Evaluation of a long day care intervention targeting the mealtime environment and curriculum to increase children's vegetable intake: a cluster randomised controlled trial using the multiphase optimisation strategy framework.

OBJECTIVE: To determine the reach, adoption, implementation and effectiveness of an intervention to increase children's vegetable intake in long day care (LDC). DESIGN: A 12-week pragmatic cluster randomised controlled trial, informed by the multiphase optimisation strategy (MOST), targeting the mealtime environment and curriculum. Children's vegetable intake and variety was measured at follow-up using a modified Short Food Survey for early childhood education and care and analysed using a two-part mixed model for non-vegetable and vegetable consumers. Outcome measures were based on the RE-AIM framework. SETTING: Australian LDC centres. PARTICIPANTS: Thirty-nine centres, 120 educators and 719 children at follow-up. RESULTS: There was no difference between intervention and waitlist control groups in the likelihood of consuming any vegetables when compared with non-vegetable consumers for intake (OR = 0·70, (95 % CI 0·34-1·43), P = 0·32) or variety (OR = 0·73 (95 % CI 0·40-1·32), P = 0·29). Among vegetable consumers (n 652), there was no difference between groups in vegetable variety (exp(b): 1·07 (95 % CI:0·88-1·32, P = 0·49) or vegetable intake (exp(b): 1·06 (95 % CI: 0·78, 1·43)), P = 0·71) with an average of 1·51 (95 % CI 1·20-1·82) and 1·40 (95 % CI 1·08-1·72) serves of vegetables per day in the intervention and control group, respectively. Intervention educators reported higher skills for promoting vegetables at mealtimes, and knowledge and skills for teaching the curriculum, than control (all P < 0·001). Intervention fidelity was moderate (n 16/20 and n 15/16 centres used the Mealtime environment and Curriculum, respectively) with good acceptability among educators. The intervention reached 307/8556 centres nationally and was adopted by 22 % eligible centres. CONCLUSIONS: The pragmatic self-delivered online intervention positively impacted educator's knowledge and skills and was considered acceptable and feasible. Intervention adaptations, using the MOST cyclic approach, could improve intervention impact on children' vegetable intake.

Screening tools used in primary health care settings to identify health behaviours in children (birth-16 years); A systematic review of their effectiveness, feasibility and acceptability.

BACKGROUND: Child health behaviour screening tools have potential to enhance the effectiveness of health promotion and early intervention. This systematic review aimed to examine the effectiveness, acceptability and feasibility of child health behaviour screening tools used in primary health care settings. METHODS: A systematic review of studies published in English in five databases (CINAHL, Medline, Scopus, PsycINFO and Web of Science) prior to July 2022 was undertaken. Eligible studies described: 1) screening tools for health behaviours (dietary, physical activity, sedentary or sleep-related behaviours) used in primary health care settings in children birth to 16 years; 2) tool effectiveness for identifying child health behaviours and changing practitioner behaviour; 3) tool acceptability or feasibility from child, caregiver or practitioner perspective and/or 4) implementation of the screening tool. RESULTS: Of the 7145 papers identified, 22 studies describing 14 screening tools were included. Only four screening tools measured all four behaviour domains. Fourteen studies reported changes in practitioner self-reported behaviour, knowledge and practice. Practitioners and caregivers identified numerous benefits and challenges to screening. CONCLUSIONS: Health behaviour screening can be an acceptable and feasible strategy to assess children's health behaviours in primary health care. Further evaluation is needed to determine effectiveness on child health outcomes.

Development and validation of a short dietary questionnaire for assessing obesity-related dietary behaviours in young children.

