Long-Term Effectiveness of a Multi-Strategy Choice Architecture Intervention in Increasing Healthy Food Choices of High-School Students From Online Canteens (Click & Crunch High Schools): Cluster Randomized Controlled Trial.

BACKGROUND: School canteens are a recommended setting to influence adolescent nutrition due to their scope to improve student food choices. Online lunch ordering systems ("online canteens") are increasingly used and represent attractive infrastructure to implement choice architecture interventions that nudge users toward healthier food choices. A recent cluster randomized controlled trial demonstrated the short-term effectiveness (2-month follow-up) of a choice architecture intervention to increase the healthiness of foods purchased by high school students from online canteens. However, there is little evidence regarding the long-term effectiveness of choice architecture interventions targeting adolescent food purchases, particularly those delivered online. OBJECTIVE: This study aimed to determine the long-term effectiveness of a multi-strategy choice architecture intervention embedded within online canteen infrastructure in high schools at a 15-month follow-up. METHODS: A cluster randomized controlled trial was undertaken with 1331 students (from 9 high schools) in New South Wales, Australia. Schools were randomized to receive the automated choice architecture intervention (including menu labeling, positioning, feedback, and prompting strategies) or the control (standard online ordering). The foods purchased were classified according to the New South Wales Healthy Canteen strategy as either "everyday," "occasional," or "should not be sold." Primary outcomes were the average proportion of "everyday," "occasional," and "should not be sold" items purchased per student. Secondary outcomes were the mean energy, saturated fat, sugar, and sodium content of purchases. Outcomes were assessed using routine data collected by the online canteen. RESULTS: From baseline to 15-month follow-up, on average, students in the intervention group ordered significantly more "everyday" items (+11.5%, 95% CI 7.3% to 15.6%; P<.001), and significantly fewer "occasional" (-5.4%, 95% CI -9.4% to -1.5%; P=.007) and "should not be sold" items (-6%, 95% CI -9.1% to -2.9%; P<.001), relative to controls. There were no between-group differences over time in the mean energy, saturated fat, sugar, or sodium content of lunch orders. CONCLUSIONS: Given their longer-term effectiveness, choice architecture interventions delivered via online canteens may represent a promising option for policy makers to support healthy eating among high school students. TRIAL REGISTRATION: Australian Clinical Trials ACTRN12620001338954, https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380546 ; Open Science Framework osf.io/h8zfr, https://osf.io/h8zfr/.

Research outcomes informing the selection of public health interventions and strategies to implement them: A cross-sectional survey of Australian policy-maker and practitioner preferences.

BACKGROUND: A key role of public health policy-makers and practitioners is to ensure beneficial interventions are implemented effectively enough to yield improvements in public health. The use of evidence to guide public health decision-making to achieve this is recommended. However, few studies have examined the relative value, as reported by policy-makers and practitioners, of different broad research outcomes (that is, measures of cost, acceptability, and effectiveness). To guide the conduct of research and better inform public health policy and practice, this study aimed at describing the research outcomes that Australian policy-makers and practitioners consider important for their decision-making when selecting: (a) public health interventions; (b) strategies to support their implementation; and (c) to assess the differences in research outcome preferences between policy-makers and practitioners. METHOD: An online value-weighting survey was conducted with Australian public health policy-makers and practitioners working in the field of non-communicable disease prevention. Participants were presented with a list of research outcomes and were asked to select up to five they considered most critical to their decision-making. They then allocated 100 points across these - allocating more points to outcomes perceived as more important. Outcome lists were derived from a review and consolidation of evaluation and outcome frameworks in the fields of public health knowledge translation and implementation. We used descriptive statistics to report relative preferences overall and for policy-makers and practitioners separately. RESULTS: Of the 186 participants; 90 primarily identified as policy-makers and 96 as public health prevention practitioners. Overall, research outcomes of effectiveness, equity, feasibility, and sustainability were identified as the four most important outcomes when considering either interventions or strategies to implement them. Scores were similar for most outcomes between policy-makers and practitioners. CONCLUSION: For Australian policy-makers and practitioners working in the field of non-communicable disease prevention, outcomes related to effectiveness, equity, feasibility, and sustainability appear particularly important to their decisions about the interventions they select and the strategies they employ to implement them. The findings suggest researchers should seek to meet these information needs and prioritize the inclusion of such outcomes in their research and dissemination activities. The extent to which these outcomes are critical to informing the decision of policy-makers and practitioners working in other jurisdictions or contexts warrants further investigation.

Unpacking the cost of the lunchbox for Australian families: a secondary analysis.

