Lloyd et al.

International Journal of Behavioral Nutrition and Physical Activity 2011, 8:73

http://www.ijbnpa.org/content/8/1/73

RESEARCH Open Access

Evidence, theory and context - using intervention

mapping to develop a school-based intervention
to prevent obesity in children
Jennifer 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-based
interventions to prevent and reduce obesity in children. Clear documentation of the rationale, process of
development and content of such interventions is essential to enable other researchers to understand why
interventions succeed or fail.
Methods: This paper describes the development of the Healthy Lifestyles Programme (HeLP), a school-based
intervention to prevent obesity in children, through the first 4 steps of the Intervention Mapping protocol (IM). The
intervention 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-based
activities, 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 phase
suggested that the 9-10 year olds were both receptive to the messages and more able and willing to translate
them into possible behaviour changes than older or younger children and engaged their families to the greatest
extent. 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 enables
behaviour change. Activities include whole school assemblies, parents evenings, sport/dance workshops, classroom
based 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 based
intervention aimed at motivating children and their families to make small sustainable changes to their eating and
activity behaviours. Although the process was time consuming, this systematic approach ensures that the
behaviour change techniques and delivery methods link directly to the Programme’s performance objectives and
their associated determinants. This in turn provides a clear framework for process analysis and increases the
potential of the intervention to realise the desired outcome of preventing and reducing obesity in children.

Background Programme reported that by age 10-11 years (Year 6)

Over a very short timescale there has been a substantial one in three children were either overweight or obese
increase in the proportion of children in the UK who [2]. Being overweight in childhood is associated with
are overweight [1] The Health Survey for England adverse consequences including metabolic abnormalities,
(2008) reported that 19% of girls and 18% of boys aged increased risk of Type II diabetes, and musculo-skeletal
11-15 were obese and 34% of girls and 33% of boys and psychological problems [3]. Over 50% of obese chil-
were overweight [1]. The National Child Measurement dren become obese adults [4] with significant health
consequences [5].
Unfortunately there is currently little evidence that
* Correspondence: jennifer.lloyd@pms.ac.uk
Institute for Health Service Research, Peninsula College of Medicine and
existing, school-based intervention programmes are
Dentistry, University of Exeter, Exeter, UK effective in preventing or reducing obesity in children.
© 2011 Lloyd et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
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In addition, most intervention programmes have not considerations (e.g. stakeholder opinions, feasibility data)
reported on their rationale, development, exact content, also guide the choice of intervention methods and stra-
or method of implementation which further hampers tegies to achieve these objectives. We used a variety of
our understanding about what works and why. In tack- methods to gather the appropriate information to enable
ling childhood obesity, securing scientific information us to produce a feasible and acceptable intervention that
on what constitutes a healthy diet and an active lifestyle has the potential to change behaviours at a school, child
is only the first step. The second step, requiring an and family level. These included literature reviews, dis-
equally scientific approach, is to find methods of achiev- cussions with stakeholders (teachers, head teachers, edu-
ing behaviour change. The determinants of behaviours cation advisors, local public health leads in physical
linked to obesity are complex and inevitably changing activity and obesity) and experts in behavioural science
these behaviours is difficult and interventions are likely and obesity research. We also carried out focus groups
to be complex and multi-faceted. The 2008 MRC Fra- with children and interviews with parents and teachers
mework for developing and evaluating complex inter- during early pilot work to inform our selection of inter-
ventions recommends that the mechanisms by which vention techniques and strategies and to ensure that
interventions work need to be made explicit during these remained feasible to deliver within normal school
development [6] and such interventions need to be com- activities.
prehensively described if they are to be replicable by The following sections provide a summary of the first
others. This is important as it provides a basis for 4 steps of the IM process used to produce the HeLP
checking intervention fidelity, a necessary pre-requisite intervention. Steps 5 and 6 involve programme imple-
to understand efficacy. It also provides a basis for pro- mentation, adoption, monitoring and evaluation and are
cess analysis (relating mechanisms of change to out- not presented here. While the steps are described in lin-
comes) which can shed light on why complex ear fashion they are, in fact, iterative. For example,
interventions succeed or fail and how they can poten- defining a more specific behaviour change objective (e.g.
tially be optimised. parents need to buy and provide healthier snacks) might
Schools have the potential to play a critical role in the lead to the consideration of additional behavioural
prevention of overweight and obesity. With their exist- determinants (those which affect parental shopping
ing organisational, social and communication structures behaviours as well as those which affect the child’s eat-
they provide opportunities for regular health education ing behaviour).
and for a health enhancing environment. They also
enable the researcher to engage children and families Step 1: Needs Assessment
across the social spectrum. In England, children attend a The IM process begins with a needs assessment of the
primary or junior school up to the age of 11, where they health problem, which includes identification of the pro-
usually have one class teacher who teaches all subjects. blem behaviours (and to some extent their determi-
This allows for joined up cross-curriculum activities and nants) and of desired programme outcomes as well as
facilitates communication making both intervention and the environmental conditions associated with the
research in this setting particularly attractive. problem.
In this paper we describe the application of a systema- Reviewing the evidence base
tic process, Intervention Mapping (IM) (see Figure 1) [7] The starting point was to review the literature to identify
to plan a school-based obesity prevention intervention. (i) risk factors for childhood obesity and children’s cur-
rent eating/drinking and physical activity behaviours (ii)
Methods the determinants of these behaviours and (iii) apparently
Intervention Mapping successful and unsuccessful components of previous
The six main steps of IM (Figure 1) are: i) needs assess- school-based interventions to prevent and reduce obesity.
ment; ii) detailed mapping of programme objectives and (i)Possible risk factors for obesity Obesity results from
their behavioural and environmental determinants; iii) an imbalance between consumption and expenditure of
selecting techniques and strategies to modify the deter- energy. Controlled experimental and epidemiological
minants of behaviour and the environment; iv) produ- studies suggest a number of dietary risk factors asso-
cing intervention components and materials; v) planning ciated with increased energy intake in children and
for adoption, implementation and sustainability; and vi) adults. These included, diets with a high energy density
creating evaluation plans and instruments. IM uses [8] usually characterised by foods high in fat and low in
behavioural theory and research evidence to develop fibre, including fast food [9,10] and large habitual por-
specific learning and change objectives for the target tion sizes [11]. Experimental studies also report that
population and to identify the personal and external liquid calories have lower satiating properties than solid
determinants of these objectives. Theory and other food [12] and epidemiological studies report an
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Products Tasks

