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Interventions targeting nutrition and physical activity levels of pre-schoolers through early childhood education and care (ECEC) increasingly aim to involve families and the home setting. How to optimise the reach and adoption of interventions by parents remains an important question. This study aimed to assess the feasibility and acceptability of a take-home kit to promote nutrition and physical activity (PA) of pre-schoolers at home, while exploring the participatory approach of its development, implementation and evaluation. Three successive versions of the take-home kit were developed and distributed among 21 ECEC centres and 199 families in South-Limburg, the Netherlands. Acceptability and feasibility of the kit were monitored and acted upon throughout the research period. The take-home kit included a stuffed toy, PA and nutrition cards with simple activities, a journal in which parents were asked to record their activities, and written instructions. One kit per ECEC centre rotated between families. Thirty-seven parents participated in open-ended questionnaires, and ECEC teachers from six centres and five implementers participated in interviews. Both questionnaires and interviews included questions about the acceptability (i.e. content, design), feasibility and self-reported impact of the take-home kit. Parents appreciated the tangible and practical aspects of the materials. Using children’s play experience and clear instructions from ECEC teachers facilitated implementation at home. Both implementers and ECEC teachers needed room for contextualised solutions to barriers to implementing the take-home kit in practice. Based on the present study, we conclude that take-home kits can be a valuable tool for ECEC to reach and support parents in adopting healthy energy balance-related behaviours at home.
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It is important to establish healthy lifestyle behaviours early in life, as food preferences and physical activity (PA) patterns are formed at a very young age (Telama et al., 2014; Ventura & Worobey, 2013). Together, a healthy diet (i.e. energy intake) and time spent active or sedentary (i.e. energy output) represent energy balance-related behaviours (EBRBs). Unfortunately, these behaviours are suboptimal, with only a minority of young children meeting the daily recommendations for fruit and vegetables and physical activity in other European countries (e.g. the UK: Er et al., 2018 or Finland: Leppänen et al., 2019). Once formed, EBRBs are maintained from childhood into adulthood (Craigie et al., 2011; Lounassalo et al., 2019). The development of healthy EBRBs is shaped by the interaction of different ecological systems (Bronfenbrenner, 1979). Both the home and early childhood education and care (ECEC) settings are considered to be the settings where young children spend most of their time. Various social and physical environmental characteristics of these systems have been shown to positively influence children’s EBRBs. These include positive parenting and practices of ECEC teachers (e.g. modelling, positive reinforcement) (Arts et al., 2023; Mazarello Paes et al., 2015; Scaglioni et al., 2018; Xu et al., 2015), and the availability of portable play equipment and fruits and vegetables (Kristiansen et al., 2017; Terrón-Pérez et al., 2021).
ECEC and the home setting do not influence children’s behaviour in isolation, but interact with each other (Bradley, 2010; Gubbels et al., 2018). Conflicting messages (e.g. different parenting practices and ECEC teacher practices) within and between settings can negatively influence children’s EBRBs (Bradley, 2010; Gubbels et al., 2018), highlighting the need for alignment across settings. Involving both ECEC teachers and parents has therefore been identified as crucial in previous evaluations of obesity prevention interventions in ECEC settings (Kader et al., 2015; Schlechter et al., 2016; Tomayko et al., 2021; van de Kolk et al., 2019). Although the involvement of parents and families in ECEC interventions is necessary to increase the effectiveness of interventions, questions remain about how to achieve optimal reach and adoption by parents (Harms et al., 2021; Schlechter et al., 2016; van de Kolk, Verjans-Janssen, et al., 2019).
Providing intervention materials and activities at home is one of the potential strategies to reach and engage families in healthy eating and physical activity behaviours. Previous studies have shown that providing families with a take-home kit (e.g. ideas for family activities, PA play equipment, DVD puppet shows, parent booklets), that complements the activities children do in ECEC, increases parent’s knowledge and positive parenting practices (Sosa et al., 2016) and their children’s vegetable consumption (Nicklas et al., 2017). Parents previously reported how take-home materials positively impacted their perceptions on children’s indoor and outdoor playtime (Naish et al., 2023). This suggests that take-home kits are a promising tool to reinforce healthy EBRBs at home.
