evidence, theory and context - using intervention mapping to

RESEARCH Open Access

Evidence, theory and context - using interventionmapping to develop a school-based interventionto prevent obesity in childrenJennifer J Lloyd*, Stuart Logan, Colin J Greaves and Katrina M Wyatt

Abstract

Background: Only limited data are available on the development and feasibility piloting of school-basedinterventions to prevent and reduce obesity in children. Clear documentation of the rationale, process ofdevelopment and content of such interventions is essential to enable other researchers to understand whyinterventions succeed or fail.

Methods: This paper describes the development of the Healthy Lifestyles Programme (HeLP), a school-basedintervention to prevent obesity in children, through the first 4 steps of the Intervention Mapping protocol (IM). Theintervention focuses on the following health behaviours, i) reduction of the consumption of sweetened fizzy drinks,ii) increase in the proportion of healthy snacks consumed and iii) reduction of TV viewing and other screen-basedactivities, within the context of a wider attempt to improve diet and increase physical activity.

Results: Two phases of pilot work demonstrated that the intervention was acceptable and feasible for schools,children and their families and suggested areas for further refinement. Feedback from the first pilot phasesuggested that the 9-10 year olds were both receptive to the messages and more able and willing to translatethem into possible behaviour changes than older or younger children and engaged their families to the greatestextent. Performance objectives were mapped onto 3 three broad domains of behaviour change objectives -establish motivation, take action and stay motivated - in order to create an intervention that supports and enablesbehaviour change. Activities include whole school assemblies, parents evenings, sport/dance workshops, classroombased education lessons, interactive drama workshops and goal setting and runs over three school terms.

Conclusion: The Intervention Mapping protocol was a useful tool in developing a feasible, theory basedintervention aimed at motivating children and their families to make small sustainable changes to their eating andactivity behaviours. Although the process was time consuming, this systematic approach ensures that thebehaviour change techniques and delivery methods link directly to the Programme’s performance objectives andtheir associated determinants. This in turn provides a clear framework for process analysis and increases thepotential of the intervention to realise the desired outcome of preventing and reducing obesity in children.

BackgroundOver a very short timescale there has been a substantialincrease in the proportion of children in the UK whoare overweight [1] The Health Survey for England(2008) reported that 19% of girls and 18% of boys aged11-15 were obese and 34% of girls and 33% of boyswere overweight [1]. The National Child Measurement

Programme reported that by age 10-11 years (Year 6)one in three children were either overweight or obese[2]. Being overweight in childhood is associated withadverse consequences including metabolic abnormalities,increased risk of Type II diabetes, and musculo-skeletaland psychological problems [3]. Over 50% of obese chil-dren become obese adults [4] with significant healthconsequences [5].Unfortunately there is currently little evidence that

existing, school-based intervention programmes areeffective in preventing or reducing obesity in children.

* Correspondence: [email protected] for Health Service Research, Peninsula College of Medicine andDentistry, University of Exeter, Exeter, UK

Lloyd et al. International Journal of Behavioral Nutrition and Physical Activity 2011, 8:73http://www.ijbnpa.org/content/8/1/73

© 2011 Lloyd et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.

mailto:[email protected]

http://creativecommons.org/licenses/by/2.0

In addition, most intervention programmes have notreported on their rationale, development, exact content,or method of implementation which further hampersour understanding about what works and why. In tack-ling childhood obesity, securing scientific informationon what constitutes a healthy diet and an active lifestyleis only the first step. The second step, requiring anequally scientific approach, is to find methods of achiev-ing behaviour change. The determinants of behaviourslinked to obesity are complex and inevitably changingthese behaviours is difficult and interventions are likelyto be complex and multi-faceted. The 2008 MRC Fra-mework for developing and evaluating complex inter-ventions recommends that the mechanisms by whichinterventions work need to be made explicit duringdevelopment [6] and such interventions need to be com-prehensively described if they are to be replicable byothers. This is important as it provides a basis forchecking intervention fidelity, a necessary pre-requisiteto understand efficacy. It also provides a basis for pro-cess analysis (relating mechanisms of change to out-comes) which can shed light on why complexinterventions succeed or fail and how they can poten-tially be optimised.Schools have the potential to play a critical role in the

prevention of overweight and obesity. With their exist-ing organisational, social and communication structuresthey provide opportunities for regular health educationand for a health enhancing environment. They alsoenable the researcher to engage children and familiesacross the social spectrum. In England, children attend aprimary or junior school up to the age of 11, where theyusually have one class teacher who teaches all subjects.This allows for joined up cross-curriculum activities andfacilitates communication making both intervention andresearch in this setting particularly attractive.In this paper we describe the application of a systema-

tic process, Intervention Mapping (IM) (see Figure 1) [7]to plan a school-based obesity prevention intervention.

MethodsIntervention MappingThe six main steps of IM (Figure 1) are: i) needs assess-ment; ii) detailed mapping of programme objectives andtheir behavioural and environmental determinants; iii)selecting techniques and strategies to modify the deter-minants of behaviour and the environment; iv) produ-cing intervention components and materials; v) planningfor adoption, implementation and sustainability; and vi)creating evaluation plans and instruments. IM usesbehavioural theory and research evidence to developspecific learning and change objectives for the targetpopulation and to identify the personal and externaldeterminants of these objectives. Theory and other

considerations (e.g. stakeholder opinions, feasibility data)also guide the choice of intervention methods and stra-tegies to achieve these objectives. We used a variety ofmethods to gather the appropriate information to enableus to produce a feasible and acceptable intervention thathas the potential to change behaviours at a school, childand family level. These included literature reviews, dis-cussions with stakeholders (teachers, head teachers, edu-cation advisors, local public health leads in physicalactivity and obesity) and experts in behavioural scienceand obesity research. We also carried out focus groupswith children and interviews with parents and teachersduring early pilot work to inform our selection of inter-vention techniques and strategies and to ensure thatthese remained feasible to deliver within normal schoolactivities.The following sections provide a summary of the first

4 steps of the IM process used to produce the HeLPintervention. Steps 5 and 6 involve programme imple-mentation, adoption, monitoring and evaluation and arenot presented here. While the steps are described in lin-ear fashion they are, in fact, iterative. For example,defining a more specific behaviour change objective (e.g.parents need to buy and provide healthier snacks) mightlead to the consideration of additional behaviouraldeterminants (those which affect parental shoppingbehaviours as well as those which affect the child’s eat-ing behaviour).

Step 1: Needs AssessmentThe IM process begins with a needs assessment of thehealth problem, which includes identification of the pro-blem behaviours (and to some extent their determi-nants) and of desired programme outcomes as well asthe environmental conditions associated with theproblem.Reviewing the evidence baseThe starting point was to review the literature to identify(i) risk factors for childhood obesity and children’s cur-rent eating/drinking and physical activity behaviours (ii)the determinants of these behaviours and (iii) apparentlysuccessful and unsuccessful components of previousschool-based interventions to prevent and reduce obesity.(i)Possible risk factors for obesity Obesity results froman imbalance between consumption and expenditure ofenergy. Controlled experimental and epidemiologicalstudies suggest a number of dietary risk factors asso-ciated with increased energy intake in children andadults. These included, diets with a high energy density[8] usually characterised by foods high in fat and low infibre, including fast food [9,10] and large habitual por-tion sizes [11]. Experimental studies also report thatliquid calories have lower satiating properties than solidfood [12] and epidemiological studies report an


of 15

increased risk of weight gain or obesity in consumers ofsugar-rich drinks. A single carbonated drink per day canadd 10% to a child’s energy intake [12]. According tothe National Diet and Nutrition Survey (2008/9), in theUK children’s intake of non milk extrinsic sugars(NMES) provides 15% of food energy [13], compared toa recommendation of not more than 11% [14].

