Intervention
The Vivons en Forme (VIF; “live healthy”) organization is a community-based prevention program aimed at promoting healthier lifestyles among children and their families, and involves municipal service in charge of child education and care under the supervision of a local coordinator. VIF is a continuation of the obesity prevention scheme previously known as Epode (22) in which local actors distributed toolkits fostering educational messages. However, providing information is modestly effective in changing behavior (23), and the non-governmental organization acting as a backbone structure changed its process in 2010, following four new pathways in order to improve program efficiency. First, the name of the program was changed for greater acceptance by the local stakeholders, including families and children, removing the mention of obesity in the name of the interventions. Second, a full social marketing approach was included for each yearly implemented theme (24). Third, toolkit materials were pilot-tested in living labs to collect input from users and stakeholders before application in real-life settings and the participating cities (25). Lastly, the implementation process was centered around local stakeholders, including school staff, as well as participation and empowerment (26). The principle aim was to foster self-efficacy and a long-lasting effect in local school staff newly involved in the field of prevention and health promotion. Local coordinators have the freedom to select the components on which they want to focus their interventions and can request additional interventions during the course of the program. The basic underlying principle of this “choose-and-pick” approach was to foster staff involvement and sustainably change their interactions with children and parents. Each participating municipality applies for a minimal 5-year period, and their representatives have to regularly attend regional coordination meetings to receive up-to-date information on training sessions and tool upgrades.
Study design and participant selection
A quasi-experimental design was used was to meet the study objectives (Figure 1). Four municipalities that systematically monitored the children’s weight status in the primary schools and were participating in the VIF program agreed to provide the data available in their school health records. In these municipalities, VIF counselors (a nutritionist, a sociologist, and the leading coordinator of the program) organized training sessions for the municipal staff in charge of school catering and extracurricular activities (ECAs) in primary schools. Training sessions and toolkits integrated roadmaps for conducting interactive activities with the children and to reinforce child-staff interactions via concrete experiences (Table 1). Brochures highlighting the beneficial effect of healthy eating (HE) and physical activity (PA) for children were systematically provided to parents (26). They included tips on how to help kids stay hydrated by drinking water, on breakfast preparation, food breaks (including fruit), avoiding snacking between meals, on treats and smart portion sizes, and how to easily cook healthy meals at low cost.
Table 1: Description of training and tools provided to local school staff between the first (2011) and last year (2015) of primary education by occupation and thematic component
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Occupation
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Extracurricular activities
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School canteens
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Component
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Physical activity
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Healthy eating
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Healthy eating
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Training session
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10 activities designed to involve kids in active gaming at school
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Focus on 5 activities: • Food rhythms and snacking control • Morning snacking management • Fostering breakfast consumption • Healthy snacks, treat portions, and eating more fruit • Drink water everyday
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• 48 tips for canteen cooks to cook tasteful vegetables
For canteen staff and staff in charge of extracurricular activities during meal time and leisure centers • Portion size and indulging products • Eco-gestures (no waste) • Improving lunch-time break: time to experience more balanced eating habits
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Tools
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• Training booklet and various tools to implement active games
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• For the staff: roadmaps to conduct interactive sessions with the children and brochure focusing on relevant food rhythms for children
• For staff and children: posters reminding to avoid snacking between meals and to eat healthy food on break
• For parents: dedicated booklets on how to manage treats and on drinking water
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• For canteen staff: a training booklet to set up workshops, portion posters to remind them of the guidelines discovered during the training
• For canteen cooks: a booklet with tips to cook vegetables and a brochure to answer their most common questions
• For children: a charter of good conduct to experience pleasant canteen meals (noise, respect of others)
• For parents: booklet with indication of portion sizes
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Measures
Weight status
School nurses received training and standardized weighing scales to measure body mass index (BMI) in children using a BMI chart established by the International Obesity Task Force, which allows classification of children into weight categories (27) (i.e., underweight, normal weight, overweight, and obesity). They assessed the weight status of children during the first year of primary education at the school premises several weeks before the launch of each program in 2011. Children wore light clothing and no shoes during the weighing sessions. In addition, BMI Z-scores were determined using BMI-for-age reference standards (28) in order to account for the severity of overweight/obesity. A second weight assessment was performed among the same children during the last year of their primary education in 2015.
Socio-demographics
Weight status was matched for sex and age at inclusion, and whether children were schooled in a zone of priority education (zone d’education prioritaire, ZEP) was indicated. ZEP refers to schools in deprived, usually urban, settings that are earmarked for special state support. The decision to categorize a school as a ZEP was left to the administrative authorities, who can release additional funding to finance special needs education. Households and individuals of lower socio-economic status (unemployed, single mothers) are overrepresented in ZEPs compared to other city areas.
Process indicators
The number and occupation (school catering or ECAs) of persons who attended training sessions between 2011 and 2015 were systematically recorded by thematic component (i.e., HE and/or PA).
Data blinding and confidentiality
Each municipality provided data collected in the schools under their supervision without identifying a particular school or area. A study number was attributed to each municipality (City #) and each child in the database to ensure confidentiality. The final database was completed in 2016, but anonymized data were transmitted to researchers in charge of statistical analyses in 2018 due to the administrative authorization procedure in each participating city.
Statistical analysis
Process indicators were expressed as number and occupation of school ancillary staff attending training sessions by thematic component in each municipality, and then converted into CSRs, the number of children to each trained staff member, for each occupation and thematic session. Because an average ratio of 8 children per adult was found in early childhood education and care settings (29). The CSR was classified as “low” if between 1 and 5 children per adult, and “moderate” otherwise.
Categorical data were expressed as numbers and percentages and compared using the chi-squared test, or the McNemar test. Numerical data were expressed as means and standard deviations (SDs) and compared by one-way analysis of variance or the non-parametric Wilcoxon comparison test. Outcome indicators were 4-year changes in weight status, which were considered “positive” if obesity changed to overweight/normal weight or if overweight changed to normal weight, and “negative” if normal weight changed to overweight/obesity or if overweight changed to obesity. To investigate the influence of process indicators on weight changes, we entered each CSR (low, moderate) as a covariate in a logistic regression using positive 4-year weight change as the binary outcome (yes/no), with and without adjustments for age at inclusion, gender, and school area (deprived/non-deprived). To investigate the effect of combined CSRs, the four variations of the VIF program locally implemented in the participating municipalities were entered in a regression model as a categorical covariate, as collinearity precluded the use of multiple regression with interaction terms. The same statistical procedure was carried out with negative 4-year weight change as a binary outcome in children characterized as overweight/normal weight at inclusion. Estimates were expressed as odds ratios (ORs) with 95% confidence intervals (CIs). Statistical analyses were performed using the SPSS statistical package, version 20 (SPSS, Chicago, Illinois, United States).