8. ToyBox

Overweight and obesity amongst young children is a key concern across many developed and developing countries. In the EU, for example, approximately one in eight children (12%) aged 7-8 are obese with this figure increasing to 17% for children in Malta (OECD/European Union, 2018[1]; WHO, 2018[2]). Childhood obesity is particularly concerning given its link to psychosocial problems including low self-esteem, bullying, underachievement in schools, and depression (OECD/European Union, 2018[1]). Further, it is a key determinant of obesity in adulthood, which is associated with various health issues including higher probability of developing diabetes, certain cancers and cardiovascular diseases (CVDs) (OECD, 2019[3]).

To reduce the rate of overweight and obesity amongst young schoolchildren, seven EU countries have implemented the ToyBox intervention.1 ToyBox is a Kindergarten-based intervention (i.e. for children aged between 3-4 years) aimed at promoting healthy lifestyles to prevent overweight and obesity rates among children. The intervention is run by teachers over a 24-week period, which concentrates on the four main energy balance-related behaviours (EBRBs) among young children (Manios et al., 2014[4]; ToyBox, 2020[5]):2

  • Water consumption (encouraging children to drink water when thirsty)

  • Healthy snacking

  • Physical activity

  • Sedentary behaviour (breaking up periods of sitting).3

Teachers are encouraged to introduce each of the EBRBs to students in a fun, interactive environment for example through interactive stories, experiments and games.

Countries such as Germany, Greece and Spain implemented ToyBox 2012-13 (ToyBox, 2020[5]), while Malta implemented the intervention in 2019. Teachers who deliver ToyBox receive a once-off 1.5 hour training session (with follow-up at six months), in addition, teachers receive a guidebook and classroom activity guides to help structure lessons.

To encourage children to maintain healthy behaviours in the home environment, the intervention also aims to engage parents. Specifically, parents are provided newsletters, tip cards (e.g. tips on how to motivate your child to move and decrease screen time) and posters on how good EBRBs learnt in school can be transferred into the home (Manios et al., 2014[4]; ToyBox, 2020[5]).

This section analyses ToyBox against the five criteria within OECD’s Best Practice Identification Framework – Effectiveness, Efficiency, Equity, Evidence-base and Extent of coverage (see Box 8.1 for a high-level assessment of ToyBox). Further details on the OECD Framework can be found in Annex A.

Several peer-reviewed studies evaluating the impact of ToyBox on several EBRBs are available. These include studies on:4

  • Sedentary behaviours:

    • Latomme et al. (2017[6]) found across six European countries, participation in ToyBox led to a statistically significant smaller increase in daily use of computer/video games. Specifically, children in the intervention group, on average, increased computer/video games use on weekdays by +5.48 min/day (versus +8.89 min/day in the control Group) and on weekends by +9.47 min/day (versus 15.43 min/day).

    • De Craemer et al. (2016[7]) analysed results in Belgium and concludes participation in ToyBox did not lead to statistically significant reductions in sedentary behaviour when examining the total sample. However, statistically significantly results for certain student groups:

      • Children in the intervention group among high SES kindergartens reduced sedentary behaviour on weekdays by 0.42% compared to an increase of 3.24% for the control group (p = 0.03). The same intervention group also recorded a reduction in sedentary behaviour during schools hours by -2%, whereas in the control group it increased by +0.47% (p = 0.04).

      • Among low SES kindergartens, children in the intervention group recorded a smaller increase in computer time during the weekend compared to the control group (+6.06min/day versus +12.49min/day, respectively) (p = 0.03).

  • Physical activity:

    • De Craemer et al. (2014[8]) measured the impact of ToyBox on objectively collected measures of physical activity in Belgium. Results from the study found children in the intervention group increased their moderate to vigorous and vigorous only levels of physical activity during after school hours while the opposite occurred for those in the control group (with results being statistically significant). When stratified for SES and gender, results found ToyBox was more effective in improving physical activity for boys and children in high SES kindergartens. For example, among low SES kindergartens, the intervention group only saw a small increase in vigorous physical activity after school hours compared to the intervention group in high SES kindergartens, which recorded improvements in light and moderate physical activity as well as total physical activity across the whole week.

