A pilot randomised controlled trial of a web-based implementation intervention to increase child intake of fruit and vegetables within childcare centres

Adapting the Nutrition and Physical Activity Self-Assessment: A Cross-Country Case Study of Improving Early Childhood Health Environments in the United States, Australia, and the United Kingdom

Background: Child overweight and obesity is a critical global health issue with substantial individual and societal impacts necessitating early intervention to establish healthy habits. Health promoting early childhood education (ECE) settings are important as most young children attend ECEs in high- and middle-income countries. Nutrition and Physical Activity Self-Assessment for Child Care (NAPSACC) is an evidence-based approach to support improvements to ECE environment for improving child health. While adapting proven child obesity prevention interventions from other countries offers efficiency, the process is frequently underreported and insufficiently documented. Methods: Guided by the ADAPT framework, this article describes the adaptation of NAPSACC in the United States (US), Australia (AU), and the United Kingdom (UK) from 2012 to 2023. Contextual differences in ECE systems in the US, AU, and UK and reflections on the process of adaptation were explored. Results: NAPSACC was successfully adapted, maintaining core theoretical components while allowing for implementation flexibility to meet varying contexts. The iterative adaptation process revealed that a flexible dynamic approach was essential for maintaining the relevance and effectiveness of the NAPSACC intervention in different contexts. Conclusions: Our experience highlights the importance of ongoing iteration, international collaboration, research, and responsiveness to evolving circumstances in adaptation processes. Strong and flexible leadership, such as that demonstrated by NAPSACC's founder, Dr. Dianne S. Ward, facilitates successful adaptation and continuous improvement of public health programs. Trial registration: This paper includes multiple registered trials - NCT02889198, ACTRN12619001158156, ISRCTN16287377, and ISRCTN33134697.

Assessing and Enhancing Nutrition and Physical Activity Environments in Early Childhood Education and Care Centers: Scoping Review of eHealth Tools

BACKGROUND

Early childhood is a critical period for shaping lifelong health behaviors, making early childhood education and care (ECEC) environments ideal for implementing nutrition and physical activity interventions. eHealth tools are increasingly utilized in ECEC settings due to their accessibility, scalability, and cost-effectiveness, demonstrating promise in enhancing educators' practices. Despite the potential effectiveness of these eHealth approaches, a comprehensive collection of available evidence on eHealth tools designed to assess or support best practices for nutrition or physical activity in ECECs is currently lacking.

OBJECTIVE

The primary objective of this scoping review is to map the range of available eHealth tools designed to assess or deliver interventions aimed at improving nutrition or physical activity in ECEC settings, while evaluating their components, theoretical foundations, and effectiveness.

METHODS

This scoping review adhered to the Joanna Briggs Institute methodology, in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) checklist. The objectives, inclusion criteria, and methods for this review were predefined and specified. Eligibility criteria were (1) early childhood educators (population); (2) eHealth (digital) technologies, such as websites, smartphone apps, emails, and social media; and (3) tools designed to assess or deliver interventions aimed at improving best practices for nutrition, physical activity, or both within ECEC settings (context). A search was conducted across 5 electronic databases (PubMed, Scopus, CINAHL Plus, ERIC, and Embase) to identify white literature, and 3 electronic databases (ProQuest, Google Scholar, and targeted Google search), along with hand-searching of reference lists, were used to identify gray literature. All literature was reported in English or French, with the search extending until May 2024. Separate data charting tools were used for white and gray literature.

RESULTS

The search strategy identified 3064 results for white literature, yielding 2653 unique citations after duplicates were removed. Full texts for 65 citations were retrieved and screened for inclusion, resulting in 30 studies eligible for data extraction and analysis. The most common study design was a randomized controlled trial, comprising 16 studies (53%). The largest proportion of studies were conducted in the United States (11 studies, 37%). In total, 19 eHealth tools were identified, targeting nutrition (8 tools, 42%), physical activity (5 tools, 26%), or both nutrition and physical activity (6 tools, 32%). All tools were web based (19 tools, 100%). The gray literature search yielded 1054 results, of which 17 were moved to full-text screening, and 7 met the eligibility criteria for data extraction and analysis. The tools identified in the gray literature originated in Canada (4 tools, 57%) and the United States (3 tools, 43%). The majority targeted nutrition (4 tools, 57%) and were primarily web based (6 tools, 86%), with 1 mobile app (1 tool, 14%).

