Combined Home and School Obesity Prevention Interventions for Children

Abstract

This review identifies studies describing interventions delivered across both the home and school/community setting, which target obesity and weight-related nutrition and physical activity behaviors in children. Fifteen studies, published between 1998 and 2010, were included and evaluated for effectiveness, study quality, nutrition/activity content, behavior change techniques, and theoretical basis, using validated assessment tools/taxonomies. Seven studies were rated as effective. Behavior change techniques used to engage families, and techniques associated with intervention effectiveness were coded. Effective studies used about 10 behavior change techniques, compared with 6.5 in ineffective studies. Effective interventions used techniques including providing general information on behavior–health links, prompting practice of behavior, and planning for social support/social changes. Different behavior change techniques were applied in the home and school setting. The findings of this review provide novel insights into the techniques associated with intervention effectiveness that can inform the development of public health obesity prevention strategies.

Keywords

behavior change child community obesity prevention parent school

The prevalence of overweight and obesity in children has doubled or even tripled over the past decade in most developed countries and is a global problem (Lobstein, Baur, & Uauy, 2004; Magarey, Daniels, & Boulton, 2001). Excess weight in both childhood and adulthood is associated with significant health and psychosocial consequences (Reilly et al., 2003). Between 40% and 70% of overweight children become overweight or obese adults (Reilly et al., 2003). This highlights the need for effective child obesity prevention interventions (World Health Organization, 1998).

Previous reviews have focused on different aspects of child obesity prevention interventions. These reviews have explored the association between the effectiveness of child obesity prevention interventions and study quality (Doak, Visscher, Renders, & Seidell, 2006; Summerbell et al., 2005), intervention components (e.g., the presence or absence of nutrition, activity, or behavior modification; Caballero, 2004; Summerbell et al., 2005), intervention duration (Summerbell et al., 2005), and the target population (K. Campbell & Hesketh, 2007; Doak et al., 2006; Hesketh & Campbell, 2010). Of particular relevance to the current review, the effectiveness of child obesity prevention interventions by study setting (e.g., school, the family home) has also been the focus of existing reviews (e.g., Brown & Summerbell, 2009; K. Campbell & Hesketh, 2007; De Bourdeaudhuij et al., 2010; Hesketh & Campbell, 2010). These reviews illustrate that effective child obesity prevention can occur in the range of settings in which children spend their time, including the family home, schools, child care, or other community settings.

The family home is a natural setting for obesity prevention interventions. Parents are the “gatekeepers” of the family home serving as role models, controlling the availability of food and providing opportunities for children to be active (Wansink, 2006). Parents are also the “policy makers” of the home as they set rules and create family norms that shape children’s habits (Peterson & Fox, 2007). Previous reviews have shown that child obesity prevention interventions that target parents and the family home can be effective (K. Campbell & Hesketh, 2007; Golley, Hendrie, Slater, & Corsini, 2011). Our previous review of the literature of home-based interventions highlighted that the effectiveness of these interventions was influenced by the degree to which parents are involved in the intervention as well as the behavior change strategies employed (Golley et al., 2011). Outside of the home, schools and other community-based settings are also a popular, logical, and effective setting for the implementation of child obesity prevention interventions (De Bourdeaudhuij et al., 2010; Doak et al., 2006). They offer intensive contact with children (Brown & Summerbell, 2009) and are in a unique position to access a vast majority of children and potentially their parents (Peterson & Fox, 2007).

Child obesity prevention interventions that target multiple settings simultaneously, such as the school and the home environments, are emerging. It has been suggested that a multisetting or multifaceted approach may enhance the effectiveness or sustainability of interventions by influencing the range of settings in which children learn and perform eating and activity behaviors (Summerbell et al., 2005). This is consistent with social ecological models, which suggest that children’s behaviors are influenced by personal as well as wider environmental factors such as parents and the school environment (Livingstone, McCaffrey, & Rennie, 2006). Although previous reviews provide some support for the involvement of parents in school-based interventions (Barlow & the Expert Committee, 2007; Peterson & Fox, 2007), little attention has been given to the specific strategies used in interventions to engage parents and children across both settings. The specific intervention content may influence the effectiveness of combined-setting interventions.

Therefore the aims of this review were to (a) examine the effectiveness of combined-setting (school or community centers and the home) obesity prevention interventions to change children’s weight-related dietary, activity, and sedentary behaviors and risk of obesity and (b) determine whether there is an association between the effectiveness of these combined-setting interventions and the food and activity behaviors targeted and the behavior change techniques (BCTs) used.

Method

Criteria for Considering Studies for Review

A detailed description of the systematic search strategy was published elsewhere (Golley et al., 2011). A brief description is provided below.

Inclusion criteria

Types of intervention studies were the following:

Prospective studies of any duration, published in English, between 1998 and March 2010 (i.e., the initial search covered the 10-year period 1998-2008 and was updated to include March 2010)

Studies evaluating the effectiveness of an intervention run in parallel with a control/comparison group, with outcomes measured at baseline and postintervention

Studies that described community-based (e.g., child care, community centers) or school-based interventions that included a nutrition or activity component AND a behavior change component targeting an increase in physical activity, decrease in sedentary behavior, change in nutrition intake or weight status in children AND involved parents or caregivers. Parental involvement was defined using the following criteria: able to identify parental exposure to intervention, able to identify parental participation (i.e., beyond receipt of a newsletter or pamphlet), and having assessed parental or home outcomes.

