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.

Study protocol for an economic evaluation and budget impact of implementation strategies to support routine provision of antenatal care for gestational weight gain: a stepped-wedge cluster trial.

BACKGROUND: Antenatal clinical practice guidelines recommend routine assessment of weight and provision of advice on recommended weight gain during pregnancy and referral to additional services when appropriate. However, there are barriers to clinicians adopting such best-practice guidelines. Effective, cost-effective, and affordable implementation strategies are needed to ensure the intended benefits of guidelines are realised. This paper describes the protocol for evaluating the efficiency and affordability of implementation strategies compared to the usual practice in public antenatal services. METHOD: The prospective trial-based economic evaluation will identify, measure, and value key resource and outcome impacts arising from the implementation strategies compared with usual practice. The evaluation will comprise of (i) costing, (ii) cost-consequence analyses, where a scorecard approach will be used to show the costs and benefits given the multiple primary outcomes included in the trial, and (iii) cost-effectiveness analysis, where the primary outcome will be incremental cost per percent increase in participants reporting receipt of antenatal care for gestational weight gain consistent with the guideline recommendations. Affordability will be evaluated using (iv) budget impact assessment and will estimate the financial implications of adoption and diffusion of this implementation strategy from the perspective of relevant fund-holders. DISCUSSION: Together with the findings from the effectiveness trial, the outcomes of this economic evaluation will inform future healthcare policy, investment allocation, and research regarding the implementation of antenatal care to support healthy gestational weight gain. TRIAL REGISTRATION: Trial Registration: Australian and New Zealand Clinical Trials Registry, ACTRN12621000054819 (22/01/2021) http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380680&isReview=true .

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

BACKGROUND: Increased outdoor play time in young children is associated with many health and developmental benefits. This study aims to evaluate the impact of a multi-strategy implementation strategy delivered at scale, to increase opportunities for outdoor free play in Early Childhood Education and Care (ECEC) services. METHODS: The study will employ a parallel-group randomised controlled trial design. One hundred ECEC services in the Hunter New England region of New South Wales, Australia, will be recruited and randomised to receive either a 6-month implementation strategy or usual care. The trial will seek to increase the implementation of an indoor-outdoor routine (whereby children are allowed to move freely between indoor and outdoor spaces during periods of free play), to increase their opportunity to engage in outdoor free play. Development of the strategy was informed by the Behaviour Change Wheel to address determinants identified in the Theoretical Domains Framework. ECEC services allocated to the control group will receive 'usual' implementation support delivered as part of state-wide obesity prevention programs. The primary trial outcome is the mean minutes/day (calculated across 5 consecutive days) of outdoor free play opportunities provided in ECEC services measured at baseline, 6-months (primary end point) and 18-months post baseline. Analyses will be performed using an intention-to-treat approach with ECEC services as the unit of analysis, using a linear mixed effects regression model to assess between-group differences. A sensitivity analysis will be undertaken, adjusting for service characteristics that appear imbalanced between groups at baseline, and a subgroup analysis examining potential intervention effect among services with the lowest baseline outdoor free play opportunities. DISCUSSION: Identifying effective strategies to support the implementation of indoor-outdoor routines in the ECEC setting at scale is essential to improve child population health. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ( ACTRN12621000987864 ). Prospectively registered 27th July 2021, ANZCTR - Registration.

Scale-up of the Physical Activity 4 Everyone (PA4E1) intervention in secondary schools: 24-month implementation and cost outcomes from a cluster randomised controlled trial.