One intervention that could benefit from the development of tailored take-home kits is SuperFIT: an obesity prevention intervention approach developed in the Netherlands. It uses a setting alignment approach targeting parents and ECEC teachers to promote the development of healthy EBRBs in children aged 2–4 years (van de Kolk et al., 2020). The approach consists of a preschool-based component (PC) and a family-based component (FC), the latter consisting of parent sessions to promote knowledge and sharing of experiences, child and family sessions with simple nutrition and PA activities; factsheets summarising relevant information, and newsletters informing parents about SuperFIT preschool activities. PA and health coaches were responsible for the implementing SuperFIT and will referred to as SuperFIT coaches. SuperFIT has previously been pilot tested, including effect and process evaluation studies (Harms et al., 2021; Harms et al., 2023a; van de Kolk et al., 2019; van de Kolk et al., 2021). Although participating parents rated the FC positively, there were several areas for improvement in terms of outreach to parents (particularly parents from lower socio-economic positions), adoption by parents, implementation at home and perceived impact of the FC (Harms et al., 2021). More specifically, parents needed further support to routinise learned parenting practices, achieve active translation of learned strategies into the home setting, and incentives to sustain such positive changes (Harms et al., 2021). The FC of SuperFIT therefore needed further optimisation. These findings, together with practice-based experiences (e.g. previous take-home kits used by ECEC centres to promote literacy at home), were used to develop a take-home kit to complement SuperFIT and the initial FC.
In order to develop take-home kits that are appropriate for all families, differences between parents, children and ECEC centres need to be taken into account. Therefore, in addition to targeting relevant determinants (e.g. knowledge, parenting practices), interventions need to be tailored to the needs and wishes of intermediate and end users. Furthermore, interventions need to align with the complex and dynamic nature of practice to promote sustainable uptake and hence dissemination and implementation of interventions (Brownson et al., 2018; Lobb & Colditz, 2013). One way to do this is through implementation science, more specifically the use of a participatory approach in the form of end-user involvement, co-learning or co-creation (Leask et al., 2019). Involving end-users is likely to increase the applicability, fit with everyday use and effectiveness of interventions by tailoring outcomes to their personal context (Craig et al., 2008; Green et al., 1996). However, this requires an iterative process of evaluation and refinement (Leask et al., 2019), preferably throughout the entire research process (Meloncelli et al., 2023). Such a process should not only include feedback on materials (e.g. content, design or layout), but also evaluate the implementation of these materials (using Proctor et al. (2011) implementation outcomes such as acceptability, adoption and feasibility). This should involve parents as end users, but also intermediate users who are part of the implementation chain, in order to address the barriers, they may encounter.
Literature on the feasibility and acceptability studies of similar interventions is rather limited, with a predominance of primary school-age children and use of only one evaluation iteration (Kroshus et al., 2023). Furthermore, previous literature reviews have shown how co-creation is often used as formative research (McGill et al., 2022), whereas it should preferably be carried out continuously and non-linearly (Greenhalgh et al., 2016) and with clarity in reporting (Meloncelli et al., 2023; McGill et al., 2022). More information is needed to understand what works for whom and to identify barriers, facilitators and strategies that promote the adoption and implementation of take-home kits.
The present study used a participatory approach to explore the development, implementation and evaluation of a take-home kit to promote healthy EBRBs in young children (2–4 years) and their families. Iterations were used to evaluate the acceptability, adoption, feasibility and self-reported impact of the take-home kit. Effectiveness in terms of health outcomes was not included as the primary focus of this study was to achieve an acceptable and feasible take-home kit for SuperFIT. In order to gain a thorough understanding of the entire implementation chain (i.e. from introduction in ECEC to use at home), three different levels of stakeholders were involved: (1) SuperFIT coaches, responsible for initiating the adoption and implementation process; (2) ECEC teachers, as intermediate users; and (3) parents, as end user of the take-home kit. Based on the findings, the study aimed to further optimise the FC of SuperFIT.
Method
Overview
The present study used a participatory approach with three iterations (or cycles) of development, implementation, qualitative evaluation and refinement to arrive at an appropriate SuperFIT take-home kit. The present study aimed to identify possible barriers and facilitators to the implementation of the SuperFIT take-home kit and the self-reported impact on children, parents and ECEC teachers. Evaluation outcomes included parental appreciation, identification of barriers and facilitators to implementation (for parents, ECEC teachers and SuperFIT coaches) and self-reported impact on children’s and families’ behaviour. Evaluation output (e.g. barriers to use the take-home kit) was continuously used as input to refine the content of the take-home kit and related implementation strategy. The use of such iterations corresponds to the PAR cycles used in participatory action research (Cornish et al., 2023). The study took place within the ECEC setting in South-Limburg, the Netherlands. The Dutch ECEC system distinguishes between full-day childcare and half-day preschool. For the latter, families can receive financial support (Belastingdienst, 2024), resulting in a wide coverage of families. The Faculty of Health, Medicine and Life Science Research Ethics Committee of Maastricht University (FHML-REC/2020/067) have approved this study.
