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.

Assessing the implementation of healthy eating and physical activity policies and practices in Early Childhood Education and Care in New South Wales, Australia: A cross-sectional study.

ISSUE ADDRESSED: Australian children are not meeting the recommended physical activity (PA) and healthy eating (HE) guidelines. Health behaviour practices implemented in community settings such as early education services can improve child's health outcomes and are therefore key to help meet guidelines. This study aimed to measure the implementation of HE and PA policies and practices in Early Childhood Education and Care (ECEC) services in New South Wales (NSW), Australia, and to examine their association with service characteristics. METHODS: A random sample of 1122 centre-based ECEC services were invited to a cross-sectional survey measuring HE and PA policy and practice implementation. Regression analyses were conducted to assess the relationship between the service characteristics and implementation of policies/practices. RESULTS: In total, 565 ECEC services completed the survey. Results show that while some practices are implemented, the implementation of practices promoting HE and PA education is low. Practices related to educator training for HE (18%) and PA (13%) were poorly implemented. The implementation of practices such as 'providing educator training around child PA', 'engaging families in activities to increase child PA' and 'encouraging supportive feeding practices' were significantly higher in services located in major cities than regional/remote services. 'Having a PA policy' and the practice of 'limiting the use of screen time' was significantly higher in long day care services than in preschools. The implementation of 'providing educator-led PA', 'providing free play opportunities' and 'having a PA policy' was significantly lower in private not-for-profit community managed services than in private for-profit services. CONCLUSIONS: Implementation of various HE and PA policies and practices in regional/remote services, private not-for-profit services and preschools across NSW could be improved. SO WHAT?: Future research should be prioritised towards identifying factors influencing the implementation of these policies and practices to best tailor implementation support efforts for those who need it the most.

Home-based interventions to promote physical activity for people living with HIV - a systematic review.

Although physical activity (PA) improves the physical, mental, and social outcomes of people living with HIV (PLH), multiple barriers prevent them from exercising. In this systematic review, we investigated the effect of home-based interventions to promote physical activity (HBI) among PLH. Randomised trials and quasi-experimental studies published in English until March 2020 were sought in five databases. Independent reviewers performed data extraction, risk of bias assessment and pragmatic-explanatory (PRECIS-2) evaluation of study characteristics. Outcomes included engagement in PA, body composition, cardiorespiratory fitness, strength, metabolic disturbances, and quality of life (QoL). Out of 480 retrieved references, six studies met inclusion criteria. Interventions lasted 12-48 weeks and involved 400 individuals (57.8% women). Ninety-eight (24.5%) participants completed interventions, but dropout rates varied considerably (5.0-54.5%). Resulted showed increased PA (two studies) and improved cardiorespiratory fitness or strength (three and two studies, respectively). Four studies demonstrated reduction of waist circumference and increase in lean body mass. QoL improved in two of three studies. We conclude HBI (aerobic and/or resistance exercises) may contribute to improve PA and/or cardiorespiratory fitness, body composition, strength and QoL of PLH. Further investigation using multi-centre standardised protocols is warranted to provide stronger evidence of their effectiveness in health promotion for PLH.

Strengthening local government policies to address health inequities: perspectives from Australian local government stakeholders.

BACKGROUND: With their close connection to community and increasing preventive health remit, local governments are well positioned to implement policies and programs to address health inequities. Nevertheless, there is a lack of evidence of equity-focused policy action in this sector. We aimed to understand how local government representatives approach equity in the development and implementation of health and wellbeing policies and programs, and to identify potential enablers for strengthening an equity focus. METHODS: We conducted semi-structured interviews (June 2022-January 2023) with 29 health directorate representatives from 21 local governments in Victoria, Australia. Representatives were recruited from urban, regional and rural local government areas, with varying levels of socioeconomic position. Data was analysed inductively using Braun and Clarke's reflexive thematic analysis, informed by social determinants of health theory and a public policy decision making framework. RESULTS: Local governments approach health equity in different ways including focusing on priority populations, disadvantaged geographic areas, or by targeting the upstream determinants of health, such as housing and employment. Enabling factors for more equity-oriented local government policy action included those internal to local governments: (i) having a clear conceptualisation of equity, (ii) fostering a strong equity-centric culture, and (iii) developing organisational-wide competency in health equity. External factors related to key stakeholder groups that support and/or influence local governments included: (iv) strong support from community, (v) state government leadership and legislation, and (vi) supportive local partners, networks and NGO's. CONCLUSIONS: Local governments have a responsibility to implement policies and programs that improve health and reduce health inequities. Local government's capacity to leverage resources, structures, processes and relationships, internally and across sectors and community, will be key to strengthening equity-oriented local government health policies and programs.