BACKGROUND: Physical Activity 4 Everyone (PA4E1) is an evidence-based program effective at increasing adolescent physical activity (PA) and improving weight status. This study aimed to determine a) the effectiveness of an adapted implementation intervention to scale-up PA4E1 at 24-month follow-up, b) fidelity and reach, and c) the cost and cost-effectiveness of the implementation support intervention. METHODS: A cluster randomised controlled trial using a type III hybrid implementation-effectiveness design in 49 lower socio-economic secondary schools, randomised to a program (n = 24) or control group (n = 25). An adapted implementation intervention consisting of seven strategies was developed to support schools to implement PA4E1 over 24-months. The primary outcome was the proportion of schools implementing at least four of the 7 PA practices, assessed via computer assisted telephone interviews (CATI) with Head Physical Education Teachers. Secondary outcomes included the mean number of PA practices implemented, fidelity and reach, cost and cost-effectiveness. Logistic regression models assessed program effects. RESULTS: At baseline, no schools implemented four of the 7 PA practices. At 24-months, significantly more schools in the program group (16/23, 69.6%) implemented at least four of the 7 PA practices than the control group (0/25, 0%) (p < 0.001). At 24-months, program schools were implementing an average of 3.6 more practices than control schools (4.1 (1.7) vs. 0.5 (0.8), respectively) (P < 0.001). Fidelity and reach of the implementation intervention were high (> 75%). The total cost of the program was $415,112 AUD (2018) ($17,296 per school; $117.30 per student). CONCLUSIONS: The adapted implementation intervention provides policy makers and researchers with an effective and potentially cost-effective model for scaling-up the delivery of PA4E1 in secondary schools. Further assessment of sustainability is warranted. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12617000681358 prospectively registered 12th May 2017.

An implementation intervention to increase the routine provision of antenatal care addressing gestational weight gain: study protocol for a stepped-wedge cluster trial.

BACKGROUND: Weight gain during pregnancy that is outside of recommended levels is associated with a range of adverse outcomes for the mother and child, including gestational diabetes, pre-eclampsia, preterm birth, and obesity. Internationally, 60-80% of pregnant women report gaining weight outside of recommended levels. While guideline recommendations and RCT evidence support the provision of antenatal care that supports healthy gestational weight gain, less than 10% of health professionals routinely weigh pregnant women; discuss weight gain, diet, and physical activity; and provide a referral for additional support. This study aims to determine the effectiveness of an implementation intervention in increasing the provision of recommended gestational weight gain care by maternity services. METHODS: A stepped-wedge controlled trial, with a staggered implementation intervention, will be conducted across maternity services in three health sectors in New South Wales, Australia. The implementation intervention will consist of evidence-based, locally-tailored strategies including guidelines and procedures, reminders and prompts, leadership support, champions, training, and monitoring and feedback. Primary outcome measures will be the proportion of women who report receiving (i) assessment of gestational weight gain; (ii) advice on gestational weight gain, dietary intake, and physical activity; and (iii) offer of referral to a telephone coaching service or local dietetics service. Measurement of outcomes will occur via telephone interviews with a random sample of women who attend antenatal appointments each week. Economic analyses will be undertaken to assess the cost, cost-consequence, cost-effectiveness, and budget impact of the implementation intervention. Receipt of all care elements, acceptance of referral, weight gain during pregnancy, diet quality, and physical activity will be measured as secondary outcomes. Process measures including acceptability, adoption, fidelity, and reach will be reported. DISCUSSION: This will be the first controlled trial to evaluate the effectiveness of a implementation intervention in improving antenatal care that addresses gestational weight gain. The findings will inform decision-making by maternity services and policy agencies and, if the intervention is demonstrated to be effective, could be applied at scale to benefit the health of women and children across Australia and internationally. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry, ACTRN12621000054819 . Registered on 22 January 2021.

Acceptance of smoking cessation support and quitting behaviours of women attending Aboriginal Maternal and Infant Health Services for antenatal care.

