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www.elsevier.es/psicod

Original

Effects of a school-based intervention on physical activity, sleep

duration, screen time, and diet in children夽
Miguel Angel Tapia-Serrano a,∗ , Javier Sevil-Serrano b , David Sánchez-Oliva c , Mikel Vaquero-Solís a ,
and Pedro Antonio Sánchez-Miguel a
a
Department of Didactics of Musical, Plastic and Body Expression, Faculty of Teaching Training, University of Extremadura, Avenida Universidad, S/N, 10071, Cáceres, Spain
b
Department of Didactics of Musical, Plastic, and Body Expression, Faculty of Health and Sport Sciences, University of Zaragoza, Spain
c
Department of Didactics of Musical, Plastic and Body Expression, Faculty of Sports Sciences, University of Extremadura, Avenida Universidad, S/N, 10071, Cáceres, Spain

a r t i c l e i n f o a b s t r a c t

Article history: Multiple health-risk behaviors such as physical inactivity, sedentary behaviors or unhealthy diet rep-
Received 1 February 2021 resent a public health problem among adolescents. The aim of this study is to examine the effects of a
Accepted 26 May 2021 school-based intervention on 24-hour movement behaviors (i.e., physical activity, screen-based behav-
Available online xxx
iors, and sleep), Mediterranean diet, and self-rated health status. A quasi-experimental design has been
carried out for two months and a half in a sample of 121 children, aged 8-9 years (M = 9.01 ± .09 years
Keywords: old; 47.11% girls), from two elementary schools. Sixty-six students from one of the schools has been
diet
assigned to the control group and 55 students from the other school has been included in the experi-
exercise
health
mental group. In the experimental group, ten one-hour weekly sessions about knowledge, awareness,
school-based intervention and practices of health-related behaviors have been implemented by a research group member through
sedentary the tutorial action plan. 24-hour movement behaviors, Mediterranean diet, and self-rated health status
sleep has been measured before and after the school-based intervention using self-reported questionnaires.
youth Experimental group children show a significant increase in adherence to the Mediterranean diet and
being physically active during the weekdays compared to their baseline values. Moreover, the greater
baseline values in the adherence to the Mediterranean diet, as well as being physically active during
weekend days in the control group, disappear between both groups after the intervention. Ten one-hour
sessions of a school-based intervention conducted through the tutorial action plan seem effective in
improving children’s adherence to the Mediterranean diet and the proportion of active children, but not
other health-related behaviors.
© 2021 Published by Elsevier España, S.L.U. on behalf of Universidad de Paı́s Vasco.

Efectos de una intervención escolar en la actividad física, el tiempo de sueño, el

tiempo de pantalla y la dieta en niños

r e s u m e n

Palabras clave: La inactividad física, los comportamientos sedentarios y el consumo de alimentos no saludables repre-
dieta sentan un problema de salud pública entre los adolescentes. El objetivo es examinar los efectos de una
ejercicio intervención escolar en los comportamientos de movimiento que interaccionan durante las 24 horas
salud
(actividad física, pantallas y sueño), la dieta mediterránea y el estado de salud. Se ha llevado a cabo un

PII of original article:S1136-1034(21)00045-9.

夽 Please cite this article as: Tapia-Serrano MA, Sevil-Serrano J, Sánchez-Oliva D, Vaquero-Solís M, Sánchez-Miguel PA, Efectos de una intervención escolar en la actividad
física, el tiempo de sueño, el tiempo de pantalla y la dieta en niños, Revista de Psicodidáctica, 2021, https://doi.org/10.1016/j.psicod.2021.05.002
∗ Corresponding author.
E-mail addresses: matapiase@unex.es (M.A. Tapia-Serrano), jsevils@unizar.es (J. Sevil-Serrano), davidsanchez@unex.es (D. Sánchez-Oliva), mivaquero@alumnos.unex.es
(M. Vaquero-Solís), pesanchezm@unex.es (P.A. Sánchez-Miguel).

2530-3805/© 2021 Published by Elsevier España, S.L.U. on behalf of Universidad de Paı́s Vasco.

PSICOE-93; No. of Pages 10

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intervención escolar diseño cuasi-experimental, durante dos meses y medio. Han participado 121 niños, entre 8 y 9 años
sedentario
(M = 9.01 ± .09 años; 47.11% niñas), de dos escuelas de Educación Primaria, de los cuales 66 se han asignado
sueño
al grupo control y 55 al grupo experimental. Se han desarrollado diez sesiones de tutoría, de una hora
jóvenes
semanal, sobre hábitos saludables. Se han medido la actividad física, el tiempo de pantallas, la duración
de sueño, la dieta mediterránea y el estado de salud, antes y después de la intervención, a través de
cuestionarios. Los niños del grupo experimental muestran un incremento significativo en la adherencia
a la dieta mediterránea y en los valores de actividad física entre semana en comparación con sus valores
iniciales. Además, los mayores valores iniciales en el grupo control en la adherencia a la dieta mediterránea
y en la proporción de sujetos activos, han desaparecido entre los dos grupos después de la intervención.
Un programa escolar implementado en las tutorías, a través de diez sesiones de una hora de duración,
parece eficaz para mejorar la adherencia a la dieta mediterránea y la proporción de niños activos, pero no
para otros comportamientos relacionados con la salud.
© 2021 Publicado por Elsevier España, S.L.U. en nombre de Universidad de Paı́s Vasco.