Carbonated soft drinks are a major source of NMESproviding 19% of NMES intake in children aged 4-10and over one-third in children aged 11-18 [13].Reduced energy expenditure has also been associated

with weight gain [15] and numerous studies in adultsand children reported an association between lowerweight gain and higher levels of physical activity [16].

Step 1 Needs Assessment

- Plan needs assessment - Assess health, quality of life,

behavior and environment - Assess capacity - Establish programme outcomes

Step 2 Proximal Programme Objective Matrices

- State expected changes in behavior and environment

- Specify performance objectives - Specify determinants - Create matrices of learning and

change objectives

Step 3 Theory-Based Methods And Practical Strategies

- Review programme ideas with interested participants

- Identify theoretical methods - Choose programme methods - Select or design strategies - Ensure that strategies match change

objectives Step 4 Programme

- Consult with intended participants and implementers

- Create programme scope, sequence, theme and materials list

- Develop design documents and protocols

- Review available materials - Develop programme materials - Pretest programme materials with

target groups and implementers and oversee materials production

Step 5 Adoption and Implementation Plan

- Identify adopters and users - Specify adoption, implementation and

sustainability performance objectives - Specify determinants and create

matrix - Select methods and strategies - Design intervention to affect

programme use Step 6 Evaluation Plan

- Develop evaluation model - Develop effect and process evaluation

questions - Develop indicators and measures - Specify evaluation designs - Write an evaluation plan

Evaluation

Implementation

Products Tasks

Figure 1 The Intervention Mapping process.


of 15

Stratton et al reported a decrease in the levels of cardio-vascular fitness in 9-11 year olds in England between1997 and 2003 while the prevalence of obesity increasedover the same time period [17]. Children’s TV viewingtime and time spent playing electronic games has beenassociated with overweight and obesity [18-20], totalcalorific intake [21] and the consumption of snack foods[22]. Longitudinal data from the Avon LongitudinalStudy of Parents and Children (ALSPAC), found strongassociations between children’s fat mass at age 14 andtheir physical activity at age 12 [23]. We also know thattoday’s children are spending more time in front of thetelevision or computer screen than in previous genera-tions - an average of two and a half hours of TV and 1hour and 50 minutes online a day [24]. (i.e. nearly 4 1/2hours a day of screen time). An attempt to encouragechildren to replace screen-based sedentary behaviourswith more active pursuits is clearly an appropriate aimin preventing obesity in children and promoting ahealthy lifestyle.(ii)Determinants of behaviours A variety of family andsocial determinants affecting children’s eating and activ-ity behaviours have been identified. For eating, theseinclude food preferences, food availability and accessibil-ity, modeling (copying the behaviour of others), meal-time structure (social context of meals, the role of TVduring mealtimes, eating out, portion size, school meals,snacking habits), feeding styles (the caregivers approachto maintain or modify children’s behaviours with respectto eating) and socio-economic and cultural factors (e.g.family time constraints, education, income, ethnicity andculture) [25]. In terms of children’s physical activity,parental support (e.g. transporting the child, observingthe activity, encouraging the child, providing equipment,participating with the child and reinforcing physicalactivity behaviours) has been identified as a key determi-nant both directly and indirectly through its positiveassociation with self efficacy perceptions [26]. Griew etal recently reported that children’s school time physicalactivity varied according to the primary school theyattended even after accounting for individual demo-graphic and the school compositional factors with a‘school effect’ explaining 14.5% of the variation in pupils’school-time physical activity [27]. However, it is lessclear that school based activities have a substantial effecton total, as opposed to school time, activity. In a studyof 3 schools from one area, with different sporting facil-ities and opportunity for physical activity in the curricu-lum, Mallam et al (2003) reported large differences inschool time activity levels but virtually no differences inthe total activity of the children [28].This research suggests that while it appears that

schools have the potential to create a positive physicalactivity culture that can influence whether children

engage in physical activity it will be crucial in interven-tion studies to assess whether any effects translate in tochanges in total as opposed to only school time activity.Drawing on the social ecological approach [29] we

began from the theoretical perspective that, while botheating and activity behaviours in children are partlydetermined by choices made by the children, they arehighly dependent both on direct intervention by parents(e.g. the food provided, opportunities for physical activ-ity) and by patterns of behaviour within the family,within the school and within peer groups. As childrenget older the relative importance of self directed, asopposed to family directed, behaviours increases andthese behaviours are influenced by wider social factorswhich include the school environment and peer groupnorms. Therefore any intervention we designed neededto affect behaviour through influencing the children,their families and the school environment. There issome evidence from previous studies of interventions inchildren that the use of drama/theatre can be an effec-tive tool to engage children, increase knowledge andchange behaviours [30-33]. For example, in an obesityprevention programme aimed at low income childrenand their parents, an after school theatre-based inter-vention was shown to motivate and engage both parentsand children and increase awareness of the need formaking changes. However, the authors did concludethat theatre alone is not enough to lead to behaviouralchange and that the next step should be to incorporatethis delivery method into more comprehensive pro-grammes with both educational and environmentalcomponents [31]. Two small studies in primary schoolsin the UK based on drama/the arts reported increases invegetable, salad and fruit juice consumption [32,33].Although both these studies had serious methodologicalweaknesses, the use of drama to engage children tochange specific behaviours looked promising and wasexplored at length with experts from drama and educa-tion as a possible implementation strategy in step 3 ofthe intervention mapping process.We were mindful that there were other key drivers

including intrinsic factors such as genes and the widersocial environment but these are less modifiable and sowere not considered as potential points of intervention.(iii) School-based interventions The most recent sys-tematic review (2009) of controlled trials of school-based interventions identified 38 studies; 3 dietary inter-vention only, 15 physical activity only and 20 combineddiet and physical activity [34]. The authors concludedthat there was insufficient evidence to determine theeffectiveness of dietary interventions alone, but sug-gested that interventions which increase activity andreduce sedentary behaviour may help children to main-tain a healthy weight, although results were short-term


of 15

and inconsistent. Results for combined diet and activitywere also inconsistent, although there was a suggestionthat the combined approach might be more effective inpreventing children becoming overweight in the longterm. Social Cognitive Theory (SCT), which proposesthat a dynamic interaction exists between personal,behavioural and environmental factors, provides a basisfor many of these programmes, particularly the con-structs of self efficacy, behavioural capability (knowledgeand skills to perform a behaviour), outcome expecta-tions, self regulation and reinforcement [35]. Environ-mental conditions of eating behaviour such as schoollunch provision and parental/home environment wereoften targeted [36,37]. A review of reviews of effectiveelements of school health promotion across behaviouraldomains (substance abuse, sexual behaviour and nutri-tion) found that five elements from the highest qualityreviews were found to be effective for all three domainsusing two types of analysis. These were use of theory;addressing social influences (especially social norms);addressing cognitive behavioural skills; training of facili-tators and multiple components. Using one type of ana-lysis only, another two elements were identified:parental involvement and a large number of sessions[38].The authors concluded that the 5 elements identified

should be primary candidates to include in programmestargeting these behaviours.Stakeholder consultationA second approach to needs assessment is to collectinformation to enable a deeper understanding of thecontext or community in which the intervention is to bedelivered [7]. The next step in our needs assessmentwas therefore to run a workshop with practitioners, pol-icy makers and researchers from education, child health,sports science, the local PCT and the local healthyschools team. In the workshop we addressed the natureof the problem and the findings of our literature review,seeking ideas about possible behavioural objectives forschools, children and their families and what the desiredoutcomes of the programme should be.This workshop resulted in agreement about four key

