The relative impact of underweight, overweight, smoking, and physical inactivity on health and associated costs in Indonesia: propensity score matching of a national sample.

BACKGROUND: Indonesia is in the middle of a rapid epidemiological transition with an ageing population and increasing exposure to risk factors for chronic conditions. This study examines the relative impacts of obesity, tobacco consumption, and physical inactivity, on non-communicable diseases multimorbidity, health service use, catastrophic health expenditure (CHE), and loss in employment productivity in Indonesia. METHODS: Secondary analyses were conducted of cross-sectional data from adults aged ≥ 40 years (n = 12,081) in the Indonesian Family Life Survey 2014/2015. We used propensity score matching to assess the associations between behavioural risk factors and health service use, CHE, employment productivity, and multimorbidity. RESULTS: Being obese, overweight and a former tobacco user was associated with a higher number of chronic conditions and multimorbidity (p < 0.05). Being a former tobacco user contributed to a higher number of outpatient and inpatient visits as well as CHE incidences and work absenteeism. Physical inactivity relatively increased the number of outpatient visits (30% increase, p < 0.05) and work absenteeism (21% increase, P < 0.06). Although being underweight was associated with an increased outpatient care utilisation (23% increase, p < 0.05), being overweight was negatively associated with CHE incidences (50% decrease, p < 0.05). CONCLUSION: Combined together, obesity, overweight, physical inactivity and tobacco use contributed to an increased number of NCDs as well as medical costs and productivity loss in Indonesia. Interventions addressing physical and behavioural risk factors are likely to have substantial benefits for individuals and the wider society in Indonesia.

Provincial heterogeneity in the management of care cascade for hypertension, diabetes, and dyslipidaemia in China: Analysis of nationally representative population-based survey.

Background: This study aims to examine (1) province-level variations in the levels of cardiovascular disease (CVD) risk and behavioral risk for CVDs, (2) province-level variations in the management of cascade of care for hypertension, diabetes, and dyslipidaemia, and (3) the association of province-level economic development and individual factors with the quality of care for hypertension, diabetes, and dyslipidaemia. Methods: We used nationally representative data from the China Health and Retirement Longitudinal Study in 2015, which included 12,597 participants aged 45 years. Using a care cascade framework, we examined the quality of care provided to patients with three prevalent NCDs: hypertension, diabetes, and dyslipidaemia. The proportion of WHO CVD risk based on the World Health Organization CVD risk prediction charts, Cardiovascular Risk Score (CRS) and Behavior Risk Score (BRS) were calculated. We performed multivariable logistic regression models to determine the individual-level drivers of NCD risk variables and outcomes. To examine socio-demographic relationships with CVD risk, linear regression models were applied. Results: In total, the average CRS was 4.98 (95% CI: 4.92, 5.05), while the average BRS was 3.10 (95% confidence interval: 3.04, 3.15). The weighted mean CRS (BRS) in Fujian province ranged from 4.36 to 5.72 (P < 0.05). Most of the provinces had a greater rate of hypertension than diabetes and dyslipidaemia awareness and treatment. Northern provinces had a higher rate of awareness and treatment of all three diseases. Similar patterns of regional disparity were seen in diabetes and dyslipidaemia care cascades. There was no evidence of a better care cascade for CVDs in patients who reside in more economically advanced provinces. Conclusion: Our research found significant provincial heterogeneity in the CVD risk scores and the management of the cascade of care for hypertension, diabetes, and dyslipidaemia for persons aged 45 years or more. To improve the management of cascade of care and to eliminate regional and disparities in CVD care and risk factors in China, local and population-based focused interventions are necessary.

Use of quality-of-life instruments for people living with HIV: a global systematic review and meta-analysis.

