The business case for hospital mobility programs in the veterans health care system: Results from multi-hospital implementation of the STRIDE program.

OBJECTIVE: To conduct a business case analysis for Department of Veterans Affairs (VA) program STRIDE (ASsisTed EaRly MobIlization for hospitalizeD older VEterans), which was designed to address immobility for hospitalized older adults. DATA SOURCES AND STUDY SETTING: This was a secondary analysis of primary data from a VA 8-hospital implementation trial conducted by the Function and Independence Quality Enhancement Research Initiative (QUERI). In partnership with VA operational partners, we estimated resources needed for program delivery in and out of the VA as well as national implementation facilitation in the VA. A scenario analysis using wage data from the Bureau of Labor Statistics informs implementation decisions outside the VA. STUDY DESIGN: This budget impact analysis compared delivery and implementation costs for two implementation strategies (Replicating Effective Programs [REP]+CONNECT and REP-only). To simulate national budget scenarios for implementation, we estimated the number of eligible hospitalizations nationally and varied key parameters (e.g., enrollment rates) to evaluate the impact of uncertainty. DATA COLLECTION: Personnel time and implementation outcomes were collected from hospitals (2017-2019). Hospital average daily census and wage data were estimated as of 2022 to improve relevance to future implementation. PRINCIPAL FINDINGS: Average implementation costs were $9450 for REP+CONNECT and $5622 for REP-only; average program delivery costs were less than $30 per participant in both VA and non-VA hospital settings. Number of walks had the most impact on delivery costs and ranged from 1 to 5 walks per participant. In sensitivity analyses, cost increased to $35 per participant if a physical therapist assistant conducts the walks. Among study hospitals, mean enrollment rates were higher among the REP+CONNECT hospitals (12%) than the REP-only hospitals (4%) and VA implementation costs ranged from $66 to $100 per enrolled. CONCLUSIONS: STRIDE is a low-cost intervention, and program participation has the biggest impact on the resources needed for delivering STRIDE. TRIAL REGISTRATION: ClinicalsTrials.gov NCT03300336. Prospectively registered on 3 October 2017.

Evaluation of strategies to support implementation of a hospital walking program: protocol for a type III effectiveness-implementation hybrid trial.

BACKGROUND: STRIDE is a supervised walking program designed to address the negative consequences of immobility during hospitalization for older adults. In an 8-hospital stepped wedge randomized controlled trial, STRIDE was associated with reduced odds of hospital discharge to skilled nursing facility. STRIDE has the potential to become a system-wide approach to address hospital-associated disability in Veteran's Affairs; however, critical questions remain about how best to scale and sustain the program. The overall study goal is to compare the impact of two strategies on STRIDE program penetration (primary), fidelity, and adoption implementation outcomes. METHODS: Replicating Effective Programs will be used as a framework underlying all implementation support activities. In a parallel, cluster randomized trial, we will use stratified blocked randomization to assign hospitals (n = 32) to either foundational support, comprised of standard, low-touch activities, or enhanced support, which includes the addition of tailored, high-touch activities if hospitals do not meet STRIDE program benchmarks at 6 and 8 months following start date. All hospitals begin with foundational support for 6 months until randomization occurs. The primary outcome is implementation penetration defined as the proportion of eligible hospitalizations with ≥ 1 STRIDE walks at 10 months. Secondary outcomes are fidelity and adoption with all implementation outcomes additionally examined at 13 and 16 months. Fidelity will be assessed for STRIDE hospitalizations as the percentage of eligible hospital days with "full dose" of the program, defined as two or more documented walks or one walk for more than 5 min. Program adoption is a binary outcome defined as ≥ 5 patients with a STRIDE walk or not. Analyses will also include patient-level effectiveness outcomes (e.g., discharge to nursing home, length of stay) and staffing and labor costs. We will employ a convergent mixed-methods approach to explore and understand pre-implementation contextual factors related to differences in hospital-level adoption. DISCUSSION: Our study results will dually inform best practices for promoting successful implementation of an evidence-based hospital-based walking program. This information may support other programs by advancing our understanding of how to apply and scale-up national implementation strategies. TRIAL REGISTRATION: This study was registered on June 1, 2021, at ClinicalTrials.gov (identifier NCT04868656 ).

If You Build It, Will They Come? Patient and Provider Use of a Novel Hybrid Telehealth Care Pathway for Low Back Pain.

