obesity reviews
doi: 10.1111/obr.12184
Obesity Prevention
Reliability of primary caregivers reports on lifestyle behaviours of European pre-school children: the ToyBox-study E. M. González-Gil1,7, T. Mouratidou1, G. Cardon2, O. Androutsos3, I. De Bourdeaudhuij2, M. Góz´dz´4, N. Usheva5, J. Birnbaum6, Y. Manios3 and L. A. Moreno1,7 on behalf of the ToyBox-study group 1
GENUD (Growth, Exercise, Nutrition and
Development) Research Group, University of Zaragoza, Zaragoza, Spain; 2Department of Movement and Sport Sciences, Ghent University, Ghent, Belgium; 3Department of Nutrition and Dietetics, Harokopio University, Athens, Greece; 4The Children’s Memorial Health Institute, Warsaw, Poland; 5Department of Social Medicine and Health Care Organization, Medical University Varna, Varna, Bulgaria; 6Division of Metabolic and Nutritional Medicine Dr. von Hauner Children’s Hospital Ludwig-Maximilians-University of Munich, München, Germany; 7Faculty of Health Sciences, University of Zaragoza, Zaragoza, Spain
Received 4 April 2014; accepted 9 April 2014
Address for correspondence:
Summary 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.
E M González-Gil, GENUD (Growth, Exercise, Nutrition and Development) Research Group,
Keywords: European, lifestyle, pre-schoolers, reliability.
Universidad de Zaragoza, C/ Pedro Cerbuna, 12, Zaragoza 50009, Spain.
obesity reviews (2014) 15 (Suppl. 3), 61–66
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
61 15 (Suppl. 3), 61–66, August 2014
obesity reviews
62 Lifestyle assesment in pre-schoolers E. M. González-Gil et al.
Introduction The adoption of healthy lifestyle behaviours early in life increases the likelihood for good long-term health in adulthood. Early childhood is a critical period to prevent obesity as key obesity-related behaviours and psychological traits develop during this stage (1). Parental and home environmental factors are some of the determinants that could play an important role in determining children’s energy balancerelated behaviours (EBRBs) that lead to overweight and obesity (2), which are present even in pre-schoolers (3). For this reason, a multifactorial kindergarten-based intervention design could be considered ideal in positively influencing such behaviours. The kindergarten provides an ideal setting where many children can be targeted at once making it also a potentially cost-effective approach. Evidence in prevention and treatment of weight-related problems through EBRBs in pre-schoolers is limited (1,4). The ToyBox-study (multifactorial evidence-based approach using behavioural models in understanding and promoting fun, healthy food, play and policy for the prevention of obesity in early childhood, http://www.toyboxstudy.eu) aimed to develop, implement and evaluate a kindergarten-based, family-involved intervention in six European countries, involving pre-school children, their teachers and their families (5). The four EBRBs targeted in the ToyBox-intervention were water and beverages consumption, physical activity, snacking and sedentary behaviour. Information regarding the ToyBox-intervention design can be found in this supplement (6). For the study purposes, a self-administered primary caregivers questionnaire (PCQ) was developed to assess the above-mentioned EBRBs and record family socioeconomic characteristics and perinatal information (7–13). Reliable assessment of these data is essential to estimate intervention effects. For this reason, the reliability of caregiver’s reports should be quantified. The aim of the current study was to assess the test–retest reliability of responses on EBRBs and their determinants, sociodemographic and perinatal factors, included in the ToyBox PCQ, in a sample of parents/primary caregivers.
Methods Study design The reliability of the PCQ was assessed in the six participating countries: Belgium, Bulgaria, Germany, Greece, Poland and Spain. The recruitment and data collection took place from January 2012 until March 2012. In all countries, ethical approval was obtained from the respective ethical committees. Parents/caregivers who provided informed consent were asked to complete the PCQ twice, within a 2-week interval. Detailed information on procedures and timeframe followed are described in the paper by 15 (Suppl. 3), 61–66, August 2014
Mouratidou et al. included in this supplement (14). In short, researchers contacted kindergartens via phone calls and then an appointment with the headmaster was arranged to explain the purpose of the study. An information letter and information regarding the background and objectives of the study was sent to the parents/caregivers of the children attending the participating kindergartens, and written informed consents were obtained. More than one class was recruited in order to reach the number of 20 children per country.
Sample For the purposes of the reliability study, selection of the kindergarten classes was based on convenience and was not representative of the kindergarten population as a whole. One hundred and eighty-five parents were asked to complete the questionnaire; however, 93 completed the questionnaire twice and were finally included in the analyses. Twenty-nine children attended kindergartens from the lowest tertile of socioeconomic status, 26 from the middle tertile and 38 from the highest tertile. Because of an endemic flu in the selected kindergarten only three participants from Bulgaria were included in the final analysis. Further information on sampling procedures and kindergarten selection in the ToyBox-intervention is described elsewhere (5,6).
