Applying the Intervention Mapping protocol to develop a kindergarten-based, family-involved...

Obesity Prevention

Applying the Intervention Mapping protocol to developa kindergarten-based, family-involved intervention toincrease European preschool children’s physicalactivity levels: the ToyBox-study

M. De Craemer1, E. De Decker1, I. De Bourdeaudhuij1, M. Verloigne1, K. Duvinage2, B. Koletzko2,S. Ibrügger2, S. Kreichauf3, E. Grammatikaki4, L. Moreno5, V. Iotova6, P. Socha7, K. Szott7, Y. Manios4 andG. Cardon1 on behalf of the ToyBox-study group

1Department of Movement and Sport Sciences, Ghent

University, Ghent, Belgium; 2Division of Metabolic and

Nutritional Medicine, Dr. von Hauner Children’s

Hospital, Ludwig-Maximilians-University of Munich,

München, Germany; 3State Institute of Early

Childhood Research, Munich, Germany; 4Department

of Nutrition and Dietetics, Harokopio University,

Athens, Greece; 5Growth, Exercise, Nutrition and

Development Research Group, University of

Zaragoza, Zaragoza, Spain; 6Department of Social

Medicine and Health Care Organization, Medical

University Varna, Varna, Bulgaria; 7Children’s

Memorial Health Institute, Warsaw, Poland

Received 3 April 2014; revised 08 April 2014;

accepted 08 April 2014

Address for correspondence: M De Craemer, Ghent

University, Department of Movement and Sport

Sciences, Watersportlaan 2, 9000 Ghent, Belgium.

E-mail: [email protected]

SummaryAlthough sufficient physical activity is beneficial for preschoolers’ health, activity levels inmost preschoolers are low. As preschoolers spend a considerable amount of time at homeand at kindergarten, interventions should target both environments to increase their activ-ity levels. The aim of the current paper was to describe the six different steps of theIntervention Mapping protocol towards the systematic development and implementationof the physical activity component of the ToyBox-intervention. This intervention is akindergarten-based, family-involved intervention implemented across six European coun-tries. Based on the results of literature reviews and focus groups with parents/caregiversand kindergarten teachers, matrices of change objectives were created. Then, theory-basedmethods and practical strategies were selected to develop intervention materials at threedifferent levels: (i) individual level (preschoolers); (ii) interpersonal level (parents/caregivers) and (iii) organizational level (teachers). This resulted in a standardized inter-vention with room for local and cultural adaptations in each participating country.Although the Intervention Mapping protocol is a time-consuming process, using this sys-tematic approach may lead to an increase in intervention effectiveness. The presentedmatrices of change objectives are useful for future programme planners to develop andimplement an intervention based on the Intervention Mapping protocol to increase physi-cal activity levels in preschoolers.

Keywords: Intervention Mapping protocol, physical activity, preschool child.

obesity reviews (2014) 15 (Suppl. 3), 14–26

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 and 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 Gózdz, 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.

obesity reviews doi: 10.1111/obr.12180

14 © 2014 World Obesity15 (Suppl. 3), 14–26, August 2014

mailto:[email protected]

Introduction

Physical activity (PA) is defined as ‘any bodily movementproduced by skeletal muscles that results in energy expendi-ture’ (1) and primarily occurs through unstructured activeplay among 4- to 6-year-old preschool children (2,3). Higherlevels of PA during childhood might have an influence on PApractices during adolescence and adulthood, as this behav-iour tracks from year to year (4–6). PA provides a number ofhealth benefits and is associated with cardiovascular health,improved motor skills, psychosocial health and cognitivedevelopment (7). In addition, PA may contribute to theprevention and/or treatment of childhood overweight andobesity (7–9). Because of the positive health outcomes asso-ciated with high levels of PA, and growing evidence of lowlevels of preschoolers’ PA, guidelines have been formulated.These PA guidelines recommend that preschoolers accumu-late 3 h (180 min) of total PA per day, irrespective of inten-sity (10–12). Other guidelines recommend 15 min of PA perhour per day, which is equivalent to 3 h of PA across a periodof 12 waking hours (13).

Despite formulated guidelines and evidence that suffi-cient PA is beneficial to health, recent systematic reviewsdemonstrated that PA levels in most preschool children arelow (9,14–16). Interventions aiming to increase preschool-ers’ PA levels have been previously developed, but theeffects were limited (17–19). In a Belgian study, increasing4- to 6-year-old preschoolers’ PA by decreasing the pre-school playground density resulted in small improvementsin their PA levels (19). In addition, changing 3- to 5-year-old US preschoolers’ preschool curriculum led to significantchanges in gross motor skills, but no intervention effectswere found for PA (17). Reilly et al. targeted both thepreschool and the home environment in their interventionstudy to increase 4-year-old Scottish preschoolers’ PA levels(18). Preschool PA sessions and home-based health educa-tion were part of the intervention, but these strategies didnot increase preschoolers’ PA (18).

As preschool children spend a considerable amount oftime at some form of out-of-home care (e.g. preschools,childcare centres), these settings provide the ideal opportu-nity to increase preschoolers’ PA levels (20). Additionally,involving parents/caregivers may be promising as well, aspreschool children spend most of their time at the homeenvironment (21,22), which is an important place for thedevelopment of healthy behaviours (23–26). Consequently,interventions aiming at increasing preschoolers’ PA levelsshould focus on both the preschool and the home environ-ment. The ToyBox-intervention – a kindergarten-basedintervention with family involvement – was developed toprevent overweight and obesity in 4- to 6-year-old pre-schoolers across six European countries (Belgium, Bulgaria,Germany, Greece, Poland and Spain) by improving theirenergy balance-related behaviours and implemented over

the academic year 2012–2013 (www.toybox-study.eu)(27,28). This intervention targets four behaviours that werefound to be related with the development of overweightand obesity in preschoolers: (i) PA; (ii) sedentary behaviour;(iii) water consumption and (iv) snacking (27). To addressthese four different behaviours, four different interventioncomponents were developed of which some parts weresequentially implemented, and some parts were concur-rently implemented. The development and implementationof the ToyBox-intervention was carried out on a scientificand systematic basis using the Intervention Mapping (IM)protocol (29).

