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The family environment plays an important role in the development of children’s energy balance–related behaviors. As a result, parents’ energy balance–related parenting practices are important targets of preventive childhood obesity programs. Families with a lower socioeconomic position (SEP) may benefit from participating in such programs but are generally less well reached than families with a higher SEP.
This paper describes the application of the Intervention Mapping Protocol (IMP) for the development of an app-based preventive intervention program to promote healthy energy balance–related parenting practices among parents of children (aged 0-4 years) with a lower SEP.
The 6 steps of the IMP were used as a theory- and evidence-based framework to guide the development of an app-based preventive intervention program.
In step 1, behavioral outcomes for the app-based program (ie, children have a healthy dietary intake, sufficient sleep, and restricted screen time and sufficient physical activity) and sociocognitive (ie, knowledge, attitudes, and self-efficacy) and automatic (ie, habitual behaviors) determinants of energy balance–related parenting were identified through a needs assessment. In step 2, the behavioral outcomes were translated into performance objectives. To influence these objectives, in step 3, theory-based intervention methods were selected for each of the determinants. In step 4, the knowledge derived from the previous steps allowed for the development of the app-based program
The IMP allowed for the effective development of the app-based parenting program
Netherlands Trial Register NL6727, https://www.trialregister.nl/trial/6727; Netherlands Trial Register NL7371, https://www.trialregister.nl/trial/7371.
Although childhood obesity rates have been reported to stabilize in many developed countries [
Parents are considered the main agents of change in effective preventive intervention programs for childhood obesity, especially in the first years of life [
In addition, our program uses an innovative approach to address 2 frequently reported limitations of traditional (parent focused) obesity prevention programs: the costly, time-intensive face-to-face setting [
Therefore, we developed the app-based prevention program
The Dutch title of the app-based parenting program (
The
The first step of the IMP was to conduct a needs assessment of our target group (ie, parents of children aged 0 to 4 years with a lower SEP) to build a logic model of the health problem [
In the second step of the IMP, the performance objectives were defined for the behavioral outcomes specified in step 1. These performance objectives constituted behaviors that are expected to contribute to achieving the program goal when performed by the target group [
The third step of the IMP evolved around the selection of theory- and evidence-based change methods to affect the determinants selected in step 1. We aimed to select a limited number of theoretical methods per determinant as interventions that use a small number of behavior change techniques are generally more effective for people with a lower SEP than interventions that use a larger number of techniques [
The fourth step of the IMP involved building the program themes and components and drafting, pretesting, and producing the program materials based on the information gathered in the previous steps [
The fifth step of the IMP involved the identification of potential program users (eg, implementers or adopters) and the design of a program implementation plan [
The sixth and last step of the IMP involved the development of a program evaluation plan [
Our logic model of the health problem is presented in
Ample research has established the intake of energy-rich foods and sugar-sweetened drinks [
Parenting practices are broadly divided into 3 overarching dimensions of food parenting [
Both general parenting and parental well-being may moderate the associations between parental energy balance–related parenting practices and child EBRBs. With respect to general parenting (ie, the broader emotional climate in which specific parenting practices are performed [
For the selection of determinants, we were informed by the results of our focus groups and the empirical literature. Moreover, the I-Change model [
Knowledge plays an important role in changing EBRBs and is a basic component of existing preventive intervention programs for childhood obesity [
Knowledge should be targeted by carefully considering the beliefs of the target group [
Self-efficacy refers to a parent’s beliefs in their capabilities to organize and execute a course of action (ie, performing energy balance–related parenting practices) in particular situations [
Parents often report a discrepancy between what they intend to do in terms of energy balance–related parenting practices and what they actually do [
Change objectives for dietary intake, sleep, and restricted screen time and sufficient physical activity by crossing the determinants with the performance objectives.