principles which it was suggested should guide ourintervention design. Firstly, that a public healthapproach should be adopted including all childrenrather than targeting the overweight. The adverse healthconsequences of obesity are not limited to those at theextreme end of the BMI distribution and, although mostchildren remain lean, many will gain weight as adults. Inaddition, separating children within a class for specialintervention risks stigmatising them. Secondly, the inter-vention needed to engage parents and offer them strate-gies through which they could directly (throughparenting) or indirectly (through the creation of

supportive environments) foster the development ofhealthy eating and activity behaviours among their chil-dren/family. Thirdly, in order to provide an interventionthat was not only feasible and acceptable to schools, buthad potential for long term sustainability, the interven-tion should dovetail with healthy lifestyle initiativesalready present in schools and aim to meet NationalCurriculum requirements for the age group targeted,something previously recommended by Doak et al(2006) in a review of interventions and programmes toprevent obesity in children [39]. Finally, the methodschosen to deliver the intervention to children and par-ents not only needed to engage, motivate and inspirebut should also be realistically deliverable by teachersand relevant external groups operating within a schoolsetting.OutputsBased on the above needs assessment process wedecided to develop an intervention which aimed to sup-port children to achieve small sustainable changes acrosschildrens’ patterns of diet and physical activity but witha focus on three key behavioural objectives:1. to reduce the consumption of sweetened fizzy

drinks2. to increase the proportion of healthy snacks con-

sumed and3. to reduce TV viewing and other screen based

activities.

Step 2: Detailed mapping of programme objectivesStep 2 provides the foundation for intervention develop-ment by specifying in detail who and what will changeas a result of the programme. The products of step 2are proximal programme objectives or PPOs. These arestatements of demonstrable behaviours (in the targetgroup) or changes in the environment that need tooccur in order affect the determinants of the overallbehavioural objectives that have been identified in step1 (and further refined in step 2). To define PPOs, wefirst defined key behavioural objectives (see above) andbroke these down into smaller steps (performanceobjectives) and then identified the determinants of eachperformance objective. Then we specified ‘proximal pro-gramme objectives’ (i.e. the most immediate targets ofintervention - what needs to be learnt or changed inorder to modify behavioural determinants and conse-quently the key behavioural objectives).As the aim of our intervention was to develop a

school-based intervention which was delivered to chil-dren but was able to influence parents and the school aswell, activities needed to include parents/families, tea-chers and the senior management team (SMT). Further,more specific behavioural objectives, called performanceobjectives (POs) were developed for each group


of 15

(children, parents/family, teachers, SMT). These consti-tuted individual behaviours, motivations, abilities andenvironmental opportunities in the home and within theschool for each group in order for the three key beha-vioural objectives to be achieved. The performanceobjectives developed for the parents/family, teachers andthe SMT were focused on engaging the school and thechildren’s families in order to create the necessary con-ditions to enable children make sustainable changes totheir eating and activity behaviours. For example, at theoutset, a PO for the SMT was for them to ‘buy into’ theProgramme and believe it would benefit the school andthe children and would dovetail with the existing year 5curriculum and school initiatives already in operation.For the purposes of this paper we will confine ourexamples to the performance objectives related to thechild, however, a detailed intervention specification sup-porting this paper is available to view (See Additionalfile 1) which shows the POs, determinants (change tar-gets), BCTs and methods of delivery for all the targetgroups.a) Defining overall behavioural objectivesThe creation of a behavioural objective requires break-ing down the desired outcome, in this case, preventingobesity, into component parts that influence or arerequired to achieve the desired outcome. The three keytarget behaviours, reducing consumption of sweetenedfizzy drinks, increasing the proportion of healthy snacksconsumed and reducing TV viewing and other screen-based activities were expanded into a set of sub-compo-nent behaviours (performance objectives, POs). Theseperformance objectives clarified the exact behaviouralperformances expected from children, parents and tea-chers in order to meet these key objectives and referredto individual level behaviours, motivations, abilities aswell as to environmental opportunities for such beha-viours at the home and school level. As involvement ofparents was vital in achieving the three key target beha-viours, we knew we needed children to clearly commu-nicate the messages to their parents and engage them insupporting their goals. This was originally construed asa PPO related to the determinants of social support,modelling and reinforcement but was promoted to a POso that the intervention could explicitly focus on strate-gies to promote this dialogue between the child andtheir family. The iterative process of identifying perfor-mance objectives was added to over time as the map-ping process identified additional issues. For examplethe concept of enabling children to recognize and resisttemptation for unhealthy snacks was originally a PPO(which aims to address the determinant of ‘urges forunhealthy foodstuff’ as related to the objective of ‘redu-cing unhealthy snacks’) which we also promoted to aperformance objective to allow a more detailed analysis

of this key issue. Although this process was time con-suming, it was useful in creating a more focused andconsidered intervention.b) Identification of DeterminantsIn order to specify our ‘change targets’ i.e. those poten-tially modifiable determinants of obesity related beha-viours we i) reviewed the determinants of children’seating and physical activity behaviours reported byexperimental and epidemiological studies and compo-nents of previous school-based interventions to preventand reduce obesity; ii) sought expert opinion from anadvisory panel of researchers in the field and beha-vioural scientists; and iii) made reference to theories ofbehaviour and/or behaviour change. The determinantswere categorised as personal (factors within the indivi-dual under their direct control) or external (factors out-side of the individual that can directly influence thehealth behavior or environmental conditions). The finallist of determinants to be targeted is provided inTable 1. These were selected based on their links to the-oretical models of behavior change which have formed abasis for previous school-based interventions and theirpotential to be modified within a school setting.A focus on delivering the Programme in such a way

that children enjoyed the activities and were motivatedto participate was also seen as a key determinant for anumber of POs, as affective responses are linked to bothphysical activity and eating behaviours. It is likely thatchildren will be motivated and enjoy activities if theyhave positive attitudes towards the behaviour [40], feelcompetent to make changes [41], perceive significantothers to be motivated and perceive they have somecontrol over outcomes [42]. The main determinants or‘change targets’ for the HeLP Programme therefore,were (i) knowledge and skills (ii) self efficacy, (iii) selfawareness, (iv) taste, familiarity and preference, (v) per-ceived norms (vi) support, modelling and reinforcementfrom family members and (vii) access and availability ofopportunity. Having selected our change targets ordeterminants the next step was to identify the specificbehaviours necessary to modify them.c) Define proximal program objectivesThe final part of this step is to define the proximal pro-gramme objectives (PPOs) by mapping performanceobjectives (row headings in tables 2, 3 and 4) againstdeterminants (column headings in table 2, 3 and 4) in atable to form a matrix. In the tables, cells created frompersonal determinants record what the target groupshould do and/or know and cells created from externaldeterminants record what should change in the environ-ment in order for there to be a positive impact on eachdeterminant so that the performance objective can beachieved. These end statements are the PPOs. Forexample, for children to communicate healthy lifestyle


of 15

messages to parents and seek their help and support,change in three personal and two external determinantsare required (see Table 2). From a personal perspective,the child needs specific knowledge and skills to commu-nicate the messages to their parents and seek their helpand support (taught throughout the intervention using avariety of methods) and perceive that their peers aretalking about the project and also seeking their parentssupport. Practising communication through role playand engaging parents using homework tasks, drama pro-ductions and school assemblies may increase self effi-cacy in communicating messages to parents and makingsuggestions for support. From an external perspective,the child requires support and reinforcement from par-ents, teachers and peers. This increased communicationwith parents/family needs to increase family awarenessof healthy lifestyles and in turn lead to the familyincreasing availability and accessibility of healthy snacksand active pursuits at home.The end point of step 2 in the intervention mapping

