obesity reviews

doi: 10.1111/obr.12176

Obesity Prevention

Developing the intervention material to increase physical activity levels of European preschool children: the ToyBox-study K. Duvinage1, S. Ibrügger1, S. Kreichauf2, A. Wildgruber2, M. De Craemer3, E. De Decker3, O. Androutsos4, M. Lateva5, V. Iotova5, P. Socha6, K. Zych6, T. Mouratidou7, M. I. Mesana Graffe7, Y. Manios4 and B. Koletzko1 on behalf of the ToyBox-study group 1Division

of Metabolic and Nutritional Medicine, Dr.

von Hauner Children’s Hospital, LudwigMaximilians-University of Munich, München, Germany; 2State Institute of Early Childhood Research, Munich, Germany; 3Department of

Summary 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 inter-

Dietetics, Harokopio University, Athens, Greece;

vention was to improve four energy balance-related behaviours (i.e. healthy snacking, water consumption, physical activity and sedentary behaviour) by implementing a kindergartenbased, family-involved intervention in six European countries (Belgium, Bulgaria, Germany,

5Department

Greece, Poland and Spain). The intervention material was developed following the inter-

Movement and Sport Sciences, Ghent University, Ghent, Belgium; 4Department of Nutrition and

of Pediatrics and Medical Genetics,

Medical University Varna, Varna, Bulgaria; 6Children’s Memorial Health Institute, Warsaw, Poland; 7GENUD (Growth, Exercise, NUtrition and Development)

vention 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/

Spain

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

Received 7 April 2014; revised 9 April 2014;

increase preschoolers’ physical activity levels. The ToyBox-intervention material was dis-

accepted 9 April 2014

tributed 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.

Research Group, University of Zaragoza, Zaragoza,

Address for correspondence: Ms K Duvinage, Division of Metabolic and Nutritional Medicine, Dr. von Hauner Children’s Hospital, Ludwig-

Keywords: Intervention, kindergarten, obesity prevention, physical activity.

Maximilians-University of Munich, Lindwurmstr. 4, 80337 München, Germany.

obesity reviews (2014) 15 (Suppl. 3), 27–39

E-mail: [email protected]

ToyBox-study group: Coordinator: Yannis Manios; Steering committee: Yannis Manios, Berthold Koletzko, Ilse De Bourdeaudhuij, Mai Chin A Paw, Luis Moreno, Carolyn Summerbell, Tim Lobstein, Lieven Annemans, Goof Buijs; External advisors: John Reilly, Boyd Swinburn, Dianne Ward; Harokopio University (Greece): Yannis Manios, Odysseas Androutsos, Eva Grammatikaki, Christina Katsarou, Eftychia Apostolidou, Eirini Efstathopoulou; Ludwig Maximilians Universitaet Muenchen (Germany): Berthold Koletzko, Kristin Duvinage, Sabine Ibrügger, Angelika Strauß, Birgit Herbert, Julia Birnbaum, Annette Payr, Christine Geyer; Ghent University (Belgium): Department of Movement and Sports Sciences: Ilse De Bourdeaudhuij, Greet Cardon, Marieke De Craemer, Ellen De Decker; Department of Public Health: Lieven Annemans, Stefaan De Henauw, Lea Maes, Carine Vereecken, Jo Van Assche, Lore Pil; VU University Medical Center EMGO Institute for Health and Care Research (the Netherlands): EMGO Institute for Health and Care Research: Mai Chin A Paw, Saskia te Velde; University of Zaragoza (Spain): Luis Moreno, Theodora Mouratidou, Juan Fernandez, Maribel Mesana, Pilar De Miguel-Etayo, Esther M. González-Gil, Luis Gracia-Marco, Beatriz Oves; Oslo and Akershus University College of Applied Sciences (Norway): Agneta Yngve, Susanna Kugelberg, Christel Lynch, Annhild Mosdøl, Bente B Nilsen; University of Durham (UK): Carolyn Summerbell, Helen Moore, Wayne Douthwaite, Catherine Nixon; State Institute of Early Childhood Research (Germany): Susanne Kreichauf, Andreas Wildgruber; Children’s Memorial Health Institute (Poland): Piotr Socha, Zbigniew Kulaga, Kamila Zych, Magdalena Góz´dz´, Beata Gurzkowska, Katarzyna Szott; Medical University of Varna (Bulgaria): Violeta Iotova, Mina Lateva, Natalya Usheva, Sonya Galcheva, Vanya Marinova, Zhaneta Radkova, Nevyana Feschieva; International Association for the Study of Obesity (UK): Tim Lobstein, Andrea Aikenhead; CBO B.V. (the Netherlands): Goof Buijs, Annemiek Dorgelo, Aviva Nethe, Jan Jansen; AOK-Verlag (Germany): Otto Gmeiner, Jutta Retterath, Julia Wildeis, Axel Günthersberger; Roehampton University (UK): Leigh Gibson; University of Luxembourg (Luxembourg): Claus Voegele.

