5-Year Follow-Up of a Telephone Intervention to Increase Fruit and Vegetable Consumption in Preschoolers: The 'Healthy Habits' Cluster Randomised Trial.

Little is known about the long-term impact of telephone-based interventions to improve child diet. This trial aimed to assess the long-term effectiveness (after 5 years) of a telephone-based parent intervention in increasing children's fruit and vegetable consumption. Parents of 3-5 year olds were recruited from 30 Australian preschools to participate in a cluster randomised controlled trial. Intervention parents received four, weekly, 30-min support calls aimed at modifying the home food environment. Control parents received printed materials. Consumption was assessed using the Fruit and Vegetable subscale of the Children's Dietary Questionnaire (F&V-CDQ) (children) and daily servings of fruit and vegetables (children and parents) via parent telephone interview. Of the 394 parents who completed baseline, 57% (99 intervention, 127 control) completed follow-up. After 5-years, higher intervention F&V-CDQ scores, bordering on significance, were found in complete-case (+1.1, p = 0.06) and sensitivity analyses (+1.1, p = 0.06). There was no difference in parent or child consumption of daily fruit servings. Complete-case analysis indicated significantly higher consumption of child vegetable servings (+0.5 servings; p = 0.02), which was not significant in sensitivity analysis (+0.5 servings; p = 0.10). This telephone-based parent intervention targeting the family food environment may yield promising improvements in child fruit and vegetable consumption over a 5-year period.

A Cluster Randomised Controlled Trial of an Intervention to Increase Physical Activity of Preschool-Aged Children Attending Early Childhood Education and Care: Study Protocol for the 'Everybody Energise' Trial.

The use of 'Energisers,' short bouts of moderate-to-vigorous physical activity (MVPA), have been shown to significantly increase children's physical activity within the school setting but not within Early Childhood Education and Care (ECEC) centres. The aim of this study is to assess the efficacy of an intervention involving the provision of educator-led daily Energisers to increase the time children spend in MVPA while attending ECEC. Fourteen ECEC centres in the Hunter region of New South Wales, Australia, will be randomised to either an intervention or control group. The intervention group will be supported by the research team to implement three brief (5-min) educator-led Energisers each day for children aged three to six years between the hours of 9:00 a.m. to 3.00 p.m. Control ECEC centres will continue to provide 'normal practice' to children. The primary trial outcome is child minutes of MVPA whilst in ECEC, assessed objectively via accelerometery over three days. Outcome assessment will occur at baseline and 6 months post-baseline. Linear mixed models under an intention-to-treat framework will be used to compare differences between groups in MVPA at follow-up. This will be the first cluster randomised controlled trial to test the efficacy of Energisers in isolation on increasing the time children spend in MVPA.

The association between the receipt of primary care clinician provision of preventive care and short term health behaviour change.

Primary healthcare services are recommended to provide preventive care to address chronic disease risk behaviours. However, all care elements are infrequently provided, and there is a need to understand the impact of partial care provision on behaviour change. This study examined the association between variable levels of preventive care receipt from primary care clinicians on short-term behaviour change for four risk behaviours. A survey was undertaken with 5639 Australian community health service clients (2009-2014). Clients self-reported: engagement in risk behaviours (tobacco smoking, harmful alcohol consumption, inadequate fruit and/or vegetable consumption, physical inactivity) in the month prior to and four week post their community health service appointment; receipt of preventive care during appointments (assessment, advice, referral/follow-up) for each behaviour. Univariate regression models explored the association between change in risk status and preventive care received. The odds of behaviour change for those receiving all three care elements was significant for all behaviours, compared to no care, ranging from 2.02 (alcohol consumption, 95% CI 1.16-3.49) to 4.17 (inadequate fruit and/or vegetable consumption, 95% CI 2.91-5.96). Receipt of both assessment and advice increased the odds of behaviour change, compared to no care, for all behaviours except smoking, ranging from 2.32 (physical inactivity, 95% CI 1.60-3.35) to 2.83 (alcohol consumption, 95% CI 1.84-4.33). Receipt of 'assessment only' increased the odds of behaviour change, compared to no care, for inadequate fruit and/or vegetable consumption (OR = 2.40, 95% CI 1.60-3.59) and physical inactivity (OR = 2.81, 95% CI 1.89-4.17). Results highlight the importance of primary care clinicians providing best practice preventive care to maximise client behaviour change.

