Effectiveness of a School-Based Multimodal Intervention on Promoting Healthy Lifestyle Behaviours Among Schoolchildren. Previene-Cádiz Study.

doi:10.21203/rs.3.rs-5327407/v1

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Effectiveness of a School-Based Multimodal Intervention on Promoting Healthy Lifestyle Behaviours Among Schoolchildren. Previene-Cádiz Study.

https://doi.org/10.21203/rs.3.rs-5327407/v1

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Background

Childhood obesity is a global health concern with significant implications for long-term health outcomes. To address this issue, this study aimed to evaluate the effectiveness of a school-based multimodal intervention targeting healthy lifestyle behaviours among schoolchildren in the province of Cádiz. Methods: A quasi-experimental design was employed to compare outcomes between the experimental and control groups. The study sample consisted of 833 schoolchildren between 8 and 9 years of age who were enrolled in the third grade of primary education from 25 schools in the province of Cádiz. The intervention adopted a multimodal approach, targeting students, their families, and educational institutions, and was implemented over a 6-month period. The students participated in a healthy educational programme of 10 sessions and were provided with two workbooks to use at home with their families. Additionally, parents attended three training courses aimed at improving their children's lifestyle behaviours. The intervention aimed to achieve significant improvements in body composition, physical fitness, physical activity levels, sedentary behaviours, dietary patterns, and sleep patterns. Two statistical tests were conducted to compare groups before and after the intervention. First, the Mann‒Whitney U test was used for numerical variables, and second, the delta of the study variables was calculated, and a difference‒in-differences analysis was performed. Numerical delta variables were analysed via the Mann‒Whitney U test, and categorical delta variables were analysed via the chi‒square test. Results: The results suggested that the intervention produced moderate and variable effects in promoting healthier lifestyle behaviours among schoolchildren. While improvements were noted in the experimental group compared with the control group, these improvements did not fully meet the initial expectations. Conclusions: This outcome underscores the need for further research and adjustments in implementation, such as the integration of specialised external personnel to support teachers, embedding the intervention into the school curriculum, and extending its duration throughout an entire academic year. This study contributes valuable insights into childhood obesity prevention and intervention strategies, paving the way for future research aimed at promoting the health and well-being of children worldwide.

childhood obesity

school-based multimodal intervention

healthy lifestyle behaviours

school curriculum integration

external support

effectiveness assessment

Childhood obesity represents a global public health problem. According to the World Health Organization (WHO), since 1975, obesity has nearly tripled worldwide (1). While it is historically prevalent in developed nations, it is increasingly affecting developing countries (2). For example, Mexico reported a prevalence of overweight and obesity in children of 33.2% in 2016 (3). Across developed countries, approximately 23% of children and adolescents have excess weight, with a 13% prevalence in developing nations (4).. In the United States, one in three children currently grapples with overweight or obesity (5). Southern European countries, including Bulgaria, Greece, Italy, and Spain, present obesity rates exceeding 40% (6–9). Over the past two decades, Spain has experienced a three- to fourfold increase in obesity prevalence, significantly impacting chronic disease rates, healthcare costs, and overall population well-being (10). In 2019, the Aladdin study reported a 40.6% prevalence of overweight and obesity among Spanish children aged 6–9 years (11). Additionally, a study from our project (Previene-Cádiz) reported in 2019 a prevalence of overweight and obesity of 35.2% (12.9% obesity) among schoolchildren aged 8–9 years in the province of Cádiz (southwest Spain), indicating a considerable prevalence compared with other regions (12).

Excess weight has serious health consequences, especially for children. Children and adolescents with elevated body weights face a heightened risk of maintaining this condition into adulthood (13). Obesity during childhood and adolescence significantly increases the likelihood of developing metabolic syndrome and cardiovascular diseases such as hypertension, type 2 diabetes mellitus, dyslipidemia, and arteriosclerosis in adulthood (14, 15). Moreover, obesity in childhood and adolescence is associated with an increased risk of cardiovascular diseases during these developmental stages (16). These noncommunicable diseases not only contribute to premature mortality but also result in long-term morbidity (17). Given the dramatic increase in the prevalence of obesity and its profound public health implications, obesity represents one of the most critical public health challenges of the twenty-first century (18).