There are few short, validated tools to assess young children's obesity-related dietary behaviours, limiting the rapid screening of dietary behaviours in research and practice-based early obesity prevention. This study aimed to develop and assess the reliability and validity of a caregiver-reported short dietary questionnaire to rapidly assess obesity-related dietary behaviours in children aged 6 months to 5 years. The Early Prevention of Obesity in Childhood Dietary Questionnaire (EPOCH-DQ) was developed using a rigorous process to determine content and structural validity. Three age-appropriate versions were developed for (1) infants, aged 6-12 months, (2) toddlers, aged 1-2.9 years and (3) pre-schoolers, aged 3-5 years. The questionnaire (7-15 items) measures dietary behaviours, including diet risk from non-core food and beverage intake, diet quality from vegetable frequency, bread type and infant feeding practices. Test-retest reliability was assessed from repeated administrations 1 week apart (n = 126). Internal consistency, concurrent validity (against a comparison questionnaire, the InFANT Food Frequency Questionnaire), construct validity and interpretability were assessed (n = 209). Most scores were highly correlated and significantly associated (p < 0.05) for validity (rs: 0.45-0.89, percentage agreement 68%-100%) and reliability (intraclass correlation coefficient: 0.61-0.99) for diet risk, diet quality and feeding practice items. The EPOCH-DQ shows acceptable validity and reliability for screening of obesity-related behaviours of children under 5 years of age. The short length and, thus, low participant burden of the EPOCH-DQ allows for potential applications in various settings. Future testing of the EPOCH-DQ should evaluate culturally and socio-economically diverse populations and establish the predictive validity and sensitivity to detect change.

Evaluation of a menu box delivery service for Australian long-day care services to improve food provision and child intake: a cluster randomised controlled trial.

OBJECTIVE: To evaluate the impact of a menu box delivery service tailored to the long-day care (LDC) setting on improving menu compliance with recommendations, children's diet quality and dietary intake while in care. DESIGN: A cluster randomised controlled trial in LDC centres randomly assigned to an intervention (menu box delivery) or comparison (menu planning training) group. The primary outcome was child food provision and dietary intake. Secondary outcomes include menu compliance and process evaluation, including acceptability, fidelity and menu cost (per child, per day). SETTING: South Australian LDC centres. PARTICIPANTS: Eight LDC centres (n 224 children) provided data. RESULTS: No differences were observed in serves/d between intervention and comparison centres, for provision (intervention, 0·9 inter-quartile range (IQR) 0·7-1·2; comparison, 0·8 IQR 0·5-1·3) or consumption (intervention, 0·5 IQR 0·2-0·8; comparison, 0·5 IQR 0·3-0·9) of vegetables. Child food provision and dietary intake were similar across both groups for all food groups (P < 0·05). At follow-up, all intervention centres met menu planning guidelines for vegetables, whereas only one comparison centre met guidelines. Intervention centre directors found the menu box delivery more acceptable than cooks. Cost of the intervention was AUD$2·34 greater than comparison centres (intervention, AUD$4·62 (95 % CI ($4·58, $4·67)); comparison, AUD$2·28 (95 % CI ($2·27, $2·30)) per child, per day). CONCLUSIONS: Menu compliance can be improved via a menu delivery service, delivering equivalent impacts on child food provision and dietary intake compared with an online training programme. Further exploration of cooks acceptability and cost is essential before scaling up to implementation.

Development of an initiatives package to increase children's vegetable intake in long day care centres using the Multiphase Optimisation Strategy (MOST) randomised factorial experiment.

OBJECTIVE: To inform a package of initiatives to increase children's vegetable intake while in long day care (LDC) by evaluating the independent and combined effects of three initiatives targeting food provision, the mealtime environment and the curriculum. DESIGN: Using the Multiphase Optimisation Strategy (MOST) framework, a 12-week, eight-condition (n 7 intervention, n 1 control) randomised factorial experiment was conducted. Children's dietary intake data were measured pre- and post-initiative implementation using the weighed plate waste method (1× meal and 2× between-meal snacks). Vegetable intake (g/d) was calculated from vegetable provision and waste. The optimal combination of initiatives was determined using a linear mixed-effects model comparing between-group vegetable intake at follow-up, while considering initiative fidelity and acceptability. SETTING: LDC centres in metropolitan Adelaide, South Australia. PARTICIPANTS: 32 centres, 276 staff and 1039 children aged 2-5 years. RESULTS: There were no statistically significant differences between any of the intervention groups and the control group for vegetable intake (all P > 0·05). The curriculum with mealtime environment group consumed 26·7 g more vegetables/child/day than control (ratio of geometric mean 3·29 (95 % CI 0·96, 11·27), P = 0·06). Completion rates for the curriculum (> 93 %) and mealtime environment (61 %) initiatives were high, and acceptability was good (4/5 would recommend), compared with the food provision initiative (0-50 % completed the menu assessment, 3/5 would recommend). CONCLUSION: A programme targeting the curriculum and mealtime environment in LDC may be useful to increase children's vegetable intake. Determining the effectiveness of this optimised package in a randomised controlled trial is required, as per the evaluation phase of the MOST framework.