Intervention
Development of the Take-Home Kit
An initial SuperFIT take-home kit was developed in June 2020, based on the intervention objectives, activities and design of previously developed SuperFIT materials. This initial version was the starting point for the present study and was adapted through three rounds of evaluation. The initial version was a backpack containing PA and nutrition cards describing simple activities (from the SuperFIT PC), a fruit and vegetable ‘bingo card’, and a stuffed toy that the children were already familiar with from their ECEC centre. An introduction to the take-home kit and its relationship to SuperFIT was included in the take-home kit and in separate parent newsletters. As part of the intervention, parents were asked to share their experiences with other parents by providing a summary and/or pictures of their activities using the kit in a journal. This served as social support and inspiration for other parents and ECEC teachers, as a take-home kit rotated between families attending the same ECEC centre. Next, the content and design of the take-home kit was adapted after each evaluation round (Fig. 1). A photograph of one of the later versions of the take-home kit can be found in the Supplementary Materials.
Fig. 1
Timeline of the three evaluation rounds in relation to the development and implementation of the SuperFIT take-home kit
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Implementation of the Take-Home Kit
Eight SuperFIT coaches responsible for implementing SuperFIT in general, delivered the take-home kit to participating ECEC centres (Fig. 2). The contents of the take-home kit, the underlying objective (i.e. a tool to achieve adoption of SuperFIT at home). ECEC teachers were responsible for the introduction and distribution of the take-home kit to parents, and were allowed to decide the order and duration for which families could take the kit home. ECEC teachers could add centre-specific materials based on their own insights, such as storybooks (often in consultation with the SuperFIT coach). Families were introduced to the kit as a ‘sleepover’ with the included stuffed toy and parents were encouraged to use the kit at home.
Fig. 2
Implementation chain of the SuperFIT take-home kit (adapted from Paulussen, 1994). Note: take-home kit content and design of the take-home kit highlighted in orange, implementation highlighted in green and outcome highlighted in blue
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Procedures
This study evaluated three successive versions of the take-home kit, developed and implemented between June 2020 and August 2022. COVID-19 and related restrictions such as the closure of ECEC centres and home confinement only occurred for a limited number of months (±3 months in total) during the study period. The take-home kit was distributed through the ECEC centres when they were open. Distribution was paused during periods of home confinement. SuperFIT coaches distributed take-home kits among 21 ECEC centres (day-care centres and preschools) located in different cities and neighbourhoods within South Limburg (the Netherlands), of which several centres (n = 9) also participated in the previously conducted pilot study of SuperFIT (van de Kolk et al., 2020). The study population increased with each evaluation round, as more ECEC centres (1, 7 and 21 respectively), and thus more families participated (Fig. 1).
ECEC teachers were instructed to distribute the take-home kit among all families attending the ECEC centre. All parents of children attending the participating preschools received the SuperFIT take-home kit at some point (N = 199, see Fig. 1) and were eligible to participate in this study. Participation was voluntary. For the first evaluation round, ECEC teachers recruited parents who were willing to participate in interviews after the distribution of the take-home kit. They were given verbal and written explanations of the parental research activities involved. Parents were given information about the study and verbal consent was required to participate. This procedure was time consuming and had a high burden on participants. We therefore decided in the middle of the first evaluation round to change the interview questions to an open-ended parent questionnaire that was included in each take-home kit. During evaluation rounds two and three, the questionnaires and informed consent could be completed using the paper version in the SuperFIT take-home kit or online using the included QR code. Additional interviews with a sub-sample of parents were used to clarify answers questionnaire responses.
All ECEC teachers (N = 21 ECEC centres, see Fig. 1) and SuperFIT coaches (N = 8) were invited to participate in the interviews by email and were provided with written information about the research activities. They gave verbal consent for their participation and audio recording prior to the start of the interview.
