**Meet the editor**

Jay Maddock, Ph.D., FAAHB is Professor and Director of the Office of Public Health Studies at the University of Hawai'i at Mānoa and Luojia Chair Professor at Wuhan University. Professor Maddock has extensive experience in system, environmental and policy research to improve population level risk factors for chronic disease. Dr. Maddock chaired the state board of health and was

a charter member of the NIH study section on Community-Level Health Promotion. He is an author of over 75 scientific articles. He is the Honorary Secretary for the Asia-Pacific Academic Consortium for Public Health. His research has been featured in several national magazines including Eating Well, Prevention and Good Housekeeping.

Contents

**Preface IX**

**Section 1 Obesity, Food and Physical Activity 1**

Chapter 1 **The IDEFICS Intervention Toolbox – A Guide to**

Vera Verbestel, Stefaan De Henauw,

Chapter 2 **Testing the Assumptions of Stage of Change**

Chapter 3 **Strategies for Cardiovascular Disease Prevention**

Jay E. Maddock, Jodi D. Barnett, Carrie S. Marshall and Claudio R. Nigg

Chapter 4 **Gender Differences in Food Choice and**

Claudia Arganini, Anna Saba,

Steven Garasky, Craig Gundersen,

Chapter 7 **Critical Appraisal of Selected Body Composition**

Chapter 5 **Iron Food Fortification**

Chapter 6 **Economic Stressors and**

Joel Alves Lamounier,

Laura Fernández Celemín, Katharina Gallois, Holger Hassel and Ilse De Bourdeaudhuij

**Successful Obesity Prevention at Community Level 3**

**in Rural Southern African American Communities 59**  Ralphenia D. Pace, Norma L. Dawkins and Melissa Johnson

**Dietary Intake in Modern Western Societies 83**

**for the Control of Childhood Anemia in Brazil 103**

**Childhood Obesity: Differences by Child Age and Gender 115**

Susan D. Stewart, Joey C. Eisenmann and Brenda J. Lohman

**Data Acquisition Techniques in Public Health 133**  Steven Provyn, Aldo Scafoglieri, Jonathan Tresignie, Céline Lumé, Jan Pieter Clarys and Ivan Bautmans

Raffaella Comitato, Fabio Virgili and Aida Turrini

Flávio Diniz Capanema and Daniela Silva Rocha

**for Fruit and Vegetable Consumption: A Naturalistic Study 41**

Staffan Marild, Stefan Storcksdieck genannt Bonsmann,

## Contents

#### **Preface XIII**

X Contents

Contents VII

Chapter 18 **Disseminating an Evidence-Based Disease**

Chapter 19 **Strategy and Practice of Support**

Chapter 20 **TB Control in Prisons 433**  J. Noeske

Chapter 21 **Social Determinants**

Chapter 22 **Anxiety and Emotional**

Chapter 24 **Gun Violence**

Syuichi Ooki and Kiyomi Hiko

**Section 4 Special Populations and Settings 431**

**of Health in Deaf Communities 449** Scott R. Smith and Nancy P. Chin

**Discomfort in the School Environment:**

**and Children's Mental Health 461**

L. Tramonte and J. D. Willms

Chapter 23 **Re-Emergence of HIV Infection and**

Amy J. Thompson

Chapter 25 **The Public Health Intervention**

Adam Davis and Mindy Benson

Chapter 27 **An Integrated Theoretical Framework**

**The Interplay of School Processes, Learning Strategies,**

**Syphilis Among Men Who Have Sex with Men 477**  Maria Antonella Di Benedetto, Nino Romano and Alberto Firenze

**in the United States: A Public Health Epidemic 501**

**of Skin Care for All: Community Dermatology 523**  Terence J. Ryan, Steven J. Ersser and Lucinda Claire Fuller

**Women and Girls for Involuntary Prostitution 555**

Chapter 26 **Addressing Asthma from a Public Health Perspective 537**

**to Describe Human Trafficking of Young**

Thozama Mandisa Lutya and Mark Lanier

**Self-Management Program for Older Americans:**

**Participatory Research (CBPR) Approach 405**

**for Families with Multiple Births Children: Combination of Evidence-Based Public Health (EBPH) and Community-Based**

**Implications for Diversifying Participant Reach Through Delivery Site Adoption 385**  Matthew Lee Smith, Basia Belza, Mary Altpeter, SangNam Ahn, Justin B. Dickerson and Marcia G. Ory

Chapter 13 **The Relationship Between Alcohol Consumption and Human Immunodeficiency Virus Infection and Risk Behaviour: A Systematic Literature Review of High-Risk Groups, with a Focus on South Africa 243**  Manuela G. Neuman, Michelle Schneider, Radu M. Nanau, Charles Parry and Matthew Chersich

#### **Section 3 Emerging Methods 293**

VI Contents

Chapter 8 **Physical Activity, Inactivity,**

**Section 2 Addictive Behaviors 185**

Chapter 10 **Alcohol Consumption Among**

Chapter 12 **Self Medication, Drug Dependency**

A. O. Afolabi

**Section 3 Emerging Methods 293**

Chapter 15 **Public Health Research and Action:**

Chapter 17 **How Can the Empowerment Role of**

Teresa Cawley

Chapter 14 **Challenges in**

Chapter 9 **U.S. Food Policy and Obesity 165**

**and Nutrition Behavior Among Children:**

Judith Väth, Katie Amato and Claudio R. Nigg

**Adolescents in Estonia 1994 – 2010 187**

Chapter 11 **Public Health and Indigenous Australian Gambling: Risky Lifestyle or Harmless Recreation? 205** Helen Breen, Nerilee Hing and Ashley Gordon

Chapter 13 **The Relationship Between Alcohol Consumption**

Manuela G. Neuman, Michelle Schneider,

**Healthcare in Multi-Ethnic Societies:**

Emine Kale and Bernadette Nirmal Kumar

Chapter 16 **Nature Therapy and Preventive Medicine 325**

**Reflections on Challenges and Possibilities of Community-Based Participatory Research 309**  S. Lazarus, B. Duran, L. Caldwell and S. Bulbulia

**Public Health Nurses (PHNs) Be Fostered? A Review of an Exploratory Research Study Conducted in Ireland and Current Evidence 351**

Juyoung Lee, Qing Li, Liisa Tyrväinen, Yuko Tsunetsugu, Bum-Jin Park, Takahide Kagawa and Yoshifumi Miyazaki

**Investigating Compensation and Transfer Effects 153**

Julian M. Alston, Abigail M. Okrent and Joanna C. Parks

Kersti Pärna, Mariliis Tael, Inge Ringmets and Katrin Aasvee

**and Self-Managed Health Care – A Review 223**

**and Human Immunodeficiency Virus Infection and Risk Behaviour: A Systematic Literature Review of High-Risk Groups, with a Focus on South Africa 243**

Radu M. Nanau, Charles Parry and Matthew Chersich

**Communication as a Barrier to Achieving Health Equity 295**

Preface

population level behaviors.

Human health is greatly influenced by the daily behaviors and patterns that make up our lives.  Over the last couple of decades, the role of the social sciences in influencing and changing human behaviors has become more prominent. Psychology, sociology, political science, economics, anthropology, communications and political science have all played an important role in health counseling, group based interventions, social marketing and policy change. A student being trained in a Master's of Public Health program in Health Promotion needs to be versed in all of these areas to be effective at changes

This book provides an overview of the influence of the social and behavioral sciences to many public health issues that confront us today. In the first section, the chapters explore the growing problem of obesity and the related behavioral factors of physical inactivity and poor nutrition. Chapters examine the effects of food policies including iron fortification of foods, psychological theory testing to improve health, gender differences, the effect of stress on obesity and strategies to prevent childhood obesity and reach rural communities. In the second section, the chapters explore the effects of addictive behaviors. Issues around alcohol use, drugs and gambling are explored both in comprehensive reviews and in county level analyses. The third section examines a variety of different approaches and methods to changing health behaviors. These include evidence-based public health, community-based participatory research, empowerment, communication and dialog and even nature therapy.  Reviews of important but often neglected public health

areas such as gun violence, skin care for all and asthma are also presented.

This book exemplifies the global nature of public health. All six inhabited continents are represented by authors in this book. The home country of the authors include Australia, Estonia, South Africa, Nigeria, Brazil, Canada, Korea, Finland, Japan, Great Britain, Ireland, USA, Belgium, Sweden and Italy. This trans-national list of authors provides an important view of the future of public health and the increased need to

## Preface

Human health is greatly influenced by the daily behaviors and patterns that make up our lives.  Over the last couple of decades, the role of the social sciences in influencing and changing human behaviors has become more prominent. Psychology, sociology, political science, economics, anthropology, communications and political science have all played an important role in health counseling, group based interventions, social marketing and policy change. A student being trained in a Master's of Public Health program in Health Promotion needs to be versed in all of these areas to be effective at changes population level behaviors.

This book provides an overview of the influence of the social and behavioral sciences to many public health issues that confront us today. In the first section, the chapters explore the growing problem of obesity and the related behavioral factors of physical inactivity and poor nutrition. Chapters examine the effects of food policies including iron fortification of foods, psychological theory testing to improve health, gender differences, the effect of stress on obesity and strategies to prevent childhood obesity and reach rural communities. In the second section, the chapters explore the effects of addictive behaviors. Issues around alcohol use, drugs and gambling are explored both in comprehensive reviews and in county level analyses. The third section examines a variety of different approaches and methods to changing health behaviors. These include evidence-based public health, community-based participatory research, empowerment, communication and dialog and even nature therapy.  Reviews of important but often neglected public health areas such as gun violence, skin care for all and asthma are also presented.

This book exemplifies the global nature of public health. All six inhabited continents are represented by authors in this book. The home country of the authors include Australia, Estonia, South Africa, Nigeria, Brazil, Canada, Korea, Finland, Japan, Great Britain, Ireland, USA, Belgium, Sweden and Italy. This trans-national list of authors provides an important view of the future of public health and the increased need to

#### XIV Preface

collaborate with public health professionals across the world to address the myriad of public health issues. I hope you enjoy reading the following chapters. I find them to be insightful and to provide an excellent collection of the ways that the social and behavioral health sciences are being used to protect and promote the public's health. Aloha.

> **Prof. Jay Maddock**  Department of Public Health Sciences, University of Hawai'i at Mānoa USA

**Section 1**

**Obesity, Food and Physical Activity**

## **Section 1**

**Obesity, Food and Physical Activity**

X Preface

Aloha.

collaborate with public health professionals across the world to address the myriad of public health issues. I hope you enjoy reading the following chapters. I find them to be insightful and to provide an excellent collection of the ways that the social and behavioral health sciences are being used to protect and promote the public's health.

**Prof. Jay Maddock**

USA

Department of Public Health Sciences,

University of Hawai'i at Mānoa

**1**

**The IDEFICS Intervention**

*1Ghent University, Ghent,*

*1,3Belgium 2Sweden 4,5Germany*

*4University of Bremen, Bremen,*

**Toolbox – A Guide to Successful**

Vera Verbestel1, Stefaan De Henauw1, Staffan Marild2,

*2Department of Public Health and Community Medicine, Gothenburg,*

*3European Food Information Council (EUFIC), Brussels,*

*5Hochschule Coburg, University of Applied Sciences, Coburg,*

**Obesity Prevention at Community Level**

Stefan Storcksdieck genannt Bonsmann3, Laura Fernández Celemín3, Katharina Gallois4, Holger Hassel4,5 and Ilse De Bourdeaudhuij1

The chapter provides an overview of the IDEFICS (Identification and prevention of Dietaryand lifestyle-induced health EFfects In Children and infantS) intervention and its general content and structure, including the core set of intervention modules, communication strategies and corresponding standard operating procedures for use in preschools, primary

The chapter does not present information on the development of the IDEFICS intervention but aims to provide practical guidance and recommendations for local policy makers and/or local public health authorities who wish to implement the intervention in their cities or communities. Every authority or institution wishing to implement the intervention will have to adapt all the intervention modules to account for local and/or culture-specific constraints. This can be done on the basis of qualitative research or equally valid sources of relevant information. General aspects of the IDEFICS project and the development of the IDEFICS community-oriented intervention programme have been described in detail elsewhere (Ahrens et al., 2006; Ahrens et al., 2011; De Henauw et al., 2011; Pigeot et al., 2010;

The timeline of the IDEFICS intervention is divided into three parts, referring to the classical phasing of establishing interventions (see Table 1): intervention adoption phase,

schools and other settings and dissemination channels.

