co-designing obesity prevention interventions together ... · the relevance, implementation and...

METHODOLOGY Open Access

Co-designing obesity preventioninterventions together with children:intervention mapping meets youth-ledparticipatory action researchManou Anselma1* , Teatske M. Altenburg1, Helga Emke1, Femke van Nassau1, Merlin Jurg2, Robert A. C. Ruiter3,Janine M. Jurkowski4 and Mai J. M. Chinapaw1

Abstract

Background: Youth-led Participatory Action Research (YPAR) involves children throughout the process ofdeveloping and implementing interventions. Combining YPAR with a structural approach for designing andplanning interventions, such as Intervention Mapping (IM), may further improve implementation and effectivenessof interventions. This paper describes how YPAR and IM were combined in the Kids in Action study.

Methods: The Kids in Action study aims to improve health behaviors of 9–12-year old children living in a lowsocioeconomic neighborhood in Amsterdam, by co-designing interventions with these children. At each of fourschools 6–8 children (N = 18–24 total per year) and two academic researchers formed participatory groups that metweekly or every fortnight during two school years. An IM expert panel advised the participatory groups on theapplication of IM.

Results: Following the IM protocol, we conducted a participatory needs assessment with children, parents andprofessionals, in IM-step 1. In IM-step 2, the IM expert panel constructed matrices of program objectives, and thechildren provided feedback. In collaboration with children programs were designed and produced using aniterative process during IM-steps 3–4. In IM-step 5, the participatory groups and professional community partnersdesigned the implementation plan. Finally, in IM-step 6, the protocol of the process and effect evaluation –executed by academic researchers with input from children – was developed.

Conclusions: By combining YPAR and IM, several interventions have been developed and implemented, varyingfrom a school water policy to extracurricular sports activities. Sharing responsibility with children was challengingwhen combining IM with YPAR. In YPAR children are given as much autonomy as possible, while traditional IMdevelopment work is primarily done by academic researchers. Strengths in combining IM and YPAR include theinvolvement of the end-users - children - throughout the process while at the same time developing interventionsbased on existing evidence. Time-management, a multidisciplinary team, and flexibility are important conditionswhen combining IM with YPAR. A strong community project group, with professionals who were willing to helpchildren develop and execute their ideas, was an important success factor. This study can serve as an example toother YPAR studies developing interventions using the IM protocol.

Keywords: Youth-led participatory action research, Intervention mapping, Health behavior

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

* Correspondence: [email protected] of Public and Occupational Health, Amsterdam Public Healthresearch institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Van derBoechorststraat 7, NL-1081, BT, Amsterdam, The NetherlandsFull list of author information is available at the end of the article

Anselma et al. International Journal of Behavioral Nutrition and Physical Activity (2019) 16:130 https://doi.org/10.1186/s12966-019-0891-5

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BackgroundMany children have unhealthy diets and are insufficientlyphysically active [1–4]. Unhealthy behavior in children isgenerally more common in low socioeconomic neighbor-hoods and in certain ethnic groups [5–7]. Interventionspromoting a healthy lifestyle in children have shown smalleffects [8, 9], and those most in need to benefit from theseinterventions are often hard to include [10, 11]. Few stud-ies involve the perspectives of children themselves in thedevelopment of behavioral interventions [12–14]. Involv-ing children in intervention development may improvethe relevance, implementation and effectiveness of inter-ventions, as children are experts of their own lives.In Youth-led Participatory Action Research (YPAR)

youth are involved as co-researchers throughout the entireresearch process [15], from designing the research questionto the actual intervention development, implementationand evaluation [12]. This bottom-up approach ensures thatthe designed intervention meets the needs and interests ofthe targeted children and increases ownership of the inter-vention [16]. Children can benefit from the feeling of em-powerment and social justice by being involved in YPAR[17–19]. Children learn and develop new skills that are notlimited to conducting research, as they for example alsodevelop in public speaking, debating, and critical thinking[15, 20–23]. These empowering skills increase when adultslisten to children’s ideas and collaborate with them to turntheir ideas into actions [24]. Moreover, instead of merelyfocusing on problem identification, YPAR focuses on creat-ing solutions and implementing action(s) to improve thesituation [15, 17, 20, 25]. Because improvements are morecommonly needed in oppressed and deprived communi-ties, YPAR is often used in these communities.YPAR is an iterative process of planning, acting and

observing, in collaboration with children and is influ-enced by continuous reflection [26]. Therefore, interven-tion development using YPAR is iterative; problemidentification and implementing actions can go hand inhand. For example, when children come up with a goodsolution they immediately want to implement it. Com-bining YPAR with a structural stepwise approach foridentifying behavioral determinants and evidence-basedstrategies, such as the Intervention Mapping (IM) proto-col, may improve the effectiveness of actions [27, 28].IM is a systematic approach which ensures that interventionsare evidence-based and grounded in theory [29]. IM has pre-viously been combined with community-based participatoryresearch (CBPR) in adults and adolescents [30, 31]. To thebest of our knowledge, IM has not been used in combinationwith YPAR yet.In the Kids in Action study we use YPAR to involve

children from a low socioeconomic neighborhood in de-veloping, implementing and evaluating interventionsaimed at the promotion of a healthy lifestyle [32]. To

structure the intervention development process and im-prove the evidence-base and potential effectiveness of in-terventions, the IM approach was applied to the processof YPAR. This paper aims to describe our approach tostructure the intervention development process throughcombining IM with YPAR within the Kids in Actionstudy.