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.

Barriers and facilitators to the implementation of healthy eating, physical activity and obesity prevention policies, practices or programs in family day care: A mixed method systematic review.

Family day care (FDC) services provide care to young children typically within the carer's own home and represents a unique setting to deliver public health programs to improve child health. To support the implementation of programs targeting healthy eating, physical activity and obesity prevention in the FDC setting, an understanding of the factors influencing their implementation is required. This mixed methods systematic review aimed to describe the barriers and facilitators to the implementation of healthy eating, physical activity or obesity prevention policies, practices and programs (hereafter referred to as programs) in the FDC setting, and synthesise these according to the Theoretical Domains Framework (TDF). Electronic searches were conducted in 7 databases up to July 2020 to identify studies reporting the barriers and/or facilitators to program implementation in the FDC setting. Methodological quality assessments of included studies were conducted using the Mixed Methods Appraisal Tool (MMAT). Twenty studies met the review inclusion criteria (12 qualitative, 6 quantitative, 2 mixed methods). Of the 20 included studies, 16 reported barriers and facilitators mapped to the 'environmental contexts and resources' TDF domain; 10 reported barriers mapped to the 'social influences' TDF domain. Ten of the 12 qualitative studies and none of the quantitative or mixed method studies met all relevant MMAT criteria. This review comprehensively describes barriers and facilitators that need to be addressed to improve the implementation of healthy eating, physical activity and obesity prevention programs in FDC to ensure the expected health benefits of such programs reach children attending FDC.

School-level factors associated with the sustainment of weekly physical activity scheduled in Australian elementary schools: an observational study.

BACKGROUND: We aimed to: (1) identify school-level factors associated with the sustainment of weekly physical activity (PA) scheduled in elementary schools following withdrawal of effective implementation support; and (2) determine teacher's perceived usefulness of suggested strategies for sustaining the scheduling of weekly PA. METHODS: A secondary exploratory analysis was employed of data from the intervention arm (n = 31 schools) of a randomised controlled trial. Self-report survey data from 134 classroom teachers in New South Wales, Australia, collected following withdrawal of initial implementation support (follow-up T1) and six-months following completion of support (follow-up T2) were used. The outcomes of sustainment of weekly overall PA and energisers (short classroom PA breaks) scheduled were measured via teachers' completion of a daily activity logbook, with results presented as the difference in mean minutes of PA and energisers scheduled at T1 and T2. An adapted version of the Program Sustainability Assessment Tool (PSAT) was used to measure capacity for program sustainability across seven key domains at follow-up T2. Linear mixed regressions were conducted to evaluate associations between school-level sociodemographic characteristics (e.g., school size, remoteness, and type), teacher-reported school factors (i.e., seven adapted PSAT domains) and the sustainment of PA and energisers scheduled across the school week. Perceived usefulness of 14 proposed sustainability strategies was measured via the teacher survey at follow-up T2 and reported descriptively. RESULTS: No school-level factor was statistically associated with the sustainment of overall weekly PA or energisers scheduled. Teacher-reported factors in two PSAT domains - 'strategic planning' and 'program evaluation' were statistically negatively associated with the sustainment of weekly energisers scheduled (- 6.74, 95% CI: - 13.02; - 0.47, p = 0.036 and - 6.65, 95% CI: - 12.17; - 1.12, p = 0.019 respectively). The proposed support sustainability strategy - 'provision of PA equipment packs that enable energisers or integrated lessons' was perceived useful by the most teachers (85%). CONCLUSIONS: Further research is required to explore additional contextual-specific, and end-user appropriate factors associated with schools' sustainment of weekly PA scheduled. This will help accurately inform the development of strategies to address these determinants and support the sustainment and long-term benefits of school-based health interventions more broadly.

