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Aristova A, Spence AC, Irwin C, Elford A, Graham L, Love P. Nutrition environments in early childhood education: do they align with best practice? Public Health Nutr 2024; 27:e124. [PMID: 38680073 DOI: 10.1017/s136898002400096x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
OBJECTIVE To assess the comprehensiveness (scope of nutrition guidance) and strength (clarity of written language) of centre-based nutrition policies (CBNP) within early childhood education (ECE) centres. To also consider the applicability of an existing CBNP assessment tool and policy alignment with best practice food provision and feeding practices. DESIGN Cross-sectional online study to assess written ECE CNBP using the Wellness Child Care Assessment Tool. SETTING Licenced ECE centres in the state of Victoria, Australia. PARTICIPANTS ECE centres (operating at least 8 h per d, 48 weeks per annum), stratified by location (rural and metropolitan), centre management type (profit and not-for-profit) and socio-economic area (low, middle, high). RESULTS Included individual CBNP (n 118), predominantly from metropolitan centres (56 %) and low-medium socio-economic areas (78 %). Policies had low overall Wellness Child Care Assessment Tool scores, particularly strength scores which were low across all four domains (i.e. nutrition education, nutrition standards, health promotion and communication/evaluation). The nutrition standards domain had the lowest strength score. The communication/evaluation domain had the lowest comprehensiveness score. Content analysis indicated low scores may relate to the Wellness Child Care Assessment Tool applicability for the Australian context due to differences in best practice guidance. CONCLUSION Despite the presence of written nutrition policies in ECE centres, many showed weak language and lacked comprehensiveness and strength. This may relate to poor implementation of best practice food provision or feeding practices. Low scores, however, may partly stem from using an assessment tool that is not country-specific. The redevelopment of country-specific tools to assess ECE CNBP may be warranted.
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Affiliation(s)
- Anna Aristova
- School of Exercise and Nutrition Sciences, Deakin University, Waurn Ponds, VIC3216, Australia
| | - Alison C Spence
- Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC, Australia
| | - Christopher Irwin
- School of Health Sciences and Social Work (SHS), Nutrition and Dietetics, Griffith University, Southport, QLD, Australia
| | - Audrey Elford
- Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC, Australia
| | - Laura Graham
- School of Exercise and Nutrition Sciences, Deakin University, Waurn Ponds, VIC3216, Australia
| | - Penelope Love
- Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC, Australia
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Jerebine A, Heering T, Barnett LM. Educator-Perceived Barriers and Facilitators to Structured-Physical Activity in Early Childhood Centres: A Systematic Review. RESEARCH QUARTERLY FOR EXERCISE AND SPORT 2024; 95:243-262. [PMID: 37327492 DOI: 10.1080/02701367.2023.2193243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 03/10/2023] [Indexed: 06/18/2023]
Abstract
Purpose: Physical activity (PA) and motor competence development are vital for young children, yet many early childhood education and care (ECEC) centers struggle to successfully implement PA programs, particularly those organized and led by educators. This review aimed to synthesize qualitative literature to (1) identify educator-perceived barriers and facilitators to structured-PA in ECEC centers, and (2) map these to the COM-B model and Theoretical Domains Framework (TDF). Methods: Following PRISMA guidelines, a systematic search of five databases was conducted in April 2021 and updated in August 2022. Records were screened in Covidence software using predefined eligibility criteria. Using the framework synthesis method, data extraction and synthesis were conducted in coding forms in Excel and NVivo. Results: Of 2382 records identified, 35 studies were included, representing 2,365 educators across 268 ECEC centers in 10 countries. Using the COM-B model and TDF, an evidence-informed framework was developed. Findings revealed the greatest barriers concerned educator "opportunity" (e.g. competing time and priorities, policy tensions, indoor/outdoor space constraints) and "capability" (e.g. lack of PA knowledge and practical, hands-on skills) to implement structured-PA. Although fewer studies reported factors that influenced educator "motivation", several themes intersected across the three COM-B components illustrating the complexity of behavioral determinants in this setting. Conclusions: Interventions grounded in theory that utilize a systems approach to target multiple levels of influence on educator behavior, and are flexible and adaptable locally, are recommended. Future work should seek to address societal barriers, structural challenges in the sector, and the PA educational needs of educators. PROSPERO Registration: CRD42021247977.
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Wenden EJ, Budgeon CA, Pearce NL, Christian HE. Organizational readiness and implementation fidelity of an early childhood education and care-specific physical activity policy intervention: findings from the Play Active trial. J Public Health (Oxf) 2024; 46:158-167. [PMID: 37993975 PMCID: PMC10901271 DOI: 10.1093/pubmed/fdad221] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 10/10/2023] [Accepted: 10/25/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND Many children do not accumulate sufficient physical activity for good health and development at early childhood education and care (ECEC). This study examined the association between ECEC organizational readiness and implementation fidelity of an ECEC-specific physical activity policy intervention. METHODS Play Active aimed to improve the ECEC educator's physical activity practices. We investigated the implementation of Play Active using a Type 1 hybrid study (January 2021-March 2022). Associations between organizational readiness factors and service-level implementation fidelity were examined using linear regressions. Fidelity data were collected from project records, educator surveys and website analytics. RESULTS ECEC services with higher levels of organizational commitment and capacity at pre-implementation reported higher fidelity scores compared to services with lower organizational commitment and capacity (all Ps < 0.05). Similarly, services who perceived intervention acceptability and appropriateness at pre-implementation to be high had higher fidelity scores (P < 0.05). Perceived feasibility and organizational efficacy of Play Active were associated with higher but nonsignificant fidelity scores. CONCLUSIONS Results indicate that organizational readiness factors may influence the implementation of ECEC-specific physical activity policy interventions. Therefore, strategies to improve organizational readiness should be developed and tested. These findings warrant confirmation in the ECEC and other settings and with other health behavior interventions.
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Affiliation(s)
- Elizabeth J Wenden
- Telethon Kids Institute, University of Western Australia, Crawley, WA, Australia
- School of Population and Global Health, University of Western Australia, Crawley, WA, Australia
| | - Charley A Budgeon
- School of Population and Global Health, University of Western Australia, Crawley, WA, Australia
| | - Natasha L Pearce
- Telethon Kids Institute, University of Western Australia, Crawley, WA, Australia
- School of Population and Global Health, University of Western Australia, Crawley, WA, Australia
| | - Hayley E Christian
- Telethon Kids Institute, University of Western Australia, Crawley, WA, Australia
- School of Population and Global Health, University of Western Australia, Crawley, WA, Australia
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Lum M, Grady A, Wolfenden L, Lecathelinais C, Lin Yoong S. Implementation of healthy eating and physical activity practices in Australian early childhood education and care services: A cross-sectional study. Prev Med Rep 2023; 36:102455. [PMID: 37840588 PMCID: PMC10571023 DOI: 10.1016/j.pmedr.2023.102455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 08/29/2023] [Accepted: 10/01/2023] [Indexed: 10/17/2023] Open
Abstract
Background The monitoring of healthy eating and physical activity environments is recommended to support population health. Early childhood education and care (ECEC) services are a key setting to deliver obesity prevention strategies as they reach the majority of children aged under five years and have existing supporting infrastructure. Objectives The aim of this study was to i) describe the prevalence of implementation of evidence-based healthy eating and physical activity practices in an Australian sample of ECEC services, and ii) examine associations between implementation of practices and service characteristics. Methods A random sample of 2,100 centre-based ECEC services across Australia were invited to participate in a cross-sectional survey online or via telephone (August 2021-April 2022). Service characteristics and implementation of 18 evidence-based healthy eating and physical activity practices were assessed. Descriptive statistics and linear mixed regression analyses were performed. Results A total of 1,028 (51.8%) eligible services participated. The healthy eating and physical activity practices with the lowest prevalence of implementation were related to encouraging children to consume age-appropriate beverages (17.9%) and providing families with child physical activity education via workshops or meetings (14.6%), respectively. There was a statistically significant difference in the implementation of healthy eating practices by service characteristics, with long day care services implementing significantly more practices than preschools (p < 0.01). Conclusion There is room to improve the implementation of evidence-based healthy eating and physical activity practices ECEC services. Implementation efforts should be directed towards preschools.