Introduction
Overweight and obesity among European children have
increased during the last two decades (Zhao et al., 2019). The preva-
lence of overweight or obesity is significantly higher in Iberian
countries such as Spain, where rates among children are higher
than 30% (Garrido-Miguel et al., 2019). Although the multifactorial
aetiology of overweight and obesity is complex, adopting a healthy
lifestyle could prevent or reduce its prevalence. It is well-known
that high levels of physical activity (PA), low screen time, opti-
mal sleep duration, and the adoption of a Mediterranean diet are
both independently and synergistically associated with physical,
social/mental, and cognitive benefits in children (Saunders et al.,
2016). However, many children do not meet recommendations for
PA (i.e. ≥ 60 min/day of moderate to vigorous intensity), screen time
(i.e. ≤ 2 h/day), sleep duration (i.e. 9–11 h/day) (Rollo et al., 2020),
and Mediterranean diet (Iaccarino Idelson et al., 2017).
School is considered to be an ideal setting for promoting
healthy lifestyles in children (Sevil-Serrano et al., 2019). How-
ever, most school-based interventions exclusively targeting single
health behaviours such as PA, screen time, sleep duration, or diet
(Cotton et al., 2020), reveal small or insignificant post-intervention
effects (Goldthorpe et al., 2020). Despite limited evidence, it has
been suggested that multiple health behaviour change (MHBC)
interventions (i.e. targeting two or more health-related behaviours)
may have a greater potentially beneficial health effect than single-
behaviour interventions (Busch et al., 2013). These additional
health effects could be explained by carry-over mechanisms (i.e.
the improvement of one health-related behaviour may serve as a
gateway for another) (Geller et al., 2017). This could be because
experiences, skills, knowledge, and self-efficacy can be transferred
to different behaviours and domains (Geller et al., 2017).
Multicomponent school-based interventions have also been
considered to be one of the most promising approaches to improv-
ing health-related behaviours (van de Kop et al., 2019). Moreover,
theory-based interventions could be helpful in identifying the
modifiable factors and mechanisms that relate to health-related
behaviours (Hagger & Weed, 2019). Creating Active Schools (CAS)
Framework (Daly-Smith et al., 2020), based on the behaviour
change wheel (Michie et al., 2011), by including capability, opportu-
nity, and motivation through initial and in-service teacher training,
has recently emerged as a comprehensive framework to involve the
whole school community to promote healthy lifestyles. Different
school opportunities have been identified in this framework for
the adoption of a healthy lifestyle: events/visits, recess, physical
education, other curricular subjects, before/after school sport par-
ticipation, active commuting to and from school, and intervention
by family/community. Moreover, Self-Determination Theory (SDT;
Ryan & Deci, 2017), has been shown to be effective in modifying
health behaviours (Ntoumanis et al., 2020). SDT posits that the basic
psychological needs for autonomy, competence, and relatedness
need to be satisfied in order to enhance autonomous motivation
and, consequently, health-related behaviours (Ryan & Deci, 2017).
Grounded in CAS and SDT as theoretical frameworks, a previ-
ous multicomponent school-based intervention for Spanish youth,
developed through the tutorial action plan, featuring an interdis-
ciplinary project, school break, extracurricular activities, and so on
revealed an improvement in most of the health-related behaviours
examined (Sevil-Serrano et al., 2019). Therefore, both theoretical
frameworks can be useful to design and guide school-based lifestyle
interventions.
The present study
To date, most school-based interventions have independently
addressed PA, screen time, sleep duration, or an (un)healthy diet
among school-children (Jones et al., 2020). A systematic review
of systematic reviews showed that school-based interventions
have mostly had small effects and Body Mass Index (BMI) and
BMIz (Goldthorpe et al., 2020). Given that the few existing MHBC
interventions conducted in school settings have mainly exam-
ined their effects on BMI, but not on other lifestyle behaviours
(Goldthorpe et al., 2020), future MHBC interventions are required.
To the best of our knowledge, to date, only one eight-month
school-based lifestyle intervention, targeting up to four health-
related behaviours among children, had been developed (Pablos
et al., 2018). These authors only found significant improvements
in breakfast habits and quality of diet (Pablos et al., 2018). There-
fore, examining the effects of school-based lifestyle interventions
on multiple health behaviours is required. Moreover, to our knowl-
edge, no previous multicomponent intervention studies have been
conducted exclusively in the tutorial action plan. A tutorial action
plan may help to improve health-related behaviours given its
potential effects on health-literacy skills and health-related knowl-
edge. Furthermore, a tutorial action plan offers the possibility
of designing activities for school breaks to connect with other
extracurricular activities (e.g. community sports events, families’
involvement, etc.) (Sevil-Serrano et al., 2019). Examining the mul-
tiple effects of the tutorial action plan on a range of energy
balance-related behaviours (e.g. PA, screen time, sleep duration,
and diet) might be particularly useful when considering its inclu-
sion in more complex multicomponent interventions. Therefore,
grounded in CAS and SDT frameworks, the main aim of this study
was to examine the effects of a multicomponent school-based
intervention, conducted in the tutorial action plan, on 24-hour
movement behaviours (i.e. PA, screen-based behaviours, and sleep),
Mediterranean diet, and health-rated status.

