A
A
Development of an intervention to optimise preschoolers’ 24-hour movement behaviours: a co-creation process with parents
Abstract
Background
Establishing healthy 24-hour movement behaviours from an early age is essential for long-term health.
A
Yet, few preschoolers comply with the 24-hour movement behaviour guidelines. As parents play a central role in shaping their children’s health habits, parent-focused interventions may help to optimise these behaviours in preschoolers.
A
This study describes the co-creation process and feasibility testing with parents to develop the ‘Move ARound And Get Active’ (MARGA) intervention. The aim of the intervention is to optimise 24-hour movement behaviours in preschoolers, with attention to specific needs of preschoolers with overweight and obesity.
Methods
A
Two co-creation groups with 11 and 10 parents and one group to test the feasibility of the co-created intervention with 7 parents were recruited through a hospital and school. The development of the intervention was guided by the Intervention Mapping (IM) Approach. The Self-Determination Theory was used as a framework for conceptualizing parenting practices related to preschoolers’ 24-hour movement behaviours. The content of the sessions and working methods are described.
Results
A
The results describe 1) the key general findings per co-creation session and the final decisions per IM step; 2) how the feasibility group perceived the co-created intervention and which of the group’s comments led to adaptations; 3) the final MARGA intervention program consisting of seven group sessions for parents and preschoolers spread over 15 weeks with four types of sessions: Information sessions, Planning sessions, Support groups, and physical activity games for parents and preschoolers together.
Conclusion
The transparent and detailed development process presented in this study serves as a blueprint for future research and practice, demonstrating how IM can be pragmatically combined with co-creation to create behavioural change interventions. A key next step is to evaluate the intervention’s effectiveness in improving 24-hour movement behaviours in preschoolers.
Key word:
Intervention development
intervention mapping
co-creation
parenting
preschoolers
24-hour movement behaviours
A
A
A
Introduction
A
A
In early childhood, the time spent on sleep, sedentary behaviour (SB), and physical activity (PA) form an essential foundation for a child’s health and development ("WHO Guidelines Approved by the Guidelines Review Committee," 2019). Every activity one conducts during a day can be categorized in one of these behaviours. This means that time spent on one behaviour affects the time available for the others within a 24 hour time span. This interrelationship has given rise to the concept of “24-hour movement behaviours” (Rollo et al., 2020).
A
In this context, as requested by the Commission on Ending Childhood Obesity, the World Health Organisation (WHO) released 24-hour movement behaviour guidelines for early childhood in 2019 ("WHO Guidelines Approved by the Guidelines Review Committee," 2019).
A
For preschoolers (3–4 years of age), these guidelines recommend 10 to 13 hours of good-quality sleep, no more than 60 minutes of sedentary screen time (ST) and at least 180 minutes of PA, including 60 minutes of higher-intensity activity (i.e., moderate-to-vigorous PA; MVPA) ("WHO Guidelines Approved by the Guidelines Review Committee," 2019). Complying with these guidelines provides an opportunity to favour preschoolers’ physical and mental health and wellbeing (Rollo et al., 2020), and, overall, aims to tackle childhood overweight and obesity, which is a global burden. To exemplify, in 2022, approximately 37 million children under the age of 5 years were classified as being overweight or obese, and were therefore at risk to develop numerous physical and psychological co-morbidities in the long term, including non-communicable diseases, such as cancer, cardiovascular disease and diabetes mellitus type 2 (WHO, 2024; "WHO Guidelines Approved by the Guidelines Review Committee," 2019). It is striking that only a small proportion of preschoolers worldwide (11%) comply with these WHO guidelines (Tapia-Serrano et al., 2022). Therefore, establishing sufficient sleep, minimizing ST, and increasing PA are key public health priorities in this young age group. Knowing that (un)healthy habits are developed under the age of five and that these habits are likely to persist throughout life (Jones et al., 2013; Telama et al., 2014), it is extremely important to develop strategies to increase compliance with the 24-hour movement behaviour guidelines.
Developing healthy habits in young children is influenced by a complex ecological system in which parents play a leading role (Davison et al., 2012; Ling et al., 2017). Therefore, parent-focused interventions are essential for promoting healthy habits in preschoolers. However, parenting is shaped by a broad range of various factors, including family demographics, cultural beliefs, economic constraints, and community environment (Davison et al., 2012), making it challenging to develop effective interventions. Generic top-down approaches to shape parenting practices to better promote healthy lifestyles in preschoolers may furthermore not align with parents’ specific needs, leading to dissatisfaction and low intervention uptake which ultimately results in having no effect. Therefore, a bottom-up approach, such as co-creation, that actively involves parents in the intervention development process could provide invaluable insights into parents’ and children’s needs when implementing a lifestyle intervention within the family or home environment (Durand et al., 2014; Leask et al., 2019). Co-creation is defined as active collaboration between academic researchers and stakeholders - in this case parents - to design, implement and evaluate health initiatives (Leask et al., 2019; van Dijk-de Vries et al., 2020; Vargas et al., 2022), and has shown to empower the population of interest by allowing them to shape solutions and ensuring that intervention strategies align with their experiences and needs. This approach is believed to enhance participant engagement in the intervention and improves its effectiveness and sustainability (Durand et al., 2014; Halvorsrud et al., 2021; Leask et al., 2019; Verloigne et al., 2017). Accordingly, co-creating an intervention with parents to optimise preschoolers’ 24-hour movement behaviours might be a promising strategy that addresses the current challenges of developing lifestyle interventions. While the value of co-creation in intervention development is well-recognised (Latomme et al., 2021; "Maenhout, L., Verloigne, M., Cairns, D., Cardon, G., Crombez, G., Melville, C., ... & Compernolle, S. (2023). Co-creating an intervention to promote physical activity in adolescents with intellectual disabilities: lessons learned within the Move it, Move ID!-project. Research Involvement and Engagement, 9(1), 1–16.," ; Verloigne et al., 2017), its application to interventions targeting all three 24-hour movement behaviours remains unexplored. This paper aims to bridge this gap by providing a detailed account of the co-creation process and feasibility testing with parents to develop an intervention, along with its implementation and evaluation procedures. In addition, it outlines the content of the co-created intervention designed to optimise 24-hour movement behaviours in preschoolers. Reporting on this co-creation process, feasibility testing and how it resulted in the final intervention enhances transparency, supports reproducibility, and provides valuable insight into stakeholder involvement in this process, which might favourably contribute to future intervention development.
Methods
This paper is part of a four-year (2021–2025) project aiming to develop, implement and evaluate an intervention to optimise 24-hour movement behaviours in preschoolers. It describes the development of the “Move ARound and Get Active” (MARGA) intervention.
A
Ethical approval was provided by the Ethics Committee of Ghent University Hospital (BC-11699 and ONZ-2023-0229). Materials used in the development process are described and visualised in OSF (DOI 10.17605/OSF.IO/BP8Y7).
1. Participants and recruitment
Originally, the study aimed to recruit parents of preschoolers (2.5-5 years old) with overweight and obesity, as these children are considered an at-risk group and might need a different intervention approach. As the recruitment of parents of preschoolers with overweight and obesity for the co-creation process progressed very slowly and because of the limited timeframe of the study, the age range of the children was broadened to 10 years. As a result, an intervention was created for the complete age range. However, this paper focusses on the development results for preschoolers only, as it was clear from the beginning that preschoolers and older children had different needs. Recruitment was carried out in two waves, with the first wave recruiting for the co-creation process and the second wave for the feasibility testing. The first wave took place from February to June ‘22. Two recruitment channels were used, dividing parents into two groups. A first group of parents (Group 1; hospital group) was recruited through a paediatrician of a local hospital in Flanders (Belgium).
A
The parents had to have at least one child between 2.5 and 10 years old with overweight or obesity based on their Body Mass Index (BMI) growth curves in their medical file (≥ 85th percentile), which was not caused by a known medical condition. A second group of parents (Group 2; school group) was recruited through a primary school in Flanders (Belgium) with a disadvantaged student population based on the Flemish Education Deprivation Index (Opgroeien, 2024). This index is based on four factors: not having Dutch as the mother tongue, a low educational level of the mother, receiving a school allowance, and living in a neighbourhood with a high level of educational disadvantage.