OBJECTIVE: The purpose of this study was to describe the referrals and use of a hybrid care model for low back pain that includes on-site care by physical therapists, physical activity training, and psychologically informed practice (PiP) delivered by telehealth in the Improving Veteran Access to Integrated Management of Low Back Pain (AIM-Back) trial. METHODS: Data were collected from November 2020 through February 2023 from 5 Veteran Health Administration clinics participating in AIM-Back, a multisite, cluster-randomized embedded pragmatic trial. The authors extracted data from the Veteran Health Administration Corporate Data Warehouse to describe referral and enrollment metrics, telehealth use (eg, distribution of physical activity and PiP calls), and treatments used by physical therapists and telehealth providers. RESULTS: Seven hundred one veterans were referred to the AIM-Back trial with 422 enrolling in the program (consult-to-enrollment rate = 60.2%). After travel restrictions were lifted, site visits resulted in a significant increase in referrals and a number of new referring providers. At initial evaluation by on-site physical therapists, 92.2% of veterans received pain modulation (eg, transcutaneous electrical nerve stimulation, manual therapy). Over 81% of enrollees completed at least 1 telehealth physical activity call, with a mean of 2.8 (SD = 2.0) calls out of 6. Of the 167 veterans who screened as medium to high risk of persistent disability, 74.9% completed at least 1 PiP call, with a mean of 2.5 (SD = 2.0) calls out of 6. Of those who completed at least 1 PiP call (n = 125), 100% received communication strategies, 97.6% received pain coping skills training, 89.6% received activity-based treatments, and 99.2% received education in a home program. CONCLUSION: In implementing a hybrid care pathway for low back pain, the authors observed consistency in the delivery of core components (ie, pain modulation, use of physical activity training, and risk stratification to PiP), notable variability in telehealth calls, high use of PiP components, and increased referrals with tailored provider engagement. IMPACT: These findings describe variability occurring within a hybrid care pathway and can inform future implementation efforts.

Effects of Implementation of a Supervised Walking Program in Veterans Affairs Hospitals : A Stepped-Wedge, Cluster Randomized Trial.

BACKGROUND: In trials, hospital walking programs have been shown to improve functional ability after discharge, but little evidence exists about their effectiveness under routine practice conditions. OBJECTIVE: To evaluate the effect of implementation of a supervised walking program known as STRIDE (AssiSTed EaRly MobIlity for HospitalizeD VEterans) on discharge to a skilled-nursing facility (SNF), length of stay (LOS), and inpatient falls. DESIGN: Stepped-wedge, cluster randomized trial. (ClinicalTrials.gov: NCT03300336). SETTING: 8 Veterans Affairs hospitals from 20 August 2017 to 19 August 2019. PATIENTS: Analyses included hospitalizations involving patients aged 60 years or older who were community dwelling and admitted for 2 or more days to a participating medicine ward. INTERVENTION: Hospitals were randomly assigned in 2 stratified blocks to a launch date for STRIDE. All hospitals received implementation support according to the Replicating Effective Programs framework. MEASUREMENTS: The prespecified primary outcomes were discharge to a SNF and hospital LOS, and having 1 or more inpatient falls was exploratory. Generalized linear mixed models were fit to account for clustering of patients within hospitals and included patient-level covariates. RESULTS: Patients in pre-STRIDE time periods (n = 6722) were similar to post-STRIDE time periods (n = 6141). The proportion of patients with any documented walk during a potentially eligible hospitalization ranged from 0.6% to 22.7% per hospital. The estimated rates of discharge to a SNF were 13% pre-STRIDE and 8% post-STRIDE. In adjusted models, odds of discharge to a SNF were lower among eligible patients hospitalized in post-STRIDE time periods (odds ratio [OR], 0.6 [95% CI, 0.5 to 0.8]) compared with pre-STRIDE. Findings were robust to sensitivity analyses. There were no differences in LOS (rate ratio, 1.0 [CI, 0.9 to 1.1]) or having an inpatient fall (OR, 0.8 [CI, 0.5 to 1.1]). LIMITATION: Direct program reach was low. CONCLUSION: Although the reach was limited and variable, hospitalizations occurring during the STRIDE hospital walking program implementation period had lower odds of discharge to a SNF, with no change in hospital LOS or inpatient falls. PRIMARY FUNDING SOURCE: U.S. Department of Veterans Affairs Quality Enhancement Research Initiative (Optimizing Function and Independence QUERI).

