Development and Feasibility of a Physiotherapist-Led Intervention to Increase Physical Activity Among Preschool Children: Using the Medical Research Council's (MRC) Guidelines for Developing Complex Health Service Interventions

Abstract

Thesis Abstract Background: Insufficient physical activity (PA) in early childhood is a key risk factor associated with adverse health outcomes, including an increased risk of obesity. Early childhood represents an optimal period for implementing programmes and interventions aimed at promoting PA among young children. Despite the recognised importance of such interventions, many countries, including the Kingdom of Saudi Arabia (KSA), lack targeted programmes for preschool-aged children. Notably, most research in this field has been conducted in industrial countries, such as the United States and Australia, with mixed results regarding improvements in children’s PA levels, despite the documented health benefits of positive behaviour. Given that a significant proportion of preschool-aged children in the KSA attend childcare settings, these environments present a valuable opportunity to foster healthy lifestyle habits through interventions focused on behaviour modification. Consequently, this PhD project aims to develop, design, and implement a multi-component preschool-based intervention to promote PA among preschool children (aged 3–5 years) in the KSA. Methods: This PhD thesis presents the development and testing of the feasibility of a behaviour-change preschool intervention implemented in two Saudi preschool centres, guided by the MRC Guidelines for Developing and Evaluating Complex Interventions. There were four inter-related phases involved in this thesis. Phase 1 a systematic review was conducted to explore the correlation between behaviour change techniques (BCTs) and the effectiveness of interventions designed to enhance PA among young children. Phase 2 utilised a thematic analysis of data collected from focus groups (n=13) and interviews with key stakeholders (n=2), including teachers, classroom assistants, and principals. The results of the systematic review and the qualitative analysis were used to inform the development of the intervention. Phase 3 involved a trial (n=52) to evaluate the feasibility, appropriateness, and fidelity of a 10 week PA intervention and its evaluation for the target population and setting. Finally, Phase 4 comprised a process evaluation involving preschool staff and parents who participated in the post-intervention focus groups (n=10) and completed questionnaires (n=14). This phase assessed the acceptability of the intervention and gathered feedback on areas for improvement to inform the design of a further optimised intervention and future large-scale RCT. Results: The systematic review (Chapter 3) revealed a global scarcity of PA interventions targeting young children as well as the poor quality and design of existing interventions. The review provided insights into the most promising, effective, and commonly used BCTs including their candidature for being incorporated into future PA promotion interventions for young children . The analysis of data from focus groups and interviews with stakeholders ii (Chapter 4) pointed to three core themes or areas of programme design and development: (i) children’s motivation and (ii) barriers to engaging in PA, and (iii) factors that influence the implementation of a preschool-based multicomponent intervention. This results from the process of eliciting and analysing stakeholder input were used to refine key intervention components, tailor the intervention to suit specific preschool needs and capabilities and facilitate intervention adaptation to match the implementation setting. The feasibility of conducting a cluster randomised controlled trial (cRCT) of the intervention (Chapter 6) was tested within two public preschools in Saudi Arabia; one served as the intervention site and the other as the control. A total of 52 children and their parents participated in the study. In the intervention preschool, 27 participants received a 10-week behaviour change intervention, while the 25 participants at the control school continued with their usual physical activities. The intervention implemented in the preschool setting achieved a high-fidelity rate of 93.3%, compared to a lower fidelity rate of 74% in the home-based component. The recruitment response rates varied notably, with a cluster-level recruitment rate of 12% achieved across 112 centres and an individual-level recruitment rate of 36% among 143 children (mean age 4.16 years; 23 (44%) of whom were girls). The study experienced an attrition rate of 10%. Compliance rates exhibited variability across different measures: 90% for Body Mass Index (BMI) assessments, 71% for accelerometery, and 45% for questionnaire completion. At follow-up, the intervention group showed slight improvements in PA levels, decreases in sedentary times, and slight decreases in BMI as compared to the control group. Parents and teachers, including assistant teachers and facilitators, found the intervention to be feasible to implement and beneficial. The findings from the fourth phase (process evaluation) (Chapter 7) provided a nuanced understanding about the facilitators and barriers to implementation. Key facilitators included the use of user-friendly materials and the intervention’s alignment with existing preschool curriculum, which aided seamless integration into daily routines. However, the implementation of the intervention faced challenges due to time constraints, spatial limitations within the preschool settings, and conflicts with existing policies. Despite the intervention materials being well-received and an appreciation for their clarity and visual appeal, time restrictions significantly affected parental engagement. Conclusion: The work contained in this thesis demonstrated that the intervention and trial procedures were feasible and acceptable for education providers, parents, and children in the Saudi preschool environment, contributing to the evidence base for PA interventions within this group. However, there were barriers to intervention delivery and engagement related to recruitment rates, compliance with completing outcome measures, and home environment acceptability that should be considered when designing a future cluster RCT.