A
Group 2 was recruited to make sure parents with a disadvantaged socio-economic position (SEP) were represented in the co-creation process, as they are often underrepresented in research.
A
Parents were recruited by the care coordinator at the gate of the preschool section, who was recognised as a trusted confidant for parents, together with the primary investigator (MD). The care coordinator approached parents whom she knew had a child with overweight or obesity.
A
This could also include parents of a preschooler with an older sibling (up to 10 years old) with overweight or obesity. To avoid stigmatisation, also parents from preschoolers without overweight or obesity were eligible to participate. From July to September ‘23 the second wave of recruitment resulted in a third group of parents (Group 3) for the feasibility testing. This group was recruited through the same paediatrician as Group 1 with the same selection criteria, but this time only for preschoolers (2.5 to 5 years old) as the feasibility testing focussed on the part of the development of the intervention for preschoolers and this part does not meet the needs of older children. Based on the recommendations of Leask et al. (2019) (Leask et al., 2019), the aim was to include approximately 10 parents per group, which accounts for a potential dropout and attendance variations over multiple co-creation sessions. All parents within the three groups needed the ability to speak and understand Dutch. Their children had to be without disabilities (e.g.
A
chronic wheelchair patient) that may obstruct adherence to the 24-hour movement behaviour guidelines.
A
Prior to participation in the study, parents had to complete an Informed Consent Form. During the study participants were asked to complete a form asking for their age, sex, and education, and their children’s age and sex.
A
2. Intervention development protocol
The Intervention Mapping (IM) approach was used to guide the intervention development (Bartholomew et al., 1998; Fernandez et al., 2019). IM provided a detailed procedure for evidence-based, step-by-step decision making throughout the development of the MARGA intervention. IM consists of six iterative steps. Step 1 focusses on a needs assessment to obtain a comprehensive understanding of the health problem and factors contributing to the problem. Step 2 defines the desired outcomes in terms of behavioural or environmental changes (Performance Objectives, PO), establishes objectives to address the determinants of these behaviours or environmental factors (Change Objectives, CO), and set clear, actionable goals for the intervention program. Primary objective of the intervention was for preschoolers to spend a sufficient amount of time on the 24-hour movement behaviours. PO’s and CO’s were structured in matrices, in which each PO get CO’s structured per determinant. A potential model to select determinants is the Self-Determination Theory (SDT) (Deci & Ryan, 1975; Ryan & Deci, 2000). SDT is suggested as a useful framework for understanding and organising parenting practices related to preschoolers’ health behaviours (Deci & Ryan, 1975; Pasquale & Rivolta, 2018; Ryan & Deci, 2000). Parenting practices can be interpreted as specific behaviours and strategies that parents use to raise and guide their children. The SDT offers a model to examine the degree to which an individual’s behaviour (e.g., preschoolers’ sleep, SB or PA) is self-motivated, going from a behaviour driven by pressure or fear from an external source (low self-motivation, e.g. driven by expectations from a parent) to personal commitment toward the behaviour (high self-motivation, e.g. the preschooler enjoys to perform a behaviour)(Ng et al., 2012). To be self-motivated three fundamental needs should to be satisfied: autonomy, competence and relatedness. These fundamental needs could function as determinants in the PO and CO matrices of preschoolers. Subsequently, this could offer a clear and structured approach for parents, as the agents of preschooler’s behavioural change (i.e. environmental agents). PO’s for parents, then, would emphasize supporting the basic needs of their preschoolers, in relation to the preschoolers’ 24-hour movement behaviours by 1) supporting the autonomy of the preschooler when engaging in 24-hour movement behaviours (e.g. letting the child choose a bedtime story), 2) providing adequate structure to facilitate the sense of competence when engaging in these behaviours (e.g. clear and consistent rules about screentime) and 3) being positively involved in the engagement in these behaviours (e.g. showing interest for the child’s active play) (Pasquale & Rivolta, 2018). In step 3 of IM selecting evidence-based behaviour change methods are selected and adapted for practical application within the intervention context to address the CO’s in step 2. In step 4 the intervention program is designed by creating the support materials with its program messages and protocols so that the methods and applications are effectively operationalized and the CO’s accomplished. Step 5 focusses on defining implementation strategies for adoption, implementation, and maintenance of the intervention, for example who should disseminate the materials and how should they be disseminated. Step 6 includes planning evaluation strategies to assess the implementation of the intervention and effectiveness, for example what evaluation materials (e.g. accelerometer, questionnaire) are adequate to evaluate whether the intervention goals were obtained.
All IM steps were addressed within the co-creation sessions together with Groups 1 and 2. Nonetheless, these steps were not performed chronologically as IM applies an iterative process, but also to ensure a practical and engaging variation throughout the development process. Group 3 (feasibility group) did not engage in the co-creation process but tested the feasibility of the different co-created intervention components, materials and evaluation procedures (e.g. questionnaires, accelerometers, anthropometry) before final production (Bartholomew et al., 1998). Both co-creation and feasibility testing were facilitated by MD. MD is referred to as “the researcher” in the remainder of the paper. All co-creation and feasibility testing were conducted at the recruitment location (i.e. hospital and primary school), except for feasibility testing of the evaluation procedures, which was performed in the participants’ homes.
2.1 Co-creation sessions
A
All co-creation sessions were conducted between May and October ’22. Each session was facilitated by the researcher, who was assisted by a colleague or Master’s student in Health Promotion. During the sessions, general participatory research principles were applied (Baum, 2016; Leask et al., 2019): 1) creating an informal atmosphere in which co-creators can safely express their opinion and ideas, 2) invest in an enjoyable team atmosphere, 3) allowing co-creators being themselves and have respect for each other, and 4) encouraging parents being co-researchers and co-creators of the intervention and making sure they perceive a feeling of equality.
A
All co-creation sessions were semi-structured and based on IM, but the participants were encouraged to propose their own idea’s related to the topic, which could change the direction of the session. However, the researcher made sure that the content of the sessions remained focussed on the overall goal of the co-creation session.
A
Each session started with a short game or informal chatter to loosen up, followed by explaining the goal of the session. The content of the different sessions and co-creation methods are described in Table 1. In Group 1, seven sessions were conducted and in Group 2, five sessions were conducted. The content of the sessions differed for Group 1 and Group 2 based on difference in pace between the groups and a language barrier in Group 2. In Group 2, all participants had an Arabian mother tongue and were not advanced in Dutch nor English. In Sessions 4 and 5, an interpreter from the primary school assisted to overcome this barrier. When parts of a session in Group 1 were difficult (e.g. conducting PO and CO matrices and selecting methods), it was decided not to conduct these parts in Group 2. The input of both groups was cross-pollinated by the researcher to end up with one intervention that fitted both groups.
Table 1: Overview of sessions in Group 1 (Hospital group), and Group 2 (school group)
Timeframe and number (n) of participants
Step(s) IM
Content and aim
Co-creation methods (Agnello et al., 2024)
Group
Session 1
(n
Group 1 = 7, Group 2 = 4)
1
▪ Introduction to 24-hour movement behaviours and situating the problem of low guideline compliance and consequences on health outcomes
▪ Exploration of barriers and facilitators of a sufficient amount of sleep, less SB and screen time and more PA (part 1)
▪ Introduction to Photovoice (Sutton-Brown, 2014): parents were asked to take pictures of how 24-hour movement behaviours are incorporated in the daily lives of their children by the next session
▪ PowerPoint presentation and online polls (Poll Everywhere, pollev.com) leading to group discussions
1
▪ Presentation with visuals on paper leading to group discussions
2
▪ Discuss barriers and facilitators based on pictures of potential situations
1 and 2
6
▪ Introduction to Fitbits charge 4 as a tool to objectively measure 24-hour movement behaviours. Parents were asked to make their children wear and try-out a Fitbit by next session in order discuss its usability. (https://canarywww.fitbit.com/sg/charge4)
 
