School Gardening, Cooking and Sports Participation Intervention to Improve Fruits and Vegetables Intake and Moderate-to-Vigorous Physical Activity among Chinese Children: Study Protocol for a Cluster Randomized Controlled Trial
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design
2.2. Recruitment
2.2.1. Recruitment of the Schools
2.2.2. Recruitment of the School Children
2.3. Sample Size Estimation
2.4. Randomisation Procedures
2.5. Intervention Selection and Theoretical Basis
2.6. Description of the Intervention
2.6.1. SGC Intervention
2.6.2. SP Intervention
2.6.3. Regular Practice Group
2.7. Process Evaluation
2.8. Outcome Evaluation
2.9. Outcomes Measure
2.9.1. Primary Outcome
- Daily intake of FV (unit: g).
- Daily minutes of MVPA (unit: minutes).
2.9.2. Secondary Outcome
- The children’ FV preferences, identification and the attitude and willingness to eat FV.
- PA frequency and attitudes of children.
- Daily sedentary time, video screen time and sleep time (unit: minutes).
- Parental attitudes towards children’s FV intake and SP.
- Children’s height, weight and waistline.
- Questions and recommendations on the implementation of the interventions.
2.10. Statistical Analyses
2.11. Cost-Effectiveness Analysis
- Cost of intervention services for one primary school child.
- Cost for each case of improved fruit and vegetable intake.
- Cost for each case of improved MVPA.
2.12. Patient and Public Involvement
3. Discussion
4. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
- Grimm, K.A.; Kim, S.A.; Yaroch, A.L.; Scanlon, K.S. Fruit and Vegetable Intake During Infancy and Early Childhood. Pediatrics 2014, 134, S63–S69. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Koo, H.C.; Poh, B.K.; Lee, S.T.; Chong, K.H.; Bragt, M.C.E.; Talib, R.A.; on behalf of the SEANUTS Malaysia Study Group. Are Malaysian Children Achieving Dietary Guideline Recommendations? Asia-Pac. J. Public Health 2016, 28, 8s–20s. [Google Scholar] [CrossRef] [PubMed]
- Peltzer, K.; Pengpid, S. Fruits and Vegetables Consumption and Associated Factors among In-School Adolescents in Five Southeast Asian Countries. Int. J. Environ. Res. Public Health 2012, 9, 3575–3587. [Google Scholar] [CrossRef] [PubMed]
- Ignat, I.; Volf, I.; Popa, V.I. A critical review of methods for characterisation of polyphenolic compounds in fruits and vegetables. Food Chem. 2011, 126, 1821–1835. [Google Scholar] [CrossRef]
- Liu, R.H. Health-Promoting Components of Fruits and Vegetables in the Diet. Adv. Nutr. 2013, 4, 384s–392s. [Google Scholar] [CrossRef] [Green Version]
- Aune, D.; Giovannucci, E.; Boffetta, P.; Fadnes, L.T.; Keum, N.; Norat, T.; Greenwood, D.C.; Riboli, E.; Vatten, L.J.; Tonstad, S. Fruit and vegetable intake and the risk of cardiovascular disease, total cancer and all-cause mortality-a systematic review and dose-response meta-analysis of prospective studies. Int. J. Epidemiol. 2017, 46, 1029–1056. [Google Scholar] [CrossRef] [Green Version]
- Slavin, J.L.; Lloyd, B. Health Benefits of Fruits and Vegetables. Adv. Nutr. 2012, 3, 506–516. [Google Scholar] [CrossRef] [Green Version]
- Daly, C.M.; Foote, S.J.; Wadsworth, D.D. Physical Activity, Sedentary Behavior, Fruit and Vegetable Consumption and Access: What Influences Obesity in Rural Children? J. Commun. Health 2017, 42, 968–973. [Google Scholar] [CrossRef]
- Matthews, V.L.; Wien, M.; Sabate, J. The risk of child and adolescent overweight is related to types of food consumed. Nutr. J. 2011, 10, 71. [Google Scholar] [CrossRef] [Green Version]
- Bedard, C.; King-Dowling, S.; Obeid, J.; Timmons, B.W.; Ferro, M.A. Correlates of Moderate-to-Vigorous Physical Activity in Children with Physical Illness and Physical-Mental Multimorbidity. Health Educ. Behav. 2022, 49, 780–788. [Google Scholar] [CrossRef]