process, i.e. defining proximal programme objectives, is aniterative process and we moved back and forth betweenthe tasks of defining POs and their associated determi-nants from the ones targeted in the HeLP Programme (seeTable 1) and the creation of statements of demonstrablebehaviours. e.g. ‘practices skills to seek parental support’that would modify a particular determinant and thus helpachieve the performance objective. This process producedan overwhelming amount of information which we had tocondense in order to develop a feasible and acceptableintervention within the school setting.During the process of creating the matrix, in order to

guide the sequential order in which behaviour change

techniques were delivered in our intervention, wedecided to map performance objectives onto a processmodel of behaviour change. The Health Action ProcessModel (HAPA) [42] was selected as a ‘starting point’ as itis consistent with the theoretical models of behaviourchange mentioned earlier and suggests that behaviourchange occurs through a sequence of adoption, initiationand maintenance processes. This phased model implies aclear order of distinct actions which is easily understoodand is compatible with a sequential application of techni-ques spread across the curriculum of a school year. Bytaking these phases into account, performance objectivesand their associated PPOs were mapped onto three pro-cesses of behaviour change; Establish motivation (developconfidence and skills, make decisions); Take action (cre-ate an action plan and implement it); Stay motivated(monitor progress, assess and adapt goals).Tables 2, 3 and 4 present matrices of performance

objectives and a selection of the key determinants tar-geted in the HeLP intervention for each of the threeprocesses of behavior change. The combination of per-formance objectives, and behavioural determinants, gen-erates (in the cells of the table) the proximal objectivesfor the Programme (PPOs). These have then beenmapped onto the appropriate process of behaviorchange in the HAPA model. This provided a clear fra-mework to guide the selection and sequencing of thebehavior change techniques and practical strategieswhich constitute the intervention.

Step 3: Specify behaviour change techniquesThe product of step 3 is an inventory of behaviourchange techniques selected to match each proximal

Table 1 Examples of determinants of eating and physical activity behaviour in children targeted by the HealthyLifestyles Programme

Personal Determinant External Determinants

Knowledge and skills to perform tasks required by the intervention (e.g.communicating with parents, select healthy snacks/drinks)

Norms

Food preferences and perceived enjoyment Modelling by parents

Food cravings (urges for unhealthy foods) Modelling by peers

Activity preferences and perceived enjoyment (sedentary activities vs moreactive pursuits)

Availability and accessibility of healthy and unhealthy foods in andoutside the home and in the school environment

Perceived familiarity of foods/physical activities Availability and accessibility of physical activity opportunities inschool and during parental care

Perceived norms regarding choice of food/leisure activities in family and peergroup

Family support (emotional, instrumental and informational)

Self efficacy regarding selection of food/physical activity Reinforcement from parents, teachers and peers

Self awareness regarding diet and physical activity and screen-basedsedentary behaviours

Attitude to the Programme (intention to make changes)

Perceived importance of eating healthily and exercising (pros and cons ofmaking a change)


of 15

Table 2 Matrix of performance objectives and determinants for ‘Establish Motivation’

Personal Determinants External Determinants

PerformanceObjectives

Knowledge/Skills

Self-efficacy Self-awareness TasteFamiliarityPreference

Perceivednorms

Family support,ModellingReinforcement

AvailabilityAccessibility

*A Communicatehealthy lifestylemessages toparents and seektheir help andsupport

1Understandsmessages andenergybalanceconcept2Practices skillstocommunicatewith parents3Understandshow parentscan support ahealthylifestyle4Practices skillsto seekparentalsupport

5Showsconfidenceknowledge ofhealthy lifestyle6 Showsconfidence totalk to parents7Showsconfidence andknowledge offamily strategiesto support ahealthy lifestyle8Showsconfidence toseek parentalsupport

9Perceives otherpupils aretalking aboutthe project10Perceivesothers areseeking parentalsupport

11Receives socialreinforcementfrom parents/family forinterest inhealthy lifestyles12Receivesreinforcementfrom parents/family forsuggestedsupportstrategies

13Increases inavailability ofhealthy snacks/drinks andactive pursuits

BSelect and tryhealthyalternatives tounhealthy snacksand drinks athome and atschool

14Identifieshealthyalternatives tounhealthysnacks anddrinks15Practicesskills to ask forhealthyalternatives indifferentsettings16Taste healthyalternatives tounhealthysnacks anddrinks

17showsconfidence toselect healthysnacks and drinks18showsconfidence to trynew snacks anddrinks

19Is familiarwith andchooseshealthysnacks anddrinks

20Perceivesfamily, peers,teacherexpecting themto selecthealthyalternatives

21Receivesreinforcementfrom family,peers andteachers

22Increases inavailability andaccessibility ofhealthy snacksand drinks athome

CSelect feasibleactive alternativesto sedentaryactivities

23Identifiesactivealternatives tosedentaryleisure pursuits24AttendsactivityworkshopsParticipates inactive games

25Showsconfidence andenthusiasm

26Is familiarwith range ofactivealternativesto sedentarypursuits

27Perceivesfamily expectingactive choices

28Receivesreinforcementfrom family,peers, teachers

29Increases inactive leisureopportunities athome

D*Understand andresist temptation

30Identifiesgeneralbarriers tobeing healthy31Understandsmarketingstrategies usedto temptchildren32Practicesskills to resisttemptations

33Showsconfidence toresist temptation

34Records whattempts them intoeating unhealthysnacks and drinksand beingsedentary

35Perceivespeers andfamily areresistingtemptation

36Sees parents,family and peersresist temptation

37Decreases intemptations inthe home

* POs originally construed as PPOs which have been promoted to a higher level


of 15

programme objective. A behaviour change technique(BCT) e.g. ‘model/demonstrate behaviour’ is a techniquedesigned to change a specified theoretical process ordeterminant of behaviour. For example, using strategiesin the intervention that enable children to practice a tar-geted behaviour and/or see role models perform thebehaviour, is designed to increase self efficacy

(confidence in being able to perform the target beha-viour), which is a construct of social cognitive theory.Finding appropriate techniques begins with the ques-

tion “How can the learning and change objectives (thePPOs) for each performance objective be accomplished?”Methods for identifying suitable techniques included a)discussions with stakeholders, and experts in behaviour

Table 3 Matrix of performance objectives and determinants for ‘Take Action’



Knowledge/Skills

Self-efficacy Self-awareness

TasteFamiliarityPreference

Perceivednorms



EReflect ownsnacking andleisurechoices

38Identifies unhealthysnacks in diet andsedentary leisurechoices39Compares toguideline

40Showsconfidence inability to assessown behaviour

41Completes2 day foodrecord42Completes24 houractivityrecord

43Receivesreinforcementfrom parentsand teachers44Sees peersevaluatesnacking andactivity choices

FSet goalsand makechanges

45Knows role of goalsetting in helping tochange behaviours46Knows goals needto be SMART47Writes 3 SMARTgoals48Knows range ofstrategies to helpachieve goals49Identifies personalstrategies to helpachieve goals

50Showsconfidence inability to makesmall changes

51Perceivespeers aremakingchanges

52Receivesreinforcementfrom parentsand family

53Increases in theavailability and accessibilityof healthy snacks anddrinks at home54Increases in active leisureopportunities at home

Table 4 Matrix of performance objectives and determinants for ‘Stay Motivated’



Knowledge/Skills

Self-efficacy Self-awareness TasteFamiliarityPreference

Perceivednorms



G Monitorgoals

55Produces apersonalmonitoring chart56Knows 80/20message

57Showsconfidence inmonitoring goals

58Completespersonalmonitoringchart

59Perceivespeers aremonitoringgoals

60Receivesreinforcement fromteachers and parentsfor monitoring goals

HAssessbarriers togoalachievement

61Knows how theirenvironmentaffects theirchoices62Knows howpersonaltemptations haveaffected achievinggoals63Plans newstrategies toovercome barriers