Questionnaire The PCQ aimed to assess sociodemographic and perinatal factors and information on the four EBRBs targeted in the ToyBox-intervention, namely, water and beverages consumption, physical activity, snacking and sedentary behaviour (8). The PCQ was composed of 229 questions divided into six sections: sociodemographic (32 questions), water and beverages consumption (24 questions), snacking (71 questions), physical activity (27 questions), sedentary behaviour (38 questions) and perinatal section (37 questions). The intervention mapping protocol (5) was used to define performance objectives formulated for the individual, the interpersonal and the organizational level of the intervention separately, with personal determinants of behaviours as described elsewhere (3). Therefore, questions to assess key behaviours were specifically developed to reflect performance objectives and to capture their potential changes following the ToyBox-intervention. The development of the questions included in the PCQ was also based on questionnaires previously used in large European studies such as IDEFICS (Identification and prevention of Dietary- and lifestyle-induced health EFfects In Children and infantS), HELENA (Healthy Lifestyle in Europe by Nutrition in Adolescence), ENERGY (EuropeaN Energy balanced Research to prevent excessive weight Gain among Youth) and the Healthy Growth Study, mainly in relation © 2014 World Obesity
obesity reviews
Lifestyle assesment in pre-schoolers E. M. González-Gil et al.
to questions on sociodemographic and perinatal factors (15–18). The questionnaire was initially developed in English and then it was translated in six different languages and backtranslated to English to ensure consistency across all language versions. Harmonization and standardization procedures of the preparatory and follow-up phases at the ToyBox-intervention can be found in this supplement. The English version of the questionnaires used in the ToyBoxintervention is also provided online (14).
Statistical analysis The agreement of categorical, continuous and dichotomous items was analysed with a two-way random effect single
Table 1 Characteristics of the primary caregivers included in the reliability analysis Total (N) Test–retest reliability Total Belgium Bulgaria Germany Greece Poland Spain Age, years (mean ± SD) % Males Body mass index (BMI) BMI, kg m–2 BMI, kg m–2 (partner) Level of education (%) Less than 7 years 7–12 years 13–14 years 15–16 years More than 16 years
93 16 3 14 20 26 14 36.4 ± 0.57 12.1 23.2 ± 0.43 26.2 ± 0.4 1.0% 7.3% 17.7% 25.0% 49.0%
SD, standard deviation.
63
measure intra-class correlation coefficient (ICC). ICCs were classified as ‘excellent’ (>0.81), ‘good’ (0.61–0.80), ‘moderate’ (0.41–0.60) and ‘poor’ (0.81), ‘good’ (0.61–0.80), ‘moderate’ (0.41–0.60) and ‘poor’ (
doi: 10.1111/obr.12184
Obesity Prevention
Reliability of primary caregivers reports on lifestyle behaviours of European pre-school children: the ToyBox-study E. M. González-Gil1,7, T. Mouratidou1, G. Cardon2, O. Androutsos3, I. De Bourdeaudhuij2, M. Góz´dz´4, N. Usheva5, J. Birnbaum6, Y. Manios3 and L. A. Moreno1,7 on behalf of the ToyBox-study group 1
GENUD (Growth, Exercise, Nutrition and
Development) Research Group, University of Zaragoza, Zaragoza, Spain; 2Department of Movement and Sport Sciences, Ghent University, Ghent, Belgium; 3Department of Nutrition and Dietetics, Harokopio University, Athens, Greece; 4The Children’s Memorial Health Institute, Warsaw, Poland; 5Department of Social Medicine and Health Care Organization, Medical University Varna, Varna, Bulgaria; 6Division of Metabolic and Nutritional Medicine Dr. von Hauner Children’s Hospital Ludwig-Maximilians-University of Munich, München, Germany; 7Faculty of Health Sciences, University of Zaragoza, Zaragoza, Spain
Received 4 April 2014; accepted 9 April 2014
Address for correspondence:
Summary 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.
E M González-Gil, GENUD (Growth, Exercise, Nutrition and Development) Research Group,
Keywords: European, lifestyle, pre-schoolers, reliability.
Universidad de Zaragoza, C/ Pedro Cerbuna, 12, Zaragoza 50009, Spain.