A scoping review of outcomes commonly reported in obesity prevention interventions aiming to improve obesity-related health behaviors in children to age 5 years.

This scoping review was undertaken as the first stage of development of the Core Outcome Sets for Early Prevention of Obesity in CHildhood (COS-EPOCH). The aim of this review is to identify the outcomes collected and reported in randomized controlled trials of early childhood obesity prevention interventions. A systematic scoping review was undertaken following published guidelines. Trial registries and Medline were searched, and records retrieved were screened by two reviewers. Included trials aimed to prevent childhood obesity in the first 5 years of life and were randomized. Data were extracted using a standardized form. Outcomes were assigned to outcome domains, and similar definitions within each domain were merged, based on key literature and expert consensus. Outcome and domain frequencies were estimated and presented in outcome matrices. Eighteen outcome domains were identified from 161 included studies: "anthropometry," "dietary intake," "physical activity," "sedentary behaviour," "emotional functioning/wellbeing," "feeding," "cognitive/executive functioning," "sleep," "other," "study-related," "parenting practices," "motor skill development," "environmental," "blood and lymphatic system," "perceptions and preferences," "quality of life," and "economic," "oral health." The most frequently reported outcome domain was anthropometry (92% of studies), followed by dietary intake (77%) and physical activity (60%). 221 unique outcomes were identified, indicating a high degree of heterogeneity. Body mass index was the only outcome reported in >50% of studies. The considerable heterogeneity in outcomes supports the need for the development of COS-EPOCH.

Application of the multiphase optimisation strategy to develop, optimise and evaluate the effectiveness of a multicomponent initiative package to increase 2-to-5-year-old children's vegetable intake in long day care centres: a study protocol.

INTRODUCTION: Globally, children do not eat enough core foods, with vegetable intakes persistently low. Early life is critical for establishing vegetable acceptance and intake. Increased usage of formal childcare has led to the importance of childcare settings shaping children's food intake. This study will use the multiphase optimisation strategy to develop, optimise and evaluate the effectiveness of a multicomponent initiative package to increase 2-to-5-year-old children's vegetable intake in long day care centres. METHODS AND ANALYSIS: The preparation phase will use existing literature and best practice guidelines to develop three initiatives aiming to: (1) increase vegetable provision at mealtimes, (2) deliver a vegetable-focused sensory curriculum and (3) use supportive mealtime practices encouraging children's tasting of vegetables. The optimisation phase (N=32 centres) will use a 12-week, eight-condition factorial experiment to test main and synergistic effects of the initiatives. The optimum combination of initiatives producing the largest increase in vegetable intake will be identified. The evaluation phase (N=20 centres) will test the effectiveness of the optimised package using a 12-week waitlist randomised controlled trial. Primary outcomes are children's vegetable intake and food group intake at long day care. Secondary outcomes are menu guideline compliance, cook and educator knowledge and skills, and reach. Process evaluation will include fidelity, acceptability, barriers and facilitators, and compatibility with practice. Repeated measures ANOVA with interaction effects (optimisation phase) and linear mixed modelling (evaluation phase) will test effects of the initiatives on vegetable intake. ETHICS AND DISSEMINATION: This study has received ethics approval from the Flinders University Research Ethics Committee (Project No: 1873) for the optimisation phase. Approval for the evaluation phase will be obtained following completion of optimisation phase. Findings will be disseminated to stakeholders, including long day care centres and childcare organisations; and to researchers via peer-reviewed journals and conferences. TRIAL REGISTRATION NUMBERS: ACTRN12620001301954, ACTRN12620001323910p.

The food and nutrient intake of 5- to 12-year-old Australian children during school hours: a secondary analysis of the 2011-2012 National Nutrition and Physical Activity Survey.