Performance objectives | Determinants | ||||||||
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Knowledge | Attitudes | Self-efficacy | Habits | |||||
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Parents apply clear rules about the consumption of healthy and unhealthy food products and drinks. | Parents explain how they can apply clear rules about the consumption of healthy and unhealthy food products or drinks. | Parents express positive feelings toward having clear rules for the consumption of healthy food products or drinks. | Parents express confidence in applying clear rules about the consumption of healthy and unhealthy food products or drinks. | Parents consistently apply clear rules about the consumption of healthy and unhealthy food products or drinks. | ||||
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Parents act as a role model by eating or drinking healthy food or drinks themselves. | Parents explain how they can act as positive role models by eating or drinking healthy food or drinks themselves. | Parents express positive feelings toward acting as a role model by eating or drinking healthy food or drinks themselves. | Parents express confidence in acting as a role model by eating or drinking healthy food or drinks themselves. | Parents consistently act as a role model by eating or drinking healthy food or drinks themselves. | ||||
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Parents praise their child when he or she eats healthy food products or drinks water. | Parents explain how they can praise their child when he or she eats healthy food products or drinks water. | Parents express positive feelings toward praising their child when he or she eats healthy food products or drinks water. | —a | — | ||||
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Parents apply clear rules about bed times. | Parents explain how they can apply clear rules about bed times. | Parents express positive feelings toward applying clear rules about bed times. | — | — | ||||
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Parents make use of bedtime routines. | Parents explain how they can make use of bedtime routines. | Parents express positive feelings toward making use of bedtime routines. | Parents express confidence in making use of bedtime routines. | Parents consistently make use of bedtime routines. | ||||
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Parents ensure a safe and quiet sleep environment for their child. | Parents explain how they can ensure a safe and quiet sleep environment for their child. | Parents express positive feelings about ensuring a safe and quiet sleep environment for their child. | — | — | ||||
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Parents apply clear rules about screen time. | Parents explain how they can apply clear rules about screen time. | Parents express positive feelings toward applying clear rules about screen time. | Parents express confidence in applying clear rules about screen time. | Parents consistently apply clear rules about screen time. | ||||
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Parents facilitate activities without the use of screens. | Parents explain how they can facilitate activities without the use of screens. | Parents express positive feelings toward facilitating activities without the use of screens. | Parents express confidence in facilitating activities without the use of screens. | Parents consistently facilitate activities without the use of screens. | ||||
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Parents encourage their child to be physically active (eg, playing outside). | Parents explain how they can encourage their child to be physically active. | Parents express positive feelings toward encouraging their child to be physically active. | — | — |
aNot all performance objectives were translated into change objectives.
The theoretical methods we selected for each of the determinants (ie, knowledge, attitudes, self-efficacy, and habits) were derived from the taxonomies described by Kok et al [
Theoretical methods that were selected to address the determinants and examples of how these methods were applied in the app-based program.
Determinant and method | Definition | Example of practical application in the app | |||
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Consciousness raising | Giving information about the causes and consequences of a problem behavior and providing alternatives to substitute problem behaviors [ |
Parents are advised not to comfort or reward their children with food (ie, emotional and instrumental feeding). We explain that in doing so, children might learn to comfort themselves using food later in life or learn that they will be rewarded for demonstrating unwanted behavior. As alternatives for the problem behavior, we suggest to comfort or reward children with attention and affection (eg, giving a compliment, thumbs up, or hug) | ||
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Instruction on how to perform a behavior | Advise on how to perform the behavior [ |
We provide both simple and more elaborate advice on how to perform parenting behaviors. For instance, when parents want to encourage water consumption but their child is used to drinking fruit juice, we advise to gradually substitute parts of the fruit juice by water over the course of several weeks. A more elaborate advice is provided when parents want to decide which type of fruit juice is the healthier option. This advice involves 3 steps (ie, grab 2 drinks, turn them around and look at the food label, and pick the option with the least calories). For the second step (reading the food label), we advise parents to look at the amount of sugar and explain how they can calculate the amount of sugar per serving | ||