CONCLUSIONS

This scoping review mapped the available eHealth tools designed to improve nutrition or physical activity environments in ECEC settings, highlighting the growing emphasis on web-based tools and the need for psychometric testing. Future research should systematically evaluate the effectiveness of these tools, particularly those addressing both nutrition and physical activity, to identify the key factors that contribute to long-term behavior change.

TRIAL REGISTRATION

Open Science Framework XTRNZ; https://osf.io/xtrnz.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/52252.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Testing the effects of interventions designed to increase children's consumption of fruit and vegetables, including those focused on specific child-feeding strategies or broader multicomponent interventions targeting the home or childcare environment, is required to assess the potential to reduce this disease burden.

OBJECTIVES

To assess the benefits and harms of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 March 2023. We searched Proquest Dissertations and Theses in December 2022. We reviewed reference lists of included trials and contacted authors of the included trials to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), including cluster-randomised controlled trials (C-RCTs) and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both amongst children aged five years and under compared to no-intervention control, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. We used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the certainty of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 53 trials with 120 trial arms and 12,350 participants. Sixteen trials examined the impact of child-feeding practice interventions only (e.g. repeated food exposure) in increasing child vegetable intake. Twenty trials examined the impact of multicomponent interventions primarily conducted in the childcare setting (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Seventeen trials examined the impact of parent nutrition education only in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children only in increasing child fruit and vegetable intake and one each examined a child-focused mindfulness intervention or providing families with fruit and vegetable interventions. We judged nine of the 53 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is moderate-certainty evidence that child-feeding practice interventions versus no-intervention control probably have a small positive effect on child vegetable consumption, equivalent to an increase of 15.5 grams as-desired consumption of vegetables (SMD 0.44, 95% confidence interval (CI) 0.24 to 0.65; 15 trials, 1976 participants; mean post-intervention follow-up = 12.3 weeks). No trials in this comparison reported information about intervention costs. One trial reported no harms or serious unintended adverse consequences (low-certainty evidence). Multicomponent interventions versus no-intervention control probably have a small effect on child consumption of fruit and vegetables (SMD 0.27, 95% CI 0.11 to 0.43; 14 trials, 4318 participants; moderate-certainty evidence; mean post-intervention follow-up = 4.0 weeks), equivalent to an increase of 0.34 cups of fruit and vegetables a day. One trial, which tested a multicomponent garden-based intervention, reported the installation of the garden as part of the intervention to be USD 1500 per childcare centre (low-certainty evidence). No trials in this comparison reported information about unintended adverse consequences of interventions. Parent nutrition education interventions may have little to no short-term impact on child consumption of fruit and vegetables versus no-intervention control (SMD 0.10, 95% CI -0.02 to 0.22; 14 trials, 4122 participants; low-certainty evidence; mean post-intervention follow-up = 6.4 weeks). One trial reported the total estimated cost of delivering a parent nutrition education intervention for infant feeding, physical activity and sedentary behaviours delivered by a dietitian as approximately AUD 500 per family (low-certainty evidence). One trial reported no unintended adverse consequences on family food expenditure following implementation of an intervention delivered over the telephone to improve parental knowledge and skills about the home food environment (low-certainty evidence). Trials reported receiving governmental or charitable funds, except for one trial reporting industry funding.

AUTHORS' CONCLUSIONS

There was moderate-certainty evidence that child-feeding practice interventions and multicomponent interventions probably lead to only small increases in fruit and vegetable consumption in children aged five years and under. Parent nutrition education interventions may have little or no effect on increasing fruit and vegetable consumption in children aged five years and under. Future research should be prioritised on assessment and reporting of both intervention cost and adverse effects, and development and evaluation of interventions in research gaps, including in a broader range of settings and in low- and middle-income countries. This review continues to be maintained as a living systematic review with monthly searches for new evidence and incorporation of relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Factorial randomised controlled trial to examine the potential effect of a text message-based intervention on reducing adolescent susceptibility to e-cigarette use: a study protocol

INTRODUCTION

Adolescent e-cigarette use, globally and within Australia, has increased in recent years. In response, public health agencies have called for the development of education and communication programmes targeting adolescents. Despite such recommendations, few rigorous evaluations of such interventions currently exist. The main objective of this study is to examine the potential effect of a text message intervention targeting parents and adolescents on adolescent susceptibility to e-cigarette use (eg, intentions towards using e-cigarettes). Secondary objectives are to (1): examine the effect of the intervention on adolescent e-cigarette and combustible tobacco use and (2) examine the acceptability of the intervention.