Intensification of Implementation Strategies: Developing a Model of Foundational and Enhanced Implementation Approaches to Support National Adoption and Scale-up.

Implementation strategies are activities to support integration of evidence-based programs (EBPs) into routine care. Comprised of 170+ facilities, the Veterans Affairs Healthcare System is conducive to evaluating feasibility and scalability of implementation strategies on a national level. In previous work evaluating implementation of three EBPs for older Veterans (hospital-based walking, caregiver skills training, group physical therapy), we found facilities varied in their need for implementation support, with some needing minimal guidance and others requiring intensive support. Committed to national scalability, our team developed an implementation intensification model consisting of foundational (low-touch) and enhanced (high-touch) implementation support. This Forum article describes our multilevel and multistep process to develop and evaluate implementation intensification. Steps included (a) review completed trial data; (b) conduct listening sessions; (c) review literature; (d) draft foundational and enhanced implementation support packages; (e) iteratively refine packages; and (7) devise an evaluation plan. Our model of implementation intensification may be relevant to other health care systems seeking strategies that can adapt to diverse delivery settings, optimize resources, help build capacity, and ultimately enhance implementation outcomes. As more health care systems focus on spread of EBPs into routine care, identifying scalable and effective implementation strategies will be critical.

Adapting to CONNECT: modifying a nursing home-based team-building intervention to improve hospital care team interactions, functioning, and implementation readiness.

BACKGROUND: Clinical interventions often need to be adapted from their original design when they are applied to new settings. There is a growing literature describing frameworks and approaches to deploying and documenting adaptations of evidence-based practices in healthcare. Still, intervention modifications are often limited in detail and justification, which may prevent rigorous evaluation of interventions and intervention adaptation effectiveness in new contexts. We describe our approach in a case study, combining two complementary intervention adaptation frameworks to modify CONNECT for Quality, a provider-facing team building and communication intervention designed to facilitate implementation of a new clinical program. METHODS: This process of intervention adaptation involved the use of the Planned Adaptation Framework and the Framework for Reporting Adaptations and Modifications, for systematically identifying key drivers, core and non-core components of interventions for documenting planned and unplanned changes to intervention design. RESULTS: The CONNECT intervention's original context and setting is first described and then compared with its new application. This lays the groundwork for the intentional modifications to intervention design, which are developed before intervention delivery to participating providers. The unpredictable nature of implementation in real-world practice required unplanned adaptations, which were also considered and documented. Attendance and participation rates were examined and qualitative assessment of reported participant experience supported the feasibility and acceptability of adaptations of the original CONNECT intervention in a new clinical context. CONCLUSION: This approach may serve as a useful guide for intervention implementation efforts applied in diverse clinical contexts and subsequent evaluations of intervention effectiveness. TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov ( NCT03300336 ) on September 28, 2017.

Self-Organization of Interprofessional Staff to Improve Mobility of Hospitalized Patients with STRIDE: a Complexity Science-Informed Qualitative Study.

BACKGROUND: Inpatient mobility programs can help older adults maintain function during hospitalization. Changing hospital practice can be complex and require engagement of various staff levels and disciplines; however, we know little about how interprofessional teams organize around implementing such interventions. Complexity science can inform approaches to understanding and improving multidisciplinary collaboration to implement clinical programs. OBJECTIVE: To examine, through a complexity science lens, how clinical staff's understanding about roles in promoting inpatient mobility evolved during implementation of the STRIDE (assiSTed eaRly mobIlity for hospitalizeD older vEterans) hospital mobility program. DESIGN: Qualitative study using semi-structured interviews. PARTICIPANTS: Ninety-two clinical staff at eight Veterans Affairs hospitals. INTERVENTIONS: STRIDE is a supervised walking program for hospitalized older adults designed to maintain patients' mobility and function. APPROACH: We interviewed key staff involved in inpatient mobility efforts at each STRIDE site in pre- and post-implementation periods. Interviews elicited staff's perception of complexity-science aspects of inpatient mobility teams (e.g., roles over time, team composition). We analyzed data using complexity science-informed qualitative content analysis. KEY RESULTS: We identified three key themes related to patterns of self-organization: (1) individuals outside of the "core" STRIDE team voluntarily assumed roles as STRIDE advocates, (2) leader-champions adapted their engagement level to match local implementation team needs during implementation, and (3) continued leadership support and physical therapy involvement were key factors for sustainment. CONCLUSIONS: Staff self-organized around implementation of a new clinical program in ways that were responsive to changing program and contextual needs. These findings demonstrate the importance of effective self-organization for clinical program implementation. Researchers and practitioners implementing clinical programs should allow for, and encourage, flexibility in staff roles in planning for implementation of a new clinical program, encourage the development of advocates, and engage leaders in program planning and sustainment efforts.