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Affiliation(s)
- Melanie Lum
- Global Centre for Preventive Health and Nutrition, Institute for Health Transformation, Deakin University, School of Health and Social Development, Faculty of Health, Geelong VIC 3220 Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308 Australia
- Population Health, Hunter New England Local Health District, Locked Bag 10, Wallsend NSW 2287 Australia
- National Centre of Implementation Science, University of Newcastle, Locked Bag 10, Wallsend NSW 2287 Australia
| | - Alice Grady
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308 Australia
- Population Health, Hunter New England Local Health District, Locked Bag 10, Wallsend NSW 2287 Australia
- National Centre of Implementation Science, University of Newcastle, Locked Bag 10, Wallsend NSW 2287 Australia
| | - Luke Wolfenden
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308 Australia
- Population Health, Hunter New England Local Health District, Locked Bag 10, Wallsend NSW 2287 Australia
- National Centre of Implementation Science, University of Newcastle, Locked Bag 10, Wallsend NSW 2287 Australia
| | - Christophe Lecathelinais
- Population Health, Hunter New England Local Health District, Locked Bag 10, Wallsend NSW 2287 Australia
| | - Sze Lin Yoong
- Global Centre for Preventive Health and Nutrition, Institute for Health Transformation, Deakin University, School of Health and Social Development, Faculty of Health, Geelong VIC 3220 Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308 Australia
- Population Health, Hunter New England Local Health District, Locked Bag 10, Wallsend NSW 2287 Australia
- National Centre of Implementation Science, University of Newcastle, Locked Bag 10, Wallsend NSW 2287 Australia
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Finch M, Lum M, Yoong SL, Hodder RK, Grady A, Wolfenden L. Dissemination of public health research evidence and guidelines to Australian Early Childhood Education and Care staff: Views about source, content and format. Health Promot J Austr 2023. [PMID: 37827995 DOI: 10.1002/hpja.820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 09/15/2023] [Accepted: 10/03/2023] [Indexed: 10/14/2023] Open
Abstract
ISSUE ADDRESSED Effective dissemination of public health research and evidence-based guidelines to Early Childhood Education and Care (ECEC) staff is critical for promoting research transfer and uptake and achieving positive outcomes for children. METHODS A cross-sectional study was conducted during August 2021 to March 2022, with a sub-sample of Australian ECEC services participating in a larger survey completed online and via Computer-Assisted Telephone Interview. Survey items assessed: influential source for receiving research, type of content that would influence decisions to adopt research and preferred formats for receiving research. RESULTS Overall, 993 service managers or staff from 1984 (50.0%) invited and eligible services completed the larger survey. Of these, 463 randomly allocated services (46.7%) had staff complete the dissemination items. The Australian Children's Education and Care Quality Authority, ECEC agencies and Government Departments were most frequently selected as influential sources of research evidence. Staff were most interested in content providing evidence-based recommendations for future actions and descriptions of health issues addressed. Workshops or conferences and webinars were the preferred format for receiving research. CONCLUSIONS Findings highlight the importance of tailoring dissemination strategies to meet ECEC staff needs and engaging influential sources to disseminate research evidence. SO WHAT?: Understanding dissemination preferences of ECEC staff is crucial for supporting uptake of evidence-based health promotion in this setting. By developing tailored strategies based on ECEC preferences, research transfer and evidence-based decision making can be supported more effectively. These findings contribute to bridging the evidence-practice gap and improving the quality of care and health outcomes for children in ECEC settings.
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Affiliation(s)
- Meghan Finch
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- National Centre of Implementation Science, University of Newcastle, Wallsend, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Melanie Lum
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- National Centre of Implementation Science, University of Newcastle, Wallsend, New South Wales, Australia
- Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
- Global Centre for Preventive Health and Nutrition, Institute for Health Transformation, School of Health and Social Development, Deakin University, Geelong, Victoria, Australia
| | - Sze Lin Yoong
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- National Centre of Implementation Science, University of Newcastle, Wallsend, New South Wales, Australia
- Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
- Global Centre for Preventive Health and Nutrition, Institute for Health Transformation, School of Health and Social Development, Deakin University, Geelong, Victoria, Australia
| | - Rebecca K Hodder
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- National Centre of Implementation Science, University of Newcastle, Wallsend, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
| | - Alice Grady
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- National Centre of Implementation Science, University of Newcastle, Wallsend, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
| | - Luke Wolfenden
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- National Centre of Implementation Science, University of Newcastle, Wallsend, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
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Lum M, Yoong SL, Wolfenden L, Turon H, Reilly K, Grady A. Impact of a dissemination strategy on family day care educators' intentions to adopt outdoor free play guidelines introduced in response to COVID-19: a randomized controlled trial. HEALTH EDUCATION RESEARCH 2023; 38:458-468. [PMID: 36943373 PMCID: PMC10516333 DOI: 10.1093/her/cyad014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 03/02/2023] [Accepted: 03/06/2023] [Indexed: 06/18/2023]
Abstract
In 2021, guidelines for early childhood education and care were released recommending children are provided access to outdoor areas during all free play sessions to reduce the risk of coronavirus disease of 2019 transmission, aligning with the existing recommendations to increase children's physical activity. There is a need to understand how to disseminate guidelines in this setting as dissemination is a prerequisite of adoption and implementation. This randomized controlled trial explored the impact of a video-based strategy to disseminate guidelines on family day care educators' intentions to adopt outdoor free play guidelines. Educators (N = 255) were randomized to receive a video (intervention) or text-based (usual care) resource via email describing recommendations. Educators were invited to participate in a post-intervention survey at 5-week follow-up assessing intentions to adopt guidelines. The secondary outcomes included knowledge, beliefs about capabilities, beliefs about consequences, social/professional role and identity, goals, implementation of guidelines, acceptability of resource and intervention reach. There was no statistically significant difference between groups in intentions to adopt guidelines [ß = 0.01 (95% confidence interval -0.50 to 0.52), P = 0.97], nor for any secondary outcomes. Further investigation is needed to identify effective dissemination strategies in the family day care setting to increase the adoption of public health guidelines.