INTRODUCTION: Due to the effectiveness of combined antiretroviral therapy and its growing availability worldwide, most people living with HIV (PLHIV) have a near-normal life expectancy. However, PLHIV continue to face various health and social challenges that severely impact their health-related quality-of-life (HRQoL). The UNAIDS Global AIDS Strategy discusses the need to optimize quality-of-life, but no guidance was given regarding which instruments were appropriate measures of HRQoL. This study aimed to review and assess the use of HRQoL instruments for PLHIV. METHODS: We conducted a global systematic review and meta-analysis, searching five databases for studies published between January 2010 and February 2021 that assessed HRQoL among PLHIV aged 16 years and over. Multivariable regression analyses were performed to identify factors associated with the choice of HRQoL instruments. We examined the domains covered by each instrument. Random-effects meta-analysis was conducted to explore the average completion rates of HRQoL instruments. RESULTS AND DISCUSSION: From 714 publications, we identified 65 different HRQoL instruments. The most commonly used instruments were the World Health Organization Quality-of-Life- HIV Bref (WHOQOL-HIV BREF)-19%, Medical Outcome Survey-HIV (MOS-HIV)-17%, Short Form-36 (SF-36)-12%, European Quality-of-Life Instrument-5 Dimension (EQ-5D)-10%, World Health Organization Quality-of-Life Bref (WHOQOL BREF)-8%, Short Form-12 (SF-12)-7% and HIV/AIDS Targeted Quality-of-Life (HAT-QOL)-6%. There were greater odds of using HIV-specific instruments for middle- and low-income countries (than high-income countries), studies in the Americas and Europe (than Africa) and target population of PLHIV only (than both PLHIV and people without HIV). Domains unique to the HIV-specific instruments were worries about death, stigma and HIV disclosure. There were no significant differences in completion rates between different HRQoL instruments. The overall pooled completion rate was 95.9% (95% CI: 94.7-97.0, I2 = 99.2%, p < 0.01); some heterogeneity was explained by country-income level and study type. CONCLUSIONS: A wide range of instruments have been used to assess HRQoL in PLHIV, and the choice of instrument might be based on their different characteristics and reason for application. Although completion rates were high, future studies should explore the feasibility of implementing these instruments and the appropriateness of domains covered by each instrument.

Low physical activity is associated with adverse health outcome and higher costs in Indonesia: A national panel study.

Aims: To assess the association between low physical activity, cardiovascular disease (CVD) and risk factors, health service utilization, risk of catastrophic health expenditure, and work productivity in Indonesia. Methods: In this population-based, panel data analysis, we used data from two waves of the Indonesian Family Life Survey (IFLS) for 2007/2008 and 2014/2015. Respondents aged 40-80 years who participated in both waves were included in this study (n = 5,936). Physical activity was assessed using the International Physical Activity Questionnaire (IPAQ-SF). Multinomial logistic regression model was used to examine factors associated with physical activity levels (low, moderate, and high). We applied a series of multilevel mixed-effect panel regression to examine the associations between physical activity and outcome variables. Results: The prevalence of low physical activity increased from 18.2% in 2007 to 39.6% in 2014. Compared with those with high physical activity, respondents with low physical activity were more likely to have a 10-year high CVD risk (AOR: 2.11, 95% CI: 1.51-2.95), use outpatient care (AOR: 1.26, 95% CI: 1.07-1.96) and inpatient care (AOR 1.45, 95% CI: 1.07-1.96), experience catastrophic health expenditure of 10% of total household expenditure (AOR: 1.66, 95% CI: 1.21-2.28), and have lower labor participation (AOR: 0.24, 95% 0.20-0.28). Conclusions: Low physical activity is associated with adverse health outcomes and considerable costs to the health system and wider society. Accelerated implementation of public health policies to reduce physical inactivity is likely to result in substantial population health and economic benefits.

Socioeconomic inequalities in effective service coverage for reproductive, maternal, newborn, and child health: a comparative analysis of 39 low-income and middle-income countries.