MethodsKids in actionThe Kids in Action study started in 2016 as a collabor-ation between the Amsterdam University Medical Centers(Amsterdam UMC) and Kids Aktief, an after-school day-care organization located in Amsterdam. The MedicalEthics Committee of the VUmc (2016.366) approved thestudy. One researcher (MA) was appointed at both organi-zations. The local government in the northern part ofAmsterdam was involved to support embedding the studywithin existing networks in the neighborhood. Togetherwith these local authorities, a neighborhood in a low so-cioeconomic area in Amsterdam, the Netherlands, was se-lected as the study area. In this neighborhood 30% of the10-year-olds had overweight/obesity in 2016–2018 [33],31% of the children grew up in a low-income householdin 2017 [34], and 38% of the community perceived theirneighborhood as unsafe in 2017 [34]. In 2019, the neigh-borhood had a little over 14,000 inhabitants, with 51%from a non-Western background, mostly from Turkeyand Morocco [35]. All four primary schools in this neigh-borhood were invited and agreed to participate in TheKids in Action study. Control schools were selected fromother neighborhoods but with similar characteristics onoverweight/obesity, family characteristics and householdincome [32]. At each intervention school a participatory(YPAR) group was formed consisting of six to eight child-researchers aged 9–12 years (grade 6–8 in theNetherlands) and one or two academic researchers. Theparticipating children and their parents provided writteninformed consent for the children’s participation. Moredetails on the design of the study can be found elsewhere[32]. The collaborations within this study include:

� YPAR groups: Six to eight child-researchers andone or two academic researchers from theAmsterdam UMC;

� Planning group: Academic researchers from theAmsterdam UMC, youth policy managers of thelocal government of the North of Amsterdam, child-researchers from YPAR groups;

� IM expert panel: Six academic researchers withexpertise in applying IM; and

� Community project group: Academic researchersfrom Amsterdam UMC, youth policy managers ofthe local government in the North of Amsterdam,

Anselma et al. International Journal of Behavioral Nutrition and Physical Activity (2019) 16:130 of 15

representatives of other organizations working withchildren in the neighborhood such as social workers,teachers and principals of primary schools.

Participatory meetings with childrenDuring three school years (2016–2019), the YPAR groupsmet weekly or every fortnight to work on the study, de-pending on the preferences of the school. The meetingswere facilitated by one or two academic researchers. Whenthere were two facilitators, one researcher led most of themeetings and the other made observations, took notes,monitored the planning of the meeting, asked questions ifshe felt clarification was needed and helped the child-researchers with their assignments. The meetings were or-ganized at the children’s school in a classroom or teacher’sroom. The academic researchers established a collaborativeatmosphere in the meetings in which relationships andtrust were built with the children, for example by reorganiz-ing chairs and tables, setting ground rules in the first meet-ing, and starting the meetings with an icebreaker/game andmaking jokes. If needed, children could work in smallergroups somewhere else in the room or school to feel less ofthe group pressure or increase their focus.

Intervention mapping (IM)IM provides program planners with a framework to struc-turally develop theory-based interventions [29]. IM struc-tures this process by providing six steps that supportprogram planners towards effective decision making, con-sidering the community as well as scientific theories: 1)Creating a logic model of the problem, 2) Describing theprogram outcomes and objectives, and creating a logicmodel of change, 3) Designing the program, 4) Producingprogram components and materials, 5) Developing theprogram implementation plan, and 6) Planning for evalu-ation. A detailed description of the IM steps are describedelsewhere [28, 29, 36] and in Additional file 1 an overviewof the IM steps and their application in Kids in Action canbe found. An IM expert panel was installed to 1) discusshow the IM process could be conducted in close collab-oration with the child-researchers; and 2) conduct theparts of IM that would be inappropriate for the child-researchers. The panel met twice, and provided feed-back on the first three steps. In the first meeting(March 2017) the outline of the study was discussedand in particular the design of the first step of IM. Add-itionally, the panel decided which parts of IM would beconducted by the panel and which parts by the YPARgroups, based on the complexity of the IM parts andhow and if this could be simplified in the YPAR groups.During the second meeting (April 2017) the outline ofthe matrices of step two were discussed and how toproceed with these matrices in the YPAR groups.

Below we explain step-by-step how the combination ofIM and YPAR was applied. Each IM step begins with thekey objectives of the tasks in that step, followed by thepractical application in the Kids in Action study.

Step 1: logic model of the problemThe first step of IM includes establishing a planninggroup, conducting a needs assessment, assessing thecommunity’s context, linking this to program goals andcreating a logic model of the problem [29].

Partnerships for YPARThe academic researchers approached the local govern-ment in the north of Amsterdam and discussed whichlow socioeconomic neighborhood could benefit fromparticipating in this study. The local government thenselected a neighborhood and helped to create partner-ships in the community. We created sustainable partner-ships among the community, experts in the field of IMand YPAR, and the children. The selected neighborhoodalready had a community project group, representingdifferent community organizations such as youth socialwork, a theater group, and an after-school daycare. Thiscommunity project group discussed and assisted eachother in projects and new project ideas. By joining thisexisting community project group, their network couldbe used and therefore it was not needed to form a newproject group. The community project group supportedthe study and was willing to collaborate in the process ofintervention development.Schools’ preference guided the selection of children

and planning for the YPAR groups. For example someschools preferred that teachers selected children for theYPAR groups while at other schools children could signthemselves up. Depending on the schools’ preferences,meetings were held for one hour during school hours, orfor 45 min after school hours followed by a 45-minsports activity, to motivate children to come to themeetings in their free time. Each school year YPARgroups changed as children of the highest grade left theschool and new children could fill these spots. Thereforeafter the first year, the YPAR groups included childrenparticipating for the first time as well as children whoalready participated in the previous year.

