The Covid-19 pandemic has changed children’s eating and physical activity behaviours. These changes have been positive for some households and negative for others, revealing health inequalities that have ramifications for childhood obesity. This study investigates the pandemic’s impact on families of children aged 2–6 years with overweight or obesity.n = 70, representing 68 families) were interviewed twice during a period of 6 months in three countries with markedly different pandemic policies – Sweden, Romania, and Spain. The analysis is informed by Bronfenbrenner’s ecological systems theory, which embeds home- and school-based influences within societal and policy contexts.Drawing on interviews conducted as part of a randomised controlled trial (RCT) for childhood obesity, thematic analysis was used to examine how parents of pre-schoolers perceived changes in their eating, screentime and physical activity behaviours between the first and second waves of Covid-19. Parents (The findings show that, although all participants were recruited from an RCT for families of children with excess weight, they reported different responses to the pandemic’s second wave, with some children engaging in healthier eating and physical activity, and others engaging in comfort eating and a more sedentary lifestyle. Differences in children’s obesity-related behaviours were closely related to differences in parents’ practices, which were, in turn, linked to their emotional and social wellbeing. Notably, across all sites, parents’ feeding and physical activity facilitation practices, as well as their emotional and social wellbeing, were embedded in household resilience. In resilient households, where parents had secure housing and employment, they were better able to adapt to the challenges posed by the pandemic, whereas parents who experienced household insecurity found it more difficult to cope.As the Covid-19 pandemic is turning into a long-term public health challenge, studies that address household resilience are crucial for developing effective prevention and treatment responses to childhood obesity.The online version contains supplementary material available at 10.1186/s12889-022-13351-1. In 2020, as the Covid-19 pandemic spread around the world and governments reacted with lockdowns and school closures, researchers cautioned that this global crisis could lead to the exacerbation of an existing public health challenge – childhood obesity . The panTo understand why the Covid-19 pandemic has had a complex impact on children’s eating and physical activity, we frame this study through Bronfenbrenner’s ecological systems theory , 11. ThrIn this study, we examine how parents of preschool-aged children with obesity perceived changes in their eating, screen time and physical activity behaviours between the first and second waves of Covid-19 in three countries – Sweden, Romania, and Spain. This multinational design allows us to investigate whether different macro level contexts and policies have led to diverging manifestations of behaviour change in these households, and thereby highlight how the various components of children’s ecologies have interacted to produce obesogenic or protective behaviours during the pandemic. To our knowledge, this is the first study that attends to obesity-related behaviour changes between the first and second Covid-19 pandemic waves, while also accounting for changes in national policies and in household routines and capabilities.The participants were parents recruited to a three-site randomised controlled trial (RCT) of an early childhood obesity intervention, conducted in Stockholm (Sweden), Timisoara (Romania), and Mallorca (Spain). The design of the RCT has been described previously . In brieThe interview guide was developed by the Swedish team under the supervision of KE. Interview questions were designed to allow the interviewed parents to describe how the pandemic affected them, the child, and the entire family. The questions captured pandemic-related disruptions in routines and treatment, for example: “How has the Coronavirus pandemic affected your family’s everyday life? Do you see any differences in your child? If so, can you describe these differences? Can you tell me about an activity you did with your child around food  that is different now compared to how it was before the pandemic?” For the full interview guide, please refer to supplementary file The Wave 1 interview data were analysed using inductive thematic analysis , with a When the interim analysis of the Wave 1 was complete, Europe was entering the second wave of the Covid-19 pandemic, heralding public health policy shifts and potential new challenges for the participating families. From September 2020, the RCT was conducted mostly online due to the pandemic. And by November 2020, about 6 months after our initial data collection, Romania, Spain, and Sweden had begun lockdowns of varying extents, ranging from a lockdown with school closure in Romania, to lockdowns where schools remained open in Spain and Sweden. In all three countries, children with any potentially Covid-related symptoms were subject to self-isolation restrictions, and indoor gatherings (such as in sports facilities) were limited. Whereas in Sweden, which remained open during Wave 1, the Wave 2 lockdown introduced new restrictions, in both Romania and Spain, the Wave 2 lockdowns were more flexible than the Wave 1 lockdowns, which featured strict restrictions on leaving the home, with police enforcement.Recognizing that the pandemic was a dynamic and long-term event, we decided our study should take a long view of obesity-related changes, and account for shifts between pandemic waves and how these might have affected the participating families. We therefore developed a follow-up study, with new interview questions about place of residence and work situation, reflecting the insights we gained from the interim analysis of the Wave 1 data. We also included questions similar to the ones we asked in the Wave 1 interviews, but these were designed to take the interviewees’ Wave 1 responses into account . Is this still the same or have you seen any change?”). We contacted all 78 families who participated in the Wave 1 interviews and asked if they would agree to take part in the follow-up interviews. Sixty-eight families  were interviewed again in November–December 2020: 23 families  in Romania, 25  in Spain and 20  in Sweden. All participants who took part in the Wave 2 interviews had also taken part in the Wave 1 interviews.Data collected at baseline and follow-up were used to describe the population and to calculate child weight status at the time for the interviews. All participating families had filled out questionnaires regarding family background . To describe the children’s weight status development between the interviews, available measurements on children’s weight and height within 4 months (pre or post) of the interviews were used. Children’s weight status (mean BMI z-scores) was derived using age and gender specific reference data . Child BThe study was approved by the Ethics Committee of Scientific Research in University of Medicine and Pharmacy “Victor Babes”, Timisoara, Romania, October 31st, 2018 (25/31.10.2018), the Balearic Islands Ethics Committee, Mallorca, Spain, February 13th, 2019 (IB 3814/18 PI), and the Research Ethics Committee, Stockholm, Sweden, December 11th, 2018 (2018/2082–31/1). All parents/caregivers provided written informed consent for participation in the RCT, including consent to participate in a voluntary recorded interview. In both the Wave 1 and Wave 2 interview studies, all participating parents/caregivers, in addition to the written consent, were asked to provide an oral informed consent on record before the interview started.The Wave 2 interview data were analysed in two stages. First, in each of the study sites, a local researcher  familiarised herself with the data, and then wrote an informal summary of the interview responses; this ensured that researchers were not entirely led by the template provided by the Wave 1 coding table. Each of the researchers then worked with the Wave 1 coding table, for a guided thematic analysis  that maiHow have children’s obesity-related behaviours, as perceived by parents, changed between the first wave and the second?How have parents’ practices changed  between the first wave and the second?From an ecological perspective, why have these changes occurred?In the second stage of the analysis, KE reviewed the Wave two summaries and code tables  and tabulated the findings ecologically, case-by-case, using Excel. This process was guided by three key questions:Identify what changed in the three key obesity-related behaviours  and in parents’ practices related to these behaviours;Identify what other changes occurred in these families’ lives  in relation to macro-level processes ;Identify which changes were directly related by participating parents to their children’s obesity-related behaviours (e.g. school opened so the child is more active);Draw connections between other changes, which parents did not directly relate to their children’s eating, physical activity or screen time, and changes in obesity-related behaviours.The ecological tabulation highlighted the micro , meso (relationships between these systems), exo (changes parents experienced that did not directly relate to the children), and macro (policy and socioeconomic conditions) levels, with the following objectives:The sample’s characteristics are described in Table n = 78) were on average 5.5 years old at the time for the first interview. Among the children with parents who were interviewed twice, 59 children had valid measures at the time of the first Interview; 2% (n = 1) were classified as having a normal weight, 15% (n = 9) overweight, 39% (n = 23) obesity and 44% (n = 26) severe obesity. At the time for the second interview, 58 children had valid measures; 5% (n = 2) were classified as having a normal weight, 14% (n = 8) overweight, 33% (n = 19) obesity and 50% (n = 29) severe obesity. Child weight status body mass index (BMI) z-score was 3.1 at the time for the first interview and 3.0 at the time for the second interview and mean change in weight status was − 0.06 between the two interviews. How long families had participated in the study differed at the time of the interviews; thus, the timepoints when child