Parent and child care provider partnerships: Protocol for the Healthy Me, Healthy We (HMHW) cluster randomized control trial

Assessing the scalability of healthy eating interventions within the early childhood education and care setting: secondary analysis of a Cochrane systematic review

OBJECTIVE

Early childhood education and care (ECEC) is a recommended setting for the delivery of health eating interventions 'at scale' (i.e. to large numbers of childcare services) to improve child public health nutrition. Appraisal of the 'scalability' (suitability for delivery at scale) of interventions is recommended to guide public health decision-making. This study describes the extent to which factors required to assess scalability are reported among ECEC-based healthy eating interventions.

DESIGN

Studies from a recent Cochrane systematic review assessing the effectiveness of healthy eating interventions delivered in ECEC for improving child dietary intake were included. The reporting of factors of scalability was assessed against domains outlined within the Intervention Scalability Assessment Tool (ISAT). The tool recommends decision makers consider the problem, the intervention, strategic and political context, effectiveness, costs, fidelity and adaptation, reach and acceptability, delivery setting and workforce, implementation infrastructure and sustainability. Data were extracted by one reviewer and checked by a second reviewer.

SETTING

ECEC.

PARTICIPANTS

Children 6 months to 6 years.

RESULTS

Of thirty-eight included studies, none reported all factors within the ISAT. All studies reported the problem, the intervention, effectiveness and the delivery workforce and setting. The lowest reported domains were intervention costs (13 % of studies) and sustainability (16 % of studies).

CONCLUSIONS

Findings indicate there is a lack of reporting of some key factors of scalability for ECEC-based healthy eating interventions. Future studies should measure and report such factors to support policy and practice decision makers when selecting interventions to be scaled-up.

Healthy eating interventions delivered in early childhood education and care settings for improving the diet of children aged six months to six years

BACKGROUND

Dietary intake during early childhood can have implications on child health and developmental trajectories. Early childhood education and care (ECEC) services are recommended settings to deliver healthy eating interventions as they provide access to many children during this important period. Healthy eating interventions delivered in ECEC settings can include strategies targeting the curriculum (e.g. nutrition education), ethos and environment (e.g. menu modification) and partnerships (e.g. workshops for families). Despite guidelines supporting the delivery of healthy eating interventions in this setting, little is known about their impact on child health.

OBJECTIVES

To assess the effectiveness of healthy eating interventions delivered in ECEC settings for improving dietary intake in children aged six months to six years, relative to usual care, no intervention or an alternative, non-dietary intervention. Secondary objectives were to assess the impact of ECEC-based healthy eating interventions on physical outcomes (e.g. child body mass index (BMI), weight, waist circumference), language and cognitive outcomes, social/emotional and quality-of-life outcomes. We also report on cost and adverse consequences of ECEC-based healthy eating interventions.

SEARCH METHODS

We searched eight electronic databases including CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, ERIC, Scopus and SportDiscus on 24 February 2022. We searched reference lists of included studies, reference lists of relevant systematic reviews, the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov and Google Scholar, and contacted authors of relevant papers.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), including cluster-RCTs, stepped-wedge RCTs, factorial RCTs, multiple baseline RCTs and randomised cross-over trials, of healthy eating interventions targeting children aged six months to six years that were conducted within the ECEC setting. ECEC settings included preschools, nurseries, kindergartens, long day care and family day care. To be included, studies had to include at least one intervention component targeting child diet within the ECEC setting and measure child dietary or physical outcomes, or both.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently screened titles and abstracts and extracted study data. We assessed risk of bias for all studies against 12 criteria within RoB 1, which allows for consideration of how selection, performance, attrition, publication and reporting biases impact outcomes. We resolved discrepancies via consensus or by consulting a third review author. Where we identified studies with suitable data and homogeneity, we performed meta-analyses using a random-effects model; otherwise, we described findings using vote-counting approaches and via harvest plots. For measures with similar metrics, we calculated mean differences (MDs) for continuous outcomes and risk ratios (RRs) for dichotomous outcomes. We calculated standardised mean differences (SMDs) for primary and secondary outcomes where studies used different measures. We applied GRADE to assess certainty of evidence for dietary, cost and adverse outcomes.