- Llorente-Cantarero, F.J.; Aguilar-Gomez, F.J.; Bueno-Lozano, G.; Anguita-Ruiz, A.; Ruperez, A.I.; Vazquez-Cobela, R.; Flores-Rojas, K.; Aguilera, C.M.; Moreno, L.A.; Gil, A.; et al. Impact of Physical Activity Intensity Levels on the Cardiometabolic Risk Status of Children: The Genobox Study. Int. J. Sport Nutr. Exerc. 2022, 32, 102–110. [Google Scholar] [CrossRef] [PubMed]
- Trivic, I.; Sila, S.; Batos, A.T.; Misak, Z.; Kolacek, S.; Hojsak, I. Moderate-to-Vigorous Physical Activity Is Associated with Higher Bone Mineral Density in Children with Inflammatory Bowel Disease. J. Pediatr. Gastr. Nutr. 2022, 74, 54–59. [Google Scholar] [CrossRef] [PubMed]
- Verdonschot, A.; Follong, B.M.; Collins, C.E.; de Vet, E.; Haveman-Nies, A.; Bucher, T. Effectiveness of school-based nutrition intervention components on fruit and vegetable intake and nutrition knowledge in children aged 4–12 years old: An umbrella review. Nutr. Rev. 2022, 1–18. [Google Scholar] [CrossRef]
- Peiris, D.L.I.H.K.; Duan, Y.P.; Vandelanotte, C.; Liang, W.; Yang, M.; Baker, J.S. Effects of In-Classroom Physical Activity Breaks on Children’s Academic Performance, Cognition, Health Behaviours and Health Outcomes: A Systematic Review and Meta-Analysis of Randomised Controlled Trials. Int. J. Environ. Res. Public Health 2022, 19, 9479. [Google Scholar] [CrossRef] [PubMed]
- Liu, Z.; Gao, P.; Gao, A.-Y.; Lin, Y.; Feng, X.-X.; Zhang, F.; Xu, L.-Q.; Niu, W.-Y.; Fang, H.; Zhou, S.; et al. Effectiveness of a Multifaceted Intervention for Prevention of Obesity in Primary School Children in China: A Cluster Randomized Clinical Trial. JAMA Pediatr. 2022, 176, e214375. [Google Scholar] [CrossRef] [PubMed]
- Khan, M.; Bell, R. Effects of a School Based Intervention on Children’s Physical Activity and Healthy Eating: A Mixed-Methods Study. Int. J. Environ. Res. Public Health 2019, 16, 4320. [Google Scholar] [CrossRef] [Green Version]
- Denova-Gutierrez, E.; Mendez-Sanchez, L.; Araiza-Nava, B.; Gonzalez-Rocha, A.; Shamah, T.; Bonvechio, A.; Barquera, S.; Rivera, J. Overview of systematic reviews of health interventions that aim to prevent and treat overweight and obesity among children. Syst. Rev. 2022, 11, 168. [Google Scholar] [CrossRef]
- Wang, Z.; Xu, F.; Ye, Q.; Tse, L.A.; Xue, H.; Tan, Z.; Leslie, E.; Owen, N.; Wang, Y. Childhood obesity prevention through a community-based cluster randomized controlled physical activity intervention among schools in china: The health legacy project of the 2nd world summer youth olympic Games (YOG-Obesity study). Int. J. Obes. 2018, 42, 625–633. [Google Scholar] [CrossRef] [Green Version]
- Liu, Z.; Wu, Y.; Niu, W.-Y.; Feng, X.; Lin, Y.; Gao, A.; Zhang, F.; Fang, H.; Gao, P.; Li, H.-J.; et al. A school-based, multi-faceted health promotion programme to prevent obesity among children: Protocol of a cluster-randomised controlled trial (the DECIDE-Children study). BMJ Open 2019, 9, e027902. [Google Scholar] [CrossRef] [Green Version]
- Liu, Z.; Xu, H.M.; Wen, L.M.; Peng, Y.Z.; Lin, L.Z.; Zhou, S.; Li, W.H.; Wang, H.J. A systematic review and meta-analysis of the overall effects of school-based obesity prevention interventions and effect differences by intervention components. Int. J. Behav. Nutr. Phys. 2019, 16, 95. [Google Scholar] [CrossRef]
- Wiersma, R.; Rijnks, R.H.; Bocca, G.; Boezen, H.M.; Hartman, E.; Corpeleijn, E. Regional variation in lifestyle patterns and BMI in young children: The GECKO Drenthe cohort. Int. J. Health Geogr. 2022, 21, 7. [Google Scholar] [CrossRef] [PubMed]
- Rabbani, B.; Chiti, H.; Sharifi, F.; Mazloomzadeh, S. Effect of lifestyle modification for two years on obesity and metabolic syndrome components in elementary students: A community-based trial. Casp. J. Intern. Med. 2022, 13, 555. [Google Scholar] [CrossRef]