OBJECTIVE: School food intake of Australian children is not comprehensively described in literature, with limited temporal, nationally representative data. Greater understanding of intake at school can inform school-based nutrition promotion. This study aimed to describe the dietary intake of primary-aged children during school hours and its contribution to daily intake. DESIGN: This secondary analysis used nationally representative, cross-sectional data from the 2011 to 2012 National Nutrition and Physical Activity Survey. Dietary intake was assessed using validated 24-h dietary recalls on school days. Descriptive statistics were undertaken to determine energy, nutrients, food groups and food products consumed during school hours, as well as their contributions to total daily intake. Associations between school food intake and socio-demographic characteristics were explored. SETTING: Australia. PARTICIPANTS: Seven hundred and ninety-five children aged 5-12 years. RESULTS: Children consumed 37 % of their daily energy and 31-43 % of select nutrient intake during school hours, with discretionary choices contributing 44 % of school energy intake. Most children consumed less than one serve of vegetables, meat and alternatives or milk and alternatives during school hours. Commonly consumed products were discretionary choices (34 %, including biscuits, processed meat), bread (17 %) and fruit (12 %). There were limited associations with socio-economic position variables, apart from child age. CONCLUSIONS: Children's diets were not aligned with national recommendations, with school food characterised by high intake of discretionary choices. These findings are consistent with previous Australian evidence and support transformation of the Australian school food system to better align school food consumption with recommendations.

Protocol for the development of Core Outcome Sets for Early intervention trials to Prevent Obesity in CHildren (COS-EPOCH).

INTRODUCTION: Childhood overweight and obesity is prevalent in the first 5 years of life, and can result in significant health and economic consequences over the lifetime. The outcomes currently measured and reported in randomised controlled trials of early childhood obesity prevention interventions to reduce this burden of obesity are heterogeneous, and measured in a variety of ways. This variability limits the comparability of findings between studies, and contributes to research waste. This protocol presents the methodology for the development of two core outcome sets (COS) for obesity prevention interventions in children aged from 1 to 5 years from a singular development process: (1) a COS for interventions targeting physical activity and sedentary behaviour and (2) a COS for interventions targeting child feeding and dietary intake. Core outcomes related to physical activity and sedentary behaviour in children aged ≤1 year will also be identified to complement an existing COS for early feeding interventions, and provide a broader set of core outcomes in this age range. This will result in a suite of COS useful for measuring and reporting outcomes in early childhood obesity prevention studies, including multicomponent interventions. METHODS AND ANALYSIS: Development of the COS will follow international best practice guidelines. A scoping review of trial registries will identify commonly reported outcomes and associated measurement instruments. Key stakeholders involved in obesity prevention, including policy-makers/funders, parents, researchers, health practitioners and community and organisational stakeholders will participate in an e-Delphi study and consensus meeting regarding inclusion of outcomes in the COS. Finally, recommended outcome measure instruments will be identified through literature review and group consensus. ETHICS AND DISSEMINATION: Deakin University Human Research Ethics Committee (HEAG-H 231_2020). The COS will be disseminated through peer-reviewed publications and engagement with key stakeholders.

Cluster randomised controlled trial of a menu box delivery service for Australian long day care services to improve menu guideline compliance: a study protocol.

INTRODUCTION: Globally, children are not meeting the recommended serves of the five food group foods, particularly vegetables. Childcare is an opportune setting to improve children's diet quality. This study aims to assess the effectiveness of a menu box delivery service tailored to the long day care setting to improve menu compliance with recommendations and improve children's food intake while in care. METHODS AND ANALYSIS: This study will employ a cluster randomised controlled trial and will recruit eight long day care centres, randomly allocated to the intervention or comparison groups. The intervention group will trial the delivery of a weekly menu box service that includes all ingredients and recipes required to provide morning snack, lunch and afternoon snack. The menu boxes are underpinned by a 4-week menu developed by dietitians and meet menu planning guidelines. The comparison group will receive access to online menu planning training and a menu assessment tool for cooks. The primary outcomes are child dietary intake and menu guideline compliance. Secondary outcomes include within-trial cost-effectiveness and process evaluation measures including intervention acceptability, usability and fidelity. If effective, the menu box delivery will provide an easy strategy for childcare cooks to implement a centre menu that meets menu planning guidelines and improves child intake of five food group foods, including vegetables. ETHICS AND DISSEMINATION: This study was approved by the Flinders University Social and Behavioural Research Ethics Committee. Study outcomes will be disseminated in peer-reviewed publications, via local, national and international presentations. Non-traditional outputs including evidence summaries and development of a business case will be used to disseminate study findings to relevant stakeholder groups. Data will be used in a doctoral thesis. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry (ACTRN12620000296932).