**1.1 Timing of the IDEFICS intervention activities**

**1. Introduction**

Verbestel et al., 2011).

## **The IDEFICS Intervention Toolbox – A Guide to Successful Obesity Prevention at Community Level**

Vera Verbestel1, Stefaan De Henauw1, Staffan Marild2, Stefan Storcksdieck genannt Bonsmann3, Laura Fernández Celemín3, Katharina Gallois4, Holger Hassel4,5 and Ilse De Bourdeaudhuij1 *1Ghent University, Ghent, 2Department of Public Health and Community Medicine, Gothenburg, 3European Food Information Council (EUFIC), Brussels, 4University of Bremen, Bremen, 5Hochschule Coburg, University of Applied Sciences, Coburg, 1,3Belgium 2Sweden 4,5Germany*

## **1. Introduction**

The chapter provides an overview of the IDEFICS (Identification and prevention of Dietaryand lifestyle-induced health EFfects In Children and infantS) intervention and its general content and structure, including the core set of intervention modules, communication strategies and corresponding standard operating procedures for use in preschools, primary schools and other settings and dissemination channels.

The chapter does not present information on the development of the IDEFICS intervention but aims to provide practical guidance and recommendations for local policy makers and/or local public health authorities who wish to implement the intervention in their cities or communities. Every authority or institution wishing to implement the intervention will have to adapt all the intervention modules to account for local and/or culture-specific constraints. This can be done on the basis of qualitative research or equally valid sources of relevant information. General aspects of the IDEFICS project and the development of the IDEFICS community-oriented intervention programme have been described in detail elsewhere (Ahrens et al., 2006; Ahrens et al., 2011; De Henauw et al., 2011; Pigeot et al., 2010; Verbestel et al., 2011).

#### **1.1 Timing of the IDEFICS intervention activities**

The timeline of the IDEFICS intervention is divided into three parts, referring to the classical phasing of establishing interventions (see Table 1): intervention adoption phase,

The IDEFICS Intervention Toolbox –

local intervention team.

(Davison & Birch, 2001).

stores)

kindergarten and the community level

**1.2 Dimensions of the IDEFICS intervention**

A Guide to Successful Obesity Prevention at Community Level 5

This phase covers the period from September to August of Year 3 and starts right after the adoption phase (Year 2). During this period, the intervention will be sustained and further progressed by the community, schools and families themselves without continuous material

This period starts in September of the school year after the implementation phase (Year 3) and aims at continuing the IDEFICS intervention without support and supervision of the

The development of the child has to be viewed from an interactive and contextual perspective. The ecological environment of a child includes the family and the school which are in turn situated in the community and the society at large. Interactions within and among these social contexts result in changes within, and influence the development of, the individual child

> - Residents' associations - Organisations targeting persons with low socioeconomic status - Social services and welfare

doctor, …)

Fig. 1. Dimensions of the IDEFICS intervention: the individual, the family, the school and

sector

media

support from the local intervention team, but still with some degree of supervision.

**Third intervention period = Dissemination phase (Year 4 and onwards)**

**Second intervention period = Implementation phase (Year 3)**

intervention implementation phase and intervention dissemination phase. The intervention adoption phase was proceeded by a one-year preparation phase.

#### **Intervention preparation phase (Year 1)**

The implementation of a culturally adapted version of the IDEFICS intervention needs to be planned in advance. Therefore, local authorities or institutions aiming to implement the intervention, are recommended to consider a preparation phase of at least one year. During this period, necessary arrangements can be made for the start of the adoption phase.

One of the most important arrangements that needs to be made during the preparation phase is to build a local intervention team. A local intervention team is a group of people that is preferably composed by the local authority or institution that aims to implement the intervention. It should consist of local experts in the field of health promotion and/or representatives of the respective authority or institution. The local intervention team needs to be able to prepare the adoption phase of the intervention and to support and supervise the implementation of the intervention during the first year. This support and supervision will gradually decrease so that local structures (community, family and schools) can independently continue the health-promoting efforts initiated by the intervention. The role of the local intervention team throughout the phases of the intervention is described in more detail below.

#### **First intervention period = Adoption phase (Year 2)**

Assuming that a school year starts in September, this phase should cover the period from September to August of Year 2 and starts right after the preparation phase (Year 1). During this period, the intervention will be launched and installed in the community, family and schools. This period is characterised by the continuous provision of material and logistic input, support and supervision from the local intervention team.

Table 1. Timeline of the IDEFICS intervention activities

intervention implementation phase and intervention dissemination phase. The intervention

The implementation of a culturally adapted version of the IDEFICS intervention needs to be planned in advance. Therefore, local authorities or institutions aiming to implement the intervention, are recommended to consider a preparation phase of at least one year. During

One of the most important arrangements that needs to be made during the preparation phase is to build a local intervention team. A local intervention team is a group of people that is preferably composed by the local authority or institution that aims to implement the intervention. It should consist of local experts in the field of health promotion and/or representatives of the respective authority or institution. The local intervention team needs to be able to prepare the adoption phase of the intervention and to support and supervise the implementation of the intervention during the first year. This support and supervision will gradually decrease so that local structures (community, family and schools) can independently continue the health-promoting efforts initiated by the intervention. The role of the local intervention team throughout the phases of the intervention is described in more

Assuming that a school year starts in September, this phase should cover the period from September to August of Year 2 and starts right after the preparation phase (Year 1). During this period, the intervention will be launched and installed in the community, family and schools. This period is characterised by the continuous provision of material and logistic

Year 1 Year 2 Year 3 Year 4 and

Intervention implementation phase (only supervision)

Intervention adoption phase (support and supervision)

onwards

Intervention dissemination phase (no support, no supervision)

this period, necessary arrangements can be made for the start of the adoption phase.

adoption phase was proceeded by a one-year preparation phase.

**Intervention preparation phase (Year 1)**

**First intervention period = Adoption phase (Year 2)**

Preparation phase

Table 1. Timeline of the IDEFICS intervention activities

input, support and supervision from the local intervention team.

detail below.

Sep

Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug

#### **Second intervention period = Implementation phase (Year 3)**

This phase covers the period from September to August of Year 3 and starts right after the adoption phase (Year 2). During this period, the intervention will be sustained and further progressed by the community, schools and families themselves without continuous material support from the local intervention team, but still with some degree of supervision.

#### **Third intervention period = Dissemination phase (Year 4 and onwards)**

This period starts in September of the school year after the implementation phase (Year 3) and aims at continuing the IDEFICS intervention without support and supervision of the local intervention team.

## **1.2 Dimensions of the IDEFICS intervention**

The development of the child has to be viewed from an interactive and contextual perspective. The ecological environment of a child includes the family and the school which are in turn situated in the community and the society at large. Interactions within and among these social contexts result in changes within, and influence the development of, the individual child (Davison & Birch, 2001).

Fig. 1. Dimensions of the IDEFICS intervention: the individual, the family, the school and kindergarten and the community level

The IDEFICS Intervention Toolbox –

**DIET**

**PHYSICAL ACTIVITY**

**STRESS, COPING AND RELAXATION**

A Guide to Successful Obesity Prevention at Community Level 7

Module 4 Module 8 Module 9

Module 4 Module 6 Module 7

Module 1 Module 2 Module 3

Module 1 Module 2 Module 3

Module 1 Module 2 Module 3

Module 2: Long-term media campaign and public relations strategy

Module 3: Lobbying for community environmental and policy interventions

Module 6: Environmental changes related to physical activity – The Active Playground

Module 8: Environmental changes and school policy related to water consumption Module 9: Environmental changes and school policy related to fruit and vegetables

Table 3. Overview of the IDEFICS modules by behavioural focus and intervention level

All the community partners will be engaged in the intervention by means of a community platform, i.e. a working group on meta (community) level in which all relevant stakeholders need to be represented. The local intervention team is an essential leading actor in the implementation of this module as it is responsible for triggering and coordinating the establishment and the operation of the community platform. This means that the implementation quality of this intervention module strongly depends on the leadership

changes that encourage the healthy behaviours targeted in the intervention.

increasing independence of the stakeholders in the community.

Module 1: Involvement of community partners

Module 7: Health-related physical education curricula

**2. IDEFICS intervention modules at community level**

**2.1 Module 1: Involvement of community partners**

Module 4: Building partnerships Module 5: Education of children

Module 10: Education of parents

capacity of the local intervention team.

**Objectives**

**COMMUNITY SCHOOL FAMILY INDIVIDUAL**

Module 10 Module 5

Module 10 Module 5

Module 4 Module 10 Module 5

The community-based IDEFICS intervention takes a holistic approach associated with this contextual and interactive perspective of human development and is being executed on three intertwining levels: community level, school level and family level (Figure 1). Possible stakeholders in the community that can have an impact on the prevention of obesity are illustrated. The local intervention team has to analyse its own intervention community and identify the key persons and stakeholders.

## **1.3 Behaviours targeted by the IDEFICS intervention**

The behaviours that were targeted by the IDEFICS intervention can be found in Table 2. From this point onwards, these target behaviours will be called the "key messages".

The selection of these key messages was based on the available evidence in the scientific literature. Detailed information on this selection process is outside the scope of this chapter and can be found elsewhere (Verbestel et al., 2011). Due to the complex nature of the problem, there is also scientific evidence available showing additional behaviours having an influence on the development of childhood obesity (e.g. portion sizes and snacking). This means that multi-topic interventions for the prevention of childhood obesity do not necessarily have to focus on the below mentioned key messages. Other behaviours can be chosen as the focus of the intervention, as long as they are supported by scientific evidence in the childhood obesity preventive literature.

Table 2. The six key messages targeted by the IDEFICS intervention

#### **1.4 Overview of the IDEFICS intervention modules**

The identification and elaboration of the IDEFICS intervention modules was predominantly carried out during the first year of the project on the basis of literature reviews, expert consultations and focus group research (Verbestel et al., 2011). The modules have been developed as distinct sets of activities but it should be realised that some of these modules are partly overlapping and/or interacting with one another. Table 3 illustrates how different modules have been conceived within a grid of targeted behaviours and intervention levels. Some modules have a more general scope whereas others are much more specific and focusing on a particular intervention level or behavioural dimension. The general content and structure supplemented with a description of the core actions for all the IDEFICS intervention modules is provided in the sections below.

The community-based IDEFICS intervention takes a holistic approach associated with this contextual and interactive perspective of human development and is being executed on three intertwining levels: community level, school level and family level (Figure 1). Possible stakeholders in the community that can have an impact on the prevention of obesity are illustrated. The local intervention team has to analyse its own intervention community and

The behaviours that were targeted by the IDEFICS intervention can be found in Table 2.

The selection of these key messages was based on the available evidence in the scientific literature. Detailed information on this selection process is outside the scope of this chapter and can be found elsewhere (Verbestel et al., 2011). Due to the complex nature of the problem, there is also scientific evidence available showing additional behaviours having an influence on the development of childhood obesity (e.g. portion sizes and snacking). This means that multi-topic interventions for the prevention of childhood obesity do not necessarily have to focus on the below mentioned key messages. Other behaviours can be chosen as the focus of the intervention, as long as they are supported by scientific evidence

Diet Physical activity Stress, coping and

consumption of water Reduce TV-viewing Spend more time together

Stimulate daily physical activity

The identification and elaboration of the IDEFICS intervention modules was predominantly carried out during the first year of the project on the basis of literature reviews, expert consultations and focus group research (Verbestel et al., 2011). The modules have been developed as distinct sets of activities but it should be realised that some of these modules are partly overlapping and/or interacting with one another. Table 3 illustrates how different modules have been conceived within a grid of targeted behaviours and intervention levels. Some modules have a more general scope whereas others are much more specific and focusing on a particular intervention level or behavioural dimension. The general content and structure supplemented with a description of the core actions for all the IDEFICS

Table 2. The six key messages targeted by the IDEFICS intervention

**1.4 Overview of the IDEFICS intervention modules**

intervention modules is provided in the sections below.

relaxation

Ensure adequate sleep duration

From this point onwards, these target behaviours will be called the "key messages".

identify the key persons and stakeholders.

in the childhood obesity preventive literature.