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 Multicomponent mHealth-Based Intervention (SWAP IT) to Decrease the Consumption of Discretionary Foods Packed in School Lunchboxes: Type I Effectiveness-Implementation Hybrid Cluster Randomized Controlled Trial.

BACKGROUND: There is significant opportunity to improve the nutritional quality of foods packed in children's school lunchboxes. Interventions that are effective and scalable targeting the school and home environment are therefore warranted. OBJECTIVE: This study aimed to assess the effectiveness of a multicomponent, mobile health-based intervention, SWAP IT, in reducing the energy contribution of discretionary (ie, less healthy) foods and drinks packed for children to consume at school. METHODS: A type I effectiveness-implementation hybrid cluster randomized controlled trial was conducted in 32 primary schools located across 3 local health districts in New South Wales, Australia, to compare the effects of a 6-month intervention targeting foods packed in children's lunchboxes with those of a usual care control. Primary schools were eligible if they were not participating in other nutrition studies and used the required school communication app. The Behaviour Change Wheel was used to co-design the multicomponent SWAP IT intervention, which consisted of the following: school lunchbox nutrition guidelines, curriculum lessons, information pushed to parents digitally via an existing school communication app, and additional parent resources to address common barriers to packing healthy lunchboxes. The primary outcome, mean energy (kilojoules) content of discretionary lunchbox foods and drinks packed in lunchboxes, was measured via observation using a validated school food checklist at baseline (May 2019) and at 6-month follow-up (October 2019). Additional secondary outcomes included mean lunchbox energy from discretionary foods consumed, mean total lunchbox energy packed and consumed, mean energy content of core lunchbox foods packed and consumed, and percentage of lunchbox energy from discretionary and core foods, all of which were also measured via observation using a validated school food checklist. Measures of school engagement, consumption of discretionary foods outside of school hours, and lunchbox cost were also collected at baseline and at 6-month follow-up. Data were analyzed via hierarchical linear regression models, with controlling for clustering, socioeconomic status, and remoteness. RESULTS: A total of 3022 (3022/7212, 41.90%) students consented to participate in the evaluation (mean age 7.8 years; 1487/3022, 49.22% girls). There were significant reductions between the intervention and control groups in the primary trial outcome, mean energy (kilojoules) content of discretionary foods packed in lunchboxes (-117.26 kJ; 95% CI -195.59 to -39.83; P=.003). Relative to the control, the intervention also significantly reduced secondary outcomes regarding the mean total lunchbox energy (kilojoules) packed (-88.38 kJ; 95% CI -172.84 to -3.92; P=.04) and consumed (-117.17 kJ; 95% CI -233.72 to -0.62; P=.05). There was no significant difference between groups in measures of student engagement, consumption of discretionary foods outside of school hours, or cost of foods packed in children's lunchboxes. CONCLUSIONS: The SWAP IT intervention was effective in reducing the energy content of foods packed for and consumed by primary school-aged children at school. Dissemination of the SWAP IT program at a population level has the potential to influence a significant proportion of primary school-aged children, impacting weight status and associated health care costs. TRIAL REGISTRATION: Australian Clinical Trials Registry ACTRN12618001731280; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376191&isReview=true. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s12889-019-7725-x.

Assessing the implementation of healthy eating and physical activity policies and practices in the family day care setting: A cross-sectional study.