© 2014 World Obesity

27 15 (Suppl. 3), 27–39, August 2014

28 Increased physical activity in preschool K. Duvinage et al.

Introduction Physical activity (PA) is an essential aspect of child health and development (1,2) and helps to prevent the risk for overweight and obesity (3,4) and cardiovascular disease (5). High levels of PA during childhood are seen as an important basis for a physically active lifestyle in adolescence and adulthood (6), whereas low levels of PA are associated with the risk for overweight and obesity in childhood (7). To achieve a high level of PA, the development of motor skills has to be taken into account (8). Children with poor motor competencies are less capable to successfully participate in various physical activities, while their better coordinated peers are more likely to perform well in many physical activities (9,10). As a consequence, less developed motor skills may reduce the level of PA (11). Wrotniak et al. (2006) (12), Stodden et al. (2009) (13) and Riethmuller et al. (2009) (14) stressed that the development of motor skill competences in childhood is an important predictor of health-related physical fitness and PA levels in adulthood. Preschool age comprises an important period for establishing health-related behaviours (15–17). Since more than 95% of preschool children in Europe attend some form of out-of-home care (e.g. kindergarten, preschool) (18), these settings are ideal to implement interventions targeting PA and consequently enhance children’s health (19,20). However, only a limited number of intervention studies have attempted to implement health education programmes in these settings. The ToyBox-study is a research project including 15 institutes in 10 European countries that aimed at developing, implementing and evaluating a kindergarten-based, family-involved intervention to prevent overweight and obesity in preschool children aged 4–6 years in six European countries (Belgium, Bulgaria, Germany, Greece, Poland and Spain) (21) (www.toybox-study.eu). ToyBox is a multi-component study, not only focusing on PA, but targeting four different energy balance-related behaviours (EBRBs): (i) healthy snacking; (ii) drinking behaviour; (iii) PA and (iv) sedentary behaviour. Additional to the kindergarten environment in which preschool children and teachers were targeted, the home environment was also defined as an important target setting in ToyBox. The present paper aims to describe the development of the ToyBox-intervention material for the PA component, which was used in kindergartens and at home during the implementation phase of the ToyBox-intervention.

Methods The basis for the development of the ToyBox-intervention was the PRECEDE-PROCEED Model (22), an educational and ecological approach in health programme planning. 15 (Suppl. 3), 27–39, August 2014

obesity reviews

Each of the eight phases of the PRECEDE-PROCEED model was conducted when developing the ToyBoxintervention. The development of the ToyBox-intervention material is embedded in the PRECEDE-PROCEED model. Prior to the development of the ToyBox-intervention, the key EBRBs associated with overweight and obesity in early childhood, as well as their correlates and influencing factors were identified (23–25). Furthermore, behavioural models and educational strategies to promote healthy EBRBs were reviewed (20,26–28). Existing policies, regulation, legislation and ongoing health promotion activities in kindergarten settings in the six intervention countries were also analysed (29). Based on the preceding findings, the ToyBox-intervention focused on the four EBRBs that were found to be associated with early childhood overweight and obesity: (i) healthy snacking; (ii) drinking behaviour; (iii) PA and (iv) sedentary behaviour. The intervention mapping protocol (30) was used to develop the ToyBox-intervention in a structured, evidencebased way and to ensure that a scientific and systematic approach for the development of the intervention and the respective material was followed. For each of the four targeted behaviours, separate intervention mapping matrices were developed. More information on the intervention mapping for the PA component of the intervention and its link to the PRECEDE-PROCEED model is provided in this supplement (31). Material from the evaluated TigerKids programme (15) and experience gathered from its practical implementation (www.tigerkids.de) was used for the development of the ToyBox-intervention. Additional concepts and ideas were adopted from other previous intervention programmes of the current consortium such as the ENERGY project (63,64), the POP study (65,66) and the Cretan Health and Nutrition Intervention (67–69). Kindergarten settings differed between the six intervention countries because of differences in the age ranges of preschool children, class sizes, national curricula and the availability of equipment for PA (29). The ToyBoxintervention tried to accommodate all the different policies and practices into one intervention. To ensure the highest success in implementing the ToyBox-intervention, a core concept allowing for only minor adaptations was developed. For successful implementation of the ToyBoxintervention, three target groups were identified. As preschool-aged children are considered the ideal age group to implement health-related behaviours (15–17), they were considered as the first target group. The second target group were preschoolers’ teachers, as they spend a considerable amount of time with preschoolers and are able to implement the intervention in a kindergarten setting. Furthermore, their knowledge of PA and motor development is of major importance in supporting preschool children in being physically active (20). Finally, parents/ © 2014 World Obesity