BACKGROUND: Acceptance of smoking cessation support during antenatal care and associated quitting behaviours of pregnant Aboriginal women or women having an Aboriginal baby has not been investigated. This study aimed to determine, among pregnant women who smoke and attended AMIHS for their antenatal care: 1. The acceptance of smoking cessation support, factors associated with acceptance and barriers to acceptance; 2. The prevalence of quitting behaviours and factors associated with quitting behaviours. METHODS: A cross-sectional telephone survey of women who attended 11 AMIHSs for their antenatal care during a 12 month period in the Hunter New England Local Health District of New South Wales. RESULTS: One hundred women contacted consented to complete the survey (76%). Of those offered cessation support, 68% accepted NRT, 56% accepted follow-up support and 35% accepted a Quitline referral. Participants accepting NRT had greater odds of quitting smoking at least twice during the antenatal period [OR = 6.90 (CI: 1.59-29.7)] and those reporting using NRT for greater than eight weeks had six times the odds of quitting smoking for one day or more [OR = 6.07 (CI: 1.14-32.4)]. CONCLUSIONS: Aboriginal women or women having an Aboriginal baby who smoke make multiple attempts to quit during pregnancy and most women accept smoking cessation support when offered by their antenatal care providers. Acceptance of care and quitting success may be improved with increased focus on culturally appropriate care and enhanced training of antenatal care providers to increase skills in treating nicotine addiction and supporting women to use NRT as recommended by treatment guidelines.

Making space for Aboriginal and Torres Strait Islander community health workers in health promotion.

Despite a clear need, 'closing the gap' in health disparities for Aboriginal and Torres Strait Islander communities (hereafter, respectfully referred to as Aboriginal) continues to be challenging for western health care systems. Globally, community health workers (CHWs) have proven effective in empowering communities and improving culturally appropriate health services. The global literature on CHWs reflects a lack of differentiation between the types of roles these workers carry out. This in turn impedes evidence syntheses informing how different roles contribute to improving health outcomes. Indigenous CHW roles in Australia are largely operationalized by Aboriginal Health Workers (AHWs)-a role situated primarily within the clinical health system. In this commentary, we consider whether the focus on creating professional AHW roles, although important, has taken attention away from the benefits of other types of CHW roles particularly in community-based health promotion. We draw on the global literature to illustrate the need for an Aboriginal CHW role in health promotion; one that is distinct from, but complementary to, that of AHWs in clinical settings. We provide examples of barriers encountered in developing such a role based on our experiences of employing Aboriginal health promoters to deliver evidence-based programmes in rural and remote communities. We aim to draw attention to the systemic and institutional barriers that persist in denying innovative employment and engagement opportunities for Aboriginal people in health.

Protocol for an effectiveness- implementation hybrid trial to assess the effectiveness and cost-effectiveness of an m-health intervention to decrease the consumption of discretionary foods packed in school lunchboxes: the 'SWAP IT' trial.

BACKGROUND: At a population level, small reductions in energy intake have the potential to contribute to a reduction in the prevalence of childhood obesity. In many school systems, there is the potential to achieve a reduction in energy intake through modest improvements in foods packed in children's school lunchboxes. This study will assess the effectiveness and cost-effectiveness of a multi-component intervention that uses an existing school-based communication application to reduce the kilojoule content from discretionary foods and drinks consumed by children from school lunchboxes whilst at school. METHODS: A Type I hybrid effectiveness-implementation cluster randomised controlled trial will be conducted in up to 36 primary schools in the Hunter New England, Central Coast and Mid North Coast regions of New South Wales, Australia. Designed using the Behaviour Change Wheel, schools will be randomly allocated to receive either a 5-month (1.5 school terms) multi-component intervention that includes: 1) school lunchbox nutrition guidelines; 2) curriculum lessons; 3) information pushed to parents via an existing school-based communication application and 4) additional parent resources to address common barriers to packing healthy lunchboxes or a control arm (standard school practices). The study will assess both child level dietary outcomes and school-level implementation outcomes. The primary trial outcome, mean energy (kJ) content of discretionary lunchbox foods packed in children's lunchboxes, will be assessed at baseline and immediately post intervention (5 months or 1.5 school terms). Analyses will be performed using intention to treat principles, assessing differences between groups via hierarchical linear regression models. DISCUSSION: This study will be the first fully powered randomised controlled trial internationally to examine the impact of an m-health intervention to reduce the mean energy from discretionary food and drinks packed in the school lunchbox. The intervention has been designed with scalability in mind and will address an important evidence gap which, if shown to be effective, has the potential to be applied at a population level. TRIAL REGISTRATION: Australian Clinical Trials Registry ACTRN:12618001731280 registered on 17/10/2018. Protocol Version 1.