BACKGROUND: Reducing socioeconomic inequalities in access to good quality health care is key for countries to achieve Universal Health Coverage. This study aims to assess socioeconomic inequalities in effective coverage of reproductive, maternal, newborn and child health (RMNCH) in low- and middle-income countries (LMICs). METHODS: Using the most recent national health surveys from 39 LMICs (between 2014 and 2018), we calculated coverage indicators using effective coverage care cascade that consists of service contact, crude coverage, quality-adjusted coverage, and user-adherence-adjusted coverage. We quantified wealth-related and education-related inequality using the relative index of inequality, slope index of inequality, and concentration index. FINDINGS: The quality-adjusted coverage of RMNCH services in 39 countries was substantially lower than service contact, in particular for postnatal care (64 percentage points [pp], p-value<0·0001), family planning (48·7 pp, p<0·0001), and antenatal care (43·6 pp, p<0·0001) outcomes. Upper-middle-income countries had higher effective coverage levels compared with low- and lower-middle-income countries in family planning, antenatal care, delivery care, and postnatal care. Socioeconomic inequalities tend to be wider when using effective coverage measurement compared with crude and service contact measurements. Our findings show that upper-middle-income countries had a lower magnitude of inequality compared with low- and lower-middle-income countries. INTERPRETATION: Reliance on the average contact coverage tends to underestimate the levels of socioeconomic inequalities for RMNCH service use in LMICs. Hence, the effective coverage measurement using a care cascade approach should be applied. While RMNCH coverages vary considerably across countries, equitable improvement in quality of care is particularly needed for lower-middle-income and low-income countries. FUNDING: None.

Examining supports and barriers to breastfeeding through a socio-ecological lens: a qualitative study.

BACKGROUND: Early breastfeeding cessation is a societal concern given its importance to the health of mother and child. More effective interventions are needed to increase breastfeeding duration. Prior to developing such interventions more research is needed to examine breastfeeding supports and barriers from the perspective of breastfeeding stakeholders. One such framework that can be utilized is the Socio-Ecological Model which stems from Urie Broffenbrenner's early theoretical frameworks (1973-1979). The purpose of this study was to examine supports and barriers to breastfeeding across environmental systems. METHODS: A total of 49 representatives participated in a telephone interview in Nebraska, USA in 2019. Interviewees represented various levels of the model, based on their current breastfeeding experience (i.e., mother or significant other) or occupation. A direct content analysis was performed as well as a constant comparative analysis to determine differences between level representatives. RESULTS: At the Individual level, breastfeeding is a valued behavior, however, women are hindered by exhaustion, isolation, and the time commitment of breastfeeding. At the Interpersonal level, social media, peer-to-peer, and family were identified as supports for breastfeeding, however lack of familial support was also identified as a barrier. At the community level, participants were split between identifying cultural acceptance of breastfeeding as support or barrier. At the organizational level, hospitals had supportive breastfeeding friendly policies in place however lacked enough personnel with breastfeeding expertise. At the policy level, breastfeeding legislation is supportive, however, more specific breastfeeding legislation is needed to ensure workplace breastfeeding protections. CONCLUSION: Future efforts should target hospital-community partnerships, family-centered education, evidence-based social media strategies and improved breastfeeding legislation to ensure breastfeeding women receive effective support throughout their breastfeeding journey.

Temporal trends and variation in out-of-pocket expenditures and patient cost sharing: evidence from a Chinese national survey 2011-2015.

OBJECTIVES: This study aims to examine: (1) temporal trends in the percentage of cost-sharing and amount of out-of-pocket expenditure (OOPE) from 2011 to 2015; (2) factors associated with cost-sharing and OOPE; and (3) the relationships between province-level economic development and cost-sharing and OOPE in China. SETTING: A total of 10,316 adults aged ≥45 years from China followed-up from 2011 to 2015 were included in the analysis. We measured two main outcome variables: (1) patient cost sharing, measured by the percentage of OOPE as total healthcare expenditure, and (2) absolute amount of OOPE. RESULTS: Based on self-reported data, we did not find substantial differences in the percentage of cost sharing, but a significant increase in the absolute amount of OOPE among the middle-aged and older Chinese between 2011 and 2015. The percentage of cost-sharing was considerably higher for outpatient than inpatient care, and the majority paid more than 80% of the total cost for prescription drugs. Provinces with higher GDP per capita tend to have lower cost-sharing and a higher OOPE than their counterparts, but the relationship for OOPE became insignificant after adjusting for individual factors. CONCLUSION: Reducing out-of-pocket expenditure and patient cost sharing is required to improve financial protection from illness, especially for those with those with chronic conditions and reside in less developed regions in China. Ongoing monitoring of financial protection using data from various sources is warranted.