weight status was measured differed as well , 68 families were interviewed twice. More fathers were interviewed in the Swedish sample and more of the Swedish families had a foreign background  as compared to both Romania and Spain. In the total sample, the mean age of mothers was 38.4 years, 32% were born abroad, 53% had a university degree, and 27, 43, and 31% were classified as having a normal weight, overweight, and obesity or severe obesity, respectively. For fathers, the mean age was 41.0 years, 28% were born abroad, 39% had a university degree, and 14, 39 and 47% were classified as having a normal weight, overweight, and obesity or severe obesity, respectively. The children  followed a four-digit number, where the first digit represents country of interview  and the last three represent the participant’s ID.Four themes were developed through qualitative longitudinal analysis: (1) Children’s diverging directions of behaviour change; (2) Parents’ responses to the pandemic; (3) Emotional and social resources; (4) Household resilience.The activity has increased because they do physical education at school, but before the pandemic, [the child] used to go dancing twice a week and we have not done this again. (M3001)My child no longer has that vitality of children… usually they run, scream; she is much quieter, more lazy, she got used to sitting at school, doing homework and so on, not doing much effort. (M2014)Somehow, she seems to play more by herself and is playing with her sister… she has a little sister who is almost two years old, so then it became interesting to play with her. Another thing, I think she has lost weight, so now she has more energy to run and jump and has more energy, not just sit and watch [the screen]. (M1068)Similarly divergent accounts arose in response to questions about children’s food choices and eating behaviours. Many parents, like this mother from Spain, reported their children engaged in emotional eating:She is more anxious and wants to eat at all hours, but I have been able to introduce more fruit and new foods, for example, turkey. (M3051)Some parents, however, reported no change in children’s lifestyles and habits between the first and the second waves, while others said their children’s eating improved. For example, a mother from Sweden (M1005) said her son had learned to recognize satiety and was less preoccupied with food.Across the three study sites, parents’ reports about children’s obesity-related behaviours diverged markedly. While some children experienced positive changes between the first and the second pandemic waves, others experienced negative changes. For example, when asked about their children’s physical activity, the following three mothers offered substantially different responses – whereas a mother from Spain said her child was more physically active than during lockdown but less active than before the pandemic, a mother from Romania said her daughter grew used to sedentary behaviours, and a mother from Sweden said her child’s interest in physical activity increased, though this was related to her growing up, rather than to the pandemic:The time spent in front of the screens is considerably more. But what I can say is that, since he attends online school, he seems to have developed a bit of a repulsion [towards the tablet] (…). He doesn’t spend that much time with the tablet anymore. (M2003)Screen time behaviours likewise differed between families. The great majority of Spanish parents reported their children engaged in less screen time compared to the first wave, due to the opening of schools and the closure of online education. However, some parents in the Swedish and Romanian samples said their children increased their use of screens, albeit for different reasons. A father from Sweden (F1071) said his children engaged in less screen time, because of other activities at home like reading and playing, implying that screen time reduction was directly related to the increase in home-based leisure activities. In contrast, a mother from Romania said her child engaged in more screen time due to online school, but that he chose to spend his playtime engaged in other activities:We try to avoid white bread, and homemade bread, because last spring, we started making bread at home and it smelled all over the house and she was eating almost the entire bread core on her own. (M2014)Changes in children’s obesity-related behaviours, particularly eating and physical activity, were linked to changes in how parents responded to the challenges presented by the pandemic and their children’s reactions to these challenges. Across the three study sites, parents reported diverging responses. As mentioned in Theme 1, many of the parents said their children craved comfort foods and asked for treats. However, their responses differed. For example, one mother from Romania, who said her daughter gained weight due to stress, eating and snacking, responded by ending home baking:In contrast, a mother from Sweden (M1026), who said her daughter wanted treats and acted out if she did not receive food, responded by increasing home cooking. She said that working from home enabled her to “cook between some meetings, between some jobs you have to do, you start a bolognaise, you start something in the oven, so that it’s ready for the evening. So, it’s much more homemade food [served in the home]”. It also allowed her to collect her children from school earlier, meaning that they did “not have to wait around and be hungry”.It is very hard to handle. He has constant cravings for something [to eat]. And all the time we have to check what he wants. And I really try to avoid sweets as much as possible, but, you know, the days are long, morning to night and all the time… There's been some candy here and there and salty snacks here and some popcorn there, just to keep him sitting still for a bit. (M1063)Whereas parents’ main challenge in regulating children’s eating behaviours was in responding to their increased appetites and desire for comfort foods, their main challenge in facilitating physical activity was finding creative solutions when faced with the closure of schools and indoor sports facilities. For parents in the Swedish subsample, this was a particular challenge as the closure of sports facilities was introduced in the second wave. This proved to be a barrier to some activities, as one mother (M1051) explained, her child took up swimming instead of football, but could not progress to an intermediate swimming class as all indoor public pools had closed. Some parents mitigated these barriers by facilitating alternative physical activity outdoors. For example, one father (F1066) said, “we try to be outdoors with them as much as before. It is [now] usually calmer in the playgrounds…”, while a mother said she and her partner took turns going outside with the children to facilitate their activity:…we still walk to the school and back, or ride a bike or a kick-bike or something like that and I think that because both I and (partner's name) work from home, we also have a great need to get out on the weekends. So maybe we are out a little more due to Corona because you feel like you have a need to be outside more. … And when one parent sits and does homework with (one child), the other (parent) tries as a routine to do some physical activity with (the other child), go out and kick a ball, or throw a frisbee or something like that. (M1005)Other parents said they ‘gave in’ to their children’s food demands, rather than negotiating or regulating them. This was often linked to expressions of overwhelming stress. A mother from Sweden, whose son was self-isolating with cold symptoms, said her son was constantly asking her for food, and explained she did not have the energy to resist:We have a neighbour who is sick or so, I think it's mentally, because when (child's name) moves around a little, or runs, [then] she [the neighbour] knocks on the ceiling all the time, so we try to walk slowly or just sit, do something that doesn’t involve moving around as much…. even when we are in the yard she shouts, shouts at them “Can you be quiet!” (M1030)Having no access to yards made encouraging children’s physical activity particularly problematic. A father (F1064) said he felt guilty for not facilitating children’s activities at home, particularly since his daughter had to quit dancing and he could not take the children swimming due to his vulnerability to Covid.Additionally, for this mother, as for other parents who lived in houses, access to backyards was an important element of facilitating physical activity at home. This, however, was impossible for parents who lived in flats, even where there was access to shared courtyards. One mother described the difficulties she faced when trying to facilitate her son’s physical activity inside their flat as well as in the courtyard:In August, September and at the beginning of October, I took him swimming outdoors. But as time went on, it became too cold, they [the coaches] could no longer make the children swim in the pool outside. They did not have access to a space, so they were exercising outside, as much as possible. Finally, they received a room [for indoor exercises]. He went there for a while, but the coaches and probably also the parents were not satisfied, only doing these strength exercises, push-ups, knee bends, running... so they decided to move again. I couldn't take him there, we don't have a car. Before, one of the coaches who lived in the area, was coming to take him to swim. I went with him for a few weeks, but then I couldn't, it was too difficult for me. (GM2012)In Romania and Spain, where restrictions on physical activity had eased from the first to the second wave, parents described differently how they facilitated physical activity. In the Spanish subsample, most parents focused on the availability of gardens and yards as enabling physical activity during the first wave’s lockdown, with many saying that after lockdown the yard diminished in importance as their children became more active at school and elsewhere. However, few parents spoke directly about facilitating their children’s physical activity  beyond providing them access to an outdoors space, whether domestic (yard) or public (playground). This might have reflected weather-related differences between the sites: whereas in Sweden and Romania parents spoke about the challenges