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.

Menu planning practices in early childhood education and care - factors associated with menu compliance with sector dietary guidelines.

ISSUE ADDRESSED: Despite recommendations, early childhood education and care services do not plan menus in accordance with sector dietary guidelines. This study aimed to examine the following among Australian long day care services: (a) menu planning practices; (b) prevalence of menu compliance with sector dietary guidelines; and (c) menu planning practices associated with higher menu compliance with sector dietary guidelines. METHODS: Long day care services within Hunter New England, NSW participated in a pen and paper survey assessing menu planning practices and socio-demographic and service characteristics. Two-week menus were assessed for compliance with sector dietary guidelines, based on the number of servings of food groups and discretionary foods provided per child, per day. RESULTS: Staff from 72 services completed the survey and 69 provided their menu. Results indicated the service cook was fully responsible for planning the menu in 43% of services, and 57% had received written support to assist with menu planning. Service menus were compliant with an average of 0.68 out of six food groups and discretionary foods. In poisson regression models, a shorter menu cycle length (P = .04) and the receipt of training opportunities to support menu planning (P < .01) were significantly associated with higher menu compliance. CONCLUSIONS: Menu compliance with sector dietary guidelines is low among participating long day care services. SO WHAT?: The implementation of practices such as shortening of the menu cycle and the provision of training opportunities may assist in the planning of menus that are more compliant with dietary guidelines in this setting.

Prevalence of night sleep duration, sleep quality and sleep hygiene practices among children attending childcare services in New South Wales, Australia.

AIM: To describe parent-reported child: (i) sleep duration; (ii) sleep quality; (iii) sleep hygiene practices; and (iv) the proportion of children meeting sleep duration recommendations. METHODS: A convenience sample of parents of Australian pre-school-aged children (3-5 years) were surveyed from the Hunter New England region of New South Wales. The cross-sectional survey was conducted via computer-assisted telephone interview. The survey assessed parent and child demographic characteristics and parent-reported child sleep duration, quality and sleep hygiene practices. RESULTS: A total of 488 eligible parents or guardians took part in the study. Parents reported that children slept an average of 11.03 h per night. Approximately 96% of children met daily sleep duration recommendations from sleep guidelines for their age group. The majority of parents reported that their child had 'good' sleep quality (86.89%). Almost 40% reported that their child woke at least once a night. Sleep hygiene practices were relatively well established; however, a small proportion of parents indicated that they had no rules surrounding bedtime (13.52%) or television use before bed (14.52%). CONCLUSIONS: The current study describes the sleep duration, quality and sleep hygiene practices of a sample of pre-school-aged children in New South Wales, Australia. Future research using objective measures of sleep duration and hygiene, as well as assessing a broader spectrum of sleep hygiene practices, is needed.

Dietary intake and physical activity levels of children attending Australian childcare services.

AIM: The primary aim of this study was to describe the dietary intake and physical activity levels of children while attending childcare. METHODS: A cross-sectional study was conducted with 18 centre-based childcare services in the Hunter region of New South Wales, Australia. Childcare service characteristics were assessed via telephone interview. Child dietary intake and physical activity levels were assessed during a one-day observation conducted at participating childcare services using previously validated tools. RESULTS: Children consumed a mean of 0.2 serves of vegetables, 0.7 serves of fruit, 1.4 serves of grain (cereal) foods, 0.1 serves of lean meat and poultry, fish, eggs, nuts and seeds and legumes/beans, 0.6 serves of milk, yoghurt, cheese and alternatives, and 0.7 serves of discretionary foods during attendance at childcare. Of all child physical activity counts, 48.6% were classified as 'sedentary', and 22.3% classified as 'very active'. Bivariate analyses indicated that children attending services located in rural areas consumed significantly more serves of vegetables (0.3 serves (SD 0.7) vs 0.1 serves (SD 0.2), P = 0.05). Multivariate analyses indicated that services with large child enrolments had a significantly greater proportion of child counts classified as 'very active' (23.6% of child counts (95% CI 1.6, 29.5) vs 14.9% of child counts (95% CI 9.1, 20.6), P = 0.007). CONCLUSIONS: There is considerable scope to improve the diet and activity behaviours of children during attendance at childcare. Future research is needed to identify effective strategies to best support childcare services in implementing policies and practices to improve such behaviours in children.