obesity reviews (2014) 15 (Suppl. 3), 61–66
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
61 15 (Suppl. 3), 61–66, August 2014
obesity reviews
62 Lifestyle assesment in pre-schoolers E. M. González-Gil et al.
Introduction The adoption of healthy lifestyle behaviours early in life increases the likelihood for good long-term health in adulthood. Early childhood is a critical period to prevent obesity as key obesity-related behaviours and psychological traits develop during this stage (1). Parental and home environmental factors are some of the determinants that could play an important role in determining children’s energy balancerelated behaviours (EBRBs) that lead to overweight and obesity (2), which are present even in pre-schoolers (3). For this reason, a multifactorial kindergarten-based intervention design could be considered ideal in positively influencing such behaviours. The kindergarten provides an ideal setting where many children can be targeted at once making it also a potentially cost-effective approach. Evidence in prevention and treatment of weight-related problems through EBRBs in pre-schoolers is limited (1,4). The ToyBox-study (multifactorial evidence-based approach using behavioural models in understanding and promoting fun, healthy food, play and policy for the prevention of obesity in early childhood, http://www.toyboxstudy.eu) aimed to develop, implement and evaluate a kindergarten-based, family-involved intervention in six European countries, involving pre-school children, their teachers and their families (5). The four EBRBs targeted in the ToyBox-intervention were water and beverages consumption, physical activity, snacking and sedentary behaviour. Information regarding the ToyBox-intervention design can be found in this supplement (6). For the study purposes, a self-administered primary caregivers questionnaire (PCQ) was developed to assess the above-mentioned EBRBs and record family socioeconomic characteristics and perinatal information (7–13). Reliable assessment of these data is essential to estimate intervention effects. For this reason, the reliability of caregiver’s reports should be quantified. The aim of the current study was to assess the test–retest reliability of responses on EBRBs and their determinants, sociodemographic and perinatal factors, included in the ToyBox PCQ, in a sample of parents/primary caregivers.
Methods Study design The reliability of the PCQ was assessed in the six participating countries: Belgium, Bulgaria, Germany, Greece, Poland and Spain. The recruitment and data collection took place from January 2012 until March 2012. In all countries, ethical approval was obtained from the respective ethical committees. Parents/caregivers who provided informed consent were asked to complete the PCQ twice, within a 2-week interval. Detailed information on procedures and timeframe followed are described in the paper by 15 (Suppl. 3), 61–66, August 2014
Mouratidou et al. included in this supplement (14). In short, researchers contacted kindergartens via phone calls and then an appointment with the headmaster was arranged to explain the purpose of the study. An information letter and information regarding the background and objectives of the study was sent to the parents/caregivers of the children attending the participating kindergartens, and written informed consents were obtained. More than one class was recruited in order to reach the number of 20 children per country.
Sample For the purposes of the reliability study, selection of the kindergarten classes was based on convenience and was not representative of the kindergarten population as a whole. One hundred and eighty-five parents were asked to complete the questionnaire; however, 93 completed the questionnaire twice and were finally included in the analyses. Twenty-nine children attended kindergartens from the lowest tertile of socioeconomic status, 26 from the middle tertile and 38 from the highest tertile. Because of an endemic flu in the selected kindergarten only three participants from Bulgaria were included in the final analysis. Further information on sampling procedures and kindergarten selection in the ToyBox-intervention is described elsewhere (5,6).
Questionnaire The PCQ aimed to assess sociodemographic and perinatal factors and information on the four EBRBs targeted in the ToyBox-intervention, namely, water and beverages consumption, physical activity, snacking and sedentary behaviour (8). The PCQ was composed of 229 questions divided into six sections: sociodemographic (32 questions), water and beverages consumption (24 questions), snacking (71 questions), physical activity (27 questions), sedentary behaviour (38 questions) and perinatal section (37 questions). The intervention mapping protocol (5) was used to define performance objectives formulated for the individual, the interpersonal and the organizational level of the intervention separately, with personal determinants of behaviours as described elsewhere (3). Therefore, questions to assess key behaviours were specifically developed to reflect performance objectives and to capture their potential changes following the ToyBox-intervention. The development of the questions included in the PCQ was also based on questionnaires previously used in large European studies such as IDEFICS (Identification and prevention of Dietary- and lifestyle-induced health EFfects In Children and infantS), HELENA (Healthy Lifestyle in Europe by Nutrition in Adolescence), ENERGY (EuropeaN Energy balanced Research to prevent excessive weight Gain among Youth) and the Healthy Growth Study, mainly in relation © 2014 World Obesity
obesity reviews
Lifestyle assesment in pre-schoolers E. M. González-Gil et al.
to questions on sociodemographic and perinatal factors (15–18). The questionnaire was initially developed in English and then it was translated in six different languages and backtranslated to English to ensure consistency across all language versions. Harmonization and standardization procedures of the preparatory and follow-up phases at the ToyBox-intervention can be found in this supplement. The English version of the questionnaires used in the ToyBoxintervention is also provided online (14).
Statistical analysis The agreement of categorical, continuous and dichotomous items was analysed with a two-way random effect single
Table 1 Characteristics of the primary caregivers included in the reliability analysis Total (N) Test–retest reliability Total Belgium Bulgaria Germany Greece Poland Spain Age, years (mean ± SD) % Males Body mass index (BMI) BMI, kg m–2 BMI, kg m–2 (partner) Level of education (%) Less than 7 years 7–12 years 13–14 years 15–16 years More than 16 years
93 16 3 14 20 26 14 36.4 ± 0.57 12.1 23.2 ± 0.43 26.2 ± 0.4 1.0% 7.3% 17.7% 25.0% 49.0%
SD, standard deviation.
63
measure intra-class correlation coefficient (ICC). ICCs were classified as ‘excellent’ (>0.81), ‘good’ (0.61–0.80), ‘moderate’ (0.41–0.60) and ‘poor’ (0.81), ‘good’ (0.61–0.80), ‘moderate’ (0.41–0.60) and ‘poor’ (