of facilitating physical activity in cold winter weather, this was not a concern in the Spanish sample. In the Romanian subsample, parents emphasized the renewed importance of yards, with the second wave’s closure of schools and sports facilities; accordingly, parents who lived in apartment buildings said they felt disadvantaged. Parents also described trying to find replacements for indoor sports and school-based physical education. This, however, proved challenging in cold weather, as one grandmother described:Changes in parents’ facilitation of healthy eating and physical activity were nested in the household’s emotional and social environment. Across the study sites, parents who described pandemic measures in positive terms – for example, as allowing more time for family, and reducing job and commuting stress – also tended to describe handling their children’s eating and physical activity with greater ease. Similarly, parents who described the pandemic and/or pandemic measures in negative terms – for example, as leaving them feeling isolated, overwhelmed with stress, or anxious about infection – also tended to describe difficulties in handling their children’s eating and physical activity.I think we are closer to each other, in the sense that we do family meetings, as my child likes to say, she comes to us very often, she just wants to talk to us, not necessarily that something happened, or that there is a problem in her life, but simply socializing and debating certain things. (M2014)A frequent source of both joy and conflict was the intense togetherness of the household ‘bubble’. Many parents described spending more time together with their children due to working from home, being placed on furlough, or becoming unemployed, combined with school closures and/or self-isolation measures. Some parents said this newfound family togetherness allowed them to develop stronger emotional bonds with their children, while others described it as stressful. One mother from Romania explained that the advantages and disadvantages of forced togetherness could coexist. The lockdown, she said, enhanced the family’s sense of closeness, as both parents worked from home:It is not easy to stay non-stop with the child at home, neither for the child, nor for the adults; at a certain moment my little girl said to me ‘mother I am tired of you, I love you madly, but I am tired of you, I want to do something else’.” (M2014)For this mother, as for others, the stress of intense togetherness was connected to a sense of social isolation.Our family life has been greatly affected in several aspects: emotional, eating behaviour and many others. We got isolated. We didn’t interact with others physically; we have just stayed in the family. We struggle with the online school, we aren’t going anywhere. (M2014)At the same time, this mother also found the unrelenting socializing with her daughter difficult:Many parents reported they missed socializing with their family and friends; they also reported their children missed their classmates and grandparents. For some parents, this meant making the decision to socialize, despite pandemic restrictions, while other parents waited for the easing of restrictions. Across the sample, parents considered renewed socializing, and particularly the re-entry of grandparents into their families’ lives, an important means of improving their own and their children’s wellbeing.It was hard for me to distribute time; to make cards for kindergarten [as a teacher]… to be a farmer and a cook [for my family]... (M2035)Another aspect of the household ‘bubble’ was the increased pressure on parents, and particularly mothers, to perform as employees, educators, and caregivers. This was particularly an issue in Romania, where schools had closed again with the second wave, as described by one mother:However, even in Sweden, where schools remained open, and in Spain, where schools reopened after the first wave’s lockdown, parents described being stressed over the prospect of their child having to self-isolate due to Covid symptoms or after being in contact with an infected friend. Because many parents continued working from home, this meant that their workday could be interrupted at a moment’s notice, as captured in the following quotes by a mother from Spain and a father from Sweden, respectively:Interviewer: What is the biggest change your family has experienced since we last spoke?Participant: The fact of not being able to commit to a job or to people in case the girls have to self-isolate due to some contagion at school. (M3007)… so, we [have] two children going to preschool, they are sent home, then I have to stay home, then in March and May, I think I was more at home than at work. (F1064)Family support was key to managing these uncertainties. As a mother from Sweden described, sharing parenting responsibilities allowed her to navigate the children’s self-isolation periods:In preschool they are stricter than normal [requiring self-isolation] with a few symptoms [of Covid]. (…) it gets a little harder, but because we share with my husband, he is also at home, then it works. It is possible that you are a little stressed for half the day, but the other half it is a little calmer when he is with [the children]. (M1068)Beyond the day-to-day stresses of parenting in a pandemic without social support, parents expressed stress and uncertainty about the future. A mother from Sweden (M1026) said her daughter worried she may never see her grandparents again. Others, including a mother (M1030) and a father (F1071) from Sweden and a mother from Spain (M3011), worried they or their clinically vulnerable children might become infected with Covid. And still others were worried life may never be the same again. As one father from Sweden, weary of facing the unknown, asked:For how long will this continue? (F1005)Parents’ approaches to managing their children’s eating and physical activity, as well as their experiences of emotional and social wellbeing or distress, were closely linked with pandemic-related regulations. Restrictions on socializing, school, and sports facilities closures and reopenings, self-isolation measures, home working and furlough all had an impact on how households negotiated the pandemic. However, the resources and responses parents described when facing these macro-level changes were ultimately linked to household resilience. Across the three study sites, parents whose households faced insecurity, particularly in the form of potential or actual job loss, were most affected by the changes in pandemic-related regulations.It influences in a positive way. Because this way we all spend more time together, the family environment is much better, we go out together and do everything as a family. On the subject of food, I am still in control. (M3051)Going back to the parents whose quotes were introduced in the first three themes, their reported experiences can be contextualized within insecurity and resilience. A mother from Spain, who reported that her child was craving more food, also said she managed these cravings by providing him fruit and new foods. With her husband now working from home, and with her own work as a stay-at-home mother, she felt that they were able to spend more time together and be more relaxed:… now we are home for long days, he is whiny, he wants to go to kindergarten, he cannot. So, it's really hard. So, he asks for something to eat, right… I try to avoid as much as possible, but some days, it gets too annoying, and I do [give in]. No. And I don’t have the energy. (M1063)In contrast, a mother from Sweden, who was on sick leave and whose husband worked 13-hour days outside the home, said she felt too overwhelmed to negotiate her son’s food cravings:Similarly, a mother from Sweden (M1005) who worked at home with her husband and found this arrangement less stressful than before the pandemic, found it easy to facilitate her child’s physical activity, whereas a father from Sweden (F1064), who was clinically vulnerable and anxious about potentially losing his job, felt it was impossible for him to pursue physical activity opportunities for his children.This study is the first to explore parents’ perceptions of changes in their children’s eating, physical activity, and screen time behaviours between the first two waves of the Covid-19 pandemic in Europe. Using an ecological approach, we analysed interviews with parents of preschool-age children with obesity in Spain, Romania, and Sweden. Our analysis found that, across the three study sites, parents’ reports about changes in children’s obesity-related behaviours diverged markedly. Although all children began the study with overweight or obesity, they experienced the pandemic differently, with some engaging in healthier eating and physical activity, and others engaging in comfort eating and a more sedentary lifestyle. These differences in children’s behaviours were closely related to differences in parents’ feeding and activity facilitation practices. Some parents reported feeling overwhelmed and unable to negotiate the challenges posed by the pandemic and their children’s responses to it, whereas others described successful strategies that helped their children practice healthy eating and become more physically active. Importantly, parents who reported greater emotional and social distress, as a result of the pandemic, also said they found it difficult to manage their children’s eating and activity, while those who described pandemic measures as positively impacting on their stress levels  also described healthy feeding and activity as easier. The intersection of feeding and physical activity facilitation with emotional and social resources was further embedded in overall household resilience. Parents who had secure employment and financial/housing resources were better able to adapt to the challenges posed by the pandemic. In contrast, parents who experienced job insecurity – in many cases, due to the pandemic – found it difficult to cope with eating- and activity-related changes. In a number of cases, this socioeconomic vulnerability was compounded by clinical vulnerability to Covid-19, leading to feelings of anxiety and chronic stress. This finding was consistent across the three study sites, suggesting that household resilience is central to children’s healthy eating and physical activity, regardless of differences in