Stimulate daily

Stimulate daily consumption of fruit and vegetables

**1.3 Behaviours targeted by the IDEFICS intervention**

Module 1: Involvement of community partners

Module 2: Long-term media campaign and public relations strategy

Module 3: Lobbying for community environmental and policy interventions

Module 4: Building partnerships

Module 5: Education of children

Module 6: Environmental changes related to physical activity – The Active Playground

Module 7: Health-related physical education curricula

Module 8: Environmental changes and school policy related to water consumption

Module 9: Environmental changes and school policy related to fruit and vegetables

Module 10: Education of parents

Table 3. Overview of the IDEFICS modules by behavioural focus and intervention level

## **2. IDEFICS intervention modules at community level**

## **2.1 Module 1: Involvement of community partners**

All the community partners will be engaged in the intervention by means of a community platform, i.e. a working group on meta (community) level in which all relevant stakeholders need to be represented. The local intervention team is an essential leading actor in the implementation of this module as it is responsible for triggering and coordinating the establishment and the operation of the community platform. This means that the implementation quality of this intervention module strongly depends on the leadership capacity of the local intervention team.

#### **Objectives**

The IDEFICS Intervention Toolbox –

for chairing the platform the year afterwards.

**Guidelines for the meetings of the community platform**

different sectors involved in the platform.

implementation process of the intervention.

successful but also address any challenges or failures.

still have to be performed.

the prevention of childhood obesity.

responsible for coordinating the community platform.

community platform members.

following actions are recommended:

beginning of Year 3 (see Table 3).

**(Year 3)**

intervention team.

intervention team.

A Guide to Successful Obesity Prevention at Community Level 9

• make an inventory of the local initiatives related to the prevention of obesity in the

• always write a meeting report, as these reports can be used to analyse the

• evaluate the aspects of the intervention modules that have been executed and provide strong support for the implementation of the (parts of the) modules that

• do not only discuss and evaluate the aspects of the intervention that have been

• continuously observe and detect what is going on inside the community related to

• do not ignore but take notice of new initiatives that are proposed by the

The second part of the adoption phase (July – August, year 2) is the transition period between the intervention adoption phase and the intervention implementation phase. This transition period is an intermediate stage between the intensively supported operation and the supervised operation of the community platform. During the transition period,

The community platform is expected to continue with the activities and to work out new initiatives with minimal supervision and without continuous support of the local

From September of Year 3 onwards, the local intervention team no longer participates in the monthly meetings of the community platform. Starting from this moment, the local coordinator (of the community platform) has to be able to take over the role of the local

**Operation of the community platform during the intervention implementation phase**

## **Establishment and composition of the community platform**

## **Task and responsibilities of the community platform**

The community platform is responsible for the development and implementation of all the intervention modules at community level, i.e.:

Within this section, the tasks and responsibilities of the community platform are briefly outlined. More detailed and concrete descriptions can be found in the relevant module sections.

Because of the ecological perspective associated with the IDEFICS intervention, interactions within and among the different contexts in the community - as illustrated in Figure 1 above are essential. The community platform is therefore expected to support the implementation of modules at other levels:

The community platform will not be responsible for the intervention modules at the school level. The implementation of these modules will be organised by a working group at the school level (see module 4). Regarding module 5 and 10, the community platform will mainly provide logistic and reinforcing support (e.g. the provision of posters to the school working group). This support is explained in more detail within the appropriate module sections.

#### **Operation of the community platform during the intervention adoption phase (Year 2)**

The first part of the adoption phase (September – June, Year 2) is dedicated to building the infrastructure for implementing the intervention modules:

#### **Guidelines for the meetings of the community platform**

8 Public Health – Social and Behavioral Health

The community platform is responsible for the development and implementation of all the

Within this section, the tasks and responsibilities of the community platform are briefly outlined. More detailed and concrete descriptions can be found in the relevant module

Because of the ecological perspective associated with the IDEFICS intervention, interactions within and among the different contexts in the community - as illustrated in Figure 1 above are essential. The community platform is therefore expected to support the implementation

The community platform will not be responsible for the intervention modules at the school level. The implementation of these modules will be organised by a working group at the school level (see module 4). Regarding module 5 and 10, the community platform will mainly provide logistic and reinforcing support (e.g. the provision of posters to the school working group). This support is explained in more detail within the appropriate module

**Operation of the community platform during the intervention adoption phase (Year 2)**  The first part of the adoption phase (September – June, Year 2) is dedicated to building the

about the modules that have to be implemented in the community.

**Establishment and composition of the community platform**

significantly to the prevention of (childhood) obesity.

**Task and responsibilities of the community platform**

intervention modules at community level, i.e.:

infrastructure for implementing the intervention modules:

implement the community-level modules.

intervention team.

sections.

sections.

of modules at other levels:

a larger intervention region).

IDEFICS platform within the existing one.

	- always write a meeting report, as these reports can be used to analyse the implementation process of the intervention.
	- evaluate the aspects of the intervention modules that have been executed and provide strong support for the implementation of the (parts of the) modules that still have to be performed.
	- do not only discuss and evaluate the aspects of the intervention that have been successful but also address any challenges or failures.
	- continuously observe and detect what is going on inside the community related to the prevention of childhood obesity.
	- do not ignore but take notice of new initiatives that are proposed by the community platform members.

The second part of the adoption phase (July – August, year 2) is the transition period between the intervention adoption phase and the intervention implementation phase. This transition period is an intermediate stage between the intensively supported operation and the supervised operation of the community platform. During the transition period, following actions are recommended:

#### **Operation of the community platform during the intervention implementation phase (Year 3)**

The community platform is expected to continue with the activities and to work out new initiatives with minimal supervision and without continuous support of the local intervention team.

From September of Year 3 onwards, the local intervention team no longer participates in the monthly meetings of the community platform. Starting from this moment, the local coordinator (of the community platform) has to be able to take over the role of the local intervention team.

The IDEFICS Intervention Toolbox –

attractive slogan.

reputation to be very effective.

poster) and 1 poster about sleep duration.

Minimum A3-format

up the poster)

…

Window (and street) poster related to physical activity and diet (1st poster)

Year 2 of the IDEFICS project are shown in Table 5.

(maximum 50 - 70 cm, however, this size can already be a barrier to hang

Very suitable to hang up in public places, supermarkets and grocery stores, libraries, houses of residents,

Table 4. Recommended characteristics of the window and street posters

should be a bigger copy of the window posters.

below.

**Dimensions of the poster**

**Preferred places**

project

street posters:

A Guide to Successful Obesity Prevention at Community Level 11

• The local intervention team is recommended to develop 3 posters: 2 posters about physical activity and diet (one key message of each theme combined on each

• The window and street posters should reflect the same message. The street poster

• The posters should be simple and attractive: the message should be readable and understandable in a couple of seconds and the text should be a short, striking and

• Multi-colour printing is very expensive and may distract the attention of the message. Black and white printing is much cheaper and more clearly visible. A message in black and white printing (can be printed on coloured paper) has the

**Window posters Street posters**

**Target groups** Pedestrians, cyclists and car drivers Pedestrians, cyclists and car

Because the visibility of the window and street posters will be synchronised with the integration of the key messages in the school curriculum (see module 5), the turnover of the posters is recommended to be set at 4 months for physical activity and diet and at 3 months for stress, coping and relaxation. The timing and turnover of the window posters during

**Intervention adoption phase (Year 2)**

Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug

Table 5. Timing and turnover of the window (and street posters) in Year 2 of the IDEFICS

Window (and street) poster related to physical activity and diet (2nd poster)

Minimum 50 – 70 cm

On the street site, preferably on places where a lot of people have to stop (e.g. traffic lights)

> Window (and street) poster related to sleep duration (3rd poster)

drivers

The local intervention team must keep itself informed about the initiatives of the community platform. For this reason, the local intervention team and the community platform are recommended to meet 3 times during the intervention implementation phase, i.e. once between September and December of Year 3 and twice between January and August of Year 3.

Between the obligatory meetings, the community platform should have the possibility to keep in touch with the local intervention team in order to solve practical problems or get advice if necessary.

#### **Operation of the community platform during the intervention dissemination phase (Year 4 onwards)**

From year 4 onwards, the community platform is expected to operate completely independently, without any support or supervision from the local intervention team.

## **2.2 Module 2: Long-term media campaign and public relations strategy**

A first topic in the long-term media campaign and public relations strategy is the overall approach by which the intervention will become well known and the key messages will be spread in the community. A second issue in module 2 is the specific promotion campaign for the key messages by means of a slogan intervention.

## **2.2.1 Multimedia and public relations campaign (overall strategy)**

#### **Objectives**

The local intervention team can develop its own public relations strategy and timing, depending on the local needs and resources. Some examples of multimedia and public relation instruments that can be useful to fulfil the objectives of the overall strategy are leaflets (newsletters), information events, posters and a website in the local language. It is also recommended to not only rely on contacts and infrastructure of universities or health institutions but to establish own local media relations by developing for example a media kit (including press kit, contact list, media server) and/or organise media briefings (e.g. local kick-off event in September of Year 2).

#### **2.2.2 Promotion campaign for the key messages (slogan intervention)**

#### **Objectives**

#### **Window and street posters as a promotion campaign for the key messages**

Window and street posters can be used to promote the key messages within the community:

The local intervention team must keep itself informed about the initiatives of the community platform. For this reason, the local intervention team and the community platform are recommended to meet 3 times during the intervention implementation phase, i.e. once between September and December of Year 3 and twice between January and August of Year

Between the obligatory meetings, the community platform should have the possibility to keep in touch with the local intervention team in order to solve practical problems or get

**Operation of the community platform during the intervention dissemination phase (Year**

From year 4 onwards, the community platform is expected to operate completely

A first topic in the long-term media campaign and public relations strategy is the overall approach by which the intervention will become well known and the key messages will be spread in the community. A second issue in module 2 is the specific promotion campaign

The local intervention team can develop its own public relations strategy and timing, depending on the local needs and resources. Some examples of multimedia and public relation instruments that can be useful to fulfil the objectives of the overall strategy are leaflets (newsletters), information events, posters and a website in the local language. It is also recommended to not only rely on contacts and infrastructure of universities or health institutions but to establish own local media relations by developing for example a media kit (including press kit, contact list, media server) and/or organise media briefings (e.g. local

independently, without any support or supervision from the local intervention team.

**2.2 Module 2: Long-term media campaign and public relations strategy**

**2.2.1 Multimedia and public relations campaign (overall strategy)**

**2.2.2 Promotion campaign for the key messages (slogan intervention)**

Window and street posters can be used to promote the key messages within the community:

for the key messages by means of a slogan intervention.

3.

advice if necessary.

**4 onwards)**

**Objectives**

**Objectives**

intervention team.

kick-off event in September of Year 2).

	- The local intervention team is recommended to develop 3 posters: 2 posters about physical activity and diet (one key message of each theme combined on each poster) and 1 poster about sleep duration.
	- The window and street posters should reflect the same message. The street poster should be a bigger copy of the window posters.
	- The posters should be simple and attractive: the message should be readable and understandable in a couple of seconds and the text should be a short, striking and attractive slogan.
	- Multi-colour printing is very expensive and may distract the attention of the message. Black and white printing is much cheaper and more clearly visible. A message in black and white printing (can be printed on coloured paper) has the reputation to be very effective.

Table 4. Recommended characteristics of the window and street posters

Because the visibility of the window and street posters will be synchronised with the integration of the key messages in the school curriculum (see module 5), the turnover of the posters is recommended to be set at 4 months for physical activity and diet and at 3 months for stress, coping and relaxation. The timing and turnover of the window posters during Year 2 of the IDEFICS project are shown in Table 5.