- Van den Berg, A.; Warren, J.L.; McIntosh, A.; Hoelscher, D.; Ory, M.G.; Jovanovic, C.; Lopez, M.; Whittlesey, L.; Kirk, A.; Walton, C.; et al. Impact of a Gardening and Physical Activity Intervention in Title 1 Schools: The TGEG Study. Child Obes. 2020, 16, S44–S54. [Google Scholar] [CrossRef] [PubMed]
- Qi, Y.; Hamzah, S.H.; Gu, E.; Wang, H.; Xi, Y.; Sun, M.; Rong, S.; Lin, Q. Is School Gardening Combined with Physical Activity Intervention Effective for Improving Childhood Obesity? A Systematic Review and Meta-Analysis. Nutrients 2021, 13, 2605. [Google Scholar] [CrossRef]
- Davis, J.N.; Martinez, L.C.; Spruijt-Metz, D.; Gatto, N.M. LA Sprouts: A 12-Week Gardening, Nutrition, and Cooking Randomized Control Trial Improves Determinants of Dietary Behaviors. J. Nutr. Educ. Behav. 2016, 48, 2–11.e1. [Google Scholar] [CrossRef] [Green Version]
- Shull, E.R.; Dowda, M.; Saunders, R.P.; McIver, K.; Pate, R.R. Sport participation, physical activity and sedentary behavior in the transition from middle school to high school. J. Sci. Med. Sport 2020, 23, 385–389. [Google Scholar] [CrossRef]
- Christian, M.S.; El Evans, C.; Nykjaer, C.; Hancock, N.; Cade, J.E. Evaluation of the impact of a school gardening intervention on children’s fruit and vegetable intake: A randomised controlled trial. Int. J. Behav. Nutr. Phys. 2014, 11, 99. [Google Scholar] [CrossRef] [Green Version]
- Hutchinson, J.; Christian, M.S.; Evans, C.E.L.; Nykjaer, C.; Hancock, N.; Cade, J.E. Evaluation of the impact of school gardening interventions on children’s knowledge of and attitudes towards fruit and vegetables. A cluster randomised controlled trial. Appetite 2015, 91, 405–414. [Google Scholar] [CrossRef] [Green Version]
- Staub, D.; Colby, S.E.; Olfert, M.D.; Kattelmann, K.; Zhou, W.J.; Horacek, T.M.; Greene, G.W.; Radosavljevic, I.; Franzen-Castle, L.; Mathews, A.E. A Multi-Year Examination of Gardening Experience and Fruit and Vegetable Intake During College. Nutrients 2019, 11, 2088. [Google Scholar] [CrossRef] [Green Version]
- Mirzayi, C.; Ferris, E.; Ozcebe, H.; Swierad, E.; Arslan, U.; Unlu, H.; Araz, O.; Yardim, M.S.; Uner, S.; Bilir, N.; et al. Structural equation model of physical activity in Turkish schoolchildren: An application of the integrated behavioural model. BMJ Open 2021, 11, e046317. [Google Scholar] [CrossRef]
- Navarro-Paton, R.; Arufe-Giraldez, V.; Sanmiguel-Rodriguez, A.; Ramos-Alvarez, O. Differences on Habitual Physical Activity Index in Primary Schoolchildren according to Age and Gender. Sustainability 2021, 13, 7806. [Google Scholar] [CrossRef]
- Lochbaum, M.; Kenyon, J.; Kim, Y. Physical Activity Levels of 1053 Omani 4th Grade Children: The Importance of Gender and Sport Team Participation in Achieving 60 Minutes of Daily Moderate-to-Vigorous Physical Activity. Int. J. Environ. Res. Public Health 2021, 18, 8504. [Google Scholar] [CrossRef] [PubMed]
- Baumgartner, L.; Postler, T.; Graf, C.; Ferrari, N.; Haller, B.; Oberhoffer-Fritz, R.; Schulz, T. Can School-Based Physical Activity Projects Such as Skipping Hearts Have a Long-Term Impact on Health and Health Behavior? Front. Public Health 2020, 8, 352. [Google Scholar] [CrossRef]
- Day, R.E.; Sahota, P.; Christian, M.S. Effective implementation of primary school-based healthy lifestyle programmes: A qualitative study of views of school staff. BMC Public Health 2019, 19, 1239. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Chan, A.W.; Tetzlaff, J.M.; Altman, D.G.; Laupacis, A.; Gotzsche, P.C.; Krleza-Jeric, K.; Hrobjartsson, A.; Mann, H.; Dickersin, K.; Berlin, J.A.; et al. SPIRIT 2013 Statement: Defining standard protocol items for clinical trials. Rev. Panam. Salud. Public 2015, 38, 506–514. [Google Scholar] [CrossRef] [Green Version]