1
Session 2
(n
Group 1 = 7, Group 2 = 4)
6
▪ Evaluation of usability of Fitbit
▪ Discuss usability of Fitbit
1
1
▪ Exploration of barriers and facilitators of a sufficient amount of sleep, less SB and screen time and more PA (part 2)
▪ Pictionary to explore barriers and facilitators
▪ Discuss pictures of photovoice on how 24-hour movement behaviours are incorporated in the daily lives of the children (Sutton-Brown, 2014)
▪ Discuss cartoon scenarios
1 and 2
 
2
▪ Exploration of intervention goals
▪ Discuss determinants: the researcher questioned parents’ determinants e.g. “do you feel uncertain as a parent (self-efficacy”), “do you know where to find sport activities for children” (skills ) etc.
2
Session 3
(n Group 1 = 3, Group 2 = 5)
2
▪ Deciding intervention goals (PO and CO)
▪ Order barriers and facilitators based on impact on behaviour and effort to change
▪ Brainstorm: what do we need to change (CO) and what needs to be fulfilled to be able to change it (determinants)?
1 and 2
▪ Order barriers and facilitators based on kind of determinant: e.g. knowledge, self-efficacy, skills. Determinants were explained using emoticons
1
▪ Introduction to Self-Determination theory-based parenting (25, 26)
▪ Discuss visual representation of the Self-Determination theory and applying this theory to the intervention goals
1
3
▪ Explanation and selection of evidence-based applications to obtain the intervention goals (part 1)
▪ Discuss applications for behaviour change
2
Session 4 for Group 1
(n Group 1 = 4)
3
▪ Explanation and selection of evidence-based methods and applications to obtain the intervention goals (part 2)
▪ Individual exploration of a list of evidence-based behaviour change methods and applications
▪ Brainstorm methods: draw a card with an intervention goal from a blinded box and decide on a suitable method to obtain the goal
▪ Brainstorm applications: Order potential applications based on impact and effort per goal
1
Session 5 for Group 1
Session 4 for Group 2
(n Group 1 = 3, Group 2 = 7)
3
▪ Selection of evidence-based methods and applications to obtain the intervention goals (part 3)
▪ Brainstorm applications: Order potential applications based on impact and effort per goal, select favourite applications with smileys per goal
1
3,4,5
▪ Deciding on the program structure (i.e., scope and sequence), intervention theme, channels for delivery and program materials
▪ Order selected applications on a visual delivery timeline with post-its
2 and 1
▪ Brainstorm theme, channels for delivery and program materials – the researcher provided concrete examples for inspiration (e.g. visuals of different kinds of sleep routine templates)
2 and 1
▪ Discuss location, timing, order, content, and design of intervention components
2
Session 6 for Group 1
(n Group 1 = 6)
3,4
▪ Designing program materials
▪ Deciding program structure (i.e. scope and sequence)
▪ Discuss overview of timeline with intervention components
▪ Design stations: several stations were set-up, one for each intervention component to be developed. The group was divided into subgroups and brainstormed using a rotation system at each workstation about the design of the materials, based on examples and questions provided by the researcher
1
Session 7 for Group 1
Session 5 for Group 2
(n Group 1 = 3, Group 2 = 10)
3,4,5
▪ Revision of program materials
▪ Deciding program structure (i.e. scope and sequence), channels for delivery
▪ Discuss presentation of a prototype of the developed intervention
▪ Discuss location, timing, order, content, and design of intervention components
▪ Brainstorm recruitment strategies
▪ Discuss intervention priorities within a certain budget
1 and 2
6
▪ Deciding implementation and evaluation
▪ Brainstorm implementation: who, when and where?
▪ Brainstorm evaluation strategies with concrete measure examples: i.e. questionnaires, accelerometer…
1 and 2
Abbreviations: IM = intervention mapping, SB = sedentary behaviour, PA = physical activity, PO = performance objective, CO = change objective
2.2 Feasibility testing
Feasibility testing was performed in October ’23. Group 3 engaged in four feedback moments in which intervention components, intervention materials and evaluation procedures were tested. This was conducted by the researcher with assistance of master students in health promotion or physical education. The content of these feedback moments was based on the outcomes of the co-creation sessions of Groups 1 and 2, and can be found in the results section. Participants were asked to complete small process evaluation forms and discuss strengths and weaknesses of certain intervention parts. The form contained following questions: 1) “To what extent was the goal of the session clear?”, 2) “To what extent was the content of the session new to you?”, 3) “To what extent are you satisfied with the session?”, 4) “To what extent do you think you can apply the content of the session at home?” Participants could score these questions from 1 to 5 with "1 = not at all" and "5 = to a great extent". Based on the outcomes from this group, final adaptations were made to the intervention program to make it ready to be tested.
Results
1.
Participant characteristics
Table 2 presents the characteristics of the study samples by group. On average, parents were 35.2 years old (SD = 2.82) and had 15.2 years of education (SD = 3.13). The majority of parents were mothers (78.6%). In Group 1 and Group 3 all parents had a child with overweight or obesity, whereas in Group 2, this applied to only 50% of the parents.
Abbreviations:
IM = intervention mapping, 24hMB = 24-hour movement behaviours, PO = performance objective, CO = change objective, h = hours, min = minutes, ST = screen time, PA = physical activity, MVPA = moderate-to-vigorous physical activity
SDT = Self-Determination Theory, group 1 = Hospital group, group 2 = School group
2.
Feasibility testing
It was decided to test only the feasibility of each type of intervention session (i.e., Information sessions, Planning sessions, Support groups and PA games for parents and preschoolers together), rather than all sessions. Also, the support group session was excluded, as its structure closely resembled the co-creation sessions and was therefore already considered feasible. The content and key outcomes of the feasibility testing were described in Supplementary Table S6. Overall the sessions were considered to have a clear goal, to be innovative, satisfying and be applicable to perform at home with an average rating of at least 2.75 (SD = 0.88) out of 5. Several key adjustments were made to the intervention components, materials and evaluation procedures based on the feedback received. The total number of sessions was reduced from ten to seven, as there was additional time left in the information session, and a ten-session intervention was considered too intensive. Parents expressed the need for a presentation by an expert, as the researcher, who facilitated the sessions, was not perceived as sufficiently authoritative in this regard. To address this, a video featuring a worldwide expert of the SDT in the context of parenting was added to explain SDT, instead of having the researcher present it. In the planning session, the explanation by the researcher of what to do after the interactive story, was performed chaotically and unclear as the preschoolers interrupted the explanation by making a lot of noise. To prevent this, additional time for explanation was allocated while preschoolers engaged in a game supervised by session assistants. The weekly schedule's activity cards were considered too extensive and were therefore simplified, for example instead of many different kind of physical activity cards, there would be only one card that represents all physical activities. The questionnaire about parenting practices was revised to make it shorter and more clearly formulated.
3.
The final MARGA intervention program
A
The final MARGA intervention program is outlined in Table 5. The intervention consists of seven group sessions spread over 15 weeks. In the sessions parents and preschoolers gather to optimise the preschoolers 24-hour movement behaviours. Several groups will be created on different locations. Each group is linked to a location and would consist of maximum 12 parent-preschooler dyads. There are four types of sessions (i.e., Information sessions (session 1 and 7), Planning sessions (session 2 and 5), Support group sessions (session 3 and 6), PA games for parents and preschoolers together (session 4). The following is a detailed description of each intervention session:
Session 1 is an introduction session into 24-hour movement behaviours in preschoolers. Parents follow the session and in the meantime preschoolers perform some sport activities with PA master students. To the parents, a Power Point presentation will be given by the researcher who introduces the behaviours through a case example of “What Kamiel the preschooler does during a day”.
A
The 24-hour movement behaviours are linked to health and development outcomes and the 24-hour movement behaviours guidelines are introduced through an online poll who let the parents guess what the guidelines are.
A
A
This is followed by a discussion on whether the parents think their preschooler comply with the guidelines and what makes facilitates and hinders compliance. Thereafter, the researcher provides some information on how the intervention was developed and the SDT is introduced through a video of a professor who is an expert in applying this theory on parenting behaviours. Then, there will be a focus on screen time. Advantages and disadvantages of preschoolers’ screen time will be outlined and discussed and the researcher provides inspiration for alternatives for screen time. This is a “calendar” with small physical activities for preschoolers, a game in which the preschooler can blindly pick activity cards, but screen time activity cards can be only picked once and used for a limited amount of time, and a material box. Every session of the intervention preschoolers can pick a toy from the material box and exchange it to another toy the next session. The parents are encouraged to try these alternatives at home.
Session 2 is a planning session that focusses on week scheduling. The researchers tells an interactive story about a puppet “Mini” who made a week schedule with her parents. The story goes through two of these days as an example for how to use the week schedule. For example, Mini has some screen free days on her week schedule and each day she completed all of her activities she can stick a star on the schedule. On the schedule there are some physical activities that are performed together with the participating preschoolers and parents. After the story, parents and preschoolers make their own week schedule and present their week schedule to other parents and preschoolers. Therefore, they receive a week schedule template with visual activity cards that they can stick on the template. They are encouraged to use the week schedule at home.
Session 3 is a support group session. Preschoolers have a sport session and parents discuss what went well and what did not with regard to the week schedule. Together they help each other on how to deal with difficulties. The researcher also let them link the parenting practices related to the week schedule to the SDT.
A
Parents are also encouraged to further use the week schedule and alternatives for screen time from session 1.
Session 4 consists of PA games for parents and preschoolers together with materials everyone has at home (e.g. blankets, chairs, sweeping brush). Games include a parachute game, an obstacle course, core and lower body work-out, rhythmic games with a drum etc. Parents are encouraged to try the games at home.
Session 5 and 6
are very similar to session 2 and 3, but instead of focussing on a week schedule, these sessions focus on a sleep routine.
In the final session, session 7, preschoolers perform sport activities and the parents reflect on what was learned throughout the sessions with the researcher. Parents also practice tools to help them sustain behavioural change or to deal with a relapse. Examples of tools are setting concrete goals, i.e. SMART goals, SMART stands for Specific, Measurable, Achievable, Relevant, and Time-Bound; if-then plans for problem solving; advantage- and disadvantage schedules to reflect on doing or not doing a behaviour.
Table 2
Characteristics of the parents in both co-creation groups and the feasibility group
 
