Process evaluation of a kindergarten-based, family involved intervention to prevent obesity in early childhood: The Toybox Study Malaysia

Abstract Background: Toybox is a kindergarten-based intervention programme targeting physical activity, sedentary behaviour, snacking and drinking in improving healthy energy balance-related behaviour among children attending kindergartens in Malaysia. It was based on a quasi-experimental design involving 780 children from 22 intervention kindergartens and 26 control kindergartens. This paper aims to report the process evaluation of this intervention. Methods: We assessed five process indicators: recruitment, retention, dosage, fidelity, and satisfaction in the intervention kindergartens. Data collection included teachers’ monthly logbook, and post-intervention feedback through questionnaire and focus group discussion with teachers, parents, and children. Results: A total of 1072 children were invited and 837 children completed the programme. Retention with the programme was 88.4% (with 110 children dropping out). 91% of the 44 teachers and their assistants engaged positively with one or more of the process evaluation data collection methods. In terms of dosage and fidelity, 76% of parents had received newsletters, tip cards and posters at the appropriate times. All teachers and their assistants reported being satisfied with the intervention programme, but also that there were some barriers to implementation including suitable environments (one example, insufficient space indoors to carry out activities to reduce sedentary behaviour), and that some of the kangaroo stories were not of sufficient interest to the children or too long to hold their attention. Parents reported that the materials were easy to understand and had improved their knowledge. More than 88% of parents were satisfied with the family-based activities, and had enjoyed them. The children were reported to show a change in positive behaviour in drinking water and consumption of fruits and vegetables.Conclusions: The Toybox programme was feasible to implement and acceptable, although several factors were usefully identified which could easily be improved before this intervention is scaled up and embedded into normal practice across Malaysia.