The following were the only types of participants

Children aged 1 to 18 years and with at least one parent or caregiver.

Types of outcome measures were the following:

Studies with at least one objectively measured primary outcome or a self-reported subjective outcome assessed using a validated tool

Primary outcomes were assessed at the child level. Secondary outcomes included a variety of measures such as determinants of children’s lifestyle behaviors, focusing on parental characteristics such as knowledge; parent and child interactions such as feeding practices; environmental measures such as food availability; and predictors of behavior change such as self-efficacy

Exclusion criteria

Studies not applicable to the general population (e.g., pregnancy, preterm infants, athletes, weight loss diets, and children with disabilities) and where the intervention description was not sufficiently clear to code its content were excluded. No exclusion criteria regarding study quality or intervention duration were applied.

Search Methods for Identification of Studies

A three-step search strategy was used. A list of search terms and keywords were developed and refined by an information specialist. Search terms were combined under the following headings: Child (1-18 years); School; Caregiver or home; Nutrition-related, activity-related, weight-related; Behavior change theory; Study design; Limits applied—1998-2010 Human, English language. Pubmed (MESH and keyword), Web of Science, Cochrane databases, PsycINFO, and dissertation abstracts were searched. Finally, reference lists of identified reviews and articles were searched for additional studies.

Data Extraction and Synthesis

Reviewers independently extracted data from included studies. Two reviewers independently scored the methodological quality of all studies using the Effective Public Health Practice Project quality assessment tool (Thomas, Ciliska, Dobbins, & Micucci, 2004). Eight quality components were scored (weak/moderate/strong). These included selection bias, study design and allocation bias, confounders, blinding, data collection methods, withdrawals and dropouts, intervention integrity, and analysis. An overall quality rating was assigned: “strong” where four of six key quality assessment criteria are rated as strong, with no weak ratings; “moderate” if less than four criteria were rated strong and one criterion was rated weak; and “weak” where two or more criteria are rated weak. Reviewer differences in rating the quality components were infrequent. In three articles, differences in quality rating were a result of differences in the interpretation of the study details and were resolved by discussion.

The nutrition and activity intervention content were coded independently by two reviewers using definitions developed for this review based on World Health Organization recommendations and existing literature (World Health Organization, 2003). The behavioral change component was coded based on the BCTs used in the intervention using standardized definitions outlined in the taxonomy by Abraham and Michie (2008). The taxonomy defines 26 BCTs with standard definitions. A brief description of each technique is presented in a table later in text. The BCTs taxonomy was developed based on psychological theory and provides a standardized protocol for coding techniques across a range of interventions (Abraham & Michie, 2008). The coding manual for the taxonomy, which was requested from Abraham and Mitchie, clearly describes how to recognize and code each of the BCTs and was used to train coders for this review.

In addition to coding the BCTs, strength of the theoretical basis of the interventions was classified using a taxonomy by Michie and Prestwich (2010). This taxonomy provides instruction as to how strongly theory was used to create intervention, distinguishing reference to theory from using theory to develop and implement interventions. The method for coding the use of theory was similar to a previous review of Internet-based health intervention (Webb, Joseph, Yardley, & Michie, 2010). In total, 11 of 19 original items in the taxonomy were used to rate how strongly theory was applied to the intervention development and implementation. These 11 items cover three elements of theory including how theory was mentioned, whether theory was used to screen or tailor to participants, and how relevant theoretical constructs were targeted.

Two health psychologists independently coded all interventions using both taxonomies. Coding differences were infrequent and were resolved by discussion and consensus using the technique definitions and coding guidelines.

Because of heterogeneity in outcomes, meta-analysis was not conducted. Results are presented in narrative form. A study was classified as effective when there was (a) a significant group effect (intervention vs. control) for an objectively measured outcome including child’s adiposity (e.g., body mass index [BMI] z score or percent overweight) or health risk factors (e.g., cholesterol) OR (b) at least one significant change in a self-reported measure of child’s dietary intake or activity behaviors AND a significant change for at least one determinant of nutrition/activity behavior. Despite the use of validated tools, self-report has the potential for bias. Therefore, significant changes in two self-reported outcomes were needed for a study to be classified as effective. The frequency of “intervention effectiveness” by study characteristics and intervention content was assessed.

Results

Study Description and Quality Assessment

Figure 1 summarizes review article selection. A total of 15 studies evaluated community or school-based interventions that included parental involvement and were reviewed here. These articles are summarized below (additional detail is available online in Supplementary Table 1 at http://heb.sagepub.com/supplemental).

Figure 1.