ISSUE ADDRESSED: While the family day care setting provides a unique opportunity to improve child health, few studies have assessed obesity prevention practices of this setting. This study aimed to examine the (a) prevalence of implementation of evidence-based healthy eating and physical activity policies and practices among schemes (ie overarching governing agency) and educators in the family day care setting in Australia; and (b) associations between educator socio-demographic characteristics and implementation of healthy eating and physical activity practices. METHODS: Family day care schemes (n = 16) responsible for educators (n = 174) located in the Hunter New England region of NSW participated in a telephone survey in 2018, reporting their implementation of evidence-based healthy eating and physical activity policies and practices. Linear mixed regression analyses were used to determine whether educator characteristics were associated with higher percentages of implementation. RESULTS: Few schemes had comprehensive breastfeeding (0%) and screen time (19%) policies. However, the majority of educators (81%) communicated with families when lunchboxes were not consistent with guidelines. Educators implemented an average of 64.3% of practices assessed. Educators located in higher socioeconomic areas implemented a significantly higher percentage of practices than those in lower socioeconomic areas (P < .000). Educator years of experience was positively associated with percentage of implementation (P = .009). CONCLUSIONS: The implementation of obesity prevention policies and practices in the family day care setting is variable and associated with educator socio-demographic characteristics. SO WHAT?: There is a need to support family day care schemes to improve their obesity prevention environments, particularly those related to policies.

A cross-sectional study to determine the energy density and nutritional quality of primary-school children's lunchboxes.

OBJECTIVE: The present study describes the energy content of primary-school children's lunchboxes and the proportion of lunchbox foods considered discretionary. Subgroup analyses by sex, socio-economic status, age and weight status were undertaken. DESIGN: A cross-sectional study was conducted. Mean kilojoule content, number of items and categorisation of foods and drinks in lunchboxes as 'everyday' (healthy) or discretionary (sometimes) foods were assessed via a valid and reliable lunchbox observational audit. SETTING: Twelve Catholic primary schools (Kindergarten-Grade 6) located in the Hunter region of New South Wales, Australia. PARTICIPANTS: Kindergarten to Grade 6 primary-school students. RESULTS: In total, 2143 children (57 %) had parental consent to have their lunchboxes observed. School lunchboxes contained a mean of 2748 kJ, of which 61·2 % of energy was from foods consistent with the Australian Dietary Guidelines and 38·8 % of energy was discretionary foods. The proportion of lunchboxes containing only healthy foods was 12 %. Children in Kindergarten-Grade 2 packed more servings of 'everyday' foods (3·32 v. 2·98, P < 0·01) compared with children in Grades 3-6. Children in Grades 3-6 had a higher percentage of energy from discretionary foods (39·1 v. 33·8 %, P < 0·01) compared with children in Kindergarten-Grade 2 and children from the most socio-economically disadvantaged areas had significantly higher total kilojoules in the school lunchbox compared with the least disadvantaged students (2842 v. 2544 kJ, P = 0·03). CONCLUSIONS: Foods packed within school lunchboxes may contribute to energy imbalance. The development of school policies and population-based strategies to support parents overcome barriers to packing healthy lunchboxes are warranted.

Translation of two healthy eating and active living support programs for parents of 2-6 year old children: a parallel partially randomised preference trial protocol (the 'time for healthy habits' trial).