Ninety per cent of Australian school children bring a home-packed lunch to school, with 44% of the food consumed during school hours being unhealthy. Among other factors, cost is a key consideration for food provision; however, the costs to Australian families are not well understood. Therefore, we aimed to determine what families are currently paying for school lunchboxes in Australian primary schools and to examine associations between food costs and socio-demographic factors with dietary quality. An audit of local retail outlets was used to determine the food costs of lunchbox contents. Costs (AUD) were adjusted for inflation as of early 2023. The lunchboxes of 1026 children aged 4-12 years at 12 Catholic primary schools in New South Wales, Australia, were assessed at the start of the day, using photography assessment methods and a validated School Food Checklist. The mean cost of lunchbox contents was $4.48 AUD (SD 1.53), containing a mean energy of 2699 kJ (SD 859), with 37.3% (SD 23.9) of energy sourced from unhealthy foods. Multiple linear regression analyses found that the strongest predictors of higher lunchbox cost (P < 0.05) were a higher proportion of energy from unhealthy foods (B = 0.016) and lower Socio-Economic Indexes for Areas (B = -0.178), when controlling for child socio-demographics. The results indicated that lunchbox food costs to Australian families are comparable to alternative school food service models in Australia and internationally. Results demonstrate the cost of food is not the only barrier to providing a healthy school lunchbox. Demonstrating a need for cost-considerate systematic interventions addressing food provision challenges and socio-economic disparities faced by families.

A rapid review of the scalability of interventions targeting obesity prevention in infants.

ISSUE ADDRESSED: Obesity in children is one of the most significant public health issues globally. Given the high prevalence of overweight and obesity in children, there is a need to identify effective obesity prevention efforts that can be delivered at scale to improve child health. We aimed to (i) identify obesity prevention interventions targeted at children aged 0-2 that have been scaled-up, and their relative efficacy compared to their pre-scale trial, (ii) describe adaptations made, and the extent to which factors related to scalability have been reported. METHODS: We conducted a rapid review of pre-scale randomised controlled trials targeting nutrition, physical activity and obesity prevention in infants, and calculated the relative effect size for relevant outcomes in the corresponding scaled up trial. We documented adaptations made to the pre-scale trial for scale up, and explored how different components of scalability had been reported according to the Intervention Scalability Assessment Tool. RESULTS: Of the 14 identified pre-scale trials, only one formal evaluation of the scale-up trial was identified. For body mass index, <10% of the effect was retained, however for nutrition and behavioural outcomes, the proportion of effect retained varied from -11.1% to 144%. Significant adaptations to modality were made in the scaled up trial primarily to reduce cost and increase reach of the intervention. Reporting of scalability components varied across the 14 trials, with only one trial reporting information for all assessed components. CONCLUSIONS: The majority of effective interventions targeting obesity prevention in infants have not been evaluated in a scaled up form. The magnitude of effect retained for the single trial that was scaled up was variable. In general, reporting of components of scalability was sub-optimal. SO WHAT?: The findings suggest that there is substantial need for the development and rigorous evaluation of obesity prevention interventions in children aged 0-2 which are amenable for scale.

Evaluating the scaling up of an effective implementation intervention (PACE) to increase the delivery of a mandatory physical activity policy in primary schools.

BACKGROUND: Physically Active Children in Education (PACE) is an effective implementation intervention for increasing the number of minutes classroom teachers schedule physical activity each week. To date, evaluations of PACE have included a smaller number of schools from only one region in New South Wales Australia. If PACE is to have population-wide benefits we must be able to deliver this support to a larger number of schools across multiple regions. This study aimed to evaluate the scale-up of PACE. METHODS: An uncontrolled before and after study, with 100 schools from three regions was conducted. Participating schools received PACE for approximately 12 months. We assessed the following outcomes: delivery of the evidence-based intervention (EBI) (i.e. minutes of physical activity scheduled by classroom teachers per week); delivery of the implementation strategies (i.e. reach, dose delivered, adherence and indicators of sustainability); and key determinants of implementation (i.e. acceptability of strategies and cost). Data were collected via project officer records, and principal and teacher surveys. Linear mixed models were used to assess EBI delivery by evaluating the difference in the mean minutes teachers scheduled physical activity per week from baseline to follow-up. Descriptive data were used to assess delivery of the implementation strategies and their perceived acceptability (i.e. PACE). A prospective, trial-based economic evaluation was used to assess cost. RESULTS: Delivery of the EBI was successful: teachers increas their average minutes of total physical activity scheduled across the school week by 26.8 min (95% CI: 21.2, 32.4, p < 0.001) after receiving PACE. Indicators for delivery of implementation strategies were high: 90% of consenting schools received all strategies and components (reach); 100% of strategies were delivered by the provider (dose); >50% of schools adhered to the majority of strategies (11 of the 14 components); and acceptability was > 50% agreement for all strategies. The incremental cost per additional minute of physical activity scheduled per week was $27 per school (Uncertainty Interval $24, $31). CONCLUSIONS: PACE can be successfully delivered across multiple regions and to a large number of schools. Given the ongoing and scalable benefits of PACE, it is important that we continue to extend and improve this program while considering ways to reduce the associated cost.

Dissemination of public health research to prevent non-communicable diseases: a scoping review.

