Improving healthy energy balance- and obesity-related behaviours among preschoolers in Malaysia: feasibility of adapting the ToyBox-Study

This research addresses the urgent need to tackle the rise of childhood obesity; Malaysia is suffering more than other Southeast Asian countries in terms of increasing numbers of young children becoming overweight or obese. There are many adverse consequences of obesity, including development of non-communicable diseases such as Type-2 diabetes, cardiovascular disease and some cancers. These diseases will occur at younger ages and increase in prevalence in the population if obesity levels continue to grow. In addition, obesity can harm both physical and mental development and function, thus harming both individual wellbeing and national welfare and economy. A recent report from the World Health Organisation recognises that ending childhood obesity will require multiple and multifaceted interventions, involving changes to policy, education and the environment, in order to deliver sustained changes in behaviours related to obesity risk. Since many of these behaviours rapidly become habitual, key recommendations include targeting early childhood to encourage healthy eating, physical activity, less sedentary behaviour and reduced intake of sugar-sweetened beverages. However, to do this successfully requires not just education, but also removal of environmental barriers to these behaviours, and engagement of the young children's families. The ToyBox-Study programme (www.toybox-study.eu) is one intervention that incorporates these facets and has already been trialled in 4-6 year-old kindergarten children across six European countries. The intervention is designed to be carried out in kindergartens, involving the kindergarten teachers encouraging healthy behaviours in the children, by educating through specially focussed activities, and by changing the kindergarten environments. This permits hands-on learning to instil healthy habits, such as drinking water as the main fluid in place of sweetened drinks, healthier snacking, enjoying more physical activity, and avoiding prolonged periods of sedentary behaviour. The kindergarten setting is also a relatively inexpensive and less disruptive, than a school setting for such an intervention.
The ToyBox-Study programme has a complete set of materials to guide kindergarten teachers, and the primary caregivers of the children, in achieving these healthier behaviours. However, it is recognised that some adaptation of the materials, as well as translation, may be necessary for the Malaysian sociocultural context. Thus, the primary aim of this research is to conduct a feasibility study of the adaptation and application of the ToyBox intervention in Malaysian kindergartens, in sites in both Peninsular Malaysia, and in Sarawak. The intervention will run for 24 weeks across a kindergarten year. Similar measurements will be taken at baseline and post-intervention as in the original study, including height and weight of the children, so that comparisons can be made with published evidence from the ToyBox-Study. These will evaluate whether the intervention has altered the health-related behaviours, as well as the acceptability of the intervention to stakeholders, teachers and families of the children. In addition, a follow-up set of measurements will be made 6 months later, to determine how sustainable any behavioural changes have been. Comparison will be made to kindergartens not enrolled in the intervention but whose children will be measured in the same way over the same period. The kindergartens will be recruited from the KEMAS pool of kindergartens, so that a greater number of underprivileged children and families can benefit.
The research will be conducted by experienced University staff with expertise in obesity, nutrition, behaviour and education: a separate team will be based at each site. The local teams will be strongly supported by UK experts, two of whom worked on the original ToyBox-Study programme. Guidance and training will be provided at every stage.

This study will assess the feasibility of adapting the ToyBox-Study programme to the Malaysian kindergarten setting, and to conduct a pilot RCT, which will inform development of a full RCT. ToyBox-Study is an evidence-based intervention conducted in 6 European countries on 7000 children and their families, and over 100 kindergartens. The Toybox-Study programme is designed to improve four energy balance-related behaviours which impact on obesity in kindergarten children: water drinking, snacking, physical activity and sedentary behaviour. All materials (training manuals, questionnaires, caregiver information) from that study have been made available to the applicants. Stage I will apply a Theory of Change framework for complex behavioural interventions, initiated by a stakeholder workshop. Stage II is adaptation of ToyBox material to the Malaysian social and language contexts. Stage III is a pilot RCT in 10 kindergartens: 5 in Peninsular Malaysia and 5 in Sarawak, of which 2 in each region will be controls. 300 children will be recruited, with 200 in intervention kindergartens, from KEMAS (Community Development Department) kindergartens, so as to target more underprivileged families, as well as including a strong representation from Iban and Bidayuh ethnic groups, who may be particularly vulnerable to developing obesity. Experienced UK partners, who were involved in the original ToyBox-Study will train Malaysian research staff, who in turn will train kindergarten staff to carry out the intervention across the kindergarten year, with an additional 6-month follow-up for key outcomes. Emphasis will be placed on evaluation of intervention feasibility including assessing ease of adaptation, acceptability of ToyBox-Study to parents, facilitators, and kindergarten teachers; recruitment and retention rates; parental adherence to or engagement with ToyBox; intervention fidelity; and feasibility of collecting outcome measures.

This research is expected to have impacts in the following areas or groups:
(1) Children and families The success of this proposed intervention depends on involvement and engagement of both the children and their caregivers. Integral to the ToyBox-Study material are leaflets, newsletters and posters that allow families to engage with their children over the benefits of participation in the intervention. We will establish a project website that communicates the importance of participating in its four main behavioural objectives.
(2): Public policy: This research will help the relevant stakeholders in child health care delivery in Malaysia to address the present challenges in that segment. Stakeholders impacted in this way include the Ministry of Health, Ministry of Education, the Community Development Department (KEMAS), State nutritionists, kindergarten teachers, the Nutrition Society of Malaysia (NSM), and the Malaysian Association for the Study of Obesity (MASO). These stakeholders will be invited to a Theory of Change workshop in Kuala Lumpur (UKM) and in Kuching (UNIMAS) at the start of the project, so that they are engaged at the outset and in turn are able to express their own needs and viewpoints concerning potential impact of this research.
(3) Clinical and public health guidelines: The expected policy and service-level interventions following the availability of evidence from this feasibility study will help the Federal and local government to adopt strategies for improving child health outcomes. Professor Poh (Malaysian PI) has excellent contact with the Ministry of Health and Ministry of Education and educational institutions (kindergartens) at local, regional and national levels. Her roles with various Ministries will be used for the wider professional and policy-making purposes of this project.
(4) The scientific community: The results from the proposed research will benefit academics from a wide range of disciplines including physicians and nurses, social workers, teachers in early education, paediatricians, dieticians, psychologists, and those working in public health and nutrition. Lessons learned from the present research are also expected to benefit both the academic community and other government bodies towards the fine-tuning of their funding for healthy lifestyle and future research. Dissemination will be via published papers and conference presentations, as specified elsewhere.
(5) General public: the principle of obesity prevention, and the behaviours targeted by the ToyBox intervention, are in the longer term extremely important for the health and welfare of the Malaysian nation and its economy. It is therefore crucial to communicate any key health messages, for example to potential and current parents, other family members, and indeed teachers at schools beyond kindergartens. Professor Poh's membership of the Positive Parenting Editorial Board of the Malaysian Paediatric Association, will be invaluable in this regard. We will engage with a variety of media both nationally and locally, and with community leaders, to ensure effective education in healthy lifestyles, and to encourage changes to local environments that can help promote healthier energy balance-related behaviours.
(6) Researcher capacity building: The research team members from all of the participating universities will be involved in all the different stages of the project including literature review, data analysis and interpretation, and dissemination. Their involvement will expand their perspective of understanding and improve their research skills (e.g., co-author journals and conference papers, field-based research methods), and deepen their knowledge on evidence-based human resources for health policies, strategies and plans. This project will contribute to the capacity building through contributing to the further development of staff, professional skills and international research competencies.