policy responses to the pandemic. Thus, although policy – such as the closure of schools and sports facilities – made a difference, how families adapted to it depended on the emotional and material resources they had.Our finding that parents’ emotional and social resources were linked to their capacity to facilitate children’s healthy eating and physical activity is consistent with the family ecology literature on childhood obesity. This literature, which has investigated how family contexts interact with community, organisational, and other contexts in childhood obesity, has found that parents who experience chronic stress and lack of social support have reduced ability to support their children in adopting healthy eating, physical activity and screen time behaviours . Along sA key contribution of our study is the finding that household resilience was closely related to how families adapted to the Covid-19 pandemic and its food- and activity-related consequences. The childhood obesity literature has emphasized family resilience – e.g., family structure, coherence, and routines – as central in mitigating the impact of adverse childhood experiences and environmental stressors on children’s weight status –22. Our The findings suggest that, as childhood obesity treatment programs adapt to the Covid-19 pandemic, the advice provided to parents should take into account differences between the capabilities of households in responding to the challenges posed by the pandemic and policy measures that address it. Although SES is a key factor in childhood obesity, how SES influences families’ willingness and ability to engage in treatment is rarely measured , 30. TreThe study has several notable strengths. The sample was drawn from an international RCT for the families of young children with weight excess, allowing us to focus on families whose children had similar weight status. At the same time, by recruiting participants from three countries with different Covid-19 pandemic responses, the study could address how policy might account for potential differences in the experiences of families with children with obesity. Moreover, the high participant response rate in both the Wave 1 and Wave 2 interviews and the low dropout rate, with 68 families participating in both interviews, meant that the sample was diverse, including parents from different socioeconomic groups, thereby enabling an analysis of participants’ responses in light of differences between households. In addition, the study’s follow-up design allowed us to adapt the interview questions to each individual participant, thereby increasing the relevance and continuity of data collection between the Wave 1 and Wave 2 interviews. The study had some limitations. By necessity, the study was limited by its focus on parents’ perceptions, and we cannot be sure that what parents reported reflected accurately what happened in practice. An additional limitation was the study’s focus on parents who had enrolled in a childhood obesity RCT, as their perceptions may differ from those of parents whose children have obesity but who have not enrolled in treatment. Finally, as in the majority of studies on childhood obesity, mothers greatly outnumbered fathers. Recent research on family treatment for childhood obesity has suggested that fathers’ and mothers’ experiences of and responses to obesity treatment may differ in important ways . AlthougUsing an ecological approach, this study was the first to explore how parents perceived changes in their children’s eating, physical activity and screen time behaviours between the first two waves of the Covid-19 pandemic in Romania, Spain and Sweden. The study found that, although all participants were recruited from an RCT for families of children with obesity, they reported markedly different responses to the second wave of the pandemic, with some children engaging in healthier eating and physical activity, and others engaging in comfort eating and a more sedentary lifestyle. Notably, differences in children’s obesity-related behaviours were closely related to differences in parents’ feeding and physical activity facilitation practices, which were, in turn, linked to parents’ emotional and social wellbeing. Moreover, across all study sites, despite differences in national policy, parents’ feeding, and physical activity facilitation practices as well as their emotional and social wellbeing were embedded in household resilience. In resilient households, where parents had secure housing and employment, they were better able to adapt to the challenges posed by the pandemic and the policy responses to it, whereas parents who experienced household insecurity found it more difficult to cope. As the Covid-19 pandemic is turning into a long-term public health challenge, studies such as ours are crucial for developing effective prevention and treatment responses in the childhood obesity field.Additional file 1.


Research about using physical activity (PA) to improve health, quality of life, and participation after moderate-to-severe traumatic brain injury (TBI) is receiving growing attention. However, best-practices for maintaining PA participation after TBI have yet to be defined. In this context, a team of researchers and stakeholders with a moderate-to-severe TBI (including program participants and peer mentors) participated in a co-creation process to optimize a 9-month, 3-phased, community-based, adapted PA program named TBI-Health.The study aimed to provide a detailed account of the participation in and co-creation of a new TBI-Health Program to enhance sport and exercise participation for adults with moderate-to-severe TBI. Specifically, we carried out an in-depth exploration of the perceived experiences and outcomes of users over one cycle of the program to assist the co-creation process.n = 10; peer mentors n = 4) were involved in audio-recorded focus groups after each program phase. Reflexive thematic analyses within and across the phases identified three higher-order themes.An interpretive case study approach was used to explore the experiences and outcomes of the participatory co-creation within and across phases of the TBI-Health program. A purposeful sample of fourteen adults with moderate-to-severe TBI (program participants Program Participation included barriers, facilitators, sources of motivation and suggested modifications to optimize the program; Biopsychosocial Changes highlighted perceived physical, psychological, and social outcomes, by self and others, that resulted from program participation; PA Autonomy emphasized transitions in knowledge, sex- and gender-related beliefs, and abilities related to exercise and sport participation.Study findings suggest the TBI-Health program can increase autonomy for and reduce barriers to PA for adults with moderate-to-severe TBI, which results in increased PA participation and important physical, psychological, and social benefits. More research is needed about the TBI-Health program with larger samples. Research about using physical activity (PA) to improve long-term problems  after moderate-to-severe traumatic brain injury (TBI) has received growing attention –3 and suTaking a participatory approach to modifying a PA- and nutrition-based program for the TBI community has been documented in previous research. For instance, consulting with an advisory committee of key stakeholders helped specifically tailor the content and delivery of an evidence-based diabetes prevention program for adults with moderate-to-severe TBI . A 10-meTBI-Health program to enhance sport and exercise participation for adults with moderate-to-severe TBI. Specifically, we carried out an in-depth exploration of the perceived experiences and outcomes of program users and peer mentors over one 9-month cycle of the program and co-creation process.In a similar participatory context, a team of researchers, community stakeholders, and persons with moderate-to-severe TBI (including program participants and peer mentors) collaborated for the purpose of optimizing a 9-month, 3-phased, community-based PA program named TBI-Health. The grass-roots initiative was first established in response to a need for PA support in the community after moderate-to-severe TBI  and was safely in a smaller machine-based section of the gym, (2) independently in the larger free-weight and machine-based section of the gym, and (3) for a sport challenge on an outdoor walking trail near the gym.The third iteration of the TBI-Health program discussed here See  was firsGroup-based exercises and instruction during TBI-Health were delivered by the PI, a certified personal trainer at the YMCA. In phase one (weeks 1–12), group programs took a generic approach to prescribing 10–15 min of warming up on cardiovascular machines, before completing 8–10 resistance training exercises (2–3 sets of 12–15 repetitions) on major muscle groups of the body for 45–60 min in a smaller gym located on the second floor of the YMCA Center. The sessions always finished with body-weight exercises for the core muscle groups and stretching to cool down in a studio for 20–30 min.Phase two (weeks 13–24) followed the same approach but took place in a larger gym with more equipment, located on the third floor of the YMCA Center. Similar programs were provided to the participants through mobile fitness applications, which they accessed on their personal mobile devices. In phase three (weeks 25–36), participants continued their individual programs on the third floor in addition to following a progressive run/walk program to prepare for a community organized, 5-kilometer (k) sport challenge on an outdoor walking trail near the YMCA. Exercises across phases were modified for participants with mobility limitations from an ability perspective . Participants were also encouraged to exercise at the center outside program hours, but adherence was measured by program attendance. Motivational strategies were regularly provided in the form of positive encouragement by the PI and peer mentors (past participants from the program).The starting level for cardiovascular and resistance training exercise was established by the participants, while supervised by the PI, based on their perceived rate of exertion. Subsequent progressions were guided by incremental increases in time and intensity of approximately 10% per week. There was no home program component, but non-exercise