BACKGROUND: Dissemination is a critical element of the knowledge translation pathway, and a necessary step to ensure research evidence is adopted and implemented by key end users in order to improve health outcomes. However, evidence-based guidance to inform dissemination activities in research is limited. This scoping review aimed to identify and describe the scientific literature examining strategies to disseminate public health evidence related to the prevention of non-communicable diseases. METHODS: Medline, PsycInfo and EBSCO Search Ultimate were searched in May 2021 for studies published between January 2000 and the search date that reported on the dissemination of evidence to end users of public health evidence, within the context of the prevention of non-communicable diseases. Studies were synthesised according to the four components of Brownson and colleagues' Model for Dissemination of Research (source, message, channel and audience), as well as by study design. RESULTS: Of the 107 included studies, only 14% (n = 15) directly tested dissemination strategies using experimental designs. The remainder primarily reported on dissemination preferences of different populations, or outcomes such as awareness, knowledge and intentions to adopt following evidence dissemination. Evidence related to diet, physical activity and/or obesity prevention was the most disseminated topic. Researchers were the source of disseminated evidence in over half the studies, and study findings/knowledge summaries were more frequently disseminated as the message compared to guidelines or an evidence-based program/intervention. A broad range of dissemination channels were utilised, although peer-reviewed publications/conferences and presentations/workshops predominated. Practitioners were the most commonly reported target audience. CONCLUSIONS: There is a significant gap in the peer reviewed literature, with few experimental studies published that analyse and evaluate the effect of different sources, messages and target audiences on the determinants of uptake of public health evidence for prevention. Such studies are important as they can help inform and improve the effectiveness of current and future dissemination practices in public health contexts.

A cluster randomised controlled trial to assess the effectiveness of a multi-strategy sustainability intervention on teachers' sustained implementation of classroom physical activity breaks (energisers): study protocol.

BACKGROUND: Governments internationally have invested hugely in the implementation and scale-up of school-based physical activity interventions, but have little evidence of how to best sustain these interventions once active implementation support ceases. This study will assess the effectiveness of a multi-strategy sustainability intervention on classroom teachers' sustainment of energisers (short 3-5 min physical activity breaks during class-time) scheduled across the school day from baseline to 12 and 24-month follow-up. METHODS: A cluster randomised controlled trial will be conducted in 50 primary schools within the Hunter New England, Illawarra Shoalhaven, Murrumbidgee and Northern New South Wales (NSW) Local Health Districts of NSW Australia. Schools will be randomly allocated to receive either usual support or the multi-strategy sustainability intervention that includes: centralised technical assistance from a trained project officer; formal commitment and mandated change obtained from school principals; training in-school champions; reminders for teachers; educational materials provided to teachers; capturing and sharing local knowledge; and engagement of parents, carers and the wider school community. The primary trial outcome will be measured via a teacher logbook to determine the between-group difference in the change in mean minutes of energisers scheduled across the school day at 12 and 24-month follow-up compared to baseline. Analyses will be performed using an intention to treat framework. Linear mixed models will be used to assess intervention effects on the primary outcome at both follow-up periods. DISCUSSION: This study will be one of the first randomised controlled trials to examine the impact of a multi-strategy sustainability intervention to support schools' sustainment of a physical activity intervention. The proposed research will generate new evidence needed for the partnering organisations to protect their considerable investments to date in physical activity promotion in this setting and will provide seminal evidence for the field globally. TRIAL REGISTRATION: ACTRN12620000372987 version 1 registered 17th March 2020. Version 3 (current version) updated 4th August 2023.

Exploratory analysis of a cluster randomized controlled trial of a multi-strategy intervention delivered via online canteens on improving the nutritional quality of primary school students' pre-ordered foods & drinks at recess.

School canteens are a recommended setting to deliver public health nutrition strategies given their wide reach, and frequent use by children. Online canteens, where users (i.e. students or their carers) pre-order and pay for food and drinks online, represent attractive systems to deliver strategies that encourage healthier food choices. There have been few studies exploring the efficacy of public health nutrition interventions in online food ordering environments. Therefore, this study aims to assess the efficacy of a multi-strategy intervention implemented in an online school canteen ordering system in reducing the energy, saturated fat, sugar, and sodium content of students' online recess orders (i.e. foods ordered during the mid-morning or afternoon snack period). This was an exploratory analysis of recess purchases for a cluster randomized controlled trial that initially sought to examine the efficacy of the intervention on lunch orders. A total of 314 students from 5 schools received the multi-strategy intervention (involving menu labelling, placement, prompting and availability) that was integrated into the online ordering system, and 171 students from 3 schools received the control (usual online ordering). Analysis of main outcomes found that the mean energy (difference: -269.3 kJ; P = 0.006), saturated fat (difference: -1.1 g; P = 0.011) and sodium (difference: -128.6 mg; P = 0.014) content per student recess order was significantly lower in the intervention group than the control group at 2-month follow-up. Findings suggest that embedding strategies to encourage healthier choices within online canteen ordering systems can improve the nutrient composition of student recess purchases. These results add to the current evidence base suggesting that interventions delivered via online food ordering systems represent an effective strategy for improving child public health nutrition in schools.

The Effectiveness of Strategies to Improve User Engagement With Digital Health Interventions Targeting Nutrition, Physical Activity, and Overweight and Obesity: Systematic Review and Meta-Analysis.