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Affiliation(s)
- M Lum
- Hunter New England Population Health, Hunter New England Local Health District, Booth Building, Longworth Ave, Wallsend, NSW 2287, Australia
- School of Medicine and Public Health, University of Newcastle, University Dr, Callaghan, NSW 2308, Australia
- Hunter Medical Research Institute, University of Newcastle, Lot 1 Kookaburra Cct, New Lambton Heights, NSW 2305, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, University Dr, Callaghan, NSW 2308, Australia
| | - S L Yoong
- Hunter New England Population Health, Hunter New England Local Health District, Booth Building, Longworth Ave, Wallsend, NSW 2287, Australia
- School of Medicine and Public Health, University of Newcastle, University Dr, Callaghan, NSW 2308, Australia
- Hunter Medical Research Institute, University of Newcastle, Lot 1 Kookaburra Cct, New Lambton Heights, NSW 2305, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, University Dr, Callaghan, NSW 2308, Australia
- Global Centre for Preventive Nutrition and Health, Institute for Health Transformation, School of Health and Social Development, Deakin University, 221 Burwood Highway, Burwood, VIC 3125, Australia
| | - L Wolfenden
- Hunter New England Population Health, Hunter New England Local Health District, Booth Building, Longworth Ave, Wallsend, NSW 2287, Australia
- School of Medicine and Public Health, University of Newcastle, University Dr, Callaghan, NSW 2308, Australia
- Hunter Medical Research Institute, University of Newcastle, Lot 1 Kookaburra Cct, New Lambton Heights, NSW 2305, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, University Dr, Callaghan, NSW 2308, Australia
| | - H Turon
- School of Medicine and Public Health, University of Newcastle, University Dr, Callaghan, NSW 2308, Australia
- Hunter Medical Research Institute, University of Newcastle, Lot 1 Kookaburra Cct, New Lambton Heights, NSW 2305, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, University Dr, Callaghan, NSW 2308, Australia
| | - K Reilly
- School of Medicine and Public Health, University of Newcastle, University Dr, Callaghan, NSW 2308, Australia
- Hunter Medical Research Institute, University of Newcastle, Lot 1 Kookaburra Cct, New Lambton Heights, NSW 2305, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, University Dr, Callaghan, NSW 2308, Australia
| | - A Grady
- Hunter New England Population Health, Hunter New England Local Health District, Booth Building, Longworth Ave, Wallsend, NSW 2287, Australia
- School of Medicine and Public Health, University of Newcastle, University Dr, Callaghan, NSW 2308, Australia
- Hunter Medical Research Institute, University of Newcastle, Lot 1 Kookaburra Cct, New Lambton Heights, NSW 2305, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, University Dr, Callaghan, NSW 2308, Australia
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Yoong SL, Lum M, Wolfenden L, Jackson J, Barnes C, Hall AE, McCrabb S, Pearson N, Lane C, Jones JZ, Nolan E, Dinour L, McDonnell T, Booth D, Grady A. Healthy eating interventions delivered in early childhood education and care settings for improving the diet of children aged six months to six years. Cochrane Database Syst Rev 2023; 8:CD013862. [PMID: 37606067 PMCID: PMC10443896 DOI: 10.1002/14651858.cd013862.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
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.
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Affiliation(s)
- Sze Lin Yoong
- Global Centre for Preventive Health and Nutrition, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Victoria, Australia
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Melanie Lum
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Luke Wolfenden
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Jacklyn Jackson
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Courtney Barnes
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Alix E Hall
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Sam McCrabb
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Nicole Pearson
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Cassandra Lane
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Jannah Z Jones
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Erin Nolan
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Lauren Dinour
- College of Education and Human Services, Montclair State University, Montclair, New Jersey, USA
| | - Therese McDonnell
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | - Debbie Booth
- Auchmuty Library, University of Newcastle, Callaghan, Australia
| | - Alice Grady
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
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Neshteruk C, Burkart S, Flanagan EW, Melnick E, Luecking C, Kracht CL. Policy, systems, and environmental interventions addressing physical activity in early childhood education settings: A systematic review. Prev Med 2023; 173:107606. [PMID: 37414226 PMCID: PMC10699121 DOI: 10.1016/j.ypmed.2023.107606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 05/30/2023] [Accepted: 07/02/2023] [Indexed: 07/08/2023]
Abstract
Policy, systems, and environmental (PSE) approaches can facilitate physical activity in priority populations (e.g., racial and ethnic minority, low wealth groups) within early childhood education (ECE) settings. The purpose of this review was to 1) characterize the inclusion of priority populations within ECE physical activity interventions containing PSE approaches and 2) identify and describe interventions within these populations. Seven databases were systematically searched (January 2000-Febrary 2022) for ECE-based interventions focusing on children (0-6 years) that utilized at least one PSE approach. Eligible studies included a child physical activity or physical activity environment outcome and child or center-level population characteristics. Forty-four studies, representing 42 interventions were identified. For Aim 1, half of interventions included one PSE approach (21/42), with only 11/42 including three or more approaches. Physical environment changes [e.g., adding play equipment, modifying space (25/42)] were the most used PSE approaches followed by system [e.g., integrating activity into routines, (21/42)] and policy [e.g., outdoor time (20/42)] approaches. Nearly half of interventions were conducted in predominantly priority populations (18/42). Studies were primarily rated as good (51%) or fair (38%) methodological quality using the Downs and Black checklist. In Aim 2, of the 12 interventions assessing child physical activity in priority populations, 9/12 reported at least one physical activity outcome in the expected direction. Of the 11 interventions assessing the physical activity environment, 9/11 reported an effect in the expected direction. Findings indicate clear opportunities exist to target priority populations by incorporating PSE approaches in ECE physical activity interventions.
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Affiliation(s)
- Cody Neshteruk
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States of America.
| | - Sarah Burkart
- Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States of America
| | - Emily W Flanagan
- Pennington Biomedical Research Center, 6400 Perkins Road, Baton Rouge, LA 70808, United States of America
| | - Emily Melnick
- College of Health Solutions, Arizona State University, Phoenix, AZ, United States of America
| | - Courtney Luecking
- Department of Dietetics and Human Nutrition, College of Agriculture, Food and Environment, University of Kentucky, Lexington, KY, United States of America
| | - Chelsea L Kracht
- Pennington Biomedical Research Center, 6400 Perkins Road, Baton Rouge, LA 70808, United States of America
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9
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Reilly K, Jackson J, Lum M, Pearson N, Lecathelinais C, Wolfenden L, Turon H, Yoong SL. The impact of an e-newsletter or animated video to disseminate outdoor free-play information in relation to COVID-19 guidelines in New South Wales early childhood education and care services: a randomised controlled trial. BMC Public Health 2023; 23:1306. [PMID: 37420179 PMCID: PMC10326923 DOI: 10.1186/s12889-023-16177-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/22/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND State-based Guidelines were issued for Early Childhood Education and Care (ECEC) services (caring for children 0-6 years) recommending greater time outdoors and inclusion of indoor-outdoor programs to facilitate social distancing to reduce spread of COVID-19. The aim of this 3-arm randomised controlled trial (RCT) was to examine the impact of different dissemination strategies on increasing ECEC service intentions to adopt recommendations from the Guidelines. METHODS This was a post-intervention only RCT. A sample of eligible ECEC services in New South Wales (n = 1026) were randomly allocated to one of three groups; (i) e-newsletter resource; (ii) animated video resource; or (iii) control (standard email). The intervention was designed to address key determinants of guideline adoption including awareness and knowledge. Following delivery of the intervention in September 2021, services were invited to participate in an online or telephone survey from October-December 2021. The primary trial outcome was the proportion of services intending to adopt the Guidelines, defined as intention to; (i) offer an indoor-outdoor program for the full day; or (ii) offer more outdoor play time. Secondary outcomes included awareness, reach, knowledge and implementation of the Guidelines. Barriers to Guideline implementation, cost of the dissemination strategies and analytic data to measure fidelity of intervention delivery were also captured. RESULTS Of the 154 services that provided post-intervention data, 58 received the e-newsletter (37.7%), 50 received the animated video (32.5%), and 46 received the control (29.9%). Services who received the animated video had nearly five times the odds (OR: 4.91 [1.03, 23.34] p = 0.046) than those in the control group, to report having intentions to adopt the Guidelines. There were no statistically significant differences in awareness or knowledge of the Guidelines between either intervention or control services. Development costs were greatest for the animated video. The extent to which the dissemination strategy was viewed in full, were similar for both the e-newsletter and animated video. CONCLUSION This study found potential for the inclusion of interactive strategies to disseminate policy and guideline information within the ECEC setting, in the context of the need for rapid communication. Further research should explore the added benefits of embedding such strategies within a multi-strategy intervention. TRIAL REGISTRATION Retrospectively registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) on the 23/02/2023 (ACTRN 12,623,000,198,628).