obesity reviews

caregivers were defined as an important target group in ToyBox, as parents/caregivers have also been identified as key players in kindergarten-based interventions (32–34). The implementation of the ToyBox-intervention was conducted at four levels. The first three levels were implemented in the kindergarten setting, whereas the fourth level addressed parents/caregivers aiming to induce certain changes at children’s social and physical environment at home in order to promote the four targeted EBRBs. More specifically: Level 1. Teachers conducted permanent environmental changes in the classroom/kindergarten, in order to create a classroom and kindergarten environment supportive to the execution of the four targeted EBRBs (i.e. installations of water stations and the ‘magic snack plate’ to assist water and healthy snack consumption and rearrangements of the classroom/kindergarten to assist children’s movement). Level 2. Teachers promoted the four targeted EBRBs on a predefined, regular basis in the classroom/kindergarten, aiming at total class participation (i.e. reminded children every day to drink water regularly and do short movement breaks twice in the morning and twice in the afternoon, arranged a daily break for the whole class to eat healthy snacks and performed two physical education sessions per week with a duration of 45–60 min each). Level 3. Teachers implemented interactive classroom activities, aiming at total class participation, minimum for 1 h per week (e.g. children’s participation in experiments, kangaroo stories with children following the movements described in the stories, etc.). Teachers were also instructed to use the kangaroo handpuppet and perform these four EBRBs themselves, so as to enhance the effects of the intervention via role modelling. Level 4. Parents/caregivers were encouraged and advised via simple and easy to read material (nine newsletters, eight tip cards and four posters) to apply relevant environmental changes at home, act as role models and implement these lifestyle behaviours together with their children. The ToyBox-intervention material was divided into Material used at kindergarten and Material used at home. The Material used at kindergarten addressed levels 1–3 and consisted of: 1. The teacher’s general guide, a handbook designed to guide teachers through the programme and support intervention implementation. 2. Four classroom activities guides: each handbook focused on one of the four targeted behaviours. 3. A kangaroo hand puppet, which was used for implementing and supporting the classroom activities. © 2014 World Obesity

Increased physical activity in preschool K. Duvinage et al. 29

The Material used at home addressed level 4 of the intervention and consisted of: 1. Nine newsletters communicating the key messages of the ToyBox-intervention to parents/caregivers and updating them in parallel with the activities taking place in the kindergarten; two newsletters were used during the implementation of the PA component. 2. Eight tip cards with simple tips and strategies on how to incorporate desired health behaviours into the daily family routine; two tip cards were used during the implementation of the PA component. 3. Four posters that were coloured by the preschool children in kindergarten and handed out to the parents/ caregivers, each focusing on one targeted behaviour; one poster was used during the implementation of the PA component. A common time frame was followed by all intervention countries (Table 1). The implementation of the ToyBoxintervention was conducted throughout the academic year 2012–2013. The baseline measurements of the ToyBoxintervention were conducted between May and June 2012 on children born between January 2007 and December 2008 (i.e. the age range was from 3.5 to 5.5 years at baseline). The follow-up measurements were conducted 1 year later between May and June 2013 (35–38). During the implementation of the ToyBox-intervention, process evaluation was performed. Detailed information on the design and tools of the process evaluation is provided in this supplement (39). The intervention kindergarten teachers participated in three teachers’ training sessions. The first teachers’ training session took place in September 2012 or earlier. The second teachers’ training session took place in September/October 2012. During the first and the second training sessions, the teachers were informed about and prepared for their role as implementers of the intervention programme. In addition, a detailed explanation of the intervention time frame was provided. Furthermore, the ToyBox material was presented, classroom activities and movement games from the ToyBox-intervention were performed together in the group, and opportunities for discussion and brainstorming on implementation strategy were provided. A third teachers’ training session was conducted at the beginning of February 2013. Detailed information about the development and content of the teachers’ training sessions is provided in this supplement (40,41). The present paper focuses on the intervention material for PA, therefore only this component of the intervention will be described and discussed in detail. In accordance with health-enhancing guidelines for PA (42–45), the ToyBox-intervention was guided by the recommended 180 min of total PA per day for preschoolers. In addition, the PA guidelines for preschoolers of the National 15 (Suppl. 3), 27–39, August 2014

15 (Suppl. 3), 27–39, August 2014

PA poster PA newsletters PA tip cards

Material used at home

Start

Beginning of academic year



1–4

Week of the intervention:

Given out 1st

Start

Start



5

PA







6

1st







7







8





9–12

HS





13–16

SB





17 and 18

DB

2nd







19

PA

Repetition period

*After finishing the ToyBox-intervention period, teachers were able to choose between activities from all EBRBs until the end of the academic year. DB, drinking behaviour; HS, healthy snacking; PA, physical activity; SB, sedentary behaviour.

Work with parents

Classroom activities guide: Part 3: classroom activities (kangaroo stories, excursions)

Classroom activities guide: Part 2: Child performing the actual behaviour (structured physical education sessions)

Classroom activities guide: Part 1: Setting environmental changes in the kindergarten (e.g. movement landscapes, rearranging furniture to create space to be physically active)

Material used in the kindergarten

DB

Targeted behaviour:

First focus of the intervention

Table 1 Overview of the material for physical activity and time frame for implementation of the physical activity component of the ToyBox-intervention

2nd







20





21 and 22

HS





23 and 24

SB

*





End of academic year

30 Increased physical activity in preschool K. Duvinage et al.

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© 2014 World Obesity

obesity reviews

Association for Sport and Physical Education (46) with its distinction on two different concepts (i) the concept of unstructured PA (e.g. free play) and (ii) the concept of structured PA (e.g. structured physical education sessions) were included in the ToyBox-intervention. Consequently, the recommended 180 min of total PA per day as well as structured and unstructured active opportunities were included in the ToyBox-intervention.