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Method
Design and participants
A quasi-experimental design was developed over two and a half
months in two elementary schools from one city in the south-west
of Spain (Figure 1). A convenience sample of 121 schoolchildren (64
boys and 57 girls), aged 8 to 9 years (M = 9.01 ± 0.09 years old), in
their fourth year of Primary Education, participated in this study.
Of the total sample, 66 children (M = 9.00 ± .00 years old), from two
classes of one of the two schools, were assigned to the control group
(50% girls) and 55 children (M = 9.00 ± .00 years old), from two
classes of the other school, were assigned to the experimental group
(43.6% girls). Both schools were in two neighbourhoods with simi-
lar sociodemographic and built environment characteristics (Junta
de Extremadura, 2018). They were also similar regarding school
community size (i.e. 350 students), school schedules, and sports
facilities. Both schools had one hour of tutorial action per week. In
Spain, each class has a homeroom teacher (also called a tutor) who
teaches most of the subjects. The study criteria were attending at
least half the sessions in the experimental group and completing
both pre- and post-test measurements. The participation rate was
100%.
Measures
Sociodemographic characteristics
Age, sex, and socioeconomic status (SES) were self-reported.
Children’s SES was measured using the Family Affluence Scale-II
(FAS II; Currie et al., 2008). An SES score range from 0 to 9 was
calculated based on the responses to four questions.
Body mass index
Body weight and height were measured in children, wearing
light indoor clothing without shoes, by trained research staff of the
same sex as the student. Weight was measured to the nearest 0.1 kg
using a digital electronic scale (model SECA 877) and height was
measured to the nearest 1 mm, in the Frankfort horizontal plane,
using a telescopic height-measuring instrument. Both measure-
ments were performed twice, and the mean value was used for
further analysis.
Physical activity
PA is defined as any bodily movement produced by skeletal
muscles that requires energy expenditure (Caspersen et al., 1985).
PA was assessed using the Spanish version of the Physical Activ-
ity Questionnaire for Children (PAQ-C; Benítez-Porres et al., 2016).
The PAQ-C is a valid (r = .30 – .40) (Marasso et al., 2021) and reliable
(␣ = .76 and Intraclass Correlation Coefficient [ICC] = .96) measure
to assess PA levels in Spanish older children (Manchola-Gonzalez
et al., 2017). In the present study, Cronbach’s alpha for physical
activity on this scale was .86. The scale comprises nine items assess-
ing participation in physical activities over the last seven days. To
calculate a PA index score, the frequency of participation of a list of
activities such as PA in Physical Education (PE) lessons, during the
school break, at lunchtime, right after school, and evenings, as well
as during the last weekend were asked. Each statement is scored
on a 5-point scale ranging from 1 to 5. Based on a cut-score over
2.9 and 2.7 points for boys and girls respectively, children were
classified as ‘active’ and ‘non-active’ (Voss et al., 2013).
Sedentary screen time
Children self-reported their daily average time spent on five
sedentary screen behaviours (i.e., television [TV], video gaming,
computer use, mobile phone use, and tablet use) for both week-
days and weekend days through the Youth Leisure-Time Sedentary
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Behaviour Questionnaire (YLSBQ; Cabanas-Sánchez et al., 2018). The
YLSBQ is a valid (r = .36) and reliable (ICC = .75) measure to assess
12 sedentary behaviours among Spanish young people aged 8 to
18 years (Cabanas-Sánchez et al., 2018). In the present study, only
questions referring to the five sedentary screen behaviours of this
questionnaire were used. Sedentary screen time has been defined
as the time spent using a screen-based device while being seden-
tary in any context (Tremblay et al., 2017). The daily average time
spent on each sedentary screen behaviour was calculated using a
ratio of 5:2 (e.g. [Daily tablet use on weekdays x 5] + [Daily tablet
use on weekends x 2]/7). Total daily sedentary screen time was cal-
culated summing the different daily screen time behaviours. Screen
time guidelines were also calculated using the recommendations
for children (<2 h/day) (Tremblay et al., 2016).
Sleep duration
Mean sleep duration was defined as time in bed (calculated from
bedtime to rising time) (Øyane et al., 2008). Children self-reported
their daily average sleep duration for weekdays and weekend
days using a Spanish translation of a self-reported sleep ques-
tionnaire (Yamakita et al., 2014). Participants reported their usual
bedtime (the time when the child is ready to fall asleep) and waking
time (the time when the child gets up) for weekdays and week-
end days separately. These four questions have been shown as
a valid (r = .45–.90) and reliable (ICC = .71–.99) measure to assess
sleep duration in children aged 9 to 12 years old (Yamakita et al.,
2014). Daily sleep time was calculated by weighting weekday and
weekend day using a ratio of 5:2 (e.g. [Daily sleep time on week-
days x 5] + [Daily sleep time on weekend days x 2]/7). Sleep duration
guidelines were also calculated using the recommendations for
children (9–11 h/day) (Tremblay et al., 2016).
Adherence to the Mediterranean diet
This diet has been characterised by a high quantity of veg-
etables, legumes, cereals, fish, fruits and nuts, edible grain and
bread, potatoes, poultry, beans, nuts, olive oil, and fish, as well
as being low in red meat (Serra-Majem et al., 2004). Adherence
to the Mediterranean diet was assessed using the Spanish version
of the Mediterranean diet Quality Index (KIDMED) questionnaire
(Altavilla et al., 2020; Serra-Majem et al., 2004). This question-
naire is a valid and reliable instrument to measure adherence to the
Mediterranean diet in children (Altavilla et al., 2020; Serra-Majem
et al., 2004). This questionnaire consists of 16 yes/no questions,
12 have a positive connotation (+1, e.g. fresh or cooked vegetables
daily) and four have a negative connotation (-1, e.g. consumption
of sweets several times a day). The adherence to the Mediterranean
diet index is calculated as the sum of each answer and ranges from
-4 to 12. Levels of adherence to the Mediterranean diet were clas-
sified into three groups: low adherence (≤ 3), medium adherence