MAIN RESULTS

We included 52 studies that investigated 58 interventions (described across 96 articles). All studies were cluster-RCTs. Twenty-nine studies were large (≥ 400 participants) and 23 were small (< 400 participants). Of the 58 interventions, 43 targeted curriculum, 56 targeted ethos and environment, and 50 targeted partnerships. Thirty-eight interventions incorporated all three components. For the primary outcomes (dietary outcomes), we assessed 19 studies as overall high risk of bias, with performance and detection bias being most commonly judged as high risk of bias. ECEC-based healthy eating interventions versus usual practice or no intervention may have a positive effect on child diet quality (SMD 0.34, 95% confidence interval (CI) 0.04 to 0.65; P = 0.03, I2 = 91%; 6 studies, 1973 children) but the evidence is very uncertain. There is moderate-certainty evidence that ECEC-based healthy eating interventions likely increase children's consumption of fruit (SMD 0.11, 95% CI 0.04 to 0.18; P < 0.01, I2 = 0%; 11 studies, 2901 children). The evidence is very uncertain about the effect of ECEC-based healthy eating interventions on children's consumption of vegetables (SMD 0.12, 95% CI -0.01 to 0.25; P =0.08, I2 = 70%; 13 studies, 3335 children). There is moderate-certainty evidence that ECEC-based healthy eating interventions likely result in little to no difference in children's consumption of non-core (i.e. less healthy/discretionary) foods (SMD -0.05, 95% CI -0.17 to 0.08; P = 0.48, I2 = 16%; 7 studies, 1369 children) or consumption of sugar-sweetened beverages (SMD -0.10, 95% CI -0.34 to 0.14; P = 0.41, I2 = 45%; 3 studies, 522 children). Thirty-six studies measured BMI, BMI z-score, weight, overweight and obesity, or waist circumference, or a combination of some or all of these. ECEC-based healthy eating interventions may result in little to no difference in child BMI (MD -0.08, 95% CI -0.23 to 0.07; P = 0.30, I2 = 65%; 15 studies, 3932 children) or in child BMI z-score (MD -0.03, 95% CI -0.09 to 0.03; P = 0.36, I2 = 0%; 17 studies; 4766 children). ECEC-based healthy eating interventions may decrease child weight (MD -0.23, 95% CI -0.49 to 0.03; P = 0.09, I2 = 0%; 9 studies, 2071 children) and risk of overweight and obesity (RR 0.81, 95% CI 0.65 to 1.01; P = 0.07, I2 = 0%; 5 studies, 1070 children). ECEC-based healthy eating interventions may be cost-effective but the evidence is very uncertain (6 studies). ECEC-based healthy eating interventions may have little to no effect on adverse consequences but the evidence is very uncertain (3 studies). Few studies measured language and cognitive skills (n = 2), social/emotional outcomes (n = 2) and quality of life (n = 3).

AUTHORS' CONCLUSIONS

ECEC-based healthy eating interventions may improve child diet quality slightly, but the evidence is very uncertain, and likely increase child fruit consumption slightly. There is uncertainty about the effect of ECEC-based healthy eating interventions on vegetable consumption. ECEC-based healthy eating interventions may result in little to no difference in child consumption of non-core foods and sugar-sweetened beverages. Healthy eating interventions could have favourable effects on child weight and risk of overweight and obesity, although there was little to no difference in BMI and BMI z-scores. Future studies exploring the impact of specific intervention components, and describing cost-effectiveness and adverse outcomes are needed to better understand how to maximise the impact of ECEC-based healthy eating interventions.

Healthy eating interventions delivered in early childhood education and care settings for improving the diet of children aged six months to six years

BACKGROUND

Dietary intake during early childhood can have implications on child health and developmental trajectories. Early childhood education and care (ECEC) services are recommended settings to deliver healthy eating interventions as they provide access to many children during this important period. Healthy eating interventions delivered in ECEC settings can include strategies targeting the curriculum (e.g. nutrition education), ethos and environment (e.g. menu modification) and partnerships (e.g. workshops for families). Despite guidelines supporting the delivery of healthy eating interventions in this setting, little is known about their impact on child health.