BACKGROUND: Digital health interventions (DHIs) are effective in improving poor nutrition, physical inactivity, overweight and obesity. There is evidence suggesting that the impact of DHIs may be enhanced by improving user engagement. However, little is known about the overall effectiveness of strategies on engagement with DHIs. OBJECTIVE: This study aims to assess the overall effectiveness of strategies to improve engagement with DHIs targeting nutrition, physical activity, and overweight or obesity and explore associations between strategies and engagement outcomes. The secondary aim was to explore the impact of these strategies on health risk outcomes. METHODS: The MEDLINE, Embase, PsycINFO, CINAHL, CENTRAL, Scopus, and Academic Source Complete databases were searched up to July 24, 2023. Eligible studies were randomized controlled trials that evaluated strategies to improve engagement with DHIs and reported on outcomes related to DHI engagement (use or user experience). Strategies were classified according to behavior change techniques (BCTs) and design features (eg, supplementary emails). Multiple-variable meta-analyses of the primary outcomes (usage and user experience) were undertaken to assess the overall effectiveness of strategies. Meta-regressions were conducted to assess associations between strategies and use and user experience outcomes. Synthesis of secondary outcomes followed the "Synthesis Without Meta-Analysis" guidelines. The methodological quality and evidence was assessed using the Cochrane risk-of-bias tool, and the Grading of Recommendations Assessment, Development, and Evaluation tool respectively. RESULTS: Overall, 54 studies (across 62 publications) were included. Pooled analysis found very low-certainty evidence of a small-to-moderate positive effect of the use of strategies to improve DHI use (standardized mean difference=0.33, 95% CI 0.20-0.46; P<.001) and very low-certainty evidence of a small-to-moderate positive effect on user experience (standardized mean difference=0.29, 95% CI 0.07-0.52; P=.01). A significant positive association was found between the BCTs social support (effect size [ES]=0.40, 95% CI 0.14-0.66; P<.001) and shaping knowledge (ES=0.39, 95% CI 0.03-0.74; P=.03) and DHI use. A significant positive association was found among the BCTs social support (ES=0.70, 95% CI 0.18-1.22; P=.01), repetition and substitution (ES=0.29, 95% CI 0.05-0.53; P=.03), and natural consequences (ES=0.29, 95% CI 0.05-0.53; P=.02); the design features email (ES=0.29, 95% CI 0.05-0.53; P=.02) and SMS text messages (ES=0.34, 95% CI 0.11-0.57; P=.01); and DHI user experience. For secondary outcomes, 47% (7/15) of nutrition-related, 73% (24/33) of physical activity-related, and 41% (14/34) of overweight- and obesity-related outcomes reported an improvement in health outcomes. CONCLUSIONS: Although findings suggest that the use of strategies may improve engagement with DHIs targeting such health outcomes, the true effect is unknown because of the low quality of evidence. Future research exploring whether specific forms of social support, repetition and substitution, natural consequences, emails, and SMS text messages have a greater impact on DHI engagement is warranted. TRIAL REGISTRATION: PROSPERO CRD42018077333; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=77333.

From trials to communities: implementation and scale-up of health behaviour interventions.

BACKGROUND: To maximise their potential benefits to communities, effective health behaviour interventions need to be implemented, ideally 'at scale', and are often adapted as part of this. To inform future implementation and scale-up efforts, this study broadly sought to understand (i) how often health behaviour interventions are implemented in communities, (ii) the adaptations that occur; (iii) how frequency it occurred 'at scale'; and (iv) factors associated with 'scale-up'. METHODS: A cross-sectional survey was conducted of corresponding authors of trials (randomised or non-randomised) assessing the effects of preventive health behaviour interventions. Included studies of relevant Cochrane reviews served as a sampling frame. Participants were asked to report on the implementation and scale-up (defined as investment in large scale delivery by a (non)government organisation) of their intervention in the community following trial completion, adaptations made, and any research dissemination strategies employed. Information was extracted from published reports of the trial including assessments of effectiveness and risk of bias. RESULTS: Authors of 104 trials completed the survey. Almost half of the interventions were implemented following trial completion (taking on average 19 months), and 54% of those were adapted prior to doing so. The most common adaptations were adding intervention components, and adapting the intervention to fit within the local service setting. Scale-up occurred in 33% of all interventions. There were no significant associations between research trial characteristics such as intervention effectiveness, risk of bias, setting, involvement of end-user, and incidence of scale-up. However the number of research dissemination strategies was positively associated to the odds of an intervention being scaled-up (OR = 1.50; 95% CI: 1.19, 1.88; p < 0.001). CONCLUSIONS: Adaptation of implemented trials is often undertaken. Most health behaviour interventions are not implemented or scaled-up following trial completion. The use of a greater number of dissemination strategies may increase the likelihood of scaled up.

Disseminating health research to public health policy-makers and practitioners: a survey of source, message content and delivery modality preferences.

BACKGROUND: Understanding the views of policy-makers and practitioners regarding how best to communicate research evidence is important to support research use in their decision-making. AIM: To quantify and describe public health policy-makers and practitioners' views regarding the source, content and form of messages describing public health research findings to inform their decision-making. We also sought to examine differences in preferences between public health policy-makers and practitioners. METHODS: A cross sectional, value-weighting survey of policy-makers and practitioners was conducted. Participants were asked to allocate a proportion of 100 points across different (i) sources of research evidence, (ii) message content and (iii) the form in which evidence is presented. Points were allocated based on their rating of influence, usefulness and preference when making decisions about health policy or practice. RESULTS: A total of 186 survey responses were received from 90 policy-makers and 96 practitioners. Researchers and government department agencies were the most influential source of research evidence based on mean allocation of points, followed by knowledge brokers, professional peers and associations. Mean point allocation for perceived usefulness of message content was highest for simple summary of key findings and implications, and then evidence-based recommendations and data and statistical summaries. Finally, based on mean scores, policy-makers and practitioners preferred to receive research evidence in the form of peer-reviewed publications, reports, evidence briefs and plain language summaries. There were few differences in scores between policy-makers and practitioners across source, message content or form assessments or those with experience in different behavioural areas. CONCLUSIONS: The findings should provide a basis for the future development and optimization of dissemination strategies to this important stakeholder group.