Participants
In total, six ECEC centres (28.6%) and five SuperFIT coaches (62.5%) participated in the evaluation rounds. Of the 199 children and their families who received the take-home kit (see Fig. 1), 37 parents (18.6%) completed the questionnaire (2, 18 and 17 in the different evaluation rounds, respectively). The majority of participating parents were mothers (81.1%) with two children (54.1%) and a mean age of 35 (±3.5) years. The ages of their children ranged from zero to 12 years, with 3 years being the most common (40.5%). Three mothers participated in (additional) interviews (two in evaluation round 1 and one in evaluation round 3, see Fig. 1).
Measures
The parent questionnaires included background variables such as parental age, number and age of children in the household, which parent completed the questionnaire and which ECEC centre their child attended. Open-ended questions covered acceptability of the take-home kit (e.g. satisfaction with various aspects, elements that stood out most, missing materials), if and what instructions parents received from ECEC teachers, feasibility of implementation at home (e.g. details of use, favourite activity), and possible tips for improving the kit. Participating parents were also asked to reflect on possible changes in their behaviour at home (e.g. PA games played more often, recipes used).
Interviews with SuperFIT coaches and ECEC teachers focused on barriers and facilitators to implementing the take-home kit. Participating ECEC teachers were also asked to reflect on the strengths and weaknesses of the take-home kit, as well as changes in child or parent behaviour, either self-observed or heard directly from parents. All interviews were conducted in Dutch and by the first researcher.
Finally, the SuperFIT coaches were asked to complete a logbook on whether the ECEC centres had adopted the take-home kit, any adaptations to the contents of the take-home kit (i.e. materials added), and the number of children who had received the take-home kit. This was done separately for each ECEC centre separately, with input from the ECEC teachers.
Data Preparation and Analysis
Questionnaire data were entered in Excel and anonymised. All interviews were transcribed verbatim and anonymised. Both questionnaire data and interview transcripts were imported into NVivo 12.0 software (QSR International, Doncaster, Victoria, Australia) for inductive qualitative analysis. The implementation chain of the SuperFIT take-home kit and a multi-level curriculum definition as defined by Paulussen (1994) formed the basis of the a priori coding tree (Fig. 2). Paulussen’s (1994) thematic distinction between ‘intervention as intended’ (SuperFIT coaches to ECEC teachers), ‘intervention as implemented’ and ‘intervention as realised' was supplemented with ‘child nodes’ such as barriers and facilitators to capture the implementation process within each link (Table 1). Self-reported impact was defined as changes in the behaviour of parents, children or intermediate users (i.e. ECEC teachers), as well as changes in the physical environment (e.g. purchase of PA-related materials) and factors that facilitated or hindered self-reported impact. The coding procedure was the same for both questionnaires and interviews.
Table 1
Structure of the code tree and findings
Level in chain
Codes
Description
Intervention
Acceptability of the take-home kit
Facilitators
Positive points on the take-home kit and materials.
Barriers
Negative points on the take-home kit and materials.
Other
Other comments regarding the take-home kit.
Implementation
Actions among SuperFIT coaches
- Intervention as intended
Actions by SuperFIT coaches and ECEC teachers, and related facilitators and barriers.
Status
Facilitators
Barriers
- Intervention as implemented
Status
Actions by ECEC teachers and parents, and related facilitators and barriers.
Facilitators
Barriers
- Intervention as realised
Status
Actions by parents at home, and related facilitators and barriers.
Facilitators
Barriers
Other
Reported impacta
Behaviour child
References to changes in behaviour (positively, negatively or none), attributable to the SuperFIT take-home kit.
Behaviour parent
Behaviour intermediate user (i.e. ECEC teachers)
Facilitators
Factors inhibiting the impact of the take-home kit.
Barriers
Factors facilitating the impact of the take-home kit.
aAs reported by parents, ECEC teachers or SuperFIT coaches
Two researchers (first and fourth) independently analysed one of the 13 interviews and used a consensus meeting to arrive at a final coding tree and decision rules. The same two researchers then independently analysed two interviews and two parent questionnaires, for which they established inter-coder reliability with a Kappa of 0.97. A final consensus meeting was held to refine the code tree, after which the first researcher analysed the remaining interviews and questionnaires.
Results
Acceptability of the Take-Home Kit
A summary of the improvements made to the take-home kit over the different evaluation rounds is shown in Fig. 3. Suggestions for additions continued to emerge from the questionnaires and interviews in evaluation round three.