Co-creation groups
Feasibility group
Group
Group 1
Group 2
Group 3
Total number of participants*
11
10
7
Mean age (SD) (n)
37.7 (3.64) (7)
35.7 (4.07) (7)
32.14 (3.34) (7)
Sex % (female)
64%
100%
71%
Mean years of education (SD) (n)
17.9 (3.62) (8)
11 (4.38) (8)
16.75 (2.55) (7)
Mean age child (SD) (n)
7.30 (2.21) (46% was a preschooler)
Unknown
3.8 (1.00) (8) (all preschoolers)
Sex child % (n, female)
55% (11)
Unknown
40% (8)
Disadvantaged SEP**
0%
100%
0%
Child with overweight or obesity***
100%
50%
100%
* The number of attending parents per session are reported in table 1 for the co-creation groups and table 5 for the feasibility group.
**Verbally reported by the participants during the session. For Group 1 and 2 this was based on their job and for Group 3 this was based on a reference to a Flemish facility that serves as an indicator of SEP as it is only granted when you are subject to the right for an increased allowance by your obligatory health insurance fund, debt mediation or budget management or when you receive an integration income ( https://stad.gent/nl/uit-in-gent/uitpas).
***For Group 1 and 3 overweight or obesity was diagnosed by a paediatrician. For Group 2 this was based on the perception of school staff and verbally reported by the participating parent.
4. Outcomes of the co-creation sessions
All key findings of the co-creation sessions are presented in Table 3. In summary individual outcome objectives of the intervention were that preschoolers engage in: (1) 10 to 13 h of sleep/night, (2) less ST/day (a decrease of ST going from pre to post intervention and no more than 60 min of ST/day post intervention) and (3) more PA/day (an increase in time spent on PA from pre to post intervention and at least PA for 3 h/day of which 60 min MVPA) in the family/home environment. The environmental outcome objective was for parents to actively encourage their preschoolers to get sufficient sleep, reduce ST, and engage in more PA through supportive parenting practices in the family/home environment. The co-creation group decided not to specify a strict minimum amount of change for each movement behaviour, as they believed that "every step counts." For some families, an increase of 5 minutes of PA per day might already be a significant improvement, while others might find it easy to add 30 minutes per day. Ultimately, the key focus was ensuring that there was an increase in preschoolers complying with the 24-hour movement guidelines. These objectives are further detailed in matrices of POs and COs (see Supplementary Table S1-S4). PO’s for preschoolers were:
• “Preschoolers perform more PA/day, at least 3 hours/day of which 1 hour MVPA”,
• “Preschoolers limit screen time to less than 1 hour/day”, and
• “Preschoolers perform a sleep routine before a fixed bedtime every day”.
The determinants to create the CO’s were “Autonomy (perceived control)”, “Competence (self-efficacy and skills)”, and “Relatedness (perceived social support and perceived social bonding)”, based on the SDT that was introduced to the parents. Matrices for parents were created per behaviour of the preschooler. Parents’ PO’s for their preschooler’s sleep were:
• “Parents decide to encourage a sufficient amount of sleep in their preschooler (10 to 13 hours)”,
• “Parents involve their preschooler in developing a sleep routine (structure/competence support, autonomy support)”,
• “Parents let their preschooler choose within their sleep routine, e.g. “which bedtime story do you want?” (autonomy support)”,
• “Parents participate in (parts of) the preschooler’s sleep routine (relatedness/positive involvement)”,
• “Parents consistently implement a sleep routine for their preschooler with a fixed bedtime (structure/competence)”.
PO’s for ST were:
• “Parents decide to encourage less ST in their preschooler”,
• “Parents offer their preschoolers alternatives to screen time to choose from (autonomy support)”,
• “Parents work together with their preschoolers to set rules for the preschooler’s ST (structure/competence support)”,
• “Parents explain why ST rules are important to their preschooler (relatedness/positive involvement)”,
• “Parents consistently implement their preschooler’s ST rules (structure/competence support)”.
PO’s for PA were:
• “Parents decide to encourage more PA in their preschooler”,
• “Parents let their preschooler choose PA (autonomy support)”,
• “Parents compliment their preschooler’s PA (competence support)”,
• “Parents involve the preschooler in planning their preschooler’s PA (structure/competence support, autonomy support)”,
• “Parents involve positively in their preschooler’s PA (relatedness/positive involvement), by showing interest in their preschooler’s PA and by engaging in PA together with their preschooler”.
For all matrices for parents the determinants to create the CO’s were “Knowledge”, “Attitude”, “Skills”, “Self-Efficacy”, and “Perceived social support”, based on input from the co-creation sessions. Once the CO’s were established, appropriate intervention methods were selected. Since parents found this process too abstract, theoretically complex and not engaging, the researcher took the lead in method selection. Parents, however, were more comfortable making practical choices when provided with concrete applications. The connection between COs, methods, and applications is outlined in Supplementary Table S5. Some examples are:
1) verbal persuasion (method) through a PowerPoint presentation to introduce 24-hour movement behaviours and SDT (application);
2) Modelling (method) through an interactive story to parents and preschoolers about a puppet who made a week schedule or sleep routine with her parents;
3) goal setting and planning (method) through a weekly schedule with visual activity cards to stick on the schedule and plan activities (application).
Overall, the selected methods were:
“verbal persuasion”, “consciousness raising”, “modelling”, “goal setting”, “facilitation”, “public commitment”, “repeated exposure”, “guided practice”, “feedback”, “provide opportunities for social comparison”, “planning coping responses/problem-solving”, “direct exposure”, “mobilizing social support”, “self-monitoring of behaviour”, “planning coping responses”, and “set graded tasks”.
The other applications were described in the outlining of the final MARGA intervention in the last part of the result section, as were the intervention materials. The co-creation groups decided to deliver the intervention through group sessions of approximately 1 hour and 30 minutes, held every two weeks over the course of a semester and guided by the same experienced facilitator. Parents, mostly of Group 1, played a key role in designing the intervention materials, incorporating both researcher suggestions and their own input. However, due to time constraints, the full content of all sessions and materials was ultimately developed by the researcher. Parents also preferred not to target preschoolers with overweight or obesity specifically, therefore it was decided to target a general population of preschoolers to avoid stigma. Based on the suggestions of parents, it was also decided to recruit participants through schools, as this would be most efficient to reach a large amount of preschoolers and parents. With regard to implementation, the co-creation groups decided that the researcher who facilitated the co-creation sessions will implement the intervention for parents and preschoolers in a school setting after school hours and in weekends. There will be different intervention groups in different schools at different timepoints to make it more feasible for parents to attend the sessions. Parents will implement the intervention at home for their preschoolers. In the sessions the researchers would also disseminates. As a final outcome, a prototype intervention was developed, consisting of the four types of group sessions – information sessions, planning sessions, support groups and PA games for parents and preschoolers together - spread across 10 sessions. Additionally, parents reviewed the evaluation measures that were suggested by the researcher and agreed they were feasible. Evaluation measures will be planned at three time-points: before the intervention (pretest, T0), immediately after the intervention (posttest, T1), and three months post-intervention (follow-up, T2). These assessments included a demographic questionnaire, a parenting practices questionnaire, and a diary tracking the preschooler's ST and accelerometer wear time, all to be completed by the parents. Additionally, the preschooler will be required to wear an accelerometer for seven consecutive days, 24 hours per day. Anthropometric measurements, including height, weight, waist circumference, and hip circumference, will be conducted to have an estimation of the child’s adiposity. The researcher will coordinate the evaluation procedures and perform the anthropometric measurements.
Table 3
Outcomes of the co-creation sessions: overview of general findings and final decisions per step of the Intervention Mapping
IM steps
Group
General findings
Final decisions
Step 1:
Needs assessment
Session 1
The groups decided to continue co-creating an intervention to fulfil the need to increase PA, limit ST and establish a sufficient amount of sleep in preschoolers in order to improve their preschoolers’ health and wellbeing.
The groups found themselves capable as a planning group within the context of changing 24hMB in preschoolers
The groups will focus on determinants (barriers and facilitators) related to parenting – an interpersonal environmental factor of preschoolers’ 24hMB:
• Parents’ knowledge on a healthy amount of time spent on 24hMB, and inspiration for PA and ST alternatives
• Parents’ self-efficacy due to lack of time or energy, other parents’ or caregivers’ that are not performing the desired parenting behaviour, or the child being defiant
• Parents’ perceived social support to perform desired parenting behaviour in the context of their preschoolers’ 24hMB
*Note
 
Overall findings
1 and 2
Parents acknowledged importance of more PA, less ST and a sufficient amount of sleep
1 and 2
Parents addressed ST guideline is most difficult to comply to
1 and 2
Most parents believed their child has enough PA and were not sure if there child sleep enough
1
Parents addressed their need to improve the self-image of their child
 
Barriers
 
• Lack of knowledge about healthy amount of time spent on the 24hMB
1 and 2
• Time and energy of parent (PA and ST)
1
• Lack of inspiration by parent (PA and alternative for ST)
1
• Others (e.g. grandparents have a different mindset) (24hMB)
1 and 2
• Uncertain about parenting and explaining why (24hMB)
2
• Child is ill (PA and ST)
1 and 2
• Child is defiant
 
Facilitators
1 and 2
• Sport club and playgrounds (PA)
1 and 2
• Sharing experiences with other parents (24hMB)
1 and 2
• Let the child help with household (PA and ST)
1 and 2
• Child has others to play with (PA and ST)
1 and 2
• Weather (PA)
Session 2
 