Establishing healthy behaviours early in life is crucial for preventing childhood obesity and ensuring long-term health. Childhood obesity often persists into adulthood, making early intervention essential. Although cross-sectional evidence clearly supports the promotion of healthy behaviours for prevention and prevention of obesity, more intervention evidence is still needed (12). In fact, interventions targeting healthy behaviours in childhood are pivotal for preventing obesity, as addressing obesity later in adulthood can be more challenging (17). Recent systematic reviews have highlighted the effectiveness of lifestyle-based interventions, emphasizing the need for multidisciplinary interventions tailored to the needs of children and adolescents (19).

However, previous intervention programs aimed at children and adolescents with excess weight have frequently encountered challenges when applied in real-life scenarios, highlighting the crucial need to create interventions that are both feasible and sustainable (20). Lifestyle modifications, including dietary changes and increased physical activity, are central to preventing childhood obesity (21). School-based interventions have shown promise in promoting healthy behaviours, but other settings, such as communities and families, also play vital roles in supporting healthy lifestyles from an early age (21).

With the aim of shedding light on a possible strategy to address this global health issue, with a particular focus on youth, the present study aims to evaluate the effectiveness of an intervention aimed at promoting healthy lifestyle behaviours among schoolchildren in the province of Cádiz. It is intended to determine whether the intervention leads to significant changes in body composition, physical fitness, levels of physical activity, sedentary behaviours, dietary patterns, and sleep behaviours among participants. By comparing the results between the experimental and control groups, the relative effectiveness of the intervention in fostering healthier lifestyle behaviours will be assessed. The hypothesis posits that the intervention will significantly improve various health-related parameters, with greater improvements expected in the experimental group than in the control group.

Study Design and Participants

The current study used a quasi-experimental design with an intervention group and a control group. An educational intervention was carried out in the experimental group to evaluate the effectiveness of the intervention in preventing childhood overweight and obesity in schoolchildren in the province of Cádiz.

The study sample consisted of 833 schoolchildren between 8 and 9 years of age who were enrolled in the third grade of primary education from 25 schools in the province of Cádiz. The parents of each schoolchild were part of that same study subject (the father, mother or caregivers and child were the same subject of study). The inclusion criteria were as follows: children belonging to the selected school, who were in the third grade of primary school, regardless of their age, who provided informed consent signed by their parents or legal guardians, who responded to the questionnaires and who submitted to the anthropometric measurements. The exclusion criterion was that some of these requirements were not met.

The sample was divided into two groups: the intervention group and the control group. The intervention group included 469 schoolchildren and consisted of 12 of the 25 school centres that participated in the study. The control group included 364 schoolchildren and consisted of the other 13 school centres that participated in the study. Both groups underwent pre- and postintervention measurements, and only the experimental group underwent the intervention to compare the results with those of the control group and determine whether an effect had emerged.

The project was conducted in accordance with the Declaration of Helsinki and in accordance with Organic Law 3/2018, of December 5, on the Protection of Personal Data, Regulation (EU) 2016/679 of the European Parliament and of the Council, of 27 April 2016 (General Data Protection Regulation). Additionally, it was approved by the Andalusian Biomedical Research Ethics Committee, along with approval from the Department of Education and Science of the province of Cádiz (PI-007-2017, 21 March 2018). Parents or legal guardians were provided with a project information sheet and asked to provide written informed consent. Participation was voluntary, and schoolchildren could leave the study at any time. The methodological details have been previously published (22).

Calculation of the Sample Size

The sample size calculation details have been previously published (22). Briefly, the sample size was calculated to determine the effectiveness of the intervention on the prevalence of overweight and obesity in the study population. After reviewing the results obtained by different studies carried out in our environment, an estimated prevalence of overweight and obesity of 35% was assumed, which was previously reported (23) in a population from Cádiz, similar to our study. The sample size necessary to test the hypotheses was calculated by comparing two proportions. The percentages of overweight and obese schoolchildren were compared before and after the intervention in both groups (intervention and control; paired data) and between groups (independent data). In our case, for an estimated difference of 9% (35% vs 26%) with a confidence level of 95% and a power of 80%, the minimum sample size required was 410 participants in each group (intervention and control), which resulted in a total of 820 children.