(4–7), and high adherence (≥ 8) (Serra-Majem et al., 2004).
Self-rated health status
Consistent with previous studies (Zhang et al., 2020), self-rated
health was assessed with a single question: ‘In general, how would
you say your health is?’ The question had five response options:
‘excellent’, ‘very good’, ‘good’, ‘fair’, and ‘poor’.
Procedure
The research team contacted the school principal and teachers
of the fourth grade of two elementary schools. After agreeing to
participate in the study, one school was randomly selected as the
intervention and the other school as the control. The school-based
lifestyle intervention was offered to the control school at the end
of the study. Parents were informed by letter about the nature and
purpose of the study and written informed consent was required
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Figure 1. Design of this school-based lifestyle intervention.
from both children and their parents/legal guardians. Children’s
health-related behaviours were measured by a paper-and-pencil
survey, before (pre-test) and immediately after the school-based
intervention (post-test). The questionnaire was filled out in a quiet
classroom in approximately 25 minutes. The study was conducted
in accordance with the Declaration of Helsinki and was approved by
the Ethics Committee of the University of Extremadura (243/2019).
Intervention programme
This two-and-a-half-month school-based intervention was
implemented between October 2019 and the first half of December
2019, before the COVID 19 pandemic. The school-based interven-
tion was conducted in the experimental group, whereas the control
group followed their usual education curriculum without addi-
tional health intervention. In the experimental group, ten one-hour
weekly sessions were implemented through the tutorial action plan
using CAS and SDT as theoretical frameworks (see supplementary
material 1). In Spain, most schools include a weekly hour of tuto-
rial action in their schedules to learn content related to academic,
social, and emotional aspects of their lives, as well as to discuss
educational concerns. It should be noted that although this school-
based intervention was only developed in the tutorial action plan,
agents such as families and other components such as school break
and leisure-time PA were indirectly involved in this intervention.
It is important to note that although the school-based intervention
was implemented by a member of a research group with exper-
tise in developing school-based lifestyle interventions based on
CAS and SDT frameworks, schoolteachers were present in the dif-
ferent sessions to acquire knowledge, health literacy skills, and
motivation and behaviour change techniques (MBCTs) (Teixeira
et al., 2020) in order to be able to implement this intervention in
future studies. To ensure also the sustainability of this school-based
intervention, all sessions were co-developed and co-supervised by
school teachers and some members of a research group (Herlitz
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et al., 2020). The aims of the 10 sessions of this school-based inter-
vention were (1) to increase health-related knowledge, attitudes,
and behaviours; (2) to educate on an optimal balance between dif-
ferent 24-hour movement behaviours (i.e. high PA, low sedentary
behaviours, and optimal sleep duration), and (3) to empower chil-
dren to design their own physical activities at school break and
outside of school. Grounded in SDT, sixteen MBCTs (Teixeira et al.,
2020) were used in this school-based intervention (see supple-
mentary material 2). Details of the specific programme content
delivered in each of the ten sessions, as well as the health-related
behaviours addressed, have also been described in supplementary
material 1. For more information on the 10 sessions developed in
this school-based intervention, please consult the following book
(Tapia-Serrano et al., 2020).
Data analysis
The SPSS Statistics v.23.0 software was used for data analy-
sis. Frequency, mean, and standard deviation were calculated for
each health-related behaviour. Based on previous studies that have
shown between-day differences in movement behaviours among
children, weekday and weekend PA, sedentary screen time, and
sleep duration were also calculated. To verify the homogeneity and
normality of data, the Levene and Kolmogorov–Smirnov tests were
performed. To examine the effects of this school-based lifestyle
intervention, a 2 x 2 (time x group) repeated measures multivariate
analysis of covariance was performed on health-related behaviours
(pre- and post-test). Gender, SES, and BMI were included as covari-
ates in these analyses. For continuous variables, multiple paired
t-test with Bonferroni correction was calculated to determine
intragroup (i.e. between the experimental and control group) and
intergroup (between pre- and post-test) differences. For categor-
ical variables, a chi-square test was performed. While Cramer’s
V was used to describe the degree of association between cate-
gorical variables and experimental and control groups, McNemar’s
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test was used to analyse baseline and post-intervention differences
in categorical variables in both control and experimental groups,
respectively. Effect sizes were assessed by Partial Eta Squared Val-
ues (p 2 ) and Cramer’s V for continuous and categorical variables,
respectively. Effect sizes were considered small, moderate, or large,
when p 2 were above .01, .06, and .14, respectively, and when
Cramer’s Vs were above .10, .30, and .50, respectively.
Results
Before conducting the main analyses, we tested the normality
and homogeneity of data. Kolmogorov–Smirnov tests demon-
strated the normality of data both for the whole sample and
independently for the control group and experimental group
(p > .05), while homogeneity of variance between the control and
experimental groups was also confirmed through Levene’s test
(p > .05).
Interaction effects
No significant differences were found in the time x group
interaction effects in any health-related behaviour: PA levels:
Wilks’ Lambda = .981, F(3, 114) = .750, p = .525, p 2 = .019; seden-
tary screen time: Wilks’ Lambda = .960, F(8, 109) = 2.422, p = .804,
p 2 = .040; sleep duration: Wilks’ Lambda = .960, F(2, 115) = 2.422,
p = .093, p 2 = .040; adherence to the Mediterranean diet: Wilks’
Lambda = .888, F(16, 102) = 0.801, p = .682, p 2 = .112; and self-