A cluster randomised trial of an intervention to increase the implementation of physical activity practices in secondary schools: study protocol for scaling up the Physical Activity 4 Everyone (PA4E1) program.

BACKGROUND: The implementation of interventions at-scale is required to maximise population health benefits. 'Physical Activity 4 Everyone (PA4E1)' was a multi-component school-based program targeting adolescents attending secondary schools in low socio-economic areas. An efficacy trial of the intervention demonstrated an increase in students' mean minutes of moderate-to-vigorous physical activity (MVPA) per day and lower weight gain at low incremental cost. This study aims to assess the effectiveness and cost effectiveness of a multi-component implementation support intervention to improve implementation, at-scale, of the evidence based school physical activity (PA) practices of the PA4E1 program. Impact on student PA levels and adiposity will also be assessed, in addition to the cost of implementation. METHODS: A cluster randomised controlled trial, utilising an effectiveness-implementation hybrid design, will be conducted in up to 76 secondary schools located in lower socio-economic areas across four health districts in New South Wales (NSW), Australia. Schools will be randomly allocated to a usual practice control arm or a multi-component implementation support intervention to embed the seven school PA practices of the PA4E1 program. The implementation support intervention incorporates seven strategies including executive support, in-School Champion, teacher training, resources, prompts, audit and feedback and access to an external Support Officer. The primary trial outcome will be the proportion of schools meeting at least four of the seven physical activity practices of the program, assessed via surveys with Head Physical Education teachers at 12 and 24-months. Secondary outcomes will be assessed via a nested evaluation of student PA and adiposity at 12-months (Grade 8 students) and 24 months (Grade 9 students) undertaken in 30 schools (15 per group). Resource use associated with the implementation intervention will be measured prospectively. Linear mixed effects regression models will assess program effects on the primary outcome at each follow-up period. DISCUSSION: This study is one of few evidence-based multi-component PA programs scaled-up to a large number of secondary schools and evaluated via randomised controlled trial. The use of implementation science theoretical frameworks to implement the evidence-based program and the rigorous evaluation design are strengths of the study. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12617000681358 registered 12th May 2017. Protocol Version 1.

The impact of an alcohol consumption intervention in community sports clubs on safety and participation: an RCT.

OBJECTIVE: Sports clubs have been identified as settings where high levels of risky alcohol consumption occurs. Settings characterised by such behaviour are likely to negatively impact on levels of safety, participation and amenity. DESIGN: The study was part of a randomised control trial, designed to help community sports clubs responsibly manage the sale and consumption of alcohol; the primary outcome was reduction in alcohol consumption. This study examined the secondary effects of safety and participation. METHODS: A multilevel analysis examining the pathways between the alcohol intervention, risky alcohol consumption, and safety and participation was undertaken. RESULTS: It was identified that average overall risky consumption at the club level mediated the association between the intervention and increased participation; the intervention reduced overall hazardous consumption, which in turn increased participation at the club. CONCLUSION: Interventions that target responsible alcohol management can also increase club participation. Implications for public health: Given the number of individuals involved with sports clubs, responsibly managing alcohol will also ensure that sports clubs are health promoting settings that promote community participation and engagement.

Supporting Aboriginal Women to Quit Smoking: Antenatal and Postnatal Care Providers' Confidence, Attitudes, and Practices.