PREVIENE-CÁDIZ Intervention

The intervention details have been previously published (22). In short, the intervention adopted a multimodal approach, targeting students, their families, and educational institutions, and was implemented over a 6-month period. The activities and sessions of the intervention programme were carried out by the teachers from the participating schools after receiving training from the research team in a 10-hour in-person course. The students from the intervention group took part in the 10 sessions of the healthy educational programme, which were delivered by the teachers in the classroom, and were provided with two workbooks to use at home: one exclusively designed to delve into the programme's content, directed at the students, and another aimed at both the students and their families to encourage family involvement in the addressed participants. Additionally, the parents received training in an in-person session held one afternoon in each of the intervention schools, where three training courses focused on improving their children's lifestyles were delivered: healthy nutrition, physical activity, and the resources available in their environment to increase nutrition and increase levels of physical activity.

Procedures and Assessments

The procedures and assessment details have been previously published (12). However, a summary of how the procedures and assessments were conducted is provided below.

Anthropometric Measurements

Measurements were conducted by proficient members of the research team in accordance with the standardized protocol outlined by the International Society for the Advancement of Kinanthropometry (ISAK) (24). Body weight was assessed via a precise mechanical scale sensitive to 100 g (SECA Colorata 760, Hamburg, Germany), whereas height was determined via a portable stadiometer with an accuracy of 0.1 cm (SECA 213, Hamburg, Germany). Body mass index (BMI) was computed by dividing weight in kilograms by the square of height in meters and served as an indicator of overweight or obesity. On the basis of Cole's established thresholds (25), individuals with a BMI between 18.44 and 19.84 were classified as overweight, whereas those with a BMI between 21.60 and 24.00 were classified as obese. Furthermore, BMI categories were stratified on the basis of age-specific percentiles recommended by the WHO, categorizing schoolchildren between the 50th and 80th percentiles as overweight and those above the 85th percentile as obese.

Physical Fitness

The physical fitness of both the children and parents was assessed via self-reports via the International Physical Fitness Scale (IFIS) (26, 27). The IFIS scale is a questionnaire designed to subjectively evaluate the physical fitness of individuals, which replaces the need to use a battery of objective tests. It has been translated into nine languages and evaluates both overall physical condition and each of its primary components, specifically, cardiorespiratory fitness, muscular strength, speed-agility and flexibility. Validation studies with both children and adults have demonstrated its reliability (26, 27). Although there are separate versions for adults and children, they measure the same constructs.

Physical Activity

Physical activity was recorded by the students through a self-report questionnaire (28, 29). They were asked about the weekly frequency of engaging in physical activity with their parents, as well as the mode of transportation used to go to school, distinguishing between active modes (such as walking, cycling, skateboarding, or nonelectric scootering, among others) and passive modes (such as travelling by car, motorcycle, bus, electric scooter, or other passive means of transportation). Other topics related to physical activity were also addressed, including the weekly frequency of participation in extracurricular physical activities, the type of activity, and the time spent in active play with friends. Additionally, to complement the information provided by the students, parents also provided information through a questionnaire (28, 29) and by direct observation of their children’s levels of physical activity. Additional information was gathered on weekly family physical activity, the mode of transportation used to go to school, and details about the quantity and type of extracurricular activities in which the children participated and the time spent in active play with friends, among other aspects.

Eating behaviours

The daily/weekly consumption of processed baked products, fried foods, snacks, sugary soft drinks, fruits, vegetables, packaged juices, sandwiches, dairy products, carbohydrates, meats, cold cuts, fish, and vegetables, among other products, was recorded through two questionnaires administered to both students (who provided self-reports) and their families (who reported on their children) (28, 29). Additionally, using the same questionnaires (28, 29), five questions regarding knowledge and beliefs about food were recorded. These were used to create an index to establish the students' knowledge and beliefs about food on a scale from 0 to 6, where 0 represents no knowledge and 6 represents excellent knowledge.