Table 5. Timing and turnover of the window (and street posters) in Year 2 of the IDEFICS project

The IDEFICS Intervention Toolbox –

intervention adoption phase.

play outdoors). **Concept of play streets**

easy way to remedy this situation.

**Objective**

time).

used.

A Guide to Successful Obesity Prevention at Community Level 13

The community environmental interventions to promote physical activity and the consumption of water are strongly recommended to be put on the agenda of the community

The short-term perspective of community-based prevention of childhood obesity requires efforts of the community platform to undertake actions/activities that contribute to the

The long-term perspective of the intervention aims at triggering new initiatives during the intervention adoption phase. Therefore, the community platform should start to advocate for environmental and policy interventions as soon as possible but the implementation of these interventions is not intended to be accomplished in the

Because the time children spend outdoors is positively correlated with higher physical activity levels in children (Ferreira et al., 2007), it is important that all children in the community at least have the possibility to be active outside. Community playgrounds are very important and the most favourable way to promote playing outside among young children. However, the establishment of community playgrounds is not possible everywhere. In such cases, play streets can provide children with safe opportunities to be active outside the home and attract children to different recreational activities. Play streets are spaces within neighbourhoods where road space is made available for children's play on weekend days and/or holidays (streets are closed for traffic during that

The organisation of play streets is mostly focused on specific areas in the community with few options for leisure activities and/or opportunities to spend active time outdoor. It is supposed that families with a low(er) socio-economic status live in neighbourhoods with busy streets and no gardens, thus lack safe structures to play outside. Play streets are an

The local intervention team has to identify if the concept of play streets already exists in the

community. In some countries, the concept of play streets is already well known.

**2.3.1 Community environmental interventions to promote physical activity:**

platform and should be implemented during the adoption phase.

**establishment of 'play streets' and community playgrounds**

**Identification of the concept of play street in the community**

strong cooperation with the local municipalities.

prevention of obesity within the adoption phase.

The window posters that were used in the IDEFICS intervention, are displayed below. These posters are available in the languages of those countries where the IDEFICS intervention was tested for its effectiveness (Belgium, Cyprus, Estonia, Germany, Hungary, Italy, Spain and Sweden).

#### **Tasks and responsibilities of the community platform**

## **2.3 Module 3: Lobbying for community environmental and policy interventions**

Module 3 requires the community platform to lobby for improving the community environment and for policy interventions to prevent obesity in the community. This task consists of four separated parts:

The community environmental interventions to promote physical activity and the consumption of water are strongly recommended to be put on the agenda of the community platform and should be implemented during the adoption phase.

The short-term perspective of community-based prevention of childhood obesity requires efforts of the community platform to undertake actions/activities that contribute to the prevention of obesity within the adoption phase.

The long-term perspective of the intervention aims at triggering new initiatives during the intervention adoption phase. Therefore, the community platform should start to advocate for environmental and policy interventions as soon as possible but the implementation of these interventions is not intended to be accomplished in the intervention adoption phase.

#### **2.3.1 Community environmental interventions to promote physical activity: establishment of 'play streets' and community playgrounds**

### **Objective**

12 Public Health – Social and Behavioral Health

The window posters that were used in the IDEFICS intervention, are displayed below. These posters are available in the languages of those countries where the IDEFICS intervention was tested for its effectiveness (Belgium, Cyprus, Estonia, Germany, Hungary, Italy, Spain

**2.3 Module 3: Lobbying for community environmental and policy interventions**

2. Community environmental interventions to promote the consumption of water

1. Community environmental interventions to promote physical activity

3. A short-term perspective of community-based prevention of obesity 4. A long-term perspective of community-based prevention of obesity

Module 3 requires the community platform to lobby for improving the community environment and for policy interventions to prevent obesity in the community. This task

**Tasks and responsibilities of the community platform**

received the window posters in time.

this module).

consists of four separated parts:

and Sweden).

#### **Concept of play streets**

Because the time children spend outdoors is positively correlated with higher physical activity levels in children (Ferreira et al., 2007), it is important that all children in the community at least have the possibility to be active outside. Community playgrounds are very important and the most favourable way to promote playing outside among young children. However, the establishment of community playgrounds is not possible everywhere. In such cases, play streets can provide children with safe opportunities to be active outside the home and attract children to different recreational activities. Play streets are spaces within neighbourhoods where road space is made available for children's play on weekend days and/or holidays (streets are closed for traffic during that time).

The organisation of play streets is mostly focused on specific areas in the community with few options for leisure activities and/or opportunities to spend active time outdoor. It is supposed that families with a low(er) socio-economic status live in neighbourhoods with busy streets and no gardens, thus lack safe structures to play outside. Play streets are an easy way to remedy this situation.

#### **Identification of the concept of play street in the community**

The local intervention team has to identify if the concept of play streets already exists in the community. In some countries, the concept of play streets is already well known.

The IDEFICS Intervention Toolbox –

**Stakeholder Possible actions**

of political parties).

nutrition labelling.

pieces of apple, …).

facilities outside the school hours. - Organise active after-school programmes.

certain season.

community.

healthy snacks.

(family events).

**Local**

**municipality (public health authorities) and local politicians**

**Private sector**

**(food companies, grocery stores)**

**Working groups of the schools/kinder-**

**gartens**

**Sport and youth organisations**

**Health care providers**

childhood obesity

A Guide to Successful Obesity Prevention at Community Level 15

provide free water during working hours.

vegetables as a snack during working hours.

stress, coping and relaxation as part of health care.

physical activity, diet, stress, coping and relaxation.

Table 6. List of possible actions that can be undertaken by the stakeholders of the community as part of the short-term perspective of community-based prevention of

initiatives and trigger their execution by working with the relevant actors.

**2.3.4 Long-term perspective of community-based prevention of childhood obesity**  In addition to the short-term perspective, the IDEFICS intervention also considers a longterm perspective in the prevention of childhood obesity. The start of the intervention is the best moment to start this process. The community platform should advocate for environmental and policy interventions that contribute to the prevention of childhood obesity. Based on the examples provided by Crawford & Jeffery (2005), Table 7 provides a list of possible initiatives that can be accomplished within the long term. These initiatives are linked to three different actors in the community which potentially have the ability to execute these proposals. The community platform should decide on the number of

## **Identification of the community areas "at risk"**

The community platform has to identify the areas in the community where children have no or not enough opportunities to spend time outdoors. This can be done by identifying the number of community playgrounds, their location and condition (in areas where children have enough opportunities for outdoor activity) and by identifying the areas in the community where play streets need to be established (in areas with no or not enough places for outdoor activity).

#### **Guidelines for the establishment of the play streets or safe playgrounds in the selected areas**

#### **2.3.2 Community environmental interventions to promote the consumption of water: installation of water fountains in public places**

### **Objective**

### **Tasks and responsibilities of the community platform**

## **2.3.3 Short-term perspective of community-based prevention of childhood obesity**

Every stakeholder represented in the community platform should try to undertake activities related to the prevention of obesity during the intervention adoption phase. Table 6 is a nonexhaustive list of possibilities that can be pursued by the stakeholders of the community. It is recommended that the stakeholders make efforts to realise some of these or similar initiatives.

The community platform has to identify the areas in the community where children have no or not enough opportunities to spend time outdoors. This can be done by identifying the number of community playgrounds, their location and condition (in areas where children have enough opportunities for outdoor activity) and by identifying the areas in the community where play streets need to be established (in areas with no or not enough places

**Guidelines for the establishment of the play streets or safe playgrounds in the selected**

**2.3.2 Community environmental interventions to promote the consumption of water:**

**2.3.3 Short-term perspective of community-based prevention of childhood obesity**  Every stakeholder represented in the community platform should try to undertake activities related to the prevention of obesity during the intervention adoption phase. Table 6 is a nonexhaustive list of possibilities that can be pursued by the stakeholders of the community. It is recommended that the stakeholders make efforts to realise some of these or similar

**Identification of the community areas "at risk"**

for outdoor activity).

residents of the street.

community playgrounds.

**installation of water fountains in public places**

**Tasks and responsibilities of the community platform**

fountains in public places in the community.

**areas**

**Objective**

initiatives.

places.

Table 6. List of possible actions that can be undertaken by the stakeholders of the community as part of the short-term perspective of community-based prevention of childhood obesity

#### **2.3.4 Long-term perspective of community-based prevention of childhood obesity**

In addition to the short-term perspective, the IDEFICS intervention also considers a longterm perspective in the prevention of childhood obesity. The start of the intervention is the best moment to start this process. The community platform should advocate for environmental and policy interventions that contribute to the prevention of childhood obesity. Based on the examples provided by Crawford & Jeffery (2005), Table 7 provides a list of possible initiatives that can be accomplished within the long term. These initiatives are linked to three different actors in the community which potentially have the ability to execute these proposals. The community platform should decide on the number of initiatives and trigger their execution by working with the relevant actors.

The IDEFICS Intervention Toolbox –

action:

and kindergartens.

basic principle of this module.

prevent childhood obesity.

**intervention Objectives**

individually.

**3.1 Module 4: Building partnerships**

2. Creation of a school working group

3. Creation of a school platform at community level

**Get in contact with the principals of the schools**

**Inform coordinating school organisations**

set up a school platform at community level.

A Guide to Successful Obesity Prevention at Community Level 17

Building partnerships in the participating schools and kindergartens contains three levels of

By means of the first part of module 4, the local intervention team will aim for teachers to take part in the intervention and to support the overall content of the project in the schools

The second part of module 4, the creation of a school working group, is intended to create involvement and commitment among staff members and to facilitate the implementation of the intervention. Good cooperation with all staff members in all participating schools is the

The creation of a school platform makes it possible to gather all school working groups. This third part of module 4 creates a structure in which the schools can exchange knowledge and experiences, share a collective opinion and together elaborate on and start new initiatives to

If several different schools are gathered in a coordinating school organisation, it is suggested to inform this organisation that the local intervention team will contact each of their schools

Make ample use of coordinating school organisations because they can play an important role in stimulating and supporting their schools during the implementation of the intervention. Additionally, they can be a starting point and negotiation partner in order to

**3.1.1 Alerting staff members of the schools and kindergartens to the IDEFICS**

in the school working group (explained in the second part of module 4).

**3. IDEFICS intervention modules at school and kindergarten level**

1. Alerting the staff members of the schools and kindergartens to the intervention

Table 7. Overview of possible initiatives for the long-term perspective of community-based prevention of childhood and adult obesity (Crawford & Jeffery, 2005)

## **3. IDEFICS intervention modules at school and kindergarten level**

## **3.1 Module 4: Building partnerships**

Building partnerships in the participating schools and kindergartens contains three levels of action:

By means of the first part of module 4, the local intervention team will aim for teachers to take part in the intervention and to support the overall content of the project in the schools and kindergartens.

The second part of module 4, the creation of a school working group, is intended to create involvement and commitment among staff members and to facilitate the implementation of the intervention. Good cooperation with all staff members in all participating schools is the basic principle of this module.

The creation of a school platform makes it possible to gather all school working groups. This third part of module 4 creates a structure in which the schools can exchange knowledge and experiences, share a collective opinion and together elaborate on and start new initiatives to prevent childhood obesity.

## **3.1.1 Alerting staff members of the schools and kindergartens to the IDEFICS intervention**

### **Objectives**

16 Public Health – Social and Behavioral Health

trails, and crosswalks that facilitate walking and cycling.

have access to physical activity and recreation facilities.

safely cross the streets on and from their way to school.

buses or bicycle trains, provide safe bicycle sheds).

Table 7. Overview of possible initiatives for the long-term perspective of community-based

(e.g. organise walk/bike to school days, organise walking school

important and busy intersections around the school so that children can

school environment and replace them with water and/or other healthy

children in a safe environment and at minimal cost.

This applies also to other sports infrastructures.

for children (e.g. include fruit as a dessert).

the use of sports and recreation facilities in the community.

needed to participate in such programmes.

(e.g. ice-skating, indoor swimming, …).

**Stakeholder Possible initiatives**

contribution.

environment.

healthy food.

options, or water dispensers.

prevention of childhood and adult obesity (Crawford & Jeffery, 2005)

industry-sponsored collaborations.