OBJECTIVES

To assess the effectiveness of healthy eating interventions delivered in ECEC settings for improving dietary intake in children aged six months to six years, relative to usual care, no intervention or an alternative, non-dietary intervention. Secondary objectives were to assess the impact of ECEC-based healthy eating interventions on physical outcomes (e.g. child body mass index (BMI), weight, waist circumference), language and cognitive outcomes, social/emotional and quality-of-life outcomes. We also report on cost and adverse consequences of ECEC-based healthy eating interventions.

SEARCH METHODS

We searched eight electronic databases including CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, ERIC, Scopus and SportDiscus on 24 February 2022. We searched reference lists of included studies, reference lists of relevant systematic reviews, the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov and Google Scholar, and contacted authors of relevant papers.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), including cluster-RCTs, stepped-wedge RCTs, factorial RCTs, multiple baseline RCTs and randomised cross-over trials, of healthy eating interventions targeting children aged six months to six years that were conducted within the ECEC setting. ECEC settings included preschools, nurseries, kindergartens, long day care and family day care. To be included, studies had to include at least one intervention component targeting child diet within the ECEC setting and measure child dietary or physical outcomes, or both.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently screened titles and abstracts and extracted study data. We assessed risk of bias for all studies against 12 criteria within RoB 1, which allows for consideration of how selection, performance, attrition, publication and reporting biases impact outcomes. We resolved discrepancies via consensus or by consulting a third review author. Where we identified studies with suitable data and homogeneity, we performed meta-analyses using a random-effects model; otherwise, we described findings using vote-counting approaches and via harvest plots. For measures with similar metrics, we calculated mean differences (MDs) for continuous outcomes and risk ratios (RRs) for dichotomous outcomes. We calculated standardised mean differences (SMDs) for primary and secondary outcomes where studies used different measures. We applied GRADE to assess certainty of evidence for dietary, cost and adverse outcomes.  MAIN RESULTS: We included 52 studies that investigated 58 interventions (described across 96 articles). All studies were cluster-RCTs. Twenty-nine studies were large (≥ 400 participants) and 23 were small (< 400 participants). Of the 58 interventions, 43 targeted curriculum, 56 targeted ethos and environment, and 50 targeted partnerships. Thirty-eight interventions incorporated all three components. For the primary outcomes (dietary outcomes), we assessed 19 studies as overall high risk of bias, with performance and detection bias being most commonly judged as high risk of bias. ECEC-based healthy eating interventions versus usual practice or no intervention may have a positive effect on child diet quality (SMD 0.34, 95% confidence interval (CI) 0.04 to 0.65; P = 0.03, I2 = 91%; 6 studies, 1973 children) but the evidence is very uncertain. There is moderate-certainty evidence that ECEC-based healthy eating interventions likely increase children's consumption of fruit (SMD 0.11, 95% CI 0.04 to 0.18; P < 0.01, I2 = 0%; 11 studies, 2901 children). The evidence is very uncertain about the effect of ECEC-based healthy eating interventions on children's consumption of vegetables (SMD 0.12, 95% CI -0.01 to 0.25; P =0.08, I2 = 70%; 13 studies, 3335 children). There is moderate-certainty evidence that ECEC-based healthy eating interventions likely result in little to no difference in children's consumption of non-core (i.e. less healthy/discretionary) foods (SMD -0.05, 95% CI -0.17 to 0.08; P = 0.48, I2 = 16%; 7 studies, 1369 children) or consumption of sugar-sweetened beverages (SMD -0.10, 95% CI -0.34 to 0.14; P = 0.41, I2 = 45%; 3 studies, 522 children). Thirty-six studies measured BMI, BMI z-score, weight, overweight and obesity, or waist circumference, or a combination of some or all of these. ECEC-based healthy eating interventions may result in little to no difference in child BMI (MD -0.08, 95% CI -0.23 to 0.07; P = 0.30, I2 = 65%; 15 studies, 3932 children) or in child BMI z-score (MD -0.03, 95% CI -0.09 to 0.03; P = 0.36, I2 = 0%; 17 studies; 4766 children). ECEC-based healthy eating interventions may decrease child weight (MD -0.23, 95% CI -0.49 to 0.03; P = 0.09, I2 = 0%; 9 studies, 2071 children) and risk of overweight and obesity (RR 0.81, 95% CI 0.65 to 1.01; P = 0.07, I2 = 0%; 5 studies, 1070 children). ECEC-based healthy eating interventions may be cost-effective but the evidence is very uncertain (6 studies). ECEC-based healthy eating interventions may have little to no effect on adverse consequences but the evidence is very uncertain (3 studies). Few studies measured language and cognitive skills (n = 2), social/emotional outcomes (n = 2) and quality of life (n = 3).