Walking All over COVID-19: The Rapid Development of STRIDE in Your Room, an Innovative Approach to Enhance a Hospital-Based Walking Program during the Pandemic.

Hospitalization is common among older adults. Prolonged time in bed during hospitalization can lead to deconditioning and functional impairments. Our team is currently working with Department of Veterans Affairs (VA) medical centers across the United States to implement STRIDE (assiSTed eaRly mobIlity for hospitalizeD older vEterans), a hospital-based walking program designed to mitigate the risks of immobility during hospitalization. However, the COVID-19 pandemic made in-person, or face-to-face, walking challenging due to social distancing recommendations and infection control concerns. In response, our team applied principles of implementation science, including stakeholder engagement, prototype development and refinement, and rapid dissemination and feedback, to create STRIDE in Your Room (SiYR). Consisting of self-guided exercises, light exercise equipment (e.g., TheraBands, stress ball, foam blocks, pedometer), the SiYR program provided safe alternative activities when face-to-face walking was not available during the pandemic. We describe the methods used in developing the SiYR program; present feedback from participating sites; and share initial implementation experiences, lessons learned, and future directions.

Video-Enhanced Care Management for Medically Complex Older Adults with Cognitive Impairment.

OBJECTIVE: This pilot study assessed feasibility of video-enhanced care management for complex older veterans with suspected mild cognitive impairment (CI) and their care partners, compared with telephone delivery. DESIGN: Pilot randomized controlled trial. SETTING: Durham Veterans Affairs Health Care System. PARTICIPANTS: Participants were enrolled as dyads, consisting of veterans aged 65 years or older with complex medical conditions (Care Assessment Need score ≥90) and suspected mild CI (education-adjusted Modified Telephone Interview for Cognitive Status score 20-31) and their care partners. INTERVENTION: The 12-week care management intervention consisted of monthly calls from a study nurse covering medication management, cardiovascular disease risk reduction, physical activity, and sleep behaviors, delivered via video compared with telephone. MEASUREMENTS: Dyads completed baseline and follow-up assessments to assess feasibility, acceptability, and usability. RESULTS: Forty veterans (mean (standard deviation (SD)) age = 72.4 (6.1) years; 100% male; 37.5% Black) and their care partners (mean (SD) age = 64.7 (10.8) years) were enrolled and randomized to telephone or video-enhanced care management. About a third of veteran participants indicated familiarity with relevant technology (regular tablet use and/or experience with videoconferencing); 53.6% of internet users were comfortable or very comfortable using the internet. Overall, 43 (71.7%) care management calls were completed in the video arm and 52 (86.7%) were completed in the telephone arm. Usability of the video telehealth platform was rated higher for participants already familiar with technology used to deliver the intervention (mean (SD) System Usability Scale scores: 65.0 (17.0) vs 55.6 (19.6)). Veterans, care partners, and study nurses reported greater engagement, communication, and interaction in the video arm. CONCLUSION: Video-delivered care management calls were feasible and preferred over telephone for some complex older adults with mild CI and their care partners. Future research should focus on understanding how to assess and incorporate patient and family preferences related to uptake and maintenance of video telehealth interventions.

Improving Veteran Access to Integrated Management of Back Pain (AIM-Back): Protocol for an Embedded Pragmatic Cluster-Randomized Trial.