**Local**

**municipality (public health authorities) and local politicians**

**Private sector**

**(food companies, grocery stores)**

**Working groups of the schools and kindergartens**

### **Get in contact with the principals of the schools**

#### **Inform coordinating school organisations**

If several different schools are gathered in a coordinating school organisation, it is suggested to inform this organisation that the local intervention team will contact each of their schools individually.

Make ample use of coordinating school organisations because they can play an important role in stimulating and supporting their schools during the implementation of the intervention. Additionally, they can be a starting point and negotiation partner in order to set up a school platform at community level.

The IDEFICS Intervention Toolbox –

kindergartens.

**General recommendations**

group, try to cooperate with it.

socio-economic status)

**Appointment of a project leader in the school**

kindergarten.

recess

included)

principal of the school.

**groups**

A Guide to Successful Obesity Prevention at Community Level 19

The following strategy, guidelines and recommendations can be used to set up a school

• Teachers whose field of study is related to the content of the intervention

• Educator(s): persons who are responsible for supervision during free time and

• Representative(s) of staff members who have the ability to reach children at risk of developing excessive body fatness (especially those with obese parents and low(er)

After the meeting, all staff members of the school receive an information letter describing the aim and content of the intervention and the responsibilities of a person engaging in the school working group. This letter should be formulated by the local intervention team in cooperation with the school board. The letter has to make clear that staff members can also engage in the school working group as a co-worker. Co-workers are contact persons for the school working group which can be asked for the organisation or support of certain activities related to the intervention. Staff members who are motivated to participate in the school working group or as a co-worker can present themselves to the

The school working group is responsible for the implementation of the intervention. With the implementation and dissemination phase of the intervention in mind, it is advisable

**Inventory of motivated staff members who wish to participate in the school working**

that support the health behaviours advocated in the intervention.

**Establishment and composition of the school working group**

working group in every participating school/kindergarten.

intervention, power) should also be considered.

• Representative(s) of the parents' council

## **Organise a first appointment with the principals**

Table 8. Possible content of the introduction booklet that can be used during the first contacts with the schools

#### **Organise a meeting for all staff members of a participating school**

After having informed the school principals, it is important to alert the staff members of the schools or kindergartens. Therefore, the local coordinating team has to organise an information session for all employees of each school or kindergarten that will participate in the intervention. The following guidelines can be used for the organisation of this meeting:

## **3.1.2 Creation of a school working group**

#### **Objectives**

#### **Establishment and composition of the school working group**

The following strategy, guidelines and recommendations can be used to set up a school working group in every participating school/kindergarten.

#### **General recommendations**

18 Public Health – Social and Behavioral Health

school participates in the intervention. Table 8. Possible content of the introduction booklet that can be used during the first

After having informed the school principals, it is important to alert the staff members of the schools or kindergartens. Therefore, the local coordinating team has to organise an information session for all employees of each school or kindergarten that will participate in the intervention. The following guidelines can be used for the organisation of this meeting: - Organise the first meeting in April or May of Year 1 at the latest (assuming that the

which puts the project in a broader social context.

work out the intervention modules in their school.

Document which describes the aim and content of the project and

The manuals provide, for each module, the culturally adapted ideas which can be used by the school working groups in order to

A presentation based on the document which briefly outlines the intervention. This presentation can be used by the school to inform parents or a third party about the intervention.

An example of an article that can be used to include in the school newspaper. This article informs the parents about the fact that the

**Organise a first appointment with the principals**

**Documents Aim and content of the documents**

**Organise a meeting for all staff members of a participating school**

informed about the intervention.

still necessary).

Brief overview of the

Article for the school

contacts with the schools

working group).

**Objectives**

school year starts in September).

school board supports the project.

(aim, content, manual, guidelines).

**3.1.2 Creation of a school working group**

Manuals for each module prepared by the local intervention team

intervention

PowerPoint Presentation

newspaper

	- Representative(s) of the school board (most important link)
	- Teachers whose field of study is related to the content of the intervention
	- Educator(s): persons who are responsible for supervision during free time and recess
	- Representative(s) of the parents' council
	- Representative(s) of staff members who have the ability to reach children at risk of developing excessive body fatness (especially those with obese parents and low(er) socio-economic status)

## **Inventory of motivated staff members who wish to participate in the school working groups**

After the meeting, all staff members of the school receive an information letter describing the aim and content of the intervention and the responsibilities of a person engaging in the school working group. This letter should be formulated by the local intervention team in cooperation with the school board. The letter has to make clear that staff members can also engage in the school working group as a co-worker. Co-workers are contact persons for the school working group which can be asked for the organisation or support of certain activities related to the intervention. Staff members who are motivated to participate in the school working group or as a co-worker can present themselves to the principal of the school.

#### **Appointment of a project leader in the school**

The school working group is responsible for the implementation of the intervention. With the implementation and dissemination phase of the intervention in mind, it is advisable

The IDEFICS Intervention Toolbox –

the link to the community platform.

intervention.

school paper.

platform meetings.

implementation team.

working group members.

to preventing childhood obesity.

of the intervention.

A Guide to Successful Obesity Prevention at Community Level 21

cooperation with local intervention teams andother useful information for the implementation

**Operation of the school working group during the intervention adoption phase (Year 2)**  During the first part of the adoption phase (September – June Year 2), the implementation of

• Discuss and evaluate the aspects of the intervention modules that have been executed as well as the ones forthcoming. Highlight things that went well (to be repeated), but also challenges (to find solutions) and things that went wrong (to try to avoid them happening again in the future). Provide strong support to the

• Continuously monitor activities going on inside the school or kindergarten related

• Do not ignore but take notice of new initiatives that are proposed by the school

• Use the meeting as an opportunity to ensure the communication to all staff members of the school/kindergarten by publishing a newsletter or newsflash in the

The second part of the adoption phase (July – August, Year 2) is the transition period between the strongly supported and the supervised operation of the school working group.

During the transition period, the following actions are recommended:

his/her responsibilities with regard to the school working group.

the intervention modules will be strongly supported by the local intervention team:

about the modules that must be implemented in the schools/kindergartens.

organise internal meetings whenever needed without the local coordinator.

to discuss and solve practical problems that have occurred or are expected.

that someone, besides the local intervention team, takes the lead in the entire process. For this reason it is suggested to appoint a project leader in every participating school. It is up to the principal to decide who will be the project leader in the school.

Despite the fact that the school working group will be composed by the school project leader, the local intervention team is expected to stay in close contact with the school project leader in order to stimulate/support the organisation and composition of the school working group.

If the kindergarten and primary school are gathered in the same school and thus both belong to the same school board, it is recommended to set up two project leaders and two school working groups. This is necessary to be able to implement an intervention which is adapted to the different age groups that are part of the intervention.

#### **Tasks and responsibilities of the school working group**

The school working group will be responsible for the organisation of a cooking and activity competition in their own kindergarten or school and the implementation of all the intervention modules at school level. The school working group will therefore be responsible for the implementation of the following modules:

In the relevant modules, the task and responsibilities are explained in more detail.

## **3.1.3 Operation of the school working group**

After setting up the school working groups, it is essential that local intervention teams start to talk with the school working groups as soon as possible in order to make a final decision on how the different modules will be implemented in the school.

As soon as the school working groups are set up, they have to act as a team. It must be avoided that the school project leader has to work out the whole project. For this reason a guideline has to be developed which supports the school project leader to implement the intervention. This guideline will include a well-defined description of the tasks of the school project leader, members and co-workers of the school working group, time table and description of the

that someone, besides the local intervention team, takes the lead in the entire process. For this reason it is suggested to appoint a project leader in every participating school. It is up

Despite the fact that the school working group will be composed by the school project leader, the local intervention team is expected to stay in close contact with the school project leader in order to stimulate/support the organisation and composition of the school

If the kindergarten and primary school are gathered in the same school and thus both belong to the same school board, it is recommended to set up two project leaders and two school working groups. This is necessary to be able to implement an intervention which is

The school working group will be responsible for the organisation of a cooking and activity competition in their own kindergarten or school and the implementation of all the intervention modules at school level. The school working group will therefore be

After setting up the school working groups, it is essential that local intervention teams start to talk with the school working groups as soon as possible in order to make a final decision

As soon as the school working groups are set up, they have to act as a team. It must be avoided that the school project leader has to work out the whole project. For this reason a guideline has to be developed which supports the school project leader to implement the intervention. This guideline will include a well-defined description of the tasks of the school project leader, members and co-workers of the school working group, time table and description of the

In the relevant modules, the task and responsibilities are explained in more detail.

to the principal to decide who will be the project leader in the school.

contact with the school, school board, staff members and children.

adapted to the different age groups that are part of the intervention.

**Tasks and responsibilities of the school working group**

responsible for the implementation of the following modules:

on how the different modules will be implemented in the school.

**3.1.3 Operation of the school working group**

every participating school.

working group.

cooperation with local intervention teams andother useful information for the implementation of the intervention.

#### **Operation of the school working group during the intervention adoption phase (Year 2)**

During the first part of the adoption phase (September – June Year 2), the implementation of the intervention modules will be strongly supported by the local intervention team:

	- Produce a meeting report with the main points discussed and decisions taken. These reports can be used to analyse the implementation process of the intervention.
	- Discuss and evaluate the aspects of the intervention modules that have been executed as well as the ones forthcoming. Highlight things that went well (to be repeated), but also challenges (to find solutions) and things that went wrong (to try to avoid them happening again in the future). Provide strong support to the implementation team.
	- Continuously monitor activities going on inside the school or kindergarten related to preventing childhood obesity.
	- Do not ignore but take notice of new initiatives that are proposed by the school working group members.
	- Use the meeting as an opportunity to ensure the communication to all staff members of the school/kindergarten by publishing a newsletter or newsflash in the school paper.

The second part of the adoption phase (July – August, Year 2) is the transition period between the strongly supported and the supervised operation of the school working group. During the transition period, the following actions are recommended:

The IDEFICS Intervention Toolbox –

avoid stigmatisation of affected children.

**Concept of module 5**

schools and kindergartens).

and diet.

**Month of Year 2**

(Year 2)

A Guide to Successful Obesity Prevention at Community Level 23

Module 5 includes the integration of the key messages in the class curriculum and the promotion of the key messages in the entire school. The key messages have to be integrated in the framework of (classroom) health education and not as part of obesity prevention to

To integrate the key messages in the class curriculum and to promote the key messages in the school, every participating school has to organise the **Healthy Weeks**: these are weeks in which a specific key message will be highlighted (with different exposures for primary

**Intervention adoption phase (Year 2)**

**Healthy Week Key message to be highlighted**

**Nov** Diet Stimulating daily consumption of **fruit and vegetables**

**Mar** Diet Stimulating daily consumption of **fruit and vegetables**

relaxation Ensure adequate **sleep duration**

Table 9. Themes of the Healthy Weeks per month during the intervention adoption phase

**Jan** Diet Stimulating the daily **consumption of water Feb** Physical activity Stimulating daily **physical activity**

**May** Diet Stimulating the daily **consumption of water**

**Oct** Physical activity Stimulating daily **physical activity**

**Dec** Physical activity Reduce **TV-viewing**

**Apr** Physical activity Reduce **TV-viewing**

**Jul Vacation period: No Healthy Weeks Aug**

**Organisation of the Healthy Weeks during the adoption phase (Year 2)**

Healthy Week about adequate sleep duration.

integrated within the other Healthy Weeks.

**Theme of the**

**Jun** Stress, coping and

#### **Operation of the school working group during the intervention implementation phase (Year 3)**

The school working group is expected to continue the activities and to work out new initiatives with minimal supervision and without continuous support of the local intervention team.

From September of Year 3 onwards, the local coordinator no longer participates in the meetings of the school working group. From that moment, the school working group coordinator should fully take over the tasks of the local coordinator.

The local coordinator must be kept informed about the initiatives of the school working group. For this reason, the local coordinator and the school working group or the school working group coordinator should meet at least twice during the intervention implementation phase, i.e. once between September and January of Year 3 and once between February and June of Year 3.