Barriers
1 and 2
• Energy of the child (ST)
1
• No time for active transport to school (PA)
2
• Priorities of the father (e.g. works late and wants to see the children before bedtime) (Sleep)
2
• Parent does not perform PA (PA)
2
• Inconsistent in ST rules (ST)
 
Facilitators
1 and 2
• Explaining child why there are rules (24hMB)
1
• Checklist with activities, when ST is checked preschoolers are not allowed to do more and PA needs to be done (ST and PA)
1 and 2
• Inspiration list with activities (ST and PA)
2
• Discount for sports club (PA)
2
• Lack of social support/network (24hMB)
1 and 2
• Parental involvement (PA)
2
• Reinforcements for the child (ST)
1 and 2
• Rules and structure(ST)
Step 2:
Goals
Session 2
The overall intervention objective: More preschoolers spent a sufficient amount of time on the 24hMB
Individual outcome: In the family/home environment, preschoolers engage in
• 10 to 13 h/night sleep
• less ST: a decrease of ST going from pre to post intervention and no more than 60 min of ST/day
• more PA: an increase time spent on PA from pre to post intervention and at least PA for 3 h/day of which 60 min MVPA
Environmental outcome: In the family/home environment, parents encourage preschoolers in sufficient amount of sleep, less ST and more PA through parenting practices
Based on the input of the parents, the researcher created matrices with PO’s and CO’s for preschoolers and parents (see supplementary Tables S1 to S4). SDT was used to categorize the determinants of preschoolers and to conceptualize the PO’s and CO’s of parents
2
Preliminary ideas of determinants to work on: attitude towards consistent rules and structure, self-efficacy especially when lack of time or energy, parenting skills and social support for parenting
Session 3
 
Solutions for barriers and facilitators with most impact and least effort
1 and 2
• Rules, structure, planning
1 and 2
• Explaining why
1
• List with inspiration
1 and 2
• Parents being positively involved
1
• Letting child choose
1 and 2
• Children play with parents or other children
1 and 2
• Sharing experiences with other parents
2
• Having materials
 
Focus on SDT
1
They recognized how the basic needs of SDT could be linked to previously mentioned barriers and facilitators. They perceived this as a clear model and saw the basic needs as feasible determinants to work on with their preschooler. For the sake of simplicity in the program, they found it a good idea to focus specifically on these determinants in preschoolers.
Step 3:
Methods, strategies, applications, and program theme, scope and sequence
Session 3
An overview of the final included methods with their applications can be found in supplementary Table S5
Theme of the intervention is a healthy amount of time spent on 24hMB in preschoolers
Several fortnightly group sessions for parents and preschoolers will be organised over the course of about one semester. The order of the sessions can be found in Table 4, presenting the overview of the final intervention.
2
Parents considered support groups and making a plan as helpful to obtain intervention goals
Session 4 for group 1
 
Methods
1
Based on the discussion with parents the following methods were selected.
• Modelling (example: experiences of other parents)
• Planning coping-responses (example: scenarios of difficult situations)
• Verbal persuasion (example: informative presentation by an expert)
• Goal setting (example: plan to sport together with child once/week)
• Mobilizing social support (example: buddy to support)
These methods were supplemented by the researcher after the session.
Session 5 for group 1 and session 4 for group 2
 
Program theme
1
Parents addressed it should be clear that the program is about improving sleep, ST and PA habits. They felt no need for a mascot with a storyline throughout the intervention, nor for a specific intervention name.
 
Program scope and sequence
1 and 2
Parents preferred:
• an intervention for a general preschooler population, not specific for preschoolers with overweight or obesity
• intervention duration of six months
• fortnightly gatherings or sessions for parents and preschoolers of about 1h30min
• no specific order of sessions as long as there is some variation
• the same experienced facilitator throughout the sessions
• to provide the sessions several times on different timepoints and locations to give as many parents as possible the opportunity to participate
Session 6 for group 1 and session 5 for group 2
 
Program scope and sequence
1 and 2
Parents confirmed that the visual timeline presented by the researcher represents their needs and preferences.
Session 7 for group 1
 
Program scope and sequence
1
Parents addressed info about SDT should be provided in the beginning of the intervention, so parents understand the theoretical basis of the intervention.
Parents suggested to address limiting screen time in most sessions as this is the most difficult behaviour to change.
Step 4:
Program materials
Session 5 for group 1
Materials used in the intervention can be found in OSF (DOI 10.17605/OSF.IO/BP8Y7)
The main materials in the intervention are:
• Introduction PowerPoint
• Templates for a week schedule and sleep routine
• Alternatives for ST (e.g., a calendar with PA games, instructions for the use of game pots from which preschoolers can blindly pick a card with a game on)
• Parenting tips from parents
• Overview of movement games that will be performed throughout the sessions
• Tips to sustain behavioural change
• Toys from a material box as an alternative for ST
1
Parents wanted:
• that information sessions should be designed and presented by an expert
• to work with week schedules and sleep routine schedules. There should be a joker for when plans do not work out. It should include a reinforcement aspect. It should be with images.
• support groups facilitated by the same person. Parents suggested to work with cartoon scenario’s similar to the ones in the co-creation session
• a material box to exchange play toys as an alternative for ST
• inspiration to be physically active together with the preschooler
Parents provided some suggestions for games as inspiration for other parents.
Session 4 for group 2
2
Parents were very enthusiastic about the designed materials (note that Group 2 had this session after all sessions in Group 1). The support groups, material box and PA together get the most positive reactions. Opinions varied about the week scheduling and some of the parents had a negative attitude towards planning, structure and rules. It also seemed that SDT was not well understood. The researcher decided to invest in a more clear and visual presentation with practical examples showing the importance of planning, structure, rules and SDT and come back to it in a following session
Session 6 for group 1
1
In the design stations, parents created the drafts and play rules or user manuals for the week schedule, sleep routine, material box and scenario’s for the support group.
There was not enough time to create the content of all sessions and materials. This was taken on by the researcher.
Session 7 for group 1
1
Based on budget limitations, parents suggested to let participants fill the material box with toys they do not use anymore
Session 5 for group 2
2
The revision of the week schedule was well received by the parents. There was a more positive attitude towards planning, structure and rules. The researcher concluded that the improved presentation (cf. session 4 for group 2) effectively communicated the importance of these elements.
Step 5:
Implementation plan
Session 5 for group 1
The researcher who facilitated the co-creation sessions will implement the intervention for parents and preschoolers in a school setting after school hours and in weekends. There will be different intervention groups in different schools at different timepoints.
Parents will implement the intervention at home for their preschoolers
 
Channels for delivery
1
Parents suggested to deliver the intervention through sessions. These should take place on a convenient location e.g. school
Session 7 for group 1
1
Program implementation
Parents advised to reach potential participants through schools and suggested to share contact details of school managements in their network.
If there has to be a focus on preschoolers with overweight, parents adviced to work with paediatricians and not with CLB**, as they felt no bond of trust with CLB staff. However they preferred no focus on overweight and obesity.
When asked who should implement the sessions, parents preferred someone who is an expert in the content of the intervention, like the researcher. Teachers or health professionals might also be adequate, however there is uncertainty about their motivation and availability. Parents preferred the same implementer for all sessions to create a bound of trust.
Parents addressed the intervention will be intense. However, when asked what can be done differently or cancelled, they addressed they preferred to keep the suggested intervention the way it is now as this would meet best their needs and preferences. They suggested to provide intervention sessions at different timepoints and locations to make it more feasible for parents to attend the sessions.
Based on the input of the researcher, parents thought it is a good idea to provide parents with tools to sustain behaviour change and deal with relapse.
Session 5 for group 2
2
Parents addressed implementation is feasible and is not too much, they would be happy to implement the materials at home.
Step 6:
Evaluation
plan
Session 2
The researcher will coordinate and conduct the evaluation of the intervention.
Evaluation measures were planned at three time-points: before the intervention (pretest, T0), immediately after the intervention (posttest, T1), and three months post-intervention (follow-up, T2). These assessments include a demographic questionnaire, a parenting practices questionnaire, and a diary tracking the preschooler's ST and accelerometer wear time, all to be completed by the parents. The preschooler will be required to wear an accelerometer for 7 consecutive days, 24 h/day hours per day. Anthropometric measurements, including height, weight, waist circumference, and hip circumference, will also be conducted to have an estimation of the child’s adiposity.
1
Parents observed that their child was excited to wear the Fitbit. After discussing the result, the Fitbits were found to be unreliable to measure 24hMB in preschoolers
Session 7 for group 1 and session 5 for group 2
1
Parents thought it would be helpful to make the child wear the accelerometer when they also wear one themselves.
Parents suggested to shorten the questionnaire and revise some of the wording to make it more clear. The researcher adapted the questionnaire based on these comments.
2
Parents thought reinforcement is necessary to make their child wear an accelerometer for one week
1 and 2
Parents preferred a diary to measure ST and accelerometer wear time in which they can involve their child, e.g. colour a star every day the accelerometer was worn.
There was a discussion whether the questionnaire should be in different languages. Based on budget limitations the sessions will be in Dutch, and therefore no translation of the questionnaire is required. However there should be an option to go through it verbally for people with Dutch literacy difficulties.
Parents thought the evaluation measurements will take some effort, but they said this to be expected when you participate in this project and get free sessions instead.
*Note for IM step 1: Some decisions later on in the IM process could also be categorized in the needs assessment (step 1), nonetheless those decisions came out of discussions that not specifically addressed step 1. (For example, attitude and skills were added as determinants in the PO and CO matrices, but arised out of discussions about intervention objectives. Also, SDT was used to categorize preschoolers’ determinants. However SDT was mainly introduced to conceptualize parents’ PO’s and CO’s, and therefore categorized as a decision for step 2)
**CLB = Centrum voor Leerlingenbegeleiding (Centre for School Guidance), one of the tasks of this organisation is to perform a health check in children on regularly basis. This includes a check for overweight or obesity based on height and weight measures.
Table 4
Overview of the final MARGA intervention program
Week
Themes
 