- Plan needs assessment

Step 1 - Assess health, quality of life,
behavior and environment
Needs Assessment - Assess capacity
- Establish programme outcomes

- State expected changes in behavior

Step 2 and environment
- Specify performance objectives
Proximal Programme - Specify determinants
Objective Matrices - Create matrices of learning and
change objectives

- Review programme ideas with

Step 3 interested participants
- Identify theoretical methods
Theory-Based Methods - Choose programme methods
And Practical Strategies - Select or design strategies
- Ensure that strategies match change
Evaluation objectives
- Consult with intended participants
Step 4 and implementers
- Create programme scope, sequence,
Programme 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

- Identify adopters and users

Step 5 - Specify adoption, implementation and
sustainability performance objectives
Adoption and Implementation
- Specify determinants and create
Plan
matrix
- Select methods and strategies
- Design intervention to affect
programme use
- Develop evaluation model
Step 6 - Develop effect and process evaluation
questions
Evaluation Plan - Develop indicators and measures
- Specify evaluation designs
- Write an evaluation plan

Implementation

Figure 1 The Intervention Mapping process.

increased risk of weight gain or obesity in consumers of Carbonated soft drinks are a major source of NMES
sugar-rich drinks. A single carbonated drink per day can providing 19% of NMES intake in children aged 4-10
add 10% to a child’s energy intake [12]. According to and over one-third in children aged 11-18 [13].
the National Diet and Nutrition Survey (2008/9), in the Reduced energy expenditure has also been associated
UK children’s intake of non milk extrinsic sugars with weight gain [15] and numerous studies in adults
(NMES) provides 15% of food energy [13], compared to and children reported an association between lower
a recommendation of not more than 11% [14]. weight gain and higher levels of physical activity [16].
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Stratton et al reported a decrease in the levels of cardio- engage in physical activity it will be crucial in interven-
vascular fitness in 9-11 year olds in England between tion studies to assess whether any effects translate in to
1997 and 2003 while the prevalence of obesity increased changes in total as opposed to only school time activity.
over the same time period [17]. Children’s TV viewing Drawing on the social ecological approach [29] we
time and time spent playing electronic games has been began from the theoretical perspective that, while both
associated with overweight and obesity [18-20], total eating and activity behaviours in children are partly
calorific intake [21] and the consumption of snack foods determined by choices made by the children, they are
[22]. Longitudinal data from the Avon Longitudinal highly dependent both on direct intervention by parents
Study of Parents and Children (ALSPAC), found strong (e.g. the food provided, opportunities for physical activ-
associations between children’s fat mass at age 14 and ity) and by patterns of behaviour within the family,
their physical activity at age 12 [23]. We also know that within the school and within peer groups. As children
today’s children are spending more time in front of the get older the relative importance of self directed, as
television or computer screen than in previous genera- opposed to family directed, behaviours increases and
tions - an average of two and a half hours of TV and 1 these behaviours are influenced by wider social factors
hour and 50 minutes online a day [24]. (i.e. nearly 4 1/2 which include the school environment and peer group
hours a day of screen time). An attempt to encourage norms. Therefore any intervention we designed needed
children to replace screen-based sedentary behaviours to affect behaviour through influencing the children,
with more active pursuits is clearly an appropriate aim their families and the school environment. There is
in preventing obesity in children and promoting a some evidence from previous studies of interventions in
healthy lifestyle. children that the use of drama/theatre can be an effec-
(ii)Determinants of behaviours A variety of family and tive tool to engage children, increase knowledge and
social determinants affecting children’s eating and activ- change behaviours [30-33]. For example, in an obesity
ity behaviours have been identified. For eating, these prevention programme aimed at low income children
include food preferences, food availability and accessibil- and their parents, an after school theatre-based inter-
ity, modeling (copying the behaviour of others), meal- vention was shown to motivate and engage both parents
time structure (social context of meals, the role of TV and children and increase awareness of the need for
during mealtimes, eating out, portion size, school meals, making changes. However, the authors did conclude
snacking habits), feeding styles (the caregivers approach that theatre alone is not enough to lead to behavioural
to maintain or modify children’s behaviours with respect change and that the next step should be to incorporate
to eating) and socio-economic and cultural factors (e.g. this delivery method into more comprehensive pro-
family time constraints, education, income, ethnicity and grammes with both educational and environmental
culture) [25]. In terms of children’s physical activity, components [31]. Two small studies in primary schools
parental support (e.g. transporting the child, observing in the UK based on drama/the arts reported increases in
the activity, encouraging the child, providing equipment, vegetable, salad and fruit juice consumption [32,33].
participating with the child and reinforcing physical Although both these studies had serious methodological
activity behaviours) has been identified as a key determi- weaknesses, the use of drama to engage children to
nant both directly and indirectly through its positive change specific behaviours looked promising and was
association with self efficacy perceptions [26]. Griew et explored at length with experts from drama and educa-
al recently reported that children’s school time physical tion as a possible implementation strategy in step 3 of
activity varied according to the primary school they the intervention mapping process.
attended even after accounting for individual demo- We were mindful that there were other key drivers
graphic and the school compositional factors with a including intrinsic factors such as genes and the wider
‘school effect’ explaining 14.5% of the variation in pupils’ social environment but these are less modifiable and so
school-time physical activity [27]. However, it is less were not considered as potential points of intervention.
clear that school based activities have a substantial effect (iii) School-based interventions The most recent sys-
on total, as opposed to school time, activity. In a study tematic review (2009) of controlled trials of school-
of 3 schools from one area, with different sporting facil- based interventions identified 38 studies; 3 dietary inter-
ities and opportunity for physical activity in the curricu- vention only, 15 physical activity only and 20 combined
lum, Mallam et al (2003) reported large differences in diet and physical activity [34]. The authors concluded
school time activity levels but virtually no differences in that there was insufficient evidence to determine the
the total activity of the children [28]. effectiveness of dietary interventions alone, but sug-
This research suggests that while it appears that gested that interventions which increase activity and
schools have the potential to create a positive physical reduce sedentary behaviour may help children to main-
activity culture that can influence whether children tain a healthy weight, although results were short-term
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and inconsistent. Results for combined diet and activity supportive environments) foster the development of
were also inconsistent, although there was a suggestion healthy eating and activity behaviours among their chil-
that the combined approach might be more effective in dren/family. Thirdly, in order to provide an intervention
preventing children becoming overweight in the long that was not only feasible and acceptable to schools, but
term. Social Cognitive Theory (SCT), which proposes had potential for long term sustainability, the interven-
that a dynamic interaction exists between personal, tion should dovetail with healthy lifestyle initiatives
behavioural and environmental factors, provides a basis already present in schools and aim to meet National
for many of these programmes, particularly the con- Curriculum requirements for the age group targeted,
structs of self efficacy, behavioural capability (knowledge something previously recommended by Doak et al
and skills to perform a behaviour), outcome expecta- (2006) in a review of interventions and programmes to
tions, self regulation and reinforcement [35]. Environ- prevent obesity in children [39]. Finally, the methods
mental conditions of eating behaviour such as school chosen to deliver the intervention to children and par-
lunch provision and parental/home environment were ents not only needed to engage, motivate and inspire
often targeted [36,37]. A review of reviews of effective but should also be realistically deliverable by teachers
elements of school health promotion across behavioural and relevant external groups operating within a school
domains (substance abuse, sexual behaviour and nutri- setting.
tion) found that five elements from the highest quality Outputs
reviews were found to be effective for all three domains Based on the above needs assessment process we
using two types of analysis. These were use of theory; decided to develop an intervention which aimed to sup-
addressing social influences (especially social norms); port children to achieve small sustainable changes across
addressing cognitive behavioural skills; training of facili- childrens’ patterns of diet and physical activity but with