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Affiliation(s)
- Kathryn Reilly
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia.
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia.
- Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia.
- Hunter New England Population Health Unit, Hunter New England Local Health District, Wallsend, NSW, Australia.
| | - Jacklyn Jackson
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia
- Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia
| | - Melanie Lum
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia
- Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia
- Hunter New England Population Health Unit, Hunter New England Local Health District, Wallsend, NSW, Australia
- Global Obesity Centre, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Geelong, Australia
| | - Nicole Pearson
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia
- Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia
- Hunter New England Population Health Unit, Hunter New England Local Health District, Wallsend, NSW, Australia
| | - Christophe Lecathelinais
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia
- Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia
- Hunter New England Population Health Unit, Hunter New England Local Health District, Wallsend, NSW, Australia
| | - Luke Wolfenden
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia
- Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia
- Hunter New England Population Health Unit, Hunter New England Local Health District, Wallsend, NSW, Australia
| | - Heidi Turon
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia
- Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia
| | - Sze Lin Yoong
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia
- Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia
- Hunter New England Population Health Unit, Hunter New England Local Health District, Wallsend, NSW, Australia
- Global Obesity Centre, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Geelong, Australia
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Yoong SL, Lum M, Wolfenden L, Jackson J, Barnes C, Hall AE, McCrabb S, Pearson N, Lane C, Jones JZ, Dinour L, McDonnell T, Booth D, Grady A. Healthy eating interventions delivered in early childhood education and care settings for improving the diet of children aged six months to six years. Cochrane Database Syst Rev 2023; 6:CD013862. [PMID: 37306513 PMCID: PMC10259732 DOI: 10.1002/14651858.cd013862.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
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.
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Affiliation(s)
- Sze Lin Yoong
- Global Centre for Preventive Health and Nutrition, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Victoria, Australia
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Melanie Lum
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Luke Wolfenden
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Jacklyn Jackson
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Courtney Barnes
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Alix E Hall
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Sam McCrabb
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Nicole Pearson
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Cassandra Lane
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Jannah Z Jones
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Lauren Dinour
- College of Education and Human Services, Montclair State University, Montclair, New Jersey, USA
| | - Therese McDonnell
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | - Debbie Booth
- Auchmuty Library, University of Newcastle, Callaghan, Australia
| | - Alice Grady
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
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11
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Kracht CL, Burkart S, Flanagan EW, Melnick E, Luecking C, Neshteruk C. Policy, system, and environmental interventions addressing obesity and diet-related outcomes in early childhood education settings: A systematic review. Obes Rev 2023; 24:e13547. [PMID: 36601716 PMCID: PMC10214414 DOI: 10.1111/obr.13547] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 12/06/2022] [Indexed: 01/06/2023]
Abstract
Early childhood education (ECE) settings play an important role in child dietary intake and excess weight gain. Policy, systems, and environment (PSE) approaches have potential to reduce disparities in children at higher risk for obesity. The purpose of this review was to (1) characterize the inclusion of populations at higher risk for obesity in ECE interventions and (2) identify effective ECE interventions in these populations. Seven databases were searched for ECE interventions. Intervention characteristics and methodological quality were assessed in 35 articles representing 34 interventions. Interventions identified were mainly a combination of ECE and parent interventions (41%) or stand-alone ECE intervention (29%), with few multisector efforts (23%) or government regulations assessed (5%). Many included policy (70%) or social environment components (61%). For Aim 1, two thirds were conducted in primarily populations at higher risk for obesity (67%). Studies were rated as fair or good methodological quality. For Aim 2, 10 studies demonstrated effectiveness at improving diet or reducing obesity in populations at higher risk for obesity. Most included a longer intervention (i.e., >6 months), multiple PSE components, and formative work. Opportunities to incorporate more PSE components in ECE-based interventions and collaborate with parents and communities are warranted to improve child health.
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Affiliation(s)
- Chelsea L. Kracht
- Clinical Science Department, Pennington Biomedical Research Center, Baton Rouge, Louisiana, USA
| | - Sarah Burkart
- Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - Emily W. Flanagan
- Clinical Science Department, Pennington Biomedical Research Center, Baton Rouge, Louisiana, USA
| | - Emily Melnick
- College of Health Solutions, Arizona State University, Phoenix, Arizona, USA
| | - Courtney Luecking
- Department of Dietetics and Human Nutrition, College of Agriculture, Food and Environment, University of Kentucky, Lexington, Kentucky, USA
| | - Cody Neshteruk
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
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12
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Economos CD, Calancie L, Korn AR, Allender S, Appel JM, Bakun P, Hennessy E, Hovmand PS, Kasman M, Nichols M, Pachucki MC, Swinburn BA, Tovar A, Hammond RA. Community coalition efforts to prevent childhood obesity: two-year results of the Shape Up Under 5 study. BMC Public Health 2023; 23:529. [PMID: 36941543 PMCID: PMC10026415 DOI: 10.1186/s12889-023-15288-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 02/17/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Cross-sector collaborations and coalitions are promising approaches for childhood obesity prevention, yet there is little empirical evidence about how they affect change. We hypothesized that changes in knowledge of, and engagement with, childhood obesity prevention among coalition members can diffuse through social networks to influence policies, systems, and environments. METHODS We studied a community coalition (N = 16, Shape Up Under 5 "SUU5 Committee") focused on early childhood obesity prevention in Somerville, MA from 2015-17. Knowledge, engagement, and social network data were collected from Committee members and their network contacts (n = 193) at five timepoints over two years. Policy, systems, and environment data were collected from the SUU5 Committee. Data were collected via the validated COMPACT Stakeholder-driven Community Diffusion survey and analyzed using regression models and social network analysis. RESULTS Over 2 years, knowledge of (p = 0.0002), and engagement with (p = 0.03), childhood obesity prevention increased significantly among the SUU5 Committee. Knowledge increased among the Committee's social network (p = 0.001). Significant changes in policies, systems, and environments that support childhood obesity prevention were seen from baseline to 24 months (p = 0.003). CONCLUSION SUU5 had positive effects on "upstream" drivers of early childhood obesity by increasing knowledge and engagement. These changes partially diffused through networks and may have changed "midstream" community policies, systems, and environments.