Parent
Child
1
Information session:
● Introduction into 24-hour movement behaviours
● Background information about the intervention development
● Introduction to the Self-Determination Theory
● Alternatives for screen time
Sport: Introduction to ball sports
3
Planning session:
● Introduction to week scheduling through interactive story
● Parent and child make a week schedule together
5
Support group:
● Sharing experiences with regard to week scheduling
● Practice Self-Determination Theory
Sport: Introduction to dance
7
Activity games with common home equipment
9
Planning session:
● Introduction to sleep routine through interactive story
● Parent and child make a sleep routine together
11
Support group:
● Sharing experiences with regard to sleep routine
Sport: Introduction to gymnastics
15
Information session:
● Workshop on how to maintain healthy behaviour and how to deal with relapse
Sport: Introduction to athletics
Discussion
Combining co-creation with IM resulted in the successful development of an intervention to optimise 24-hour movements behaviours in preschoolers with overweight and obesity. Despite a focus on preschoolers with overweight and obesity, parents in our study expressed a preference for a general-population intervention to protect their child's self-esteem. This preference guided the intervention’s development while still addressing the needs of preschoolers with overweight and obesity.
In this discussion, we compared our key findings with those of a similar intervention. We discuss how the combination of the IM and co-creation was executed. The level of parental participation was addressed, as well as the way Group 1 influenced the co-creation process in Group 2. Additionally, we reflected on the use of feasibility testing and considered the fact that preschoolers were not involved in the co-creation process. Finally, we outlined the strengths and limitations of the study.
Although developed independently, our intervention shared several similarities with a study of Feng et al. (2022) (Feng et al., 2024), who also developed a parent-focused intervention to optimise the integrated 24-hour movement behaviours in preschoolers. Both studies incorporated behaviour change strategies such as goal setting and planning, and applications such as planning schedules and inspiration for increasing PA and limiting ST. Group workshops were also a shared element in both interventions, although Feng et al. (2022) conducted these workshops online considering the impact of the COVID-19 pandemic. Also, the intervention of Feng et al. (2022) was limited to three group workshop. Further the intervention mainly existed of sending educational materials via e-mail. The parents in our study expressed a preference for in-person meetings. They wanted to experience activities together in the group, such as trying-out movement games together and learning from experiences from other parents and preschoolers. The parents emphasized the importance of real-life connectedness, seeking to establish bonds of trust and fulfil their need for social support in an informal environment. As such a behaviour change method as “mobilizing social support” seemed to be lacking in the intervention of Feng et al. (2022), whereas our study addressed this parental need. In addition, the parents of our study were really enthusiastic about a material box to exchange play toys as an alternative for ST. They believed a new toy every two weeks would facilitate limiting ST. There is no similar intervention material reported for the study of Feng et al. (2022). These differences highlights the importance of actively involving parents in the development process, as it helps identify important behaviour change methods that might otherwise be overlooked. Notably, Feng et al. (2022) did not involve parents in the development process (Feng et al., 2024).
Combining IM with co-creation led to a pragmatic execution of both methodologies. Certain aspects of the intervention’s development were carried out exclusively by the researcher due to the need for strong theoretical knowledge about IM and the underlying processes (e.g. evidence-based methods), and time constraints. These tasks were for example creating PO and CO matrices, selecting behaviour change methods, and finalizing material development. In two previous studies co-creating health interventions with youth, also reported that certain parts of IM necessitated more researcher-driven decisions because they were not engaging, time-consuming, and theoretically complex (Leta et al., 2024; Vandendriessche et al., 2023). Hence, this may have inadvertently led towards more decision-making power of the researcher within certain parts of the co-creation process (Bettencourt, 2018).
The level of parental participation varied across different stages of the intervention development. Davidson’s Wheel of Participation categorizes participation into four quadrants, none of which is inherently superior to another: 1) Informing—participants are informed about decisions made by others; 2) Consulting—participants provide feedback but do not make final decisions; 3) Participating—participants actively collaborate, engaging in joint decision-making with shared responsibilities; and 4) Empowering—participants have full decision-making authority (Carter, 2006; Davidson, 1998). In our study, a continuum ranging from consulting to participating and empowering was applied to the co-creation groups. For example, a method like photovoice allows a more empowering approach as this completely start from the perspective of the parents that took photos in their own living environment to address their specific needs. In this approach there is no interference of the researcher that proposed potential needs to discuss. In the stages where needs were discussed, goals were decided, practical applications selected, and materials designed the parents had predominantly a participating function with shared decision making. In the stages where implementation and evaluation was planned, parents had rather a consulting function. This was mainly due to time constraints. For example parents rather provided feedback on evaluation materials instead of trying-out different materials and making a selection together, which would have been a more participating approach. Group 3, the feasibility group, primarily had a consulting role and provided feedback. Parents were also asked if they desired more responsibility in these later phases of the study, i.e. implementing and evaluating the intervention, such as facilitating group sessions. However, most parents preferred that these sessions would be led by an experienced facilitator. The researcher interpreted that deeper involvement in implementation and evaluation seemed to require more commitment than parents were willing to provide. Their preference for remaining engaged solely in the development phase suggests that they may not have fully perceived the intervention as their own. Nonetheless, the researcher addressed several times that the parents were “co”-creators and “co”-researchers as much as the researcher herself and that the whole group, including the researcher, were equal in the development process. Nevertheless, the researcher got the impression that the parents preferred the researcher to have the final responsibility. This could be attributed to the fact that the researcher initiated the project, rather than it emerging organically from the parents' needs. As is often the case, the research was constrained by funding, and funding organisations typically require a predefined research topic before a study begins (Emke et al., 2024). Additionally, we might have needed to use other co-creation methods to further empower co-researchers and help them feel more comfortable making final decisions and taking responsibility (Agnello, 2023). However, it would have required more time to explore which methods would be most effective, as we did implement some methods – such as voting and ranking during discussions – that should foster decision-making (Agnello, 2023). The study of Agnello et al. (2023) could help finding potential decision-making methods. In fact, the study of Agnello et al. (2023) could be beneficial in general to guide the selection of relevant methods for specific purposes throughout the co-creation process. They created the Co-Creation Rainbow framework in which they categorized a total of 430 methods into five sections (Informing, Understanding, Stimulating, Collaborating and Collective Decision-making) and three themes (Engage, Participate, and Empower) on a continuum of engaging co-creators on an individual to collective basis (Agnello, 2023). Unfortunately, this framework was not yet available when developing the MARGA intervention. In the study of Vandendriessche et al. (2023) (Vandendriessche et al., 2023), the researcher also clearly addressed that all co-creators were equal, but still the researcher took the lead in the implementation process, whereas they addressed that it would have been more beneficial for sustainably embedding the intervention in the desired school setting if a member from the participatory team of teachers could serve as an “internal advocate” to convince school management to take the lead in implementing the intervention (Durlak & DuPre, 2008; Vandendriessche et al., 2023).