rated health status: Wilks’ Lambda = .978, F(1, 115) = 2.601, p = .110,
p 2 = .022. However, in the within-group and between-group
effects some significant differences were found.
Within-group effects
Regarding continuous variables (Table 1), no significant differ-
ences were found between the experimental and control groups
before the intervention programme in most of the health-related
behaviours, except adherence to the Mediterranean diet and self-
rated health status which were significantly higher in the control
group (p < .001). After the school-based intervention, no signifi-
cant differences were found between the experimental and control
groups. Regarding categorical variables (Table 2), no significant
differences were found between both groups before the interven-
tion programme in most of the health-related behaviours, with
the exception of the proportion of active children during weekend
days (medium effect size) and adherence to the Mediterranean diet
(small effect size), which were significantly higher in the control
group, and self-rated health status (small effect size), which were
significantly higher in the experimental group (all, p < .001). After
the development of the school-based intervention, no significant
differences were found between both groups.
Between-group effects
Regarding continuous variables (Table 1), the experimental
group students only reported a statistically significant increase in
the adherence to the Mediterranean diet (p < .005). In contrast control
group students only showed a statistically significant decrease in
weekend day screen time (p < .001) in comparison to their baseline
values. Regarding categorical variables (Table 2), the experimental
group students showed a significant increase in the proportion of
active children during the week (p < .005) and a significant decrease
in meeting Internet recommendations (p < .005). The control group
students reported a significant increase in meeting daily screen time
recommendations (p < .005) and meeting weekend day screen time
guidelines (p < .001).
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Discussion
Multicomponent school-based lifestyle interventions based on
behaviour change theories such as CAS and SDT are required to
provide further evidence as to whether school can be an effective
setting to promote a healthy lifestyle among children. Specifically,
the present study has been conducted in the tutorial action plan to
examine the multiple effects of this potential component. Know-
ing the isolated effects of the tutorial action plan on a broad range
of health-related behaviours might be particularly useful to con-
sider its inclusion in more complex multicomponent school-based
interventions. To fill these gaps in the literature, this study aimed
to examine the effects of a multicomponent school-based inter-
vention, conducted on the tutorial action plan, on all movement
behaviours (i.e. PA, screen time, and sleep duration), Mediterranean
diet, and health-rated status.
After ten one-hour sessions of a school-based intervention con-
ducted through the tutorial action plan, Spanish children only
experienced significant improvements in Mediterranean diet and
the proportion of active children during the week, but not in other
health-related behaviours self-reported health status. Given that
this programme was only conducted in the tutorial action plan
during the short-term, results can be considered promising. A pre-
vious multicomponent school-based lifestyle intervention found
improvements in all energy balance-related behaviours (i.e. PA,
sleep duration, sedentary time, and [un]healthy diet) among Span-
ish adolescents (Sevil-Serrano et al., 2019). The differences in the
characteristics of these two multicomponent interventions may
explain the differences found between these two school-based
lifestyle interventions. Sevil-Serrano et al. (2019) developed not
only ten sessions in the tutorial action plan but also other curricular
(i.e. an interdisciplinary project-based learning activity and a school
break) and extracurricular activities (i.e. family involvement, com-
munity and extracurricular activities, and dissemination of health
information and sports events) during one academic year. Although
the nature of the multicomponent intervention mentioned did not
allow the determination of which action was more effective, the
authors also suggested that the tutorial action plan was one of
the most effective dimensions (Sevil-Serrano et al., 2019). All of
these results suggest that although the tutorial action plan may
play a key role in improving children’s Mediterranean diet and
PA levels, long-term multicomponent lifestyle interventions that
directly involve the whole school community (i.e. school principals,
school teachers, families, and community members) and several
dimensions (i.e. Physical Education, the school break, interdisci-
plinary projects, active commuting to and from school, after-school
intervention programmes, and tutorial action plans and so on) are
required to obtain additional health benefits. However, the low
costs and extra time associated with the implementation of this
multicomponent intervention and the high feasibility of developing
it among teachers in ‘real settings’ may be a first step in address-
ing school-based lifestyle interventions. Therefore, this study can
provide some effective ‘ingredients’ for the development of more
complex multicomponent school-based healthy interventions.
Delving more deeply into the movement behaviours, exper-
imental group students showed a significant increase in the
proportion of active children during the week than their baseline
values, but not compared to control group students. Given that the
proportion of active children during weekend days in favour of the
control group disappeared after the school-based intervention, it
should be noted that the improvement of PA levels was particu-
larly prominent during weekend days. Although the school-based
intervention was exclusively developed in ten sessions of the tuto-
rial action plan, the fact that in some sessions different activities
and PA goals were proposed for the school break and leisure-time
PA could explain these results.
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Table 1
Descriptive statistics of energy balance-related behaviors and self-rated health of the control and experimental group in pre-and post-test: within-and between-group differences, and interaction effects