64Showsconfidence toovercomebarriersexperienced

65Recordsbarriers andstrategies

66Perceivespeersplanningstrategies

67Receivesreinforcement fromteachers and parents

68Increases in availabilityand access to healthysnacks and drinks athome

IAdapt goals

69Knows if goalsare SMART70Knows how toadapt goals

71Showsconfidence toadapt goalsbased onexperience

72Receives socialreinforcement fromparents for beingmotivated

73Increases in activeleisure opportunitiesand healthy snacks anddrinks at home

SMART goals - goals that are Specific, Measurable, Achievable, Realistic and Time-based


of 15

change (behavioural science academics/health promo-tion staff); b) reference to a taxonomy of behaviouralchange techniques [43,44]; c) consideration of theoryand practice in other school-based interventions; d)applying criteria for feasibility, acceptability and costwithin a school setting.A range of suitable BCTs were then selected and

included: role modelling, skill and knowledge building,communication skills training, self monitoring, problemsolving, modelling/demonstrating behaviour, barrieridentification, goal setting, decision balance and socialsupport. For example, to practice skills to communicatethe desired healthy lifestyle messages to their parentsand seek their support, children modelled and demon-strated the behaviour by participating in a variety of roleplay scenes, followed up with discussions of issues ledby the drama facilitator. Many BCTs may need to beapplied to bring about a single PPO e.g. for children to‘practice skills to resist temptation’ (PPO number 32,

see Table 2), the BCTs used were ‘prompt barrier identi-fication’, ‘problem solving’, ‘decision balance’, ‘model/demonstrate behaviour’ and communication skills train-ing’. This linked to the PO of ‘understand and resisttemptation’. (see Table 5).

Step 4: specifying practical strategies and designing theinterventionThe implementation strategy is simply the process fordelivery of a particular behavior change technique. Thestrategy needs to be appropriate for the target popula-tion and the setting in which the intervention will beconducted. We were mindful (as per our needs assess-ment) that strategies chosen needed to be deliverable byteachers and relevant external groups operating within aschool setting, dovetail with healthy lifestyle initiativesalready going on in schools at the time and, where pos-sible, meet National Curriculum requirements for thisage group.

Table 5 Behaviour change techniques and strategies for performance objectives associated with ‘Establish Motivation’

Performance objectives Behaviour changetechniques(theoreticalframework)

Implementation strategies

ACommunicate healthy lifestyle messages toparents and seek their help and support

Exchange information(IMB)Prompt barrieridentificationModel/demonstratebehaviourCommunication skillstraining(SCT)Prompt identificationas a role model (SCT)

Children learn about the healthy lifestyle messages and support strategiesthrough a variety of individual and group tasks delivered by the teacher inPSHE lessons and by actors in drama workshops. ‘80/20’ used as a generalmessage throughout suggesting we should eat healthily and be active atleast 80% of the time.Parent information sheets given to children following each drama workshop.Characters and children role play scenes to communicate messages toparents and seek their support. Discussion and role play of ways toencourage whole family to make changes.Characters present scenes, where after having made changes to theirbehaviours, become role models to others (siblings, parents, friends)followed by group discussion.

BSelect and try healthy alternatives tounhealthy snacks and drinks at home and atschool

Exchange information(IMB)ProvideencouragementModelling (SCT)

Children view and discuss with their chosen character ingredients of bothhealthy and unhealthy food and drink. Compare fat, sugar and salt contentto recommended guidelines.Children observe characters taste healthy snacks and drinks while roleplaying in different settingsCharacters provide encouragementChildren taste healthy snacks and drinks with their chosen character

CSelect feasible active alternatives to sedentaryactivities

Modelling (SCT) Children and actors role play home and school scenes focussing onreplacing sedentary leisure pursuits with active alternatives.Children play interactive games to choose and mime active leisure pursuits.Children observe the characters mime their 24 hour clock and discuss theiractivity in relation to the ‘80/20’ message.

DUnderstand and resist temptation

Prompt barrieridentification (SCT)Problem solving (SCT)Decision balance(SCT)Prompt barrieridentification (SCT)Model/demonstratebehaviour (SCT)Communication skillstraining (SCT)

Children make personalised ‘Temptation T shirts’Children work with their chosen character to prepare ways to tempt theother 3 characters and help their own character to resist temptation.Children participate in the ‘Temptation Ladder’ activity that enables them topractise skills to resist temptations and help others.Children observe characters role play marketing scenesChildren participate in the role play.

Theoretical framework: IMB = Information Motivation Behavioural Skills Model; SCT = Social Cognitive Theory


of 15

a) Specifying implementation strategiesIt was clear the strategies chosen to deliver the key mes-sages needed to inspire and motivate the children sothat they discussed the Programme at home with theirparents and each other. Previous research has suggestedthat drama may be an appropriate means of engagingchildren, increasing knowledge and changing healthbehaviours [30-33]. Following discussions with expertsin education and drama, it was hypothesised that inter-active drama based activities where the children takeownership of the issues was more likely to motivatechildren to become engaged with the process, makechanges and to engage their parents than passive receiptof messages. We also hypothesised that, if the childrenwere involved in the development of materials, includingthe scenarios they produce (facilitated by actors), theywould be more likely to be receptive to the health mes-sages. Drama sessions were also compatible with theexisting school curriculum and could provide a frame-work within which to deliver many of the proposedbehaviour change techniques in a way which is accessi-ble and engaging for children.Table 5 presents a summary of behaviour change

techniques and implementation strategies chosen toaccomplish PPOs (not shown) for each performanceobjective related to ‘establishing motivation’. To viewthe table showing techniques and strategies for ‘takeaction’ and ‘stay motivated’ see Additional file 2.b) Designing the ProgrammeUtilising the Health Action Process Model, our chosenimplementation strategies were then ordered to createthree intervention components (components 2-4) fol-lowing the sequence of the three broad behaviourchange processes in the HAPA model, with an addi-tional component (component 1) designed to create areceptive context within the school (Table 6). The HeLPintervention runs over 3 school terms (Spring and Sum-mer term of year 5 and Autumn term of year 6) so thatit is feasible and acceptable to schools and to encouragetransfer of knowledge and skills into year 6. Table 6provides a summary of each component of the interven-tion (with timescales), summarised implementation stra-tegies and their associated performance objectives.Performance objectives marked * for component 1 havenot been discussed in this paper as they do not relatedirectly to the child but a detailed intervention specifica-tion showing performance objectives for all targetgroups is available to view (See Additional file 1).

Pilotinga) MethodsThe intervention was piloted in two phases and processevaluation methods included semi structured interviews(teachers and parents), focus groups (children),

questionnaire responses (parents), documentation ofparental and child involvement and observations ofintervention delivery. The aim of phase 1 was to ensurethat the initial intervention components were feasible,appropriate and suitably engaging for the target popula-tion (8-11 year olds). We therefore worked with chil-dren, parents and teachers from a single primary schoolto assess a variety of possible activities, materials andmodes of delivery to 119 children from three age groups(8-9 year olds; 9-10 year olds and 10-11 year olds) usingeducation lessons and either drama or goal setting.Based on the results/feedback from phase 1, the inter-vention was further developed and a second phase ofpiloting took place in a second primary school, in anarea of high deprivation, with 77 children from threeyear 5 classes (aged 9-10 years). The aim of the secondphase was to assess ‘proof of concept’ (i.e whether theintervention could change obesity related behaviours)and the feasibility of taking measures. Height, weight,waist circumference, % body fat, objective physical activ-ity (using accelerometry), food intake (using an adaptedversion of the Food Intake Questionnaire) [45] andscreen time (using an adapted version of the Childrens’TV Viewing Habits Questionnaire [46] were measuredat baseline and 6 weeks post intervention.