INTRODUCTION: Tobacco use during pregnancy is substantially higher among Aboriginal women compared to non-Aboriginal women in Australia. However, no studies have investigated the amount or type of smoking cessation care that staff from Aboriginal antenatal and postnatal services provide to clients who smoke or staff confidence to do so. This study examined Aboriginal antenatal and postnatal staff confidence, perceived role and delivery of smoking cessation care to Aboriginal women and characteristics associated with provision of such care. METHODS: Staff from 11 Aboriginal Maternal and Infant Health Services and eight Aboriginal Child and Family Health services in the Hunter New England Local Health District in Australia completed a cross-sectional self-reported survey (n = 67, response rate = 97.1%). RESULTS: Most staff reported they assessed clients' smoking status most or all of the time (92.2%). However, only a minority reported they offered a quitline referral (42.2%), provided follow-up support (28.6%) or provided nicotine replacement therapy (4.7%) to most or all clients who smoked. Few staff felt confident in motivating clients to quit smoking (19.7%) and advising clients about using nicotine replacement therapy (15.6%). Staff confident with talking to clients about how smoking affected their health had significantly higher odds of offering a quitline referral [OR = 4.9 (1.7-14.5)] and quitting assistance [OR = 3.9 (1.3-11.6)] to clients who smoke. CONCLUSIONS: Antenatal and postnatal staff delivery of smoking cessation care to pregnant Aboriginal women or mothers with young Aboriginal children could be improved. Programs that support Aboriginal antenatal and postnatal providers to deliver smoking cessation care to clients are needed. IMPLICATIONS: Aboriginal antenatal and postnatal service staff have multiple opportunities to assist Aboriginal women to quit smoking during pregnancy and postpartum. However, staff confidence and practices of offering various forms of smoking cessation support to pregnant Aboriginal women is unexplored. This is the first study to examine the amount and type of smoking cessation support Aboriginal antenatal and postnatal service staff provide to Aboriginal women, staff confidence and their perceived role in delivering smoking cessation care. This information is valuable for developing strategies that assist antenatal and postnatal staff to improve their delivery of smoking cessation care to Aboriginal women.

Cost effectiveness of a multi-component school-based physical activity intervention targeting adolescents: the 'Physical Activity 4 Everyone' cluster randomized trial.

BACKGROUND: Few school-based interventions have been successful in reducing physical activity decline and preventing overweight and obesity in adolescent populations. As a result, few cost effectiveness analyses have been reported. The aim of this paper is to report the cost and cost effectiveness of the Physical Activity 4 Everyone (PA4E1) intervention which was a multi-component intervention implemented in secondary schools located in low-income communities. Cost effectiveness was assessed using both the physical activity and weight status trial outcomes. METHODS: Intervention and Study Design: The PA4E1 cluster randomised controlled trial was implemented in 10 Australian secondary schools (5 intervention: 5 control) and consisted of intervention schools receiving seven physical activity promotion strategies and six additional strategies that supported school implementation of the intervention components. Costs associated with physical activity strategies, and intervention implementation strategies within the five intervention schools were estimated and compared to the costs of usual physical activity practices of schools in the control group. The total cost of implementing the intervention was estimated from a societal perspective, based on the number of enrolled students in the target grade at the start of the intervention (Grade 7, n = 837). Economic Outcomes: The economic analysis outcomes were cost and incremental cost effectiveness ratios for the following: minutes of moderate-to-vigorous physical activity (MVPA) per day gained, MET hours gained per person/day; Body Mass Index (BMI) unit avoided; and 10% reduction in BMI z-score. RESULTS: The intervention cost AUD $329,952 over 24 months, or AUD$394 per student in the intervention group. This resulted in a cost effectiveness ratio of AUD$56 ($35-$147) per additional minute of MVPA, AUD$1 ($0.6-$2.7) per MET hour gained per person per day, AUD$1408 ($788-$6,570) per BMI unit avoided, and AUD$563 ($282-$3,942) per 10% reduction in BMI z-score. CONCLUSION: PA4E1 is a cost effective intervention for increasing the physical activity levels and reducing unhealthy weight gain in adolescence, a period in which physical activity typically declines. Additional modelling could explore the potential economic impact of the intervention on morbidity and mortality. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12612000382875.