In the current paper, we aimed to provide information onhow the different steps of the IM protocol were implementedand to present the developed matrices for the PA componentof the ToyBox-intervention. We will first introduce the IMprotocol, followed by a description on how we applied theIM protocol for the development of the PA component of theToyBox-intervention. Finally, we will formulate suggestionsfor programme planners of future interventions.

Methods

The IM protocol consists of six steps: (i) needs assessment;(ii) formulation of the change objectives; (iii) selection oftheory-based methods and practical strategies, (iv) devel-opment of the PA-intervention components and materials;(v) development of an adoption and implementation planand (vi) evaluation planning (29). As described in the fol-lowing steps, data and feedback from all participatingcountries were provided.

Step 1: needs assessment

The PRECEDE-PROCEED model, an educational and eco-logical approach in health programme planning, waschosen to support the development of the ToyBox-intervention (30). The IM protocol has been incorporatedas an intermediary step between the PRECEDE andPROCEED components of the PRECEDE-PROCEEDmodel within the ToyBox-study (27,30). In the first step ofthe IM protocol, a needs assessment was executed toanalyse the prevalence of overweight and obesity in pre-schoolers and its association with PA. For this first step, thePRECEDE phases of the PRECEDE-PROCEED modelwere used (30). In phases 1 and 2 of the PRECEDE model,a description of the prevalence of preschoolers’ overweightand obesity was formulated and quality of life indicatorswere investigated. The association between PA and over-weight at the individual level of the preschool child wasidentified during the third phase of the PRECEDE model.Furthermore, an environmental analysis – next to thebehavioural analysis – was performed (30), which includedthe environmental factors at the interpersonal (i.e. parents/

obesity reviews Intervention Mapping in preschoolers M. De Craemer et al. 15

© 2014 World Obesity 15 (Suppl. 3), 14–26, August 2014

http://www.toybox-study.eu

caregivers in the home environment) and organizationallevel (i.e. teachers in the kindergarten environment) thatinfluence the prevalence of preschoolers’ overweight andobesity directly or indirectly through its behavioural causes(29) (pp. 9–12). Focus groups with preschoolers’ parents/caregivers and teachers were conducted in all six interven-tion countries to gather information on preschoolers’ PAlevels, ways to increase preschoolers’ PA levels, barriers andfacilitators of PA and recommendations for the develop-ment of the intervention (31). At the end of the needsassessment, the programme goal or programme objectivewas stated; it described what and how much had to bechanged in which target group and in what time frame.

Step 2: formulation of the change objectives

In the second step of the IM protocol, the programmeobjective was subdivided into performance objectives.These performance objectives are the expected targets thathave to be accomplished by the target groups (i.e. pre-schoolers, parents/caregivers, teachers) to achieve the pro-gramme objective. Based on literature reviews and resultsfrom the focus groups, specific behavioural and environ-mental determinants of PA were listed. Next, determinantswere selected in terms of relevance (strength of the associa-tion with PA) and changeability (likelihood that the inter-vention influences a change in the determinant). Then,specific intervention objectives (i.e. change objectives) werecreated by crossing the determinants with the performanceobjectives. These change objectives specify what needs tochange in the determinants’ behavioural or environmentaloutcomes, in order to accomplish the performance objec-tives. As three target groups were selected, three differentmatrices of change objectives were developed.

Step 3: selection of theory-based methods andpractical strategies

In step three, theoretical methods that can influencechanges in determinants were identified and selected.During this selection process, theoretical methods providedby Bartholomew et al. (2011) were used (29). A list of allchange objectives that were linked with a specific determi-nant (e.g. self-efficacy) was made, and the theoreticalmethods (e.g. guided practice) were then matched with thecorresponding determinant. Then, practical strategies weredesigned to put the theoretical methods into practice. Theresults of the focus groups were used to develop new prac-tical strategies.

Step 4: development of the physicalactivity-intervention component and materials

In this step of the IM protocol, the information from theprevious three steps was combined and summarized into

the intervention programme. The preparation and thedesign of the intervention materials – that met the pro-gramme objective – were based on the suggestions thatwere made by the parents/caregivers and teachers duringthe focus groups. Regulatory and cultural differencesbetween countries were taken into account to ensure fea-sibility of implementing the intervention in all participatingcountries.

Step 5: development of an adoption andimplementation plan

The focus of the fifth step of the IM protocol was ondeveloping an adoption and implementation plan for theintervention. Parents/caregivers and teachers were chosenas intervention adopters and implementers, based on thefour previous steps in the IM protocol. In addition, localdifferences between and within the participating Europeancountries were considered. Furthermore, an implementa-tion plan was made for the researchers that consisted of aclear outline on the central components of the intervention.Details about the different steps in delivering the materialswere extensively explained and documented. All pro-cedures and materials (e.g. Classroom Activities Guide)used during the intervention were the same across partici-pating countries, but some small cultural adaptations at alocal level were possible to ensure easy adoption and sus-tainability. For example, teachers could use materials thatwere already available in the classroom (e.g. balls, jumpingropes) and did not need to use project-specific materialsthat were imposed by the intervention. Also, if kindergar-tens already provided structured physical education ses-sions, kindergarten teachers could choose to focus more onthe other activities provided in the teachers’ handbook(Classroom Activities Guide).

Step 6: evaluation planning

In the sixth and last step of the IM protocol, a plan toevaluate the effectiveness of the ToyBox-intervention wasdeveloped. Furthermore, the implementation of the inter-vention was assessed by the process–evaluation (32).Finally, the evaluation of the cost-effectiveness of the inter-vention was included in the last part of this step (33).

Results

Step 1: needs assessment

In the first step of the needs assessment, literature reviewsand secondary data analyses were executed to gain insightinto the prevalence of overweight and obesity among Euro-pean preschoolers. The secondary data analyses indicatedthat the prevalence of overweight and obesity across the

16 Intervention Mapping in preschoolers M. De Craemer et al. obesity reviews

© 2014 World Obesity15 (Suppl. 3), 14–26, August 2014

intervention countries ranged from 8% to 30% and 1% to13%, respectively (34). A systematic review found strongevidence for an inverse association between total PA andoverweight (35). Based on the results of the focus groupswith European parents/caregivers and teachers, bothparents/caregivers and teachers perceive preschoolers to besufficiently active and they do not see the need to increasepreschoolers’ PA levels (31). Also, teachers argued that‘preschool children need to learn to sit still in preparationfor primary school’ (31). Based on the information of theliterature reviews (34–39) and the focus groups (31), thefollowing programme objective was formulated at the indi-vidual level: ‘Children between four and six years oldincrease their total PA throughout the whole day by 10% atthe end of the intervention’. Also for the interpersonal andorganizational level, programme objectives were formu-lated and are depicted in Table 1.