Results Intervention material for PA used at kindergarten The classroom activities guide for PA was divided into three parts and provided information on how levels of PA in preschool children could be increased at kindergarten. Part 1 of the classroom activities guide for PA focused on ‘Setting environmental changes in the kindergarten’, and on the concept of unstructured PA. The term ‘unstructured PA’ refers to any kind of PA preschool children are involved in during recess time with a low degree of intervention and guidance by the teacher (47). In this section of the classroom activities guide, examples were given on how to rearrange the kindergarten setting and classroom into a PA-friendly environment. For instance, creating movement landscapes or rearranging furniture in the classroom to create space to be physically active could achieve this. Teachers were also reminded to ask the parents/caregivers to dress their preschool children in comfortable clothes so they could move freely. Tight skirts, flip-flops or jewellery were indicated as not suitable for physical activity. The ToyBox-intervention suggested implementing the environmental changes prior to the start of the academic year and continuing with these changes until the end of the academic year (Table 1). In part 2 of the classroom activities guide, ‘Child performing the actual behaviour’, 26 physical education sessions were developed that guided teachers on how to perform structured PA with the preschool children. Besides unstructured PA in part 1, structured PA in this part provided children with additional stimuli to be physically active in order to develop their movement abilities and increase their PA level. The sessions included playful exercise games that improve children’s motor abilities, namely endurance, coordination, speed, strength and flexibility. The description of motor abilities and skills according to Bös (1987) (48,49) served as the basis for the development of the intervention programme. Bös (48) differentiated motor performance abilities on a first level into conditioning (energetically determined) and coordinative (information-oriented) abilities. On a second level, these two abilities were divided into five motor abilities, namely endurance, strength, speed, coordination and flexibility. Furthermore, the execution of these physical education sessions aimed to increase the energy expenditure and dem© 2014 World Obesity

Increased physical activity in preschool K. Duvinage et al. 31

onstrated that PA can be fun (47). Each session was planned to last about 45–60 min and focused on clearly defined motor abilities using two to three different pieces of equipment that are typically available in kindergartens. For example, the session ‘A day at the construction site’ focussed on coordination, flexibility and strength and used coasters, balls and sticks as material. Another session ‘Newspapers and clothes pegs’ focussed on endurance and strength and made use of newspapers, clothes pegs and tennis balls. Because availability of equipment for PA in kindergartens (e.g. benches, mats, balls) can vary between the intervention countries, the handbook for PA presented examples of everyday material that could be used alternatively during the structured PA sessions (e.g. newspapers, balloons, neckties). Fundamental movement patterns should be practised in an intensive, varied way and always in accordance with children’s age and PA level (50). Proposed activity variations were included in the material to enable the adaptation of the sessions to accommodate the different needs of preschool children and different kindergarten conditions. As teachers were able to adapt each session based on the needs of their preschoolers, preschool children from the whole class could participate in the physical education sessions. The 26 sessions were divided into four different levels of difficulty: beginners, advanced, professionals and experts (Table 2). The teachers were recommended to start the structured physical education sessions at the beginners level. Within each difficulty level, all sessions could be performed in a random order. The four levels of physical education sessions varied in difficulty and comprehensibility of the games as well as the complexity of motor skills involved. With each session, preschool children were expected to improve their movement skills with the aim that after a given time, sessions from the next level of difficulty could be performed (47). Repetition of games, materials and movements was prescribed at all levels to ensure that children had enough time to practise and develop their movement skills. The teachers were free to choose when their class was ready to move up to the next level or if further repetition of sessions from a lower level was necessary. The flexibility of each session made it possible to advance the difficulty level within every session. If classes comprised children across various difficulty levels, it was recommended to choose sessions from lower levels and adapt the session when necessary to increase its difficulty. All structured PA sessions could be performed in a gym, a garden or in the classroom, taking the different kindergarten conditions into account. The ToyBox-intervention suggested implementing the physical education sessions (level 2 of the PA component) in week 5 of the ToyBox-intervention time frame and continuing until the end of the academic year (Table 1), conducting two physical education sessions per week for 45–60 min per session. 15 (Suppl. 3), 27–39, August 2014

32 Increased physical activity in preschool K. Duvinage et al.

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Table 2 ToyBox-intervention physical education sessions: levels, topics, targeted skills, example activities and material used

Sessions

Topic of sessions

Level 1 1

Beginners Chiffon cloths and parachute

2

A day at the construction site (part a)

Targeted skills (gross and fine motor skills)

Examples for active games

Material used for game examples

Endurance

Different running games; e.g. running around the parachute.

Strengthening of arm muscles

Running like Superman, holding the cloths high above the head.

Chiffon cloths, parachute Chiffon cloths

Coordination

Running across the room wearing coasters as ‘protective clothing’; e.g. coasters on the head, neck, shoulder, knee, back. Coasters are spread around the room represents bricks. Children touch the bricks with different parts of their body, e.g. with the chest, belly, elbow, knee. Children represent lorries and transport coasters (bricks) on their belly whereby coasters under the hands and feet serve as tires.

Flexibility

Strengthening of arms, legs and trunk muscles 3

Cardboard roles (part a)

Flexibility Endurance Eye-hand coordination Fine motor skills

Snowball fight with cardboard rolls. Running through the room and jumping over the vertically standing cardboard rolls. Throwing and catching of cardboard rolls with both hands, one hand or from one hand to the other hand. One child lies on the belly and the other child sits next to them and gives a massage with the massage or tennis ball.

