Happy Homework 2.0: A Trial of Daily Movement Habits in Scottish Primary School Children Aged 4-8 Years Old

Purpose:The Happy Homework (HH) intervention included homework activities which aimed to improveboth activity‐related behaviours across the whole day and key dietary behaviours. Thephysical activity (PA) activities were informed by the World Health Organisation (WHO)recommendations for children aged 5‐17 years that most of children's daily activityshould be aerobic, and vigorous‐intensity activities should be incorporated includingactivities which strengthen muscle and bone at least 3 times per week. Additionalactivities encouraged children to break‐up sedentary behaviour (SB) by standing ormoving, limit recreational screen‐time (ST) to no more than 2 h per day, have adequatesleep durations of between 9 and 11 h per night and maintain consistent bed and waketimes. The activities did not require any equipment or large spaces and were mappedin‐line with the Scottish Curriculum for Excellence (CfE). The development of the HHintervention was informed by Self‐determination theory (SDT). The intervention aimed todevelop children's motivation to lead healthier lifestyles by meeting their three basicpsychological needs: autonomy (i.e., feeling one has choice and is willingly endorsingone's behaviour), competence (i.e., the experience of mastery and being effective inone's activity), and relatedness (i.e., the need to feel connected and a sense ofbelongingness with others). Satisfying children's three needs has been shown to bepredictive of PA participation and positive health behaviours.HH workbooks were provided to children on a Monday, Wednesday, and Friday to encouragehabitual involvement in the activities over an 8‐week period from February ‐ April 2019(i.e., Winter ‐ Spring), which included 2 Easter holiday weeks. Additional activities andhealth promotion reminders were also provided in the workbooks for the days when thechild did not receive HH. Parents were required to sign off each activity that theycompleted with their child which the teachers subsequently recorded in their logbook, tobe used as a measure of fidelity. If a child completed the weekly HH activities, theirteacher would place a happy face sticker on their HH workbook at the end of each week asa small reward to foster adherence.A pilot study in 9‐12 year olds found that Happy Homework was effective in improvingchildren's physical activity and sleep, as well as fruit and vegetable consumption, yetrecommendations to improve the interventions efficacy included moving to a digitalplatform and away from traditional paper‐based homework tasks. As such, Happy Homework2.0 was co‐developed as an app‐based intervention, with the same goal of improvingchildren's 24‐hour movement behaviours. As such, the purpose of this randomised controlfeasibility trial will be to examine the feasibility, acceptability and efficacy of HappyHomework 2.0 in improving the 24‐hour movement of younger children (i.e., 4‐8 years old).Justification:Canada first published 24‐hour movement guidelines for children in 2016, followed by NewZealand and Australia in 2017. These guidelines emphasize the importance of higher levelsof PA and sleep, alongside lower levels of SB, for optimal health. Despite growingevidence, the United Kingdom (UK) has not yet developed or adopted 24‐hour movementguidelines for children. In the UK, only 8% of children meet all three movementguidelines, while 11% meet none. This highlights a clear gap between recommendedbehaviours and children's actual movement patterns, yet research exploring 24‐hourmovement guidelines within the UK remains limited.The home environment may play an important role in promoting 24‐hour movement, aschildren spend roughly half their day at home, and parents have been shown to positivelyinfluence children's PA, SB, and sleep. While school‐based interventions are commonlyused to encourage these behaviours, a recent review found that school‐based interventionsincorporating homework significantly improved children's sleep and reduced sedentarybehaviour. Longer interventions were also associated with increased PA. These findingssuggest that future school‐based programmes should include homework components thattarget reductions in SB and improvements in sleep.Happy Homework is a school‐based intervention designed to promote adherence to 24‐hourmovement guidelines and help prevent non‐communicable diseases. The programme requires nospecial facilities or equipment, making it accessible to all children regardless ofsocioeconomic status. The intervention has shown success in improving PA (e.g., steppingtime) and sleep in primary school children aged 9‐12 years. However, it has not yet beenadapted or tested for younger primary school children aged 4‐8 years. Research clearlyshows that physical inactivity tends to increase as children grow older, especiallyduring the transition into adolescence. Therefore, intervening earlier may prevent thisdecline before sedentary habits become established. With UK children failing to attainpositive 24‐hour movement behaviours, and Scottish children being amongst the mostinactive globally, development of scalable interventions, which show success, such asHappy Homework, is warranted.Design:This mixed‐methods study will include a maximum of 2 co‐design workshops which willinform the randomised feasibility trial we will undertake. Stakeholders included in thestudy will be: ‐ Primary school head teachers and classroom teachers ‐ Parents of children attending school ‐ School children.An iterative co‐design process with 4‐8 year olds will be used to refine the existingco‐produced app. This protocol was developed in accordance with the SPIRIT 2013 Statementand reporting will follow the CONSORT extension for pilot and feasibility trials. Thestudy will be registered on ClinicalTrials.gov prior to participant recruitment.Methodology:Participants who provide both parental consent and child assent will be invited to takepart in the study. To maintain study integrity and minimise contamination, schools andparticipants will be allocated to either the co‐design workshops or the randomisedfeasibility trial study, but not both.A maximum of three connected co‐design workshops, and one co‐production workshops witheach of the 3 different stakeholder