Step 2: formulation of the change objectives

For the programme objective of PA, specific performanceobjectives were formulated at three different levels: the

individual level (preschool child), the interpersonal level(parents/caregivers) and the organizational level (teachers).An overview of each performance objective for each level ofthe intervention can be found in Table 1. The performanceobjectives were formulated based on the current PA guide-lines for preschoolers, namely 180 min of total PA per day,irrespective of intensity (10–13).

After formulation of all performance objectives for PAfor each target group, specific determinants for each per-formance objective of PA were listed based on the results ofthe literature reviews and the focus groups. The personaldeterminants selected for preschoolers at the individuallevel were (i) attitude, (ii) knowledge, (iii) self-efficacy, (iv)habit and (v) capability. For parents/caregivers at the inter-personal level, and for teachers at the organizational level,four determinants – (i) attitude, (ii) knowledge, (iii) self-efficacy and (iv) habit – were selected. After the selection ofthe determinants, the performance objectives were crossedwith the selected determinants, resulting in matrices ofchange objectives. As performance objectives were formu-lated separately for each level of the intervention – individ-ual, interpersonal and organizational – three different

Table 1 Overview of the formulated programme and performance objectives for physical activity at each level of the intervention

Level of theintervention

Target group Programme objective Performance objectives (PO)

Individuallevel

Preschool child Children between four and sixyears old increase their totalphysical activity throughoutthe entire day by 10% at theend of the intervention

PO1. Children increase their current physical activity levels by 10% over theentire day on weekdays.PO2. Children increase their current physical activity levels by 10% over theentire day on weekend days.PO3. Children experience a variety of structured and unstructured physicalactivity at kindergarten.PO4. Children experience a variety of unstructured physical activity at home.

Interpersonallevel

Preschoolers’parents at thehome environment

Parents increase their child’sphysical activity by 10% athome at the end of theintervention

PO1. Parents facilitate children to be more physically active.PO2. Parents use active transport to move from place to place together withtheir child.PO3. Parents participate in sports activities and/or unstructured physicalactivities inside, together with their child(ren).PO4. Parents participate in sports activities and/or unstructured physicalactivities outside, together with their child(ren).PO5. Parents motivate (verbally) their children to play outside.PO6. Parents are a role model for their child(ren) by being physically activethemselves.

Organizationallevel

Preschoolers’teachers at thekindergartenenvironment

Teachers increasepreschoolers’ physical activityby 10% at kindergarten at theend of the intervention

PO1. Every day, teachers organize movement breaks that last between 1 and5 min in the kindergarten classroom, two in the morning and two in theafternoon.PO2. Teachers encourage the children’s parents to use active transport.PO3. Teachers use an active way to teach, (e.g. counting, expressions,stories).PO4. Teachers encourage the children to be active at the playground.PO5. Teachers are a role model for the children by being physically activethemselves.PO6. Teachers encourage the parents to dress the preschoolers correctly toplay indoors and outdoors.PO7. Teachers provide two physical education lessons per week.



matrices were developed for preschool children, parents/caregivers and teachers, respectively and are depicted inTables 2–4. For example, the performance objective forparents/caregivers stated that parents/caregivers facilitatechildren to be more physically active and was crossed withthe determinant ‘habit’, which resulted in the change objec-tive ‘parents/caregivers plan more PA into their children’sdaily routine’. The change objectives were formulated withthe use of action words (e.g. ‘express’, ‘plan’, ‘organise’,‘explain’) – listed by Bartholomew et al. – and were fol-lowed by a statement of what is expected to result from theintervention (29).

Step 3: selection of theory-based methods andpractical strategies

During the third step of the IM protocol, theory-basedmethods to influence changes in determinants were chosen.The first step was to list all determinants that were includedin the matrices at the different intervention levels. Thesedeterminants were then matched with theory-basedmethods, mentioned by Bartholomew et al. (29). Forexample, the result of crossing the performance objective‘parents/caregivers facilitate children to be more physicallyactive’ with the determinant ‘knowledge’ was the changeobjective ‘Parents explain the current PA guidelines forpreschoolers of three hours of total PA per day’ at theinterpersonal level. The selected theory-based method thatcorresponded to the determinant ‘knowledge’ in order toachieve the change objective was ‘persuasive communica-tion’. This theory-based method was then translated into apractical strategy. In this case, a practical strategy that waschosen for the method ‘persuasive communication’ was toprovide parents/caregivers with newsletters with informa-tion and tips on how to increase their child’s PA. In addi-tion, suggestions from the focus groups were also used todevelop practical strategies. For example, teachers men-tioned that they would like to have ready-to-use materials– so that they do not need extra time to develop thematerials themselves – together with practical tips andinformation with new ideas and activities (31). Table 5provides an overview of all the methods and strategies thatwere selected and used to achieve the change objectives foreach level of the intervention.

Step 4: development of the physicalactivity-intervention component and materials

Based on the results of the first three steps of the IMprotocol, the intervention programme and materials weredeveloped. For teachers (organizational level), a teachers’guide (‘Teacher’s General Guide’) and a handbook withclassroom activities (‘Classroom Activities Guide’) weredeveloped to change preschoolers’ PA behaviour at the Ta

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tran

spor

tto

mov

efro

mp

lace

top

lace

tog

ethe

rw

ithth

eir

child

,ev

enw

hen

the

wea

ther

isra

iny

orco

ld.

CO

3.2.

2.P

aren

tsex

pre

ssco

nfid

ence

that

itis

pos

sib

leto

use

activ

e

tran

spor

tto

mov

efro

mp

lace

top

lace

tog

ethe

rw

ithth

eir

child

,ev

enw

hen

they

have

tog

etto

wor

kin

the

mor

ning

.

CO

3.2.

3.P

aren

tsex

pre

ssco

nfid

ence

that

they

are

able

tous

eac

tive

tran

spor

tto

mov

efro

mp

lace

top

lace

tog

ethe

rw

ithth

eir

child

,ev

enw

hen

thei

rne

ighb

ours

/frie

nds/

fam

ilyd

ono

td

oth

is.