Participatory needs assessmentThe needs assessment was conducted over two schoolyears in collaboration with the YPAR groups and thecommunity project group. At the start of the Kids in Ac-tion study in 2015, the academic researchers collabo-rated with children in YPAR groups, joined informalmeetings with parents, and interviewed professionals(policy makers working on sports and/or child develop-ment and health behavior, social workers working with


youth and a teacher) and parent-child dyads, to gatherdata for the needs assessment [37].In 2016, the following school year, newly formed

YPAR groups conducted their own research to verifyfindings from the previous year. To prepare the child-researchers for conducting their own research, one ofthe first YPAR meetings was dedicated to basic researchprinciples and methods. The child-researchers for ex-ample learned about privacy, asking permission, actingprofessional, conducting interviews, focus groups, andtaking pictures and other potential research methodsand techniques. Next, the YPAR groups formulated re-search questions regarding why children do not regularlyparticipate in sports and other physical activities andwhy they often choose unhealthy dietary options. TheYPAR groups were divided into smaller subgroups andeach of these groups chose one or more research ques-tions they wanted to answer. An example of a researchquestion was: “In what way is the neighborhood encour-aging or discouraging children to play outside?”. The sub-groups decided together with the academic researchersupon an appropriate research method to answer the re-search question(s). The academic researchers facilitatedthe necessities for the research. Chosen methods were: in-terviews, questionnaires (on paper and online), photos,and focus groups. In the following meetings the subgroupsorganized their data on large sheets of paper assisted bythe academic researchers and presented their conclusionsto the other subgroups.To achieve data saturation, the IM expert panel ad-

vised to perform focus groups with the child-researchersenriched with some of their peers. These focus groupswere co-organized by child-researchers from the YPARgroups. In these focus groups an ordinary school daywas discussed from the moment the children wake upuntil they go to bed, with the focus on which physicalactivities they performed and their dietary intake. Add-itionally, potential underlying determinants were dis-cussed. At three schools two focus groups were conducted(five to eight children per group); one on dietary behaviorand one on physical activity. At one school both topicswere combined in one focus group, because only ninechildren were present. The children placed notes of alltheir activities and their intake of foods and drinks on atimeline. The academic researchers asked clarifying ques-tions and initiated discussions by stimulating the childrento form clusters of related behaviors. Clusters of dietaryintake were breakfast, snacks during the school break,lunch, after school snack, dinner and evening snack. Clus-ters of physical activities were activities before going toschool, transport to school, playing outside during theschool break, playing outside after school and going to asports club. The academic researchers analyzed the focusgroups and in the next meeting the findings were

discussed within the YPAR groups to explore the credibil-ity of the researcher’s analyses [38].

Step 2: program outcomes and objectives and logicmodel of changeThe second IM step specifies what needs to be changedand by whom in order to reduce the health problem [29].Expected program health outcomes are stated, and behav-ioral and environmental outcomes are divided into per-formance objectives. Performance objectives andchangeable determinants of the behavior in matrices arecrossed, thereby creating change objectives. Matrices ofthese change objectives are created for each relevant eco-logical level for the intervention.In the current study, the academic researchers con-

structed the matrices based on the data collected in theneeds assessment with multiple feedback rounds fromthe IM expert panel. Matrices were created for multiplestakeholders: children, parents, local government, andschool staff.Together with the IM expert panel we decided not to in-

clude the child-researchers in the creation of the matrices asthis would require educating them on behavioral theories,which we perceived as unrealistic and inefficient [24, 25].The IM expert panel designed performance objectives thatrepresented the goals that needed to be reached to accom-plish the overall program goals. The YPAR groups wereasked to give feedback on the matrices by showing them alist of all performance objectives of the children’s matrix, de-scribed to them as goals. The IM expert panel decided notto discuss the change objectives with the children as therewere too many.

Step 3: program designIn the third IM step program ideas are generated withthe planning group: theoretical methods that can belinked to the program goals are determined and formthe program methods [29, 39]. Subsequently, methodsare translated into practical applications that address thechange objectives and fulfill the theoretical parametersfor effectiveness.After agreeing on the final performance objectives (in

step 2), each member of the YPAR groups could vote forthree dietary performance objectives/goals he or shewanted to work on and three physical activity perform-ance objectives/goals. The YPAR groups decided to workon the most popular goals in subgroups, each subgroupworking on one goal. The child-researchers discussed intheir group how they could achieve the goal. They didnot directly have to take feasibility into account, butcould pretend they were somebody else, for example: “IfI was the mayor of Amsterdam, how would I reach thisgoal?”. The child-researchers did not think of practicalintervention strategies straight away, but first mentioned


change objectives; they knew what they wanted tochange but did not directly know how. The academic re-searcher asked questions to help the child-researchersthink of practical intervention ideas, based on the datafrom the needs assessment. For example, “In the focusgroups we discovered this [the feeling that the neighbor-hood is not safe] was a problem, how can we take thatinto account?”. Furthermore, the academic researcherhad the change objectives ready to help children incorp-orate those in their intervention ideas. The YPAR groupsformulated a list of 20–30 intervention ideas for the per-formance objectives they were working on and voted forthe best ideas. The researcher explained that ideas thatwere not chosen at that moment, could be worked on ata later stage. To identify feasible and effective methodsfor intervention strategies the academic researcherschecked the IM literature describing effective strategies[29]. For this step the IM expert panel provided adviceon how to match the program ideas to theoretical/effect-ive methods of change and how to structure the programideas, strategies and implementation plans. Additionally,the researchers conducted a literature review summarizingevidence-based intervention strategies in similar targetgroups (protocol registered in PROSPERO: registrationnumber CRD42016052599). These two steps ensured thatevidence-based components were included in the devel-oped actions. If there were no evidence-based strategiesthat could be linked to children’s intervention ideas, theYPAR groups discussed if the idea could be shaped differ-ently to include evidence-based strategies. From the list ofpotential effective ideas, the YPAR groups chose one ortwo ideas they wanted to develop into a detailed programplan. Developing a detailed program plan took three tofour meetings.

Step 4: program productionIn the fourth IM step the program structure andorganization from step 3 are specified [29]. Productionplans for the intervention materials are developed andpiloted.In this step, program materials and components were de-

veloped together with the planning group and professionalsfrom the community project group. This step was inter-twined with the previous step, as the child-researchersalready came up with input for materials and componentswhile thinking of program ideas. For example, in step 3 theYPAR groups had the idea of organizing extra sports activ-ities and discussed which objectives they would addresswith these activities. At the same time, they discussedwhich sports they wanted to organize, where and when. Tohelp the child-researchers develop a detailed program planfor each of their programs, the academic researchers askedquestions to help them think of all aspects of a programplan. For example “Who is going to guide that [the sports

activity]?”, “What materials do you think you need?”, “Howare we going to make sure many children sign up?”, or “Doyou think you can execute this by yourself, or do you needto ask others for help?”. During the YPAR meetings thegroups worked on developing materials, ideas for promo-tion materials, and asked their peers what would convincechildren to participate. Next, the YPAR groups chose oneor two program plans that they pre-tested before the sum-mer break in 2017. At one school the pilot was canceled be-cause of bad weather conditions. The YPAR groupsevaluated the pilots and if needed adapted the programplans for the actual implementation.