BACKGROUND: Parents are key decision makers and role models in establishing and maintaining healthy behaviours in their children. Interventions involving parents have been shown to be more effective than those that do not, but there are barriers to participation. Efficacy trials have previously been conducted on two such parent-focussed healthy eating and active living interventions with the potential to overcome these barriers - Healthy Habits (telephone-based) and Time2bHealthy (online) with promising results. Further research is now required to determine the effectiveness of these interventions in a real-world context. The Time for Healthy Habits study is a 3-arm partially randomised preference trial which aims to evaluate the effectiveness and cost-effectiveness of two theory-based programs to promote healthy eating and appropriate levels of movement behaviours (physical activity, sedentary behaviour and sleep) for parents of 2- to 6-year-old children (Healthy Habits Plus telephone-based program and Time2bHealthy online program), when compared to a comparison group receiving written materials. METHODS: Participants will be recruited across five Local Health Districts in New South Wales, Australia. The partially randomised preference design initially allows for participants to decide if they wish to be randomised or opt to select their preferred intervention and has been recommended for use to test effectiveness in a real-world setting. Both interventions incorporate multiple behaviour change techniques and support parents to improve their children's healthy eating, and movement behaviours (physical activity, sedentary behaviour and sleep) and run for 12 weeks, followed by a 3-month and 9-month post-baseline follow-up. Participants will also be asked to complete a process evaluation questionnaire at the completion of the intervention (3-months post-baseline). Outcomes include fruit and vegetable intake (primary outcome), non-core food intake, weight status, physical activity, sedentary behaviour, and sleep habits. DISCUSSION: To our knowledge, this is the first translational research trial evaluating the effectiveness and cost-effectiveness of a healthy eating and active living intervention in the 2- to 6-years age group. The results will build the evidence base in regard to translation of effective childhood obesity prevention interventions and inform the implementation and delivery of community based childhood obesity prevention programs. TRIAL REGISTRATION: UTN: U1111-1228-9748, ACTRN: 12619000396123p.

A randomized controlled trial to assess the potential efficacy, feasibility and acceptability of an m-health intervention targeting parents of school aged children to improve the nutritional quality of foods packed in the lunchbox 'SWAP IT'.

BACKGROUND: Scalable interventions that improve the nutritional quality of foods in children's lunchboxes have considerable potential to improve child public health nutrition. This study assessed the potential efficacy, feasibility and acceptability of an m-health intervention, 'SWAP IT', to improve the energy and nutritional quality of foods packed in children's lunchboxes. METHODS: The study employed a 2X2 factorial cluster randomized-controlled trial design. Twelve primary schools in New South Wales, Australia were randomly allocated to one of four groups: (i) no intervention;(ii) physical activity intervention only;(iii) lunchbox intervention only; or(iv) physical activity and lunchbox intervention combined. The two intervention strategies were evaluated separately. This paper focuses on the effects of the lunchbox intervention only. The lunchbox intervention comprised four strategies: 1) school nutrition guidelines; 2) lunchbox lessons; 3) information pushed to parents via a school-communication app and 4) parent resources addressing barriers to packing healthy lunchboxes. Outcome measures were taken at baseline and immediately post-intervention (10 weeks) and included measures of effectiveness (mean energy (kJ) packed in lunchboxes, total energy and percentage energy from recommended foods consistent with Australian Dietary Guidelines), feasibility (of delivering intervention to schools, parent app engagement and behaviour change) and acceptability to school staff and parents. Linear mixed models were used to assess intervention efficacy. RESULTS: Of the 1915 lunchbox observations, at follow-up there was no significant differences between intervention and control group in mean energy of foods packed within lunchboxes (- 118.39 kJ, CI = -307.08, 70.30, p = 0.22). There was a significant increase favouring the intervention in the secondary outcome of mean lunchbox energy from recommended foods (79.21 kJ, CI = 1.99, 156.43, p = 0.04), and a non-significant increase in percentage of lunchbox energy from recommended foods in intervention schools (4.57%, CI = -0.52, 9.66, p = 0.08). The views of the messages pushed via the app ranged from 387 to 1550 views per week (mean views =1025 per week). A large proportion (71%) of parents reported awareness of the intervention, making healthier swaps in the lunchbox (55%), and pushed content was helpful (84%). CONCLUSION: The study is the first RCT to assess the potential of a multi-component m-health lunchbox intervention. The intervention was feasible, acceptable and potentially effective in improving the nutritional quality of foods packed within children's lunchboxes. TRIAL REGISTRATION: Australian Clinical Trials Registry ACTRN: ACTRN12616001228471 .

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.

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.

Two-year follow-up of a randomised controlled trial to assess the sustainability of a school intervention to improve the implementation of a school-based nutrition policy.