Effectiveness of an intervention to facilitate the implementation of healthy eating and physical activity policies and practices in childcare services: a randomised controlled trial.

BACKGROUND: The primary aim of this study was to evaluate the effectiveness of an intervention to increase the implementation of healthy eating and physical activity policies and practices by centre-based childcare services. The study also sought to determine if the intervention was effective in improving child dietary intake and increasing child physical activity levels while attending childcare. METHODS: A parallel group, randomised controlled trial was conducted in a sample of 128 childcare services. Intervention strategies included provision of implementation support staff, securing executive support, staff training, consensus processes, academic detailing visits, tools and resources, performance monitoring and feedback and a communications strategy. The primary outcome of the trial was the proportion of services implementing all seven healthy eating and physical activity policies and practices targeted by the intervention. Outcome data were collected via telephone surveys with nominated supervisors and room leaders at baseline and immediately post-intervention. Secondary trial outcomes included the differences between groups in the number of serves consumed by children for each food group within the Australian Guide to Healthy Eating and in the proportion of children engaged in sedentary, walking or very active physical activity assessed via observation in a random subsample of 36 services at follow-up. RESULTS: There was no significant difference between groups for the primary trial outcome (p = 0.44). Relative to the control group, a significantly larger proportion of intervention group services reported having a written nutrition and physical activity policy (p = 0.05) and providing adult-guided activities to develop fundamental movement skills (p = 0.01). There were no significant differences between groups at follow-up on measures of child dietary intake or physical activity. CONCLUSIONS: The findings of the trial were equivocal. While there was no significant difference between groups for the primary trial outcome, the intervention did significantly increase the proportion of intervention group services implementing two of the seven healthy eating and physical activity policies and practices. High levels of implementation of a number of policies and practices at baseline, significant obesity prevention activity in the study region and higher than previously reported intra-class correlation of child behaviours may, in part, explain the trial findings. TRIAL REGISTRATION: Australian Clinical Trials Registry (reference ACTRN12612000927820 ).

Improving availability, promotion and purchase of fruit and vegetable and non sugar-sweetened drink products at community sporting clubs: a randomised trial.

BACKGROUND: Amateur sporting clubs represent an attractive setting for health promotion. This study assesses the impact of a multi-component intervention on the availability, promotion and purchase of fruit and vegetable and non sugar -sweetened drink products from community sporting club canteens. We also assessed the impact the intervention on sporting club revenue from the sale of food and beverages. METHOD: A repeat cross-sectional, parallel group, cluster randomized controlled trial was undertaken with amateur community football clubs in New South Wales, Australia. The intervention was conducted over 2.5 winter sporting seasons and sought to improve the availability and promotion of fruit and vegetables and non sugar-sweetened drinks in sporting club canteens. Trial outcomes were assessed via telephone surveys of sporting club representatives and members. RESULTS: Eighty five sporting clubs and 1143 club members participated in the study. Relative to the control group, at follow-up, clubs allocated to the intervention were significantly more likely to have fruit and vegetable products available at the club canteen (OR = 5.13; 95% CI 1.70-15.38), were more likely to promote fruit and vegetable selection using reduced pricing and meal deals (OR = 34.48; 95% CI 4.18-250.00) and members of intervention clubs were more likely to report purchase of fruit and vegetable (OR = 2.58 95% CI; 1.08-6.18) and non sugar -sweetened drink (OR = 1.56; 95% CI 1.09-2.25) products. There was no significant difference between groups in the annual club revenue from food and non-alcoholic beverage sales. CONCLUSION: The findings demonstrate that the intervention can improve the nutrition environment of sporting clubs and the purchasing behaviour of members. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12609000224224 .

Increasing preventive care by primary care nursing and allied health clinicians: a non-randomized controlled trial.

