ECEC teachers and parents will be asked to fill in a questionnaire at baseline, 4 months follow-up (only applicable for ECEC teachers) and 9 months follow-up (close-out). At the same time, anthropometric measurements in ECEC teachers and toddlers will be carried out. Furthermore, observations on the playgrounds will be performed at 4 and 9 months follow-up. The questionnaire for ECEC teachers includes questions on knowledge, attitude and practices regarding healthy eating and physical activity, and questions on the level of confidence in promoting healthy eating and physical activity in toddlers. For parents, the questionnaire includes questions on knowledge, attitude and practices regarding healthy eating and physical activity of their toddler. In addition, ECEC teachers and parents will be asked to fill in a 3-day food and physical activity record at baseline and 9 months follow-up (parents fill in the records for their toddler).
All measurements will be carried out by trained research staff and students of the Amsterdam University of Applied Sciences using Standard Operation Procedures. The study team is coordinated by 3 unblinded researchers (SM/MJ/NT) and 1 blinded researcher (MS).
Questionnaires, score forms and records will be coded to protect the privacy of the participants. Data from paper questionnaires and score forms will be handled into Microsoft Excel by double data-entry. Records will be entered in Microsoft Excel and checked by trained research staff and students of the Amsterdam University of Applied Sciences.
Demographic data
The questionnaire for ECEC teachers and parents includes demographic questions to obtain general characteristics of the study population. Data of ECEC teachers, toddlers and parents will be collected, including the date of birth (age will be calculated in years (adults) and months (toddlers)), gender, country of birth (migration background) and level of education (proxy for socio-economic status, only applicable for ECEC teachers and parents).
Knowledge, attitude and practices regarding healthy eating and physical activity
The knowledge of ECEC teachers and parents will be assessed by 2 types of questions. Firstly, subjects will be asked to answer 10 statements on the Dutch food-based dietary guidelines with ‘True’, ‘False’ or ‘Don’t know’ [
19]. Secondly, subjects will indicate in 3 separate questions if 5 food products (in total 15 food products) are ‘High’ or ‘Low’ in respectively added sugars, salt and fibres (or if they ‘Don’t know’) [
20]. A sum score for Knowledge will be calculated; each correctly answered question yields one point with a maximum of 25 points.
Attitudes will be evaluated through individual statements regarding healthy eating and physical activity. The statements are compiled by the research staff. For example, ECEC teachers and parents will be asked to answer to what extent they do agree with the following statement: ‘I feel responsible for healthy nutrition- and physical activity patterns of my/the child(ren). A 5 point Likert-scale will be used. Answering options for the statements are 1) totally disagree (1 point), slightly disagree (2 points), neutral (3 points), slightly agree (4 points) or totally agree (5 points).
A modified version of the Child-care Food and Activity Practices Questionnaire (CFAPQ) [
21] will be used to assess the practices of ECEC teachers related to food and physical activity. The original CFAPQ consists of 63 items (40 food-related and 23 activity-related items), divided over 12 CFAPQ scales (7 food-related and 5 activity-related scales). For the original CFAPQ, Gubbels et al. show a sufficient internal consistency in the CFAPQ scales with a Cronbach’s α ranging from 0.53 to 0.96 [
21]. In PS@HW, a modified version of the CFAPQ will be used as not all CFAPQ scales are applicable for preschools. The PS@HW questionnaire for ECEC teachers includes the following 7 CFAPQ scales: Food-related Modelling/Encourage balance and variety, Food-related Teaching about nutrition, Food-related pressure to eat, Activity-related modelling, Activity-related psychological control, Activity-related teaching/autonomy support, Activity-related going outdoors and 1 single item about the availability of outdoor toys. Answering options for the questions are 1) totally disagree (1 point), slightly disagree (2 points), neutral (3 points), slightly agree (4 points), totally agree (5 points) or 2) never (1 point), rarely (2 points), sometimes (3 points), mostly (4 point), always (5 points). A mean score per CFAPQ scale will be calculated.