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Affiliation(s)
- Christina D Economos
- Friedman School of Nutrition Science and Policy, Tufts University, Tufts University, 150 Harrison Ave., Boston, MA, 02111, USA.
| | - Larissa Calancie
- Friedman School of Nutrition Science and Policy, Tufts University, Tufts University, 150 Harrison Ave., Boston, MA, 02111, USA
| | - Ariella R Korn
- Friedman School of Nutrition Science and Policy, Tufts University, Tufts University, 150 Harrison Ave., Boston, MA, 02111, USA
| | - Steven Allender
- Institute for Health Transformation, Deakin University, Geelong, Australia
| | - Julia M Appel
- Friedman School of Nutrition Science and Policy, Tufts University, Tufts University, 150 Harrison Ave., Boston, MA, 02111, USA
| | - Peter Bakun
- Friedman School of Nutrition Science and Policy, Tufts University, Tufts University, 150 Harrison Ave., Boston, MA, 02111, USA
| | - Erin Hennessy
- Friedman School of Nutrition Science and Policy, Tufts University, Tufts University, 150 Harrison Ave., Boston, MA, 02111, USA
| | - Peter S Hovmand
- Center for Community Health Integration, Case Western Reserve University, Cleveland, OH, USA
| | - Matt Kasman
- Economic Studies, Brookings, Washington, D.C., USA
| | - Melanie Nichols
- Institute for Health Transformation, Deakin University, Geelong, Australia
| | - Mark C Pachucki
- Sociology and Computational Social Science Institute, University of Massachusetts, Amherst, MA, USA
| | - Boyd A Swinburn
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - Alison Tovar
- Behavioral and Social Sciences, Brown University, Providence, RI, USA
| | - Ross A Hammond
- Economic Studies, Brookings, Washington, D.C., USA
- Brown School, Washington University in St Louis, St Louis, MO, USA
- Santa Fe Institute, Santa Fe, NM, USA
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Imad N, Pearson N, Hall A, Shoesmith A, Nathan N, Giles L, Grady A, Yoong S. 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. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:5043. [PMID: 36981955 PMCID: PMC10048850 DOI: 10.3390/ijerph20065043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/08/2023] [Accepted: 03/09/2023] [Indexed: 06/18/2023]
Abstract
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.
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Affiliation(s)
- Noor Imad
- School of Health Sciences, Department of Nursing and Allied Health, Swinburne University of Technology, Hawthorn, VIC 3122, Australia
- Faculty of Health, School of Health and Social Development, Global Centre for Preventive Health and Nutrition, Institute for Health Transformation, Deakin University, Geelong, VIC 3220, Australia
- Hunter New England Population Health, Wallsend, NSW 2287, Australia
| | - Nicole Pearson
- Hunter New England Population Health, Wallsend, NSW 2287, Australia
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Alix Hall
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Adam Shoesmith
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Nicole Nathan
- Hunter New England Population Health, Wallsend, NSW 2287, Australia
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Luke Giles
- Hunter New England Population Health, Wallsend, NSW 2287, Australia
| | - Alice Grady
- Hunter New England Population Health, Wallsend, NSW 2287, Australia
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Serene Yoong
- Faculty of Health, School of Health and Social Development, Global Centre for Preventive Health and Nutrition, Institute for Health Transformation, Deakin University, Geelong, VIC 3220, Australia
- Hunter New England Population Health, Wallsend, NSW 2287, Australia
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW 2308, Australia
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Wenden EJ, Virgara R, Pearce N, Budgeon C, Christian HE. Movement behavior policies in the early childhood education and care setting: An international scoping review. Front Public Health 2023; 11:1077977. [PMID: 37113169 PMCID: PMC10126357 DOI: 10.3389/fpubh.2023.1077977] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 03/20/2023] [Indexed: 04/29/2023] Open
Abstract
Background Meeting 24-h movement behavior guidelines for the early years is associated with better health and development outcomes in young children. Early childhood education and care (ECEC) is a key intervention setting however little is known about the content and implementation of movement behavior polices in this context. To inform policy development this international scoping review examined the prevalence, content, development and implementation of ECEC-specific movement behavior policies. Methods A systematic literature search of published and gray literature since 2010 was conducted. Academic databases (EMBASE, Cinahl, Web of Science, Proquest, Scopus, EBSCO, PubMed) were searched. A Google search was undertaken and limited to the first 200 results. The Comprehensive Analysis of Policy on Physical Activity framework informed data charting. Results Forty-three ECEC policy documents met inclusion criteria. Most policies originated in the United States, were subnational and developed with government, non-government organizations and ECEC end-users. Physical activity was specified in 59% (30-180 min/day), sedentary time in 51% (15-60 min/day) and sleep in 20% (30-120 min/day) of policies. Daily outdoor physical activity was recommended (30-160 min/day) in most policies. No policy permitted screen time for children <2 years, with 20-120 min/day for children >2 years. Most policies (80%) had accompanying resources but few provided evaluation tools (e.g., checklists; action plan templates). Many policies had not been reviewed since the publication of 24-h movement guidelines. Conclusion Movement behavior policies in the ECEC setting are often vaguely worded, missing a comprehensive evidence base, siloed in development and often not tailored for the 'real world.' A focus on evidence informed ECEC-specific movement behavior policies proportionally aligned with national/international 24-h Movement Behaviors Guidelines for the Early Years is needed.
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Affiliation(s)
- Elizabeth J. Wenden
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia
- *Correspondence: Elizabeth J. Wenden,
| | - Rosa Virgara
- Allied Health and Human Performance, University of South Australia, Adelaide, SA, Australia
| | - Natasha Pearce
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia
| | - Charley Budgeon
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia
| | - Hayley E. Christian
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia
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Manzano-Felipe MÁ, Cruz-Cobo C, Bernal-Jiménez MÁ, Santi-Cano MJ. Validation of the General and Sport Nutrition Knowledge Questionnaire (GeSNK) in Spanish Adolescents. Nutrients 2022; 14:nu14245324. [PMID: 36558482 PMCID: PMC9786199 DOI: 10.3390/nu14245324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/12/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022] Open
Abstract
The General and Sport Nutrition Knowledge Questionnaire (GeSNK) is an instrument that has been developed and validated to assess the level of nutrition knowledge in adolescents and young adults. The aim of the present study was to validate the GeSNK questionnaire in a group of Spanish adolescents in the framework of a Nutrition Education Programme in Secondary Schools in Andalusia, Spain. This cross-sectional questionnaire validation study was developed in two phases: translation-cultural adaptation and validation. A total of 305 adolescents aged 11 to 17 years, studying from the first to the third year of compulsory secondary education, participated on a voluntary basis. The GeSNK questionnaire consists of 62 items: 29 items for the General Nutrition section and 33 items for the Sports Nutrition section. Cronbach's alpha coefficient for the complete questionnaire (GeSNK Total) was: 0.934; for the GeSNK General Nutrition section it was 0.918; and for the GeSNK Sports Nutrition section it was 0.856. The stability measured by the correlation coefficient for the General Nutrition section was 0.406 (p = 0.000); for the Sports Nutrition section it was 0.198 (p = 0.017); and for GeSNK Total the stability was 0.545 (p = 0.000). The questionnaire also demonstrated adequate construct validity. We therefore conclude that the Spanish version of the GeSNK questionnaire is a valid instrument to measure the level of knowledge in general nutrition and sports nutrition in adolescents.
