Using the intervention mapping protocol to reduce European preschoolers’ sedentary behavior, an application to the ToyBox-Study

International Journal of Behavioral Nutrition and Physical Activity Using the intervention mapping protocol to reduce European preschoolers' sedentary behavior, an application to the ToyBox-Study Ellen De Decker 0 1 2 Marieke De Craemer 0 1 2 Ilse De Bourdeaudhuij 0 1 2 Vera Verbestel 0 1 2 Kristin Duvinage 1 2 4 Violeta Iotova 1 2 3 Evangelia Grammatikaki 1 2 7 Andreas Wildgruber 1 2 6 Theodora Mouratidou 1 2 5 Yannis Manios 1 2 7 Greet Cardon 0 1 2 0 Department of Movement and Sports Sciences, Ghent University , Watersportlaan 2, 9000 Ghent , Belgium 1 Core questionnaire Process evaluation parents/caregivers 2 Process evaluation teachers 3 Clinic of Paeditric Endocrinology, UMHAT "St. Marina" , Hr. Smirnenski Blvd, Varna , Bulgaria 4 Division Metabolic and Nutritional Medicine, Dr. Von Hauner Children's Hospital, Ludwig-Maximilians-University of Munich , Lindwurmstr.4, D-80337 Munchen , Germany 5 University of Zaragoza, GENUD Group , Edificio Cervantes, C/ Corona de Aragon 42, 50009 Zaragoza , Spain 6 Staatsinstitut fur Fruhpadagogik (IFP), State Institute of Early Childhood Research, IFP , Winzererstr. 9, Eckgebaude Nord, 80797 Munchen , Germany 7 Department of Nutrition and Dietetics, Harokopio University , 70 El. Venizelou ave, 17671 Kallithea , Greece Background: High levels of sedentary behavior are often measured in preschoolers, but only a few interventions have been developed to counteract this. Furthermore, detailed descriptions of interventions in preschoolers targeting different forms of sedentary behavior could not be located in the literature. The aim of the present paper was to describe the different steps of the Intervention Mapping Protocol used towards the development of an intervention component of the ToyBox-study focusing on decreasing preschoolers' sedentary behavior. The ToyBox-study focuses on the prevention of overweight in 4- to 6-year-old children by implementing a multi-component kindergarten-based intervention with family involvement in six different European countries. Methods: Applying the Intervention Mapping Protocol, six different steps were systematically completed for the structured planning and development of the intervention. A literature search and results from focus groups with parents/caregivers and kindergarten teachers were used as a guide during the development of the intervention and the intervention materials. Results: The application of the different steps in the Intervention Mapping Protocol resulted in the creation of matrices of change objectives, followed by the selection of practical applications for five different intervention tools that could be used at the individual level of the preschool child, at the interpersonal level (i.e., parents/caregivers) and at the organizational level (i.e., kindergarten teachers). No cultural differences regarding preschoolers' sedentary behavior were identified between the participating countries during the focus groups, so cultural and local adaptations of the intervention materials were not necessary to improve the adoption and implementation of the intervention. Conclusions: A systematic and evidence-based approach was used for the development of this kindergarten-based family-involved intervention targeting preschoolers, with the inclusion of parental involvement. The application of the Intervention Mapping Protocol may lead to the development of more effective interventions. The detailed intervention matrices that were developed as part of the ToyBox-study can be used by other researchers as an aid in order to avoid repetitive work for the design of similar interventions. Kindergarten; Preschoolers; Sedentary behavior; Intervention Mapping Protocol - Background Sedentary behavior is often defined as activities involving sitting down [1]. Recently, the Sedentary Behavior Research Network suggested the use of a standardized definition of sedentary behavior. This definition describes that sedentary behavior includes activities that are characterized by an energy expenditure of 1.5 Metabolic equivalent of Task (MET), mostly during sitting or in a reclining position (e.g., watching television (TV), using the computer) [2]. Recent studies found that higher levels of sedentary behavior were associated with negative health outcomes, like less desirable cognitive and behavioral outcomes [3,4], and with a lower bone mineral content in children [5]. Furthermore, sedentary behavior (and in particular screen viewing behaviors) has been associated with overweight in children [6-8]. Consequently, different health-enhancing guidelines have been formulated that recommend limiting the length of time in sedentary behaviors in general [1,9-12], minimizing screen time including TV viewing and the use of other electronic media (e.g., DVD, computers, electronic games) to less than one to two hours per day in young children [13]. However, objective and subjective monitoring studies indicate that preschoolers (4 to 6 years) spend much of their time in sedentary activities [14-16]. Screen-based activities are generally included in preschoolers daily routine [16], with reports that indicated that children below the age of six years watched almost two hours of TV per day [17]. Furthermore, parental reports in the study of Cardon and De Bourdeaudhuij indicated that preschoolers between 4- and 5-years-old viewed TV or played on the computer for an average of 74 minutes on weekdays and 140 minutes on weekends [18]. High levels of sedentary behavior are observed at home as well as at organized out-of-home care (e.g., in preschools or child-care centers), with great variabilitys of this behavior between centers [19,20]. Brown et al. for example reported that almost 89% of preschoolers time at preschool was spent in a sedentary way [21], while Temple et al. reported that preschoolers spent 39.5 minutes per hour in sedentary behavior in family child care [22]. Preschoolers are not only sedentary during the time they spend inside the classroom; high sedentary behavior levels were also objectively measured during preschool recess [23,24]. Although high levels of sedentary behavior are reported in different forms and settings, only a limited number of interventions focusing on decreasing this behavior has been conducted in preschoolers. Two review articles evaluated interventions focusing on decreasing screen time in children [25] and on limiting sedentary behavior [26]. The review of DeMattia et al. [26] included only one school-based intervention targeting preschoolers that executed a 7-session program with a weekly 20-minutes educational session in children between 2 and 5 years old [27]. Findings showed that such a classroom-based health promotion intervention in preschools resulted in a decrease in TV viewing by almost 25% in the intervention group, while the control group increased their TV viewing by almost 12%. However, no differences were observed in terms of body mass index (BMI) between the two (...truncated)