- Evans, A.; Ranjit, N.; Hoelscher, D.; Jovanovic, C.; Lopez, M.; McIntosh, A.; Ory, M.; Whittlesey, L.; McKyer, L.; Kirk, A.; et al. Impact of school-based vegetable garden and physical activity coordinated health interventions on weight status and weight-related behaviors of ethnically diverse, low-income students: Study design and baseline data of the Texas, Grow! Eat! Go! (TGEG) cluster-randomized controlled trial. BMC Public Health 2016, 16, 973. [Google Scholar] [CrossRef] [Green Version]
- Bandura, A. Health promotion by social cognitive means. Health Educ. Behav. 2004, 31, 143–164. [Google Scholar] [CrossRef]
- Craig, P.; Dieppe, P.; Macintyre, S.; Michie, S.; Nazareth, I.; Petticrew, M. Developing and evaluating complex interventions: The new Medical Research Council guidance. Int. J. Nurs. Stud. 2013, 50, 587–592. [Google Scholar] [CrossRef] [Green Version]
- Saunders, R.P.; Evans, M.H.; Joshi, P. Developing a process-evaluation plan for assessing health promotion program implementation: A how-to guide. Health Promot. Pract. 2005, 6, 134–147. [Google Scholar] [CrossRef]
- Hankonen, N.; Heino, M.T.J.; Araujo-Soares, V.; Sniehotta, F.F.; Sund, R.; Vasankari, T.; Absetz, P.; Borodulin, K.; Uutela, A.; Lintunen, T.; et al. ‘Let’s Move It’—A school-based multilevel intervention to increase physical activity and reduce sedentary behaviour among older adolescents in vocational secondary schools: A study protocol for a cluster-randomised trial. BMC Public Health 2016, 16, 451. [Google Scholar] [CrossRef]
Intervention | Intervention Components | Target | Descriptions of the Content, Frequency and Duration | Person Responsible |
---|---|---|---|---|
School Gardening & Cooking | SGC Training | Teachers | Content: SGC intervention introduction; the specific operation method of each intervention process; the teacher version of the intervention process diary and partial data collection. Frequency: Only once before the intervention. Time: 1–2 h. | Project team leader and members |
Gardening Practice Intervention | Students | Content: Planting 16 seasonal vegetables and fruits in the school garden. Among the vegetables are peppers, cucumbers, beans, aubergines, red amaranth, hollow cabbage, perilla, spinach, oleander, cabbage, string beans and lettuce. Fruits include strawberries, thumb watermelon, melon and cherry tomatoes Frequency: one intervention every one to two weeks, ten times in the last semester, and six times in the next semester. Time: Each intervention lasts for 45 min. | Teachers, volunteers, and project team members | |
Gardening and Nutrition Theory Intervention | Students | Content: A total of 16 gardening theory courses, including the needs of plant growth, human body growth, the importance of vegetables and fruits, 24 four solar terms and planting, etc. Frequency: one intervention every two weeks, eight times in the last semester, and eight times in the next semester. Time: Each intervention lasts for 45 min. | Teachers, volunteers, and project team members | |
Cooking Intervention | Students, Primary caregivers | Content: eight seasonal vegetable and fruit salad cooking demonstration and tasting, and share the eight vegetable and fruit recipes. Frequency: One intervention every four weeks, four times in the last semester, and four times in the next semester. Time: Each intervention lasts for 45 min. | Teachers, volunteers, and project team members | |
Home Gardening Intervention | Students, Primary caregivers | Content: Students grow fruits and vegetables with their parents in simple containers at home, and share gardening and nutrition theories with their parents. Frequency: no requirement. Time: No requirement. | Teachers | |
Student Diary | Students | Content: Students should take the initiative to write a small diary of about 300 words after completing the activities related to gardening practice, gardening and nutrition theory knowledge learning, and salad tasting. Frequency: Writing is required after each intervention. Time: No requirement. | Teachers | |