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Affiliation(s)
- María Ángeles Manzano-Felipe
- Primary Health Care District of Bay of Cádiz-La Janda, 11006 Cádiz, Spain
- Research Group on Nutrition, Molecular, Pathophysiological and Social Issues, University of Cádiz, 11009 Cádiz, Spain
- Institute of Biomedical Research and Innovation of Cádiz (INiBICA), 11009 Cádiz, Spain
| | - Celia Cruz-Cobo
- Research Group on Nutrition, Molecular, Pathophysiological and Social Issues, University of Cádiz, 11009 Cádiz, Spain
- Institute of Biomedical Research and Innovation of Cádiz (INiBICA), 11009 Cádiz, Spain
- Faculty of Nursing and Physiotherapy, University of Cádiz, 11009 Cádiz, Spain
| | - María Ángeles Bernal-Jiménez
- Research Group on Nutrition, Molecular, Pathophysiological and Social Issues, University of Cádiz, 11009 Cádiz, Spain
- Institute of Biomedical Research and Innovation of Cádiz (INiBICA), 11009 Cádiz, Spain
- Faculty of Nursing and Physiotherapy, University of Cádiz, 11009 Cádiz, Spain
| | - María José Santi-Cano
- Research Group on Nutrition, Molecular, Pathophysiological and Social Issues, University of Cádiz, 11009 Cádiz, Spain
- Institute of Biomedical Research and Innovation of Cádiz (INiBICA), 11009 Cádiz, Spain
- Faculty of Nursing and Physiotherapy, University of Cádiz, 11009 Cádiz, Spain
- Correspondence: ; Tel.: +34-956-019042; Fax: +34-956-015685
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16
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Kracht CL, Gustat J, Gourley M, Lewis L, Staiano AE. STRATEGIES IN ADDRESSING STATE SCREEN TIME POLICIES IN EARLY CARE AND EDUCATION CENTERS IN LOUISIANA. JOURNAL OF THE LOUISIANA PUBLIC HEALTH ASSOCIATION 2022; 3:44-58. [PMID: 36939439 PMCID: PMC10019469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
Background Multiple state and local governments have legislated screen time policy regulations in early care and education (ECE) centers in the United States, though little is known about how and whether these are enacted within these settings. This study examined the implementation, communication, monitoring, enforcement, and evaluation strategies of recently enacted state-level early childhood education (ECE) center screen time regulations in a southern U.S. state. Methods ECE directors (n=12) participated in semi-structured interviews after the regulations were enacted, and interview transcripts were evaluated using thematic analysis. Results Most directors reported making environmental changes (e.g., removing screens from the classroom) and limiting children's and staff members' access to devices (e.g., restricting classroom time spent on screens), including regulating staff members' own screen time (i.e., phone usage). ECE center directors reported daily monitoring for adherence to regulations and used a variety of enforcement strategies, and most reported no adverse effects from implementing the policy. A few directors reported receiving resources from agencies or organizations to assist in implementing, monitoring, or enforcing screen time regulations. Discussion In this sample, environmental and individual changes helped ECE centers adhere to the regulations, along with frequent monitoring. Conclusions Development of technical assistance resources to support environmental and logistical changes, along with continued evaluation of the regulations, are warranted to minimize or eliminate screen time at ECE centers.
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Affiliation(s)
| | - Jeanette Gustat
- Tulane University School of Public Health and Tropical Medicine, New Orleans, LA
| | - Maranda Gourley
- Tulane University School of Public Health and Tropical Medicine, New Orleans, LA
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Swindle T, Bellows LL, Mitchell V, Johnson SL, Shakya S, Zhang D, Selig JP, Whiteside-Mansell L, Curran GM. Predictors of sustainment of two distinct nutrition and physical activity programs in early care and education. FRONTIERS IN HEALTH SERVICES 2022; 2:1010305. [PMID: 36925855 PMCID: PMC10012648 DOI: 10.3389/frhs.2022.1010305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/17/2022] [Indexed: 11/11/2022]
Abstract
Introduction The goal of the present study was to investigate factors associated with sustainment of two evidence-based programs for nutrition promotion in early care and education (ECE) settings - Food Friends (FF) and Together, We Inspire Smart Eating (WISE). Materials and methods In a cross-sectional study design, ECE directors (N = 55) from centers that had previously been trained in WISE or FF completed a survey. Program-specific measures included Steckler's Perception of Innovations, the Program Sustainability Assessment Tool (PSAT), and the Organizational Readiness for Change Assessment (ORCA). For our primary outcomes, two measures of sustainment were examined: Nutrition Continued Practice (i.e., the use of or general focus on nutrition programs) and Program Fidelity (i.e., how well centers used specific evidence-based practices of WISE or FF). Multiple regression was used to determine the association of these outcomes with program, years since last implementation, and overall scores on predictors. Follow-up correlation analyses were used to investigate outcome relationships with context submeasures due to high intercorrelations between predictor submeasures. Results Nutrition Continued Practice was significantly predicted by program and overall PSAT score. WISE programs had significantly higher Nutrition Continued Practice scores than FF program (p = 0.03). All subscales of the PSAT (e.g., environmental support, funding stability, organizational capacity, program adaptation, communications, and strategic planning) were significantly correlated with Nutrition Continued Practice (all rs > 0.30, all ps < 0.03). Program Fidelity was significantly predicted by PSAT and Steckler Perception of Innovation scores. All subscales of the PSAT were strongly positively correlated with Program Fidelity (all rs > 0.48, all ps < 0.001); relative advantage (r = 0.54, p < 0.001) and level of institutionalization (r = 0.61, p < 0.001) were positively correlated with Program Fidelity. Conclusion This study suggests that factors associated with the continued practice of program principles are partially distinct from those that are associated with the sustainment of specific practices driving program fidelity. Results suggest capacity building strategies may be important for both continued attention to nutrition and physical activity as well as sustaining fidelity to specific evidence-based practices.
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Affiliation(s)
- Taren Swindle
- Department of Family and Preventive Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Laura L. Bellows
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, United States
| | | | - Susan L. Johnson
- Section of Nutrition, Department of Pediatrics, University of Colorado Anschutz, Aurora, CO, United States
| | - Samjhana Shakya
- Department of Family and Preventive Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Dong Zhang
- Department of Family and Preventive Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - James P. Selig
- Department of Biostatistics, College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Leanne Whiteside-Mansell
- Department of Family and Preventive Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Geoffrey M. Curran
- Department of Pharmacy Practice, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, United States
- Center for Mental Health and Outcomes Research, Central Arkansas Veterans Heathcare System, Little Rock, AR, United States
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18
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Wenden EJ, Pearce N, George P, Christian HE. Educators' Barriers and Facilitators to Physical Activity Policy Implementation in the Childcare Setting: Qualitative Findings From the Play Active Project. Am J Health Promot 2022; 36:1326-1334. [PMID: 35612922 DOI: 10.1177/08901171221105052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE We explored childcare educators' perceived barriers and facilitators to policy implementation in order to inform the development and implementation of an early childhood education and care (ECEC) specific physical activity policy. This study was part of the Play Active (2019-2023) project which aimed to develop, implement and evaluate evidence-based physical activity policy to improve physical activity levels in children attending ECEC. APPROACH Stakeholder focus groups. Setting: ECEC centers in Perth, Western Australia. Sample: Educators (n=66) from 11 ECEC centers participated in 13 focus groups (August-September 2019). METHODS Semi-structured questions explored educators' perceptions of barriers and facilitators to implementing a new physical activity policy. A qualitative descriptive approach within a naturalistic framework informed data analysis. Focus group data were reviewed and grouped through several iterations to produce core themes. RESULTS Four core themes resulted from focus groups: (1) leadership; (2) educator mindset: (3) parent engagement; and (4) organisational and educator capacity. Educators needed supportive leadership and a commitment of resources for physical activity policy implementation. Educators acknowledged physical activity practices can be influenced by knowledge, attitudes, beliefs and change capacity and stressed the need for parent engagement for successful implementation. CONCLUSIONS Educators' voices are important for informing implementation of physical activity policy and practices leading to improvements in children's physical activity levels.