METHODS AND ANALYSIS

A randomised controlled trial employing a 2×2 factorial design will be conducted with parent-adolescent dyads (aged 12-15 years). Dyads will be randomly allocated to one of four arms: arm 1-a text message intervention delivered to adolescents only; arm 2-a text message intervention delivered to the parents of adolescents only; arm 3-a text message intervention delivered to both the parents and adolescents; and arm 4-an information only control, consisting of an e-cigarette factsheet provided to parents only. Participant recruitment commenced in March 2023 with the aim to recruit 120 parent-adolescent dyads. Data collection to assess study outcomes will occur at baseline, 6, 12 and 24 months post the commencement of the intervention. The primary endpoint will be 6-month follow-up. The primary outcome will be adolescent susceptibility to e-cigarette use, assessed using validated items. Analyses of trial outcomes will be undertaken under an intention-to-treat framework, with all participants included in the analysis in the group they were allocated.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the human research ethics committee of the University of Newcastle (H-2022-0340). Findings will be disseminated in peer-reviewed journals and at conferences.

TRIAL REGISTRATION NUMBER

The trial was registered prospectively with Australian New Zealand Clinical Trials Registry (ACTRN12623000079640).

"I'm not sure whether I will implement it": exploring barriers and facilitators to implementing a digital "healthy eating" resource in early education and care settings - teachers' perspectives

BACKGROUND

Scaling up effective interventions to promote healthy eating habits in children in real-world settings is a pressing need. The success of implementation hinges crucially on engaging end-users and tailoring interventions to meet their specific needs. Building on our prior evaluation of a digital "healthy eating" resource for early childhood education and care (ECEC) staff; this qualitative study aims to pinpoint the barriers and facilitators that influence the successful implementation of such interventions.

METHODS

We conducted twelve semi-structured interviews with ECEC teachers in a Norwegian municipality. Interview participants were later invited to participate in focus groups where two discussions were conducted with five of the participants to reflect on the initial interview findings. Thematic analysis, facilitated by NVivo software, was employed to analyse the data, aiming to identify and summarize teachers' subjective experiences and perspectives.

RESULTS

Teachers' perceptions of barriers to the implementation of an upcoming digital "healthy eating" resource included: (1) No established tradition of using digital resources at work; (2) Uncertainty regarding the achievable outcomes of implementation; (3) Perception of the new "healthy eating" resource as cooking-focused and unnecessary; and (4) Hectic everyday life serving as a barrier to the long-term use of a digital resource. Facilitators for implementation included: (1) A user-friendly format; (2) Newsletters featuring seasonal tips inspire and serve as effective reminders; (3) Emphasis on research and legislation; and (4) Structuring the resource as a series and an idea bank.

CONCLUSIONS

The findings underscore the essential need for tailored strategies and comprehensive support structures to successfully implement a culturally appropriate digital "healthy eating" resource for ECEC staff, ensuring effectiveness and feasibility.

TRIAL REGISTRATION

This study was not registered in a trial registry as it is not a clinical trial or intervention study but serves as a pilot for the Nutrition Now study, trial identifier ISRCTN10694967 ( https://doi.org/10.1186/ISRCTN10694967 ), registration date: 19/06/2022.

Interactive Malaysian Childhood Healthy Lifestyle (i-MaCHeL) programme: a single-arm pilot study

BACKGROUND

The growing obesity epidemic in Malaysia presents a public health challenge that requires innovative intervention strategies. In an effort to address this problem, an Interactive Malaysian Childhood Healthy Lifestyle (i-MaCHeL) programme, which is a web-based initiative designed for preschool child-parent dyads offers a novel approach. Nevertheless, the success of such a web-based intervention depends on several interrelated factors. This research aims to examine the feasibility of i-MaCHeL in the Malaysian context, its usability for preschool child-parent dyads, and the acceptability of the programme among these user groups.

METHODS

This was a single-arm pilot study involving 46 child-parent dyads recruited from six government preschools in Terengganu, Malaysia. The preschools were selected using a cluster random sampling technique at the preschool level. The intervention feasibility was determined based on the retention rate of participants in the pilot study. The System Usability Scale (SUS) and intervention process evaluation were used to assess the usability and acceptability of the web-based i-MaCHeL programme.