2002 Quorum statement flow diagram: School-based interventions involving parents or caregivers to facilitate improvements in children’s nutrition, activity, or weight status

All studies included in this review involved preschool- or primary school–aged children, none targeted older children. Two interventions targeted girls only (Baranowski et al., 2003; Story et al., 2003). The intervention setting included schools directly in eight studies, afterschool programs in three studies (Robinson et al., 2003; Story et al., 2003; Tanner, Duhe, Evans, & Condrasky, 2008), child care centers in two studies (Dennison, Russo, Burdick, & Jenkins, 2004; Fitzgibbon, Stolley, Schiffer, Van Horn, & KauferChristoffel, 2005), a kindergarten (Bayer et al., 2009), and a summer day camp (Baranowski et al., 2003). Most studies (n = 10) evaluated interventions up to 6 months duration (5-20 weeks’ duration). The school- or community-based components of all interventions included a group session with children as their primary mode of delivery. The majority of these were teacher or carer administered and incorporated into the curriculum. Home components typically incorporated some level of family participation, for example, setting homework for children to complete with parents or sending out fact sheets for the family.

Outcome evaluation focused on short-term effects (end of intervention) with only four studies conducting follow-up postintervention (Eisenmann et al., 2008; Fitzgibbon et al., 2005; Hopper, Munoz, Gruber, & Nguyen, 2005; Reynolds et al., 2000). Four studies were rated as strong quality (Angelopoulos, Milionis, Grammatikaki, Moschonis, & Manios, 2009; Davis et al., 2003; Eisenmann et al., 2008; Reynolds et al., 2000), eight studies rated as moderate, and three as weak quality (Dennison et al., 2004; Tanner et al., 2008; Warren, Henry, Lightowler, Bradshaw, & Perwaiz, 2003) according to the Effective Public Health Practice Project quality assessment tool. The quality criteria on which studies performed most poorly were those relating to selection bias and withdrawals and dropouts.

Intervention Outcomes

Interventions targeted children’s weight and weight-related behaviors of nutrition, physical activity, and sedentary behaviors. A summary of study outcomes is discussed below and shown in Table 1.

Table 1.

Results Summary of Combined-Setting Interventions to Change Children’s Weight-Related Nutrition Intake or Activity Patterns or Determinants of Behavior