    • De Craemer et al. (2017[9]) analysed the impact of ToyBox on physical activity levels across six European countries, which found no statistically significant differences in the intervention and control group across the whole sample. When analysed at the country level, the authors found average steps per day increased in the intervention group for children in Bulgaria (+542 steps/day versus -634 steps/day) (p = 0.03).

  • Eating behaviours:

    • Pinket et al. (2016[10]) found across six European countries studied that children in the intervention group experienced a statistically significant reduction in pre-packed fruit juice when compared to the control group. Specifically, consumption of pre-packaged juice fell by -33ml compared to -10ml for the control group (p < 0.001). However, results for other beverages such as water, soft drinks, sugared and chocolate milk were not statistically significant.

    • Lambrinou et al. (2019[11]) found ToyBox did not have a statistically significant impact on unhealthy snack consumption, however, it was shown to have a positive impact on parental rules and knowledge regarding snacking (e.g. restriction while watching television).

The impact of ToyBox on BMI is not available, however, a systematic review of the wider literature concluded that interventions targeting diet and physical activity “can reduce the risk of obesity in young children aged 0 to 5 years” (Brown et al., 2019[12]).

The long-term impact of ToyBox is not known given it was first implemented in 2012. Previous analysis by OECD, however, can shed light on the potential health and economic impact of school-based obesity prevention schemes (OECD, 2019[3]). Specifically, OECD estimated that school-based obesity prevention programs will reduce the number of cardiovascular disease (CVD) and diabetes cases by 48 154 and 136 586 each year, respectively, between 2020 and 2050 for the 36 countries analysed (which includes all ToyBox country sites) (OECD, 2019[3]).

Finally, in addition to the evidence outlined above, the WHO within its “Best Buys” guidelines for tackling NCDs recommended school-based programme to reduce unhealthy diets as well as increase physical activity (WHO, 2017[13]).

Publically available studies regarding the efficiency of ToyBox focus on the impact of changes to sedentary behaviour. To calculate the effect, sedentary behaviour data was used to estimate the probability of a child being obese or not (i.e. the relative risk (RR) of being obese is 1.86 when a child engages in more than 1 hour of computer games / weekday) (Annemans and Pil, n.d.[14]). Second, to calculate obesity into adulthood, RRs were used which differ based on gender (overweight girls are at 5 times greater risk of being obese in adulthood compared to 4.4. times at risk for boys). Thirdly, the RR of developing certain NCDs (e.g. diabetes, certain cancers and stroke) for obese adults was estimated used RRs. Finally, results from step 3 were transformed into QALYs using EQ-5D results from the published literature (Annemans and Pil, n.d.[14]).

Costs for the intervention covered several inputs including materials, training and transport with final figures estimating the cost between EUR 5 248 (USD PPP 7 672) (Poland) and EUR 28 840 (USD PPP 42 161) (Germany) per 1 000 children, depending on the country (Annemans and Pil, n.d.[14]).

Results of the cost-effectiveness analysis (CEA) are publically available for Greece and Poland. For Greece, the incremental cost-effectiveness ratio (ICER) (cost per QALY gained) was estimated at EUR 14 587 for men and EUR 28 080 for women (USD PPP 21 324 and USD PPP 41 050), assuming investment every five years (i.e. it costs between EUR 14 587 and EUR 28 080 to gain one year in full health). In Poland these figures are markedly less at EUR 3 149 and EUR 1 703 (USD PPP 4 603 and 2 490), respectively (Annemans and Pil, n.d.[14]).