Increasing the provision of preventive care by community healthcare services: a stepped wedge implementation trial.

BACKGROUND: Although clinical guidelines recommend the provision of care to reduce client chronic disease risk behaviours, such care is provided sub-optimally by primary healthcare providers. A study was undertaken to determine the effectiveness of an intervention in increasing community-based clinician implementation of multiple elements of recommended preventive care for four risk behaviours. METHODS: A three-group stepped-wedge trial was undertaken with all 56 community-based primary healthcare facilities in one health district in New South Wales, Australia. A 12-month implementation intervention was delivered sequentially in each of three geographically and administratively defined groups of facilities. The intervention consisted of six key strategies: leadership and consensus processes, enabling systems, educational meetings and training, audit and feedback, practice change support, and practice change information and resources. Client-reported receipt of three elements of preventive care: assessment; brief advice; referral for four behavioural risks: smoking, inadequate fruit and/or vegetable consumption, alcohol overconsumption, and physical inactivity, individually, and for all such risks combined were collected for 56 months (October 2009-May 2014). Segmented logistic regression models were developed to assess intervention effectiveness. RESULTS: A total of 5369 clients participated in data collection. Significant increases were found for receipt of four of five assessment outcomes (smoking OR 1.53; fruit and/or vegetable intake OR 2.18; alcohol consumption OR 1.69; all risks combined OR 1.78) and two of five brief advice outcomes (fruit and/or vegetable intake OR 2.05 and alcohol consumption OR 2.64). No significant increases in care delivery were observed for referral for any risk behaviour, or for physical inactivity. CONCLUSIONS: The implementation intervention was effective in enhancing assessment of client risk status but less so for elements of care that could reduce client risk: provision of brief advice and referral. The intervention was ineffective in increasing care addressing physical inactivity. Further research is required to identify barriers to the provision of preventive care and the effectiveness of practice change interventions in increasing its provision. TRIAL REGISTRATION: Australian Clinical Trials Registry ACTRN12611001284954 . Registered 15 December 2011. Retrospectively registered.

Multi-strategic intervention to enhance implementation of healthy canteen policy: a randomised controlled trial.

BACKGROUND: Internationally, governments have implemented school-based nutrition policies to restrict the availability of unhealthy foods from sale. The aim of the trial was to assess the effectiveness of a multi-strategic intervention to increase implementation of a state-wide healthy canteen policy. The impact of the intervention on the energy, total fat, and sodium of children's canteen purchases and on schools' canteen revenue was also assessed. METHODS: Australian primary schools with a canteen were randomised to receive a 12-14-month, multi-strategic intervention or to a no intervention control group. The intervention sought to increase implementation of a state-wide healthy canteen policy which required schools to remove unhealthy items (classified as 'red' or 'banned') from regular sale and encouraged schools to 'fill the menu' with healthy items (classified as 'green'). The intervention strategies included allocation of a support officer to assist with policy implementation, engagement of school principals and parent committees, consensus processes with canteen managers, training, provision of tools and resources, academic detailing, performance feedback, recognition and marketing initiatives. Data were collected at baseline (April to September, 2013) and at completion of the implementation period (November, 2014 to April, 2015). RESULTS: Seventy schools participated in the trial. Relative to control, at follow-up, intervention schools were significantly more likely to have menus without 'red' or 'banned' items (RR = 21.11; 95% CI 3.30 to 147.28; p ≤ 0.01) and to have at least 50% of menu items classified as 'green' (RR = 3.06; 95% CI 1.64 to 5.68; p ≤ 0.01). At follow-up, student purchases from intervention school canteens were significantly lower in total fat (difference = -1.51 g; 95% CI -2.84 to -0.18; p = 0.028) compared to controls, but not in energy (difference = -132.32 kJ; 95% CI -280.99 to 16.34; p = 0.080) or sodium (difference = -46.81 mg; 95% CI -96.97 to 3.35; p = 0.067). Canteen revenue did not differ significantly between groups. CONCLUSION: Poor implementation of evidence-based school nutrition policies is a problem experienced by governments internationally, and one with significant implications for public health. The study makes an important contribution to the limited experimental evidence regarding strategies to improve implementation of school nutrition policies and suggests that, with multi-strategic support, implementation of healthy canteen policies can be achieved in most schools. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ( ACTRN12613000311752 ).