Screen Time

Screen time was recorded through two questionnaires administered to schoolchildren and their parents (28, 29) to obtain information from the schoolchildren about themselves and from the parents about their children. Both were asked about the average daily time spent on television (TV), computer, mobile, tablet and video games during weekdays and weekends.

Hours of Sleep

Hours of sleep were recorded through a questionnaire administered to parents (28, 29), who provided information about their children's daily sleep hours, both from Monday to Friday and on weekends. To assess compliance with the recommendation for healthy behaviours, the cut-off points recommended by the Canadian 24-hour Movement Guidelines (30) were established.

Lifestyle Behaviours Score

Lifestyle behaviours were assessed based on various variables impacting the behaviours of schoolchildren, including levels of physical activity, sedentary behaviour, dietary patterns, and sleep routines. These factors, combined with self-reported physical fitness, contributed to a composite score reflecting overall lifestyle behaviours. In essence, one variable was selected from each category (eating behaviours, sedentary behaviour, sleep duration, and self-reported physical fitness), followed by summation and recategorization into three lifestyle behaviour categories (good/regular/bad). Thus, schoolchildren with respective scores exhibited healthier/more regular/less healthy lifestyle behaviours and corresponding levels of self-reported physical fitness.

Statistical Analysis

A descriptive analysis of the outcome variables was conducted, including measures of central tendency, dispersion, and 95% confidence intervals (CIs). Frequency analysis was performed to obtain percentages and the prevalence of categorical variables. The data are presented as the means ± standard deviations unless otherwise specified. The normality of the study variables was assessed, and as none met the normality criterion, nonparametric analyses were conducted. Two analyses were conducted to compare groups before and after the intervention. First, the Mann‒Whitney U test was used for numerical variables, and second, the delta of the study variables was calculated, and a difference‒in-differences analysis was performed. Numerical delta variables were analysed via the Mann‒Whitney U test, and categorical delta variables were analysed via the chi‒square test. Statistical analyses were conducted via IBM SPSS Statistics software (version 24.0), with the significance level set at 0.05.

Overview of Descriptive Characteristics in Pre- and Postintervention Analysis

A comprehensive overview of the descriptive characteristics of the schoolchildren before and after the intervention, differentiated by control and experimental groups, is provided in Table 1. Additionally, the table includes the delta variables, showing the results of the difference-in-differences analysis. This table provides an overview of the study results.

Changes in Body Composition

BMI Distribution Across Weight Categories

A chi-square analysis of the BMI delta variable (difference-in-differences study) revealed a significant difference in the distribution of BMI categories between the intervention and control groups before and after the intervention (p = 0.029). As shown in Fig. 1, the intervention group exhibited slight reductions in the normal weight and obesity categories postintervention, alongside modest increases in the underweight and overweight categories. In contrast, the control group experienced a slight decrease in both the underweight and normal weight categories, coupled with a slight increase in the overweight and obesity categories.

Figure 1. (a) BMI distribution across weight categories of the experimental group before and after intervention. (b) BMI distribution across weight categories of the control group before and after the intervention. A chi-square analysis of the delta variable revealed a significant difference in BMI distribution across weight categories between the pre- and postintervention groups (p = 0.029). The numbers above the boxes represent the delta.

Changes in Waist Circumference

Figure 2 illustrates the changes in waist circumference across both groups following the intervention. In the experimental group, waist circumference remained virtually unchanged postintervention. Conversely, the control group exhibited a slight increase. A Mann‒Whitney U test of the delta variable for waist circumference (difference-in-differences test) revealed a significant difference between the pre- and postintervention groups (p < 0.001).

Figure 2. Changes in waist circumference before and after intervention according to group. Mann‒Whitney U analysis of the delta variable indicated a significant difference in waist circumference changes between the pre- and postintervention groups (p < 0.001). The numbers above the boxes represent the delta.