b) ResultsPilot 1(one primary school; n = 119 children, aged 8-11)In the questionnaire feedback, many parents reportedpositive parent/family behaviour changes. Qualitativedata from teachers, children and their parents suggestedthat Year 5 s (9-10 year olds) were more receptive tothe messages than the year 4 and 6 children and moreable and willing to translate them into possible beha-viour changes. In addition, it appeared that this yeargroup engaged their families to the greatest extent. Tea-chers thought that the education lessons should betaught consecutively over one week to maintain momen-tum and that the drama and goal setting had the poten-tial to work synergistically by engaging the childrenthrough the drama and following this up with encoura-ging the children, with their parents support, to makechanges through setting simple goals. Parents and chil-dren also highlighted the need for a greater variety ofactivities to introduce the key messages and concepts inorder to engage both boys and girls.Implications In order to build a trusting relationship, arange of activities was developed to introduce theschool, children and their families to the project’s keymessages. A ‘Healthy Lifestyles Week’ was developedconsisting of education lessons in the morning (deliv-ered by teachers) which dovetailed with interactivedrama activities in the afternoon (delivered by a localdrama group).


of 15

Pilot 2 (one primary school; n = 77 children, aged 9-10)Staff were enthusiastic about the Programme, in partbecause it met the National Curriculum guidelines forPersonal Social Health Education (PHSE) and Citizen-ship, and importantly because they felt it promotedfamilies’ engagement with the school. Some teachers feltthat the drama had a positive effect on the self esteemof the children, particularly those with additional learn-ing needs. Some teachers suggested further activities forthe subsequent term to reinforce the messages and refo-cus the children and their parents on their goals. Manyparents reported that their family had made lifestylechanges and that their child was willing to try newfoods. The children enjoyed the drama activities and feltthat they could relate to the characters within thedrama framework that made them more motivated toset their own goals. Some children reported that theyhad started going to more after school clubs. Table 7below presents some supporting quotesQuantitative data from the pre and post intervention

behavioural and anthropometric measures showed a

significant self reported decrease in the consumption ofenergy dense snacks (p = 0.001), TV viewing (p =0.033). Objective measures of physical activity showed asignificant decrease in girls’ sedentary behaviours (p =0.03) and a significant increase in girls’ moderate to vig-orous physical activity (p = 0.001). We note that this isonly before and after data and some measures were selfreport and therefore unreliable, however, these resultsdid provide ‘proof of concept’.Implications An additional component was added to theintervention - ‘reinforcement activities’ to take place atthe beginning of year 6. In addition, minor refinementswere made to the education lessons and the dramascripts to enhance delivery and continuity. Table 6 showsthe final intervention components, associated processesof change, implementation strategies and POs.A paper providing more detail of these two piloting

phases, including a randomised exploratory trial hasbeen published [47].The drama/school assembly scripts for the actors and

a step by step guide for the drama facilitator have been

Table 6 The HeLP Programme and associated POs

Component Process of Behaviour change Summary of implementationstrategies

Performance objectives (POs)

Component 1Engaging schools,children & familiesSpring term (Yr 5)

Establish motivation and create areceptive environment

Whole school assemblyActivity workshopsParents’ eveningNewsletter articles

*Senior management team (SMT) see that theProgramme benefits the school and the childrenand dovetails with existing school initiatives*Year 5 teachers see that the programme isfeasible and acceptable to them and their childrenand does not substantially increase their workloadMethods of delivery enthuse children*Parents understand the value of the Programme

Component 2Intensive HealthyLifestyles Week -one weekSummer term (Yr5)

Establish motivation by developingchildren’s confidence and skills andhelping them make decisions

PSHE lessons (morning)§Drama (afternoon) (forum theatre;role play; food tasting, discussions,games etc)

A, B, C, D (see Table 2)

Component 3Goal Setting -goals set duringweek followingdramaSummer term (Yr5)

Take action by helping childrencreate an action plan andimplement goals.

Questionnaire to enable children toreflect on snacking, consumption offizzy drinks and physical activity.Goal setting sheet to go home toparents to complete with child.1:1 goal setting interviewParent’s evening (child involvement -Forum Theatre)

E, F (see Table 3)

Component 4Reinforcementactivities - oneterm post-interventionAutumn term (Yr6)

Stay motivated by helping childrento monitor, assess and adapt goals

Whole school assembly followed bydrama workshop to remind school/children of messages.PSHE lesson to remind children ofmessages and goals.Children monitor goals onpersonalised chartClass to deliver assembly about theproject to rest of school1:1 goal supporting interview todiscuss facilitators/barriers and toplan new coping strategies.

G, H, I (see Table 4)

§The drama framework includes 4 characters, each represented by one of the actors, whose attributes related to the three overall behavioural objectives.Children choose which of the characters they most resemble then work with that actor to help the character learn to change their behaviour


of 15

manualised to enable delivery by a local theatre/dramagroup. The PSHE lessons (with learning outcomes relat-ing to the National Curriulum) and their associatedresources have also been manualised so that class tea-chers are able to deliver the sessions with minimumpreparation (these can be obtained from the correspond-ing author).

DiscussionThis paper describes the use of Intervention Mapping todevelop a school-based intervention to prevent obesityin children. Intervention Mapping was a useful tool toguide us through the process of developing the HeLPintervention, as was Abraham and Michie’s taxonomy ofBCTs [43] which helped us to select feasible BCTs foruse in the HeLP Programme. However, these tools didnot provide much guidance on how to organise thesemany BCTs and their associated delivery methods into acoherent, efficient and appropriately sequenced frame-work. As a result we took further steps to select techni-ques and strategies to fit around a process model ofbehavior change The HAPA model provided a frame-work to order the implementation techniques into acoherent, multi component intervention (Table 6) thatcould run over three school terms and would enable thechildren and their families to make lifestyle changes.The HAPA model is consistent with a number of the-

ories of behavior change including social cognitive the-ory and control theory [35]. We selected the HAPA as

being the ‘closest fit’ to the set of theoretical determi-nants we had identified. However, although the HAPAmodel was useful in helping to identify a broad strategyfor sequencing the delivery of BCTs, it did not providecomplete coverage of the theoretical determinants weidentified. Additional processes we have incorporatedincluded the need to address cravings for unhealthysnacks (affective processes) (see table 1) and the need tobuild a receptive context within the school environment,component 1 of the intervention (see table 6). Twofurther BCTs (not addressed in the taxonomy) [43,44]we used to help create a receptive context within theschool were the ‘identification of barriers’ with teachersand the senior management team to delivering the inter-vention within school time and ‘discussion of possiblesolutions’ to these. We also understood the importanceof ‘showing empathy’ (i.e. understanding the natureschool life) when liaising with teachers and the SMTwhich, we felt, was key in building a trusting relation-ship - essential in getting the school to ‘buy into’ theProgramme. (See Additional file 1).The development process was also consistent with the

new MRC framework for the development and evalua-tion of complex interventions [6] which suggests aniterative approach in which an understanding of contextis central. The evidence that existing school-based pro-grammes actually prevent obesity is weak [48]. Werecognize that there are important social determinantsof behaviours related to diet and physical activity which

Table 7 Provides example quotations supporting a selection of performance objectives for teachers, children and theirfamilies

Performance Objective Illustrative quotes

Year 5 teachers need to see that the programme is feasible andacceptable to them and their children and does not substantially increasetheir workload

’I really appreciated you giving me all the lesson plans and resources andthat they linked to the National Curriculum. I found them easy to follow’’’I knew the drama would work well with our children’’The parents evening did increase my workload a bit but I thought it wasworthwhile’

Class teachers need to be enthused by the programme and developtheir understanding and appreciation of the issues