The literature on childhood and adult obesity indicate those from lower socio-economic status (SES) groups are more likely to be overweight or obese. For example, an analysis of preschool-aged children in countries where ToyBox has been implemented found 17.8% of children whose mothers have a low level of education were overweight or obese compared to 12.1% for mothers with a medium/high level of education (Manios et al., 2018[15]). OECD analysis of HBSC (Heath Behaviour in School-Aged Children) data support these findings by estimating that across 26 European countries, overweight and obesity rates are 8 percentage points higher for children in the lowest income quintile compared to those in the highest income quintile (25% versus 17%) (OECD/European Union, 2018[1]).

Previous OECD analyses on the impact of obesity interventions indicate those delivered at schools are effective at tackling socio-economic inequalities, particularly when attendance is compulsory. School-based interventions are particularly effective amongst OECD countries given high attendance levels amongst children with a low-SES.

By addressing a health issue that disproportionally affects children from lower-SES groups, ToyBox aims to reduce health inequalities. However, it is unclear whether specific efforts were made to address other disadvantaged groups such as children from different ethnic backgrounds and/or who live in remote/regional areas.

Finally, results from (De Craemer et al., 2016[7]) and (De Craemer et al., 2014[8]) indicate the intervention (as implemented in Belgium) has been more successful in changing the behaviours of children from high SES kindergartens (see “Effectiveness” results for further details). This is a key limitation of the intervention.

Several studies evaluating ToyBox are available, most of which use RCTs to assess impact. For the purpose of this case study, the study undertaken by Latomme et al. (2017[6]) has been used to assess the evidence-base. This study was chosen given: it includes data from six European countries; it recorded statistically significant results; and the outcome of interest (i.e. sedentary behaviour) was used to evaluate efficiency.

Latomme et al. (2017[6]) utilised a randomised cluster (pre-test/post-test) design to evaluate the impact of ToyBox on sedentary behaviours across six countries. Kindergartens were randomised using a sophisticated approach to ensure equal representation of pre-schoolers across different socio-economic contexts. Sedentary behaviour was measured using the Primary Caregivers’ Questionnaire (PCQ), which included questions such as “How much time does your child spend on TV-viewing?” PCQ is a valid and reliable tool for measuring sedentary behaviour in children.

Using the Quality Assessment Tool for Quantitative Studies from the Effective Public Health Practice Project, the quality of Latomme et al.’s (2017[6]) study is rated as “strong” in two areas (study design and data collection methods); “moderate” in three areas (selection bias, confounders, and withdrawals and dropouts); and “weak” in one area (blinding) (Effective Public Health Practice Project, 1998[16]). Details of the assessment are in Table 8.2.

Participation rates in ToyBox differ depending on the country. In Malta, of the 37 schools who were invited to participate, 27 (14 who were independents and 13 church schools) chose to participate (organisation participation rate of 73%). Of the 991 children eligible to participate in these schools, 733 parents gave consent for their children to participate (individual level participation rate of 74%). Comparatively, across the six other European sites (i.e. Belgium, Bulgaria, Germany, Greece, Poland and Spain) the individual participation rate was lower at 63.3% (Manios et al., 2014[4]).

A review of various school-based childhood obesity interventions identified a range of factors associated with success including parental and community involvement as well as appropriate training and support for teachers (see Box 8.2). Based on a gap analysis comparing these factors against the design of ToyBox, several policy options to enhance effectiveness are outlined below.

The importance of involving parents in school-based nutrition intervention is reflected in WHO’s Nutrition-Friendly Schools Initiative (NFSI) (WHO, 2021[17]). Specifically, a review of the available evidence found parental involvement was positively associated with better health outcomes (e.g. BMI and dietary outcomes), particularly for younger age groups. Further, direct methods of involving parents in school-based interventions (e.g. face-to-face as opposed to newsletters) is associated with better health outcomes (WHO, 2021[17]).

