Inactivity and an unhealthy diet amongst others have led to an increased prevalence of overweight and obesity even in young children. Since most health behaviours develop during childhood health promotion has to start early. The setting kindergarten has been shown as ideal for such interventions. “Join the Healthy Boat” is a kindergarten-based health promotion programme with a cluster-randomised study focussing on increased physical activity, reduced screen media use, and sugar-sweetened beverages, as well as a higher fruit and vegetable intake. Intervention and materials were developed using Bartholomew’s Intervention Mapping approach considering Bandura’s social-cognitive theory and Bronfenbrenner’s ecological framework for human development. The programme is distributed using a train-the-trainer approach and currently implemented in 618 kindergartens. The effectiveness of this one-year intervention with an intervention and a control group will be examined in 62 kindergartens using standardised protocols, materials, and tools for outcome and process evaluation. A sample of 1021 children and their parents provided consent and participated in the intervention. Results of this study are awaited to give a better understanding of health behaviours in early childhood and to identify strategies for effective health promotion. The current paper describes development and design of the intervention and its implementation and planned evaluation.
Although some countries report a plateau of childhood obesity, the prevalence of overweight and obesity has risen continuously during the last decades and plateaued at an unhealthy high level [
Therefore, interventions to promote a healthy lifestyle must start early. Risk factors are already present in young children [
There are many health promoting interventions for children—some more successful than others. Effective and sustainable health promotion programmes are multicomponent and include physical activity as well as nutrition components and are tailored to a specific target group but also include the whole environment around that group [
Intervention planning for health promotion programmes should be scientifically sound and based on a theoretical model [
Based on experiences and results of the sister project “Join the Healthy Boat” in primary schools [
The aim of this paper is to address the development of the health promotion programme “Join the Healthy Boat – Kindergarten,” its implementation and planned evaluation including sample and methods. Development steps are shown in detail as well as the particular intervention contents and their implementation.
“Join the Healthy Boat” is a multicomponent health promotion programme for kindergarten children (three to six years old) in southwest Germany, which was developed by means of Bartholomew’s Intervention Mapping Approach (IMA; see Figure
Protocol for the Intervention Mapping Approach by Bartholomew et al. [
The IMA offers guidance for a theory-based development of interventions for health promotion and includes six detailed steps: (1) needs assessment; (2) identification of intervention targets; (3) selection of theory-based intervention methods and applications; (4) integration of methods and applications into an organised programme; (5) plan for adoption, implementation, and sustainability; and (6) an evaluation plan [
During the first step “needs assessment,” literature was systematically reviewed for the topics “physical activity and leisure time activities” and “diet and nutrition” as well as for kindergarten and school-based health promotion interventions. In addition, weekly meetings of an interdisciplinary scientific team were held as well as regular focus groups with kindergarten staff and parents. For “Join the Healthy Boat,” four key topics evolved out of the needs assessment: “promotion of (everyday) physical activity,” “reduction of screen media use,” “decrease of sugar-sweetened beverages,” and “increase of fruit and vegetable intake.” These key topics were oriented towards the children’s needs, specific to the target group and well implementable in a kindergarten-based health promotion programme.
These main topics, which were compiled during the needs assessment, were concretised and defined more thoroughly in the second step “identification of intervention targets.” With the use of so-called matrixes (extensive table templates), which are prestructured by IMA, behaviours and programme targets were developed and specified and resulted in children having to receive new knowledge and opportunities to try out new, alternative behaviours (e.g., activity games, different foods). For nutrition-specific topics, direct offers of healthy food played an important role.
Subsequently, during step three, methods and practical strategies to attain behaviour changes were chosen, which suit target group and intervention aims (defined in step two) best. For the health promotion programme “Join the Healthy Boat,” the social-cognitive theory (SCT) by Bandura [
The SCT assumes that behaviours are determined by personal and environmental factors as well as behaviours. Bronfenbrenner on the other hand presumes that personal relationships and social interactions influence people’s (health) behaviours [
To ensure sustainability and long-term integration into the kindergarten routine, the programme applies a teacher-centred approach, which enables the implementation of profound health promoting changes in kindergarten environments and the support of children’s behaviour change continuously.
During step four “integration of methods and applications into an organised programme,” intervention materials were designed and based on the defined programme targets and selected theoretical models from the previous steps. The materials were developed following the so-called orientation plan for kindergartens in southwest Germany [
Structured overview of intervention’s content.