’I enjoyed observing the children in the drama sessions as I saw what agreat impact it had on my class’’The project inspired me as I saw what a positive effect it was having onthe children with statements’’It was good for us to have to teach the PSHE lessons as this helped me tounderstand what the project was about’

The methods of delivery need to enthuse children so that they discussmessages with their parents and are motivated to seek family support tomake small and simple lifestyle changes

’[Name] talked a lot about the project. She loved the Chiefs and dance visitdespite not being coordinated!’’The project encouraged [Name] to become interested in cooking andpreparing food.’’[Name] plays an active part in choosing healthy options when we shop’

Children need to be able to select feasible, active alternatives tosedentary activities

’Since moving house, [Name] no longer cycles to school but he realised hemisses it so he is now going to cycle to school again even though he hasfurther to go now. It has come from him and that it good’’[Name] has definitely increased her activity and chooses this option insteadof TV’

Parents/families need to make changes ’I buy more fruit and veg ‘’We do more activity as a family now’’I try to make her packed lunches more healthy and interesting’’We will only buy brown or wholemeal bread now’


of 15

are difficult to address and which will inevitably militateagainst successful interventions delivered to individualsand within micro-environments such as schools. None-theless we hope that the rigorous approach employed todevelop the HeLP Programme and its modificationthrough iterative pilot phases will increase the likelihoodof both efficacy and effectiveness. It also provides uswith the basis for the process evaluation we are con-ducting alongside the efficacy trials which will help usto explore possible reasons for its success or failure.Strength and Limitations: This is one of the few stu-

dies to describe in detail the theoretical basis, interven-tion techniques and strategies of an intervention forreducing and preventing childhood obesity. Through theuse of IM methods, the theoretical basis, behaviorchange techniques and implementation strategies can beseen to fit together as a coherent intervention model.Each technique delivered has a clear purpose and a clearplace in the model. The IM approach was very useful,although there was a tendency to generate a long list ofbehavior change techniques, which were not necessarilycoherent or compatible. We were able to correct this byapplication (and extension) of a process model of beha-vior change (The HAPA model). In order to make surethat certain behaviours were targeted (such as encoura-ging the children to engage their parents and talk mean-ingfully about the project’s messages) we decided topromote some PPOs to POs so that there could be asecond level of ‘peeling down’ that would enable us toestablish more focused and specific implementation stra-tegies related to a key programme objectives.Future directions: Two stages of piloting and refine-

ment of the intervention have taken place. In additionan exploratory randomised controlled trial has just beencompleted involving 202 children to establish feasibilityand acceptability of the Programme and the trial designfor a future large cluster RCT. The results of this pilotwork will be reported elsewhere.Implications for practice: Interventions to address

overweight/obesity (and other complex behaviouralinterventions) in children could adopt similar methodsto clearly outline their intervention methods and thecausal processes hypothesised to underlie the desiredchanges in child and parent behaviour. We believe thatthis framework allows a deeper understanding of theprocesses through which such interventions work,improving our ability to design and deliver consistentlyeffective interventions.

ConclusionAlthough time consuming, we found intervention map-ping to be a useful tool for developing a feasible, theorybased intervention aimed at motivating children and theirfamilies to make small sustainable changes to their eating

and activity behaviours. The next phase of the researchwill involve evaluating the effectiveness and cost effective-ness of the HeLP Programme in a large scale cluster RCT.

Additional material

Additional file 1: Detailed Intervention Specification of the HeLPProgramme.

Additional file 2: Behaviour change techniques and strategies forperformance objectives associated with ‘Take Action’ and ‘StayMotivated’.

AcknowledgementsThe authors are very grateful to the participating schools, children and theirfamilies who gave up their time for the study. We would also like toacknowledge Sandy Akerman (Headbangers Theatre Company) whosupported the design of the drama component of the intervention. Phase 1,2 and 3 (the ongoing exploratory trial) of development was funded by theChildren’s Research Fund (registered charity no. 226128) and the NIHRResearch for Patient Benefit (RfPB) Programme. SL, KW and JL were partiallysupported by PenCLAHRC, the National Institute for Health Research (NIHR)CLAHRC for the Southwest Peninsula. This paper presents independentresearch commissioned by the National Institute for Health Research (NIHR).The views expressed are those of the author(s) and not necessarily those ofthe NHS, the NIHR or the Department of Health.

Authors’ contributionsJL and KW led the intervention mapping process and conducted theliterature review with CG providing advice on the use of IM and BCTs. JL ledthe design of intervention delivery methods and the production ofintervention materials, coordinated the implementation of the interventionduring the piloting phases and conducted interviews with teachers andparents. JL drafted the manuscript and provided the main ideas of thispaper with KW, CG and SL providing critical revision. JL and KW conductedthe focus groups and with SL designed the study and obtained funding. JLwill act as guarantor of the paper. All authors read and approved the finalmanuscript.

Competing interestsThe authors declare that they have no competing interests.

Received: 27 October 2010 Accepted: 13 July 2011Published: 13 July 2011

References1. Health Survey for England - 2008 Trend Tables. The NHS Information

centre; 2009 [http://www.ic.nhs.uk/pubs/hse08trends].2. National Child Measurement Programme: results from the school year

2009/10. [http://www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles/obesity/national-child-measurement-programme-england-2009-10-school-year].

3. Gunnell DJ, Frankel SJ, Nanchahal K, Peters TJ, Davey Smith G: Childhoodobesity and adult cardiovascular mortality: a 57-y follow-up study basedon the Boyd Orr cohort. Am J Clinical Nutrition 1998, 67(6):1111-1118.

4. Serdula MK, Ivery D, Coates RJ, Freedman DS, Williamson DF, Byers T: Doobese children become obese adults? A review of the literature. PrevMed 1993, 22(2):167-177.

5. Choi BC, Hunter DJ, Tsou W, Sainsbury P: Diseases of comfort: primarycause of death in the 22nd century. J Epidemiol Community Health 2005,59:1030-4.

6. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M:Developing and evaluating complex interventions: the new MedicalResearch Council guidance. BMJ 2008, 337:979-983.

7. Bartholomew K, Parcel GS, Kok G, Gottleib NH: Planning Health PromotionProgrammes: An intervention mapping approach San Francisco: Jossey-Bass;2006.


of 15

http://www.biomedcentral.com/content/supplementary/1479-5868-8-73-S1.DOC

http://www.biomedcentral.com/content/supplementary/1479-5868-8-73-S2.DOCX

http://www.ic.nhs.uk/pubs/hse08trends

http://www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles/obesity/national-child-measurement-programme-england-2009-10-school-year



http://www.ncbi.nlm.nih.gov/pubmed/8483856?dopt=Abstract




8. Stubbs J, Ferres S, Horgan G: Energy density of foods: effects on energyintake. Crit Rev Food Sci Nutr 2000, 40:481-515.

9. Pereira MA, Kartashov AI, Ebbeling CB, Van Horn L, Slattery ML, Jacobs DRJr, Ludwig DS: Fast food habits, weight gain and insulin resistance (theCARDIA study): 15-year prospective analysis. Lancet 2005, 365:36-42.

10. Prentice AM, Jebb SA: Fast foods, energy density and obesity: a possiblemechanistic link. Obesity Reviews 2003, 4:197-194.

11. Ello-Martin JA, Ledikwe JH, Rolls BJ: The influence of food portion size andenergy density on energy intake: implications for weight management.Am J Clin Nutr 2005, 82(Suppl 1):236-241.

12. DiMeglio DP, Mattes RD: Liquid versus solid carbohydrate: effects on foodintake and body weight. Int J Obes 2000, 24:794-800.

13. Bates B, Lennox A, Swan G: National Diet and Nutrition Survey: Headlineresults from Year 1 Rolling Programme (2008/9). London: TSO; 2008.