RESULTS

The retention data demonstrated that 42 out of 46 participants completed the 13-week intervention programme, which showed that the overall retention rate was 91.3%. A mean (SD) SUS score of 84.70 (13.82) was obtained from parents, indicating that the web-based i-MaCHeL had an acceptable usability level. The mean scores of the process evaluation items ranged from 4.52 (0.63) to 4.83 (0.38), demonstrating that the web-based i-MaCHeL was highly accepted by the parents. The acceptability data also indicated that at least 92.9% (39/42) of the parents agreed/strongly agreed that the web content, programme duration, intervention dose, WhatsApp group, and delivery mode were appropriate.

CONCLUSIONS

According to these findings, the i-MaCHeL intervention using a web-based approach was feasible, usable, and acceptable as part of a weight-related behaviour change intervention for preschool child-parent dyads. This pilot study demonstrated that the web-based i-MaCHeL was feasible and promising for delivering weight-related behavioural intervention to child-parent dyads.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04711525 . Registered on January 15, 2021.

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 Pilot Randomised Controlled Trial to Increase the Sustainment of an Indoor-Outdoor-Free-Play Program in Early Childhood Education and Care Services: A Study Protocol for the Sustaining Play, Sustaining Health (SPSH) Trial

Early Childhood Education and Care (ECEC) settings are important environments to support children's physical activity (PA). In 2021, COVID-19 regulations recommended the provision of indoor-outdoor free-play programs in ECEC settings to reduce the transmission of COVID-19, resulting in an increased uptake of this practice. As the context has since changed, research suggests that ECEC services could cease the implementation of these practices. Therefore, this pilot randomised controlled trial (RCT) aims to examine the feasibility, acceptability, and impact of a sustainment strategy to ensure the ongoing implementation (sustainment) of ECEC-delivered indoor-outdoor free-play programs. Twenty ECEC services located in New South Wales, Australia that have implemented indoor-outdoor free-play programs since the release of COVID-19 guidelines will be recruited. The services will be randomly allocated either the sustainment strategy or usual care. The "Sustaining Play, Sustaining Health" program consists of eight strategies, developed to address key barriers against and facilitators of sustainment informed by the Integrated Sustainability Framework. The outcomes will be assessed via internal project records, staff surveys, and a self-reported measure of free play. This study will provide important data to support the performance of a fully powered trial within Australian ECEC settings and to inform the development of future sustainment strategies.

Facilitators and Barriers to Implementation and Sustainability of Nutrition and Physical Activity Interventions in Early Childcare Settings: a Systematic Review

A stronger understanding of the factors influencing implementation of interventions in community-based early childcare settings is needed. The purpose of this systematic review was to synthesize existing research on facilitators and barriers to implementation and sustainability of nutrition and physical activity interventions in early childcare settings targeting 2-5-year-old children, including considerations for equitable implementation. This review adhered to PRISMA 2020 guidelines. Peer-reviewed literature was searched in PubMed, EMBASE, CINAHL, ERIC, and PsycINFO databases up to September 2020. Primary research studies that examined facilitators and barriers (or related synonyms) to the implementation and sustainability of nutrition and physical activity interventions in early childcare settings were eligible for inclusion. The search yielded 8092 records that were screened by four analysts in Covidence software with a final review of 24 studies. Two independent reviewers conducted study selection, data extraction, and quality appraisal (Mixed Methods Appraisal Tool). A "best fit" framework was applied using the Consolidated Framework for Implementation Research (CFIR) constructs to code barriers and facilitators. The most salient constructs were (1) "Available Resources," which was composed of time, staffing, space, and staff trainings; (2) adaptability; and (3) compatibility, the latter two indicating that easily modifiable interventions facilitated a smoother "fit" and were more likely to be successful, given adequate site-level resources. Only nine (28%) reported the use of a theory, model, or framework to guide evaluation; six studies (24%) included factors related to sustainability; and nine studies (38%) conducted their interventions with low-income or minoritized groups. The findings point to the need for intervention evaluations examining nutrition and physical activity to more consistently consider (a) sustainability factors early on in design and adoption phases; (b) use of theory, model, or framework to guide evaluation; and (c) equity-related frameworks and considerations for how equitable implementation.

A randomised controlled trial of an implementation strategy delivered at scale to increase outdoor free play opportunities in early childhood education and care (ECEC) services: a study protocol for the get outside get active (GOGA) trial

BACKGROUND

Increased outdoor play time in young children is associated with many health and developmental benefits. This study aims to evaluate the impact of a multi-strategy implementation strategy delivered at scale, to increase opportunities for outdoor free play in Early Childhood Education and Care (ECEC) services.