Changes in the Waist-to-Hip Ratio

A Mann‒Whitney U analysis of the delta variable for the waist-to-hip ratio (difference-in-differences study) revealed a significant difference between the pre- and postintervention groups (p < 0.001). As shown in Fig. 3, the intervention group experienced a slight decrease in the waist‒to-hip ratio following the intervention, whereas the control group maintained consistent values.

Figure 3. Changes in the waist-to-hip ratio before and after the intervention according to group. Mann‒Whitney U analysis of the delta variable revealed a significant difference in the waist-to-hip ratio between the pre- and postintervention groups (p < 0.001). The numbers above the boxes represent the delta.

Changes in the Waist-to-Height Ratio

As depicted in Fig. 4, the waist-to-height ratio slightly decreased in the experimental group following the intervention, whereas it slightly increased in the control group. A Mann‒Whitney U analysis of the delta variable for the waist-to-height ratio (difference-in-differences study) revealed a significant difference between the pre- and postintervention groups (p < 0.001).

Figure 4. Changes in the waist-to-height ratio before and after intervention according to group. Mann‒Whitney U analysis of the delta variable indicated a significant difference in waist-to-height ratio changes between the pre- and postintervention groups (p < 0.001). The numbers above the boxes represent the delta.

Changes in Physical Activity Levels

Weekly Frequency of Family Physical Activity

A Mann‒Whitney U test of the delta variable (difference-in-differences test) revealed a significant difference between the groups in the weekly frequency of family physical activity before and after the intervention (p = 0.004). As illustrated in Fig. 5, the average number of days per week that schoolchildren engaged in family physical activity slightly increased in the experimental group postintervention. Conversely, the control group experienced a slight decrease.

Figure 5. Weekly frequency of family physical activity before and after the intervention according to group. Mann‒Whitney U analysis of the delta variable revealed a significant difference in the weekly frequency of changes in family physical activity between the pre- and postintervention groups (p = 0.004). The numbers above the boxes represent the delta.

School Transportation Mode

The mode of transportation to school before and after the intervention was analysed for both the experimental and control groups. A chi-square analysis of the delta variable for the mode of transportation to school (difference-in-differences study) revealed a significant difference between the pre- and postintervention groups (p = 0.009). As shown in Fig. 6, the experimental group experienced a slight increase in active travel to school and a corresponding decrease in passive travel after the intervention. Conversely, the control group presented a slight decrease in active transportation and a subtle increase in passive transportation.

Figure 6. (a) School transportation mode of the experimental group before and after intervention. (b) School transportation mode of the control group before and after the intervention. Chi-square analysis revealed a significant difference in school transportation mode between the pre- and postintervention groups (p = 0.009). The numbers above the boxes represent the delta.

Changes in Eating Behaviours

Feeding Beliefs and Knowledge Index

The eating beliefs and knowledge indices were evaluated before and after the intervention for both the experimental and control groups. As depicted in Fig. 7, the experimental group presented a slight increase in dietary knowledge after the intervention, whereas in the control group, this knowledge slightly decreased following the intervention. A chi-square analysis conducted on the delta variable of the eating beliefs and knowledge index (difference-in-differences study) revealed a significant difference between the pre- and postintervention groups (p = 0.042).

Figure 7. (a) Feeding beliefs and knowledge indices of the experimental group before and after the intervention. (b) Feeding beliefs and knowledge indices of the control group before and after the intervention. A chi-square analysis of the delta variable revealed a significant difference in feeding beliefs and knowledge indices between the pre- and postintervention groups (p = 0.049). The numbers above the boxes represent the delta. Abbreviations: Ek, excellent knowledge; Gk, good knowledge; Lk, little knowledge; Nk, no knowledge; Sk, some knowledge; VGk, very good knowledge.

Notably, all these variables displayed similar trends of subtle improvement. While the changes observed in each specific parameter may appear modest individually, collectively, they indicate a positive shift in various aspects of health behaviour and outcomes following the intervention. These findings suggest that the intervention had a nuanced but overall beneficial impact on the studied variables for the experimental group.