Co-creation was conducted in two groups, with sessions first performed in Group 1 and subsequently in Group 2. This staggered approach allowed insights and experiences from Group 1 to inform and refine the co-creation sessions and the intervention in Group 2. This approach was particularly useful given the reduced time available for Group 2, both in terms of the number of sessions and the overall pace of co-creation. A language barrier further slowed down the co-creation process in Group 2. As a result, certain aspects of the co-creation that did not work well in Group 1, such as method selection, were omitted in Group 2 to optimise the process. However, a potential limitation of this approach is that the input from Group 1 may have been overly dominant in shaping the intervention, with Group 2 primarily fulfilling a consultative role, particularly in the later stages. Instead of engaging in creative material design, Group 2 mainly provided feedback on materials developed by Group 1. To know whether Group 2 would have generated similar ideas, both groups would have needed to develop the intervention independently. Nonetheless by having two groups a wider range of parents was reached from different backgrounds, which might have provided more diverse perspectives and might make the intervention more generalizable (O’Loughlin et al., 2021). Furthermore, assessing whether the final intervention meets the needs of other parents requires effectiveness testing and a comprehensive process evaluation. However, feasibility testing provided initial insights into whether the intervention aligns with parental needs.
Feasibility testing is rarely mentioned in intervention development, but is inherently part of IM. Several factors often contribute to omitting this part during intervention development such as a lack of resources and time (Bartholomew et al., 1998; Fernandez et al., 2019; Willoughby & Furberg, 2015). Nonetheless, by testing the feasibility of implementing the intervention, its materials and evaluation procedures, we were able to identify and rectify some issues that might hamper the quality and impact of the intervention. By conducting this iterative refinement our intervention aligns more closely to the needs and preferences of the population of interest, which is essential for achieving desired behavioural outcomes (Bartholomew et al., 1998; Fernandez et al., 2019; Willoughby & Furberg, 2015). The decision to focus on preschoolers with overweight and obesity during feasibility testing - given that parents in the co-creation sessions expressed a preference for targeting the general preschool population - was driven by the original project proposal, for which funding was specifically allocated.
Lastly, preschoolers were not involved as co-creators in the intervention development. We decided to focus on parents due to their central role in shaping preschoolers behaviours. Although previous studies have already incorporated preschoolers in co-creation processes (Gray & Winter, 2011; Lundy et al., 2011; Pascal & Bertram, 2009). Various methods have been used to engage young children, including playful activities such as designing games, storytelling, a wishing tree, role-playing, and arts-and-crafts-based brainstorming sessions (Gray & Winter, 2011; Pascal & Bertram, 2009). Additionally, observational methods in natural environments have been employed to capture young children’s perspectives and behaviours (Gray & Winter, 2011; Pascal & Bertram, 2009). Co-creating with both parents and preschoolers may offer a more comprehensive approach for future interventions aimed at influencing preschoolers’ behaviours. In our study, a preliminary indication of child satisfaction was observed during the feasibility testing phase, when children enthusiastically participated during the sessions.
This study has several strengths. First, this study focused on parents of children with overweight and obesity, who are considered an at-risk group. This ensured that their specific needs were represented in the intervention. Second, the study successfully and pragmatically combined IM with a co-creation approach, ensuring that the intervention was both theory-driven and collaboratively developed with parents. This participatory approach tailored the intervention and evaluation procedure to the needs of parents in optimising 24-hour movement behaviours in their preschoolers. Third, the study specifically engaged a population with a low SEP, a group that is often hard to reach in public health interventions. Finally, feasibility testing was conducted, which is frequently overlooked in early intervention development research but is critical for refining program implementation.
There were also some limitations. First, while the intervention primary outcome targeted preschoolers’ behaviours, the co-creation sessions also included parents of children up to 10 years old, due to recruitment issues. This broader age range may have influenced the discussions, as the needs and experiences of parents with older children could differ from those of preschoolers' parents and these parents might have a recall bias from their preschooler parent years. Second, participant attendance varied across sessions. Although the groups had a total of 7 to 11 participants, some sessions had as few as three attendees, which may have limited the diversity of input and the depth of discussions. Third, selection bias could have occurred in our study. Since the co-creation sessions were conducted in person, parents who preferred physical meetings, have the organisational capacity to attend and are interested in healthy behaviour, might have been more likely to participate. This may have led to in-person meetings during the intervention sessions, while other parents might have preferred online or individual sessions. Future research should explore strategies to enhance recruitment of the intended population of interest, and improve participant engagement throughout the co-creation process. Lastly, this study lacks a profound and comprehensive implementation plan as suggested by IM (Bartholomew LK, 2011; Fernandez et al., 2019). This is mainly due to time constraints and the fact that the researcher herself would be responsible for implementing the intervention. Nonetheless, this cannot lead to a sustainable intervention implementation (Fernandez et al., 2019). A clear implementation plan is needed to promote the use of the intervention and to make it able for others to take the researcher’s role (Bartholomew LK, 2011; Fernandez et al., 2019).
Conclusion
This study demonstrates our use of a co-creative research approach, where parents actively participated in shaping the MARGA intervention. We combined this collaborative process with the IM to ensure a systematic, theory- and evidence-based approach to develop this intervention. In this study, feasibility testing proved valuable in refining the intervention and helped solve issues that might hamper the quality and impact of the intervention. The transparent and detailed development process presented in this study serves as a blueprint for future research and practice, demonstrating how IM can be pragmatically combined with co-creation to create behavioural change interventions. A key next step is to evaluate the intervention’s effectiveness in improving 24-hour movement behaviours in preschoolers.
A
Acknowledgement
The authors thank all parents and staff members of the hospital and school who helped making this study possible. Also, the authors like to acknowledge all researchers and students involved in data collection.
A
Funding
The current study has received financial support from Ghent University-Special Research Fund. The funding body had no input in study design, data collection, analysis, interpretation of data, the writing of the article and the decision to submit it for publication.
Contributions
MD designed and coordinated the paper with the help of MDC and VV. MD collected the data, interpreted the results and wrote the manuscript. GC, RDB, MV, MDC and VV read, provided feedback and approved the final manuscript.
A
Data Availability
The co-creation and intervention materials are available through OSF (DOI 10.17605/OSF.IO/BP8Y7). Data that is lacking in OSF (e.g. notes from the co-creation sessions) are available from the corresponding author on reasonable request.
Ethics approval and consent to participate
A
Ethical approval was obtained from the Ethical Committee of Ghent University Hospital (BC-11699 and ONZ-2023-0229).
A
Parents completed written informed consent for themselves and their preschooler before the start of the study.
Consent for publication
Not applicable.
Declaration of Interest
statement
The authors declare no competing interests.
Declarations
of generative AI and AI-assisted technologies in the writing process
During the preparation of this work MD used ChatGPT to improve language and readability (with caution).
A
After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.
Electronic Supplementary Material
Below is the link to the electronic supplementary material
A
Author Contribution
MD designed and coordinated the paper with the help of MDC and VV. MD collected the data, interpreted the results and wrote the manuscript. GC, RDB, MV, MDC and VV read, provided feedback and approved the final manuscript.
References:
Agnello, D. M., An, Q., de Boer, J., Calo, F., Delfmann, L., Hutcheon, D., Longworth, G. R., Loisel, Q., Mazzei, M., McCaffrey, L., Renzella, J., Smith, N., Steiner, A., Vogelsang, M., & Chastin, S. (2023). Developing and Validating the Co-Creation Rainbow Framework: Assessing Whether Methods Enact Co-Creation Characteristics in a Mixed-Methods Health CASCADE Study. In. Zenodo.
Agnello, D. M., Balaskas, G., Steiner, A., & Chastin, S. (2024). Methods Used in Co-Creation Within the Health CASCADE Co-Creation Database and Gray Literature: Systematic Methods Overview. Interact J Med Res, 13, e59772. https://doi.org/10.2196/59772
Bartholomew, L., Parcel, G., & Kok, G. (1998). Intervention Mapping: A Process for Developing Theory and Evidence-Based Health Education Programs. Health Education & Behavior, 25, 545–563. https://doi.org/10.1177/109019819802500502
Bartholomew, L. K. (2011). e. a. Planning Health Promotion Programs: An Intervention Mapping Approach. (J.-B. S-F, Ed. 3rd Edition ed.). https://doi.org/Planning Health Promotion Programs: An Intervention Mapping.
Approach (2011). 3rd Edition ed. Jossey-Bass S-F, editor.