Identifying essential implementation strategies: a mixed methods process evaluation of a multi-strategy policy implementation intervention for schools.

BACKGROUND: Physically Active Children in Education (PACE) is composed of eight implementation strategies that improves schools' implementation of a government physical activity policy. A greater understanding of each discrete implementation strategy could inform improvements to PACE for delivery at-scale. This study aimed to: (A) measure the dose delivered, fidelity, adoption and acceptability of each strategy using quantitative data; (B) identify implementation barriers and facilitators using qualitative data; and (C) explore the importance of each strategy by integrating both data sets (mixed methods). METHODS: This study used data from a cluster randomised noninferiority trial comparing PACE with an adapted version (Adapted PACE) that was delivered with reduced in-person external support to reduce costs and increase scalability. Data were collected from both trials arms for between-group comparison. Descriptive statistics were produced using surveys of principals, in-school champions and teachers; and project records maintained by PACE project officers (objective A). Thematic analysis was performed using in-school champion and project officer interviews (objective B). Both data sets were integrated via a triangulation protocol and findings synthesized in the form of meta-inferences (objective C). RESULTS: Eleven in-school champions and six project officers completed interviews; 33 principals, 51 in-school champions and 260 teachers completed surveys. Regardless of group allocation, implementation indicators were high for at least one component of each strategy: dose delivered =100%, fidelity ≥95%, adoption ≥83%, acceptability ≥50%; and several implementation barriers and facilitators were identified within three broad categories: external policy landscape, inner organizational structure/context of schools, and intervention characteristics and processes. All strategies were considered important as use varied by school, however support from a school executive and in-school champions' interest were suggested as especially important for optimal implementation. CONCLUSION: This study highlights the importance of both executive support and in-school champions for successful implementation of school physical activity policies. In particular, identifying and supporting an in-school champion to have high power and high interest is recommended for future implementation strategies. This may reduce the need for intensive external support, thus improving intervention scalability.

Optimising a multi-strategy implementation intervention to improve the delivery of a school physical activity policy at scale: findings from a randomised noninferiority trial.

BACKGROUND: To maximise their potential health benefits, school-based physical activity policies need to be implemented at scale. This paper describes the third in a sequence of trials that sought to optimise an effective strategy (PACE) to assist schools' implementation of a physical activity policy. Specifically, it aimed to determine the probability that a multi-strategy intervention adapted to reduce in-person contact (Adapted PACE) was "as good as" the original intervention (PACE) in increasing the weekly minutes of structured physical activity implemented by classroom teachers. METHODS: A noninferiority cluster randomised controlled trial was undertaken with 48 primary schools in New South Wales, Australia. Schools were randomised to receive PACE or a model with adaptations made to the delivery modes (Adapted PACE). Teachers' scheduled minutes of weekly physical activity was assessed at baseline (Oct 2018-Feb 2019) and 12-month follow-up (Oct-Dec 2019). The noninferiority margin was set at - 16.4 minutes based on previous data and decision panel consensus. A linear mixed model analysed within a Bayesian framework was used to explore noninferiority between the two PACE models. A cost minimisation analysis was conducted from the health service provider perspective, using the Australian dollar (AUD). RESULTS: The posterior estimate for the between group difference at follow-up was - 2.3 minutes (95% credible interval = - 18.02, 14.45 minutes). There was an estimated 96% probability of Adapted PACE being considered noninferior (only 4% of the posterior samples crossed the noninferiority margin of - 16.4 minutes). That is, the minutes of physical activity implemented by teachers at Adapted PACE schools was not meaningfully less than the minutes of physical activity implemented by teachers at PACE schools. The mean total cost was AUD$25,375 (95% uncertainty interval = $21,499, $29,106) for PACE and AUD$16,421 (95% uncertainty interval = $13,974, $19,656) for Adapted PACE; an estimated reduction of AUD$373 (95% uncertainty interval = $173, $560) per school. CONCLUSIONS: It is highly probable that Adapted PACE is noninferior to the original model. It is a cost-efficient alternative also likely to be a more suitable approach to supporting large scale implementation of school physical activity policies. TRIAL REGISTRATION: Retrospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12619001229167).

The efficacy of a multi-strategy choice architecture intervention on improving the nutritional quality of high school students' lunch purchases from online canteens (Click & Crunch High Schools): a cluster randomized controlled trial.