components included social activities organized between members and a social media page that facilitated discussions between past/present participants in the program. The PI kept a written log about participants' involvement, fidelity, and attendance during sessions, in addition to any adverse events.Supplementary File S1; The study was guided by participatory and interpretive case study methods to provide a multi-faceted exploration of a particular case over time through an in-depth collection of multiple sources of evidence in a real-life context , 16. TheTBI-Health program. Eligible participants (1) were at least 18 years of age, (2) lived with a moderate-to-severe TBI, (3) and were able to speak English or French. Exclusion criteria were (1) not being able to safely participate in general forms of PA, (2) having a heart, blood, or respiratory conditioning that could be worsened through PA, and (3) not being an in-or out-patient in a rehabilitation hospital center. Recruitment was facilitated by the Montreal-based Quebec TBI Association, based on their members’ medical records, which were kept on file. Program participants included six new  and four returning members , in addition to four peer mentors . One participant was partially hemiplegic, two participants used a walking cane, and another wore an ankle brace. All participants could communicate effectively and had sufficient cognitive ability to understand program instructions and travel independently to and from the YMCA. Peer mentors were past participants onboarded as YMCA volunteers to help run the program as expert members and positive role models for the others. Demographic characteristics of the 17 participants are included  were recruited to participate and contribute to the new uded See . Study pThe process of co-creation (involving capturing participant experiences) was conducted over 9-months of program delivery through participatory work groups, focus groups, and field note observations. Whereas the nine monthly participatory workgroups tailored the content and delivery of each phase as it was being delivered, the focus groups at the end of each 3-month phase reflected the perceived experiences of all the participants involved See .In addition to their leadership roles with the program, the four peer mentors collaborated with the research team through nine work groups, lasting approximately 60 min each, in a private office at the YMCA with the PI and a senior member of the research team (BS/SW). Work groups were structured with five guiding questions about how (1) the program was running, (2) the group was responding, (3) program components should be modified, (4) the mentors’ responsibilities should be defined, and (5) they would self-rate their contribution to the development of the program in each meeting on a scale from 1 to 10 . Individual responses to the questions in the work groups were recorded in written text, with a pen, on paperback journals assigned to each one of the mentors. Data from these sessions were not analyzed, but rather integrated within the modules and delivery of the program as it was being offered .Program participants and peer mentors were involved in audio-recorded 60–90-minute semi-structured focus groups at three time points across the 9-month program, approximately three months apart, after each respective phase of the program. Focus groups took place in a private studio at the YMCA and were divided in two sections to accommodate the number of people and provide the opportunity to discuss individual and shared experiences . They were led by the PI, who had previous experience interviewing adults with moderate-to-severe TBI , and a sThe semi-structured question guide and probes for the focus groups were based on a question guide developed with the multidisciplinary team's expertise and piloted with past participants for optimal length and prompts. The questions focused on gathering perceptions about (a) experiences, including program impacts and sex and gender considerations; (b) positive/negative aspects of each phase of the program, including what was successful, challenging, and required modification; and (c) any personal changes that had occurred in that phase, in relation to their capabilities, opportunities, and motivations. Interview questions across the three time points were the same to achieve conceptual depth about the peer mentors and program participants’ experiences and outcomes in the participatory co-creation process.The PI supervised the TBI-Health program two days per week over a period of nine months for a total of 72 of the 75 program sessions (∼108 h). He was involved as a program coordinator to onboard, guide, and monitor the participants throughout the different phases of the program, but also maintained the role of participant observer throughout the 90-minute program sessions. As an observer, he walked around and spoke with participants to note his perceptions of their behaviors and gain entry to their everyday program experiences. During and after program sessions, the PI typed these observation and field note entries in a personal journal on his laptop computer, along with preliminary interpretations about his perceptions. The PI maintained similar field notes before and after each one of the participatory work groups and audio-recorded focus groups, to document contextual information about the meetings and his possible influence on participants in his dual role as PI and program coordinator.Braun and Clarke's  reflexivwithin phases, before developing inter-analysis themes across phases. The first step of this analysis involved becoming familiar with the data by reading and re-reading transcripts, while taking notes about initial ideas. In the second step, a codebook was generated using the qualitative analysis software (NVivo 12). Once all segments were coded, the RA met with the PI to carefully discuss and revise the codes, and ensure they accurately represented the semantic content. In third step, the RA began collating the codes into potential sub-themes within each phase, while maintaining consistent language to help identify similarities and differences across cases.To capture the perceived changes about the participants’ perceptions over time, the analysis team determined that pooling the data and systematically coding by phase of the program would facilitate the interpretive goal of generating intra-analysis themes fourth step, the RA, PI, and Co-Is worked closely through an iterative process of critically reviewing the sub-themes to ensure they accurately represented the coded extracts within each phase and the larger data set, in addition to discussing the direction of analysis, and guiding research question. The fifth step involved refining the similarities and differences of sub-themes, within and then across the phases, which revealed the types of changes that were occurring over time. Sub-themes identified from the intra-analyses within each phase were reviewed and defined before themes were identified from the inter-analyses across phases.For the sixth step involved producing a graphic report of the intra- and inter-analysis process (Supplementary File S2), as well as compiling vivid and compelling extracts relating back to the research question. In this final step, the analysis team critically reviewed every step of the process, ensuring that each intra-phase sub-theme did not belong to a different inter-phase theme, by asking whether the sub-theme itself was problematic or needed to be re-named. The analysis was finalized by reviewing the final themes in relation to the data set and the research question to ensure that the overall story of analysis was reflected within the report. Included quotes were translated by a professional translator , with no prior connection to the participants.The final Ongoing methods were upheld to ensure the qualitative rigor of this study , 22, sucProgram Participation, Biopsychosocial Changes, and PA Autonomy) were generated from the inter-analyses across the program phases, representing 10 sub-themes developed from the intra-analyses within each program phase, and 123 initial codes identified from the exploration . Program attendance varied per participant over the 9-months and 75 sessions . Three participants  stopped attending for personal reasons after three, four, and six months of the program respectively, but the 14 others were involved in the 9-month project until the end. No adverse (undesirable) events were reported throughout the program. Eleven individuals (79%) participated in the 5k sport challenge, indicating the success with which the program was carried out as planned. Stemming from the six, semi-structured focus groups, three higher-order themes  there with big muscles, and a little voice inside you says that’s putting the bar high.” Similarly, in phase two, M3 explained how “it’s not written in our forehead that we have a TBI, you know. You can only see it because sometimes we have difficulties, or we get tired very fast – chronic fatigue.” Communication difficulties were mentioned again in phase three, so M1 emphasized that “when there is an important message, maybe you can translate it to me because most of them (participants) speak French, but I don’t.”The “I love the machines on the third floor, but it seems that the people there are just interested in their own thing, because they don’t talk, they’re … uh, concentrated.” Whereas M3 further explained that building connections (with other members) just required a little more time, “It will be three years that I’m on the third (floor), since the beginning of the program, and it took ages before I could engage in a conversation with those people.” No external barriers were identified in phase three.In phase one, external barriers included difficulties getting to the YMCA . P7, who lived in the suburbs, explained that “it’s getting here that’s complicated … As my mobility is more reduced than for the rest of you. It’s accessibility. Finding a parking place, then getting to the gym, for me is the greatest barrier.” Participants also experienced difficulties when the smaller gym area was overcrowded because they felt that space was limited. In contrast, the external barrier experienced by some participants in phase two related to fewer opportunities for social interaction. P12 shared, Program Facilitators sub-theme. In phase one, the participants