							Intervention Effective*
Study	Weight Status/Lipids		Nutrition Intake/Activity Patterns		Determinants of Nutrition/Activity Behavior		End-I	FU
Hopper, Munoz, Gruber, and Nguyen (2005)	BMI	✘	Total fat intake (g): End-I: 57.05 ± 4.21 vs. 64.68 ± 0.87, p < .05	✓	Child knowledge	✓	Yes	No
	Skin fold sum	✘	Kilojoules	✘
	Cholesterol	✘	Physical activity	✘
Story et al. (2003)	BMI	✘	Physical activity	✘	Child intentions to choose healthy foods, diet knowledge, child’s perception of parental encouragement	✓	No	—
	Waist circumference	✘	Fruit and vegetables (serves), sweetened beverage (serves), water	✘	Child self-efficacy, perceived fruit and vegetable snack availability	✘
			Kilojoules	✘	Child physical activity preference	✓
			% Energy from fat	✘	Parent reported availability of high-fat food, low-fat food practices, self-efficacy for healthy food preparation	✓
					Parent reported activity variables	✘
Baranowski et al. (2003)	BMI	✘	Kilojoules	✘	Physical activity preference	✘	No	—
	Waist circumference	✘	% Energy from fat	✘	Sweetened beverage preference	✘
	% Body fat	✘	Physical activity	✘
			Fruit and vegetables (serves), sweetened beverage (serves), water	✘
Dennison, Russo, Burdick, and Jenkins (2004)	BMI	✘	TV/video viewing (hours/day), End-I: Weekdays	✓			No	—
	Skin folds	✘	0.37 ± 0.15 vs. 0.25 ± 0.17, p < .05; Sundays 0.78 ± 0.22 vs. 0.21 ± 0.26, p < .05
Reynolds et al. (2000) ^a			Fruit and vegetable (serves), FU: 3.20 vs. 2.21, p < .01	✓	Child knowledge, outcome expectancy, self-efficacy	✓	Yes	Yes
			Macronutrient intake (%kJ), FU: % kJ fat: 31.56 vs. 33.23, p < .05; FU: % kJ carbohydrate: 55.18 vs. 53.17, p < .05	✓	Child asking skills, perceived social norms	✘
			Selected micronutrient and fiber intake, Fiber(g): FU: 10.68 vs. 9.23, p < .05	✓	Parent outcome expectancy, perceived fruit and vegetable availability	✘
			Parent fruit intake	✘	Parent self-efficacy and knowledge	✓
			Parent vegetable intake (serves), End I: 2.43 vs. 2.22, p < .05	✓
Fitzgibbon, Stolley, Schiffer, Van Horn, and KauferChristoffel (2005)	BMI, End-I: Difference −0.53(−0.91 to −0.14), p < .05, FU: −0.54 (−0.98 to −0.10), p < .05	✓	Saturated fat (% kJ)	✓	Child knowledge	—	No	Yes
			End-I: −1.15 (−1.74 to −0.56), p < .01
	BMI z score, End-I:	✓	Total fat and dietary fiber	✘	Parental support and role modeling	—
	Difference −0.23		TV viewing (hours/day)	✘
	(−0.38 to −0.09), p < .01; FU: −0.18(−0.31 to −.04), p < .05		Physical activity (frequency and intensity)	✘
			Parent intake	-
Eisenmann et al. (2008)	BMI (boys only), FU: 19.1 vs. 19.4, p < .05	✓	Parent reported screen time (hours/week), End-I: 22.8 ± 0.7 vs. 24.6 ± 0.3, p < .05; FU: 23.7 ± 0.5 vs. 25.7 ± 0.5, p < .05	✓	Child-perceived TV exposure, parental monitoring, attitudes, pleasure in nonscreen activity, sleep, snacking habits	—	Yes	Yes
			Parent reported fruit and vegetable intake (frequency), End I: 24.9 ± 0.7 vs. 22.6 ± 0.4, p < .05 FU: 22.5 ± 0.7 vs. 21.3 ± 0.3, p < .05	✓	Parent reported family media habits, attitudes, monitoring, rules	—
			Child reported fruit and vegetable intake (frequency), End-I: 4.1 ± 0.2 vs. 4.0. ± 0.1, p < .05	✓	Teacher-reported prosocial habits	—
Bayer et al. (2009)	Weight status (classification overweight and obese)	✘	Higher fruit consumption, End-I: Odds ratio (control group as reference) 1.59 (1.26-2.01), p < .01	✓	Purchasing of low-fat milk	✘	No	—
			Higher vegetable consumption, 1.48 (1.08, 2.03), p < .05	✓
			Low-kilojoules drinks, energy-dense sweets, and unhealthy snack in front of TV	✘
			Fitness	✘
Angelopoulos, Milionis, Grammatikaki, Moschonis, and Manios (2009)	BMI End-I: −1.1 (−1.2 to−0.9) vs. 0.1 (−0.03 to 0.2), p < .05	✓	Physical activity (minutes), End-I: 2.2 (−2.6 to 7.1) vs. −16.4 (−21.1 to −11.7), p < .05	✓			Yes	—
	BMI z score	✘	Food group intake—Meat, grains, vegetables	✘
	Blood pressure (mmHg) End-I: Systolic decreased −1.6 vs. 1.9; Diastolic decreased −0.5 vs. 2.3, p < .05	✓	Food group intake (serves), End-I: Fruit increased 0.4 vs. −0.2, fats and oils decreased −1.0 vs. 0.7, dairy decreased −0.2 vs. 0.2, sweets and beverages decreased −0.8 vs. 0.2, all p < .05	✓
Burgess-Champouxt, Chan, Rosen, Marquart, and Reicks (2007)			Wholegrain and refined grain intakes (serves), End-I: Wholegrain increased 1.05 ± 0.2 vs. 0.09 ± 0.1, p < .01; Refined grain decreased −1.11 ± 0.2 vs. −0.46 ± 0.2, p < .01	✓	Child knowledge, usual food choice, availability and self-efficacy	✘	Yes	—
			Dietary fiber (g), End-I: Increased 1.3 ± 3.7 vs. −0.4 ± 2.4, p < .05	✓	Parent role modelling and enabling behavior	⎫
			Riboflavin and iron (mg), End-I: Riboflavin increased 0.03 ± 0.24 vs. −0.06 ± 0.24, Iron increased 0.4 ± 2.4 vs. −0.4 ± 1.7, p < .05	✓	Parent perceived health benefits and availability	✘
			Other micronutrients (B vitamins)	✘
			Parent dietary intake	✘
Warren, Henry, Lightowler, Bradshaw, and Perwaiz (2003)	Weight status (classification overweight and obese)	✘	Fruit and vegetables (frequency)	✘	Child knowledge	✘	No	—
			Confectionary and crisps (frequency)	✘	Parent knowledge	✘
			Active transport and play (time effect only)	—
			Parent dietary intake	✘
Robinson et al. (2003)	BMI	✘	Physical activity	✘	Eating dinner in front of TV	✓	No	—
	Waist circumference	✘			Eating breakfast in front of TV	✘
					Household TV use	✓
					Child activity liking	✘
Lytle et al. (2004)			Fruit and vegetable	✘	Child food choice preferences	✓	No	—
			Fat intake (% energy)	✘	Parent food choice preference	✓
					Home availability	✘
Tanner, Duhe, Evans, and Condrasky (2008)			Fruit and vegetable intake	✘	Parent social support and perceived fruit and vegetable availability	✓	No	—
					Parent emotional support, motivation	✘
					Child self efficacy, motivation, and perceived parental support	✘
Davis et al. (2003)	% Body fat	✘	Physical activity (index score), End-I: 0.27 vs. 0.24, p < .01	✓	Child knowledge, attitudes, activity self-efficacy, food choice intentions	✓	Yes	—
	Skin fold	✘	Kilojoules, End-I: 1,892 vs. 2,157, p < .01, Total fat (% kJ), End-I: 31.1 vs. 33.6, p < .01	✓	Child food self-efficacy	✘

Note. End-I = end of intervention; FU = follow-up; BMI = body mass index. Means (Intervention vs. Control unless otherwise stated) are shown for objective measures and self-reported behaviors from effective studies only. ✓ indicates significant result, ✘indicates nonsignificant result, — indicates variable measured but not reported.

Only 24-month data are shown.

Effective intervention = (a) a significant group effect for an objectively measured outcome or (b) at least one significant change in a self-reported measure and a significant change for at least one determinant of behavior.