Study variables Control group Experimental group Interaction

Pre-test Post-test Pre-test Post-test

M SE M SE Mean Diff. SE p M SE M SE Mean Diff. SE p F p p 2

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PA levels: Wilks’ Lambda = .981; F (3, 114) = .750;
p = .525; p 2 = .019
Weekday PA score (range: 1-5) 3.3a 0.1 3.3a 0.1 0.2 0.9 .856 3.1a 0.1 3.2a 0.1 0.1 0.10 .283 0.43 .509 .004
Weekend day PA score (range: 1-5) 3.3a 0.2 3.1a 0.2 -0.2 0.2 .213 2.6a 0.2 2.7a 0.2 0.1 0.21 .640 1.35 .246 .012
Total PA score per week (range: 1-5) 2.6a 0.1 2.6a 0.1 -0.02 0.1 .722 2.4a 0.06 2.5a 0.2 0.1 0.06 .267 1.08 .299 .009
Sedentary screen time: Wilks’ Lambda = .960, F(8,
109) = 2.422, p = .804, p 2 = .040
Daily screen time (min/day) 265.2a 31.9 270.3a 37.8 3.6 23.8 .881 229.8a 35.1 210.0a 41.5 -19.8 26.66 .460 0.28 .595 .002
Weekday screen time (min/day) 176.5a 30.5 217.9a 38.0 38.7 38.7 .107 158.6a 33.5 153.6a 40.3 -5.00 26.22 .849 0.01 .920 .000
Weekend day screen time (min/day) 487.1a 43.7 401.7a 48.1 -83.9 36.9 .122 407.6a 48.0 350.8a 50.4 -56.9 40.62 .164 0.80 .374 .007
Daily TV viewing (min/day) 73.8a 7.9 71.9a 9.1 -1.9 8.3 .825 75.2a 8.7 73.8a 10.0 -1.3 9.17 .885 0.45 .968 .000
Daily video game playing (min/day) 55.1a 8.1 53.8a 8.8 -1.3 7.4 .860 42.8a 8.9 38.5a 9.7 -4.3 8.17 .603 0.10 .794 .001
6

Daily Internet surfing (min/day) 43.3a 9.1 36.6a 8.3 -6.60 11.7 .568 38.1a 10.0 21.5a 9.1 -16.5 12.7 .212 0.31 .582 .003
Daily mobile phone using (min/day) 31.5a 5.7 37.8a 8.8 6.2 6.3 .321 23.7a 6.3 25.1a 9.7 1.4 6.87 .841 0.26 .610 .002
Daily tablet using (min/ day) 61.7a 9.3 68.2a 10.2 6.5 8.8 .464 50.3a 10.2 49.5a 11.2 0.8 9.72 .932 0.30 .586 .003
Sleep duration: Wilks’ Lambda = .960, F(2,
115) = 2.422, p = .093, p 2 = .040
Daily sleep duration (min/day) 587.0a 6.7 581.0a 7.4 -6.00 7.7 .435 585.1a 7.4 598.1a 8.1 13.0 8.39 .124 2.65 .106 .022
Weekday sleep duration (min/day) 607.5a 13.1 622.9a 12.8 -15.5 13.7 .270 624.3a 14.5 615.6a 12.8 -8.7 15.24 .568 1.31 .253 .011
Weekend day sleep duration (min/day) 592.9a 6.4 593.0a 6.8 0.2 7.3 .980 596.3a 7.0 603.1a 7.5 6.8 8.08 .401 0.35 .552 .003
Adherence to the Mediterranean diet: Wilks’
Lambda = .888, F(16, 102) = 0.801, p = .682,
p 2 = .112
KIDMED Index (0-12) 6.5a 0.3 6.6a 0.3 0.1 0.3 .739 5.2b 0.3 5.9a 0.3 0.7 0.28 < .050 2.63 .108 .022
Self-rated health status: Wilks’ Lambda = .978, F(1,
115) = 2.601, p = .110, p 2 = .022
Health index (range: 1-5) 2.0a 0.1 2.1a 0.1 -0.04 0.1 .706 2.5b 0.1 2.3a 0.1 0.2 0.10 .110 2.01 .158 .017

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Note. SE = Standard error; Diff. = Differences; Between-group differences (control and experimental group) are shown in the Table 1 with different superscripts (a, b) in pre-and post-test, respectively. A mean is significantly
different from another mean if they have different superscript. Interaction effects are shown on the right side.
 M.A. Tapia-Serrano, J. Sevil-Serrano, D. Sánchez-Oliva et al.