AUTHORS' CONCLUSIONS

ECEC-based healthy eating interventions may improve child diet quality slightly, but the evidence is very uncertain, and likely increase child fruit consumption slightly. There is uncertainty about the effect of ECEC-based healthy eating interventions on vegetable consumption. ECEC-based healthy eating interventions may result in little to no difference in child consumption of non-core foods and sugar-sweetened beverages. Healthy eating interventions could have favourable effects on child weight and risk of overweight and obesity, although there was little to no difference in BMI and BMI z-scores. Future studies exploring the impact of specific intervention components, and describing cost-effectiveness and adverse outcomes are needed to better understand how to maximise the impact of ECEC-based healthy eating interventions.

A qualitative comparison of parent and childcare provider perceptions of communication and family engagement in children's healthy eating and physical activity

BACKGROUND

Parents and childcare providers play a substantial role in the development of health behaviours among the children they care for. In order to ensure the optimal growth and development of children, communication and family engagement in childcare is critical. Previous studies examining parent or provider perceptions about healthy eating or physical activity have explored these concepts individually and/or have only included only parents or providers. Therefore, the purpose of this study was to compare childcare provider and parent perceptions of communication regarding healthy eating and physical activity as well as use of best practice strategies on family engagement for these topics.

METHODS

Childcare providers (n = 12) in childcare centres or a family childcare home and a parent (n = 12) of a child they provide care for participated in a semi-structured interview guided by the Social Ecological Model. Interviews were transcribed verbatim and uploaded to NVivo for data analysis. Data were analysed using a directed content analysis. Three trained qualitative researchers developed a codebook and then compared responses between parents and providers.

RESULTS

Similarities in provider and parent responses included agreement on healthy eating; influences on child development; parents being the most influential on children's healthy eating; how they identified physical activity opportunities; and the use of family engagement principles. Differences that arose included parents' roles in promoting children's physical activity; challenges for parents in promoting healthy eating and physical activity; and providers' encouragement of physical activity. Importantly, few parents mentioned providers were top influences on their child's healthy eating or physical activity. Providers also mentioned having difficult conversations with parents was challenging.

CONCLUSIONS

Future efforts are needed to (1) help parents understand the providers' role in the development of their child's health behaviours and (2) strengthen efforts to engage families in healthy behaviours outside of childcare facilities.

Efficacy of an Enhanced Implementation Strategy to Increase Parent Engagement with a Health Promotion Program in Childcare

Previous efforts to involve parents in implementation of childcare-based health promotion interventions have yielded limited success, suggesting a need for different implementation strategies. This study evaluated the efficacy of an enhanced implementation strategy to increase parent engagement with Healthy Me, Healthy We. This quasi-experimental study included childcare centers from the second of two waves of a cluster-randomized trial. The standard approach (giving parents intervention materials, prompting participation at home, inviting participation with classroom events) was delivered in 2016-2017 (29 centers, 116 providers, and 199 parents). The enhanced approach (standard plus seeking feedback, identifying and addressing barriers to parent participation) was delivered in 2017-2018 (13 centers, 57 providers, and 114 parents). Parent engagement was evaluated at two levels. For the center-level, structured interview questions with providers throughout the intervention were systematically scored. For the parent-level, parents completed surveys following the intervention. Differences in parent engagement were evaluated using linear regression (center-level) and mixed effects (parent-level) models. Statistical significance was set at p < 0.025 for two primary outcomes. There was no difference in parent engagement between approaches at the center-level, β = -1.45 (95% confidence interval, -4.76 to 1.87), p = 0.38l. However, the enhanced approach had higher parent-level scores, β = 3.60, (95% confidence interval, 1.49 to 5.75), p < 0.001. In the enhanced approach group, providers consistently reported greater satisfaction with the intervention than parents (p < 0.001), yet their fidelity of implementing the enhanced approach was low (less than 20%). Results show promise that parent engagement with childcare-based health promotion innovations can positively respond to appropriately designed and executed implementation strategies, but strategies need to be feasible and acceptable for all stakeholders.