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Affiliation(s)
- Elizabeth J Wenden
- Telethon Kids Institute, 117610University of Western Australia, Crawley, WA, Australia.,School of Population and Global Health, 85075University of Western Australia, Crawley, WA, Australia
| | - Natasha Pearce
- Telethon Kids Institute, 117610University of Western Australia, Crawley, WA, Australia
| | - Phoebe George
- Telethon Kids Institute, 117610University of Western Australia, Crawley, WA, Australia
| | - Hayley E Christian
- Telethon Kids Institute, 117610University of Western Australia, Crawley, WA, Australia.,School of Population and Global Health, 85075University of Western Australia, Crawley, WA, Australia
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19
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Thinking inside the box: The future of young children's physical activity and the home environment. Soc Sci Med 2022; 301:114930. [PMID: 35344777 PMCID: PMC9350970 DOI: 10.1016/j.socscimed.2022.114930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 02/07/2022] [Accepted: 03/15/2022] [Indexed: 11/20/2022]
Abstract
Parrish et al.'s (2021) investigation of caregiver perceptions of preschoolers' physical activity (PA) within the home environment posits important opportunities for public policy to consider space and available opportunities for PA for preschoolers. This study uncovered qualitative themes on preschoolers' PA in the home, referencing the use of indoor and outdoor spaces, adaptations within the home, interplay between space and caregiving, and variability in child's PA. This work sparks a discussion into the current understanding of the home environment for preschooler PA and future research directions. We propose three main areas to bring forward physical activity and public health research, including 1) role of policies and community (e.g., societal norms) on the home environment and child physical activity, 2) reimagination of the home environment beyond the physical components as a complex system, and 3) advanced measurement of child physical activity using modern technology. Merging these new opportunities with past efforts may help design and facilitate healthier PA and movement patterns for preschoolers now and into the future.
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20
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Grady A, Jackson JK, Lum M, Delaney T, Jones J, Kerr J, Falkiner M, Yoong S. Barriers and facilitators to the implementation of healthy eating, physical activity and obesity prevention policies, practices or programs in family day care: A mixed method systematic review. Prev Med 2022; 157:107011. [PMID: 35248680 DOI: 10.1016/j.ypmed.2022.107011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 02/14/2022] [Accepted: 02/26/2022] [Indexed: 10/18/2022]
Abstract
Family day care (FDC) services provide care to young children typically within the carer's own home and represents a unique setting to deliver public health programs to improve child health. To support the implementation of programs targeting healthy eating, physical activity and obesity prevention in the FDC setting, an understanding of the factors influencing their implementation is required. This mixed methods systematic review aimed to describe the barriers and facilitators to the implementation of healthy eating, physical activity or obesity prevention policies, practices and programs (hereafter referred to as programs) in the FDC setting, and synthesise these according to the Theoretical Domains Framework (TDF). Electronic searches were conducted in 7 databases up to July 2020 to identify studies reporting the barriers and/or facilitators to program implementation in the FDC setting. Methodological quality assessments of included studies were conducted using the Mixed Methods Appraisal Tool (MMAT). Twenty studies met the review inclusion criteria (12 qualitative, 6 quantitative, 2 mixed methods). Of the 20 included studies, 16 reported barriers and facilitators mapped to the 'environmental contexts and resources' TDF domain; 10 reported barriers mapped to the 'social influences' TDF domain. Ten of the 12 qualitative studies and none of the quantitative or mixed method studies met all relevant MMAT criteria. This review comprehensively describes barriers and facilitators that need to be addressed to improve the implementation of healthy eating, physical activity and obesity prevention programs in FDC to ensure the expected health benefits of such programs reach children attending FDC.
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Affiliation(s)
- Alice Grady
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia; Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW 2305, Australia; Priority Research Centre for Health Behaviour (PRCHB), University of Newcastle, Callaghan, NSW 2308, Australia; Hunter New England Population Health, Hunter New England Local Health District, Wallsend, NSW 2287, Australia.
| | - Jacklyn Kay Jackson
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia; Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW 2305, Australia; Priority Research Centre for Health Behaviour (PRCHB), University of Newcastle, Callaghan, NSW 2308, Australia.
| | - Melanie Lum
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia; Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW 2305, Australia; Priority Research Centre for Health Behaviour (PRCHB), University of Newcastle, Callaghan, NSW 2308, Australia; Hunter New England Population Health, Hunter New England Local Health District, Wallsend, NSW 2287, Australia.
| | - Tessa Delaney
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia; Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW 2305, Australia; Priority Research Centre for Health Behaviour (PRCHB), University of Newcastle, Callaghan, NSW 2308, Australia; Hunter New England Population Health, Hunter New England Local Health District, Wallsend, NSW 2287, Australia.
| | - Jannah Jones
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia; Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW 2305, Australia; Priority Research Centre for Health Behaviour (PRCHB), University of Newcastle, Callaghan, NSW 2308, Australia; Hunter New England Population Health, Hunter New England Local Health District, Wallsend, NSW 2287, Australia.
| | - Jayde Kerr
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, NSW 2287, Australia.
| | - Maryann Falkiner
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, NSW 2287, Australia.
| | - Serene Yoong
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia; Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW 2305, Australia; Priority Research Centre for Health Behaviour (PRCHB), University of Newcastle, Callaghan, NSW 2308, Australia; Hunter New England Population Health, Hunter New England Local Health District, Wallsend, NSW 2287, Australia; School of Health Sciences, Swinburne University of Technology, Hawthorn, VIC 3122, Australia.
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21
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Yoong SL, Pearson N, Reilly K, Wolfenden L, Jones J, Nathan N, Okely A, Naylor PJ, Jackson J, Giles L, Imad N, Gillham K, Wiggers J, Reeves P, Highfield K, Lum M, Grady A. 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. BMC Public Health 2022; 22:610. [PMID: 35351035 PMCID: PMC8961494 DOI: 10.1186/s12889-022-12883-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Sze Lin Yoong
- School of Health Sciences, Department of Nursing and Allied Health, Swinburne University of Technology, Hawthorn, VIC, 3122, Australia.
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.
- Hunter New England Population Health, Wallsend, NSW, 2287, Australia.
- Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia.
- Priority Research Centre for Health Behaviour, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.