tators and multiple components. Using one type of ana- a focus on three key behavioural objectives:
lysis only, another two elements were identified: 1. to reduce the consumption of sweetened fizzy
parental involvement and a large number of sessions drinks
[38]. 2. to increase the proportion of healthy snacks con-
The authors concluded that the 5 elements identified sumed and
should be primary candidates to include in programmes 3. to reduce TV viewing and other screen based
targeting these behaviours. activities.
Stakeholder consultation
A second approach to needs assessment is to collect Step 2: Detailed mapping of programme objectives
information to enable a deeper understanding of the Step 2 provides the foundation for intervention develop-
context or community in which the intervention is to be ment by specifying in detail who and what will change
delivered [7]. The next step in our needs assessment as a result of the programme. The products of step 2
was therefore to run a workshop with practitioners, pol- are proximal programme objectives or PPOs. These are
icy makers and researchers from education, child health, statements of demonstrable behaviours (in the target
sports science, the local PCT and the local healthy group) or changes in the environment that need to
schools team. In the workshop we addressed the nature occur in order affect the determinants of the overall
of the problem and the findings of our literature review, behavioural objectives that have been identified in step
seeking ideas about possible behavioural objectives for 1 (and further refined in step 2). To define PPOs, we
schools, children and their families and what the desired first defined key behavioural objectives (see above) and
outcomes of the programme should be. broke these down into smaller steps (performance
This workshop resulted in agreement about four key objectives) and then identified the determinants of each
principles which it was suggested should guide our performance objective. Then we specified ‘proximal pro-
intervention design. Firstly, that a public health gramme objectives’ (i.e. the most immediate targets of
approach should be adopted including all children intervention - what needs to be learnt or changed in
rather than targeting the overweight. The adverse health order to modify behavioural determinants and conse-
consequences of obesity are not limited to those at the quently the key behavioural objectives).
extreme end of the BMI distribution and, although most As the aim of our intervention was to develop a
children remain lean, many will gain weight as adults. In school-based intervention which was delivered to chil-
addition, separating children within a class for special dren but was able to influence parents and the school as
intervention risks stigmatising them. Secondly, the inter- well, activities needed to include parents/families, tea-
vention needed to engage parents and offer them strate- chers and the senior management team (SMT). Further,
gies through which they could directly (through more specific behavioural objectives, called performance
parenting) or indirectly (through the creation of objectives (POs) were developed for each group
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(children, parents/family, teachers, SMT). These consti- of this key issue. Although this process was time con-
tuted individual behaviours, motivations, abilities and suming, it was useful in creating a more focused and
environmental opportunities in the home and within the considered intervention.
school for each group in order for the three key beha- b) Identification of Determinants
vioural objectives to be achieved. The performance In order to specify our ‘change targets’ i.e. those poten-
objectives developed for the parents/family, teachers and tially modifiable determinants of obesity related beha-
the SMT were focused on engaging the school and the viours we i) reviewed the determinants of children’s
children’s families in order to create the necessary con- eating and physical activity behaviours reported by
ditions to enable children make sustainable changes to experimental and epidemiological studies and compo-
their eating and activity behaviours. For example, at the nents of previous school-based interventions to prevent
outset, a PO for the SMT was for them to ‘buy into’ the and reduce obesity; ii) sought expert opinion from an
Programme and believe it would benefit the school and advisory panel of researchers in the field and beha-
the children and would dovetail with the existing year 5 vioural scientists; and iii) made reference to theories of
curriculum and school initiatives already in operation. behaviour and/or behaviour change. The determinants
For the purposes of this paper we will confine our were categorised as personal (factors within the indivi-
examples to the performance objectives related to the dual under their direct control) or external (factors out-
child, however, a detailed intervention specification sup- side of the individual that can directly influence the
porting this paper is available to view (See Additional health behavior or environmental conditions). The final
file 1) which shows the POs, determinants (change tar- list of determinants to be targeted is provided in
gets), BCTs and methods of delivery for all the target Table 1. These were selected based on their links to the-
groups. oretical models of behavior change which have formed a
a) Defining overall behavioural objectives basis for previous school-based interventions and their
The creation of a behavioural objective requires break- potential to be modified within a school setting.
ing down the desired outcome, in this case, preventing A focus on delivering the Programme in such a way
obesity, into component parts that influence or are that children enjoyed the activities and were motivated
required to achieve the desired outcome. The three key to participate was also seen as a key determinant for a
target behaviours, reducing consumption of sweetened number of POs, as affective responses are linked to both
fizzy drinks, increasing the proportion of healthy snacks physical activity and eating behaviours. It is likely that
consumed and reducing TV viewing and other screen- children will be motivated and enjoy activities if they
based activities were expanded into a set of sub-compo- have positive attitudes towards the behaviour [40], feel
nent behaviours (performance objectives, POs). These competent to make changes [41], perceive significant
performance objectives clarified the exact behavioural others to be motivated and perceive they have some
performances expected from children, parents and tea- control over outcomes [42]. The main determinants or
chers in order to meet these key objectives and referred ‘change targets’ for the HeLP Programme therefore,
to individual level behaviours, motivations, abilities as were (i) knowledge and skills (ii) self efficacy, (iii) self
well as to environmental opportunities for such beha- awareness, (iv) taste, familiarity and preference, (v) per-
viours at the home and school level. As involvement of ceived norms (vi) support, modelling and reinforcement
parents was vital in achieving the three key target beha- from family members and (vii) access and availability of
viours, we knew we needed children to clearly commu- opportunity. Having selected our change targets or
nicate the messages to their parents and engage them in determinants the next step was to identify the specific
supporting their goals. This was originally construed as behaviours necessary to modify them.
a PPO related to the determinants of social support, c) Define proximal program objectives
modelling and reinforcement but was promoted to a PO The final part of this step is to define the proximal pro-
so that the intervention could explicitly focus on strate- gramme objectives (PPOs) by mapping performance
gies to promote this dialogue between the child and objectives (row headings in tables 2, 3 and 4) against
their family. The iterative process of identifying perfor- determinants (column headings in table 2, 3 and 4) in a
mance objectives was added to over time as the map- table to form a matrix. In the tables, cells created from
ping process identified additional issues. For example personal determinants record what the target group
the concept of enabling children to recognize and resist should do and/or know and cells created from external
temptation for unhealthy snacks was originally a PPO determinants record what should change in the environ-
(which aims to address the determinant of ‘urges for ment in order for there to be a positive impact on each
unhealthy foodstuff’ as related to the objective of ‘redu- determinant so that the performance objective can be
cing unhealthy snacks’) which we also promoted to a achieved. These end statements are the PPOs. For
performance objective to allow a more detailed analysis example, for children to communicate healthy lifestyle
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Table 1 Examples of determinants of eating and physical activity behaviour in children targeted by the Healthy
Lifestyles Programme
Personal Determinant External Determinants
Knowledge and skills to perform tasks required by the intervention (e.g. Norms
communicating with parents, select healthy snacks/drinks)
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 more Availability and accessibility of healthy and unhealthy foods in and
active pursuits) outside the home and in the school environment
Perceived familiarity of foods/physical activities Availability and accessibility of physical activity opportunities in
school and during parental care
Perceived norms regarding choice of food/leisure activities in family and peer Family support (emotional, instrumental and informational)
group
Self efficacy regarding selection of food/physical activity Reinforcement from parents, teachers and peers
Self awareness regarding diet and physical activity and screen-based
sedentary behaviours
Attitude to the Programme (intention to make changes)
Perceived importance of eating healthily and exercising (pros and cons of
making a change)

