. doi: 10.1136/bmj.38979.623773.55.
    1. MIller WJ, Crabtree BF. In: Doing Qualitative Research. MIller WJ, Crabtree BF, editor. Vol. 2. Thousand Oaks, London, Greater Kailash: Sage Publications; 1999. The Dance of Interpretation; pp. 127–144.
    1. Cargo M, Mercer SL. The value and challenges of participatory research: strengthening its practice. Annu Rev Public Health. 2008;29:325–350. doi: 10.1146/annurev.publhealth.29.091307.083824.
    1. Viswanathan M, Ammerman A, Eng E, Garlehner G, Lohr KN, Griffith D, Rhodes S, Samuel-Hodge C, Maty S, Lux L. Community-based participatory research: assessing the evidence. Evid Rep Technol Assess (Summ) 2004. pp. 1–8.

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