Understanding the influence of physical resources and social supports on primary food providers' snack food provision: a discrete choice experiment.

BACKGROUND: Snack eating occasions contribute approximately a third of children's energy intake, with approximately half of all unhealthy foods consumed during snack times. Therefore, it is critical to understand the drivers of primary food providers' snack provision. The study aims were to determine the relative importance of physical resources and social supports when primary food providers are choosing snacks to provide to their child, and to investigate how these attributes differ in social versus non-social occasions, and between subgroups of primary food providers based on socio-economic position. METHODS: Primary food providers of three to seven-year olds completed an online discrete choice experiment, by making trade-offs when completing repeated, hypothetical choice tasks on the choice of snacks to provide to their child in: 1) non-social and 2) social condition. Choice tasks included two alternatives consisting of varying attribute (i.e. factor) levels, and an opt-out option. The order of conditions shown were randomized across participants. Multinomial logit model analyses were used to determine utility weights for each attribute. RESULTS: Two-hundred and twenty-five primary food providers completed the study, providing 1125 choice decisions per condition. In the non-social condition, the top three ranked attributes were type of food (utility weight 1.94, p < 0.001), child resistance (- 1.62, p < 0.001) and co-parent support (0.99, p < 0.001). In the social condition, top ranking attributes were child resistance (utility weight - 1.50, p < 0.001), type of food (1.38, p < 0.001) and co-parent support (1.07, p < 0.001). In both conditions, time was not a significant influence and cost was of lowest relative importance. Subgroup analyses revealed cost was not a significant influence for families from higher socio-economic backgrounds. CONCLUSIONS: Type of food, child resistance and co-parent support were of greatest relative importance in primary food providers' snack provision decision-making, regardless of social condition or socio-economic position. In designing future interventions to reduce unhealthy snacks, researchers should prioritize these influences, to better support primary food providers in changing their physical and social opportunity. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry no. ACTR N12618001173280.

Stakeholder Generated Ideas for Alternative School Food Provision Models in Australia Using the Nominal Group Technique.

Good nutrition is important for children's learning, growth, and development, yet food intake during school hours does not align with recommendations. In Australia, most school children currently bring a packed lunch from home, but what if there was a different way? This project aimed to engage a diverse range of stakeholders to (1) generate, refine and prioritize ideas for novel models of food provision to Australian children within school hours, and (2) to determine and rank the potential barriers and facilitators to changing the school food provision system. This study used nominal group technique virtual workshops-three idea generation workshops (n = 21 participants) and one consensus workshop (n = 11 participants). School lunch prepared onsite was the top ranked food provision model option based on impact and achievability. Potential barriers (n = 26) and facilitators (n = 28) to changing the school food system were generated. The top ranked barrier and facilitator related to government support. This study highlights that there is an opportunity to explore partnerships and utilize existing skills and infrastructure to introduce a universal school-provided lunch model in Australia. The next steps should focus on building the business case capturing the social value of investing in school lunches, including considering parent-paid and subsidized options.

Improving the Reporting of Young Children's Food Intake: Insights from a Cognitive Interviewing Study with Mothers of 3-7-Year Old Children.

Short food questions (SFQ) allow for rapid reporting of food intake across a variety of settings but are limited by poor validity and reliability. Understanding the recall process used by parents to report children's food intake can improve question design and psychometric performance. This study aimed to improve understanding of how parents report children's dietary intake using SFQ. Semi-structured, cognitive interviews were conducted with 21 mothers of 3-7-year-old children. Mothers were asked to 'think-aloud' while answering SFQ about their child's food intake. Thematic analysis identified themes relating to parent's question and answer process and barriers to recall. Information retrieval strategies focused on 'use-of-time' and 'sphere of food provision' and differed for core versus unhealthy foods. Recall of routine and home food provision were used to report core food intake, whereas recall of special occasions and food provision outside the home guided recall of discretionary foods. Mothers utilize different recall strategies for core and discretionary foods based on use of time and the sphere of food provision. The ease of reporting children's dietary intake may be improved by utilizing a shorter recall time frame, clear and direct question wording, and use of food examples and recall prompts.