discussed external facilitators related to receiving support and guidance from the mentors, as well as the YMCA staff and research team. P13 explained how, “the major success of phase one was the structure, like say putting a frame around a picture, which was provided by you and the whole team to facilitate things for us.”Throughout the 9-month program, participants discussed the external factors that affect program participation, in addition to the structure  and technology aids that make the program easier to follow and affect program experiences, as highlighted in the Participants appreciated the program aids in phase one, like having the training program written on a visible whiteboard. M4 remarked: “it just makes things easier and … well that’s it. And with all those little reminders about the major muscle groups, or the rules, things like that.” But in phase two, the external facilitators related more to the progression of the program and technology aids, which were both specific to the transition to the larger gym area and use of an online software to facilitate the use of digital programs on the participants' smart devices. M4 explained, “the visual aspect, and that it's well explained  …  each rhythm is explained, then each muscle it activates is shown … Then you can also see the training progress over time, which is also interesting.” P2 added that having access to a mobile training application “gave us more autonomy.” External facilitators were not identified in phase three.Program Motivation sub-theme. Participants' motivation in phase one was related to biopsychosocial outcomes, the structure the program provided in the week, being an example for others with TBI, and contributing to the research project. For instance, P13 explained the way he felt: “participating in the research is truly motivating … the altruistic part of me and that part that wants to help the brain injured also comes in when considering the possibility of developing a post-rehabilitation reference that may be recognized and publicized.” Motivation in phase two related again to the perceived biopsychosocial outcomes and structure in the week, but was extended by accountability and an increased interest in PA. For example, P4 discussed how: “everyone is more motivated in phase two. In phase one, you knew it was good for you, so you went. But ahhh … by phase two, people are happy to be there!”The sources of motivation for participating in the program varied considerably and in relation to the changing focus of the phases in the Participants also expressed how being around others from the group helped maintain their motivation to participate in PA. P10 shared, “if it’s me who is deciding on my own, it won’t work. I can’t get there. Someone must help me … push me to go forward. That encourages me .” P4 also shared, “Simply put, it’s the ripple effect. When we see people like us training, it pulls you into the wave.” In phase three, however, the motivation for participating in the program was more related to having a training routine, pushing personal limits, and the 5k sport challenge. P6 explained: “it motivates me more because it means the moment approaches when we leave the YMCA. The fact of going out to the mountain, with no machines. You run or you walk … you are with nature.” Similarly, M1 added: “I enjoy it because … it’s challenging. I never did that  before and then … you started to join with a group and meeting a lot of people.”Program Modifications sub-theme. A variety of recommendations for improving phase one of the program were provided, such as maintaining the program's structure while encouraging more freedom of discovery, including personal training goals and group activities, in addition to advertising the program externally, and clearly defining the mentors' roles and responsibilities. Confusion about the mentors' roles and responsibilities was discussed on several occasions, in addition to the mentors' desire for more responsibility. M4 explained, “I’d rather have a framework with precise objectives to respect, so I have a title and suitable role as a mentor.” On several occasions, mentors also expressed their desire to proudly represent the group through TBI-Health logos on their clothing, in addition to a desire to give back to the community. M2 shared, “it’s like we’ve become … we want people to become aware, for example, of the accident we’ve had, and everything to do with TBI.”Suggestions from participants about improving the program structure across the three phases of the program are grouped in the Further suggestions during the focus groups about improving program structure in phase two included maintaining the existing progression across phases, including progressions within phases, adding a nutritional component, scheduling group classes once a week, and adapting the walks outside the center by walking speed and ability. M3 shared, “I would love if it would be possible just to go up the mountain at your own speed, and to have a breakpoint … somewhere where we all meet together no matter what.” Suggestions about improving program structure in phase three included providing access to YMCA trainers and classes, in addition to maintaining the program's 9-month length and clearly defined phases. M3 offered his impression of why this approach works: “I feel that basically, the program is like a cooking recipe and basically if you carefully list how to add all the ingredients, well everyone will make a success of the recipe.”Biopsychosocial Changes theme reflected the perceived changes, by self and others, related to the physical, cognitive, psychological, and social outcomes from the program. The Physical Outcomes sub-theme in phase one reflected the participants' perceptions about their improved physical endurance and management of TBI impairments related to sleep, energy, and recovery as well as the perceptions of others. Some were not aware of these potential benefits. For instance, P2 explained: “I never thought … that physical activity would make me progress that well. I have so much more energy than before.” Perceptions about physical outcomes in phase two had more to do with strength and endurance, in addition to the management of TBI-related impairments with balance, mobility, and migraines. This was the first time that participants spoke about these kinds of changes, which they related specifically to the program. P8 shared, “the workout that you developed for us unblocked something in my back. So that now, I can walk straight. I no longer need a brace, no longer need a cane, so for me it’s just like, wow!” In phase three, perceptions about improvements in physical abilities were extended with cardio and endurance in addition to the management of TBI related impairments with balance, movement, mobility aids, and migraines. P5, who is partially hemiplegic explained “when I walk, I have more confidence in myself because I am more stable. I lose my balance less often … I like that better.” In addition, P3 no longer used a cane following the program, and P12 no longer required her orthotics (ankle brace).The Cognitive Outcomes sub-theme. M1, explained that in phase two “I’ve started memorizing, I feel like my brain is working now. Before, like every second … I always checked in the paper that you gave me what’s next … But now, I know what I need to do once I get inside, I know what I need to do.” Similar examples were shared in phase three by P6:In addition to physical outcomes, and beginning in the second phase, participants spoke about their perceived improvements with concentration and memory within the We're not less intelligent than other people. Personally, I tend to forget things. It doesn't make me less capable of understanding. But the fact of training upstairs, more than on the second floor, gives us more opportunities to use our memory and remember the exercises.M3 further emphasized, “the more important muscle is up there (the head). And that’s why we’re training. And that’s why we’re doing this study as well … I think the concentration and I think that the memory is working hard as well as we’re training.” Findings about cognitive outcomes, which surfaced in phases two and three, were not identified in phase one of the program.Psychological Outcomes sub-theme, participants expressed perceptions by self and others about positive changes to their mood states related to self-confidence, feelings of enjoyment, pride, and privilege, as well as feeling valued and validated as someone with a TBI in phase one. M3 shared his sentiments:Within the It makes me proud to take part as mentor in a research study about the subject that has been the most terrible experience of my life, the accident that nearly killed me … and to have saved myself and to have gotten where I am today and the people around me, my family, are so proud of that, and when I tell them about it, and how we participate, you know, we're here! I hold that close to my heart.These positive feelings were mirrored by the impressions of others too, as seen with P2’s personal example: “I started the program in April, and my daughter, two or three weeks ago said to me: mom, you’ve changed so much. You’re so much better, she says. You’re starting to be more … she thinks I’m slowly becoming as happy as I was before.”In phase two, the positive perceptions about the participants’ mood states were extended to feelings of capability, empowerment, motivation, physical improvements, and having a positive role in the program. Participants shared how they felt accomplished and empowered to carry out more daily activities, which would have otherwise been restricted by fatigue. They were energized and motivated about their perceived physical improvements and felt positive about helping others in the program. P4 said, “it brings me, well, a lot of pleasure, but it also brings me a satisfaction, like a feeling of duty accomplished.” Phase three included positive changes to mood states related to self-care, pride, and capability of completing the outdoor 5k sport challenge. P7 explained, “me personally, I felt surprised, I never thought I’d do so well …” The mentor M2 added, “as for the (sport) challenge, it was really awesome. Outdoing yourself … a great success, and why not do a bigger challenge (in the future)?”Social Outcomes sub-theme was identified the most frequently within the Biopsychosocial Changes theme. In the first