Evaluating a child care-based social marketing approach for improving children's diet and physical activity: results from the Healthy Me, Healthy We cluster-randomized controlled trial

Child care-based interventions offer an opportunity to reach children at a young and impressionable age to support healthy eating and physical activity behaviors. Ideally, these interventions engage caregivers, including both childcare providers and parents, in united effort. This study evaluated the impact of the Healthy Me, Healthy We intervention on children's diet quality and physical activity. A sample of 853 three- to four-year-old children from 92 childcare centers were enrolled in this cluster-randomized control trial. Healthy Me, Healthy We was an 8-month, social marketing intervention delivered through childcare that encouraged caregivers (childcare providers and parents) to use practices that supported children's healthy eating and physical activity behaviors. Outcome measures, collected at baseline and post-intervention, assessed children's diet quality, physical activity, and BMI as well as caregivers' feeding and physical activity practices. Generalized Linear Mixed Models were used to assess change from baseline to post-intervention between intervention and control arms. No significant changes were noted in any of the outcome measures except for small improvements in children's sodium intake and select parent practices. Despite the negative findings, this study offers many lessons about the importance and challenges of effective parent engagement which is critical for meaningful changes in children's health behaviors.

Evaluation of the impact of the Healthy Start/Départ Santé intervention on improving menu planning practices and improving the congruence between planned menus and actual food served in Saskatchewan childcare centres

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The majority of centres did not comply with the recommended nutrition guidelines.

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More than 50% of centres listed processed foods in amounts exceeding recommendations.

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The interventions may effectively improve the accuracy and reliability of menus.

The objective of this study was to evaluate the impact of the Healthy Start/Départ Santé (HS/DS) intervention program on improving menu planning practices and improving the congruence between planned menus and actual food served in licensed childcare centres in Saskatchewan.

Overall, 39 licensed childcare centres in the province of Saskatchewan, Canada, were selected through a cluster randomized control trial to evaluate the impact of the HS/DS intervention. The pre and post intervention food menus of these centres were analyzed and compared to the Saskatchewan Childcare Nutrition Guidelines (SCNG). The food and beverages served at lunch were observed and digitally recorded using digital plate-waste measures. The congruence between the planned menus and the actual food served was assessed. Descriptive analyses and non-parametric tests were performed to determine the impact of the intervention.

The results of this study indicated that there was no significant difference between the groups regarding the distribution and proportion of centres that adhered to the SCNG. The centres that received the intervention demonstrated significant improvements in adherence to their written menus, with the proportions of match between the items that served and listed (p-value = 0.029), and additional items served (p-value = 0.014). Within each group, intervention and usual practice, there were significant differences in centres that met the foods to limit guideline among the usual practice centres (p-value = 0.035). Findings from this study indicated that the HS/DS intervention had a positive impact on improving the adherence of the participating centres to the centres’ planned menus.

HS/DS trial registration number: NCT02375490.

Fidelity and factors influencing implementation of Healthy Me, Healthy: process evaluation of a social marketing campaign for diet and physical activity behaviors of children in childcare

The effectiveness of interventions targeting children's eating and physical activity behaviors through childcare settings is inconsistent. To enhance public health impact, it is imperative to evaluate fidelity of implementing complex interventions in real-world settings. This study evaluated fidelity and contextual factors influencing implementation of Healthy Me, Healthy We (HMHW). HMHW was an 8-month social marketing campaign delivered through childcare to support children's healthy eating and physical activity. HMHW required two levels of implementation support (research team and childcare providers) and two levels of campaign delivery (childcare providers and parents). Process evaluation was conducted among childcare centers in the intervention group (n=48) of the cluster-randomized control trial. Measures included attendance logs, self-report surveys, observation checklists, field notes, and semi-structured interviews. A 35-item fidelity index was created to assess fidelity of implementation support and campaign delivery. The fidelity with which HMHW was implemented by childcare providers and parents was low (mean 17.4 out of 35) and decreased between childcare providers and parents. Childcare providers had high acceptability of the program and individual components (80 - 93%). Only half of parents felt intervention components were acceptable. Frequently cited barriers to implementation by childcare providers included time constraints, parent engagement, staff turnover, and restrictive policies. The lack of observable effect of HMHW on children's dietary or physical activity behaviors may be due to inadequate implementation at multiple levels. Different or additional strategies are necessary to support implementation of multilevel interventions, particularly when individuals are expected to deliver intervention components and support others in doing so.