For parents, the Comprehensive Feeding Practices Questionnaire (CFPQ) [
22] and the Preschooler Physical Activity Parenting Practices (PPAPP) instrument [
23] will be used to assess parenting practices. The parenting practices questionnaires are both starting points for the CFAPQ (selected items of the questionnaires are converted to the child care setting by Gubbels et al.). The original CFPQ includes 12 CFPQ scales on food related practices. One CFPQ scale about restriction for weight control is considered to be too extensive for the purposes of PS@HW. Consequently, the following 11 CFPQ scales are incorporated in the PS@HW questionnaire for parents: Child control, Emotion regulation, Encourage balance and variety, Environment, Food as reward, Involvement, Modeling, Monitoring, Pressure, Restriction for health and Teaching about nutrition. The PPAPP concerns questions about encouraging and discouraging practices related to physical activity of children. The encouraging practices consist of 1 PPAPP scale (Engagement) and 2 single items (Not register the child for sports or dance due to lack of money and Having outdoor toys available for the child). The discouraging practices consist of 4 PPAPP scales, namely Promote inactivity, Promote screen time, Psychological control and Restriction for safety. The complete PPAPP is incorporated in the PS@HW questionnaire for parents. Answering options for the questions are 1) totally disagree (1 point), slightly disagree (2 points), neutral (3 points), slightly agree (4 points), totally agree (5 points) or 2) never (1 point), rarely (2 points), sometimes (3 points), mostly (4 point), always (5 points). A mean score per CFPQ and PPAPP scale will be calculated.
Anthropometry and body composition
In ECEC teachers and toddlers, body weight (kg) will be measured using a portable weighing scale (Seca 813) without shoes or heavy clothing. Moreover, body height (cm) will be measured with a portable stadiometer (Seca 213) without shoes. BMI (kg/m
2) will be calculated. For toddlers, also the BMI z-score will be assessed using World Health Organization reference data (WHO Anthro). Weight status of the toddlers (underweight, normal weight, overweight and obesity) will be evaluated by reference data of Cole et al. [
25]. In addition, the weight perception of parents concerning the weight status of their toddler will be examined via a question in the questionnaire for parents (answering options are: underweight, normal weight, overweight, severe overweight).
Total body resistance will be measured in ECEC teachers and toddlers by Bioelectrical Impedance Analysis (Bodystat 1500 MDD). The measured resistance will be used to calculate Total Body Water and subsequently Fat Free Mass and Fat Mass (kg/%) [
26,
27]. For toddlers, hydration constants discussed by Fomon et al. will be used in the calculation of Fat Free Mass [
28]. Furthermore, the Fat Mass Index (kg/m
2) will be evaluated for toddlers.
Dietary intake
The dietary intake of ECEC teachers and toddlers will be estimated by 3-day food records. Food records are described to be useful in the estimation of dietary intakes in culturally diverse populations [
29]. ECEC teachers will be asked to record their dietary intake per meal on 2 working days and 1 weekend day. Parents will be asked to fill in the 3-day food record for their toddler on 2 week days and 1 weekend day. Written and oral instructions will be given by the research staff. The intake of foods will be converted (by coding and converting household measures into grams) into energy and nutrient intake using the Dutch Food Composition Database 2016 [
30] and a database with portion sizes [
31].
Physical activity level
The physical activity level of ECEC teachers and toddlers will be determined using 3-day physical activity records. Self-report measures are commonly used to estimate physical activity levels [
32] and are considered to be feasible for the purposes of PS@HW. ECEC teachers will be asked to record activities per 0.5 h on 2 working days and 1 weekend day. Parents will be asked to fill in activities for their toddler per 0.5 h during 2 week days and 1 weekend day. MET-scores will be assigned to each activity in order to calculate physical activity levels. For ECEC teachers, the 2011 Compendium of Physical Activities will be used as a reference for MET-scores [
33]. For toddlers, a Youth Compendium of Physical Activities described by Butte et al. will be used [
34]. In addition, ECEC teachers will be asked to wear an accelerometer (ActiGraph ActiTrainer) for 6 days to obtain objective data on their physical activity level. The data obtained by the ActiTrainers will be processed in the ActiLife Data Analysis Software version 5.10.0. Counts per minute will be assessed and the intensity of physical activity will be evaluated (sedentary to very vigorous).
The activating role of ECEC teachers and amount & type of physical activity in toddlers on the playground
To investigate the activating role of ECEC teachers regarding physical activity of toddlers on the playground, it was chosen to perform systematic observations on the playground of preschools. Furthermore, the amount and type of physical activity in toddlers on the playground will be systematically observed. As part of the ‘PLAYgrounds for Toddlers’ program, trained research assistants will perform the observations based on the SOPLAY protocol (physical activity levels during play time) [
35]. This standardized protocol includes observations on the amount of physical activity, type of physical activity and aspects related to the physical environment (for example, weather conditions and provision of playground equipment). Before and after the ‘PLAYgrounds for Toddlers’ program, 2 observations on each playground will be performed.