Coasters Coasters

Coasters

Cardboard rolls Cardboard rolls Cardboard rolls Massage or tennis ball

4

With the Indians (part a)

Endurance

Indians on an animal hunt: Some children representing the Indians catching other children representing the animals.

None

5

Newspaper session (part a)

Coordination

Newspapers are rolled to stable ‘paperboard sticks’. Balloons must be balanced in the air using the paperboard sticks. Passing balloons back and forth between two children with the paperboard stick. Rolling newspapers to form stable ‘paperboard sticks’ or screwing them up into a ball.

Balloons, newspapers Balloons, newspapers Newspapers

One child is the horse and the other child is the carriage driver. The carriage driver indicates to the horse the direction and speed of movement by pulling on the rope. ‘Skipping rope’ with a hoop; alone or in pairs. Children walk through the room with a stick in their right/left hand. In time, the children stamp with their right/left foot on the ground/ with the alternate foot on the ground.

Rope

Flexibility Fine motor skills 6

Material journey

Endurance

Flexibility Coordination

Level 2 7

Advanced Barefoot land

Coordination Fine motor skills

8

In the jungle

Coordination

Balance

15 (Suppl. 3), 27–39, August 2014

Lying on the ground, in pairs the children cycle while placing the soles of their feet on each other. Barefoot course: – Children place preserving jar rubber bands with the feet on a chair leg – Children make a knot in a rope with their feet – Children place different small materials with their feet in a cardboard box with holes. Rocks (carpet tiles) are spread out in the room, which represents a large opening with a lot of flowers. While jumping from rock to rock, children pick up ‘flowers’, which they give to the teacher as a present. Balancing on ropes representing tree trunks; walking backwards along the trunk, making a 180-degree turn on the tree trunk.

Hoop Stick

None Preserving jar rubber bands, Rope, Corks, yoghurt pots Carpet tile or newspaper Ropes

© 2014 World Obesity

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Increased physical activity in preschool K. Duvinage et al. 33

Table 2 Continued

Sessions

9

Topic of sessions

Targeted skills (gross and fine motor skills)

Examples for active games

Material used for game examples

Ball games

Coordination

Children try to keep a balloon in the air; e.g. using the balloon like a volley ball moving forwards/ backwards/sideways, hit the balloon with certain body parts (back of their hands, elbow, knee), hit the balloon while sitting/standing on one leg. Can knock down: Children try to hit clubs by throwing their balls at a distance of 2–6 meters.

Balloons

Strength

10

Cardboard roles (part b)

Flexibility Endurance Eye-hand coordination Fine motor skills

11

Children’s Olympics

Strength Balance Coordination

12

Newspapers and clothes pegs

Endurance Fine motor skills

13

Level 3 14

In the circus

Professionals A day at the construction site (part b)

Trip to the bakery and the playground

Different running games; e.g. fast running with a newspaper attached to different body parts. Hanging up the newspapers on the leash with clothes pegs.

Children shoot down the newspapers from the leash with the balls.

Endurance

Children playing tag

Coordination Balance

Children move like their favourite animals. Balancing on ropes like circus artists; forwards/ backwards, with/ without a ball in the hand.

Coordination

Running across the room wearing coasters as ‘protective clothing’; e.g. coasters on the head, neck, shoulder, knee, back. Coasters that are spread out in the room represent bricks. Children touch the bricks with different parts of their body, e.g. with the chest, belly, elbow, knee. Children represent lorries and transport coasters (bricks) on their belly whereby coasters under the hands and feet serve as tires.

Flexibility

Coordination

Strengthening of arm muscles

© 2014 World Obesity

Children move forward like crabs (on all fours with the belly facing upwards) and passing a soft ball with their hands and feet. Shadow gymnastics on a carpet tile; one child shows the exercise (sit down and stand up again, stand on one leg . . .), which the group has to imitate without touching the floor.

Strengthening of arm muscles

Strengthening of arms, legs and trunk muscles 15

Snowball fight with cardboard rolls. Running through the room and jumping over the vertically standing cardboard rolls; jumping with one or two legs, forwards/ backwards. Throwing and catching of cardboard rolls with both hands, one hand or from one hand to the other hand. Construction of a spider net with a role of parcel string: children sit on the floor in a circle. The first child holds the end of the parcel string in their hand and rolls the string to another child. This way the string is rolled to all children until a spider net has been made. After each child has climbed and crawled like spiders through the net, the string role is rolled up again in reverse (advisable on a cardboard roll).

Games with a gymnastic ball; e.g. throwing and catching the ball with one hand/ both hands, bouncing the ball on the ground and catching again, children bounce balls in the same rhythm. Can knock down: Children try to hit clubs or yoghurt pots by throwing their balls (different sizes; tennis or gymnastic balls) at a distance of 2–6 meters.