BACKGROUND: Coordinated efforts between the National Institutes of Health, the Department of Defense, and the Department of Veterans Affairs have built the capacity for large-scale clinical research investigating the effectiveness of nonpharmacologic pain treatments. This is an encouraging development; however, what constitutes best practice for nonpharmacologic management of low back pain (LBP) is largely unknown. DESIGN: The Improving Veteran Access to Integrated Management of Back Pain (AIM-Back) trial is an embedded pragmatic cluster-randomized trial that will examine the effectiveness of two different care pathways for LBP. Sixteen primary care clinics will be randomized 1:1 to receive training in delivery of 1) an integrated sequenced-care pathway or 2) a coordinated pain navigator pathway. Primary outcomes are pain interference and physical function (Patient-Reported Outcomes Measurement Information System Short Form [PROMIS-SF]) collected in the electronic health record at 3 months (n=1,680). A subset of veteran participants (n=848) have consented to complete additional surveys at baseline and at 3, 6, and 12 months for supplementary pain and other measures. SUMMARY: AIM-Back care pathways will be tested for effectiveness, and treatment heterogeneity will be investigated to identify which veterans may respond best to a given pathway. Health care utilization patterns (including opioid use) will also be compared between care pathways. Therefore, the AIM-Back trial will provide important information that can inform the future delivery of nonpharmacologic treatment of LBP.

Implementation of a stepped wedge cluster randomized trial to evaluate a hospital mobility program.

BACKGROUND: Stepped wedge cluster randomized trials (SW-CRT) are increasingly used to evaluate new clinical programs, yet there is limited guidance on practical aspects of applying this design. We report our early experiences conducting a SW-CRT to examine an inpatient mobility program (STRIDE) in the Veterans Health Administration (VHA). We provide recommendations for future research using this design to evaluate clinical programs. METHODS: Based on data from study records and reflections from the investigator team, we describe and assess the design and initial stages of a SW-CRT, from site recruitment to program launch in 8 VHA hospitals. RESULTS: Site recruitment consisted of thirty 1-h conference calls with representatives from 22 individual VAs who expressed interest in implementing STRIDE. Of these, 8 hospitals were enrolled and randomly assigned in two stratified blocks (4 hospitals per block) to a STRIDE launch date. Block 1 randomization occurred in July 2017 with first STRIDE launch in December 2017; block 2 randomization occurred in April 2018 with first STRIDE launch in January 2019. The primary study outcome of discharge destination will be assessed using routinely collected data in the electronic health record (EHR). Within randomized blocks, two hospitals per sequence launched STRIDE approximately every 3 months with primary outcome assessment paused during the 3-month time period of program launch. All sites received 6-8 implementation support calls, according to a pre-specified schedule, from the time of recruitment to program launch, and all 8 sites successfully launched within their assigned 3-month window. Seven of the eight sites initially started with a limited roll out (for example on one ward) or modified version of STRIDE (for example, using existing staff to conduct walks until new positions were filled). CONCLUSIONS: Future studies should incorporate sufficient time for site recruitment and carefully consider the following to inform design of SW-CRTs to evaluate rollout of a new clinical program: (1) whether a blocked randomization fits study needs, (2) the amount of time and implementation support sites will need to start their programs, and (3) whether clinical programs are likely to include a "ramp-up" period. Successful execution of SW-CRT designs requires both adherence to rigorous design principles and also careful consideration of logistical requirements for timing of program roll out. TRIAL REGISTRATION: ClinicalsTrials.gov NCT03300336 . Prospectively registered on 3 October 2017.

Implementation of a group physical therapy program for Veterans with knee osteoarthritis.

BACKGROUND: A previous randomized clinical trial found that a Group Physical Therapy (PT) program for knee osteoarthritis yielded similar improvements in pain and function compared with traditional individual PT. Based on these findings the Group PT program was implemented in a Department of Veterans Affairs Health Care System. The objective of this study was to evaluate implementation metrics and changes in patient-level measures following implementation of the Group PT program. METHODS: This was a one-year prospective observational study. The Group PT program involved 6 weekly sessions. Implementation metrics included numbers of referrals and completed sessions. Patient-level measures were collected at the first and last PT sessions and included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC; self-report of pain, stiffness and function (range 0-96)) and a 30-s chair rise test. RESULTS: During the evaluation period, 152 patients were referred, 80 had an initial session scheduled, 71 completed at least one session and 49 completed at least 5 sessions. The mean number of completed appointments per patient was 4.1. Among patients completing baseline and follow-up measures, WOMAC scores (n = 33) improved from 56.8 (SD = 15.8) to 46.9 (SD = 14.0); number of chair rises (n = 38) completed in 30 s increased from 10.4 (SD = 5.1) to 11.9 (SD = 5.0). CONCLUSIONS: Patients completing the Group PT program in this implementation phase showed clinically relevant improvements comparable to those observed in the previous clinical trial that compared group and individual PT for knee osteoarthritis. These results are important because Group PT can improve efficiency and access compared with individual PT. However, there were some limitations with respect to attendance and completion rates, and program adaptations may be needed to optimize these implementation metrics. Larger, longer-term studies are required to more fully evaluate the effectiveness of this program.