CO

4.2.

1.P

aren

tsor

gan

ize

thei

rfa

mily

,so

that

they

have

enou

gh

time

tous

eac

tive

tran

spor

tto

mov

efro

mp

lace

top

lace

tog

ethe

rw

ithth

eir

child

.

CO

4.2.

2.P

aren

tssc

hed

ule

activ

etr

ansp

ort

into

thei

r

child

’sd

aily

rout

ine.

PO

3.P

aren

tsp

artic

ipat

ein

spor

tsac

tiviti

esan

d/o

r

unst

ruct

ured

phy

sica

lact

iviti

es

insi

de,

tog

ethe

rw

ithth

eir

child

(ren

).

CO

1.3.

Par

ents

exp

ress

pos

itive

feel

ing

sab

out

par

ticip

atin

gin

spor

tsac

tiviti

esan

d/o

r

unst

ruct

ured

phy

sica

lact

iviti

es

insi

de,

tog

ethe

rw

ithth

eir

child

ren.

CO

2.3.

1.P

aren

tsex

pla

inth

atp

artic

ipat

ing

insp

orts

activ

ities

insi

de,

tog

ethe

rw

ithth

eir

child

,is

ben

efici

alan

dhe

alth

yfo

rth

eir

child

ren.

CO

2.3.

2.P

aren

tsca

nlis

tse

vera

lsp

orts

activ

ities

and

/or

unst

ruct

ured

phy

sica

lact

iviti

esth

atth

eyca

n

do

insi

de

tog

ethe

rw

ithth

eir

child

.

CO

3.3.

1.P

aren

tsex

pre

ssco

nfid

ence

that

they

can

par

ticip

ate

insp

orts

activ

ities

and

/or

unst

ruct

ured

phy

sica

lact

iviti

esin

sid

eto

get

her

with

thei

r

child

,ev

enw

hen

they

had

aro

ugh

day

atw

ork.

CO

3.3.

2.P

aren

tsex

pre

ssco

nfid

ence

that

they

can

par

ticip

ate

insp

orts

activ

ities

and

/or

unst

ruct

ured

phy

sica

lact

iviti

esin

sid

eto

get

her

with

thei

r

child

,ev

enw

hen

they

are

tired

.

CO

3.3.

3.P

aren

tsex

pre

ssco

nfid

ence

that

they

can

par

ticip

ate

insp

orts

activ

ities

and

/or

unst

ruct

ured

phy

sica

lact

iviti

esin

sid

eto

get

her

with

thei

r

child

,ev

enw

hen

they

have

tom

anag

eth

eir

hous

ehol

d.

CO

4.3.

Par

ents

pla

nth

e

par

ticip

atio

nin

spor

ts

activ

ities

insi

de,

tog

ethe

rw

ith

thei

rch

ildre

n,in

toth

eir

dai

ly

rout

ine.

PO

4.P

aren

tsp

artic

ipat

ein

spor

tac

tiviti

esan

d/o

r

unst

ruct

ured

phy

sica

lact

iviti

es

outs

ide,

tog

ethe

rw

ithth

eir

child

(ren

).

CO

1.4.

Par

ents

exp

ress

pos

itive

feel

ing

sab

out

par

ticip

atin

gin

spor

tsac

tiviti

esan

d/o

r

unst

ruct

ured

phy

sica

lact

iviti

es

outs

ide,

tog

ethe

rw

ithth

eir

child

ren.

CO

2.4.

1.P

aren

tsex

pla

inth

atp

artic

ipat

ing

insp

orts

activ

ities

outs

ide,

tog

ethe

rw

ithth

eir

child

,is

ben

efici

alan

dhe

alth

yfo

rth

eir

child

ren.

CO

2.4.

2.P

aren

tsca

nlis

tse

vera

lsp

orts

activ

ities

and

/or

unst

ruct

ured

phy

sica

lact

iviti

esth

atth

eyca

n

do

outs

ide

tog

ethe

rw

ithth

eir

child

.

CO

3.4.

1.P

aren

tsex

pre

ssco

nfid

ence

that

they

can

par

ticip

ate

insp

orts

activ

ities

and

/or

unst

ruct

ured

phy

sica

lact

iviti

esou

tsid

eto

get

her

with

thei

r

child

,ev

enw

hen

they

had

aro

ugh

day

atw

ork.

CO

3.4.

2.P

aren

tsex

pre

ssco

nfid

ence

that

they

can

par

ticip

ate

insp

orts

activ

ities

and

/or

unst

ruct

ured

phy

sica

lact

iviti

esou

tsid

eto

get

her

with

thei

r

child

,ev

enw

hen

they

are

tired

.

CO

3.4.

3.P

aren

tsex

pre

ssco

nfid

ence

that

they

can

par

ticip

ate

insp

orts

activ

ities

and

/or

unst

ruct

ured

phy

sica

lact

iviti

esou

tsid

eto

get

her

with

thei

r

child

,ev

enw

hen

they

have

tom

anag

eth

eir

hous

ehol

d.

CO

4.4.

Par

ents

pla

nth

e

par

ticip

atio

nin

spor

ts

activ

ities

outs

ide,

tog

ethe

rw

ith

thei

rch

ildre

n,in

toth

eir

dai

ly

rout

ine.

PO

5.P

aren

tsm

otiv

ate

(ver

bal

ly)

thei

rch

ildre

nto

pla

y

outs

ide.

CO

1.5.

1.P

aren

tsex

pre

ssp

ositi

ve

feel

ing

sab

out

thei

rch

ildre

n

pla

ying

outs

ide.

CO

1.5.

2.P

aren

tsex

pre

ssp

ositi

ve

feel

ing

sab

out

pla

ying

outs

ide

bei

ngb

enefi

cial

for

thei

rch

ild.

CO

2.5.

1.P

aren

tsca

nlis

tap

pro

pria

tew

ays

tod

ress

thei

rch

ildto

the

wea

ther

cond

ition

s.

CO

2.5.

2.P

aren

tsca

nlis

tre

ason

sw

hyp

layi

ng

outs

ide

isb

enefi

cial

and

heal

thy

for

thei

rch

ild.