Gymnastic/ tennis/ soft balls, clubs Cardboard rolls Cardboard rolls Cardboard rolls One role of parcel string

Soft ball Carpet tile

Newspapers Newspapers, clothes pegs, a leash Gymnastic balls Two different coloured cloths None Ropes, balls

Coasters Coasters

Coasters

Gymnastic ball

Clubs or yoghurt pots, tennis balls, gymnastic balls

15 (Suppl. 3), 27–39, August 2014

34 Increased physical activity in preschool K. Duvinage et al.

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Table 2 Continued

Sessions

Topic of sessions

Targeted skills (gross and fine motor skills)

Examples for active games

Material used for game examples

16

Small pirates

Endurance Speed Reaction skills

Children playing tag. Children running through the room. Upon different commands by the teacher the children fulfil the according task; e.g. fire: children gather at a certain place, water: children climb on objects, storm: children lie down flat on the floor.

None Gymnastic or camping mat, benches, carpet tiles

17

Games with a balloon

Coordination

Children place a balloon between their knees and try to jump as far as possible forwards/ backwards/ sideways, from hoop to hoop, . . . One child lies on their belly and the other child sits next to them and gives a massage with a massage or tennis ball.

Balloons, hoops

Fine motor skills 18

Journey to different countries

Coordination

Balance

19

We all are astronauts

Speed Fine motor skills

Every child attaches 4–5 clothes pegs onto their clothes. The children steal each other’s clothes pegs and collect them on their own clothes.

Reaction skills

Children run around the room. The children respond to different commands from the teacher; e.g. ice age: children freeze while they are standing, earthquake: children hold on with both hands to an object/material, night: every child looks for a partner. Alternating, one child guides their night-blinded partner by the hand. Children pretend to be astronauts. Before the astronauts’ rocket can start, the children lie down on their bellies and stretch their arms forward. The countdown to start the flight is counted this way: Children hit their right and left hand alternating on the floor and count down from 9.

Strengthening of back muscles

20

Ties and clothes pegs

Endurance Speed Fine motor skills

Level 4 21

Experts In the throwing park

In a foreign country

Different throwing games with various materials; e.g. ropes, knotted together, are thrown through a hoop, tennis rings are thrown over the legs of an upside-down chair.

Coordination

Two children stand with their back/ bellies to each other, a coaster glued between contact areas. Children try to move forward without losing the coasters. Children move together in pairs. One child lies on their belly; the other child bakes cookies on the back of the lying child. The sitting child imitates backing activities with the hands and thus gives the lying child a massage.

Strength

Reaction skills

15 (Suppl. 3), 27–39, August 2014

Ties hanging on a leash, guarded by two children. The other children are robbers and try to steal the ties. Every robber may only steal one tie and then runs as fast as possible back to the already captured ties. Every child attaches 4–5 clothes pegs onto their clothes. The children steal each other’s clothes pegs and collect them on their own clothes.

Strength

Fine motor skills

22

Three-legged-children: A pair of children is bound together with a chiffon cloth around their ankles (one ankle of each child) and clothes pegs are put on their trouser legs. Children move forward three-legged. Every child has a stick. In pairs, children transport different balls with the aid of their sticks.

Children imitate flying like an airplane (arms stretched out), drive like cars (having an imaginary steering wheel in their hands), swim like a ship (crawl with their belly on the floor on a carpet tile), . . . Carpet tiles are spread out all over the room. Children run through the room without touching the carpet tiles.

Massage or tennis ball Clothes pegs, chiffon cloths Different balls (gymnastic, tennis, soft balls), sticks Clothes pegs None

Hoops or carpet tiles

Ties, a leash

Clothes pegs

Coasters, gymnastic or soft balls, tennis balls, ropes or ties, tennis rings, yoghurt pots Coasters

None

Carpet tile

Carpet tile

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Increased physical activity in preschool K. Duvinage et al. 35

Table 2 Continued

Sessions

Topic of sessions

Targeted skills (gross and fine motor skills)

Examples for active games

Material used for game examples

23

Newspaper session (part b)

Endurance

Different running games; e.g. fast running with a newspaper attached to different body parts. Two holes are torn into a newspaper sheet. Children put one foot in each hole and try to move without ripping the newspaper. Snowball fight with newspapers crumpled into snowballs.

Newspapers

Coordination Flexibility Fine motor skills 24

With the Indians (part b)

Endurance Speed Reaction skills

25

At the fête

Endurance Speed

Coordination

Strengthening of arms and torso 26

Ties and coasters

Endurance

Strength

Coordination Flexibility

Indians on an animal hunt: Some children representing the Indians catching other children representing the animals. One child is the bear, standing in the middle of the room. The other children are the Indians. Upon the teachers’ call, the bear tries to catch the Indians. One child is sitting/kneeling on the parachute. The other children move the parachute faster and faster. One child is a tiger, standing on one side of the room, facing the wall. The other children sneak up to the tiger and try to wake it up. Upon the teachers’ call, the tiger tries to catch as many children as possible. One child is the catcher and tries to tag the other children with a cardboard role. Depending on where a child was tagged, they must hold the respective body part and run after the catcher. Can knock-down: Children try to hit clubs or yoghurt pots by throwing their balls (different sizes; tennis or gymnastic balls) at a distance of 2–6 meters. Ties hanging on a leash, guarded by two children. The other children are robbers and try to steal the ties. Every robber may only steal one tie and then runs as fast as possible back to the already captured ties. Children move like helicopters (turning in horizontal circles), propeller planes (vertical circles), like a bird (tie as a swing), an elephant (swing ties like a trunk). Throwing and catching; e.g. catching the thrown up ties with different parts of the body (head, knee, shoulder).