Fig. 3
Improvements made to the take-home kit (underlined) over the different evaluation rounds. Note: content highlighted in orange and implementation process highlighted in green
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The majority of parents (range 67–100% in the different rounds) regarded the intervention materials in each round as clear, easy to use and aesthetically pleasing. Parents were pleasantly surprised by the variety of materials, the journal with photo reports from other parents, and particularly appreciated the practicality of things: ‘It’s nice to see these simple little activities that you can easily do with your child’ (parent, round 1). Examples of such practical activities were the PA and nutrition cards in the first version and the addition of a PA counting game (i.e. children practise counting while doing fun motor exercises such as clapping or jumping) in the second version of the take-home kit. In line with this, the third version of the take-home kit added practical activities on nutrition, such as a soup cookbook and two aprons, inspired by an ECEC centre that had already added a children’s cookbook to the second take-home kit. Parents often mentioned the recognisability and ‘playability’ of the stuffed toy for the child as a positive aspect of the take-home kit. Improvements in the second kit, such as a wheeled suitcase instead of backpack and toiletries and pyjamas for the stuffed toy, seemed to contribute to the child’s positive play experience.
There were some concerns about the hygiene of the stuffed toy, with some parents feeling the need to wash the stuffed toy upon receiving the take-home kit. In addition, the large amount of paperwork (i.e. instructions, PA and nutrition cards and journal) caused confusion, as not all parents knew what was expected of them: ‘Great initiative, but it feels somehow obligatory to do all the activities included’ (Parent, round 2). ECEC teachers also commented on the amount of written information: ‘The separate folders are not practical, having all the information in one folder would be clearer’ (ECEC teacher, round 1). In response, the third take-home kit included references to a video explaining the kit and videos demonstrating the specific SuperFIT PA and nutrition cards. Although only a minority of participating parents (29.4%) reported watching these videos, those who did regarded them informative and stimulating. The ECEC teachers who had seen the videos had doubts about the content of the videos. For example, whether the message should be communicated through the stuffed toy to appeal to the children, or whether the videos were fun enough for the children, even though the target group of the videos were parents and not children.
Implementation
SuperFIT coaches reported an increasing sense of ownership of the take-home kit over time, which facilitated implementation. The process of implementing the take-home kit over several evaluation rounds was well received and contributed to this increase in support: “We [SuperFIT coaches] also discuss this [internally]: ‘this is where we started, we adapted these things (…) and this is what we have achieved so far.’ And at the same time, ‘what can we do to move forward?’” (SuperFIT coach, round 3). SuperFIT coaches also reported an increased availability of funding for the intervention at an organisational level over time. This facilitated the purchase of materials needed to implement the take-home kit in several ECEC centres.
Intervention as Intended
SuperFIT coaches delivered take-home kits to 21 ECEC centres. This process evolved over time, due to the iterative design of the study. For example, implementers found that making site visits, discussing the implementation of the take-home kit with ECEC teachers and responding to barriers experienced by teachers (e.g. helping to disseminate information to parents, providing translations of instructions) facilitated the adoption and improved feasibility of the take-home kit. In addition, there was gradually more room for centre-specific suggestions from ECEC teachers, and these were often included in a new version of the kit if they were positively received by parents and in line with the objectives of SuperFIT (Fig. 3). Specific examples are the refined instructions for parents, a wheeled suitcase instead of a backpack, the PA counting game and a cookbook. Interviews with SuperFIT coaches also confirmed this: ‘The feedback from the field was a positive point and allowed us to respond to the needs of the ECEC centres. But also their [ECEC teachers] ability to implement certain things. We are increasingly aware of our role in this.’ (SuperFIT coach, round 3).
Overall, previous experience with a similar literacy take-home kit and with SuperFIT activities in general (i.e. the PC) facilitated the implementation of the take-home kit, while lack of previous experience hindered implementation. On the one hand, a lack of knowledge about SuperFIT’s PC hindered the implementation of related materials in the take-home kit: ‘After I explained that they [ECEC teachers] would also receive the SuperFIT PA and the nutrition cards [in addition to the take-home kit for parents] and that I would make a link between them, it became clearer to them [ECEC teachers]’ (SuperFIT coach, round 2). ECEC centres that had a lot of experience with SuperFIT or had used a similar take-home kit before needed little additional support. In response, SuperFIT coaches considered introducing the take-home kit as part of the implementation of the SuperFIT PC during evaluation round three. Furthermore, identifying ECEC teachers as role models or ambassadors of the SuperFIT take-home kit was suggested by one SuperFIT coach as a future implementation strategy to encourage other colleagues to implement the take-home kit.