CO

3.5.

1.P

aren

tsex

pre

ssco

nfid

ence

that

they

are

able

tom

otiv

ate

thei

r

child

ren

top

lay

outs

ide,

even

whe

nit

isco

ld.

CO

3.5.

2.P

aren

tsex

pre

ssco

nfid

ence

that

they

have

the

skill

sto

mot

ivat

e

thei

rch

ildre

nto

pla

you

tsid

e,ev

enw

hen

the

wea

ther

isb

ad.

CO

3.5.

3.P

aren

tsex

pre

ssco

nfid

ence

that

they

can

mot

ivat

eth

eir

child

ren

top

lay

outs

ide,

even

whe

nth

eir

neig

hbou

rs/fr

iend

s/fa

mily

do

not

do

this

.

CO

4.5.

Par

ents

pla

nto

mot

ivat

eth

eir

child

top

lay

outs

ide

into

thei

rd

aily

rout

ine.

PO

6.P

aren

tsar

ea

role

mod

el

for

thei

rch

ildre

nb

yb

eing

phy

sica

llyac

tive

them

selv

es.

CO

1.6.

Par

ents

exp

ress

pos

itive

feel

ing

sab

out

bei

nga

role

mod

el

for

thei

rch

ildre

nb

yb

eing

phy

sica

llyac

tive

them

selv

es.

CO

2.6.

Par

ents

exp

lain

that

they

are

aro

lem

odel

for

thei

rch

ildre

nb

yb

eing

phy

sica

llyac

tive

them

selv

es,

and

that

the

child

ren

will

cop

yth

eb

ehav

iour

ofth

e

par

ents

.

CO

3.6.

Par

ents

exp

ress

confi

den

ceto

be

role

mod

els

for

thei

rch

ildre

nb

y

bei

ngp

hysi

cally

activ

eth

emse

lves

,ev

enw

hen

they

have

anof

f-d

ay.

CO

4.6.

Par

ents

pla

nto

be

a

role

mod

elfo

rth

eir

child

ren

by

bei

ngp

hysi

cally

activ

ed

urin

g

thei

rd

aily

rout

ine.

CO

,ch

ang

eob

ject

ive;

PA,

phy

sica

lact

ivity

;P

O,

per

form

ance

obje

ctiv

e.



Tab

le4

Mat

rixof

chan

ge

obje

ctiv

esfo

rp

resc

hool

ers’

teac

hers

atth

eor

gan

izat

iona

llev

elof

the

PAco

mp

onen

tof

the

ToyB

ox-in

terv

entio

n

Pro

gra

mm

eob

ject

ive:

Teac

hers

incr

ease

pre

scho

oler

s’p

hysi

cala

ctiv

ityb

y10

%at

kind

erg

arte

nat

the

end

ofth

ein

terv

entio

n.

Teac

hers

’PO

sP

erso

nald

eter

min

ants

Atti

tud

eK

now

led

ge

Sel

f-ef

ficac

yH

abit

PO

1.E

very

day

,te

ache

rsor

gan

ize

mov

emen

tb

reak

sth

atla

stb

etw

een

one

and

5m

inin

the

kind

erg

arte

ncl

assr

oom

,tw

oin

the

mor

ning

and

two

inth

eaf

tern

oon.

CO

1.1.

Teac

hers

exp

ress

pos

itive

feel

ing

sab

out

the

ben

efits

ofm

ovem

ent

bre

aks

for

the

child

ren.

CO

2.1.

1.Te

ache

rsd

escr

ibe

how

mov

emen

tb

reak

sin

the

kind

erg

arte

ncl

assr

oom

are

ben

efici

alfo

rth

ech

ildre

n.C

O2.

1.2.

Teac

hers

can

list

diff

eren

tac

tiviti

es,

whi

chth

eyca

nd

od

urin

gth

em

ovem

ent

bre

aks

inth

eki

nder

gar

ten

clas

sroo

m.

CO

3.1.

1.Te

ache

rsex

pre

ssco

nfid

ence

that

they

can

pro

vid

em

ovem

ent

bre

aks

inth

eki

nder

gar

ten

clas

sroo

md

urin

gth

ed

ay/le

sson

s,ev

enw

hen

they

have

atig

htsc

hed

ule.

CO

3.1.

2.Te

ache

rsex

pre

ssco

nfid

ence

that

they

can

pro

vid

em

ovem

ent

bre

aks

inth

eki

nder

gar

ten

clas

sroo

mev

enw

hen

othe

rte

ache

rsd

ono

tp

rovi

de

them

.

CO

4.1.

Teac

hers

pla

nan

dim

ple

men

tm

ovem

ent

bre

aks

inth

eki

nder

gar

ten

clas

sroo

md

urin

gth

ed

ay.

PO

2.Te

ache

rsen

cour

age

the

child

ren’

sp

aren

tsto

use

activ

etr

ansp

ort.

CO

1.2.

1.Te

ache

rsex

pre

ssp

ositi

vefe

elin

gs

abou

tth

eb

enefi

tsof

activ

etr

ansp

orta

tion

for

the

child

ren.

CO

1.2.

2.Te

ache

rsex

pre

ssp

ositi

vefe

elin

gs

abou

tus

ing

activ

etr

ansp

ort

them

selv

es.

CO

2.2.

Teac

hers

can

list

two

ben

efits

for

child

ren’

she

alth

ifth

eyw

ould

use

activ

etr

ansp

ort.

CO

3.2.

1.Te

ache

rsex

pre

ssco

nfid

ence

that

they

can

enco

urag

eth

ech

ildre

n’s

par

ents

tous

eac

tive

tran

spor

t,ev

enw

hen

they

do

not

feel

like

itb

ecau

sefo

rex

amp

leth

eyar

etir

ed.

CO

3.2.

2.Te

ache

rsex

pre

ssco

nfid

ence

that

they

can

enco

urag

eth

ech

ildre

n’s

par

ents

tous

eac

tive

tran

spor

t,ev

enw

hen

the

othe

rte

ache

rsd

ono

td

oth

is.

CO

4.2.

1.Te

ache

rsp

lan

toen

cour

age

the

child

ren’

sp

aren

tsto

use

activ

etr

ansp

ort

into

thei

rd

aily

rout

ine.

CO

4.2.