messages to parents and seek their help and support, techniques were delivered in our intervention, we
change in three personal and two external determinants decided to map performance objectives onto a process
are required (see Table 2). From a personal perspective, model of behaviour change. The Health Action Process
the child needs specific knowledge and skills to commu- Model (HAPA) [42] was selected as a ‘starting point’ as it
nicate the messages to their parents and seek their help is consistent with the theoretical models of behaviour
and support (taught throughout the intervention using a change mentioned earlier and suggests that behaviour
variety of methods) and perceive that their peers are change occurs through a sequence of adoption, initiation
talking about the project and also seeking their parents and maintenance processes. This phased model implies a
support. Practising communication through role play clear order of distinct actions which is easily understood
and engaging parents using homework tasks, drama pro- and is compatible with a sequential application of techni-
ductions and school assemblies may increase self effi- ques spread across the curriculum of a school year. By
cacy in communicating messages to parents and making taking these phases into account, performance objectives
suggestions for support. From an external perspective, and their associated PPOs were mapped onto three pro-
the child requires support and reinforcement from par- cesses of behaviour change; Establish motivation (develop
ents, teachers and peers. This increased communication confidence and skills, make decisions); Take action (cre-
with parents/family needs to increase family awareness ate an action plan and implement it); Stay motivated
of healthy lifestyles and in turn lead to the family (monitor progress, assess and adapt goals).
increasing availability and accessibility of healthy snacks Tables 2, 3 and 4 present matrices of performance
and active pursuits at home. objectives and a selection of the key determinants tar-
The end point of step 2 in the intervention mapping geted in the HeLP intervention for each of the three
process, i.e. defining proximal programme objectives, is an processes of behavior change. The combination of per-
iterative process and we moved back and forth between formance objectives, and behavioural determinants, gen-
the tasks of defining POs and their associated determi- erates (in the cells of the table) the proximal objectives
nants from the ones targeted in the HeLP Programme (see for the Programme (PPOs). These have then been
Table 1) and the creation of statements of demonstrable mapped onto the appropriate process of behavior
behaviours. e.g. ‘practices skills to seek parental support’ change in the HAPA model. This provided a clear fra-
that would modify a particular determinant and thus help mework to guide the selection and sequencing of the
achieve the performance objective. This process produced behavior change techniques and practical strategies
an overwhelming amount of information which we had to which constitute the intervention.
condense in order to develop a feasible and acceptable
intervention within the school setting. Step 3: Specify behaviour change techniques
During the process of creating the matrix, in order to The product of step 3 is an inventory of behaviour
guide the sequential order in which behaviour change change techniques selected to match each proximal
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Table 2 Matrix of performance objectives and determinants for ‘Establish Motivation’