Step 5: program implementation planIn the fifth IM step a program implementation plan ismade [29]. Potential adopters and implementers areidentified, matrices of change objectives are developedfor adoption, implementation and maintenance of theprogram, and requirements for successful implementa-tion are noted.The YPAR groups developed the implementation plan

together with relevant stakeholders, such as the schoolprincipal, sports coaches, and social workers. Meetingswith stakeholders were mostly held without the child-researchers, as planning these meetings together withchildren was rarely possible because of their scheduleand logistics. When child-researchers needed help froma stakeholder, they discussed with the academic re-searchers who they thought was suitable to contact.Preferably, this was a partner from the community pro-ject group, because they already knew the study, theneighborhood and the target group. The main researcherpresented the implementation plan made by the YPARgroup to the community partner to discuss interventionadoption, implementation requirements and sustainabil-ity of the intervention. The academic researcher sharedthe community partner's view with the YPAR groupsand if they agreed the new ideas were incorporated inthe implementation plan. The implementation plan wasfinalized in agreement with the YPAR groups and thecommunity partners.Implementation plans were developed for and imple-

mented one intervention at a time. Once successfully im-plemented, the YPAR groups could decide on a newintervention to work on (steps 3–5). In this way interven-tion development remained a continuous process wheremultiple performance objectives could gradually be real-ized. If different YPAR groups had similar interventionideas, organization of the intervention was shared. For ex-ample if the intervention was available for children withinthe whole neighborhood, one YPAR group was in chargeof recruitment while the other group was responsible forthe content. If a similar intervention was organized at twoschools on two separate days, one implementation plan


was created where the YPAR groups could incorporatetheir own creativity in the execution.

Step 6: development of evaluation planIn the last IM step, the process and effect evaluation isdeveloped, for which indicators, measures and designshave to be developed [29].The Kids in Action study includes a process and effect

evaluation. For both the process and effect evaluation ofthe Kids in Action study, we asked child-researchers toprovide input for designing the evaluation. The evalu-ation itself was conducted by academic researchers.

ResultsThis section describes the results per IM-step. At the endof each IM-step one example is described in more detail.

Step 1: logic model of the problemA detailed description of the results of the needs assess-ment can be found elsewhere [37]. The two main identifiedcauses for unhealthy behavior were insufficient physical ac-tivity and unhealthy dietary behavior. Underlying hypothe-sized determinants for insufficient physical activity includedperceiving the neighborhood as unsafe for example due toa youth gang in the community. This is also related to par-ents not wanting their children to go to activities by them-selves, and the perception that all organized activities thatwere not at school or close to the home are too far. Fur-thermore, a lack of finances and knowledge, social normsand culture were important underlying determinants for

children being insufficiently physically active and also forunhealthy dietary behavior. For the latter, difficulties withchanging habits were also mentioned and children havingtoo much decisive power. If they for example do notlike a meal with vegetables, parents will cook somethingelse. The results of the needs assessment were used asinput for the Logic Model of the Problem (see Fig. 1).This model depicts which aspects of the physical activ-ity and dietary behavior environment impact the behav-ioral factors underlying overweight/obesity in children.Based on the needs assessment, four program goalswere set: 1) Children participate in more outside play,2) Children participate in more organized sports activ-ities, 3) Children drink fewer sugar-sweetened bever-ages, 4) Children eat fewer unhealthy snacks. Needsthat were identified related to physical activity were forexample more supervised sports activities at a nearbylocation and for a low price. Related to dietary behaviorthe most important expressed need was more educationon healthy dietary behavior.

An example of a health problem identified by theYPAR groups in the needs assessment was thatchildren drink a lot of sugar-sweetened beverages [37].Many schools in Amsterdam have a policy thatchildren can only drink water at school. Not allschools adhere strictly to this policy, and one of theparticipating schools had not implemented this policy.At this particular school, children identified that a lotof children drank sugar-sweetened beverages at school.

Fig. 1 Logic model of the problem


Step 2: program outcomes and objectives and logicmodel of changeBased on the needs assessment, the academic researcherscreated a logic model of change (see Fig. 2). The PARgroups and their peers provided intervention ideas relatedto the four program goals. The community partners wereidentified as important for implementation and creatingsupport for adoption. Lastly the input of academic re-searchers was needed for a theoretical foundation of IMand YPAR and applying for extra funding for the developedinterventions. The logic model of change further shows thatvia the output (e.g. satisfaction of children with interventionand uptake by the community), behavioral determinantswill improve (e.g. skills, knowledge, attitude), leading tointermediate behavior change outcomes (improved dietarybehavior, physical activity levels and reduced sedentarytime) resulting in the decline in childhood overweight/obesity.Next matrices of change objectives were developed.

Tables 1 and 2 present examples of performance andchange objectives on the level of children, parents, localgovernment and school staff, related to two of the manyintervention ideas of the YPAR groups: the Olympic

sports event (Table 1) and cooking classes (Table 2).Determinants that were crossed with the performanceobjectives were skills and self-efficacy, knowledge, per-ceived social norms and attitude, leading to the changeobjectives. The YPAR group provided feedback on theperformance objectives of the children’s matrices, describedas goals. As expected the child-researchers brought up per-formance objectives for other stakeholders, especially theirparents. For example the performance objective ‘Childrenonly drink water at school’ was identified as highlydependent on how strict teachers are with maintaining therules. Overall, children agreed with the performance objec-tives. Mainly the performance objectives focusing onhealthy dietary behavior were judged important but not ap-preciated, as children for example enjoyed soft drinks andwere not willing to lower this consumption.In the community project group, an academic re-

searcher presented the performance objectives for thelocal government and community partners who thenprovided feedback. The performance objective ‘Childrenonly drink water at school’ was extensively discussed.The community project group supported this perform-ance objective and committed to only serving water to

Fig. 2 Logic model of change


children and educate them on reasons why, thereby alsotrying to change the social norms in the community.