groups (i.e., parents, children and teachers/headteachers) will be conducted. The co‐design workshops will involve the following: (1)stakeholders reviewing paper‐based, low‐fidelity prototypes of the HH app; (2)stakeholders providing feedback on the existing design (informed by ongoing study); (3)stakeholders engaging in individual/group design with blank wireframe templates provided(a process referred to as 'feature prioritisation') with their own ideas and features;(4) the 'feature prioritisation' from each workshop informing the proceeding round ofco‐design; and (5) consolidating the best ideas into a final design that represents aminimal viable product design (a product developed with sufficient features for thoseinvolved in early testing) which will be represented through online wireframes. Theco‐design workshops will be conducted in person.Workshop guides will build upon previous findings within the workshop before each, butwill involve the following: (1) stakeholders reviewing an online wireframe of HH app; (2)stakeholders providing feedback on the design and perceived usability (which will beinformed by co‐design workshops); (3) stakeholders engaging in individual/group designwith blank wireframe templates with changes or edits they suggest to change within theonline wireframes (feature prioritisation); and (5) consolidating the best ideas into afinal design that represents a minimal viable product design (a product developed withsufficient features for those involved in early testing).All workshops will be conducted within the school setting as detailed in the riskassessment, providing a familiar and supportive environment for children. Adultparticipants (e.g., teachers) will be encouraged to attend in person, although an onlineoption will be made available where necessary. Workshops will be audio‐recorded using auniversity‐issued device and transcribed verbatim for analysis.During the feasibility RCT, children will be measured at two time‐points:pre‐intervention (1 week prior to intervention delivery) and post‐intervention (1 weekafter the intervention). The included cluster‐RCT measurements which will be takeninclude:Demographic information ‐ home postcode, child's eligibility for free school meals,parental/guardian occupation, household annual combined income, highest educationqualification achieved by parents/guardian, family status, and number of children livingat home will be obtained. The gender of each participant will be obtained to measuregender homogeneity in our sample.Body mass‐ The height and weight of agreeing children will be collected to allow for theclassification of Body Mass Index. Alternatively, children will be provided will theopportunity to self‐report their height and weight. Weight will be measured barefoot tothe nearest 0.1kg with an electronic scale (university supplied) while height will bemeasured barefoot to the nearest 0.1cm using a stadiometer in accordance with standardprocedures.Additionally, children will be fitted with accelerometer devices which must be worn forthe duration of the week prior to intervention delivery and 1 week after interventiondelivery. Full details of the devices will be shared will children and parents in aninformation sheet, including general upkeep, what do to if they fall off, and contactdetails for the primary researcher for further questions. During both the measurementperiods, individuals will be encouraged to resume normal activity. The included devicesare as follows:PA ‐ The ActiGraph GT3X will be used to measure the PA levels of children. This devicedetects accelerations in three axes (i.e., vertical, Mediolateral, and anteroposterior).Prior to data collection, parents, teachers, and children will be instructed on thepositioning of the accelerometer (i.e., non‐dominant wrist) and advised that theaccelerometer should be worn for 7 days over the full day (24‐hours), except duringwater‐based activities (e.eg., showers or swimming).SB ‐ The activPAL 3TM monitors will be used with placement on the participants rightthigh, midway between the anterior superior iliac spine and the knee, using ahypoallergenic Hypafix dressing. This device uses accelerometer‐derived information aboutthigh position to determine the start and end of each period spent sitting/lying,standing, and stepping, as well as stepping speed, step counts, and postural transitions.This device will be worn for 7 days (24 hours) and will be made waterproof by thedressing; therefore, it can be worn during water‐based activities.Sleep ‐ The activPAL 3TM monitors (thigh placement) will be used and has been validatedfor use within children, with a 24‐hour wear time supporting estimates of sleep duration.The 'primary lying' outcome, derived from the activPAL software, will be used by the CREA(version 1.3) and GHLA (version 2.2) algorithms to estimate sleep time duration. Thedevice will be placed on the right thigh, midway between the anterior superior iliacspine and the knee, using a hypoallergenic Hypafix dressing. This device will be worn for7 days (24 hours) and will be made waterproof by the dressing; therefore, it can be wornduring water‐based activities.The randomised feasibility trial will involve four primary schools in South Lanarkshire(two intervention and two control), with two classes from each school recruited toparticipate. Findings from the co‐design workshops will inform key aspects of theintervention, including the nature and frequency of homework tasks. The intervention willrun for a minimum of 8 weeks and a maximum of 12 weeks. Outcome measures will becollected at two time points: baseline (one week prior to intervention delivery) andpost‐intervention (the week immediately after the intervention is completed).The primary researcher will familiarise themselves with each school's safeguardingprocedures and identify the designated child protection officer prior to studycommencement. Although the study is not expected to elicit sensitive disclosures, anyconcerns arising will be reported to the relevant child protection officer in line withsafeguarding protocols. The primary researcher has experience in both qualitative andquantitative methods and holds current PVG clearance for work with children. They willensure adherence to ethical guidelines throughout, including the rights and welfare ofthe child.