Intervention as Implemented
Teachers in three ECEC centres (14%) decided not to adopt the take-home kit, all of them in the third evaluation round (Fig. 1). The ECEC teachers concerned had indicated that they were too busy with other tasks. Although teachers in other centres implemented the take-home kit, some also had periods when they forgot the take-home kit or did not want to distribute the take-home kit a second time: ‘We will start again next school year. We have to consider the timing of the implementation. It just doesn’t work if you’re already involved in other activities, then it’s too much’ (ECEC teacher, round 3).
The data showed differences ECEC teachers’ strategies for introducing the kit to families. These ranged from ECEC centres deliberately introducing the stuffed toy (and its link to PA and nutrition) to the children at the ECEC, an explanatory letter to parents, messages on an online parent portal, explicit instructions to parents when they received the take-home kit, to no instructions at all. Parents’ responses seemed to indicate differences in the preferred route of instructions. A combination of instructions (e.g. written, videos, messages on an online parent portal), seemed to increase the likelihood that parents would receive some instructions to limit the influence of contextual factors (e.g. grandparents picking up the child from ECEC preventing direct communication with the parent).
Differences were also found in the number of days families had the kit at home, with the child’s attendance at ECEC regularly used as a reason for this: ‘It depends, some [children] attend [ECEC] once a week (…) and others can take it home for half a week, so it varies’ (ECEC teacher, round 3). The enthusiasm of the children for the take-home kit and stuffed toy in ECEC, as well as the questioning of the children during circle time in ECEC about the activities carried out at home, was appreciated by the parents. This proactive attitude was also noticed by the SuperFIT coaches: “She [ECEC teacher] told me ‘we will do the PA counting game here too, so the children will recognise the game when they open the kit at home - which in turn might prompt the parents - and maybe the child can explain how it works’” (SuperFIT coach, round 3).
Intervention as Realised
All families participating in this study were able to use the kit to some extent at home (i.e. indicating high feasibility). When asked to specify implementation, it was clear that several family members (e.g. grandparents, siblings) were involved in addition to the participating child and their parents. Implementation of the stuffed toy in particular varied from using it ‘mostly during the morning and evening routines’, probably because of the emphasis on sleeping in, to ‘all day long’ (e.g. cooking together, pretending to feed it, playing with it, dragging it around and sleeping with it). Parents mentioned several facilitating factors for implementation, including sufficient time, no competing commitments (e.g. work, sports clubs), the self-explanatory aspects of (some) materials and the enthusiasm of the children: ‘Since she [the child] liked the stuffed toy so much, you just go along with it’ (Parent, round 1).
Both parents and ECEC teachers noted that the take-home kit still required parents to translate the nutrition and PA-related activities into the children’s perspective. In other words, the link between nurturing the stuffed toy and engaging in EBRBs was not self-evident: ‘(…) and we made that [link], but I can imagine that a lot of people don’t make that link’ (Parent, round 3).
Self-Reported Impact
ECEC Teachers
The distribution and use of the take-home kit had a positive impact on the ECEC teachers. Enthusiastic reactions from parents were contagious and encouraged staff to continue implementing the take-home kit. According to one implementer, it increased the willingness of ECEC teachers to work with SuperFIT in general, including the PC. However, this did not correspond to the responses of some ECEC teachers: ‘Nothing has changed for us since the arrival of the backpack.’ (ECEC teacher, round 1). In addition, the SuperFIT coaches felt that the take-home kit could be used as a tool to start the conversation between ECEC teachers and parents about children’s EBRBs in general. However, they also wondered whether ECEC teachers saw or used the take-home kit as a conversation starter.
Parents
Parents indicated how the take-home kit increased their awareness of healthy EBRBs, how it inspired them and how it served as a cue: ‘[The kit is] an addition to our repertoire. For example, we have never made smoothies together, or tasted new types of fruit. It’s not something you do easily and it disappears due to daily routines, now we have been reminded of it’ (Parent, round 1). The disappearance of this reminder, once the take-home kit had to be returned, hindered the continuation of the new healthy EBRBs. Some parents planned to continue their favourite activities after the take-home kit was returned, or to try out the ones they did not have time to do.