Health Service Utilization and Out-of-Pocket Expenditure Associated with the Continuum of Disability in Vietnam.

Reducing the burden of disability is key priority in many countries where the population is aging rapidly. The relationships between disability, health expenditure and economic burden are complex, particularly when disability is recognized as a continuum rather than a dichotomous phenomenon. However, these complex relationships are not adequately addressed in national health policy and management plans in Vietnam. This paper examines the economic consequences of disability across its continuum or levels of severity. Two-part regression models were applied to assess the relationships between disability, health service use and the out-of-pocket expenditure. We found that Vietnamese adults with disabilities had multiple characteristics of vulnerability, e.g., older, less likely to be employed, lower education, and poorer than adults without disabilities. These characteristics are associated with poorer health and higher need of healthcare utilization but, after controlling for these factors, disability still had an independent association with higher health expenditure and greater economic burden at their household (p < 0.05). Our study provides empirical evidence of the economic burden associated across the continuum of disability in Vietnam. Decisive action is critical for protecting persons with disability from medical impoverishment, and such targeted interventions should include those with moderate disability rather than the current focus on severe disability.

Use of social impact bonds in financing health systems responses to non-communicable diseases: scoping review.

There is an interest to understand how social impact bonds (SIBs), a type of innovative financing instrument used in impact investment, can be used to finance the prevention of non-communicable diseases (NCDs). This is the first scoping review that explores the evidence of SIBs for NCDs and their key characteristics and performance. The review used both published and grey literature from eight databases (MEDLINE, NCBI, Elsevier, Cochrane Library, Google, Google Scholar, WHO publications and OECD iLibrary). A total of 83 studies and articles were eligible for inclusion, identifying 11 SIBs implemented in eight countries. The shared characteristics of the SIBs used for NCDs were impact investment companies as investors, local governments as outcome payers, not-for-profit service providers and an average US$2 015 456 private initial investment. The review revealed a lack of empirical evidence on SIBs for NCDs. Conflict of interest and lack of public disclosure were common issues in both the published and grey literature on SIBs. Furthermore, only three SIBs implemented for financing NCDs were meeting all their target outcomes. The common characteristics of the SIBs meeting their target outcomes were evidence-based interventions, multiple service providers and an intermediated structure. Overall, there is a need for more high-quality studies, particularly economic evaluations and qualitative studies on the benefits to target populations, and greater transparency from the private sector, in order to ensure improved SIBs for preventing NCDs.

The association between mental-physical multimorbidity and disability, work productivity, and social participation in China: a panel data analysis.

BACKGROUND: The co-occurrence of mental and physical chronic conditions (mental-physical multimorbidity) is a growing and largely unaddressed challenge for health systems and wider economies in low-and middle-income countries. This study investigated the independent and combined (additive or synergistic) effects of mental and physical chronic conditions on disability, work productivity, and social participation in China. METHODS: Panel data study design utilised two waves of the China Health and Retirement Longitudinal Study (2011, 2015), including 5616 participants aged ≥45 years, 12 physical chronic conditions and depression. We used a panel data approach of random-effects regression models to assess the relationships between mental-physical multimorbidity and outcomes. RESULTS: After adjusting for socio-economic and demographic factors, an increased number of physical chronic conditions was independently associated with a higher likelihood of disability (Adjusted odds ratio (AOR) = 1.39; 95% CI: 1.33, 1.45), early retirement (AOR = 1.37 [1.26, 1.49]) and increased sick leave days (1.25 days [1.16, 1.35]). Depression was independently associated with disability (AOR = 3.78 [3.30, 4.34]), increased sick leave days (2.18 days [1.72, 2.77]) and a lower likelihood of social participation (AOR = 0.57 [0.47, 0.70]), but not with early retirement (AOR = 1.24 [0.97, 1.58]). There were small and statistically insignificant interactions between physical chronic conditions and mental health on disability, work productivity and social participation, suggesting an additive effect of mental-physical multimorbidity on productivity loss. CONCLUSION: Mental-physical multimorbidity poses substantial negative health and economic effects on individuals, health systems, and societies. More research that addresses the challenges of mental-physical multimorbidity is needed to inform the development of interventions that can be applied to the workplace and the wider community in China.