To ensure sustainability and long-term integration of “Join the Healthy Boat,” during the fifth step of IMA a train-the-trainer approach (i.e., kindergarten teachers are trained to train further kindergarten teachers) was chosen and developed [
The last step of IMA guides through the planning of an evaluation of the intervention programme, which for “Join the Healthy Boat” is the so-called “Health Survey.” It was designed as a prospective, stratified, cluster-randomised longitudinal trial with an intervention and a control group and is registered at the German Clinical Trials Register (DRKS), Freiburg University, Germany, ID:
Participating kindergartens were recruited from all kindergartens in southwest Germany, which have received written information about programme and study, asking interested kindergarten teachers to participate. Only kindergartens which have not previously taken part in the programme were included in the study. To ensure a similar number of children in intervention and control group, stratification of randomisation was carried out on three levels on the basis of kindergarten size, that is, kindergartens with 15 or less participating children, with 16–25 participating children, and with more than 25 participating children. Therefore, 31 kindergartens were assigned to intervention group and 31 kindergartens to control group. Children within the recruited kindergartens were eligible if they were between three and five years old at the time of baseline measurements and their parents provided a signed consent form.
Further, power considerations were made prior to the study. Because of the explorative nature of this study, no adjustment for multiple testing will be made. A
Overview of main analysis of the two treatment groups.
Main outcomes
Outcome | Statistical analysis |
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Change in variables for nutrition (consumption of sugar-sweetened beverages, fruit, vegetables, high-calorie food; all variables are ordinal) | GEE model for follow-up measurement |
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Change in child’s time spent with screen media (hours per week, ordinal/quasi-continuous variables) | GEE model for follow-up measurement |
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Change in child’s physical activity/energy expenditure (physical activity: dichotomous, energy expenditure: continuous variables) | GEE model for follow-up measurement |
| |
Change in health knowledge and attitude of parents and kindergarten teachers (nominal/ordinal variables) | GEE model for follow-up measurement |
Secondary outcomes
Outcome | Statistical analysis |
---|---|
Change in anthropometric parameters (waist circumference, waist-to-height ratio, BMI, subcutaneous fat; all variables are continuous) | GEE model for difference between follow-up and baseline |
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Change in child’s quality of life (EQ5D-Y Proxy Version, KINDL parent’s version; continuous variables) | GEE model for difference between follow-up and baseline |
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Child: change in days sick leave, doctor’s consultation, hospitalisation; parents: absence from work due to children’s illness (continuous variables) | GEE model for difference between follow-up and baseline |
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Change in child’s motor skills (continuous variables) | GEE model for difference between follow-up and baseline |
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Environment of kindergarten and change in environment of kindergarten (continuous and categorical variables; measured on kindergarten level) | |
| |
Change in laboratory parameters (saliva, cheek swab): metabolic and inflammatory parameters, for example, IL-6, TNF | GEE model for difference between follow-up and baseline |
An overview of all baseline analysis can be found in Table
Assessments on children’s level include anthropometric measurements, such as height, body weight, waist circumference, and body fat percentage (using bioelectrical impedance analysis). Further, motor skills will be assessed using a standardised test battery including standing long jump, one-leg stand, sitting and reaching, and a 3-minute run [
Moreover, in order to receive a more thorough picture of the child’s health, parents will receive a comprehensive questionnaire rating their children’s well-being, health-related quality of life and provide details on their children’s and their own dietary and physical activity habits, as well as their leisure time activities. Furthermore, sociodemographic variables such as household income, parental education, and size of living space will be asked about in the questionnaire. In addition, children whose parents provided consent for saliva analyses will receive a supplementary questionnaire giving more detailed information about the child’s dietary habits.
On kindergarten level, all participating kindergarten teachers as well as the head of each kindergarten will be given a questionnaire including questions about the characteristics, routines, and surroundings of the kindergarten but also about their own health behaviours and attitudes.
In order to organise and prepare those assessments, pretests were performed to plan and practice tests and procedures. Although validated questionnaires will be used, these were sent out to parents and kindergarten teachers to evaluate whether they are understandable and how long it took them to complete them. Moreover, all measurements which will be obtained from the child directly were performed at several kindergartens to ensure practicability and feasibility. Baseline measurements took place in autumn of 2016; follow-up measurements will take place one year later.
Further, as part of an extensive process evaluation, the whole course of the programme will be documented and evaluated (training courses of trainers and kindergarten teachers, implementation of intervention materials).