Step 3: program designThe YPAR groups received a list of performance ob-jectives from the children’s matrices – phrased asgoals – and could choose which goal they wanted towork on. Generally, children were more interested inphysical activity than dietary behavior. They were en-couraged to choose performance objectives for bothtopics and also work out ideas for both topics. Table 3presents the selected performance objectives and ini-tial intervention ideas. Below an example is providedof a program idea which relates to the example in theprevious steps:

Two boys from the YPAR group at the school withouta water policy chose to work on the performanceobjective ‘Children only drink water at school’. A result

from their own research during the needs assessmentwas that a lot of children drink sugar-sweetenedbeverages at school. They also knew that other schoolshad a water drinking policy, prohibiting sugar-sweetened beverages at school. Therefore, their ideawas to introduce a water policy at their school.

Step 4: program productionThe YPAR groups developed detailed program plans forone or two of their program ideas. For some YPARgroups it was difficult to go into detail or find solutionsfor barriers. One YPAR group for example wanted toorganize tasting sessions to stimulate their peers to tastetea without sugar. But as children did not have access tothe school’s kitchen, lack of access to hot water was abarrier. As can be seen in Table 3, eventually multipleperformance objectives led to similar practical applica-tions. This happened iteratively as in one YPAR group,

Table 1 Examples of performance and change objectives related to the Olympic sports event

Program goal: More children participate in sports activities

Performance objectivechildren

Skills + self-efficacy Knowledge Perceived social norms Attitude

Children participate insports activities of theirown preference:- Children ask theirparents for financial aidto participate in a sportsactivity

- Children choose thesports activity that theylike most

- Children structurallyparticipate in a sportsactivity of their ownpreference

- Children participate in asports activityindependent of wheretheir friends are going

- Children demonstrateconfidence inparticipating in sportsactivities independent oftheir friends

- Children know the sportsactivities that are on offer

- Children know the sportsactivities that they prefer

- Children know alternativefinancial possibilities tocover their sportsparticipation

- Children recognize that peersparticipate in sports activities oftheir own preference

- Children have positivefeelings towardsparticipating in sportsactivities

Parents facilitateparticipation of theirchildren in organizedsports activities

- Parents demonstrate thatthey can find alternativefinancial possibilities tocover sportsmemberships

- Parents know theadvantages of sportsparticipation

- Parents know thealternative financialpossibilities to cover theirchild’s sports participation

- Parents acknowledge that it isnothing to be ashamed of to askfor financial aid for sportsparticipation coverage

- Parents express positivefeelings towards theirchild’s sportsparticipation

Teachers and schoolmanagement stimulatechildren to participate insports activities

- Teachers have confidencethey can stimulatechildren to participate insports activities.

- School managementdemonstrates that theycan offer sports activitiesthat are of interest tochildren

- Teachers know whichsports activities forchildren are organized inthe community

- Teachers know whichalternative financialpossibilities there are forchildren to cover sportsmemberships

- Teachers and schoolmanagement recognize thatchildren at other schools arebeing stimulated to participatein sports activities

- Teachers and schoolmanagement feelpositive about childrenparticipating in sportsactivities

Policy makers increasethe capacity of popularsports activities organizedby the local government

- Policy makers know thesports activities for whichhigher capacity is wanted

- Policy makers feelpositive about makingmore sports coaches/

materials/centersavailable for children’ssports activities

For each level – children, parents, schools, local government – one performance objective and its change objectives are given


two or three subgroups worked on different ideas. Atthe end of each session they had to explain to the othersubgroups what they had worked on to inspire eachother and form new collaborations. Also, if differentYPAR groups worked on similar ideas, the researchersshared this information. This led to all YPAR groupsworking on the cooking workshops and the Olympicsports event. For most interventions, meeting-by-meetingmore detail was added to the production plan. Below anexample is provided of how a production plan was shapedand how a program was piloted:

Two boys decided together with the principal to start a3-week pilot before the summer holiday so childrenand parents would get used to drinking only water atschool. To motivate children, the class with the mostchildren drinking water during the pilot could win anextra 15 minutes of outside play. The two boys madeposters where teachers could keep track of how manychildren only drank water. The boys were alsoresponsible for weekly collecting the posters and count-ing the scores. Lastly, the principal wanted to informthe parents about the new policy, and invited the boys

to write a paragraph for the newsletter, explainingtheir motivation for introducing the policy.

Not all program ideas were pilot tested, for exampledue to lack of finances for the execution. For example,finances were obtained to organize the Olympic sportsevent, but this did not include pilot testing. Since theYPAR groups organized multiple sports activities, theycould learn from the iterative evaluations of these activ-ities and thereby pilot test certain elements of the Olym-pic sports event. The YPAR groups could for examplemonitor which sports were most popular and whetherchildren appreciated yellow and red penalty cards forlack of sportsmanship (see Additional file 2 for the im-plementation plan of the Olympic sports event).

Step 5: program implementation planIn this step the implementation plans were developed.Additional file 2 and Additional file 3 describe the im-plementation plans of the Olympic sports event and thecooking workshops. The YPAR groups made their ownoverviews and decided on the division of tasks. The re-searchers made a separate overview, which is depicted in

Table 2 Examples of performance and change objectives related to the cooking classes

Performance objective children Skills + self-efficacy Knowledge Perceived social norms Attitude

Children always eat a healthy(amount of) breakfast in themorning before they go toschool

- Children demonstrate thatthey can make their ownbreakfast

- Children know differentkinds of healthy breakfast(for example for children forwhom bread is too heavy,they describe alternatives)

- Children know theimportance of a healthybreakfast

- Children recognize thatpeers have a healthybreakfast

- Children have positivefeelings towardshaving a healthybreakfast everymorning

Parents automatically offerhealthy snacks to theirchildren

- Parents demonstrate theconfidence that givinghealthy snacks is good fortheir children’s health