At present, ToyBox engages parents through the provision of tip cards and posters to encourage healthy behaviours in the home. To further boost parental involvement, administrators could consider more interactive strategies such as school information sessions with parents; joint child-school-parent activities; school-led family cooking workshops; family activity nights; and child-parent goal setting (Lloyd et al., 2018[18]; Waters et al., 2011[19]; National Cancer Institute, 2020[20]). Given lack of time is a key barrier for parental involvement (e.g. due to work commitments or over-saturation of school activities), other more accessible activities could also be considered, for example, phone and internet-based services and support (Wolfenden et al., 2012[21]). Further, staff could use the opportunity at events with high attendance from parents to further promote the ToyBox intervention (e.g. school carnivals, fetes, and fundraisers) as opposed to relying on attendance at separate information sessions (Jones et al., 2014[22]).

Community involvement in nutrition action in schools is recommended by the WHO – NFSI essential criteria 2.2 (“Activities for families and community, community involvement and outreach in the area of nutrition and health related issue”) (WHO, 2021[17]). Example policies to boost community involvement in ToyBox include procuring healthy fruit and vegetables from local suppliers (in line with EU’s Farm to Fork Strategy) (European Commission, 2019[23]), and collaborating with community providers with relevant facilities (e.g. kitchens for preparing and cooking healthy meals, edible community gardens, gyms) (Gerritsen, 2016[24]).

One of the essential criteria within WHO’s NFSI is to ensure “school staff training in nutrition and health related issues” (WHO, 2021[17]). A review of the available evidence found the provision of ongoing training, support and communication positively affects child health outcomes such as BMI, physical activity levels and diet (WHO, 2021[17]).

ToyBox provides teachers with an initial 1.5-hour training session in addition to a guidebook and classroom activity guides to help structure lessons. Given the complexity of obesity, expanding the amount of training teachers receive could improve health outcomes particularly if confidence in delivering nutrition and activity based activities is low amongst teachers. At a wider, systematic level, obesity prevention topics could be added to the curriculum to become a kindergarten teacher (CDC, 2017[25]).

Reviews of school-based obesity interventions found those that last longer than one year were more likely to achieve their objectives (Silveira et al., 2011[26]; Gonzalez-Suarez et al., 2009[27]; WHO, 2021[17]). Extending ToyBox beyond 24 weeks may therefore yield better outcomes.

Efficiency is calculated by obtaining information on effectiveness and expressing it in relation to inputs used. Therefore policies to boost effectiveness without significant increases in costs will have a positive impact on efficiency.

The impact of ToyBox on different outcome indicators of interest indicate the intervention is more effective among children in high-SES kindergartens (see “Effectiveness”). Possible reasons for this disparity include:

  • Lower levels of access to outdoor space – e.g. private gardens or nearby parks – for children living in low-SES areas thereby making it difficult for parents/caregivers to implement ToyBox recommendations on physical activity (De Craemer et al., 2014[8])

  • Lower levels of health literacy among parents/caregivers in low-SES areas

  • Less funding among schools in low-SES areas to implement and deliver ToyBox as intended.

The points outlined above represent possible explanations only – therefore, future studies should explore this topic in further detail to understand why ToyBox affects SES groups differently. Findings from this research can be used to adapt ToyBox to ensure it reduces, as opposed to exacerbates, existing health inequalities.

Without this information, specific recommendations on how to enhance equity for ToyBox is not possible. Nevertheless, previous research on school-based obesity interventions in low SES areas can shed light on effective strategies (Box 8.3).

Several RCTs evaluating ToyBox across multiple European sites are available (see assessment of “Effectiveness”). These studies focus on intermediate outcomes namely changes in sedentary behaviour, physical activity and eating behaviours. Given ToyBox is ultimately interested in reducing rates of overweight and obesity in children, further studies are encouraged to include objectively measured BMI as an outcome.