Between these meetings, if needed, the school working group can keep in touch with the local coordinator in order to solve practical problems or get advice.

#### **Operation of the school working group during the intervention dissemination phase (September of Year 4 onwards)**

The school working group is expected to operate completely independently, without any support or supervision from the local intervention team.

## **3.1.4 The creation of a school platform at community level**

A school platform is a committee in which the school working groups of all the schools in the community can be represented.

#### **Objectives**

#### **General recommendations**

#### **3.2 Module 5: Education of children**

#### **Objectives**

#### **Concept of module 5**

22 Public Health – Social and Behavioral Health

The school working group is expected to continue the activities and to work out new initiatives with minimal supervision and without continuous support of the local

From September of Year 3 onwards, the local coordinator no longer participates in the meetings of the school working group. From that moment, the school working group

The local coordinator must be kept informed about the initiatives of the school working group. For this reason, the local coordinator and the school working group or the school working group coordinator should meet at least twice during the intervention implementation phase, i.e. once between September and January of Year 3 and once

Between these meetings, if needed, the school working group can keep in touch with the

The school working group is expected to operate completely independently, without any

A school platform is a committee in which the school working groups of all the schools in

be considered as an important and full member of the community platform.

**Operation of the school working group during the intervention dissemination phase**

coordinator should fully take over the tasks of the local coordinator.

local coordinator in order to solve practical problems or get advice.

support or supervision from the local intervention team.

instead of all school working groups separately.

**3.1.4 The creation of a school platform at community level**

start new initiatives for the prevention of childhood obesity.

**Operation of the school working group during the intervention implementation phase**

**(Year 3)**

intervention team.

between February and June of Year 3.

**(September of Year 4 onwards)**

the community can be represented.

**General recommendations**

**3.2 Module 5: Education of children**

**Objectives**

**Objectives**

Module 5 includes the integration of the key messages in the class curriculum and the promotion of the key messages in the entire school. The key messages have to be integrated in the framework of (classroom) health education and not as part of obesity prevention to avoid stigmatisation of affected children.

To integrate the key messages in the class curriculum and to promote the key messages in the school, every participating school has to organise the **Healthy Weeks**: these are weeks in which a specific key message will be highlighted (with different exposures for primary schools and kindergartens).

#### **Organisation of the Healthy Weeks during the adoption phase (Year 2)**

Table 9. Themes of the Healthy Weeks per month during the intervention adoption phase (Year 2)

The IDEFICS Intervention Toolbox –

key message.

9 Healthy Weeks.

guidelines described below.

**Tasks and responsibilities of the local intervention team**

**Tasks and responsibilities of the school working group**

**Practical guidelines to develop the education manuals**

• The ideas have to be concrete, original and age-adapted. • The information provided in the manual has to be ready to use.

of how to handle the key messages in the classroom.

• Increase awareness and knowledge

Hungary, Italy, Spain and Sweden).

designing their lessons.

• Increase self-efficacy • Increase skills in children

school.

**Development of an education manual for the organisation of the Healthy weeks**

and teachers to implement this module.

discuss them during the meetings).

module.

A Guide to Successful Obesity Prevention at Community Level 25

• Kindergarten: every day of the Healthy Week has to be in the theme of the handled

• Primary school: teachers have to spend 1 class hour per Healthy Week for a total of

Table 11 below provides possibilities and ideas that can be used for the development of the education manuals. These examples can count as a guideline but have to be worked out by the local intervention team, which implies an adaptation to the culture and the specific kindergarten and school structure in each country. It is not always necessary to develop new materials, and local intervention teams should also search for and select existing materials that can be included in the education manuals and that are able to fulfil the objectives of this

strategies must aim to fulfil the following objectives for every key message:

The themes of the Healthy Weeks have to be synchronised with the themes of the window posters (module 2) and the themes of the educational folders (see later module 10). Table 10 shows how the Healthy Weeks can be synchronised with the window posters and the educational folders, respectively.

Table 10. Synchronisation between the Healthy Weeks (module 5), the window posters (module 2) and the educational folders (module 10) during the intervention adoption phase (Year 2)

#### **Tasks and responsibilities of the school working group and teachers to organise the Healthy Weeks**

The school working group should:

The teachers should:

The themes of the Healthy Weeks have to be synchronised with the themes of the window posters (module 2) and the themes of the educational folders (see later module 10). Table 10 shows how the Healthy Weeks can be synchronised with the window posters and the

**Intervention adoption phase (Year 2)**

Sleep duration

Vacation period

related to sleep duration Jul

Table 10. Synchronisation between the Healthy Weeks (module 5), the window posters (module 2) and the educational folders (module 10) during the intervention adoption phase

**Tasks and responsibilities of the school working group and teachers to organise the**

poster for the parents about the handled key message.

the Healthy Weeks Folders

Physical Activity Distribution of folders

Physical Activity Distribution of folders

related to physical activity and diet

related to physical activity and diet

Distribution of folders

educational folders, respectively.

Oct Window poster related to

Feb Window poster related to

Jun Window posters related to

The school working group should:

and the primary school:

Aug

(Year 2)

**Healthy Weeks**

The teachers should:

chapter).

physical activity and diet (1st poster)

physical activity and diet (2nd poster)

> sleep duration (3rd poster)

Window and street posters Theme of

Dec Physical Activity

Apr Physical Activity

Nov Diet

Jan Diet

Mar Diet

May Diet

#### **Tasks and responsibilities of the local intervention team**

#### **Tasks and responsibilities of the school working group**

## **Development of an education manual for the organisation of the Healthy weeks**

Table 11 below provides possibilities and ideas that can be used for the development of the education manuals. These examples can count as a guideline but have to be worked out by the local intervention team, which implies an adaptation to the culture and the specific kindergarten and school structure in each country. It is not always necessary to develop new materials, and local intervention teams should also search for and select existing materials that can be included in the education manuals and that are able to fulfil the objectives of this module.

### **Practical guidelines to develop the education manuals**

	- The ideas have to be concrete, original and age-adapted.
	- The information provided in the manual has to be ready to use.
	- Increase awareness and knowledge
	- Increase self-efficacy
	- Increase skills in children

The IDEFICS Intervention Toolbox –

**Awareness**

**Skills**

**Awareness**

A Guide to Successful Obesity Prevention at Community Level 27

**REDUCE TV VIEWING**

watched TV, the programmes watched, …) **Self-efficacy** - See guidelines provided for daily physical activity and use them for

**DAILY CONSUMPTION OF FRUIT AND VEGETABLES**

How can we eat fruits and vegetables?

assigning pictures).

fruits and vegetables.

came home from school?, …).

How many hours can we watch a day? Is it good to watch TV?

worksheet (did you watch TV while eating supper? Did you turn on the TV before school? Did you turn on the TV when you

 Encourage group reporting about time spent watching TV. Self report activities by means of an attractive education

your parents in the kitchen during commercial breaks, …) - Teach self-monitoring techniques to children (for example: children make a diary in which they can report the amount of hours they

the activities related to the key message about TV viewing.

combination with education material (posters, photographs, …):

How many fruit and vegetables should we be eating each day?

What is good about eating fruits and vegetables?

Where can we buy and eat fruits and vegetables?

skill acquisition).

viewing.

 Let the children make an individual line graph of their progress. Give students frequent opportunities to update their progress. Provide a monthly calendar to record their daily progress. However, avoid class charts where individual progress is displayed because children will compare their progress in relationship to others. This will have a detrimental effect on the self-efficacy of those who do not progress as fast as others. Children have to learn to compare with themselves. - Use peer modelling during the lessons by working in small groups (this has an important influence on children's self-efficacy during

**DAILY PHYSICAL ACTIVITY**

What does being physically active mean?

assigning pictures (depending on the age).

some examples (case study).

accomplishment plan").

performed an activity goal.

physical activity (see above).

feedback).

avoid it as well).

things that you can say to yourself? What are your feelings about …?

children aware of what they have learned.

success: help children recognise their progress.

physical activity.

 What are the advantages of being physically active? When can you be physically active at home and at school? How much physical activity should we be getting each day? - Self report activities in class or for homework: children can fill in the physical activities they performed the day before on an attractive education worksheet, they can make a collage in which they present

their physical activities or they can report their activities by

 Communicate interactively (what are physical activity goals, what are the most important characteristics, …) and discuss

 Provide educational worksheets on which children can report their physical activity goals at school and at home ("My

 In a next step, the children have to report which activities they actually have done (review of the accomplishment plan). Performance against physical activity goals can be associated with a game: a child can gain a stamp or a sticker if they

Are the following sentences examples of positive or negative

How can you change negative sentences into positive sentences?

combination with education material (posters, photographs, …):

**Awareness**

**Skills**

**Self-efficacy**

The IDEFICS Intervention Toolbox –

**Possibilities to create an active playground**

**Change the physical design of the playground**

**Provide attractive play tools in the playground**

**Structural changes related to recess period**

**Development of a manual for the creation of the active playground**

**Playground Objectives**

school.

moments.

with the following actions:

A Guide to Successful Obesity Prevention at Community Level 29

The creation and the promotion of an active playground is part of improving the school environment with the aim to stimulate the children to be physically active while at

The local intervention team has the opportunity to create an active playground in the schools and kindergartens by means of one or a combination of the following strategies:

Redesign the playground, using multicolour playground markings (e.g. hopscotch) and physical structures (e.g. soccer goal posts, basketball hoops). This is found to be a sufficient stimulus for increasing children's school physical activity levels during recess and is also a

Providing game equipment during recess (e.g. balls, ropes, small bikes) is found to be effective in increasing children's physical activity levels. These findings suggest that promoting physical activity through game equipment provision during recess can contribute to reaching the daily

The playground space available for children (number children/m²) during recess periods is found to be an important predictor of children's physical activity levels (Cardon et al.,2008). Therefore, structural changes that reduce the number of children on the same surface area can be an inexpensive way to increase physical activity levels during recess: e.g. divide all children in two groups and let them have playtime at different

In addition to the environmental and structural possibilities to create an active playground, as described above, it is strongly recommended to combine one or more of these strategies

Every school participating in the intervention should be offered a manual for the creation of an active playground. This school manual should enable the schools to implement this module. Because the content of the manual will differ according to the age of the children, it

**3.3 Module 6: Environmental changes related to physical activity - The Active**

(contribute to the daily recommended norm of physical activity).

method that is low in cost (Stratton & Mullan, 2005; Ridgers et al., 2007).

recommended activity levels in children (Verstraete et al., 2006).

Table 11. Ideas for the content of the education manuals

#### **3.3 Module 6: Environmental changes related to physical activity - The Active Playground**

#### **Objectives**

28 Public Health – Social and Behavioral Health

that visualises the different steps in cutting a certain

front of the children and show that you like them. **DAILY CONSUMPTION OF WATER**

preference to water over other drinks?

leaves, pieces of apple or strawberry).

How much water should we be drinking each day?

 If a video camera is available, tape the children while they are participating in the preparation of fruit and vegetables and allow to view themselves being successful (or take photographs of the activity). While showing the tape or photographs, give positive feedback about the skills that the children acquired and

combination with education materials (posters, photographs, …): What are the advantages of drinking water? Why should I give

 Where can we drink water? In which forms can we drink water? - Self report activities in class or for homework: children can fill in the amount of water they drank the day before on an attractive education worksheet (or report it by making a collage or assigning

vegetable).

vegetables.

preparation skills. - Organise recognition games.

were demonstrating.

on repeated occasions.

pictures).

of water.

water. Table 11. Ideas for the content of the education manuals

**Skills**

**Self-efficacy**

**Taste/preference**

**Awareness**

**Skills**

**Self-efficacy**

#### **Possibilities to create an active playground**

The creation and the promotion of an active playground is part of improving the school environment with the aim to stimulate the children to be physically active while at school.

The local intervention team has the opportunity to create an active playground in the schools and kindergartens by means of one or a combination of the following strategies:

#### **Change the physical design of the playground**

Redesign the playground, using multicolour playground markings (e.g. hopscotch) and physical structures (e.g. soccer goal posts, basketball hoops). This is found to be a sufficient stimulus for increasing children's school physical activity levels during recess and is also a method that is low in cost (Stratton & Mullan, 2005; Ridgers et al., 2007).