SGC Toolkit | Teachers, Volunteers | Content: Materials, tools, and textbooks. | Teachers | |
Sports Participation | SP Training | Teachers | Content: SP intervention introduction; the specific operation method of each intervention process; the teacher version of the intervention process diary and some data collection. Frequency: Only once before the intervention. Time: 1–2 h. | Project team leader and members |
Sports skills performance | Students | Content: Show some interesting jumping methods of pattern rope skipping, and organize students to participate in group games. Frequency: Only once before the intervention. Time: 1 h. | Members of the project team | |
Exercise Skills Practice Intervention | Students | Content: Learn 24 kinds of pattern rope skipping movements, including individual patterns, double cooperation and multi-person fun rope skipping. Frequency: one intervention every two weeks, eight times in the last semester, and eight times in the next semester. Time: Each intervention lasts for 45 min. | Teachers, volunteers, and project team members | |
Exercise Health Theory Intervention | Students, Primary caregivers | Content: Learn an overview of different sports, the benefits of sports, and learn how to deal with sports injuries. Frequency: one intervention every two weeks, eight times in the last semester, and eight times in the next semester. Time: Each intervention lasts for 45 min. | Teachers, volunteers, and project team members | |
Sports Competitions | Students | Content: Arrange eight synchronized rope skipping competitions. Students can choose to participate in different forms of competitions according to their wishes. Frequency: One intervention every four weeks, four times in the last semester, and four times in the next semester. Time: Each intervention lasts for 45 min. | Teachers, volunteers, and project team members | |
SP Toolkit | Teachers, Volunteers | Content: Materials, tools, teaching materials, certificates. | Teachers |
Outcomes | Time | Equipment (Model Number, Manufacturer) | Method | ||
---|---|---|---|---|---|
Baseline | 6 Months after Baseline | 12 Months after Baseline | |||
Anthropometric measures | |||||
Height | √ | √ | √ | GMCS-I (Xindong Huateng) | Measured to the nearest 0.1 cm at least twice |
Weight | √ | √ | √ | RGT-140 (Weighing) | Measured to the nearest 0.1 kg at least twice |
Waistline | √ | √ | √ | Tape (MyoTape) | Measured to the nearest 0.1 cm at least twice |
Step number | √ | √ | √ | Huawei Band 6 (Huawei, validity (R = 0.72) and reliability (intraclass correlation coefficient = 0.71) | Wear for one week to calculate the average |
Calorie expenditure | √ | √ | √ | Huawei Band 6 (Huawei, validity (R = 0.67) and reliability (intraclass correlation coefficient = 0.86) | Wear for one week to calculate the average |
Daily minutes of MVPA | √ | √ | √ | Huawei Band 6 (Huawei, validity (R = 0.65) and reliability (intraclass correlation coefficient = 0.76) | Wear for one week to calculate the average |
Daily sleep time | √ | √ | √ | Huawei Band 6 (Huawei, validity (R = 0.85) and reliability (intraclass correlation coefficient = 0.91) | Wear for one week to calculate the average |
Daily sedentary time | √ | √ | √ | Huawei Band 6 (Huawei, validity (R = 0.74) and reliability (intraclass correlation coefficient = 0.82) | Wear for one week to calculate the average |
PA and other behavioral conditions | |||||
PA frequency and attitudes of children. | √ | √ | 6 to 17-year-old Chinese children physical activity questionnaire, CCPAQ (The CCPAQ is a valid (R = 0.78) and trustworthy (intraclass correlation coefficient = 0.70) device for measuring PA) | Students should finish the questionnaires in the classroom in the presence of the trained outcome assessors, who can provide guidance and help. | |