Changes in Physical Fitness, Sedentary Behaviours and Sleep Behaviours

The analysis revealed that there were no statistically significant differences in physical fitness, sedentary behaviours, or sleep behaviours between the experimental and control groups following the intervention. Although both groups exhibited similar patterns and trends in these areas, the intervention did not lead to notable changes in these variables. This indicates the need for further refinement and enhancement of intervention strategies to more effectively target these specific aspects of children's health.

This study aimed to evaluate the effectiveness of an intervention designed to promote healthy lifestyle behaviours among schoolchildren in the province of Cádiz and to assess its impact on various outcomes, including body composition, self-reported physical fitness, physical activity levels, sedentary behaviours, eating behaviours, and sleep behaviours, among the participants. Overall, the intervention led to improvements in several key areas. Specifically, there were subtle increases in BMI distribution, waist circumference, waist‒to‒hip ratio, and waist‒to‒height ratio among participants in the experimental group. Additionally, the experimental group demonstrated modest increases in knowledge regarding dietary habits, as well as a slight increase in the frequency of family physical activity and active transportation to school.

The intervention had a slight effect on schoolchildren, albeit not to the extent expected in our hypothesis. Overall, obesity indicators slightly improved for those in the intervention group. Moreover, several physical activity indicators, such as weekly family activity days and children’s active transport, increased after the intervention. Finally, beliefs and knowledge about nutrition behaviours slightly but significantly improved. This modest change in pattern indicates that the impact of the intervention on the various health and behavioural parameters that have been analysed thus far was small.

Despite favourable changes observed in body composition parameters, such as reductions in BMI and waist circumference or waiting-to-hip/height ratios, the magnitude of these changes was not relevant enough from a biological point of view. Consequently, the intervention seems to have had a certain positive effect on schoolchildren, the intensity of which should be improved in future studies with adjustments to the multimodal intervention. These findings align with previous studies that reported modest effects of school-based interventions on body composition outcomes. In fact, several systematic reviews and meta-analyses (31–39) have analysed, among other parameters, the effectiveness of educational interventions on the body composition of schoolchildren, showing efficacy in less than 50% of the interventions. Other studies (40–42) have shown the efficacy of improving the body composition of students in more than 50% of interventions. These findings highlight the variability in the effectiveness of school-based interventions on body composition outcomes and underscore the importance of identifying strategies that yield more consistent and impactful results.

Notably, the intervention consisted of only 10 sessions, which is a relatively limited exposure period, so the likelihood of significant changes in body composition is inherently low. Instead, the primary aim of the intervention was to encourage healthier behaviours among the schoolchildren. By focusing on behaviour modification and promoting healthier lifestyle choices, the intervention sought to lay the groundwork for long-term improvements in body composition and obesity reduction. The rationale behind this approach lies in the understanding that the sustained adoption of healthy behaviours over time is more likely to yield meaningful changes in body composition and overall health outcomes among schoolchildren. Thus, even these modest changes in body composition should be explained by some behavioural changes promoted by the current study.

The analysis of another relevant component of health, physical fitness, revealed no significant changes after the intervention between the groups. This result contradicts the findings of Seo, Y et al. (43), who showed how a specific 16-week physical exercise program yields satisfactory results regarding the physical condition of a group of children and adolescents with obesity, which suggests that short-term interventions, such as the 10-session program in our study, may not be sufficient to produce noticeable changes in physical fitness. Moreover, it is possible that a specific exercise intervention, rather than a multimodal approach, would provide more intense and effective improvements in physical fitness. Thus, we believe that for meaningful improvements to occur, interventions should be integrated into the school curriculum and include a greater number of sessions, both within and outside of school, providing more time for students to engage in physical activity and aiming to achieve moderate to high intensity. By prioritizing consistent physical activity participation in both school and extracurricular settings over time, we anticipate observing more significant improvements in physical fitness among schoolchildren.