Weight status and health risk factors

Eleven interventions included a measure of weight status reporting BMI, weight status classification, or percent body fat. Eight studies reported BMI as their primary outcome, of which three reported significant decreases (Angelopoulos et al., 2009; Eisenmann et al., 2008; Fitzgibbon et al., 2005). Two studies included a health risk factor outcome—cholesterol (Hopper et al., 2005) and blood pressure (Angelopoulos et al., 2009). One study targeted obesity indices and blood pressure and reported significant decreases in systolic and diastolic blood pressure (Angelopoulos et al., 2009).

Nutrition and activity

Thirteen studies included a self-reported measure of dietary intake and nine studies included a measure of energy expenditure. Nine studies reported children’s consumption of fruit and vegetables (Angelopoulos et al., 2009; Baranowski et al., 2003; Bayer et al., 2009; Eisenmann et al., 2008; Lytle et al., 2004; Reynolds et al., 2000; Story et al., 2003; Tanner et al., 2008; Warren et al., 2003), four with significant results (Angelopoulos et al., 2009; Bayer et al., 2009; Eisenmann et al., 2008; Reynolds et al., 2000). Seven studies reported on changes in fat intake, three reported significant decreases in total fat (Davis et al., 2003; Hopper et al., 2005; Reynolds et al., 2000), and one a significant reduction in saturated fat (Fitzgibbon et al., 2005). Five studies reported changes in children’s total energy intake, with two studies reporting a significant reduction in kilojoules consumed (Bayer et al., 2009; Davis et al., 2003).

Nine studies reported outcomes of children’s physical activity (Angelopoulos et al., 2009; Baranowski et al., 2003; Bayer et al., 2009; Davis et al., 2003; Fitzgibbon et al., 2005; Hopper et al., 2005; Robinson et al., 2003; Story et al., 2003; Warre et al., 2003), and three studies reported on television viewing (Dennison et al., 2004; Eisenmann et al., 2008; Robinson et al., 2003). Three studies reported significant changes in children’s physical activity (Angelopoulos et al., 2009; Bayer et al., 2009; Davis et al., 2003), one using a self–reported measure (Davis et al., 2003). Significant changes in television viewing was reported in two (Dennison et al., 2004; Eisenmann et al., 2008) of the three studies.

Factors influencing lifestyle behaviors

In all, 13 of the 15 interventions included one or more influences or determinants of lifestyle behaviors as study outcomes. These included child characteristics such as knowledge, food preferences, and activity preferences; parent characteristics such as knowledge, attitudes, and outcome expectancy; and parent and child interactions such as role modeling, perceived encouragement, and support; environmental measures such as food availability; and predictors of behavior such as parent and child self-efficacy. Study results for these outcomes are summarized in Table 1.

Intervention Effectiveness and Quality

Study outcomes favored “intervention effectiveness” in 7 of the 15 studies (Table 1). Fitzgibbon et al.’s (2005) effort to reduce children’s BMI was not effective in the short term (postintervention); however, in the longer term (1-2 years’ follow-up), the difference in BMI between the intervention and control groups was significant. This study was rated as effective because of this longer term effect.

Four of the effective studies received a strong quality rating (Angelopoulos et al., 2009; Davis et al., 2003; Eisenmann et al., 2008; Reynolds et al., 2000), the remaining were moderate quality (Burgess-Champouxt, Chan, Rosen, Marquart, & Reicks, 2007; Fitzgibbon et al., 2005; Hopper et al., 2005). Of the ineffective studies, three were rated as weak (Dennison et al., 2004; Tanner et al., 2008; Warren et al., 2003) and the other five as moderate quality (Baranowski et al., 2003; Bayer et al., 2009; Lytle et al., 2004; Robinson et al., 2003; Story et al., 2003).

Intervention Behavior Change Techniques and Behavioral Components With a Focus on Effectiveness

Number and setting where techniques were applied

Effective studies used a median of 10 BCTs (range 8-13), whereas studies classified as ineffective used a median of 6.5 techniques (range 1-14). For effective studies, the median number of techniques applied in the school or community setting was 8 (range 5-10) and in the home 7 (range 5-9). In the ineffective studies, the median number of techniques used in the school or community setting was 5.5 (range 1-11) and in the home 4.5 (0-9).

Description of the techniques used

Table 2 lists the BCTs used to code intervention descriptions. The additional brief descriptions provided here are taken from Abraham and Michie’s (2008) coding manual. The most commonly used techniques were prompting intention formation (i.e., “encouraging a person to set a general goal”) and providing instruction (i.e., “telling them how to perform a behavior”). These techniques were used in 13 of the 15 studies reviewed (Table 2). Self-monitoring and modeling/demonstrating the behavior were also frequently used (in 10 of the 15 studies reviewed). There was no apparent association with effectiveness as these techniques were commonly used in both effective and ineffective interventions.

Table 2.