- Parents know that givinghealthy snacks are good fortheir children’s health

- Parents recognize thatother parents give theirchildren healthy snacks

- Parents recognize thathealthy snacks are alsoenjoyable/a goodalternative/good fortheir children’s healthand are tasty

The school management checksthe adherence of the policiessupporting fruits andvegetables during break timeand healthy birthday snackswith teachers and inclassrooms

- The school managementdemonstrates how they caninvolve teachers in adheringto the policies

- The school managementrecognizes how otherschools successfullyimplement and adhereto the health snackingpolicies

- The schoolmanagementacknowledges theimportance of thepolicies and what theystand for

- The schoolmanagement feelspositive towards strictadherence of thepolicies

The municipal health servicesregularly checks all schools onthe progress andimplementation of policiessupporting fruits andvegetables during break timeand healthy birthday snacks

- The local governmentdemonstrates that they canconvince schools toincorporate and adhere topolicies supporting fruits andvegetables during break timeand healthy birthday snacks

- The local governmentknows how they can worktogether with schoolstowards successfulimplementation of policiessupporting fruits andvegetables during breaktime and healthy birthdaysnacks

For each level – children, parents, schools, local government – one performance objective and its change objectives are given


Table 3 Overview of goals, initial ideas, change objectives and the developed intervention activities

Goals retrieved fromperformance objectives

Initial ideas that were voted for Examples of relatedchange objectives onthe children’s level

Intervention activities andimplementation status

Children always eat ahealthy (amount of)breakfast in the morningbefore they go to school

Create a lesson series on whata healthy breakfast is and combineit with quiz elements, thenchildren will like it more andremember the message (school 1, 2, 3)

Children know different kindsof healthy breakfastChildren recognize that peershave a healthy breakfastChildren have positive feelingstowards a healthy breakfast

Cooking workshops (implementation planin Additional file 3): at first of a duration of1 month, then they were taken over by acommunity partner who organizes itthroughout the yearQuiz at school (once) and regularlyrecurring at after-school activities

Children eat less unhealthysnacks at school

Organize a competition at schoolwhere you can win a prize if youtake healthy snacks and lunch toschool (every month a differentprize) (school 2)

Children describe whathealthy snacks areChildren describe theimportance of eating enoughfruits and vegetablesevery dayChildren recognize that peerseat fruits and vegetablesduring breaks

Healthy snacks and lunch competition atschool during 3 monthsCooking workshops: at first of a duration of1 month, then they were taken over by acommunity partner who organizes itthroughout the year

Children drink onlywater at school

Create a water fountain at theschool playground where you canalways drink water during and afterschool (school 1, 3)Start a policy at school that childrencan only drink water (school 3)

Children recognize that peersonly drink water at schoolIt is a habit that everybodyhas a water bottle with themChildren demonstrate how theycan make water taste better(e.g. by adding fruits)

Water fountain installed at one school,together with a policy that children canonly drink water at school (school 3)

Children drink teawithout sugar

Create a lesson series where childrenlearn to drink tea without sugar, thenthey will get used to it and like it(school 1)

Children acknowledge that teawith sugar is not healthyChildren demonstrate how theycan make tea taste better,without adding sugarChildren demonstrate theconfidence that they can breaktea drinking habits

Cooking workshops: at first of a duration of1 month, then they were taken over by acommunity partner who organizes itthroughout the year

More children playoutside (actively)

Make playgrounds with equipmentsuitable for children of different agesand teach children active games thatthey can play there (school 1, 3)

Children describe active gamesthat they can playChildren demonstrate differentkinds of active games that theycan play at a playgroundChildren recognize that peersplay fun active games outside

The local government adjusted severalalready existing playgroundsAfter school activities were organized for 4months where children learned new activegames that they could playIn after-school activities of this project andalso of community partners, more focus wasplaced on active games that childrenthemselves could play without a lot ofextra materials

More girls participate inafter-school sports activities

Organize more girls-only activities, andask girls what kind of activities theylike (school 1, 2)

Girls recognize that physicalactivity is importantGirls see other girls having funin sports activitiesGirls have positive feelingstowards the activities that areorganized for them

A weekly girls-only activity was started forthe duration of 2 years

Children participate insports activities of theirown preference

Let children themselves co-organizeactivities and make sure there aregood coaches to supervise, so theywill like it more (school 1, 2, 3)

Children know the sportsactivity that they preferChildren demonstrateconfidence in participating insports activities independentof their friendsChildren like participating insports activities (that theyhave organized)

The Olympic sports event consists of yearlyafter-school sports activities followed by asports tournament for the four schools inthe community (implementation plan inAdditional file 2)Children co-organized all interventionactivitiesIn after-school activities of this project andalso of community partners, the aim was togive children a positive sports experienceIn after-school activities of this project andalso of community partners, children couldco-decide on the activities that were offered


Additional file 2 and Additional file 3, to make sure allthe practical applications were covered and the interven-tions and its strategies were linked to methods and de-terminants. Below an example is provided on how animplementation plan was developed:

The YPAR groups wrote down everything they had todo and who they needed to successfully implement thewater-policy (for example teachers, the principal,parents, experts). The most important thing wasapproval of the principal. Together with the mainresearcher the children discussed their plan with theprincipal, who was enthusiastic and willing to help.The researchers convened with policy makers who hadexperience with implementing water-policies at schoolsas part of the Jump-in intervention [40]. The policymakers liked that teachers had to keep track ofchildren’s water consumption and that classes had tocompete against each other. The policy makersemphasized the importance of including parentsthroughout the process, for example by organizingworkshops for parents. The policy makers sharedposters and leaflets with information on the amount ofsugar in sugared-beverages and advice on how to makewater taste better (e.g. add fruit). Lastly they advisedto have a celebratory opening and have multiple activ-ities with water to give it a positive image.

Step 6: development of evaluation planIn contrast to the previous steps where children co-createdthe first drafts, the academic researchers developed a firstdraft for both the effect and process evaluation. Next,children were asked to reflect on the proposed measures andto suggest potential additional evaluation outcomes ormethods. Figure 3 presents an overview of the effect andprocess evaluation of the Kids in Action study. The results ofthe process and effect evaluation will be published separately.