Personal Determinants External Determinants
Performance Knowledge/ Self-efficacy Self-awareness Taste Perceived Family support, Availability
Objectives Skills Familiarity norms Modelling Accessibility
Preference Reinforcement
1 5 9 11 13
*A Communicate Understands Shows Perceives other Receives social Increases in
healthy lifestyle messages and confidence pupils are reinforcement availability of
messages to energy knowledge of talking about from parents/ healthy snacks/
parents and seek balance healthy lifestyle the project family for drinks and
6 10
their help and concept Shows Perceives interest in active pursuits
2
support Practices skills confidence to others are healthy lifestyles
12
to talk to parents seeking parental Receives
7
communicate Shows support reinforcement
with parents confidence and from parents/
3
Understands knowledge of family for
how parents family strategies suggested
can support a to support a support
healthy healthy lifestyle strategies
8
lifestyle Shows
4
Practices skills confidence to
to seek seek parental
parental support
support
14 17 19 20 21 22
B Identifies shows Is familiar Perceives Receives Increases in
Select and try healthy confidence to with and family, peers, reinforcement availability and
healthy alternatives to select healthy chooses teacher from family, accessibility of
alternatives to unhealthy snacks and drinks healthy expecting them peers and healthy snacks
18
unhealthy snacks snacks and shows snacks and to select teachers and drinks at
and drinks at drinks confidence to try drinks healthy home
15
home and at Practices new snacks and alternatives
school skills to ask for drinks
healthy
alternatives in
different
settings
16
Taste healthy
alternatives to
unhealthy
snacks and
drinks
23 25 26 27 28 29
C Identifies Shows Is familiar Perceives Receives Increases in
Select feasible active confidence and with range of family expecting reinforcement active leisure
active alternatives alternatives to enthusiasm active active choices from family, opportunities at
to sedentary sedentary alternatives peers, teachers home
activities leisure pursuits to sedentary
24
Attends pursuits
activity
workshops
Participates in
active games
30 33 34 35 36 37
D Identifies Shows Records what Perceives Sees parents, Decreases in
*Understand and general confidence to tempts them into peers and family and peers temptations in
resist temptation barriers to resist temptation eating unhealthy family are resist temptation the home
being healthy snacks and drinks resisting
31
Understands and being temptation
marketing sedentary
strategies used
to tempt
children
32
Practices
skills to resist
temptations
* POs originally construed as PPOs which have been promoted to a higher level
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Table 3 Matrix of performance objectives and determinants for ‘Take Action’

Personal Determinants External Determinants
Performance Knowledge/ Self-efficacy Self- Taste Perceived Family support, Availability
Objectives Skills awareness Familiarity norms Modelling Accessibility
Preference Reinforcement
38
E Identifies unhealthy 40Shows 41
Completes 43
Receives
Reflect own snacks in diet and confidence in 2 day food reinforcement
snacking and sedentary leisure ability to assess record from parents
42
leisure choices own behaviour Completes and teachers
39 44
choices Compares to 24 hour Sees peers
guideline activity evaluate
record snacking and
activity choices
45 50 51 52 53
F Knows role of goal Shows Perceives Receives Increases in the
Set goals setting in helping to confidence in peers are reinforcement availability and accessibility
and make change behaviours ability to make making from parents of healthy snacks and
46
changes Knows goals need small changes changes and family drinks at home
54
to be SMART Increases in active leisure
47
Writes 3 SMART opportunities at home
goals
48
Knows range of
strategies to help
achieve goals
49
Identifies personal
strategies to help
achieve goals

programme objective. A behaviour change technique (confidence in being able to perform the target beha-
(BCT) e.g. ‘model/demonstrate behaviour’ is a technique viour), which is a construct of social cognitive theory.
designed to change a specified theoretical process or Finding appropriate techniques begins with the ques-
determinant of behaviour. For example, using strategies tion “How can the learning and change objectives (the
in the intervention that enable children to practice a tar- PPOs) for each performance objective be accomplished?”
geted behaviour and/or see role models perform the Methods for identifying suitable techniques included a)
behaviour, is designed to increase self efficacy discussions with stakeholders, and experts in behaviour

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

Personal Determinants External Determinants
Performance Knowledge/ Self-efficacy Self-awareness Taste Perceived Family support, Availability
Objectives Skills Familiarity norms Modelling Accessibility
Preference Reinforcement
55 57 58 59 60
G Monitor Produces a Shows Completes Perceives Receives
goals personal confidence in personal peers are reinforcement from
monitoring chart monitoring goals monitoring monitoring teachers and parents
56
Knows 80/20 chart goals for monitoring goals
message
61 64 65 66 67 68
H Knows how their Shows Records Perceives Receives Increases in availability
Assess environment confidence to barriers and peers reinforcement from and access to healthy
barriers to affects their overcome strategies planning teachers and parents snacks and drinks at
goal choices barriers strategies home
62
achievement Knows how experienced
personal
temptations have
affected achieving
goals
63
Plans new
strategies to
overcome barriers
69 71 72 73
I Knows if goals Shows Receives social Increases in active
Adapt goals are SMART confidence to reinforcement from leisure opportunities
70
Knows how to adapt goals parents for being and healthy snacks and
adapt goals based on motivated drinks at home
experience
SMART goals - goals that are Specific, Measurable, Achievable, Realistic and Time-based
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change (behavioural science academics/health promo- see Table 2), the BCTs used were ‘prompt barrier identi-
tion staff); b) reference to a taxonomy of behavioural fication’, ‘problem solving’, ‘decision balance’, ‘model/
change techniques [43,44]; c) consideration of theory demonstrate behaviour’ and communication skills train-
and practice in other school-based interventions; d) ing’. This linked to the PO of ‘understand and resist
applying criteria for feasibility, acceptability and cost temptation’. (see Table 5).
within a school setting.
A range of suitable BCTs were then selected and Step 4: specifying practical strategies and designing the
included: role modelling, skill and knowledge building, intervention
communication skills training, self monitoring, problem The implementation strategy is simply the process for
solving, modelling/demonstrating behaviour, barrier delivery of a particular behavior change technique. The
identification, goal setting, decision balance and social strategy needs to be appropriate for the target popula-
support. For example, to practice skills to communicate tion and the setting in which the intervention will be
the desired healthy lifestyle messages to their parents conducted. We were mindful (as per our needs assess-
and seek their support, children modelled and demon- ment) that strategies chosen needed to be deliverable by
strated the behaviour by participating in a variety of role teachers and relevant external groups operating within a
play scenes, followed up with discussions of issues led school setting, dovetail with healthy lifestyle initiatives
by the drama facilitator. Many BCTs may need to be already going on in schools at the time and, where pos-
applied to bring about a single PPO e.g. for children to sible, meet National Curriculum requirements for this
‘practice skills to resist temptation’ (PPO number 32, age group.