Behavior Change Technique Taxonomy and Frequency of Techniques Used in Interventions, by Effectiveness and Setting

	By Effectiveness			By Setting
	Effective Studies	Ineffective Studies	Total	School Component			Home Component
Behavior Change Techniques as Defined by Abraham and Michie (2008) Taxonomy	7 Studies	8 Studies	15 Studies	Effective	Ineffective	Total	Effective	Ineffective	Total
1. Provide general information on behavior–health link	6	1	7	4	1	5	4	0	4
2. Provide information consequences	1	3	4	0	3	3	1	1	2
3. Provide information about others approval	0	0	0	0	0	0	0	0	0
4. Prompt intention formation	7	6	13	5	5	10	4	5	9
5. Prompt barrier identification	3	4	7	3	3	6	1	2	3
6. Provide general encouragement	5	4	9	4	3	7	5	3	8
7. Set graded tasks	1	0	1	0	0	0	1	0	1
8. Provide instruction	7	6	13	7	5	12	7	6	13
9. Model/demonstrate the behavior	5	5	10	5	5	10	3	0	3
10. Prompt specific goal setting	3	3	6	0	3	3	3	1	4
11. Prompt review of behavioral goals	0	1	1	0	1	1	0	1	1
12. Prompt self-monitoring of behavior	6	4	10	3	3	6	6	3	9
13. Provide performance feedback	3	1	4	2	0	2	1	1	2
14. Provide contingent rewards	5	3	8	3	2	5	4	3	7
15. Teach to use prompts/cues	0	2	2	0	2	2	0	1	1
16. Agree behavioral contract	0	0	0	0	0	0	0	0	0
17. Prompt practice	6	3	9	6	3	9	1	0	1
18. Use of follow-up prompts	0	0	0	0	0	0	0	0	0
19. Provide opportunities for social comparison	4	5	9	3	4	7	2	1	3
20. Plan social support/social change	6	3	9	2	1	3	5	3	8
21. Prompt identification as role model/position advocate	4	5	9	4	4	8	2	4	6
22. Prompt self-talk	0	0	0	0	0	0	0	0	0
23. Relapse prevention	0	0	0	0	0	0	0	0	0
24. Stress management	0	0	0	0	0	0	0	0	0
25. Motivational interviewing	0	1	1	0	0	0	0	1	1
26. Time management (including planning	0	0	0	0	0	0	0	0	0

Note. Items in italics show differences, and items in boldface show most commonly used.

One technique, providing general information about the behavior–health link, was used more commonly in effective interventions, with six of the seven effective studies using the technique. In contrast, only one ineffective study described using this technique (Warren et al., 2003). Other techniques commonly used in effective interventions were prompting practice (i.e., “rehearsing or repeating behavior numerous times”) and planning for social support or social change (i.e., “instrumental social support” or “prompting the person to think about how others could change their behavior”). These techniques were used in six of seven effective studies.

The coders identified the use of “ecological techniques” in numerous interventions. These techniques were not included in the existing BCTs taxonomy but relate to children’s surroundings. Techniques were coded as an aspect of the intervention that sought to alter children’s direct environment (i.e., implementing a healthy lunch policy at the school canteen). Four interventions (Baranowski et al., 2003; Robinson et al., 2003; Story et al., 2003; Tanner et al., 2008) were delivered outside the children’s regular school curriculum, for example, in an after-school care setting, which may have reduced the amount of exposure children had to these environmental changes, given children spent less time in these activities compared with programs delivered in schools. Therefore, because of heterogeneity in the environments targeted, these interventions were not compared with others in the use of ecological techniques.

Two of the remaining 11 interventions had strong ecological components—targeting changes in the school environments, such as the foods available from the canteen (Bayer et al., 2009; Lytle et al., 2004)—but were classified as ineffective. Three interventions using ecological techniques aimed to alter both the home and school environments (Angelopoulos et al., 2009; Burgess-Champouxt et al., 2007; Reynolds et al., 2000), and all were effective. Two interventions applied ecological techniques to the home environment only without targeting the school (Davis et al., 2003; Dennison et al., 2004), and one was effective (Davis et al., 2003).

Techniques used in the school or community compared with home settings

The number and types of techniques used in the school or community and home within the interventions were relatively similar, although a few differences were observed (Table 2). Modeling the target behavior, social comparison, and prompting practice were techniques described more commonly in the school/community setting than in the home. Ten studies used modeling in the school/community setting, whereas three used this technique at home. It is interesting to note that the three studies that used modeling in the home environment were all successful (Burgess-Champouxt et al., 2007; Davis et al., 2003; Fitzgibbon et al., 2005). Prompting practice was used by nine studies in the school/community and one in the home. Planning for social support/change was used more commonly in the home setting, with eight studies using this technique at home compared with three in school/community. It is interesting to note that prompting specific goal setting was used equally in the home and school/community; however, it was more commonly associated with effectiveness in the home setting (Table 2).

Most of the interventions analyzed used parents and the home environments to reinforce lessons or activities learnt by children in the school/community setting; however, the intensity of the parent, or home, component of interventions varied. Studies that incorporated a lower intensity parent or home component (Bayer et al., 2009; Lytle et al., 2004; Reynolds et al., 2000; Tanner et al., 2008; Warren et al., 2003) were largely ineffective (with one exception, Reynolds et al., 2000). Five studies engaged the family as a whole, with a relatively high intensity. This included setting family goals or performing activities together as a family rather than focusing on individual responsibility of a child or a parent. Four of these studies were effective (Burgess-Champouxt et al., 2007; Davis et al., 2003; Eisenmann et al., 2008; Hopper et al., 2005).