Despite observing significant changes in physical activity levels, these changes were not as impactful as anticipated. While there were improvements, they did not fully align with the expected outcomes, suggesting that the increase in physical activity levels among schoolchildren was moderate. This finding is in line with findings from other studies (32, 33, 37, 44), suggesting that short-term interventions may not effectively increase physical activity levels among school-aged children. Interventions should be extended over at least one full school year to achieve meaningful and sustainable changes. Moreover, given the complexity of behaviour change and the specialized knowledge needed, it is suggested that teachers benefit from the support of external experts to effectively deliver these interventions. This need for external support has been underscored in previous research (45, 46), where collaboration with health professionals and physical activity experts has been found to enhance the effectiveness of school-based interventions aimed at increasing physical activity levels. Another potential factor to consider is fat intensity rather than only volume or duration (47, 48).

The analysis indicated that there were no substantial differences between groups regarding sedentary behaviours, suggesting that the intervention had a limited impact on this aspect. Sedentary behaviours are complex and deeply ingrained, requiring comprehensive and sustained efforts to modify effectively. Previous studies, such as Neil-Sztramko and Dobbins's systematic review (44), support this challenge. Neil-Sztramko and Dobbins analysed 16 studies of school-based physical activity interventions and highlighted that most interventions showed little or no decrease in sedentary time among children and adolescents, emphasizing the need for multifaceted approaches addressing various aspects of sedentary behaviours, including screen time, sitting time, and overall activity patterns. Thus, while our intervention aimed to promote healthier behaviours, especially sedentary behaviours, the results suggest that a greater number of sessions emphasizing this aspect may be necessary, as well as the assistance of qualified external personnel who work directly with students and families to achieve significant and lasting changes in this area.

Additionally, while some meaningful changes in dietary behaviours were observed between groups, these changes were not as extensive as anticipated. Similar to findings in previous research, interventions with a small number of sessions may not effectively address dietary behaviours among schoolchildren (32, 33, 37). Dietary behaviours are deeply ingrained and influenced by various factors, including cultural norms, the family environment, and individual preferences. Therefore, interventions aimed at promoting healthier eating behaviours may require more extensive and targeted strategies, such as further extending the nutrition education programme, increasing the number of cooking workshops for both children and parents, and further increasing the participation of parents and caregivers. Additionally, collaboration with nutritionists or dietitians may be beneficial in providing tailored guidance and support to parents.

No significant differences in sleep behaviour were noted between the groups. However, it is encouraging that both groups reported a considerable number of hours of sleep on both weekdays and weekends. While further exploration into sleep quality may be beneficial, it is important to note that, in terms of sleep quantity, both groups generally adhered to the sleep recommendations set by the Canadian 24-hour movement guidelines (30).

As possible limitations of the study, the following can be mentioned: the duration of the intervention, consisting of only 10 sessions, may have limited its ability to achieve the anticipated outcomes. Extending the intervention period could support more substantial and lasting changes in health behaviours among schoolchildren. Additionally, the intervention could have benefited from a greater focus on the intensity of physical activity during physical education sessions, as both volume and intensity are important for achieving health benefits. Furthermore, the study faced challenges related to teacher engagement. Unlike collaborative projects such as POIBA in Barcelona (45, 46), where external personnel assisted educators, our intervention relied solely on school staff. The incorporation of external support could increase motivation and improve program delivery. Finally, the lack of integration into the school curriculum posed a barrier, as the intervention competed for time with existing school activities, leading to varied levels of commitment among teachers. Embedding health education programs into the curriculum could help prioritize their importance and ensure consistent implementation across all participating schools.

Among the strengths of this study, the comprehensive approach of the intervention, which addresses, albeit to a slightly lesser extent than initially anticipated, both school education and the involvement of parents and schoolchildren, should be noted. This holistic approach allows for greater awareness and commitment to adopting healthy lifestyle behaviours at all levels: school, family, and community. Moreover, collaboration among these different stakeholders enhances the impact of the intervention by creating a supportive environment that facilitates the implementation and maintenance of positive lifestyle changes. Another strength of the study is the rigorous assessment of multiple outcome measures, including body composition; physical fitness; physical activity levels; and sedentary, eating, and sleep behaviours. This comprehensive evaluation provides a nuanced understanding of the intervention's effects on various aspects of participants' health and lifestyle.