Table 5 Behaviour change techniques and strategies for performance objectives associated with ‘Establish Motivation’
Performance objectives Behaviour change Implementation strategies
techniques
(theoretical
framework)
A Exchange information Children learn about the healthy lifestyle messages and support strategies
Communicate healthy lifestyle messages to (IMB) through a variety of individual and group tasks delivered by the teacher in
parents and seek their help and support Prompt barrier PSHE lessons and by actors in drama workshops. ‘80/20’ used as a general
identification message throughout suggesting we should eat healthily and be active at
Model/demonstrate least 80% of the time.
behaviour Parent information sheets given to children following each drama workshop.
Communication skills Characters and children role play scenes to communicate messages to
training parents and seek their support. Discussion and role play of ways to
(SCT) encourage whole family to make changes.
Prompt identification Characters present scenes, where after having made changes to their
as a role model (SCT) behaviours, become role models to others (siblings, parents, friends)
followed by group discussion.
B Exchange information Children view and discuss with their chosen character ingredients of both
Select and try healthy alternatives to (IMB) healthy and unhealthy food and drink. Compare fat, sugar and salt content
unhealthy snacks and drinks at home and at Provide to recommended guidelines.
school encouragement Children observe characters taste healthy snacks and drinks while role
Modelling (SCT) playing in different settings
Characters provide encouragement
Children taste healthy snacks and drinks with their chosen character
C Modelling (SCT) Children and actors role play home and school scenes focussing on
Select feasible active alternatives to sedentary replacing sedentary leisure pursuits with active alternatives.
activities Children play interactive games to choose and mime active leisure pursuits.
Children observe the characters mime their 24 hour clock and discuss their
activity in relation to the ‘80/20’ message.
D Prompt barrier Children make personalised ‘Temptation T shirts’
Understand and resist temptation identification (SCT) Children work with their chosen character to prepare ways to tempt the
Problem solving (SCT) other 3 characters and help their own character to resist temptation.
Decision balance Children participate in the ‘Temptation Ladder’ activity that enables them to
(SCT) practise skills to resist temptations and help others.
Prompt barrier Children observe characters role play marketing scenes
identification (SCT) Children participate in the role play.
Model/demonstrate
behaviour (SCT)
Communication skills
training (SCT)
Theoretical framework: IMB = Information Motivation Behavioural Skills Model; SCT = Social Cognitive Theory
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a) Specifying implementation strategies questionnaire responses (parents), documentation of

It was clear the strategies chosen to deliver the key mes- parental and child involvement and observations of
sages needed to inspire and motivate the children so intervention delivery. The aim of phase 1 was to ensure
that they discussed the Programme at home with their that the initial intervention components were feasible,
parents and each other. Previous research has suggested appropriate and suitably engaging for the target popula-
that drama may be an appropriate means of engaging tion (8-11 year olds). We therefore worked with chil-
children, increasing knowledge and changing health dren, parents and teachers from a single primary school
behaviours [30-33]. Following discussions with experts to assess a variety of possible activities, materials and
in education and drama, it was hypothesised that inter- modes of delivery to 119 children from three age groups
active drama based activities where the children take (8-9 year olds; 9-10 year olds and 10-11 year olds) using
ownership of the issues was more likely to motivate education lessons and either drama or goal setting.
children to become engaged with the process, make Based on the results/feedback from phase 1, the inter-
changes and to engage their parents than passive receipt vention was further developed and a second phase of
of messages. We also hypothesised that, if the children piloting took place in a second primary school, in an
were involved in the development of materials, including area of high deprivation, with 77 children from three
the scenarios they produce (facilitated by actors), they year 5 classes (aged 9-10 years). The aim of the second
would be more likely to be receptive to the health mes- phase was to assess ‘proof of concept’ (i.e whether the
sages. Drama sessions were also compatible with the intervention could change obesity related behaviours)
existing school curriculum and could provide a frame- and the feasibility of taking measures. Height, weight,
work within which to deliver many of the proposed waist circumference, % body fat, objective physical activ-
behaviour change techniques in a way which is accessi- ity (using accelerometry), food intake (using an adapted
ble and engaging for children. version of the Food Intake Questionnaire) [45] and
Table 5 presents a summary of behaviour change screen time (using an adapted version of the Childrens’
techniques and implementation strategies chosen to TV Viewing Habits Questionnaire [46] were measured
accomplish PPOs (not shown) for each performance at baseline and 6 weeks post intervention.
objective related to ‘establishing motivation’. To view
the table showing techniques and strategies for ‘take b) Results
action’ and ‘stay motivated’ see Additional file 2. Pilot 1(one primary school; n = 119 children, aged 8-11)
b) Designing the Programme In the questionnaire feedback, many parents reported
Utilising the Health Action Process Model, our chosen positive parent/family behaviour changes. Qualitative
implementation strategies were then ordered to create data from teachers, children and their parents suggested
three intervention components (components 2-4) fol- that Year 5 s (9-10 year olds) were more receptive to
lowing the sequence of the three broad behaviour the messages than the year 4 and 6 children and more
change processes in the HAPA model, with an addi- able and willing to translate them into possible beha-
tional component (component 1) designed to create a viour changes. In addition, it appeared that this year
receptive context within the school (Table 6). The HeLP group engaged their families to the greatest extent. Tea-
intervention runs over 3 school terms (Spring and Sum- chers thought that the education lessons should be
mer term of year 5 and Autumn term of year 6) so that taught consecutively over one week to maintain momen-
it is feasible and acceptable to schools and to encourage tum and that the drama and goal setting had the poten-
transfer of knowledge and skills into year 6. Table 6 tial to work synergistically by engaging the children
provides a summary of each component of the interven- through the drama and following this up with encoura-
tion (with timescales), summarised implementation stra- ging the children, with their parents support, to make
tegies and their associated performance objectives. changes through setting simple goals. Parents and chil-
Performance objectives marked * for component 1 have dren also highlighted the need for a greater variety of
not been discussed in this paper as they do not relate activities to introduce the key messages and concepts in
directly to the child but a detailed intervention specifica- order to engage both boys and girls.
tion showing performance objectives for all target Implications In order to build a trusting relationship, a
groups is available to view (See Additional file 1). range of activities was developed to introduce the
school, children and their families to the project’s key
Piloting messages. A ‘Healthy Lifestyles Week’ was developed
a) Methods consisting of education lessons in the morning (deliv-
The intervention was piloted in two phases and process ered by teachers) which dovetailed with interactive
evaluation methods included semi structured interviews drama activities in the afternoon (delivered by a local
(teachers and parents), focus groups (children), drama group).
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Table 6 The HeLP Programme and associated POs