A theory-based evaluation of a dissemination intervention to improve childcare cooks' intentions to implement nutritional guidelines on their menus.

BACKGROUND: Childcare services represent a key setting to implement nutritional interventions to support the development of healthy eating behaviours in young children. Childcare-specific nutritional guidelines outlining recommendations for provision of food in care have been developed. Despite this, research suggests that few childcare services currently implement these guidelines. This study aimed to examine the impact of providing printed educational materials on childcare service cooks' intentions to use nutritional guidelines and provide fruit and vegetables on their menu. FINDINGS: A randomised controlled trial was conducted with 77 childcare services (38 control and 39 intervention). Intervention service cooks were mailed a two-page educational material together with a menu planning checklist. Intervention development and evaluation was guided by the theory of planned behaviour. Outcome data assessing intentions to use nutritional guidelines and serves of fruit and vegetables provided on menus (primary outcomes) as well as secondary outcomes (attitudes, behavioural regulation and social norms) were collected via a telephone interview with cooks. Relative to the comparison group, cooks in the intervention arm had significantly higher intentions to use the guidelines (p value 0.0005), accompanied by significant changes in perceived behavioural control (p value 0.0008) and attitudes (p value 0.0071). No significant difference in serves of fruit (p value 0.7278) and vegetables (p value 0.0573) was observed. CONCLUSIONS: The use of educational materials can improve childcare service cooks' intentions to use nutritional guidelines; however, as a standalone strategy, it may not improve provision of food on menus.

A longitudinal study assessing childcare services' adoption of obesity prevention policies and practices.

AIM: Despite ongoing investments to improve the obesogenic environments of childcare settings, little is known regarding how these services have changed their physical activity and nutrition-promoting practices. This study aims to describe changes in the proportion of Australian childcare services that have adopted best-practice healthy eating and physical activity practices between 2006 and 2013 and to assess whether adoption varied by socio-economic status and locality. METHODS: A randomly selected sample of nominated supervisors (n = 358) from childcare services located in New South Wales, Australia, participated in a telephone survey in 2006, 2009, 2010 and 2013. Supervisors reported on their service's adoption of six practices: (i) having written nutrition and physical activity policies; (ii) staff trained in physical activity and nutrition in the past year; (iii) scheduled time for fundamental movement skills and (iv) outdoor play; (v) weekly or less screen time opportunities; and (vi) serving only non-sweetened beverages. RESULTS: A significant increase in the prevalence of services adopting all but one practice, between 2006 and 2013 was identified. Ninety one percent of services adopted four or more practices, a significant increase from 38% in 2006. There were no differences in the proportion of services adopting each practice by locality and socio-economic status. CONCLUSIONS: Government investment in obesity prevention programmes can equitably improve childcare service's adoption of healthy eating and physical activity promoting practices on a jurisdiction-wide basis. The establishment of a routine system to monitor adoption of a broader range of practices by childcare services is warranted.

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 ).

Child physical activity levels and associations with modifiable characteristics in centre-based childcare.

OBJECTIVE: To describe children's physical activity levels during childcare and associations with modifiable characteristics. METHODS: A cross-sectional study of 328 preschool children (43% girls; age 3-5 years) and 145 staff from 20 long day care centres in the Hunter Region of NSW, Australia. Pedometers assessed child physical activity levels. Centre characteristics and staff attitudes and behaviours towards children's physical activity were assessed using surveys, interviews and observational audit. Results were analysed using descriptive statistics and linear regression. RESULTS: Over the measurement period, average step count of children was 15.8 (SD=6.8) steps/minute. Four-year-olds had the highest step counts (16.4, SD=7.1, p=0.03) with no differences by sex. Step counts were significantly higher in centres that had a written physical activity policy (+3.8 steps/minute, p=0.03) and where staff led structured physical activity (+3.7 steps/minute, p<0.001) and joined in active play (+2.9 steps/minute, p=0.06). CONCLUSIONS: Written physical activity policy, structured staff-led physical activity and staff joining in active play were associated with higher levels of physical activity. IMPLICATIONS: Childcare physical activity interventions should consider including strategies to encourage written physical activity policies and support structured staff led physical activities.

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.