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Table 2
Prevalence of energy balance-related behaviors and self-rated health of the control and experimental group (pre-and post-test): within-and between-group differences

Pre-test Post-test Within-group differences

(pre-and post-test)

Control group Experimental 2 V p Control group Experimental 2 V p Control group Experimental

group group group
n (%) n (%) n (%) n (%) p p

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PA
Active during weekdays 49 (74.2%) 40 (72.7%) 0.035(1) .022 .851 51 (77.3%) 40 (72.7%) 0.332(1) .052 .564 .815 .999
Active during weekend days 49 (74.2%) 23 (31.9%) 13.089(1) .329 40 (60.6%) 28 (50.9%) 1.146(1) .097 .284 .124 .405
Active during the week 22 (33.3%) 13 (23.6%) 1.372(1) .106 .241 20 (30.3%) 22 (40.0%) 1.245(1) .101 .265 .832
Sedentary screen time
Meeting screen time recommendations 22 (33.3%) 22 (40%) 0.576(1) .069 .448 30 (45.5%) 26 (47.3%) 0.040(1) .018 .842 .424
(≤ 2 h/day)
Meeting weekday guidelines (≤ 2 h/day) 35 (53.0%) 31 (56.4%) 0.134(1) .033 .714 40 (60.6%) 32 (58.2%) 0.073(1) .025 .787 .332 .999
Meeting weekend day guidelines (≤ 4 (6.1%) 6 (10.9%) 0.930(1) .088 .335 14 (21.2%) 8 (14.5%) 0.896(1) .086 .344 .727
2 h/day)
Meeting TV guidelines (≤ 2 h/day) 54 (81.8%) 43 (78.2%) 0.249(1) .045 .617 56 (84.8%) 43 (78.2%) 0.896(1) .086 .344 .791 .999
7

Meeting video guidelines (≤ 2 h/day) 56 (84.8%) 49 (84.8%) 0.471(1) .062 .493 56 (84.8%) 50 (90.9%) 1.015(1) .092 .314 .999 .999
Meeting Internet guidelines (≤ 2 h/day) 62 (93.9%) 50 (90.9%) 0.400(1) .058 .527 43 (65.2%) 42 (76.4%) 1.804(1) .122 .179
Meeting mobile phone guidelines (≤ 62 (93.9%) 52 (94.5%) 0.020(1) .013 .887 59 (89.4%) 53 (96.4%) 2.117(1) .132 .146 .250 .999
2 h/day)
Meeting tablet guidelines (≤ 2 h/day) 55 (83.3%) 49 (89.1%) 0.824(1) .082 .364 57 (86.4%) 49 (89.1%) 0.205(1) .041 .650 .774 .999
Sleep duration
Meeting sleep duration guidelines 51 (77.3%) 41 (74.5%) 0.122(1) .032 .726 50 (75.8%) 45 (81.8%) 0.653(1) .073 .419 .999 .388
(9-11h/day)
Meeting sleep weekday guidelines 50 (75.8%) 44 (80.0%) 0.311(1) .051 .577 54 (81.8%) 41 (74.5%) 0.941(1) .088 .332 .454 .664
(9-11h/day)
Meeting sleep weekend day guidelines 41 (62.1%) 24 (43.6%) 4.123(1) .042 .185 33 (50.0%) 24 (43.6%) 0.488(1) .063 .485 .201 .999
(9-11h/day)
Adherence to the Mediterranean diet
High adherence to the Mediterranean 24 (36.4%) 7 (12.7%) 8.795(1) .270 23 (34.8%) 14 (25.5%) 1.247(1) .102 .264 .999 .167
diet (≥ 8)

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Self-rated health status
Good, very good, and excellent 20 (30.3%) 29 (53.7%) 6.732(1) .237 22 (33.3%) 23 (41.8%) 0.925(1) .087 .336 .774 .210