7937 kindergartens in southwest Germany, which have not previously taken part in the programme, received written information about the study and the programme. A total of 398 kindergarten teachers and their heads of 66 kindergartens provided written, informed consent for participation in the “Health Survey” (see Figure
Overview of recruited children, kindergartens, and kindergarten teachers, including consent for the different substudies.
Due to stratification on the basis of kindergarten size, 33 kindergartens with less than 16 participating children, 20 kindergartens with 16–25 participating children, and 9 kindergartens with more than 25 participating children are involved in the “Health Survey.”
Per kindergarten, an average of 49% of children and parents consented to participate in the study. There was no difference in participation rate in control and intervention group. In total, 1021 parents provided consent for their children’s participation. Therefore, 511 children (247 boys, 264 girls,
In addition to the basic “Health Survey,” parents had the opportunity to agree to their children’s participation in numerous substudies. Objectively assessed physical activity as well as sonography assessment of their children’s body composition and the collection of saliva and a cheek swab needed the parents’ specific consent. 580 parents (56.8%) want their children to take part in further objective physical activity measurements, 713 children (69.8%) have consent to have their body composition assessed using sonography, as well as 751 and 706 parents (73.6% and 69.1%) provided consent for saliva collection and cheek swab, respectively (see Figure
Baseline results of this study are expected in 2017 in order to provide a better understanding of health behaviours in early childhood and follow-up results one year later to then identify strategies for effective health promotion.
The approach described herein of theory-based development of a health promotion intervention in kindergartens is one of few so far. In most published articles the focus lies on intervention effects but this very fundamental and important step is hardly mentioned or not at all, although particularlly development steps like these should be made available to other programme planners in order to standardise interventions and enable enhancements of such interventions for health promotion.
For the development of the “Join the Healthy Boat” intervention, the structured planning model “intervention mapping” [
The setting kindergarten is very well suited to implement intervention programmes for health promotion since it is possible to realise behaviour change (e.g., knowledge transfer; increase of self-efficacy) as well as environmental change (e.g., offer of healthy beverages and nutrition; gardens/surroundings which stimulate children to be physically active). That way, children get backing and motivation from their peers in all emerging health-related changes. Moreover, for children that age (kindergarten: 3 to 6 years), the SCT is an ideal framework since its implementation strategies such as model learning can be accomplished very well in the kindergarten setting [
The developed intervention is extensive and contains differentiated materials which are suitable for children of the targeted age and can be implemented directly in kindergarten’s daily routine. The detailed, elaborated intervention supports kindergarten staff during their regular activity since the key aspects of the intervention (physical activity and nutrition and leisure time activities) are topics reported in the orientation plan for kindergartens in southwest Germany [
In order to reach all families, even those with migration background or families from an underprivileged educational background, materials for parental work were designed appealingly and drafted in easy and plain language. These also offer specific action alternatives as well as health-related information. The first parental letter is actually a letter to the children, which children receive and should be read to them by their parents. This is an attempt to get families to really concern themselves with those parental letters. Furthermore, materials and training sessions provide ideas and opportunities (posters designed by children, activities such as a joint healthy breakfast, parental letters, etc.) to present health relevant information to parents without them having to feel imposed upon. All parental letters are also translated into Turkish and Russian.
Even though there are some programmes addressing physical activity and nutrition in kindergartens, the needs assessment demonstrated that long-term interventions without external staff are very rare but desired. The close peer-to-peer train-the-trainer approach of the programme can be seen as an innovation. Kindergarten teachers are coached by a trainer with expert knowledge of elementary pedagogy and physical activity and nutrition in order to enable them to implement the intervention autonomously and on the long-term. Key focus of the training sessions and materials is always the presentation and introduction of easily implemented action alternatives. In order to facilitate that, the intervention materials are anchored in a pirate story using puppets, short stories, illustrations, and so forth which are designed appealingly and suitably for children.
Besides, literature advises a duration of at least one year for successful kindergarten-based interventions for health promotion [
However, the upcoming programme’s evaluation (“Health Survey”) is scheduled for one year, with the possibility of tracking participating children through their childhood and adolescence. Its recruitment process was challenging and hindered by numerous aspects but mostly because interested kindergarten teachers had to volunteer to take in a rather extensive programme with an equally comprehensive evaluation. Most kindergartens in Germany already take part in some programmes—whether it is health promotion, language support, or dental prevention—which are all time-consuming. Further, the constant shortage of staff makes matters more difficult and adds to a reluctance to agree to any further work. Additionally, timing might not have been ideal since the new orientation plan for kindergartens, which the teachers need to adhere to, adds further work load and requires plenty of restructuring within the kindergarten setting. However, although the programme started two years ago and 1209 kindergarten teachers have already been trained and implemented “Join the Healthy Boat” in their kindergartens, it was still possible to recruit 62 kindergartens with 1021 participating children and 376 partaking kindergarten teachers, who are all willing to implement the programme in full and also document and evaluate certain aspects of the intervention during that year.