To assist policy makers compare the performance of ToyBox against similar school-based interventions, programme administrators may wish to convert data into indicators that are universally recognised (and therefore frequently reported). For example:

  • Percentage of children who consume fruits at least once per day

  • Percentage of children who consume vegetables at least once per day

  • Percentage of children whose weight-for-height is greater than 2 standard deviations above WHO Child Growth Standards median5

  • Percentage of children whose weight-for-height is greater than 3 standard deviations above WHO Child Growth Standards median6

  • Percentage of adults (i.e. parents) who consume recommended amount of fruits and vegetables everyday (i.e. 400 grammes)

To better understand the impact of ToyBox across different groups of children, a breakdown of evaluation results by priority population groups is encouraged. Previous studies have done this by presenting results by SES status and gender, however, it is also important to understand how ToyBox affects children from different ethnic backgrounds as well as by location (e.g. rural versus urban kindergartens, if possible). A breakdown of results by ethnicity, for example, would be an important contributor to the wider literature on school-based obesity interventions given the current paucity of available studies (Amini et al., 2015[31]).

To evaluate the long-term impact of ToyBox on rates of obesity, it is important to collect data frequently using the same measures, and, ideally, the same individuals (i.e. panel data). Longitudinal panel data is considered the “gold standard” as it reduces bias by taking into account differences across individuals. Given this policy requires long-term funding and support, responsibility for this policy option lies with higher-level policy makers as opposed to ToyBox administrators.

Implementation of ToyBox in Malta recorded a participation rate of around 70% at the both kindergarten and individual level. These figures are higher than those recorded in other ToyBox European sites yet lower than the 85% figure considered high for school-based obesity interventions (Fung et al., 2012[32]). In future rounds of student recruitment, a multi-pronged approach for boosting participation could be considered. Example strategies include (Jones et al., 2014[22]):

  • Promoting the intervention with support from government organisations to enhance trust among parents. For example, the Good for Kids, Good for Life intervention in New South Wales (Australia) was promoted using a support letter from the State’s Chief Health Officer. Policy makers however should first consider if messaging from government organisations may in fact reduce uptake among disadvantaged groups. For example, there is evidence showing those with a low SES and/or lower level of education are more anxious and suspicious of prevention messaging from public health authorities (Peretti-Watel and Constance, 2009[33]).

  • Promoting ToyBox as a healthy behaviour intervention that aims to boost enjoyable physical activity and healthy eating as opposed to obesity prevention. By framing ToyBox in a positive light, this may reduce stigma associated with participation.

  • Increasing efforts to recruit students whose parents are from culturally or linguistically diverse backgrounds given consent may be harder to obtain (for example, by including staff members who are knowledgeable about relevant cultural characteristics).

  • Promoting the intervention over a sufficiently long time period using colourful, “eye-grabbing” material in conjunction with frequent digital and face-to-face follow-up with parents.

This section explores the transferability of ToyBox and is broken into three components: 1) an examination of previous transfers; 2) a transferability assessment using publically available data; and 3) additional considerations for policy makers interested in transferring ToyBox.

ToyBox operates in six EU countries – Belgium, Bulgaria, Germany, Greece, Malta, Poland and Spain. As outlined under “Effectiveness”, ToyBox has led to positive outcomes across these countries, such as reducing the level of sedentary behaviour. Following the success of ToyBox, two non-EU countries, Scotland and Malaysia, transferred the intervention to their own country. The impact of ToyBox in these countries is not publically available.

A full list of reports and publications produced by the ToyBox EU study are at: http://www.toybox-study.eu/.

The following section outlines the methodological framework to assess transferability and results from the assessment.

Details on the methodological framework to assess transferability can be found in Annex A.

Several indicators to assess the transferability of ToyBox were identified (see Table 8.2). Indicators were drawn from international databases and surveys to maximise coverage across OECD and non-OECD European countries. Please note the assessment is intentionally high level given the availability of public data covering OECD and non-OECD European countries.

The owner setting for the transferability assessment of ToyBox is Spain given this was the only country where ToyBox operates and where data for all indicators was available.