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Persuasive communication | Guiding individuals toward the adoption of an idea, attitude, or action by using arguments or other means [ |
To encourage positive attitudes toward the consumption of water, we provide 3 benefits of drinking water (or tea): (1) it does not contain calories and contributes to a healthy body weight, (2) water and tea do not contain sugar, the teeth are not affected and cavities can be prevented, and (3) water supports the functioning of the body and can support learning and playing | ||
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Framing | Using gain-framed messages emphasizing the advantages of performing the healthy behavior [ |
We focused on providing gain-framed messages that emphasize the benefits for parents and/or children. Examples are “Did you know that you can save up to €150 euros per year if Maria drinks water instead of fruit juice?” and “Using a fixed bedtime routine can help Maria fall asleep faster” | ||
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Verbal persuasion | Using messages that suggest that the participant possesses certain capabilities [ |
Before making an if-then plan (see |
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Action planning | Prompt detailed planning of performance of the behavior [ |
To regulate children’s screen time, parents are prompted to make a family screen time plan. For this plan, they first describe in which rooms screens can be used (eg, living room) and then at what times screens can be used (eg, before dinner). The plan should be focused on what |
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Implementation intentions | Prompting making if-then plans that link situational cues with responses that are effective in attaining goals or desired outcomes [ |
Parents are prompted to make an if-then plan to stimulate their child’s physical activity. First, we explain what an if-then plan is and why it is important to make them. Next, 3 examples are presented (eg, “If we go outside together, then I will let Maria walk next to the stroller for a couple of minutes”). After that parents are asked to make their own plan by defining first |
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Self-nudging | Making simple changes in the presentation of choice alternatives that make the desired choice the easy, automatic, or default choice [ |
We provide parents tips that can help make healthy eating at home the easy, automatic option: (1) buy mostly healthy food such as fruits and vegetables at the grocery store; (2) buy no or only a small amount of snacks, such as candy and chocolate; (3) display healthy foods in a way that they are easily noticed, eg, by presenting fruit in a bowl on the table; and (4) store unhealthy foods out of sight, for instance, keeping snacks at the back of the storage cabinet |
In addition to potentially important theoretical methods, the form in which an intervention is delivered is also a key ingredient in behavior change interventions [
In phase 1 of the app development process, the results from our focus groups and discussions with youth health care professionals informed the development of the prototype of the app and the way in which we tailored the materials to our target group. For instance, based on parents’ negative affective attitudes toward water consumption, we asked them whether they would provide their children tea (without sugar) as an alternative, and they affirmed that they would do so. Therefore, we drafted the app content with “water or tea,” instead of focusing entirely on water consumption. Other examples of content that we based on the suggestions of parents from our focus groups included providing information about saving money on groceries and tips to stimulate vegetable consumption.
In phase 2, the content of the preventive intervention program was drafted based on national health care guidelines, relevant literature on parenting practices in relation to child EBRBs, and previous intervention projects [
The final version of the app (phase 3) was launched in September 2018.
Each of the 5 modules consisted of 2 types of activities: lessons and challenges. Screenshot 2 in
Screenshots of the
We identified national community health services and child day care centers as potential adopters of the app-based program, as representatives of these organizations were involved in the development and execution of the program. The program implementers will be youth health care professionals and pedagogical staff working at these organizations, and their tasks are to bring the app to the attention of parents (whose children they perceive as being at high risk for obesity) and motivate them to use the app. The implementation of the app-based program can support the daily practice of the program implementers in 2 ways. First, the app could function as an addition to usual care, given that youth health care professionals indicated that standard consultations are generally too brief to give parents elaborate, well-rounded advice. In this sense, it is advantageous that the app is an easy-to-use product that does not require detailed instructions from a health care provider. Second, the app could function as an educational material that creates a legitimate opening to discuss topics such as food parenting and body weight [
The process and effects of the app-based preventive intervention program were evaluated in 2 separate trials, the designs, eligibility criteria, procedures, and measures of which are explained hereafter.