| | - Nicole Pearson
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
- Hunter New England Population Health, Wallsend, NSW, 2287, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - Kathryn Reilly
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
- Hunter New England Population Health, Wallsend, NSW, 2287, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - Luke Wolfenden
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
- Hunter New England Population Health, Wallsend, NSW, 2287, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - Jannah Jones
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
- Hunter New England Population Health, Wallsend, NSW, 2287, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - Nicole Nathan
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
- Hunter New England Population Health, Wallsend, NSW, 2287, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - Anthony Okely
- Early Start, Faculty of the Arts, Social Sciences and Humanities, University of Wollongong, Wollongong, NSW, 2522, Australia
- School of Health and Society, Faculty of the Arts, Social Sciences and Humanities, University of Wollongong, Wollongong, NSW, 2522, Australia
- Illawarra Health and Medicine Research Institute, Wollongong, NSW, 2522, Australia
| | - Patti-Jean Naylor
- School of Exercise Science, Physical and Health Education, University of Victoria, Mackinnon 120, PO Box 1700, STN CSC, Victoria, BC, V8W 2Y2, Canada
| | - Jacklyn Jackson
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
- Hunter New England Population Health, Wallsend, NSW, 2287, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - Luke Giles
- Hunter New England Population Health, Wallsend, NSW, 2287, Australia
| | - Noor Imad
- School of Health Sciences, Department of Nursing and Allied Health, Swinburne University of Technology, Hawthorn, VIC, 3122, Australia
| | - Karen Gillham
- Hunter New England Population Health, Wallsend, NSW, 2287, Australia
| | - John Wiggers
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
- Hunter New England Population Health, Wallsend, NSW, 2287, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - Penny Reeves
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
| | | | - Melanie Lum
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
- Hunter New England Population Health, Wallsend, NSW, 2287, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - Alice Grady
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
- Hunter New England Population Health, Wallsend, NSW, 2287, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
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22
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Interventions to Improve Child Physical Activity in the Early Childhood Education and Care Setting: An Umbrella Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19041963. [PMID: 35206152 PMCID: PMC8872396 DOI: 10.3390/ijerph19041963] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 02/04/2023]
Abstract
Early childhood education and care (ECEC) services are a key setting to support improvements in the physical activity of young children. This umbrella review gathered and synthesised systematic review evidence of the effectiveness of interventions in the ECEC setting on the physical activity levels of children aged 0-6. We also mapped the current evidence to the existing ECEC sector-specific physical activity practice recommendations. Five electronic databases were searched to identify systematic reviews that evaluated the impact of any ECEC-based interventions on the physical activity levels (e.g., moderate-to-vigorous physical activity, total physical activity) of children aged 0-6. One reviewer extracted data on intervention effectiveness and quality of the reviews, checked by a second reviewer. Ten reviews were included. Overall, the majority of the reviews found interventions delivered in ECEC improved child physical activity. Across reviews, the impact of six intervention strategies were identified, mapped to four (of eight) broad recommendations (i.e., providing opportunity, offering educator training, educators promoting the benefits of physical activity, creating a physical activity-promoting environment). The impact of the majority of recommendations, however, did not have systematic review evidence. Further investigation of the effectiveness of ECEC-based physical activity strategies is required to demonstrate support for the existing recommended practices.
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Müller C, Hassel H. Cooperative planning in childcare centers to improve physical activity: a qualitative investigation of directors' perspectives. Health Promot Int 2021; 36:ii8-ii15. [PMID: 34905610 PMCID: PMC8670625 DOI: 10.1093/heapro/daab171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Interventions to promote physical activity (PA) in childcare centers have been shown to increase children’s PA levels; moreover, a growing number of evidence-based best practice guidelines exist for this setting. However, there is a lack of knowledge on the facilitators of and barriers to the successful implementation of PA guidelines and interventions. We used Cooperative Planning to improve capabilities for PA in childcare centers. This qualitative study aimed to explore childcare center directors’ views on the Cooperative Planning process and identify the facilitators of and barriers to its implementation. We conducted guided semi-structured interviews with the directors of nine childcare centers after completion of the 12-month Cooperative Planning process. The interviews were recorded, transcribed and analyzed using qualitative content analysis with inductive category development. Facilitators and barriers were systematized according to the Consolidated Framework for Implementation Research (CFIR). Cooperative Planning was regarded as being helpful for structuring the process and involving all team members. Several facilitators within the CFIR domains inner setting (structural characteristics, networks and communications, implementation climate), outer setting (support from parents and provider), characteristics of individuals (intrinsic motivation of the staff) and process (individual drivers) were identified. The reported barriers included structural characteristics (e.g. lack of time), networks and communications (e.g. team conflicts) and characteristics of individuals (e.g. lack of willingness to accept change). Several contextual and interpersonal factors seem to influence the extent to which a Cooperative Planning process can be implemented by a childcare center’s team. Future research is needed to evaluate the strategies needed to overcome the identified barriers.
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Affiliation(s)
- Christina Müller
- Institute of Sports Science, University of Würzburg, Judenbühlweg 11, Würzburg 97082, Germany
- Corresponding author. E-mail:
| | - Holger Hassel
- Institute of Applied Health Sciences, Coburg University of Applied Sciences and Arts, Friedrich-Streib-Straße 2, Coburg 96450, Germany
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Trandafir LM, Cojocaru E, Moscalu M, Leon Constantin MM, Miron I, Mastaleru A, Teslariu O, Datcu ME, Fotea S, Frăsinariu O. Predictive Markers of Early Cardiovascular Impairment and Insulin Resistance in Obese Pediatric Patients. Diagnostics (Basel) 2021; 11:diagnostics11040735. [PMID: 33924229 PMCID: PMC8074748 DOI: 10.3390/diagnostics11040735] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/14/2021] [Accepted: 04/19/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The increased prevalence of obesity among children determined the rising number of its comorbidities in children and adults, too. This study aimed to evaluate certain markers of inflammation and insulin resistance in obese pediatric patients, identifying those who are more likely to develop further complications. METHODS We included 115 obese pediatric patients: 85 overweight and obese patients in the study group and 30 normal-weight patients in the control group. We calculated the body mass index (BMI) and we evaluated markers (biological, inflammatory) and the hormones profile. RESULTS Low-threshold inflammation was assessed by measuring interleukin 6 IL-6 and Intercellular Adhesion Molecules (ICAM). The analysis showed that IL-6 is significantly correlated with glucose (p = 0.001) and BMI value (p = 0.031). ICAM correlates significantly with triglycerides (p = 0.001), glucose (p = 0.044) and BMI percentile (p = 0.037). For pediatric obese patients, endotoxemia has been significantly correlated only with BMI percentile (p = 0.001). Plasma cortisol did not show significant correlations with total cholesterol, triglycerides, glucose or BMI percentile. The results indicated a significant predictive power of BMI percentile on inflammatory markers: IL-6 (AUC = 0.803, p < 0.001), ICAM (AUC = 0.806, p < 0.001) and endotoxemia (AUC = 0.762, p = 0.019). Additionally, BMI percentile has a significant predictive power for metabolic markers of insulin resistance (insulin value: AUC = 0.72, p < 0.001 and HOMA index: AUC = 0.68, p = 0.003). CONCLUSIONS The study highlighted the importance of early markers of cardiovascular risk in obese pediatric patients represented by IL-6, ICAM, endotoxemia and their correlation with metabolic markers of insulin resistance represented by insulinemia, HOMA index and plasma cortisol. It can clearly be considered that the BMI percentile has significant predictive power for metabolic markers of insulin resistance.
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Affiliation(s)
- Laura Mihaela Trandafir
- Department of Mother and Child, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (L.M.T.); (I.M.); (O.T.); (O.F.)
| | - Elena Cojocaru
- Department of Morphofunctional Sciences I, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Mihaela Moscalu
- Department of Preventive Medicine and Interdisciplinarity, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania
- Correspondence: (M.M.); (M.M.L.C.)
| | - Maria Magdalena Leon Constantin
- Department of Medical Specialties I, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iaşi, Romania;
- Correspondence: (M.M.); (M.M.L.C.)
| | - Ingrith Miron
- Department of Mother and Child, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (L.M.T.); (I.M.); (O.T.); (O.F.)
| | - Alexandra Mastaleru
- Department of Medical Specialties I, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iaşi, Romania;
| | - Oana Teslariu
- Department of Mother and Child, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (L.M.T.); (I.M.); (O.T.); (O.F.)
| | - Madalina Elena Datcu
- Department of Biomedical Sciences, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Silvia Fotea
- Department of Medical Specialties, Dunarea de Jos University, 800216 Galati, Romania;
| | - Otilia Frăsinariu
- Department of Mother and Child, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (L.M.T.); (I.M.); (O.T.); (O.F.)
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