ISSUE ADDRESSED: School-based nutrition policies can have a positive effect on the school food environment. The primary aim of this study was to assess the primary school adherence to a mandatory state-wide healthy canteen policy 12 months after an effective multi-strategic implementation intervention concluded. METHODS: Primary schools were randomised to (a) a 12-14 months multi-strategic intervention or (b) no-intervention (control). The intervention aimed to improve implementation of a state-wide canteen policy by encouraging schools to remove unhealthy food and beverages (classified as ''red'' or ''banned'') from canteen menus and replace with healthy items (classified as ''green''). No implementation support was provided to either group by the research team between the 12 and 24 months data collection period. RESULTS: Seventy schools participated, of which 56 schools were assessed at 24-month follow-up. Intervention schools were less likely to have a menu which contained ''red/banned'' items at 24-month follow-up (RR = 2.28; 95% CI: 1.18-4.40; P = 0.01). Intervention schools, however, were not more likely than controls to have a menu which contained >50% ''green'' items at 24-month follow-up (RR = 1.29; 95% CI: 0.98-1.70; P = 0.10). Intervention schools were more likely to adhere to both policy components (no red/banned items and >50% green items on the menu) than control schools (RR = 2.61; 95% CI: 1.29-5.29; P = 0.006). Among intervention schools that were fully adherent to the policy following implementation support (12-month post baseline), all were also adherent at the 24-month follow-up. CONCLUSION: The intervention was effective in achieving long-term school adherence to a state-wide canteen policy at 24-month follow-up. SO WHAT?: The findings suggest that sustained improvements in implementation of school nutrition policies is possible following a period (12 months) of comprehensive implementation support.

Association of parental investment of time and cost in food provisioning with adherence to dietary guidelines for the consumption of fruits, vegetables and non-core foods in pre-schoolers.

OBJECTIVE: To assess whether parent-reported time and cost for provision of food is associated with consumption of fruits, vegetables and non-core foods in pre-schoolers. DESIGN: Cross-sectional analysis of baseline data from the Healthy Habits randomised controlled trial. Two subscales of the Children's Dietary Questionnaire (CDQ) were used to assess fruit and vegetable, and non-core food consumption. SETTING: Thirty pre-schools in the Hunter Region of New South Wales, Australia. SUBJECTS: Parents (n 396) with a child aged 3-5 years attending a participating pre-school were recruited. Parents needed to reside with that child for at least four days per week and have primary responsibility for providing meals and snacks to their child. RESULTS: Sixty-three per cent of children had a parent-reported subscale score indicating adherence to dietary guidelines for fruit and vegetable intake, while 64% of children had a subscale score indicating they were exceeding dietary guidelines for non-core foods. Regression models revealed significant positive associations between higher CDQ scores for non-core foods (indicating higher consumption levels) and minutes that parents spent preparing food (P=0·032 and 0·025) and amount spent on purchasing food (P=0·043 and 0·020). The magnitude of the effects was small (estimate=0·003 and 0·001). CONCLUSIONS: Time and cost spent by parents on provision of food was not significantly associated with child fruit and vegetable consumption. Further explorations into time spent on food preparation and cost of food procurement are warranted to help address the increased consumption of non-core foods by pre-school children.

A randomised controlled trial of a lifestyle behavioural intervention for patients with low back pain, who are overweight or obese: study protocol.