Both trials were randomized controlled trials (RCTs) with 2 parallel arms: an intervention condition in which parents received access to the
A power analysis using G*Power (version 3.1) indicated a minimum of 200 participants in trial 1. This calculation was based on child BMI as the outcome variable, which was assumed to have a mean of 16.67 (SD 1.70) [
In the end, the participants in trial 1 were 357 parents (346/357, 96.9% biological mothers, 7/357, 1.9% biological fathers, and 4/357, 1.1% nonbiological mothers or partners of the biological mother) of infants aged 5 to 15 months at baseline (ages corresponding to modules 1 and 2 of the app). Trial 2 was conducted among 153 parents (148/153, 96.7% biological mothers, 3/153, 1.9% biological fathers, and 2/153, 1.3% partners of the biological father or mother) with toddlers aged 18 to 55 months at baseline (ages correspond to modules 4 and 5).
To assess whether parents were eligible to participate in the trials, they completed a web-based screening that contained questions about their educational attainment and their child’s age and health status. Parents were respectfully refused participation when their child was younger than 5 months or older than 15 months (trial 1), younger than 20 months or older than 55 months (trial 2), or when their child had a chronic disease or disability that affected normal development. Parents with multiple children could only participate with one child and only in 1 of the 2 trials. We strived to include at least 50% of parents with lower or medium-level SEP and used educational attainment as a proxy for SEP (ie, lower SEP was conceptualized as having completed no education, primary school education, or preparatory vocational education and medium-level SEP was conceptualized as having completed vocational education). Parents with higher educational attainment (ie, preuniversity or university degree) were not actively discouraged from participating in the trials.
Parents were recruited offline (eg, through child day care centers and community health care centers for young children) and online (eg, through Facebook groups), for which we particularly considered locations that are often visited or used by parents with a lower SEP. Interested parents who fulfilled the eligibility criteria received an email in which they were asked to provide consent for their participation. After consenting, the parents were forwarded to the web-based baseline questionnaire. Randomization for each trial took place after the baseline measurement by means of a simple randomization procedure performed by an independent researcher using SPSS version 24. Among research with large sample sizes, this procedure can be trusted to produce equal samples in terms of numbers and covariates [
Two types of process evaluation data were collected: self-reported data and app user data.
We assessed parents’ self-reported app use, their user experience of the app, and their suggestions for app improvement. In the 2 follow-up questionnaires (T1 and T2), we asked parents whether they downloaded the app (and why), whether they still had the app installed on their phone (and why), and how many times they used the app. Regarding user experience, we asked parents to rate several indicators of functionality (eg, ease of use), design, and content (eg, usefulness) on a scale from 1 (bad experience) to 7 (good experience). Parents also rated the app as a whole on a scale from 1 to 10, with higher scores indicating higher appreciation. Finally, we asked open-ended questions about the ways in which the app could be improved.
Preliminary analyses of parents’ self-reported app evaluation data on the first follow-up measurement (T1) showed that most parents in the intervention condition of trial 1 (138/179, 77.1% parents) and almost half of the parents in the app-only intervention condition of trial 2 (33/76, 44% parents) reported that they downloaded the app. Most of these parents (127/179, 70.9% in trial 1 and 55/76, 72% in trial 2) indicated that they had used the app multiple times since installation but were not using it anymore at T1. Around a quarter of the parents (39/179, 21.7% in trial 1 and 21/76, 28% in trial 2) indicated that they still used the app multiple times per month. Parents in both trials generally appreciated the functionality, content, and design of the app. They graded the app with an average score of 6.7 (SD 1.45) in trial 1 and 7.2 (SD 1.05) in trial 2. The most important suggestions parents gave for improvement of the app included the incorporation of more detailed and elaborate parenting information, a clearer structure of the presented information (eg, based on weight-related themes instead of age), the option to look for specific information through a search function, and the integration of other parents’ perspectives and experiences (eg, through personal accounts or online interactions).