A systematic evaluation of digital nutrition promotion websites and apps for supporting parents to influence children's nutrition.

BACKGROUND: Globally children's diet quality is poor. Parents are primary gatekeepers to children's food intake; however, reaching and engaging parents in nutrition promotion can be challenging. With growth in internet and smartphone use, digital platforms provide potential to disseminate information rapidly to many people. The objectives of this review were to conduct a comprehensive and systematic evaluation of nutrition promotion via websites and apps supporting parents to influence children's nutrition, from three different perspectives: 1) current evidence base, 2) end user (parent) experience and 3) current commercial offerings. METHODS: Three systematic reviews were undertaken of (1) studies evaluating the effectiveness for digital platforms for improving nutrition in children and parents, (2) studies conducting user-testing of digital tools with parents, (3) websites and apps providing lunch-provision information to parents. Searches were conducted in five databases for reviews one and two, and systematic search of Google and App Store for review three. Randomised controlled trials, cohort and cross-sectional and qualitative studies (study two only) were included if published in English, from 2013, with the intervention targeted at parents and at least 50% of intervention content focused on nutrition. Search results were double screened, with data extracted into standardised spreadsheets and quality appraisal of included search results. RESULTS: Studies evaluating digital nutrition interventions targeting parents (n = 11) demonstrated effectiveness for improving nutrition outcomes, self-efficacy and knowledge. Six of the included randomised controlled trials reported digital interventions to be equal to, or better than comparison groups. User-testing studies (n = 9) identified that digital platforms should include both informative content and interactive features. Parents wanted evidence-based information from credible sources, practical tools, engaging content and connection with other users and health professionals. Websites targeting lunch provision (n = 15) were developed primarily by credible sources and included information-based content consistent with dietary guidelines and limited interactive features. Lunchbox apps (n = 6), developed mostly by commercial organisations, were more interactive but provided less credible information. CONCLUSIONS: Digital nutrition promotion interventions targeting parents can be effective for improving nutrition-related outcomes in children and parents. As demonstrated from the lunchbox context and user-testing with parents, they need to go beyond just providing information about positive dietary changes, to include the user-desired features supporting interactivity and personalisation.

Cost effectiveness and cost-utility analysis of a group-based diet intervention for treating major depression - the HELFIMED trial.

Background/objectives: Major depression has a negative impact on quality of life, increasing the risk of premature death. It imposes social and economic costs on individuals, families and society. Mental illness is now the leading cause globally of disability/lost quality life and premature mortality. Finding cost-effective treatments for depression is a public health priority. We report an economic evaluation of a dietary intervention for treating major depression. Methods: This economic evaluation drew on the HELFIMED RCT, a 3-month group-based Mediterranean-style diet (MedDiet) intervention (including cooking workshops), against a social group-program for people with major depression. We conducted (i) a cost-utility analysis, utility scores measured at baseline, 3-months and 6-months using the AQoL8D, modelled to 2 years (base case); (ii) a cost-effectiveness analysis, differential cost/case of depression resolved (to normal/mild) measured by the DASS. Differential program costs were calculated from resources use costed in AUD2017. QALYs were discounted at 3.5%pa. Results: Best estimate differential cost/QALY gain per person, MedDiet relative to social group was AUD2775. Probabilistic sensitivity analysis, varying costs, utility gain, model period found 95% likelihood cost/QALY less than AUD20,000. Estimated cost per additional case of depression resolved, MedDiet group relative to social group was AUD2,225. Conclusions: A MedDiet group-program for treating major depression was highly cost-effective relative to a social group-program, measured in terms of cost/QALY gain and cost per case of major depression resolved. Supporting access by persons with major depression to group-based dietary programs should be a policy priority. A change to funding will be needed to realise the potential benefits.