2.Te

ache

rsp

lan

tous

eac

tive

tran

spor

tth

emse

lves

.

PO

3.Te

ache

rsus

ean

activ

ew

ayto

teac

h(e

.g.

coun

ting

whi

leju

mp

ing

,m

ovem

ent

stor

ies

...)

.

CO

1.3.

1.Te

ache

rsex

pre

ssp

ositi

vefe

elin

gs

abou

tus

ing

anac

tive

way

tote

ach.

CO

2.3.

1.Te

ache

rsd

escr

ibe

that

teac

hing

inan

activ

ew

ayis

ben

efici

alfo

rth

ech

ildre

n,b

ecau

seth

eyw

illle

arn

fast

eran

dth

eyw

illex

per

ienc

ehe

alth

ben

efits

.C

O2.

3.2.

Teac

hers

des

crib

eho

wth

eyca

nte

ach

inan

activ

ew

ay.

CO

3.3.

1.Te

ache

rsex

pre

ssco

nfid

ence

that

they

can

teac

hin

anac

tive

way

,ev

enif

the

sub

ject

isno

tth

atea

sy.

CO

3.3.

2.Te

ache

rsex

pre

ssco

nfid

ence

that

they

can

teac

hin

anac

tive

way

,ev

enif

they

do

not

have

the

req

uire

dsp

ace/

with

limite

dsp

ace.

CO

3.3.

3.Te

ache

rsex

pre

ssco

nfid

ence

that

they

can

teac

hin

anac

tive

way

,ev

enw

hen

thei

rco

lleag

ues

do

not

teac

hin

anac

tive

way

.

CO

4.3.

Teac

hers

pla

nan

dim

ple

men

tac

tive

way

sto

teac

hin

toth

eir

dai

lyro

utin

e.



Tab

le4

Con

tinue

d

Pro

gra

mm

eob

ject

ive:

Teac

hers

incr

ease

pre

scho

oler

s’p

hysi

cala

ctiv

ityb

y10

%at

kind

erg

arte

nat

the

end

ofth

ein

terv

entio

n.

Teac

hers

’PO

sP

erso

nald

eter

min

ants

Atti

tud

eK

now

led

ge

Sel

f-ef

ficac

yH

abit

PO

4.Te

ache

rsen

cour

age

the

child

ren

tob

eac

tive

atth

ep

layg

roun

d.

CO

1.4.

Teac

hers

exp

ress

pos

itive

feel

ing

sab

out

enco

urag

ing

child

ren

tob

eac

tive

atth

ep

layg

roun

d.

CO

2.4.

Teac

hers

can

list

two

ben

efits

for

child

ren’

she

alth

ifth

eyar

ep

hysi

cally

activ

eat

the

pla

ygro

und

.

CO

3.4.

1.Te

ache

rsex

pre

ssco

nfid

ence

that

they

can

enco

urag

eth

ech

ildre

nto

be

activ

eat

the

pla

ygro

und

,ev

enw

hen

ther

eis

alre

ady

alo

tof

nois

eon

the

pla

ygro

und

.C

O3.

4.2.

Teac

hers

exp

ress

confi

den

ceth

atth

eyca

nen

cour

age

the

child

ren

tob

eac

tive

atth

ep

layg

roun

d,

even

whe

nth

ew

eath

eris

bad

(e.g

.co

ld,

rain

y,w

ind

y..

.).

CO

3.4.

3.Te

ache

rsex

pre

ssco

nfid

ence

that

they

can

enco

urag

eth

ech

ildre

nto

be

activ

eat

the

pla

ygro

und

,ev

enw

hen

thei

rco

lleag

ues

do

not

do

this

.

CO

4.4.

Teac

hers

pla

nto

enco

urag

eth

ech

ildre

nto

be

activ

eat

the

pla

ygro

und

into

thei

rd

aily

rout

ine.

PO

5.Te

ache

rsar

ea

role

mod

elfo

rth

ech

ildre

nb

yb

eing

phy

sica

llyac

tive

them

selv

es.

CO

1.5.

Teac

hers

exp

ress

pos

itive

feel

ing

sab

out

bei

nga

role

mod

elfo

rth

ech

ildre

nb

yb

eing

phy

sica

llyac

tive

them

selv

es.

CO

2.5.

Teac

hers

exp

lain

that

they

are

aro

lem

odel

for

the

child

ren

by

bei

ngp

hysi

cally

activ

eth

emse

lves

.

CO

3.5.

1.Te

ache

rsex

pre

ssco

nfid

ence

that

they

can

be

aro

lem

odel

for

the

child

ren

by

bei

ngp

hysi

cally

activ

eth

emse

lves

,ev

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Table 5 Theory-based methods and practical strategies to achieve the change objectives at each level of the ToyBox-intervention

Level of the

intervention

Determinant Change objective* Theory-based

method†

Theory‡ Practical strategy

Individual level

Preschoolers

Attitude CO1.1., CO1.2. Direct experience TL Physical education lessonsCO1.1., CO1.2. Repeated exposure TL Physical education lessons

Knowledge CO2.1., CO2.2. Using imagery TIP Kangaroo stories (with support of

the hand puppet)Self-efficacy CO3.1., CO3.2. Modelling SCT; TL Kangaroo storiesHabit CO4.1., CO4.2. Modelling SCT; TL Kangaroo storiesCapability CO5.1. Active learning SCT Physical education lessons

Classroom activitiesCO5.1., CO5.2. Guided practice SCT; TSR Physical education lessons

Classroom activities

Interpersonal level

Parents

Attitude CO1.1., CO1.2., CO1.3., CO1.4., CO1.5., CO1.6.1.,

CO1.6.2.

Arguments PCM; ELM Newsletters

Tip-cardsCO1.1., CO1.2., CO1.3., CO1.4., CO1.5.1., CO1.5.2.,

CO1.6.

Environmental

re-evaluation

TTM; SCT Newsletters

Knowledge CO2.1., CO2.2., CO2.6. Discussion TIP Parent-child activities at

kindergartenCO2.1., CO2.2., CO2.3.1., CO2.3.2., CO2.4.1., CO2.4.2.,

CO2.5.1., CO2.5.2., CO2.6.

Active learning PCM; ELM; SCT Newsletters

Tip-cards

PosterCO2.1., CO2.2., CO2.3.1., CO2.3.2., CO2.4.1., CO2.4.2.,

CO2.5.1., CO2.5.2., CO2.6.