Impact of non-communicable disease multimorbidity on health service use, catastrophic health expenditure and productivity loss in Indonesia: a population-based panel data analysis study.

OBJECTIVES: To examine non-communicable diseases (NCDs) multimorbidity level and its relation to households' socioeconomic characteristics, health service use, catastrophic health expenditures and productivity loss. DESIGN: This study used panel data of the Indonesian Family Life Survey conducted in 2007 (Wave 4) and 2014 (Wave 5). SETTING: The original sampling frame was based on 13 out of 27 provinces in 1993, representing 83% of the Indonesian population. PARTICIPANTS: We included respondents aged 50 years and above in 2007, excluding those who did not participate in both Waves 4 and 5. The total number of participants in this study are 3678 respondents. PRIMARY OUTCOME MEASURES: We examined three main outcomes; health service use (outpatient and inpatient care), financial burden (catastrophic health expenditure) and productivity loss (labour participation, days primary activity missed, days confined in bed). We applied multilevel mixed-effects regression models to assess the associations between NCD multimorbidity and outcome variables, RESULTS: Women were more likely to have NCD multimorbidity than men and the prevalence of NCD multimorbidity increased with higher socioeconomic status. NCD multimorbidity was associated with a higher number of outpatient visits (compared with those without NCD, incidence rate ratio (IRR) 4.25, 95% CI 3.33 to 5.42 for individuals with >3 NCDs) and inpatient visits (IRR 3.68, 95% CI 2.21 to 6.12 for individuals with >3 NCDs). NCD multimorbidity was also associated with a greater likelihood of experiencing catastrophic health expenditure (for >3 NCDs, adjusted OR (aOR) 1.69, 95% CI 1.02 to 2.81) and lower participation in the labour force (aOR 0.23, 95% CI 0.16 to 0.33) compared with no NCD. CONCLUSIONS: NCD multimorbidity is associated with substantial direct and indirect costs to individuals, households and the wider society. Our study highlights the importance of preparing health systems for addressing the burden of multimorbidity in low-income and middle-income countries.

Improving Breastfeeding Environments and Feeding Practices in Family Child Care Homes with the Go NAP SACC Program.

PURPOSE: Breastfeeding and responsive feeding are important practices that support the health of infants and women. In the United States, breastfeeding continuation rates remain lower than recommended, and working women face additional challenges with breastfeeding continuation. Providers in a family child care setting are uniquely positioned to support and provide important resources to families in their breastfeeding and infant feeding practices. METHODS: The Go NAP SACC program was designed to improve the nutrition and physical activity environments and practices in child care settings serving infants and young children. This evaluation focuses on Breastfeeding and Infant Feeding in Nebraska Family Child Care Homes (FCCH). ASSESSMENT: Paired-sample t-tests were used to examine differences in pre-post evaluation scores. A repeated measure ANCOVA was used to examine differences between rural-urban settings. Nebraska FCCH met recommendations at pre-test, and exceeded recommendations at post-test (p < .05). Rural and urban FCCH performed equally well in 18 of 22 items, indicating little difference in the ability to provide supportive environments and adhere to best practices in both settings. Improvement in family engagement items were significant at the p < .001 level. Family engagement in FCCH is an important area for intervention that was well-received by provider participants. CONCLUSION: This evaluation shows that the Go NAP SACC program improves breastfeeding and infant feeding environments and practices in rural and urban FCCH. Interventions should continue to focus on basic and practical education and professional development for FCCH providers, with emphasis on intentional family engagement and support.