Examining Constructs of Parental Reflective Motivation towards Reducing Unhealthy Food Provision to Young Children.

Parents are an ideal target to reduce children's unhealthy food intake. Motivation is one component of behavior change; however, there is a paucity of research exploring parental motivation in unhealthy food provision. This study aimed to understand the relationships between, and relative importance of, constructs of parents' reflective motivation and children's intake of unhealthy foods. An online survey captured parent-rated reflective motivation constructs based on the health action process approach (HAPA) model, and children's intake of unhealthy food using the short food survey. The HAPA model includes constructs of self-efficacy, risk perception, outcome expectancies, intention, and planning. Structural equation modelling was used to examine relationships between constructs and the HAPA model in its structural form. Four-hundred and ninety-five parents of three to seven-year olds completed the study. Model fit statistics (X2 = 210.03, df = 83, p < 0.001; Comparative fit index (CFI) = 0.96; Tucker Lewis index (TLI) = 0.94) supported suitability of the HAPA model. The HAPA model explained 9.2% of the variance in children's unhealthy food intake. Constructs of self-efficacy (action to maintenance ß = 0.69; maintenance to recovery ß = 0.70; maintenance to planning ß = 0.82) were found to be the most important constructs for reducing children's unhealthy food intake, followed by planning (to unhealthy food intake ß = -0.32) and intention (to planning ß = 0.21). This study provides an initial insight into parental motivation and identifies primary intervention targets to enhance parental motivation to reduce unhealthy food provision, and subsequently children's unhealthy food intake.

A Mediterranean-style dietary intervention supplemented with fish oil improves diet quality and mental health in people with depression: A randomized controlled trial (HELFIMED).

OBJECTIVES: We investigated whether a Mediterranean-style diet (MedDiet) supplemented with fish oil can improve mental health in adults suffering depression. METHODS: Adults with self-reported depression were randomized to receive fortnightly food hampers and MedDiet cooking workshops for 3 months and fish oil supplements for 6 months, or attend social groups fortnightly for 3 months. Assessments at baseline, 3 and 6 months included mental health, quality of life (QoL) and dietary questionnaires, and blood samples for erythrocyte fatty acid analysis. RESULTS: n = 152 eligible adults aged 18-65 were recruited (n = 95 completed 3-month and n = 85 completed 6-month assessments). At 3 months, the MedDiet group had a higher MedDiet score (t = 3.95, P < 0.01), consumed more vegetables (t = 3.95, P < 0.01), fruit (t = 2.10, P = 0.04), nuts (t = 2.29, P = 0.02), legumes (t = 2.41, P = 0.02) wholegrains (t = 2.63, P = 0.01), and vegetable diversity (t = 3.27, P < 0.01); less unhealthy snacks (t = -2.10, P = 0.04) and red meat/chicken (t = -2.13, P = 0.04). The MedDiet group had greater reduction in depression (t = -2.24, P = 0.03) and improved mental health QoL scores (t = 2.10, P = 0.04) at 3 months. Improved diet and mental health were sustained at 6 months. Reduced depression was correlated with an increased MedDiet score (r = -0.298, P = 0.01), nuts (r = -0.264, P = 0.01), and vegetable diversity (r = -0.303, P = 0.01). Other mental health improvements had similar correlations, most notably for increased vegetable diversity and legumes. There were some correlations between increased omega-3, decreased omega-6 and improved mental health. DISCUSSION: This is one of the first randomized controlled trials to show that healthy dietary changes are achievable and, supplemented with fish oil, can improve mental health in people with depression.

Brief tools to measure obesity-related behaviours in children under 5 years of age: A systematic review.