Elaboration TIP; ELM Newsletters

Tip-cards

PosterSelf-efficacy CO3.2.1., CO3.2.2., CO3.2.3., CO3.3.3., CO3.4.1.,

CO3.4.2., CO3.4.3., CO3.6.1.

Modelling SCT; TL Newsletters

CO3.1.1, CO3.1.2., CO3.2.1., CO3.2.2., CO3.2.3.,

CO3.3.1., CO3.3.2., CO3.3.3., CO3.4.1., CO3.4.2.,

CO3.4.3., CO3.5.1., CO3.5.2., CO3.5.3., CO3.6.1.

Guided practice SCT; TSR Newsletters

Tip-cards

CO3.1.1, CO3.1.2., CO3.2.1., CO3.2.2., CO3.2.3.,

CO3.3.1., CO3.3.2., CO3.3.3., CO3.4.1., CO3.4.2.,

CO3.4.3., CO3.5.1., CO3.5.2., CO3.5.3., CO3.6.1.

Verbal persuasion SCT; TSR Newsletters

Tip-cards

PosterHabit CO4.1., CO4.2.1., CO4.2.2., CO4.3., CO4.4., CO4.5,

CO4.6

Modelling SCT; TL Newsletters

Organizational level

Teachers

Attitude CO1.1., CO1.2.1., CO1.3.1., CO1.4., CO1.6., CO1.7. Consciousness

raising (providing

information)

HBM Teachers’ guide

Teachers’ training

CO1.1., CO1.2.1., CO1.2.2., CO1.3.1., CO1.4., CO1.5.,

CO1.6., CO1.7.

Environmental

re-evaluation

TTM; SCT Teachers’ guide

CO1.1., CO1.2.1., CO1.2.2., CO1.3.1., CO1.4., CO1.5.,

CO1.6., CO1.7.

Discussion TIP Teachers’ training

Knowledge CO2.1.1., CO2.1.2., CO2.2., CO2.3.1., CO2.3.2., CO2.4.,

CO2.5., CO2.6., CO2.7.

Discussion TIP Teachers’ training

CO2.1.1., CO2.1.2., CO2.2., CO2.3.1., CO2.3.2., CO2.4.,

CO2.5., CO2.6., CO2.7.

Consciousness

raising (providing

information)

HBM Teachers’ guide


Self-efficacy CO3.1.1., CO3.1.2., CO3.2.1., CO3.2.2., CO3.3.1.,

CO3.3.2., CO3.3.3., CO3.4.1., CO3.4.2., CO3.4.3.,

CO3.5.1., CO3.5.2., CO3.6., CO3.7.1., 3.7.2.

Modelling SCT; TL Teachers’ guide


CO3.1.1., CO3.1.2., CO3.2.1., CO3.2.2., CO3.3.1.,

CO3.3.2., CO3.3.3., CO3.4.1., CO3.4.2., CO3.4.3.,

CO3.5.1., CO3.5.2., CO3.6., CO3.7.1., 3.7.2.

Guided practice SCT; TSR Teachers’ guide Teachers’ training

Habit CO4.1., CO4.2.1., CO4.2.2., CO4.3., CO4.4., CO4.5.,

CO4.6., CO4.7.

Modelling SCT; TL Teachers’ guide Teachers’ training

*The detailed change objectives can be found in Tables 2, 3 and 4.†The theory-based methods can be found in Bartholomew et al. (29), pages 327–344 [34], but a brief description can be found here. Direct experience, encouraging a

process whereby knowledge is created through the interpretation of experience; Repeated exposure, making a stimulus repeatedly accessible to the individual’s sensory

receptors; Using imagery, using artifacts that have a similar appearance to some subject; Modelling, providing an appropriate model being reinforced for the desired action;

Active learning, encouraging learning from goal-driven and activity-based experience; Guided practice, prompting individuals to rehearse and repeat the behaviour various

times, discuss the experience, and provide feedback; Arguments, using a set of one or more meaningful premises and a conclusion; Environmental re-evaluation,

encouraging realizing the negative impact of the unhealthy behaviour and the positive impact of the healthful behaviour; Discussion, encouraging consideration of a topic in

open informal debate; Elaboration, stimulating the learner to add meaning to the information that is processed; Verbal persuasion, using messages that suggest that the

participant possesses certain capabilities; Consciousness raising, providing information, feedback or confrontation about the causes, consequences and alternatives for a

problem or a problem behaviour.‡ELM, elaboration likelihood model; HBM, health-belief model; PCM, persuasion-communication matrix; SCT, social cognitive theory; TIP, theories of information processing;

TL, theories of learning; TPB, Theory of planned behaviour; TRA, theory of reasoned action; TSR, theory of self-regulation; TTM, trans-theoretical model.



individual level. This teachers’ guide provided some generalinformation, for example on the definition of PA andthe importance of increasing preschoolers’ PA levels toestablish healthy PA behaviour. In the Classroom ActivitiesGuide, three different themes were included, namely (i)setting environmental changes in the classroom (i.e. how torearrange the classroom); (ii) the child performing theactual behaviour (i.e. being physically active during struc-tured PA sessions) and (iii) classroom activities (i.e. kanga-roo stories and PA excursions).

To involve the parents/caregivers in the PA componentof this kindergarten-based intervention, preschoolers’parents/caregivers received two newsletters, two tip-cardsand one poster. The newsletters and tip-cards containedtips and strategies to increase preschoolers’ PA levels. Theposter provided key messages on PA and pictures ofthe physically active ‘Little Kangaroo’ (role model of theToyBox-study) that could be coloured at kindergarten andtaken home. After the end of the ToyBox-study (April2014), the intervention material will be made availableon the ToyBox website (www.toybox-study.eu). Detailedinformation on the content of the intervention materialsfor PA is provided in another paper elsewhere in thissupplement (40).