The Joint Effect of Physical Multimorbidity and Mental Health Conditions Among Adults in Australia.

INTRODUCTION: The prevalence of chronic physical and mental health conditions is rising globally. Little evidence exists on the joint effect of physical and mental health conditions on health care use, work productivity, and health-related quality of life in Australia. METHODS: We analyzed data from the Household, Income and Labour Dynamics in Australia (HILDA) Survey, waves 9 (2009), 13 (2013), and 17 (2017). Economic effects associated with multimorbidity were measured through health service use, work productivity loss, and health-related quality of life. We used generalized estimating equations to assess the effect of the association between physical multimorbidity and mental health conditions and economic outcomes. RESULTS: From 2009 through 2017 the prevalence of physical multimorbidity increased from 15.1% to 16.2%, and the prevalence of mental health conditions increased from 11.2% to 17.3%. The number of physical health conditions was associated with the number of health services used (general practitioner visits, incidence rate ratio = 1.41), work productivity loss (labor force participation, adjusted odds ratio = 0.71), and reduced health-related quality of life (SF-6D score: Coefficient = -0.03). These effects were exacerbated by the presence of mental health conditions and low socioeconomic status. CONCLUSION: Having multiple physical health conditions (physical multimorbidity) creates substantial health and financial burdens on individuals, the health system, and society, including increased use of health services, loss of work productivity, and decreased health-related quality of life. The adverse effects of multimorbidity on health, quality of life, and economic well-being are exacerbated by the co-occurrence of mental health conditions and low socioeconomic status.

Comparison of Urban and Rural Physical Activity and Outdoor Play Environments of Childcare Centers and Family Childcare Homes.

The purpose of this study was to examine the physical activity environment in childcare programs across type (childcare centers [CCCs] and family childcare homes [FCCHs]) and geographic location (urban and rural) as assessed by physical activity best practices according to the Go Nutrition and Physical Activity Self-assessment in Child Care. Results showed CCCs compared with FCCHs reported higher achievement of best practices. Further, urban childcare programs (CCCs and FCCHs) reported higher achievement of best practices in comparison to rural childcare programs. There is a need to deliver targeted interventions that promote children's physical activity in FCCHs and CCCs in rural areas.

Provider reported implementation of nutrition-related practices in childcare centers and family childcare homes in rural and urban Nebraska.

Approximately 15 million children under age 6 are in childcare settings, offering childcare providers an opportunity to influence children's dietary intake. Childcare settings vary in organizational structure - childcare centers (CCCs) vs. family childcare homes (FCCHs) - and in geographical location - urban vs. rural. Research on the nutrition-related best practices across these childcare settings is scarce. The objective of this study is to compare nutrition-related best practices of CCCs and FCCHs that participate in the Child and Adult Care Food Program (CACFP) in rural and urban Nebraska. Nebraska providers (urban n = 591; rural n = 579) reported implementation level, implementation difficulty and barriers to implementing evidence-informed food served and mealtime practices. Chi-square tests comparing CCCs and FCCHs in urban Nebraska and CCCs and FCCHs in rural Nebraska showed sub-optimal implementation for some practices across all groups, including limiting fried meats and high sugar/ high fat foods, using healthier foods or non-food treats for celebrations and serving meals family style. Significant differences (p < .05) between CCCs and FCCHs also emerged, especially with regard to perceived barriers to implementing best practices. For example, CCCs reported not having enough money to cover the cost of meals for providers, lack of control over foods served and storage problems, whereas FCCHs reported lack of time to prepare healthier foods and sit with children during mealtimes. Findings suggest that policy and public health interventions may need to be targeted to address the unique challenges of implementing evidence-informed practices within different organizational structures and geographic locations.

Contextual Factors Influence Professional Development Attendance Among Child Care Providers in Nebraska.