Part 3 of the classroom activities guide for PA, ‘Classroom activities’, provided various examples of activities, which could be easily included in the daily kindergarten routine. The material included fun, interactive, non-competitive classroom activities, aiming at participation of the whole class. For example, four funny PA kangaroo stories were developed to be read with the preschool children. The Little Kangaroo, developed to serve as a role model for the children, was the lead character not only in the stories, but also in the whole ToyBox-intervention. The basis for developing the stories was a clear definition of all characters (Little Kangaroo, Rabbit, Bear, Owl, and Cat) occurred in the stories because they served as role models for the behaviour of the children. The characters described in the stories demonstrated that being active is a lot of fun. In addition, these characters received misleading advice about the best way to be active and had to find ways to overcome such obstacles. The stories included small suggestions for discussions and encouraged the children to re-enact the movements the animals make in the stories. Furthermore, © 2014 World Obesity

Newspapers Newspapers None None

Parachute None

Paperboard role

Clubs or yoghurt pots, tennis balls, gymnastic balls Ties, a leash

Ties

Ties

different kinds of excursions were suggested that could be performed with the children, such as a walk in the countryside, a trip to a maize field labyrinth or an adventure playground. The ToyBox-intervention suggested implementing the interactive classroom activities for a minimum of 1 h per week (Table 1). During the teachers’ training sessions, teachers were informed about their position as a role model for preschoolers. This point was also emphasized in the ToyBox-intervention material. All intervention kindergarten teachers were informed on how to incorporate the intervention into their daily kindergarten routine.

Intervention material for PA used at home During the time the intervention was implemented at kindergarten, parents/caregivers received two newsletters, two tip cards and one poster on PA. These educational materials (newsletters and tip cards) included practical advice and were written in an easily understandable and adaptable way to target families of all levels of socioeconomic status 15 (Suppl. 3), 27–39, August 2014

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36 Increased physical activity in preschool K. Duvinage et al.

that participated in the ToyBox-intervention. The newsletters included information for parents/caregivers on why being physically active on a daily basis is important for their child and gave tips on how PA could be integrated into the daily family life, e.g. using the stairs instead of the elevator or leaving the car at home and going to the supermarket on foot or by bike. The newsletters also included tips and suggestions on how to rearrange their preschoolers’ room into a PA-friendly environment or ways to bring children to kindergarten by active transportation. In addition to the newsletters, parents/caregivers received two tip cards on PA that suggested small movement ideas for everyday life, proposed weekend excursions for the whole family and encouraged parents/caregivers to be physically active together with their children, without using expensive sports equipment. As parents/caregivers have a decisive influence on the development of their preschool children’s behaviours, newsletters and tip cards reminded parents/ caregivers of being role models for their children. The third piece of educational material that was provided to the parents/caregivers was a poster. This poster showed black-and-white-pictures of the character ‘Little Kangaroo’ being physically active. Children could colour the pictures on the poster (e.g. the ‘Little Kangaroo’ riding a bicycle, swimming with the fishes and playing on a slide) during their time at kindergarten. For the parents/ caregivers, short messages were printed on the poster to emphasize to them that PA should be implemented in their daily family routine (i.e. ‘Keep moving!’, ‘The car is a ’movement killer’! Come to kindergarten actively!’, ‘Be physically active for at least 2–3 h per day!’ and ‘There is no such thing as bad weather! There is only unsuitable clothing!’). The idea behind the poster was that parents/ caregivers would hang up the poster, e.g. on the fridge, together with other pictures drawn by their children, and thus would read and be reminded of the short messages regularly and adapt their behaviour accordingly. Although the ToyBox-intervention material recommended 180 min PA per day for preschool children, the recommended amount of time differed in the material for parents/caregivers. While material for parents/caregivers with its newsletters, tip cards and poster had the purpose to motivate parents/caregivers to integrate more PA in their family life, the term ‘at least 2–3 h PA per day’ was used instead of ‘3 h per day’. With the reduction of the total time for PA to 2–3 h with an ‘at least’ placed in front, we tried to avoid setting too high goals for parents/caregivers and still refer to the recommended 3 h.

Additional intervention material: the Little Kangaroo as a role model The ToyBox-intervention material was accompanied by the Little Kangaroo, which was intended to become a role 15 (Suppl. 3), 27–39, August 2014

model for the preschool children (51). The Little Kangaroo was gender-neutral with the intention that this would allow both boys and girls the opportunity to be able to identify with it. Preschool children love figures such as the kangaroo and immerse cheerfully in stories and fairy tales, because it fits into their so called ‘magical thinking’, which is typical at this stage of development (52,53). In this way, the kangaroo served as a role model in the ToyBoxintervention and aimed to help children improve their PA behaviour. Other studies that used a main character in their intervention were the German TigerKids study (15) with the tiger as a role model, and the American Brocodile the crocodile (54) with the crocodile as a main character. Whereas Brocodile the crocodile aimed to reduce television viewing in preschool children, TigerKids aimed at enhancing regular physical activity and modifying habits of food and drink consumption in preschoolers. The use of such main characters in other intervention studies for preschoolers supports the decision to also use a character, which is intended to become a role model for the children.