Baum, F. (2016). Power and glory: applying participatory action research in public health. Gaceta sanitaria, 30 6, 405–407. https://doi.org/10.1016/j.gaceta.2016.05.014
Bettencourt, G. (2018). Embracing problems, processes, and contact zones: Using youth participatory action research to challenge adultism. Action Research, 18, 153–170. https://doi.org/10.1177/1476750318789475
Carter, C. (2006). Environmental Governance: The Power and Pitfalls of Participatory Processes Environmental Science, Political Science. https://consensus.app/papers/environmental-governance-the-power-and-pitfalls-of-carter/899aeb34c16054c7bff71f63b0aeebb2/.
Davidson, S. (1998). Spinning the wheel of empowerment. Planning, 1262, 14–15.
Davison, K., Jurkowski, J., & Lawson, H. (2012). Reframing family-centred obesity prevention using the Family Ecological Model. Public Health Nutrition, 16, 1861–1869. https://doi.org/10.1017/S1368980012004533
Deci, E., & Ryan, R. (1975). Intrinsic Motivation and Self-Determination in Human Behavior. 1-371. https://doi.org/10.1007/978-1-4899-2271-7
Durand, M. A., Carpenter, L., Dolan, H., Bravo, P., Mann, M., Bunn, F., & Elwyn, G. (2014). Do interventions designed to support shared decision-making reduce health inequalities? A systematic review and meta-analysis. PLoS One, 9(4), e94670. https://doi.org/10.1371/journal.pone.0094670
Durlak, J. A., & DuPre, E. P. (2008). Implementation matters: a review of research on the influence of implementation on program outcomes and the factors affecting implementation. American Journal Of Community Psychology, 41(3–4), 327–350. https://doi.org/10.1007/s10464-008-9165-0
Emke, H., Vandendriessche, A., Chinapaw, M., Deforche, B., Verloigne, M., Altenburg, T., & Anselma, M. (2024). Facilitating co-research: lessons learned from reflection forms within three participatory action research projects. Health Research Policy and Systems, 22(1), 117. https://doi.org/10.1186/s12961-024-01210-x
Feng, J., Huang, W. Y., Sit, C. H., Reilly, J. J., & Khan, A. (2024). Effectiveness of a parent-focused intervention targeting 24-hour movement behaviours in preschool-aged children: a randomised controlled trial. Int J Behav Nutr Phys Act, 21(1), 98. https://doi.org/10.1186/s12966-024-01650-2
Fernandez, M., Ruiter, R., Markham, C., & Kok, G. (2019). Intervention Mapping: Theory- and Evidence-Based Health Promotion Program Planning: Perspective and Examples. Frontiers in Public Health, 7. https://doi.org/10.3389/fpubh.2019.00209
Gray, C., & Winter, E. (2011). Hearing voices: participatory research with preschool children with and without disabilities. European Early Childhood Education Research Journal, 19, 309–320. https://doi.org/10.1080/1350293X.2011.597963
Halvorsrud, K., Kucharska, J., Adlington, K., Rüdell, K., Hajdukova, B., Nazroo, E., Haarmans, J., Rhodes, M., J., & Bhui, K. (2021). Identifying evidence of effectiveness in the co-creation of research: a systematic review and meta-analysis of the international healthcare literature. J Public Health (Oxf), 43(1), 197–208. https://doi.org/10.1093/pubmed/fdz126
Jones, R. A., Hinkley, T., Okely, A. D., & Salmon, J. (2013). Tracking physical activity and sedentary behavior in childhood: a systematic review. American journal of preventive medicine, 44(6), 651–658. https://doi.org/10.1016/j.amepre.2013.03.001
Latomme, J., Morgan, P. J., De Craemer, M., Brondeel, R., Verloigne, M., & Cardon, G. (2021). A Family-Based Lifestyle Intervention Focusing on Fathers and Their Children Using Co-Creation: Study Protocol of the Run Daddy Run Intervention. International Journal of Environmental Research and Public Health, 18(4), 1830. https://doi.org/https://doi.org/10.3390/ijerph18041830
Leask, C. F., Sandlund, M., Skelton, D. A., Altenburg, T. M., Cardon, G., Chinapaw, M. J. M., De Bourdeaudhuij, I., Verloigne, M., & Chastin, S. F. M. (2019). Framework, principles and recommendations for utilising participatory methodologies in the co-creation and evaluation of public health interventions. Research Involvement and Engagement, 5, 2. https://doi.org/10.1186/s40900-018-0136-9
Leta, K., Lauwerier, E., Willems, S., Demeester, B., Sabbe, S., & Verloigne, M. (2024). Joining forces: Developing a smoking prevention intervention in social work organisations through co-creation with adolescents and youth workers. Children and Youth Services Review. https://doi.org/10.1016/j.childyouth.2024.107781
Ling, J., Robbins, L. B., Wen, F., & Zhang, N. (2017). Lifestyle Interventions in Preschool Children: A Meta-analysis of Effectiveness. American journal of preventive medicine, 53(1), 102–112. https://doi.org/10.1016/j.amepre.2017.01.018
Lundy, L., McEvoy, L., & Byrne, B. (2011). Working With Young Children as Co-Researchers: An Approach Informed by the United Nations Convention on the Rights of the Child. Early Education and Development, 22, 714–736. https://doi.org/10.1080/10409289.2011.596463
A
Maenhout, L., Verloigne, M., Cairns, D., Cardon, G., Crombez, G., Melville, C., & Compernolle, S. (2023). Co-creating an intervention to promote physical activity in adolescents with intellectual disabilities: lessons learned within the Move it, Move ID!-project. Research Involvement and Engagement, 9(1), 1–16.
Ng, J. Y., Ntoumanis, N., Thøgersen-Ntoumani, C., Deci, E. L., Ryan, R. M., Duda, J. L., & Williams, G. C. (2012). Self-Determination Theory Applied to Health Contexts: A Meta-Analysis. Perspectives on psychological science: a journal of the Association for Psychological Science, 7(4), 325–340. https://doi.org/10.1177/1745691612447309
O’Loughlin, K., Huffstetler, A., Shadowen, H., Brooks, E., Hinesley, J., Huebschmann, A., Glasgow, R., Bohannon, A., & Krist, A. (2021). Stakeholder input on a care planning tool to address unhealthy behaviors, mental health needs, and social risks: The value of different stakeholder perspectives. Journal of Clinical and Translational Science, 5. https://doi.org/10.1017/cts.2021.864
Opgroeien (2024). Gezinsinkomen en (kans)armoede. Retrieved June, 2024 from https://www.opgroeien.be/kennis/cijfers-en-onderzoek/gezinsinkomen-en-kansarmoede#toc-kinderen-in-kansarmoede-naar-woonplaats-type-gemeente-en-origine-moeder
Pascal, C., & Bertram, T. (2009). Listening to young citizens: the struggle to make real a participatory paradigm in research with young children. European Early Childhood Education Research Journal, 17, 249–262. https://doi.org/10.1080/13502930902951486
Pasquale, R. D., & Rivolta, A. (2018). Parenting Influences on Child Obesity-Related Behaviors: A Self-Determination Theory Perspective. https://doi.org/10.5772/intechopen.75118
Rollo, S., Antsygina, O., & Tremblay, M. S. (2020). The whole day matters: Understanding 24-hour movement guideline adherence and relationships with health indicators across the lifespan. Journal of sport and health science. https://doi.org/10.1016/j.jshs.2020.07.004
Ryan, R. M., & Deci, E. L. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. The American psychologist, 55(1), 68–78. https://doi.org/10.1037//0003-066x.55.1.68
Sutton-Brown, C. (2014). Photovoice: A Methodological Guide. Photography and Culture, 7, 169–185. https://doi.org/10.2752/175145214X13999922103165
Tapia-Serrano, M. A., Sevil-Serrano, J., Sánchez-Miguel, P. A., López-Gil, J. F., Tremblay, M. S., & García-Hermoso, A. (2022). Prevalence of meeting 24-Hour Movement Guidelines from pre-school to adolescence: A systematic review and meta-analysis including 387,437 participants and 23 countries. J Sport Health Sci, 11(4), 427–437. https://doi.org/10.1016/j.jshs.2022.01.005
Telama, R., Yang, X., Leskinen, E., Kankaanpää, A., Hirvensalo, M., Tammelin, T., Viikari, J. S., & Raitakari, O. T. (2014). Tracking of physical activity from early childhood through youth into adulthood. Medicine and science in sports and exercise, 46(5), 955–962. https://doi.org/10.1249/mss.0000000000000181
van Dijk-de Vries, A., Stevens, A., van der Weijden, T., & Beurskens, A. (2020). How to support a co-creative research approach in order to foster impact. The development of a Co-creation Impact Compass for healthcare researchers. PLoS One, 15(10), e0240543. https://doi.org/10.1371/journal.pone.0240543
Vandendriessche, A., Deforche, B., Dhondt, K., Altenburg, T. M., & Verloigne, M. (2023). Combining participatory action research with intervention mapping to develop and plan the implementation and evaluation of a healthy sleep intervention for adolescents. Health Promot Perspect, 13(4), 316–329. https://doi.org/10.34172/hpp.2023.37
Vargas, C., Whelan, J., Brimblecombe, J., & Allender, S. (2022). Co-creation, co-design, co-production for public health - a perspective on definition and distinctions. Public Health Res Pract, 32(2). https://doi.org/10.17061/phrp3222211
Verloigne, M., Altenburg, T. M., Chinapaw, M. J. M., Chastin, S., Cardon, G., & De Bourdeaudhuij, I. (2017). Using a Co-Creational Approach to Develop, Implement and Evaluate an Intervention to Promote Physical Activity in Adolescent Girls from Vocational and Technical Schools: A Case Control Study. International Journal of Environmental Research and Public Health, 14(8). https://doi.org/10.3390/ijerph14080862
WHO. (2024). Obesity and overweight. children%20under%205%20years,WHO%20Child%20Growth%20Standards%20median. https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight#:~:text=For%20
WHO Guidelines Approved by the Guidelines Review Committee. (2019). Guidelines on Physical Activity, Sedentary Behaviour and Sleep for Children under 5 Years of Age. World Health Organization.
© World Health Organization 2019.
Willoughby, J., & Furberg, R. (2015). Underdeveloped or Underreported? Coverage of Pretesting Practices and Recommendations for Design of Text Message–Based Health Behavior Change Interventions. Journal of Health Communication, 20, 472–478. https://doi.org/10.1080/10810730.2014.977468
Yes
Total words in MS: 11024
Total words in Title: 15
Total words in Abstract: 290
Total Keyword count: 6
Total Images in MS: 0
Total Tables in MS: 4
Total Reference count: 43