Online canteens: awareness, use, barriers to use, and the acceptability of potential online strategies to improve public health nutrition in primary schools.

Issue addressed This study of primary school principals assessed the awareness, use, barriers to use and acceptability of online canteens. Methods A telephone survey of 123 primary school principals within the Hunter New England Region of New South Wales, Australia was conducted from September 2014 to November 2014. Results Fifty-six percent of principals were aware of the existence of online canteens, with 8% having implemented such a system, and 38% likely to do so in the future. Medium/large schools were more likely to be aware of or to use online canteens, however there were no differences in awareness or use in relation to school rurality or socioeconomic advantage. Principals cited parent internet access as the most commonly identified perceived barrier to online canteen use, and the majority of principals (71-93%) agreed that it would be acceptable to implement a range of consumer behaviour strategies via an online canteen. Conclusions Study findings suggest that despite relatively low levels of current use, online canteens have the potential to reach a large proportion of school communities in the future, across geographical and socioeconomic divides, and that the nutrition interventions which they have the capacity to deliver are considered acceptable to school principals. So what? Online canteens may represent an opportunity to deliver nutrition interventions to school communities. Future research should examine the feasibility and potential effectiveness of interventions delivered via this modality.

A randomised controlled trial of an intervention to increase the implementation of a healthy canteen policy in Australian primary schools: study protocol.

BACKGROUND: The implementation of healthy school canteen policies has been recommended as a strategy to help prevent unhealthy eating and excessive weight gain. Internationally, research suggests that schools often fail to implement practices consistent with healthy school canteen policies. Without a population wide implementation, the potential benefits of these policies will not be realised. The aim of this trial is to assess the effectiveness of an implementation intervention in increasing school canteen practices consistent with a healthy canteen policy of the New South Wales (NSW), Australia, government known as the 'Fresh Tastes @ School NSW Healthy School Canteen Strategy'. METHODS/DESIGN: The parallel randomised trial will be conducted in 70 primary schools located in the Hunter region of New South Wales, Australia. Schools will be eligible to participate if they are not currently meeting key components of the healthy canteen policy. Schools will be randomly allocated after baseline data collection in a 1:1 ratio to either an intervention or control group using a computerised random number function in Microsoft Excel. Thirty-five schools will be selected to receive a multi-component intervention including implementation support from research staff, staff training, resources, recognition and incentives, consensus and leadership strategies, follow-up support and implementation feedback. The 35 schools allocated to the control group will not receive any intervention support as part of the research trial. The primary outcome measures will be i) the proportion of schools with a canteen menu that does not contain foods or beverages restricted from regular sale ('red' and 'banned' items) and ii) the proportion of schools where healthy canteen items ('green' items) represent the majority (>50%) of products listed on the menu. Outcome data will be collected via a comprehensive menu audit, conducted by dietitians blind to group allocation. Intervention effectiveness will be assessed using logistic regression models adjusting for baseline values. DISCUSSION: The proposed trial will represent a novel contribution to the literature, being the first randomised trial internationally to examine the effectiveness of an intervention to facilitate implementation of a healthy canteen policy. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12613000311752.