In addition, to objectively assess parents’ exposure to the preventive intervention program, their app usage was automatically monitored and collected in an online database. This database allowed us to examine the lessons and challenges that parents started and/or finished, the specific lesson cards they saved as
The primary outcome measures of the effect evaluation were EBRBs of the child (ie, dietary intake, sleep, and screen time), weight-for-height z scores (trial 1), and BMI z scores (trial 2) and parents’ parenting practices related to their child’s EBRBs. The following secondary outcomes were assessed: parents’ general parenting style, parental well-being (ie, depressive symptoms, life satisfaction, stress, and self-reported overall health), and parents’ EBRBs (eg, snacking behavior and sugar-sweetened beverage consumption). An overview of the constructs, variables, and assessment points addressed in the evaluation of the program can be found in
Child weight-for-height and BMI z scores were calculated using height and weight data reported by the parents in the questionnaires. We asked parents to draw this information from the measurement overview in the child’s personal (digital) file, which is updated by the youth health care professional each time the parent and child visit the child health clinic. During the second follow-up questionnaire (T2), we additionally asked parents to send us a picture or screenshot of this measurement overview. This strategy not only allowed us to compare the information parents provided in the questionnaires with that in the child’s file but also allowed us to collect more detailed anthropometric data as the overview contains height and weight measurements from the moment of birth to present day. Moreover, in the second follow-up questionnaire, we asked parents for their permission to be contacted again 12 months and 48 months after T2, so that they could send us a picture or screenshot of the updated measurement overview. This information allowed us to examine the effect of the preventive intervention program on the BMI of the child until approximately 2 years after the last follow-up measurement.
The trials were completed in November 2019 (trial 1) and February 2020 (trial 2). We are currently in the process of data cleaning. Effect analyses are thus underway, and the first results are expected to be submitted for publication in 2021.
The need for effective preventive intervention programs for childhood obesity is high, particularly among families with a lower SEP. The app-based parenting program
Besides the use of the IMP, the app-based parenting program has several other notable strengths. First, previous digital preventive intervention programs for childhood obesity focused solely on the sociocognitive determinants of energy balance–related parenting [
One of the challenges of mobile health interventions is to keep users engaged for longer periods, which is particularly important for interventions targeting behavior change maintenance [
The app-based prevention program also has some limitations. With respect to the design of the trials, it was not possible to blind both participants and investigators to the allocation of conditions (ie, double blinding). As we used a waitlist control condition, the participating parents knew they would eventually receive an app about healthy parenting. However, neither the participants nor the investigators knew which trial condition the participants would be allocated to before randomization took place. Although double blinding in RCTs is generally recommended, methodological studies have shown that adequate allocation concealment is most important in minimizing bias [
In addition, future preventive intervention programs for childhood obesity should consider involving both caregivers. Although we intentionally targeted only primary caregivers (who turned out to be primarily mothers) for the recruitment, program materials, and questionnaires of our program, recent research has indicated that parents within a family differ in the energy balance–related parenting practices they perform [
In conclusion, the IMP allowed for effective development of the app-based parenting program
Logic model of the health problem addressed in the Samen Happie! program.
Overview of the performance objectives (Tables a-c) and change objectives (Tables d-f) specified for the Samen Happie! program.
Illustrated examples of a lesson and a challenge in the Samen Happie! program.
Overview of the modules and corresponding lessons and challenges of the Samen Happie! app.
Flowchart of the design and timelines for both trials of the Samen Happie! program.
Overview of constructs, variables, and assessment points included in the evaluation of the Samen Happie! program.
energy balance–related behavior
Intervention Mapping Protocol
randomized controlled trial
socioeconomic position
The authors want to thank Dio Agency for building the
JKL wrote the funding application. JKL, LTK, JMV, and CW designed the study. JKL, CPMK, RCJH, ELMR, LTK, JMV, and CW developed the preventive intervention program and questionnaires. LTK and JKL drafted the manuscript. JKL, JMV, CW, SPJK, and ELMR supervised the project. All authors read and approved the final manuscript.
None declared.