Some parents reported that they were already engaging in healthy EBRBs and saw the take-home kit as confirmation that they were doing well. One barrier was maintaining the novelty or relevance of the take-home kit content: ‘I wonder about the purpose of the kit. My son already eats fruit and vegetables, drinks water and we can play games, we do not need cards for that. For us, it was of little value’ (Parent, round 2). One parent emphasised that they preferred to do such activities in ‘their own way’ rather than using the suggested activities. Perceptions of the take-home kit or individual attitudes towards such lifestyle activities may also play a role, as other parents stated: ‘We always provide physical activity and fruit or vegetables, but it is nice to do such behaviours in a different way’ (Parent, round 3).
Child
Parents and ECEC teachers reported that most children were overjoyed with the take-home kit, especially because they were allowed to take the stuffed toy home. The presence of the stuffed toy made it easier for parents to get their child to sleep in their own bed, taught nurturing skills and new words and promoted healthy eating behaviours: ‘My son finished his plate because the stuffed toy asked him to and sat at the table’ (Parent, round 2). Children also seemed to play a ‘change agent’ role, in overcoming parental resistance to the intervention: ‘When the children are having fun, it has so much more impact than just giving ‘dry’ information [to parents]’(ECEC teacher, round 3).
Discussion
This study aimed to explore the use of a participatory approach to develop and evaluate the implementation process in terms of barriers and facilitators, acceptability, adoption, feasibility as well as self-reported impact of the SuperFIT take-home kit. Providing tangible materials and practical activities that tap into the child’s (play) experience was a successful element of the take-home kit and facilitated implementation at all levels (i.e. from SuperFIT coach to ECEC teacher, from ECEC teacher to parents, by parents at home). Nevertheless, this required a well-functioning implementation chain at all levels (Fig. 2), as the findings highlighted how interactions between different stakeholders (e.g. SuperFIT coaches reminding ECEC teachers) could strengthen implementation, but also how weak links (e.g. parents not receiving any instructions from ECEC teachers) hindered implementation. We will elaborate on the most relevant findings below.
The take-home kit served as an acceptable and feasible intervention to reach a broad group of parents, increased parental awareness of their child’s healthy EBRBs and encouraged them to engage in family activities related to EBRBs. The tangible and versatile aspect of the materials was valued in our and previous studies (Naish et al., 2023; Pini et al., 2023). The proposed underlying mechanism could be that easy-to-use materials lead to an increase in parental self-efficacy (Delisle Nyström et al., 2022) through experiential learning (Kolb, 2014). The next step will be to get parents to sustain these activities after the take-home kit is no longer physically present. In addition, the novelty of receiving such a take-home kit needs to be maintained in order to remain relevant for long-term implementation. Nevertheless, the findings suggest that take-home kits could act as a stepping stone to engage parents in other intervention activities, using the momentum created by the home experience. These findings are in line with previous studies that addressed the differences between parents who are only involved in EBRBs-related activities and parents that engage in interactive processes with other parents or ECEC teachers (Luecking et al., 2021), for which two-way communication is key (Luecking et al., 2020). This communication should start with simple, practical and readable materials. This provides an opportunity to combine the initial FC of SuperFIT with the SuperFIT take-home kit to increase the reach of parents before the start of the intervention and to promote changes at home afterwards, thereby increasing overall parental involvement.
The implementation chain, as the underlying framework of the coding tree (Fig. 2), represented actions from ECEC teachers to parents and from parents to their children. However, children’s enthusiasm and willingness to play with the stuffed toy appeared to be an important facilitator of implementation at home. Furthermore, children’s enthusiasm reinforced ECEC teachers to sustain the implementation of the take-home kit. This adds a new perspective to the body of literature on the importance of parental involvement (Hingle et al., 2010), as the findings of the present study put more emphasis on the role of children in the ‘involvement pathway’. Children acting as change agents at home is not new (Hahnraths et al., 2021; Jakobovich et al., 2019; Wingert et al., 2014), and it fits with the mesosystem perspective where children are the linking pin between two settings (Bronfenbrenner, 1979). Given this active role of children, researchers and practitioners should extend their attention to the involvement of families.
In contrast to previous studies (Kroshus et al., 2023), multiple iterations and the focus on the implementation process allowed for adaptation at the multi-stakeholder level. However, the findings on the implementation of the take-home kit did not provide a list of successful implementation strategies that could be generalised to other settings. What worked for one SuperFIT coach, ECEC centre, staff member or family, did not work for others. Actions within the implementation chain (i.e. between SuperFIT coaches and ECEC teachers, and between ECEC teachers and parents) were found to influence the adoption, implementation and reported impact of the SuperFIT take-home kit. This could work both ways—a motivated stakeholder could facilitate implementation, and a lack thereof at one or more levels of the chain could hinder successful implementation. This makes it difficult to achieve impact at home and highlights the need for a context-sensitive approach to the implementation of the SuperFIT take-home kit. However, continuously adapting the intervention to the context without losing sight of evidence-based practice requires skill, time and flexibility from implementers (Head & Alford, 2015; Kremers & Crutzen, 2018).