BACKGROUND: High school canteens are an ideal setting for public health nutrition intervention, and choice architecture strategies that facilitate the purchase of healthier foods and beverages from school canteens are recommended by the World Health Organization. The rapid uptake of online lunch ordering within school canteens provides a unique opportunity to implement choice architecture strategies that support healthier food choices with high fidelity. Despite this, no trial has tested the efficacy of choice architecture strategies within an online lunch ordering system on improving the nutritional quality of high school student lunch purchases. The objective of this study was to assess the impact of embedding choice architecture strategies into an online lunch ordering system on the nutritional quality of the school canteen lunch purchases of high school students (aged 12-19 years). METHODS: A cluster randomized controlled trial was conducted with nine high schools in one Australian state. Schools were randomized to receive either a 2-month choice architecture intervention (involving menu labelling, prompts, item positioning, and feedback), or usual online ordering. Nutrient quality of online canteen lunch purchases was assessed using routine data collected by the online ordering system. Primary outcomes were the proportion of 'Everyday', 'Occasional', and 'Should not be sold' items purchased, categorized using the state healthy canteen policy. Secondary outcomes were the mean energy, saturated fat, sugar, and sodium content of purchases and the mean weekly revenue from online lunch orders. Linear mixed models were analyzed to assess outcomes. RESULTS: Analysis of the student cohort (Intervention: 4 schools, 656 students; Control: 5 schools, 675 students) showed significant between group differences over time for the intervention group for the mean percentage of online lunch items per student that were 'Everyday' (+ 5.5%; P < 0.001) and 'Should not be sold' (- 4.4%; P < 0.001). There were no between group differences over time in the mean percentage of online lunch items that were 'Occasional'; the average energy, saturated fat, sugar, or sodium content of lunch orders. There was also no difference in mean weekly revenue from high school student online lunch orders (P = 0.23). CONCLUSIONS: These findings suggest that a low intensity, choice architecture intervention embedded within an online ordering system can increase the purchase of healthier food items for high school students in one Australian state without any adverse impact on canteen revenue. TRIAL REGISTRATION: This trial was prospectively registered on Open Science Framework on 23rd October 2020 as osf.io/h8zfr.

Strategies for enhancing the implementation of school-based policies or practices targeting diet, physical activity, obesity, tobacco or alcohol use.

BACKGROUND: Several school-based interventions are effective in improving child diet and physical activity, and preventing excessive weight gain, and tobacco or harmful alcohol use. However, schools are frequently unsuccessful in implementing such evidence-based interventions. OBJECTIVES: 1. To evaluate the benefits and harms of strategies aiming to improve school implementation of interventions to address student diet, physical activity, tobacco or alcohol use, and obesity. 2. To evaluate the benefits and harms of strategies to improve intervention implementation on measures of student diet, physical activity, obesity, tobacco use or alcohol use; describe their cost or cost-effectiveness; and any harms of strategies on schools, school staff or students. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search was between 1 September 2016 and 30 April 2021 to identify any relevant trials published since the last published review. SELECTION CRITERIA: We defined 'Implementation' as the use of strategies to adopt and integrate evidence-based health interventions and to change practice patterns within specific settings. We included any trial (randomised controlled trial (RCT) or non-randomised controlled trial (non-RCT)) conducted at any scale, with a parallel control group that compared a strategy to implement policies or practices to address diet, physical activity, overweight or obesity, tobacco or alcohol use by students to 'no intervention', 'usual' practice or a different implementation strategy. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Given the large number of outcomes reported, we selected and included the effects of a single outcome measure for each trial for the primary (implementation) and secondary (student health behaviour and obesity) outcomes using a decision hierarchy. Where possible, we calculated standardised mean differences (SMDs) to account for variable outcome measures with 95% confidence intervals (CI). For RCTs, we conducted meta-analyses of primary and secondary outcomes using a random-effects model, or in instances where there were between two and five studies, a fixed-effect model. The synthesis of the effects for non-randomised studies followed the 'Synthesis without meta-analysis' (SWiM) guidelines. MAIN RESULTS: We included an additional 11 trials in this update bringing the total number of included studies in the review to 38. Of these, 22 were conducted in the USA. Twenty-six studies used RCT designs. Seventeen trials tested strategies to implement healthy eating, 12 physical activity and six a combination of risk factors. Just one trial sought to increase the implementation of interventions to delay initiation or reduce the consumption of alcohol. All trials used multiple implementation strategies, the most common being educational materials, educational outreach and educational meetings. The overall certainty of evidence was low and ranged from very low to moderate for secondary review outcomes. Pooled analyses of RCTs found, relative to a control, the use of implementation strategies may result in a large increase in the implementation of interventions in schools (SMD 1.04, 95% CI 0.74 to 1.34; 22 RCTs, 1917 participants; low-certainty evidence). For secondary outcomes we found, relative to control, the use of implementation strategies to support intervention implementation may result in a slight improvement on measures of student diet (SMD 0.08, 95% CI 0.02 to 0.15; 11 RCTs, 16,649 participants; low-certainty evidence) and physical activity (SMD 0.09, 95% CI -0.02 to 0.19; 9 RCTs, 16,389 participants; low-certainty evidence). The effects on obesity probably suggest little to no difference (SMD -0.02, 95% CI -0.05 to 0.02; 8 RCTs, 18,618 participants; moderate-certainty evidence). The effects on tobacco use are very uncertain (SMD -0.03, 95% CIs -0.23 to 0.18; 3 RCTs, 3635 participants; very low-certainty evidence). One RCT assessed measures of student alcohol use and found strategies to support implementation may result in a slight increase in use (odds ratio 1.10, 95% CI 0.77 to 1.56; P = 0.60; 2105 participants). Few trials reported the economic evaluations of implementation strategies, the methods of which were heterogeneous and evidence graded as very uncertain. A lack of consistent terminology describing implementation strategies was an important limitation of the review. AUTHORS' CONCLUSIONS: The use of implementation strategies may result in large increases in implementation of interventions, and slight improvements in measures of student diet, and physical activity. Further research is required to assess the impact of implementation strategies on such behavioural- and obesity-related outcomes, including on measures of alcohol use, where the findings of one trial suggest it may slightly increase student risk. Given the low certainty of the available evidence for most measures further research is required to guide efforts to facilitate the translation of evidence into practice in this setting.