Theoretical basis of intervention

Coding from the Michie and Prestwich (2010) taxonomy was used to create a score out of 11—a higher score reflecting a more theoretically based intervention. Effective studies scored a median of 7 (range 3-9), compared with the ineffective studies with a median of 5 (range 0-9). Most interventions scored similarly in their reference to theory—all but two studies (Bayer et al., 2009; Dennison et al., 2004) used at least one theory to develop their intervention content. The most common theory used to guide the development of the interventions was Bandura’s (1986) social cognitive theory (SCT) or social learning theory. Nine articles described the use of these theories (SCT: Baranowski et al., 2003; Burgess-Champouxt et al., 2007; Lytle et al., 2004; Reynolds et al., 2000; Robinson et al., 2003; Story et al., 2003; Tanner et al., 2008; social learning theory: Davis et al., 2003; Hopper et al., 2005). Three interventions were based on multiple theories (Angelopoulos et al., 2009; Fitzgibbon et al., 2005; Story et al., 2003), and one intervention was developed using an ecological model (Eisenmann et al., 2008).

No interventions used theory to select or tailor the intervention to participants, although some tailoring and participant selection was based on culture (Baranowski et al., 2003; Davis et al., 2003; Fitzgibbon et al., 2005; Robinson et al., 2003; Story et al., 2003). The degree to which interventions were designed to target appropriate theoretical constructs varied between effective and ineffective studies (Table 3). In terms of how well interventions targeted theoretical constructs, six effective studies were rated as moderate or strong, whereas six ineffective studies were rated as weak.

Table 3.

Number of Effective and Ineffective Studies Meeting Criteria for Theory-Based Interventions

	Effective Studies	Ineffective Studies
Theory mentioned^a (scored 3 out of a possible 3)	5	5
Theory used to screen participants^b (scored 2 out of a possible 2)	0	0
Score for targeted theoretical constructs (out of a possible score of 5)^c
Weak (scored 0-1)	1	6
Moderate (scored 2-3)	3	1
Strong (scored 4-5)	3	1

Note. All item numbers mentioned in the table notes refer to those published in the original taxonomy (Michie & Prestwich, 2010). Details for Item 5 are viewable in Supplementary Table 1.

Items 1 and 2.

Items 4 and 6.

Items 7-11.

Discussion

Children’s weight status and weight-related lifestyle behaviors are influenced by the different settings in which they spend their time. Obesity prevention interventions that target multiple settings—including community settings such as schools and children’s homes via parents—may enhance the impact and sustainability of obesity prevention efforts. This review aimed to evaluate the effectiveness of combined-setting obesity prevention interventions with a parental component, and explore whether effectiveness is influenced by the specific intervention content. We identified 15 obesity prevention studies that targeted both the school/community setting and home—7 were considered to be effective. Three studies were able to reduce obesity in children, shown by reductions in BMI. Eight studies were shown to be effective in improving diet, with children’s fruit and vegetable and fat intakes most commonly targeted. Two studies were effective in increasing physical activity, and one study decreased television viewing. Our results, consistent with others (Eisenmann et al., 2008; Katz, O’Connell, Njike, Yeh, & Nawaz, 2008), suggest that implementing obesity prevention interventions across multiple settings can be successful in reducing obesity and improving children’s weight-related behaviors.

We examined whether the BCTs used were associated with intervention effectiveness and whether this differed by setting. We found a link between intervention effectiveness and the number of BCTs incorporated, with effective interventions including about 10 techniques. In the effective interventions, a similar number of techniques were used in both the school/community and home settings, implying that in combined-setting interventions parents still have an important role in supporting behavior change in their children. The key BCTs that distinguished effective from ineffective interventions were the provision of information about the behavior–health link (providing knowledge), prompting practice (repeating behavior many times), and planning for social support (thinking how others could change their behavior; Table 4).

Table 4.

Summary of Behavior Change Techniques Used in Effective Combined-Setting Interventions and in the School or Community and Home Settings Specifically

Behavior Change Techniques Associated With Intervention Effectiveness
• Providing general information on behavior-health links
• Prompting practice
• Planning social support/social change
In the school/community setting	In the home setting
• Providing general information on behavior-health links	• Providing general information on behavior-health links
	• Model/demonstrate the behavior
• Prompting practice	• Prompting self-monitoring of behavior

Using complementary BCTs in the both home and school environments can improve outcomes in children. For example, when teachers provide children and their families with information about the behavior–health link, children can be encouraged to practice or repeat the desired behavior, and the home environment can provide additional opportunities for practicing and modeling the desired behavior learnt at school. Another example of the complementary role of the family in school-based intervention is the finding from this review suggesting that when school-based interventions ask parents and children to set goals together or make changes as a family they were more successful than when they did not address the family as a unit.

It is expected that the findings from interventions targeting single versus combined settings would differ. Factors such as the diversity in intervention design and study outcomes can influence effectiveness in a given setting. Using multiple settings means that the interventions may be more immersive and that children receive intervention messages through more than one environment. As a result, these interventions have the potential to be more effective than a single-setting approach. However, there is a high degree of complexity when spreading intervention strategies across multiple settings as each setting may require its own distinct approach.