Component Process of Behaviour change Summary of implementation Performance objectives (POs)
strategies
Component 1 Establish motivation and create a Whole school assembly *Senior management team (SMT) see that the
Engaging schools, receptive environment Activity workshops Programme benefits the school and the children
children & families Parents’ evening and dovetails with existing school initiatives
Spring term (Yr 5) Newsletter articles *Year 5 teachers see that the programme is
feasible and acceptable to them and their children
and does not substantially increase their workload
Methods of delivery enthuse children
*Parents understand the value of the Programme
Component 2 Establish motivation by developing PSHE lessons (morning) A, B, C, D (see Table 2)
Intensive Healthy children’s confidence and skills and §Drama (afternoon) (forum theatre;
Lifestyles Week - helping them make decisions role play; food tasting, discussions,
one week games etc)
Summer term (Yr
5)
Component 3 Take action by helping children Questionnaire to enable children to E, F (see Table 3)
Goal Setting - create an action plan and reflect on snacking, consumption of
goals set during implement goals. fizzy drinks and physical activity.
week following Goal setting sheet to go home to
drama parents to complete with child.
Summer term (Yr 1:1 goal setting interview
5) Parent’s evening (child involvement -
Forum Theatre)
Component 4 Stay motivated by helping children Whole school assembly followed by G, H, I (see Table 4)
Reinforcement to monitor, assess and adapt goals drama workshop to remind school/
activities - one children of messages.
term post- PSHE lesson to remind children of
intervention messages and goals.
Autumn term (Yr Children monitor goals on
6) personalised chart
Class to deliver assembly about the
project to rest of school
1:1 goal supporting interview to
discuss facilitators/barriers and to
plan new coping strategies.
§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

Pilot 2 (one primary school; n = 77 children, aged 9-10) significant self reported decrease in the consumption of
Staff were enthusiastic about the Programme, in part energy dense snacks (p = 0.001), TV viewing (p =
because it met the National Curriculum guidelines for 0.033). Objective measures of physical activity showed a
Personal Social Health Education (PHSE) and Citizen- significant decrease in girls’ sedentary behaviours (p =
ship, and importantly because they felt it promoted 0.03) and a significant increase in girls’ moderate to vig-
families’ engagement with the school. Some teachers felt orous physical activity (p = 0.001). We note that this is
that the drama had a positive effect on the self esteem only before and after data and some measures were self
of the children, particularly those with additional learn- report and therefore unreliable, however, these results
ing needs. Some teachers suggested further activities for did provide ‘proof of concept’.
the subsequent term to reinforce the messages and refo- Implications An additional component was added to the
cus the children and their parents on their goals. Many intervention - ‘reinforcement activities’ to take place at
parents reported that their family had made lifestyle the beginning of year 6. In addition, minor refinements
changes and that their child was willing to try new were made to the education lessons and the drama
foods. The children enjoyed the drama activities and felt scripts to enhance delivery and continuity. Table 6 shows
that they could relate to the characters within the the final intervention components, associated processes
drama framework that made them more motivated to of change, implementation strategies and POs.
set their own goals. Some children reported that they A paper providing more detail of these two piloting
had started going to more after school clubs. Table 7 phases, including a randomised exploratory trial has
below presents some supporting quotes been published [47].
Quantitative data from the pre and post intervention The drama/school assembly scripts for the actors and
behavioural and anthropometric measures showed a a step by step guide for the drama facilitator have been
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Table 7 Provides example quotations supporting a selection of performance objectives for teachers, children and their
families
Performance Objective Illustrative quotes
Year 5 teachers need to see that the programme is feasible and ’I really appreciated you giving me all the lesson plans and resources and
acceptable to them and their children and does not substantially increase that they linked to the National Curriculum. I found them easy to follow’’
their workload ’I knew the drama would work well with our children’
’The parents evening did increase my workload a bit but I thought it was
worthwhile’
Class teachers need to be enthused by the programme and develop ’I enjoyed observing the children in the drama sessions as I saw what a
their understanding and appreciation of the issues great impact it had on my class’
’The project inspired me as I saw what a positive effect it was having on
the children with statements’
’It was good for us to have to teach the PSHE lessons as this helped me to
understand what the project was about’
The methods of delivery need to enthuse children so that they discuss ’[Name] talked a lot about the project. She loved the Chiefs and dance visit
messages with their parents and are motivated to seek family support to despite not being coordinated!’
make small and simple lifestyle changes ’The project encouraged [Name] to become interested in cooking and
preparing food.’
’[Name] plays an active part in choosing healthy options when we shop’
Children need to be able to select feasible, active alternatives to ’Since moving house, [Name] no longer cycles to school but he realised he
sedentary activities misses it so he is now going to cycle to school again even though he has
further to go now. It has come from him and that it good’
’[Name] has definitely increased her activity and chooses this option instead
of 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’