The effectiveness of canteen manager audit and feedback reports and online menu-labels in encouraging healthier food choices within students' online lunch orders: A pilot cluster randomised controlled trial in primary school canteens in New South Wales, Australia.

Online school canteen lunch ordering systems may offer a unique opportunity to support the implementation of school canteen nutrition polices, while delivering behavioural interventions directly to consumers to influence healthy student purchasing. This cluster randomised controlled trial aimed to test the effectiveness of a menu audit and feedback strategy alone, and in combination with online menu labels in encouraging healthier purchasing from an online school canteen ordering system. Five intervention schools received a menu audit and feedback strategy, plus online menu labels; and five control schools received a delayed menu audit and feedback strategy. Data from 19,799 student lunch orders, containing over 40,000 items were included in the evaluation. Outcomes were assessed at baseline (pre-intervention), follow-up 1 (menu audit and feedback vs control), and follow-up 2 (menu audit and feedback plus online menu labels vs menu audit and feedback alone). From baseline to follow-up 1, the menu audit and feedback strategy alone had no significant effect on the proportion of healthy ('Everyday') and less healthy ('Occasional' or 'Should not be sold') items purchased. From baseline to follow-up 2, schools that received menu audit and feedback plus online menu labels had significantly higher odds of students purchasing 'Everyday' items (OR: 1.19; p = 0.019), and significantly lower odds of students purchasing 'Occasional' (OR: 0.86; p = 0.048) and 'Should not be sold' (OR: 0.52; p < 0.001) items. Menu audit and feedback with the addition of online menu labels was effective in increasing the proportion of healthy items purchased relative to menu audit and feedback in isolation. There may be a greater role for online menu labelling as part of a suite of strategies to improve public health nutrition in schools.

An mHealth Intervention to Reduce the Packing of Discretionary Foods in Children's Lunch Boxes in Early Childhood Education and Care Services: Cluster Randomized Controlled Trial.

BACKGROUND: Interventions in early childhood education and care (ECEC) services have the potential to improve children's diet at the population level. OBJECTIVE: This study aims to test the efficacy of a mobile health intervention in ECEC services to reduce parent packing of foods high in saturated fat, sugar, and sodium (discretionary foods) in children's (aged 3-6 years) lunch boxes. METHODS: A cluster randomized controlled trial was undertaken with 355 parent and child dyads recruited by phone and in person from 17 ECEC services (8 [47%] intervention and 9 [53%] control services). Parents in the intervention group received a 10-week fully automated program targeting barriers to packing healthy lunch boxes delivered via an existing service communication app. The program included weekly push notifications, within-app messages, and links to further resources, including websites and videos. The control group did not receive any intervention. The primary outcomes were kilojoules from discretionary foods and associated nutrients (saturated fat, free sugars, and sodium) packed in children's lunch boxes. Secondary outcomes included consumption of kilojoules from discretionary foods and related nutrients and the packing and consumption of serves of discretionary foods and core food groups. Photography and weights of foods in children's lunch boxes were recorded by trained researchers before and after the trial to assess primary and secondary outcomes. Outcome assessors were blinded to service allocation. Feasibility, appropriateness, and acceptability were assessed via an ECEC service manager survey and a parent web-based survey. Use of the app was assessed via app analytics. RESULTS: Data on packed lunch box contents were collected for 88.8% (355/400) of consenting children at baseline and 84.3% (337/400) of children after the intervention. There was no significant difference between groups in kilojoule from discretionary foods packed (77.84 kJ, 95% CI -163.49 to 319.18; P=.53) or the other primary or secondary outcomes. The per-protocol analysis, including only data from children of parents who downloaded the app, also did not find any statistically significant change in primary (-1.98 kJ, 95% CI -343.87 to 339.90; P=.86) or secondary outcomes. Approximately 61.8% (102/165) of parents in the intervention group downloaded the app, and the mean service viewing rate of weekly within-app messages was 26% (SD 14.9). Parents who responded to the survey and participating services agreed that it was appropriate to receive lunch box information via the app (40/50, 80% and 6/8, 75%, respectively). CONCLUSIONS: The intervention was unable to demonstrate an impact on kilojoules or associated nutrients from discretionary foods packed in children's lunch boxes. Low app downloads and program message views indicate a need to explore how to improve factors related to implementation before further testing similar mobile health interventions in this setting. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618000133235; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374379.

Multi-strategy intervention increases school implementation and maintenance of a mandatory physical activity policy: outcomes of a cluster randomised controlled trial.