phase of the program, participants discussed examples related to their program participation together, indicating an area that was relevant to their lives. They recalled experiencing positive social time with non-program participants, as well as with program-peers, in addition to feeling equal to other members at the YMCA. M3 explained, “People from the Y here, we’re quite different from them, as we’ve seen. They do not look down on us, nor do they look up to us. We’re equal with everyone, we have our place here … this is where I discovered it, in fact.” They also compared their tight-knit group to a family, due to the inclusive nature of the program. In phase one for instance, they discussed the self-improvements that resulted from their shared experiences together. M1, who was encouraged by her peers to become a mentor explained, “yes … I did improve a lot. Before like M2 said, I’m just always shy, hiding … I don’t talk to anyone that I don’t know, but now I’m starting to talk to someone (in reference to the young man she is in a relationship with).” In phase one, the mentors asked to join the participants in future focus groups. M4 explained, “I don’t feel my title makes me any better than the others. I’m … lucky enough to be a mentor because I’ve been here since the first cohort … but I don’t feel less or better than anyone else. I think we’re all on the same level.”The In the second phase, social outcomes remained similar. Participants continued speaking about how the strength of TBI-Health was related to the inclusive nature of the program for people with all ranges of abilities, in addition exchanging socially with members outside of the program. M2 shared his perception about, “establishing a contact with them (other YMCA members), many of us even made some good friends, chatting with people who don’t belong to our group, I’ve noticed …” Then, in phase three, the participants discussed how the program brought them together in solidarity. P2 explained, “We help each other a lot. Because, with TBI … you become, how can I say, a little less confident maybe … So being together makes you feel a little more solid.” By this final phase, participants were discussing increased confidence to expand their social circle through their program participation and the outdoor 5k sport challenge. P5 spoke about a member who started assisting her by running arm-in-arm on the YMCA track, “as for me … I found someone to help me out every session, and he’s almost always there … he’s a member of the YMCA but from another group … we’d like to do something outside of the gym, but it hasn’t happened yet. This way I have a friend though, that I can meet outside.”PA Autonomy theme highlighted the perceived transitions that occurred in knowledge, abilities, and sex- and gender-related beliefs relating to exercise and sport participation within and outside of the gym, which provided the participants with the confidence and independence to be more autonomous in their PA participation. Participants discussed the evolution in their sex- and gender-related beliefs and confidence about PA participation, as captured in the Sex and Gender sub-theme. For instance, in phase one, preconceived sex- and gender-related beliefs about preferences for type and intensity of PA were identified. Participants commented about their sex- or gender-based observations. M1, a female mentor, remarked that “I think some of the men are always working hard training, and women sometimes just do more social.” Others discussed sex- or gender-based observations about exercise preferences. P12 added, “it seems normal to me that guys prefer certain exercises, but not women. Even in (fitness) classes, it’s like that.”The Interestingly, in phase two, participants began challenging their own preconceived sex- and gender-related beliefs through a newfound appreciation for different PA modalities, incentives, and preferences. M3 asserted, “there’s no gender! [Everyone laughing]. Gender wise! I mean, there’s like something here that brings the group together. And my preference is to come here to the YMCA to see you guys.” However, M1, the mentor, still felt that “they  just like to always say like they don’t want to do something because they’re busy talking. They’re not even exercising.” And while P12 first remarked that “I was always under the impression that guys were more about strength training, and girls it’s more cardio.” she further added, “finally discovered that I loved weight training. It’s fun! I neglected that … but no, it sure helps because I no longer need orthotics.”By phase three, the participants did not speak about as many differences and continued to challenge what they perceived to be others’ preconceived sex- and gender-related beliefs about personal exercise preferences in the gym. Apparently, the groups’ sex- and gender-related beliefs had changed. For instance, P11 concluded that “if you look carefully at the clientele up there, you’ll see that there are many women, and women who train. Some are even body building. It’s crazy … you’ll see all sorts” P12 shared a personal example,Exercises like barbell lifting, all those exercises I had, there were just guys doing them. And the guys, it seemed, were staring at me … (imagining them saying) “What do you think you’re doing? You shouldn’t be here.” - I'm doing my workout, that's all. So basically, you could say there is a zone for women and a zone for men (in the gym), but for me, I like to be able to do all the exercises …P3 further added, “girls … guys, it’s all the same,” thereby demonstrating, once again, how their previous impressions about the sex- and gender-related beliefs about exercise had changed.PA Autonomy theme, participants also discussed their capability as a gym-goer and knowledge of PA benefits after a TBI that supported independent PA, as highlighted in the PA Capability sub-theme. P8 shared how following and remembering a PA program, “it makes you realize you can do it.” Then P13 added, “for sure, differently, but nevertheless, you can do it.” Participants felt that others should be informed about the PA benefits after TBI too. P12 explained, “when you’ve been in the hospital for a few months because you’re not able to function, they (doctors) should be the ones to tell us: you should be moving. It will help you with your concentration, it will help you.” Then, in phase two, participants noted how the self-discipline of coming to the gym twice a week, as well as their increased PA knowledge, confidence, autonomy, and freedom contributed to their overall ability to participate in PA. P2 explained, “I think we all realized that we were able to do our activities on our own, well it gives you, it gives confidence.” Participants also discussed how their newfound confidence made them curious to try out new forms of PA, in different places, like the larger gym on the third floor or the walking trail. For example, P6 shared: “in phase two, I find there is greater freedom, you train all by yourself, you look for the machines you’re more …” P11 added “at ease with,” and P6 continued: “more successful with.”Within the PA Capability sub-theme. Notably, they discussed how they began enjoying the run/walk activities in preparation for the 5k sport challenge. M3 shared, “It’s a good idea to integrate that (outdoor outings) in the program … I think it’s super important to get fresh air outside … makes your worries go away, as they say.” The participants also discussed how their increased autonomy and freedom allowed them to experience more pleasure from doing PA. P12 explained, “now we’re a lot more familiar with the YMCA and we all know that we’re good at doing what we’ve learnt to do. So, it’s just more exciting, and we’re just able to go and have fun.” There was even an interest to start something of their own, “I was asking myself if it is possible, next year for example, to have a group within our group, like in a special team, like basketball for example, and they play against another group that has difficulties too” (M2). Based on their examples, it was evident participants wanted to continue their PA participation in and outside the program.In phase three, participants began identifying the increased capability and freedom associated with their independent exercise, in addition to an appreciation for outdoor PA, and a desire to explore new PA avenues (such as creating a sports team), as captured in the Suggested modifications from the focus groups were incorporated in the final version of the program. For instance, the existing program schedule, reminders, and supports  were maintained. However, newly integrated items in the program manual included providing French and English versions, clearly outlining the objectives and step-by-step progressions within each program phase, as well as defining the mentors’ and participants’ roles and responsibilities with a code of conduct. To further promote participation, the mentors began visiting group classes provided at the YMCA  with participants outside program hours, and the run/walk outings in preparation for the sport challenge were divided into walking speed groups depending on the participants’ abilities. To advertise the program externally, TBI-Health was showcased at provincial and national conferences, with support from the mentors as spokespersons.The purpose of this interpretive case study was to provide an in-depth account of the experiences and outcomes of the participation in and co-creation of a new community-based TBI-Health program to enhance sport and exercise participation for adults with moderate-to-severe TBI. The results identified themes, which will help enhance the program, and can inform future research and practice that promotes participation after moderate-to-severe TBI.The program participants discussed feeling anxious about participating correctly in PA, by comparing themselves physically to other members in the gym-based environment and commenting about invisible difficulties with fatigue after TBI. This finding is relevant because participation and long-term recovery after TBI may be influenced by social comparisons with peers, caregivers, and others after injury. For example, comparing oneself to an individual who is functioning well (upward comparison) can be positive if it is inspiring, but it can also be negative if the situation highlights one's deficits . The latPonsford and colleagues  