BACKGROUND: Although primary care nurse and allied health clinician consultations represent key opportunities for the provision of preventive care, it is provided suboptimally. PURPOSE: To assess the effectiveness of a practice change intervention in increasing primary care nursing and allied health clinician provision of preventive care for four health risks. DESIGN: Two-group (intervention versus control), non-randomized controlled study assessing the effectiveness of the intervention in increasing clinician provision of preventive care. SETTING/PARTICIPANTS: Randomly selected clients from 17 primary healthcare facilities participated in telephone surveys that assessed their receipt of preventive care prior to (September 2009-2010, n=876) and following intervention (October 2011-2012, n=1,113). INTERVENTION: The intervention involved local leadership and consensus processes, electronic medical record system modification, educational meetings and outreach, provision of practice change resources and support, and performance monitoring and feedback. MAIN OUTCOME MEASURES: The primary outcome was differential change in client-reported receipt of three elements of preventive care (assessment, brief advice, referral/follow-up) for each of four behavioral risks individually (smoking, inadequate fruit and vegetable consumption, alcohol overconsumption, physical inactivity) and combined. Logistic regression assessed intervention effectiveness. RESULTS: Analyses conducted in 2013 indicated significant improvements in preventive care delivery in the intervention compared to the control group from baseline to follow-up for assessment of fruit and vegetable consumption (+23.8% vs -1.5%); physical activity (+11.1% vs -0.3%); all four risks combined (+16.9% vs -1.0%) and for brief advice for inadequate fruit and vegetable consumption (+19.3% vs -2.0%); alcohol overconsumption (+14.5% vs -8.9%); and all four risks combined (+14.3% vs +2.2%). The intervention was ineffective in increasing the provision of the remaining forms of preventive care. CONCLUSIONS: The intervention's impact on the provision of preventive care varied by both care element and risk type. Further intervention is required to increase the consistent provision of preventive care, particularly referral/follow-up.

Validity of a measure to assess healthy eating and physical activity policies and practices in Australian childcare services.

BACKGROUND: Childcare services represent a valuable obesity prevention opportunity, providing access to a large portion of children at a vital point in their development. Few rigorously validated measures exist to measure healthy eating and physical activity policies and practices in this setting, and no such measures exist that are specific to the childcare setting in Australia. METHODS: This was a cross sectional study, comparing two measures (pen and paper survey and observation) of healthy eating and physical activity policies and practices in childcare services. Research assistants attended consenting childcare services (n = 42) across the Hunter region of New South Wales, Australia and observed practices for one day. Nominated Supervisors and Room Leaders of the service also completed a pen and paper survey during the day of observation. Kappa statistics and proportion agreement were calculated for a total of 43 items relating to healthy eating and physical activity policies and practices. RESULTS: Agreement ranged from 38%-100%. Fifty one percent of items showed agreement of greater than or equal to 80%. Items assessing the frequency with which staff joined in active play with children reported the lowest percent agreement, while items assessing availability of beverages such as juice, milk and cordial, as well as the provision of foods such as popcorn, pretzels and sweet biscuits, reported the highest percent agreement. Kappa scores ranged from -0.06 (poor agreement) to 1 (perfect agreement). Of the 43 items assessed, 27 were found to have moderate or greater agreement. CONCLUSIONS: The study found that Nominated Supervisors and Room Leaders were able to accurately report on a number of healthy eating and physical activity policies and practices. Items assessing healthy eating practices tended to have higher kappa scores than those assessing physical activity related policies or practices. The tool represents a useful instrument for public health researchers and policy makers working in this setting.

A randomised controlled trial of an intervention to facilitate the implementation of healthy eating and physical activity policies and practices in childcare services.