The primary effect outcomes were based on the targetbehaviors identified in the needs assessment and relatedoutcomes: dietary behavior, physical activity, sedentary be-havior, physical fitness, and self-rated health. Dietary be-havior, sports participation, screen time and self-ratedhealth were measured using a questionnaire with validateditems from the ENERGY-child questionnaire [41], theDOiT questionnaire [42], and the EuroQol [43]; physicalactivity and sedentary time were measured using acceler-ometers; and neuromotor fitness was measured using theMOPER fitness test [44]. The effect outcomes weremeasured at baseline (throughout first school year;2016–2017) and at the end of the two subsequent schoolyears (April–May 2018 and March–May 2019) at fourintervention schools and four control schools. More de-tails on the evaluation design are described in the protocolpaper [32]. All YPAR groups agreed with the proposedoutcome measures selected by the academic researchers,and did not want to include additional ones.We applied a qualitative process evaluation because

we were interested in how the respondents perceived theIM and YPAR process and the developed interventions.The process evaluation was designed by the academicresearchers to suit the YPAR process and included threemain focus points: the IM + YPAR process, children’sempowerment, and the experiences of children and profes-sionals with Kids in Action and its interventions. Through-out this study, data on experiences and empowerment ofchildren was gathered through reflection forms which werefilled in by the academic researcher at the end of everyYPAR meeting. The reflection form included a summary ofthe meeting and a reflection on the collaboration with chil-dren and the group process. These reflection forms will beused for a detailed evaluation of developing and imple-menting interventions together with children using IM andYPAR. Yearly focus groups were organized to evaluateeffects on individual, organizational and community em-powerment as we wanted to know how each of these

Table 3 Overview of goals, initial ideas, change objectives and the developed intervention activities (Continued)

Goals retrieved fromperformance objectives

Initial ideas that were voted for Examples of relatedchange objectives onthe children’s level

Intervention activities andimplementation status

Less children are behinda screen after school(computer, television, phone)

Organize more after-school sportsactivities and events so children arestimulated to play outside (school 1, 2)

Children describe theadvantages of playing outsideover screen timeChildren acknowledge thatscreen activities are for the lateafternoon/eveningChildren perceive that peersare not behind a screen afterschool

After-school sports activities were organizedduring 4 months where children learnednew active games that they could playIn after-school sport activities of this project

and also of community partners, more focuswas placed on activities that children themselves could play without a lot of extramaterialsThe Olympic sports event consists of yearlyafter-school sports activities followed by asports tournament for the four schools inthe community (implementation plan inAdditional file 2)


components developed during the study [45, 46]. The focusgroups were held with children from the YPAR groups aswell as with other children from the participating schools.The focus groups included two exercises: one exercise eval-uated individual empowerment and another exercise evalu-ated organizational and community empowerment [32]. Aspart of the second exercise children’s judgement of the de-veloped interventions was also discussed. Furthermore,children evaluated the reach of, and experiences with, theinterventions they implemented using their own evaluationmethods, as shown in the following example:

During and after the pilot the principal was askedabout his/her experiences regarding theimplementation of the water-policy. In the followingschool year, the new YPAR group designed a short sur-vey, in which questions were asked regarding children’sexperiences with the water policy.

At the end of the study, as part of the processevaluation, professionals from the community project

group were interviewed about their experiences withthe Kids in Action study and the developed interven-tions. We based the interview guide on the RE-AIMframework. The RE-AIM framework is designed tostructurally evaluate top-down interventions on fivedimensions: reach, effectiveness, adoption, implemen-tation, and maintenance [47]. However, as the frame-work is not created to evaluate the whole process ofYPAR, we used RE-AIM as a basis for the processevaluation and added topics related to the process ofYPAR. Respondents were for example questioned re-garding the reach of the interventions, the perceivedeffects of the interventions, embedding within andimplementation by the community project group andthoughts regarding the continuation of the interven-tions after the Kids in Action study. The interviewguide was completed by adding questions regardingthe evaluation of the participatory process with chil-dren and the Kids in Action study as a whole; for ex-ample questions were asked about the perceivedeffects on children’s participation in the study and

Fig. 3 Overview of all evaluations within the Kids in Action studyWith legends: Abbreviations: MVPA: Moderate-to-Vigorous Physical Activity; RE-AIM: reach, effectiveness, adoption, implementation, maintenance


their experiences with the collaboration and commu-nication during the study.

DiscussionThis paper describes how IM and YPAR are combined inthe development of health promoting interventions togetherwith children. By combining a structural approach for de-signing and planning interventions and evidence-based the-ories with participation of the target group, we aimed todevelop interventions that are relevant and attractive to thetarget group and thereby more implementable and effectivethan top-down implemented interventions.We experienced that combining YPAR and IM has mul-

tiple strengths. In YPAR studies it can be difficult to in-clude existing evidence in developing interventions, aschildren want to act really fast. As a researcher it can bedifficult to not give in to the children’s enthusiasm. TheIM approach provides the needed structure to take a stepback and first reflect on ideas and relate them to theory[48]. Within this process, children learned to structuretheir ideas, set up research questions, contact and com-municate with stakeholders, reflect on feasibility of ideasand voicing their opinion. This was also appreciated bydecision makers (policy makers, school principal), who ad-mired the children’s ideas and drive for change. One ofthe core elements of Participatory Action Research is thatit “seeks to understand and improve the world by chan-ging it” [17], where understanding of the local contexthappens by valuing the expertise of the target group.Through this understanding, interventions can be devel-oped that might better fit their local context. Our processevaluation will give us insight in whether this was true.In our study we experienced that the participation of

the target group and community partners from the startof the study was very valuable, and that children from 9 to12 years old were capable of actively participating in astudy that combined YPAR and IM. Similar to collaborat-ing with adolescents and adults [30, 31], the present studydemonstrated that children aged 9–12 could also success-fully execute certain IM-tasks, such as looking at change-ability and feasibility of program ideas, prioritizing them,thinking about who to involve and possible barriers. Theperspectives of children on both the problem as well as so-lutions provides a thorough understanding of the problemand stronger ownership of interventions as they have co-developed them. In this way more attractive, relevant andthereby effective interventions may be developed. Futureresearch should evaluate if interventions that are devel-oped by combining IM and YPAR are more sustainableand effective in improving health behavior in the longterm than only using one of both methods.The iterative manner in which we combined IM and