The intervention demonstrated moderate effectiveness on markers of obesity and behaviours related to physical activity, as well as beliefs and knowledge about feeding. These results suggest that while the intervention partially achieved its objectives, it did not meet all expected outcomes. This outcome is consistent with the challenges inherent in implementing interventions in real-world settings, especially within school environments where teacher engagement can vary. The varying levels of teacher involvement in delivering the intervention may have contributed to differences in its effectiveness, with some teachers potentially demonstrating greater commitment and effectiveness in implementing the intervention protocols than others do. This variability in implementation fidelity could explain the mixed results observed across different health and behavioural parameters.

Moreover, the reliance on self-reported measures for certain outcomes introduces the possibility of response bias and measurement error, which may have influenced the study results. Therefore, while the intervention showed promise in certain areas, the overall effectiveness may have been limited by these contextual factors and methodological challenges. Further research incorporating strategies to increase intervention fidelity and employing objective measures of health behaviours may provide deeper insights into the factors influencing the effectiveness of lifestyle interventions among schoolchildren.

Ethics approval and consent to participate:

The study was conducted in accordance with the Declaration of Helsinki and approved by the Andalusian Biomedical Research Ethics Committee, along with approval from the Delegation of Education and Science of the province of Cádiz (PI-007-2017, 21 March 2018) for studies involving humans. Informed consent was obtained from all parents or caregivers of the subjects involved in the study.

Consent for publication:

Consent to participate in the study included consent for publication. The parents or guardians of the participating subjects signed both informed consent and publication consent simultaneously.

Competing interests:

The authors declare that they have no competing interests.

Funding:

Grants were obtained for the financing of Research and Biomedical Innovation and in Health Sciences, within the framework of the Integrated Territorial Initiative 2014–2020, for the province of Cádiz. This research was 80% co-financed by funds from the FEDER (European Regional Development Fund) Andalusia Operational Program 2014–2020. Ministry of Health and Families.

Author Contribution

RAM contributed to the data collection, analysis, interpretation, and literature search and was primarily responsible for creating the figures and drafting the manuscript. MMGS played a key role in data collection, analysis, interpretation, and literature search while providing a critical review with suggestions for improvement. JMMN and MSR were involved in the study design, literature search, data collection, analysis, and interpretation and critically reviewed the manuscript with recommendations for refinement. ARM contributed to the study design, data interpretation, and literature search, offering a thorough review of the manuscript. DJP participated in the study design, data analysis, interpretation, and literature search and critically reviewed the manuscript. All the authors contributed to the writing of the manuscript and approved the final submitted and published versions.

Acknowledgement

FEDER funds from the European Union (CB16/10/00477), Ministry of Health and Family, Andalusian School of Public Health and Biomedical Research Networking Centre on Frailty and Healthy Aging (CIBERFES).

Data Availability

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

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Table 1 is available in the Supplementary Files section.

No competing interests reported.

Table1.xlsx

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Effectiveness of a School-Based Multimodal Intervention on Promoting Healthy Lifestyle Behaviours Among Schoolchildren. Previene-Cádiz Study.

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Abstract

Background

Figures

Background

Materials and Methods

Study Design and Participants

Calculation of the Sample Size

PREVIENE-CÁDIZ Intervention

Procedures and Assessments

Anthropometric Measurements

Physical Fitness

Physical Activity

Eating behaviours

Screen Time

Hours of Sleep

Lifestyle Behaviours Score

Statistical Analysis

Results

Overview of Descriptive Characteristics in Pre- and Postintervention Analysis

Changes in Body Composition

BMI Distribution Across Weight Categories

Changes in Waist Circumference

Changes in the Waist-to-Hip Ratio

Changes in the Waist-to-Height Ratio

Changes in Physical Activity Levels

Weekly Frequency of Family Physical Activity

School Transportation Mode

Changes in Eating Behaviours

Feeding Beliefs and Knowledge Index

Changes in Physical Fitness, Sedentary Behaviours and Sleep Behaviours

Discussion

Conclusions

Declarations

Competing interests:

Funding:

Author Contribution

Acknowledgement

Data Availability

References

Table 1

Additional Declarations

Supplementary Files

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