INTRODUCTION: Childhood overweight and obesity tracks into adulthood, increasing the risk of developing future chronic disease. Implementing initiatives promoting healthy eating and physical activity in childcare settings has been identified as a priority to prevent excessive child weight gain. Despite this, few trials have been conducted to assess the effectiveness of interventions to support population-wide implementation of such initiatives. The aim of this study is to assess the effectiveness of a multicomponent intervention in increasing the implementation of healthy eating and physical activity policies and practices by centre-based childcare services. METHODS AND ANALYSIS: The study will employ a parallel group randomised controlled trial design. A sample of 128 childcare services in the Hunter region of New South Wales, Australia, will be recruited to participate in the trial. 64 services will be randomly allocated to a 12-month implementation intervention. The remaining 64 services will be allocated to a usual care control group. The intervention will consist of a number of strategies to facilitate childcare service implementation of healthy eating and physical activity policies and practices. Intervention strategies will include implementation support staff, securing executive support, consensus processes, staff training, academic detailing visits, performance monitoring and feedback, tools and resources, and a communications strategy. The primary outcome of the trial will be the prevalence of services implementing all healthy eating and physical activity policies and practices targeted by the intervention. To assess the effectiveness of the intervention, telephone surveys with nominated supervisors and room leaders of childcare services will be conducted at baseline and immediately postintervention. ETHICS AND DISSEMINATION: The study was approved by the Hunter New England Human Research Ethics Committee and the University of Newcastle Human Research Ethics Committee. Study findings will be disseminated widely through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER: Australian Clinical Trials Registry ACTRN12612000927820.

Changes in injury-related hospital emergency department presentations associated with the imposition of regulatory versus voluntary licensing conditions on licensed venues in two cities.

INTRODUCTION AND AIMS: Regulatory and collaborative intervention strategies have been developed to reduce the harms associated with alcohol consumption on licensed venues around the world, but there remains little research evidence regarding their comparative effectiveness. This paper describes concurrent changes in the number of night-time injury-related hospital emergency department presentations in two cities that implemented either a collaborative voluntary approach to reducing harms associated with licensed premises (Geelong) or a regulatory approach (Newcastle). DESIGN AND METHODS: This paper reports findings from Dealing with Alcohol-Related problems in the Night-Time Economy project. Data were drawn from injury-specific International Classification of Disease, 10th Revision codes for injuries (S and T codes) presenting during high-alcohol risk times (midnight--5.59 am, Saturday and Sunday mornings) at the emergency departments in Geelong Hospital and Newcastle (John Hunter Hospital and the Calvary Mater Hospital), before and after the introduction of licensing conditions between the years of 2005 and 2011. Time-series, seasonal autoregressive integrated moving average analyses were conducted on the data obtained from patients' medical records. RESULTS: Significant reductions in injury-related presentations during high-alcohol risk times were found for Newcastle since the imposition of regulatory licensing conditions (344 attendances per year, P < 0.001). None of the interventions deployed in Geelong (e.g. identification scanners, police operations, radio networks or closed-circuit television) were associated with reductions in emergency department presentations. DISCUSSION AND CONCLUSIONS: The data suggest that mandatory interventions based on trading hours restrictions were associated with reduced emergency department injury presentations in high-alcohol hours than voluntary interventions.

Clinician assessment, advice and referral for multiple health risk behaviors: prevalence and predictors of delivery by primary health care nurses and allied health professionals.

OBJECTIVE: Primary care clinicians have considerable potential to provide preventive care. This study describes their preventive care delivery. METHODS: A survey of 384 community health nurses and allied health clinicians from in New South Wales, Australia was undertaken (2010-11) to examine the assessment of client risk, provision of brief advice and referral/follow-up regarding smoking inadequate fruit and vegetable consumption, alcohol misuse, and physical inactivity; the existence of preventive care support strategies; and the association between supports and preventive care provision. RESULTS: Preventive care to 80% or more clients was least often provided for referral/follow-up (24.7-45.6% of clinicians for individual risks, and 24.2% for all risks) and most often for assessment (34.4-69.3% of clinicians for individual risks, and 24.4% for all risks). Approximately 75% reported having 9 or fewer of 17 supports. Provision of care was associated with: availability of a paper screening tool; training; GP referral letter; and number of supports. CONCLUSION: The delivery of preventive care was limited, and varied according to type of care and risk. Supports were variably associated with elements of preventive care. PRACTICE IMPLICATIONS: Further research is required to increase routine preventive care delivery and the availability of supports.