Step 5: development of an adoption andimplementation plan

During the fifth step of the IM protocol, the implemen-tation plan of the intervention was developed. The entireToyBox-intervention was implemented over the academicyear 2012–2013. Before the start of the intervention,environmental changes for PA occurred in the classroom,which were retained throughout the whole school year.The PA component of the intervention also includedphysical education sessions and classroom activities.Before the start of the intervention, all kindergartenteachers were invited to attend two teacher training ses-sions in which the goals of the ToyBox-intervention wereexplained and the materials were presented (41,42).During the first training session, teachers were providedwith the ‘ToyBox’, i.e. a plastic box which contained ateachers’ guide, four handbooks, nine newsletters, eighttip-cards, four posters and a kangaroo hand puppet.Before the start of the implementation of the repetitionperiod, teachers received a third teachers’ training session.During this third training session, a short repetition wasprovided concerning the goals, behaviours and thematerials of the ToyBox-intervention, while selectedteachers were invited to present their experiences from theintervention implementation. At the end of each trainingsession, there was time allocated for questions anddiscussion.

Step 6: evaluation planning

In the final step of the IM protocol, a plan to evaluate theeffectiveness of the ToyBox-intervention was developed.The general effectiveness of the intervention will beevaluated on different levels. First, the changes inanthropometric measures (height, weight, waist circumfer-ence), body mass index and the prevalence of overweightand obesity will be investigated (43). Furthermore, changesin behaviour related to the specific programme objectiveswill be examined. This will be performed using a parental/caregivers’ questionnaire that parents/caregivers filled inbefore and after the implementation of the intervention(44). With this questionnaire, child’s membership in asports club, time per week that the child spends doing sportin a sports club, what kind of sport the child does and howthe child usually gets to and from kindergarten (i.e. activetransportation) and how long it takes, were reported. Addi-tionally, questions about parents/caregivers’ PA levels werereported. Finally, preschoolers’ steps per day and steps perhour were objectively measured before and after theintervention using pedometers (Omron Walking Style ProPedometer, HJ-720IT-E2; Omron Healthcare, Kyoto,Japan) (45). Process–evaluation questionnaires for bothparents/caregivers and teachers were developed to recordthe implementation of the intervention (32). Finally, thecost-effectiveness of the intervention will be analysed usinga health economics model (33).

Discussion

The aim of the current paper was to describe how the IMprotocol was applied towards the development of the PAcomponent of the ToyBox-intervention to prevent over-weight and obesity in 4- to 6-year-old European preschoolchildren. The way the different steps of the IM protocolwere implemented is described, and the developed matricesare presented.

During the needs assessment, focus groups with parents/caregivers and teachers of preschoolers were conducted inthe six intervention countries to inform the development ofthe PA component of the intervention (31). As these focusgroups were implemented in all six intervention countries,the challenge was to find the balance between the moregeneral information and country-specific details. Therefore,as a first step, the findings from all countries were summa-rized into a covering report, with recommendations for theintervention development. Country-specific details werethen used to make minor local and cultural adaptations.Although the materials and instructions provided to theteachers were common in all six countries, teachers wereable to make some adaptations themselves. For example, inthe developed Classroom Activities Guide, teachers wereasked to provide two physical education sessions per week.



http://www.toybox-study.eu

However, in countries that already provided such physicaleducation sessions (like Belgium and Spain) (46,47), it wassuggested to spend extra time on the classroom activitiesthat were mentioned in the teachers’ handbook. In thisway, cultural and local adaptations were included inthe development and implementation of the ToyBox-intervention. Programme planners are advised to use theinformation from the focus groups during the needs assess-ment step to prepare for local and cultural adaptation (31).

The evaluation of the effectiveness of the PA componentof the ToyBox-intervention will be based on both subjectiveparental/caregivers’ information (a questionnaire in whichparents/caregivers filled in information about their child’sPA during after school hours, in combination with ques-tions about the parents/caregivers’ PA levels) and objectiveinformation (with the use of pedometers). The objectivemeasurement will provide reliable data on preschoolers’steps per hour and steps per day, while the subjectiveparental/caregivers’ questionnaire will provide the contextof preschoolers’ physical activities. This general evaluationof the effectiveness of the intervention, in combination withthe process–evaluation, can indicate where the PA compo-nent of the ToyBox-intervention was effective and where ithad some shortcomings. Future programme planners areadvised to carefully select the method of evaluation toassess the effectiveness of the intervention.

The IM protocol was used as the conceptual frame-work for developing the ToyBox-intervention. Using theIM protocol has the benefit that the intervention is devel-oped in a systematic, evidence-based and theory-drivenmanner. Every decision during the development andimplementation of the IM protocol is well thought-outand carefully considered. In addition, different implemen-tation levels are included in the IM protocol; thisincreases complexity, but also might raise effectiveness.Yet, the development of the intervention was perceived asa time-consuming process, which was not only the casefor the current ToyBox-intervention but has also beenmentioned in the previously developed interventions thatalso used the IM protocol (e.g. IDEFICS, Pro Children)(48,49). In this case, the first steps that were taken for theneeds assessment occurred in March 2010, and the sixthand last step (i.e. evaluation) will be finished in April2014. This means that the total duration of the IM proto-col process will have taken 4 years and 2 months. There-fore, it is important for future programme planners toallocate adequate time and accordingly an adequatebudget for the development and implementation of anintervention based on the IM protocol. Also, a scientificstaff is required to develop and implement an interven-tion, and this scientific staff should be experienced andhave a background in using the IM protocol. In addition,this scientific staff should also be capable of trainingthe implementers of the intervention (i.e. kindergarten

teachers) to ensure a successful implementation of theintervention. However, to alleviate the work-load, futureprogramme planners could use and adapt the currentdeveloped matrices of change objectives to use in theirintervention to increase preschoolers’ PA.

Conclusion

In conclusion, the PA component of the ToyBox-intervention was carefully developed based on the IMprotocol and resulted in a standardized kindergarten-basedintervention with family involvement to increase 4- to6-year-old preschoolers’ PA across six European countries,allowing for minor cultural adaptations. While the use ofthe IM protocol was perceived as time-consuming, it maylead to an increase in the effectiveness of the intervention.Therefore, future programme planners should allocateadequate time, budget and experienced scientific staff todevelop and implement an intervention.

Conflict of interest statement

The authors have no conflicts of interest to declare.

Acknowledgements

The ToyBox-study is funded by the Seventh FrameworkProgramme (CORDIS FP7) of the European Commissionunder grant agreement n° 245200. The content of thisarticle reflects only the authors’ views and the EuropeanCommunity is not liable for any use that may be made ofthe information contained therein.

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