INTRODUCTION: Valid and reliable tools for measuring obesity-related behaviours in young children that are brief and can be administered quickly and cost-effectively in large-scale population studies are needed. The objectives of this systematic review were to describe brief tools that measure dietary intake, physical activity, sedentary behaviour, and sleep in young children. METHODS: A systematic review of studies published in English in six databases (CINAHL, Medline, Embase, PsycINFO, HaPI, and Cochrane) prior to April 2018 was undertaken using the PROSPERO protocol and PRISMA guidelines. Included studies were those reporting the psychometric properties of brief (≤15 items) tools that measure dietary, activity, or sleep-related behaviours, alone or in combination, in children birth to 4.9 years of age. RESULTS: The search identified 11 379 papers, 200 full-text articles were screened for eligibility, and 12 met the inclusion criteria. Three studies measured two behavioural domains, while most assessed a single behaviour (three diet, five physical activity, one sleep, and none sedentary behaviour). Only two (one diet, one sleep) focused on the under 2 age group. Few studies assessed reliability, and validity and findings were mixed. CONCLUSIONS: There is a need to develop brief tools to measure early life obesity-related behaviours, particularly those assessing sedentary behaviour and sleep and tools that cover multiple domains.

Feasibility of Implementing Infant Home Visiting in a Central Australian Aboriginal Community.

The Australian Nurse-Family-Partnership Program, an adaption of the Olds' Nurse-Family-Partnership (NFP), commenced in Alice Springs in 2009 (Central Australia FPP), aiming to improve the health and social outcomes of Aboriginal mothers and infants. This study explores the feasibility of NFP implementation in a remote Australian Aboriginal community. Feasibility was defined by programme uptake by eligible women, retention in the programme, actual vs. scheduled visits and extent of programme content delivery. Programme uptake was established from pregnancy data in the patient Clinical Information System and programme referrals to December 31, 2015. Rates of withdrawal, retention and content delivery were derived from FPP data and compared with published NFP data. Modified Poisson regression was used to identify client characteristics associated with retention beyond the child's first birthday. There were 469 valid referrals (43% of eligible pregnancies) and 299 women with at least one completed home visit by December 31, 2015. Of these, 41% completed the programme to the child's second birthday and 53% beyond the child's first birthday. Dominant reasons for leaving were "moved out of service area" (35%) and "declined further participation" (35%). There was a statistically significant positive association for programme retention with later gestational age at referral (RR = 1.27, p value = 0.03). A high proportion (75%) of scheduled visits was achieved and high delivery of programme content (80%). Central Australia FPP is the first implementation of the NFP model in a remote Aboriginal community. This study found that it can be implemented successfully in this setting. Outcome evaluation is needed to test achievement of hypothesised benefits.

The Australian Nurse-Family Partnership Program for aboriginal mothers and babies: Describing client complexity and implications for program delivery.

CONTEXT: The Australian Nurse-Family Partnership Program is a home visiting program for Aboriginal mothers and infants (pregnancy to child's second birthday) adapted from the US Nurse Family Partnership program. It aims to improve outcomes for Australian Aboriginal mothers and babies, and disrupt intergenerational cycles of poor health and social and economic disadvantage. The aim of this study was to describe the complexity of Program clients in the Central Australian family partnership program, understand how client complexity affects program delivery and the implications for desirable program modification. METHODS: Australian Nurse-Family Partnership Program data collected using standardised data forms by nurses during pregnancy home visits (n = 276 clients from 2009 to 2015) were used to describe client complexity and adversity in relation to demographic and economic characteristics, mental health and personal safety. Semi-structured interviews with 11 Australian Nurse-Family Partnership Program staff and key stakeholders explored in more depth the nature of client adversity and how this affected Program delivery. FINDINGS: Most clients were described as "complicated" being exposed to extreme poverty (66% on welfare), living with insecure housing, many experiencing domestic violence (almost one third experiencing 2 + episodes of violence in 12 months). Sixty-six percent of clients had experienced four or more adversities. These adversities were found challenging for Program delivery. For example, housing conditions mean that around half of all 'home visits' could not be conducted in the home (held instead in staff cars or community locations) and together with exposure to violence undermined client capacity to translate program learnings into action. Crises with the basics of living regularly intruded into the delivery of program content, and low client literacy meant written hand-outs were unhelpful for many, requiring the development of pictorial-based program materials. Adversity increased the time needed to deliver program content. CONCLUSIONS: Modifications to the Australian Nurse-Family Partnership Program model to reflect the specific complexities and adversities faced by the client populations is important for effective service delivery and to maximise the chance of meeting program goals of improving the health and well-being of Australian Aboriginal mothers and their infants.