Implementing a Mandated Program Across a Regional Health Care System: A Rapid Qualitative Assessment to Evaluate Early Implementation Strategies.

BACKGROUND: Rapid qualitative assessment was used to describe early strategies to implement an evidence-based walking program for hospitalized older adults, assiSTed eaRly mobIlity for hospitalizeD older vEterans (STRIDE), mandated by a regional Department of Veterans Affairs health care system office (Veterans Integrated Service Network [VISN]). METHODS: Data were collected from 6 hospital sites via semistructured interviews with key informants, observations of telephone-based technical assistance, and review of VISN-requested program documents (eg, initial implementation plans). An overarching framework of actionable feedback for VISN leadership and specification of locally initiated implementation strategies, using the Expert Recommendations for Implementing Change (ERIC) compilation, was used. Actionable feedback was shared with VISN leadership 1 month after the initiative. RESULTS: ERIC implementation strategies identified were as follows: (1) promoting adaptability-4 sites had physical therapists/kinesiotherapists instead of assistants walk patients; (2) promoting network weaving-strengthening nursing and PT/KT partnership with regular communication opportunities or a point person was important for implementation; (3) distributing educational materials-2 sites distributed information about STRIDE via e-mail and in person; and (4) organizing clinician implementation team meetings-3 sites used interdisciplinary team meetings to communicate with the clinical staff about STRIDE. CONCLUSION: This qualitative study sheds light on early experiences with implementing STRIDE; the results have been instructive for ongoing implementation and future dissemination of STRIDE, and the approach can be applied across contexts to inform implementation of other programs.

Early Mobility in the Hospital: Lessons Learned from the STRIDE Program.

Immobility during hospitalization is widely recognized as a contributor to deconditioning, functional loss, and increased need for institutional post-acute care. Several studies have demonstrated that inpatient walking programs can mitigate some of these negative outcomes, yet hospital mobility programs are not widely available in U.S. hospitals. STRIDE (assiSTed eaRly mobIlity for hospitalizeD older vEterans) is a supervised walking program for hospitalized older adults that fills this important gap in clinical care. This paper describes how STRIDE works and how it is being disseminated to other hospitals using the Replicating Effective Programs (REP) framework. Guided by REP, we define core components of the program and areas where the program can be tailored to better fit the needs and local conditions of its new context (hospital). We describe key adaptations made by four hospitals who have implemented the STRIDE program and discuss lessons learned for successful implementation of hospital mobility programs.

Strength of obesity prevention interventions in early care and education settings: A systematic review.

TIME AND PLACE OF STUDY: 2010-2015; INTERNATIONAL: Given the high levels of obesity in young children, numbers of children in out-of-home care, and data suggesting a link between early care and education (ECE) participation and overweight/obesity, obesity prevention in ECE settings is critical. As the field has progressed, a number of interventions have been reviewed yet there is a need to summarize the data using more sophisticated analyses to answer questions on the effectiveness of interventions. We conducted a systematic review of obesity prevention interventions in center-based ECE settings published between 2010 and 2015. Our goal was to identify promising intervention characteristics associated with successful behavioral and anthropometric outcomes. A rigorous search strategy resulted in 43 interventions that met inclusion criteria. We developed a coding strategy to assess intervention strength, used a validated study quality assessment tool, and presented detailed descriptive information about interventions (e.g., target behaviors, intervention strategies, and mode of delivery). Intervention strength was positively correlated with reporting of positive anthropometric outcomes for physical activity, diet, and combined interventions, and parent engagement components increased the strength of these relationships. Study quality was modestly related to percent successful healthy eating outcomes. Relationships between intervention strength and behavioral outcomes demonstrated negative relationships for all behavioral outcomes. Specific components of intervention strength (number of intervention strategies, potential impact of strategies, frequency of use, and duration of intervention) were correlated with some of the anthropometric and parent engagement outcomes. The review provided tentative evidence that multi-component, multi-level ECE interventions with parental engagement are most likely to be effective with anthropometric outcomes.