BACKGROUND: Low back pain is a highly prevalent condition with a significant global burden. Management of lifestyle factors such as overweight and obesity may improve low back pain patient outcomes. Currently there are no randomised controlled trials that have been conducted to assess the effectiveness of lifestyle behavioural interventions in managing low back pain. The aim of this trial is to determine if a telephone-based lifestyle behavioural intervention is effective in reducing pain intensity in overweight or obese patients with low back pain, compared to usual care. METHODS/DESIGN: A randomised controlled trial will be conducted with patients waiting for an outpatient consultation with an orthopaedic surgeon at a public tertiary referral hospital within New South Wales, Australia for chronic low back pain. Patients will be randomly allocated in a 1:1 ratio to receive a lifestyle behavioural intervention (intervention group) or continue with usual care (control group). After baseline data collection, patients in the intervention group will receive a clinical consultation followed by a 6-month telephone-based lifestyle behavioural intervention (10 individually tailored sessions over a 6-month period) and patients in the control group will continue with usual care. Participants will be followed for 26 weeks and asked to undertake three self-reported questionnaires at baseline (pre-randomisation), week 6 and 26 post randomisation to collect primary and secondary outcome data. The study requires a sample of 80 participants per group to detect a 1.5 point difference in pain intensity (primary outcome) 26 weeks post randomisation. The primary outcome, pain intensity, will be measured using a 0-10 numerical rating scale. DISCUSSION: The study will provide robust evidence regarding the effectiveness of a lifestyle behavioural intervention in reducing pain intensity in overweight or obese patients with low back pain and inform management of these patients. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry, ACTRN12615000478516 , Registered 14/05/2015.

Population-referenced percentiles for total movement and energetic play at early childhood education and care.

OBJECTIVES: Childcare services such as preschools and long day care centres have been identified as a key setting to promote physical activity in early childhood as they provide access to large numbers of children for prolonged periods. Yet, specific standards for the type and amount of physical activity (PA) children accumulate whilst attending childcare are lacking. The purpose of this study was to derive population-referenced percentile values for children's total movement and energetic play whilst attending early childhood education and care services. DESIGN: We analysed accelerometer data collected in four Australian studies involving over 150 long day care services and 3893 accelerometer records from 1945 children to derive population-referenced percentile values for total movement and energetic play whilst attending formal early childhood education and care. METHODS: Accelerometer data were processed into time spent in total movement and energetic play using a random forest physical activity classification model. Total movement and energetic play estimates were transformed to a standard normal distribution and percentiles were calculated for a 4-, 6-, 8-, and 10-hour early childhood education and care day. RESULTS: On an average 8-hour early childhood education and care day (50th percentile), Australian pre-schoolers spend between 269 and 292 min, or 60 % of their day in movement. In contrast, Australian pre-schoolers only accumulate between 15 and 29 min of energetic play. CONCLUSIONS: The percentile reference values can be used to monitor young children's physical activity and energetic play levels whilst attending childcare. Educators can use the percentiles to assign norm-referenced ratings to identify children who could benefit from additional support for physical activity.

Sleep behavioral outcomes of school-based interventions for promoting sleep health in children and adolescents aged 5 to 18 years: a systematic review.

Study Objectives: Insufficient sleep is common among children and adolescents, and can contribute to poor health. School-based interventions potentially could improve sleep behavior due to their broad reach, but their effectiveness is unclear. This systematic review focused on the effects of school-based interventions on sleep behavior among children and adolescents aged 5 to 18 years. Methods: Five electronic databases were searched for randomized controlled trials of sleep health interventions initiated or conducted in school settings and in which behavioral sleep outcomes were measured. Cochrane risk of bias tools were used to assess study quality. Results: From the 5303 database records and two papers from other sources, 21 studies (22 papers) met the inclusion criteria for this review. These studies involved 10 867 children and adolescents at baseline from 13 countries. Most studies (n = 15) were conducted in secondary schools. Sleep education was the most common intervention, either alone (n = 13 studies) or combined with other initiatives (stress management training, n = 2; bright light therapy, n = 1; health education, n = 1). Interventions were typically brief in terms of both the intervention period (median = 4 weeks) and exposure (median = 200 minutes). Behavioral outcomes included actigraphy-measured and self-reported sleep patterns, and sleep hygiene. All outcomes had high risk of bias or some concerns with bias. Sleep education interventions were typically ineffective. Later school start times promoted longer sleep duration over 1 week (1 study, high risk of bias). Conclusions: Current evidence does not provide school-based solutions for improving sleep health, perhaps highlighting a need for complex, multi-component interventions (e.g. whole-of-school approaches) to be trialed.