Daily Screen time | √ | √ | 6 to 17-year-old Chinese children physical activity questionnaire, CCPAQ (The CCPAQ is a valid (R = 0.78) and trustworthy (intraclass correlation coefficient = 0.70) device for measuring PA) | Students should finish the questionnaires in the classroom in the presence of the trained outcome assessors, who can provide guidance and help. | |
Dietary behavior | |||||
Daily intake of FV and food intake frequency | √ | √ | The Food Frequency Questionnaires, FFQ required for the study was developed using the food frequency questionnaire compiled by the 2016 Chinese Resident Dietary Survey with appropriate adjustments according to the study content and purposes of the study, with Cronbach’s > 0.7. | The questionnaires should be self-reported by parents or other primary caregivers of the students. | |
Children’s FV preferences, identification and the attitude and willingness to eat FV | √ | √ | Using the Dutch Eating Behavior Questionnaire child-version, DEBQ-C.Zhao Yan et al.developed the Chinese version of the children’s dietary behavior scale according to the English version of DEBQ-C, with Cronbach’s > 0.7 | Students should finish the questionnaires in the classroom in the presence of the trained outcome assessors, who can provide guidance and help. | |
Parental attitudes towards children’s FV intake and SP | √ | √ | The questionnaire will be adapted from the nutrition knowledge, attitude and praxis questionnaire (KAP) to evaluate children’s knowledge, attitudes and praxis about FV, with Cronbach’s> 0.7. | Students should finish the questionnaires in the classroom in the presence of the trained outcome assessors, who can provide guidance and help. | |
Questions and recommendations on the implementation of the interventions | √ | Interview questions included school climate and barriers to implementation of interventions, perceived benefits and challenges to intervention, opinions and perceptions about the intervention’s effects on student involvement, behaviorand class-related outcomes, beliefs about parental involvement, potential for sustainability, overall recommendations to other school principals and ideas for improvements. | The questionnaires should be filled by the trained investigators after face-to-face interviews with school principals, teachers and volunteers. |
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Qi, Y.; Rong, S.; Liao, K.; Huo, J.; Lin, Q.; Hamzah, S.H. School Gardening, Cooking and Sports Participation Intervention to Improve Fruits and Vegetables Intake and Moderate-to-Vigorous Physical Activity among Chinese Children: Study Protocol for a Cluster Randomized Controlled Trial. Int. J. Environ. Res. Public Health 2022, 19, 14096. https://doi.org/10.3390/ijerph192114096
Qi Y, Rong S, Liao K, Huo J, Lin Q, Hamzah SH. School Gardening, Cooking and Sports Participation Intervention to Improve Fruits and Vegetables Intake and Moderate-to-Vigorous Physical Activity among Chinese Children: Study Protocol for a Cluster Randomized Controlled Trial. International Journal of Environmental Research and Public Health. 2022; 19(21):14096. https://doi.org/10.3390/ijerph192114096
Chicago/Turabian StyleQi, Yufei, Siyu Rong, Kunlong Liao, Jiaqi Huo, Qian Lin, and Sareena Hanim Hamzah. 2022. "School Gardening, Cooking and Sports Participation Intervention to Improve Fruits and Vegetables Intake and Moderate-to-Vigorous Physical Activity among Chinese Children: Study Protocol for a Cluster Randomized Controlled Trial" International Journal of Environmental Research and Public Health 19, no. 21: 14096. https://doi.org/10.3390/ijerph192114096