OBJECTIVES: To assess if a multi-strategy intervention effectively increased weekly minutes of structured physical activity (PA) implemented by classroom teachers at 12 months and 18 months. METHODS: A cluster randomised controlled trial with 61 primary schools in New South Wales Australia. The 12-month multi-strategy intervention included; centralised technical assistance, ongoing consultation, principal's mandated change, identifying and preparing school champions, development of implementation plans, educational outreach visits and provision of educational materials. Control schools received usual support (guidelines for policy development via education department website and telephone support). Weekly minutes of structured PA implemented by classroom teachers (primary outcome) was measured via teacher completion of a daily log-book at baseline (October-December 2017), 12-month (October-December 2018) and 18-month (April-June 2019). Data were analysed using linear mixed effects regression models. RESULTS: Overall, 400 class teachers at baseline, 403 at 12 months follow-up and 391 at 18 months follow-up provided valid primary outcome data. From baseline to 12-month follow-up, teachers at intervention schools recorded a greater increase in weekly minutes of PA implemented than teachers assigned to the control schools by approximately 44.2 min (95% CI 32.8 to 55.7; p<0.001) which remained at 18 months, however, the effect size was smaller at 27.1 min (95% CI 15.5 to 38.6; p≤0.001). CONCLUSION: A multi-strategy intervention increased mandatory PA policy implementation. Some, but not all of this improvement was maintained after implementation support concluded. Further research should assess the impact of scale-up strategies on the sustainability of PA policy implementation over longer time periods. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry (ACTRN12617001265369).

Increased use of knowledge translation strategies is associated with greater research impact on public health policy and practice: an analysis of trials of nutrition, physical activity, sexual health, tobacco, alcohol and substance use interventions.

BACKGROUND: Greater use of knowledge translation (KT) strategies is recommended to improve the research impact of public health trials. The purpose of this study was to describe (1) the research impact of setting-based public health intervention trials on public health policy and practice; (2) the association between characteristics of trials and their research impact on public health policy and practice; and (3) the association between the use of KT strategies and research impacts on public health policy and practice. METHODS: We conducted a survey of authors of intervention trials targeting nutrition, physical activity, sexual health, tobacco, alcohol or substance use. We assessed the use of KT strategies aligned to domains of the Knowledge-To-Action Framework. We defined "research impact" on health policy and practice as any one or more of the following: citation in policy documents or announcements, government reports, training materials, guidelines, textbooks or court rulings; or endorsement by a (non)governmental organization; use in policy or practice decision-making; or use in the development of a commercial resource or service. RESULTS: Of the included trials, the authors reported that 65% had one or more research impacts. The most frequently reported research impact was citation in a policy document or announcement (46%). There were no significant associations between the effectiveness of the intervention, trial risk of bias, setting or health risk and trial impact. However, for every one unit increase in the total KT score (range 0-8), reflecting greater total KT activity, the odds of a health policy or practice research impact increased by approximately 30% (OR = 1.30, 95% CI: 1.02, 1.66; p = 0.031). Post hoc examination of KT domain scores suggests that KT actions focused on providing tailored support to facilitate program implementation and greater use of research products and tools to disseminate findings to end-users may be most influential in achieving impact. CONCLUSIONS: Trials of public health interventions frequently have public health impacts, and the use of more comprehensive KT strategies may facilitate greater research impact.

A cluster randomised controlled trial of a secondary school intervention to reduce intake of sugar-sweetened beverages: Mid-intervention impact of switchURsip environmental strategies.

ISSUE ADDRESSED: Secondary schools provide an opportune setting for interventions addressing excessive sugar-sweetened beverage (SSB) intake in adolescence. This trial aimed to assess the impact of school environmental strategies, delivered as part of a broader intervention, among Year 7-9 students' SSB consumption. METHODS: Between March and July 2018, we conducted a cluster randomised controlled trial with 862 students attending six secondary schools (3 intervention and 3 control) in New South Wales. The intervention targeted SSB availability, placement, promotion and pricing, and increased availability and promotion of water. Control schools followed their usual programmes. Primary outcomes included mean daily SSB consumption (millilitres) and mean daily percentage energy from SSB (kilojoules). Sub-group analysis explored primary outcomes for gender, school year level and frequency of canteen use. RESULTS: Of the 2265 eligible students, 1092 (50.2%) provided active parental consent and 940 (86.0%) participated in baseline data collection. No significant differences were observed between groups at follow-up for mean daily SSBs consumed (-10.17 mL, CI: -24.78; 45.12, P = 0.57) or mean daily percentage energy from SSBs (-0.20%, CI: -0.87; 0.47, P = .56). Significant effects were observed among girls in intervention compared to girls in control schools for mean daily SSB consumption (-52.02 mL, CI 99.8; 94.14, P = .03) and mean daily percentage of energy from SSBs (-0.90%, CI: -1.82; 0.02, P = .05). CONCLUSIONS: At 3-month mid-intervention evaluation, the intervention failed to impact on mean daily consumption and mean percentage energy from SSBs, overall. However, an intervention effect was observed in girls. The limited overall effect is likely due to inadequate intervention dose related to the short duration, limiting opportunities for schools to fully implement the environmental strategies. SO WHAT?: A longer intervention duration with additional implementation support to allow adequate time to embed the strategies within the school is recommended. Implementation support strategies would ensure staff are supported throughout the process.