OBJECTIVE: To examine contextual factors that may influence child care providers' motivators for attending nutrition-related training and their preferences and barriers to attending professional development training. DESIGN: Cross-sectional survey completed between January and April 2017. SETTING: Licensed child care programs (n = 1,490) across urban and rural Nebraska. PARTICIPANTS: Child care center directors (n = 336) and family child care home providers (n = 1,154). MAIN OUTCOME MEASURE(S): Motivators, preferences, and barriers of child care providers for attending professional development. ANALYSIS: Descriptive statistics and multiple logistic regression analyses were conducted. RESULTS: Top motivators for attending nutrition-related training included meeting licensure requirements and improving job performance. Child care providers most commonly selected preferences for receiving training included in-person and online delivery. Top barriers to obtaining training were schedule conflicts, accessibility, and cost. Child care centers and participants in the Child and Adult Care Food Program (CACFP) and Nutrition and Physical Activity Self-Assessment in Child Care (Go NAP SACC) were more likely to be motivated by licensure requirements. Rural providers were also more likely to report barriers such as inability to travel and limited access to training. Results revealed that child care type, geographic location, CACFP and Go NAP SACC participation can influence child care providers' motivators, preferences, and barriers to attending training. CONCLUSIONS AND IMPLICATIONS: Results highlight the importance of offering professional development training that best fits child care providers' needs and preferences.

Improving the nutrition and screen time environment through self-assessment in family childcare homes in Nebraska.

OBJECTIVE: To determine if family childcare homes (FCCH) in Nebraska meet best practices for nutrition and screen time, and if focusing on nutrition and screen time policies and practices improves the FCCH environment. DESIGN: A pre-post evaluation was conducted using the Go Nutrition and Physical Activity Self-Assessment for Childcare (Go NAP SACC). SETTING: FCCH in Nebraska, USA. SUBJECTS: FCCH enrolled in the Child and Adult Care Food Program (CACFP; n 208) participated in a pre-post evaluation using Go NAP SACC. RESULTS: At baseline, all FCCH met the minimum childcare standards for fifty-four of fifty-six practices in nutrition and screen time. After the intervention, FCCH demonstrated significant improvement in fourteen of the forty-four Child Nutrition items and eleven of the twelve Screen Time items. However, FCCH providers did not meet best practices at post-intervention. Lowest scores were found in serving meals family-style, promoting visible support for healthy eating, planned nutrition education and written policy on child nutrition. For screen time, lowest scores were reported on the availability of television, offering families education on screen time and having a written policy on screen time. CONCLUSIONS: FCCH in Nebraska were able to strengthen their policies and practices after utilizing Go NAP SACC. Continued professional development and participation in targeted interventions may assist programmes in sustaining improved practices and policies. Considering the varying standards and policies surrounding FCCH, future studies comparing the current findings with childcare centres and non-CACFP programmes are warranted.

Improving the Physical Activity and Outdoor Play Environment of Family Child Care Homes in Nebraska Through Go Nutrition and Physical Activity Self-Assessment for Child Care.

BACKGROUND: The purpose of this study was to determine if the Go Nutrition and Physical Activity Self-Assessment in Child Care (Go NAP SACC) intervention was effective in improving best practices in the areas of infant and child physical activity and outdoor play and learning in family child care homes (FCCHs) in Nebraska. METHODS: FCCHs (n = 201) participated in a pre-post evaluation using the Infant and Child Physical Activity and Outdoor Play and Learning assessments from the Go NAP SACC validated measure to assess compliance with best practices. RESULTS: At post, FCCHs demonstrated significant differences in 85% of the Infant and Child Physical Activity items (17 of 20) and 80% of the Outdoor Play and Learning items (12 of 15). Significant differences in best practices between urban and rural FCCH providers were also found. CONCLUSION: Go NAP SACC appears to be an effective intervention in Nebraska as, after participation in the initiative, providers were improving child care physical activity best practices. Additional research is needed to objectively determine if these changes resulted in objective improvements in children's physical activity levels. Further, efforts are needed to develop and/or identify geographic-specific resources for continued improvement.