In our previous review of interventions delivered within the home only, the number of techniques used was not associated with effective behavior change in children. Instead, the types of techniques distinguished effective from ineffective interventions (Golley et al., 2011). Effective interventions used prompting of barrier identification, self-monitoring, and specific goal setting as techniques to change children’s behavior (Golley et al., 2011). In effective combined-setting interventions, we also found that self-monitoring formed part of the home component. From a practical perspective, self-monitoring can be relatively easily incorporated into a family routine, school curriculum, or community programs through activities such as food and physical activity diaries or checklists. The inclusion of self-monitoring into obesity prevention interventions, regardless of the setting, appears to be associated with effectiveness (Golley et al., 2011; McLean, Griffin, Toney, & Hardeman, 2003).

It is well recognized that interventions, particularly complex behavioral interventions such as those for obesity prevention, with a theoretical underpinning may be more successful (M. Campbell et al., 2000; Cerin, Barnett, & Baranowski, 2009; Webb et al., 2010). We found that almost all studies reviewed reported the use of theory to guide the development of interventions. However, the degree to which a theory promotes success depends on how well it is used. Analysis of the application of theory in interventions revealed that the use of theory to guide the development of intervention techniques and the inclusion of theoretically derived constructs was associated with effectiveness. In studies where theory was embedded into their design (i.e., constructs derived from the theory were applied in intervention components), the interventions were more likely to be effective than those that simply cited having a theoretical framework.

SCT is commonly used in obesity interventions (Sharma, 2006), and was referred to in most of the studies reviewed here. SCT suggests that learning and the acquisition of behavioral patterns are determined by reciprocal determinism between behavior, environments, and personal factors (Bandura, 1986). The theoretical coding used here did not rate how truly the constructs measured by studies reflected SCT but rather relied on the interpretation of this theory by the authors describing the intervention. Therefore, it is difficult to comment on how well the interventions represented the theories presented. Nevertheless, there appears to be a relationship between the strength with which interventions target theoretical constructs and intervention effectiveness. It is important that health professionals recognize the importance of careful theory-based intervention planning for behavior change (Cerin et al., 2009; Green & Kreuter, 1999; Sallis et al., 2000).

In this review, we have described the BCTs associated with effective intervention. In addition to specific techniques, we found that study quality was linked to effectiveness. Four of the 7 effective studies but no ineffective studies were of strong quality. In addition, 8 of 15 studies were considered to be ineffective. This highlights the need to improve the study design and quality as well as the reporting of obesity interventions to aid our understanding about which intervention components are associated with effectiveness.

This review focused on intervention setting and the effectiveness of techniques used within each setting, under the premise that effectiveness could be associated with the use and appropriateness of techniques for different settings. Although our focus was on intervention setting, it is also possible that the targeted health behaviors themselves may interact with setting and effectiveness. We discuss behavior change related to weight-related outcomes and therefore the studies analyzed assessed a variety of discrete health behaviors, including both diet and activity behaviors. Some interventions targeted a unique behavior (e.g., Dennison et al., 2004), and others focused on a combination of outcomes (e.g., Eisenmann et al., 2008). It is possible that some behaviors are easier to change or that interventions targeting certain behaviors are more effective in certain settings. For example, physical activity is generally part of the school curriculum and therefore it may be considered a natural behavior to target in this setting. Although analysis at this level was outside the scope of the current review, our finding that setting can influence how different techniques are associated with effectiveness indicates that considering the discrete behavioral targets in combination with the intervention setting and BCTs is a promising avenue for future research.

One limitation of this review is that intervention effectiveness was based on significance of results without concession for pilot study design. Very few articles included a power calculation (Angelopoulos et al., 2009; Eisenmann et al., 2008; Fitzgibbon et al., 2005; Lytle et al., 2004), and therefore it is not possible to say, conclusively, whether the intervention themselves were ineffective or the samples lacked sufficient statistical power to determine differences. To allow the authors to make judgment on the effectiveness of interventions, this review was limited to studies with comparison groups. We acknowledge that other study designs can provide insight and suggest a range of evidence should be considered in the development of public health obesity prevention strategies.

Fifteen studies informed this review and results should be interpreted with caution. The studies identified were generally short in duration (5-20 weeks), possibly influencing their ability to detect significant changes in BMI. All studies involved preschool- or primary school–aged children. It would appear that more interventions for adolescents are needed, or it is possible that adolescents are being treated in different settings to younger children. Child age and gender are potential moderators of effectiveness not explored in detail in this study. Some techniques may be more appropriate for children of a certain age or more effective if delivered to parents rather than children. Future research may establish whether the techniques used and the effectiveness of combined-setting obesity prevention interventions differ by the demographic characteristics of children and whether delivery to parents or to children is more effective.

Conclusion and Implications for Practitioners

Seven studies reviewed here provide support for the effectiveness of combined-setting interventions in changing children’s nutrition, activity or sedentary behaviors, or risk of obesity. Family involvement in combined-setting interventions is recommended to increase the likelihood of effectiveness. Intervention effectiveness was also associated with study quality and the clearer use of theory to guide their design. Although different BCTs were associated with effectiveness in the home and school/community setting, providing general information on behavior–health links, prompting practice, and planning social support were used more commonly in effective interventions.

Footnotes

Acknowledgements

Thanks to Mikaela Lawrence and Darren Jones (Information Specialists, CSIRO) for assisting with the development and execution of the review search strategy.

The authors declared no potential conflicts of interests with respect to the research, authorship, and/or publication of this article.

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article:

Rebecca K. Golley is supported by a National Health and Medical Research Council Public Health Training Award (478115).

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