Results from the transfer assessment show ToyBox is likely to have political support given it targets childhood obesity, which is a political priority in most countries (see Table 8.3). Further, in countries where data is available, teacher motivation levels and spending on early childhood education and care (ECEC) are on average higher than the owner setting, Spain. For example, Spain spends USD PPP 7 759 on ECEC compared to USD PPP 9 729, which is the average spend across OECD and non-OECD EU countries. Nevertheless, ToyBox may have a lower extent of coverage in other countries given enrolment rates in ECEC are relatively high in Spain (97% versus 83%, which is the OECD and non-OECD EU average).

To help consolidate findings from the transferability assessment above, countries have been clustered into one of three groups, based on indicators reported in Table 8.3. Countries in clusters with more positive values have the greatest transfer potential. For further details on the methodological approach used, please refer to Annex A.

Key findings from each of the clusters are below with further details in Figure 8.2 and Table 8.4:

  • Countries in cluster one have political, economic and sector specific arrangements in place to transfer ToyBox. Countries in this cluster are therefore less likely to experience issues in implementing and operating ToyBox in their local context.

  • Countries in cluster two also have political and sector specific arrangements in place to transfer ToyBox, but would benefit from increasing spending on early childhood education and care (ECEC) to ensure affordability.

  • Countries in cluster three would benefit from undertaking further analyses to ensure ToyBox is affordable (given relatively low levels of funding for early childhood education) and that it aligns with overarching political priorities.

  • It is important to note that Spain and Greece, which operate ToyBox, fall under clusters two and three, respectively, meaning conditions in which these clusters could improve on, although ideal, are not pre-requisites.

Data from publically available datasets is not ideal to assess the transferability of ToyBox. For example, there is no international data measuring the level of parental engagement in schools. Therefore, Box 8.4 outlines several new indicators policy makers should consider before transferring ToyBox.

ToyBox is a school-based childhood obesity intervention targeting children aged 3-4 years. The intervention aims to alter four energy-related behaviours with the greatest impact on weight, as identified within the academic literature. The intervention operates in several European countries and two non-EU countries.

ToyBox has led to statistically significant improvements in intermediate outcomes related to obesity including reductions in sedentary behaviour. However, statistically significant results typically do not apply to the whole population being studied or for all indicators being measured – for example, results from ToyBox in Belgium indicate the intervention is more effective among high SES kindergartens. Further, there is limited evidence on the impact of ToyBox on BMI directly (a final health outcome). Regarding efficiency, economic evaluations of ToyBox found it is cost-effective, however, these results are limited in scope (i.e. by focusing on sedentary behaviour only).

An assessment of ToyBox against the OECD Framework as well as a review of the literature on school-based obesity prevention programs identified several policy options to enhance implementation. These include, but are not limited to: boosting parental and community engagement; increasing duration beyond 24 weeks; integrating obesity prevention into the curriculum for kindergarten teachers; and boosting participation by using government supported promotional material. In addition, researchers are encouraged to report the impact of ToyBox on BMI directly, and, to the extent possible, provide results by different population groups beyond SES and gender (e.g. by ethnicity and location (urban versus regional)).

Box 8.5 outlines next steps for policy makers and funding agencies regarding ToyBox.


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[2] WHO (2018), WHO European Childhood Obesity Surveillance Initiative (COSI).

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[21] Wolfenden, L. et al. (2012), “Engaging parents in child obesity prevention: Support preferences of parents”, Journal of Paediatrics and Child Health, Vol. 48/2, https://doi.org/10.1111/j.1440-1754.2010.01776.x.


← 1. Participating countries include Belgium, Bulgaria, Germany, Greece, Malta, Spain and Poland.

← 2. The intervention concentrates on each EBRBs for four weeks (16 weeks) which is then repeated, however, for only two weeks (eight weeks).

← 3. In addition, the importance of good oral health is also being emphasised in Malta.

← 4. An evaluation of the ToyBox (Malta) was planned for year 2020, however, due to unforeseen barriers caused by COVID-19, the evaluation was put on hold indefinitely.

← 5. See following link for WHO Child Growth Standards: https://www.who.int/childgrowth/standards/weight_for_height/en/ (indicator designed for children under five years of age)

← 6. Ibid.

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