The iterative approach of the present study allowed room for feedback and could be seen as a practical application of a context-sensitive approach. However, the development of explanatory videos in the third evaluation round (Fig. 3), clearly showed that the development of intervention materials needs accompanied by the development of appropriate implementation strategies (e.g. communication to ECEC teachers). These findings extend the literature advocating a combination of top-down and bottom-up intervention development and implementation (Patton, 2010; Van Kann et al., 2015; Verjans-Janssen et al., 2020). Furthermore, it adds to the fidelity versus adaptation debate, where the implementation of core intervention components may conflict with the adaptations needed to fit the context (Bopp et al., 2013; Dusenbury et al., 2003; Harms et al., 2023b). The question is whether implementers would be able to continue this iterative, context-sensitive approach independently after the initial introduction or whether they would need support to do so (e.g. implementation protocol, or advisory stakeholders (Verjans-Janssen et al., 2020)).
Strengths and Limitations
The participatory, multi-stakeholder approach is a strength of the present study. The involvement of stakeholders at all levels (SuperFIT coaches, ECEC teachers and parents) in three iterative rounds provided a deep and thorough understanding of the the everyday context in which the SuperFIT take-home kit was implemented. Moreover, the iterative approach is ought to increase the acceptability and feasibility of the take-home kit and is considered more effective than ‘one size fits all’ interventions (Durand et al., 2014).
However, the present study had some limitations. Although the take-home kit was able to reach a relatively large group of families (N = 199), participation in the evaluation study remained limited. The small sample size and the voluntary nature of participation in the research are likely to have introduced self-section bias. Participating parents may have been more interested in SuperFIT, the intervention materials or healthy EBRBs of their children in general. A detailed description of the participating parents in terms of their attitudes or motivation towards healthy EBRBs was not collected due to the nature of the study and the burden on the participants, but would provide a better understanding of for who the take-home kit was most acceptable or feasible. Engaging parents in the design of research methods in addition to intervention materials could be a promising future strategy to increase research involvement (Vanderloo et al., 2021). Furthermore, the iterative approach and changes in measurement methods (i.e. interviews or questionnaires) limit generalisability to other implementers, ECEC teachers or parents. Finally, for the purposes of the present study, the SuperFIT take-home kit was implemented and evaluated in isolation from other SuperFIT FC activities. Take-home kits that complement activities in ECEC are expected to enhance setting alignment and have been shown to be effective (Nicklas et al., 2017; Sosa et al., 2016). Future research should evaluate the implementation and (self-reported) impact of the SuperFIT take-home kit in co-occurrence with the PC and the initial FC of the SuperFIT approach. Future implementation research should provide guidance or tools for implementers to make participatory approaches feasible in intervention development and implementation in practice.
Conclusion
The detailed description of the participatory and iterative nature of the present study provided a thorough understanding of the SuperFIT take-home kit in practice. Our findings suggest that take-home kits are an acceptable and feasible tool for encouraging families to engage in healthy EBRBs, with tangible materials and practical activities. The content of the intervention should focus on the child’s play experience to increase family engagement and use tangible, practical activities to facilitate use at home. The implementation of take-home kits should be context-specific and allow room for overcoming barriers between different levels of stakeholders to achieve impact at home. Input and feedback from parents, ECEC teachers and implementers led to valuable refinements and should continuously be considered. A participatory approach, as used in the current study, is a feasible way to achieve this.
We are grateful to all the implementers, ECEC centres and families who participated in this study and the SuperFIT intervention as a whole. We would like to thank all the practitioners who supported the development and data collection for the SuperFIT take-home kit.
Compliance with Ethical Standards
Conflict of Interest
The authors declare no competing interests.
Ethics Approval
This study was conducted according to the guidelines laid down in the Declaration of Helsinki. The Faculty of Health, Medicine and Life Science Research Ethics Committee of Maastricht University (FHML-REC/2020/067) approved the study. Written or verbal informed consent was obtained from participating parents, ECEC teachers and implementers.
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