Using a social marketing approach to develop Healthy Me, Healthy We: a nutrition and physical activity intervention in early care and education

Although social marketing principles have been successfully employed in school-based interventions to prevent obesity, use in early care and education (ECE) settings has been limited. This paper describes the use of the social marketing approach to develop an ECE-based intervention that encourages an ECE provider-parent partnership to improve the quality of preschool children's diets and their level of physical activity. A six-step social marketing approach for public health interventions guided the development of this ECE-based intervention. These steps were as follows: (i) initial planning, (ii) formative research, (iii) strategy development, (iv) program development, (v) implementation, and (vi) monitoring and evaluation. During this process, we reviewed current literature, conducted focus groups with ECE providers and parents, developed a detailed conceptual model and content map, created and tested the campaign concept, and developed final campaign materials along with strategies for its implementation. The final intervention resulting from this process was an 8-month campaign known as Healthy Me, Healthy We. The campaign is delivered by the child care center and includes branded materials for use in the classroom and at home. The final campaign is being evaluated in a cluster-randomized trial. Healthy Me, Healthy We offers an innovative approach to promoting healthy eating and physical activity during early childhood, a key developmental period, that leverages partnership between ECE providers and parents to affect behavior change.

Strategies to improve the implementation of healthy eating, physical activity and obesity prevention policies, practices or programmes within childcare services

BACKGROUND

Despite the existence of effective interventions and best-practice guideline recommendations for childcare services to implement evidence-based policies, practices and programmes to promote child healthy eating, physical activity and prevent unhealthy weight gain, many services fail to do so.

OBJECTIVES

The primary aim of the review was to examine the effectiveness of strategies aimed at improving the implementation of policies, practices or programmes by childcare services that promote child healthy eating, physical activity and/or obesity prevention. The secondary aims of the review were to: 1. Examine the cost or cost-effectiveness of such strategies; 2. Examine any adverse effects of such strategies on childcare services, service staff or children; 3. Examine the effect of such strategies on child diet, physical activity or weight status. 4. Describe the acceptability, adoption, penetration, sustainability and appropriateness of such implementation strategies.

SEARCH METHODS

We searched the following electronic databases on February 22 2019: Cochrane Central Register of Controlled trials (CENTRAL), MEDLINE, MEDLINE In Process, Embase, PsycINFO, ERIC, CINAHL and SCOPUS for relevant studies. We searched reference lists of included studies, handsearched two international implementation science journals, the World Health Organization International Clinical Trials Registry Platform (www.who.int/ictrp/) and ClinicalTrials.gov (www.clinicaltrials.gov).

SELECTION CRITERIA

We included any study (randomised or nonrandomised) with a parallel control group that compared any strategy to improve the implementation of a healthy eating, physical activity or obesity prevention policy, practice or programme by staff of centre-based childcare services to no intervention, 'usual' practice or an alternative strategy. Centre-based childcare services included preschools, nurseries, long daycare services and kindergartens catering for children prior to compulsory schooling (typically up to the age of five to six years).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened study titles and abstracts, extracted study data and assessed risk of bias; we resolved discrepancies via consensus. We performed meta-analysis using a random-effects model where studies with suitable data and homogeneity were identified; otherwise, findings were described narratively.