suggest Study participants emphasized the types of external facilitators that enabled their program participation, such as the structured framework in place that afforded support and guidance from the program peer mentors, YMCA staff, and research team. In this way, having structure and routines to follow facilitated their involvement in PA. An appreciation for structure may be linked to the types of sequelae with which people with TBI live, including difficulties with social cognition and dysexecutive behavior, which are both shown to be significant predictors of vocational and social participation after moderate-to-severe TBI .Program aids, like clear instructions and visual reminders were emphasized by participants to facilitate their involvement and execution of program exercises. Having access to technology aids resonated with participants as an extra tool to help them understand how to carry out exercises and what muscles were being used in the process. These findings are important for PA participation after moderate-to-severe TBI in the long-term/chronic period because frequently reported problems include memory difficulties, and problems related to cognitive aspects of executive functioning . Thus, iMotivation after TBI is a multi-dimensional problem because studies have consistently shown that injuries to the brain commonly lead to apathy, or a decrease in the cognitive and psychological processes involved with goal-directed activity . HoweverInterestingly, our participants' motivation to participate in the adapted PA program evolved over the course of the intervention, as revealed by the similarities and differences across the three time points. The support and accountability afforded by the group-based activities stood out, because participants discussed overcoming motivational difficulties thanks to the positive influence of training with peers. This suggests that motivational problems rooted in psychological mechanisms may be attenuated through peer-assisted activities. Similar outcomes about the ways in which community-based peer-support programs can have a positive impact on recovery after TBI through acceptance and encouragement have been identified . Our finIn the community-based context, tailoring a PA-based health promotion program for adults with moderate-to-severe TBI through stakeholder input is relevant to its overall success . Based oOur participants discussed perceived improvements with their cognitive functions beginning in the second phase of the program, with examples about how training programs engaged their concentration and memory. Studies that investigate the potential impact of cardiovascular exercise on memory consistently show promise , althougBased on the findings about the perceived social outcomes, it was apparent that participants felt comfortable in their social environment. This is important because community-based programs have been proposed as the logical transition from the rehabilitation continuum for people living with disabilities  and few The transitions in sex- and gender-related beliefs about PA participation are noteworthy because sex- and gender-based stereotypes may present barriers to recommended amounts of PA  guidelines, the reflexive thematic analysis undertaken here fully embraces the subjective skills researchers bring to the interpretive process. The open coding and inductive theme development did not seek to ensure the accuracy and reliability of the process through coder agreement, but rather through a reflexive, critical, and iterative process informed by the team of authors. Therefore, codes and themes may be different for other analysts.This study identified three themes across the participatory co-creation experience of a 9-month 3-phased adapted PA program for adults with moderate-to-severe TBI, which highlighted the participants' Program Participation, Biopsychosocial Changes, and PA Autonomy. Findings from this study were integral to the design and implementation of the new and enhanced TBI-Health program and provide evidence-based recommendations for promoting continued PA participation after neurotrauma. We hope that future research and practice related to the design and implementation of community-based PA interventions will undertake similar methodological approaches to partnering with key stakeholders, based on the associated benefits with mood, quality of life and participation that may be obtained throughout the collaborative process.


Environmental chemicals, including endocrine disrupting chemicals (EDCs), pose a threat to human health. Actions are taken by scientists, assessors, regulators, and policymakers around the world to improve testing strategies for chemical substances, including pushing towards greater reliance on data from new approach methodologies to replace animal toxicity studies. This paradigm shift is envisioned to ultimately replace animal testing altogether for many purposes. As regards identification and regulation of EDCs, this poses certain challenges in that current guidelines—at least within the European regulatory framework—stipulate that adverse outcomes are to be demonstrated in an intact organism. The new testing paradigm is, of course, to find ways of dealing with this dilemma. However, another challenge still remains, even if the “intact organisms” definition changes or is replaced, namely the challenge of predicting apical adverse effects resulting from endocrine disruption. The adverse outcome pathway (AOP) framework provides a good platform for identifying and regulating EDCs based on both non-animal and animal (or human) data, but also here we are confronted with the same challenge: how to predict adverse effects in complex organism from simple test assays that are based on reductionist principles? In this article, the challenge of “emergent properties” in predictive toxicology is highlighted as a cautionary footnote because, although a future relying far less on animal toxicity testing is both desirable and sensible, the pace at which we transition to the new paradigm should ensure that human health, and the environment, is safeguarded from harmful chemical substances. Huge efforts are currently being put towards developing non-animal testing strategies for assessing and regulating chemicals, not least within the European Union . The endin vivo effect outcomes using data from new approach methodologies (NAMs) is challenging, as we recently argued  concept, particularly since this framework also offers great opportunities to improve on the predictive power of alternative test methods and strategies. I will also narrow the discussion to endocrine disrupting chemicals (EDCs), for two reasons. Firstly, because the AOP framework is very well suited for addressing the current regulatory needs for identifying EDCs. Secondly, because EDC identification represents an area of chemical toxicology where predicting y argued .Science back in 1972. In this now classic article with the three-word title More Is Different, Anderson argues that even though we can understand complex systems by breaking it down into smaller units (or laws), we cannot just as easily use our knowledge of these smaller units to construct complex systems. Or to quote: “The ability to reduce everything to simple fundamental laws does not imply the ability to start from those laws and reconstruct the Universe”  of the endocrine system and consequently causes adverse health effects in an intact organism, or its progeny, or (sub) populations”.As the name implies, an EDC is a chemical substance that can disrupt normal hormone action. However, as recently discussed , there iadverse health effects” in the definition. By this, it is understood that it is not enough to show that a chemical substance has the potential to disrupt hormone action by, for instance, in vitro data or altered hormone profiles in intact animals. Rather, adverse effect must also be shown in an intact organism . Incidentally, this inclusion introduces another challenge in that “adversity” itself does not have a universal, agreed-upon, definition.A key point that needs further elaboration is the inclusion of “a change in morphology, physiology, growth, development or lifespan of an organism which results in impairment of functional capacity or impairment of capacity to compensate for additional stress or increase in susceptibility to the harmful effects of other environmental influences”, as discussed in  regulated based on their EDC properties , which lMuch has been written about the AOP concept and it is not my intent to repeat it here. For the interested reader, some reviews can be recommended as a starting point . Here, iThe other point that becomes apparent with the AOP approach to risk assessment is the increasing complexity as one moves from an MIE towards and AO. As depicted in one-or-the-other debate that divides proponents for different approaches into trenches from where they can engage in intellectual warfare. Rather, it would be best served with a one-and-the-other debate, where there is a gradual transition phase best suited for whatever area of health effects or regulatory toxicology being adressed.Regulatory toxicology is moving towards greater reliance on NAMs to identify, assess and regulate potential harmful chemical substances. This will greatly reduce the number of animals used for regulatory testing purposes and, at the same time, speed up at the process of chemical assessment. This is a positive thing and a widely shared sentiment. However, if we are to also protect human health or the environment from possible harm caused by unintentional, or unwitting, exposure to industrial chemicals with potential to cause injurious health effects, then we should also consider the many limitations with new approaches. This should not be a More is Different” paper, as it so elegantly summarizes the potential pitfall of assuming that any simplified model can truly capture the essence of complex systems: “The constructionist hypothesis does not and cannot live up to its promise since the reduction on which it is based had not included the equally fundamental fact that “entirely new properties” arise at each new level of complexity and scale” (Thus, although I am convinced we will make great strides towards improving the predictive power of NAMs over the next decade, I will end with another quote from P.W. Anderson’s classic “d scale” . Again,