METHODS

The study will employ a parallel-group randomised controlled trial design. One hundred ECEC services in the Hunter New England region of New South Wales, Australia, will be recruited and randomised to receive either a 6-month implementation strategy or usual care. The trial will seek to increase the implementation of an indoor-outdoor routine (whereby children are allowed to move freely between indoor and outdoor spaces during periods of free play), to increase their opportunity to engage in outdoor free play. Development of the strategy was informed by the Behaviour Change Wheel to address determinants identified in the Theoretical Domains Framework. ECEC services allocated to the control group will receive 'usual' implementation support delivered as part of state-wide obesity prevention programs. The primary trial outcome is the mean minutes/day (calculated across 5 consecutive days) of outdoor free play opportunities provided in ECEC services measured at baseline, 6-months (primary end point) and 18-months post baseline. Analyses will be performed using an intention-to-treat approach with ECEC services as the unit of analysis, using a linear mixed effects regression model to assess between-group differences. A sensitivity analysis will be undertaken, adjusting for service characteristics that appear imbalanced between groups at baseline, and a subgroup analysis examining potential intervention effect among services with the lowest baseline outdoor free play opportunities.

DISCUSSION

Identifying effective strategies to support the implementation of indoor-outdoor routines in the ECEC setting at scale is essential to improve child population health.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ( ACTRN12621000987864 ). Prospectively registered 27th July 2021, ANZCTR - Registration.

Feasibility of a Web-Based Implementation Intervention to Improve Child Dietary Intake in Early Childhood Education and Care: Pilot Randomized Controlled Trial

Background

Internationally, the implementation of evidence-based healthy eating policies and practices within early childhood education and care (ECEC) settings that encourage children’s healthy diet is recommended. Despite the existence of evidence-based healthy eating practices, research indicates that current implementation rates are inadequate. Web-based approaches provide a potentially effective and less costly approach to support ECEC staff with implementing nutrition policies and practices.

Objective

The broad aim of this pilot randomized controlled trial is to assess the feasibility of assessing the impact of a web-based program together with health promotion officer (HPO) support on ECEC center implementation of healthy eating policies and practices. Specifically, we seek to describe the completion rate of study evaluation processes (participant consent and data collection rates); examine ECEC center uptake, acceptability, and appropriateness of the intervention and implementation strategies; understand the potential cost of delivering and receiving implementation support strategies; and describe the potential impact of the web-based intervention on the implementation of targeted healthy eating practices among centers in the intervention group.

Methods

A 6-month pilot implementation trial using a cluster-randomized controlled trial design was conducted in 22 ECEC centers within the Hunter New England region of New South Wales, Australia. Potentially eligible centers were distributed a recruitment package and telephoned by the research team to assess eligibility and obtain consent. Centers randomly allocated to the intervention group received access to a web-based program, together with HPO support (eg, educational outreach visit and local technical assistance) to implement 5 healthy eating practices. The web-based program incorporated audit with feedback, development of formal implementation blueprints, and educational materials to facilitate improvement in implementation. The centers allocated to the control group received the usual care.

Results

Of the 57 centers approached for the study, 22 (47%) provided consent to participate. Data collection components were completed by 100% (22/22) of the centers. High uptake for implementation strategies provided by HPOs (10/11, 91% to 11/11, 100%) and the web-based program (11/11, 100%) was observed. At follow-up, intervention centers had logged on to the program at an average of 5.18 (SD 2.52) times. The web-based program and implementation support strategies were highly acceptable (10/11, 91% to 11/11, 100%). Implementation of 4 healthy eating practices improved in the intervention group, ranging from 19% (2/11) to 64% (7/11).

Conclusions

This study provides promising pilot data to warrant the conduct of a fully powered implementation trial to assess the impact of the program on ECEC healthy eating practice implementation.

Trial Registration

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12619001158156; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378099

International Registered Report Identifier (IRRID)

RR2-10.1186/s40814-020-00707-w

Parent Website Engagement and Health Equity Implications in a Child Care-Based Wellness Intervention

OBJECTIVE

To evaluate demographic differences in parent website engagement in a child care-based wellness intervention.

DESIGN

Parent-reported demographic characteristics and observed website engagement were averaged by child care centers participating in the web-based intervention arm of a cluster randomized controlled trial of wellness interventions.

SETTING AND PARTICIPANTS

Parents of preschoolers in 17 Maryland child care centers.

MAIN OUTCOME MEASURES

Website engagement: (1) webpage views, (2) average time on webpage, and (3) intervention activity completion.