Meanwhile, the “Health Survey” will—hopefully—provide detailed information on determinants and influencing health behaviours of kindergarten children and their parents and kindergarten teachers as well as relevant data on the programme’s effectiveness and acceptance, which may support decisions for public health policies regarding further health promotion programmes on kindergarten level.
Although the “Join the Healthy Boat” intervention has several strengths, its limitations also have to be considered. The standardisation of its intervention materials and teacher training sessions as well as evaluation and implementation protocols is a major strength of this study. Nevertheless, irrespective of several objective assessment methods which will be used in the “Health Survey,” most data will be based on self-report by either kindergarten teachers or parents, which may be prone to social desirability or recall bias, especially considering that teachers and parents knew about the aims of this study. Moreover, since only very few of the addressed kindergartens were prepared to take part in the study, those then might be more determined or committed kindergarten teachers and representative results cannot be expected. However, since kindergartens and their teachers and children did not differ in control and intervention group, intervention effects should not be affected. Likewise, even though the recruited sample size is relatively large and spread all over the southwest of Germany, generalisation of results will not be possible. Also, a one-year intervention might be not long enough and the one follow-up assessment the following year might not be sufficient to provide enough details and insight on the impact of the programme. Still, due to the application of IMA it was possible to document the development process of the programme in detail and, therefore, that information can now be made available to other researchers wanting to develop interventions like this. Because of the transparency, a standardisation and comparability are possible, which increases an evidence-based public health requests [
When developing and implementing such a multicomponent health promotion programme, some things should be considered beforehand. As mentioned previously, the use of IMA is desirable as very structured but also very time-consuming and complex; therefore, because lead time is necessary when using that framework in order to develop a health promotion programme, also, access to different scientific qualifications is advantageous if not essential, if different components want to be included in such an intervention.
Further, numerous and intense talks in focus groups with potentially participating people are crucial, since programmes which are not tailored directly towards the needs of the targeted group will not be accepted and implemented by them.
Moreover, in order to plan and recruit for an appropriate evaluation, additional considerations have to be made. First and foremost, an open and honest communication with participants (in this case: parents and kindergarten teachers) about what they have to expect is essential. Kindergarten teachers have to know exactly how much time it will take them to prepare and implement the materials and how much extra time the evaluation will take. Furthermore, the design of attractive and appealing promotion and recruitment materials, which contain all aspects of the evaluation in easy language, has shown to be important in order to reach all possible participants. Also, plenty of time is necessary in order to recruit sufficient kindergartens and to explain to all participants the necessity of a control group. Besides, the choice of measurements and methods is a complex one which should not be underestimated.
In summary, “Join the Healthy Boat” was developed by a multidisciplinary team using the intervention mapping approach [
For the upcoming evaluation of the here described intervention, 62 kindergartens, 376 kindergarten teachers, and 1021 children could be recruited. The outcome and process evaluation along with other variables for the “Join the Healthy Boat” intervention will be assessed shortly and its results are awaited to give a better understanding of health behaviours in early childhood and to identify strategies for effective health promotion.
Baden-Württemberg Stiftung had no influence on the content of the manuscript. Further information about the programme and the Health Survey are found on
The authors declare that there is no conflict of interests regarding the publication of this paper.
The programme “Join the Healthy Boat” is financed by the Baden-Württemberg Stiftung. The research team would also like to thank all kindergarten teachers, children, and parents who participate in the Health Survey. Contributing members of the study group are Jens Dreyhaupt, Eva-Maria Friedemann, Eleana Georgiou, Sabrina Heinrich, Lina Hermeling, Belinda Hofmann, Anne Kelso, Dorothea Kesztyüs, Sarah Kettner, Susanne Kobel, Claire Kutzner, Christine Lämmle, Romy Lauer, Rainer Muche, Olga Pollatos, Luise Steeb, Jürgen M. Steinacker, Meike Traub Olivia Wartha, and Tamara Wirt.