Note. Within-group differences (pre-and post-test), in both control group and experimental group, are shown on the right side.
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ARTICLE IN PRESS
M.A. Tapia-Serrano, J. Sevil-Serrano, D. Sánchez-Oliva et al.
Contrary to what was expected, no significant differences in
sedentary screen behaviours and sleep duration were identified
after the intervention. These results suggest that the school-based
lifestyle intervention may not be sufficiently intense or long enough
to change these behaviours. The increase in the number, features,
and applications of screen-based behaviours over the past decade
(Thomas et al., 2019) suggests the difficulty of reducing screen
time among children. The lack of sleep duration differences could
be because three out of four of the experimental group children
met sleep recommendations before the intervention, and a low
number of sessions were mainly focussed on improving sleep
hygiene (see supplementary material 1). Moreover, the fact that
families were not directly involved in this school-based interven-
tion may also explain these results. The influence of family support
on children’s bedtime and screen-based behaviours (Rhodes et al.,
2020), as well as the establishment of rules and routines (Pyper
et al., 2017), has been evidenced in previous studies. These results
suggest the importance of long-term school-based lifestyle inter-
ventions involving parents to help shape health-related behaviours
in their children (Rhodes et al., 2020).
However, our findings suggest that this short-term school-
based lifestyle intervention was particularly effective in improving
Mediterranean diet. These results suggest that although a tutorial
action plan may not be effective for improving some health-related
behaviours, it may play a key role in improving children’s Mediter-
ranean diet. Several explanations can be given for these findings.
One of them might be that two specific lessons were conducted
to address Mediterranean diet (see supplementary material 1) as
opposed to other behaviours. Another possible explanation for our
result may be related to the game carried out since the second ses-
sion of this school-based intervention. A gamification approach was
introduced to improve food intake during school breaks. A recent
systematic review has shown that gamification can be an inno-
vative approach to change nutrition-related behaviour in young
people over the short term (Yoshida-Montezuma et al., 2020).
Finally, in the present study, parents/caregivers were indirectly
involved in the school-based intervention through nutritional chal-
lenges, tip cards, and the food game via their children. Previous
studies have shown parents’ influence on children’s (un)healthy
food consumption (Yee et al., 2017). These results suggest that the
tutorial action plan may also offer the possibility of connecting
indirectly with the families (Sevil-Serrano et al., 2019).
Finally, no differences in self-rated health status were found
in this school-based intervention. The lack of health behaviour
changes may explain that children did not perceive an improve-
ment in their self-rated health status (Grgic et al., 2018). While
discouraging, all these results are consistent with a previous
school-based lifestyle intervention that targeted these four health-
related behaviours among children, which also revealed significant
improvements only in diet quality (Pablos et al., 2018). Therefore,
our results suggest that the improvement in PA levels or Mediter-
ranean diet does not necessarily have a downstream effect on
other health-related behaviours (Olds et al., 2018). These findings
reinforce the importance of long-term school-based interventions
targeting multiple health behaviours simultaneously.
Strengths, limitations, and future directions
In this school-based intervention, several strengths should be
highlighted. First, the two selected schools had similar character-
istics and were far away from each other so as to avoid a contagion
effect of the health-related actions carried out. Second, this is
one of the first school-based interventions that address not only
24-hour movement behaviours but also Mediterranean diet and
health-rated status among children. Third, this is the first school-
based intervention conducted exclusively in the tutorial action
8
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plan to avoid bias in the interpretation of the causal effect of the
intervention. Fourth, although teachers did not implement this
school-based intervention, they participated in the design and were
present in the different sessions. Moreover, a detailed description
of each session of this intervention was given to the tutors (Tapia-
Serrano et al., 2020). It can overcome the main perceived barriers
(e.g. lack of skills and knowledge, lack of training, etc.) to imple-
ment this school-based lifestyle intervention among teachers in
the future (Herlitz et al., 2020).
Several limitations and future directions should also be con-
sidered. First, all children were exclusively recruited from two
elementary schools. Second, a small convenience sample of chil-
dren participated in this study and, therefore, the power of
analysis may have introduced bias. To overcome these two lim-
itations, future school-based randomised controlled trials, using
a representative sample of children of different ages from dif-
ferent schools, are required. Thirdly, health-related behaviours
were measured by self-reported questionnaires. Device-measured
movement behaviours during the whole 24-hour period, as well
as the use of compositional data analysis, will provide informa-
tion of the reallocation of these movement behaviours after the
school-based intervention. Moreover, to prevent risk of type 2,
future studies should also employ qualitative methods such as dis-
cussion groups, one-to-one semi-structured interviews, and field
notes, which also will help to understand the feasibility and accept-
ability of the intervention, as well as the possible barriers and
facilitators of the behaviour changes. Fourthly, only ten one-hour
weekly sessions over two and a half months were implemented
by a research group member through the tutorial action plan. In
futures studies it could be interesting to extend the intervention
period with more health-related sessions. The future development
of this school-based intervention by schoolteachers could ensure
their sustainability. Finally, although in the initial design of this
study three- and six-month follow-up post-intervention assess-
ments were considered, the COVID-19 pandemic did not allow for
the collection of a full data set. Therefore, the lack of follow-up
assessments makes it impossible to examine the changes in health-
related behaviours over time.
Conclusion
Grounded in CAS and SDT frameworks, ten one-hour sessions of
a school-based lifestyle intervention, conducted through the tuto-
rial action plan by a member of a research group, seems effective in
improving children’s adherence to the Mediterranean diet and the
proportion of active children, but not in having a positive impact on
other health-related behaviours and health self-rated status. These
results suggest that although a tutorial action plan may be an inno-
vative way to improve some health-related behaviours, long-term
multicomponent interventions, that involve the whole school com-
munity and different areas, are required to obtain additional health
benefits. However, the low costs and time associated with its imple-
mentation and the high feasibility of developing it among teachers
may be a first step to address complex school-based healthy inter-
ventions.
Funding
This study was funded by the European Community and Min-
istry of Economy of Extremadura (IB16193) and FEDER, FSE and
Govern of Extremadura, grant numbers GR18102 and TA18027.
M.A.T-S is supported by the Ministry of Economy and Infrastruc-
tures of Extremadura (PD18015).
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M.A. Tapia-Serrano, J. Sevil-Serrano, D. Sánchez-Oliva et al.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Acknowledgments
The authors wish to thank the schools, children, and their par-
ents who, generously, volunteered to participate in the study. We
also thank the reviewers and the editor for the corrections and
suggestions for improvements made during the review process,
which have contributed significantly to improving the quality of
the manuscript.
Appendix A. Supplementary data
Supplementary material related to this article can be
found, in the online version, at:https://doi.org/10.1016/j.
psicoe.2021.06.001.
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