INTERVENTION

Parents received access to a website containing content on wellness-promoting topics (eg, parenting, nutrition, physical activity) and their child care center's activities.

ANALYSIS

Cross-sectional differences in website engagement by demographic characteristics were assessed using ANOVA.

RESULTS

Centers with a high proportion of parents who identified as other than non-Hispanic White and had less than a bachelor's degree had significantly fewer webpage views, and completed significantly fewer intervention activities compared with centers with parents who were predominantly non-Hispanic White and had more than a bachelor's degree.

CONCLUSIONS AND IMPLICATIONS

Demographic differences in parents' child care center website engagement represent disparities that could contribute to health inequities in parents' access to wellness-promoting material. Future efforts could identify factors that eliminate demographic disparities in parent engagement in web-based interventions.

The Association between Australian Childcare Centre Healthy Eating Practices and Children's Healthy Eating Behaviours: A Cross-Sectional Study within Lunchbox Centres

The association between healthy eating practices and child dietary intake in childcare centres where parents pack foods from home has received little attention. This study aimed to: (1) Describe the nutritional content of foods and beverages consumed by children in care; and (2) Assess the association between centre healthy eating practices and child intake of fruit and vegetable servings, added sugar(grams), saturated fat(grams) and sodium(milligrams) in care. A cross-sectional study amongst 448 children attending 22 childcare centres in New South Wales, Australia, was conducted. Child dietary intake was measured via weighed lunchbox measurements, photographs and researcher observation, and centre healthy eating practices were assessed via researcher observation of centre nutrition environments. Children attending lunchbox centres consumed, on average 0.80 servings (standard deviation 0.69) of fruit and 0.27 servings (standard deviation 0.51) of vegetables in care. The availability of foods within children’s lunchboxes was associated with intake of such foods (p < 0.01). Centre provision of intentional healthy eating learning experiences (estimate −0.56; p = 0.01) and the use of feeding practices that support children’s healthy eating (estimate −2.02; p = 0.04) were significantly associated with reduced child intake of saturated fat. Interventions to improve child nutrition in centres should focus on a range of healthy eating practices, including the availability of foods packed within lunchboxes.

An Overview of Research Opportunities to Increase the Impact of Nutrition Intervention Research in Early Childhood and Education Care Settings According to the RE-AIM Framework

Objective: To highlight opportunities for future nutrition intervention research within early childhood and education care (ECEC) settings, with a focus on generating evidence that has applicability to real-world policy and practice. Methods: An overview of opportunities to progress the field was developed by the authors using a collaborative writing approach and informed by recent research in the field. The group developed a list of recommendations aligned with the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) framework. Pairs of authors drafted individual sections of the manuscript, which were then reviewed by a separate pair. The first and senior author consolidated all sections of the manuscript and sought critical input on the draft iterations of the manuscript. Results: Interventions that employ digital platforms (reach) in ECEC settings, as well as research in the family day care setting (effectiveness) were identified as areas of opportunities. Research understanding the determinants of and effective strategies for dissemination (adoption), the implementation of nutrition programs, in addition to de-implementation (implementation) of inappropriate nutrition practices, is warranted. For maintenance, there is a need to better understand sustainability and the sustainment of interventions, in addition to undertaking policy-relevant research. Conclusions: The ECEC setting is prime for innovative and practical nutrition intervention research.

Guidance for conducting feasibility and pilot studies for implementation trials

BACKGROUND

Implementation trials aim to test the effects of implementation strategies on the adoption, integration or uptake of an evidence-based intervention within organisations or settings. Feasibility and pilot studies can assist with building and testing effective implementation strategies by helping to address uncertainties around design and methods, assessing potential implementation strategy effects and identifying potential causal mechanisms. This paper aims to provide broad guidance for the conduct of feasibility and pilot studies for implementation trials.

METHODS

We convened a group with a mutual interest in the use of feasibility and pilot trials in implementation science including implementation and behavioural science experts and public health researchers. We conducted a literature review to identify existing recommendations for feasibility and pilot studies, as well as publications describing formative processes for implementation trials. In the absence of previous explicit guidance for the conduct of feasibility or pilot implementation trials specifically, we used the effectiveness-implementation hybrid trial design typology proposed by Curran and colleagues as a framework for conceptualising the application of feasibility and pilot testing of implementation interventions. We discuss and offer guidance regarding the aims, methods, design, measures, progression criteria and reporting for implementation feasibility and pilot studies.

CONCLUSIONS

This paper provides a resource for those undertaking preliminary work to enrich and inform larger scale implementation trials.