Discussion Kindergarten-based intervention programmes such as the ToyBox-intervention can provide opportunities to promote child health and to reduce the risk of overweight and obesity (15,21,55). The extensive experience from the development and application of a preceding preschool intervention, the TigerKids programme (15), was of key importance in the successful building of the ToyBox intervention. In addition, experience gained from other previous interventions implemented from the current consortium such as the ENERGY project (63,64), the POP study (65,66) and the Cretan Health and Nutrition Intervention (67–69) were proved very useful. The development of an obesity prevention intervention programme on a European scale requires the pooling of knowledge and experiences of scientists from different countries and the consideration of each country’s policies and practices, regulations and legislation. In particular, cultural differences between countries presented special challenges during the development of the intervention material. The conditions in the six participating countries differed for example with regard to country-specific age ranges for children attending kindergartens, the national kindergarten curricula (29) and kindergarten characteristics such as class sizes, equipment for PA, implementation by personnel of the physical education sessions and daily routines. The ToyBox-intervention attempted to accommodate these varied policies and practices into one intervention, for example, by designing the PA component to be independent of age. In some countries, kindergarten groups are mixed with children from 4–6year-old in one group and in some countries, the groups are separated by age. The intervention material can be adapted © 2014 World Obesity

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to suit different class characteristics as the teaching material included variations to meet the requirements of 4-year-old children as well as for 6-year-old children. As it cannot be expected that every kindergarten in each of the intervention countries has access to a gym or a garden, the physical education sessions could also be performed in the classroom, and were therefore developed accordingly. The handbook for PA also aimed to incorporate a large variety of everyday materials for use in the PA sessions, taking into account the classroom resources available to the kindergartens in different countries. Previous ToyBox-study findings served as the basis for the development of the intervention material for PA (28) and all recommendations were taken into account during the development of the material. One general recommendation for a successful kindergarten-based intervention was the inclusion of the preschoolers’ family. To explore which strategy would be most feasible for this target group (56– 58), focus group interviews with teachers and parents/ caregivers in all six participating countries were performed. As a result, the ToyBox-intervention engaged parents/ caregivers by employing information-based newsletters, tip cards and posters. The study of De Bock (59) used a participatory approach and involved the parents/caregivers more actively in the intervention than the ToyBoxintervention did, e.g. active transportation by walking buses or promotion of outdoor activities through organizing camps on weekends (60). However, such an intensive participatory approach requires considerable engagement on the part of the teachers and parents/caregivers, and may set high barriers for successful implementation. Although a participatory approach with an active involvement of parents/caregivers might have the potential to be better tailored to local needs and thus potentially more sustainable (60), this approach increases the risk of dropouts by potentially exceeding parental and teacher resources (59,60). Therefore, the ToyBox-intervention employed a more passive method of parental involvement via newsletters, tip cards and posters with the intention to minimize dropout rates in the six participating countries. Recommendations from previous research (28) were used to develop the ToyBox-intervention material for teachers. The emphasis of this material was on playful activities, which ensured total class participation and suitability for different kindergarten and class conditions. The classroom activities guide for PA advised teachers how to integrate PA into the daily kindergarten routines and highlighted opportunities to adopt the intervention to special conditions. Similar to level 1 with its environmental changes in the classroom, level 2 with its structured sessions was also designed for implementing throughout the academic year. That means no limitations are given, although we have only 26 structured PA sessions. For this purpose, the structured PA sessions can be repeated throughout the course of the © 2014 World Obesity

Increased physical activity in preschool K. Duvinage et al. 37

children’s entire kindergarten experience by adapting the sessions based on the variation in difficulty level that was suggested in the teaching material. Previous studies showed the importance of an active lifestyle and the necessity of interdisciplinary cooperation and conceptual development (61,62). In addition, the study of Barnett (8) showed a positive relationship between motor skill proficiency in primary school children and adolescent PA. Thus, this evidence supports the concept (i) to start the intervention for an increased PA level in kindergarten and (ii) to combine the intervention with its unstructured and structured PA parts.

Conclusion The ToyBox-intervention is a kindergarten-based, familyinvolved intervention for preschool children aiming to promote healthy EBRBs and prevent overweight and obesity. The PA component of the ToyBox-intervention addressed preschool children, their parents/caregivers and their teachers, targeting both children’s social and physical environment. When developing the PA intervention material, minor cultural adaptations among the six intervention countries were included to maximize the adaptability of the intervention programme and therefore to size the target group. The results of the ToyBox-intervention developing experience provided useful knowledge for the development of larger scaled intercultural interventions for preschoolers.

Conflict of interest statement The authors have no conflicts of interest to declare.

Acknowledgements This article is part of the PhD thesis by Kristin Duvinage at the Dr. von Hauner Children’s Hospital, LudwigMaximilians-University of Munich, München, Germany. The ToyBox-study is funded by the Seventh Framework Programme (CORDIS FP7) of the European Commission under grant agreement n° 245200. The content of this article reflects only the authors’ views and the European Community is not liable for any use that may be made of the information contained therein.

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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 kindergart...
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