manualised to enable delivery by a local theatre/drama being the ‘closest fit’ to the set of theoretical determi-
group. The PSHE lessons (with learning outcomes relat- nants we had identified. However, although the HAPA
ing to the National Curriulum) and their associated model was useful in helping to identify a broad strategy
resources have also been manualised so that class tea- for sequencing the delivery of BCTs, it did not provide
chers are able to deliver the sessions with minimum complete coverage of the theoretical determinants we
preparation (these can be obtained from the correspond- identified. Additional processes we have incorporated
ing author). included the need to address cravings for unhealthy
snacks (affective processes) (see table 1) and the need to
Discussion build a receptive context within the school environment,
This paper describes the use of Intervention Mapping to component 1 of the intervention (see table 6). Two
develop a school-based intervention to prevent obesity further BCTs (not addressed in the taxonomy) [43,44]
in children. Intervention Mapping was a useful tool to we used to help create a receptive context within the
guide us through the process of developing the HeLP school were the ‘identification of barriers’ with teachers
intervention, as was Abraham and Michie’s taxonomy of and the senior management team to delivering the inter-
BCTs [43] which helped us to select feasible BCTs for vention within school time and ‘discussion of possible
use in the HeLP Programme. However, these tools did solutions’ to these. We also understood the importance
not provide much guidance on how to organise these of ‘showing empathy’ (i.e. understanding the nature
many BCTs and their associated delivery methods into a school life) when liaising with teachers and the SMT
coherent, efficient and appropriately sequenced frame- which, we felt, was key in building a trusting relation-
work. As a result we took further steps to select techni- ship - essential in getting the school to ‘buy into’ the
ques and strategies to fit around a process model of Programme. (See Additional file 1).
behavior change The HAPA model provided a frame- The development process was also consistent with the
work to order the implementation techniques into a new MRC framework for the development and evalua-
coherent, multi component intervention (Table 6) that tion of complex interventions [6] which suggests an
could run over three school terms and would enable the iterative approach in which an understanding of context
children and their families to make lifestyle changes. is central. The evidence that existing school-based pro-
The HAPA model is consistent with a number of the- grammes actually prevent obesity is weak [48]. We
ories of behavior change including social cognitive the- recognize that there are important social determinants
ory and control theory [35]. We selected the HAPA as of behaviours related to diet and physical activity which
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are difficult to address and which will inevitably militate and activity behaviours. The next phase of the research
against successful interventions delivered to individuals will involve evaluating the effectiveness and cost effective-
and within micro-environments such as schools. None- ness of the HeLP Programme in a large scale cluster RCT.
theless we hope that the rigorous approach employed to
develop the HeLP Programme and its modification Additional material
through iterative pilot phases will increase the likelihood
of both efficacy and effectiveness. It also provides us Additional file 1: Detailed Intervention Specification of the HeLP
with the basis for the process evaluation we are con- Programme.
ducting alongside the efficacy trials which will help us Additional file 2: Behaviour change techniques and strategies for
performance objectives associated with ‘Take Action’ and ‘Stay
to explore possible reasons for its success or failure. Motivated’.
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 for
Acknowledgements
reducing and preventing childhood obesity. Through the The authors are very grateful to the participating schools, children and their
use of IM methods, the theoretical basis, behavior families who gave up their time for the study. We would also like to
change techniques and implementation strategies can be acknowledge Sandy Akerman (Headbangers Theatre Company) who
supported the design of the drama component of the intervention. Phase 1,
seen to fit together as a coherent intervention model. 2 and 3 (the ongoing exploratory trial) of development was funded by the
Each technique delivered has a clear purpose and a clear Children’s Research Fund (registered charity no. 226128) and the NIHR
place in the model. The IM approach was very useful, Research for Patient Benefit (RfPB) Programme. SL, KW and JL were partially
supported by PenCLAHRC, the National Institute for Health Research (NIHR)
although there was a tendency to generate a long list of CLAHRC for the Southwest Peninsula. This paper presents independent
behavior change techniques, which were not necessarily research commissioned by the National Institute for Health Research (NIHR).
coherent or compatible. We were able to correct this by The views expressed are those of the author(s) and not necessarily those of
the NHS, the NIHR or the Department of Health.
application (and extension) of a process model of beha-
vior change (The HAPA model). In order to make sure Authors’ contributions
that certain behaviours were targeted (such as encoura- JL and KW led the intervention mapping process and conducted the
literature review with CG providing advice on the use of IM and BCTs. JL led
ging the children to engage their parents and talk mean- the design of intervention delivery methods and the production of
ingfully about the project’s messages) we decided to intervention materials, coordinated the implementation of the intervention
promote some PPOs to POs so that there could be a during the piloting phases and conducted interviews with teachers and
parents. JL drafted the manuscript and provided the main ideas of this
second level of ‘peeling down’ that would enable us to paper with KW, CG and SL providing critical revision. JL and KW conducted
establish more focused and specific implementation stra- the focus groups and with SL designed the study and obtained funding. JL
tegies related to a key programme objectives. will act as guarantor of the paper. All authors read and approved the final
manuscript.
Future directions: Two stages of piloting and refine-
ment of the intervention have taken place. In addition Competing interests
an exploratory randomised controlled trial has just been The authors declare that they have no competing interests.
completed involving 202 children to establish feasibility Received: 27 October 2010 Accepted: 13 July 2011
and acceptability of the Programme and the trial design Published: 13 July 2011
for a future large cluster RCT. The results of this pilot
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