#### **Provide attractive play tools in the playground**

Providing game equipment during recess (e.g. balls, ropes, small bikes) is found to be effective in increasing children's physical activity levels. These findings suggest that promoting physical activity through game equipment provision during recess can contribute to reaching the daily recommended activity levels in children (Verstraete et al., 2006).

#### **Structural changes related to recess period**

The playground space available for children (number children/m²) during recess periods is found to be an important predictor of children's physical activity levels (Cardon et al.,2008). Therefore, structural changes that reduce the number of children on the same surface area can be an inexpensive way to increase physical activity levels during recess: e.g. divide all children in two groups and let them have playtime at different moments.

In addition to the environmental and structural possibilities to create an active playground, as described above, it is strongly recommended to combine one or more of these strategies with the following actions:

#### **Development of a manual for the creation of the active playground**

Every school participating in the intervention should be offered a manual for the creation of an active playground. This school manual should enable the schools to implement this module. Because the content of the manual will differ according to the age of the children, it

The IDEFICS Intervention Toolbox –

**Objectives**

discuss them during the meetings).

**3.4 Module 7: Health-related physical education curricula**

(trying to reach a high activity level during the lessons).

increase physical activity during time spent at the kindergarten.

following guidelines (Bagby & Adams, 2007; SPARK, 2011):

**physical education curricula and emphasise them in the manual**

playground and/or at home, e.g. rope skipping, Frisbee, …).

education classes (e.g. restrict waiting time for children).

**Provide strategies to integrate the guidelines in practice**

are necessary to lead an active lifestyle. - Aspire to give every child positive experiences.

**of health-related physical education curricula**

children.

activity rate.

which are necessary to lead an active lifestyle. - Building children's confidence in their physical abilities. **Manual for the optimisation of physical education classes**

A Guide to Successful Obesity Prevention at Community Level 31

**Inform teachers, educators and/or nurses about the basic characteristics of health-related**

**Integrate guidelines for teachers, educators and/or nurses to fulfil the basic characteristics**

is suggested that a different manual be prepared for the kindergarten and the primary school. The school manual can be written by the local intervention team on the basis of the following guidelines:

## **Provide ideas to change the physical design of the playground**

### **Provide ideas for materials that can be provided in the playground**

#### **Provide suggestions on how the active playground can be promoted in the school**

#### **Include information about the importance of active supervision and coaching by teachers and/or educators**

#### **Tasks and responsibilities of the school working group**

## **3.4 Module 7: Health-related physical education curricula**

### **Objectives**

30 Public Health – Social and Behavioral Health

is suggested that a different manual be prepared for the kindergarten and the primary school. The school manual can be written by the local intervention team on the basis of the

**Include information about the importance of active supervision and coaching by teachers**

**Provide suggestions on how the active playground can be promoted in the school**

**Provide ideas to change the physical design of the playground**

**Provide ideas for materials that can be provided in the playground**

and the primary school) and that they reach both boys and girls.

(e.g. sports balls or a (suit)case with circus materials).

following guidelines:

both boys and girls.

possibilities of the playground equipment.

**Tasks and responsibilities of the school working group**

the school newspaper).

physically active.

**and/or educators**

minute?).

## **Manual for the optimisation of physical education classes**

#### **Inform teachers, educators and/or nurses about the basic characteristics of health-related physical education curricula and emphasise them in the manual**

#### **Integrate guidelines for teachers, educators and/or nurses to fulfil the basic characteristics of health-related physical education curricula**

#### **Provide strategies to integrate the guidelines in practice**

The IDEFICS Intervention Toolbox –

(environment – school policy).

(regulations – school policy)

availability of water can be promoted:

initiative).

during the breaks.

vegetables to the school. **Practical implications**

**vegetables Objective**

**kindergartens**

**changes)**

year.

and make them visible in the school.

Examples of how the beverages supply can be changed:

or other healthier options (environment – school policy).

A Guide to Successful Obesity Prevention at Community Level 33

It is strongly recommended to promote all the initiatives to the children, parents and staff members of the school. It is also essential to communicate to the children, parents and staff members about the regulations related to the consumption of water. Examples of how the

The local intervention team can increase the daily consumption of fruit and vegetables in schools and kindergartens by means of one or a combination of the following strategies: **Availability and accessibility of fruit and vegetables in the school (make environmental**

The working group of the school can make a contract with a local fruit and vegetable trader or merchant who can deliver at least once a week fresh and seasonable fruit and/or

**3.6 Module 9: Environmental changes and school policy related to fruit and**

**Possibilities to increase the consumption of fruit and vegetable in schools and**

**Promote the availability of water and clearly communicate about the regulations**

which guidelines they already apply and which ones are new. The teacher, educator or nurse tries the new ones and evaluates the effect. Over the next weeks, the teacher, educator or nurse can then focus on other guidelines.

Note: Such a manual is available for those countries where the IDEFICS intervention has been tested for its effectiveness (Belgium, Cyprus, Estonia, Germany, Hungary, Italy, Spain and Sweden).

#### **Tasks and responsibilities of the school working group**

## **3.5 Module 8: Environmental changes and school policy related to water consumption**

#### **Objectives**

#### **Possibilities to increase the daily water consumption in schools and kindergartens**

The local intervention team can increase the daily water consumption in schools and kindergartens by means of one or a combination of the following strategies:

#### **Permanently provide free water during breaks, play time and/or lessons**

It is of special importance that the provision of water facilities is in proportion to the number of children in the school and adapted to the student population (location, height, hygiene, …). It is for example better to allow drinking cups in the kindergarten whereas the placing of water fountains is rather recommended in primary schools. The provision of water should also be clearly communicated to the students and the staff members: when, where, how, …

#### **Reorientation of the beverage supply in the school (changing the environment and/or the school policy)**

Favour water as the main drink supply in school. This reorientation will require clear regulations about the consumption of sugar-sweetened beverages and water and possibly a change to the school policy. If it is possible to change the school policy or to set regulations about the consumption of sugar-sweetened beverages, this should be clearly communicated to the children, staff members and parents.

Examples of how the beverages supply can be changed:

## **Promote the availability of water and clearly communicate about the regulations**

It is strongly recommended to promote all the initiatives to the children, parents and staff members of the school. It is also essential to communicate to the children, parents and staff members about the regulations related to the consumption of water. Examples of how the availability of water can be promoted:

#### **3.6 Module 9: Environmental changes and school policy related to fruit and vegetables**

#### **Objective**

32 Public Health – Social and Behavioral Health

Note: Such a manual is available for those countries where the IDEFICS intervention has been tested for its effectiveness (Belgium, Cyprus, Estonia, Germany, Hungary, Italy, Spain

**3.5 Module 8: Environmental changes and school policy related to water consumption**

The local intervention team can increase the daily water consumption in schools and

It is of special importance that the provision of water facilities is in proportion to the number of children in the school and adapted to the student population (location, height, hygiene, …). It is for example better to allow drinking cups in the kindergarten whereas the placing of water fountains is rather recommended in primary schools. The provision of water should also be clearly communicated to the students and the staff members: when,

**Reorientation of the beverage supply in the school (changing the environment and/or the**

Favour water as the main drink supply in school. This reorientation will require clear regulations about the consumption of sugar-sweetened beverages and water and possibly a change to the school policy. If it is possible to change the school policy or to set regulations about the consumption of sugar-sweetened beverages, this should be clearly communicated

educator or nurse can then focus on other guidelines.

**Tasks and responsibilities of the school working group**

kindergartens by means of one or a combination of the following strategies: **Permanently provide free water during breaks, play time and/or lessons**

integrate a "water drinking moment" (school policy).

**Possibilities to increase the daily water consumption in schools and kindergartens**

and Sweden).

**Objectives**

beverages.

during the meetings).

desk (school policy).

to the children, staff members and parents.

where, how, …

**school policy)**

which guidelines they already apply and which ones are new. The teacher, educator or nurse tries the new ones and evaluates the effect. Over the next weeks, the teacher,

> - At least once a week, make fruit and vegetables available in the school environment during the breaks.

#### **Possibilities to increase the consumption of fruit and vegetable in schools and kindergartens**

The local intervention team can increase the daily consumption of fruit and vegetables in schools and kindergartens by means of one or a combination of the following strategies:

#### **Availability and accessibility of fruit and vegetables in the school (make environmental changes)**

The working group of the school can make a contract with a local fruit and vegetable trader or merchant who can deliver at least once a week fresh and seasonable fruit and/or vegetables to the school.

#### **Practical implications**

The IDEFICS Intervention Toolbox –

**Guidelines for the development of the folders**

environments that promote and encourage a healthy lifestyle.

family environments. **Educational folders**

Sweden).

A Guide to Successful Obesity Prevention at Community Level 35

Parents should receive educational folders and videos to learn about parenting strategies that can remove barriers and facilitate them in their ability to create health-promoting

The local intervention team can develop 3 folders: 1 folder about diet, 1 folder about physical activity and 1 folder about sleep duration. The key message about spending more time together has to be integrated in these folders. The educational folder about physical activity that was used in the IDEFICS intervention, is displayed below. All of the folders are already available in the languages of those countries where the IDEFICS intervention was tested for its effectiveness (Belgium, Cyprus, Estonia, Germany, Hungary, Italy, Spain and

Four aspects of parenting can be the focus of the educational folders and can provide a framework for the development of the educational materials, i.e. beliefs and knowledge of the parents, parental modelling, availability and/or accessibility and shaping. For a detailed description of these aspects of parenting, references are made to Crawford and Jeffery (2005). Based on the examples provided by Crawford and Jeffery (2005), Table 12 offers an overview of strategies that can help parents in their ability to create family

**Concept of module 10: educational folders and videos for parents**

## **Other possibilities**

#### **Reorientation of the food supply in the schools (changing the environment and/or the school policy)**

Change the food supply in the school to include fruits and vegetables as an alternative to less healthy snacks. This reorientation will require clear regulations and possibly a change to the school policy. If it is possible to change the school policy or to set regulations about the consumption of less healthy snacks and fruits and vegetables, this should be clearly communicated to the children, staff members and parents. Examples of how the food supply can be changed:

#### **Promote the availability/accessibility of fruit and vegetables and clearly communicate about the regulations**

It is strongly recommended to promote all the initiatives to the children, parents and staff members of the school. It is also essential to communicate to the children, parents and staff members about the regulations related to the consumption of water. Examples of how the availability/accessibility of fruit and vegetables can be promoted:

## **4. IDEFICS intervention modules at family level**

#### **4.1 Module 10: Education of parents**

#### **Objectives**

### **Concept of module 10: educational folders and videos for parents**

Parents should receive educational folders and videos to learn about parenting strategies that can remove barriers and facilitate them in their ability to create health-promoting family environments.

#### **Educational folders**

34 Public Health – Social and Behavioral Health

Change the food supply in the school to include fruits and vegetables as an alternative to less healthy snacks. This reorientation will require clear regulations and possibly a change to the school policy. If it is possible to change the school policy or to set regulations about the consumption of less healthy snacks and fruits and vegetables, this should be clearly communicated to the children, staff members and parents. Examples of how the food supply

**Reorientation of the food supply in the schools (changing the environment and/or the**

availability/accessibility of fruit and vegetables can be promoted:

vegetables and make them visible in the school.

**4. IDEFICS intervention modules at family level**

accessibility and availability of fruit and vegetables at home.

**4.1 Module 10: Education of parents**

**Promote the availability/accessibility of fruit and vegetables and clearly communicate**

It is strongly recommended to promote all the initiatives to the children, parents and staff members of the school. It is also essential to communicate to the children, parents and staff members about the regulations related to the consumption of water. Examples of how the

and vegetable day' for the rest of the school year.

vegetables instead of less healthy snacks. - School gardens (children grow vegetables at school).

**Other possibilities**

their agenda.

**school policy)**

can be changed:

**about the regulations**

newspaper.

involve them.