YPAR provided us with challenges and lessons learned.The main challenge we experienced in combining IM

and YPAR was the balance in sharing responsibility withchildren. In YPAR it is preferred to have as much auton-omy for children as possible [49]. However, by aiming toapply a structural stepwise approach for identifying be-havioral determinants and evidence-based strategies,some parts of the Kids in Action study were conductedwithout participation of the child-researchers such asthe development of the matrices. Future studies mayexperiment with even more child responsibility, for ex-ample, exploring alternative fun and energetic ways toinvolve children in the development of the matrices, ordesigning child-appropriate IM workshops [30]. Studiescombining participatory research and IM with adultshave shown opportunities towards more power andshared-decision making concerning the execution of theIM steps and knowledge of the theory [30, 31]. Anotheropportunity could be to include parents or other com-munity stakeholders for these more theoretical steps.Involving these stakeholders earlier in the process couldalso have a positive effect on implementation and main-tenance of the interventions.The second challenge was collaborating with children

and all community partners. On the side of the academicresearchers, IM expert panel and schools, it requiredtime-management and flexibility to conduct a study inwhich YPAR and IM was applied. Researchers have mul-tiple roles and responsibilities that may limit their abilityto spend extensive time on YPAR meetings. The IM ex-pert group needed to be flexible as preferably feedbackwas provided to the YPAR groups within a week. It washelpful to organize meetings during school hours, aschildren tend to be more focused. However, this doesask a lot of schools because the work is outside of therequired curriculum. Investing in a transparent and mu-tually beneficial relationship with schools is therefore es-sential for successful implementation of YPAR [50–52].But the most important relationship is that with the chil-dren, as the entire research process is dependent on theavailability and motivation of children [24]. It is import-ant to recognize the potential limitations of children’sability, which depends on their cognitive developmentalstage. It can be challenging to have children work effi-ciently on highly complex intellectual tasks for thelength of time needed to work through IM-steps. Thismakes it difficult to anticipate how long certain IM stepswill take. When conducting such a process with adultsor adolescents the process is still iterative and flexible,but it is a bit easier to anticipate the execution of theprocess [30, 31]. In our study we experienced that chil-dren were very enthusiastic and could rush through the-ory, or found certain steps difficult which then resultedin needing multiple meetings to work through details.As this also differed between groups and exercises, itwas difficult to decide when to give children


responsibilities to work on something by themselves, aswe did not have unlimited time.An important success factor in the Kids in Action study

was that the study collaborated with a multidisciplinary plan-ning group consisting of a community-based organization fa-miliar with the neighborhood. This facilitated the contactswith the schools and other stakeholders. By being part of thecommunity project group, we could add items of our interestto the agenda in meetings which resulted in more involve-ment and support of partner organizations. Establishing thisposition was time-consuming at the start of the study, but itstrengthened the study and network in the area and facili-tated implementation and sustainability of actions. Throughthis network the researcher could also easily pitch the chil-dren’s ideas to partners who in turn could help the childrenwith development and implementation [16].

ConclusionsWe experienced that combining YPAR and IM strength-ened the development process of interventions. TheYPAR methodology supports that interventions matchthe needs of the target group; while IM promotes thatintervention design is structured and based on existingevidence. Success factors for combining IM and YPARare a multidisciplinary team with experts in both ap-proaches, willingness from academia and communitypartners to collaborate with children from the commu-nity, and flexibility from all stakeholders. A strength wasthat facilitators in the YPAR groups were flexible, result-ing indynamic sessions where children could be creativeand were not too much bounded by frameworks. Futureresearch may explore how children can be more in-volved in the theoretical steps of IM.

Supplementary informationSupplementary information accompanies this paper at https://doi.org/10.1186/s12966-019-0891-5.

Additional file 1. Steps of Intervention Mapping and how they areapplied when combined with YPAR.

Additional file 2. Graphic implementation plan of the Olympic sportsevent.

Additional file 3. Graphic implementation plan of the cookingworkshops.

AbbreviationsAmsterdam UMC: Amsterdam University Medical Centers; IM: InterventionMapping; YPAR: Youth-led Participatory Action Research

AcknowledgementsThe authors want to thank all participating children and community partnersfor their effort and contributions to this study. A special thanks to Kids Aktiefand Hehuat Designs for their support during the study and in designing theactions.

Authors’ contributionsThe study was designed by MC, TA and MA. MA, MC, TA, FN, MJ and RRformed the IM expert panel. MA was part of all YPAR groups, often assisted

by HE. JJ provided support in the design of the paper. The paper wasdrafted by MA, with all authors providing feedback to drafts. All authorsapproved the final version.

FundingThis study is part of the Kids in Action study, which was funded by FNO(grant number 101569). The Medical Ethics Committee of the VUmc(2016.366) approved the study.

Availability of data and materialsData and materials accompanying this publication are available uponrequest.

Ethics approval and consent to participateParents of participating children signed a consent form for children toparticipate in the Action Teams.

Consent for publicationNot applicable.

Competing interestsThe authors declare to have no competing interests.

Author details1Department of Public and Occupational Health, Amsterdam Public Healthresearch institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Van derBoechorststraat 7, NL-1081, BT, Amsterdam, The Netherlands. 2InReturn,Sustainable employability and vitality, Koog aan de Zaan, The Netherlands.3Department of Work and Social Psychology, Maastricht University, P.O. Box616, NL-6200, MD, Maastricht, the Netherlands. 4Department of Health Policy,Management, & Behavior, University at Albany School of Public Health, StateUniversity of New York, Albany, New York, USA.

Received: 15 January 2019 Accepted: 25 November 2019

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