MAIN RESULTS

Twenty-one studies, including 16 randomised and five nonrandomised, were included in the review. The studies sought to improve the implementation of policies, practices or programmes targeting healthy eating (six studies), physical activity (three studies) or both healthy eating and physical activity (12 studies). Studies were conducted in the United States (n = 12), Australia (n = 8) and Ireland (n = 1). Collectively, the 21 studies included a total of 1945 childcare services examining a range of implementation strategies including educational materials, educational meetings, audit and feedback, opinion leaders, small incentives or grants, educational outreach visits or academic detailing, reminders and tailored interventions. Most studies (n = 19) examined implementation strategies versus usual practice or minimal support control, and two compared alternative implementation strategies. For implementation outcomes, six studies (one RCT) were judged to be at high risk of bias overall. The review findings suggest that implementation strategies probably improve the implementation of policies, practices or programmes that promote child healthy eating, physical activity and/or obesity prevention in childcare services. Of the 19 studies that compared a strategy to usual practice or minimal support control, 11 studies (nine RCTs) used score-based measures of implementation (e.g. childcare service nutrition environment score). Nine of these studies were included in pooled analysis, which found an improvement in implementation outcomes (SMD 0.49; 95% CI 0.19 to 0.79; participants = 495; moderate-certainty evidence). Ten studies (seven RCTs) used dichotomous measures of implementation (e.g. proportion of childcare services implementing a policy or specific practice), with seven of these included in pooled analysis (OR 1.83; 95% CI 0.81 to 4.11; participants = 391; low-certainty evidence). Findings suggest that such interventions probably lead to little or no difference in child physical activity (four RCTs; moderate-certainty evidence) or weight status (three RCTs; moderate-certainty evidence), and may lead to little or no difference in child diet (two RCTs; low-certainty evidence). None of the studies reported the cost or cost-effectiveness of the intervention. Three studies assessed the adverse effects of the intervention on childcare service staff, children and parents, with all studies suggesting they have little to no difference in adverse effects (e.g. child injury) between groups (three RCTs; low-certainty evidence). Inconsistent quality of the evidence was identified across review outcomes and study designs, ranging from very low to moderate. The primary limitation of the review was the lack of conventional terminology in implementation science, which may have resulted in potentially relevant studies failing to be identified based on the search terms used.

AUTHORS' CONCLUSIONS

Current research suggests that implementation strategies probably improve the implementation of policies, practices or programmes by childcare services, and may have little or no effect on measures of adverse effects. However such strategies appear to have little to no impact on measures of child diet, physical activity or weight status.

Contributions of Early Care and Education Programs to Diet Quality in Children Aged 3 to 4 Years in Central North Carolina

BACKGROUND

Parents and early care and education (ECE) are the key influencers of young children's diets, but there is limited information about how each contribute to children's overall diet quality.

OBJECTIVE

This study aimed to determine what proportion of children's dietary intake occurs within the ECE setting and whether diet quality is higher at ECE centers and, consequently, on weekdays than weekends.

DESIGN

This cross-sectional analysis of a larger cluster randomized controlled trial used multiple 24-hour dietary intakes measured through a combination of the Dietary Observation in Child Care protocol and parent-reported food diaries.

PARTICIPANTS/SETTING

Participants (N=840) included children aged 3 to 4 years enrolled in ECE centers in central North Carolina for whom 24-hour dietary intake was captured via observation of meals and snacks consumed at ECE and parent-report of all remaining meals and snacks. Data were collected from 2015 to 2016.

MAIN OUTCOME MEASURES

Diet quality at ECE and elsewhere was evaluated using the Healthy Eating Index 2015.

STATISTICAL ANALYSES PERFORMED

Mixed-effects models were used to determine differences in mean Healthy Eating Index 2015 component and total scores. Models were adjusted for children's age and sex and accounted for clustering within ECE centers and families.

RESULTS

Children consumed approximately 40% of daily energy, nutrients, and food groups at ECE centers. The mean total Healthy Eating Index 2015 score was higher for foods and beverages consumed at ECE centers (58.3±0.6) than elsewhere (52.5±0.6) (P<0.0001). The mean total Healthy Eating Index 2015 score was also higher on weekdays (58.5±0.5) than on weekends (51.3±0.5) (P<0.0001).

CONCLUSIONS

Children consume a majority of dietary intake away from ECE centers. Overall, diet quality is low, but the quality of foods consumed by children at ECE centers is higher than that consumed elsewhere. ECE centers remain an important source of nutrition and further investigation is warranted to identify ways to support both ECE centers and families to provide healthier eating environments.