**Objectives**

The local intervention team can develop 3 folders: 1 folder about diet, 1 folder about physical activity and 1 folder about sleep duration. The key message about spending more time together has to be integrated in these folders. The educational folder about physical activity that was used in the IDEFICS intervention, is displayed below. All of the folders are already available in the languages of those countries where the IDEFICS intervention was tested for its effectiveness (Belgium, Cyprus, Estonia, Germany, Hungary, Italy, Spain and Sweden).

#### **Guidelines for the development of the folders**

Four aspects of parenting can be the focus of the educational folders and can provide a framework for the development of the educational materials, i.e. beliefs and knowledge of the parents, parental modelling, availability and/or accessibility and shaping. For a detailed description of these aspects of parenting, references are made to Crawford and Jeffery (2005). Based on the examples provided by Crawford and Jeffery (2005), Table 12 offers an overview of strategies that can help parents in their ability to create family environments that promote and encourage a healthy lifestyle.

The IDEFICS Intervention Toolbox –

**Beliefs and**

**Modelling**

**Availability and/or accessibility**

**Shaping**

**Beliefs and knowledge**

**Modelling**

**Availability and/or accessibility**

**Shaping**

2005)

A Guide to Successful Obesity Prevention at Community Level 37

**DAILY CONSUMPTION OF WATER**

**knowledge** - Use the daily recommended norm related to water as a guideline.

a guideline.

like them.

vegetables.

before.

with negative outcome.

with positive outcome.

child as a snack at school (instead of less healthy snacks).

water with mint leaves or pieces of strawberry, apple, … - Provide your child with a nice tin or their favourite cup which is

a punishment for a behaviour with negative outcomes.

always filled with water and accessible to take.

reward for behaviours with positive outcome.

**DAILY CONSUMPTION OF FRUIT AND VEGETABLES**

home environment and during family trips.

Table 12. Examples of parenting strategies for diet and physical activity (Crawford & Jeffery,

**DAILY PHYSICAL ACTIVITY**

hiking or cycling with the entire family).

perform them together with your child.

**REDUCE TV VIEWING**

guideline.

and vacations.

balls, bicycles).

organisations).

child.

outcome.

a guideline.

programmes).

outcome.

eating.

negative outcome.

walking or cycling instead of driving, playing outside) and include physical activity in family events such as birthday parties, picnics,

**Shaping** - Do not use watching TV as a reward for behaviours with positive

**Beliefs and knowledge**

**Modelling**

**Availability and/or accessibility**

**Shaping**

**Beliefs and knowledge**

**Modelling**

**Availability and/or accessibility**

Table 12. Examples of parenting strategies for diet and physical activity (Crawford & Jeffery, 2005)

The IDEFICS Intervention Toolbox –

University Press.

*(Lond), 35 Suppl 1*:S 16-23.

levels. *Prev Med., 44*, 393-397.

physical education class. *http://www.sparkpe.org/*

*Rev, 8*, 129-154.

*Meth, 10* (10).

82.

143.

*Cardiovasc Dis, 16*, 302-308.

A Guide to Successful Obesity Prevention at Community Level 39

Ahrens, W., Bammann, K., De Henauw, S., Halford, J., Palou, A., Pigeot, I., Siani, A.,

Bagby, K. & Adams, S. (2007). Evidence-based practice guideline: increasing

Cardon, G., Van Cauwenberghe, E., Labarque, V., Haerens, L., & De Bourdeaudhuij, I.

Crawford, D. & Jeffery, R. W. (2005). Obesity Prevention and Public Health. Oxford

Davison, K.K. & Birch, L.L. (2001). Childhood overweight: a contextual model and

De Henauw, S., Verbestel, V., Marild, S., Barba, G., Bammann, K., Eiben, G., Hebestreit, A.,

Ferreira, I., van der, H. K., Wendel-Vos, W., Kremers, S., van Lenthe, F. J., & Brug, J. (2007).

Pigeot, I., De Henauw, S., Foraita, R., Jahn, I., Ahrens, W. (2010). Primary prevention from

Ridgers, N. D., Stratton, G., Fairclough, S. J., & Twisk, J. W. (2007). Long-term effects of a

Sports, Play and Activity Recreation for Kids (SPARK) (2011). Pre-developed curricula

Stratton, G. & Mullan, E. (2005). The effect of multicolor playground markings on children's

Verbestel, V., De Henauw, S, Maes, L, Haerens, L., Mårild, S., Eiben, G., Lissner,

physical activity level during recess. *Prev Med., 41*, 828-833.

physical activity during recess. *Int J Behav Nutr Phys Act, 26*, 5:11.

recommendations for future research. *Obes Rev*, 2, 3.

Sjöström, M. (2006). Understanding and preventing childhood obesity and related disorders–IDEFICS: a European multilevel epidemiological approach. *Nutr Metab*

physical activity in schools--kindergarten through 8th grade. *J Sch Nurs, 23,* 137-

(2008). The contribution of preschool playground factors in explaining children's

Iacoviello, L., Gallois, K., Konstabel, K., Kovacs, É., Maes, L., Molnar, D., Moreno, L.A., Reisch, L., Siani, A., Tornaritis, M., Williams, G., Ahrens, W., De Bourdeaudhuij, I., Pigeot, I. (2011). The IDEFICS Community-Oriented Intervention Program: A new model for childhood obesity prevention in Europe? *Int J Obes*

Environmental correlates of physical activity in youth - a review and update. *Obes*

the epidemiology perspective: Three examples from the practice. *BMC Med Res*

playground markings and physical structures on children's recess physical activity

specifically designed to increase levels of physical activity in children during

L., Moreno, L.A., Lascorz Frauca, N., Barba, G., Kovács, É., Konstabel, K., Tornaritis, M., Gallois, K., Hassel, H., De Bourdeaudhuij, I. (2011). Using the intervention mapping protocol to develop a community-based intervention for the prevention of childhood obesity in a multi-centre European project: the IDEFICS intervention. *Int J Behav Nutr Phys Act, 8*,

### **Distribution of the folders**

## **Educational videos**

A media agency could develop scenarios for the educational videos based on the content and ideas provided in this intervention manual.

## **5. Conclusion**

The fundamental idea of the IDEFICS project was that obesity prevention should be triggered by local policy makers or local public health authorities and supported by initiatives taken by local stakeholders in the community. As part of this project, a community-based intervention for the prevention of childhood obesity was developed and tested for its effectiveness. The content and the implementation strategy of the IDEFICS intervention are now available and provide local policy makers and public health authorities with the opportunity to explore a model for obesity prevention in Europe.

This chapter was written in a way that local policy makers or local public health authorities have the necessary guidance and recommendations at their disposal to implement the intervention in their local city or community. The major advantage of the intervention framework is that it can be culturally adapted to the local needs and requirements which increases the feasibility of implementation in European countries.

## **6. Acknowledgements**

This work was done as part of the IDEFICS Study (www.idefics.eu). We gratefully acknowledge the financial support of the European Community within the Sixth RTD Framework Programme Contract No. 016181 (FOOD).

## **7. References**

Ahrens, W., Bammann, K., Siani, A., Buchecker, K., De Henauw, S., Iacoviello, L., Hebestreit, A., Krogh, Vittorio, L., Lauren, M., Staffan, Molnar, D., Moreno, L.A., Pitsiladis, Y., Reisch, L.A., Tornaritis, M., Veidebaum, T., Pigeot, I., on behalf of the IDEFICS consortium (2011). The IDEFICS cohort: Design, characteristics and participation in the baseline survey. *Int J Obes, 35* (Suppl.1):S3 - S15.

A media agency could develop scenarios for the educational videos based on the content

The fundamental idea of the IDEFICS project was that obesity prevention should be triggered by local policy makers or local public health authorities and supported by initiatives taken by local stakeholders in the community. As part of this project, a community-based intervention for the prevention of childhood obesity was developed and tested for its effectiveness. The content and the implementation strategy of the IDEFICS intervention are now available and provide local policy makers and public health authorities with the opportunity to explore a model for obesity prevention in

This chapter was written in a way that local policy makers or local public health authorities have the necessary guidance and recommendations at their disposal to implement the intervention in their local city or community. The major advantage of the intervention framework is that it can be culturally adapted to the local needs and requirements which

This work was done as part of the IDEFICS Study (www.idefics.eu). We gratefully acknowledge the financial support of the European Community within the Sixth RTD

Ahrens, W., Bammann, K., Siani, A., Buchecker, K., De Henauw, S., Iacoviello, L., Hebestreit,

A., Krogh, Vittorio, L., Lauren, M., Staffan, Molnar, D., Moreno, L.A., Pitsiladis, Y., Reisch, L.A., Tornaritis, M., Veidebaum, T., Pigeot, I., on behalf of the IDEFICS consortium (2011). The IDEFICS cohort: Design, characteristics and participation in

highlighted on the window poster and in the Healthy Weeks.

increases the feasibility of implementation in European countries.

the baseline survey. *Int J Obes, 35* (Suppl.1):S3 - S15.

Framework Programme Contract No. 016181 (FOOD).

**Distribution of the folders**

**Educational videos**

**5. Conclusion**

Europe.

**6. Acknowledgements**

**7. References**

receive the folders in time.

and ideas provided in this intervention manual.

**2**

*USA*

**Testing the Assumptions of Stage of Change**

Jay E. Maddock\*, Jodi D. Barnett, Carrie S. Marshall and Claudio R. Nigg

Chronic disease now accounts for 7 of every 10 deaths in the United States and 60% of the nation's health expenditures [1]. Poor nutrition is a substantial contributor to the chronic disease burden, accounting for over \$33 billion in medical costs and \$9 billion in lost productivity per year [1]. Fortunately, many detriments of chronic disease, such as increased risk for heart disease [2-4], stroke [5, 6], diabetes [7, 8], osteoporosis [9], and cancer [10, 11], can be prevented through adoption of a healthy diet. Fruit and vegetables are an integral part of a healthy diet, and they provide many nutrients that may reduce the risk for some types of cancers and chronic disease [12-16]. To achieve this protective effect, disease prevention guidelines recommend that individuals consume at least five servings of fruits and vegetables a day [17, 18]. However, data from the 50 US states indicates that 70-80% of

The substantiated link between poor diet and the epidemic prevalence of chronic disease in America necessitates population-based interventions aimed at increasing fruit and vegetable consumption. Explanatory theories of behavior change, such as the Transtheoretical Model (TTM), can help guide intervention programs in developing the most effective strategies for promoting and sustaining change in a population. Over the past two decades, the central organizing construct of the TTM, the stages of change has experienced widespread use as well as pointed criticisms [20]. The model postulates that people move through a series of five stages of change in their attempts to modify their problem behaviors [21]. As people change stages, they employ mediating processes such as self-efficacy and decisional balance, differentially making each stage unique. Five stages of change have been identified: precontemplation (no intention to change behavior in the foreseeable future, or denial of need to change); contemplation (intention to change within the next 6 months); preparation (serious intention to change in the next 30 days); action (initiation of overt behavioral change); and maintenance (sustaining behavioral change for

**1. Introduction**

6 months or more) [21].

Corresponding Author

 \*

US adults fall short of these recommendations [19].

**for Fruit and Vegetable Consumption:**

**A Naturalistic Study**

*Department of Public Health Sciences University of Hawai'i at Mānoa,*

Verstraete, S. J., Cardon, G. M., De Clercq, D. L., & De Bourdeaudhuij, I (2006). Increasing children's physical activity levels during recess periods in elementary schools: the effects of providing game equipment. *Eur J Public Health, 16*, 415-419.

## **Testing the Assumptions of Stage of Change for Fruit and Vegetable Consumption: A Naturalistic Study**

Jay E. Maddock\*, Jodi D. Barnett, Carrie S. Marshall and Claudio R. Nigg *Department of Public Health Sciences University of Hawai'i at Mānoa, USA*

#### **1. Introduction**

40 Public Health – Social and Behavioral Health

Verstraete, S. J., Cardon, G. M., De Clercq, D. L., & De Bourdeaudhuij, I (2006). Increasing

effects of providing game equipment. *Eur J Public Health, 16*, 415-419.

children's physical activity levels during recess periods in elementary schools: the