14. Department of Health: Dietary Reference Values (DRVs) for Food Energyand Nutrients for the UK. HMSO: London; 1991.

15. Ravussin E, Lillioja S, Knowler WC, Christin L, Freymond D, Abbott WG,Boyce V, Howard BV, Bogardus CN: Reduced Rate of Energy Expenditureas a Risk Factor for Body-Weight Gain. Engl J Med 1988, 318(8):467-72.

16. Wareham NJ, van Sluijs EM, Ekelund U: Physical activity and obesityprevention: A Review of current evidence. In Proceedings of the NutritionSociety: May 2005. Volume 64. Edited by: Westerterp KR. CambridgeUniversity Press; 2005:229-247.

17. Stratton G, Canoy D, Boddy LM, Taylor SR, Hackett AF, Buchan IE: Cardiorespiratory fitness and body mass index of 9-11 year old Englishchildren: a serial cross-sectional study from 1998 to 2004. Int J Obes2007, 31:1172-1178.

18. Stetter N, Singer TM, Suter PM: Electronic games, environmental factorsassociated with childhood obesity in Switzerland. Obes Res 2004,12:869-903.

19. Hancox RJ, Milne BJ, Poulton R: Association between child health andadolescent TV viewing and adult health: a longitudinal birth cohortstudy. Lancet 2004, 364:257-262.

20. Marshall SJ, Biddle SJ, Gorely T, Cameron N, Murdey I: Relationshipsbetween media use, body fatness and physical activity in children andyouth: a meta analysis. Int J Obes Relat Met Disord 2004, 28(10):1238-46.

21. Wiecha JL, Peterson KE, Ludwig DS, Kim J, Sobol A, Gortmaker SL: Whenchildren eat what they watch. Impact of television viewing on dietaryintake in youth. Archives of Pediatrics & Adolescent Medicine 2006,160:436-42.

22. Halford JCG, Gillespie J, Brown V, Pontin EE, Dovey TM: Effect of televisionadvertisements for foods on food consumption in children. Appetite2004, 42:221-5.

23. Riddoch CJ, Leary SD, Ness AR, Blair SN, Deere K, Mattocks C, Griffiths A,Davey-Smith G, Tilling K: Prospective associations between objectivemeasures of physical activity and fat mass in 12-14 year old children:the Avon Longitudinal Study of Parents and Children (ALSPAC). BMJ2009, 339.

24. Childwise: The Childwise Monitor Trends report 2010/11. ChildwiseChildwise, Norwich; 2011 [http://www.childwise.co.uk/childwise-published-research-detail.asp?PUBLISH=53].

25. Patrick H, Nicklas PA: Review of Family and Social Determinants ofChildren’s Eating Patterns and Diet Quality. J Am Col Nutr 2005,24(2):83-92.

26. Trost SG, Sallis JF, Pate RR, Freedson PS, Taylor WC, Dowda M: Evaluating amodel of parental influence on youth physical activity. Am J Prev Med2003, 25(4):277-82.

27. Griew P, Page A, Thomas S, Hillsdon P, Cooper AR: The school effect onchildren’s school time physical activity: The PEACH Project. Prev Med2010, 51(3-4):282-286.

28. Mallam KM, Metcalf BS, Kirkby J, Voss LD, Wilkin TJ: Contribution oftimetabled physical education to total physical activity in primary schoolchildren: cross sectional study. BMJ 2003, 327:529-593.

29. Egger G, Swinburn B: An “ecological” approach to the obesity pandemic.British Medical Journal 1997, 315:477-480.

30. Aslan D, Sahin A: Adolescent peers and anti-smoking activities. PromotEduc 2007, 14:36-40.

31. Neumark-Sztainer D, Haines J, Robinson-O’Brian R, Hannan J, Robins M,et al: ’Ready. Set. ACTION!’ A theatre-based obesity prevention programfor children: a feasibility study. Health Education Research 2008,24:407-420.

32. Fox L: A drama project to promote the ‘Give Me 5’ message to primaryschool children. Health promotion Service, Avon; 2001.

33. Pearson T, Lambert N, Barker ME: Increasing fruit and vegetableconsumption in children: the development and evaluation of a school-based intervention using art/play therapy N09008. Project Report FSA,London; 2003.

34. Brown T, Summerbell C: Systematic review of school-based interventionsthat focus on changing dietary intake and physical activity levels toprevent childhood obesity: an update to the obesity guidance producedby the NICE. Obes Rev 2009, 10(1):110-41.

35. Bandura A: Social foundations of thought and action: A social cognitivetheory Englewood Cliffs, NJ: Prentice-Hall; 1986.

36. Taylor RW, McAuley KA, Barbezat W, Strong A, Williams SM, Mann JI: APPLEProject: 2-y findings of a community-based obesity prevention programin primary school-age children. Am J Clin Nutr 2007, 86(3):735-742.

37. Singh AS, Chin A Paw MJM, Brug J, Mechelen W: Effectiveness of aSchool-Based Program on Body Composition and Behaviour DutchObesity Intervention in Teenagers. Arch Pediatr Adolesc Med 2009,163(4):309-317.

38. Peters A, Kok LHW, Ten Dam G, Buijs GTM, Paulussen GJ, TGW M: Effectiveelements of school health promotion across behavioral domains: Asystematic review of reviews. BMC Public Health 2009.

39. Doak CM, Visscher TLS, Renders CM, Seidell JC: The prevention ofoverweight and obesity in children and adolescents: a review ofinterventions and programmes. Obes Rev 2006, 7:111-136.

40. Ajzen I: From intentions to actions: A theory of planned behavior. InAction-control: From cognition to behaviour. Edited by: Kuhl J, Beckmann J.Springer: Heidelberg; 1985:11-39.

41. Harter S: Effectance Motivation Reconsidered Toward a DevelopmentalModel. Hum Dev 1978, 21:34-64.

42. Schwarzer R: Self-efficacy in the adoption and maintenance of healthbehaviors: Theoretical approaches and a new model. In Self-efficacy:thought control of action. Edited by: Schwarzer R. London: Hemisphere;1992:217-243.

43. Abraham C, Michie S: A taxonomy of behavior change techniques usedin interventions. Health Psychology 2008, 27(3):379-387.

44. Michie S, Johnston M, Francis J, Hardeman W, Eccles M: From Theory toIntervention: Mapping Theoretically Derived Behavioural Determinantsto Behaviour Change Techniques. Applied Psychology: an internationalreview 2008, 57(4):660-680.

45. Johnson B, Hackett AF: Eating habits of 11-14 year old school childrenliving in less affluent areas of Liverpool, UK. Journal of Human Nutritionand Dietetics 1997, 10:135-144.

46. Owens J, Maxim R, McGuinn M, Nobile C, Msall M, Alario A: Television-viewing habits and sleep disturbance in school children. Pediatrics 1999,104:e27.

47. Wyatt K, Lloyd J, Creanor S, Logan S: The development, feasibility andacceptability of a school-based obesity prevention programme: resultsfrom three phases of piloting. BMJ Open 2011.

48. Summerbell CD, Waters E, Edmunds L, Kelly SAM, Brown T, Campbell KJ:Interventions for preventing obesity in children. Cochrane Database ofSystematic Reviews 2005, , 3: CD001871.

doi:10.1186/1479-5868-8-73Cite this article as: Lloyd et al.: Evidence, theory and context - usingintervention mapping to develop a school-based intervention toprevent obesity in children. International Journal of Behavioral Nutritionand Physical Activity 2011 8:73.


of 15













http://www.childwise.co.uk/childwise-published-research-detail.asp?PUBLISH=53

http://www.childwise.co.uk/childwise-published-research-detail.asp?PUBLISH=53


























evidence, theory and context - using intervention mapping to

Documents